Chapter 1
The political events of the past two weeks have overshadowed the latest Covid-19 wave in the United Kingdom, but they have simultaneously provided a window of opportunity for the country’s new leadership to reset the national approach to managing the disease while charting a course for future pandemics.
The UK’s current strategy is outlined in its “Living with Covid-19” plan, which has three key pillars: vaccines, testing and treatment. In April 2022, the Tony Blair Institute for Global Change undertook a critical analysis of this plan: what worked well, what didn’t, and what needed to change to manage Covid more effectively, and to protect society and the economy. Our recommendations were not burdensome wholesale changes, but incremental steps amounting to a responsible and proactive strategy. Unfortunately, as we see from the recent rapid rise in cases – most involving people who are being infected for the first time – as well as from the increasing hospitalisations and the rise in deaths, the strategy shows what living with Covid means in reality.
To support the government, this paper sets out immediate and practical measures to safely guide the country through the latest Covid wave and to outline the longer-term shifts that will better prepare it for public-health emergency management in the future – including by restoring trust with the public.
Some of these are short term, in recognition of the inevitability that BA.5 will most likely be replaced by a more transmissible subvariant this autumn-winter, leading to concurrent Covid and flu waves. It is reassuring that the government has now pivoted in line with our April advice to make boosters more widely available, but this could have happened sooner.
Without delay, we recommend the government:
Implements the newly announced “autumn booster” immediately, in combination with an early flu vaccine, to those aged 50 and over.
Positions itself to respond to the emerging epidemiological picture over the coming weeks by preparing to extend boosters to more of the population.
While the autumn booster won’t significantly reduce infection rates, it will reduce severity of disease and, therefore, hospitalisations.
Other recommendations are more strategic, and recognise that vaccines alone can’t solve our need to live alongside Covid. Tackling the disease has always been a collective endeavour, and the public has responded best when asked to take responsibility not only for themselves but for others too. If there is an overreliance on asking people to take personal responsibility, this will hamper the ability of government to confidently coordinate a national response that brings the public along with it. Understanding this will help the government in its response when new risks to health emerge because people will be willing to collectively respond – for example, by taking up next-generation vaccines – and it will be well-placed to advise on effective behavioural changes.
In the mid term, we recommend the government:
Learns from best practices around the world to develop a strategy of national coherence to health emergencies. This should include a national centre for response that is properly resourced and empowered to deal with crises such as this.
Restores trust with the public by investing in, and engaging with, rapid anthropological research, proving to communities it is listening to and responding to their beliefs and fears. This will mean shifting away from “nudge theory” to more consultative-based risk communications. Despite warnings of messaging fatigue, communities stand ready to do the right thing when government is able to close the gap between evidence and insights, then take action on those insights.
Ultimately, we need to stop acting like each wave is the last. Today, the government – through a reset in its Covid-19 approach – can take the opportunity to build stronger defences against Covid and other threats to health, rather than simply waiting for the storm to pass.
Chapter 2
Covid-19 cases are on the rise in the UK, driven by the fast spread of the Omicron subvariant BA.5, which is reinfecting wide swaths of the population – even some who were very recently infected. It is estimated that approximately 70 per cent of those who have Covid-19 in England are having it for the first time, even though they account for just 15 per cent of the population.
Hospitalisations are also increasing but not at the same rate as we have seen in previous waves. However, a spike in cases inevitably means an eventual rise in hospitalisations and deaths.
Our immunity wall – with extensive prior infections, vaccination and boosters – is providing a strong initial defence against BA.5. As our immunity wanes over time, however, and combined with the fast-moving mutations of Omicron, the risk of hospitalisations and death is becoming higher. The UK Health Security Agency (UKHSA) forecasts that hospitalisations in this wave are set to exceed those seen in April this year.
What Is Omicron BA.5?
Omicron continues to mutate into variants and subvariants that have greater immune escape and, consequently, greater transmissibility. This has been the rhythm since Omicron emerged. While we certainly do not know everything about BA.5, the scientific evidence demonstrates that this is the most transmissible subvariant to date – although it certainly won’t be the last. Its ability to evade the protection that vaccines and prior infection have afforded us feeds into a vicious cycle that we have observed with each Omicron variant.
