NHS England and NHS Improvement Board meetings held in common
Paper Title: Covid-19 response overview
Agenda item: 4 (Public Session)
Report by: National Directors, NHSE/I
Paper type: For discussion
Organisation Objective:
NHS Mandate from Government ☐ Statutory item ☐
NHS Long Term Plan ☒ Governance ☐
NHS People Plan ☐
Executive summary:
This paper provides an overview of the work of the NHS to prepare for and respond
to Covid-19. It recognises the extraordinary contribution and burden placed on NHS
and other staff to care for and treat Covid and non-Covid patients. Covid-19 has
been the greatest public health emergency since the foundation of the National
Health Service. In the face of a pandemic, NHS staff working flexibly alongside other
key workers responded magnificently while working under unprecedented pressure,
innovating and adapting to l those in need of treatment and care.
Action required:
The Boards are asked to consider the Covid-19 response and the clinical and
operational innovations achieved across the NHS. This is not an assessment of the
overall UK response to the pandemic, which will be a matter for Parliament and the
promised future public inquiry.
Background:
1. Since the first two Covid patients were treated at the High Consequences
Infectious Diseases Unit at Newcastle Royal Victoria Infirmary at the end of
January 2020, the NHS in England has cared for over 380,000 Covid-positive
patients with around one person with the virus admitted to critical care every 30
minutes, inevitably impacting on other areas of patient care (as has also been
seen in most other European countries). At the peak of the pandemic in
January 2021, around 4,000 Covid patients were being looked after in critical
care every day. In order to ensure that all those who needed critical care
received it, hospitals expanded critical care capacity by around 50% above their
usual capacity, with some areas surging to over 80% above their usual
capacity. The NHS has provided over 33,620 Covid-19 patients with the most
intensive level of care since the first case was diagnosed. One of the benefits of
having a National Health Service are the mechanisms in place to allow trusts to
offer and seek mutual support. This ensured that critical care units could be
decompressed making use of established critical care network capability.
NHS England and NHS Improvement
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Thanks to these efforts and the hard work of NHS staff, the NHS did not run out
of capacity to provide critical care anywhere in the country at any point in the
pandemic.
2. In addition to treating Covid-19 patients, hospitals transformed to continue to
support non-Covid patients. At each point in the pandemic the NHS has looked
after at least twice as many inpatients without Covid-19 as Covid-19 patients,
with nearly 20 million people receiving emergency care in England’s A&Es in
2020. In primary care, many GPs switched to providing some care virtually,
which meant more than 280 million appointments could be carried out over the
past year.
3. NHS hospitals and primary care teams have been at the forefront of recruitment
into and delivery of clinical trials which have identified effective Covid-19
treatments benefitting patients across the NHS and around the world. Over one
million (1,075, 000) people have taken part in Covid-19 research in the UK.
NIHR-supported platform trials, such as RECOVERY and REMAP-CAP, have
been pivotal in generating key evidence for the mortality and recovery benefits
conferred by dexamethasone (now the standard of care in the treatment of
hospitalised patients with COVID-19 requiring oxygen) and tocilizumab. The
NHS has therefore contributed to saving approximately 22,000 lives in the UK
and close to one million lives across the world. The RAPID C-19 collaboration
has ensured UK-wide adoption of these effective Covid-19 therapies in an
average of just 6 days from material research findings becoming available to
treating patients in the NHS.
4. The NHS was also the first health service in the world to deliver the Pfizer and
Oxford Astra-Zeneca vaccines outside of a trial, and has also now delivered
over 22 million vaccine doses to those most vulnerable to Covid-19 in the
largest vaccine roll out in the history of the health service and the fastest and
best targeted vaccine roll out in Europe and for any large country in the world.
5. Responding to Covid-19 has placed extraordinary pressures on the NHS,
impacting significantly on the experience of staff and patients. The task ahead
facing the NHS will be to embed the innovations achieved, supporting the
flexibility and adaptability of NHS staff working across team and organisational
boundaries. We need to continue to support NHS staff, and continue to support
patients by tackling the backlog in care created by this pandemic, while
responding to future prevalence of Covid-19 and delivering the vaccines that
will secure recovery.
