In only their second joint editorial in 100 years, the British Medical Journal (BMJ) and Health Service Journal (HSJ) called on the prime minister to change tack because of rising cases of coronavirus across parts of England.
The BMJ is published by the doctors’ union the British Medical Association, and the HSJ is read by NHS staff, managers and professionals.
They both warned that hospital bed capacity risked being overwhelmed if there was a Christmas relaxation, calling on the government to “reverse its rash decision to allow household mixing [...] in order to bring numbers down in the advance of a likely third wave”.
Crucially, the journals say a third wave would hit non-Covid treatments hardest, as it “could wipe out almost all the reductions in waiting times for elective procedures achieved in the past 20 years”.
“This joint editorial is only the second in the more than 100-year histories of The BMJ and HSJ,” they write.
“We are publishing it because we believe the government is about to blunder into another major error that will cost many lives. If our political leaders fail to take swift and decisive action, they can no longer claim to be protecting the NHS.”
The urgent plea came amid growing alarm that the health service is at risk of being overwhelmed in the new year, a time when it traditionally comes under most pressure because of winter flu and other diseases.
The PM is planning on a five-day Christmas relaxation of the Covid rules to allow up to three different households to mix from December 23 to December 28. Overnight stays will be allowed as part of the festive changes.
But with London and key parts of the south-east being put into the highest tier of restrictions from Wednesday, and falling Covid case rates beginning to flatten off in other parts of England, the whole plan is now under intense scrutiny.
The prime minister’s official spokesperson today insisted that the rules were being kept under review but refused to go into any detail.
Asked directly about HuffPost UK reports that No.10 was looking at cutting the period for exemptions from five days to three or cutting the number of households that mix from three to two, he said: “We have set out the guidance for Christmas bubbling arrangements, but we obviously keep all advice under constant review.”
The spokesperson added: “We’ve always said that Christmas this year will not be normal. But we wanted to ensure that families and friends have the option to meet up in a limited and cautious way should they should they wish.”
Labour leader Keir Starmer demanded on Tuesday that the PM convene an emergency Cobra committee meeting to urgently review the Christmas rules.
BMJ editor in chief Fiona Godlee told BBC’s Radio 4 that unless action was taken “we will have people sitting in ambulances, we will have people in corridors, we will have people who can’t get the emergency care that they need,”
The joint BMJ/HSJ editorial warns that on current projections, “hospitals in England will have just short of 19,000 Covid patients on New Year’s Eve”.
“This figure, derived by extrapolating a straight line from December 5 to December 14 through to December 31, would be almost exactly the same as the 18,974 peak of the first wave on April 12,” it states.
Both magazines are also scathing about Johnson’s Test and Trace service and about plans to use controversial rapid testing to replace more reliable tests.
″‘NHS Track and Trace’, which has almost nothing to do with the NHS, continues to squander money on failure. So too does the mass testing of asymptomatic people using lateral flow tests that are not fit for purpose,” they write.
Former health secretary Jeremy Hunt said ministers should listen “very carefully” to calls for a rethink of the planned relaxation of coronavirus restrictions over Christmas.
“To go into the start of January, which I remember from my own time as health secretary is always the nightmare period for the NHS, with the same number of beds taken up by Covid as was the case in the peak of this April would be a very, very dangerous and precarious situation,” he told BBC Radio 4’s The World at One.
Hunt, who chairs the Commons health and social care committee, added: “Curiously the economic impact could be worse from taking our foot off the pedal for Christmas if it meant that we then had to go into another national lockdown.”
The joint editorial in full
Since the UK’s first lockdown in March, the government has had one (perhaps only one) consistent message – protect the NHS.
Now, with the number of hospital patients with Covid-19 again on the rise, and a third wave almost inevitable, the new year is likely to see NHS trusts facing a stark choice: be overwhelmed or stop most elective and non-urgent work.
Rather than lifting restrictions over Christmas as currently planned, the UK should follow the more cautious examples of Germany, Italy and the Netherlands.
By and large the NHS has coped well with the additional case load of Covid-19 patients during the autumn. The second wave began to hit hospitals at the start of September. Government figures report 451 inpatients with Covid-19 in England on September 2. Over the ensuing 10 weeks, the numbers rose steadily and then rapidly, peaking at a reported 14,712 inpatients with Covid-19 in England on November 23.
