IN a week when physical distancing requirements ended and venues from pubs and restaurants to cinemas, trains and nightclubs were allowed to return to full capacity for the first time in 17 months, there was one crucial corner of society conspicuously excluded: the health service.
Confirmation that spaces including GP waiting rooms, dental surgeries, and hospital wards would still be bound by Covid restrictions requiring people to remain two metres apart was quietly released by the Scottish Government on Saturday, having gone unmentioned during the First Minister’s virtual statement to parliament on August 3.
Nicola Sturgeon declared that the move to Beyond Zero would restore a “substantial degree of normality” by lifting “most of the remaining legal restrictions – most notably on physical distancing” and no longer legally requiring any venue to remain closed.
But for staff on the NHS frontline and patients languishing on waiting lists who may have seen planned operations such as hip replacements cancelled and delayed multiple times already, a return to pre-pandemic normality still seems bitterly far off.
Exactly when, and how, the NHS can begin to function at full capacity remains unclear, although the Scottish Government is expected to publish an update on its NHS remobilisation plan in the coming days.
To date, however, there has been no clarity – not only in Scotland, but across the UK – on the circumstances under which it might be considered safe to roll back physical distancing within the NHS.
Will it be once the vaccine rollout is completed? But how might that be defined: once every willing adult has been fully vaccinated, or every eligible child over-12, or once we reach a certain threshold of coverage?
Should we postpone until winter boosters have also been issued to the elderly and vulnerable.
Should it be based on reaching very low community infection rates, and, if so, would we count only confirmed cases from symptomatic people presenting for testing, or from wider surveillance such as wastewater analysis?
Unlike nightclubs (if they opted to), hospitals and other healthcare settings cannot run a door policy refusing entry to individuals who are not fully vaccinated or requiring patients to test negative before admission.
Limiting the spread of the virus has to rely on alternative mitigations: providing effective PPE to staff, adequate ventilation, keeping Covid and non-Covid patients separate, and cleaning.
But at some point shouldn’t these measures on their own be enough, without also requiring physical distancing limits which severely curb the number of patients who can be seen and treated at any one time?
Researchers behind a study published in the Lancet on Friday into hospital-onset Covid in the UK during the pandemic estimate that 2-5% of the Covid patients in hospital during the third wave became infected following admission.
However, that compares to more than 11% during the first wave, when far less was understood about the virus’ symptoms (that they could be gastrointestinal as well as a dry cough or fever) and its mode of transmission (that it was airborne as well as spread by touching contaminated surfaces).
At the same time, provision of PPE has improved and testing capacity significantly expanded to identify patient cases before symptoms emerge and, with lateral flow kits, to allow NHS staff to self-test at home as a precaution – potentially preventing them from bringing the virus into their workplace.
In the most recent report from Public Health Scotland, for the week ending July 18, there were 191 hospital-onset Covid cases (meaning that the patient first tested positive for the virus subsequent to admission).
However, only 18 of these were “definite” hospital infections (meaning the positive swab was taken 15 days or more after admission), with five “probable” (a positive swab collected five to 14 days after admission).
By contrast, at the height of the second wave half of hospital-onset cases in Scotland were definitely or probably contracted by patients in hospital.
Before Covid, regular monitoring of a number of potentially deadly healthcare-associated infections (HAIs) such as MRSA and C.Diff was the norm throughout the NHS, with 213 reported healthcare outbreaks and incidents in 2019.
Surveillance is similarly undertaken for flu and norovirus rates in the community, with hospital outbreaks of the latter typically resulting in wards being closed to new admissions.
At some point it seems likely that Covid will become another notifiable disease which would result in infected patients being isolated in quarantine bays, but how we get there has not been set out.
Of course, hospitals and healthcare facilities are not like the wider community: they are disproportionately occupied by older people and those with conditions which make them more vulnerable to the Covid.
Yet as long as physical distancing continues in the NHS, the health ramifications for the population as a whole are huge.
Fewer surgeries can be performed because there are fewer recovery beds on wards.
Outpatient and day case procedures are similarly curbed by capacity limits, while a push for more patients to be seen face-to-face in GP surgeries is complicated not only by the two-metre rule for waiting rooms but requirements that GPs don and doff PPE and clean consultation rooms between patients.
Similarly, dental practices – even with high-grade ventilation – have to wait 15 minutes between patients to allow for cleaning after aerosol-procedures.
Those who can afford to will increasingly seek treatment privately, exacerbating health inequalities.
With community cases creeping up and autumn looming, the Beyond Zero freedoms may ultimately slow a return to greater normality within healthcare.
But reversing record-breaking waiting list backlogs will require tough decisions to be made about a balance of risk that has so far prioritised minimising the spread of Covid above all else.