As many had predicted, the relaxation of covid-19 restrictions over the Christmas period started to take its toll on the NHS before 2020 was out. [1] Between 28 December 2020 and 3 January 2021, 366,435 people tested positive for covid-19 in the UK, a 47.6% rise from the previous week. As of 3 January, 24,957 people with covid-19 were hospitalised in England, with 2181 patients on ventilators. This surpassed the numbers seen during the peak of the first wave in April (18,974), with cases continuing to rise as our curve becomes almost vertical. [2,3] 

In the community, the London Ambulance Service reported its busiest day on record, receiving almost 8000 calls on Boxing Day alone [4]. This demand spilled over into the NHS111 and GP out of hours services and the Christmas Bank Holiday saw high volumes of calls, which had ramped up further by the New Year.

One of the roles of a GP working within the out of hours service is to reduce the demands on both the ambulance services and emergency department by assessing callers remotely and providing alternate options where appropriate, such as self-care advice, remote prescriptions, and use of alternate services such as walk-in centres or pharmacies. As reports rolled in over the Christmas period of ambulances queuing up outside overflowing emergency departments, and a London hospital declared a major incident due to shortages of oxygen, it was particularly concerning to see a certain level of disconnect in the community. [5,6] Images of  “covid deniers” and protestors gathering outside St Thomas’ hospital in London recently  represent the extreme, but what is perhaps more demoralising is the incomprehension and apathy of many callers to primary care who repeatedly disregard their symptoms of covid-19. [7]

For months now, it has been the norm in primary care to speak with patients calling to discuss their new coughs and fevers, and to be greeted with surprise and often outrage when a covid test and household isolation are suggested. “I know it’s not covid” or “I always get a cough at this time of year” are the commonest protestations, alongside the belief that an intact sense of smell invalidates all the other symptoms. After the well-rehearsed debate is over, what follows is typically an unconvincing agreement to follow the government advice, which inspires zero confidence that this will actually happen.

Meanwhile, on the wards, a similar narrative occurs while checking that the relatives of covid-19 patients are isolating. The response is often simply: “I can’t isolate”, with financial hardship acknowledged as the main influence. While we are sympathetic to this situation, there remains a profound lack of understanding about this disease, despite its omnipresence in our lives. The many patients dying of covid-19 in hospital invariably all ask: “How did this happen to me?”

The general public cannot be criticised for these misperceptions, since the guidance from the government throughout this pandemic has been confusing, ambiguous, and inconsistent, often changing at the last minute. The lack of financial support for those needing to self isolate has left some people unable to follow the guidance for fear of financial hardship or ruin. Instead of following the lead of countries like Australia, who isolated and tested anyone presenting with any upper respiratory symptoms (including rhinorrhoea and pharyngitis ), here in the UK clinicians have been forced to have daily disputes with patients about the nature of their cough, while ignoring patients who present with snotty noses and sore throats as these symptoms somehow aren’t included as covid-19 in the UK. [8]

The data confirms what clinicians are seeing in their clinics or in hospital. Between March and August 2020 over 30,000 people in the UK were asked to name the key symptoms of covid-19 – with only half of the sample able to do so. The same study found that of those sampled, who reported having the key symptoms of the virus, only 18.2% self- isolated and 11.9% obtained testing. Of those that had been alerted by NHS contact tracing that they had been in close contact with a confirmed case of covid-19, only 10.9% reported staying at home to quarantine for the following 14 days [9].

Vaccination may offer us the best way out of this pandemic, but this will realistically take months. There is undoubtedly value in well executed mass testing programmes to limit asymptomatic transmission, but we urgently need to double down on the basics, if we are to find a way out of lockdown. To control infection rates until mass vaccination takes effect, we must broaden our definition of the symptoms of covid-19, and exit lockdown with a reliable way of persuading those with symptoms to come forward for testing, tracing, and isolation. Support for self isolation will form a critical part of this. 

It’s with a weary, heavy heart and a sense of déjà vu that we hear talk of relaxing lockdown, when the vaccination rollout has progressed. It’s hard not to feel dismay when at this late stage, we can’t even persuade patients who present to general practice with a cough that they might have covid-19. We don’t have any apparent strategy or support system to help people who need to self isolate, and thereby increase compliance with isolation rules, and help us to exit this lockdown safely.

Ellen Welch, out of hours GP, Cumbria.

Katie Sanderson, junior clinical fellow in palliative care, London.

Competing interests: none declared.

References:

[1] McLellan A, Godlee F. Covid 19: Christmas relaxation will overwhelm services. BMJ 2020; 371:m4847 https://www.bmj.com/content/371/bmj.m4847

[2] NHS England. Covid-19 hospital activity. 31 Dec 2020 

https://www.england.nhs.uk/statistics/statistical-work-areas/covid-19-hospital-activity

[3] Government Coronavirus Data. https://coronavirus.data.gov.uk

[4] London Ambulance Service. Please help us to help you during extremely busy time. 27 Dec 2020 https://www.londonambulance.nhs.uk/2020/12/27/please-help-us-to-help-you-during-extremely-busy-time/ 

[5] Mahase E. Covid-19: Hospitals in crisis as ambulances queue and staff are asked to cancel leave. BMJ 2020; 371:m4980 https://www.bmj.com/content/371/bmj.m4980

[6] Kmietowicz Z. Covid-19: England tightens restrictions as NHS struggles to deliver care. BMJ 2020; 371:m4972 https://www.bmj.com/content/371/bmj.m4972?ijkey=48b1911047c5a298ed4c0181a72409e398d3e9f9&keytype2=tf_ipsecsha

[7] Peat J. Hundreds turn up for anti-lockdown protest held outside covid ward. The London Economic. Jan 1 2021 https://www.thelondoneconomic.com/news/hundreds-turn-up-for-anti-lockdown-protest-held-outside-covid-ward/01/01/

[8]COVID-19-Frequently asked questions. NSW Government https://www.health.nsw.gov.au/Infectious/covid-19/Pages/frequently-asked-questions.aspx#1-4

[9] King’s College London. Effective test, trace and isolate needs better communication and support. 25 September 2020 https://www.kcl.ac.uk/news/effective-test-trace-and-isolate-needs-better-communication-and-support