Blog posts

General Practice in England: The Current Crisis, Opportunities and Challenges

General practice or family medicine has historically been lauded as the “jewel in the crown” of the English National Health Service (NHS). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons and evidence from several decades of research has shown that general practice in the UK has improved the nation’s health. Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models. However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS. This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in “crisis”. In this article published in the Journal of Ambulatory Care Management, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.

The full article can be read in the Journal of Ambulatory Care Management.

DOI: 10.1097/JAC.0000000000000410

Covid-19: Implications of ending the legal requirement to self isolate for employers and people who are clinically vulnerable

The government has just announced that all covid-19 restrictions in England are set to end. Boris Johnson, the UK prime minister, told MPs that he plans to remove the remaining restrictions, including the legal requirement to self isolate for people infected with covid-19. Instead of legislation, voluntary guidance will “advise” people with covid-19 not to attend workplaces. Employers will once again need to develop and implement new rules for their workplaces when the legal requirement to self isolate with covid-19 comes to an end. They should consider carefully how to develop and implement new policies fairly and safely in the workplace so that staff and customers—particularly those who are clinically vulnerable—are not put at risk.

Presenteeism occurs when employees go to work despite not being well enough to perform their duties. The NHS is the largest employer in England and the NHS Staff Survey showed a drop in presenteeism in 2020 compared to preceding years. This is likely an effect of covid-19, which forced workers and employers to endorse sick leave to prevent workplace outbreaks and has therefore gone some way to changing attitudes to calling in sick. Despite this, around 40% of NHS staff surveyed still reported coming to work in 2020, despite not being well enough to work.

Reasons why employees attend work while unwell include financial pressures. Statutory sick pay (currently £96.35 per week in England) is the minimum amount employers must pay to unwell employees; though not all workers are entitled to statutory sick pay—loopholes include agency work and zero hour contracts in certain situations. Though some workers are entitled to contractual sick pay which is closer to their normal salary, for many workers in England, taking sick leave means taking home less money; and sometimes no money at all.

Now that the legal requirement to self isolate will be scrapped, the government has announced that they will return to pre covid provisions of sick pay, with self isolation payments ending. Statutory sick pay and employment support will no longer be paid immediately, but only after four and seven days of absence. Workers who voluntarily decide to self isolate, but are unable to work from home, will in some cases face a loss in pay. The end to financial support for people to self isolate, or take sick leave, is concerning as people will no longer be financially supported to stay at home if they are ill. Those workers who are unable to work from home are more likely to be older, from lower socio-economic groups, and from ethnic minority backgrounds—factors that have cumulatively contributed to a higher occupational risk of death from covid-19 over the last two years.

The need for local health and safety policies will also leave employers with a dilemma. Should employers develop internal policies mandating self isolation for those infected with covid-19 to protect their workforce and their customers? The Health and Safety at Work Act 1974 places responsibility upon employers to ensure “as far as reasonably practicable” that both employees and non-employees are protected from workplace risks. The Equality Act 2010 mandates that employers make “reasonable adjustments” for employees with disability to protect them from workplace discrimination. For example, a retail assistant undergoing chemotherapy for cancer, for whom working from home is not possible, may be at high risk of acquiring covid-19 at work with significant medical complications now that the legislation mandating self isolation is going to be withdrawn. Who takes on the responsibility for this risk, and how can discrimination along the social gradient or against those with disability be avoided?

Presenteeism is not good for the individual attending work while unwell, nor is it good for the organisation. Covid-19, even when asymptomatic, brings risks of workplace outbreaks with significant impact on the operation of services due to sickness absences. Employers should consider workforce wide policies to encourage self isolation with fair pay when employees are infectious with covid-19, now that the legal mandate will be removed. Where this is not possible, individual occupational health risk assessments for employees vulnerable to severe covid-19 infection and its consequences should inform reasonable adjustments to their workplace duties. This will include, for example, examining how many people are allowed into the workplace at one time, ensuring good indoor ventilation, and mitigation measures such as high quality face masks are used as appropriate.

Employers will also need to consider factors such as the vaccination status of their staff and current community covid-19 infection rates in their health and safety policies. Most adults in the UK have now had two covid-19 vaccinations, but a large proportion (around one in three) have not yet come forward for a booster vaccine. Recent data show that the booster dose is essential in reducing the risk of serious illness, hospital admission, and death from a covid-19 infection caused by the omicron SARS-CoV-2 variant. Employers will need to work with their staff to promote covid-19 vaccination, but as the recent reversal in government policy for mandatory vaccination of healthcare workers shows, this is not straight forward. For the time being, community covid-19 rates are falling from the very high levels we saw in late 2021; and may remain at tolerable levels during the spring and summer of 2022. By next winter, however, we can expect a seasonal increase in respiratory viral infections, which will coincide with waning population immunity, placing more people at risk from covid-19.

