This winter, the UK potentially faces a perfect storm of resurgent covid-19, winter flu, a large backlog of untreated long term conditions due to the pandemic, and excess cold-related mortality, along with the effects of economic  collapse and a possible no deal Brexit. The individual parts of the perfect storm are brewing on the horizon, charted for us by the Academy of Medical Sciences in their recent report. At worst, food shortages, civil unrest, and breakup of the union are potential scenarios. Unless, as the emergency planning cliché goes, we plan for the worst, while hoping for the best. Now is the time for preparation, not celebration. We need clear evidence that there is political understanding and commitment to action to avoid a second wave of covid-19.  

How likely is it that we face a second wave of covid? Is this more public health scaremongering? Calling it a second “wave” may be academic. When you are drowning it doesn’t matter how many waves are going over your head. The US and UK are not even out of the first wave. There is no sign, in England, that the virus is going away, in fact it is creeping back again. The Institute for Health Metrics and Evaluation in Washington predicts resurgent covid-19 for most northern hemisphere countries, particularly those without universal mask protection. We are seeing new resurgences in Israel, Spain, Australia, Iran, and elsewhere as lockdown measures are relaxed. New Zealand has just reported its first case of covid-19 in over 100 days.

So we have to plan for a full resurgence of covid-19 as we approach winter, as social interactions increase and as more people will start to meet indoors in enclosed spaces, which evidence suggests increases the spread of covid-19. There is unlikely to be a vaccine, no herd immunity, and no political appetite for complete lockdown as in the first part of the pandemic. All of the public health interventions that we failed to do at the scale needed, by the right people, in the right place, will need to be done correctly this time. We need enhanced surveillance through Directors of Public Health (DSPH), test and trace through DSPH, physical distancing, public information through DSPH, quarantine and isolation policies separating out covid-19 care from routine and emergency clinical care, and protection of staff and early intervention in high risk care and workplace settings.      

We haven’t seen a severe winter flu season since 2015, so we should certainly expect it and be ready for it this year. It is reassuring that governments across Europe have ordered in 20-40% higher stocks of seasonal flu vaccine. The government’s intentions on this year’s flu campaign are sound; but delivery is key. Health staff need to embrace flu vaccination, for themselves and for their patients. Mask use by the public will have the added benefit of preventing spread of other respiratory viruses. 

Health and care services also face the “recoiled spring effect” of unmet health needs, poorly managed or controlled long term conditions, new cases of chronic disease, and new lockdown related diseases of inactivity, such as overcrowding and loneliness, as well as abuse, addiction, and overeating. The NHS plan for “phase 3” looks good in a list. It is easy to recommend taking the coming months to reduce waiting lists and a backlog of referrals, but this is set against physical distancing and infection control precautions, which themselves limit capacity in healthcare, and also the toll on exhausted staff. Managing expectations may be all that can be delivered, but there will be more excess deaths and disability.  

The deepening economic recession will lead to increasing unemployment and the associated adverse effects on health. So far the UK government’s economic and social measures also look good in a list, but are tokenistic, and unlikely to have any impact on inequalities in health or give any protection to disadvantaged communities. Many countries are recognising the need to provide for basic household income. The government’s commitment to additional support to prevent cold homes through the Green Homes Grant is welcome, but will barely scratch the surface of the problem of 4 million households in fuel poverty. Failure to address the social and economic protections needed, compounded by the collapse of some commercial sectors like tourism and leisure, and a potential no-deal Brexit, will lead us to economic collapse, possible civil unrest, and maybe even, the breakup of the union.  

Much of the commentary has been focused on the “UK’s terrible record” in this pandemic: over 46 000 deaths directly from covid-19, 56 000 with a recording of covid-19 anywhere on the death certificate, and excess mortality that stands at more than 68 000 deaths. Only relatively recently have we seen the reality that these are deaths in England.  

The fault lines have been opened wide between the four nation’s public health policies on covid, as Scotland and Northern Ireland pursue zero covid strategies. These public health policy differences will amplify political and national divisions. Plagues have had profound political impacts throughout history and this one will be no different if it is allowed to happen. We are not yet seeing sufficient commitment in our plans for winter, and we are not seeing political commitment to seriously tackle the virus and improve the economy. A zero covid strategy will be best for the economy in the long run and best for the health and survival of the UK. 

John Middleton, president of the Association of Schools of Public Health in the European Region (ASPHER)

Competing interests: None declared.