In May 2009, the then Labour health secretary Alan Johnson was questioned by the House of Lords science and technology committee. The committee was, in the midst of the 2009 swine flu outbreak, investigating the threat of pandemic influenza. Swine flu would infect 780,000 people in the UK in 2009, but only 203 died. The Lords committee was particularly concerned about a far more lethal hypothetical threat – one such as Covid-19, which researchers from Imperial College London have estimated to be about 50 times deadlier than swine flu.
Four weeks before Alan Johnson responded to the committee, the health department had issued a 127-page document suggesting that the NHS could double critical care capacity during a lethal pandemic. Nevertheless, the document went on, at the peak of the outbreak, “there may be ten times as many patients requiring mechanical ventilatory support as the number of beds available”. Under a worst-case scenario, Johnson conceded in a letter to the committee that “intensive care capacity may well be inadequate”.
Johnson was not describing a black swan event. He was describing a threat that had, two years earlier, been classified as the number one national security risk to the United Kingdom. A pandemic as lethal as coronavirus has, for the past 13 years, been deemed a “level 5” threat. The only other level 5 threat has been large-scale biological or nuclear attack, but this was deemed to have a less than one-in-200 chance of happening in the next five years. The risk of a pandemic in that time was deemed to be between one-in-20 and one-in-two.
On its website, MI5, the home security service, states that terrorism is “the biggest national security threat that the UK currently faces” but that conclusion is not supported by the National Risk Register. This is a document “given no publicity at all”, according to David Spiegelhalter, professor of risk at Cambridge University. While it is true that terror attacks are considered to be more probable than a pandemic, they are classified as only having a Level 3 impact. Other key threats – cyber attacks on infrastructure, widespread flooding, a nationwide blackout – are all rated as both less likely and less impactful than a severe pandemic.
Covid-19 is that pandemic. That it is a novel virus and the government’s plans were for influenza is “immaterial”, says David Alexander, professor of disaster risk reduction at University College London. The coronavirus closely resembles the threat anticipated in government planning documents, of a highly infectious respiratory disease that critically hospitalises between one and four per cent of those it infects. And yet the government appears to have been unprepared. The UK lacks ventilators, personal protective equipment and testing kits, while emergency procedures for manufacturers and hospitals are being improvised on the fly.
But the government’s planning documents – which date from 2005 to 2018 but are mainly based on the 2011 “Influenza Preparedness Strategy” – suggest that Britain may in fact have been prepared, just for the wrong outcome. The UK’s plans appear to have rested on a false assumption: if a pandemic such as Covid-19 struck, the UK intended only to mitigate rather than suppress the impact.
Mitigation accepts that the virus will spread. Suppression does not. Boris Johnson did not come up with the concept of taking the virus “on the chin”, as he put in an interview on 5 March. Nor did Dominic Cummings, his most senior adviser, who is reported to have at first welcomed the idea. The strategy predates them both.
Strict social distancing of the kind that Britain has now enforced does not underpin any of its planning documents. As Alan Johnson told the Lords in 2009, foreshadowing the initial advice of Boris Johnson’s government many years later, “even in a full pandemic… people should only stay at home if they have symptoms”. This approach dated back to the 2005 national strategy, which argued that, “Local restrictions in the movement of people, eg in a community or town, are unlikely to have much impact”. That thinking carried over to the updated version in 2011, the most recent version of the plan. Local measures to disrupt transmission, the document says, “cannot be relied on as a way to ‘buy time’”.
“It will not,” the strategy continues categorically, “be possible to stop the spread” of a virus as contagious as Covid-19.
In that 2011 document, banning mass gatherings is not only deemed ineffectual (“there is very limited evidence… [it] will have any significant effect on… transmission”) but is discouraged, because such events “may help maintain [to] public morale”. Technological tracking of the type being employed in Singapore does not figure in the plans. Neither does mass testing on the scale of South Korea. The deaths of between 210,000 and 315,000 people are accepted as a plausible planning outcome under a worst-case scenario.
This is the playbook that the government followed throughout February and into early March. Under the 2011 plan, 50 per cent of deaths were expected over a three-week period. When Professor Chris Whitty, the chief medical officer for England, appeared before the Commons health committee on 5 March, he outlined the same timetable. “One of the things that is clear if you model the epidemic is that we will get 50 per cent of all the cases over a three-week period”, he said. His comments, reiterated by Patrick Vallence, the chief scientific officer, did not anticipate a significant flattening of the curve: that would have spread cases out over a longer period of time.
Whitty and Vallence were not necessarily anticipating many deaths, as under the worst-case scenario – Whitty raised the hope that most people may suffer from Covid-19 asymptomatically – but their comments show that they were not attempting to suppress the outbreak; to reduce the rate of transmission, R, below 1.
