Dr Simon Clarke

If tiers don’t work, expect a third wave in the new year

If tiers don’t work, expect a third wave in the new year
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‘The difficulty is that we’re coming out of the tough autumn measures, out of the lockdown… with the incidence of the disease still pretty high,’ Boris Johnson explained on Friday.

It is against this backdrop that he finds himself trying to sell tougher Covid rules as England emerges from the November lockdown. It is an especially difficult sell, of course, when an area has been placed in a higher tier than before the lockdown – even if, as in many instances, cases are now lower than when the tier system was first introduced. It understandably appears incoherent and arbitrary.

The Prime Minister’s case is that he hates lockdowns too, but observing the Tier system properly is the quickest way to normality. A failure to do so will mean we end up back in lockdown. 

Realism, on this score, is vital. And it’s a hard sell. Fatigued by restrictions on everyday life, people are questioning the effectiveness of the second lockdown. If it worked, why are we being put in a tougher tiers regime than we were in before?

This, however, misses the point: we were not in a great place at the end of October.

The original tier restrictions were ineffective at stopping the virus spreading (at least for those in the lower two levels), which meant tougher restrictions were needed.

Now, if we do not get the rules right in the coming weeks – properly regulating our contacts in a way that is effective – then we could well find ourselves in the same position again, facing a third lockdown in early 2021.

It is inevitable that relaxing restrictions over Christmas, with two million students returning home, will increase the number of new infections. What’s more, January and February are the worst months for respiratory infections anyway, regardless of the current pandemic. These factors combined will, inevitably, translate into more hospital admissions and fatalities.

It’s not just Britain: people are being cautious all over Europe: France will be in lockdown until 15 December, but bars and restaurants will remain closed; Spain is in a state of emergency that allows each region to impose their own set of restrictions; and Italy has a tier system but there are increasing calls for another lockdown. In Germany, lockdown has just been extended until 20 December and possibly into January, save for a few days of Christmas respite. This is necessary, according to Angela Merkel, because ‘the daily cases are still far too high, and our intensive care units are still very full’. She is absolutely right, of course (and Germany is a country with more hospital beds than almost any other European country).

Lockdowns are principally used to lower human contact, reduce the risk of transmission and consequently ease the pressure on healthcare systems. It is easy to forget that. The main rationale for lockdowns is that they stop the health system being overwhelmed: if critical care is allowed to fill up with Covid-19 patients, where are people going to end up if they’re seriously hurt? This covers anyone and everyone, whether that’s someone young involved in a serious traffic accident or someone of working age who suffers a ruptured brain aneurysm.

The issue with Covid-19 is that when you should act, you appear mad; and when you have to act, it is usually too late, as fatalities are sky-high and gross damage has already been done to the healthcare system. This is because of the in-built delays in infections leading to hospitalisations and deaths. This makes Covid a guessing game: working out how today’s infections translate into tomorrow’s hospitalisations and deaths. Governments, therefore, need to constantly be aware of the state of their healthcare systems when they formulate post-lockdown restrictions, tiered or not. This is why the Tier system – that takes into account NHS capacity – makes sense.

What’s more, even as infection numbers decline, many patients will remain in hospital receiving treatment. By the time that non-essential shops were allowed to open and mask wearing was mandated on 15 June, English hospitals had more than 300 Covid-19 patients requiring a ventilator to keep them alive. Throughout the summer it stayed at around 50 to 70 patients. Today, that number is over 1,200; there are around 4,100 regular adult intensive care beds in England.

If infections start to climb again anytime soon, the NHS could be burdened with third wave patients before it’s finished dealing with the second wave. Senior NHS management are privately very worried about these sorts of yo-yoing waves of infection and the consequent pressures on intensive care facilities.

There is a popular notion that we could simply ‘learn to live with the virus’ and that lockdowns are unnecessary: the elderly and vulnerable could shield while the rest of society gets on with life. A seductive notion, certainly – but the sad truth is that, while 90 per cent of deaths are amongst the over-65s, the age of hospitalisations is more broadly spread.

The average age of a Covid-19 patient admitted to intensive care in England, Wales and Northern Ireland is 60, according to data from the Intensive Care National Audit and Research Centre. Shockingly, more men in their 40s, in fact, are currently being admitted to ICUs with Covid-19 than people aged 80 and over. If there was a surge in hospitalisations and doctors were finding it difficult to cope, a great deal more of these younger patients would be at greater risk of dying than they are now.

Remember, intensive care is the most serious and harsh level of care available – it is a battle to keep the very sickest people alive, without which they will almost certainly die. If we were simply to tough it out and get on with our lives, it would mean a battle of attrition with hospitals trying to save a great deal of working-age people. People with families, young children and lives not yet fulfilled.

While the Nightingale field hospitals stand ready, they are not the easy shock-absorber they are often portrayed as. It is absurd to think that the NHS has an army of doctors and nurses ready, trained to slip from the wards and into intensive care. It takes time to understand the blood results and the physiological signs that mean a patient requires an instant response in intensive care. Likewise, knowing how to administer drugs to keep patients sedated and pain free, to tailor ventilation exactly to the needs of individual patients and ensure that they are being fed properly via their nasogastric tube, requires experience. The NHS is already pretty full.

MPs and metro mayors are already turning up the volume when it comes to special pleading for their areas and the Prime Minister has said that restrictions will be reviewed in little more than a fortnight on December 16. But that will be too early to really have an idea about how well the tiered restrictions are working and only about a week before they’re lifted for the Christmas amnesty, which seems likely to make things worse, not better. Indeed, Chris Whitty has said that it can take up to three weeks for the impact of restrictions to appear.

Andy Burnham, Mayor of Greater Manchester, bitterly resisted efforts to move Manchester into Tier 3. Around the country, other local politicians, from all sides of the political spectrum, followed his lead, sometimes in the face of professional medical advice. As a result, they now find themselves with higher virus levels – and in Tier 3 rather than in Tier 2. Liverpool, however, which had a terrible outbreak, took a starkly different approach and is now in Tier 2. The city region accepted the urgent need for action – so far it has paid off.

History could now repeat itself and the obstinate refusal by the same people to accept the current restrictions could very well tip us into a third lockdown, with all the societal and economic costs that involves. Ministers are rightly pointing to Liverpool, which accepted Tier 3 status but has since seen its cases fall by three-quarters.

No one in Liverpool wanted to take tougher local lockdowns, or Tier 3. But it has made more progress than almost anywhere else in tackling the second wave. In a recent interview on this topic, Tory MP Neil O’Brien summed it up perfectly, when he advised his colleagues: ‘It’s more important than ever that you try and present what is true, rather than what you hope is true.’

Nobody sane enjoys lockdown – but that’s the point. Observing restrictions properly will mean they are over quicker. The Tier system is local, proportionate and yes – I’m afraid – necessary. We can all understand why so many Tory MPs wish that things were different. But we can also all understand why that isn’t a policy.