There is a meme from 2016 of a dog sitting in a room engulfed in fire proclaiming “THIS IS FINE”. It feels increasingly relevant to healthcare. As the flames of Covid rose around the world, the response from New Zealand continued to invoke international admiration. We could smell the smoke, but there was no fire. Within the healthcare sector, business – mostly – continued as usual.
We knew it would not always be this way. Overseas we witnessed patients and colleagues disappearing under successive waves of case numbers, hospitalisations, intensive care admissions and deaths. Many of us applauded our national response which stood in stark opposition to strategies chosen elsewhere.
Listen to the experts. Keep the disease out. Wait for the vaccine. And when it became available, we took the opportunity with the best of them. We kicked the can down the road with a mixture of good public health policy and a great deal of good fortune.
As intensive care beds became an international talking point, the same questions were asked here. How many do we have? How many will we need? This is where things started to get weird. Most people have never been to an intensive care unit, nor indeed should they want to. The same is true of politicians, unless perhaps when opening one. As an intensive care doctor of 20 years I considered the concept of an intensive care to be immutable but now this turned out to not be so.
The inconvenient truth of their scarcity could be at least partially addressed by altering the definition.
A bed is a piece of furniture, incapable of providing any form of care, never mind intensively. To do so it needs a specialist intensive care nurse standing next to it 24 hours a day. This requires five to six intensive care nurses per bed as, inconveniently, they also want to sleep, have families, and not live in a hospital.
Caring intensively also requires equipment, drugs, doctors, a large array of allied health professionals (physiotherapists, pharmacists, radiographers etc) cleaners and administration staff. It costs around NZ$1.5m (£750,000) a year to keep one intensive care bed open, with the availability of intensive care nurses being the rate-limiting step. As the world realised we didn’t have enough, they became one of the most valuable (but not valued) people in healthcare. By necessity, at wave peak, their expertise was diluted. Rather than the optimal 1:1 ratio of critically ill patients to expert nurses, team structures “allowed” them to supervise others with little or no intensive care experience (with an entirely predictable effect on mortality). This may be politically appealing but, as a professor of intensive care medicine at Cambridge University commented, “no one sane would suggest this was the appropriate planning strategy for Covid if you had the opportunity to do otherwise”.
In 2001, a report was commissioned by the Health Ministry into the state of New Zealand intensive care. Four years later it was published and remains publicly available on the ministry’s own website. Subsequent governments came and went and, inevitably it was all forgotten. Expert recommendations remained as bullet points in a dusty pdf. Then came the pandemic and suddenly New Zealand’s status as the second lowest in the OECD per capita for ICU beds (half as many as Australia, a third of the UK, and only beaten to the bottom by Mexico) was remembered. Indeed the OECD, in its report on New Zealand published last month recommends urgently increasing intensive care capacity as its first priority. As with other politically problematic issues (“Downing Street gathering”), efforts to redefine words followed.
In this case, the words were “intensive care bed”. The definition was extended to include areas outside the intensive care unit (such as operating theatre recovery areas) and neonatal intensive care cots. The former would only be used in exceptional circumstances (and require surgery to cease); the latter are physically incapable of providing care to any adult with Covid and are nearly always full of newborn babies. Inconvenient but accurate national data from intensive care unit directors was dismissed as “one health group says”, and capability and ICU bed numbers were revised ever upwards as business-as-usual and surge capacity were conflated.
In the last few months, efforts to address decades of health underfunding seem to be gathering momentum. The largest ever investment in intensive care infrastructure has been announced. But two years have passed since Covid began and we do not have a single additional operational ICU bed. Those promised will not materialise overnight. New Zealand has avoided the worst of Delta, and the decreased intensive care demands of Omicron may yet spare us from the fate of most other countries. The public health response to the pandemic was world-leading, but with no intensive care beds at the bottom of the cliff, there was little choice but to build a very strong wall at the top.
Alex Psirides is the co-director of Wellington ICU. He writes in a personal capacity