In this post I look at four things: what the first year did to the NHS, what it did to the people working in it, what it did to the families left behind, and what the Inquiry shows about how much of it could have been prevented.

Scale of NHS strain

However bad the first wave was in England - and it was awful - the second wave was worse. More than twice as many people were admitted to hospital with Covid in the second wave compared to the first wave.

Critically-ill Covid patients filled our ICUs, pushing the units over their limits, and staff over theirs.

“The healthcare systems coped with the pandemic, but only just. On a number of occasions, they teetered on the brink of collapse and only coped thanks to the almost superhuman efforts of healthcare workers and all the staff who support them.” - Baroness Hallet, Introduction to the Module 3 report, page x.

The word “coped” is doing a lot of work in that sentence. Baroness Hallet goes on to say:

“Healthcare workers and support staff were obliged … to work under intolerable pressure for months on end. Some patients suffering from Covid-19 did not get the quality of treatment they needed and some non-Covid-19 patients had their diagnoses and treatments delayed to the point where their conditions became untreatable.”

Impact on NHS staff

Physical health consequences

NHS staff were among the most exposed people during that first year of the pandemic. They had neither the protection of effective treatments or - for the first 9 months - a vaccine. And this had consequences.

Healthcare workers were much more likely to have been infected - the ONS infection survey found that by June 2020 16% of healthcare workers in England tested positive for Covid antibodies compared to 7% of the overall population.

Compared to non-key working age adults, healthcare staff were much more likely to die in that first year. For those who survived, Long Covid was a risk. According to the gold standard ONS infection survey, by April 2021, 4% of all healthcare workers reported ongoing symptoms for at least 4 weeks and almost 3% for more than 12 weeks. Healthcare workers were the occupation with the highest rates of reported Long Covid out of all employment sectors. It contributed (and still is contributing) to thousands of NHS staff unable to work for months.

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Mental health consequences

Beyond the physical tolls of Covid infection, the mental health of NHS staff suffered during those terrible first two waves. Module 3 reports that by April 2021 half of NHS staff said work or study had harmed their mental health; and by November 2021 64% were suffering from a work- or study-related mental health condition.

Among intensive care staff in England in January 2021, 52% reported symptoms consistent with severe depression and 47% with probable PTSD. Repeated surveys found 12% to 15% reporting suicidal ideation or thoughts of self-harm. Not only is this a tragedy for NHS staff, but it is directly associated with worse patient care1.

The distress experienced by NHS staff was more than burnout - it was also the impact of moral injury, where “sustained moral distress leads to impaired function or longer-term psychological harm”. The Inquiry found that 80% of healthcare staff reported having to act in ways that conflicted with their values - for many front line staff this happened every day.

This devastating, emotional, 2-minute clip of the oral evidence from Professor Kevin Fong discussing his hospital visits at the height of the second wave perhaps explains it best.

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The bereaved

The “unimaginable scale of deaths” that Professor Fong talks about in the clip were people - people who left behind devastated loved ones up and down the country. There have been more than 200,000 Covid-related deaths in England to date; 140,000 of them were during the first two waves.

The final set of oral hearings for the Covid inquiry were given by the bereaved. Some of their stories are also captured in the Inquiry’s “Every Story Matters” collection. The collection explained how many bereaved families and friends said how distressing it still is to think of their loved ones not understanding why their family and friends were not with them at the end.

“I cannot move beyond my trauma, I cannot move through this grief…my father died from the effects of isolation, from the heartbreak of not being able to see his wife and family, from the lack of care and love he should have so rightfully received.” - Bereaved family member, Every Story Matters

“There’s been about 6 or 7 instances where he texted us to say goodbye. We would try and phone or text back but, you know, his texts, because he couldn’t hold his phone very well, were often a little bit confusing to us. The other thing was he was so weak at times, he couldn’t pick up his phone…he’s bedridden, he can’t move…he can’t access any forms of communication and they [healthcare professionals] were so busy when often he would press the bell, and nobody would come.” - Bereaved family member, Every Story Matters

The Inquiry makes clear that the scale of this suffering was worsened by political failure.

It didn’t have to be this way

This is where the findings of Module 2 on government decision-making are so important. In meticulous detail over two volumes, the overall conclusion is that the scale of deaths in the first wave could have been much lower and the devastating second wave could have been largely avoided. Tens of thousands of deaths could have been prevented.

The Module 2 report lays out the missed opportunities, delayed decisions, a refusal to learn, a downplaying or failure to believe advice from SAGE, and a general unseriousness on the part of government.

Professor Edmunds, who served on the SAGE modelling subgroup Spi-M, testified that the failure to act to control the second wave “was not because of a lack of situational awareness or knowledge of how to control it. We let this second wave happen.”2 . Professor McLean, now the UK’s Chief Scientific Advisor, described it as the worst period of pandemic, saying:

“We could see what was coming and could not understand why the government did not act upon the science advice by introducing effective interventions”3

This isn’t speaking with the luxury of hindsight - witness after witness testified that SAGE was warning what was coming at the time. And it wasn’t just SAGE. The Academy of Medical Sciences published a detailed report in July 2020 (shared with the government via SAGE) on the need to prepare for a challenging winter, including advice on NHS resilience, contact tracing, and public health mitigations. Indie SAGE too published many reports that summer and autumn, on how to make contact tracing more effective, on how to improve testing, on safer return to work and study, the need to support people isolating. We highlighted the urgency of what was happening in the lead up to Christmas 2020 as things were spiralling out of control, and called for an emergency national lockdown almost two weeks before the government acted.

So it is not simply that mistakes were made under pressure; it is that failing to prepare over the spring and summer of 2020 and then to act quickly as the situation worsened transferred risk and suffering onto hospitals, staff, patients and families.

What makes it even more tragic is that the UK was the first country in the world to start vaccinating people - in early December just as the second wave was turbocharged by the new alpha variant. Our vaccine rollout was phenomenal - by mid-March 2021, over 25 million people had received at least one dose of Covid vaccine, which included over 95% of all adults over 65 years old. Early evidence was that even one dose reduced the chance of death by over 80% in older adults.

Imagine the lives that could have been saved had we managed to delay the next wave until after our population was vaccinated. Actually, we don’t need to imagine - countries that avoided significant waves until after their populations were vaccinated saw far fewer Covid deaths.

