1/27 Lots of current focus on interaction between increasing levels of COVID-19 cases and NHS, in the context of relaxing restrictions on 19 July. New thread follows. Key questions to answer: what's the likely impact on NHS, can it cope and what does this mean for 19 July?
2/27 As we said a few weeks ago, vaccines have severely weakened the link between covid-19 infection and hospitalisation / mortality. Or, as we put it, for this set of variants, vaccines have broken link between infections and previously high hospitalisation/mortality rates.
3/27 So, there’s high confidence amongst trust leaders that increasing community infection rates, even to the levels we saw in January, will not translate into the levels of hospitalisation and mortality we saw in that peak. A peak that brought extreme pressure to the NHS. But…
4/27 …There clearly will be higher levels of hospitalisations than we are seeing at the moment. And trust leaders are worried that public commentary is just focussing on potential levels of covid-19 admissions in isolation, not looking at NHS demand & capacity as a whole.
5/27 Vital to look at full NHS demand/capacity picture over next few months to get a sense of what the pressure on NHS will be like. You need to look at total planned, urgent, and covid-19 care demand as well as NHS staff/bed capacity, not just likely covid-19 admission rates!
6/27 So here, in four parts, is what full demand / capacity picture is likely to look like July-September. A. Trusts going full pelt, flat out, to recover care backlogs. Rightly so, given issues involved for patients. This is putting huge pressure on staff, services and beds.
7/27 Very important to remember this isn’t just about elective and cancer backlogs and acute hospital services. There are significant backlogs and huge pressures in community and mental health services too. For example children and young people crisis/eating disorder services.
8/27 B. Trusts reporting worryingly high levels of urgent & emergency care demand, as today's NHS stats should show. Striking how many hospital & ambulance CEOs saying they recorded highest ever levels of daily urgent care demand in June. (Note from me: several A&E broke this week their all time records for admission in 24 hours - in June !!) This also brings huge pressure on trusts.
9/27 It’s worth remembering that, over the last few years before covid-19, we’ve definitely seen a heightened summer effect in urgent & emergency care with trusts reporting “winter like” levels of pressure. Every reason to believe this phenomenon will occur again this summer.
10/27 C. The NHS is currently operating with significant capacity constraints. “Long term lost beds” due to infection control measures. But also “temporary void” beds that can’t be used as covid patient numbers rise. EG 2 covid patients in an 8 bed ward takes out 6 other beds…
11/27 …The number of void beds will, by definition, increase as community infections, and therefore hospitalisation rates, rise. Striking how many smaller hospitals are saying current urgent care pressure and small covid-19 increases now impacting speed of elective recovery.
12/27 D. Real pressure on staffing levels given numbers of staff having to self isolate – widespread concerns over last fortnight here. This will get worse after 19 July as covid infection rates rise. But better post 16 August given isolation policy changes announced recently?...
13/27 ..But, we’re also about to enter peak leave season, with many NHS staff about to take much needed and awaited leave. The impact of summer leave will be bigger than normal given how much leave had to be held over from earlier this year & last year due to covid-19 pressures.
14/27 …CEOs have been clear for weeks that the speed of backlog recovery, which has been incredibly fast over last three months, was going to dip over the summer given the levels of leave that will be taken. Trust leaders adamant staff need their leave given wellbeing concerns.
15/27 So the issue for NHS pressure here is not, as most are implying, the likely absolute level of covid-19 hospital admissions. All the current evidence suggests that, due to the vaccines, the number of covid-19 hospital admissions will be much lower than in previous waves….
16/27 …And that covid-19 patients will, in general, have lower levels of acuity and they will benefit from the new treatments NHS has developed. For example dexamethasone and remdesivir. The issue for NHS pressure is the cumulative impact of all above different elements….
17/27 …It’s the combination of the likely higher level of demand across the totality of urgent, planned and covid care. With the significant impact of reduced bed and staff capacity which higher levels of covid-19 will significantly exacerbate as community infections rise.
18/27 The NHS will come under significant extra pressure. When that happens, acute hospitals would have to dial back speed of elective recovery – the element they can control out of urgent, covid-19 and elective care. So, a clear & important trade off to recognise here.
19/27 Good illustrative anecdote from an acute hospital CEO this week. “The problem is the overall level of demand coming at us from all sides. Add in current staff and bed pressures and just a few extra covid-19 patients means we have to start slowing elective recovery down”.
20/27 But CEOs recognise it’s their job to perform this complicated juggling act as well as possible. They know their trust’s task is to provide the best possible care to all who need it, prioritising on basis of clinical need if prioritisation between patients is needed….
21/27 …Trust CEO community is keen, understandably, for everyone to realise the scale of the challenge their trusts are currently having to manage. It’s not just a simple question of low rates of covid-19 hospitalisations = low levels of NHS pressure and all will be well.
22/27 What does all this mean for July 19 relaxation of rules? Trust leader views broadly as follows. A. Government should continue to monitor evidence between now and 12th to ensure no significant changes on hospitalisation/mortality rates that alter current calculations.
23/27 B. Trust leaders can see the strong logic of “if not now, when” and the need for the nation to learn to live with covid-19. But they want everyone to be clear about the risks being run by relaxing restrictions. We can’t be sure what those risks are or how big they are.
24/27 They include higher hospitalisation and mortality, albeit at much lower levels than previous waves. The risk of new, more dangerous, variants emerging given the width of spread. And the potential impact for those who develop longer term health complications…
25/27 …In the words of one CEO today “We are really worried in our system about the number of unvaccinated young people we are seeing with mild covid-19 disease who are then developing serious long covid type symptoms shortly after. Not just a few, a significant number”
26/27 C. And trust leaders want the explicit trade off set out above to be recognised. Relaxing restrictions will lead to more pressure on the NHS. This will, by definition, mean that something has to give. Most likely, in most places, speed of care backlog recovery.
27/27 Trust leaders obviously have a mission to avoid any unnecessary harm. So they are, instinctively, uneasy about potential harm to any patient. But they also recognise wider issues at stake here. They will do all they can, as they always do, to provide best care to all.