If bird flu grips Britain, NHS doctors will need guns

The NHS will be unable to handle a pandemic

Towards the end of the film Dr Strangelove, Peter Sellers discusses who will go into the mines to survive. A surreal echo came for myself and colleagues recently when we were in discussions about planning for a bird flu pandemic in the UK as part of an ethics committee. If a true pandemic of bird flu hits these shores then our notions of what we can expect from the National Health Service will have to change. Some people will have to be denied potentially life-saving treatment: there simply will not be enough beds.

Managing such a pandemic is unimaginable. While it is possible to work out what will happen if a bomb goes off in central London - we can empty intensive care units, mobilise extra staff and stop elective work - what we cannot plan for is 200,000 extra patients who need a life support machine. Arnie Schwarzenegger, the governor of California, says his state will buy thousands more machines, but who will man them? A gut reaction is to blame the government for underresourcing. It is true that we have a chronic underinvestment in intensive care compared with the United States, Australia or other European countries. In any normal situation such a criticism would be valid, but in a pandemic it becomes a statistical irrelevancy.

Who will decide, and on what criteria, those getting the chance of survival? If you and a friend get bird flu and you both end up in hospital, the estimates are that within 48 hours one of you will need life support. At conservative estimates the need for intensive care will be about 2 times more than we can provide. Allocation of such resources will have to be either on a first come first served basis or on an explicitly utilitarian basis of capacity to benefit. This shift from an egalitarian free access to a limited one based on expected outcome represents a profound shift in how we deliver healthcare.

Exclusion criteria have already been drawn up in Canada and the United States and include such contentious issues as restriction based on age or on preexisting disease such as cystic fibrosis or metastatic cancer. Saying "no" to a desperately ill child with cystic fibrosis or to a previously fit 85-year-old is not something we are morally or emotionally prepared for. By an ethical analysis it may be the correct thing to do, but will patients or their relatives be prepared to accept it?

Such arguments may, of course, be purely academic. Assumptions as to what we can do are based on the doctors and nurses, porters and technicians turning up to work. But if we do not have enough masks to protect staff dealing with infected patients, then do the staff have a moral duty to turn up for work and get infected themselves? It may be that they go to work but only once - who will want to return home and potentially infect their own family?

In Victoria, Australia, it was suggested that patients would not go to the GP but to a "flu centre". The idea that patients would go to where flu is concentrated displays an astounding lack of comprehension of human nature. Similarly, staff will be reluctant to put themselves at risk. HSBC, the banking group, was accused of scaremongering when it announced that perhaps 40% of its staff would not turn up for work in the event of a pandemic, but the NHS may suffer just as badly.

It is not only the risk of infection that may stop staff turning up to work. With such limited access to intensive care, it would be expected that hospitals might not be safe places at all. If I decide not to ventilate someone, his or her relatives might not be too happy. Threats to staff are all too common and many are worried about personal security. Consequently it has been suggested that the decision as to who gets the intensive care bed should be taken away from frontline staff in order to protect them.

At a discussion over how we would react to a biological emergency, where casualties would be decontaminated before we resuscitated them, it was asked who would protect the staff. The answer given was hospital security. Pleasant and helpful as they are, these guys are hardly equipped to deal with an angry mob. One doctor said that the most useful thing staff could be given in such an event was a gun.

Another concern is the legal position of staff who refuse treatment. In the absence of any measures put in place to protect them, one can imagine a raft of legal actions being taken out against them. If attempting to allocate resources on the basis of capacity to benefit is the right thing to do, then those making the decisions need to be protected, otherwise people will not make the decisions required. Perhaps the only equitable and fair way is to shut the intensive care units and limit treatment to the best we can achieve without artificial ventilation.

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Australia: Entrenched and rigid bureaucracy driving away public hospital staff

More than 12 per cent of clinical staff at Queensland Health quit in 16 months, The Sunday Mail can reveal. While the State Government trumpets a successful recruitment drive, the latest figures reveal 4438 employees in the 36.000-strong workforce resigned between June 2005 and September last year - or 277 a month.

The Australian Medical Association said doctors were fed up trying to work in hospitals without enough beds or operating theatres. Queensland AMA president Zelle Hodge said: "It is so frustrating for staff, and eventually people just say they've had enough of it and leave. "Unless the culture in Queensland Health is changed, and the focus is on the people at the coalface and how they treat their patients rather than bureaucracy, then people will continue to resign." The Forster review, released in the wake of the Jayant Patel scandal at Bundaberg, said that unless the culture of secrecy and poor working conditions in Queensland Health was addressed, the high attrition of health-workers would continue to cripple the system.

One doctor who did not want to be named because Queensland Health has banned him from talking to the media. said he did not feel valued. "We are still chronically understaffed and people are so fed up with working long hours to combat the shortage that they are saying enough is enough, he said. "Queensland Health keep telling us they are addressing the problems, but it's just all talk. Nothing changes."

Figures show 1048 doctors and 2196 nurses resigned between July 2005 and September 2006. In addition, 1194 allied health professionals such as radiographers. occupational therapists and physiotherapists quit.

Queensland Health, which boasts of "caring for people" in its latest annual report, is advertising 407 jobs. Queensland University of Technology business researcher Megan Tones said: "To have 12 per cent of staff leave in just over a year is a huge amount. Obviously not enough is being done to retain staff.

But Joshua Cooney, spokesman for Health Minister Stephen Robertson, said the rate of resignations was "normal" for Queensland Health [So that is good??]. He said all the departing staff had been replaced, with an extra 2910 employed. ''The minister has spoken on many occasions about changing the culture in Queensland Health and that is what we're doing," he said.

Opposition health spokesman John-Paul Langbroek said Mr Cooney needed to stop the spin. "I am getting calls from doctors saying nothing's changed," he said. "The Government needs to start developing strategies to retain the professionals."

The above report by Hannah Davies appeared in the Brisbane "Sunday Mail" on February 11, 2007

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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