Losing progress away from presenteeism will be a backwards step in all sectors of the economy as well as putting the most vulnerable members of society at greater risk. By ending mandatory self isolation while also removing financial support packages, the government is failing to adequately support people in lower paid occupations to protect themselves and others from covid-19, and risks widening existing socio-economic and health inequalities

Lara Shemtob, Kaveh Asanati and Azeem Majeed

A version of this article was first published in the British Medical Journal

DOI: https://doi.org/10.1136/bmj.o461

Questions and Answers on the New Covid-19 Rules in England

If you only have mild symptoms how safe is it to go into an office or other workplace?

The question you should ask yourself is would you be comfortable being in the same office as someone who had a positive Covid-19 test the day before? Now that the legal requirement to isolate after a positive test in England is ending, employers will need to carry out risk assessments and implement their own infection control policies. My advice would be for employers to remain cautious for now and advise employees with symptoms or a positive Covid-19 test to stay off work for a period until we have more experience about the effect of the change in rules.

I’ve had plans to go for dinner and drinks with friends for a birthday party but have tested positive. If we’re all triple vaccinated how big a risk is it if I still go?

People who are fully vaccinated can still become infected. If you test positive for Covid-19, I would advise not attending the event, particularly if it is going to be in a crowded indoor venue where there is a significant risk of infecting others who are present. Although Covid-19 vaccination does substantially reduce the risk of serious illness and death, there is still a risk to older people and those who are clinically vulnerable even if they are fully vaccinated.

Will GPs and hospitals still only see you if you have no Covid symptoms?

If you have Covid-19 symptoms, you should inform your GP or hospital before they see you so they can take suitable precautions. We are still awaiting guidance for the NHS on how the new rules will operate for them, such as whether face masks will still be required in healthcare settings. However, because they deal with people who are clinically vulnerable, the NHS will need to take appropriate precautions to prevent someone with Covid-19 infecting other patients.

I was told to shield during the lockdowns, and now triple jabbed. Is it safe for me to go to places where people might have Covid?

If you are in a group that was advised to shield during lockdowns, Covid-19 still poses a risk to you even if you are fully vaccinated. You should continue to wear a well-fitting FFP2 mask in places like shops and on public transport. Whether you go to places with a higher risk of Covid-19 such as nightclubs is a personal decision that you need to take but I would advise being cautious until infection rates in the community fall further.

I work in a care home. What if I test positive, do I go into work as normal?

People living in care homes are at very high risk of a serious illness and death if they become infected for Covid-19. Care homes should therefore keep appropriate infection control measures in place, such as asking staff who test positive for Covid-19 to self-isolate for a period.

If everyone is going about normal life even if they have Covid, what’s likely to happen to infections and could it lead to herd immunity?

In recent weeks, the number of Covid-19 cases, hospital admissions and deaths have been falling. The high level of immunity in the population from vaccination and previous infection should keep the number of serious cases of Covid-19 at a manageable level. However, people’s immunity does decline over time, which is why the government has just announced that those at highest risk from Covid-19, people aged over 75 years and those with weak immune systems, will be offered another booster vaccination. The long-term future remains uncertain and we don’t yet know if an additional booster will be offered to a wider group of people later in the year. We also don’t know what will happen next winter when there may be a lower level of immunity in the population. Finally, there is always the risk that a more infectious variant of the coronavirus may emerge like the Omicron variant that we faced late in 2021. Unfortunately Covid-19 will remain with us for the foreseeable future and become part of our lives, like other respiratory infections such as flu.

These comments were first published in the Daily Mirror.

A national vaccination service for the NHS in England

The Health Secretary, Sajid Javid, announced on 26 January that a ‘national vaccination service’ is required to provide mass covid-19 vaccination to the population of England.[1] Speaking at a House of Commons Health and Social Care Committee meeting, Mr Javid suggested the proposed service could cover other vaccines as well as vaccines for covid-19. The rationale is that NHS General Practice is under great strain, and by removing some services that can be provided elsewhere, it will free up time for primary care teams to concentrate on their core work.

