As people in the UK go back to pubs, socialising and outdoor activities, it feels like the long, hard third wave of COVID-19 in the country is ebbing away and life is slowly returning to normal.
But the reality is that this disease still in full swing. It is devastating other parts of the world including Brazil and India. It is clear that we will all have to live with COVID-19 for some time – if not forever.
The widely debated “zero COVID” strategy, to eliminate the virus from a region or country, is laudable. But without concerted and effective travel, quarantine and contact tracing measures, it will remain a beautiful dream.
So, if we assume that COVID-19 will become endemic, what will the future of care for patients look like?
The long haul ahead
The UK’s post-Christmas COVID-19 peak showed how much we all crave “normal” human contact, touch and communion. However, it also laid bare the perils of transmission in communities with low levels of immunity.
It is entirely understandable that many hope mass vaccination will support us to get our lives back.
The speed of the development, evaluation, and roll out of highly effective vaccines is unparalleled. The UK government aims to have offered a first dose of vaccination to the entire population by August 2021.
But vaccine uptake varies widely. Although the gap is narrowing, people from black, Asian, and minority ethnic backgrounds, including healthcare workers, still appear less likely to be vaccinated. This finding is also reported in those from poorer areas or with chronic illnesses. Similarly to other vaccines, efficacy may be lower in people with cancer.
As clinicians, we should also be aware that people who are re-infected or previously vaccinated and become ill with COVID-19 may present with new, attenuated or unusual symptoms or syndromes. This is especially the case in those with impaired immune systems.
Innovations in treatment
The good news it that we are learning more and more about how to treat people with COVID-19.
Thanks to the Recovery trial run by the University of Oxford, we now know that the cheap and widely available steroid dexamethasone reduces deaths in people hospitalised with COVID-19 who require oxygen.
There are also encouraging results that indicate that the drugs tocilizumab and sarilumab may have a role in treating severely unwell, hospitalised people. These drugs act by reducing the body’s inflammatory response to COVID-19.
People hospitalised with COVID-19 are at high risk of developing blood clots. There are multiple studies that show blood-thinning medicines can prevent and treat COVID-19 clots and improve outcomes. But increased use of blood thinning agents will increase the number of people experiencing their recognised side effects, including bleeding. Using these medications more widely will require us to strike the appropriate balance and ensure that we monitor patients carefully.
Although the advances above are monumental, medicines and tests alone are not enough. We need to ensure people are at the heart of the care we provide.
Understanding the perspectives of people with COVID-19 is a good starting place.
In our Liverpool hospital, we have conducted satisfaction surveys of people admitted with COVID-19 throughout the pandemic. These are the first reported studies about the perceptions of people hospitalised with COVID-19 in the UK.
Our first wave results showed satisfaction with the care received was high and patients felt safe on the wards. It also revealed some areas for improvement including communication about medications and their side effects, food and sleep quality.
To improve patient care, in August 2020 we implemented an educational package for healthcare workers looking after people with COVID-19. Following the training, our preliminary second and third wave results showed improved care ratings, especially with regard to communication. The results also suggested that people of black, Asian and minority ethnic background reported similar satisfaction to white people.
The results are particularly encouraging given the pressures on the NHS at the time the survey was carried out.
The spectre of long COVID
A recent pre-print – a study that has not been reviewed by other scientists – suggests that nearly half of people hospitalised with COVID-19 report not feeling fully recovered on average seven months later.
Indeed, as many as one in ten of all people with COVID-19, including children, will have ongoing related symptoms some months later. This suggests that there will be millions who fall into this category around the world.
Predicting who will get long COVID is tricky. Aside from age and obesity, common risk factors for COVID-19 disease do not correlate with long COVID risk. In contrast with COVID-19 acute illness, working-age women are most likely to be affected by long COVID, according to another pre-print study.
