Cast your mind back, if you can bear it, to March last year. As the coronavirus pandemic swept the world, the number of people dying from the virus in the UK was rising with disturbing speed. But when Boris Johnson eventually announced an unprecedented national lockdown on 23 March, those death figures, although a source of great anxiety and regret, were not the reason for his decision. Instead, it was that the National Health Service was on the verge of being overwhelmed.
Why, again, did we have a semi-lockdown in England last November and now this new lockdown, which means the whole of the UK will be under strict restrictions for at least the next seven weeks? At each point, the trigger has not been the growing number of people at risk of catching and dying of coronavirus; at least, not directly. The UK has locked down every time because the NHS was dangerously close to the edge of its capacity.
We spent much of last year having a public debate over the rights and wrongs of lockdowns and other coronavirus restrictions. It was mostly conducted on the right of British politics, among Conservative MPs and commentators in right-leaning media. In its mildest form, it was a debate about how to “balance” health restrictions against the need to reopen the economy, weighing up the human and economic costs of tight restrictions against the life-saving imperative of containing the virus. At its most extreme, it was Covid denialism with a respectable veneer, exemplified by the widely discredited Great Barrington Declaration, which proposed shielding the “vulnerable” while letting everything else resume normal life (a proposition that falls apart if you think about it for more than 30 seconds).
Yet throughout this debate last year, there was a distinct failure to engage seriously with the reason we locked down in the first place. There was a failure to think about what “the NHS being overwhelmed” really meant and the implications for future coronavirus policy.
There is a limit on the amount of Covid-19 cases this country, and any country, can handle. It is set not by an implicit or explicit decision by government about how many coronavirus deaths would be acceptable, nor by a public debate about whether it is worth letting coronavirus “rip through” the population, but by the finite capacity in our health service. At the point where the NHS threatens to be overwhelmed, lockdown is no longer a choice, but an imperative.
When we talk about the health service becoming overwhelmed, we mean reaching a point at which the NHS can no longer provide care to everyone who needs it. It’s every place in intensive care being taken, such that no more patients, with Covid-19 or otherwise, can access essential treatment. It’s the choice between saving a coronavirus patient or a cancer patient, or between one coronavirus patient and another, or between two heart attack victims each needing emergency attention. It’s state failure, essentially, or at least a major aspect of it: a state’s failure to provide essential public services for its people.
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It doesn’t happen all at once, of course, nor does it happen exactly like that. Doctors and nurses don’t suddenly turn people away, declaring they have “reached capacity”. They are stretched thinner and thinner, with fewer staff doing the same work on longer shifts and less sleep. Non-urgent operations are cancelled, other rooms and corridors used for beds, people queue in ambulances and wait ever longer for emergency care, patients are transferred between hospitals, and “crisis medicine” is deployed. That probably sounds familiar, because it describes what has been happening in hospitals over the past few weeks: the NHS tottering on the edge of capacity, the government tottering on the edge of state failure.
No government can allow the health service to seriously exceed capacity and no opponent of lockdowns, as far as I’m aware, advocated for allowing people with coronavirus or cancer being left to die without adequate healthcare. The simple, unavoidable cap on the number of coronavirus hospital admissions that this country could handle was set, and acknowledged, as far back as March. It was the stated reason for locking down. “Protecting the NHS”, then as now, was the main objective. It was not just about saving lives from Covid-19, but ensuring sufficient NHS capacity such that lives could be saved from all illnesses.
[see also: Why scientists fear the “toxic” Covid-19 debate]
Yet this non-negotiable upper limit on the infection levels was often forgotten during the lockdown debate, which wasn’t just a right-leaning media phenomenon or a preoccupation of Conservative backbenchers, but a tension that existed at the very top of the government. As Rishi Sunak championed the view that coronavirus restrictions shouldn’t be allowed to hamper the economy, Johnson boasted of a “balanced” approach and ended up in the worst of all worlds: in November and now, again, in January, we have the NHS close to capacity and another late lockdown, with all of the economic damage the government hoped to avoid. But we also have a higher death toll (76,305 people at time of writing) and higher case numbers owing to ministers’ delayed action.
Allowing the NHS to be entirely overwhelmed was never an option. And once you accept that, as the government clearly does, the policy question is much more straightforward. If you can’t allow the health service to be overwhelmed but are against the human and economic harm caused by lockdowns, you avoid them by introducing measures (eg an effective test, trace and isolate system) to keep cases low, rather than idly making the case against lockdowns. Failing this, you’ll be locking down again as soon as, you guessed it, the health service approaches full capacity.
You can also increase health service capacity through initiatives such as the Nightingale hospitals, but only to a small extent. This is because capacity is not just a question of beds and equipment but also of staff – a much harder resource to expand at pace during a pandemic. And if public health measures are inadequate and cases are rising, there is a simple choice between locking down sooner, for a shorter period, or, owing to the nature of exponential growth, locking down later, for longer, with more deaths, more people seriously ill and more suffering with “Long Covid”.
The debate about the UK’s coronavirus response only became fiercer last year, with lockdown scepticism growing among Conservative backbenchers, the media, and even the cabinet. But the essential, unavoidable truth of our pandemic response was present on day one, and it was uttered by Johnson himself: “If too many people become seriously unwell at one time, the NHS will be unable to handle it – meaning more people are likely to die, not just from coronavirus but from other illnesses as well.”
Once that truth is grasped, the rest of the policy response follows from it. Boris Johnson acknowledged as much at the beginning of the first lockdown, but, as we enter the third long lockdown, it seems he may not have been listening to his own words.