Traditionally, mass vaccine programmes in England have relied largely on general practices, increasingly supported by community pharmacies in recent years. This was demonstrated to great effect during the first wave of covid-19 vaccinations where the majority of vaccines were delivered by primary care teams. GP teams have secure electronic patient record systems, and are experienced in cold storage chains, and have medical support on site, including resuscitation equipment. Patients often know and trust their family doctors, and generally respond better to recalls for vaccination when these come from their own general practices. A move towards mass vaccine centres and away from primary care delivery may explain some of the recent slow-down in England’s covid-19 vaccine programme.[2]

The public need to be fully informed about what a national vaccination service will mean for them individually as well as the NHS. The majority of all NHS contacts occur in general practice, with around one million contacts per day.[3] This means that vaccines can be offered opportunistically when patients are attending for other reasons as well as in dedicated vaccine clinics. It also allows primary care teams to have discussions about vaccination during these consultations in patients who have concerns or questions about vaccines, or who are vaccine hesitant.

When attending for vaccination, patients also have the opportunity to discuss other issues in their health with their primary care team and to benefit from opportunistic health promotion. All this helps to ensure that vaccination is viewed holistically and not just as a transactional activity. This is particularly important for children where non-attendance for vaccination can sometimes be a safeguarding issue which requires a sensitive approach from primary care teams, as well as effective inter-agency working.

When the Prime Minister, Boris Johnson, announced that he wanted all adults England to be offered a covid-19 vaccine before the end of 2021 he looked to GPs to help. As a result, GPs were asked to drop all non-essential work and focus on vaccination for the remainder of the year. This caused much debate in the national and medical press about what the priorities should be for the NHS and for primary care. Suspending “non-essential work” will have adverse effects on people’s experience of the NHS and risks worsening health outcomes, particularly for poorer groups.[4] It is clearly also a policy that cannot be sustained for long or repeated frequently (for example, for another covid-19 vaccine booster programme later this year).

The current plan to consider a separate national vaccination service for covid-19 and possibly other vaccinations seems to be an effort to ensure that GPs are not asked to stop routine medical care again. Although investment in the NHS is welcome, and removing some workload from general practice might have merits, there are some caveats that must be considered before a new national vaccination service is established.

Firstly, any new vaccination service must be more cost-effective than existing models of delivery of vaccines, such as through general practices and pharmacists. At a time when NHS budgets are under great pressure, NHS funding must be used cost-effectively and services delivered efficiently. A new national vaccination service would require substantial funding to establish and run. For example, it is difficult to see how a national vaccine service could run effectively without full access to patients’ electronic medical records. It would also require premises from which to operate, and staff to manage and deliver the programme. We need the government to show how this investment in a new service would compare in terms of cost-effectiveness with a similar investment in primary care teams.

Secondly, a national vaccination service must achieve a high uptake of vaccination. We currently have very good uptake of most childhood vaccines in England and in 2021-22, primary care teams also achieved a record uptake of flu vaccines, for an extended group of patients compared to previous years. Vaccinations must also be delivered quickly and at scale when in a pandemic, and there must be a safe and robust system to target high risk groups; such as those with frailty, long term conditions, the housebound, people living in care homes, and patients from marginalised groups.[5]

Thirdly, creating a separate vaccination service risks further fragmentation of primary care. As we have already seen with the covid-19 NHS 119 service, many patients will still contact their GPs about vaccination queries, even if this is no longer part of the NHS GP contract. This risks creating extra work for primary care teams that is not part of their core contract and for which they will not be paid; and will also be very frustrating for patients who will have to deal with more than one healthcare provider to have any issues they have about their vaccinations and how these vaccinations are recorded are dealt with. Finally, a newly established national vaccine service may recruit staff from primary care teams, both clinical and non-clinical, thereby further worsening the current shortages of staff in NHS primary care.[6]

The government must therefore carefully examine the merits of a separate national vaccination service; and any problems it may cause for existing services; including how it might affect vaccine uptake. Investing in and strengthening existing NHS primary care infrastructure in general practices and pharmacies may be a more cost effective option. Because of the importance of vaccination in allowing England to move to “living with covid-19”, vaccinations programmes must be implemented well and achieve a high take-up, particularly in the groups most at risk of serious illness, complications and death from infectious diseases such as covid-19. We cannot risk undermining the current vaccination systems that already work efficiently and cost-effectively in England’s NHS. Any proposals for a new national vaccination service must therefore be assessed with the same rigour we would with any new medical treatment with serious consideration of the risks as well as the benefits.

