Covid-19 update: 30 October

NHS leaders came together at the beginning of the week to reject a story in The Sunday Times (subscription required) claiming the NHS had denied many elderly people treatment in hospitals or intensive care units during the first phase of Covid-19.

The report claimed a centrally-commissioned triage tool was used by some hospitals, which gave patients scores for age, frailty and illness to inform the use of ventilation. However there was an immediate response from NHS England, which said the newspaper’s claims were ‘demonstrably wrong’.

NHS national medical director Stephen Powis said the ‘untrue claims’ would be deeply offensive to NHS doctors, nurses, therapists and paramedics, who had cared for more than 110,000 severely ill hospitalised Covid-19 patients during the first wave. Early work on a triage tool was commissioned, with hospitals in northern Italy and Spain being overwhelmed and modelling suggesting two million people in the UK could require hospital treatment. But it was not completed or issued as it became clear the number of patients would be kept within NHS capacity.

Katherine Henderson, president of the Royal College of Emergency Medicine said the pandemic had demanded some practical changes to the way patients were treated. ‘We had to learn at pace about how to manage a completely new illness,’ [but] we did not need to change the critical clinical decisions about the emergency care we offered,’ she added.

And Chris Hopson (pictured), NHS Providers chief executive, pointed out that critical care capacity did not run out at any point and had remained available to everybody who would benefit from it. ‘The key is the concept of “benefit from it”,’ he said in a tweet thread. Not everyone was best treated in a critical care unit. Oxygen on a general ward was the ‘best therapy for most Covid-19 patients in hospitals’ and, ‘sadly for some patients, ward or home-based palliative care was the best available clinical option for their needs’.

Virus growth

Fears of the NHS being overwhelmed by a second wave of the virus are now growing. The latest report from the Real-time Assessment of Community Transmission (React-1) programme, which is monitoring spread of the virus across England, estimates that there are now 96,000 new infections each day. The programme, led by Imperial College London and Ipsos Mori, is testing more than 150,000 randomly selected people each month over a two-week period, with the latest data covering the two weeks up to 25 October.

It says that an estimated 128 people per 10,000 had the virus compared with 60 as of 5 October. At national level, infections were found to be doubling every nine days, compared to every 29 days previously. This corresponds to an overall reproduction rate (R) of 1.6. An R above 1 means the epidemic is growing.

Latest figures show that 23,065 people actually tested positive for the virus on Wednesday (reported on Thursday) across the UK – a more than three-fold increase since the beginning of the month. Cumulative cases have more than doubled over this period – although analysis of cumulative cases needs to take account of the low levels of testing that were being undertaken in the early days and rapid increases in testing recently.

The most recent figures for UK hospital admissions, listed on the government’s Covid-19 dashboard, show that 1,404 people were admitted across the four nations on Sunday. England’s hospitals alone admitted 1,186, bringing the total number of Covid patients in hospital beds to 7,225 (and 8,535 by Wednesday).

While the 10,308 Covid patients in hospital across the UK is half the level of the April peak, there are growing concerns about NHS capacity – especially in hotspot areas. Between them, the North West region (335) and North East and Yorkshire (320) accounted for more than a half of England’s total admissions on Sunday.

Capacity was already likely to be an issue this winter with estimates suggesting infection control measures have reduced hospital capacity by up to 30%.

Stopping electives

Trusts have been working hard to increase levels of non-Covid activity compared with the first wave. However, some trusts are now being forced to pause elective activity again.

The Leeds Teaching Hospitals NHS Trust announced this week that it would be standing down some planned operations, with only essential operations going ahead in most cases. Elective inpatient orthopaedics have been stopped altogether at its Chapel Allerton site, with a rolling programme of theatre closures helping to increase critical care capacity. Airedale NHS Foundation Trust also announced a two-week postponement for any elective surgery requiring an overnight stay.

The news comes as Nottinghamshire prepared to move into tier 3 restrictions on Friday morning with West Yorkshire due to join it on Monday. The government is under increasing pressure from some quarters to impose a national lockdown, with concerns that regional restrictions are not slowing the spread of the virus enough. Both France and Germany have now announced some form of national lockdown starting from Friday and Monday respectively.

Miriam Deakin (pictured), director of policy and strategy at NHS Providers, did not back a specific approach, but said that leaders needed to be decisive. ‘Given the rising rates of infection and growing pressures on bed occupancy, we would urge the government to take a cautious and pre-emptive approach which means being tougher and quicker in its response,’ she said. ‘We don’t have enough information to say whether it’s time to move to a national lockdown, and we completely recognise the gravity and impact of such a decision.

‘However, to ensure the NHS is able to maintain high quality care for patients, Covid and non-Covid, politicians must be ready to make tough decisions early rather than late.’

In-hospital transmission

Over the summer, concerns were raised about how many Covid infections were happening in hospital settings. Data presented by government scientific advisory body Sage showed that around 20% of patients were reporting symptoms seven days after admission. The Healthcare Safety Investigation Branch this week published a report exploring the factors that could contribute to the risk in-hospital or nosocomial transmission.

