How bad is the UK’s covid situation?BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2597 (Published 27 October 2021) Cite this as: BMJ 2021;375:n2597
The UK seems to be in an invidious position in the pandemic: on 24 October there were 46 358 new cases and 136 deaths within 28 days of a positive covid test (daily averages for the previous seven days).1
Social media are abuzz with charts comparing the UK’s high rates of cases and deaths unfavourably with its continental counterparts. Italy’s prime minister, Mario Draghi, cited the UK model of rapid vaccine rollout followed by “abandoning all caution” as an example not to follow. The situation seems bad. But is it?
How do the UK’s numbers of cases, hospital admissions and deaths compare with elsewhere?
While the data indubitably show that the UK is currently facing a bigger wave of infections than the rest of western Europe, Paul Hunter, professor in medicine at the University of East Anglia, said that it’s “probably not quite as bad, relatively speaking, as it looks from the data.” This is because of key differences in testing rates.
“Comparing case number graphs between ourselves and our neighbours gives a slightly distorted picture, in part because we’re doing a lot of testing of children that many of our European neighbours are not doing,” said Hunter. At around 14 tests in every 1000 people, the UK is testing twice or three times as many people as many European countries are,2 including France and Italy. The more people tested, the more likely you are to identify positive cases.
Hunter believes that the numbers currently being seen in the UK will soon be encountered by the rest of Europe.
How does England compare with the rest of the UK?
Much has been made of a purported split between England, Scotland, Wales, and Northern Ireland in the trajectories of their covid numbers. But this may be overstated, said Linda Bauld, a behavioural scientist at the University of Edinburgh. It’s more difficult to compare England and Scotland with Northern Ireland and Wales because of the differences in sizes of the nations and the way random noise in data can disproportionately affect their output. But up until the end of August England and Scotland had roughly similar covid-19 prevalence.
Then, throughout September, Scotland diverged, to the extent that its prevalence was closer to one in 45, while in England it was one in 70. Now, those numbers have flipped, which Bauld puts down to societal differences, such as in school term dates.
Hunter thinks it is “entirely plausible” that what we’re seeing now is the “Scottish early September peak” and that within a week or we may see cases falling in England again.
Did changes in covid restrictions make a difference?
On 19 July—dubbed “Freedom Day” by the media—England lifted many covid restrictions that the other home nations chose to retain, which could have affected people’s behaviour. Scotland and Wales, for instance, require people to have masks and covid passports (given after two doses of an approved vaccine) to enter certain public spaces such as nightclubs. Yet their case rates remain similar to England’s.
Hunter pointed out that although England is one of the more relaxed countries in Europe in terms of covid restrictions it is not as relaxed as Denmark and Sweden. Mask wearing, for instance, is encouraged on public transport in England, and enforceable through codes of travel, but no such rules exist in the two Nordic countries.
The English public has also generally been more cautious than the rules allow it to be throughout the pandemic, Hunter added, and this didn’t seem to be changing much. “We are still quite a lot down on things like going into work, going to recreational venues, and visiting transport hubs like stations,” said Hunter, citing Google mobility data.3 “More so than a number of our European neighbours that are technically more restrictive than we are.”
Muge Cevik, clinical lecturer in infectious diseases and medical virology at the University of St Andrews and a member of the UK’s New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) doesn’t think the UK’s national differences can be pinned down to a single factor such as mask wearing or waning vaccine immunity. Bauld thinks it is the timing of changes rather than subtle differences in the policies of the devolved nations that probably accounts for differing numbers.
Nathalie MacDermott, an academic clinical lecturer at King’s College London, said, “Our European neighbours are certainly doing a better job of ‘learning to live with the virus’ than the UK is currently. Learning to live with the virus does not mean ignoring its presence; it means adopting lifestyle measures that we consistently apply to reduce the spread of the virus but which do not impose too significant limitations on our freedoms.
“Wearing a face mask is an option we can all implement that will protect others, but it would seem many people no longer feel the need to do this, even in locations where it is specifically requested, such as on public transport.”
What about the UK’s lauded vaccine rollout?
One hypothesis being suggested is that by being one of the first countries to start vaccinating its public (at the start of 2021) the UK is now seeing vaccine effectiveness wane. We know that immunity resulting from vaccination weakens after around six months, and that time is now up.