 A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o338

References

  1. Health secretary proposes ‘national vaccination service’ to relieve GPs.https://www.pulsetoday.co.uk/news/breaking-news/health-secretary-proposes-national-vaccination-service-to-offload-gps/
  2. Where are we with covid-19 vaccination in the United Kingdom?https://blogs.bmj.com/bmj/2021/07/09/where-are-we-with-covid-19-vaccination-in-the-united-kingdom/
  3. Appointments in General Practice.https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice–weekly-mi/current
  4. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.
  5. Covid-19 vaccines: patients left confused over rollout of third primary doses.https://blogs.bmj.com/bmj/2021/10/15/covid-19-vaccines-patients-left-confused-over-rollout-of-third-primary-doses/
  6. Oliver D. Act on workforce gaps, or the NHS will never recover BMJ 2022; 376:n3139

Reducing the covid-19 isolation period in England: a policy change that needs careful evaluation

How long people with covid-19 should self-isolate depends on the period for which they remain infectious. On 4 January, the US Centers for Disease Control (CDC) updated covid-19 isolation and quarantine recommendations with shorter isolation (for asymptomatic and mildly ill people) and quarantine periods of 5 days to focus on the period when a person is most infectious, followed by continued masking for an additional 5 days.1 This policy was based on a modelling study from the United Kingdom by Bays et al which showed that after the 5th day after a positive test, an estimated 31% of persons remained infectious.2 All the authors of this modelling study, which was published as a pre-print on 24/12/2021, work for UK Health Security Agency (UK HSA).

On 22 December 2021, the UK HSA reduced self-isolation for covid-19 cases in England from 10 to 7 days following negative lateral flow tests on days 6-7. The UK HSA stated that that a 7-day isolation period alongside 2 negative lateral flow tests had nearly the same protective effect as a 10-day isolation period without testing for people with covid-19.

On 1 January, the UK HSA published a blog on using lateral flow tests to reduce the self-isolation period.3 The blog provides background to explain the reasons for the difference between the policies. It also stated that after 10 days self-isolation, 5% of people will still be infectious; and that ending self-isolation after 7 days and two negative lateral flow tests resulted in a similar level of protection.

The two negative test results are essential in safely supporting the end of self-isolation. Without testing, modelling suggests that 16% of people would still be infectious after day 7.  On 13 January, the Health Secretary Sajid Javid stated that from 17 January people will be able leave isolation from the start of day six after two negative lateral flow tests on days 5-6.

Both the US CDC and the UK HSA have based their length of isolation policy mainly on a single modelling study. The data on which the modelling was based It is therefore very important. Bays et al provide a single reference for “infectious period distribution”, a UKHSA modelling paper by Birrell et al published on 31 May 2021.4 Hence, it did not contain any information about the Omicron variant of SARS-CoV-2. It gives as a data source: “the Wuhan outbreak additionally provides information on epidemiological parameters: the duration of infectiousness, the mean time from infection to symptom onset; the probability of dying given infection and the mean time from symptoms onset to death”.

The Wuhan report by Li et al was published in New England Journal of Medicine on 26 March 2020.5 It does not contain any empirical information on the time for which cases were infectious. It only estimates the mean serial interval (MSI), based on six cases only, which represents the average time between the time of symptom onset of a primary case and that of a secondary case.6 The MSI is widely used in infectious disease surveillance and control because it allows investigators to identify epidemiologic links between cases and to diagnose new cases that have such epidemiologic links with laboratory-confirmed cases.  The MSI in Li et al is 7.5±3.4 days (95% CI, 5.3 to 19). There is no information specifically about infectious periods.

Policies in both the UK and US are based on limited data and only on the wild-type SARS-CoV2 variant. Ideally, there should be population-based studies which included daily monitoring of culturable Omicron variant viral shedding (or even better actual transmission, which should be available from large databases) and PCR and lateral flow testing. A 2020 (so pre-Delta) rapid scoping review and analysis from Ireland of available evidence for serial testing asymptomatic and symptomatic cases showed substantial variation in the estimates, and how the infectious period was inferred.7 One study provided an approximate median infectious period for asymptomatic cases of 6.5–9.5 days. Median pre-symptomatic infectious period across studies varied over <1–4 days (and there are several recent studies of the Omicron incubation period showing it is short). Estimated mean time from symptom onset to two negative RT-PCR tests was 13.4 days (95% CI 10.9 to 15.8), but was shorter when studies included children or less severe cases. The only currently available study of the Omicron variant is a small Japanese report which showed the number and percentage of Omicron variant virus isolation positive samples as 7/17 (41.2%) after three to six days and 2/18 (11.1%) at seven to nine days.10

The change in isolation policy for people with covid-19 in England is a pragmatic step that will allow people to return to productive work, education and social activities more quickly. People may also be more likely to comply with a shorter isolation period. But the changes should have been based on careful monitoring and review based on new data on the Omicron variant, not on data on the wild type of SARS-CoV-2. We therefore need careful evaluation of the new shorter isolation period to ensure that people are following the guidance on self-testing and symptoms, and not ending their isolation period too early, and thereby putting others at risk of infection from covid-19.

