Every Thursday evening for the past month, the streets of the U.K. have erupted with noise as people stand on doorsteps or balconies, clapping or banging pots and pans, in a weekly sign of appreciation for healthcare workers.
But many doctors, nurses and carers say they don’t want applause—they want better testing and equipment. The U.K. has more than 100,000 confirmed cases of COVID-19, making it the sixth-worst affected in the world—but its real number is widely believed to be far higher due to a shortage of test kits. And more than 14,500 people are confirmed to have died in U.K. hospitals from COVID-19, putting it behind only the U.S., Italy, Spain and France. That number, too, is an underestimate: the U.K.’s official statisticians suggested Tuesday that the real number could be as much as 15% higher, due to a combination of delayed reporting of deaths, and the fact that those who died in nursing homes and private residences are not included in official figures. Although daily deaths in British hospitals appear to have flattened over the last week, there is uncertainty over the real figures, and experts worry the U.K could soon overtake its neighbors. A senior government health adviser has warned the U.K. could end up being the “worst affected country in Europe,” while a British former WHO official has questioned the “system errors” that “led us to have probably the highest death rates in Europe.”
As other European countries have started lifting their lockdowns, the U.K. announced Thursday it would be prolonging its own for at least another three weeks. Although, like in other countries, popular support for the government has skyrocketed during the crisis, politicians are now coming under fire for shortages in personal protective equipment for healthcare workers and tests—shortages that experts say could have been avoided if the government had followed WHO advice. “The government was slow to act, didn’t give coronavirus the priority and attention it deserved and has made some significant mistakes,” says Professor John Ashton, a former regional director of public health in England. “They’ve handled it very badly.”
Epidemiologists and former public health officials say the U.K.’s strategy for combating COVID-19 was muddled—leading to delays in purchasing essential equipment and tests, mixed messages about public health practices, and a lag behind its neighbors in implementing social distancing and other restrictions. That likely allowed the virus to spread fast and undetected.
Britain’s first mistake, according to Ashton, came around the time when the coronavirus was first confirmed in England, on Jan. 31. Prime Minister Boris Johnson chose not to chair a meeting of the government’s emergency COBRA committee, leaving his health secretary Matt Hancock to do so instead. “Because Johnson didn’t chair the meeting at the beginning of February, the government missed the opportunity to see that they needed to be ready to do lots of testing, that they would need to sort out stocks for personal protection and for oxygen and other supplies,” Ashton says.
Johnson’s decision not to step in until the beginning of March was “a surprise” that allowed shortages of vital health equipment, including tests, to sneak up on the British government, says Dr. Liam Smeeth, an epidemiologist at the London School of Hygiene and Tropical Medicine. The mistake, he says, was that the government placed too much confidence in Britain’s scientists and doctors, without doing enough to obtain the scarce equipment they required to do their jobs. “During the Ebola outbreak, the government could say, what we need is some personal protective equipment or test kits, so let’s find a hundred million pounds and buy them,” Smeeth told TIME. “But it very rapidly became obvious in the coronavirus pandemic that this was a global problem, and therefore global supply chains just dried up. Instantly countries were competing for the supply of goods in a way that we hadn’t really seen before. I don’t think that was something people here were really prepared for.”
Still, in the early stages of the outbreak in February, Britain appeared to be coping well with identifying the infected and doing contact tracing. When the first two cases were identified in the northern city of York at the end of January, health officials put them into isolation and traced their contacts. The same was done for a man from Brighton, who had traveled to Singapore and then France before returning home and infecting four people. “The U.K. did really well with the earliest cases,” says Helen Ward, an epidemiologist at Imperial College London, whose colleagues are mathematical modelers advising the U.K. government on the spread of the disease. “I think they did a pretty good job.”
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It didn’t become clear until later, when confirmed cases began to increase exponentially in early March, that Britain’s failure to move fast on obtaining testing kits back in February would have such a big impact.
“The catalog of us being short of things began at that point,” Ashton says of Johnson’s decision in early February to effectively delegate responsibility for tackling COVID to his health secretary, turning what could have been a whole-government response into a departmental one for a crucial month. “The government would have been able to get orders in for that sort of equipment. And now they’re at the back of the queue because they didn’t identify early on what they would need.” While Germany was testing some 20,000 people per day in the second week of March, Britain was testing on average under 2,000.
On top of what Ashton calls the “material mistake” of not moving to obtain tests early enough, Johnson’s government made a string of controversial decisions in mid-March. The first came on March 12, the day after the WHO declared COVID-19 a pandemic, when public health officials announced the U.K. would cease tracing and testing the contacts of coronavirus patients — effectively accepting that a full-scale outbreak was inevitable in the country. The U.K. was moving to the next phase of its plan, the “delay” phase, where the imperative was to “flatten the curve,” Johnson announced at a press conference. “We need to squash this sombrero,” he told a packed room of journalists and officials at his 10 Downing Street residence in London. “The decision to stop community testing, I think, was against WHO advice, which is that you need to test, test, test, and push back hard to suppress the virus,” says Ward.