If the third wave turns out to be of the same order of magnitude as the second wave, the health service should manage. But this will be the case only if that wave starts with a broadly similar extra caseload of Covid-19 inpatients as at the beginning of the second wave: around 450.
With current restrictions failing to control the virus, extrapolation suggests that the actual figure is likely to be more than 40 times higher. The planned relaxation of restrictions over Christmas will boost the numbers further as the NHS also struggles with the additional demands of winter.
England went into lockdown on November 5 and the number of inpatients with Covid-19 began to fall, down to 12,968 on December 5. If this rate of decline had continued, the English NHS would have been on course for just under 11,000 Covid-19 inpatients on 31 December. However, in the past two weeks, despite most of the country being in tiers 2 or 3, numbers of inpatients have started to rise again. By December 14 (the latest data available) Covid bed occupancy had climbed back to 15,053.
Unless something happens to change this trajectory, hospitals in England will have just short of 19,000 Covid patients on New Year’s Eve. This figure, derived by extrapolating a straight line from December 5 to December 14 through to December 31, would be almost exactly the same as the 18,974 peak of the first wave on April 12.
The NHS currently has around 95,000 general acute beds. It is operating with around 10% fewer beds than a year ago as a result of infection prevention and control measures introduced to try to stop the spread of covid in hospitals.
The cost of inaction
The main impact of a further surge in Covid-19 inpatients is likely to be felt most by those with other conditions. The NHS has learnt from the first and second waves and has robust plans to rapidly increase intensive care capacity, including through the Nightingale hospitals. However, a large influx of Covid-19 patients similar or greater than that seen in the autumn can only be managed if staff and other resources are diverted from treating non-Covid patients.
Having recovered much of their capacity for elective and non-urgent care during the autumn, NHS trusts in the most pressured regional health systems are already now having to cancel almost all such activity because of the resurgent virus.
A significant third wave could wipe out almost all the reductions in waiting times for elective procedures achieved in the past 20 years. Average waiting times are on course to reach 12 months by March next year. This will take years to recover from, at the cost of much suffering and loss of life.
The coming months are also likely to see the NHS under intense winter pressures due to seasonal outbreaks of norovirus, increased admissions of frail older people and the peak of staff absence. The NHS will also be in the middle of delivering the largest vaccination programme in its 72-year history, via already overstretched general practices and hospitals.
Even if NHS England succeeds in vaccinating all those “at risk” by Easter, this will not be in time to prevent hospitalisation and death for many during the next few months. “NHS Track and Trace,” which has almost nothing to do with the NHS, continues to squander money on failure. So too does the mass testing of asymptomatic people using lateral flow tests that are not fit for purpose.
Of particular concern is the impact on staff, many of whom have already worked through the hardest nine months of their professional lives. Levels of burnout and sickness absence are likely to exceed those already experienced.
What should be done
London and many neighbouring counties will enter tier 3 on Wednesday. However, other areas such as Kent which has been in tier 3 since December 2, are still seeing strong increases in hospital admissions. These measures are clearly inadequate.
Ministers are meeting on Wednesday to review current restrictions for England. When government devised the current plans to allow house-hold mixing over Christmas it had assumed the Covid-19 demand on the NHS would be decreasing. But it is not, it is rising, and the emergence of a new strain of the virus has introduced further potential jeopardy.
Members of the public can and should mitigate the impact of the third wave by being as careful as possible over the next few months. But many will see the lifting of restrictions over Christmas as permission to drop their guard.
The government was too slow to introduce restrictions in the spring and again in the autumn. It should now reverse its rash decision to allow household mixing and instead extend the tiers over the five-day Christmas period in order to bring numbers down in the advance of a likely third wave. It should also review and strengthen the tier structure, which has failed to suppress rates of infection and hospitalisation.
This joint editorial is only the second in the more than 100-year histories of the BMJ and HSJ. We are publishing it because we believe the government is about to blunder into another major error that will cost many lives. If our political leaders fail to take swift and decisive action, they can no longer claim to be “protecting the NHS”.
Alastair McLellan, Editor, HSJ
Fiona Godlee, Editor in Chief, The BMJ