Evidence from social interactions shows that while people had already started to change their work and travel patterns before 23 March – the day of the prime minister’s stay-at-home announcement – it’s likely that this was more than compensated for by the significant increase in shopping trips, leaving overall levels of interaction broadly similar until that date.  

The discussion paper, authored by The Whole Systems Partnership (WSP), which provides support for partnership development and system redesign in health and social care, suggests that keeping the reproduction rate (R) below one could allow those with the virus to be identified through test, track and trace (3T) and enable “a significant return to normal life”. But it warns, too, that with 3T “in its infancy in the UK”, pockets of unidentified infection would persist for many months. Consequently, the UK is thought to be highly susceptible to a resurgence of the virus if lockdown is eased too quickly or if people’s behaviours become more indulgent than they should.  

The paper offers four broad scenarios over the next three to six months:

1. The lockdown is eased gradually over the next six to eight weeks (up to early July), meaning reduced overall effectiveness of social distancing, while 3T ensures that by early-mid July the effectiveness of social distancing is at a level similar to over the first period of lockdown. 
2. A modest one-step change in social distancing effectiveness that doesn’t risk a significant second peak, with no subsequent alterations over the rest of the calendar year – the new pre-vaccine normal.
3. A more significant one-step change that causes R to rise above one, initiates a significant second peak, and therefore requires further lockdown later in the year.
4. An easing of the lockdown with only slight reductions in the effectiveness of social distancing, plus earlier impact from 3T than scenario one.

WSP’s modelling (it has been working with clients to develop a simulation model based on national assumptions but tailored to local population characteristics) suggests that scenarios one and three produce second peaks over the summer, although of different magnitudes and neither being likely to overwhelm the NHS. But it also suggests that any second peak may put more pressure on general practice in supporting larger numbers of people not requiring hospitalisation, less pressure on hospital beds, and lower risk of death. This is because the April peak was driven by fairly open transmission of the virus between all risk groups in March, while relaxing the lockdown now would still retain a good level of protection for the more vulnerable groups.

There will be further challenges for the system in addressing non-COVID needs, which have been suppressed during lockdown, the paper explains. Some of this backlog could be addressed through remote technology, but where physical attendance at hospitals is required, social distancing rules may limit the number of people allowed to attend an outpatient clinic. Visit times may also be extended owing to greater vigilance on hygiene.

Building the intelligence base

The discussion paper argues that the COVID-19 epidemic has highlighted “the relatively poor state of our intelligence about patient flow through a system of care”. It suggests that “tracking people with a COVID-flag from first symptoms through to recovery or death should be a priority in our building of the intelligence necessary to manage any subsequent peaks, and the transition to a new normal”.

The paper also says the risk of harm from the coronavirus, such as lung or kidney damage, or through non-COVID needs not being met, could extend the period of excess deaths well beyond the point when the pandemic is declared over. “Recognising this ‘COVID-shadow’ in our population health management programmes will therefore be necessary for several years,” it concludes.

With potential vaccine development some time away, the paper suggests that the transition period is likely to be staggered for different groups and for different reasons. But it believes that we need to be ready to recognise behaviours and responses to the epidemic that should be valued and, if possible, sustained. Examples include:

• while people’s reluctance to go to A&E harbours risk, a willingness for self-care could be beneficial;
• learning from the significant reduction in unscheduled hospital admissions, and the reasons for it, to encourage and support people’s wishes at the end of life;
• the development of community support groups for COVID-19 represents an opportunity to explore the effectiveness of community organising; and
• our reliance on simple and accessible technology during the epidemic needs to be seen as an opportunity to embed new ways of working.  

The new normal

The paper goes on to imagine a future in which:

• the needs of any given local population will have been reshaped by the passing of the epidemic;
• the ‘COVID-shadow’ is adequately reflected in health and care planning and remains an ongoing task;
• people’s enhanced ability to self-care and rely on local support networks is reinforced alongside new approaches to community organising, to help address some of the wider determinants of health;
• the closer working of primary, community health and social care services during the epidemic is harnessed and refined according to local needs; and
• the balance between hospital and community services will have made a stepped change, owing in part to reliance on A&E and hospital admission having been sufficiently challenged.

“The new normal should not therefore be about returning to the past,” concludes the paper. “A care system that has learned how to respond as a system rather than as individual organisations takes us a giant step forward. An epidemic also highlights the importance of population health approaches to understanding and addressing people’s needs, albeit on a drastically reduced timescale.”