London Eye: Omicron in the capital

Omicron in London

Each covid wave so far hit London first, so it’s reasonable to surmise an omicron wave would too.

After all, it’s the most internationally connected part of the UK and, just to take places with recent outbreaks, has the strongest connections with South Korea (New Malden) and South Africa (Wandsworth).

It’s early days in determining the impact of the new variant, but given England’s history of tardy responses it is worth asking what is happening to prepare for it.

New operational guidance is expected at national level today, but London leaders expect it won’t say much more than “keep doing infection prevention”.

People in primary care seem more concerned about omicron than their hospital counterparts, for a few reasons.

For one, primary and community care are going to be more involved in whatever the vaccine implications of the new strain are.

Planners will also face “really tough discussions on what has to give” outside of hospitals if the variant does have a significant impact.

One example given to London Eye was if omicron meant hot clinics and home visits (for covid-positive patients who need to be seen for another issue that can’t wait) would have to be ramped up.

This would come at the expense of supporting 111 and the urgent and emergency care system, which is also under a lot of pressure (even more so than in recent months, more on this below).

Shifting resource from hot clinics and similar will absolutely see more demand showing up in other parts of the system, as those people go to A&E later and sicker.

“There’s nothing left to give, really. Horrible scenario for planning against for NHS England,” said one primary care leader.

On hot clinics, they added: “It’s very dispiriting for GPs seeing all the griping from within the NHS when many of them have been going into covid-positive homes and getting hands-on with covid-positive patients with nothing but baseline PPE.

“Same with the GPs we’ve got on every day supporting 111, providing more appointments for them so patients don’t go to urgent care centres or emergency departments. Most of the extra service added to GP workload has been running since January, with only respite during summer.”

Hospitals’ Omicron response has been local so far, although a regional meeting with Amanda Pritchard at the end of this week might bring something new on this.

Everyone was doing infection prevention controls anyway (well, almost everyone) and trusts are now checking whether A&E attendances have come from at-risk countries.

One hospital boss said the main issue so far had been accommodating staff who needed to extend annual leave to allow for the PCR results when returning from abroad.

But that’s not to suggest there are currently no problems in London hospitals.

Under the cosh

“Inspectors found the following areas of concern:

• Infection and prevention control was not properly managed within the emergency department. Overcrowding in the children’s waiting area and the waiting area reserved for adults who were possibly infected with covid-19 meant that there was a risk of infection to patients.
• Resuscitation equipment was not checked daily.
• There were shortages of nursing staff, particularly in the children’s department.
• People could not always access the service when they needed it. Waiting times for patients to be admitted, transferred or discharged were not in line with good practice.
• Staff voiced concerns about the workload becoming unmanageable due to staff shortages.
• Inspectors were not assured the risk register covered all risks to the department.”

This is from the CQC’s inspection of Croydon’s A&E, but really could have been almost anywhere in the capital. Who doesn’t have a shortage of nurses and an unmanageable workload? Is anyone 100 per cent sure their A&E arrangements aren’t a covid infection risk?

As one CEO put it: “People are already doing everything they can.”

Only reducing demand can really make a difference at this stage.

A&Es lost a lot of capacity as they adapted to try to make themselves IPC compliant. It might be that reliable separation is just not possible this winter. And if lack of space is a problem for recently refurbished Croydon, imagine what it’s like in the less fortunate A&Es.

The CQC gets flak for inspecting places under acute pressure, and for staff it’s probably only going to tell them what they already know.

But here are some of the positives inspectors found in Croydon:

• There was a stable leadership team in place and governance processes had improved since the last inspection.
• Staff in the adult emergency department said they felt respected, supported and valued by service leaders. They were focused on the needs of patients receiving care.
• Patients had access to a psychiatric liaison nurse 24 hours a day. Staff said that although the team was increasingly busy, staff were responsive and would see patients within one hour of initial referral.

These things are not given in the understaffed, under-resourced NHS of 2021, so well done to places that can say the same as Croydon on these points.