30 March 2020

Fragile States

The NHS at capacity

The British state is obsessed with efficiency. But this also makes it vulnerable – as coronavirus is showing – in times of crisis

By Chris Cook

The UK government keeps a list of its nightmares. A risk register, listing all the non-military disasters that it can possibly think of. The document is a catalogue of horrors. These range from solar flares that might knock out our satellites to terrorist action. They include freak storms and volcanic eruptions, earthquakes and dam breaches. But pandemics sit at the top of the pile.

British officialdom has long been bracing itself for a disease that, it feared, could spread to half of the population. Officials note in some of their published planning that the “Spanish flu” of 1918-19 might have had a two per cent fatality rate. That implies a disease that could plausibly claim 600,000 lives.

That is why, in 2016, parts of the state machine did a drill. “Exercise Cygnus” tested UK institutions against the strain of a viral breakout, walking parts of local and national government through a response. In some ways, the conceit of Cygnus now looks prescient: it was war-gaming what would happen if Britain were overcome by a new disease that emerged in China.

But, in one important regard, it had a fatal flaw. When it comes to Cygnus, as elsewhere, the British state planned on the assumption that the next big thing would be an influenza virus.

But the novel coronavirus is not an influenza. It falls into another category – what the government would call an “emerging infectious disease”. Prior to Covid-19, the most famous disease in this category was Severe Acute Respiratory Syndrome (SARS), which caused widespread contagion, largely in Asia, in two bursts in 2002 and 2004.

Workers disinfect the waiting room of Beijing railway station in the fight against SARS in 2003.

It is remarkable, in retrospect, how relaxed the British state was about the risk of such a non-influenza pandemic. In 2012, the risk register warns that the impact of an emerging infectious disease “could be on the scale of the SARS outbreak in Toronto, Canada”, which had 251 cases of SARS in two waves over a period of several months.

In 2017, a revision to the risk register noted the risk of “several thousand people experiencing symptoms, potentially leading to up to 100 fatalities”. Their assessment of the balance of risks suggested flu was the real danger – not an emerging infectious disease, like the novel coronavirus.

That is why the UK’s pandemic strategy, published in 2011, is actually an influenza strategy. It was a response, in part, to the swine flu pandemic of 2009-10 – an event which, combined with a very cold winter, stretched the NHS’s capacity to its limits.

Under plans from 2011, a “National Flu Pandemic Service” (NFPS) would spring from mothballs into being – a service to determine who should get the anti-virals held in Britain’s national stockpile. But the anti-virals that we hold for these emergencies are Tamiflu and Relenza, anti-flu drugs. They do not work against the coronavirus.

Some of the government’s planning assumptions were also flu-driven. The pandemic plan assumes a vaccine could be rolled out in five to six months – a normal time frame for flu vaccines. But the time to bring a coronavirus vaccine to market is likely to be double, or triple, that.

So while the strategy discusses the potential need for “localised school closures”, there is nothing more significant when it comes to longer-term virus suppression strategies or national lockdowns, like the one we now find ourselves in. We have a protective equipment stockpile because of the flu preparations, but surprisingly little else.

Stocks of antiviral treatment, Tamiflu, stored at an undisclosed UK location.

The point here is not to criticise the government’s horizon-gazing. It is a simpler point: you just cannot see everything coming. You cannot stockpile in anticipation of every disaster. You cannot hope for a fine-tuned response to everything. You can only plan so far – especially when, as in this case, our understanding of what the disease might do can change so rapidly.

But part of any disaster response planning needs to include some generic idea of resilience – a generalised ability to absorb the unforeseeable. A uniquely British problem is that the way the country has been run for three decades pushes in the opposite direction.

We started this crisis in a weak position.

We have built a fragile state.

 

Right now, British hospitals are either in crisis, or they anticipate it. A tide is coming in – of the sick and the dying. A tide that will fill our hospitals.

That is true across the world: the healthcare systems of every major state are either filling, they are steeling themselves for the surge – or they have already been hit by it, as in Italy and Spain. What is different in Britain is that the hospitals start with the water at their waists.

Britain has had a pretty ordinary winter: three big storms hit our islands, but the weather was otherwise “notably milder than average”, according to the Met Office. The seasonal flu load came early, and has since passed. There were some weeks of unusually high death rates, but they too are gone. This, in short, was not a hard winter – except inside the health service.