Despite Johnson announcing that Britain’s new focus was to “delay” the spread of the disease on March 12, it took four more days before he formally advised the public to begin socially distancing on March 16. In the meantime, at a press conference, his chief medical adviser mentioned the government’s long-term goal was for Britain to develop “some kind of herd immunity” against the disease, or in other words, letting a large percentage of the healthy population catch COVID-19 in order to prevent it from spreading to the most vulnerable. It was never official policy, but coming when it did, at a time of a policy vacuum, it sent a confusing message, epidemiologists said. “I think that was an error,” says Smeeth, the London School of Hygiene and Tropical Medicine professor. “Briefly, the government made it sound as if they were embracing the idea of herd immunity as a tool to control the epidemic, which I don’t think it was ever intended to be.”
That message changed swiftly on March 16, three days later, when a new scientific study by modelers at Imperial and the London School of Hygiene and Tropical Medicine arrived at Downing Street. It showed that the impact of the disease could be far worse than previously thought. If the government did nothing, 510,000 people would die, it predicted. If the government continued on its current course, the study said, the death toll would still swell to 250,000.
Later that same day, Johnson pivoted. People should work from home if they could, he said in an address to the nation, and “avoid” public venues like pubs and restaurants. His government did not, however, make these measures legally binding, nor did it explicitly tell businesses to close their doors. It would be a whole week until it did. (By comparison, Italy went into lockdown on March 9, Spain on March 14, and France on March 16.) On March 23, Johnson finally appeared on television to announce the country would go into lockdown the next day, with all non-essential travel banned and most businesses being forced to close.
“That week, between the 16th and 23rd when there was no formal lockdown, was the week when we could have gained time in a more aggressive lockdown,” says Ward, the epidemiologist from Imperial College London. Johnson’s long-held conservative belief in personal freedoms, says Ashton, had obstructed a public health imperative. “It was left to individuals to choose whether they went to the pub or not, until it got really bad,” Ashton says. “Eventually the government had to make those decisions, but reluctantly.”
The government’s line was that it was important to impose the measures at the right time — not too early, not too late — to ensure they coincided with the peak of the disease. “The right moment, as we’ve always said, is to do it when it is most effective, when we think it can make the biggest difference to slowing the spread of the disease,” Johnson said March 16. And in the meantime, the government was busy trying to increase the capacity of the National Health Service (NHS), Britain’s state-funded healthcare body. The army was drafted in to help finish a giant hospital in a convention center in London, which opened on April 3 after nine days of preparations. Even as the disease has spread rapidly across the U.K., one of the government’s key aims — stopping the NHS from being overwhelmed by critical patients — has been achieved, with the new hospital in London treating just 19 patients over the Easter weekend out of a capacity of 2,900 ICU beds.
After Boris Johnson was diagnosed with COVID-19 on March 27, the country’s attention briefly shifted away from testing and PPE shortages and toward the Prime Minister’s condition. When he was taken into the hospital and then intensive care, there was a moment when it seemed possible the Prime Minister could really die in office. Although he’s now in the clear, doctors have advised Johnson to take weeks off to recover, leaving the U.K. under the temporary leadership of Foreign Secretary Dominic Raab. But the country is, to some extent, still leaderless — Raab is only governing by consent of the cabinet, and it’s unclear what power he has to take major decisions, including a strategy to exit the lockdown.
With Johnson now safe, attention has switched back to the structural problems the U.K. is facing. Into its third month fighting COVID-19, the country is still struggling with shortages of protective equipment and test kits. Hancock, the Health Secretary, pledged at the start of April to bring Britain’s daily test rate up to 100,000 per day by the end of the month, but on April 15, it tested under 20,000, missing an interim target. In the struggle to obtain antibody tests amid unprecedented global demand, the British government paid $20 million to a Chinese company for kits that turned out not to work. On Friday, NHS bosses were preparing to ask doctors and nurses to work without full-length gowns because stocks of protective equipment were set to run out within hours, the Guardian reported.
In Britain, the ongoing shortage of tests means a return to any semblance of normal life could be far slower than other countries. Already, the U.K.’s Office for Budget Responsibility, an official watchdog, said the ongoing lockdown could shrink Britain’s economy 35% by June, making more than 2 million extra people unemployed. Modeling shows that any route out of the coronavirus crisis requires widespread testing, to allow a choreographed end to the lockdown and economies to come back to life. “We’re going to face further waves and so we need to make sure we have a system in place … that enables you to test people rapidly,” Anthony Costello, director of the Institute for Global Health at University College London, told lawmakers on Friday. “We have to get the economy going.”
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