We’re coming to the end of the COVID-19 Evidence Alert in its current format. Since the first issue in June, we’ve been scanning for evidence on a range of prioritised themes to support the COVID response. As Phase 3 recovery plans within England are being finalised, it seems an opportune time to reflect on the evidence we’ve found so far and how this might inform reset and recovery.
The final three issues offer some brief reflections on the evidence we have scanned along with links to some of the studies which we think offer particularly interesting perspectives. These are organised by the following themes:
We will be updating the trackers as quickly as we can, so each tracker provides a one-stop collection of the evidence we’ve found since June. Our searches are by no means exhaustive so the trackers won’t be comprehensive - but they will provide you with a useful core collection of evidence and insights to inform planning and provide a baseline for future analysis, research and evaluation.
We welcome your feedback. Did we miss any important themes in our approach? How could we improve on our scans and alerts? Please share comments with us via mlcsu.covidevidence@nhs.net.
Analytical Collaboration for COVID-19
As previously described the collaboration is using its expertise to focus on questions that the NHS may lack the immediate resources to look at, which may be more medium-term, cut across sectors, or benefit from independent analysis. We are gradually publishing analytical outputs so keep an eye on these pages for useful findings. You can keep up to date by following @strategy_unit on Twitter.
We set out to find evidence relating to all types of residential setting (including care homes, prisons, educational institutions and sheltered housing). However, the vast majority of what we found was focused on care homes. LTC Responses to COVID-19, an international long-term care policy network, has done a great job of assembling evidence on the impact of COVID-19, including country reports and international comparisons.
A living systematic review (updated frequently) has proved useful in tracking evidence on the impacts in care homes. It is clear from emerging evidence that these impacts are similar across many different countries 1, 2.
We found a number of recurring themes specific to residential settings generally:
Reducing the spread: as well as the need for increased hygiene and decontamination, there are gaps in testing. Tests are focused on individuals with respiratory symptoms yet individuals may present with no/atypical symptoms. As the pandemic has progressed, there has been interest in the risk of infection amongst rotating staff members and how testing might be implemented, from studies based in London care homes. There is also emerging evidence on risk factors associated with hospital discharge into care homes. There are studies (from the US 1, 2 and Canada 1, 2) focused on accommodation for homeless people, and sheltered housing, noting some of the challenges (for example, some symptoms are often present in homeless people so may not a good indicator of infection) and solutions.
Surge planning: includes planning 1,2 for future peaks and protecting high-risk patients (such as those with dementia who “walk with intent”) and suggests a need for multi-agency planning 1, 2.
Staffing: the attempt to cover staffing gaps through temporary staff may exacerbate spread, particularly where staff are deployed across multiple sites. Retention is identified as a key issue to address during recovery planning. There is emerging evidence on the impact on staff wellbeing 1, 2.
PPE: highlighting issues with supply chains as well as a need for more training for staff in how to use PPE effectively. A report from the Healthcare Safety Investigation Branch highlights the issues involved in domiciliary care.
Communication: there is some evidence to suggest that awareness of the implications COVID-19 is low amongst some residents, suggesting a need for more communication 1, 2, 3. There are also recommendations to improve systematic communication both with other services and with relatives of residents.
Isolation and distancing: qualitative studies suggest a concern with the unintended consequences of distancing in a population where anxiety and depression are prevalent. Recovery planning should include procedures for reintroducing visitors safely 1, 2, 3, 4, 5.
Technology: Some studies are exploring the use of telemedicine as a means of delivering care remotely 1, 2, 3. However, access to technology remains an issue in residential settings. There are also suggestions that “no-touch technology”, which may limit spread, are not in widespread use. One study, focused on residential facilities for people with learning disabilities, emphasised the need for real-time data analysis to manage spread.
As the pandemic progressed, scrutiny increased as the impact in care homes became clearer. A population analysis from Scotland highlights the impact in the UK. There is a focus on what lessons we can learn and apply to minimise further spread and harm. Analysis from the COVID Analytical Collaboration offers valuable insights to inform recovery planning:
With thanks to Christina Maslen, Health Evidence Matters who prepared the rapid evidence scan in May.
Screening and testing strategies form only one element of an overall epidemic response and need to be considered within the context of all actions, including broader public health measures such as surveillance, that are designed to optimise healthcare requirements and successfully manage COVID-19.
The role of testing and screening
Policy has been adapted as the pandemic has progressed. The Health Foundation Policy Tracker provides a timeline of how policy developed and the health system responses in the UK. The Health System Response Monitor provides a comparison of testing strategies across different countries.
