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Update from the Senior Doctor…

Barts Health NHS Trust

What follows is a guest post from our doctor friend and regular contributor who used to be a senior NHS panjandrum.

As the COVID miasma thickens and national speculation becomes ever more shrill, Toby has kindly asked me to write an update about what we can actually measure and see in relation to COVID Hospital cases with particular reference to London and the tightening Tier 4 restrictions.

Firstly, the published figures.

Graph 1 shows Covid inpatients in London Hospitals on the brown line and Covid ICU patients in the blue columns. There is a clear long period of stability with an inflexion point upwards, on or around December 13th, which appears to be accelerating into Christmas week.

Graph 1

The pan London figures conceal important regional variations. The North East sector and to a lesser extent the South East have seen relatively greater rises than most other areas. This has been consistent for several weeks. Graph 2 shows the figures for two hospitals in the North East (Barts Health and Barking) and two in the South East (Guys and St Thomas’s and Lewisham and Greenwich). Again, there seems to be an inflexion point around December 13th – 15th. The ICU bed numbers in Graph 3 mirror the increase in patients from the North East with a lag in the South East curves.

Graph 2
Graph 3

Since these figures were published, I’m told that Covid admissions in North East and South East London have continued to increase, particularly in the last 48 hrs, to the point where several hospitals are now implementing plans to stop elective work and redeploy staff to Covid wards. Arrangements for ‘mutual aid’ between hospitals are also being discussed.

This all sounds alarming and reminiscent of Michael Gove’s apocalyptic warnings in the Sunday Times recently. Does it mean the NHS will collapse and dead bodies will pile up in the streets if the entire population does not immediately hide under the bed until next Christmas and Britain turns the clock back to the 14th century?

No, it does not. There is no doubt that pressure on London Hospitals has increased in the last week and that a substantial proportion of that pressure is due to increased Covid admissions from the community. I suspect the next two or three weeks are going to be pretty intense for the NHS in London. Elective work will probably have to stop and patients may need to be moved around the capital to areas of less intense activity. Some staff will need to work outside their comfort zones, which is always stressful. Specialist staff will be spread more thinly than usual and have to shoulder more responsibility than normal. Hospitals will need to pool resources, help each other out and everyone is going to have an uncomfortable time – but the system will not collapse.

The big difference between this year and previous winter ‘crises’ is that Hospital staff are now being repeatedly tested for Covid, regardless of whether they’re symptomatic. I understand that approximately 5% of asymptomatic staff are picked up as positive and then sent home from work. Added to the absence of staff who do have symptoms, or who have been told to self-isolate because some other close contact has tested positive, and this creates a major workforce problem. If we routinely tested staff for influenza or any other common seasonal respiratory disease, we would probably end up with the same problem every year. Under normal circumstances of course we do not test asymptomatic staff for coughs and colds – leaving it up to their own judgement to decide whether they are well enough to come to work. The staff testing programme has been implemented for a perfectly sound reason – to reduce the incidence of in-hospital infections. However, in addressing one risk, the NHS has created another, arguably just as serious. I will return to this point later.

The second big difference between 2020 and previous years is the segregation of patients into colour coded cohorts within the hospital and the overall reduction in available beds due to increased spacing for social distancing – in some hospitals this has reduced bed numbers by up to 9%.

Green Beds are routine patients who have self-isolated prior to admission and have negative tests. Amber are patients awaiting swab results and Red are patients with positive Covid tests. On the face of it, this system sounds quite sensible. In practice, it creates immense organisational friction. For example, a hospital may have plenty of Green beds, but have Amber patients queuing up in A&E, who cannot be placed in any of them. Patients may move from Amber to Red if they become Covid positive, but when they are fit to be discharged, they may occupy an acute Covid bed for days as there is no ‘home’ to send them to. Care homes are particularly reluctant to accept discharged patients after Covid care because of their experience in the spring. Discharge delays happen every year with influenza too, but the problem is worse this winter. As a result, the same burden of clinical care becomes proportionately harder to manage.