“If this goes to the top end of the range,” Whitty conceded to parliament, as Alan Johnson had done 11 years earlier, “the NHS will have huge pressure on it for a relatively short period of time.” This approach, Whitty noted, had “pros and cons”. The benefit was that the outbreak would soon be over. As he put it, “there will be a beginning, middle and end to this”.
This plan has now been reversed. The UK economy, the government finances and freedom of movement have all been sacrificed in order to avoid the potential mortality rate that the initial approach accepted. Yet government plans show no foresight of this likely outcome. A nationwide lockdown was not contemplated. And the inevitable shortage of ventilators in any pandemic is unmentioned. The documents do not anticipate what has now happened: an attempt to save as many lives as possible.
In implementing a lockdown on 23 March, Johnson’s government was not only overturning its own policies, but more than a decade of Whitehall planning. It was long assumed that critical care capacity would be breached. Indeed, in 2007 the UK created a Committee on Ethical Aspects of Pandemic Influenza, to assess how doctors should prioritise patients in such a crisis. The committee’s report was full of platitudes suited for care in peacetime, advocating such principles as “respect”, “fairness”, “working together” and “reciprocity”. This is the document that is highlighted on the government’s coronavirus website. But as the Lords select committee noted in 2009, the document was “not relevant to dealing with a pandemic. A pandemic would require disaster-management”.
To address that “reality gap”, the Department of Health produced a far more relevant and far less widely circulated document in April 2009: “Surge capacity and prioritisation in health services”. It suggests that doctors assess patients according to a stated formula for organ failure, and prioritise those most likely to be saved. The system is not foolproof and leaves the risk with doctors, who are not indemnified from the consequences of their decisions. “Additional security measures may be necessary,” the document notes, “because of the potential risks of conflict directed at staff making triage decisions” that are likely to be “controversial”.
As one doctor, Nick Tarmey, put it in a presentation to his colleagues at Salisbury District Hospital in August 2009, the formula for organ failure “in itself doesn’t exclude enough”. Having applied it, doctors would still be left with too many patients in a pandemic. “Difficult decisions,” wrote Tarmey, who had served as a military doctor in Iraq and Afghanistan, “will still need to be made.” Tarmey is now serving as a consultant at Queen Alexandra Hospital in Portsmouth, one of the largest intensive care units in Britain.
The government has downplayed the sudden and axiomatic change in its approach, with Vallence telling MPs on 16 March that there was only a “semantic difference” between mitigation and suppression. This was a direct contradiction of modelling released by Imperial College the day before, a point noted online by Steven Riley, an Imperial professor and member of the government’s modelling group. The government lockdown was not a continuation of its strategy, as Vallence implied, but a reversal of it. The strategy shifted after Imperial researchers concluded that “mitigation” – allowing the risk to spread – would create an eight-fold capacity shortage in the NHS; a gap very similar to the theoretical one outlined by Alan Johnson’s health department in 2009.
On 24 March, a paper by researchers at Oxford University suggested that Covid-19 may be a much milder threat than the government thinks. The study’s bold conclusions cannot be verified until the UK acquires a nationwide antibody test to show who has had the disease and recovered. But the accuracy of that study or the course of the crisis will not change the ill-preparedness of Johnson’s government, or those that preceded it.
Over the past decade of Conservative-led government, the UK’s pandemic preparedness team was disbanded, the NHS as a whole was under-resourced, and funding for nurses was cut. Britain is scrambling to acquire ventilators, but its lack of nurses to operate them may become its most pressing shortage. As the 2009 “Surge capacity” report made clear, “expertise in ventilator settings and rapidly applying interfaces is essential… Local training needs should be addressed in the pre-surge period.”
But the UK would not have been ready for a pandemic under New Labour either. The government’s flawed planning assumptions were first articulated under Labour governments in 2005 and 2007. Every government since has either found those assumptions to be useful or simply ignored the threat of a pandemic. The problem, as Professor Alexander puts it to me, is that pandemic preparation involves “telling governments what they don’t want to know, to spend money they don’t have, on something they don’t think will happen”.
When the coronavirus crisis hit, 50,000 ventilators were not revealed to have been bought and stored away. At a market price of £12,500, 50,000 machines would have cost one-tenth as much as the £6.2bn that the UK spent on a pair of aircraft carriers in 2011. But an aircraft carrier is a visible display of power, while 50,000 ventilators would ideally be bought in secret.
When Churchill visited the collapsing French lines in May 1940, he was briefed by General Gamelin, the chief of the French armed forces, on the dire situation. But where, Churchill asked after Gamelin had concluded, was “la masse de manœuvre” – the divisions of troops waiting in reserve? There was no reserve. The long-planned defence of France, as with the long-planned defence of Britain against a pandemic, had rested on a false assumption. In their case, that the Maginot Line could not be breached. In ours, that a virus could not be stopped. These assumptions crumbled upon contact with reality. Now the United Kingdom is, as in 1940, rushing to counter a threat for which it should have been ready.
This piece is taken from the Spring special of the New Statesman, out on Thursday (2 April)