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Why the delay to step four minimises harm and makes a return to normality more likely.

After reviewing the latest data last week, I came to the conclusion that, for the first time in this pandemic, I would recommend a delay in lifting restrictions.

I have always stressed the need to balance harms from Covid vs. the harms from restrictions and that is why I called for previous lockdowns to be lifted earlier and supported all previous steps of the roadmap.

And when faced by a similar situation in October last year, I opposed the ’circuit breaker’ lockdown as this would have just postponed the wave further into winter (as happened in Wales) - but the situation is completely different this time as the increased vaccinations will actually prevent hospitalisations and deaths.

And on these pages in February I warned of the dangers of following a zero covid policy and outlined a plan similar to the roadmap but also called for a generally faster lifting of restrictions to reach step 3 faster – but also said that all restrictions should only be lifted when all adults have been offered vaccination- as I felt that would ensure it was irreversible. And based on the experience of last summer, I assumed that the economy would grow strongly and people’s mental health would improve even with Tier 1 type restrictions – both of which, fortunately have turned out to be true.

And at the outset, I should make clear that it is the same reason that I previously called for restrictions to be lifted – i.e. to minimise overall harm - - that I believe it is right to delay step four.

First, a brief review of the evidence presented on Monday and our current situation. The much higher transmissibility and likely higher hospitalisation rate of the now dominant delta variant has led to cases increasing more rapidly with hospitalisations also now starting to follow. Although the link between cases and hospitalisations has been greatly weakened by vaccination, it has not been fully broken as a significant proportion of the population are either unvaccinated or have only had one dose. (About 3% of cases are currently being admitted vs. 8% pre-vaccination.) The good news however is that both vaccines being shown to be equally effective in reducing admissions – 57-85% from 1 dose and 85-98% from 2 doses.

The models - whether from those who support or oppose a delay – agree that while millions of people are still unvaccinated or have only had a single dose, the greater transmissibility of the Delta variant means that cases and hospital admissions will continue to increase. As Philip Thomas wrote here last week, while arguing for no delay, he estimated we will reach 100000 cases a day by the end of July based on current trends which would lead to roughly 2 to 3000 hospitalisations a day. More optimistic models suggest a peak hospitalisation rate of about a thousand cases a day by then.

And all also agree that that a further relaxation of restrictions, particularly the increased household mixing, will mean that cases and hospital admissions will increase faster.

Some people find it hard to understand how even with the majority of those at high risk being vaccinated, there could be such high numbers of hospital admissions but this is simply because while those under 50 have a much lower risk of being hospitalised, a small percentage of a very large number is still a large enough number. And the difference compared to last summer, is that we already have a higher average number of contacts per person, the-Delta variant is twice as transmissible and appears to be less seasonal and schools are open.

For those, like me, who are somewhat sceptical of models – which have so much uncertainty – and prefer to see the empirical data, we can look actual experience of Bolton where the Delta variant first spread in early May (i.e. prior to step 3 when there was less social contact than now). Cases peaked (mainly in the young) around the same level as wave 2 but hospital admissions were less than half and the total patients in hospital about a third – reflecting the impact of vaccination.

This gives an indication of what is likely to happen in the country over the coming weeks with admissions reaching 1000-1500 cases a day (a third of the January peak) but it also provides encouragement in that it was able to get over its 3rd wave with a combination of ‘surge’ testing and vaccination .

So now to address the key question as to whether the 4 week delay will cause less overall harm – to health, education, the economy and society - than going ahead.

First on health, as has been the case throughout the pandemic, my focus is on overall health – not just covid.

Looking at the current number of covid admissions per day (about 150) and patients in hospitals (about 1000, 1% of the total) people assume that hospitals aren’t that busy. But the truth is that they are now the busiest they have been since the start of the pandemic - both catching up with the backlog (caused primarily by covid disrupting NHS services – not lockdown) – and due to delayed emergency admissions, particularly those with serious conditions like cancer and heart disease .

(It is also important to remember that there were even less patients in hospital in September last year (500) but two months later there were 10000 with admissions rising from 50 to a thousand a day.)

And every admission increases the pressure - even if their length of stay is slightly shorter - and half the COVID patients we see in A&E are not admitted at all (as they are younger and less sick) but still increase pressure - and both groups can infect other patients. So while the NHS will not be overwhelmed like in Italy – it will stop being able to provide all services to non-COVID patients as happened in previous waves) – the backlog will get worse and take even longer to catch up

A four week delay allows all adults to receive one dose and all over 40s to receive two doses and this should result in a 50% reduction in covid admissions and deaths but crucially also the knock-on non-covid health harms and its primary benefit will actually be to non-covid patients.

We also know that once infections increase, patients are less likely to present with other conditions for fear of catching COVID and that fear is now increasing again despite vaccination – a higher proportion of adults now fearing catching the virus (38%) than are unvaccinated.

Secondly, on education, a delay will be beneficial as more children will be able to stay in school as infections (which are most relevant metric here) will not spread as rapidly. As seen in Bolton one third of children missed school due to the Delta variant and we need to reduce the risk of that happening across the country – children have already suffered enough during this pandemic. Children missing school also has an impact on the economy and the NHS with parents having to stay at home.

The relative harm from current restrictions is much lower than previously with the economy growing strongly and people’s overall happiness finally above pre-pandemic levels. And the potential benefits of lifting further restrictions are more uncertain because as peoples fear from the virus increases this impacts their behavior – leading to a ‘voluntary lockdown’ which decreases economy activity and people’s happiness has more closely tracked level of infections than changes in restrictions. (although it is possible the impact may be less this time with widespread vaccination.)

Also, the travel industry won’t recover if rates of infection continue to increase as we won’t be able to travel without quarantine to other countries – and they won’t allow their citizens to travel here without having to quarantine on their return.

And the impact on our mental health and the economy (and particularly hospitality) would be much worse if we allowed the virus to spread faster now and then had to reverse step three.

In my view, the more certain benefits of delay outweigh the less certain benefits of reopening and while the harms to those industries affected can (and should) be financially alleviated, lost health (and to an extent, education) cannot be recovered. My conclusion, therefore, is that a 4 week delay will minimise overall harm by reducing the size of exit wave & the risk of having to go backwards.

I fully accept that others would place a different value on the harms of having any restrictions and believe restoring freedoms is paramount and that we should rely on guidance, not laws (and I have made the same point myself) but we also know that voluntary measures were not enough to prevent previous waves.

Finally as I have said many times before, we do need to learn to live with the virus – it cannot be eliminated - but we should do so with our defences as strong as possible and the 4 week delay will allow that. We all want an end to restrictions and a return to normality – but not just for a few weeks – and this delay makes it more likely that this will be permanent.”

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