So, what has caused the increase in Covid patient numbers? The straight answer is I don’t know. It could be as simple as a change in the weather. Covid is a temperature dependent virus – it dropped off rapidly in late spring. During the summer there were localised outbreaks in isolated cold places, such as meat packing plants (and the first cases have just been detected in Antarctica) so it is not surprising that as the temperature falls we are likely to see more outbreaks and more transmission as people congregate inside and spend less time outdoors.

The burning question in the light of the revelations about the ‘new variant’ VUI-202012/01 is what role, if any, does this play in the observed tightening situation? Hard to say. It’s certainly possible that a new variant could spread with greater speed. In itself that doesn’t matter very much as long as the disease it causes is at least no worse than the old type – in general evolutionary biology one would expect a faster spreading variant to cause a milder illness. If the new variant is spreading significantly faster, the medical problem would not be a greater severity of disease but a more concentrated spike of hospitalisations.

The NERVTAG meeting notes of December 18th which seem to have sparked off the latest panic are relatively cautious about the transmissibility of the new variant, but do record:”It was noted that VUI-202012/01 has demonstrated exponential growth during a period when national lockdown measures were in place.”

This brings me to my key point: the illusion of control. In the spring, the rationale for lockdown was to “flatten the sombrero” – a temporary measure to delay viral transmission and prevent the NHS from being overwhelmed by a sudden surge in cases. Since the autumn, that message has mutated to a new variant – the Government and its associated advisers have become obsessed with the need to “control the virus” – yet the evidence shows that they have about as much chance of controlling the weather. Far too many “experts” have invested their entire professional credibility on the premise that more stringent lockdowns are the only way to “beat the virus” and to achieve “zero Covid”. Yet both of these goals are manifestly unattainable.

The Covid admissions curves in London have steepened despite increasing societal restrictions. If it is true that VUI-202012/01 has demonstrated exponential growth during this time, why are we doubling down on a failed strategy?

Stop Press: Dr Mike Yeadon is, not surprisingly, sceptical about the “mutant” strain being responsible for the NHS’s capacity problems.

It is my personal opinion that the only way to rescue UK quickly and in one step is to turn off the un-inspected, un-audited, non-accredited, private Lighthouse Labs, now conducting 90% of UK PCR tests. They are producing deficient product: untrustworthy results from PCR mass testing.

I learned earlier today from an impeccable source within the NHS that:

“Management has become totally frustrated by the unmanageable impact of staff falsely told to self isolate following Pillar 2 testing via Lighthouse Labs. Fully 10% of NHS staff are missing. They’re not ill. But having had a positive PCR test they’ve been told to “self isolate” (another made up phrase from the school of misinformation). As from eight days ago, they’ve cut over to self screening using lateral flow tests for viral proteins. Staff have been sent 200 each. If they’re positive they come into to an NHS facility, get swabbed for confirmatory tests by in-house PCR, run in NHS path Labs. Management expects self isolation absence to halve in January”.

If confirmed, that kills confidence of the public in relation to Lighthouse Labs screening stone dead.

Watch the ‘self-isolation’ absence statistics closely over the next four to six weeks.

Stop Press 2: The NHS whistleblower who leaked the slides from an internal Power Point Presentation given to senior managers has provided a snippet of info that corroborates our doctor’s analysis.

Hospital transmission is a major problem and asymptotic testing has reduced the number of staff available to work. Perhaps we should test for other respiratory viruses? Bath RUH has 233 staff isolating due to covid. A FOI request for information on the number of staff number isolating across the NHS should be available.

Hospital bed numbers have reduced by 9% to help introduce social distancing. Some new build facilities, e.g North Bristol Trust have reduced bed numbers more than Trusts, e.g. UHB&W, with older hospitals.

Nightingale hospitals are of little value. They need clinical and other support services, e.g. X-ray, blood bank, kitchen – and staff. Would have made more sense to increase capacity at existing hospital sites. For example, portacabin wards in hospital car parks.