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o184

References

  1. US Centers for Disease Control. What We Know About Quarantine and Isolation: Why CDC Shortened Isolation and Quarantine for the General Population: US Centers for Disease Control, 2022.
  2. Bays D, Whiteley T, Pindar M, et al. Mitigating isolation: The use of rapid antigen testing to reduce the impact of self-isolation periods.medRxiv2021:2021.12.23.21268326. doi: 10.1101/2021.12.23.21268326
  3. UK Health Security Agency. Using lateral flow tests to reduce the self-isolation period: UK Health Security Agency, 2022.
  4. Birrell P, Blake J, van Leeuwen E, et al. Real-time nowcasting and forecasting of COVID-19 dynamics in England: the first wave.Philosophical Transactions of the Royal Society B: Biological Sciences2021;376(1829):20200279. doi: doi:10.1098/rstb.2020.0279
  5. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia.New England Journal of Medicine2020;382(13):1199-207. doi: 10.1056/NEJMoa2001316
  6. Vink MA, Bootsma MCJ, Wallinga J. Serial Intervals of Respiratory Infectious Diseases: A Systematic Review and Analysis.American Journal of Epidemiology2014;180(9):865-75. doi: 10.1093/aje/kwu209
  7. Byrne AW, McEvoy D, Collins AB, et al. Inferred duration of infectious period of SARS-CoV-2: rapid scoping review and analysis of available evidence for asymptomatic and symptomatic COVID-19 cases.BMJ Open2020;10(8):e039856. doi: 10.1136/bmjopen-2020-039856
  8. van Kampen JJA, van de Vijver DAMC, Fraaij PLA, et al. Duration and key determinants of infectious virus shedding in hospitalized patients with coronavirus disease-2019 (COVID-19).Nature Communications2021;12(1):267. doi: 10.1038/s41467-020-20568-4
  9. Monel B, Planas D, Grzelak L, et al. Release of infectious virus and cytokines in nasopharyngeal swabs from individuals infected with non-B.1.1.7 or B.1.1.7 SARS-CoV-2 variants.medRxiv2021:2021.05.20.21257393. doi: 10.1101/2021.05.20.21257393
  10. National Institute of Infectious Diseases Disease Control and Prevention Center. Active epidemiological investigation on SARS-CoV-2 infection caused by Omicron variant (Pango lineage B.1.1.529) in Japan: preliminary report on infectious period: National Institute of Infectious Diseases Disease Control and Prevention Center, National Center for Global Health and Medicine, 2022. https://www.niid.go.jp/niid/en/2019-ncov-e/10884-covid19-66-en.html

Why the government’s new policy on face masks in England is a retrograde step

The government announced today that face masks will soon no longer be mandatory in England. Why is this a retrograde step in controlling the spread of Covid-19?

Covid-19 is an infection that is largely spread indoors – particularly in crowded, poorly ventilated areas – through inhaling droplets and aerosols produced by infected people when they cough, sneeze, sing, talk, or breathe. Face masks are a simple method of reducing the risk of infection – but masks work much better if they are worn by large numbers of people. The main function of a mask is to reduce the emission of droplets from infected people into the air. The droplets are captured by the mask and hence less virus enters the air. Much of the benefit of wearing face masks goes to other people but they can also benefit the wearer, particularly if a high-specification FFP2 mask is worn that filters out more particles and droplets when the wearer breathes in air.

Wearing face masks will reduce the spread of the coronavirus and help protect others. This is very important in settings where we are in contact with older and more vulnerable people – such as in supermarkets and on public transport. Wearing a mask has no major side effects, and does not change a person’s oxygen or carbon dioxide levels. Widespread wearing of face masks has been an important part of the pandemic control strategies of countries that have been more successful in containing the spread of Covid-19.

Vaccines are essential and can protect us from developing a more serious illness, as well as reducing the risk of death. But we must maintain the use of other control measures, such as the use of face masks, until we are past the worst of the Covid-19 pandemic.

Isolation for people with Covid-19 in England: Follow the guidance carefully

The UK government has announced that people in England self-isolating because of a Covid-19 infection will be able to end their isolation period after 5 full days instead of the previous 7 days if they test negative on both day 5 and day 6 with a lateral flow test and do not have a temperature. The change comes into force on Monday 17 January 2022. What are the implications of the government’s decision to reduce the isolation period to 5 days for people in England with Covid-19? In summary, it’s a pragmatic step with some benefits but there are also some caveats and concerns that the government needs to address.

A shorter isolation period will allow people to return to work, education and social activities more quickly than the previous 7-day or 10-day isolation periods that we had in England. This will help address workforce shortages in the economy and will also allow children and students to resume their education. A shorter isolation period may also lead to greater compliance, as many people do not comply with longer isolation periods.