The NHS’s own statistics show extreme pressure. The hospital system is supposed to deal with 95 per cent of emergency patients within four hours. This measure can be seen as a barometer of the health of the system.

In February, only around 70 per cent of patients at major emergency departments were treated within the time limit. This was not an aberration: it was the consequence of years of decline. In 2013-14, the English NHS started to fall behind. Since then, every winter has proved to be harder than the last.

This is not because hospitals are slowing down. It is because patients come, each year, in greater numbers. Take last month, February 2020. In those four weeks, 1.2 million patients presented at emergency departments across the country. That is an increase of 183,000 patients per month since February 2011. The decline is because hospitals cannot cope with a 17 per cent increase. Demand is rising.

As the reality of the Covid-19 crisis emerged, the hospitals started cancelling and delaying anything they could. No hospital managers needed convincing that it was important to send patients home and cancel any care that they can. In February, before this started, the big London hospitals were all above 95 per cent bed occupancy.

This is, in any case, not good practice: an old nostrum in healthcare was that managers should aim for about 85 per cent utilisation – that is the standard at which they ran, not so long ago. But in the course of 10 years of tight budgets and austerity, that slack has disappeared as the service has been overwhelmed by the demands on it.

Sir Simon Stevens, the chief executive of the NHS, wrote a letter on 17 March to hospital leaders. They needed to ready themselves, he said. “Assume that you will need to postpone all non-urgent elective operations from 15th April at the latest, for a period of at least three months.” And hospitals were told they should start cancelling sooner. He estimated that this, along with other measures, could free up 30,000 beds across England.

Furthermore, he noted, cancellation could create a lull when people could prepare. A senior doctor in the Imperial hospital trust, which covers a slice of west London, wrote to staff the week before last: “Every junior doctor and consultant rota/life will be affected and changed. Our definitions of safe are being redefined, our need to relearn forgotten skills can make for uncomfortable times… This feels like a career and life defining experience.”

Within Imperial, as elsewhere across the city, every staff member with a medical registration is being recalled to the front line. Surgery has been cut back to “life and limb” cases. The anaesthetists, freed from surgical duties, have already been redeployed to put patients onto ventilators, machines to mechanically breathe for the sickest patients.

A coming tragedy will be families realising that a loved one will be denied potentially life-extending care because the system cannot find the space within itself. Doctors are ranking their patients with cancer, for example. Those who might get the best part of a year of extra life from a course of treatment may soon be denied it.

The hospitals have drawn up their plans. They know what beds Covid-19 patients will be placed into, and in what order. Wards have been cleared. Treatment has been moved. Operating theatres emptied of surgeons are now intensive care units. Cancer care is being managed to keep immune-compromised patients away from the infectious.

The week before last, bed occupancy in one large London hospital was, as one hospital manager put it to me, a bit like Christmas. Major hospitals had cancelled anything that they could, and created space.

The emergency rooms have been emptying, too. In the last week, the number of attendances has roughly halved. On 9 March, 25,500 people attended an English accident and emergency department. Last week, the daily rate was about 13,000. A lot of sick people will not have sought care that they really needed.

London Ambulances outside the new Nightingale Hospital at the ExCel London Exhibition centre.

So how much room did these changes make? Hard numbers are hard to get to. But reasonable estimates for the most important beds – intensive care – are that around 1,200 of England’s 4,000 beds were freed by last week. Another 1,200 are being released to the crisis effort as elective cancellations feed through. Converted wards within hospitals will add about another 8,000 intensive care beds.

The crisis will require space elsewhere in the system. Some patients will need “step-down” care after they are released from the intensive units. Others will only need this level of help. The preparation effort probably freed up 12,000 or so of these beds. The NHS has bought bed space in private hospitals. And the government is planning field hospitals, set up by the army, to add more capacity of all sorts to the effort.

But the space is being eaten rapidly – or has already gone. Hospitals are getting busier with coronavirus patients. One day they will find the tide is over their heads. In London hospitals, that moment has either passed or it is imminent.