Preparing the NHS for COVID-19
6. By 22 January 2020, NHSEI established our formal Covid incident
management structure and national incident coordination centre. On 30 January,
the first two people in the UK tested positive for Covid-19 (then called Wuhan novel
coronavirus) and were transferred to a High Consequence Infectious Disease Unit in
Newcastle. On the same day, the first phase of the NHS’s response to the virus was
formally triggered with the declaration of a Level 4 National Incident – the highest
category of emergency – and national command and control arrangements were put in
place.
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7. At the Government’s request, NHSEI worked with local and national partners to
rapidly mobilise quarantine facilities to accommodate UK citizens who had been
evacuated from Wuhan. Accommodation on the site of Arrowe Park Hospital in
the Wirral was readied over a few days and welcomed its first 83 arrivals on 31
January. A second quarantine centre was established at Kent’s Hill Park hotel
and conference centre in Milton Keynes in early February. In total around 241
citizens were supported to isolate across these two centres.
8. NHS High Consequence Infectious Disease capacity was also expanded to
monitor and care for patients during this period. Between February and early
March, capacity of five existing units in England was increased with an
additional six infectious disease centres identified to supplement the HCID
Network.
9. NHSEI’s incident response arrangements were enhanced further through
February 2020. A National Incident Response Board was established to
oversee the NHS response, regional incident centres were established
alongside the national incident coordination centre (operating 7 days a week),
and additional expert ‘cells’ and clinical leadership mobilised to support
preparations. On 2 March, NHSEI wrote to NHS organisations asking them to
step up preparations in light of the continued spread of the virus in multiple
countries. Ten days later, on 11 March, the WHO declared a pandemic.
Chart one: Number of confirmed Covid-19 inpatients
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Ref: BM/21/07(Pu)
Chart two: Number of confirmed Covid-19 patients in HDU/ITU
Achieving Surge Capacity for Covid Care
Wave one:
10. Following the Prime Minister’s announcement on 12th March of a move from
the ‘contain’ to ‘delay’ phase and agreement with Government that week on the
actions needed to free up hospital capacity, NHSEI initiated a rapid repurposing
of NHS services, staffing and capacity to meet the expected surge in Covid
demand. Urgent actions were enacted to: free-up the maximum possible
inpatient and critical care capacity; prepare for, and respond to, the anticipated
large numbers of Covid-19 patients who would need respiratory support;
support staff, and maximise their availability; stress-test operational readiness;
and remove routine administrative burdens.
11. NHS systems acted rapidly to enact surge plans and ensure Covid patients
received the care they needed. Through conversion of operating theatres and
other clinical spaces, expansion of ITUs, and standing down non-urgent
elective activity, hospitals were able to increase the level of capacity available
for the most acutely unwell (requiring mechanical ventilation), but also increase
available capacity for those in acute beds requiring non-invasive ventilation. As
clinicians learned more about Covid-19, treatment changed as it became clear
that the optimal therapy for most hospitalised Covid-19 patients turned out to be
types of enhanced oxygen therapy which can be given in a general ward, rather
than the patient being sedated on a mechanical ventilator in intensive care. In
addition to enacting well-rehearsed surge plans, through agreement between
local partners, temporary service reconfigurations were implemented to ensure
staff could be re-deployed to bolster the services that were experiencing the
most demand. Ward capacity was also freed up through additional Government
funding for enhanced discharge arrangements to reduce inappropriate hospital
length of stay, supported by emergency legislation. At the peak of wave 1 in
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April 2020, there were 18,974 Covid-19 positive inpatients, with 2,868 on
mechanical ventilation.
12. The Covid-19 Response Service was initially established at the end of February
and rapidly increased capacity through March, in response to rapidly increasing
NHS 111 demand. At peak demand the service received 450k calls in a single
week.
Wave two:
13. At the beginning of September 2020 there were 496 hospitalised patients in the
NHS in England. On 23rd December 2020 NHSEI wrote to all provider and
system leaders to reinforce the 5 key operational planning priorities, which
were: responding to Covid-19 demand; implementation of the Covid-19
vaccination programme; maximising capacity in all settings to treat non-Covid-
19 patients; responding to other emergency demand and managing winter
pressures; Supporting the health and wellbeing of our workforce.