But some people will remain infectious after 5 days, so there are risks from this policy. A lateral flow test will identify many of the people who are infectious but some will be missed by the tests. It’s essential therefore that people also focus on their symptoms and not just rely on the results of their lateral flow tests. We need to remember the expression that doctors have: “Treat the patient and not the test result.”

If you remain unwell after 5 days – for example., if you have a high temperature or a bad cough – you should continue to isolate. Although many people of working age will have a mild infection – particularly if fully vaccinated – some people will have a more prolonged illness. The government does not mention cough as one of the symptoms that should lead to a longer isolation period – probably because a cough can persist for some time after a respiratory infection. If you feel well and have a mild cough, that is acceptable. But if you have a severe cough, you should consider extending your isolation period to longer than five days.

People should also not rush back to work and other activities too quickly. Take the time you need to fully recover from your illness before you return to work or education. Everyone is different and we recover at different speeds from an illness. This is irrespective of the results of your lateral flow tests. Base your recovery on how you feel and not just on your test results.

The government’s new policy is largely based on one modelling study which estimated that people with negative lateral flow tests on day 5 & day 6 are as likely to be infectious as people after a 10-day isolation period (7% v. 5% is the government’s estimate). Ideally, we would have stronger evidence from real-world studies about people’s infectivity after different isolation periods (5, 7 & 10 days) and what extra information is obtained about infectivity from lateral flow tests. But this research would take some time to complete and review. The government has therefore taken the decision to act now – but it must assess the impact of its new policy and collect the data needed to do this.

We need careful evaluation of the new shorter isolation period to ensure that people are following the guidance on self-testing and symptoms, and not ending their isolation period too early, and thereby putting others at risk of infection. We also need to consider how the guidance would be applied for people dealing with clinically vulnerable people. This would include guidance for NHS staff, those working in care homes, and people providing social care.

Finally, would you want to share a room with someone who was 5 days past the start of their Covid-19 infection and who was coughing all over you? Follow the guidance, particularly on symptoms, and don’t just rely on the results of the lateral flow tests to predict how infectious you are to avoid placing others at risk of infection.

London is an important barometer for the omicron wave in the United Kingdom

Over the last few weeks, the United Kingdom has experienced a record number of covid-19 infections, driven by the rapid spread of the Omicron coronavirus variant, with the daily reported case numbers approaching 200,000 on some days. This has placed considerable pressure on the NHS through a combination of people seriously ill from covid-19 and staff absences. Other parts of the economy such as public transport have also been badly affected by staff absences.

A sustained period of high infection rates would be very damaging for the UK. But there are now signs that the number of covid-19 cases in London – the first area of the UK to face the wave of infection from Omicron – may have peaked. In which case, a similar pattern of declining case numbers may be seen in other parts of the UK later this month.

There were several factors that drove the early increase in Omicron cases in London. London is the UK’s main international travel hub with the UK’s busiest airports located nearby. Overseas travellers who are infected with a new coronavirus variant are more likely to arrive in the London region than in other parts of the UK. London also has a very large number of international visitors – for activities such as work, study, tourism, leisure, and sports events. London is the also UK’s largest city and is very densely populated, with many overcrowded households, often with people from three or more generations living together, which makes infections more likely to spread, including to clinically vulnerable groups who will be at much greater risk of adverse outcomes such as hospitalisation.

London also has a lower covid-19 vaccination uptake than other parts of the UK. Around 20% of people aged 12 and over in London remain unvaccinated, compared to a national average of about 10%. Although vaccines provide less protection from symptomatic infection with Omicron than from the previously dominant Delta variant, they do still provide good protection from serious illness, particularly in people who have had  their booster vaccination. The lower vaccination rate will lead to infections from Omicron spreading more quickly in areas such as London; as well as increasing the likelihood of severe disease. This would in turn increase hospital admissions from covid-19 and pressures across the NHS in London.

After increasing vary rapidly in London, the Omicron wave now shows signs of abating with the number of covid-19 cases and hospital admission dropping in recent days. We can’t confirm yet that the drop will continue; and nor what the impact will be of schools, universities and workplaces reopening. But if the decline is sustained, other parts of the UK can also expect to see similar falls later this month with case numbers dropping first, followed by a drop in hospital admissions after a lag period. This means that the outcome of the Omicron wave well may be less severe than predicted in the more pessimistic government models, particularly in the areas of the UK with the highest vaccination rates.

