Close to the 6th anniversary of the start of the COVID-19 pandemic, the independent UK Covid-19 Inquiry has published the third of ten module reports and recommendations, this time focussed on ‘the impact of Covid-19 on healthcare systems’.
I found it challenging to read through the findings, knowing that so much could have been different. There is some solace to be taken from seeing the establishment recognise the missteps and the impact on those who lived, worked, and suffered through the pandemic. And especially those who didn’t make it through.
Inquiry chair Baroness Hallet said in her statement that ‘I can summarise that impact as: we coped, but only just.’
Among the report conclusions were two bullet points that felt close to home:
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111 services were not able to cope with the level of demand. Call demand for advice and information about Covid-19 increased dramatically, particularly in the early stages of the pandemic.
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Waiting times for emergency ambulances grew. Waiting times for even the most life-threatening calls grew, with some ambulance services resorting to military aid to ensure there was not a significant risk to life.
For my part, I was managing an NHS 111 contact centre at the time of the big spike in the inquiry’s graph below. Family members were working in the ambulance service and elsewhere in healthcare. Stopping the spread of COVID-19 wasn’t only a moral and professional imperative, it was personal too.
I am bitterly reminded of the slow and inept government leadership that led to that March spike and how it impacted us all; the dogmatic adherence to outdated directives which led to missed opportunities to isolate the infected, then Prime Minister Boris Johnson’s announcement that the entire nation should call 111 for sick notes – a process no one I could contact knew a thing about, the transformation of our 111 service into a de facto ‘National Apology Service’, and many other missteps.
And it was all so preventable.
We now all know the tragedies that came later, but I remain convinced that in early 2020 the chance was squandered to slow the ingress of COVID-19 on UK shores thereby preventing – or at least significantly reducing – the overwhelming impact of COVID-19 on healthcare systems.
On the 9th March 2020, shortly after the COBRA meeting that was infamously the first meeting of its kind that Boris Johnson deigned to attend. Even then, the government’s dithering on moving from phase 1 ‘containment’ to phase 2 ‘delay’ was an unforgivable critical failure, but not their first and certainly not their last.
At the time, I wrote an article to document my frustrations and concerns, but I did not publish it as (after much hand-wringing) I felt it would not have been in the public interest at the time. I often wonder if perhaps I should have. It is a burden of guilt I will always carry.
Instead of publishing, I sent the document to my chief executive and had a meeting with him, then went dutifully back to my post. I later passed my thoughts to the COVID enquiry. I do not know what, if any, impact my words may have had.
For the record, this is the article I can now publish in full:
An NHS 111 Clinician’s View of the Coronavirus Crisis and the Ethical Concerns Surrounding the Current Direction of Travel for Healthcare Professionals in the NHS
By Mathew Westhorpe, NHS 111 Paramedic Clinical Support Manager, 9th March 2020
In March 2020, in an NHS 111 contact centre, a GP, a pharmacist, and a paramedic sat looking at a convoluted multi-page flowchart trying to determine if a patient is eligible to be swabbed for COVID-19 under the criteria set out by Public Health England.
After much furrowing of brows and perplexed discussion, they concur that the patient does not meet the criteria, even though their circumstances as described by the anxious caller make them a credible transmission risk.
It seems clinically prudent to each of the clinicians to get that individual swabbed, but they’ve been told anyone who arrives at the NHS 111 Coronavirus Pod who doesn’t meet the PHE criteria will be turned away. So, perhaps against their collective better judgement, they follow the protocol and tell the individual they are not at risk and should treat their symptoms as they would a common cold.
The above account starts like the opening of a joke, and I wish that’s all it was, but the ramifications are very real. NHS 111 is operating as the primary point of contact for every concerned resident of England and Wales at a time of international anxiety. As news of the spread of the novel coronavirus from China has spread, the volume of incoming calls has skyrocketed, piling pressure on the national healthcare advice service which was barely taking a breath from the worst of the predictable seasonal workload.
As a clinical manager working to support the clinicians and non-clinicians in a 111 call centre in England, I’ve been witness to and an active participant in their endless endeavour of providing the best, most consistent and informed advice they can. It has been very much a requirement for everyone to think on their feet, to do their best to keep up-to-date and provide a unified voice of calm and reason to the tide of incoming callers, many of whom are frightened, angry or just confused. Everyone involved is working harder than ever to do right by our callers.