14. In preparation for a potential further wave of Covid demand, each NHSEI
Region worked with the ICS/STPs within its footprint to develop an escalation
and surge plan. Each system developed a mutual aid approach at system and
regional level to enact full regional critical care surge plans. For wave 2, NHSEI
established a new national Critical Care Capacity Panel, which reviewed
capacity in the most pressured systems daily and coordinated mutual aid. At
the peak of wave 2/3, there were 34,336 Covid-19 positive inpatients, with
3,736 on mechanical ventilation and hospitals admitted more than 100,000
patients with Covid-19 in January 2021 alone
Maintaining essential patient care and tackling the elective backlog
15. By necessity, a considerable number of elective services were disrupted in
many countries including the UK during peak Covid. This, coupled with
challenges posed by the implementation of necessary Infection Prevention and
Control (IPC) measures to limit the spread of Covid, meant that new solutions
were urgently needed to meet the key challenge of supporting elective activity
to restart and to recover towards the levels seen before the pandemic. On 29th
April 2020, NHSEI wrote to all provider and system leaders across the NHS
triggering phase 2 of the pandemic response, asking them to fully stand up
non-Covid urgent services as soon as possible. This was just 14 days after the
deadline trusts had been given for the postponement of all elective activity.
16. To support this and to support the wider re-start of elective services, NHSEI
launched the Adopt & Adapt Programme, which consisted of workstreams
supporting 5 key patient areas: Endoscopy; CT/MRI; Outpatients; Theatres;
Cancer. The approach was built on the following key components:
• Using technology, clinical reviews and standardised pathways in support
of triaging to manage demand appropriately.
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• Prioritising workforce capacity to support challenged services, in much the
same way that staff were deployed to critical care during wave 1.
• Promotion of and implementation support with PHE for IPC best practice
and guidance including on: Covid/Non-Covid pathways; self-isolation
guidance; testing; PPE; cleaning and building ventilation guidelines
relevant to the service in question.
• Taking advantage of opportunities to better utilise NHS facilities by
sharing waiting lists; using independent sector capacity and identifying
temporary facilities to support IPC measures.
17. The NHS mobilised increased Advice & Guidance services to ensure
secondary care provided clinical advice to support to primary care elective
services. Annual activity increased from 300k to a projected 1.1m requests.
Around a third of all outpatients attendances are now delivered by telephone or
video consultation – up from just 4% in 2019/20, surpassing the NHS’s original
Long Term Plan goal. Early evaluation work has shown high levels of
satisfaction with remote outpatient care – and avoiding the need for trips to
hospital benefits citizens with less time off work, school or spare time.
18. By early/mid November 2020 (in the run-in to Covid wave 2), overnight and day
case elective activity had recovered to 80% of the levels seen at the same time
last year, with outpatients still running at around 90% of last years’ levels even
into December. Diagnostic activity recovered to an even greater extent – by
mid-November colonoscopy and gastroscopy activity was back to over 95% of
the levels seen last November, and the NHS was delivering over 100% of the
CT activity at the same time in the previous year.
19. In cancer, at the start of the pandemic there was a reduction in the number of
people coming forward to have their symptoms checked, and some disruption
to cancer diagnostics and treatment. However, thanks to the efforts of NHS
staff and their partners, between March and December 2020, nearly 1.7 million
people were urgently referred and over 228,000 people started treatment for
cancer - 95% within 31 days. In December, urgent referrals were at 107% of
pre-pandemic levels and first treatments were at 102% while there has been
some impact of the current pressures on urgent cancer referrals, this is not to
the extent that was seen in the pandemic. The majority of treatment has
continued.
20. 228,000 people started treatment for cancer between March and December
2020. For people who have symptoms but have not yet contacted their GP,
public awareness raising, for example through the ‘Help us help you’ campaign,
will continue to be an important part of our approach.
Developing trials and research to support Covid-19 patients
21. NHS research adapted to focus on recruiting to urgent public health (UPH)
Covid-19 studies and vaccine studies. Over 1 million participants have been
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recruited into UPH/ONS Covid-19 studies including RECOVERY, PRINCIPLE
and REMAP-CAP.
22. In June 2020, the investigators from RECOVERY, a National Institute for Health
Research (NIHR)-sponsored randomised platform trial across 177 sites in the
UK, announced the first drug to reduce mortality from Covid-19.
