Brexit, Covid and flu: The perfect storm bearing down on the health service this winter

Pandemic has made it more difficult for manufacturers and suppliers to predict demand for some medicines

Radiologists wearing visors and masks comfort a patient before an x-ray. While the NHS has weathered the first outbreak of coronavirus a second wave this winter could prove far more difficult to handle (POOL/AFP via Getty Images)

A combination of a second wave of coronavirus, a potential flu epidemic, a rise in urgent cancer and other non-virus-related cases and Brexit chaos could leave Britain facing an unprecedented 'perfect storm' this winter, experts have warned as they called on the government to take immediate evasive action.

The four simultaneous threats to the nation’s health and its economy have the capacity to reinforce each other, with the British Medical Association's council chair warning about the "devastating" impact of a resurgence of Covid-19 as the NHS faces its annual winter pressures.

“Doctors are rightly extremely worried about a second peak of Covid-19, with around half of respondents telling a British Medical Association survey that they do not think the NHS would cope with a new surge in infections,” Dr Chaand Nagpaul told The Independent.

“If a second peak were to come later this year – as the NHS struggles to manage the huge backlog of non-Covid demand on top of forthcoming winter pressures and seasonal flu – it would be devastating for patients and the health service."

The BMA has written to the prime minister, warning him that crashing out of the UK’s current relationship with the EU this winter will come at the worst possible time for the health service.

“As the NHS struggles to provide care for tens of thousands of patients, delayed due to Covid-19, it must also consider the prospect of a second peak in infection rates this winter,” the letter reads.

Dr Nagpaul said that all steps must be taken to rule out a ‘disastrous’ no-deal scenario and to protect the NHS, patients and staff.

“We must once again urge your government to make the pragmatic decisions necessary to avoid such a disastrous scenario.

“Such an outcome would have been catastrophic for our members and their patients pre-pandemic. Its impact on an NHS, struggling to deal with the massive backlog of non-Covid-19 clinical work and threatened by a second peak in infections during the challenging winter period, simply cannot be countenanced."

Bad flu seasons tend to occur every two to four years and the past two winters have been very low impact in terms of flu. Influenza experts believe that the chance of a high impact flu season this winter is therefore considerable – and a likely coronavirus second wave could make many of those who contract it much more vulnerable to pneumonia and other flu complications. People whose lungs have been damaged by Covid-19 over recent months would be particularly at risk from flu complications.

Meanwhile, in the middle of such a winter crisis, a departure from the European single market and customs union may well generate customs and documentation-related delays at EU departure ports, and a consequent increase in medical product import transit times. The quantities of medicines and medical equipment coming into the UK by sea is also likely to increase after demand for extra air-cargo, prompted by a need for coronavirus supplies, has driven up many air charter fees. Doctors fear that all this could interfere with supplies of EU-made and other medicines and equipment at the very time the UK might be most desperate for them.

“The government must therefore do everything in its power to avoid this disastrous scenario and secure a deal that protects health, patients and the NHS” and avoids ”disruption to vital medical supplies,“ said Dr Nagpaul.

The pandemic has also made it more difficult for manufacturers and suppliers to predict demand for some medicines. In the past, the pharmaceutical industry simply used its own experience of market behaviour to predict demand. But, in the current situation, that is no longer possible and manufacturers and suppliers must now depend on receiving demand predictions from the NHS well in advance. As far as this coming autumn and winter is concerned, that has not yet happened – and to satisfy demand, branded medicine manufacturers normally need at least four months’ lead time.

Britain’s exit from the EU single market and the customs union will require huge amounts of civil service, NHS and political time and personnel – at the very moment when the nation’s health crisis might also need such finite resources.

In addition, a departure from the EU ‘freedom of movement’ zone at the end of December has implications for staff levels in the health and care sectors.

The government must ensure that “doctors who qualified in EU countries can seamlessly and safely come to practise in the UK”, said Dr Nagpaul.

Since the EU referendum in 2016, the numbers of EU-originating nurses leaving the NHS has dramatically increased – and the numbers of new EU nurses willing to replace them has plummeted. Recruitment of nurses from elsewhere in the world has not yet been able to fully compensate for that shortfall – and it’s also likely that coronavirus and an exit from the EU freedom of movement zone will combine this winter to further reduce nursing numbers.

The pandemic has been preventing most non-EU potential nursing recruits overseas from being linguistically and professionally tested to determine their suitability for NHS work – and because international air services are not functioning normally. What’s more, the UK’s departure from the EU freedom of movement zone at the end of this year will reduce still further the number of nurses coming to the UK from the EU.

