and Covid

The second coming of Covid?

As the UK faces a ‘second wave’ of Covid-19, Kathy Oxtoby looks at what preparations are, and should be, in place and potential challenges for the health and care sector

“Perilous turning point”, “invisible enemy”, “inevitable”. This is the language describing the second wave of Covid-19, voiced by the Prime Minister Boris Johnson, reported by the media, and disseminated to a population that has faced so many U-turns in strategies to limit the spread of the virus that it’s hard to predict what the next turn will be.

But while the narrative of what measures are required to tackle the virus is constantly changing, one constant has been the likelihood of a second surge of Covid-19. The UK is “now seeing a second wave”, Johnson said in September, adding: “It’s been inevitable we’d see it in this country.”

This second wave – a widespread transmission of the virus throughout communities across the whole UK – was predicted by the vast majority of doctors in England in September. A poll by the British Medical Association showed that 86% of more than 8,000 doctors and medical students believed a second peak was ‘likely’ or ‘very likely’ in the next six months.

The survey also found that a second peak is the number one concern among clinicians who want to avoid a return to the “horror and tragedy” of the early days of the pandemic.

Plan for the worst Dr Ahmed Shahrabani, co-founder of digital staff bank Locum’s Nest and a junior doctor who recently rejoined the NHS workforce during Covid-19, says: “We only have to look at our neighbours on the continent who adopted a similar strategy to us in combatting the virus.

“France and Spain have seen significant rebound rates in confirmed cases, surpassing anything seen in the first wave of the virus. It is therefore prudent for us to plan for the worst, however high our hopes remain,” he says.

Lessons were thought to have been learnt in places like care homes, and infection control is said to have improved in hospitals, “but with infection rates rising rapidly, these assumptions are about to be tested,” says Nick Hood, business risk adviser at Opus Restructuring.

“The other factor will be the arrival of winter, when there will inevitably be more close contact between people in the confined spaces of homes, public transport and offices, and when other illnesses leave some demographic groups physically weaker. Other coronavirus strains are highly seasonal – we do not yet know if Covid-19 will be too,” Hood says.

The potential challenges a second wave will present to the health and care sector can be predicted based on initial experiences of the pandemic. Health and care leaders suggest we will be better equipped to deal with a second wave because of the lessons learned during the first outbreak.

Experience of tackling tough times Niall Dickson, chief executive of the NHS Confederation says: “The challenges ahead are clear. Last time around when the virus hit hard, there was frantic activity in parts of the service and an eery calm in others. It will not be like that this time.”

Looking at what lies ahead, Dickson says: “We are in a much better place than we were when we first had to deal with a coming pandemic.

“We know how to provide Covid-19 secure services for non-Covid-19 patients. There have been major advances in treatment for Covid-19 patients. There are better and more secure supplies of PPE. We have better, but still inadequate, testing. Local relationships are more developed, and we have the experience of tackling tough times,” he says. ▶

Nick Hood, Opus Restructuring

▶However, he warns staffing, which has

“always been an issue” will become more of one, when the second surge appears. “PPE and social distancing necessarily affect productivity, and it will be different in different specialties and will be differentially affected by the local physical infrastructure.

Flu, norovirus, and all the other joys of winter will affect how services can cope,” he says.

Running Covid-19 and non-Covid-19 services simultaneously, and as near normal as possible, will be “more demanding than first time round”, Dickson believes. He says in hospitals, it will be essential to “create effective flow” with measures such as ‘111 first’ to help prevent unnecessary admission, and discharge to assess to avoid any blockages.

Dickson says governments, their expert advisors, and the regulators – can make a difference to the NHS, “by providing some flexibility about what can be achieved, clarity about funding for the next six months, and actively resisting attempts to impose bureaucratic regulatory impediments.”

“This will be a new phase, and clear support for the NHS as it embarks upon it will be essential,” says Dickson.

Just because the health service is better prepared for a second wave – from how to spot and treat the virus to how to manage staff – does not make it any less challenging.

Shahrabani points out that doctors, nurses, healthcare assistants “and all other heroes who have been blocked from taking annual leave, moved onto challenging rosters, and have been working non-stop, are the same group of people who we are all expecting to deal with a potential second wave.”

“Front line workers are tired and they need all of us to support them,” he says, adding that NHS trusts need to “lower their guard, break down their silos and start working together. As the virus moves from region to region, it is imperative that trusts enable their staff to help each other out, work across NHS trust boundaries and take the fight to the virus head-on.”