Failing to learn from the Inquiry would be a national moral failure

The world has moved on, plunged into crisis after crisis and there seems to be a collective determination to forget and never speak of the pandemic. But to ignore the findings of the Inquiry - to refuse to learn from the evidence and the pain - disrespects the sacrifices of those who held key services together and those who died. It would devalue all of us - and leave us as unprepared for the next pandemic as we were for this one.

I wrote about it in a December substack post and spoke about it on Sky News. I was worried that this was a bad use of data to scare the public - and striking doctors - into specific actions.

A month later, and it’s clear that this was not a worse flu year than previous years. Flu admissions peaked in mid December. While the most recent hopsital admission data (to 29 December) shows a small increase in hospitalisations1, we are nowhere near 2022 or 2024’s peaks, or (so far) overall numbers, even if we get a double peak like we had in 2023/24.

Meanwhile, RSV admissions steady but relatively high, and Covid admissions are low and steady.

If the government and NHS messaging was about trying to change the public’s behaviour (and behaviour might have changed), then I don’t think the approach is justified. Getting the public to get to a behaviour through misleading presentation of data from the people and organisations who are meant to be trusted experts is counterproductive and wrong. It’s also lazy when you should make the effort to improve the situation through well-established public health measures. This includes improving physical infrastructure such as better ventilation (particularly in health care, school and crowded indoor settings), improving provision (better resourced GPs and hospitals), and better public messaging (e.g. emphasising ventilation and mask wearing alongside hand washing and surface cleaning, or staying home when sick).

If the government and NHS messaging was about pressuring the doctors to call off the strike, then I find that cynical and unethical. Whatever your views on whether the doctors’ strike was justified, you don’t tackle a labour dispute through misrepresenting public health data and scaring people.

There is no doubt that we had a significant flu wave this year, that started early and made thousands of people feel terrible. But the government messaging did not help and only obscured the actual things the government could have been doing (and in fact have been doing in terms of increased NHS resources) to support the NHS this winter and the coming winters.

Below is a plot of year-by-year comparison of hospital admissions with flu using the latest data up to 30 November 2025. Yes, this year’s flu season started a few weeks earlier than normal (leading to breathless comparisons of number of admissions this year compared to the same week last year - which are always pointless in my opinion as the timing shifts year to year). But otherwise, its pattern looks very similar to 2022/23 and 2024/25.

So far the biggest increase in admissions was last week (69%) but this is normal for the rising phase of a flu season. At a similar point in the wave last year the increase was 61% and 70% the year before that.

The important question is whether this year’s flu season will peak soon (and so we have a serious flu wave but a ‘normal’ serious flu wave, just shifted a few weeks earlier) or whether it will keep going up and only peak at towards the end of the year in which case it will be a terrible flu season - i.e. are we in scenario A or scenario B in the chart below. We don’t know! The data simply doesn’t tell us that!

We do know that this week’s increase in admissions was 23%, down from last week’s 69% which suggests we might be the nearing the peak, which would chime with Option A (normal size, shifted early) rather than Option B (terrible). But both are still possible, as are strange double peaks like we saw in 2023/24.

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So why are NHS leaders and the newspapers sounding the alarm? Well, the NHS never copes well in winter and this year is no exception. Also, I imagine they want to put pressure on doctors not to strike. And we do know that this year’s flu strain is less well matched to the vaccine than normal and so more people are likely susceptible to this years’s virus.

But we see these sorts of headlines every year - it’s the sheer predictability of these headlines and the lack of any real plan to stabilise the NHS over winter that should be the front page story! Not some - in my opinion - highly misleading use of statistics!

PS Yes, get a flu vaccine (it’s not too late). Yes, if you’re sick avoid mixing with people as much as you can and wear a mask (preferably an FFP2 one). Yes, if you are in a crowded indoor space, you might consider wearing a mask to reduce your chance of infection (again, make sure it’s an FFP2 one). But this is good practice every winter!

PPS Covid admissions rose for the second week in a row at the end of November (although they are still relatively low - and far lower than flu). A new Covid wave now would be terrible timing with Christmas approaching, but there are reports of a new variant circling which is potentially driving new waves.

You may have seen this alarming headline on the BBC website today: “Hospitals facing unprecedented flu season, say NHS bosses”.

The article goes on to say that the number of flu patients in hospital is 50% higher than this time last year. This is true - as far as it goes. This year’s flu wave is earlier than previous years. But what matters more than the timing of the peak is the size of the peak and how long it takes to recede.

Below, I’ve plotted the number of hospital admissions for flu per 100,000 population for each of the last 4 winters, from UKHSA data.

So it is immediately apparent that this year is several weeks earlier than normal. At the moment admissions are 66% higher than they were at this time in 2022/23. But it could be that the whole wave is simply shifted a few weeks earlier so that the peak or overall number of admissions will be in line with previous years.

There is nothing to suggest from this data that the peak will be higher than 2022/23 or 2024/25 or that the decline will be longer. Now don’t get me wrong - these were serious flu winters, and the NHS will struggle to cope this winter, as it always does. How long it takes for the wave to recede will also really matter in terms of pressure on the NHS and the number of people falling ill. For instance, while the 2022/23 peak was higher than 2024/25, overall the winter of 2024/25 saw almost 50% more total hospital admissions than 2022/23 because it took so much longer for numbers to trail off (well into March/April 2025). We have no idea what the decline of this wave will look like and it is far too early to say that this is “an unprecedented flu season”.

I suspect what is driving the reporting is that the NHS wants to raise the alarm about winter - which is a very hard time every year. A&E delays and ambulance delays have not recovered since 2022. Plus it offers a framing to criticise the planned doctors’ strikes.

All that said, Japan is seeing a severe and early flu season with a new strain circulating. There is no evidence the new strain is more severe or more infectious, but it is less well matched to this year’s flu jab. I suspect we are in for a bad flu season, but I don’t think it will necessarily be worse than the bad flu seasons of 2022/23 and 2024/25.

What’s happening with Covid and RSV?

The other aspect impacting the NHS winter activity is the levels of other respiratory viruses. The chart below shows Covid, RSV and Flu plotted together since September 2023.

Covid levels are relatively low - back down to the baseline they were at for 10 months before September/October’s wave. With some luck, we won’t see a new wave during this year’s flu and RSV season, which will give some respite to the health service. It is definitely the least predictable virus our of the three though in terms of when a wave will come!