Dexamethasone was shown to reduce death by one-third in mechanically
ventilated patients and by one-fifth in patients receiving supplemental oxygen
only. This meant that 1 death would be prevented in treating every 8
mechanically ventilated patients or around 25 patients requiring supplemental
oxygen only. Dexamethasone also reduced median length of stay in hospital by
one day and decreased the risk of progression to mechanical ventilation (in
patients not already ventilated at the start of treatment) by 24%. These findings
led to the World Health Organisation’s global recommendation for the use of
corticosteroids in the treatment of severe and critical Covid-19. Dexamethasone
is estimated to have saved approximately 22,000 lives in the UK and close to 1
million lives globally between July 2020 and March 2021 (extrapolated from
modelling in Aguas et al, 2021).
23. The NHS also responded swiftly to emerging evidence around the benefits of
tocilizumab, a repurposed drug usually used to treat severe rheumatoid
arthritis. REMAP-CAP, an international platform trial (with NHS hospitals
forming the majority of sites within its Covid-19 domain), announced that in
patients critically ill with Covid-19 pneumonia, tocilizumab reduced ITU stay by
10 days and resulted in an 8% absolute reduction in mortality. Results from
RECOVERY subsequently showed that tocilizumab could support a 4%
absolute reduction in 28-day mortality in a broader hospitalised population
requiring supplemental oxygen. These results meant that one death could be
prevented by treating around 12 patients requiring critical care or 25 patients
with systemic inflammation requiring supplemental oxygen.
24. Following announcements from trials, NHSEI led on the finalisation of UK wide
interim clinical commissioning policies and associated delivery arrangements
to ensure the timely roll out of treatments to eligible patients. The Research to
Access Pathway for Investigational Drugs for Covid-19 (‘RAPID C-19’) is a
multi-agency collaboration that reviews the emerging evidence for potentially
promising Covid-19 treatments across all settings. This approach enables a
rapid recommendation to be made following material clinical trial results and
supports timely UK wide decisions on making these agents available for
frontline use in the NHS. It was through this approach that treatments such as
dexamethasone and tocilizumab were rolled out to the NHS, typically within just
6 days of material new trial data becoming available to treating patients outside
of a trial.
Planning and delivering the NHS vaccination programme
25. In Summer and Autumn 2020, the NHS began planning for the biggest
vaccination programme in NHS history, which continues to be critical to turning
the tide against the virus and potentially saving thousands of lives. NHS
England/Improvement was asked by Government to lead the vaccine delivery
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programme, and the NHS was the first health service globally to deliver the
Pfizer and Oxford Astra-Zeneca vaccines outside of a trial. As of 20 March, the
NHS has administered over 22 million doses in England, outperforming all other
large countries in terms of the proportion of the population vaccinated. This
achievement, managed alongside winter pressures and the demands of
treating patients with Covid-19, would not be possible without the dedication of
tens of thousands of NHS staff and volunteers.
26. A network of Covid-19 vaccination sites has been designed to provide the
capacity required and ensure safe and easy access for the whole population.
The NHSEI vaccines programme is now compromised of a fully supplied
network of 267 hospital hubs, 1,271 Local Vaccination Services and 138
vaccination centres, ensuring that over 99% of the population in England live
within 10 miles of an NHS vaccination service. In a small number of highly rural
areas, the vaccination centre will be a mobile unit.
27. A remarkable milestone was achieved by offering a vaccination to those in the
top four priority Cohorts identified by the Joint Committee on Vaccination and
Immunisation (JCVI) (c.12m people in England) within 10 weeks of the first
person being vaccinated. The programme is now vaccinating Cohorts 5-9 with
an ambition to offer first dose by 15 April, followed by Cohorts 10-12 (all
remaining adults aged 18 – 49) by 31 July.
28. Addressing health inequalities is a top priority for the vaccination programme.
Local engagement and collaboration across the NHS, local authorities and
voluntary, community and faith sectors has ensured vaccination services can
operate in underserved communities. This has given rise to new approaches
such as opening vaccination sites in places of worship and working with trusted
community voices to increase confidence and improve uptake.
Next steps
29. Covid: Following the latest peak in Covid-19 demand in January, the number of
patients in hospital with Covid-19 is declining steadily. We continue to monitor
the situation closely as lockdown restrictions are gradually eased and the
vaccination programme expands. Learning from our response to the recent
surge will be reviewed to inform preparations for any future wave of Covid-19,
as well as NHS recovery from the impact of the pandemic.
