‘It’s Unimaginably Bad.’ How Government Failures and the New COVID-19 Variant Are Pushing the U.K.’s Health System Into Crisis

Dr Rachel Clarke never dreamed that in her medical career, she would say out loud that hospitals in Britain are running out of oxygen. Yet some hospitals in the U.K. are now in that critical situation, as doctors say the U.K.’s third wave of the coronavirus pandemic is pushing the country’s National Health Service to its limits. “We’re seeing younger patients, we’re seeing sicker patients, and we’ve never really recovered from the first wave,” says Clarke, who works on an acute medical ward in a hospital in Oxfordshire, England, and also in an in-patient hospice setting. “You can’t sugarcoat the situation currently in the NHS in Britain. It is unimaginably bad.”

The U.K. is currently enduring a painful third wave of COVID-19, far worse than its European neighbors like Spain, France, Italy and Germany. (The Republic of Ireland currently has the world’s highest number of confirmed new COVID-19 cases per capita.) On Wednesday Jan. 13, the U.K. reported a record high of 1,564 deaths within 28 days of a positive COVID-19 test—the biggest figure reported in a single day since the pandemic began, bringing total deaths to more than 84,000.

Experts say that the current situation in the U.K., and particularly in London—which declared a state of emergency on Jan. 8 is a cautionary tale. They say the crisis is a result of both the struggle to deal with a new variant estimated to be up to 70% more transmissible, and because of a failure in decisive and strong government leadership.

Read More: A New, More Contagious COVID-19 Strain Has Been Reported in the U.K. Is It Headed for the U.S.?

One of those failures, they say, was that the U.K. government did not act on the scientific advice that recommended a short “circuit breaker” lockdown in September to halt rapidly rising transmissions after the easing of lockdown restrictions in the summer. Although a second round of national restrictions were introduced in November, it was eased in December and cases rapidly climbed throughout the month. On Jan. 4, Prime Minister Boris Johnson announced a third national lockdown in England, with people only allowed to leave their homes for a select few reasons and non-essential shops and businesses closing. (Wales, Scotland and Northern Ireland each have their own healthcare rules and have also instructed national lockdowns).

The U-turns in policy and the failure to enact a national lockdown early enough this autumn have likely had deadly consequences. Clarke is now seeing patients who caught the COVID-19 virus from a family member who spent Christmas Day with them (as permitted by government rules in certain parts of the country), resulting in entire families becoming infected. “When I see now people dying of COVID-19, who I know might not have caught it had the government been braver and more willing to stand up and put lives first—I find that heartbreaking,” she says.

The picture inside U.K. hospitals

Government officials said Monday that the U.K. is at the “worst point” of the pandemic, with 50% more coronavirus patients in hospital now compared to April last year. The same day, Johnson acknowledged oxygen shortages in some places, and reports emerged of hospital mortuaries reaching capacity in one south-eastern region, leading to bodies being stored at a temporary mortuary. “Off the scale” waiting and queuing times for ambulances have been reported in London and parts of the south-east, and many are warning that the worst is yet to come.

“The hospitals are full. The intensive care units are full,” says John Ashton, a former regional director of public health for north west England and the author of Blinded by Corona: How the Pandemic Ruined Britain’s Health and Wealth. “People will not be admitted, and will be very sick and dying at home, that’s what’s going to happen over the next two or three weeks.”

Clarke remembers watching in disbelief the scenes of the first wave of COVID-19 unfolding in New York City. “That’s what we are going through in Britain at the moment,” she says. “We have ambulances trapped, queued up outside hospitals for six, eight, ten hours at a time because they can’t physically offload their patient and actually get them into hospital at the moment.”

Data from Public Health England indicates that there are more people of all ages in hospital in the U.K. with COVID-19 now than in the first wave of spring 2020, including the young and the old. Infections have been highest in teenagers, students, and people in their 20s and 30s in recent months, and the highest hospital admission rate for confirmed COVID-19 has been in the over-85s. There has also been a steep rise in the number of 65-74 year olds and 45-64 year olds admitted to intensive care units.

Read More: The U.S. and U.K. Were the Two Best Prepared Nations to Tackle a Pandemic—What Went Wrong?

The overwhelming burden on the National Health Service is affecting other patients who do not have COVID-19, but who also are in pain and need treatment or other surgeries. At the north London hospital where spinal surgeon Dr. Hilali Noordeen is based, seven out of the nine operating theaters have been repurposed and made into intensive care units for COVID-19 patients. “The whole of our hospital now, save two male beds and two female beds, are not available for us because they are either full of COVID-19 patients or waiting for COVID-19 patients,” says Noordeen, author of the forthcoming book Letters to a Young Doctor, adding that his hospital is now down to 60% nursing capacity as staff have had to self-isolate at home. A letter earlier in January from the chair of the British Medical Association to its members said that over 46,000 hospital staff were off sick with COVID-19. The lack of capacity, both in terms of facilities and staff, means that on the day Noordeen speaks to TIME, he initially had a list of three pediatric patients with severe spinal deformities to attend to—all those appointments had to be canceled. “I don’t know how many months it’s going to be able to take us to deliver these treatments now,” he says.

For junior doctor Kieran Killington, who was redeployed from general practice to a west London hospital, the biggest change he’s noticed is the exhaustion of staff. During the first wave, he heard many colleagues say that it would be hard to cope with the same level of stress again, and yet they now feel they’ve been thrown into a situation where they have to. Clarke too shares that same sense of disappointment, that the mistakes made in the government’s delayed response to the first wave have been replicated now. “The fact that this is the second time round makes it so much more inexcusable and so much harder for staff,” she says. Results from a new study published in the British Medical Journal on Jan. 13 indicated that nearly half of NHS critical care staff surveyed who worked in intensive care units through the first wave reported symptoms of post-traumatic stress disorder, severe depression or anxiety. Of those surveyed, more than one in seven clinicians and more than one in five nurses working in ICUs reported thoughts of self-harm or suicide.

