COVID in the UK: Where Do We Go From Here

Program announcer

Welcome to the Peds Ethics Podcast, where we talk to leaders in pediatric bioethics about a hot topic or current controversy. Here's your host, John Lantos, from the Children's Mercy Bioethics Center in Kansas City.

Dr. John Lantos

Hi, everybody. Welcome back. This is John Lantos from the Children's Mercy Bioethics Center doing our podcasts on pediatric bioethics. Our guest today is Professor Dominic Wilkinson. He's a specialist in newborn intensive care and medical ethics at the John Radcliffe Hospital and director of medical ethics at the University of Oxford Yihiro Center for Practical Ethics. Dr. Wilkinson has been working hard on the response to the COVID pandemic in the UK. Welcome, Dom. Thanks for joining us.

Dr. Dominic Wilkinson

My pleasure.

Dr. John Lantos

So the theme for these podcasts a few months into the pandemic is what have we learned and where do we go from here? Could you tell us a little bit about what your role has been and some of the things you've learned?

Dr. Dominic Wilkinson

I've been involved in the response to the pandemic at different levels. So I've been working here in the hospital and leading the ethics element of the hospital's response as co-chair of the hospital's clinical ethics committee, but also involved At a policy level, for example, as a member of the British Medical Association Medical Ethics Committee and also part of the group writing guidelines for the Royal College of Pediatrics and Child Health. And then as an academic, writing about a variety of ethical questions.

Dr. John Lantos

So tell us a little bit about the guideline writing process. Did you find that writing them in advance helped? or did you end up facing things that the planners didn't anticipate?

Dr. Dominic Wilkinson

Well I think that the great challenge has been that in the UK there weren't ethical guidelines in advance about how to think about prioritisation in the context of the pandemic. The biggest issue here as elsewhere that we were grappling with in March was the prospect of having many more patients needing respiratory support than there were available ventilators and the problem was that simply there were there were no existing guidelines uh for what to do in that situation it's different from other parts of the world like the us that have had a a number of states have had pandemic allocation plans for a number of years and the challenge was that while different groups were attempting to grapple with this and there was a desire for a national guideline to ensure that there was a uniform approach, it was politically extremely sensitive to be contemplating writing such a guideline. And indeed, although my understanding is that such a guideline was developed at the national level, it was felt to be politically unacceptable. So there was no national guidance.

Dr. John Lantos

So there was a guideline written but never released or operationalized?

Dr. Dominic Wilkinson

That appears to be the case. There was an article in the New York Times reporting that and I have some reason to believe that that's true.

Dr. John Lantos

And luckily it seemed like things did not get to the point where there were too many patients and not enough ventilators. Is that accurate?

Dr. Dominic Wilkinson

Indeed. So like some other places, although there was a lot of anxiety and huge amounts of preparation, and there was lots of reallocation of resources within the hospital to free up space for patients needing respiratory support. In fact, the surge was not as great as feared. So the really difficult decisions were to some degree avoided. I don't think they were totally avoided. But for the most part, those patients who needed intensive care, needed respiratory support, were able to access it.

Dr. John Lantos

So were there other allocation questions that arose then, if not the most visible ones of ventilator allocation?

Dr. Dominic Wilkinson

Well, I think the biggest challenge has been how to address the needs of patients without coronavirus. Because although all the attention has been to COVID-19 and coronavirus and the healthcare needs of those patients. There are many, many more patients with other health conditions compared to the patients with coronavirus and their healthcare needs have been sort of come second best. That's not necessarily been a deliberate decision that those healthcare needs are less important. And to some degree it's been ethically justified because some of those healthcare needs could be deferred or delayed to make way for the urgent unavoidable needs of real and expected anticipated patients with COVID. However, that now puts us in a very difficult situation because we've had several months where, for example, elective surgery has been put on hold lots of clinics have been cancelled lots of medical needs have been delayed and there is now a huge backlog of medical need and that would be straightforward if for example coronavirus had completely gone away and

Dr. Dominic Wilkinson

there were ample available capacity to look after the backlog and of course all the patients with new medical needs but neither of those is the case. So there is an ongoing need for patients with coronavirus to be treated and it will certainly be the case that as lockdown is relaxed that there'll be more cases of patients with needing respiratory support for coronavirus and it's also the case that even before the crisis there was pretty little spare capacity within the system for dealing with surges in demand. So now there's a big backlog, a big waiting list, for example, for pretty much every form of surgery and a real challenge to now to meet that need. So the prioritization question now affects huge areas of medicine. It's no longer just focused with this patient or that patient who gets the ventilator. It's across the healthcare system. Who gets surgery? When do they get surgery? Who gets treatment? Who gets into hospital?

