What does ‘Living with Covid’ mean for the NHS?

NHS leaders and staff are currently experiencing the strange sensation of bouncing between two worlds. One world involves testing, masking, distancing, staff absences and significantly disrupted services, all to reduce the risk of people catching COVID-19. In the parallel world, beyond the hospital or clinic gates, it feels more like 2019. There are fewer mitigations in place to reduce the spread of COVID-19 and far more opportunities to enable its spread. That transition can be disorientating and confusing for NHS staff, patients, carers and visitors alike.

Across the country, NHS organisations are now wondering: what now? It’s very clear that COVID-19 is not going away. Hopefully the virus will continue on a trajectory of generally reducing prevalence and severity, but we know new variants and surges along the way are also likely. Minds are turning to what this means for us all. That COVID-19 mitigations are important in healthcare settings is common sense. But as NHS infection prevention and control (IPC) guidelines continue to evolve, the nature and duration of these mitigations poses an interesting question.

Implementing the current COVID-19 precautions means the service must try to achieve these myriad ambitious targets with one hand tied behind its back

We’ve heard all about what the government thinks ‘Living with Covid’ means for taking the train or going shopping, but it’s far less clear what the medium-term approach will or should be for Living with Covid in the NHS. And that matters, because expectations are high for what the NHS must achieve over the coming months and years. Implementing the current COVID-19 precautions means the service must try to achieve these myriad ambitious targets with one hand tied behind its back. And we look to the scientists to tell us if, when and how we can untie it.

So, what is the plan? At this stage we can only speculate on what it should be. There are two key schools of thought among NHS leadership:

Maintain the key safeguards

One argument is that we must maintain the key COVID-19 safeguards within the NHS, at least for the medium term. In its current dominant form, COVID-19 is extremely easy to transmit, can still make some people quite unwell in the short and long term, can affect recovery from other illnesses, and can cause NHS staff sickness, which creates capacity problems. So increasing the potential for COVID-19 transmission, especially when population levels are high, in an NHS setting where there are many vulnerable people, could be too big a risk. We have a duty to protect the people in our care. Not to mention the need to be resilient since new and more severe variants could emerge at any time.

Mitigations could outweigh the benefits

The other argument is that the disruption caused by COVID-19 mitigations in the NHS may start to outweigh the benefits

But these COVID-19 safeguards are not without their disadvantages. The other argument is that the disruption caused by COVID-19 mitigations in the NHS may start to outweigh the benefits. With the demand for urgent and emergency care at an all-time high, COVID-19 IPC protocols contribute to how long people have to wait for an ambulance or be admitted to hospital. With unprecedented numbers of people waiting for elective procedures, these protocols slow potential waiting list progress. Not to mention the expense incurred by the additional measures, and the diagnostic capacity that could be used for other things. All of these are opportunity costs, and just as COVID-19 transmission may lead to patient harm, so too might its mitigations.

There is clearly a complex balance between risks and benefits, and judgements are having to be made with incomplete information, since we cannot reliably predict what COVID-19 will do next

There is clearly a complex balance between risks and benefits, and judgements are having to be made with incomplete information, since we cannot reliably predict what COVID-19 will do next. Nor is there likely a one-size-fits-all solution, given the different contexts in which NHS organisations operate. Health leaders balance risk and benefits every day at a local and national level, and what they need is information. What should the link be between COVID-19 prevalence and mitigating actions? Should decisions continue to be taken at the national level, or take into account more local variables like local COVID-19 rates, staff absences, and variations in NHS estates? To what extent can decisions be linked to scientific protocols and to what extent are they subject to political expediency?

There may not be much messaging on the subject from government and some media right now, but COVID-19 is still circulating at a pretty high level and affecting many people. ONS survey figures are showing a drop. What should that mean? Is there a prevalence level, or other indicator, at which different actions should be taken in the NHS, and in the wider public realm? NHS leaders need to be able to plan, and right now they are having to do that in an information void. And that is another risk.

Dr Layla McCay is director of policy at the NHS Confederation. You can follow Layla on Twitter @LaylaMcCay