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Covid-19: Three tier alert system takes effect across England

BMJ 2020; 371 doi: (Published 13 October 2020) Cite this as: BMJ 2020;371:m3961

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  1. Gareth Iacobucci
  1. The BMJ

Liverpool and neighbouring local authorities will become the first area of England to have new restrictions imposed under the new three tiered risk system designed to stem rising covid-19 infections across England, the government has announced.

Liverpool itself had 609 cases per 100 000 population on 13 October, a 14.3% rise over the previous week. Neighbouring Knowsley, included in the measures that apply to the Liverpool City Region, which also includes Halton, Sefton, St Helens, and Wirral, had 669.5 cases per 100 000. Liverpool has the steepest increase in covid-19 admissions to hospital in England, and the highest number, with more than 250 patients in beds at Liverpool University Hospitals NHS Foundation Trust, around 15% of bed capacity.

In a memo seen by the Health Service Journal, Steve Warburton, chief executive of the trust, said that it was scaling back non-urgent operations to help cope with the surge.1 “We recognise that this will be distressing for patients whose elective care needs to be rescheduled. However, we must always ensure that the care we provide is safe,” he said.

In a speech to the House of Commons on 12 October the prime minister set out plans for a new “simplified” three tier system that will grade every area of England as medium, high, or very high alert, according to level of risk.2

The announcement came after warnings that the NHS faced being overwhelmed without fresh measures to reverse the increases in covid cases and hospital admissions.3 But experts disagree over the best way to control the pandemic, with advisers to the government recommending in September that a national lockdown or “circuit breaker” was needed.4

Boris Johnson said that with more people in hospital with covid-19 than when the country went into full lockdown on 23 March, restricting transmission was vital to saving lives. As at 12 October England had 3665 patients in hospital with covid-19, whereas on 23 March the number was 3097.

Initially, only the Liverpool City Region will be placed into the very high alert category, which Johnson said would apply to areas where transmission rates were rising most rapidly and where the NHS “could soon be under unbearable pressure without further restrictions.”

From 14 October pubs, bars, gyms and leisure facilities, betting shops, and casinos in the region must close, and social mixing between households will be prohibited indoors and in private gardens. All retail outlets, schools, and universities will remain open.

Other areas that are already subject to local restrictions in addition to the national rules, including Greater Manchester and Newcastle, will automatically move into the tier 2 “high alert” category, which prohibits mixing between different households indoors and applies the “rule of six” (no meetings of more than six people) outdoors. Nottinghamshire, east and west Cheshire, and a small area of the High Peak district will also move into tier 2 after seeing rises in cases.

But Johnson suggested that more areas could move into tier 3 soon and said the government was continuing discussions with other leaders in the North West, the North East, and the Yorkshire and Humber regions, where infection rates were highest.

“I know how difficult this is. They, like us, like everyone in this House, are grappling with very real dilemmas, but we cannot let the NHS fall over when lives are at stake,” he said. “I believe not to act would be unforgivable, so I hope that rapid progress can be made in the coming days.”

The remaining areas of the country that have lower infection rates will be placed into the medium risk tier 1 category, where current national measures such as the rule of six and 10 pm closing for pubs will remain in place.

Johnson told the House of Commons, “This is not how we want to live our lives, but this is the narrow path we have to tread between the social and economic trauma of a full lockdown and the massive human, and indeed, economic cost of an uncontained epidemic.”

The government also announced that regular testing would be introduced for all NHS staff in high risk areas, whether or not they are displaying symptoms.

Andrew Goddard, president of the Royal College of Physicians, welcomed the announcement. He said, “From the figures released this morning by the deputy chief medical officer, and from what our members have been telling us, we know for certain that we are now in the second wave of covid-19. It is currently centred in the North West and North East of England, but it is going to spread to other areas.”

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