15 December, 2020
Since the UK’s first lockdown in March, the government has had one (perhaps only one) consistent message — protect the NHS, write Alastair McLellan of HSJ and Fiona Godlee of The BMJ.
Now, with the number of hospital patients with covid-19 again on the rise, and a third wave almost inevitable, the new year is likely to see NHS trusts facing a stark choice: be overwhelmed or stop most elective and non-urgent work. Rather than lifting restrictions over Christmas as currently planned, the UK should follow the more cautious examples of Germany, Italy and the Netherlands.
By and large the NHS has coped well with the additional caseload of covid-19 patients during the autumn. The second wave began to hit hospitals at the start of September. Government figures report 451 inpatients with covid-19 in England on 2 September. Over the ensuing 10 weeks, the numbers rose steadily and then rapidly, peaking at a reported 14,712 inpatients with covid-19 in England on 23 November.
If the third wave turns out to be of the same order of magnitude as the second wave, the health service should manage. But this will be the case only if that wave starts with a broadly similar extra caseload of covid-19 inpatients as at the beginning of the second wave: around 450.
With current restrictions failing to control the virus, extrapolation suggests that the actual figure is likely to be more than 40 times higher (see explanation in paragraph below). The planned relaxation of restrictions over Christmas will boost the numbers further as the NHS also struggles with the additional demands of winter.
England went into lockdown on 5 November and the number of inpatients with covid-19 began to fall, down to 12,968 on 5 December. If this rate of decline had continued, the English NHS would have been on course for just under 11,000 covid-19 inpatients on 31 December. However, in the past two weeks, despite most of the country being in tiers 2 or 3, numbers of inpatients have started to rise again. By 14 December (the latest data available) covid bed occupancy had climbed back to 15,053.
Unless something happens to change this trajectory, hospitals in England will have just short of 19,000 covid patients on new year’s eve. This figure, derived by extrapolating a straight line from December 5 to December 14 through to December 31, would be almost exactly the same as the 18,974 peak of the first wave on April 12.
The NHS currently has around 95,000 general acute beds. It is operating with around 10 per cent fewer beds than a year ago as a result of infection prevention and control measures introduced to try to stop the spread of covid in hospitals.
The cost of inaction
The main impact of a further surge in covid-19 inpatients is likely to be felt most by those with other conditions. The NHS has learnt from the first and second waves and has robust plans to rapidly increase intensive care capacity, including through the Nightingale hospitals. However, a large influx of covid patients similar or greater than that seen in the autumn can only be managed if staff and other resources are diverted from treating non-covid patients.
Having recovered much of their capacity for elective and non-urgent care during the autumn, NHS trusts in the most pressured regional health systems are already now having to cancel almost all such activity because of the resurgent virus. A significant third wave could wipe out almost all the reductions in waiting times for elective procedures achieved in the past 20 years. Performance against the standard which requires the NHS to treat 92 per cent of elective patents within 18 weeks will have slipped to 12 months by March next year. The number of patients waiting over a year for treatment has risen from a hew hundreds to 160,000. This will take years to recover from, at the cost of much suffering and loss of life.
The coming months are also likely to see the NHS under intense winter pressures due to seasonal outbreaks of norovirus, increased admissions of frail older people and the peak of staff absence. The NHS will also be in the middle of delivering the largest vaccination programme in its 72-year history, via already overstretched general practices and hospitals.
Even if NHS England succeeds in vaccinating all those ‘at risk’ by Easter, this will not be in time to prevent hospitalisation and death for many during the next few months. “NHS Track and Trace,” which has almost nothing to do with the NHS, continues to squander money on failure. So too does the mass testing of asymptomatic people using lateral flow tests that are not fit for purpose.
Of particular concern is the impact on staff, many of whom have already worked through the hardest nine months of their professional lives. Levels of burnout and sickness absence are likely to exceed those already experienced.
What should be done
London and many neighbouring counties will enter tier 3 on Wednesday 16 December. However, other areas such as Kent which has been in tier 3 since 2 December are still seeing strong increases in hospital admissions. These measures are clearly inadequate.
Ministers are meeting tomorrow (16 December) to review current restrictions for England. When government devised the current plans to allow household mixing over Christmas it had assumed the covid-19 demand on the NHS would be decreasing. But it is not, it is rising, and the emergence of a new strain of the virus has introduced further potential jeopardy.
Members of the public can and should mitigate the impact of the third wave by being as careful as possible over the next few months. But many will see the lifting of restrictions over Christmas as permission to drop their guard.
The government was too slow to introduce restrictions in the spring and again in the autumn. It should now reverse its rash decision to allow household mixing and instead extend the tiers over the five-day Christmas period in order to bring numbers down in the advance of a likely third wave. It should also review and strengthen the tier structure, which has failed to suppress rates of infection and hospitalisation.
This joint editorial is only the second in the more than 100 year histories of The BMJ and HSJ. We are publishing it because we believe the government is about to blunder into another major error that will cost many lives. If our political leaders fail to take swift and decisive action, they can no longer claim to be ‘protecting the NHS.’
Alastair McLellan, editor, HSJ
Fiona Godlee, editor in chief, The BMJ
Our civilization is apparently completely screwed up!
It defies belief that this can happen in a serious country! The UK government had recently decided to relax the social distancing rules for Christmas but now it seems that it will have horrible consequences on the spread of the virus. Instead of strongly coming out and reversing the previous decision they are being indecisive. More people are going to die but they just can’t make a resolute decision.
But this is a world-wide phenomenon! All around the world people have been behaving completely irrationally, and what is more, hardly anybody has the bluntness to point that out! Less than half of Israelis plan to get vaccinated for COVID-19 – survey. How come people who see this absurdity are not screaming on the top pf their voices? What is going on? This is a global failure of common sense across the world.
Update, December 16, 2020
I cannot understand politicians. Boris Johnson in the Commons doubles down and refuses to reverse the 5 day Christmas relaxation of social distancing despite the plea in the medical journals. Keir Starmer’s criticism was spot on.
Update, December 17, 2020
Update, December 17, 2020
Boris Johnson should of all people have remembered Churchill’s blood, toil, tears and sweat May 13, 1940 speech instead of giving such a confusing message.
Update , December 19, 2020
Boris succumbed to reason, finally!
PM announces 'tier 4' Covid curbs and curtails Christmas mixing in England