They don’t like to call it a gamble, nor even a calculated risk. But if one asks civil servants, former Health Secretaries and NHS leaders how it is that Britain stands on the brink of a pandemic with so few intensive care beds that it is forced to enter partial lockdown, clear themes emerge.
The UK has probably never had enough facilities to cope with the kind of crisis it is now facing without relying on major sacrifices by the public to reduce the spread of disease.
Our overall hospital bed numbers are the second lowest in Europe compared with our population, with around 128,000 beds – down from 144,000 a decade ago following long-term trends which have also seen shorter stays and higher occupancy levels.
But when it comes to coronavirus the most critical element is intensive care capacity, including ventilators to assist those struggling to breathe. Here, Britain’s bed numbers have seen significant rises – close to a doubling in the last 20 years. And where does this leave us? With just over 4,000 critical care beds, and plans to ramp this up to 5,000 as pressures mount.
Consider this: Germany’s population may be a quarter greater than that of the UK, but it has 28,000 such beds and plans to more than double this to respond to the coronavirus pandemic. Its total hospital bed numbers are 500,000 – five times those of the UK.
Jeremy Hunt, Britain’s longest-serving Health Secretary, says: “I was always nervous about the total number of beds because of the pressures we would get, especially in January and February.”
But as pressure mounts on NHS hospitals across the country, Mr Hunt’s greatest regret is waiting too long to expand the health service’s workforce. “If I had my time again, I would have increased training places for doctors and nurses earlier,” he tells The Telegraph.
An extra 1,500 medics a year have been in training from 2018-19, but Mr Hunt is well aware that it takes seven years to train a doctor – meaning the move was too late to assist in the current crisis we face.
He does not recall Britain’s limited intensive care capacity being flagged as one of the greatest threats the NHS faced, and experts point out that many of the comparisons between countries take little account of different definitions of critical care.
Mr Hunt, who held the role for six years until 2016, recalls: “We had a lot of debate about the number of beds. I don’t remember intensive care coming up.”
As chairman of the Commons health and social care committee, Mr Hunt has raised repeated concerns about the Government’s handling of coronavirus, chief among them the NHS failure to test staff with symptoms or ensure those who need it are given protective garb.
“We need a massive ramp-up in testing and protective equipment for staff on the front line,” he says. “We need to protect large numbers of staff – we cannot afford to take them off the front line, but also because it is morally and ethically wrong to put them at risk.”
On Tuesday, he questioned NHS chief Sir Simon Stevens on exactly this. “I asked them three times to sort out distribution within a week and got no answer – that seems to me totally unreasonable,” he says.
He is worried, too, that the lack of testing for NHS staff means rising numbers – up to one in three of those on some wards – are being kept at home for weeks simply because someone in their household has a cough.
Lord Crisp, the NHS chief executive and Department of Health permanent secretary from 2000 to 2006, raises the same concern.
In a crisis like the one facing Britain, “I would want to know where the bottlenecks are – it sounds like the most obvious one is lack of testing for staff – so we know who can come back to work” he tells The Telegraph. “We are seeing these situations where you have three junior doctors living as flatmates – one has a cough and three of them are off work for two weeks. That is ridiculous.”
Hospital bed numbers, and ward occupancy levels, were a worry during his time as chief executive and permanent secretary, he says. “We always felt it was running too hot – we wanted it at 85 per cent,” he adds.
Did he call for resources to expand bed capacity, and in particular more expansion of intensive bed care? “You always want more of everything,” he says. “The bigger issue in my time was paediatric critical care beds – we reviewed that.”
When it comes to overall provision of health, decisions are made by the Government, and ultimately by the taxpayer, he points out. “These are political decisions – Germany and France spend 20 to 30 per cent more per head of population,” he says.
Lord Crisp’s biggest public health crisis came in 2005, with bird flu. The Government’s decision to stockpile 14.6 million doses later came under fire after the effectiveness of the doses was questioned, with research suggesting they cut short the course of flu by just half a day.
In the desperate search for treatments and vaccines, the current Government’s scientific advisers may face difficult dilemmas. “When there was bird flu in 2005, when we stockpiled a whole lot of antivirals we were later criticised for it. In a way, whatever you do you’re screwed,” Lord Crisp says. “People said we overreacted, but we’d have been in more trouble if we hadn’t.”
Past and present officials suggest it is easy now to say Britain made a fatal error in running its hospitals so “lean”. But even countries like Italy, whose hospitals had 60 per cent occupancy levels before the crisis, quickly became overwhelmed, they note – suggesting Britain’s strategy of trying to delay and suppress the virus in order to keep as many people out of hospital as possible has wisdom to it.
Sir David Behan, the former chief executive of watchdog the Care Quality Commission, and before that the Department of Health’s director general for social care, says no service could be in a permanent state of readiness for a crisis on such an unprecedented scale.
“In a way, this is a Black Swan event – you can’t model for it, it is unpredictable and, even if you had known about it, it wasn’t preventable for the UK,” he says.
