So I'm here with Dr. Katharina Hauck, Deputy Director of J-IDEA, who's going to talk to us about capacity planning in the context of pandemic preparedness. So there's much public discussion about flattening the curve to give health systems a chance to respond appropriately to this crisis. The reason for this is related to specific capacities of hospital care. Can you explain some of the key elements and bottlenecks of hospital care capacity and why it's important for us to assess them? Yes. Thank you. So an important part of pandemic preparedness for every country is to get the health care system ready. In particular, to get hospitals ready to assure that COVID-19 patients receive timely and appropriate medical interventions that improve their health outcomes and that increase their chance of survival, and then of course, we mustn't forget that there will be other patients requiring urgent care while the pandemic is ongoing. So there will be still patients with heart attacks, with strokes, with traffic accidents that require urgent care, and we need to incorporate that into our capacity estimates. So just to give a brief overview, we have as main inputs if you so want into the production of hospital care, we have beds, we have staff across different categories, and then we have essential equipment, and in the case of the COVID patients, we require respiratory support for them. So we need ventilation equipment of various kinds, so these are invasive ventilation and non-invasive ventilation. So some patients who will need invasive life support to help their body to fight the virus. Of course, we know that there is no effective treatment at the moment for COVID-19, although trials are underway, but we need to be ready to provide advanced life support for COVID-19 patients and other patients, and for that we need the medical staff that can operate these complicated machines. Now, critical care we know it's constrained in most countries, even in normal times. So the question is, how can hospitals cope with all these additional admissions? We're actually surprised, when we did assessments of capacity of hospitals here in England, but also in other countries, how quickly hospitals were able to increase their capacity. So that was one of the surprising things that we found with our research. So you just answered number of questions around capacities, which begs the question of, what interventions exist that could help increase capacity? Yes. So countries adopted several types of interventions in order to increase their capacity. I mean, first and foremost, I think we have to see that medical staff in all countries affected by the pandemic are working incredibly hard, and really at levels that are unsustainable, and because it places a high toll on our staff, both physically and mentally. But in addition, countries adopted others, and in our report we identified at least 19 interventions that countries adopted. So these go from cancelletions of elective, so non-emergency surgeries, to putting beds into operating theaters, some of which were not needed at the moment, or we saw the construction of whole new hospitals, so either entirely new hospitals were constructed, for example, in Wuhan in China, or existing buildings were repurposed to provide critical care and also non-critical hospital care. For example, the Nightingale hospitals in the United Kingdom, but we also see interventions such as its staff were upskilled to work in critical care. So staff that normally worked in other areas of the hospitals were trained in providing for COVID-19 patients and also other emergency patients, and then we see for example, things like that staff were asked to return to the medical workforce. So those who had left either because they retired or they went to do other things. Now there are also some more or less obvious example, the export ban on certain equipment or an efficient redistribution of personal protective equipment. Now some countries also had to raise admission thresholds into critical care, and that means that countries had to set somewhat explicit criteria for which patients should be admitted and should be reserved for receiving life supporting treatment in critical care, for example, Norway, Italy, and the United Kingdom have adopted those guidelines. Thankfully, not all of them had to apply these guidelines. Now, usually the criteria for admission into critical care are to give those with the greatest chance of survival and the greatest capacity to benefit the first call here. So what could be the possible downsides to some of these interventions? Well, I think it's very important that you asked that question because I think there are very important downsides to this, that policy-makers have to consider. But first, there are simply the financial costs of doing some of these things. So building hospital is costly in normal times, but you can imagine that if a hospital is constructed rapidly, the costs will be higher. Now, we all know that the health budget or wherever the funding comes from for these interventions is not unlimited, and if we spend this on building hospitals, we will have less funds available for other important interventions and treatments, and in economic terms, we call that opportunity costs. So we need to see what kind of adverse outcomes do we generate in other areas of the health care system, and by doing some of these interventions. Now, a very obvious one is if we cancel elective surgeries, one of the interventions that we looked at, then this will have real consequences for the patients who cannot be treated. Or at least whose treatment will be delayed. So they may experience higher morbidity and maybe also an increased risk of dying, which of course is an outcome that we do not want, but that we may generate with these interventions, and we don't know at the moment how high these costs will be. Also lastly, I think it's also important to say that there will be reductions in the quality of care. Of course, if we reduce staff ratios, then this is going to affect the health outcomes of patients. But again, we have very little insight into what these effects will be, and we won't have that also for some time. But definitely more rigorous research is needed in order to calculate these downstream impacts on patients. In this context you now explained how there is a number of different interventions that could translate in large increases in capacity in the healthcare system. Do you think that these increases are going to translate into gains in efficiencies? Could you maybe explain a bit about the concept that will theoretically explain this? Yes. So I mean, for economists we have efficiency gains, of course, coming from two concepts. The first is economies of scale, and so we see that often when a service or a good is produced, that if we increase the scale of production, so that means the number of goods or services that are produced, that the average costs of producing these goods is declining, and that is because we have high fixed costs, and if we produce more of the same thing, then these fixed costs are distributed across the bigger number of products. So for example, we have some fixed costs in the construction of a hospital. Obviously, this is the building, but these are also support services for that building, are in terms of data supporting systems, in terms of input that is shared, such as big oxygen tanks or things like that. So if we can spread the high capital costs of these purchases across many different beds, if you so want, we would expect that the cost of care would decrease. The same holds also up to a certain degree for staff. So if we have highly qualified staff in the ward anyway, and if they have the capacity to treat additional patients, then the cost of these staff would also allocate across a greater number of patients. Now, of course, the problem with all of these things is that if we have gains in efficiency, we need to take care that the quality of care does not reduce. So that's the first concept, economies of scale. Now, then we have also economies of scope, and economies of scope is if we produce things in conjunction, so if you want a hospital is a multi-product firm that produces critical care, highly complicated, life supporting treatment, but it will also produce a less invasive supportive care for patients maybe who are not as sick, and if we can share inputs across these different, if you saw want, products or patient groups, then we would also expect some cost reductions from that. Again, with the caveat that we need to take care that this doesn't reduce the quality of care for some or all patients, that are treated in this hospital. Thank you very much, Katharina. That was really very interesting. It was a pleasure. Thank you.