It is clear that the best way to prevent future cases of long COVID will be to avoid infection in the first place. But for those who do acquire long COVID, funding has been made available to expand care at specialist centres. However, evidence-based treatment and return-to-work schemes for COVID-19 remain scarce.
Garnering the required evidence to treat long COVID will require better disease recognition, diagnosis and reporting.
Throughout the pandemic, healthcare professionals have had to become adept at virtual consultations.
In future, there will be a more blended approach to communication. This will combine in-person consultations, video, phone and two-way messaging platforms. It is also likely that, as per the NHS Long Term Plan, other digital innovations such as wearable monitoring and tracking devices will become more widespread.
We have to work hard to ensure that such advances do not leave out people with limited access to the internet, including the elderly, poorer households, the learning disabled, those with language barriers and migrants.
Compassionate health systems
As UK COVID-19 cases continue to decline, reinstating routine and essential health services for non-COVID conditions is vital.
In January 2021, more than 100,000 people were admitted to hospital with COVID-19. Despite this, the NHS still managed to offer non-COVID care to 1.3 million patients, more than during the first wave’s peak in April 2020.
However, recent NHS figures show an increasing backlog of millions of people awaiting cancer care and planned surgery. Mental health services and those for other chronic illnesses, like diabetes or lung disease, are also predicted to see increased demand.
Getting “back to normal” is likely to involve additional clinics, surgery and work compared to previous years.
This will need to be delivered by a mentally scarred, depleted workforce, many of whom are now looking to reduce their hours or leave the NHS entirely. Alongside this, junior healthcare workers will need to make up their lost training hours, and rotas must be in place that are sufficiently flexible to deal with future COVID-19 surges.
We need to plan for these surges now. But without additional long-term investment and funding, and strong leadership, this is unlikely to be possible. As healthcare workers, we can make changes to improve our own practice. But these are a drop in the ocean compared to the wholesale changes in institutional values that are needed.
The government’s white paper on the future of the NHS fails to address funding and investment shortfalls. Nor does it provide a route towards narrowing the gaping breach between health and social care.
The bigger picture
A compassionate health system must be accessible and relevant to the diverse populations it serves. The 2020 Marmot review reported that health inequalities in England have widened since 2010. COVID-19 has exacerbated these inequalities.
Liverpool City Region is ranked as one of the most deprived in England. In our daily work, we have seen more COVID-19 illness and worse outcomes among people who are poor, unemployed or precarious employment, or who face challenging living circumstances including overcrowding and poor quality housing.
There are also large health disparities and marginalisation related to ethnicity. While some ethnic disparities overlap with poverty or other forms of disadvantage, racism itself is a fundamental structural and cultural driver of inequality.
Health systems need better strategies to address racism and reach under-served and ethnic minority groups. Building trust and networks with local communities will be crucial to achieve this.
Without such measures, existing inequalities will have long-term, negative intergenerational impacts on health, educational, and economic prospects.
Amid the major planned restructuring of the NHS, it is clear that a compassionate workforce won’t be enough to continue to care for people with COVID-19 or any other illness. Instead, we need a compassionate health system that works for everyone.
This is part two of a series of two articles on COVID-19 care in 2021. Read part one here.
Tom Wingfield is a Senior Clinical Lecturer at Liverpool School of Tropical Medicine, UK, and an honorary research associate at the University of Liverpool, UK, and Karolinska Institutet, Sweden. Tom Wingfield receives funding from: the Wellcome Trust, UK (209075/Z/17/Z); the Medical Research Council, Foreign Commonwealth and Development Office, and Wellcome Trust (Joint Global Health Trials, MR/V004832/1), the Academy of Medical Sciences, UK, and the Swedish Health Research Council, Sweden. Tom is also a consultant for the World Health Organisation.
Miriam Taegtmeyer currently receives funding from The NIHR, the Medical Research Council and UNITAID. She has previous received grants from the European Union, the Department for International Development, USAID, the Centres for Diseases Control and the Gilead Foundation. She is an honorary lecturer at the University of Heidelberg.