Richard North, 19/07/2021  

Well, today's the day when it is supposed to be all happening, yet I don't think there's anyone in the and who knows how this is going to play out – starting at the very top, where the ditherer-in-chief has run out of options.

Basically, as regards the relaxation of controls, Johnson has got himself in a pickle, where he is damned if he doesn't and damned if he does, leaving him hostage to uncertain events over which he has no control.

To an extent, one can have a little sympathy with his predicament. Controlling a large-scale epidemic driven by a constantly mutating virus with ever-changing transmission characteristics and differing morbidities was never going to be easy, and with the basic infectious disease control infrastructure in this country still shot to hell, it was never going to get any easier.

What has been happening over the last 18 months though is unforgivable. The element of control that has been achieved has been at the huge price of dismantling the bulk of the NHS and turning it into a single-purpose national covid service, where health care generally has been relegated to a very poor second.

That the infection control system was in an advanced stage of decay before the Covid epidemic started certainly didn't help deal with the initial surge of cases, and led to the need for measures, such as the lockdowns, which have had dramatic economic impact and disrupted people's lives.

Fortunately for Johnson, technology has come to his aid with the faster than anticipated development of a range of vaccines which currently appear to be impacting on the level of hospitalisation and on the death rate, although not noticeably on the case rate.

Unfortunately for Johnson, the initial stages of the vaccination programme offered the promise of bringing down case rates to minuscule proportions which prompted him to commit to "irreversible" relaxations of Covid controls, with the date set for removal of most measures first on 21 June and now for today, 19 July.

Now, of course, the prime minister has been caught out. Having gambled everything on the success of the vaccine programme, the emergence of the Indian variant, and then others, has pushed up the hospitalisation rate to such an extent that, if infection rates continue to increase, the NHS will be back at square one – at risk of being overwhelmed, and unable to perform its primary healthcare functions.

Effectively having over-promised on the effect of the vaccination programme, Johnson now faces an increasingly rebellious population, with many less inclined to accept restrictions, and a growing backlog of undiagnosed and untreated illness which is set to reach epidemic proportions.

With the Covid death rate declining, there is a further element which has the potential to make Johnson's political choices that much more difficult. Firstly, as the vaccination programme continues – and extends into to younger cohorts – the proportion of fatal adverse reactions, in relation to the number of Covid deaths, will increase.

Then, as we see a spike in non-Covid related deaths, as a result of reduced general healthcare services offered by the NHS, we will eventually reach a situation where dealing with Covid indirectly becomes a more important cause of death that the disease itself – if we are no already there.

Under such circumstances, we can see Johnson's administration coming under enormous pressure to restore the original functionality to the NHS – just at a time when the system is buckling under pressure from the new wave, turning away non-Covid cases and calling for a reinstatement of some or all of the Covid controls.

At that point, we can expect the background grumbling – well-evident on social media – to intensify. People will be reminding Johnson that they have been making considerable sacrifices, in assisting his government to bring the epidemic under control, against the expectation of a return to normality.

They will then be complaining that they are suffering from the worst of all possible worlds. Despite the vaccine, the NHS will still be at the brink of being overwhelmed, the restrictions will be back in force – while the burden of ill-health, in terms of pain, misery and uncertainty, will demand a response that Johnson will not be able to deliver.

This, for the prime minister, could be his very own political death trap, for there will be no way out. And to understand why, one has to go right back to the start of the NHS, which coincided with the general availability of those still-new wonder-drugs, the antibiotics.

Thus, as the new-found NHS took stock of its rambling estate, and sought to rationalise the number of hospitals, it embarked on a programme of decommissioning or converting its historic legacy of infectious disease hospitals, moving towards the single, all-purpose model of the district general hospital.

But, if there is one thing of which the Covid epidemic should have reminded us, it is that the district general hospital cannot easily – or at all – cope with the large scale incidence of infectious disease, where there is a requirement for intensive medical intervention in the absence of effective drug therapies (antibiotics or anti-virals) and/or vaccination.

That was the situation which confronted the NHS early on in 2020, a deficiency which it overcame – but only partially – by restricting much of the hospital estate to the treatment of Covid, and deferring the treatment of other conditions. Even then, perhaps 30 percent or more of the cases recorded were hospital acquired, making the NHS the most significant single reservoir of the disease.

For a short time, however, it looked as if there might be a solution to this problem, with the rapid development of the Nightingale Hospitals. But, for a variety of reasons – not all of which have been properly explained – the programme has been an expensive failure.

However, by the time the programme was wound down, the epidemic seemed to be under control, so the loss of this resource went largely unremarked, and the opportunity to reinstate an independent network of dedicated infectious disease hospitals was lost.

Now, if as seems, we are seeing another surge of hospitalisations, the backlog of 5.3 million people waiting for routine operations and other procedures in England alone could increase to 13 million.

There is no way the prime minister can fulfil his promise, repeated last week of dealing with the backlog. It is all very well him boasting of "building 40 new hospitals and recruiting 50,000 more nurses", but this will take years to put in place and will not solve the underlying problems inherent is using district generals as infectious disease hospitals.

Basically, the only way out for Johnson would be if he already had a properly-developed and functioning network of infectious disease hospitals, which would allow the NHS to cope with any surge, while maintaining its core services in its district generals – freed from the burden of dealing with Covid.

In two early pieces, I suggested how this could be done, in respect of buildings and of staff, building on well-founded experience of dealing with surge requirements.

Unfortunately, it is not only Johnson and his "genius" chief advisor who have missed the boat. Despite the hoards of newly emergent experts in epidemiology, there has been no general review of the fundamentals of infectious disease control, and the challenge of dealing with epidemics driven by novel pathogens.

Thus, we are eighteen months into this epidemic and, in terms of core capacity, no further forward than when we started. The difference will be a less tolerant electorate, with higher expectations and little forgiveness of repeated blunders. This time round, Johnson will not get away with fatuous little homilies about hand-washing to the tune of "happy birthday".

Also published on Turbulent Times.

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