Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: The roads not taken in our covid response

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4434 (Published 18 November 2020) Cite this as: BMJ 2020;371:m4434

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  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter @mancunianmedic

Stephen Sondheim’s song “The Road You Didn’t Take” includes the line, “You take one road, you try one door, there isn’t time for any more, one life consists of either/or.” The character who sings it is trying to kid himself that he has no regrets about his past choices and can brush them off, while in truth they’ve come to haunt him.

I can’t imagine that any key decision makers in our health system can sleep easy right now about the paths already picked or the choices still facing them. And, unlike the choices of Sondheim’s protagonist, they affect millions of lives.

In the 10 months since the first proven cases of covid-19 in the UK we’ve had to choose many routes, under extreme time pressure. And if we then realised it might be wrong, the pandemic itself had altered the landscape: the paths would no longer look the same, even if we turned back.

Most people realise that governments, clinical practitioners, and health service leaders facing a global pandemic are in new territory and have to make uncertain choices in a changing situation. Our pandemic planning and preparedness have included many serious errors: the speed of our initial response; public healthcare decisions over the previous decade that weakened our workforce and capacity; clarity on accountabilities; and the consistency or accuracy of public communications.

Several UK public health experts set out these errors in detail along the path.1234 This was never just a case of being wise after the event, as people were expressing well evidenced concerns in real time and sometimes accused of spreading fear or undermining the government.567 However, I do think that some decisions were made within health services where the road not taken could have been as bad or worse. The retrospectoscope contains a distorting prism.

Imagine if, back in March and April—when we’d seen hospitals overwhelmed in Wuhan and New York, Italy and Spain—we hadn’t created the capacity and flexibility to move more patients out of hospital and into community services and care homes. Imagine that we hadn’t separated streams and wards into “hot” and “cold” areas (inevitably changing bed capacity) or that we hadn’t taken precautions with planned procedures, which nonetheless caused backlogs and harmed non-covid patients. Imagine if we hadn’t shifted much primary care and hospital outpatient activity to telephone and online consulting; if we hadn’t redeployed clinical staff and equipment from operating theatres, to double and triple intensive care capacity; or if we’d continued with open visiting in hospital wards and care homes.

If we’d chosen those routes instead, we might well have seen hospitals turning patients away, patients waiting on trolleys or on floors, and avoidable hospital acquired cross infection at a bigger scale—partly from people stranded in hospital waiting to be cleared, with serial negative tests that were barely available, and visitors bringing covid into care environments for vulnerable people, or contracting and spreading infection themselves.

Surely the main thing, in a changing situation, is to be honest and open with the public about trade-offs, uncertainties, and difficult decisions. We need the agility (and humility) to change tack if something isn’t working or new evidence emerges, and we should be clear about lines of accountability.

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