Covid-19 update: 6 November

The slogan has been used since the start of the pandemic and was reiterated last weekend by the prime minister Boris Johnson as he unveiled plans for a national lockdown, which came into force on Thursday. ‘The basic message is the same,’ the prime minister said. ‘Stay at home. Protect the NHS. And save lives.’

However, the ‘Protect the NHS’ slogan has recently been criticised as ‘unhelpful’, discouraging patients from seeing their GPs in the early stages of the pandemic. Sir Simon told a Wednesday press conference that the call was for the public to observe social distancing and infection control measures to reduce their risk of needing Covid-19-related treatment, not to stay away if they  needed treatment or advice.

In moving the NHS to level 4, he underlined the increasing pressure on health services with the number of Covid patients in hospital having risen from 500 in early September to around 11,000 now. ‘That’s the equivalent of 22 or our hospitals full of coronavirus patients and even since Saturday we’ve filled the equivalent of another two hospitals with desperately sick coronavirus patients.’

He said that careful preparation had been made for the next phase of the virus – there were new treatments available and mortality rates had halved for some patients in hospital and intensive care units. Some 159 A&E departments are being remodelled to enable them more effectively separate out Covid and non-Covid patients.  And the service was also ahead of previous years in terms of delivering flu vaccines for vulnerable parts of the population and had laid plans with GPs for delivering a Covid vaccination, once one becomes available.

But Sir Simon (pictured) said that however well-prepared the NHS was, it would still be a difficult period – and the UK was not alone in this with hospitals filling up across Europe. Projections from the Scientific Pandemic Influenza Group on Modelling (SPI-M), which supports the government scientific advisory body Sage, paint a worrying picture. If left unchecked, on current trends, the April peak and the NHS current capacity for Covid patients of 20,000 could be passed in November. Surge capacity would be exceeded shortly afterwards leading to widespread postponement of non-Covid hospital services.

While hospitals in the South had been undertaking 90% of their usual activity during October, this was down to 75% in the North West as a result of rising Covid admissions. And some hospitals in the North have already had to put some elective activity on hold.

‘The key to this is to control infection rates,’ said Stephen Powis, NHS medical director. ‘If infection rates are controlled then fewer hospital admissions occur and fewer people will suffer from the long-term complications of coronavirus – long Covid. And most importantly we will see fewer deaths.’

The press conference was timed to support the new national lockdown, which was backed in an emphatic vote in the Commons on Wednesday afternoon, and to underline the importance of compliance with the restrictions.

Lockdown support

NHS Providers chief executive Chris Hopson said the vote itself sent a strong signal about the importance of public compliance. ‘The clear support from MPs for the lockdown measures should reassure people that, notwithstanding the real impact on people’s liberties, livelihoods, their mental health and the wider economy, this is the right thing to do,’ he said.

Mr Hopson summarised the NHS perspective on the second surge of the virus in a long Twitter thread at the start of the week. ‘The levels of NHS hospital admissions and inpatients that we are now seeing are, depending on area, between two and four times worse than the reasonable worst case scenario the NHS was asked by government to plan against,’ he said. ‘Put simply, we have lost control of the virus spread.’

He added that trust leaders were seriously worried that the ‘siren anti-lockdown voices….risk reducing compliance’ but the rules needed to be followed so the NHS can carry on helping everyone over winter.

There were also calls for the government to use the lockdown period to sort out its test, trace and isolate programme. Chris Ham (pictured), chair of the Coventry and Warwickshire Sustainability and Transformation Partnership and former chief executive of the King’s Fund, listed the priorities, including routine weekly testing of asymptomatic NHS and care home staff and monthly testing of care home residents. There needed to be ‘rigorous implementation’ of infection control measures to prevent nosocomial infections.

GPs should also be able to test patients and all tests should be turned around in 24 hours. Contact tracing should also be devolved to councils. ‘Resources and staff should be transferred from the failed national outsourcing model to councils to give directors of public health the tools to do the job working with Public Health England teams,’ Sir Chris said, adding that people asked to self-isolate should receive adequate financial and practical support.

Referencing the government’s apparent ‘moonshot’ plan for mass testing, Sir Chris added: ‘Focus on doing all of these basics well and be sceptical of hype around moonshots — it’s the whole package that will see us through the winter if we get it right.'

Mass testing pilot

There were significant steps forward this week in the country’s testing programme. The UK’s first whole city testing pilot was unveiled in Liverpool aiming to test 500,000 people. Using a partnership involving Liverpool City Council, NHS Test and Trace and the Ministry of Defence, everyone living or working in the city will be offered Covid-19 testing using either existing polymerase chain reaction (PCR) swab tests or new ‘lateral flow’ tests, which can give results within an hour. Lamp technology (loop-mediated isothermal amplification) will also be deployed in Liverpool University Hospitals NHS Foundation Trust for NHS staff.

The government has also announced that it will begin routine weekly testing of all patient-facing clinical staff in the NHS by December. This represents a major expansion on October’s announcement of testing for asymptomatic staff in very high risk (tier 3) areas. Again, it is use of the new saliva-based Lamp tests that is facilitating this work.

