The existence of an official NHS tool ranking patients by age and fitness to decide who should be given priority for Covid treatment during the pandemic has been revealed for the first time.
The Covid inquiry heard on Thursday how the “Covid-19 Decision Tool” was drawn up by officials at the height of the first wave in 2020 to decide who should be prioritised for care, with patients given points according to their age, frailty and pre-existing conditions.
Professor Sir Stephen Powis, NHS England’s national medical director, said he was “terrified” the NHS was going to be overwhelmed as officials drew up the document and the virus swept through the nation.
In the end, it was never officially released because the UK was nearing its peak of the first wave, Professor Powis said.
However, its existence has confirmed long-held fears by families bereaved by Covid that doctors and nurses unofficially used such methods to rank patients and deny intensive care and other treatment to the elderly and with other conditions.
Many members of the Covid-19 Bereaved Families for Justice UK Group lost loved ones because Do Not Attempt to Resuscitate (DNAR) orders were imposed on them, often without family consent.
i has also previously revealed cases where patients were given “ward-based ceilings of care” orders on their hospital notes, meaning they were not admitted to intensive care units despite being gravely ill with Covid.
Yet for years the NHS and Department of Health has denied that any decisions in which care would be given or denied according to different groups of people were acceptable in the health service, including during the pandemic.
On Thursday the Covid inquiry heard how the Covid-19 Decision Tool was written in March 2020 as a “prioritisation document” to be considered should the NHS become overwhelmed with cases.
Professor Powis told Lady Hallett that the work was something “nobody ever wants to do”.
The inquiry was shown the unpublished document, titled Covid-19 Decision Tool, which highlights three elements to consider when prioritising care: age, “clinical frailty” and “comorbidities”.
Patients were given “points” based on their age, with under-fifties placed at zero and 80-year-olds starting at six points.
It also ranked patients from one to nine, one being fit and well and nine being terminally ill, while comorbidities such as previous heart attacks, high blood pressure and heart failure also scored points. A point was taken off for women, meaning men were seen as more clinically frail.
The scores would then dictate what sort of care should be provided to the patient.
Professor Powis said: “In terms of this decision tool, which was never authorised, it was never officially released.
“It didn’t go beyond this stage other than the group that developed it subsequently published a version of it in an Intensive Care Society set of principles around decision-making.”
The inquiry heard that the “impetus” for the document came from the Department of Health and Social Care but on 28 March a decision was made that it should not go ahead.
Professor Powis added: “This was at a point in March where cases of Covid were rapidly increasing.
“The strategy that the NHS and government had taken was, on the one hand, to put in social distancing, in other words lockdown, to reduce the rate of transmission, and within the NHS our job was to surge capacity.
“But at that point in March, the number of patients with Covid in ITU (intensive care) beds was doubling every five to seven days.
“We couldn’t see – because there was no community testing at the time – what was likely to come ahead.”
Professor Powis added that at that stage it was not clear whether the public would respond to lockdown.
He added: “Frankly, I was personally terrified, terrified that the NHS was going to be overwhelmed and doctors were going to be placed in a position, and other clinicians, where they would not be able to make the professional judgement that they usually make in terms of treatments and escalation.
“And in those circumstances, I and my clinical colleagues and CMOs (chief medical officers), felt that we should begin to explore a decision tool such as this.”
But the discussions about the document were halted “because a number of us, the Chief Medical Officer [Professor Chris Whitty], myself, with input from the (then) chief executive of NHS England, came to the conclusion that it should not be released.”
He said that the peak of the pandemic was approaching and therefore it would not be needed.
Professor Powis added: “It became very apparent to me that it was not going to be needed, and I had a fear that if it was released, it might be used when it would not need to be.
“I think it was right to stand it down because we didn’t need it and it could have been used inappropriately.”
He shared a concern that the document would be controversial and risk poor reaction from the public.
“It became absolutely clear to me that this was going to be controversial, that it hadn’t had the opportunity to be discussed more widely with patient groups, with public and so my recommendation to the inquiry is that we should absolutely, in future, not try and develop one of these tools in the midst of a pandemic.
“This is a discussion that has to occur in normal times. It’s a discussion that shouldn’t be government led, it shouldn’t even be led by the profession, it needs to be located within society. This is too hard a task to do at the height of the pandemic.”
Nicola Brook, solicitor at Broudie Jackson Canter, which represents more than 7,000 families from the Covid-19 Bereaved Families for Justice UK Group, said: “While this tool may never have been rolled out we know from the evidence the inquiry has heard that the thinking behind it was shared.
“This resulted in groups like the disabled and the elderly being written off because it was considered that their lives were not worth saving which is a national disgrace.”
In the four years since the pandemic, NHS England and the Department of Health have insisted that blanket decisions about care should be made, and have never admitted that the plan was drawn up.
In autumn 2020, the Department of Health’s adult social care winter plan said: “It is unacceptable for advance care plans, including DNACPR decisions, to be applied in a blanket fashion to any group of people…
“We are aware of anecdotal reports of inappropriate practice in applying DNACPRs. This is unacceptable and we have taken national action, across a number of fronts, to prevent this from happening.”
In July 2023, when i revealed that the Covid inquiry was planning to investigate the blanket use of DNARs and clinical frailty scores, an NHS spokesperson said: “There was never any NHS directive on DNRs – the NHS repeatedly instructed local clinicians that the blanket application of DNRs is totally unacceptable and that access to treatment and care for people should always be made on an individual basis and in consultation with family and carers.”
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