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Views And Reviews Primary Colour

Helen Salisbury: When do we switch to plan B?

BMJ 2021; 375 doi: (Published 26 October 2021) Cite this as: BMJ 2021;375:n2595
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

How long do you continue with a course of action that isn’t working? When patients first have high blood pressure or diabetes diagnosed, many are keen to take the problem into their own hands, to solve it by altering their activity levels or eating habits. I’m always delighted when this happens, and I try to empower them with appropriate resources, while arranging follow-up consultations to discuss their progress.

But problems arise when the numbers keep going the wrong way. If a patient’s blood pressure, weight, and blood sugar are still rising, and their step count declining, we can find that we’ve run out of strategies, apart from medicines that my patient may not want to take. When do we stop, admit that it isn’t working, and switch to plan B?

Covid infections are rising quickly, with over 52 000 daily cases reported in England as I write on 21 October. Although the link between infection and death has been loosened by vaccination, it hasn’t been severed, and more than 100 people are dying each day. My inbox is filling with more and more positive test notifications—many from unvaccinated teenagers and some from their grandparents, whose immunity is waning but who haven’t yet been called for a booster.

The NHS is used to crises, but eight hour waiting times in emergency departments and ambulances queuing around the block are usually a feature of the bleak midwinter, not an unseasonably mild October. The care sector is short staffed, so patients who no longer need hospital care are stranded there, causing a tailback of misery on trolleys in the emergency department, all the way back to those queuing ambulances. Efforts to tackle the huge backlog of urgent elective surgery are stymied by a lack of beds and intensive care facilities, which are occupied by patients with covid. Out in the community, we GPs try to care for increasingly unhappy patients, who are waiting in pain and fear as their outpatient appointments are delayed and operations cancelled once again. Despite all of this we hear from the government that the NHS is not yet facing unsustainable pressure, so it’s not time for plan B. What exactly is the government waiting for?

Doing the same thing over and over and expecting a different result is one definition of insanity. Without a change in strategy, how can we expect things to improve? Vaccination alone won’t get us out of this mess, especially given the very slow rollout to teenagers and the number of people still waiting for boosters. Although it may be unpopular, we need to return to requiring masks in indoor public places, homeworking where possible, and focusing on ventilation or air filtration.

Small steps to protect us now may prevent worse restrictions later in the year. And I, for one, don’t want to wait until we see whatever satisfies this government’s definition of “unsustainable.”