As part of a series examining the challenges and opportunities for healthcare, Sally Williams hears from Dr Jonathan Bennett, Honorary Professor of Respiratory Sciences, University of Leicester, Respiratory Consultant at Glenfield Hospital and Chair of the British Thoracic Society. This is what he said on 4 June 2020.
The Government’s advice for people who are shielding changed at the weekend. The changes were unexpected, and doctors were not informed in advance. Our team has received a lot of calls from patients who have been shielding at home for more than ten weeks and are uncertain as to whether they should venture outside.
A more nuanced approach
The guidance to clinically vulnerable people draws on evidence, where we have it, but there’s also a lot of guess work.
In the same way there’s been talk of having local lockdowns that reflect the incidence of COVID-19 in regions, I’m hoping for more nuanced advice on shielding. People with severe respiratory conditions including cystic fibrosis, interstitial lung disease, severe asthma and severe chronic obstructive pulmonary disease (COPD), are amongst the ‘clinically extremely vulnerable groups’ who are at greatest risk of severe illness from coronavirus. Certain people with asthma are likely to have the same risks as the general population, but others will be at higher risk. We need to better understand this, as well as how people on immunosuppression therapies, and those with cancer or on treatment for cancer, for example, tend to experience COVID-19, so that we can best protect people whilst also allowing them to have some sort of “normal” life.
Several changes have been introduced to lockdown this month. Some children are returning to school, we’re allowed to spend more time outdoors in groups of up to six people from different households (still social distancing), and we can visit car showrooms and outdoor markets. With so many changes happening at once, from a scientific perspective, it will make it difficult to know which is most influential if the infection rate alters. When treating a patient, I introduce one intervention at a time to see if that’s the change that makes the difference. If I make several changes at once I won’t know which is the most significant.
The track and trace system is based on the same principles public health, respiratory and infectious diseases departments have used for decades to manage outbreaks of tuberculosis. It has worked successfully in the past, but ongoing investment in public health has been limited, so I’m unsure whether the infrastructure is there to ramp up to the magnitude needed to tackle COVID-19. Let’s hope that we are successful.
A second surge
In my organisation, our COVID-19 rate hasn’t yet reduced. We still have the same number of people in hospital with COVID as we did last week and the week before. Colleagues at other hospitals also report blips in COVID numbers.
We’re hoping that there isn’t going to be a second surge, but there’s a worry there will be one. And the strategies that enabled us to cope with the first peak may not be workable second time around. When we entered lockdown, the hospital adapted quickly. Elective care was halted, and dozens of doctors and nurses were reallocated to other clinical areas. Those staff have now returned to their usual roles. If we get a second surge, I think it’s unlikely that the same cessation of elective NHS activity will happen. This will put a lot of strain on clinicians at the front door. It’s a particular worry for the staff in respiratory medicine and intensive care, who haven’t had any respite.
If a second surge happens, maybe it will occur as early as July and August. The first peak was in April and the beginning of May, suggesting a lag period of six to eight weeks, as the virus took hold in February and March.
Over a couple of days last week, I saw about 60 patients on the admissions unit. Some had come to the unit from A&E, some from primary care and some by ambulance. Most people had been triaged as ‘query COVID’. In reality, the likelihood of COVID depends on a person’s circumstances. If you’ve been shielding for ten weeks, the chances of having COVID is small. On the other hand, if you’ve had three or four carers come into your house each day to support you, then you’ll be high risk for a positive COVID diagnosis.
Too often, we aren’t asking individuals sufficient questions as to their exposure and then undertaking risk stratification – in other words, making a clinical assessment of who is at high, medium or low risk of having contracted COVID-19. It’s a reflection of how COVID-19 has clouded clinicians’ minds. Risk stratification is important as it will influence the pathway patients take through the hospital and our ability to minimise intra-hospital transmission. It still takes 48 to 72 hours to get COVID swab results, and if everyone is queried as possibly having COVID, there aren’t enough isolation facilities to keep patients apart during the wait for test results.
Of the 60 patients I saw, I was struck that not one person had seen a GP face to face. It reflects changes in the way GPs are conducting consultations. Public behaviours are also shifting and quite a lot of people are choosing not to contact their GP. Some will be self-medicating, some will ride out pain and discomfort, or put off seeking treatment for their symptoms. Only time will tell how much significant ill-health has been missed during this period.
The follow-up of patients who have been significantly ill with COVID-19 has just begun. Some patients who were discharged from hospital having been very unwell with COVID-19, have been readmitted because they remain breathless. We don’t yet know what the medium or long-term outcomes will be for these patients, what they will require in terms of tests or other interventions, or what rehabilitation they might need in the community.
There’s a group of very bright people who are gathering data and putting in place systems to analyse it rapidly so that information can be disseminated to the frontline quickly. Data that usually take six to 12 months to collate, and another six months to publish, is being analysed and shared much sooner. An initiative is also underway to set up a registry for clinicians to enter data on outcomes for patients who’ve had significant COVID-related pneumonia. This will help us to understand how best to support these patients.
Collaboration is happening across the NHS to provide massive datasets. Experts in different fields are working out the best data to collect and new ways to maximise the information at hand. Until this becomes available, we’re relying on the modelling that scientists are doing, topped up by guess work and a healthy dose of hope!
As told to Sally Williams
Image by Devanath from Pixabay