You can see RSV is increasing rapidly, but when it is compared directly to previous years (see below), it is tracking with previous winters. So there is no obvious reason that will be worse, except that its peak is more likely to coincide with the flu peak.

Summary

This certainly looks like it will be a severe flu season, but it’s too early to say it’s going to be worse than recent severe winters. The real cause for alarm is that despite plenty of data and experience, the NHS is going into this winter stressed and stretched yet again. We should have a health system that can cope much more easily with winter pressures and we just don’t.

The BBC even ran an article about the early Flu season today. They quote the UK Health Security Agency as saying that at the moment cases are mostly in children and young people, but that pressures on hospitals will rise as more older adults become infected.

The best case scenario for the winter is that this flu wave will be ‘normal’-sized, just shifted a few weeks earlier, and that there won’t be another Covid wave this winter. The worst case scenario is that this is just the start of a terrible flu season, RSV joins the party in November and Covid might make a December/January comeback. While the best case scenrio is certainly possible, it is worrying that Japan has already declared a major early flu epidemic and has even closed many schools to try to control the spread.

What to do

About 50% of over 75s have received their free annual Covid vaccine and about 60% of over 65s have received their free annual Flu vaccine. I really do encourage those eligible to get vaccinated! And for those who are not eligible for the free vaccine(s), the Covid vaccine is expensive privately (£80-£90, although I still intend to get it) but the Flu vaccine is a lot less (£15-£20). Many pharmacies offer a walk-in service and the Flu vaccine will last the whole flu season, so please consider it if you can afford it!

The upshot is that there’s still plenty of nasty respiratory virus around, whether it’s Flu or Covid, so take care and please avoid mixing with others if you feel ill. If you do have go out and about while sick, consider wearing an FFP2 mask in crowded places like train. It’s more effective infection control for the infected person to be masked and others not, than vice versa.

Tentative signs that the latest Covid wave might have peaked (we saw a slight drop in the most recent week), but Flu hospitalisations are higher than they were at this time last year and in 2023, suggesting an early start to the Flu season. Wastewater monitoring in Scotland for Covid (which doesn’t rely on people on testing) also shows a slight decline in most recent week (although Soctland has not seen the sharp peak that we have seen in hospitalisations in England, either in its hospitalisation or wasterwater).

Note that this doesn’t mean Covid has gone away - there is still lots of around. If you can get vaccinated for both or either, I’d definitely do it!

Well it was nice while it lasted. We had an unprecedented 10 months of low and stable Covid levels in England - but this is now over. We are seeing a definite, significant wave of Covid infections across England. The below chart of Covid hospitalisations in England since September 2023 shows this clearly. The last time we had more recorded Covid hospitalisations was two years ago, and this wave isn’t over yet.

I’m sure most people now know someone in bed with Covid. If someone says they are in bed with flu, it’s almost certainly Covid, given that the number of people admitted to hospital for Covid last week was 50 times higher than the number admitted for flu! Flu is seasonal - last year we had a massive flu spike, concentrated within a few weeks around New Year, and this year’s season has barely started.

Covid simply is not seasonal yet (although winter behaviours such as mixing indoors help it spread). Even the low and stable Covid hospitalisation levels we saw between November 2024 and last month are substantially higher than the effectively zero flu and RSV hospital admissions, as is clear from the chart of hospitalisations for all three diseases below.

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Wastewater indicators

England (stupidly) isn’t doing Covid wasterwater analysis. The good thing about wastewater testing is that measured virus amounts are not reliant on people getting tested or having symptoms, so it gives a pretty good idea of levels of infection in the community. That said, it’s not a precise estimate of number of people infected because there’s variation between individuals, and between variants, on how much virus is excreted.

Scotland is still measuring wastwater and interestingly it is not showing much at the moment (a modest increase compared to a few months ago).

BUT Scotland also isn’t experiencing a as big a spike in Covid hospital admissions as England, so it’s possible that the wave England is experiencing will hit Scotland a bit later (it has hit Wales already). Many countries in Europe are however seeing Covid waves reflected in their wastewater measurements as shown in this chart by Bob Hawkins.

Variants

We are not having a wave because there’s a new Covid variant. The latest variant picture from UKHSA shows that Omicron variant XFG is firmly dominant here and has been since July. I did think it would cause a summer wave as it took over quite rapidly in May and June, but it didn’t. This suggests that the current wave is driven more by people’s waning immunity (especially given no big waves for almost a year) and more indoor mixing, from changing weather and return to work and education after summer.

Boosters

The autumn vaccine booster campaign has only just started and so far about 14% of over-75s and 8% of eligible clinically vulnerable people have had it. The eligibilty criteria keep narrowing - this round the following groups can get a free NHS vaccine.

I urge anyone eligible to get boosted! If you can afford the vaccine (currently almost £100 at Boots!!), then it might be worth doing. Personally, I am planning to buy a booster in November, to get maximum protection in December and over Christmas and New Year. Sandy Laping pointed me to a recent peer-reviewed paper looking at timing of booster vaccinations. It suggested a booster is most effective from 6 months since your last Covid infection (i.e. when immunity from your last infection has started to wane), so that’s also worth bearing in mind.

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How is the NHS faring?

As we head into another winter, let’s take stock of how the NHS is doing. Has it has recovered after the last few winters? No.

Ambulance response times are at their ‘summer’ baseline, but that baseline is notably higher than its pre-pandemic baseline. Before 2020, even the winter peak ambulance response time was below the current summer baseline.

Long waits in A&E tell an even worse story. Before 2021, it was almost unheard of to wait more than 12 hours on a trolley before being admitted. Now, tens of thousands of people do every month. The number falls every summer, but year on year that summer baseline has grown higher and we are already seeing a sharp increase in September.

What this means is that we head into winter with a stretched NHS, and which is getting more stretched every year. Labour has put resources into reducing waits and getting the backlog down but all they’ve done is stop the increase. Yes,numbers are trending better, but if the waiting list keeps reducing by only 160,000 people a year, it will be 2040 before it’s at April 2020 levels and 2050 before it’s back to 2010 levels. With government finances so stretched, not enough staff and increasing restrictions on immigration, I am not hopeful that we’ll see noticeable improvements any time soon.

