Chris Hopson

4/25 Third. Very low numbers of COVID-19 admissions where patients have had two vaccinations and protection build up post second jab. Trusts tell us the vast majority of those people who have had two vaccinations and need hospital care also have pronounced co-morbidities.

5/25 It's particularly interesting that leaders in “front of wave” hotspots are now seeing community infection and COVID-19 inpatient numbers declining. They feel they’ve coped well with this latest surge. Nobody wants to be too definitive at this point, understandably…

6/25 …But increasing confidence that, in “front of wave” hotspots, for this pattern of variant, vaccines have broken chain between COVID-19 infection and high levels of hospitalisations and then mortality in previous waves. This confirms trial data and feels very significant.

7/25 But trust leaders, as a group, are clear that, from their perspective, there are still significant risks here, to feed into decision for 21 June. They are highlighting three risks. Risk 1. The Delta variant is clearly significantly more transmissible than other variants.

8/25 Risk 2. There are still significant numbers of people who are yet to have their second dose and the subsequent period of protection build up. Risk 3 (in detail). The NHS is very busy at the moment with care backlog recovery and a busier than expected urgent care pathway…

9/25 …Busy emergency pathway including care for patients whose conditions are now more complex following lockdown. Summer weather has also added extra immediate demand. Increased crisis mental health presentations and slowing flow in discharges are further pressures.

10/25 Important to remember that NHS already had insufficient hospital capacity before we went in to COVID-19. And current hospital capacity is significantly reduced because of the need for rigorous infection control which also adds much greater complexity to care provision.

11/25 Trust leaders are therefore reporting high levels of pressure. With extra summer demand of an unknown size to come on top. It's important to recognise that some of this demand is “controllable” – for example the NHS can slow down backlog recovery if absolutely needed…

12/25 …But it is much more difficult/impossible to slow down urgent and emergency care demand or mental health crisis presentations. Some have wrongly interpreted us highlighting these pressures as meaning we don’t want to ease lockdown on 21 June or want delay…

13/25 …This is untrue. We have not called for a delay – just for a better quality debate. So what does all this mean for the decision on June 21 and what would a better debate look like? Start with some basic facts that bear constant repetition as they can get lost.

14/25 The covid virus is still present. Vaccines mitigate the effects of disease caused by the virus and slow its transmission. They don’t eliminate the virus itself. There are still significant sections of the population not fully vaccinated (double dose & protection build up).

15/25 Vaccines not 100% effective. COVID-19 spreads via social interaction. Relaxing lockdown on 21 June will increase infection rates. This will mean extra hospitalisations & higher mortality. But “front of wave” hotspots suggest lower hospitalisation/death rates than before.

16/25 And 21 June doesn’t need to be a simple, binary, “keep everything in place” or “change nothing” decision point. We can relax some restrictions and not others. And we can delay the easing of some of the restrictions for whatever period of time the Government chooses.

17/25 On that basis, here are five questions on the 21 June decision that trust leaders think need to be considered. Recognising it’s the Government’s job to balance all the different factors here (NHS, health, economic, social, personal freedom etc) and take a final view.

18/25 Q1. Do we need to wait for more evidence on hospitalisation and mortality rates – both in “front of wave” areas and to check “middle of wave” areas will behave in same way? If so, what evidence and how much more of it do we need? And how much longer will that take?

19/25 Q2. If full vaccine protection requires a double dose and a period of protection build up (2-3 weeks), how much, and which sections, of the population do we want to have passed this milestone before we ease restrictions? Should we set a data driven target here?

20/25 Q3. Relaxing restrictions will lead to higher levels of mortality. What level of risk are we prepared to accept here, recognising this is a deeply uncomfortable debate and one that we are totally unused, as a society, to having? Comparison with flu worth remembering here...

21/25 …We live with and “accept” a certain level of annual mortality due to flu, without debate. But COVID-19 is a new disease that requires us to balance prevention of harm and mortality with other harms and detriments. We need a more honest & open debate on these trade offs.

22/25 Q4. Given current pressures on NHS, increases in COVID-19 hospitalisations will likely lead to delay in treatment for other patients, for example slowing down care backlog recovery. Are we ready to accept this trade off and how do we measure whether it is the right one?

23/25 Q5. How do we balance the risks and benefits here? And if we need to strike a balance between two extremes of “delay all as precaution” and “go ahead in full as planned” what should that balance look like? Which restrictions being eased carry more and which carry less risk?

24/25 For the record, trust leaders are sceptical of value of predictive statistical models here given their performance over last 15 months. Leaders point to the crude assumptions that have to be made and the huge shifts in outcome if small changes are made to those assumptions.