It was clear from very early on that this is a fast-moving situation, with new studies published continuously. Due to time constraints and urgency needed to release findings into the public domain, much of the earlier evidence was based on case studies or modelling studies.
Imperial College published their analysis in April, using modelling to investigate the effectiveness of various testing strategies. The study found that testing is most useful when targeted at high-risk groups such as healthcare and care home staff and other at-risk groups. Weekly screening using PCR or point-of-care tests for infection irrespective of symptoms in addition to testing of symptomatic individuals may prevent an additional 25-33 % of their contribution to transmission in hospital and the community.
A systematic review of interventions to suppress the COVID-19 pandemic suggests there is some - albeit low quality - evidence that the most cost-effective interventions are swift contact tracing and case isolation and surveillance networks. Analysis 1, 2, 3, 4, 5, 6, 7 confirmed the need for adequate surveillance and contact tracing to be in place to manage lockdown and to avoid overload of health systems. There are however, some challenges with adherence to contact tracing. A number of papers 1, 2 sought to capture learning from those countries who were impacted earlier in the pandemic, to identify transferable lessons for the UK. A report from the European Centre for Disease Control compares approaches across the EU/EEA and the UK.
Delivery of testing/screening and continuity of care
Findings 1,2, 3 related to the benefits of periodic testing of healthcare staff have been confirmed by several studies, both modelling and case studies in UK hospitals, with several focusing on the role and limitations of symptom-based screening 1, 2, 3, 4. A study from London offered some insights to the transmission dynamics of COVID in a large teaching hospital.
There is limited evidence 1, 2, 3, 4, 5 that local testing and that extensive testing all have a positive impact on mortality rates, with the countries with the highest testing rates per population having the lowest death rates. Testing capacity is clearly an issue, presenting challenges to laboratory services. However, increased testing capacity alone may not provide a solution to lockdown measures in the UK. The progression of the epidemic and peak infections depends heavily on test characteristics, test targeting, and prevalence of the infection.
We found some evidence on the practicalities of setting up testing centres 1, 2, 3 and more studies are emerging which explore the role of testing/screening in restarting services 1, 2, 3, 4, 5 and the risks of nosocomial spread in healthcare settings.
Analysis from the COVID Analytical Collaboration offers useful insights to inform screening and testing strategies:
This alert has formed part of a national evidence update service, provided by the Strategy Unit, as part of a collaboration to provide analytical support to the health and care system to help inform the initial response to COVID-19. Thank you for the very helpful feedback we have received since we published the first issue back in June. We’ll be updating the evidence trackers on our web site to include all the links from the weekly alerts. In response to feedback, we’ll be adding sub-themes to the trackers on rehabilitation needs, impacts on health outcomes, and impacts on non-Covid care, to help you navigate evidence to date.
The Strategy Unit is hosting a 6-week festival of virtual events, called Insight 2020, exploring some of the challenges facing decision-makers in health and care in 2020 and beyond; emerging models of practice to make best use of analysis to inform decision-making; and some of the exciting work that is already happening in this area.
Insight 2020: a festival of analysis and learning for the NHS, Local Government and our partners will run from 28 Sep to 13 Nov 2020. The festival will comprise a mixture of events, workshops and panels, representing conversations at a local, national and international level. For example, our festival launch session includes Ben Goldacre talking about ‘How open approaches can revolutionise health data science in the UK’ and Andi Orlowski on “Dangerous analytics…and how local analysts can save you!”, with Q&A hosted by Professor Mohammed A Mohammed. We will also be running a session on the COVID Evidence Conundrum, featuring a range of perspectives from people who have been involved in generating, using and applying evidence on COVID discussing what this means for how we use evidence to inform decisions.
Who is Insight 2020 for? We’ve collaborated with inspirational people and organisations across the sector to bring together a programme which has something for everyone who is involved with decision-making in health and care.
What will Insight 2020 look like? Sessions will be varied and flexible. People can commit as little or as much time as they’d like, and most of the sessions will be recorded so you can fit them into your schedule in a way that suits you. Every session is free.
Each week will focus on a central theme, starting with a ‘headline’ presentation on the Monday. This will be supported by targeted sessions and the week’s speakers will convene each Friday for an interactive panel discussion and Q&A to respond to the key debates raised during the week. The festival themes are:
Week 1: Our decision-making context in 2020
Week 2: The role of the Midlands Decision Support Network
Week 3: The analytical priorities of the Decision Support Network
Week 4: Building momentum around addressing health inequalities
Week 5: The decision-making toolbox
Week 6: Making the most of our decision-making resources
To register your interest please go to our Eventbrite page. The full-week programmes will be released on a staggered basis starting from week commencing 7th September where you will be invited to register for specific sessions.
