The government will publish its lockdown exit roadmap in less than a week's time. NHS trust leaders are clear, as they have been throughout the pandemic, that the approach should be to remain cautious. With a strong focus on data, not dates, they want four evidence-based tests to be met before lifting restrictions.
The first test is that COVID-19 case numbers and the R number must drop significantly so we can be confident infections will not surge again as soon as restrictions are eased, as happened last year. There are currently around 9,500 daily cases of COVID-19 but when restrictions were previously eased, they were at 1,000 a day. Key members of the Scientific Advisory Group for Emergencies are also calling for total case numbers in the weekly Office for National Statistics infection survey to be 50,000 compared to the current 695,000.
The second test is that NHS capacity needs to have returned to levels where the service can treat all the patients it needs to. We are now past the peak of this wave of the pandemic. But there were still 19,000 COVID-19 patients in English hospitals at the end of last week – more than the peak of the first wave. As a sign of how much capacity the NHS can need to cope with highly contagious strains of COVID-19, on 10 September 2020 the NHS had less than 600 COVID-19 patients in hospital. But it came perilously close to being overwhelmed just 15 weeks later.
Hospital Intensive Care Units (ICUs) remain under particular pressure. In the week to 7 February, they were running at 170% capacity compared to this time last year. On 11 February, one in four ICUs had seen increases, rather than decreases, in patient numbers in the previous week. The evidence already shows that the number of COVID-19 patients in hospital will drop more slowly compared to the first peak. Thanks to the NHS successfully deploying new treatments, far fewer people are now dying from COVID-19. But the corollary is many more patients needing to stay in hospital, for much longer, than last year.
It's not just hospital beds we should worry about. Ambulance trusts are still under huge pressure, as are the community services and GPs that are vital for treating long COVID. Mental health services are dealing with much higher levels of COVID-19 triggered demand. NHS staff are exhausted, need to recover and must take the leave they have repeatedly delayed. The next five priority groups need to be vaccinated at speed. We are still at risk of higher demand due to winter weather. The government needs to take account of all these factors when ensuring the NHS can cope with any surge in cases that could follow the lifting of restrictions.
The third test is that the vaccination campaign needs to be sufficiently advanced to provide adequate levels of protection. The Joint Committee on Vaccinations and Immunology (JCVI) was clear that 99% of the mortality risk is only mitigated once the top nine groups of people are vaccinated against the virus and have built immunity, not just the top four. This milestone will only be reached in mid to late May.
NHS trust leaders are hugely proud of vaccinating 15 million people, including the over 70s, in 10 short weeks. But 90% of COVID-19 infections are in the under 70s. The current average age of COVID-19 patient in ICUs, many at serious risk of death or long term harm, is 59.5 years. The latest data from Israel – world leaders in the proportion of population vaccinated – shows hospitalisation rates in the vaccinated falling rapidly. But, despite a national lockdown beginning in the week of 8 January, hospitalisation rates for those who haven't been vaccinated have been rising, driven by the highly contagious B.1.1.7 strain first discovered in Kent.
The government will need to be clear what level of risk of mortality and harm it is prepared to accept.
The government will need to be clear what level of risk of mortality and harm it is prepared to accept. Trust leaders, whose job is to save all lives and avoid all unnecessary patient harm, are worried by concepts such as "acceptable death rates to allow the economy to re-open" or "the same death rate as seasonal flu" now in public circulation.
The fourth test is that we must have a robust and effective strategy in place to rapidly identify and control future outbreaks from the variant strains that now pose the greatest threat. Test and Trace only works effectively at much lower case numbers. It needs to have the capacity and capability to genomically sequence large quantities of tests at pace, alongside effective quarantine and outbreak response strategies.
We all want this to be the last national lockdown. But only by passing these four tests can we have reasonable confidence that the virus has been contained and that any future outbreaks can be similarly contained.
This article was first published in Times Red Box.