Doctors are already starting to ration ventilators and intensive care beds. They are making the toughest of calls – choosing between patients. Protocols, about prioritising those likeliest to survive, are being circulated. Age is likely to be a major factor – early on, at least. The first analyses, based on small numbers, show that only one quarter of people aged over 70 are surviving once they get into intensive care.

Managers, meanwhile, are already worrying that patients seem to need longer in hospital than they had budgeted for – meaning more problems down the line.

It is worth noting, however, just what was achieved in the past few weeks. We have gone through an unprecedented and remarkable one-off drive to find space. Officials believe that, across the country, this huge effort – this cancellation wave – would have been enough to shift bed occupancy down from around 95 per cent to about 80 per cent.

A big move. But think about what this means. All this effort, all those cancellations, all those people staying away from emergency departments and the health service is only just below the 85 per cent line – what was once considered its normal operating capacity.

 

To understand how it can be that our health service runs so hot, it pays to look at the data on investment into healthcare. One curiosity of the British system is how little we spend on what is known as “capital” – the budget which pays for physical things. Spending on hospitals and the machines that go in them are all considered part of capital.

For a long time, the UK has been a low spender on capital in health, in general. For example, Eurostat has attempted to estimate the replacement value of the NHS estate since the turn of the century – that is to say, how much it would cost to buy a wholly new set of facilities from scratch.

The ambition is to see what depth of capital – of kit and space – has been devoted in total, so you get credit for old kit still in use. For all the increase in healthcare demand, the value of the NHS estate, which sees so many more patients per month, is actually lower than it was in the year 2000. The average country saw a 44 per cent increase.

The buildings have been allowed to deteriorate: at the moment, the backlog of high risk repair work that needs to be completed in the hospital estate has risen to over £1bn. In 2010, it was just £300m.

This is not about squeaky doors. This is defined as repairs intended to prevent “catastrophic failure, major disruption to clinical services or deficiencies in safety, which are liable to cause serious injury and/or prosecution”. There has, in addition, been a doubling of the “significant” risk repair bill, to £2bn.

Indeed, in the last 10 years, the accounts filed by the hospital sector show that the total floor space of the English NHS has fallen. It was 29 million square metres in 2010. It stands at 26.7m today.

A service with all those extra patients is crammed into shrinking estate. Indeed, that is a good way to understand why the NHS is poorly equipped for a crisis, like the pandemic we now find ourselves in.

NHS national management has long seen trying to get more out of the estate as a core function: it is almost a point of pride that Britain has so few actual beds. It is a service that prides itself on getting ever more patients through its shrinking wards.

This approach shapes the way hospitals are organised: if you are admitted to a hospital in an emergency with a serious ailment requiring specialist care, you might initially be put into a general ward. They are often known as a “medical assessment unit”, known as a MAU. The purpose of these wards is to admit you and hold you in safety – but not admit you to a ward deeper inside the hospital.

This has a number of clinical benefits: some people recover in them. They give time for doctors to assess patients in a space that is less likely to lead to patients having a prolonged stay. It is a useful space, halfway between between the emergency department and the guts of a hospital. It can allow doctors to potentially spare some patients full-blown hospitalisation.

But managers like them because, in addition to the clinical benefits, the MAU is a way of dealing with the fact that the specialist wards are too small to cope at periods of high demand. This approach permits fantastically efficient use of space. You can have fewer beds on specialist wards and make sure that those beds are always full.

An alternative way to manage demand would be to keep enough specialist beds to cope with the number of people who will need each form of care in, say, 51 out of 52 weeks of the year. You could have enough capacity so that in any normal time, you could send a patient straight in. Then you would only need a smaller MAU.

But that would mean leaving some beds empty on slower days. This is a necessarily more expensive way to run a health system. But it is also less risky.

This desire to maintain as few beds as possible and raise efficiency by firing patients through them at an ever greater pace means that the NHS is reliant on its ability to maintain an extremely high throughput of patients through the system. Each patient must be seen, treated and discharged faster and faster.

Other countries have, like Britain, reduced bed volumes. But none as far as us. Even the closest comparator country to us, Spain, has 15 per cent more acute beds per capita. Italy has a quarter more. France has half as much again. Germany has three times as many.