Dr. John Lantos

And how are those prioritization questions being addressed? Is it on a national level or hospital by hospital?

Dr. Dominic Wilkinson

It's largely on a hospital basis. There have been some attempts to develop some global principles for example trying within surgery to develop categories of different levels of urgency

Dr. Dominic Wilkinson

but of course urgency is not the only factor that if you can't meet the needs of all patients urgency is important those patients who urgently need treatment will go towards the front of the list but there are also other patients whose healthcare needs are very substantial, but perhaps less urgent and nonetheless important. So for example, there are lots of patients suffering with chronic pain from their orthopedic conditions. Those things are not necessarily urgent, but delaying them will cause them to many months of pain and limitation in activity.

Dr. John Lantos

Do you think all this has changed the way people view the National Health Service?

Dr. Dominic Wilkinson

I think in the UK the National Health Service has a huge place in the national psyche and there's been an enormous amount of support for the Health Service and for those people who work within it.

Dr. Dominic Wilkinson

It's within the political debate. It's been right front and center of the response. The enormous measures that have been implemented, the effects on people's daily lives have been justified on the basis of protecting the health system. And people have by and large accepted that. I think the difficulty going forward is that there is going to be a very prolonged period where the health system going to struggle and that's going to be continuing to demand resources there's going to be a question about whether there's going to be political will to continue to to fund additional resources for a health care system even when it's no longer the front page headline coronavirus it's it's the less sexy less urgent but no no less important medical needs of all other health conditions. And I think there'll be a question about patients within the wider community, about whether people will lose patients with a health system that, for example, keeps asking them to wait to have access to appointments or surgery or other treatments.

Dr. John Lantos

And in the US, we also closed down elective surgery and a lot of primary care clinic visits now gradually starting to reopen. And in a similar way, the demand is enormous. And there doesn't seem to be any rigorous ethical analysis of which patients should go first. I mean, you mentioned urgent and perhaps life-threatening surgeries. Those are the easy ones. But how do you measure? different sorts of pain or the possibility of a surgery that would perhaps delay the onset of secondary problems. Is your group giving thought to those sorts of allocation algorithms?

Dr. Dominic Wilkinson

Yeah, so locally we've been talking with some of our surgical groups about how to think about that. And I think there are some easy cases. that perhaps give us a place to start because in a sense there's an overwhelming problem. Huge numbers, large waiting lists. How do we differentiate between these patients? Well, I think that there are three easy principles. So one easy principle is that you need to pick from those patients who are waiting, the ones who do have urgent, life-threatening, health-threatening conditions. and move them to the front and make sure that those healthcare needs are met.

Dr. John Lantos

That's a kind of classic triage based on acute illness.

Dr. Dominic Wilkinson

Based on urgency and medical need. The opposite end are patients whose needs can be delayed. There are some patients who might be on the waiting list whose medical needs are perhaps

Dr. Dominic Wilkinson

borderline, it would be absolutely reasonable in ordinary circumstances for them to go ahead and have surgery, to be listed for a clinic appointment, for example, even though the referring doctor doesn't think that they've got a serious problem that needs to be seen in the clinic. But in the current context, perhaps they simply need to wait. And there's a further group which is kind of an easy group which is to ask patients whether they would volunteer to wait. Because there are some patients who are on those waiting lists who might not wish to come to hospital in the current setting when the risks for them might be elevated. Being in hospital during a pandemic isn't risk-free. And there may also be patients who are willing for the sake of others whose needs may be greater to wait an extra few months or six months. And there has been an enormous willingness across the community for people to

Dr. Dominic Wilkinson

make sacrifices for the sake of others. I think that's one of the really heartening lessons of the pandemic, the degree to which our community has been willing to make sacrifices for the greater good. So one way of addressing this or at least reducing the problem is to contact those people on the waiting list and say, there's a big problem right now. We can't get everybody in as fast as we would like to. Would you be in a position to, would you be happy to wait a little bit longer, perhaps to wait until next year? even though in ordinary circumstances you'd be seeing this for example.

Dr. John Lantos

Is that something you're proposing or is that something that's actually being done now?

Dr. Dominic Wilkinson

I don't think it's being done yet. It's one of the possibilities that we've talked about with our surgical groups as a way of trying to reduce the burden of prioritization. I think once you've done those easy groups, you've moved some forward moved some perhaps to the back of the list and some patients have moved themselves off the list. The question is what you do with the remainder. And it may be very difficult to choose between them. One option is simply to deal with them in the order that they were referred and that you would have dealt with them in ordinary circumstances. So to deal with them in a first come first serve basis, for example. And that's not, perfect by any means, but it may be the best that we can do with those whose needs aren't urgent or low priority.