For all its herculean efforts, the NHS may have just about coped with Covid-19 but “only at the cost of abandoning whole swathes of patients, such as those needing cancer diagnosis or treatment and others needing ongoing disease management care”, says Hood. “Waiting lists have ballooned alarmingly, with around two million people waiting more than 18 weeks for routine NHS treatment. The ability of GPs to deliver an effective primary care service through the present preferred medium of telemedicine remains in doubt,” he says.

He suggests a second wave extending across the whole community beyond the recent local outbreaks focused on young people will risk a repeat of these overall healthcare issues piling further pressure on waiting lists in all parts of the NHS, and heightening the risk of substantial excess deaths from causes other than Covid-19.

More reliance on private sector Private hospital finances have benefited “significantly from what was effectively a bailout by the NHS through its block booking of capacity with the guarantee that all costs would be covered,” says Hood.

“They are only just starting to return to their historical operational model now, but with the loss of some vital revenue streams, notably from treating health tourists,” he says.

But a second wave would suspend their normal activities once more, assuming that the NHS experiences similar capacity issues to

the first wave, he believes. “The good news is that they could once more look to the NHS for another cost underwrite. The bad news is that the sector and its clients would be plunged back into uncertainty once more with potentially serious adverse financial implications in the medium and long term,” he says.

Given that the NHS already has a substantial backlog and waiting lists of non-Covid related treatments, this will be “further exacerbated with a second outbreak and is likely to result in more reliance on the private sector to alleviate the delays. This could be as a result of NHS commissioning or people self-funding their care rather than waiting further,” says Colin Rees-Smith, healthcare director at Savills.

Vital lifeline for providers of care The care home sector has learned a lot during the past six months and has also come a long way, with a higher profile in the eyes of the public and central government. This is evidenced by the additional support that was provided for the sector in September when the government announced an extension to the Infection Control Fund, pledging an extra £546 million in funding to bolster infection prevention and control measures in care homes during the winter.

Vic Rayner, executive director of the National Care Forum says this ring-fenced finance has been “a vital lifeline for many providers of care to ensure they are able to support staff who are isolating, and to minimise movement

Professor Martin Green, Care England

of staff within and between homes”.

But the sector will require still more consideration and support in the coming months as front line workers continue to care for some of the population’s most vulnerable people. Care England wants care services to be placed at the forefront of future policy decisions in order to prepare for a second wave, arguing that adult social care can no longer remain an addendum to the NHS.

Professor Martin Green, chief executive of Care England says: “The government cannot again invest vast amounts of its organisational capacity into the NHS whilst neglecting adequate consideration of the adult social care sector. Nor should care providers ever be pressurised to admit untested individuals in order to preserve the structural integrity of the NHS.”

In planning for a second wave and the coming winter he says the government must set out how it intends to ensure the funding, PPE, testing and clinical support is ready and available to continue to sustain the sector.

Rees-Smith says operators are “better placed” to manage any further outbreaks that may occur, with specific protocols and procedures in place, with infection control well-managed, and controls over access. But he warns the danger is that “those operators in this sector that are already struggling, possibly those in smaller, older converted buildings, may not be able to cope”.

Homes that serve the self-funded market can pass on any increased costs associated with extra staff and PPE and so on, to clients. But a second wave would mean “those outside of the private sector that were already exposed are likely to be more at risk,” Rees-Smith says.

Hood believes a second wave with further occupancy reductions “is likely to prove catastrophic for a sector where the major operators are carrying excessive debt, and where profitability across the board was marginal at best even before the crisis”, adding that “government intervention on a major scale would be both unavoidable and essential”. ▶

Julian Evans, Knight Frank

▶ Ability to cope with another spike

As for the healthcare investment market, over the course of the pandemic, “operators have proven that they are very capable in utilising their resources and expertise to manage the risk of the virus,” says Julian Evans, partner and head of healthcare at Knight Frank. “This is because they already have experience handling threats arising from norovirus, influenza and other viruses. Having dealt with the threat during the first peak, investors can have confidence in their ability to cope with another spike. Investors have understood during this period that healthcare can improve the overall asset quality in their real estate portfolio whilst also minimising reputational risk.”

