Corona Diaries: the NHS and its “difficult choices”

Unlike some people who get skittish about the effect advancing years might have on their career prospects, I have never contemplated lying about my age. Until now.

According to yesterday’s London Times, the British National Health Service has invented a “clinical frailty scale” that will determine whether or not you get a bed in an Intensive Care Unit during the COVID emergency. It applies to the over-65’s. Basically, you will be assessed on a points system. Over 70, you get four points, plus three penalty points for your implied fragility. Which takes you dangerously close to the cut-off point of eight points. So any underlying conditions – a dicky heart, lung problems, dementia and so on – will mean that you don’t make the cut.

It is, apparently “guidance”, meaning that clinicians will make the final judgement based on your points, plus your current state as indicated by vital signs. Annoyingly, the article doesn’t tell us how many points you “earn” if you’re between 65 and 70, which is my bracket.

So does this mean that it will make no difference whether you’re a marathon runner or a giant sloth, so long as your vital signs are heading in the wrong direction? Presumably your path will be oxygen on a general ward yes, but round-the -lock attention and a ventilator no.

An objective view might be that although it’s a system more likely to appeal to technocrats sitting behind desks rather than clinicians with real humans in front to them, it makes sense as long as it isn’t the sole basis for determining who is worth trying to save.

With that in mind, and considering that nobody who goes into hospital is jogging in there to show their underlying fitness, the determining factors governing whether you’ll make it out again is oxygen, medical care and, in the final analysis, luck. Though even if you’re lucky enough to get into ICU and on to a ventilator, you’re not out of jail. Your chances of making it past the ventilator stage are currently just over 30%.

Since my chances of making the cut are limited, to say the least, I shall prepare mentally in the hope that I can nudge the hospital staff towards a positive decision. This is where lying about my age might come in handy. If I thought I could get away with it, I would declare myself to be 64 until further notice. Unfortunately, with centralised records, I’m stuffed.

But given that the staff authorised to use the protocol include healthcare assistants, I shall go out of my way not to say unkind things about the apple crumble that the nice lady with the trolley brings me for lunch. A dog biscuit at dinner might be a bad sign.

Being able to complete a sudoku puzzle in five minutes might also help, as would challenging the nurses at arm-wrestling. But in the end, I suspect, I would discover that I can’t beat the system.

There is another potential dimension to the NHS’s systematised approach to assessing patients.

For now, it seems, the rationale is to stop the service from being overwhelmed, and specifically to reserve the highest level of critical care for the younger part of the population – or at least to load the dice against those who by objective criteria are less likely to survive.

I understand that, even if I don’t particularly like it. Well I wouldn’t, would I?

But what if, when the pandemic is over and the accountants start analysing the cost of the whole thing to the NHS and, by extension to the state, some bright spark comes up with the idea that “hey, this is the magic key to ensuring that universal healthcare is affordable going forward. So let’s keep using the scorecard even if we have spare capacity. That way we reduce the costs of pensions, social care and a big piece of the NHS.

Let’s encourage the private hospitals to set up their own ICUs and the health insurance companies to include the cost of intensive care in their premiums.  If the elderly who can afford it wish to even up the dice, let them pay for it, just as they pay for their care home places. This will enable us to keep the intensive care capacity for future pandemics, but take the day-to-day burden of the weaker elderly away from the state and place it onto the individuals whose lifestyle choices have led to their pre-existing conditions.”

No matter that these individuals may have paid proportionately more of the taxes that fund the NHS. No matter that some of them may have worked themselves at the expense of their health – literally half to death – over forty years to provide for their families. The wealthy must pay. Period.

I wouldn’t be surprised if that’s the way we go. Which takes us towards passive, if not active, Logan’s Run territory – if you’re over 65, you won’t be encouraged to die, but you won’t be helped overmuch to live. Or at least it moves us a little closer to the American “system” in which inequality is institutionally embedded.

I’m not making a firm prediction here. Nor am I making a political point. But when this pandemic over we will be left, in healthcare terms, with capacity but not cash. So it’s entirely possible that there will be influential people who will be making the argument I’ve set out on the utilitarian principle of “the best possible outcome for the most possible people”.

If you don’t like the idea, you’d best be marshalling your counter-arguments now.