30. Elective Recovery: As the pressures of the latest Covid impacts subsides,
attention turns immediately to the elective recovery challenge. An additional
£1bn funding has been made available to the NHS in 2021-22 to begin to tackle
the backlog that has developed. NHSEI will shortly set out the approach to
planning for recovery and how the £1bn fund will be accessed in planning
guidance for the first half of 2021-22.
31. Clinical Trials: A cross sector Research Resilience and Growth Programme
has been established to support the restoration of non-Covid-19 research and
stimulate recovery as care services return to normal. New research projects are
being developed to understand the long-term effects of Covid-19 in non-
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hospitalised individuals. A UK wide clinical research vision with action plans will
be published this month.
32. Vaccines: It is not currently known for how long people who receive a Covid-
19 vaccine will be protected as the protection vaccines confer may weaken
over time and new variants of the virus may emerge against which current
vaccines are less effective. To ensure the country is prepared, and while further
evidence is gathered, NHSEI is planning for a Covid-19 revaccination
campaign, which is likely to run later this year in autumn or winter, alongside
the annual flu vaccination programme.
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Ref: BM/21/07(Pu)
Annex: Additional Facts and Figures
• Critical Care: A total of £237m was invested to improve resilience in critical
care provision as part of preparations for Winter 20/21. Schemes have
included adult critical care transfer services, new modular builds, the
upgrading of existing ward spaces and enabling estates work such as
improved lift access, ventilation to avoid oxygen build up. Over £10m of
dedicated funding has been allocated to support critical care staff to improve
patient outcomes and reduce risk of psychological harm to staff. Half is being
used to train non-critical care staff according to international standards to
work in critical or enhanced care areas and enable them to bolster the total
available critical care workforce. The second half will enhance pastoral and
well-being support which will be available to all staff working in critical,
enhanced and respiratory care areas.
• UEC Case Mix: Analysis by the National Clinical Director for Urgent and
Emergency care found that within the reduction in A&E attendances, there
was a 14:1 ratio of lower:higher acuity volumes, indicating that those higher
acuity patients who needed care in an ED by and large still presented.
• NHS 111: The NHS has answered more than 18 million calls via NHS 111, a
19.6% increase on the previous year’s call volume, giving more people
needing urgent care an alternative to attending A&E, where appropriate.
• 111 First: Early data from the implementation of 111 First has indicated that
around 27% of patients recommended to attend ED were given a time slot,
with a further 5-10% being recommended to attend Same Day Emergency
Care, avoiding the need to visit the ED.
• Improved UEC capacity: £450m has been invested in A&E capital projects
nationally to improve A&E capacity and patient flow. 25 larger and 175 smaller
schemes started to come online in the run up to winter, to realise benefits
including the expansion of same day emergency care and priority assessment
units; reconfiguring waiting rooms to maintain social distancing; and
increasing waiting capacity and cubicle numbers. The 25 larger schemes will
continue to late 2021.
• Community Health: Staff supported community services including
supporting care homes and included 11,798 care homes receiving intensive
Infection Prevention and Control training through 371 ‘supertrainers’ and
2,474 local trainers.
• Volunteer Responders: A total of 1,574,304 tasks had been completed by
NHS Volunteer Responders for over 153,000 vulnerable individuals. The NHS
has worked with the British Red Cross, St John Ambulance, Age UK and RVS
who have offered support services to 107 NHS Trusts as part of surge
planning.
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• Enhanced laboratory capacity and testing: The NHS stood up additional
laboratory capacity in our pathology networks and 96 laboratories across the
NHS currently undertake Covid-19 testing.
• Stroke: The NHS established 20 Integrated Stroke Delivery Networks across
England to deliver integrated stroke care across the entire pathway, including
closer collaboration of providers, a networked workforce solution leading to
high-quality and sustainable stroke services. A blood pressure at home project
has been rolled out and virtual clinics for TIAs (mini strokes) have helped
ensure that patients are treated in a timely manner without having to attend
hospital where possible. More clinical teams are using virtual rehabilitation
alongside face-to-face contact to ensure every patient gets the treatment and
support they need. Almost half of stroke survivors have had virtual care since
Covid began with data reporting mostly positive or very positive experiences.
• Mental Health: Mental health services have remained open throughout the
pandemic. Whilst the first lockdown impacted referral routes and access rates,
in some cases referrals have now returned to pre-pandemic levels. Local
services have worked rapidly to respond to the changing context.
