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The quiet crisis of Britain’s missing patients

Plummeting heart attack, cancer, stroke and other admissions spell disaster for doctors in “eerily quiet” wards across the country.

You begin having a heart attack at home. You don’t know it yet. You do nothing, unsure of your symptoms and unwilling to take up NHS time or to risk catching Covid-19. Your future rapidly looks bleak.

Across the UK, people are doing this, unseen, in their houses. Coronary heart disease, a leading cause of death in the UK, is going untreated.

Since the beginning of March there has been a 50 per cent drop in the number of people attending A&E with suspected heart attacks in England, according to hospital data analysed by the British Heart Foundation. In Northern Ireland, there has been an almost 50 per cent drop in the number of people seeking medical help for serious cardiac problems, including heart attacks, since 24 March. The same trend is sweeping Scotland and Wales.

Graph by Michael Goodier

“Before an interventional approach in cardiology, patients would sit at home and complete their heart attacks, block off an entire artery, kill off a vast section of heart muscle, and then either die – 50 per cent would die. Or if they made it to hospital they would end up with life-changing morbidities such as heart failure,” says Dr Nishat Siddiqi, a consultant cardiologist at the Aneurin Bevan University Health Board, which covers a coronavirus hotspot in south Wales.

“And that’s what we’re seeing now – people are presenting to hospital later, if at all.”

Siddiqi believes this is down to fear of coronavirus and the “don’t come to hospital-type messages that were being sent out” by the government.

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On 17 March hospitals began discharging as many patients as safely possible, all so-called non-urgent elective operations were postponed for at least three months, and GP and outpatient consultations were switched to telephone or video appointments.

Weeks later, routine cancer screening programmes were paused.

Throughout the crisis, the government’s mantra has been to “Stay at home, protect the NHS, save lives”. Yet doctors and patients are discovering that last instruction could well be under threat from the first two.

Indeed, new messaging at the daily No 10 press conferences has switched focus, urging people to continue seeking healthcare for non-coronavirus related illness.

GP surgeries and pharmacies sent out text messages and emails to patients over the Easter bank holiday weekend, highlighting their extended opening hours and increased capacity.

“The NHS is open for business,” chief medical officer Chris Whitty reminded the nation on 16 April.

As A&E attendance plummets (by 59 per cent over three weeks in Scotland, 53.3 per cent in England, 50-60 per cent in Northern Ireland, and 60 per cent in Wales), there are four times more available NHS hospital beds than usual, as revealed by the Health Service Journal.

Graphs by Michael Goodier

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In a contrast to the television footage of Covid-19 patients and hectic intensive care units, doctors for other life-threatening illnesses tell us of “eerily quiet” wards.

“Hardly anyone is coming in,” says Siddiqi, whose hospital, Nevill Hall in Abergavenny, gave eight coronary care unit beds over to the intensive care unit, and has cancelled all elective work.

Of her thousands of patients, the majority are “not emergencies, they’re elective patients”, she says, keen to explain that “elective means they need surgery within, say, three months, at a push four, for serious heart valve problems. If you don’t intervene in a timely way, death is a very common occurrence.”

She adds: “With the cancellation of all of that, you think, ‘What is going to happen?’ All these things are delaying diagnosis and appropriate treatments. It’s a huge worry and it’s going to take years for us to get over this.”

The NHS has stopped producing data that specifically shows the number of urgent as opposed to non-urgent elective operations, so it is unclear how many procedures from either category have been postponed.

Hospitals in England alone have performed an average 2.1 million elective procedures between April and June over the past five years, which gives an indication of the huge number of patients who could be missing out on vital operations this year.

Stroke specialists are also concerned about a sharp fall in patients presenting with symptoms. Because of high-profile public awareness campaigns about the Fast test (Face, Arm, Speech, Time to call an ambulance), there is usually a high level of recognition of stroke symptoms among the public. 

“It is eerily quiet on the stroke unit at the moment,” says Dr Martin James, a consultant stroke physician at the Royal Devon and Exeter NHS Foundation Trust in Devon, and a medical trustee of the Stroke Association charity.

“We have fewer patients than we would normally have because they’re not presenting.”

NHS England is putting figures together on the drop in stroke patients, which we are told will be released shortly.

From speaking to colleagues around the country, James estimates “at least a third” reduction in people coming to hospital with a stroke. He has also seen a drop in those seeking medical attention for “mini strokes” (which, when caught, can help prevent future full strokes).

