Covid-19 update: 4 December

04 December 2020 Steve Brown

Introducing the motion in the House of Commons setting out the tiering proposals, prime minister Boris Johnson said that lockdown had eased the burden on the NHS and begun to reverse the advance of the virus. The reproduction or R rate was back below 1 and figures from the Office for National Statistics showed the infection rate was levelling off. HFMA Covid-19

But while the virus has been contained, it has not been eradicated. Latest ONS figures suggest one in 85 people in England had the virus and more than 3,000 people died from Covid-19 in the last week of November.

‘Despite the immense progress of the last four weeks, our NHS remains under pressure, with hospitals in three regions – the south-west, the north-east and Yorkshire – all treating more Covid patients now than at the peak of the first wave,’ he said.

However, a number of MPs objected to the crudeness of the tiering system, suggesting a more granular approach to tiering would enable more of the economy to operate more normally. And they quemerriman Pstioned whether the NHS faced the same pressures across the whole country.

For example, Huw Merriman, Conservative MP for Bexhill and Battle, focused on the NHS in his reasons for voting against the proposals. He argued that Covid rates in East Sussex had been relatively low all year and increases in November were now falling again. ‘Today’s figures for the local NHS show that we have 37 Covid inpatients across our hospitals in East Sussex, and pressure on county NHS beds is reported to be the same as this time last year,’ he said. ‘We are seeing fewer general admissions and fewer elective surgery admissions.’

The local NHS had ‘coped fantastically’ earlier in the year and had learned lessons allowing it to manage cases more effectively. ‘I do not doubt that the situation for those working in hospitals is very challenging … but I do believe the evidence shows they are currently able to cope,’ Mr Merriman (pictured) said.

Occupancy explained

Ahead of the debate, NHS Providers produced a briefing addressing questions that had been raised in media reports about current pressures on the NHS. It explained that, while current bed occupancy rates of around 85% looked as though the NHS was under less pressure than in previous winters, complexities caused by Covid meant that the NHS had fewer beds open than previously. ‘The reality on the ground is much closer to the 95% bed occupancy levels seen in the peak of winter,’ the briefing said.

Some reports have also pointed at available capacity in intensive care units and minimal use of Nightingale hospitals as evidence of the NHS not being overwhelmed. But in a parallel tweet to the briefing, NHS Providers chief executive Chris Hopson warned that ICU capacity on its own was not a good indicator of hospital pressures.

‘ICU beds account for a small proportion of a hospital’s total bed base,’ he said. ‘And many more Covid patients are now being treated on general wards without mechanical ventilators.’ He also pointed to ‘widespread misunderstanding’ about Nightingales. They were always intended as a last resort insurance policy, they are not purpose-built hospitals and they are only staffed by taking staff from existing hospitals. ‘The NHS would always want to use existing hospital capacity first,’ he added.

In summary, Mr Hopson said that hospitals were desperate not to reduce planned care and hospitals were at full stretch – a third Covid surge in January that coincided with normal winter demand would leave the service struggling to cope. And while vaccines and mass testing offered genuine hope of a way out, the sensible way forward was to ‘err on the side of caution’ in setting restrictions on social contact.

England’s tougher tiering system was backed by the Commons – despite 55 Conservative MPs voting against the plan. Meanwhile in Scotland, no changes were made to its four level-system, although first minister Nicola Sturgeon said 11 areas would remain at level four – subject to the highest restrictions until 11 December. Scotland’s R number is also estimated to be below 1.

Wales is introducing new measures on Friday 4 December, after Covid cases accelerated following the end of the recent firebreak period. Pubs and cafes will close by 6pm and not be allowed to serve alcohol. Revised restrictions came into force in Northern Ireland last week (27 November) closing hospitality and all non-essential retail.

Vaccine approval

The government continues to stress that restrictions are necessary until vaccines can be made widely available. But this week it took a huge stride towards this as it accepted the recommendation from the Medicines and Healthcare products Regulatory Agency to approve the Pfizer/BioNTech vaccine for use. The vaccine is given in two doses, three weeks apart, and offers up to 95% protection against Covid, according to published test data. The government said it would be available across the UK from next week.

The Joint Committee on Vaccination and Immunisation responded to the news by setting out its advice on priority groups for vaccination. It said at the vaccine programme should initially focus on preventing harm rather than cutting transmission, with prioritisation based mainly on age. Residents in care homes and their carers would be first in the queue, followed by those over 80 and frontline health and social care workers. After this would come those aged 75 or over, then 70, then 65. After this, individuals aged 16 to 64 with an underlying health condition would be vaccinated before moving the general age threshold down to 60, 55 and 50.

It is estimated that taken together, these groups represent around 99% of preventable mortality from Covid-19. Beyond this first phase, the key focus of vaccination is likely to be on further preventing hospitalisation and could be targeted on key occupations.

