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Covid-19: Intensive Care Treatment

Volume 807: debated on Thursday 29 October 2020

Private Notice Question

Asked by

To ask Her Majesty’s Government whether any part of the NHS has operated under policy guidelines described as a “triage tool” which determine intensive care treatment for patients with Covid-19, and whether such guidelines will be used in the future.

My Lords, claims that frail and elderly patients were denied care in wave one of the coronavirus pandemic, in part because of the triage tool developed by the NHS in case it was overwhelmed, are categorically untrue. The Government are ultimately responsible for national policy on public access to NHS services. However, decisions on who will benefit from care are made as part of normal clinical decision-making by clinicians. Guidance to help clinicians make rational evidence-based decisions in the event of ICUs being overwhelmed was commissioned but was halted when it became clear that the NHS would not be overwhelmed.

My Lords, I think that the whole House will be grateful to the Minister for his unequivocal rebuttal of that extremely concerning story. Let me be clear that this Question is not intended to criticise the NHS, for which we all have the highest regard. However, according to that Sunday Times story, under conditions of extreme stress, consideration was given to guidance that could have amounted to age discrimination. Does he agree that there is a need for the NHS to uphold its public sector equality duty? Will he provide reassurance that these triage tools should not be used to prioritise patients on any basis other than clinical need either this winter or going forward as routine?

My Lords, I am grateful for the opportunity offered by the noble Baroness to reinforce the point. Age discrimination is absolutely forbidden by the NHS constitution. The CMO wrote to NHS trusts on three occasions to reiterate that point. I quote a letter published on 7 April:

“The key principle is that each person is an individual whose needs and preferences must be taken account of individually. By contrast blanket policies are inappropriate whether due to medical condition, disability, or age.”

My Lords, the Minister’s response is indeed very reassuring. Does he agree that many elderly people will have been very worried by the Sunday Times report? They will welcome the assurances that have just been given by the NHS and the professional bodies that triage was never intended or used as a strategy for implementation. However, we have to be mindful of the fact that, as the pandemic is accelerating, fears are rising. Therefore, it is vital to get this message out as loudly as possible, just as the NHS did in April, when it said at the start of the epidemic that, far from rationing ICU care:

“All patients should be treated respectfully and equally and should receive the best available care.”

Can the Minister say now what the Government will do to support the NHS in reassuring every potential patient, irrespective of their age?

We go into the second wave in much better shape in relation to coronavirus because we know so much more about the virus. In terms of medicines, the therapeutics, the practices, the training, the configuration of our wards and the building of the Nightingales, there is a huge amount of skill, learning and capacity in the NHS to ensure that everyone has the opportunity to receive the best possible care. I remind noble Lords that these claims not only worry patients, they are deeply offensive to NHS doctors, nurses and therapists who have cared for more than 100,000 Covid patients to date in hospital settings and are committed to providing the best possible care in a second wave.

My Lords, triage is a necessary part of emergency medicine, and it will continue to be. Can the Minister say what has been learned in emergency departments in areas that have been in lockdown, such as Leicester, Bolton and Oldham? What learning has there been in those areas that can be sent to other areas to inform what will continue to be a necessary practice and part of good medicine?

Our learning has come a long way. Practices within ICU units have changed as a result of what we have learned in relation to the way that oxygen is administered, the range of drugs available and the turning of patients. To date, triage has not been necessary because the NHS is so good at load management that patients can be dispersed and deployed through the system, which has not been placed under pressure. We expect to be in good shape for the second wave. The principle remains as the national medical director, Stephen Powis, stated in his letter of 7 April:

“The key principle is that each person is an individual whose needs and preferences must be taken account of individually.”

That remains our principle.

My Lords, on precisely the point that my noble friend the Minister has just made, I know he will be aware of the revised version of ReSPECT—the Recommended Summary Plan for Emergency Care and Treatment—which was published in September by the Resuscitation Council UK. It is in wide, but rather variable, use. Will my noble friend encourage NHS England to make its use a best-practice requirement in relation to Covid-19 patients entering high-dependency or intensive care in the months ahead?

My Lords, we are extremely grateful to the Resuscitation Council for its work on this important tool. It gives an opportunity for patients to express their preference and for clinical judgment to be used at moments of acute intervention. It is being used in some places but, as the noble Lord rightly points out, its use is variable. I would be glad to take this back to the department to see what can be done to encourage its use more thoroughly.

My Lords, I am the chancellor of the University of Birmingham, and the professors at the university hospital there said that there was no way that any triage tool was used. If anything, better intensive care treatment was given during the crisis, so I am glad that the Minister very categorically said that. The Sunday Times article was trying to insinuate that people were not getting the intensive care that they needed. Can he reassure the House that in the second wave, the Nightingale hospitals that were built at such brilliant speed will be used if needed and are ready for use?