Anita Charlesworth, director of research at the Health Foundation, says: “We actually spend a similar amount on the day-to-day running cost of the health service. But, the UK is either at, or near the bottom, of the league tables on investment spending. Treating more people today always wins out over investing in training more staff, building and maintaining facilities and buying MRI and CT scanners to prepare for tomorrow.”

The British approach renders each bed more valuable – and makes the system more vulnerable to modest blockage. As Charlesworth puts it: “This makes the system appear very efficient but the result is little, if any, flex in capacity to respond to demand shocks.” An unexpected disease that takes a few beds can be – literally – fatal. Problems in social care, which left some older patients stranded in hospital, caused serious blockages in 2016-17.

While the coronavirus would overwhelm any health system, the British system has struggled with bad flu seasons. The swine flu pandemic of 2009-10, in particular, should have raised more alarms in Whitehall. That pandemic came when the NHS was high-functioning – hitting its targets and running with much more slack than it has now.

Swine flu inoculation in Cumbria, 2009.

The service needs to think more broadly about resilience. The human body works with one simple form of resilience: redundancy. Nassim Nicholas Taleb puts it in his book Anti-Fragile: “Layers of redundancy are the central risk management property of natural systems. We humans have two kidneys… extra spare parts, and extra capacity in many, many things (say, lungs, neural system, arterial apparatus)…”

We would not need to have hundreds of thousands of spare beds to make a difference. We do not need a whole spare health service. We are not talking about an NHS that could handle a coronavirus-sized event without emergency measures. But, in crisis, even tiny amounts of spare capability can be enormously important.

Consider what you could do with a bit more slack. A service that ran, consistently, at 85 per cent capacity instead of 95 per cent would need another 14,000 beds in England. That may sound a lot – but it would only take us back to the number of beds being operated in 2010-11.

One problem, early on in this crisis, was that hospitals did not have space for isolating many patients while they were tested. Just having a bit of space would have made a difference in preventing hospital-acquired Covid-19 infections. More physical space would make it easier to keep the vulnerable away from the infectious.

Extra capacity becomes enormously valuable during a demand spike. Hospitals are working on the basis that Covid-19 patients on ventilators in intensive care need 16 days of treatment, on average. Let us suppose that this crisis lasts – optimistically – 150 days. So each extra bed can be used to treat a bit more than nine extra people. Just another 100 beds means an expected 937 people treated.

The British response will rest heavily on its ability to lay on extra “surge” capacity. The state is scrambling, right now, to get more ventilators. The first “Nightingale” hospital, the name for temporary hospitals set up by the military, has been erected in the hangar-like space of the London docklands ExCel exhibition centre. It will have 500 beds – rising, if needed, to 4,000. They are still rushing to source kit. Swathes of the military have been told to be ready to deploy to these hospitals.

An inside view of newly built Nightingale Hospital London for Covid -19 at the Excel in London.

In a crisis such as this one, having more capacity on-hand means that you will get more time – perhaps days, potentially a week – to bring it all online. At this moment, given what needs doing, that is a long time. And, at the far side of the crisis, it would let you release lockdowns earlier.

Most importantly, however, if we had a hospital system running with more slack in it, it would also mean we had more staff on-hand, which would give us more ability with which to surge: a major constraint at the moment is a lack of trained people. The system was about 100,000 staff short before this began.

In a crisis, tiny margins have enormous effects. So why do we not have any slack?

 

You can understand the Treasury’s perpetual frustration with the NHS. It is, frankly, a money pit. We do spend a lot on healthcare – and the finance ministry believes that the health service assumes it will always be bailed out if things go wrong. The UK has struggled to keep its costs in check as the country’s population ages: health accounts for a growing share of the costs of the state.

It has moved from around 13 per cent of state spending in 1997 to 19 per cent today.

Officials and ministers continually look for ways to force it to become more efficient. And they fear hospital leaders believe they will always be bailed out, so do not take their threats seriously. A few years ago, one senior Treasury official told me that the money squeeze then being pressed through the service was akin to “water-boarding”: they wanted to make hospitals feel like they were financially drowning to force them to respond by raising efficiency.

The NHS has had a hard decade, like all public services. But this is an issue which goes back further. A fixation with efficiency has long been at the heart of government NHS policy. For example, the English NHS has “payment by results”. This is a misnomer: in truth, they are paid by volume of patients treated.