How did England end up here and how can other countries avoid it?

The new variant of COVID-19 first reported in mid-December is partly to blame for the grave situation in England, experts say. Mutations in the virus make this new strain 50%-70% more transmissible than others, scientists estimate. According to the U.K. government the new strain was likely present in the country as early as September. At least 50 more countries have now reported cases, according to the WHO.

British officials have repeatedly said that without the emergence of the new variant, social distancing measures which have been in place across most of England since mid-October, including bans on most indoor gatherings, would have been enough to contain COVID-19.

But public health experts say government strategy on COVID-19 contributed both to the surge in cases, and to the emergence of the new variant itself. Many have criticized the government’s decision to considerably loosen restrictions over summer after the first lockdown in spring in order to try to revitalize the economy. Researchers at the University of Warwick found that a government-backed food voucher scheme, dubbed “Eat Out to Help Out,” which encouraged people to dine at restaurants by subsidizing a portion of their meal, drove new infections up by 8% to 17% and accelerated a second wave in the fall. The scheme cost taxpayers almost $1.2 billion.

The emergence of the new variant of the virus, says Ashton, the former public health official, was made more likely by the wide spread of infections. “The more people the virus goes through, each generation of people it infects—that gives the virus an opportunity to adapt and get better at doing its deadly work,” he says.

Read More: How the U.K. Mismanaged Its Coronavirus Response

Government messaging around Christmas may also have driven transmission in December. Initial plans allowed for five days of mixing of up to three households indoors—far more than other European countries. Those plans were scrapped just a few days before Christmas as the spread of the new variant became clear, with new local measures allowing either no indoor mixing or only one day of mixing with two households. But Ashton says restrictions were not introduced early enough to stop rapid spread over the Christmas period. In a survey by the U.K.’s Office of National Statistics, 44% of adults admitted to forming a “bubble” with up to two other households on Dec. 25. “This is the beginning of the Christmas wave,” Ashton says. “We’re still in the foothills of what’s in the pipeline to come from Christmas and New Year.”

The U.K.’s overall strategy for combating COVID-19 appears to have been driven by a different understanding of the virus compared to other countries with lower death tolls, said Devi Sridhar, professor and chair of Global Public Health at the University of Edinburgh’s Medical School, speaking at a session of parliament’s Health and Social Care Committee to examine the effectiveness of previous lockdowns in November. The U.K.’s heavy toll “comes down to an early decision to treat this like a flu-like event, that would pass through the population, [with] an uncontrollable spread that you would try to mitigate through building enough hospitals and medical care,” she said. “Rather than treating this like a SARS-like event, which is what East Asian countries have done, as well as the Pacific, Australia, New Zealand, as well as some countries in Europe, like Norway, Finland, Denmark, who are diverting from that flu model and trying to keep their numbers as low as possible.”

Ashton agrees that the U.K. failed to “follow through [with successful early lockdowns] like they’ve done in other countries,” because of a focus on the economy. “The way we’ve handled it, we’re going to have the worst of both worlds: the biggest economic impact, and the worst health impact, both in terms of deaths, and people suffering with long COVID,” he says. “That’s because we haven’t been decisive.” Though national economic output bounced back as restrictions were lifted during the second and third quarters of 2020, that recovery proved short-lived, with the economy contracting again in the fourth quarter. By the end of 2020, the U.K. economy was 10% smaller than at the end of 2019.

How long will England’s lockdown last?

There’s no clear end in sight for England’s lockdown. Although the government has tentatively set a date of mid-February to begin easing measures, the legislation on the new restrictions lasts until March 31. Transmission is so high that, according to government estimates, 1 in 50 people in England currently have COVID-19. In the capital, the average is 1 in 30, or 1 in 20 in “hot spot” areas, London mayor Sadiq Khan said on Friday.

As a result, the prime minister is pinning hopes for loosening restrictions on the ability to rapidly vaccinate the 15 million people in the government’s four priority groups: care home residents and their carers, people over 70, frontline health and social care workers, and those considered “clinically extremely vulnerable.” If things go well, Johnson said on Jan. 4, those groups will all receive at least their first dose of a vaccine by the middle of February. Only then could some restrictions be relaxed, as vaccines continue for the rest of the population.

Read More: mRNA Technology Gave Us the First COVID-19 Vaccines. It Could Also Upend the Drug Industry

It’s unclear if it will be possible to roll out the vaccine that quickly, though. Since vaccines began to be administered on Dec. 8, only 2.4 million people have received a first dose. The U.K. has so far approved three COVID-19 vaccines: those produced by Pfizer-BioNTech, AstraZeneca-Oxford, and most recently Moderna. The AstraZeneca-Oxford vaccine, which can be stored at normal fridge temperatures and of which the U.K. has ordered 100 million doses, is expected to speed up the rollout.

But given the immense pressures on health service staff and resources, ramping up the necessary level of 2 million doses a week by the end of January will be extremely difficult, Ashton says. “I fully expect this vaccination program will be the next casualty of over promising and under delivering. It’s unbelievable.”

In the meantime, the outlook for England’s hospitals looks bleak. According to a report by health service news outlet HSJ, the NHS expects London’s hospitals to be short of some 2,000 beds by Jan. 19, even under a “best case scenario” of lowering transmission rates and emergency hospital facilities being opened.

Clarke, the doctor in Oxfordshire, is steeling herself for the coming weeks. “Knowing that the population is being vaccinated is pretty much the only thing that is stopping me wanting to dissolve and crumble right now,” she says. “Vaccines are the one chink of light to hold on to.”