Rates of COVID-19 infection in the community are increasing, fuelled by the Delta variant which has taken over as the dominant strain. It's striking though, talking to trusts leaders from the 'front wave' of hotspots, that hospital admissions haven't risen as they did before.
They tell us that patients with the virus are typically younger than in previous waves, with less severe symptoms, so they're not seeing the same pressures this time round on intensive care. Very few of these patients have had two vaccinations with time to build resistance, and these invariably had other serious chronic conditions alongside COVID-19.
The trust leaders dealing with this latest surge feel they're coping well, though understandably nobody wants to be too definitive at this stage. There is a growing sense that thanks to the vaccine, the chain seen in previous waves between rising infections, high rates of hospital admissions and deaths, has been broken. That feels very significant.
As we head towards decision day on unlocking remaining COVID-19 restrictions, it's clear that very significant risks remain.
However, as we head towards decision day on unlocking remaining COVID-19 restrictions, it's clear that very significant risks remain. We now know that the Delta variant is much more transmissible than earlier forms of the virus. And, despite great progress with vaccinations, there are still a lot of people yet to have their second dose plus time to build resistance.
There is also a capacity concern. The NHS is running hot at the moment dealing with backlog recovery and emergency care pressures. The busy emergency care pathway may reflect patients who delayed reporting symptoms at the height of the pandemic now presenting with more complex conditions. The warm weather has added to pressures. Mental health and community services are also encountering increased demand.
It's important to remember that even before COVID-19, the NHS was overstretched. Hospital capacity – already inadequate – was reduced significantly because of the need for more rigorous infection control, adding to the complexity of caring for patients. It's not yet clear how great these additional pressures will be over the coming weeks and months. Ultimately, some of this demand is 'controllable'. For example, the NHS can slow down backlog recovery. But it can't simply dial down emergency care demand or mental health crisis presentations.
By highlighting these concerns, we are not arguing for a delay in relaxing restrictions. What we do want though is a better debate, that takes into account some stark realities.
By highlighting these concerns, we are not arguing for a delay in relaxing restrictions. What we do want though is a better debate, that takes into account some stark realities. First, COVID-19 is still very much with us. Vaccines mitigate the effects of disease caused by the virus, and slow its transmission, but they don't eliminate the virus itself, and there are still significant sections of the population unprotected. Another reality is that the vaccine is not 100% effective. COVID-19 spreads via social interaction. Relaxing restrictions on 21 June will increase infections, hospital admissions and deaths, albeit (the evidence suggests) at lower rates than before.
Decisions over what happens on 21 June don't have to be a binary "keep everything in place" or "change nothing" dilemma. We can relax some restrictions and not others. And we can delay any changes for whatever period of time the government chooses.
It will be important to consider whether the limited impact seen on hospital admissions and deaths in "front of wave" areas is being reflected more widely, and how long will it take to confirm that. Should there be a threshold set for the proportion of the population fully vaccinated before restrictions are eased? And given that relaxing these lockdown measures will lead to increased mortality, what level of risk are we prepared to accept? It is a deeply uncomfortable debate, though not entirely removed from our settled accommodation with flu. But COVID-19 is a new disease that requires us to balance prevention of harm and mortality with other pressing concerns.
Given current NHS pressures, any increase in COVID-19 admissions will set back progress on tackling the care backlog.
For example, given current NHS pressures, any increase in COVID-19 admissions will set back progress on tackling the care backlog. Are we ready to accept this trade off? And if we need to strike a balance between two extremes of 'delay all as a precaution' and 'go ahead in full as planed' what should that balance look like? Which restrictions being eased carry more and which carry less risk?
The evidence from the 'front of wave' trusts indicates vaccines have delivered a positive and reassuring break in the chain between COVID-19 infection and high hospital admission and death rates. But relaxing everything on 21 June still brings significant risks and trade-offs, which should be examined and debated in full.
This blog was first published by the BMJ.