The care sector is likely to be even more dramatically affected. Many care workers in the UK are from the EU – and if some of them opt to return to their countries of origin, then recruiting replacements will be very difficult, given the government’s current anti-immigration measures. Most non-British care workers would not be due to earn more than the £25,000 minimum required to allow their entry into the UK.

As a consequence, care in the community and care homes may face considerable staffing problems – and if that coincides with increased operational pressure due to a coronavirus resurgence, the results could again be tragic.

At the same time, the number of urgent cancer and other operations is likely to increase very significantly. There is a backlog of an additional 516,000 operations on top of the pre-existing pre-Covid waiting list of around 440,000. By September, the 516,000 figure is predicted to rise to 660,000. As time goes by, many of the cancer and other cases involved will become ever more urgent.

But the ongoing crisis is likely to very substantially slow down any attempts to clear that ever-lengthening backlog because protecting NHS staff and patients from Covid-19 makes everything function more slowly. For instance, keyhole surgery generates aerosols which could spread the disease – so, in many cases, surgeons are avoiding keyhole surgery and opting to carry out traditional open surgery instead. The problem is that open surgery takes more time, involves much greater patient recovery time in hospital – and therefore puts much greater strain on the NHS.

In turn, growing backlogs worsen many patients’ conditions and effectively prevent them from returning to work. Large numbers of patients with such deteriorating conditions will increasingly need the help of community nurses, social care workers and others – and if heightened demand stops that being efficiently provided, many patients will need to be hospitalised. Again, this will place additional strain on the NHS.

Many surgeons believe that the only way to more rapidly clear the backlog is to use private hospitals to create dedicated sites where rigorous screening of staff and patients could ensure the maintenance of a completely Covid-free environment – but the government has not yet implemented that plan on a large enough scale.

A no-deal Brexit would also be likely to slow down the UK’s ability to rapidly receive potentially crucial new vaccines and medications from EU member states. For the past 25 years, supplies have been governed by the mutually beneficial EU-wide European Medicines Agency but that is now unlikely to continue.

In the event of a no-deal Brexit at the end of this year, the UK would not be able to fully participate in the EU’s many medical research and clinical trial schemes. This would substantially undermine Britain’s ability to be involved in any potentially vital new research collaborations between EU member states. This could in turn have implications for developing new medicines and vaccines to combat future waves of Covid-19, or indeed the arrival of other new diseases or new strains of existing ones.

There is another way in which the current phase of the pandemic could cause problems further down the line. The majority of Covid-19 sufferers survived their ordeal – but research from around the world is now revealing how the virus damages some people’s lungs, kidneys, hearts, vascular systems, livers and even their brains.

Even if the ordeal gave them potential temporary immunity to Covid-19, the damage the virus did to them would, in some cases, make it much more difficult for them to deal with other respiratory, renal, or heart-related illnesses. That Covid legacy might well put additional strain on the NHS this winter if it has to deal with a second wave of coronavirus and/or a flu epidemic.

But the potential flu factor is perhaps the largest ‘elephant in the room’ that is scaring many medical specialists.

“The prospect of Covid-19 and influenza circulating at the same time would be a big problem for public health and for Britain’s hospitals,” said Dr John McCauley, director of the London-based Worldwide Influenza Centre.

Experts are worried the NHS will be even more inundated than normal during the winter months (Getty)

Immediately after the major flu pandemic of 2009-11, flu subsided as a major problem in the UK for three years – but in the winter of 2014-15, it started to increase again. It then dipped for a year and returned in the winters of 2016-17 and 2017-18 with increased strength.

In the winters of 2018-19 and 2019-20 it dipped again – but the overall trend and behaviour of flu would suggest the possibility of a major resurgence this winter.

The key to combating it is to estimate what flu strain will arrive – so that specific strain can be included in that year’s vaccine. Usually the epidemiologists get it right – but around 15 to 20 per cent of the time they don’t.

Adding to the confusion is the unknown impact of coronavirus on the overall viral ecology that helps determine which particular flu strain – if any – might emerge later this year. The current pandemic and the global lockdown therefore makes it potentially more difficult than usual to predict which flu strain might arrive.

How to minimise the risk of a catastrophic winter is likely to become the big question facing the country.

“It is crucial that the number of cases continues to be pushed down, otherwise the disease could take off more rapidly this winter,” said Dr McCauley.