Boris Johnson’s approach to a winter wave of Covid-19 is to hope for the best but plan for the worst, he said on Friday. The worst-case scenario was spelled out earlier in the week by the Academy of Medical Sciences: as many as 120,000 hospital patients dead. Avoiding that will depend on the state of preparations in many areas.
Medicine
Even if a vaccine can be found, mass inoculation is unlikely before a winter Covid-19 surge. More than two dozen vaccine trials are under way globally, and in the UK, Imperial College London has started human tests, but bigger trials are needed. Oxford University scientists have seen signs their drug may be creating immune responses, according to reports.
The likelihood of useful levels of natural immunity are slim. As of 13 June, just 5.4% of people tested had coronavirus antibodies, according to official figures.
Hope comes from progress in treatments. The cheap steroid dexamethasone has been proven to reduce inflammation in sufferers and can save the lives of people on ventilators, according to a global trial.
“We may start to use the drug earlier, as soon as patients test positive,” said Dr Alison Pittard, the head of the Faculty of Intensive Care Medicine.
There is also more understanding of the virus’s tendency to cause blood clotting, which was not anticipated but has emerged in postmortem examinations. How to treat it though, remains uncertain.
The extra risk from seasonal flu (which can also consign the vulnerable to intensive care with breathing problems, low oxygen and secondary infections) is to be addressed with “the biggest flu vaccine programme in history”, according to the health and social care secretary, Matt Hancock. Labour wants the vaccine to be given to everyone over the age of 50.
PPE
Leaders of care homes and hospitals are hopeful that workers will not again go without masks, aprons and gloves. The government says it has ordered almost 28bn items from UK manufacturers and foreign suppliers. But fears remain of a repeat of shortages that almost certainly cost the lives of care home residents and staff. The scramble to plug the gap has led the government to allocate a staggering £15bn to spend on personal protective equipment.
The NHS chief executive, Sir Simon Stevens, told MPs late last month he had been reassured that “supply will be available on a predictable forward basis rather than some of the more just-in-time approaches”. But the British Medical Association, which represents frontline medics, wants to see the government’s numerical modelling on future demand for PPE and how this stacks up against present supplies and orders.
The government has set up a company, Supply Chain Coordination, which uses another firm, Clipper Logistics, to store and dispatch kit in vast quantities. From 25 February to 12 July, the system has sent out 353m aprons, 25m FFP3 masks, 1.3bn single gloves and, in a reminder of the importance of getting PPE right, 210,000 body bags.
Test, trace, isolate
If England is to avoid a second lockdown, the test, trace and isolate system must work. After the government scrapped its first attempt at building a “world-beating” tracing app, sent out defective test kits and became embroiled in disputes with local leaders over test data, Wednesday night brought another worrying sign. The government had to recall thousands of Randox test kits in a move one care home manager said left her “high and dry”.
Almost 340,000 tests can be carried out daily, rising to 500,000 by the end of October. Results of in-person tests now almost always come back the next day. But without any smartphone-based technology to help trace contacts, stamping down on outbreaks is only partially possible. In June, a quarter of the 31,421 people who had their case transferred to NHS test and trace were not reached. Almost a third of those who were did not provide any close contacts.
Unlike contact tracing for sexually transmitted diseases, people with Covid-19 often do not know who they may have infected. A new app based on Google and Apple technology is under development, but on 17 June James Bethell, the health minister responsible, said: “We are seeking to get something going for the winter, but it isn’t the priority for us at the moment.”
Local leaders, including Peter Soulsby, the mayor of Leicester, are frustrated at the handling of test data. Soulsby complained that Public Health England was not supplying “vital” postcodes of people who had tested positive when his city was locked down.
Department of Health and Social Care officials insist the data has been available since 22 June.
Hospitals
With Nightingale hospitals hardly used and many new ventilators not required, the first wave of Covid-19 did not overwhelm the NHS. That does not mean it will not do so this winter when combined with seasonal flu and predictions of thousands of extra fatalities caused by postponed cancer treatments. The British Medical Association estimates more than a million fewer operations and treatments than normal took place over the last three months.
“This, combined with additional winter pressures, the prospect of a second peak and a potential flu outbreak could be devastating for the NHS,” said Dr Chaand Nagpaul, the BMA council chair.
Prof Carrie MacEwen, the chair of the Academy of Medical Royal Colleges, added: “If we get a second surge it could be bigger than the last one and that could damage the NHS in the long term, especially with the backlog and flu … The public has begun to think we are free of this, but we are not.”
The AMRC has warned members to prepare for overcrowding.
Wards with oxygen supplies are being identified for turning into overflow intensive care units at a week’s notice. NHS planners concede that elective work could be cancelled again if the outbreak is considerable, but stress that many hospitals are now configured with separate Covid and non-Covid pathways to reduce that necessity. On Friday, Johnson announced more than £3bn for the NHS in England to allow Nightingale hospitals to remain available until March 2021 and the purchase of private hospital capacity.