Summary

We are definitely in another significant Covid wave. Neither flu nor RSV have kicked in yet this season, so if you feel grotty and with a fever, it’s most likely to be Covid. Try to avoid mixing with others while infectious, especially anyone who might be more vulnerable to getting seriously ill from Covid (e.g. elderly parents or grandparents, especially those who’ve not been boosted). In fact, if you feel grotty with anything infectious, best to reduce indoor mixing. Your friends, colleagues and family won’t thank you for passing it to them, whether it’s Covid, flu or even a cold!

If you are eligible for a free NHS booster, I’d encourage you to get one. If not, and you can afford to, you might want to invest in a private Covid booster. Oh, and get your flu jab too.

I thought that it was reasonably likely that one or both of these variants would cause a summer wave here, although I said I wasn’t particularly worried about either in terms of their potential to cause higher levels of severe illness. Two months later, and these variants are now the most common variants across the world (in different ratios in different countries), including the UK. They likely reached dominance in England around mid June (e.g. see the last variant chart from UKHSA below - note that sample numbers are tiny towards the end, but the picture is consistent with global patterns).

However, whether because it’s been a hot summer plus enough existing immunity in the population, or something else, they just haven’t caused a big wave of infections here. Wastewater monitoring in Scotland shows a small bump in the last month, but that is declining already - compared to the whopper of a wave we had a year ago, this really is not very significant. Remember that wastewater testing does not depend on test seeking behaviour or symptoms, so is the best guide we have to scale and trend of infection in the community.

Even better, the impact of these variants on recorded hospitalisations in England has been negligible, and numbers have fallen in the most recent week of data. (NOTE: monitoring of hospital admissions for RSV and Flu has ended for the season).

This is good news, helped along by the fact that these variants arrived not too long after the Spring vaccine booster campaign which provided extra protection to many elderly or otherwise clinically vulnerable people (although not as many as we’d like to see boosted every year).

We should be glad about this - as far as I’m concerned, the longer we go without a large Covid wave, the better. It doesn’t mean that no one is getting Covid - it’s there in the background and doesn’t almost disappear in the summer like Flu and RSV. It also doesn’t mean that there won’t be another big Covid wave in the future. But at the moment, things are calm on the Covid Front and long may they stay that way.

PS for a far more detailed look at Covid data, please do check out Bob Hawkins’ weekly substack.

Last summer we had a large Covid wave in the UK, followed by another wave in the autumn but then things have been as quiet as they’ve been since the start of the pandemic since November 2024. Lasting six months so far, this has been a very welcome respite but it looks as if this might be coming to an end in the coming months.

A new variant called NB.1.8.1 has emerged which has quickly become dominant in China, and is taking over in Singapore, Hong Kong, Taiwan and Australia. All these countries are reporting significant increases in reported cases and hospital visits. The apparent growth advantage of NB.1.8.1 over current strains prompted the World Health Organization (WHO) to designate it a “variant under monitoring” three days ago.

It remains rare in Europe but is increasing - the WHO report that its share has grown from 1% to 6% in the most recent 4 weeks of monitoring, representing an approximate doubling of just under two weeks. Since the UK and Europe have seen low Covid activity for 6 months, and most people haven’t had a Covid booster in years, our population immunity to infection (if not necessarily severe illness) is also probably lower than it’s been for a while. This combined with the significant growth means that it’s quite possible we will see a large wave of infection here in two months or so once it becomes dominant.

That said, there is no evidence that this variant causes more severe disease and because it is an offshoot of last summer’s JN.1 strain, which is the strain used for the most recent vaccines, hopefully anyone boosted in the last 12 months will be well protected from severe illness. Thus, we might see many people getting ill, but hopefully a much lower relative increase in the number needing hospital.

Newer kid on the block: XFG

There is an even newer variant popping up which has got some Covid experts’ attention. The main worry with XFG is that it is an offshoot of a much older Coronavirus strain and has added a lot of new mutations, raising concerns that it could more easily evade our immune responses. That said, a new pre-print (research that is not yet peer-reviewed) reported that while XFG is much more immune-evasive than other current variants it is less good at attaching to and entering human cells which could limit its spread and impact. We’ve seen previous variants that have found good immune evasion nevertheless die off because they were not as good as infecting humans as other circulating variants. Ma et al, in a 2023 Nature paper, found that the ability to enter cells (via “ACE2 binding”) was if anything more important than extent of immune evasion in determining virus spread, and so I’m not too worried about this variant unless it finds a way around this problem. However, XFG shows that there are still plenty of mutational spaces for the virus to explore and a new significant variant is definitely possible.

Covid is not yet in any way seasonal

As well as the likelihood of a summer wave, I want to highlight - again - that Covid is not in any way a winter virus. It is not like RSV and Flu and its waves are not predictable. There is a desire to believe that Covid is now just another ‘winter virus’, but doing so risks leaving us unprepared when the facts are very different.

The latest UKHSA report on respiratory infections came out today, so I thought I’d do a quick update!

Firstly the winter RSV and Flu waves are well and truly over. Secondly, hospitalisations with Covid remain low and stable - now almost six months of stability which we’ve not seen since the pandemic began. That said, hospitalisations have been increasing a bit (about a 15% increase over the 6 weeks), but from a low base.

This is mirrored in the wastewater data from Scotland (remember, wastewater data does not depend on testing!).

UKHSA data on variants does show a recent increase in MC* variants (MC.1.4 and MC.21.1), but data is sparse so don’t read too much into it at the moment.

The NHS spring booster campaign started on 1st April this year - two weeks in and almost a third of over 75s have been vaccinated. Uptake remains disappointingly low in clinically vulnerable groups. Please do get vaccinated if you are eligible!

State of the NHS

Finally, a quick update on NHS indicators. Ambulance times are coming down but are still way above target (which was last met in July 2020), but have at least improved considerably since 2022. Long A&E wait times remain stubbornly high, even though the winter crises have ended. March 2025 was slightly better than February, but there were still over 46,000 people waiting more than 12 hours to be admitted to a bed - compared to just 331 in 2019. Monthly numbers have been over 20,000 since 2021 and there is no sign that the NHS is getting on top of this.

For non-emergency care, waiting lists are coming down very very slowly, but over 6 million people are waiting for treatment. At the current rate of decrease (57,000 net reduction a year), it would be another 30 years before the waiting list was where it was in 2021 (still 4.5 million). Fewer than 60% of people are starting treatment within 18 weeks of referral. The interim target is 65% by 2026, but at current rates of increase, the NHS won’t hit 65% for another decade or so. The Labour government’s plan to reach 92% of patients waiting less than 18 weeks by 2029 seems unachievable without a big change somewhere. Treatment delays directly impact population health and the ability of people to remain in employment or to start new jobs. The NHS remains in crisis and we can only hope that the ongoing reforms will help.