My Lords, I completely agree with those at the University of Birmingham who confirmed that triage tools were not used. They were not necessary, and everyone had absolutely the best care that could have possibly been given to them. The Nightingale hospitals are on standby where necessary; they will be deployed if needed, but it is my hope that they will not come into play.

My Lords, it is vital to sustain the trust of older people. Does the Minister agree, therefore, that it is now vital for the NHS to follow through on the commitments it made to improve services for older people living at home or in care homes, set out in last year’s NHS Long Term Plan? What are the Government doing to make sure that that happens?

My Lords, the implementation of the long-term plan is under way, despite Covid. We have put the care of the elderly—and, in fact, all those who are vulnerable and in need of social care, half of whom are under 60—at the centre of our efforts. Returning to the point of the question and the article, I remind noble Lords that two-thirds of our Covid in-patients were over 65. Each got the support and treatment that they deserved and needed, and that will remain our commitment during any second wave.

My Lords, in April NHS England issued the Reference Guide for Emergency Medicine. Non-conveyance guidelines for ambulance services stated that any care home resident should not be taken to hospital until it was discussed with a clinical advisor. Why, therefore, was a resident in a care home not given equal treatment of access to hospital as an equivalent person outside the care home setting, and has that instruction been withdrawn?

My Lords, I do not know whether that specific instruction has been withdrawn; I will be glad to write to the noble Lord on that. I reassure him that, during an epidemic of a highly contagious disease, a hospital might not be the safest place for someone who is ill in a care home; nor would it necessarily be the safest place for someone who has gone to their GP and is sitting in the GP’s surgery. It is therefore absolutely essential that clinical risk management and advice is sought before referral to a hospital. There is no prejudice or unfairness here: it is simply good clinical practice.

My Lords, the Sunday Times has form on inaccurate stories, as does the Telegraph. Indeed, I asked the Minister a Question on 21 September about a Telegraph story about age restrictions, and he assured me that there were none. I asked him

“will he agree to place a copy of all the circulars from DHSC in the Library so that we can see what is going out?”

In reply, he said

“I will inquire as to what we can possibly share, so that these decisions are as transparent as my noble friend wishes”.—[Official Report, 21/9/20; col. 1596.]

I think it would help keep the papers on the right track if more was put into the Library. Will the Minister tell me how he is getting on with his endeavours to get this information into the public domain?

My noble friend is entirely right to chase me in this matter. I remember the commitment very well and I will endeavour to find out from my colleagues at the department how they are doing in getting those important papers into the Library.

My Lords, the Minister was very forthright today in rejecting the Sunday Times story. A month ago, he was very forthright in an answer to the noble Lord, Lord Balfe, about blanket DNR notices. Picking up on the question today from the noble Lord, Lord Balfe, does he think that there might be an issue of communication where staff are working on the front line, where impressions are given that are not in accord with official government policy? In the light of all this, has he given some thought to the way in which communications with NHS staff might be improved in order to deal with these very troubling issues?

I am not sure that I agree with the implication of the noble Lord’s question—that somehow there is a prejudice on the front line against older people and that staff take it into their own hands to make decisions that are in themselves inherently unfair. That is not my experience. Where the noble Lord absolutely has a point is that people are extremely sensitive about these kinds of issues, and, quite rightly, are deeply concerned that they are going to get the treatment and care that they deserve and will not be subject to any form of unfairness. It is imperative that the NHS builds trusts and conveys a strong communication on these issues. To push back against the noble Lord, it is not my impression that the staff at the NHS have lost sight of this important principle.

My Lords, I declare an interest in that many of my family and friends work on the front line of the NHS, which I love and respect, as all other Members do. At the height of the pandemic, I watched a programme on Italian and American doctors using algorithms for vital decisions on treatment, with one being highlighted where triage tools had indicated nil chance of a patient surviving. However, their family pleaded with the doctors and convinced them to give them a few more days to see if “a miracle could happen”. In April, my close friend’s death was predicted from the use of some kind of early triage process. Sadly, my friend lost his battle. However, the miracle occurred: against all the odds, because of one decision by one team of doctors, the Italian patient survived. Given the fiasco of the use of algorithms, although I welcome the Minister’s absolute assurance, what analysis or serious case review has been undertaken of the number of treatment decisions based on early triage tools, given that extreme pressures on doctors have returned? Where deaths have occurred, can the Minister say what proportion were individuals of Bangladeshi heritage? Can any lessons be learned to improve their survival chances in the current emergency?

My Lords, I share my sympathies with the noble Baroness for the loss of her friend, for which we are all very sad. However, I take exception to her implication of a fiasco in the use of algorithms. I do not accept the implication that it is regular practice for clinicians somehow to give up on patients who stand a chance simply because their reading of an algorithm says that they should move on to someone else. That is not how we run the NHS; it is not how we had to run it during the first wave and it is not how we intend to run it during the second.