From 'learning to live with' Covid to the NHS recovery

Far from disappearing, Covid rates have remained consistently higher than ever, with the return of familiar winter viruses such as flu and Strep A rounding off a year that has also been marked by more puzzling disease trends - from monkeypox to paediatric hepatitis.

COVID

The year began with question marks over what the emergence of the Omicron variant would mean for the pandemic.

On the one hand, the highly mutated new strain appeared to be much more transmissible than the Delta variant it had replaced, but also comparatively less virulent.

If this sounded reassuring, it was quickly apparent that its impact on the NHS would still be huge.

Even if a smaller percentage of people were becoming seriously ill, the sheer number of infections cancelled out any benefit.

The NHS quickly found itself battling record Covid-related staff absences as the virus rocketed, while requirements to keep Covid and non-Covid patients separate - regardless of symptoms - left much-needed hospital beds empty.

By January 18, there were 1,571 patients in hospital in Scotland “with Covid”, although even at the height of that first Omicron wave there were no more than 60 patients in intensive care with the infection.

A rapid rollout of booster vaccinations during December had helped to blunt severe disease.

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Nonetheless, it was clear that “living with Covid” was going to be a major obstacle for the NHS in 2022 - particularly when a second Omicron wave began spreading in Scotland from mid-February.

This even more transmissible offshoot of Omicron - BA.2 - would result in a record 2,406 people being in hospital in Scotland “with Covid” by April 2 - exceeding the previous peak of 2,053 in January 2021.

Hospital occupancy for patients with Covid peaked in April this year as BA.2 Omicron variant spread while restrictions were eased (Image: PHS)

Scientists studying Omicron described it as a “stealthy immune invader” which appeared to leave little imprint on the immune system’s memory, making reinfections - in some cases just a few months apart - more likely.

Neither vaccination nor prior infection appeared to offer a very strong defence - although protection against more serious disease remained robust.

By July, BA.2 had been usurped by Omicron BA.5, and - as we exit 2022 - analysis by the UK Health Security Agency suggests that it has now been overtaken by one of its own sublineages, the Omicron BQ.1 strain.

The spread of the virus during 2022 was accompanied by gradual lifting of all remaining mitigations, including social distancing, facemasks, and testing. According to the Office for National Statistics’ household survey, at no time during 2022 has the proportion of the population in Scotland infected with Covid ever fallen below one in 60.

Yet, in terms of lethality, analysis also found that Covid had become no more dangerous than flu - even for over-80s - thanks to a combination of vaccinations, prior infection, and Omicron.

At a population level, however, the sheer number of people infected means that Covid is still believed to have been the main cause of death for more than 2,100 Scots this year.

From April 18, rules mandating people to mask up in shops and public transport in Scotland were scrapped, with the majority of the public no longer able to access free lateral flow kits or PCR testing from May onwards.

Self-isolation was advised but optional for those with symptoms, while those with weakened immune systems - such as cancer patients - were to be supplied with Covid antivirals as an extra line of defence in the event that they became infected.

By the end of September, routine Covid testing in hospitals was also rolled back.

Staff were no longer expected to test regularly for the virus - reducing absences due to asymptomatic infection - and patients would only be tested if they had symptoms or were immunosuppressed, rather than automatically on admission and regularly throughout their stay. The goal was to free up beds and capacity ahead of winter.

To some extent, we have “learned to live with” Covid, in the sense that - for many people - it no longer affects their day-to-day life.

For critics, the policies adopted are simply about “ignoring” the dangers - from Long Covid to the risk of new variants - and this will come back to bite us.

Likewise, for thousands of the most vulnerable people in Britain - patients who are less likely to have responded to vaccines, and who fear getting hold of antivirals in time - lockdown has never really ended and, if anything, become more urgent due to the stratospheric rates of Omicron during 2022.

It is unclear what 2023 will bring.

During a recent online discussion, World Health Organisation experts warned that the global 90 per cent reduction in Covid sequencing surveillance was leaving us all exposed.

“That may come back to bit us next year - that may really harm us,” said Dr Mark Ryan, the WHO’s executive director of emergencies.

Dr Maria Van Kerkhove, an infectious disease epidemiologist and WHO’s Covid-19 technical lead, added: “[SARS-CoV2] has not settled down into predictable pattern.

"We know it will continue to evolve. And this notion that it will only become more mild is false.

“It could, and we hope so, but that’s not a guarantee.”

NHS RECOVERY?

When the Scottish Government published its five-year recovery plan for the NHS in August 2021, much of the focus was on tackling waiting lists.

Of course the projections pre-dated Omicron, but for many of those on the frontline they were always overly optimistic.

In particular, it pledged that 2022/23 would see an extra 27,500 elective inpatient and day case procedures on the NHS - a 10% increase on pre-pandemic activity.

