In my article last week, I described the framework in the NHS to manage the response to the coronavirus pandemic and the incident levels. I also suggested that in the UK, the Covid-19 pandemic is likely to start at ‘level 1’ response due to slight increases in capacity demand. I questioned that, if more cases of person-to-person transmission are confirmed in Ireland, are our ministers, given the well-known capacity issues in our health system, likely go straight to an alert level 3? I have to say I was very proud and very relived as a health professional and an Irish citizen to see Leo Varadkar and the team at the Department of Health did just that the following day.

This week I consider if we have taken the precautionary measures that we will needed to ‘flatten the curve’? And what does that mean for business as usual in our overstretched health system?

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Globally we have seen curves like the one described in the mitigation measures of the burden of disease on three occasions. The deadliest of these in modern history was in 1918, a strain of influenza known as Spanish flu caused a global pandemic, spreading rapidly and killing indiscriminately. Young, old, sick and otherwise-healthy people were infected, and at least 10% of infected patients died. It is thought to have infected a third of the world’s population, and led to at least 50 million deaths.

The challenge of managing the impact of a new virus in a community like this is that the science is evolving almost every day. Since Covid-19 first emerged in December 2019, we have learned a lot. The disease is very transmissible from one person to another, and, without intervention, each infected person will infect two other people on average.

To show how this can work, last week it was reported that after a meeting of 175 people in one hotel in Boston, more than 70 have tested positive for the virus. It has also become clear that around 1 in 5 patients will be seriously ill with this virus, and between 1 in 50 and 1 in 100 will die. Deaths are more common in  older people, with underlying medical conditions, but young healthy people have also died from Covid-19.

The initial course of this pandemic is an exponential rise in the number of cases. Therefore, if the efforts we take to flatten the curve work, the total number of cases won’t rise as quickly and therefore the Covid-19 surge will be more manageable. This delay will ensure fewer deaths – not just Covid-19 deaths, but also deaths requiring hospital admission for any emergency. The ongoing pressure will be hard for communities and our health service to deal with and in Ireland, where the surge capacity of our services is very limited, how are we ever going to keep standing our business as usual for people who need health service for other related conditions?

Should we now be enacting the preparedness proposals at incident level 4 (Red) to go into place at the earliest stage possible?

The measures that have been put into place to date may give us, as a community, enough opportunity to intervene and modify the ability of the virus to transmit. Are we doing this aggressively enough, and early enough, to dampen or slow down the transmission rates?

Should we now be enacting the preparedness proposals at incident level 4 (Red) to go into place at the earliest stage possible? This is not just to control the infection, but also to ensure that the staff on the front line have had some opportunity to understand the level of surge to expect, and what to do.

Citizens are now following the news, and people are now beginning to react in real time. However, when you are in the midst of a crises like this, is important to be able to assume good intentions on the part of others, and that the minimum steps have been taken to ensure our most vulnerable will be protected from exposure to infection.

We have all made changes in our work / education / travel and social gatherings. We know none of these interventions will work alone, but together they may change the shape of this pandemic in our community – first by delaying the peak onset, then decreasing the peak, and so potentially reducing the total number of individuals infected. The goal of this community mitigation is to bring down the infection rate, so that the surge can be managed effectively by our acute healthcare providers and ambulance services.

A strained health system under siege

Why is this much more important in Ireland then the rest of the OECD? Prior to this surge, our health care system was one of the worst in the OECD, being both expensive and poorly coordinated. It lacked sufficient investment in staffing and the basic infrastructure for community services. This means that the types of healthcare service provision available in most other countries to support our most vulnerable. is simply not available here.

Should we manage to ‘flatten the curve’, my best guess is that the surge will peak around June or July and that we may be on the ‘other side’ of this around October 2020.

The impact of this right now is that the standard care that has been available to some of our most vulnerable is slowly decreasing and the existing and inadequate  capacity in our community services is being overwhelmed. At a level 3 response this might be expected, but as I write, we are only now entering the very first stages of the surge in Ireland.

So, where is the additional surge capacity being put into the community to ensure that we can manage the healthcare and business pressures we all now know are imminent? The well-known existing failings in our system mean that all elective operations have been cancelled, and patients are now being asked not to attend A&E. Our GP’s are now overwhelmed and are being expected to triage and test patients as well as develop new processes to see and treat standard care patients.

To date, Ireland has not shared prevalence data with GP’s and I understand that the testing being conducted is not being shared with GP’s due to GDPR. Therefore neither GP’s nor their patients currently know if their community is badly impacted. Our previously under resourced community services don’t have some of the most standard systems or specialist community teams in place to support patients to stay at home or in a nursing home.

At this point I am really unsure if there has been any real consideration of the importance of pump priming the services we do have, as well as urgently implementing further services so that we can support our most vulnerable to remain at home or in a nursing home with the best clinical intervention when in need of healthcare services that currently require hospital care.

Should we manage to ‘flatten the curve’, my best guess is that the surge will peak around June or July and that we may be on the ‘other side’ of this around October 2020. If this is the case, immediately after that we will hit the annual winter pressures and have a further surge in demand shortly after that.

Learning lessons for surge capacity

Given what we know today, it is clear that 2020 will be a very difficult year for everyone. Ireland will have many lessons to learn from what worked and what didn’t work during this period, both in our health system and in the wider economy. We all need to make sure that the changes Ireland has needed for years within its Health system actually happen imminently over this period, and that we never go back!.

Accountability and putting our most vulnerable patients at the centre of this care is critical right now. To do this with the community mitigation measures we have put in place to date, we need to also now focus on ensuring that vulnerable patients have all the additional support they need to keep them out of hospital and in the community. This must become a priority for our leaders. Maximum “surge capacity” must be available both primary and secondary care, in anticipation of this additional demand. We also need to introduce the standard and specialist community teams urgently into our community to get ahead and stay ahead of the curve. This is critical and we will only do this if we are innovative about healthcare service delivery. Investing in and enabling these kinds of services is now more urgent than ever, if we are not to be held accountable at the end of all this.

Audrey Mc Donnell is chief executive of Vanguard Health Services International in Dublin, a service she has founded to advocate health care equality by enabling sustainable ethical cutting edge healthcare solutions. She was previously director of commissioning with the NHS and during her role as a commissioner in Sutton and Merton primary care trust, she led its swine flu preparedness on behalf of a population of over 350,000. She has 25 years of experience in healthcare working in both Britain and Ireland.