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Covid calculus shifts as NHS faces ‘extremely challenging’ winter

The NHS has been the lodestar of the UK government’s response to Covid-19, with restrictive lockdowns justified largely by the need to ensure infections did not overwhelm the taxpayer-funded health service.

Now, however, these calculations have entered a new and delicate phase. The number of Covid patients requiring a hospital stay is rising and on Tuesday the daily death toll reached a seven-month high. While the trajectory of these increases is less steep than a year ago, health staff are now also contending with a prospective surge in flu and other respiratory viruses owing to renewed social mixing.

Moreover, as ministers weigh whether fresh restrictions will be needed, they must also consider the NHS’s ability to tackle the pandemic’s grim legacy of postponed care. More than 5.5m people in England are awaiting treatment for officially non-urgent, but in some cases painful and debilitating, conditions.

Saffron Cordery, deputy chief executive of NHS Providers, said: “It’s just like that thing where, if you squash a beach ball full of air, it goes down in one place but pops up somewhere else . . . Essentially it’s about how we hold those things in balance and move forward on all fronts, getting through as much elective backlog as possible.” This, she noted, would be “extremely challenging”.

Scientists and health experts have suggested there is no cast-iron numerical trigger point for the potential reimposition of restrictions, with politics inevitably part of the equation. The prime minister is facing pressure from his own party, particularly its libertarian wing, to resist the reimposition of restrictions.

Sir Mark Walport, former chief scientific adviser and a member of the government advisory group Sage, said: “The policy judgment always has a qualitative element. No one has ever said ‘this specific number of deaths or hospital admissions is acceptable’ or ‘this specific number of deaths and hospital admissions is unacceptable’”. 

“There’s always a natural balancing act based on how people feel about the disease in the context of . . . its effects on people, the effects on the NHS versus all the other awful disruptions to their lives, and this balance changes over time.”

On the frontline, medics and managers are executing their own balancing acts, as they juggle a huge rise in emergency demand with a determination to continue treating those whose surgery has already been delayed for months.

Charts showing that English hospitals have very little headroom coming into the winter, risking further growth of a waiting list that already stands at 5.7m people. There are currently 121,943 hospital beds occupied in England, out of a total capacity of 123,707. Meanwhile, the number of people on waiting lists for treatment in English hospitals has climbed from 3.8m in May 2020 to 5.7m in August 2021

Extreme pressure on England’s underfunded NHS, especially in the colder months, long predates the pandemic. “Even [before Covid], we struggled through winters, we struggled through some springs and some autumns, as well,” said Professor Geoff Bellingan, medical director for cancer and surgery at University College London Hospitals.

Far more people were coming in as emergencies than had happened at the height of the lockdown, a welcome development, he suggested, as it showed people who needed help were seeking it, but this was complicating the task of tackling the surgical backlog.

In April, UCLH expanded by opening a new building with eight operating theatres. It is now dealing with complex cases from neighbouring hospitals as well as sending these institutions some of its own “high volume, low complexity” surgical cases, and had bought some capacity in private hospitals.

“We try and share the stresses and the strains”, he said.

Bellingan anticipated the winter would be “very hard” as respiratory, and other, infections threaten to return. “We’ll have a risk of quite a good lot of [Respiratory syncytial virus] and Norovirus and different adenoviruses as well as flu.”

Chart showing that UK Covid cases are high going into the winter, but vaccines have greatly reduced the share of cases that end in hospitalisation or death. Cases are at almost 75% of the level they peaked at last January, but due to the protection conferred by vaccines, the number of Covid patients in hospital is at 20% of its peak level, and deaths are just over 10%.

Charlotte Summers, a professor of intensive care medicine and a frontline ICU doctor, added: “We’ve had a definite increase in the number of RSV infections in the paediatric population and it’s much earlier [in the season] than we would normally see RSV.”

NHS leaders agree, however, the vaccination programme will reduce the number succumbing to serious illness after catching Covid this winter, as well as keeping staff protected. In the past year the disease itself has become more treatable as improvements have come on stream, added Cordery.

The flu vaccine will offer another layer of protection. Dr John McCauley, director of the Worldwide Influenza Centre at London’s Francis Crick Institute said early indications suggested the version being dispensed this year “represents a very good correspondence to one of the two main [flu] variants but a bit less so to the other. We do not know which will circulate or precisely how well the vaccine will perform in practice”, he added.

At University Hospitals Coventry and Warwickshire in the Midlands, length of stay for Covid patients has been falling, aiding efforts to keep elective surgery going. Andy Hardy, chief executive, said the number of people waiting for more than a year for treatment had fallen by 20 per cent in the past two months.

Chart showing that the NHS does have limited capacity to create “surge” ICU beds when demand soars, but this still squeezes out hundreds of non-Covid patients. In early June this year there were only 166 Covid patients in English ICUs, leaving capacity for 3,898 non-Covid ICU patients. But last January, when Covid patients numbered 4,008, even though extra beds were repurposed as "surge" ICU beds, that left only 2,084 beds for non-Covid ICU patients, half the number for June.

“So I think there’s reasons for optimism. There may come a point where we have to do some increased [national] measures, going back to masks etc, but I’m certainly on the hopeful side that we don’t go back into lockdown. I think the government has been very clear that would be a last resort,” he added.

Ministers’ dilemma about when and whether to act is not immediate, and may not arise at all if Britons heed the health secretary Sajid Javid’s injunction on Wednesday to take up booster vaccinations and wear masks in crowded indoor spaces.

At NHS Providers, however, Cordery expresses some relief that the government has a strategy should the worst happen: “I’m glad that plan B is on the table as well as plan A, given the rise in infections we are now seeing”, she said.

 

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