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Covid-19: Is the government dismantling pandemic systems too hastily?

BMJ 2022; 376 doi: (Published 28 February 2022) Cite this as: BMJ 2022;376:o515

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  1. Matthew Limb
  1. London

The UK government’s plan for “living with covid” has sparked concern that important services established during the pandemic are being dispensed with too hurriedly. Matthew Limb reports

A last minute row over funding for free covid testing between the Treasury and the Department of Health and Social Care for England nearly derailed the government’s “living with covid” strategy launch last week.1 But the Cabinet eventually signed off drastic cuts to the estimated £15.7bn (€18.7bn; $21bn) testing budget as a key plank of the prime minister’s plan to scrap all remaining covid regulations in England.2

Duncan Robertson, a policy and strategy analytics academic at Loughborough University, told The BMJ that the latest row over ending restrictions showed that the “false equivalence of the virus versus the economy” was still rearing its head almost two years into the pandemic, even though it is known that “once people are infected, they can’t go to work, and the economy suffers.”

It remains to be seen whether the right balance has now been struck and whether the short term gains to the exchequer from letting the public shoulder more responsibility for fighting SARS-CoV-2 are going to pay off, with long term benefits to health and society as a whole.3

“I can understand Mr Johnson wants covid-19 to go away, but that doesn’t mean that it will,” Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine and a member of Independent SAGE group of experts, told The BMJ. “In the absence of published evidence to justify these moves, many will suspect these decisions are more about pressure from his backbenchers than science. And that will just undermine trust even further,” he warned.

Removing free testing

A particular concern is that the government’s removal of free testing at a wide scale—both polymerase chain reaction (PCR) testing and lateral flow devices—and its stopping of payments to support people in isolation will compromise population health surveillance and people’s ability to limit any future spread of infection.

Chaand Nagpaul, the BMA’s chair of council, said, “On the one hand, the government says it will keep monitoring the spread of the virus and asks individuals to take greater responsibility for their own decisions, but by removing free testing for the vast majority of the population, on the other, ministers are taking away the central tool to allow both of these to happen.”

Members of Independent SAGE have also criticised the decision. Although the group was at first sceptical about the utility of lateral flow tests in the absence of more financial support for isolation, they said the widespread availability of the tests, alongside PCR tests, may have contributed to the reduced peaks of infections in summer 2021 and this winter.

Christina Pagel, a member of Independent SAGE and director of University College London’s clinical operational research unit, has argued that responsible behaviour on the part of the public relies on everyone being able to see there’s a potential problem.

“As testing, surveillance, and reporting of infection rates are scaled back, this will be much more difficult and it will be much less likely that enough people will change their behaviour at the same time to dampen down future waves,” she wrote in the Guardian.4

The Institute of Biomedical Science has warned that the government’s approach could lead to “false public confidence and then an upswing in the infection rate.” Johnson has acknowledged that new variants of covid worse than omicron could emerge but said that surges would be spotted where they happened and that testing could be ramped up when required.

“The capability to resume testing at scale, and the associated workforce support, must be part of the government’s contingency plan,” the institute said.

Exacerbating health inequality

There are also fears that “living with covid” will disproportionately effect many of society’s most disadvantaged and vulnerable people, and people in public facing jobs.

Jim McManus, president of the Association of Directors of Public Health, told BBC Radio 4’s Today programme on 21 February, “If you can’t afford to self isolate, is it acceptable for you to take an infection into the workplace which isn’t trivial and which could kill some people? That really is a problem we have to face together as a society.”

Nagpaul warned that ending free testing would exacerbate health inequalities by creating a “two tier system, where those who can afford to pay for testing—and indeed to self-isolate—will do so, while others will be forced to gamble on the health of themselves and others.”

Andrew Goddard, president of the Royal College of Physicians, told The BMJ that he supported a “rationalisation” of the testing programme and was in favour of a “pragmatic” approach. “I would really value some cost-benefit analysis for different groups of the public before being able to say who we should say yes or no to,” he said.

The government has said that the most elderly and vulnerable people and social care staff will still be eligible for free tests. But as at 25 February full eligibility details had yet to be released, leading to urgent calls for healthcare workers to be included.

“People visit hospitals and surgeries to get better and not to be exposed to deadly viruses, and the continuation of testing for healthcare workers is invaluable in protecting both staff and patients,” Nagpaul said.

Contact tracing

The government’s strategy proposes an end to routine contact tracing but says that local health teams can continue to use contact tracing in response to local outbreaks.

In a statement the Association of Directors of Public Health said it supported local contact tracing but warned, “Unless additional resources are available, capacity to do any contract tracing at a local authority level will be extremely limited and in many areas non-existent.”5

Robertson said he was particularly keen to see the Office for National Statistics’ covid infection survey retained, amid reports that the government was considering axing it. Although the government has now accepted the case for keeping the survey to allow tracking of the virus in “granular detail,” it is unclear whether it will continue on the same scale.

Robertson said that the exact way in which data were captured was important, as there were differences between seeing “what’s happening in Leicester compared with Leicestershire,” for example. “We have seen that cities have had different epidemic trajectories from rural areas, so it is important that we can see these different dynamics develop,” he said. “Similarly, the epidemic spreads in different age groups at different times; this too is important information that we do not want to lose if the survey is scaled back.”

With the removal of mass testing from the general public, sequenced samples may be biased towards older people and to hospital patients. “Community sampling of variants is important as an early warning and so that the now limited resources for response can be used appropriately,” Robertson added.

Infection control

In response to the government’s plan for living with covid, the healthcare sector has called for clarity on the issue of infection control in healthcare settings. NHS England responded on 23 February with a letter to healthcare leaders in which it said, “There are no immediate changes to IPC [infection prevention and control] requirements. This includes the requirement for staff, patients, and visitors to wear a mask or face covering in healthcare settings.”6 The government has also confirmed that personal protective equipment will remain free in all health and care settings in England throughout 2022-23.

Extra NHS capacity

As England learns to live with covid, there are also questions about what will happen to the Nightingale surge wards that were built this winter to boost capacity.

“It is clear we need more bed capacity in the NHS, and we are going to really struggle over the next five years without it,” said Goddard. “It doesn’t necessarily need to be in acute hospitals. We need to start thinking about increasing community hospital bed capacity. People are talking about trying surge capacity as virtual wards. I think that’s the likely model rather than carrying on with Nightingales in car parks.”

But Goddard warned, “The biggest limit is not the physical space, it’s the staffing.”

The wait continues for ministers to develop and agree on a fully costed workforce strategy that will deliver the numbers of staff experts say the NHS needs.

Selling off assets

Away from frontline care, there are also major concerns about the government’s decision to sell the UK’s Vaccine Manufacturing and Innovation Centre to the industry.

In an editorial published in The BMJ last week, Rebecca Glover, assistant professor at the London School of Hygiene and Tropical Medicine’s antimicrobial resistance centre, and colleagues argued that although the UK taxpayer spent more than £200m on the centre, to help move promising vaccines to production and provide a defence against future pandemics, this investment was justified in 2020 when it helped scientists develop the Oxford University and AstraZeneca covid vaccine.7

Glover and colleagues called the decision to sell the centre “baffling” and “difficult to justify on strategic, public health, economic, or reputational grounds.”

“Selling the VMIC signals a lack of government commitment to British biomedical research, development, and manufacturing capacity post-Brexit,” Glover told The BMJ.

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