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In last week’s evidence at the COVID Inquiry, we heard how former Prime Minister Boris Johnson had said he was “not buying this NHS overwhelm stuff” and that he had blamed the NHS’ ‘bed-blocking’ inability to discharge patients for the imperative to ‘protect the NHS’ via lockdown measures.
His friends in the right-wing media were quick to amplify this. The Spectator’s Frazer Nelson pointed out that, during the first pandemic wave, there had been four times as many overnight beds available for admissions as there had been pre-pandemic. His colleague Kate Andrews, who has spent years pushing anti-NHS propaganda, claimed that modelling estimates of the potential number of hospital admissions with COVID had been too high and that most of the additional ventilators commissioned had never been required.
Johnson’s remarks were those of a man who resented having to implement public policy measures to suppress the spread of the virus, and the commentators who supported this approach sought to show that such measures were never necessary or justifiable in the first place.
Both exhibit a wilful blindness to the context at the time, the wider realities, and a denial of the role of years of Conservative Governments in creating the conditions that put the NHS at such risk.
The first documented COVID cases in the UK were in January 2020 and the first death in March. By that time, we had already seen acute hospital systems in northern Italy, New York and Spain completely overwhelmed – modern healthcare systems with more hospital and intensive care beds and more doctors and nurses per capita than the NHS. Complacency was not an option.
During the first pandemic wave, our testing capacity as very limited. Only a few thousand COVID tests a day were available for the whole of England. I remember clearly how hard we struggled on the NHS frontline to get people tested or get the results back. The ability for testing, isolation and contact-tracing was simply not there.
Although COVID had major implications for primary and community care services, and especially for social care, “protect the NHS” in reality meant ‘protect hospitals’. This is not a surprise.
England only has around 100,000 general and acute beds for 56 million people. This is the lowest bed base in the OECD and considerably lower than the EU average or bed numbers in say France or Germany.
It also – at 6.7 intensive care beds per 100,000 – has among the lowest ICU bed capacity in the OECD. Again, far lower than other high-income Western nations There are only around 4,000 ICU beds for the whole of England.
It is also rare in the NHS for elective, planned outpatient clinics, investigations and surgical procedures to be on separate ‘cold’ hospital sites away from the emergency department and acute care hospital. The two activities tend to happen in the same building and with many of the same staff.
Considering that many COVID cases were contracted within hospitals, the notion that we could have continued to bring in lots of patients, many of them clinically vulnerable, to acute care sites where they would be put at risk and carry on with business as usual was never viable during the first or second pandemic waves.
We also had to do all we could to separate infected and non-infected patients into different admission streams and ward areas. And to create capacity for the anticipated surge of COVID admissions.
So we did empty some beds by cancelling elective care, in order to attempt infection control. The Government’s COVID discharge fund and NHS England’s COVID discharge guidance did allow NHS hospitals for a few months to clear beds far more efficiently by getting patients straight into community health and social care services outside of hospitals and reduce what Johnson referred to as ‘bed-blocking’.
Though this was not without human cost. There were COVID outbreaks in care homes, partly due to hospital discharges of untested patients, and patients warehoused in ‘discharge to assess’ care home beds without much ongoing assessment and rehab. It was a transfer of work to already overstretched community teams.
Imagine the counterfactual; the road not taken of hospitals staying on a ‘business as usual’ model and running at the usual 90%-plus midnight bed occupancy with no headroom to cope with a surge.
As for ICU beds, during both the spring 2020 and winter 2021 pandemic waves, they near doubled in size. Given that intensive care nursing and medicine are highly specialised and skilled roles with no magic reserve of trained staff, they could only expand by borrowing staff from other clinical areas and departments – notably theatres and anaesthetics and by diluting their staffing ratios. This too had a knock-on effect for planned operations – especially with those patients sometimes needing post-operative ICU themselves.
Transfer of critically ill patients to ICU is for multiple organ support and not always just for ventilation. The notion that many COVID patients were not invasively ventilated meant that the scale of the problem had been exaggerated is ridiculous.
Besides which only around one in nine patients with COVID required intensive care. There were many very sick and dying ones being managed on general wards and a huge surge in oxygen use.
The unseemly push to place contracts with private companies to buy lots of ventilators or to create lots of ICU-equipped beds in the London Nightingale Unit were the Government’s fetish alone. Beds and ventilators are pointless without staff, and the staff were already overwhelmed as bed numbers expanded.
Protecting the NHS also, in effect, meant ‘protecting the population’. In 2020, we had up to one in four hospital beds occupied by patients with COVID, and in the much higher 2021 peak it was around one in three.
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If no COVID mitigation and suppression measures had been in place and if hospitals (as they had done in Italy and New York) had been overwhelmed, that would have meant people with genuine acute care needs being turned away and the dystopian scenario we heard of at last week’s inquiry of Matt Hancock having deciding “who should live or die” becoming a grim reality.
People didn’t need much encouragement to stay at home or stay away from A&E departments at the prospect of getting sick enough to need hospital and no beds being available.
Hindsight is an unreliable witness – especially when there is no operational or clinical experience of NHS care and facts are selectively curated to suit and take them out of context.
Ultimately, we must confront the policy decisions of the party that has led the Government for 13 years and the impact they have had. If you think I am biased, just read the January 2023 Institute for Government Report on the NHS crisis.
Over the past 13 years, we have lost yet more hospital beds, experienced serial cuts to social care funding, seen a growing crisis in the social care and NHS workforce exacerbated by Brexit, had points-based immigration rules and deteriorating terms and conditions, cuts to public health grants, a sustained period of historically low real-terms funding increases to the NHS, and a failure to invest in hospital facilities and equipment, alongside a fall in GP numbers, and a collapse in both NHS staff and public satisfaction.
So if Boris Johnson was blaming the NHS for being unable to clear beds fast enough to avoid lockdown measures, he was effectively blaming his own party. Meanwhile, attempting to retro-fit the facts to suit the narrative that infection suppression measures were never necessary, won’t wash with anyone who was actually dealing with the problem on the hospital floor.
David Oliver has been an NHS acute hospital doctor for 34 years, looked after a Coronavirus ward throughout the pandemic waves, and has held a variety of medical leadership and policy roles. He is a regular columnist for the British Medical Journal