However, Jeremy Hunt (pictured), chair of the Commons Health and Social Care Committee – which recommended regular testing of all NHS staff more than five weeks ago – said he was ‘profoundly disappointed’ that this was not happening sooner.

He said that NHS Test and Trace data showed there had been spare swab testing capacity each week since 10 September – ranging from 740,000 spare capacity to over one million.  ‘These tests should have been put to use testing NHS staff regularly to give them confidence they aren’t spreading the virus and [give] patients confidence that they can use the NHS safely,’ he said. ‘It is no longer reasonable to say that testing capacity is a constraint in resolving this issue.’

Mr Hunt said any delay went against Sage advice and chief medical officer Chris Whitty’s assertion that he supported regular testing if there was a big surge in the virus. ‘We are now facing that surge and yet it appears we will be delaying roll out of this vital measure until after the second wave is finished,’ he added. He called for the plans to be brought forward.

Underlining the point about existing available capacity, figures from the government’s Covid-19 dashboard show that capacity for daily testing has been more than 500,000 since the end of October. This may have met the government’s target, but just 265,000 daily tests were processed (reported on Tuesday), which was substantially down on last week when daily testing reached as high as 348,000.

The weekly NHS Test and Trace report said that nearly 140,000 people were transferred to the service in the week to 28 October and just under 116,000 of these were reached. Some 95,000 people provided details of 327,000 close contacts and just under 60% of these were reached and asked to self-isolate.

Just 26% of in-person tests in the community (pillar 2) were received within 24 hours and looking at all testing routes, just over 13% of tests from all sites came under the 24-hour mark.

NHS Providers director of policy and strategy Miriam Deakin said it was encouraging to see that the number of people transferred to the system had increased. ‘[But] we remain disappointed at the need to play catch up as cases carried over from previous weeks are only now entering the system.’ The fact that only 60% of contacts were reached meant that more than 131,000 close contacts were not reached and told to self-isolate.

Layla McCay, director at the NHS Confederation, said the test and trace system must take advantage of the breathing space afforded by the national lockdown. ‘Lockdowns are temporary, and the aim for this one should be not just to save lives and help the NHS to provide as many services as possible, but to bring the number of cases down enough to allow the struggling test and trace system to be more effective,’ she said. ‘Our members tell us that it is vital that the system improves, rapidly and significantly. Otherwise, a national lockdown simply kicks the can down the road.’

Lifting lockdown without a viable regional alternative and vastly improved test and trace system could be ‘grave’, she added.

App progress

The contract tracing app, which was once seen as a major component in the contact tracing battle, seems to be relatively unnoticed these days. The Department of Health and Social Care reported this week that, six weeks post launch, there have now been 19 million downloads of the NHS Covid-19 app. The app covers England and Wales with separate apps in other parts of the UK. However there have been interoperability issues, which now appear to have been fixed.

Scottish residents have been told that they can keep using Scotland’s own Protect Scotland app if they travel to England and Wales – lockdowns permitting – with interoperability now achieved. Interoperability issues with apps in Northern Ireland and Jersey had already been sorted at the end of October.

No figures have been published for the performance of the English and Welsh app. However in Scotland, where 1.5 million people have downloaded the Protect Scotland app, 13,000 people have been contacted via the app to inform them of close contact with someone who has tested positive. Northern Ireland’s StopCovidNI app, which was launched much earlier in July, is reported to have been downloaded 500,000 times and has notified more than 22,500 people that they should self-isolate.

IT on a much bigger scale was on the agenda for the Public Accounts Committee. Its report – Digital transformation in the NHS – said the Department of Health and Social Care and the NHS have a long way to go to deal with, and move on from, the legacy of their track record of failed IT programmes over almost two decades. It flagged up the failure to deliver a paperless NHS, which had an original target date of 2018 – now put back six years. There has also been poor progress with shareable electronic patient records. It added that in 2020 ‘none of the components essential to successful delivery of the digital ambition for the NHS – effective governance, realistic and detailed plans, sufficient investment nationally and locally, and clear accountability – are in place’.

Meg Hillier, committee chair, said the response to the pandemic demonstrates it is possible to reset and adopt new digital solutions and technologies. ‘But there needs to be a clear strategy that works with local trusts and acknowledges the financial pressures they are under,’ she said.

Danny Mortimer, chief executive of the NHS Confederation, agreed that the successes during the pandemic needed to be built on. ‘Health leaders tell us that the response to the COVID-19 pandemic has seen a digital revolution with the creation of shared care records, a wholescale shift of GP appointments to telephone and online, and the rapid adoption of video-based outpatient and follow-up appointments, alongside continuing to provide face-to-face services where needed,’ he said.

But he said NHS bodies now needed support to take them further. ‘Health leaders shouldn’t be expected to raid their limited capital budgets to support these developments and we need to see a commitment to greater financial support from the chancellor’s one-year spending plan with a commitment to a proper longer-term plan for capital investment in all parts of the NHS, not just the repeatedly announced 40 hospitals.’

With the government having to provide unprecedented support for the economy during the pandemic, it is not clear what financial commitments it can make in the key areas of health and social care. But many people believe that failure to find the necessary funding will have an impact long beyond Covid-19. All eyes will now be on that spending review at the end of this month.