Evans says Knight Frank is now seeing lenders divest assets in sectors such as leisure and hospitality. “This is perhaps most evident in how investment has shifted from retail assets into healthcare given confidence in the sector’s performance against other real estate segments, which face more uncertain prospects,” he says.

Rees-Smith says the market has remained active throughout the pandemic with the secure, longterm covenants and underlying demographic fundamentals providing reassurance to investors.

This is evidenced by the recent announcements by investment banking firm Alantra of a UK healthcare real estate assets offering, Assura’s £300 million fundraise for further medical centre acquisitions, and Moorfield Capital confirming a new fund to support the expansion of care home group, Allegra.

Given the strong demand for product, combined with a supply/demand imbalance across the board in terms of facilities and the likely lead in time and desire to maintain or build a pipeline, there is also a “strong appetite” for land and development projects, Rees-Smith says.

He adds that the call on ‘healthtech’ is likely to continue, in various forms, while a vaccine is sought and potentially beyond one or more being produced.

Digital to the rescue Digital has come the rescue in terms of Covid and has been able to reduce infection risks by teleconsultations and home treatments, says Dr Michelle Tempest, partner for life science and healthcare consultancy Candesic. “But there is still a long road ahead and digital care will need investment in terms of government money, design time and getting implementation right,” she says.

Technology is a “potentially brighter spot”, as biosecurity issues push more and more healthcare activities, such as routine primary care and physiotherapy, online. However, “as always with technology investment, picking winners can be difficult”, cautions Hood.

He says only investors “with deep pockets, who thrive on uncertainty or who can take the long view” are likely to be interested in taking any new positions in businesses operating healthcare facilities in the event of a full blown second wave. “There will of course be opportunities to pick up assets at bargain basement prices, but not without risk,” he says.

Overall, the health and care sectors “should be in a better position to manage and mitigate the early stages of any second wave,” says Hood. The medical community has learnt much about the virus, both in terms of treatment techniques and drug therapies, “so we should expect that fewer of those who are badly affected by infection in a second wave to die or suffer long-term health issues”, he says.

While there is a huge focus on getting ‘Test, Trace and Isolate’ (TTI) right, “the existing arrangements seem to lurch from disappointment to crisis and back again”, Hood says. Capacity issues dog these efforts, either in terms of test kit availability, suitably qualified testing staff, or laboratory processing of the tests. Nevertheless, research by the Academy of Medical Sciences in July highlighted that even an effective TTI operation will only reduce transmission by 15%, “so it is not the silver bullet most people hope it could be”, says Hood.

The worldwide efforts to produce a vaccine are prodigious and their speed highly impressive, but despite some politically motivated gun jumping in some countries, there’s no certainty as to the timing when working vaccines might become widely available, what level of efficacy they might have, or indeed even whether one will be found at all.

Some in the virology community are advocating ‘multiplex’ testing, which could

simultaneously identify and differentiate between Covid-19 and influenza. “A major uncertainty as we go into the forthcoming winter is the risk that patients will be unable to tell the difference between the symptoms and either overwhelm testing systems and hospitals, or not report symptoms that turn out to be Covid-19,” says Hood.

Get the basics right Unlike the early days of the pandemic, Tempest says this time the consequences [of not being prepared] are clear and the government cannot hide behind calling this ‘novel’. “We have seen what works globally – South Korea and Germany are both solid examples. The consequences of not testing and any lack of track and trace is not an option– the economy needs our government to get the basics right in terms of public health so local outbreaks can be rapidly identified and contained”, Tempest says.

Without preparation for a second wave, the outcome will be “an overwhelmed NHS and devastated private hospital sector, the collapse of the residential and domiciliary care subsectors, and huge numbers of excess deaths from non-Covid conditions such as cancer – and an economy that might take decades to repair,” says Hood.

The risk of a third wave “will be a function of how we tackle and learn from the second one”, he believes. Some medical experts are now talking of ‘Long Covid’, referring to ongoing lung health management post-infection, as well as post-Covid heart attacks and strokes because of clotting issues and ongoing chronic fatigue.

“While the understanding of the causes and remedies for these problems is at an early stage, there seems little doubt that the pandemic will leave a serious long-term health legacy with some of its victims,” says Hood.

And future spikes cannot be ruled out given the transmission trends witnessed so far. As Evans says: “It is a risk that will be present until we have a vaccine or have developed antibodies to the virus.” n