Covid-19 update: 22 January

The first three days of the week saw cases averaging nearly 37,000 a day, compared with Sunday’s seven-day average of 42,000 – with the downward trend suggesting that the national lockdown is finally having an impact. However, the latest report from the ongoing React (Real-time Assessment of Community Transmission) study, led by Imperial College, said that one in 63 people currently have the virus. This represents 1.58% of the population, an increase of more than 50% compared with findings from early December.

The latest results are based on swab tests on a sample of the population between 6 - 15 January and also show that the prevalence in London is almost twice the national average, with one in 36 testing positive. The period covers the first weeks of the current national lockdown. ‘Across this round of the study we’ve seen that the number of infected people has remained high and we have no good evidence that infections are falling in England,’ said Steven Riley, professor of infectious disease dynamics at Imperial. ‘We are working to better understand why we are seeing these trends when the country is in lockdown, including studying the new variant, so that policy-makers can respond urgently to help bring infections down and save lives.’

The government said the report did not yet reflect the impact of the lockdown measures.

However, the daily death rate paints an inarguably grim picture. Just over 1,800 deaths were reported on Wednesday. This represents the most deaths reported on a single day since the pandemic began – although they are likely to have resulted from infections contracted several weeks ago.

There may be some signs that daily admissions to hospitals are starting to reduce slightly across the UK, although it is too early to be confident that this is a trend. However they are still high at more than 3,700 last Sunday. And while the reductions may bode well for the future, the numbers of Covid patients being looked after in hospital beds continues to grow, with admissions outstripping discharges. On Monday, the government’s official Covid dashboard reported there were more than 39,000 Covid patients in hospital beds, nearly 2,400 up on seven days earlier.

In Monday’s government press briefing, England’s health secretary Matt Hancock said that someone was being admitted to hospital every 30 seconds. NHS England’s medical director Stephen Powis said the pressure on the NHS was extreme. ‘[It’s] more than we’ve ever seen before, more than the first peak in both our general beds and in our intensive care unit (ICU) beds,’ he said. The country must stick to the social distancing rules and not rely yet on vaccines ‘coming to our rescue’ – it will be a while before the impact of vaccines is seen in reduced hospital pressure.

Some commentators suggested this week and next week could mark the toughest part of the pandemic for the NHS. In fact, NHS Providers chief executive Chris Hopson told BBC Breakfast on Thursday that there were probably four or five weeks of ‘incredibly intense pressure’ ahead for hospitals. The more than 39,000 Covid inpatients was 80% higher than during the first wave last spring, and the increased transmissibility of the new variant could mean a longer tail for the peak this time around.

And responding to the latest winter reporting data from NHS England and NHS Improvement, Mr Hopson’s colleague and director of policy and strategy, Miriam Deakin (pictured), said there was no room for complacency with the figures showing trusts under sustained pressure. ‘The number of adults occupying a critical care bed has increased once again, with 54% more intensive care beds open to treat patients than last year,’ she said. ‘Given the number of people being admitted into hospitals with Covid-19, trusts are doing all they can in to ensure there is enough capacity – in terms of beds and staff.’

Welsh challenges

Wales also published figures showing major increases in waiting times. ‘We’re currently running our critical care capacity at over 150% and one third of our hospital beds are being used to care for patients with Covid,’ said Darren Hughes, director of the Welsh NHS Confederation. ‘At the same time NHS staff are being redeployed to ensure the largest vaccination programme in history is rolled out. Sadly, this report is not surprising and it will be some time before care can be delivered at normal rates.’

Capacity is a major issue for the NHS – maximising its own capacity or extending capacity through the independent sector and Nightingale hospitals. Operational guidance issued in England in mid-January confirmed that contracts with 14 independent sector providers had been agreed nationally to provide a guaranteed minimum level of activity through quarter 4, with the ability to surge NHS use of these facilities. Systems were asked to develop surge plans by 22 January with independent sector capacity focused on P2 surgery (the second highest priority of four levels of prioritised activity) and cancer treatment in particular.

Reports this week suggested that surge clauses in private sector contracts had now been triggered for some parts of England, including London, enabling the NHS to use 100% of the relevant independent hospitals’ capacity.

The Scottish government has also announced that five independent hospitals are supporting the NHS with elective care. This is on top of extra capacity already provided by the NHS Golden Jubilee national hospital and the ‘Nightingale’ facility NHS Louisa Jordan. The Golden Jubilee hospital has performed more than 10,000 procedures – including 565 urgent cancer operations, since services recommenced in July after the initial Covid wave. The NHS Louisa Jordan has worked with four NHS boards to deliver over 19,000 outpatient appointments across 14 specialties.

Capacity is measured in staff as well as physical resources such as beds and in some cases additional physical capacity cannot be used because of clinician shortages. For example, insufficient numbers of anaesthetists are the block to using more private sector capacity in some areas, with the independent facilities often dependent on the same anaesthetists as the NHS.

Discharge support

Back in England, the focus is also on freeing up capacity by discharging patients from hospital as soon as they no longer need to be there. A letter from NHS England and NHS Improvement’s director of community health Matthew Winn sets out three schemes that will help with this – all funded from the £588m hospital discharge ‘scheme two’ fund up until the end of March.

The options include the use of hotel accommodation as a short-term measure, where there are delays in arranging care at home support, or the national framework for independent sector providers for hospital at home services. Alternatively, where local systems do not have an operating designated care home facility (due to lack of indemnity cover), the Department of Health and Social Care will provide time limited indemnity cover to the small number of designated care home facilities that need this support.