During the first six months - from April to September - a total of 115,415 procedures took place compared to 152,220 during the same period in 2019, a deficit of 24%. At some points, the number of planned operations carried out was actually lower than it had been in 2021, such was the impact of Omicron.

Activity is increasing, but slowly.

By the end of September, a total of 141,796 patients were waiting for inpatient/day case treatment, of whom 34,999 had been waiting over a year and 7,612 over two years.

In each case, that was higher than it had been at the end of September 2021 when the figures, respectively, were:105,202;19,526; and 2,326.

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Partly, the issue boils down to a lack of beds.

As of October this year, nearly 1,900 hospital beds - roughly 14% of the total - were being lost for 23 days on average to patients who were well enough to leave, but unable to be discharged.

In most cases (74%), the patients were waiting for social care. One in five (20%) were adults with incapacity.

There are 2,228 fewer registered places in adult care homes in Scotland now than there were in 2012, but the drive to support more people to live in the community has collided with severe shortages of home carers as a result of Brexit, pandemic-related burnout, and the lure of better-paid but less-stressful jobs in retail or hospitality.

As well as slowing elective recovery, hospital bed shortages have also led to worsening bottlenecks in A&E throughout 2022.

By October this year, a record 6,814 people spent over 12 hours in Scotland’s A&E departments compared to 2,638 in October 2021 and 657 in October 2019.

Logjammed A&Es have also resulted in delays for ambulances, with figures showing that some have had to wait around 12 hours to complete a patient handover.

STRIKES?

On industrial action, Scotland's NHS has yet to be affected by walkouts occurring elsewhere in the UK.

Members of Unite and Unison - which combined represent the majority of NHS Scotland's non-medical workforce, including nurses, cleaners, porters, and administrators - voted to accept the Scottish Government's pay offer: an average uplift of 7.5%.

Physiotherapists and radiographers have also accepted the deal.

However, nurses and midwives belonging to the RCN and RCM Scotland trade unions have both rejected the offer, opening the door to potential industrial action in the new year. 

Members of the GMB union - which includes 1,700 Scottish Ambulance Service workers - have rejected the 7.5% offer, meaning that the threat of a paramedic strike also remains.

Meanwhile, BMA Scotland plans to ballot junior doctors on industrial action in January over their 4.5% pay award.

STRANGE BUGS?

Covid was not the only viral disease making the headlines during 2022.

In March, doctors at the children’s hospital in Glasgow alerted Public Health Scotland to an unusual flurry of admissions for acute paediatric hepatitis with no known cause.

Similar cases were soon reported across the UK.

Most of the children sickened were under five, some required liver transplants, but none tested positive for any of the common hepatitis viruses.

By mid-July, more than 1000 cases had been identified in 35 countries worldwide - including 22 deaths. Three quarters (76%) of patients were under six.

Scientists in Scotland were among those who helped to unravel what was going on, with the outbreak eventually linked to a little-known ‘bystander’ virus called AAV2 which can lie dormant in cells for years before being “activated” by an adenovirus infection.

The cluster of unexplained acute paediatric hepatitis cases had overlapped with a surge in adenovirus as social mixing resumed.

Although cases of acute paediatric hepatitis of unknown cause had always occurred, pre-pandemic there tended to be only a few in Scotland each year.

Reduced immunity combined with many young children being exposed simultaneously created a cluster effect - triggering public health investigations which led to the discovery, for the first time, of the probable link to AAV2.

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At the end of May, meanwhile, Scotland confirmed its first case of monkeypox following alarm over an unusual global outbreak which was disproportionately affecting gay and bisexual men.

Previously, the disease had not spread easily and was largely confined to Central and Western Africa.

Since then a total of 97 cases have been identified in Scotland. Worldwide, the total was 70,000 by late October - including 26 deaths.

A rapid rollout of smallpox vaccination to high-risk groups has succeeded in slowing transmission, but it remains unclear why the disease took off when it did.

In August, public health officials launched a drive to offer all children aged one to nine in London a polio booster jag after traces of poliovirus were discovered in the capital’s sewage. Sampling indicated that it was transmitting in areas with lower vaccination rates.

It is thought that the virus had been introduced by a visitor from overseas who had been inoculated using the oral polio vaccine, which contains weakened poliovirus.

Flu rates in Scotland are now at 'extraordinary' levels (Image: PHS)

By December, the NHS was facing a triple whammy: rising Covid, flu and Strep A infections.

Covid rates in Scotland have climbed recently from one in 60 to one in 40; influenza rates are the highest in five years after a sudden spike to 'extraordinary' levels; and a spike in scarlet fever cases - caused by Strep A bacteria - has caused alarm.

To date, 24 children under 18 have died in the UK from iGAS infections - the invasive form of the disease caused when the Strep A bacteria enters the bloodstream.