As an example from a 2012 guide for hospitals puts it, a provider would get “£119 for an outpatient attendance in obstetrics or £5,323 for a hip operation”. It means hospitals get nothing for having spare capacity on-hand – only for the capacity they use. It is a payment structure to discourage slack and encourage people to run at the highest possible utilisation rate.

Nigel Edwards, chief executive of the Nuffield Trust, says that the Treasury has been “strong on restricting entrance to medical school and post-graduate training [for medical staff]. There’s been a long standing attempt to use entrance to medical school numbers and nurses trained and tight, short term budgetary control mechanisms to keep this keep health spending under control.”

In short: if you ration the medical staff, there is a limit to how much you can spend on medicine.

Charlesworth says: “Fears of what economists call ‘supplier-induced demand’ lie at the heart of a very British approach to health policy.” The terror, partly based on the American experience, is that if we employ more doctors who have more kit, we will just be drawn into treating more patients. But, she adds: “Other countries in Europe have invested in more capacity; both people and facilities and haven’t seen runaway spending growth.”

NHS workers in Manchester take part in an anti-austerity protest in 2015.

So there is a health-specific reason for this approach. But, in truth, this fixation with efficiency is everywhere. It is an understandable obsession for a finance ministry – cost control is, indeed, its core function. But, as this crisis may show, a focus on efficiency, rather than capability and effectiveness, can be short-sighted.

Lord Willetts, a former Treasury minister and official, sees the Treasury as a body obsessed with high utilisation rates: “If the Treasury was put in charge of the M25 [the London ring-road], it would have budgeted to have all the cars moving at 70 miles per hour lined up bumper to bumper with no wasteful spare space between them.”

The Treasury’s guidebook for officials making spending decisions mentions “spare capacity” within public assets, but only to note that if it cannot be sold off, “it is good practice to consider exploiting the spare capacity to generate a commercial return in the public interest”.

In the UK, the eternal drive for efficiency is associated with the rise of a set of ideas known as “New Public Management”. This is, at its root, a set of ideas to make public services do more for less – to either raise the quality of public services without busting budgets or to cut their cost. There is nothing sinister to it: it is, at root, a belief that we can make things more efficient.

The toolkit it deploys will be familiar to British voters; instead of block grants to big monopolies, you try to keep them on their toes. You use choice, competition and other market mechanisms, such as payment by results, to make sure they are straining to spend every pound well. You use league tables and inspection to encourage higher standards, and bring in private providers if the existing public sector actors are struggling.

This was a project which started with Thatcherism – an attempt to make the state run more like a business. There was a lot of overt talk of treating citizens as customers.

From that start in the 1980s, it got into the groundwater. The Blairite dominance changed politics – but this efficiency focus survived.

A day surgery unit at Coventry and Warwickshire Hospital, West Midlands, 1991.

Lord Macpherson, who stood down as the lead official in the Treasury in 2016, says: “In a post-ideological age, politicians stop arguing about questions like ‘do you nationalise British Steel?’. Instead they argue about how… ‘we can give you all the goodies you want, while taxing you less at the same time’.”

As a consequence, over the past 40 years, the British state has developed a generalised nervousness about redundancy. Jill Rutter, a former Treasury civil servant now at King’s College, said: “We had this expectation for years that departments could take one-and-a-half per cent every year out of their day-to-day budgets for efficiency. Now it wasn’t ever clear to us where that was coming from. But you can imagine you start by eliminating any sort of spare capacity.”

Even in periods over the past few decades when the spending taps were open, there was strong pressure to show capital was being used wisely. Britain’s most significant capital programme came at the height of Gordon Brown’s 10-year chancellorship. Even then, it was not lavish in a European context.

Gavin Kelly, one of Brown’s long-serving senior advisers, said: “There were two competing impulses. On the one hand, we’re going to invest a lot of capital. And that’s a good thing as public buildings and services were run down. On the other, how do you show people that money has been used wisely…? I was involved in various efficiency reviews through the 2000s …where you were really supposed to sort of show how this capital was being worked hard.”

In the 10 years since Gordon Brown left Downing Street, the combination of rising demand for services, targets and payment by results encouraged hospitals to provide ever more services.

