The coronavirus pandemic is forcing senior doctors in Britain’s National Health Service to contemplate the unthinkable: how to ration access to critical care beds and ventilators should resources fall short. The country’s public health system, the NHS, is ill-equipped to cope with an outbreak that is unprecedented in modern times. Hospitals are now striving to at least quadruple the number of intensive care beds to meet an expected surge in serious virus cases, senior physicians told Reuters, but expressed dismay that preparations had not begun weeks earlier. With serious shortages of ventilators, protective equipment and trained workers, the physicians said senior staff at hospitals were beginning to confront an excruciating debate on intensive care rationing, though Britain may be a long way from potentially having to make such decisions. Rahuldeb Sarkar, a consultant physician in respiratory medicine and critical care in the English county of Kent, said local NHS trusts across the country were reviewing decision-making procedures drawn up, but never needed, during the 2009 H1N1 flu pandemic. They cover how to choose who, in the event of a shortage, would be put on a ventilator and for how long. Decisions would always be based on an individual basis if it got to that point, taking into account the chance of survival, he said. But nevertheless, there would be difficult choices. “It will be tough, and that’s why it’s important that you know, that two or more consultants will make the decisions.” Sarkar said the choices extended not only to who was given access to a ventilator but how long to continue if there was no sign of recovery. “In normal days, that patient would be given some more days to see which way it goes,” he added. But if the worst predictions about the spread of the virus proved correct, he suspected “it will happen quicker than before”. Britain is by no means the only country that faces having its health system overwhelmed by COVID-19, but the data on critical care beds – a crucial bulwark against the disease – is concerning for UK authorities. Italy, where the coronavirus has driven hospitals to the point of collapse in some areas and thousands have died, had about 12.5 critical care beds per 100,000 of its population before the outbreak. That is above the European average of 11.5, while the figure in Germany is 29.2, according to a widely-quoted academic study https://link.springer.com/article/10.1007/s00134-012-2627-8 dating back to 2012 which doctors said was still valid. Britain has 6.6. ‘MANY TIMES MORE’ VENTILATORS Estimates of the potential death toll in Britain range from a government estimate of around 20,000 to an upper end of over 250,000 predicted by researchers at Imperial College. As of March 19, 64,621 people had been tested, with 3,269 positive. The NHS is preparing for the biggest challenge it has faced since it was founded after the ravages of World War Two, promising cradle-to-grave healthcare for all. It was stretched long before COVID-19, struggling to adapt to the vast increase in healthcare demand in recent years. Some doctors complain that it is underfunded and poorly managed. About a tenth of its more than one million staff roles in the health service are vacant while almost nine out of 10 beds are occupied. The department of health referred a request for comment to NHS England, which said it was crucial to reduce the coronavirus’s infection rate to ease peak pressure on the health system. “Unmitigated, there is no health service in the world that would be able to cope if the virus let rip,” said NHS England head Simon Stevens. “In the meantime, what the NHS is doing, of course, is pulling out all the stops to make sure that we have as many staff, beds and other facilities available.” So how many life-saving ventilators are needed? Health Secretary Matt Hancock said on Sunday that hospitals had around 5,000 but that they needed “many times more than that”. The physicians interviewed by Reuters said, if ventilators were secured, the aim was to increase intensive care beds from around 4200 to over 16,000, partly by using beds in other parts of hospitals. Rob Harwood, a consultant anaesthetist in Norfolk who has worked in the health service for almost four decades, said access to critical care could ultimately have to be determined by patient scoring systems for survivability. Systems developed for SARS, another coronavirus that broke out in 2003, could for example be refined, he added. “Once you have exhausted your capacity and exhausted your ability to expand your capacity you probably have to make other decisions about admission into intensive care.” But he emphasised that, for now, admission criteria would stay unaltered: “We are a country mile from that at the moment.”