But therein is the problem. As a healthcare professional first and foremost, it is my duty to act in the best interests of my patient. But NHS 111’s strict adherence to a redundant criteria that PHE has left relatively unchanged for nearly two weeks has seen countless potential COVID-19 patients ignored and sent on their way. At time of writing, only 16 countries were on the [PHE] travel criteria despite over 100 countries reporting cases, many as a result of local transmission.
In reality, as soon as it became apparent that person-to-person transmission was happening within the UK among people with no travel history, applying any travel criteria became an act of mindless dogma. Yet over a week later, strict instruction remained to screen people based on their recent presence in Italy, Iran or the Far East, or direct contact with a confirmed case – and in most cases then only if they also had symptoms.
We are now seeing credible projections from analysts that conclude that up to a third of the 66.5m population may be affected. In England & Wales, that means approximately 22.1 million. Based on Italy’s figures, some 10% (2.1 million) of those cases will require hospital treatment. With current bed occupancy at around 90% of a total of 128,000 beds it is painfully clear that the NHS will be unable to accommodate this cohort even if those patients are spread across a period of months, and without more robust measures a period of weeks is more likely. The impact on all healthcare sectors will be devastating.
The best chance of avoiding those admittedly (hopefully?) worst-case scenario figures would be to take far more broad measures in identifying and isolating potential COVID19 patients, but even now the only measures remain reactive, assessing only those who come forward and contact tracing those few we stumble across in our inadequate net.
The worst news is that following the COBRA meeting of 9th March 2020, the government has decided to claim we remain in the step 1 ‘contain’ phase of their 4-step plan despite the fact that the problem quite clearly is anything but contained. Putting off enabling the ‘delay’ measures ensures that the spread continues and the NHS response continues to be reactive rather than proactive. NHS 111 will be instructed to continue to deny assessment to the vast majority of the population, cases will continue to spread quicker than they are detected and the worst case scenario will be achieved.
I suspect that this is an economic decision, and that it’s been decided that the collateral damage to the population as a result of a nationwide collapse of healthcare provision is more palatable than the damage to the economy. After all, very few working age people will die from COVID-19, so best let them ride it out, get through the resultant funeral season as they bury a generation of pensioners and then get back to work.
I feel deeply uncomfortable that NHS 111 healthcare professionals will be expected to continue to offer false reassurances in the knowledge that more could have been done and wasn’t. I fear we are all complicit in looking the other way as we enact ideological policies which will result in thousands of avoidable deaths.
MJW 9/3/2020
Author’s Note: Why This Article is Being Published Now
The operational failures described in my 2020 document, specifically regarding the early 2020 Case Definition and the capacity of the NHS 111 service, have since been examined and confirmed by the UK COVID-19 Inquiry Module 3 Full Report (March 2026). These observations are now a matter of public record and historical fact.
I take some comfort in the COVID-19 Inquiry’s findings validating my concerns and my decision not to ‘whistleblow’ at the time.
This article was originally drafted in March 2020 while I served as a Clinical Support Manager within the NHS 111 system. At the time, I made the professional and ethical decision to withhold publication for three primary reasons:
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Stability of Service: In the early weeks of the pandemic, the 111 service was a critical pillar of the national response. As a manager, I recognised that publicising internal clinical critiques during a period of acute national crisis could have undermined public confidence in a vital emergency pathway, potentially risking lives.
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Respect for Due Process: I believed then, as I do now, that systemic failures of this magnitude must be addressed through formal, evidence-based channels. I chose to submit my contemporaneous observations and concerns directly to the UK COVID-19 Inquiry to ensure they were part of the official record overseen by Baroness Hallett.
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Verification of Facts: I waited for the publication of the Inquiry’s Module 3 Full Report to ensure that my personal clinical experiences were cross-referenced against the wider evidence base. The Inquiry has now officially validated the core concerns I held in 2020, specifically regarding the ‘narrow case definitions’ and the ‘intolerable strain’ placed on the 111 service.
By publishing this now, six years later, I am not divulging confidential operational secrets, but contributing a first-hand clinical perspective to a matter of significant public record. My aim is to ensure that the ‘moral injury’ experienced by frontline clinicians is never repeated in future health emergencies.
[AI Transparency Statement: The main body of this post and the 2020 document were written without AI influence in keeping with the principles of this blog. However, I did use AI to help cross-reference my 2020 document with elements of the Covid Inquiry Module 3 findings and to draft the above author’s note.]