However, we can’t yet relax our covid-19 control measures. The number of covid-19 cases in the UK will remain high – compared to previous waves – for some time. The NHS will continue to be under pressure, perhaps for many months, trying to cope with the impact of covid-19 on top of the usual winter pressures that it faces each year whilst also trying to deal with the backlog of work that has built up during the pandemic. The NHS will also continue to be affected by staff shortages due to illness. Although the government may wish to declare “victory” against Omicron and end its Plan B measures later in January, it should refrain from doing so. The public also need to continue to practise good infection control measures, building on the “Three C Approach” to personal safety limit the impact of covid-19.

Measures such as wearing face masks in indoor settings should remain in place, with the government and public health agencies encouraging people to use well-fitting FFP2 masks that provide better protection for the wearer, rather than loosely fitting surgical or cloth masks. More targeted use also needs to be made of publicly-funded lateral-flow tests. Finally, the covid-19 vaccination drive must continue – for those who are currently unvaccinated as well as for those who are now eligible for a booster vaccine. A high uptake of booster vaccines will protect against serious illness and buy time until modified vaccines that target Omicron become available later this year.

In conclusion, the experience of London offers some positive news for the rest of the UK and for the government. But we must remain cautious and continue with our covid-19 control measures until infection rates are substantially lower than they are now. We also need to be fully prepared to deliver another booster vaccination programme later this year, whilst also continuing to target the 10% of people aged 12 in the UK and over who remain unvaccinated.

A version of this article was first published in the British Medical Journal.

It’s time for more targeted use of lateral flow tests for Covid-19

Lateral flow tests for Covid-19 that give a result quickly are a key part of the government’s plans to manage the covid-19 pandemic in England.[1] They are required for key workers such as NHS staff; and for people following guidance from Test and Trace, either because they have a covid-19 infection or have been a close contact of a covid-19 case.  The government also announced recently that other groups of workers in essential industries would be required to carry out regular lateral flow tests.[2] This would be in addition to the tests required by other groups, such as school children.

And yet, despite their potential value, the government has been distributing the tests in a very haphazard fashion; with the outcome that many groups – such as NHS staff – are complaining that they are unable to obtain tests.[3] Meanwhile, other groups of people have been using the tests excessively – including families carrying out daily tests on each family member and in some cases, carrying out multiple tests each day. People have also been using the tests to “monitor” themselves daily after a positive PCR result for covid-19; something that is not currently required except for tests on day 6 and day 7 of the isolation period in fully vaccinated people.

As with any area of healthcare, the NHS in England has a limit on the number of lateral flow tests it can offer. Earlier this month, the government stated it was delivering 300 million tests per month.[4] However, even 300 million tests each month (around 10 million tests per day) is nowhere near enough to offer everyone in England a daily lateral flow test. Hence, an appropriate system is needed for prioritising who should have access to the tests; and how the tests are supplied to these groups. The current system whereby most people obtain their tests from the government’s online ordering system means that the tests may not always be  used appropriately or by the people who have the highest priority for testing.

The NHS already has well-established systems for prioritising access to health services. We saw this, for example, with the Covid-19 vaccination programme when early access to vaccination was based on clinical need and for occupational protection.[5] This meant that the elderly, the clinically vulnerable and those working in healthcare had the earliest access to vaccination. The same process has not happened in prioritising access to lateral flow tests. Given the high cost of supplying tests to England’s population and their limited global availability, as more countries aim to increase their own use of the test in the face of the wave of infection from the SARS-CoV-2 Omicron variant, it’s essential for the government to reconsider its policies on community covid-19 testing.

The government is in part responsible for the increased demand for testing from the public that has led to the current shortage of tests. It has encouraged members of the public to test regularly; for example, before social events such as parties; and before meeting friends and family from outside their immediate household. However, it has not offered clear guidance on how frequently to test. NHS staff, for example, are only advised to test twice weekly; far less than some members of the public are currently doing even though they have no medical or occupational reason to test more frequently.

How can we improve how well lateral flow tests are used? As a first step, the government needs to decide what groups should be prioritised for testing and how frequently they should test. Once the size of these groups and their frequency of testing are known, the government can allocate a large enough sample of tests to meet their needs. Priority groups for access to lateral flow tests will include NHS staff in patient-facing roles; other key workers such as the police and fire service; workers in essential parts of the economy such as public transport; carers of vulnerable people and people working in social care; and people following guidance from Test & Trace. Tests are also needed by schools where testing of pupils is taking place.