The Department has also announced £120m to support increases in social care workforce, which will help support timely discharge from hospital.

Figures published on Thursday showed that nearly 5 million people across the UK had received a first dose of vaccine – including two-thirds of over 80-year-olds. A further 10 million people would need to receive a first dose of vaccine to meet the government’s target of protecting the four top priority groups by 15 February. This would require roughly 385,000 vaccinations per day. Thursday’s daily figures – 364,000 – suggest that the programme is not far off the required pace, although it has been inconsistent over the last week and there are still reports of supply problems.

Health secretary Matt Hancock – self-isolating after being advised by the NHS Covid-19 app that he had been in contact with a positive case – told the House of Commons on Thursday that 200 vaccinations were being given every minute. Some 63% of residents in elderly care homes had been vaccinated and he said the NHS was on track to complete this cohort by the end of the month. However guidance to primary care networks had suggested the target was to finish vaccinations for the care home community by the end of this week.

Although it was announced that the programme would now be expanded to over 70-year-olds, there were also reports that vaccine supplies would be reduced in some regions that have made the most progress with the over 80-year-olds, so that more vaccine could be made available in other areas, enabling them to catch up.

In Wales, first minister Mark Drakeford was asked by BBC Radio 4’s Today programme on Monday why the vaccine programme appeared to be slower in Wales than elsewhere in the UK. Mr Drakeford said the differences were marginal and the country was on track to hit the mid-February target.

But he said that, while the government was using the Oxford vaccine as soon as it was received, it was pacing its use of the Pfizer vaccine, a further delivery of which wouldn’t arrive until the beginning of February. ‘There will be no point, I think, and certainly it will be logistically very damaging, to try to use all of that in the first week and then to have all our vaccinators standing around with nothing to do for another month,’ he said. ‘The sensible thing to do is to use the vaccine you’ve got over the period you’ve got it for.’

The comments met with widespread criticism. However, health minister Vaughan Gething (pictured) later insisted that vaccines were not being held back in Wales. He said every UK nation received a delivery of the Pfizer vaccine in December and the stocks were being worked through ‘as fast as our system can deliver them’. In a subsequent written statement he underlined that good progress was being made with the vaccination strategy with 1,000 care home residents being vaccinated every day. And in the last week four mass vaccination centres had come on stream as well as a first community pharmacy pilot.

12-week dosing concerns

Mr Hancock dismissed doubts about the UK’s approach of delaying the second dose of vaccine in favour of getting a broader section of the population some protection from a first dose. A report in The Guardian newspaper reported concerns from Israel – leading the world in terms of vaccine roll-out – that a single dose of the Pfizer/BioNTech vaccine may be providing less protection than originally hoped.

Mr Hancock insisted that the data underpinning the report supported the decision to move to a 12-week dosing schedule. However a number of clinicians and academics have called for the government to review the strategy and undertake a  robust randomised evaluation. The opinion piece in The BMJ also notes that the German and US governments have recently stated that they do not intend to delay the second dose, and that Pfizer and Moderna do not support the delay strategy.

While vaccines continue to offer a way out of current restrictions, the overall message this week was that people should not get their hopes too high about this happening anytime soon. To underline the point, Northern Ireland first minister Arlene Foster announced that the lockdown in Northern Ireland, which began on Boxing Day, was being extended until 5 March.   

And while no announcements have been made in other home nations, it is clear that wholesale lifting of restrictions is not on the table. In the meantime, testing and tracing will continue to be vital in the battle to reduce the spread of the virus. The government has already expanded its asymptomatic testing programme, first piloted in Liverpool, to all 314 lower tier local authorities. Many areas are focusing this programme on the testing of critical workers and those who must leave home for essential reasons.

But the national test and trace programmes will be vital to the virus’s containment. In England, health minister Lord Bethell said NHS Test and Trace was demonstrating its ever-increasing testing capacity. ‘More than 13% of PCR tests conducted to date were carried out in the first 13 days of January 2021 – a phenomenal achievement for a national service that has existed for just nine months,’ he said.

Nearly 331,000 people tested positive in England in the week to 13 January, according to the latest report on the service, and 352,000 cases were transferred to the contact tracing system. Some 305,000 of these were contacted (87%) and of these 228,000 (75%) provided details of 614,000 close contacts. Some 93% of these were reached and asked to self-isolate (although under changes introduced at the end of last year, the person testing positive is now asked to inform household members and this counts as all members of the household being contacted).

In terms of test result turnaround times, nearly 27% or people tested in the community were given their results within 24 hours – up from 18% the previous week. Layla McCay (pictured), director at the NHS Confederation, said the latest figures were reassuring. ‘The NHS will continue to be in an extremely precarious position for the next few weeks at least, as there are still more than 39,000 people in hospital with COVID-19, and thousands being admitted every day, meaning we cannot afford to take our eye off the ball,’ she added. ‘It’s therefore incumbent on all of us to continue abiding by lockdown restrictions.’

And Miriam Deakin, director of policy and strategy at NHS Providers, agreed there were positives to take away from the data, but also warned against complacency. ‘This is the first time in six weeks that we have seen a decrease in the number of confirmed positive cases of Covid-19, with 15% fewer cases reported than the previous week,’ she said. ‘It is essential that positive cases are transferred to the Test and Trace system as quickly as possible, and while it is encouraging that the backlog of cases from previous weeks is now being caught up, the system must improve the amount of time it takes to begin the process in the first instance.’