Dr Vin Diwakar, medical director for NHS London, said extensive preparations avoided the NHS collapsing under the pressure, despite there being more than 1,000 patients on ventilators at the peak of both waves and more than 5,200 in hospital with covid in April and 7,900 in January.
On the first anniversary of lockdown, he told the Evening Standard: “Overall, if you were to say, knowing what we knew at each point over the course of the year, do you think we in the NHS in London did absolutely everything we could, I think we did.
“We were really careful and deliberate about learning each time something happened, and if things happened again, what would we do differently? If we hadn’t done that, we wouldn’t have been able to manage as well as we did.”
His remarks came as two of London’s most senior critical care doctors recalled the struggle to cope against the rapid advance of covid with a shortage of staff and supplies. They also warned of the long-term impact of the pandemic on the mental health of frontline staff.
By last night, the London death toll had reached 18,541, based on people who had covid mentioned on their death certificate.
Dr Diwakar revealed he had volunteered for nursing nightshifts in intensive care at St Thomas’s hospital because he “just wanted to do my bit” and to understand the challenges that hospitals faced. He has also been working as a vaccinator.
Reflecting on the past year, he said: “One of my colleagues tells me that they can remember me in December 2019, at the end of a management meeting, saying: ‘Has anybody here heard of Wuhan?’”
Between January and March last year NHS London was busy planning for a possible pandemic. The first focus was on the capacity of the infectious disease units in the capital, with the Royal Free and St Thomas’s both receiving patients in February.
Then, as it became clear the virus was spreading, the priority became expanding the number of intensive care beds. At the time, London had about 900.
Dr Diwakar recalled: “The stand-out day for me personally was Saturday March 21. I can remember being phoned up by my boss, the regional director [Sir David Sloman]. We had been looking at the numbers for several weeks, watching them slowly rise. We already had pretty good plans to double the number of intensive care beds in London.
“The problem we had on Saturday March 21 was that the numbers were doubling every three days. We knew that lockdown measures would take three weeks to work. What we realised was that if the numbers kept doubling at that rate we would need 7,000 beds in three weeks’ time.
“We called all the chief executives, medical directors and nurse directors together on Sunday March 22 at 7am. We worked until 2am until we had a plan for how we were going to create 7,000 adult ITU beds in London.
“We came up with a plan to create 3,000 in the core NHS in London and then 3,000 at the Nightingale. That was where we came up with the concept of the Nightingale hospital. Then on Monday 23 at 9am I had to go in and see the Prime Minister and present the plan. He gave us the go-ahead to commission the Nightingale. That night he announced the lockdown and 16 days later we opened the Nightingale.
“Thankfully not as many patients needed to be treated in the Nightingale as we thought. I think we peaked at about 1,100 [ICU patients across London] in April.”
Dr Ganesh Suntharalingam, past president of the Intensive Care Society, said: “By this week last year, where I work in west London, we were already fully into the first surge, with multiple patients arriving into ICU every day. Although there was a lot of preparation and expansion of services, I think the speed of the first surge was pretty staggering.
“We had the first couple of suspect cases very early on in February. Everyone dealt with it very calmly but it was a new and frightening disease. Memories of the first possible cases are quite vivid, even though they turned out to be negative.
“By mid-March, there were dozens of confirmed cases coming into the hospital, and anything between five and 10 a day coming into the intensive care unit, which is an unprecedented number.
“We were realising it wasn’t just a viral pneumonia, which is serious enough in itself. This was a new disease and had other things, like blood clots and kidney failure. The characteristics of the disease were challenging because they were unknown.
“Logistically it was challenging – staff, space and equipment. A lot of work had gone into getting staff from other areas in, but they needed training. For all of us, working in PPE and communication being difficult – all of that added up to huge challenges for staff.
“Everyone took that on willingly – but with a lot of effects later on in terms of PTSD and the emotional challenges of dealing with it all.
“There was a lot of planning done but the speed at which numbers came in made it a struggle to keep up. But we did manage. There were patients having to move between hospitals because there were hotspots, but everybody who needed a bed got one.”
He said vaccine uptake was now key to determining how much pressure the NHS was likely to come under in the future. “It seems likely there will be further surges, maybe in areas where the vaccination rates are lower than elsewhere. We are not completely out of the woods yet.”
Professor Rupert Pearse, who works at Barts Health NHS Trust in east London, said: “We had been through a period which euphemistically we started calling the ‘phoney war’, where we knew that things were going to come and we were planning intensively for more beds, where we would put more patients and how we would get PPE, more ventilators and more drugs.
“We then had a patient about a year and two weeks ago. We didn’t think it was covid when they first arrived, and a lot of staff were involved in the care of the patient. Then the patient tested positive for covid afterwards. A lot of staff had been exposed to the patient. That was our first difficult realisation that people were already being put at risk.
“None of them got ill… but testing of staff at that point, at scale, was difficult. People just had to go home and wait [to see if they got ill].
“About this time a year ago we knew it was going to be a big wave. We knew the plans for massive ICU expansion, like they had in Italy, were definitely going to be needed. It was probably the most scary time because, as with the second wave around Christmas time, we just didn’t know how high it would go.
“In a way we were so busy it was difficult to find time to think about the scariness of it, in some respects. When we did have a quiet moment it wasn’t much fun. There was a lot of fear about the plans we had made which, compared to the second wave, were quite scrappy.
“There was a lot of worry about the choices we were making and the trade-off between the quantity of hospital beds and the care that they provided, and the sense you couldn’t just keep ramping up the quantity of beds and expect the quality to be maintained – and maybe that there would reach a point that having an extra bed wouldn’t really help, because there wouldn’t be anybody left to look after the patient in it.”
Asked how well-prepared the NHS was, Professor Pearse said it was “important to note that this was a once-in-a-century pandemic – it was the Spanish influenza the last time we had something quite like this”.
But he added: “I don’t think we were ideally prepared. It’s clear that both at the national and regional and local level we didn’t have the supply chain for PPE. We didn’t have supply chains for other equipment like ventilators. I don’t think we had a system for pulling in staff with relevant experience. Staff was always the biggest challenge.”
He said the NHS’s “command and control structure” was not ideal as centralised bureaucrats were unable to comprehend the different challenges in each hospital.
He said that, in the second wave, “yet again, we didn’t quite reach a point where we were hopelessly overwhelmed but we came quite close to it”.
He said: “We did manage to maintain a decent standard of quality but not the quality of care we would have liked. There were various little sacrifices we made to keep things moving for as many patients as possible.”
He said a public inquiry would be worthwhile. “I think there needs to be a no-blame discussion. Every single part of society needs to accept its bit of responsibility for what happened, rather than pointing the finger at any group of people.
“NHS staff themselves are genuinely exhausted. You hear stories of people getting really, really upset in their day-to-day work, feeling that nobody has really noticed what they had to do during the pandemic. We have seen lots of staff get really ill, close colleagues within our intensive care unit that we have had to look after. People are emotionally exhausted.
“Most staff know that the need is that we don’t stop – that we go straight back into clearing the backlog of cancer care, that we get usual services restarted. The sense that we can’t stop, and owning that responsibility to deliver healthcare, is going to wear a lot more people out. A lot more people are going to get even more tired.”
Critical care staff were also required to be the “guardians” of ensuring the best quality care was provided for those whose lives were most at risk, he said. “All of these issues comes together to create a major mental health wellbeing problem for NHS staff, and in particular ICU staff in all professions and at all levels.”