According to the latest figures available on 5 May, hospital admissions with Covid-19 are now under 1,000 per day, down 70 per cent from their peak in early April. This is the best statistic we have with which to judge our progress against the pandemic. The daily total of confirmed new cases – still hovering around the 4,000 mark – is unhelpful: increased testing is simply confirming numerous mild or moderate cases that were previously going uncounted. But the numbers of patients requiring hospital care can reasonably be assumed to represent a fixed proportion of total infections – perhaps around 5 per cent. The smaller the number of admissions, the fewer the cases in the community.
This is palpable at my surgery. A few weeks ago I was being consulted by multiple Covid-19 patients every day; now a whole day might go by without my being contacted by anyone with symptoms. And the usual stuff of general practice is creeping back: acutely inflamed joints, possible epilepsy, refractory heart failure, suspected cancer. And mental health. Lots of mental health.
The important thing to note, though, is that it has taken six weeks of hard lockdown to suppress transmission this far. Boris Johnson’s address to the nation on 10 May was undoubtedly confused, and it appears that the devolved nations are taking divergent paths, but one message seems clear: in England, at least, restrictions are easing. We’re not going to drive infection rates much lower: we’re going to try gradually to find the maximum return to normal life compatible with preventing another surge.
The challenge for the health service is how to move forward. In the space of a few exhausting weeks in late March and early April the entire system was reconfigured as an urgent- and emergency-only service. Now that the peak is behind us, and the aim is to live with endemic (as opposed to epidemic) Covid-19, a further reconfiguration is required. We’re going to have to find ways of safely caring for patients with every other health condition, while assessing and treating the Covid-19 cases that will continue to present for the foreseeable future.
The key concept is going to be “hot” and “cold” work streams. To continue to suppress viral transmission, those with potential Covid-19 symptoms will need to be treated in separate facilities. Primary care has addressed this by triaging everyone on the phone first, and diverting anyone with viral symptoms to “hot hubs” for further assessment. At a minimum, this approach is going to need to continue well into 2021. Hospitals face huge challenges segregating wards into Covid-19 and non-Covid-19 zones. During the peak, private hospitals have been co-opted to act as “cold” sites for much urgent work, such as cancer care. This may need to continue for a considerable time, too.
Even within a “cold” clinical environment, some asymptomatic people may be spreading the virus. To mitigate this risk, all patients coming into surgery are given masks and required to hand sanitise. Clinicians are using PPE and appointments are being spaced out to ensure a near-empty waiting room. In this way, we have been able to continue essential cold work such as childhood immunisations and certain high-risk disease and drug monitoring throughout the first wave. But the more routine work we bring back, the more difficult it will be to sustain these precautions. We are identifying our least well-controlled diabetics, respiratory patients and those with high blood pressure in order to prioritise their reviews.We will do as much as possible by phone, but many of these patients require face-to-face contact. And as they constitute some of the most vulnerable to Covid-19, it is imperative we keep the surgery “cold”.
The reality is that much low-risk work is going to have to be shelved for the time being. This may, in fact, be a positive development. Many doctors have become increasingly sceptical about the direction in which government has been pushing the profession over the past two decades. Non-evidence-based “health checks” and a target-driven culture have led us to medicalise ever more healthy people as “at risk” of conditions such as heart disease, and to “treat” their risk with drugs, which themselves require ongoing blood tests and monitoring. Jettisoning all such activity – potentially alongside public health gains won by a lockdown-inspired enthusiasm for exercise, home cooking and a less frenetic pace of life – may be an extremely valuable reset.
So, too, in secondary care. Remember the endless headlines about burgeoning demand on A&E departments? Attendances have halved during the peak. There may be some people in need of hospital care who stayed away for fear of contracting coronavirus, or through concern about burdening the NHS. These sorts of patients we want to come back. But the others who really didn’t need an emergency department for their minor problems? If they have discovered more self-reliance, or alternative sources of care, then that is all to the good.
At present, patients presenting with viral symptoms are highly likely to have Covid-19, so can be channelled into hot areas irrespective of testing. Fast forward to the autumn and winter, and the annual resurgence of other viral infections is going to pose an enormous challenge. Reliably distinguishing the Covid-19 “signal” from the rest of the viral “noise” is going to become impossible – particularly for patients with mild symptoms. Even if we have widespread rapid testing by then, the false negative rate – estimated to be around 30 per cent with current methodology – makes it an unreliable tool. The NHS is going to have to configure hot and cold services in a way that will allow a rapid expansion of hot capacity to cope with the next winter’s viral season. Otherwise the health service itself may become a major factor in driving a second wave.
This article appears in the 13 May 2020 issue of the New Statesman, Land of confusion