Whether we will come of the 4-week lockdown on schedule will depend on how low the government’s Covid-19 strategy brings the R-value for the country. The R value is the average number of people that each new case of Covid-19 infects. If the R value for England is less than one, the daily number of cases will start to fall; and if the R value is greater than one, the daily number of cases will continue to increase. Once the R value is below one, and the daily number of cases start to fall, the number of people being admitted to hospital and the number of deaths will also start to fall.
There is though a lag before the number of hospital admissions and deaths begin to fall. This is because it can take 1-2 weeks from becoming infected before a person is unwell enough to need hospital treatment. There is then as further period of time before death. Hence, case numbers start to fall first, followed by the number of people admitted to hospital and then finally, the number of people dying from Covid=19.
The “nightmare scenario” that we will face is that the new lockdown measures are not strict enough or people do not comply with them, meaning that the R value stays above one and the numbers of cases, hospital admissions and deaths do not fall. This will mean continuing restrictions after the 4-week lockdown period ends. Even if the number of Covid-19 cases does fall to a more manageable level by the end of the lockdown, there will still be ongoing restrictions on social activities, resulting in Christmas 2020 being very different from a normal Christmas.
It’s also possible that we will see future waves of Covid-19 infection after lockdown measures are relaxed – as we saw earlier in the year – meaning that we may get further lockdowns followed by periods of relaxation of lockdown measures. Unfortunately, ever since the start of the pandemic, England’s Test and Trace system has not worked well enough to suppress local outbreaks promptly and keep the number of cases low – as we have seen in countries such as New Zealand, Taiwan and South Korea.
Hence, this cycle of lockdowns and restrictions of activities, followed by some loosening of these restrictions, may not end until we have a safe and effective vaccine that can finally bring Covid-19 under control in England and across the rest of the world. The encouraging news is that the early results about the safety and effectiveness of the new vaccines being developed for Covid-19 are very positive; and we may be able to launch a large-scale vaccine programme in the United Kingdom very soon. This vaccine programme is going to be complex and challenging to deliver but the NHS does have the expertise to do this.
In a recent article
, I discuss the primary care response to Covid-19 in England. The first case of COVID-19 in England was identified at the end of January 2020. Cases increased during February, and by early March, it became apparent that England faced a large COVID-19 epidemic. This led to the Department of Health and Social Care and NHS England (the bodies that respectively fund and manage the NHS in England) to recommend radical changes to the provision of NHS primary care services.
For most general practices, these changes began to be implemented in the week beginning 16 March 2020. As a first step, general practices switched from the traditional model of face-to-face service provision to one where all patients were initially assessed through a telephone or a video call. Patients were encouraged to register for online booking of these appointments if they had not already done this.
All patients requesting advice spoke first to a health professional, usually general practitioners. The aim was to deal with as many queries as possible by telephone or a video call. Patients who required a face-to-face appointment were booked to be seen in later that day. This ensured that patients were largely managed on the same day they sought medical advice. These changes have resulted in around three-quarters of patients being managed remotely compared to the same time last year when only one-quarter were, with the total volume of primary care activity falling by about 25%.
We have seen rapid changes in primary care in England, but challenges remain, particularly if the number of people with COVID-19 infection increases rapidly and starts to overwhelm the health system, or if second and subsequent waves of infection occur. Other challenges include providing medical care for people who are self-isolating at home because of their age or because of underlying medical problems that increase their risk of complications and death if they contract a COVID-19 infection. There are also problems that will arise from the cutting back of many specialist hospital services, which will have negative effects on health outcomes if restrictions in health services remain in place for a prolonged period.
Overall, primary care in England has responded well to the COVID-19 pandemic, making radical changes to how primary care services are delivered in a very short period of time. Key to allowing this to happen is the commitment by the UK government to support general practices financially to prevent the loss of income that has occurred to primary care practices in countries such as the USA. However, the future will remain challenging for primary care teams in England until such time as a vaccine or effective drug treatment can be found for COVID-19.
My article in the Journal of the Royal Society of Medicine discusses the wider impact of COVID-19 on health systems and the potential for changes to health services to increase health inequalities. We report a 44% decrease in emergency department attendances in England in March 2020. We must not overlook the importance of good infection control for outsourced NHS staff such as cleaners, security guards and caterers. They can acquire COVID-19, thereby putting themselves at risk, and transmit COVID-19 to patients and other NHS staff.
My editorial in the British Journal of General Practice discusses how we can protect healthcare workers during the Covid-19 pandemic. Some of the key steps we can take include:
1. Maximise remote working
2. Implement good infection control
3. Use PPE effectively.
4. Risk assessment for staff based on age and medical history
Too many health and care workers have died and we must take urgent action to protect them. When we protect staff, we also protect patients because we reduce the risk of hospital acquired infection.
National and global spread of COVID-19 is accelerating. To reduce COVID-19-related hospitalisations, intensive care unit admissions and deaths, we recommend that those aged between 60 and 69 years are particularly stringent when implementing public health measures such as social distancing and personal hygiene. In the absence of government guidance, people in this group can make their own informed decisions on how to minimise their risks of COVID-19 infection. This can include using precautionary measures to reduce the risk of infection in a similar manner to that recommended by the UK government for people aged 70 years and over.
Read the article in the Journal of the Royal Society of Medicine.
We have seen varying estimates of the case fatality rate from Covid-19 (Coronavirus) infection. The case fatality rate is the percentage (or proportion) of patients with a disease who die. We should be cautious about accepting the estimates that have been published in medical journals as valid because many people will have undiagnosed infections. This is particularly likely in children, who often have mild symptoms (or no symptoms) when they contract a viral infection. Hence, the reported case fatality rates we have seen published in medical journals will overestimate the true death rate. As testing for Covd-19 infection becomes more widespread, we will get better estimates of the true infection rate in the population from the virus, and hence better estimates of the complication rate and death rate from the illness. In England, the new testing programme in people with respiratory tract infections announced by Public Health England will provide some of ths information.