• Enhanced support for NHS staff: Investments in new health and wellbeing
services to support our staff through the pandemic are continuing, including a
confidential support service, apps (including one aimed specifically at BAME
staff), online resources and a specialist bereavement support service. A
specific package has been developed to support critical care staff. A national
staff health and wellbeing support offer was developed to ensure NHS staff’s
psychological and physical safety and has been accessed over 780,000 times
by NHS staff. NHS England and NHS Improvement has invested £15 million
to ensure NHS staff get rapid access to assessment and evidence-based
mental health services and support as required which include critical care
nurses, paramedics, therapists, pharmacists and support staff, with conditions
such as anxiety or depression. A range of resources for both individuals and
teams, such as free apps, coaching support, helpline and text service,
leadership support for line managers and executives has been well evaluated
throughout the pandemic. The ‘end to end pathway approach’ spans primary
prevention through to specialist mental health treatment for staff who will need
it, accessed through 40 Mental Health Hubs.
• Workforce: The NHS attracted new staff with workforce growth of 46,000
whole time equivalents over the past year. This included staff returning
through the Bring Back Staff campaign and up to 2,000 MOD staff at times of
pressure. International recruitment continued with 6,800 nurses joining the
NHS since April 2020 from across the world. Students and trainees from
across professions also contributed to patient care provision. During wave 1,
the NHS rapidly onboarded retired and sessional GPs to the NHS111 CCAS
service, recruiting over 2000 GPs. These GPs have delivered over 495,000
calls in the course of the pandemic.
• Independent Sector: The NHS agreed a contract with the independent sector
to provide 8,000 beds including nearly 6,000 with piped oxygen, over 16,000
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clinical staff and more than 1,000 ventilators. The contract initially provided
capacity, staff and equipment and evolved to focus on elective recovery and
support further surges. In total from March 2020 to February 2021 almost 3
million NHS patients have been seen within independent sector facilities.
• Oximetry at Home: NHS systems rapidly moved to implement COVID
Oximetry @home (CO@h) and COVID Virtual Ward (CVW) models during the
pandemic to allow self-identification of silent hypoxia and supported discharge
of COVID inpatients respectively with all CCGs setting up a CO@h service by
the end of December 2020 and over 90% of systems with CVWs by March
2021. Estimates are that over 100k patients have benefited from these
pathways.
• Nightingales: To provide a ‘safety net’ for the acute sector, Nightingale
Hospitals were established to provide additional capacity as a ‘last resort’
insurance policy. It is a success that they were not required to care for large
numbers of inpatients. Initially introduced in London, but implemented in other
regions of the country, these centres provided additional critical care support,
increased medical ward-based provision, step-down care to facilitate
discharge from acute hospitals, and additional diagnostic and out-patient
capacity. They were rapidly stood up again for this winter, adapting their offer
as needed. Some are now also supporting the Covid vaccine roll-out.
• Primary care: All primary care providers across general practice, pharmacy,
dental and optometry continue to deliver care which is safe, necessary and
clinically prioritised. Providers of dentistry and optometry reopened for non-
urgent and essential care.
o General Practice: General practice care has been transformed, adopting
a total triage model, streaming Covid and non-Covid patients, and
delivering an enhanced service for care homes, the Oximetry at Home
service, and maintaining the shielded patient list. 99% of practices now
have video consultation capability, and over 95% have online consultation
capability. Rates of requests submitted by patients via online consultation
systems to general practice have more than doubled from around 250,000
per week to over 550,000 per week between March 2020 and January
2021. Overall GP appointments have increased by ~15% by late January,
once Covid vaccinations are included, bringing general practice up to a
~7m per week run rate. This is 1m per week above pre-pandemic levels.
o Community Pharmacy: The community pharmacy sector has continued
to delivery high levels of activity on the front line of the pandemic
response, delivering a significant share of Covid-19 vaccinations, and
stepping up a home delivery service for shielding patients.
o Dental: Notwithstanding elevated IPC requirements which continue to
have significant impacts on productivity, over 650 urgent dental centres
were established early in the pandemic to maintain access to urgent care
and urgent courses of treatment were back to pre-pandemic levels by
August 2021.
o Optometry: The Optometry sector was impacted in the first wave when
routine services closed but activity levels have since been successfully
recovered and maintained.
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Ref: BM/21/07(Pu)
