The Impact of a Pandemic on a Rural Hospital in England.


When I became a consultant physician in Dorset in 2001 specialising in respiratory medicine, I did not expect to be treating wards of people suffering from a pandemic viral infection.  Chest physicians are used to dealing with infectious lung diseases – the most common one worldwide being tuberculosis - but those conditions tend not to stray into rural Dorset very much.

Tuberculosis cases tend to originate from inmates at the local prisons in Weymouth that have been transferred from London and a few Eastern European workers.  People in West Dorset don’t travel far generally - a long-haul summer holiday usually involves crossing the border into Devon – so we don’t see tropical diseases much.  We get a regular influx of elderly summer holidaymakers from London and Birmingham to Weymouth, Lulworth Cove and Durdle Door, who often bring their diseases with them, but they find their way back home after a week or two with us. I sometimes think that there must be a travel agent somewhere in Birmingham where you can book a fortnight on the coronary care unit at Dorset County Hospital.

Neither is Dorset well known for its sizeable ethnic diversity – it is an amazingly white county – especially in the rural West.   It is, however, one of the oldest counties in the UK, with a large proportion aged over 65, and many people are retiring down here, with a large population in nursing homes.  So the winter influenza season provides a useful practice each year in managing epidemics, albeit cushioned by the annual flu vaccination programme.

At the back of our minds has always been the concern that if Ebola, or a similar disease, were to hit Britain, how would we cope?  The NHS is always running at over 95% capacity even on a good day with increasing pressures from our ageing population and resources not keeping up with the increasing demand, so a pandemic of a novel virus would be the straw that breaks the system.

In fact, as an insider, I have been very impressed (and pleasantly surprised) by how the NHS has managed to coordinate the changes needed to contain the coronavirus pandemic.  In particular, the massive expansion in ICU capacity has been achieved very effectively, so that, with lockdown, we have managed to avoid the terrible prospect of having to prioritise limited life-or-death resources between competing patients. 

We are used to making judgments about the use of medical interventions for patients. Still, they have always been judgments based on the characteristics of the individual, rather than a comparison with other individuals.  So thankfully it has not yet come to that. I am sure time will show that we could have prepared better, especially in terms of stockpiling PPE and ventilators and improving testing capacity. It seems likely that earlier action in terms of testing and isolating people in the community would have prevented deaths.

The impression given on TV is that all hospitals are inundated with COVID-19 patients, and the staff are all struggling to cope.   That may well be true in London and the more populous areas. Still, in Dorset and the other regions of the South West where population density is relatively low, the prevalence of COVID-19 is probably a quarter of London. So our hospitals have been under much less pressure. 

There has been a fantastic reduction in hospital admissions for the common diseases – heart attacks, strokes, asthma – so our wards have been quieter than I have ever known them. This is something of a worry since I am sure those diseases have not gone away.  As a chest physician, I look after most of the COVID-19 patients in the hospital that are not on ICU.  My ward rounds are done wearing personal protective equipment. There has been no shortage of that with us. 

Many –but not all – of the patients are elderly, and while some do succumb, many are leaving the hospital after a week or so of treatment.  It has been interesting to have to learn about a new disease on the job – getting the feel about the various ways it may manifest itself and learning from other doctors’ experiences online. 

There is no established truth about the condition yet – all speculation and anecdote.  We do not have any useful, specific drugs to combat the virus. Still, we are recruiting patients into a trial of medications with the most potential, so we should know by June if anything is likely to work. 

But nothing will be a miraculous cure – possibly mortality may be reduced by a few percentage points at best or the disease shortened by a few days.  What we are not sure about is what the long term consequences of the infection will be – will there be significant lung damage that will lead to permanent breathlessness in some people?  

Alongside the reductions in other emergency admissions, referrals from GPs for outpatient appointments for lung conditions such as cancer have also dried up, so my working life has been very different for the last eight weeks.  Our clinics have all become phone consultations, which is a bit of a novelty, but seem to work reasonably well, and saves the patients having to emerge from their isolation and sit in a hospital waiting room for an hour or so. 

I was previously involved in all sorts of projects to improve respiratory services locally and nationally, but all those have been shelved in favour of managing the COVID-19 crisis.  Emails about the cost of delivering services, training staff and meeting targets have been replaced by just one topic – COVID-19. 

Previously, having travelled across the country for a fair number of management meetings, we have now discovered how effective teleconferencing can be, enabling meetings to occur more frequently with less disruption to the clinical work.  I have been holding teleconference multidisciplinary team meetings with GPs and nurses in surgeries in West Dorset, giving advice about patients, which seem to work as well as, if not better than, doing it in person. 

Indeed, the COVID-19 crisis will, I am sure, see many positive developments in healthcare and beyond, which otherwise would have taken years to achieve, if at all.  And best of all, the crisis has instilled a renewed sense of collective effort and camaraderie that has been lacking in recent years in the health service.  It would be good to feel that we could maintain that beyond the initial wave.
 
So, as I write, we are now standing on the brink of the beginning of the end of the lockdown.  Our primary concern in the South West of England is if everyone in Birmingham and London decides to take their caravans down to visit us over the next few weeks, which could cause a second and much worse wave of infections. 

The impact of this has been seen in several places around the country already – in Gloucestershire when visitors flocked to Cheltenham for the Gold Cup and in Cumbria where the number of cases per head of population is one of the highest outside London.    Great care is going to be needed as we get Britain back to work.