With the help of some amazing volunteers, Catherine Finnecy, Sandy Laping and Sue Davies and my unnamed web developer, I’ve created a simple, easy to use, website that let’s you explore all of the official reports that fed into, or were produced by, the SAGE scientists advising the UK government. The website is called SAGEsearch: sagesearch.info .

Together, we’ve curated a set of 905 documents produced from January 2020 to February 2022 (after which SAGE was stood down for Covid response). Documents cover a whole range from SAGE minutes to the behavioural subgroup (SPI-B) reports, the mathematical modelling from SPI-M, to variants reports and detailed epidemiological papers on transmission, hospital admissions, public health measures and more.

Each document has been assigned to one or more topic categories (e.g. “Variants”, “Education”, “Hospitalisations”, “Public Health Measures”) and to one document type (e.g. “SAGE Minutes”, “ONS”, “Vaccines update group”). You can filter on any combination of these and on date range, where the date is the date of the meeting/report.

For each document, I’ve also generated a short summary of the content in three or four bullets that is super helpful in getting a quick overview to see what was discussed and whether you want to read the whole thing. These summaries have been generated using AI (I used a variety of tools) and so I can’t guarantee their accuracy - that said, I’ve checked a fair few and they were all pretty good. You can do a free text search (as well as any filtering you like) on the summary content. The screenshot belows shows me searching for “children” in documents between June and September 2021.

Each document is given with its summary and a link to the government website and a link to the PDF version. Note that I can’t be held responsible if the government changes its links, but hopefully they won’t!

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Who is SAGESearch.info for?

I see SAGEsearch as being most useful for anyone contributing to the Covid-19 public Inquiry (e.g. as a witness or core participant) or for journalists/writers covering the Inquiry - or the pandemic more generally. It is also useful for interested members of the public or those in other countries who want to understand more about what the official science advice was and when it was given.

If people are also interested in the reports and public briefings given by the more public facing and not official government group Indie SAGE (of whom I’m a member), then they are all available and searchable on our website IndependentSAGE.org. You can read about that website in this short post.

Thanks again to the incredible volunteers who helped me and I hope others find this resource useful.

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Was lockdown, despite its harms, better than the alternative?

First let’s revisit the actual choice that faced the government in March 2020. Lockdown was not instituted on a whim. It was a drastic response to a drastic situation. No one had any immunity and we had barely any treatments. We knew it was infectious and serious, with a mortality rate 4-20 times higher than seasonal flu, depending on age. We had no idea what the medium to long impacts of Covid infection were. We knew older adults were most vulnerable, but we didn’t know how it would affect children or if there were other differences such as by sex or other health conditions.

By the time the first lockdown was called on 23 March 2020, there were over 1,000 daily hospital Covid admissions in England and that number had been doubling every four days. We had no idea how many people were infected, no population level testing, no contact tracing, little PPE (including masks), and did not understand well how it spread (how it transmitted, how common asymptomatic spread was). Essentially, we had very few ways to stop the spread and any chance we did have to stop it gaining a foothold was over weeks before.

Lockdown worked – it brought Covid under control. Hospitalisations peaked at 3,000 per day at the beginning of April and deaths at 1,000 a day about a week later. By the end of June hospital admissions were in the low hundreds and falling. Nonetheless, by the end of June 2020 7% of people had been infected and 53,000 people had died of Covid. Hospitals did not cope, but they did not collapse completely.

Without lockdown, the number of people infected and the number of people dying would have been far higher, and hospitals would have collapsed. Even delaying lockdown by a week from 16^th to 23^rd March likely resulted in 20,000 extra deaths. The illness and death from the first wave was not felt equally. Health care workers and other key workers (disproportionately from Black and South Asian minorities) were two- to three- times more likely to have been infected than non-essential workers. Chances of Long Covid from that original Covid variant (in the context of no vaccine or previous infection) were much higher than now – the Imperial REACT study estimated that about 20% of infected people developed Long Covid in 2020. They also reported that only 31% of people with Long Covid had recovered within a year.

Without lockdown, both the absolute size and the inequality of impact would have been more extreme. Those able to stay home voluntarily would have been far better off than those who worked in public facing settings, or those in overcrowded accommodation. Businesses that relied on footfall would have been severely damaged but this time possibly without furlough or as generous government support.

Had that original variant of Covid infected millions more people, the impact on people’s lives (the tens of thousands more dead, the hundreds of thousands more bereaved, the millions more newly long-term sick) – and our economy – would have been even more devastating. There was never a choice between lockdown and carrying on as normal. It was a choice between the devastation of lockdown and an even worse devastation.

Other choices should have been possible – especially by the end of 2020

Had we been better prepared, it could have gone differently. The Covid-19 Inquiry Module 1 report laid out all the ways in which we weren’t prepared and I’ve written about how the very aims of the government’s preparation were flawed.

But by the autumn of 2020, we knew so much more. We knew it was airborne and we knew that testing and contact tracing was key – and we could have learned how to do it better from other countries such as South Korea, Japan and Germany. We knew that a vaccine was on its way sooner than we thought. Covid levels in England were very low in the summer of 2020 – we should have been able to keep them low for long enough to allow our population to be vaccinated. But we didn’t. Twice more the government faced the consequences too late of its hodge-podge of policies not working, despite ample warning from SAGE and others, and was forced into further lockdowns as a last resort. The second large wave (at a time when about 90% of the population were still uninfected and susceptible) and the final lockdown are particularly unforgivable – over 70,000 people died when they were weeks away from being vaccinated.

The real lessons from lockdown

So - these are my lessons from lockdown. Firstly, lockdowns are devastating in their impacts, both in the short and long term, particularly on younger people and on more deprived communities. Secondly, lockdowns can and should be avoided – but by tackling the spread of an infectious disease not by doing nothing! Preventing future lockdowns requires planning, preparation, investment in public health infrastructure, and investment in testing, virology and medical research - and the fundamental acceptance that you can’t wing a pandemic.

Finally, it’s possible that a future pandemic will be severe enough – just reaching our shores too quickly, or being too infectious or too deadly - that our preparation still fails and a lockdown is needed as a last resort. This too needs to be planned for, with economic, educational and day-to-day support measures ready to go. There needs to be a recovery plan for after – and rapid learning to prevent the need for further lockdowns if at all possible. The best way to avoid future lockdowns is to learn the right lessons from the last ones.