We also need to look at the costs of supplying these tests and determine what we can afford to spend on them. Although the tests are supplied at no cost to the public, they are not free and will come at a considerable cost to the taxpayer. Access to diagnostic services and other health services always has to be limited; and based on factors such as clinical need, health outcomes, and cost-effectiveness. The same rules should apply to lateral flow tests so that the maximum benefit is obtained from spending on covid-19 tests.[6]

With the UK now facing record numbers of people with covid-19, we need the government to act quickly, decisively and rationally to ensure we maximise the benefits of England’s covid-19 testing capacity. Lateral flow tests can play an important in England’s pandemic response but the same principles of prioritisation should apply in their use as in any other area of healthcare provision.

A version of this article was first published in the British Medical Journal.

References

  1. Majeed A. Questions and Answers about Lateral Flow Tests for Covid-19.https://blogs.imperial.ac.uk/medical-centre/2021/12/23/questions-and-answers-about-lateral-flow-tests-for-covid-19/
  2. Walker P.100,000 key workers in England told to take Covid test every working day. https://www.theguardian.com/world/2022/jan/04/100000-key-workers-in-england-told-to-take-covid-test-every-working-day
  3. Majeed A. Of course England is running out of Covid tests – the strategy is a flawed one.https://www.theguardian.com/commentisfree/2021/dec/30/running-out-covid-tests-strategy-flawed
  4. Johnson B. PM statement to the House of Commons on COVID-19: 5 January 2022.https://www.gov.uk/government/speeches/pm-statement-to-the-house-of-commons-on-covid-19-5-january-2022
  5. Majeed A, Molokhia M. Vaccinating the UK against covid-19 BMJ 2020; 371 :m4654 doi:10.1136/bmj.m4654
  6. Raffle A E, Gill M. Mass screening for asymptomatic SARS-CoV-2 infection BMJ 2021; 373 :n1058 doi:10.1136/bmj.n1058.

Questions and Answers About New Variants of SARS-CoV-2

Why are some scientists concerned about the new Covid variant that has been found in France?

Whenever a new variant of the coronavirus that causes Covid-19 is identified, there are always concerns that it may prove to be more infectious than previous variants and spread quickly in the population. We saw this previously with the Alpha, Delta and Omicron variants, each of which spread rapidly in the UK, leading to waves of infection that put a lot of pressure on the NHS.

Should we be worried, and why?

The B.1.640.2 variant was first identified over a month ago and so far, it has not caused the massive global spike in Covid-19 cases we have seen with the Omicron variant. There is now very good identification of variants in many countries, so that the spread of a new variant can be monitored. If a variant is spreading rapidly, the World Health Organization will label it as a Variant of interest (VOI) or a Variant of Concern (VOC) depending on its severity. This has not happened yet with B.1.640.2. We should remain cautious, monitor the spread of any new variant, including B.1.640.2, but not get over-anxious.

Both Omicron and the new variant appear to have emerged in Africa, which has the lowest vaccination rate. Is that the reason?

Variants can emerge anywhere. The Alpha variant was first identified in the South-East of England and the Delta variant was first identified in India.

Will it become normal for variants to emerge and spread around the world like Omicron?

The coronavirus that causes Covid-19 will mutate constantly. Most mutations are of no great consequence but occasionally a mutation will appear that can cause a wave of infections – such as the Alpha, Delta and Omicron variants. We may well see other variants emerge and spread around the world in the future.

Are variants getting milder, or is it possible that another variant will be deadlier?

There is no guarantee that a variant will be milder. The Alpha and Delta variants were shown to be more likely to cause a serious illness that the original version of the Coronavirus. In the case of Omicron, the evidence thus far shows that it generally causes a milder illness than other variants. However, because of the very large number of Omicron cases, some people will still have a serious illness.

Could Omicron bring about the end of the coronavirus pandemic?

It’s unlikely that Omicron will bring an end to the Coronavirus pandemic. However, with updated vaccines that can target a new variant such as Omicron and antiviral drugs that can be used early in an illness, we can suppress the severity of disease caused by Covid-19 and allow people to live more normally.

If the world has to live with Covid, what might that look like?

This will vary from country to country. In the UK, high levels of vaccination – including with a modified booster vaccine later this year to target Omicron if the government approves this – combined with antiviral drugs will allow our society to function more normally. Countries with low vaccination rates and weak health services are still likely to face large waves of infection. It’s possible that we will need regular vaccinations – as for flu – to allow us to live with Covid-19. It is also always possible that a variant will emerge against which vaccines are less effective. But the good news is that vaccine manufacturers can modify their vaccines quickly if this happens.

Why is the booster important for Omicron?

The immunity provided by Covid-19 vaccines weakens after a few months. A booster vaccine substantially increase people’s protection from serious illness, including from Omicron. Ensuring that people are fully vaccinated with three doses of vaccine will reduce the number of people who are seriously from Covid-19, and keep down pressures on the NHS.

A version of this article was first published in the Daily Mirror.