While BA.5’s severity is still uncertain, most countries are observing upticks in hospitalisations and deaths, although not quite at the rate seen in earlier Covid waves.
Omicron BA.2.75
Another subvariant – BA.2.75 – is very new but causing some concern in at least ten countries, including the UK and the United States, even competing with BA.5 in India and parts of Europe. It appears to be associated with either increased severity of illness or increased immune escape, having a pattern of mutations that signals the need to be even more vigilant.
These regular indications of new variant and subvariant development perfectly reflect our situation: unprecedented rapid mutations of Omicron, with variant spread that we collectively hope is the last. To pivot from variant-chasing reactiveness to proactive management, however, we need enduring mechanisms and leadership across health-emergency preparation, surveillance and response.
Covid-19 Cases, Hospitalisations and Deaths Are Increasing
Testing is difficult to access – limited to a small group of eligible people – and the Covid dashboard is now updated weekly rather than daily. This means we are increasingly looking at hospitalisations and deaths as the indicator of where we are at any given time while relying on data coming from other countries to inform our response.
The most recent figures from the Office for National Statistics survey indicate that the number of people infected in the UK has more than doubled since the start of June. The percentage of people testing positive is increasing, with the most recent data (first week of July) showing rates of 5.27 per cent in England, 6.04 per cent in Wales, 5.86 per cent in Northern Ireland and 6.34 per cent in Scotland.
Hospitalisations across the UK are steadily increasing with admissions of Covid-confirmed patients increasing to 17.90 per 100,000 people in the week ending 10 July. Of this total, people aged 55 and over represented the highest proportion of those hospitalised. Throughout the pandemic, hospital-admission rates have consistently been highest in the oldest age groups. The good news is that, compared with the previous Covid wave in March this year, the UK is starting this one with slightly fewer patients in hospital.
Covid-related deaths have also been on the rise, albeit less quickly than cases and hospitalisations. According to the latest ONS data, the number of deaths in the UK involving Covid increased from 347 to 412 in the week ending 1 July, with increased rates across all groups aged 55 and over. The same ONS data show that deaths involving Covid accounted for 3.5 per cent of all deaths in that same week, an increase from 2.8 per cent on the previous week.
Covid and the Flu
Taking into account the lingering and unpredictable impact of Covid, exacerbated by the co-circulation of flu, the autumn-winter period is very likely to be challenging. Limited hospital capacity to manage the influxes of ill people will simply add to the existing backlog. Patients with Covid or flu will be higher urgency than those currently on the NHS waiting list, lengthening waiting times to unprecedented levels.
The slower flu seasons over the past couple of pandemic years have led to greater susceptibility among the population and the earlier onset of flu, which – if countries like Australia are any indication – will have a significant impact on the health system. In Australia, flu emerged early and quickly across all age groups, suggesting it could begin as early as September or October in the UK.
To be prepared, the government should consider the administration of flu vaccines in early September, pairing these with fourth and fifth Covid-19 doses. Targeting the most vulnerable ahead of autumn will help to combat a simultaneous increase in Covid cases at a time when hospital capacity is traditionally strained.
Increasing Pressure on the NHS Backlog
Naturally, the impact of recurrent Covid waves will fall on the NHS. Last winter, the Royal College of Emergency Medicine (RCEM) claimed the “next worrying phase” of the pandemic would be the expected resurgence of a flu and respiratory syncytial virus (RSV) in winter alongside rising Covid cases. This was averted with a widespread vaccine rollout for Covid and the flu. Coming into this winter, the low levels of hospital capacity are likely to exacerbate NHS waiting times, with the current rise in Covid cases and subsequent increase in hospitalisations hindering the ability to clear the record-high NHS backlog. Approximately six million people were on NHS waiting lists for elective care in February 2022, an increase from the 4.4 million waiting for treatment before the pandemic. Any increase in the number of hospitalisations involving Covid-19 risks adding to the backlog and extending the amount of time it takes for it to be cleared.
