Throughout the pandemic, NHS trust leaders have argued for appropriate restrictions on social contact to bring Covid-19 under control. It is they and their teams who have to deal, in a distressing and direct way, with the daily death and harm that this dreadful virus brings. They know that, until we can vaccinate our population, restrictions on social contact are the only way to prevent unnecessary deaths, reduce patient harm and give the NHS the best chance to treat all the patients it needs to.
So it should be no surprise that, as discussions start on loosening the current round of restrictions, trust leaders remain deeply cautious. There can be no simple, blanket approach to decision-making here. Each phase of the pandemic has its own characteristics and dynamics. Any relaxation will need to be evidence-based and take account of significant local variations in infection rates. And trust leaders have always been clear that these must be decisions for elected politicians as only they can balance the complex and difficult trade-offs required using the evidence and advice they receive. But trust leaders believe there are a number of reasons to be very cautious at this point.
First, the new variant is behaving in very different ways from the virus in the first phase. We know it’s significantly more transmissible. But there’s a lot we don’t know. There are, for example, good reasons to believe that the drop in case numbers will be significantly slower than in the first phase. One of the distinguishing features last summer was how quickly case numbers dropped once the peak had been crested. If we relax restrictions on the basis that case numbers will decline on a similarly rapid basis this time, we risk loosening too quickly. We need an appropriate amount of data on how steep and rapid the drop in case numbers will be after this peak before making precipitate decisions. This will also give us more time to understand the risk from the other new mutations now in circulation.
Second, trust leaders point to the importance of infection rates dropping to a very low level before relaxing restrictions. The experience of trusts in the north of England between September and November was that virus prevalence never really went away in their areas over the summer and, as soon as restrictions were lifted, case rates, hospital admissions and deaths rose rapidly. NHS leaders want to see case numbers drop consistently to much lower levels, for a longer period of time, before we start lifting restrictions this time.
This links to the importance of the NHS having sufficient capacity. Because of the NHS’s success in developing treatments for Covid-19, the mortality rate from the disease has dropped significantly. But the corollary is that any outbreak means NHS hospitals will have larger numbers of seriously ill recovering patients needing long hospital stays than in the first phase.
If we want to manage the risk to the NHS, we need to ensure the service stabilises and returns to more manageable levels of demand. Current predictions are that the NHS has at least four to six more weeks of the current levels of intense pressure and will need time thereafter to be confident of dealing with any new surge triggered by loosening restrictions.
We can be confident that the current vaccination campaign will, over time, reduce the pressure on hospitals as more people are inoculated against the worst effects of the disease. But the precise interaction between increasing vaccination rates, reducing rates of hospital admissions and relaxing restrictions remains opaque because there’s a lot we still don’t know.
We still don’t fully understand the impact of vaccination on transmission and need more data
We still can’t guarantee what the supply of vaccines will be and therefore how quickly we will be able to vaccinate the population. We still don’t fully understand the impact of vaccination on transmission and need more data before deciding how soon we can loosen restrictions without triggering infection and resulting in death and harm in those who haven’t been vaccinated.
Mortality and harm rates are highest among the four priority groups who are due to be vaccinated by mid-February, including care home residents and carers, frontline health and care workers, the clinically vulnerable and people over 70. But it’s vital to remember the impact of Covid-19 on those who will have to wait longer. They can still die, contract long Covid and require hospital treatment.
There is a strong link here to pressures on the NHS. The government has rightly said it will take full account of these pressures in its decision-making. But the pressure in hospitals is twofold – on both general and intensive care beds. While hospital admissions are very strongly skewed to the over-70 age group, that is not the case for ICU admissions. According to data from the Intensive Care National Audit and Research Centre, the current mean age for ICU patients since September has been a disturbing 60 years old. So the vaccination campaign will help with the pressure on general hospital beds much more quickly than it will with pressures in intensive care units.
NHS trust leaders are as keen as everyone else to return to normal. They can see the adverse impacts of the current restrictions on mental health and the wider economy. But the shocking number of Covid deaths and widespread patient harm of the last few weeks make them deeply concerned about loosening restrictions too rapidly. There is already a growing chorus of voices pushing for a loosening of restrictions. That will only grow over the next few weeks. Those voices need to be resisted. We should only loosen restrictions when we have the evidence and data to confirm that we can do so without triggering a further full-blown wave of infections.
Chris Hopson is chief executive of NHS Providers, the membership organisation for England’s 216 hospital, ambulance, community and mental health trusts