Prof Sir Stephen Powis, who has held the role of national medical director at NHS England throughout the challenging periods of the Covid-19 pandemic, provided compelling testimonies during the Covid inquiry taking place in west London.
Expressing his deep concerns, the most senior doctor within NHS England admitted that he was “personally terrified” at the prospect of hospitals being completely overwhelmed during the initial waves of the pandemic, adding significant weight to the discussion about pandemic preparedness.
During his testimony, Prof Sir Stephen Powis revealed that officials had prepared a draft document that contained crucial recommendations on how to prioritize patient care should the NHS face insurmountable pressure due to the influx of Covid patients.
This controversial ‘Covid-19 decision tool’ utilized a point system that evaluated patients based on age, frailty, and pre-existing health conditions; a higher score indicated a diminished likelihood of receiving intensive care if the healthcare system became inundated.
Although the tool was crafted during a critical moment in the pandemic, it was ultimately never disseminated to the public, as it became evident by March 2020 that Covid infections were beginning to peak.
Sir Stephen praised the senior clinicians tasked with developing these emergency plans under intense time constraints, acknowledging their “magnificent job” in a scenario that “nobody ever wants to do”.
However, he emphasized that the process was inherently contentious and lacked vital discussions with patient advocacy groups and the public at large, which raised ethical concerns regarding the equitable treatment of patients.
The draft document explicitly instructed doctors to assess Covid patients based on three specific criteria utilizing a frailty scale, intending to guide decisions during the most dire moments.
It was delineated that patients who accumulated a total score exceeding eight points would likely not be considered for intensive care, highlighting the stark reality of medical resource allocation in times of crisis.
For instance, patients aged between 70 and 75 were automatically allocated four points, while those above the age of 80 received a more severe score of six points, with additional points assigned for existing chronic conditions like heart disease or diabetes.
Notably, individuals who were terminally ill—defined as having a life expectancy of less than six months—would be assigned an alarming nine points under this system.
Sir Stephen noted that the development of this guidance began early in the pandemic, a period marked by a rapid increase in intensive care admissions across England, doubling approximately every 5 to 7 days.
Reflecting on those uncertain times, he said, “It was not clear that the public would respond to lockdown – they did wonderfully – but that wasn’t clear [at that point].” This uncertainty heightened his fears about NHS capacity.
The initiative was abruptly halted on the 28th of March 2020 when it became increasingly clear that the peak of the first wave of Covid cases was imminent, with the health service poised to avoid breaching its capacity.
Sir Stephen also warned that the point-scoring system posed a risk of being “used inappropriately,” potentially undermining the essential individual clinical judgment exercised by medical professionals.
In his closing remarks to the inquiry, he strongly recommended that such complex tools should not be developed during a pandemic, stressing the importance of conducting such discussions and preparations during more stable times.
He asserted that crucial conversations about healthcare priorities should involve broad public consultation and not be dominated by government agendas or professional interests; rather, they should find their roots within society itself.
**Interview with Prof Sir Stephen Powis on the UK COVID-19 Inquiry**
**Editor:** Welcome, Prof Sir Stephen Powis. Thank you for joining us today to discuss your recent testimony during the UK COVID-19 Inquiry. You mentioned feeling “personally terrified” at the start of the pandemic. Can you elaborate on what made you feel that way?
**Prof Powis:** Thank you for having me. The sheer volume of patients we anticipated, coupled with the available resources, truly created a daunting scenario. It was a time when we were all acutely aware that our hospitals could become overwhelmed, jeopardizing the care of countless individuals.
**Editor:** During your testimony, you touched on the controversial “Covid-19 decision tool.” Can you explain what this tool was intended for?
**Prof Powis:** Certainly. The decision tool was created as a framework to prioritize patient care if our resources became critically stretched. It assessed patients based on age, frailty, and pre-existing health conditions. The goal was to make rapid, informed decisions about intensive care allocation during an unprecedented crisis.
**Editor:** It sounds like a challenging ethical dilemma. Was there any consideration given to involving patient advocacy groups in the discussions surrounding this tool?
**Prof Powis:** That’s a significant point. While the clinicians developed these plans under extreme pressure and did an extraordinary job, the process was indeed contentious. There was a lack of engagement with patient advocacy groups and the public, which raised legitimate ethical concerns about how we would ensure fair and equitable treatment.
**Editor:** You indicated that the tool was never published as the situation changed in March 2020. What lessons do you think we can learn from this experience regarding preparedness for future pandemics?
**Prof Powis:** One vital lesson is the importance of flexibility in our response strategies. We must also prioritize engaging with stakeholders, including patients and advocacy groups, in our decision-making processes. This ensures transparency and ethical considerations are at the forefront when we prepare for potential crises.
**Editor:** What are your thoughts on the criteria used to score patients, especially concerning age?
**Prof Powis:** The scoring system, while necessary under dire circumstances, was alarming when viewed through an ethical lens. Older age contributed to a higher score, along with chronic conditions, reflecting a grim reality of resource allocation. It’s crucial we have ongoing discussions about how we approach these hard choices and ensure that our systems are as equitable as possible.
**Editor:** Thank you for your insights, Prof Powis. It’s clear that the pandemic has revealed critical areas for improvement within our healthcare system.
**Prof Powis:** Thank you for having me. I hope that our experiences during this crisis lead to a more robust and ethically grounded healthcare system in the future.