Covid-19 transmission in hospitals made eight recommendations, including increasing capacity for testing NHS patients and staff (pillar 1 testing). It called on the Department of Health and Social Care and its partners to give NHS trusts access to rapid testing as soon as supplies were available. A transparent process to coordinate the development, dissemination and implementation of national guidance should also be produced.

Meanwhile a new report from Labour called for urgent action to protect black, Asian and minority ethnic (BAME) people from a second spike of Covid-19 over winter. The report said that not only are BAME people dying at a disproportionate rate, they are also over-exposed to the virus and more likely to suffer the economic consequences.

BAME people are more likely to work in frontline or shutdown sectors, which have been overexposed to Covid-19 and more likely to have comorbidities that increase the risk of serious illness.

The report called for the government to set out a plan for tackling these issues and to suspend the ‘no recourse to public funds’ rule, which prevents migrants accessing state assistance. Access to personal protective equipment also needed to be improved in all high-risk workplaces.

One of the arguments for a national lockdown is to give the NHS Test and Trace system some breathing space to improve performance. Last week chief scientific officer Patrick Vallance stated that it was more difficult for the service to have an impact when the numbers of cases were high.

Some argue that a lockdown would take the pressure off the service, which has been hit by fast rising numbers of positive-testing people. It would also give more time for additional testing capacity to come on stream and make the service better prepared to support virus control once a national lockdown had ended.

Tracing challenges

This week’s report on NHS Test and Trace underlines the pressure the service is under with the 126,000 people testing positive for Covid-19 representing a 23% increase on the previous week. Just over 120,000 people were transferred to the contact tracing service in the week to 21 October, and 81% of these were reached – meaning more than 20,000 weren’t contacted.

From those that were reached, 285,000 close contacts were identified, and of these just 60% were reached and asked to self-isolate. Turnaround times for in-person testing in the community improved, but only 23% of test results were received within 24 hours, albeit an improvement on the 14% from the previous week.

Interim executive chair of the National Institute for Health Protection Dido Harding (pictured) said that as the number of cases rises, the service is processing more tests and reaching more people than ever before. ‘We are expanding the reach of our service and improving performance in key areas such as turnaround times for tests as we continue to increase capacity,’ she said. ‘But we recognise there is more to be done. We are working hard to meet these increased demands whilst improving the service we offer to the public.’

Dr Layla McCay, director at the NHS Confederation, said the figures reflected an ‘extremely precarious position’ and that ‘immediate strengthening of the test and trace regime’ was needed

‘Capacity within the NHS is already stretched, and numbers of patients being admitted with Covid-19 are rising,’ she said. ‘If the current trajectory continues, this situation will become worse, particularly as we concurrently start to experience the usual winter pressures. Furthermore, if staff and hospital spaces need to be redeployed to meet Covid-19 demand, it will become harder to restore and maintain routine services.’

NHS Providers Ms Deakin acknowledged that the number of people tested has risen, turnaround times are slightly better, and more people are being transferred to the contact tracing system. ‘But far too few contacts of those carrying the virus are ever reached, which has hampered the system’s effectiveness from the outset,’ she said. ‘And as infections rise the challenges become even greater.’

However, testing capacity does appear to be on course for the government’s target of 500,000 daily tests by the end of October. Figures reported on Wednesday, suggested capacity now stood at 468,000, although just 309,000 tests had been processed. The big capacity increase in recent days has been in pillar 1 testing, which is testing in Public Health England laboratories and NHS hospitals. On Wednesday pillar 1 capacity was reported as nearly 162,000 tests almost double the capacity being reported at the weekend. However, the number of processed tests was just under 82,000, the same as the middle of last week.

Keeping track

One thing the pandemic has generated is a huge amount of statistical data and policy initiatives. It can be hard to keep track, but this week, the job of keeping up to date became a little easier. A new initiative from The Health Foundation has pulled all the government’s and health system responses to the Covid-19 pandemic into a new policy tracker.

The tracker is organised in quarters of the year and covers measures to limit the virus spread, health and social care responses, research and development, broader policy issues and policy narratives.  The full tracker can be downloaded split by these five areas and includes details of the measures/ announcements and web links.

It is not the first such endeavour. The HFMA has been producing a regularly updated Covid-19 guidance map since early on in the pandemic. This provides a more focused summary of key guidance for finance managers and non-executives. It is spilt into six sections: financial arrangements; financial governance; annual accounts and annual report; fraud prevention; workforce; and ways to keep up to date.

However, it is arguably the Office for National Statistics that has provided the biggest amount of weekly statistics on the prevalence and impact of the virus throughout the pandemic. And this week it pulled its work to date together into a thematic overview covering the period March to October. All its key statistical outputs including levels of infection, deaths, impact on mental health and labour market impacts are included.

With recognition that the UK faces a long tough winter ahead, these statistical sources and signposting services look set to remain important for a long while yet.