Both hospital and wastewater measurements agree that we’ve had a very quiet winter in terms of Covid infection levels. Hospital admissions have been stable and low since the beginning of November 2024 - so that’s four months now. We’ve not seen such a long stable period since the start of the pandemic.

This probably saved the NHS this winter given the large 2024/25 flu wave - you can see very clearly how both Covid and Flu rose together in the winters of 2022/23 and 2023/24.

Of course, hospital data is limited by reduced testing since 2023 and only people sick enough to be in hospital being tested. That’s where wastewater testing is useful, because it doesn’t depend on testing behaviour (or symptoms) and so gives a fair representation of levels of Covid in the community.

England (stupidly in my opinion) stopped wastewater testing in March 2022, but Scotland still does it. The latest data from there shows exactly the same picture as hospitalisations - very low levels for the last several months.

Several European countries monitor wastewater as well - and show the same situation, including Ireland, Austria, Netherlands, Finland and Belgium. I’ve shown Belgium below where you can see a very similar pattern to the hospital admissions in England - a drop and then steady low state since November 2024.

There is simply no evidence of high Covid levels in the UK since November, and we should be thankful for that.

A couple of variants to watch out for

That said, there are a few things happening now in the variant space that are worth keeping an eye on. In England there are two closely related variants on the rise: LP.8.1 (darker blue) and LP.8.1.1 (lighter blue). They emerged towards the end of last year and now comprise about a third of newly sequenced cases. It is possible that they will become dominant but not be immune evasive enough to cause a significant wave, especially with the advent of warmer weather where people spend more time outside or with the windows open. But if a new Covid wave starts in England soon, it will come from these variants and it’s something I will keep an eye on over the coming weeks.

The second thing to watch out for is the re-emergence of Omicron BA.3 in South Africa after three years of nothing (!). It faded pretty quickly back in the winter of 2022 because it could not compete with BA.1, BA.2 and BA.5 which caused massive UK waves in January, March and July 2022 repsectively. However, it seems that it has been evolving quietly and significantly in someone with a chronic Covid infection (likely immunocompromised) and that recently it has started spreading to other people. Note that we don’t know where it emerged - just that it has been spotted in South Africa first.

It is still lacking some key mutations that might help it spread more easily, but if it picks them up it could cause the next big global wave. It’s very early days and could still easily just fade away but this is also something I’ll be keeping an eye on over the coming months. Also worth noting that LP.8.1 is growing rapidly in South Africa at the moment, just as it is here.

To summarise, we’ve had by far the quietest Covid winter since the start of the pandemic but there are signs that activity might rise again over the spring and summer.

Covid situation

As a reminder we have very little real time information on Covid levels in England. Essentially we have hospital admissions with Covid (who are almost all people with Covid symptoms who are tested in hospital) and we have wastewater information from Scotland.

Nonetheless, both these data sources are consistent with the picture that Covid levels are as low as they’ve been since the end of the last lockdown in April 2021, and no signs of any increases. I’m not aware of anything new and concerning on the variant front either which is good news.

Flu situation

After the awful spike we had in December, levels of flu are dropping rapidly and we were spared a second peak which is good. That said, because the spike was so high, levels of flu are still not that far off the peak we saw in the winter of 2023/24.

It’s clear that Covid admissions have been low and flat for 3 months now, and if anything, trending further down.

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NHS still struggling

However, all that said, the January performance metrics for the NHS are still concerning.

Ambulance times for category 2 calls have reduced since December but are still double the target of 18 minutes. The NHS is targeting a more forgiving value of 30 minutes for the next year but for the patients in crisis, scared and waiting for an ambulance, things will remain bleak.

Even though ambulance response times are falling, as are levels of Flu, wait times for admission to hospital have increased again and are near peak levels. We urgently need a way to free up capacity within hospitals, and this cannot be done without addressing adult social care and providing a safe space for vulnerable, but medically fit, adults to be discharged to.

I will next do one of these posts when there is something more to say - for now assume ‘business as usual’ which means a struggling NHS but no obvious crisis heading our way. Do subscribe to Bob Hawkins for more regular and detailed updates.

The authors considered four outcomes: A&E attendance, hospital admission for Covid, severe hospital admission for Covid, and death with Covid on the death certificate. They only included admissions where there was evidence of covid infection and a respiratory reason for admission (i.e. they exluded hospital admissions not because of Covid as far as possible). They also defined a severe admission as one needing at least two days in hospital and some evidence of oxygen or intensive care support.

The time range of 2023/24 is well within the “living with Covid” era where most adults barely think about Covid at all. Their results are pretty shocking - not because of what they show about the risk profile for adults, but because of what they show on the risk profile for babies.

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I was recently an author on a paper looking at how Covid outcomes have changed for children over the course of the pandemic - this showed that babies were the only age group where things had not improved over time, as I explained in this substack post. This new paper builds on that work by separating out infants into under 6 months old, 6 months to 1 year old and also comparing outcomes to adults of all ages. The main findings are shown below, where I plotted the data given in Table 1 of their paper.

There are two main takeaways. Firstly, the risk of death for babies is very low and is highest by far in adults over 60, increasing steeply by age. Secondly, for A&E attendance, hospital admission and severe hospital admission, the risk was highest in babies under 6 months old - higher even than for people over 90! While much lower than for the youngest babies, the risk for babies aged 6 months - 1 year was also higher than most other age groups - comparable to adults in their 70s or 80s.

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In absolute numbers, adverse outcomes are worse in older populations (because there are simply many more of them than the 350,000 or so babies under 6 months old). But the absolute numbers for babies are still significant for all outcomes other than death.

In our paper last month, we suggested that young babies were especially vulnerable because they are already at high risk of respiratory illness while their immune systems develop and because they mostly have no preexisting immunity to Covid.

The good news is that you can protect babies to some extent - either through a safe and effective Covid vaccine once they reach 6 months old, and/or by vaccinating their mother during pregnancy for the youngest babies.