As the initial excitement over the vaccine’s approval died down, the logistics involved with what will be a phased, mass vaccination programme quickly became the focus of attention. With just 800,000 vaccines initially available – or 400,000 double doses – this clearly falls far short of all the vulnerable population in care homes, over-80s and care staff. Mr Johnson acknowledged that it would ‘inevitably take some months before all the most vulnerable are protected’ and the country needed to stick to the existing winter plan.simon.stevens P

NHS England chief executive Simon Stevens (pictured) explained that the vaccine, which needs to be transported at minus 70 degrees Celsius, comes in packs of 975 doses and can’t just be distributed to pharmacies and GP surgeries as with other vaccines.

Next week 50 hospital hubs will start offering the vaccine to over 80s and care home staff and others – some will be those already going to hospital for a prearranged appointment. This will be followed in subsequent weeks with GP practices coming together in local vaccination centres, growing to over 1,000 centres across England. ‘We’ve had an excellent response from GPs across the NHS wanting to participate in this programme and as more of the vaccine becomes available, we’ll be able to turn on more of those GP-led clinics,’ Sir Simon said.

A letter to GP practices and clinical commissioning groups from NHS England and NHS Improvement has set out the next steps in the vaccination programme. An enhanced service specification has been agreed with the British Medical Association setting out how practices will be paid for administering the vaccine.

Designated primary care network vaccination sites are expected to be able to deliver around 1,000 vaccinations per week. These sites could be expanded to individual practices as vaccine supplies increase.

Deliveries direct to care homes are expected once the MHRA has approved a safe way for splitting the large packs. Then with even more vaccine available, large vaccination centres will be switched on and local community pharmacists, possibly as early as January, will be invited to begin to offer vaccination as well.

In the meantime, social restrictions and testing will remain important in ensuring the virus stays under control. There were some signs of improvement in the NHS Test and Trace statistics reported this week, but further progress is needed particularly in the run up to Christmas.

In the week to 25 November, nearly 111,000 people tested positive for coronavirus, a 28% decrease on the previous week, and 116,000 people were transferred to the contact tracing system. 99,000 of these were reached (85%) and 78,000 of them provided details of 247,000 close contacts. Some 73% of these close contacts were reached and asked to self-isolate. This is a significant improvement on previous weeks, although it also reflects a change in how household contacts under 18 are reached. They are no longer contact traced individually. Instead the parent or guardian confirms that they will inform the child of the need to self-isolate.

Just over 54% of the results for in-person tests undertaken in the community were delivered within 24 hours, a small increase on the previous week. Looking at all test routes, the 24-hour target was hit in 26% of cases – also a small improvement.Saffron Cordery

NHS Providers deputy chief executive Saffron Cordery (pictured) said there were some encouraging signs with the reduction in positive cases. ‘This has resulted in lower numbers transferred into the Test and Trace system this week, and with over 100,000 fewer close contacts to trace, the proportion of these able to be reached and told to self-isolate improved considerably. However, 68,000 people were not reached by the system, and this must be addressed rapidly.’

And on testing turnaround times, she said that despite marginal improvements ‘we are still far from a perfect system with some key routes remaining much too slow’.

Tracing failure

Testing and contact tracing has also been a key focus for the All-Party Parliamentary Group on Coronavirus (APPG). The group – not an official House of Commons group – was set up in July to conduct a rapid inquiry into the government’s handling of the pandemic. In its interim report this week, it said that the Test and Trace system in England had failed, with the government prioritising arbitrary testing targets over a co-ordinated strategy.

‘It has consistently failed to meet the required target of 80% of contacts traced to be effective,’ the report said, adding that chains of transmission were not being broken.

The cross-party MPs called for local authorities to be empowered to deliver a find, test, trace, isolate and support system, backed up with proper financial support and assistance for those isolating. Testing turnaround times also had to improve and meet the international standard of 24 hours. Public health laboratory capacity should be increased to help deal with the current crisis and any future pandemics.

Returning to where the week started – and concerns over the NHS – the group called on the government to commit to at least repeating the emergency uplift in funding due to Covid-19 for 2021/22. Total health spending should then increase by at least 4.1% per year in real terms going forward.

A UK-wide plan to improve recruitment, retention and support of NHS staff was also needed, along with a system of risk assessment for all frontline staff, including those from black, Asian and minority ethnic backgrounds to ensure they could work in ways to minimise risk to themselves and patients.

Next week will start to reveal whether the revised tiers in England and restrictions across the UK are managing to contain the virus spread. The focus remains on ensuring the NHS is not overwhelmed. But with the vaccination programme due to get underway, there is real hope that if the country can make one last effort with social distancing, normal life may start to return in the spring.