“Protecting the NHS” has been a mantra for the government throughout the pandemic, as it has sought to get the public on board with adhering to repeated lockdowns and restrictions on everyday life.
Covid restrictions in England have been lifted, but it’s clear that Covid is far from over. Although the most recent data shows a more complex picture, case numbers have been soaring. Despite the impact of the vaccine in reducing severe disease, the numbers of people admitted to hospitals and even Covid deaths are increasing.
What does this mean for the NHS? And will protecting the NHS once again need to become the focus of our pandemic response?
Direct effects of Covid-19 on the NHS
Hospital admissions are the most widely reported measure of the impact of Covid – and these are going up, along with the number of Covid patients in hospital. Covid patients spend a median of seven days in hospital, although this may reduce in this wave as the age of patients admitted is lower. But even so, 38% more beds were occupied by Covid patients on 18 July compared with the previous week, and significant numbers of patients are requiring critical care.
The rising number of people in hospital beds is not the only manifestation of rising Covid cases. Surveillance data from GP practices, 111 services and A&E all show increasing demand on health services from more cases of the virus.
While demand is increasing, there are also pressures on the supply side. Staff absences related to Covid doubled from 6,713 to 13,771 between 1 and 30 June this year. These include people off sick with Covid, but also a substantial number who may be self-isolating or caring for children or other dependants who are isolating.
While Covid cases are high, hospital and clinic capacity is reduced, even without staff shortages. The demands of social distancing to reduce infections mean there are fewer beds available, and separate treatment areas for Covid and non-Covid patients are needed. And teams need to use additional PPE and cleaning of equipment, so it takes longer to deliver care than before the pandemic.
Further, over a third of people who have had Covid report persistent symptoms lasting more than 12 weeks, sometimes referred to as “Long Covid”. Research into long-term Covid symptoms and effective treatments is ongoing, but there is already evidence that hospitalised Covid patients experience higher mortality and increased chances of readmission than other hospitalised patients. One in three patients were readmitted within 140 days, and one in 10 died after leaving hospital.
Rising numbers of Covid cases and the direct pressure this is causing are the very last thing the NHS and social care system needs right now.
The disruption caused during the pandemic has left a massive backlog in people needing treatment, along with a significant upheaval in how patients seek care.
By May this year the waiting list for planned NHS treatment was 5.3 million, the highest since records began – but numbers treated each week have not returned to pre-pandemic levels. The NHS has been tasked with fully resuming services, but this will be difficult to achieve while Covid rates remain high. As well as the factors noted above, patients waiting for complex surgery that might require admission to intensive care are likely to be particularly impacted. Covid patients typically require longer stays in intensive care than surgical patients, so each additional Covid patient admitted can result in several postponed operations.
The backlog of patients waiting for surgery and investigations is putting pressure on primary care teams, to support these patients and manage ongoing symptoms while they wait for treatment. These same teams are also part of the Covid-19 vaccination programme: over a quarter of the 31.6 million appointments with GPs and practice staff in May this year were to deliver Covid vaccines.
There is also increasing pressure on services in the community, for example, to support people at the end of life. During the pandemic a third more people are dying at home, raising concerns about the capacity of community services to provide care and support for patients and families.
Meanwhile, our social care system is not fit for purpose, and this has a direct impact on people needing social care and support at home to manage health problems. Local authorities are receiving increased numbers of requests for support from people waiting for treatment, or after being discharged after a stay in hospital.
The net result of these demand and supply pressures, combined with a resurgence of other infections as people mix more, is unseasonal levels of demand for urgent treatment. In June this year over 2.1 million people attended A&E, the highest number for any June on record.
Will the NHS be overwhelmed?
The NHS went into the pandemic with fewer doctors, nurses and capital assets than health services in comparable countries, and with deteriorating performance – as measured by growing waiting lists and increased time spent for patients to be seen in A&E.
By the second wave the backlog of people waiting for planned treatment, and how long they had waited, had both increased. The NHS worked to maintain urgent treatment, including cancer, but with nearly 30% of hospital beds occupied by Covid patients, other services were severely impacted. One ameliorating factor last winter was that lockdown and social distancing measures, along with exceptionally high flu vaccine uptake, prevented the circulation of flu and other seasonal illnesses. But the NHS workforce emerged from the second wave exhausted.
As the third Covid wave gathers pace, it is clear that the NHS and social care system is in a worse state than at the start of previous waves. Demand for urgent care and the backlog of patients waiting for planned treatment are both growing, staff are exhausted, and non-Covid infections are increasing and likely to get worse over this autumn and winter.
So will the NHS be overwhelmed this time?
Growing numbers of patients mean Covid wards are already being reopened, and planned operations are being cancelled. If hospital cases continue to rise, as expected given the rapid growth in cases, it will once again result in other services being reduced, in and out of hospital.
In previous waves, the NHS coped partly because patients deferred seeking help, in response to pleas to “protect the NHS”, and in part because lockdowns reduced some other demands and preserved capacity for Covid patients. But now the public is being told to learn to “live with Covid”. Patients will understandably be less tolerant of delays and worsening quality of care, and in the medium term patient survival for cancer and other conditions could get worse.
While the NHS will prioritise the most urgent treatment to cope with demand during this Covid wave, this will be at a cost in terms of postponed care and poorer outcomes for many.
Scobie S (2021) “Will the third Covid-19 wave overwhelm the NHS?”, Nuffield Trust comment.