The bad news is that these routes are not available in the UK. The UK’s vaccine body, JCVI, has recommended that only clinically extremely vulnerable children over 6 months receive the Covid vaccine. Up until now, the Covid vaccine has been available in pregnancy as part of the biannual booster programme - but this is now being withdrawn! [Thanks to Steve Griffin & Sheena Cruickshank for pointing this out]

It’s not clear quite how JCVI assessed the cost effectiveness in pregancy - the published cost-effectiveness modelling I’ve found [thank you to Duncan Robertson] only considered ages 15 years and up, while the hospitalisation data used grouped together children aged 0-4 [again thanks to Duncan Robertson]. Doing such a grouping masks the much higher vulnerability of very young babies.

The other worry I have about the JCVI analysis is that they seem to be prioritising mortality above all else. While it of course matters a lot, and babies very rarely die from Covid, hospitalisation and severe hospitalisation are nonetheless important outcomes to avoid! There is also - still - no consideration given to the benefit of vaccination in reducing chance of developing new Long Covid or other long term impacts from infection for any age group. [As an aside, a new peer-reviewed paper just reported on the signficant economic costs of Long Covid and impact on employment in the UK].

England has excellent population linked data which enables rigorous studies like this that builds the evidence on what “living with Covid” means five years since Covid arrived. And the more data we get, the clearer it is that young babies are at risk from Covid.

We need to urgently update our assumptions that “kids are fine if they get Covid” - not least by disaggregating outcomes for the under 5’s into finer age groupings - and adapt our vaccination policies accordingly. I would like to see JCVI explicitly address this new paper by Aziz and colleagues and our recent paper, and either update their advice or explain - with tranparent modelling for these age groups - why they do not think it is cost effective to either offer vaccines in pregancy and/or for children over 6 months old.

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PS I covered this content as well on a Bluesky thread today - if you are a Twitter use and considering jumping ship, Bluesky is a pretty good option!

Unfortunately, the Scottish wastewater dashboard hasn’t been updated since this summer, so we don’t have any wastewater information on general population prevalence in the UK. That said, waterwater monitoring from Belgium, Denmark and Ireland all show a Sept/Oct peak, with levels that are now coming down.

Flu is still at very low levels, but RSV has definitely started its annual winter increase. At the moment, if you have cold or flu symptoms, it is very unlikely to be flu! Instead it’s likely to be either a common cold (rhinovirus) or Covid.

Unfortunately, judging by last winter, when there was also a September/October Covid wave, there is plenty of potential for there to be another significant Covid wave before winter is out. Combined with RSV and Flu single annual spike, this would cause significant additional strain on the NHS.

Vaccination

There is increasing evidence that an annual Covid booster not only reduces chance of developing severe disease, but also boosts your antibody levels for up to a year , reduces your chance of infection, and protects against new Long Covid. As pointed out by Prof Devi Sridhar this week, other countries like the US, Australia and Canada, offer a free annual booster to all adults. In contrast, the UK is shrinking its vaccine offer every year.

UKHSA report that for those eligible, the autumn 2024 booster campaign currently has 30-50% coverage. Particularly concerning is that the lowest coverage is among clinically at risk groups. Please, if you are eligible, do consider topping up your protection with a booster. And don’t forget a flu vaccine too! They can be easily booked via the NHS.

Given that the beneficial impact of an annual Covid booster is only becoming clearer as more evidence accumulates, I hope that the JCVI consider other outcomes such as reducing Long Covid in their future decision making on the UK vaccine offer.

Our study, published yesterday in the Journal of Pediatrics and led by Prof Kate Brown, looked at all hospitalisations in England in children with a Covid diagnosis or positive test from August 2020-August 2023.

We then excluded all admissions where a Covid diagnosis was incidental (ie not why they were in hospital), using a rigorous classification method that we developed and published in a previous BMJ paper.

Infants (babies under 1) are generally at higher risk from respiratory infections, plus they are the age group that, if infected, are overwhelmingly (>99%) meeting the virus for the first time. They are also not vaccinated.

Over the whole period of our study, Covid admissions in infants accounted for 43% of all admissions in children under 18 (19,700/45,900).

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As children over one year old gained some immunity from infection or were vaccinated (vaccination mostly in teens), their risk of needing hospital fell.

But this doesn't help infants in their first encounter with the virus. In the most recent 12 months of our data to August 2023, infants accounted for 64% of all covid child admissions.

We also checked for evidence of underlying health conditions considered high risk by JCVI. We found that by the most recent 12 months of data, 52% of Covid admissions in children over 1 had an underlying condition. But only 10% of infants did.

While most infants were in hospital for only a short time - about 2 days, a significant minority did need intensive care. For instance, in last 12 months about 5% needed intensive care and 8 babies died.

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We also found that children of ethnic minority background or in deprived areas were more at risk of Covid admission to hospital.

So what are the implications? There is a safe and effective covid vaccine for 6 month-4 yr olds. It's part of routine childhood immunisation in some countries like the US and Ireland. It's approved in UK, but JCVI has not recommended its use in otherwise healthy babies.

However, while personally I am in favour including the Covid vaccine in the standard childhood immunisation programme, it's not quite that simple.

Firstly, newborn babies are by far the most vulnerable and there is no available vaccine (anywhere) before 6 months old. US analysis has shown that Covid hospitalisations in babies under 6 months old are higher than any other age group apart from over 75s! Similar to adults aged 65-74! Almost 1 in 5 babies under 6 months in the US needed intensive care.

The most effective thing to protect newborns is for their mothers to be vaccinated during pregnancy (ideally in 3rd trimester). It's not perfect but far better than nothing and, most importantly, Covid vaccines in pregnancy are recommended in the UK.

Dr Viki Male curates a comprehensive google document answering all your questions on the covid vaccine in pregnancy! Please do check it out.

In fact, pregnant women can protect their newborns against all sorts of nasty respiratory viruses by being vaccinated in pregnancy. As well as Covid, there's flu, whooping cough, and - now - RSV!

The problem is that uptake of vaccines in pregnancy is quite low. About 40% for the Covid vaccine and 42% for flu vax in pregnancy. Uptake of whooping cough vaccine was only 60% last winter - 15% points lower than in 2017. This year has seen more babies died of whooping cough.

We also know that uptake of routine childhood vaccinations in childhood is declining in England, and we've seen not just whooping cough outbreaks this year, but several measles ones as well.

Given increasing vaccine hesitancy, perhaps the most important immediate effort is to tackle that across all existing childhood vaccines and uptake in pregnant women- esp whooping cough & RSV, two of the nastiest things for babies (worse than Covid). For instance, while average stay in hospital for babies with Covid is 2 days., it’s more than a week for babies with RSV.

