John Middleton: Is the NHS prepared for the coming winter? 

Recent NHS performance data show that the NHS is currently under huge pressures. Although lifting all coronavirus restrictions in England on 19 July 2021 hasn’t resulted in the feared 100,000 covid cases a day, the NHS is still nevertheless under pressure, with NHS leaders saying that it feels like “winter in summer.”

And yet, we are experiencing groundhog day in terms of pandemic planning for the winter of 2021-22. Many of the concerns we voiced this time last year are still evident—or even stronger. Last year, we did not have a detailed appreciation of the impact of new lethal covid-19 variants such as the alpha and delta variants that we have now experienced. Last year, we were planning for a second wave expecting it to be worse than the first, but perhaps not understanding how. Now, again, the UK potentially faces a perfect storm of covid-19, winter flu, a large backlog of untreated long-term conditions, and excess cold-related mortality, along with the impact of Brexit.

The Academy of Medical Sciences has launched a report, “Preparing for the future: looking ahead to winter 2021-22 and beyond.The report highlights the risks of a resurgence of respiratory viruses, especially respiratory syncytial virus (RSV) and influenza, which both declined to low levels last year. The Academy calls for efforts to maximise covid vaccination uptake. They recommend financial and social support for people self-isolating, particularly in areas of persistent high circulating virus and the most deprived communities. They call for boosting capacity in the NHS, especially staffing and beds, infection prevention, and vaccination and testing capacity for covid-19 and influenza, adequately resourcing primary care, and reducing the backlog of non-covid-19 care. They recommend clear guidance about environmental and behavioural precautions that individuals and organisations should follow.

The Association of Schools of Public Health in the European Region, ASPHER, sets out its concerns about the new ecology of viruses and humans. There is an expanding range of symptoms and signs that covid-19 is presenting with which need to influence our clinical suspicion and testing pathways. Long covid manifestations are also widening and might more properly be considered as “enduring,” or “persistent” covid-19. The available tests are blunt instruments, with high possibility for false positive and false negative results. Increasing use of self-testing gives individuals control of the results, renders surveillance systems inadequate and unreliable, and further jeopardises the control of spread.  

As we head into our second winter with covid-19, we have the benefit of over 75% of the adult UK population being doubly vaccinated against SARS-COV-2 in the UK. This is an extraordinary feat of science, of healthcare delivery, and public trust and support. Results from the REACT study gives us reassurance about the efficacy of vaccines, with infections three times less common in fully vaccinated people. However, vaccine efficacy is declining in Israel which may be evidence of declining efficacy against the Delta variant, or a decline in serological protection for individuals vaccinated early in the programme. So there is need for caution, especially as every virus transmission is an opportunity for a new mutation

Levels of vaccine confidence are extremely high in the UK, but this is not the case elsewhere, for example, France, and confidence declines sharply further into eastern Europe and Russia.

There is a risk that “vaccine over-confidence” is leading the UK into a false sense of freedom, and an abandoning of all the physical distancing and basic public health protections that we need to limit this virus spreading. Our political leaders’ responses to the pandemic have been one-dimensional—focused either on lockdown, or testing, or vaccination. But, we need all of these measures to contain the virus. None of them alone dispenses with our needs for basic infection control measures such as physical distancing, meeting outdoors where possible, ventilation indoors, masks indoors and on public transport. These measures also protect us from other respiratory viruses which will resurface again this winter. Our government tells us it is our individual responsibility to decide whether to wear masks indoors, throwing away a low cost, enforceable law, for a high cost unenforceable exhortation—paid for by the taxpayer in ineffective adverts.

The UK government has been reckless in its abandonment of all social measures and placing complete reliance on vaccination. By default, this places a new and additional burden on children who are not vaccinated, or sufficiently protected in schools. We enter the autumn with levels of infection about 20 times the level of last year. While hospital admission and deaths are levelling, they are doing so at high levels, so it is hard to imagine we are through this. It seems likely that the NHS and public health authorities will be stretched again this winter with children’s care and wellbeing the new frontline. 

The gap between socioeconomic groups has grown wider through the pandemic, whether at a global economic level, or through the unequal impact of the pandemic in our towns and cities. For families living in poverty, this is about to be made worse as the £20 “pandemic boost” to Universal Credit is to be removed. Such a shock to the incomes of the very poorest in our society is a concern for food banks at the very sharp end of destitution UK, but it could also trigger civil unrest more widely. The impacts of Brexit are still to be fully experienced. Some are being masked by the pandemic. Import controls from the EU have been delayed for six months by the UK government. Early effects of Brexit are emerging with the lack of truck drivers, born out in supply shortages of blood specimen tubes. The NHS must factor into its plans the full impact of Brexit shortages, including staffing.

Public health authorities and health services in the UK, and in the rest of Europe, need to remain vigilant. They need to plan for further waves of covid-19 and for new variants of concern. They need to plan again for winter and for unpredictable climate events as we have seen this summer. The backlog in healthcare is an international concern. The backlog in NHS waiting times for non-covid care is massive and needs considerable attention, but no-one should understate the action taken by the NHS  in the last year. There is added concern this year for children’s health, with likely impacts of covid and RSV, inadequate protection through the current vaccination policy in the UK, poor protections in the classroom, and wider concerns for children’s mental, social, and educational wellbeing.  

More than ever, governments need to commit to reducing the gross inequalities caused and highlighted by the pandemic, within countries and between countries. This pandemic will not be over until it is over for everyone. There is no reason to believe the pandemic will just die out. All of the interventions we have against the virus need to be applied. Careless relaxations of public health measures in rich countries, inadequate support for local public health and primary care and the communities they serve, and failure to support the global delivery of vaccines will keep us all in a state of perpetual covid

John Middleton, honorary professor of public health, Wolverhampton University and President, Association of Schools of  Public Health in the European Region.

Competing interests: none declared.