People are even spending over a week struggling at home without medical attention after suffering strokes.

“We’re finding our community rehabilitation teams are encountering people now who stayed at home when they’ve had a stroke, and they’re coming to light because they’re struggling to manage,” says James. “They are being referred late on because they’ve spent the past few days or even a week or more trying to manage at home.”

As with the heart attack decline, James and other doctors at the Stroke Association do not believe the lack of stroke patients has a medical explanation.

“People are thinking that hospitals are bound to be far too busy with coronavirus cases, and so we’re very concerned that the net result of that is that they are not coming forward and not being treated,” he says. “There’s a big worry that we’re storing up trouble for the future.”

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Both current and future cancer patients are also drastically impacted by coronavirus. The former are facing treatment delays and tougher decisions (opting for chemotherapy, for example, will make you more vulnerable to Covid-19), and the latter are far less likely to go to the GP with suspected symptoms.

Graph by Michael Goodier

Cancer referrals have fallen by nearly 80 per cent in some areas, according to research by NHS Providers, with one NHS trust executive seeing GP referrals drop from 500 a week to 105. GPs were warned last month by NHS England and NHS Improvement that they would have to delay some suspected cancer referrals (which are all supposed to happen within two weeks). There has been a 75 per cent drop in urgent cancer referrals, according to new figures from Cancer Research UK.

“While these are demanding circumstances for health services, it must be remembered that early GP referrals and fast diagnosis is crucial in improving outcomes for people diagnosed with cancer,” says Dr Rosie Loftus, chief medical officer at Macmillan Cancer Support, and a GP principal in Kent since 1989.

She warns: “If people are not presenting symptoms to their GP and appropriate steps are not taken, we are concerned that in the long run there will be a cohort of cancer patients diagnosed in this time who will have fewer treatment options available, with a knock on effect on their outcomes, physically and psychologically.”

“Everyone is really worried that people aren’t presenting – it’s not that people aren’t developing cancers, they are, but it’s just not getting picked up,” says Dr Lucy Gossage, a consultant oncologist at the Nottingham University NHS Hospitals Trust.

She is seeing far fewer emergency cancer admissions than usual. “Where are all these patients?” she asks.

Gossage also has to remind cancer outpatients not to feel reluctant to call the hospital if they feel ill when undergoing or recovering from treatment.

“I think people are scared to come into hospital and it’s very important for us to explain to our patients that it’s far more dangerous to have a fever at home and not tell us about it than it is to come to hospital to get checked,” she says.

Patients making treatment decisions are also warned of the higher risk of life-threatening infections from undergoing chemotherapy. Such treatment would also mean self-isolating for three months when at one’s weakest.

“It’s just such a lonely time for people with cancer,” says Gossage, who also notes the emotional difficulty for doctors speaking to cancer patients over videolink or from behind personal protective equipment.

“I can’t describe how horrible it is standing behind a mask two metres away, delivering bad news; it’s awful,” she says.

“One of the biggest messages we should be trying to get out of the NHS, I think, is we are open for services. I worry enormously about the backlog that will come through in three, four months’ time. And we’ll still have coronavirus then; it’s not going to suddenly disappear.”

A high number of cancer waiting time targets were being missed before the epidemic hit the UK. In England, 85 per cent of patients should be treated within two months of an urgent referral from their GP – a target which hasn't been met since December 2015. As of February, this year, the figure stood at 74 per cent.

Similarly, 93 per cent of cancer patients should be seen by a consultant within two weeks of their GP's referral, however this target hasn't been met since February 2019. 

On 5 April, Professor Charles Swanton, Cancer Research UK’s chief clinician, who works at the Francis Crick Institute, told the Times that cancer survival rates would drop, and the delay in diagnosis and treatment would render some cancers “inoperable” when they would have been curable if caught earlier.

A source quoted by the paper as close to the Department of Health admitted it was “possible” that more would die of delays to treatment than coronavirus.

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Doctors fear a disastrous mix of patient reluctance and postponed referrals and procedures is creating a greater crisis further down the line.

“What we’re going to see is the NHS spending over 12 months playing catch-up in a scenario where we didn’t even have the resources to keep up with the workload that was already there, prior to the pandemic,” says Dr Nishat Siddiqi. "This is going to be, and it is, a disaster.”

Anoosh Chakelian is the New Statesman’s Britain editor.

Michael Goodier is a data journalist at New Statesman media group