Dr. John Lantos

Yeah, when that came up here, there was a lot of talk about how getting onto the waiting list is itself a reflection of empowerment and resources. People who get on the list tend to be the ones who know how to work the system.

Dr. Dominic Wilkinson

Waiting lists and a first come first served basis it is not completely egalitarian as you point out some patients might for reasons of having greater personal resources have managed to get to start off higher up in the list and of course if there are patients who are waiting whose needs are more urgent and more serious then those potentially should be identified and moved further up I think the other thing that is important is to look at ways to meet the medical needs of patients who are waiting while they're waiting. So that might include taking advantage of some of the things that we've suddenly learned how to do during the pandemic. For example, remote consultations, speaking to patients on the phone, identifying compromises other ways of managing their symptoms without them being in hospital or without them having surgery, and making sure, for example, that they have access to allied healthcare, medications, other forms of therapy that might mitigate their symptoms, as well as

Dr. Dominic Wilkinson

keeping a track of the severity of their symptoms so that if, for example, their chest pain is worsening, they get to be seen urgently and, if necessary, moved forward in the queue.

Dr. John Lantos

Any idea what percentage of doctor-patient encounters or patient healthcare system encounters have gone to telemedicine or remote medicine?

Dr. Dominic Wilkinson

I don't have any numbers on it, but huge, across the health system, huge numbers of consultations have been occurring by telephone or using other technology. And I think it's been really interesting to see just what is possible that perhaps we didn't think was previously possible and also clearly identify what's very challenging. And I think that one interesting possibility will be the use of these technologies as a form of triage, as a way of identifying which assessments and conversations can occur remotely and which need to occur in person. And that might mean that a smaller proportion of patient encounters occur actually in person.

Dr. John Lantos

So it sounds like you think post-COVID the entire system of healthcare delivery might look pretty different, that COVID was sort of a nudge.

Dr. Dominic Wilkinson

I think there'll be some things that change in a lasting way. I think there will be a very long period where the health system is under very substantial strain because of the combined impact of COVID and the additional backlog. It's worth highlighting that the other element that is going to affect the health care system for months, if not years, are the changes in health care delivery to mitigate risk. that actually make healthcare delivery much less efficient. So we're used now, at least in the UK, and I imagine it's the same in the US, to having queues outside our supermarkets and reduced numbers of people at a time that makes going to the supermarket less efficient. Well, the same sort of issues are going to apply in healthcare. For example, in surgery, if there are additional precautions that are needed to reduce aerosol generation and to to mitigate risk those in fact mean that you have a lower throughput smaller numbers of patients can have surgery and of course that then affects the capacity of the healthcare system to deal with the backlog so that so it's a perfect storm in terms of

Dr. Dominic Wilkinson

of demand You've got increased demand from COVID. You've got increased backlog. You've got reduced efficiency. And that's on top of a healthcare system that was pretty much at its limit in terms of its ability to address healthcare needs.

Dr. John Lantos

Well, thanks so much for giving us a little insight into what's going on in the UK. Were there any other sort of surprise take-home lessons for you as you... went through this both as clinician and policymaker?

Dr. Dominic Wilkinson

One of the issues that we mentioned at the start was the need for policymaking in advance. So I was struck thinking about looking at some of the guidelines that came out in advance in the US. It struck me that it's possible when there isn't a pandemic to have a calm and rational conversation with the wider community about, well, how would you allocate ventilators? How would you make these very difficult decisions? And to come up with some guidelines. And everybody within the community can think carefully about it because it's not affecting them or their family members. And the politicians can accept it because it's all theoretical. But in the heat of the moment, those discussions become extremely difficult and politically sensitive so that our politicians then have been completely unable to make or accept allocation guidelines because they judged it was just too politically sensitive. So I think that really points to the need for a level of ethical preparation and advanced planning and consultation with the community so that we can inform decisions when there's a crisis.

Dr. John Lantos

That's interesting because there were many efforts after the last threatened pandemic, H1N1 and again after Ebola, to come up with these allocation guidelines. But as is often the case, the pandemic that came was a little different than the pandemic that people had. Some of the guidelines proved inapplicable, but some of the principles proved to be pretty robust.

Dr. Dominic Wilkinson

I think that's right. I think what you can identify are the principles, and the application of them is going to have to depend on the circumstances.

Dr. John Lantos

Well, this has been great. Once again, listeners, we're speaking with Professor Dominic Wilkinson, a neonatologist at the John Radcliffe Hospital. in Oxford and Director of Medical Ethics at the University of Oxford, the Hero Center for Practical Ethics. Don, thanks so much for taking the time. My pleasure.