Similar case rate increases were seen in Israel, which started vaccinating its population around the same time as the UK but completed it much more quickly. Spikes there have been quelled by the efficient rollout of a vaccine booster programme, something the UK is also doing, although debate continues about its speed and whether younger children should also be vaccinated.
Bauld believes this waning vaccine effectiveness to be a “genuine phenomenon” that we’re now wrestling with. And, because the rest of Europe’s vaccine rollout lagged behind the UK’s, it’s a problem those countries may face in the near future.
How is the NHS coping in comparison with the rest of Europe?
At the time of writing, just over 8200 people in the UK were in hospital with covid-19. This is a problem, in part, because we run a much tighter ship throughout our health service than elsewhere. At 2.5 hospital beds per 1000 people the NHS has far less capacity than France (5.9 per 1000) and Germany (8 per 1000).4
The NHS is also struggling with staff shortages triggered by exposure to SARS-CoV-2 and the resultant need to self-isolate. With 2.8 doctors covering every 1000 people5—less than in Bulgaria, the Czech Republic, Denmark, and Georgia—it is affected by absences more acutely than other healthcare systems.
The NHS is currently seeing 14 times as many patients as it did last year, the Royal College of Emergency Medicine has said.6 Its president, Katherine Henderson, said, “Trusts continue to deliver elective care but there is a real threat that in the coming months this may once again have to be paused to manage pressures on urgent and emergency care and the rising number of covid cases.”
What is the government doing?
The UK government has so far declined to enact its “Plan B” higher levels of restrictions, believed to include the reintroduction of mandatory mask wearing and encouraging a return to working from home where possible.7 Downing Street said that it reserves the right to trigger it if the situation worsens (though the exact threshold for this is unknown).
Doctors are unimpressed. Matthew Taylor, chief executive of the NHS Confederation, said last week, “Without pre-emptive action, we risk stumbling into a winter crisis . . . The government should not wait for covid infections to rocket and for NHS pressures to be sky high before the panic alarm is sounded.”8 The BMA called the government “wilfully negligent” for not acting to bring down infection levels.9
Cevik said the government also needed to look beyond the pandemic towards more systemic and societal problems. For a rich European country the UK regularly scored alarmingly highly on public health and socioeconomic inequalities, she said. “There’s a huge gap between the most deprived and least deprived communities in terms of education, access to health services, income—everything is getting worse.” That meant looking, for example, at the underlying factors behind people’s reluctance to isolate, such as sick pay.
What about sick pay?
The UK has between 10 million and 15 million “essential workers,” many of whom are unable to abide by government requests to work from home. Many of them also happen to work in the most cramped environments and live in dense, multigenerational households at higher risk of covid transmission.
Cevik said the government was failing to properly support people and encourage them to self-isolate should they become infected or if they had symptoms that indicated they may be infected. “It should be a right to self-isolate without thinking about food and rent,” she said.
“Going into winter, it’ll be much more challenging because we’ll see much more flu, and that presents with similar symptoms,” Cevik added. “There needs to be a culture that if you get symptoms you need to get tested and self-isolate.”
Is the UK heading back into lockdown?
“I don’t think it should [follow] that if cases are rising we should lock down,” said Cevik. She advocates for a different calculus from policy makers: resources (that is, support for people to self-isolate safely) before restrictions. “I think there needs to be a much more transparent discussion about trade-offs and benefits and who we’re helping and harming with restrictions.”
Cevik doesn’t think the current spike will be as severe as previously, because of vaccination and built-up immunity. Hunter agrees, pointing out that the percentage change in seven day case numbers in the UK has yo-yoed up and down almost week by week for the past few months.10 “We’re not under the same pressure we were last year, because things aren’t rising anywhere near as quickly,” he said.
“Even though case numbers and hospitalisations are increasing, and deaths are increasing, they’re not doing so anywhere near as rapidly as they were last year,” Hunter added. “[Then] the number of people in hospital with covid was doubling every two weeks. The most recent data suggest they’re doubling about every three months.
“Personally, one thing I can be comfortable with saying is that we’re not going to see anything like last January again with covid.”