Vaccinations in the UK
The UK’s vaccine-rollout programme has played an integral role in reducing hospitalisations and deaths from Covid-19. Vaccines continue to be effective at preventing serious illness and death but over time, six months or more from the last dose, protection wanes substantially. What this means is that, as Omicron is quickly learning how to slip through the protection of our immunity wall and immunity continues to wane, serious illness and death become more likely as does the strain on the wider health system. This makes additional doses necessary for the maintenance of protection both for the health of the individual and the collective.
The protection provided by vaccinations or from a prior Omicron infection – even a very recent one – is less effective against infection or reinfection than it used to be. Even those who are perceived to have “super-immunity” – those who have been vaccinated and boosted, and have had a prior Covid infection – are similarly susceptible.
There is also increasing certainty that boosters have little protection against infections from BA.5, but they are extremely effective at preventing hospitalisations and death. Evidence from the United States has shown that adults aged 50 years and older who have had two booster doses were four times less likely to die from Covid than those who have had just one. Compared with the unvaccinated, two boosters reduce likelihood of death by 99 per cent, one booster by 86 per cent and two shots by 81 per cent.
In addition to reduced protection against infection, effectiveness against hospitalisations is slowly dropping too. For instance, less than three months after three doses of an mRNA vaccine, the protection is:
Delta: 89 per cent
Omicron BA.1: 80 per cent
Omicron BA.2: 74 per cent
Omicron BA.5: unknown (highly likely to be lower)
This represents a continuing decline of protection against hospitalisations, with a corresponding likely increase in deaths, underscoring the importance of rolling out further boosters to the most vulnerable and pushing their uptake.
The UK has solid vaccine uptake although there are significant numbers who haven’t received any doses, including higher-risk older people. And this uptake has been diminishing over time as subsequent boosters have been made available:
First dose: 93.2 per cent
Second dose: 87.2 per cent
Third dose: 69.4 per cent
Some have pointed to “vaccine fatigue” as a reason for this diminishing uptake. It is important to note that uptake is complex and has been shown to be improved with targeted communications that emphasise perceived benefit, efficacy and safety, ease of access, and seeing others with whom you identify being vaccinated. The UK’s strategy should be targeted towards ensuring optimal uptake and learning lessons from the first three doses to better understand why uptake is diminishing, while reconsidering how funding and approaches to vaccine advocacy might be better applied to reduce vaccine inequality between different groups of the population.
An additional dose has been shown to be effective at increasing both antibody levels and immunity. In spring 2022, a fourth dose was offered to adults in the UK aged 75 and over, residents in care homes, and individuals aged 12 and over with weakened immune systems. It has now been announced, in line with our April recommendations and the view of the UK’s Joint Committee on Vaccination and Immunisation, that a further Covid-19 vaccine will be offered to:
health and social-care staff
everyone aged 50 and over
carers aged over 16
people aged over five whose health puts them at greater risk, including pregnant women
people aged over five who share a house with somebody who has a weakened immune system
In consideration of waning immunity and rapid mutations of Omicron, this step could arguably have been instigated sooner and should be rolled out immediately, rather than in September, as seems to be suggested. In addition, and dependent on the emerging epidemiological picture over the coming weeks, we should be prepared to extend booster availability to even more of the population. We need to bolster our immunity wall, even if this only results in a temporary reprieve, and bring the UK's vaccination policy in line with comparable countries.
New Vaccines Are Imminent
Next-generation vaccines designed to target Omicron BA.5 are likely to be rolled out at the end of 2022. However, we know that BA.5 is unlikely to be the dominant subvariant circulating at that point. Since it is impossible to keep up with the rapid speed of Covid mutations, this variant-chasing strategy will fail. What the government needs is a proactive plan to get ahead of the virus while taking a more aggressive stance on next-generation vaccines within our reach because with each new subvariant, we risk encountering even higher rates of immunity escape.
New versions of the vaccine tweaked to better protect against Omicron are already being mass-manufactured but are yet to be approved. These new vaccines – directed at the BA.1 variant – are effective against infection, but are less effective at generating immunity against BA.5. To try to get ahead of the next mutation, the Vaccines and Related Biological Products Advisory Committee (VRBPAC) in the United States has urged manufacturers to add an Omicron BA.5-specific vaccine to their products.
Chapter 3
The country needs a comprehensive, understandable and actionable plan to manage Covid-19.
