Intended for healthcare professionals


Covid-19: England tightens restrictions as NHS struggles to deliver care

BMJ 2020; 371 doi: (Published 31 December 2020) Cite this as: BMJ 2020;371:m4972

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  1. Zosia Kmietowicz
  1. The BMJ

Most of England moved into the highest tier of restrictions on 31 December because of an escalation in cases, hospital admissions, and deaths from covid-19, a measure that the health and social care secretary described as “absolutely necessary” as the new variant of the virus spread across the country.

Matt Hancock announced on 30 December that the Midlands, North East, and parts of the North West and South West were among the areas to come under tier 4 restrictions, with almost all remaining areas, including Liverpool, escalated to tier 3.

Planned reopening of schools was also delayed by at least two weeks for most secondary schools pupils, while some primary schools in the hardest hit areas would take in only vulnerable children and those of key workers, while providing online teaching to all others, said the government.

Universities were asked to reduce the number of students who return in January and to prioritise those who need practical learning, such as medical students.

The new restrictions were announced as figures showed that 981 covid related deaths were recorded in the UK on 30 December, one of the highest daily totals since April. In the previous 24 hours 50 023 new cases of the disease were recorded and 2430 people were admitted to hospital.

There were also reports of ambulances queuing outside hospitals as wards reached capacity, of patients being transferred across the country for intensive care beds,1 and a London hospital declaring a major incident because of a shortage of oxygen.

Chaand Nagpaul, the BMA’s chair of council, commented, “The simple fact is that if we continue at this trajectory the health service will struggle to get patients in urgent need of care the care they need. We must all be able to depend on the NHS. The message now and in the coming weeks ahead must be one of utmost caution and safety, as many lives will depend upon it.”

Earlier the same day members of the Independent Scientific Advisory Group for Emergencies called for a national lockdown in England to match restrictions in the rest of the UK, for schools to remain closed throughout January to allow time for them to be made safe, and for universities to teach courses online until Easter.2

Christina Pagel, professor of operational research at University College London and a member of Independent SAGE, said that the NHS had not yet seen the effects of household mixing over Christmas. “Things are as bad as they have ever been. The frightening thing is that they are going to continue to get worse. Action is needed now to avoid the collapse of the NHS in a few weeks. It is that serious,” she said.

The group called for the government to assemble a taskforce, including teaching unions, local authorities, governing bodies, and parents, to implement this plan.

It also said that a fully operating find, test, trace, isolate, and support system needed to be put in place, through local public health services and the army, and be appropriately funded. And although there had been a good start to rolling out vaccination, this must speed up to ensure coverage of priority groups by Easter 2021, it said. In a statement the group said, “Necessary primary-care-led upscale requires new resources and staffing now. Appropriate support and messaging to all communities is required to ensure sufficient uptake to establish population immunity, and minimise death, disease and long-term physical and mental ill-health.”

Finally the group called for a rapid rollout of the vaccine to low and middle income countries, along with an effective covid control strategy at the UK’s borders.

What success looks like, according to Independent SAGE

On 30 December members of Independent SAGE outlined what could be learnt from countries that have successfully controlled covid-19:

  • Mobilise communities—Anthony Costello, professor of global health and sustainable development at University College London, said that the 750 000 members of the public who in April had volunteered to help out in the pandemic (along with doctors who had come out of retirement) had been frustrated not to be called on. “All successful countries have mobilised communities, and they don’t necessarily bring in the army. Devolving power to local communities and having a system whereby volunteers and retired staff can help out as well as the system of moving clinicians around the country from low intensity to high intensity areas is a fundamental part of any pandemic response,” he said. “China brought 9000 health workers into Wuhan within two weeks in order to get things under control for 10 million people. We only ever had 270 to contact trace for 55 million people in England.”

  • Test, trace, and isolate—This is more important than ever and an essential part of an exit strategy out of lockdown, said Independent SAGE. Even with two vaccines now available in the UK, it is not known whether they will be effective against the new variant of the virus. Deenan Pillay, professor of virology at University College London, said that many hundreds of variants of SARS-CoV-2 were now circulating. Some of the mutations sit in the bit of the virus that is also targeted by vaccines and are known to compromise other immune therapies, such as monoclonal antibodies and convalescent plasma. He said, “One big concern is that we will see continuing evolution of this virus—more and more variants that build on the one that is highly transmissible—and that will happen with ongoing transmission and replication. In order to maximise the effectiveness of the vaccines coming through we need to really lock down and reduce all chances of transmission.”

  • Support people who need to isolate—Costello said that during the mass testing programme in Liverpool only 4% of people from the poorest areas were getting tested because they had seen that 80% of applicants were turned down for financial support. “We have spent more than £22bn on a test and trace system, yet the fundamental thing that all successful countries have shown is to give proper clinical and financial support to those people who are asked to isolate,” he said. “They are followed up; they have their bills and salaries paid and so on. We haven’t done that. We have offered £500 for two weeks, which is well below the minimum wage. There seems to be masses of money for everything else, but when you want to help poor families to obey the rules they are not being helped to isolate. If they have to choose between feeding their children and isolating, you know which they will choose.”

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