But, under the coalition and Tory austerity, the health service did this without building out its capacity. In fact, it sold off one third of its land in order to keep the show on the road: the land, after all, is redundant capacity. It might be useful one day, but not today – so flog it.

This approach is an issue which is at its most acute in the health service – but it is not confined to it. When the Greater Manchester Fire and Rescue Service attended the Bolton Cube fire, a massive conflagration, in November 2019, 40 engines rushed to the scene. That night, for a brief period, there was only one pump left for the whole of the rest of the city.

The fire at The Cube building in Bolton, 2019.

That is where we are: the state is run on the thinnest of margins. Andy Burnham, the mayor of Manchester, says that part of the problem is we have national rules on financial control – but not national rules on safety. He told me: “Isn’t it just revealing though that there isn’t a yardstick about fire cover?”

When he was being asked to draw up budgets for the fire service, he asked officials: “Well, what’s the recommended safe level of fire cover per thousand or 10,000 population? Oh, there isn’t one. And it’s like, you know, ‘What!?’”

Building in more capacity is, in a technical sense, simple. You ask hospitals to budget and plan to be 85 per cent full. Not 95 per cent. But the politics hurt. Every pound goes a little less far. But people with experience of this approach cannot see a way out. Kelly says “significant” surplus capacity is “counter cultural” to much of Whitehall.

Much of it – but not all.

 

You might remember the Bedford RLHZ Self-Propelled Pump – the fire appliances better known as “Green Goddesses”. These 1950s machines, flat-bed trucks with a pump and tank on the back, made regular cameos in British public life. During firefighter strikes, they were manned by the army. This fleet of more than 1,000 vehicles was kept maintained in hangars, ready for emergencies.

Last deployed in 2002, the Goddesses were slow and unsophisticated. They lacked even rudimentary radios and had to be escorted to fires by police cars. But they were a useful investment – hardy and fairly uncomplicated. Back in the 1960s, if a fire brigade were overwhelmed by a major incident, a Green Goddess could offer support.

But their core purpose was far bleaker. In the early 1950s, the UK assumed a nuclear war would be devastating. But, early on in the nuclear race, it was assumed an attack would leave a semi-functioning country behind it – probably one engaged in “broken-backed” regular warfare with the USSR. So we needed to keep things going on the home front.

The Green Goddesses were kept in safe storage, intended to act as water pumps to help supply cities with water in the event of a nuclear attack. They could be deployed into the cities to replace the devastated urban fire brigades.

A 'Green Goddess' fire engine at Chelsea Barracks in London.

The reason for bringing up this ancient fire-fighting equipment is to note their unusual place in British life: they were bought as redundant capacity. They were there just in case. And there is some symbolism in the British decision to sell the Goddesses off in 2004. You can see it as a moment when older ways of worrying about resilience finally passed away.

But the story of the Goddesses also highlights something else. We think differently about redundancy in national defence than we do about other sorts of risk. As soon as there is a need for spare fire trucks to fight the Soviets, we will find a way – even if we will not use them much for half a century.

Fundamentally, the state thinks redundancy is normal in defence. Philip Hammond, when defence secretary in 2012, told an interviewer: “When I asked a question recently about if we wanted to have a Typhoon aircraft available at point X in the UK – what would it take, the answer was we’d need to deploy four aircraft and 60 engineers.”

“Why four aircraft, I asked? Well, you say one but we always like to have two and we need a back-up aircraft just in case and we’d need the fourth just in case something went catastrophically wrong with the back-up.”

“Now if you asked G4S [a large government civilian contractor] the question, they’d have the aircraft and they’d probably fly it in with two blokes in case anything went wrong with it. It is a completely different ethos and way of operating.”

Part of the issue here is that we understand the whole purpose of our defence forces is that we are preparing for the worst. It is an area where it is uncontested that the state should be prepared for all eventualities – and where resilience and redundancy is essential.

Sir Lawrence Freedman, an expert on strategy and a former member of the Chilcot Inquiry into the Iraq war, said: “If I was running an inquiry on this, clearly capacity would be the main thing we would look at.”

The alternative is what we see before us. A state where the main contingency capacity is the Treasury’s chequebook – and the army. Do not underestimate the surge capability of those two things: we may yet get ventilators designed, built and into action on the back of that combination. The army is, before it is anything, a logistics operation.