In April this year, the Institute published an assessment of the government’s “Living with Covid-19” plan, in which we put forward practical recommendations for each pillar: vaccination, testing and treatment. While they were not taken up by the ministers responsible for these elements of the Covid response, we believe that if they had been, the UK would now be in a better position to respond to the rising wave of cases in a proactive, rather than reactive, way and to bring the public along with it.
This latest wave of cases is yet another opportunity for the government – and its new ministers – to reset its approach to Covid-19 and to build on the positive results the UK has demonstrated in many parts of its response to date, including on rapid and mass vaccinations. It is also an opportunity to consider how to properly address important topics such as statutory-sick-pay reform and adequate ventilation. While on the surface, sick pay and ventilation might seem to be unrelated topics, the lack of both represents structural issues that propagate transmission of Covid, the former because people feel obliged to work even when symptomatic with infection, and the latter because inadequate airflow allows the virus to more easily access and infect people in a closed space.
We are calling on the government to announce and undertake a review of its “Living with Covid-19” plan, assessing progress and adapting it in line with the latest public-health advice while setting measurable indicators of success and creating sustainable structures that work across government – not in silos.
There are two areas in which there are clear pragmatic lessons from the pandemic that can be incorporated into a reset of the plan:
Central management of emergency-response operations
Risk communications and engagement with communities
Central Management of Emergency-Response Operations
The UK’s Covid-19 response was characterised by an inability to initiate a centralised command-and-control response; the reality instead involved parallel workstreams that were poorly coordinated across testing, tracing and vaccines. Countries regarded as having the most successful Covid responses implemented – and continue to implement – whole-of-government responses that are centrally coordinated in line with guidance issued by the World Health Organisation, based on many years of global experience in managing public-health emergencies.
A tangible and immediate illustration of why this future management is necessary is that a large percentage of the population will catch Covid between one and four times in any given year. Therefore, an improved approach to emergency response will have enormous immediate and ongoing value. A large burden of ongoing Covid-disease incidence will translate into significant time off work – in some cases, up to several weeks – with additional absences from seasonal flu and other illnesses. Nationally coordinating the government response in support of businesses, schools and hospitals will be critical to minimising duplication of work and effort and creating a common understanding. Such coordination will also benefit the UK’s approach to Long Covid, a condition that is and will continue to create long-term NHS and social-care demand that the system will struggle to absorb.
A plan to manage Covid-19 should be governed by an unambiguous centre of gravity for health emergencies that has a clear mandate to lead on this and future threats. The government now has the opportunity to tightly coordinate and control the various strands of its response, with strong political leadership and operational alignment between public-health experts, response organisations and other support structures – such as civil society and the military. This will enable better coordination between regional and local structures, an improved flow of information and greater collective situational awareness, but also more efficient and effective resource allocation based on need. It will also allow the UK to capitalise on international experiences and build a system that can manage Covid with confidence today while adapting to the health emergencies of tomorrow with agility.
The UK is not alone in needing to regroup and implement a better governance approach. The World Health Organisation (WHO) has begun work on a revision to its guidance for health-emergencies preparedness, response and resilience – a vital approach when taking into account the increasing threats to human health from disease, armed conflict, food scarcity, climate change and fuel insecurity. The UK should show both willingness and leadership by collaborating with international stakeholders such as the WHO when building its pandemic legacy.
Risk Communications and Community Engagement
The second area in which the UK’s approach to Covid management can be improved is engagement with communities and risk communications. This relates to the application of social-science driven insights to communications that better inform protective behaviours, and help maintain trust between the public and the authorities.
At this point in the pandemic, there is not only an immunological jigsaw of protection, with different people having different levels of immunity, but also a jigsaw of personal and behavioural insights with implications for public-health messaging. Our resilience has been tested in physical, social, financial and emotional domains, and this impact on people and communities has been cumulative. While this is an issue in its own right, with the trauma of the past two-and-a-half years affecting areas of life beyond Covid, the immediate task is to deal with the implications for each successive wave of Covid or other infectious diseases, learning the right lessons and applying them with confidence.