The workforce is looking ahead to winter with trepidation. BMA research shows 44% of doctors in England and Wales are experiencing anxiety, depression and burnout caused by work, with 31% saying this has been worse during the pandemic.
“There is a lot of anxiety about winter and another surge,” said Pittard. “If the surge coincides with seasonal flu there are concerns we will be in a very difficult situation again. But because of what we have gone through, we do have experience and knowledge.”
Care homes
Care homes, where more than 21,000 residents have died of Covid-19, have used government grants to replace carpets with cleanable wooden floors, build visiting pods and divide homes into “hot” and “cold”, Covid and non-Covid, areas. Supplies of PPE look stronger, and understanding of infection control has improved. But with 77% of beds in care homes in England provided by private companies, financial distress could be the biggest threat. Occupancies are substantially down and emergency government funding has not reached many. Four Seasons Health Care, which went into administration in April, said it was on course to spend £6.5m on PPE this year – over 30 times more than normal.
“There may be providers who look at a second wave as just not affordable and just close their doors,” said Nadra Ahmed, the executive chair of the National Care Association.
Cost will prevent homes from bringing staff to live in-house to prevent infections, as a small number did successfully this spring, she added. Limiting the number of homes a carer can work in will also increase costs and so may not be done.
“Some organisations will go bankrupt and that will mean a lack of capacity,” said Martin Green, the chief executive of Care England, which represents the largest providers. “We need much greater support from the NHS into care homes, we need clearer guidance on the isolation process and how to manage people with advanced dementia and learning disabilities.”
Ethnic minorities
From hospital doctors to minicab drivers, black, Asian and ethnic minority Britons have been much more likely to contract and die from Covid-19. Black men were almost three times as likely to become infected than white men. Why remains a subject of research into co-morbidities, living conditions and the effects of institutional racism. But efforts to mitigate the problem in a second wave are under way. Councils are obliged to identify ways to do this in their local outbreak plans and must show how they will work to protect those communities. In the NHS, where many ethnic minority doctors and nurses died from Covid-19, employers have been asked to undertake risk assessments.
Prof Stephen Powis, NHS England’s national medical director, has told MPs this could result in redeployment to another work setting or working from home.
“Risk assessments should now be happening across the NHS for every higher-risk health worker, including all black staff,” said Sara Gorton, the head of health at the Unison trade union. “Regular testing, plentiful supplies of the right protective kit, making it easier for staff to raise concerns, and ensuring protected status and earnings for anyone redeployed to less risky locations all need to be in place should the virus come surging back.”
Local lockdowns
The government’s “whack-a-mole” strategy for quashing second-phase outbreaks locally hands power back to councils’ directors of public health, who have been tasked with drawing up local outbreak plans. They rely on two things: the quality of the plan and the flow of data from the centralised NHS test-and-trace programme. Both have been patchy.
“Clearly, [local outbreak plans] will only work with strong national action as well – including NHS test and trace being fully operational and the government providing clear and consistent messages,” said Jeanelle de Gruchy, the president of the Association of Directors of Public Health.
On Friday, the prime minister announced new powers for councils in England to close premises and parks and cancel events if they need to quell outbreaks.
The local plans set out how to contain hotspots in vulnerable locations, such as care homes, schools, rough sleeper accommodation and dormitories for migrant workers. They set out how local testing will integrate with the national efforts and include roles for the police, volunteers and councillors. The plan for Newcastle upon Tyne, for example, is broken into four response categories – green, amber, red, and red-plus for multiple outbreaks.
Hertfordshire’s plan warns of the possibility of “a second wave of infection as bad or worse than the first … [that] would result in many people needing hospital treatment, and possibly many more deaths”.
Some fear local lockdowns may be compromised if the public is fatigued from the three months of restrictions this spring and resent losing freedoms that people in neighbouring towns continue to enjoy.
Economy and jobs
The economy is already heading into historically bad conditions. Public sector net borrowing stands at its highest peacetime level in 300 years. Four million people could be unemployed by next year, according to a worst-case scenario by the Office for Budget Responsibility – the worst jobs crisis in a generation. The wages of 9.4 million people are being paid by the furlough scheme that ends in October.
“The fear is that with the first wave having battered many firms, a second could push them further towards mass redundancies and possible closure,” said James Smith, the research director at the Resolution Foundation.
More coronavirus will mean more lockdowns, which means a possible return to job and business protection schemes. Another three months of furlough payments would cost £12bn; more self-employment support would cost another £3bn; and a £15 per person boost to universal credit payments to reduce gaps in protection would cost another £3bn. That is another £18bn for three months, without accounting for long-term effects on the economy.
“While the cost of doing so will be large, the cost of not doing so would be even greater, in terms of job losses, insolvencies and a huge income shock,” Smith said.
