Our new paper published in the Journal of the Royal Society of Medicine discusses excess mortality during the Covid-19 pandemic. The scale of the COVID-19 pandemic has forced policy-makers to operate with limited evidence for the relative success of different control measures. Excess mortality is one key outcome measure. The highest excess mortality per million population is seen in Spain, followed by England and Wales. The majority of these excess deaths are caused by COVID-19, but a significant proportion are not directly related to COVID-19. In measuring the impact of COVID-19, mortality is however only one of many important outcomes. Even in ‘mild’ cases not requiring hospitalisation, symptoms can be long-lasting, and heart and lung complications are common, affecting quality of life and ability to work. Beyond the effects on health, the pandemic has disrupted all aspects of society – many countries have experienced record economic recessions, while school closures affect children’s educational attainment.
The COVID-19 pandemic has had a dramatic effect on people’s lives globally. For academics working in fields such as primary care and public health, the pandemic led to major changes in professional roles as I discuss in an article published in the JRSM. Universities across the United Kingdom closed their campuses in March 2020 and switched to remote working. Staff began to work from home and teaching of students moved online. University staff rapidly had to put in place systems for teaching, monitoring and assessing students remotely. For many universities, these changes will be in place until the end of 2020, with no return to a more normal mode of working until January 2021 at the earliest.
The ‘lockdown’ of the United Kingdom on 23 March had pronounced impacts on travel patterns as we discussed in our recent JRSM paper. As many millions of people moved to either working at home or were furloughed from their jobs, there were large decreases in trips to workplaces alongside even steeper decreases in recreational journeys. Transport is an often overlooked influence on the health of populations and health inequalities, affecting physical activity, road traffic incidents and air pollution, in addition to being a major contributor to climate change. There is ongoing uncertainty around the longer-term trajectory of COVID-19, including risks of a second wave, meaning that the medium-term changes to transport and society are hard to predict. Nevertheless, the current easing of the lockdown in England presents both opportunities and threats to the health impacts of transport.
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.