The government needs to present public-health information in a way that allows people to protect themselves and others, because exposure to Covid isn’t up to the individual alone but a matter for the community as a whole. An example is the low rate of mask usage despite rising Covid cases and the real risk to the vulnerable; most people are no longer willing to take such a preventative measure to protect others. Despite most people being open to hearing what they can do, and willing to adapt when provided with a compelling case, there is a tendency to underestimate public will and engagement. There is equally a tendency to underestimate the importance of behavioural insights and the communications they can generate.
When it comes to influencing public behaviour, there is a substantial difference in the behavioural-insights approach normally applied by government, and those practised within risk communications during health emergencies. The former, practised by the Cabinet Office, tends to relate to the economically driven “nudge theory” and involves top-down assumptions. The latter, more associated with the UKHSA (formerly Public Health England), takes a consultative approach based on rapid anthropological research and seeks to understand what people are actually thinking, fearing and believing. While both converged at some point over the course of the pandemic, the time taken to recognise the differences in these behavioural insights led to a delay in learning from best practice. The government needs to close the gap between evidence and insight, as well as between the application of that insight into action, by putting risk communications on an equal footing with the analysis of epidemiological data.
There is now an opportunity for government to coherently reset its response to health emergencies by addressing these two major areas in which the UK has fallen short – alongside leaders overtly setting examples by adopting the measures themselves. Together, this will help ensure the severe restrictions we lived through in 2020 and 2021 are a thing of the past – even if a deadly new variant emerges.
Chapter 4
As we have seen over the past two-and-a-half years, the management of Covid involves not only having access to the lifesaving tools at our disposal – vaccines, therapeutics and testing – but also maximising their uptake and harnessing their benefits. This is an opportunity to build infrastructure to continue managing today’s pandemic – and to respond to tomorrow’s emergencies by creating a system that is always on and able to confidently manage any threat.
Many developed countries continue to treat Covid as a crisis – holding their breath and waiting for the storm to pass before reverting to business-as-usual – rather than seeing it as a catalyst for a different public-health reality in which resilience is built against all hazards to human health.
This is an opportunity to erect stronger defences, and refine and formalise systems and frameworks by building practical and real-time lessons into the UK’s management of the virus.
It is an inevitability that BA.5 will be replaced by a new, more transmissible variant or subvariant in the autumn-winter, leading to another wave. When this does happen, the government could be in a better position. To support this, we set out practical measures that it can take today as well as long-term decisions for greater resilience in the future.
With this in mind, we have developed a set of practical recommendations for the UK government on vaccines, management, testing and community engagement.
Recommendations
Covid-19 and Flu Vaccines
Implement the newly announced “autumn booster” immediately, coupled with flu vaccines, ensuing there is a low threshold for expanding it to cover a greater proportion of the population.
Treat the development, manufacture and approval of next-generation vaccines (including universal/bivalent/multivalent) for novel variants of concern with the same urgency as Covid-vaccine development in 2020. The existing vaccines have filled our short-term needs, but we now need long-term solutions.
Release a detailed, strategic vaccination plan that integrates new, next-generation vaccines into the cadence of the plan while making it clear to all age groups when they can expect to be eligible for their shots and with which vaccines.
“Living with Covid-19” Plan
Undertake a review of the “Living with Covid-19” plan to assess progress – adapting as required in line with the latest public-health advice – and set key, measurable metrics for success and triggers for action. These can include when to reintroduce free testing and for whom; when to roll out existing vaccines and next-generation ones and for whom; and when to push for greater behavioural changes, such as physical distancing and working from home.
Covid management should be overseen by a health-emergencies response centre that has a clear mandate to lead on this and future management of health threats.
Testing
Bring back accessible testing – including free lateral-flow tests and better access to PCRs – so that citizens and policymakers can make better-informed decisions about when to isolate and so protect those at risk.
Community Engagement
Re-energise the approach to behavioural insights-led messaging about increasing levels of risk, ensuring the most senior levels of government have visibility of these insights and can take action on them.
Close the gap between evidence and insight, as well as between the application of that insight into action, by putting risk communications on an equal footing with the analysis of epidemiological data.
Ensure there are clear, actionable messages about the complex and increasing levels of Covid risk, and the simple actions people and organisations can take to protect themselves and others.
Ensure that leaders in government set an example to others by adopting such measures themselves.
Lead Image: Getty Images