CRISIS PLANNING
American ACEP and the Australian ACEM (Fig. 2). HBN 22 was designed based on ‘Lean’ principles , suggesting that the healthcare system is driven by management processes, rather than the development of physical infrastructure.3
The HBN was
later replaced with HBN 15-01 (2013), which takes into consideration resilience; however, these considerations were limited to major incidents and potential future needs, with no reference to mass casualty events. As a result, the new approach advocated in the later HBN moved away lightly from focusing on the limitation of space, but nevertheless still centred around management. It thus sets out an effective strategy for controlling healthcare expenditure and quality, but can compromise resilience in the event of mass casualties,4
4000 8000
Guidelines l ACP l HBN22 l ACEM
6000 2000 0
0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 Annual accesses (patients)
Figure 2: Total area trend on the annual accesses under ACEP, HBN22, and ACEM guidelines.4
which explains why
operations were cancelled in order to deal with COVID-19 patients, and the Government’s decision to set up a temporary Nightingale Hospital with a 4,000-bed capacity at the ExCeL Centre in London.
Backlog of maintenance and critical systems
Disruption to the gas supply at Watford General Hospital resulted in patients being transferred to other hospitals, and indeed led to the Police’s involvement in temporarily blocking access to the hospital’s facilities and only admitting women in labour. There isn’t much information available on the reasons why the gas supply failed; however, based on international experience and information on the performance of hospital assets, it seems likely that the system failed due to over-reaching its operational capacity. Medical gas systems, like all other critical systems in hospitals and other healthcare facilities, have only a certain capacity, and will fail when this is exceeded. The NHS has been struggling with a significant backlog in its asset maintenance, mostly as a result of delayed capital expenditure. The King’s Fund indeed reported that the cost of backlog maintenance in 2018/19 increased by 8.4% to reach £6.5 bn, £3.4 bn of which centred on issues ‘that present a high or significant risk to patients and staff’.5
Among the
many recognised incidents in the NHS are those involving infrastructure failure (e.g. of power, gas, and heating). As systems age, they are expected to lose some of their performance and functionality. After around 20 years in use, such a system may lose
20 Health Estate Journal July 2020
approximately 6% of its original functionality, and after 45 years’ use, this loss in performance can reach 35% (Fig. 3). However, if systems are well maintained, their performance and functionality can be relatively independent from their age (Fig. 4), indicating that assets can preserve their resilience and functionality when well maintained.3
Incomplete resilience and preparedness strategies/plans A significant number of technical and strategic documents have been developed to help NHS hospitals enhance their estate’s resilience by looking at a variety of issues, and covering potential hazards likely to occur in the event of a major ‘crisis’. For example, NHS England’s Emergency Preparedness, Resilience and Response (EPRR) programme of work provides a set of plans for responding to a number of hazards, such as pandemics, severe weather, and HAZMAT incidents. It also included resources to help hospitals develop business continuity plans. Health Building Note (HBN) 00-07 is another document that provides technical
120 100 80 60 40 20 0
0 10 20 30 Average hospital age (years) Figure 3: Average loss of functionality of hospital critical systems.3 40 50
guidance to NHS estates personnel on preparing for a number of hazards, including extreme weather events and explosions. Hospitals were encouraged, and in some cases rushed, to develop business continuity plans, resulting in the impression that the NHS is ready and able to cope with any sort of major emergencies. However, the COVID-19 outbreak has shown that this is not the case – despite the fact that these documents include plans for events such as pandemic influenza, and Hazardous Materials (HAZMAT), and chemical, biological, radiation, and nuclear (CBRN) scenarios. So, what are the reasons for the NHS being overstretched, and appearing not to have ready capacity to deal with the COVID-19 outbreak?
‘Generic’ business continuity plans These official UK guidance documents I have referred to were developed from a risk management standpoint, and often only consider relatively small and localised risks, events, and incidents. Such small, localised scenarios often involve planning for anything from a few dozen to a few hundred patients requiring immediate medical attention, and can thus often be addressed using resources pulled from different areas and regions, and perhaps by cancelling or transferring some clinical activity to neighbouring areas. Such an approach is viable for situations involving explosions or major accidents, but not so for major disasters such as pandemics or earthquakes, which tend both to cause mass casualties, and to significantly reduce resources. In addition, hospital activities were clearly not well defined or reflected in these documents, as there is either very generic information for guiding management and coordination at senior level, or excess detail only readily understandable to particular individuals with specialised and specific skills (e.g. electricians and plumbers). The resulting
Total area (m2
)
Average critical system functionality (%)
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