On Monday, just before Boris Johnson announced another lockdown, the chief medical officers of the four UK nations issued a plainly worded joint statement warning that the health service could soon by overwhelmed.
“Many parts of the health systems in the four nations are already under immense pressure,” they said, “with substantial numbers of Covid patients in hospitals and in intensive care.
“We are not confident that the NHS can handle a further sustained rise in cases and without further action there is a material risk of the NHS in several areas being overwhelmed over the next 21 days.”
It’s less than 21 days now: so how bad is it, and what can be done?
We spoke to clinicians across the NHS, who described a perilous and unprecedented situation that is now almost beyond their control.
‘We are now in disaster mode’
The most dramatic illustration of the NHS’s potential to fall over came in a memo sent by managers at the Royal London hospital in the capital’s East End to staff just before new year.
“We are now in disaster medicine mode,” it said.
“We are no longer providing high-standard critical care, because we cannot. While this is far from ideal, it’s the way things are, and the way they have to be for now.”
It added: “Every hospital in north-east London is struggling, some with insufficient oxygen supplies, all with insufficient nursing numbers. Believe it or not, Royal London critical care is coping well relative to some sites.”
In recent weeks queues of ambulances have built up outside A&E units, each with a patient in the back unable to get into the hospital because staff are already so busy, and each with a crew who cannot answer other 999 calls because they are stuck there, sometimes for hours at a time.
Scores of patients are being transferred from areas where hospitals have no spare beds to ones that, for the moment at least, do, for example in Kent and the south-west.
Some London hospitals have looked into the possibility of patients they would usually treat instead going to Yorkshire.
And no wonder: earlier this week, the Health Service Journal reported that NHS England feared London hospitals could be short of 5,422 beds by 19 January.
Official figures already show there are far more people in hospital across the UK who are seriously ill with the disease than at the peak of the pandemic last spring.
Back then, the NHS was treating 21,000 patients; this week, the total passed 30,000. On Thursday, Sir Simon Stevens, the chief executive of NHS England, said 10,000 people had been admitted since Christmas Day.
And with more than 1,000 deaths recorded across the UK on each of the last two days, there is every likelihood the current surge may prove more deadly than the first – unless the lockdown quickly breaks the chain of transmission.
Which means the health service is the closest it has ever come to not being able to give all those who need it the timely, high-quality care that until the pandemic hit was its central aim.
“To those arguing winter is always like this in the NHS: you are wrong,” said Jeremy Hunt, whose six years in the job made him the longest-serving health secretary ever.
“I faced four serious winter crises as health secretary and the situation now is off-the-scale worse than any of those.”
While the NHS has cancelled operations in winter before, this chaotic, lethal upsurge of the pandemic was different, he argued.
He pointed to record trolley waits faced by patients awaiting a hospital bed and a fall in the number of people ending up in hospital after a heart attack, “perhaps because they are not dialling 999 when they need to”.
Earlier this week, one exhausted intensive care consultant summed up the situation in a desperate plea on Twitter. “Please stay at home as Covid-19 is running amok in London and it really is getting desperately bad,” said Dr Peter Sherren.
“Worst that I’ve seen it in my 20-odd years by a cataclysmic margin.”
Cancelling surgery and rationing beds
More and more hospitals are cancelling operations, both to free up personnel to bolster those looking after Covid patients and also so that operating theatres and recovery rooms can become makeshift extra mini-intensive care units, for example at University College London hospital.
In September and October many hospitals in the north of England and Midlands had to postpone surgery because they just did not have the resources to do them as well as cope with the second wave of Covid, which hit them hard then.
Now trusts in London and the south-east, the areas under most pressure with the virus, are doing the same thing for the same reason. On Tuesday, Frimley health trust, which runs hospitals in Surrey and Berkshire, called off most non-urgent operations and appointments.
On New Year’s Day, Hampshire hospitals NHS trust took what the chief executive, Alex Whitfield, called “the difficult decision to start postponing some planned operations”.
She warned that while its three hospitals would like to keep doing as many procedures as possible, “over the coming days it is likely that more of our patients will be affected”.
Some of the operations being cancelled now are unusual in that they are classed as urgent – that is, they need to be done within 28 days or the patient’s health may suffer, and they may even die. When “call-offs” happen, they usually involve elective surgery, such as a cataract removal or joint replacement.
But when urgent operations are involved, that could have very serious consequences. For example, King’s College hospital in London had to call off urgent cancer surgery earlier this week because it had too few intensive care beds in which to put those needing post-op observation.
There are also signs that overstretched hospitals may be starting to, in effect, ration access to potentially life-saving care. An intensive care consultant at a Midlands hospital said: “We are not far off the NHS ‘breaking’ here.
“Already trusts are rationing ICU beds. If you have multiple co-morbidities you’re much less likely to be given one and palliative care is considered much earlier than usual. Hospitals in the Midlands, London and Greater Manchester have been doing that for a week now.”
A London GP reported how some of the hospitals she routinely sent patients to had raised the bar for how sick someone with Covid had to be before they got admitted.
Previously they would accept patients whose oxygen saturation had fallen to 92% or 93% but – as a temporary response to the unprecedented demand for care – now insisted the person’s levels must be as low as 90% or below.
“I tried to admit a 65-year-old with proven Covid with sats of 90-91% to one hospital,” said the doctor. “But they said there was no point in sending him because they would send him home. This is worrying because patients with sats as low as 92% or 93% need oxygen, which can’t easily be given at home.”
Ominously, senior doctors and NHS leaders told the Guardian they expected things to get even worse over the coming days and weeks, given the mutant strain of the virus is fast becoming the main strain across the UK.
“The big increase in admissions we’re seeing doesn’t reflect whatever mixing went on over Christmas. Cases linked to that should arrive this weekend,” said one weary hospital boss.
Hospital chiefs are worried that they will soon stop being able to keep creating more and more “surge capacity” because they will have run out of the space or staff to do so.
What is the NHS’s plan if that nightmare scenario occurs? One chief executive ponders the question and replies: “I don’t know.”