Sir Lawrence noted: “I have actually argued, on the basis of the Australian fires, that this is one reason why you need quite a big army… Our contribution to the Iraq war was almost curtailed because of the firefighter’s strike in 2002, when soldiers were needed to run the Green Goddesses.”

But the army can only do so much. We need to start taking the national risk register seriously. And it would be a mistake to assume the next big crisis is going to look like this one. We do not want to fight the last war.

We are currently suffering with a misreading of the balance of risks from the 2000s – seeing flu as the only plausible dangerous pandemic, and underestimating a SARS-like disease. It is unfortunate that the lesson we took from 2009-10 was that a race to get drugs and vaccines was the best way to handle a pandemic.

Members of the 101 Logistic Brigade of the British Army after delivering a consignment of medical masks to St Thomas' hospital London, 2020.

Bill Morgan, who advised Andrew Lansley, the health secretary in 2010-12, told me: “Hindsight is 20-20, but there are a couple of warnings we might have heeded. We continued to rely on the assumption that the pandemic we had to worry about was a flu pandemic even though SARS and MERS were coronaviruses. This perhaps led us to take comfort in the antiviral stockpile [which does not work against coronaviruses] a little too much.”

If, instead, we had thought about increasing generic resilience, we might be in a better place. Keeping a higher strategic capacity for intensive care, which could help with a range of disease outbreaks, might have been a better way to proceed. We did get a hard lesson in 2009-10 that pandemic response would place a serious burden on our intensive care capacity, even if it was flu.

Andy Burnham, who became health secretary three days before the swine flu pandemic was officially declared in the summer of 2009, said: “I walked into this situation, and sort of straight away, was in the midst of it, Cobra the whole lot… The work that we were doing through the summer months… I was obsessed with that question about can we source enough [intensive care] capacity?”

Morgan added that “in the midst of the flu pandemic in the 2010 winter, [we] ran out of intensive care beds. We’ve increased their number since, but we might also have invested in an emergency stockpile of ventilators as other countries did.” One of the concerns raised by Exercise Cygnus, the flu pandemic drill from 2016, was about intensive care capacity.

We should think more broadly about other hospital equipment, ready for surge deployment. Not just ventilators, but also laboratory testing equipment, catering, linen and waste services, mortuary provision, intravenous fluids, antibiotics, sedatives and palliative care drugs. We do not know what the next pandemic will be. Do not just plan for the crises we have had.

We need to think more about supply lines – and make sure that we can ramp up drug production or equipment production in a hurry; this crisis has already led to export restrictions appearing around the world.

Look beyond care, too. It has been 12 years since the financial crisis caused a sudden stop in the world economy; the Treasury needs to ask why it does not have off-the-shelf means of getting cash to the public rapidly. They might not have foreseen this crisis, but why is the toolbox for any shocks not better developed?

But, above all, we need on-line capacity, ready and running all the time. However good our surge preparations are, they need staff to run them. You cannot keep your surge doctors and nurses in a warehouse.

Covid-19 tests at a drive-by site outside the theme park, Chessington World of Adventures.

But whatever comes next needs to look beyond the big hospital system. Discharging patients promptly in the coming weeks will rely on social care – a sector that is, more even than the hospitals, wildly short of capacity.  It has been starved of cash and allowed to wither. Some of the most serious problems are likely to emerge in the community.

We will also see the perils of having run our network of GPs into the ground. They are responding to the virus, building their emergency responses: setting up “hot” hubs for suspected Covid-19 patients and visiting the sick in their homes.

But they, too, have been run down and kept under-resourced. Their current caseloads are already beyond them. And one-third of GPs are over 50, too, putting them at risk from the virus. Dr Habib Zaidi, a GP in Essex, has already died – a victim of his vocation.

Macpherson said: “I’m certain there will be lots of inquiries and a new consensus will emerge that we need more capacity in the NHS. And, if government’s got any sense, it’ll use that as an opportunity to introduce a health tax.”

Gavin Kelly, Gordon Brown’s former adviser, says: “Maybe this thing will be so epoch-changing that you can frame things differently for a long period of time.”

Maybe.

Pictures by Getty Images/10 Downing Street/Andrew Parsons/Handout

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