Sir David, now executive chairman of the HC-One care home group, calls on the Government to urgently address areas of concern that are affecting care homes just as badly as the NHS.
“We need to be getting the PPE [personal protective equipment] to the right people – quickly,” he says. “And we do need staff to be being tested so we don’t have so many taken out of the workforce for two weeks when they may not be suffering from the virus – which means they may well need another fortnight off further down the line. We don’t have the capacity for that.”
On Thursday, the Government published a suite of 30 reports explaining the thinking behind the most draconian demands being made of the public in modern history. The messages, from the Scientific Advisory Group for Emergencies (Sage), co-chaired by Professor Chris Whitty, the chief medical officer, and Sir Patrick Vallance, the chief scientific adviser, are stark.
One report, dated February 26, warns: “In the event of a pandemic, without action the NHS will be unable to meet all demands placed on it. Demand on beds is likely to overtake supply well before the peak is reached.”
Decisions to enact strict measures, such as discouraging non-essential travel, social distancing and school closures, are “political”, it notes. The report also contains some hostages to fortune, suggesting large scale rioting is unlikely though queues for takeaways are not.
On Monday, it became clear that decisions about restriction of public movement are being driven by one key factor – the ability of the NHS to cope.
Modelling by Professor Neil Ferguson, of Imperial College London, shows that if Britain took no measures it could expect to see 510,000 deaths, as well as requiring 180,000 critical care beds at the peak of the pandemic. NHS plans to provide 5,000 such beds – and to attempt to obtain up to 20,000 ventilators – pale by comparison.
This, and news from Italy that one in three hospitalised cases have required intensive care, is what triggered this week’s new measures, which have continued to ramp up day by day.
The calculations by Prof Ferguson – now in self-isolation after showing symptoms of the virus – show that a raft of policies are required to suppress the outbreak sufficiently to give the NHS a fighting chance of coping.
The estimates suggest the combined policies of case isolation, 14-day quarantine for households of suspected cases, school closures and social distancing such as shunning pubs, offices and non-essential travel, could significantly lift the pressures on the NHS.
As well as bringing deaths down to around 20,000, it could mean the NHS needs between 1,200 and 4,900 intensive care beds at the peak.
But the domesday document is littered with health warnings, notably that such measures would need to be maintained until a vaccine becomes available, which it notes could take 18 months or more.
Many of the assumptions of its working groups have yet to be tested – they require changes in human behaviour which have never yet been seen. They also require altruism and public understanding on an unprecedented scale.
On Friday night, Boris Johnson ordered the closure of pubs, bars and gyms amid concern that too many people were ignoring advice to stay home. Meanwhile, individuals throughout the UK are taking private decisions about whether their journey is “essential”.
This weekend, Mothering Sunday comes as perhaps the biggest test yet. The country’s chief scientific advisers have been clear. If you love your mother, or your grandmother, do not visit for Sunday lunch. On Friday, Mr Johnson said he “hoped” to see his own mother, while advising the country to follow the scientific advice.
For at least four months, all those aged 70 or over, pregnant women, and adults of all ages with underlying health conditions, are being told to stay at home as much as they can and “significantly limit face-to-face interaction with friends and family if possible”.
For most of us, this is a very high price to pay. Families across the country are trying to find ways to keep human contact with the ones they most love without endangering them.
While Skype and Facetime may save the digitally savvy, for others the best hope of getting through the toughest times may be a simpler solution. Prof Whitty was enthusiastically in favour when asked this week if meeting one’s elderly parents for a walk in the park (at two metres distance) could prove a solution for some.
As well as the idea providing human contact – even if a hug is out of the question – officials are keen to emphasise that daily exercise, indoors or out, is vital because four months of isolation will mean the most vulnerable lose mobility and health.
But officials fear there is one message that keeps getting lost in translation. Young and healthy people who are cavalier about their own risk of getting the virus – knowing they are likely to suffer mild symptoms – may not realise that the reasons for restrictive actions are twofold.
Firstly, suppression of the virus in the public could save the nation’s parents, and grandparents – and secondly, it could save the NHS.
Professor Stephen Powis, the NHS national medical director, says the health service is working hard to prepare for the surge in demand it is expecting, freeing up tens of thousands of beds, ramping up testing and bringing in more staff and protective equipment.
“However, this is an unprecedented global health threat,” he says. “No health service in the world could cope if the virus was left to let rip, which is why countries around the world are bringing in social distancing measures to slow down the spread.
“It is vital that people follow the expert guidance and wash their hands, stay at home and use the NHS responsibly so that services are there for those who really need it.”
Sir Patrick also calls on young people to do right by their grandparents. “The mixing in pubs and restaurants and so on is really part of allowing the disease to spread,” he says. “It needs to stop, and it needs to stop among young people as well as among older people.”
The advice on social distancing is not just about individuals, but about the need for younger generations to behave altruistically to protect those who are most vulnerable, experts stress.
Caroline Abrahams, the charity director at Age UK, says: “Now is the time to do the right thing by listening to the experts’ advice and by staying in at night time. We must do this for the safety of our mums, dads and grandparents – and for all of our older friends.”