We need to be vaccine champions! Decline in vaccine uptake, particularly in pregnant women, is risking babies’ lives.

Then, in the medium term, I believe we should offer infants and young children the covid vaccination, as part of routine immunisation. This is so that those not already infected can meet their first infection (e.g. on starting nursery) with good protection against severe disease.

In summary, our new paper shows clearly that for babies, the pandemic is as bad as it ever was. There are things we can do to protect them, and we should.

Another Covid wave has hit England, with recorded hospital admissions with Covid increasingly sharply over the last two weeks. While there has been lots written about the new subvariant XEC, it’s not nearly prevalent enough (yet) in England to be behind this wave. Instead, I think this is being driven by return to education and work combined with a cold and wet September.

This is now our fourth or fifth wave this year depending on how you count - and they are coming quickly enough that the troughs never reach the lows we saw in 2023. It’s enough to keep the risk of coming away from big events with Covid quite high (e.g current Fresher’s week or party conferences), enough to disrupt people’s jobs and lives, and enough to keep too high a number of people developing new Long Covid.

Prof Kevin Fong’s testimony at the Covid Inquiry

Prof Kevin Fong, an ICU clinician and academic, had a senior role in NHS England during the pandemic. As part of his role, he went on several visits to hospitals all across the country during the first 18 months of the pandemic, covering the devastating first two waves. Today, he testifed as a witness at the Covid Inquiry’s hearings.

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Frequently on the verge of tears, his testimony was incredibly powerful. As he said “there is more to know than you can count”. There are lives and experiences behind every point on the above chart.

Prof Fong explained how traumatising the waves and deaths were for ICU staff, trying to care for dying patients separated from their family.

He explained how totally beyond any normal experience the sheer scale of deaths was, how it left staff traumatised with no time to recover and feeling that they could not give patients a dignified death. He later explained how smaller hospitals suffered in particular: as they filled up, more stable ICU patients were transferred to bigger hospitals (they had to be more stable to survive an ambulance trip), leaving the very sickest patients behind. Some hospitals experience more than 7 out of 10 ICU patients dying during the height of the pandemic. An unimaginable experience for staff.

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Despite the line trotted out last November at the Inquiry by some such as Hancock saying the NHS coped, the NHS was dangerously overwhelmed. Prof Fong described visiting hospitals as close to collapse as he had ever seen, of the waves leaving staff broken by the summer of 2021, angry at how they ran out of everything during the peaks.

Watching his testimony reminded me yet again of how much we owe to NHS staff and other front line workers and how much we let them down.

The consequences of the NHS struggle of the first two waves

As the report from Module 1 of the Inquiry found, the UK went into the pandemic unprepared - we had much lower ICU capacity than most peer countries, and our stocks of PPE had been allowed to run far too low. We had never planned to prevent or mitigate the pandemic and so we were far too slow to reduce transmission - eventually resorting to the extreme of lockdown very late.

In a dangerous case of the tail wagging the dog, it seems as if lack of PPE contributed to the infamous “infection prevention cell” (IPC) refusing to adapt to Covid being airborne and downgrading required protective equipment for staff to the flappy blue surgical face masks (FSRMs). This piece by David Osborn digging into the decisions of the IPC and the consequences is a sobering must read. Hospital staff and patients were left far more exposed to infection than they should have been.

Overwhelmed hospitals contributed directly to the disastrous decision to discharge elderly patients into care homes without testing, where PPE was also lacking in the first wave. By the second wave, Boris Johnson was so obsessed with the feel good vibes of “saving Christmas” that he, and his government, ignored all the obvious and scary data about the surge of the new Alpha variant in December and didn’t lock down till early January. This delay, given all the learning from the first wave and the fact that we had literally just started vaccinating people, was and remains unforgiveable and criminal. Thousands died who could have lived had we been able to delay the spread of alpha until at least the most vulnerable had received a first vaccine dose.

The embrace of ‘freedom day’ in the summer of 2021, despite the rise of Delta, meant that an exhausted NHS had to cope with a high Covid burden for the rest of the year - and then into 2022 with the arrival of Omicron. NHS staff were depleted by Long Covid and burned out, with thousands leaving the NHS entirely . This directly contributed to the huge NHS waiting lists continuing to this day - the NHS never had the respite to cope with the backlog. It directly contributed to the collapse of NHS emergency services in the winter of 2022/23, as a triple wave of Covid, RSV and Flu broke the fragile system.

Refusal to learn

We seem stuck in a phase of denial about Covid - we don’t want to remember. We don’t want to think about it. People justify this deliberate forgetting by minimising what happened, what Covid is now (still here!), and what could happen in the future with new diseases.

Despite all the evidence on clean indoor air, there has been no push to improve the air quality of our buildings, private or public. This is particularly egregious in settings where clinically vulnerable people have no choice but to be: hospitals, pharmacies and care homes. We know that good quality masks work (when worn!), and we should be normalising their wearing within hospitals and health care settings.

Despite knowing that forcing people to go to work when sick is bad for their health and risks the health of others, there has been no push to improve statutory sick pay in the UK or encourage people (including children) to stay home when sick. The consequences of this shortsightedness will become even clearer when the next airborne pandemic hits us.

Finally…

The autumn vaccine booster campaign has started, and the NHS is using the latest version of the vaccine tuned to the JN.1 variant. Please do get a booster if you are eligible! If you are not eligible for an NHS booster, and are in a position to afford it (it’s up to £100 depending on provider), you could also consider getting a booster privately (there are many places that offer it, including Boots). Vaccines work - please avail yourself of them!

And - really encouragingly - the new generation of nasal spray vaccines are performing really well in trials and might provide us all with much longer lasting immunity within a few years.

That said, the latest UKHSA data of admissions up to the 8 September was released today. After steep falls from the summer “FLiRT” variant peak, admissions have started creeping up again - earlier than I would have expected since people are only just returning to work and education.

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As the third module of the Covid Inquiry gets underway looking at the NHS response, it is worth reiterating that in-hospital transmission of coronavirus remains a problem. A recent Nature analysis estimated that between 95,000 and 167,000 patients caught Covid in hospitals during the second wave (June 2020 - March 2021). Our hospitals have few single rooms and are often in old outdated buildings but we know that HEPA filtration to clean the air can reduce rates of transmission in hospitals (especially if combined with high quality mask wearing).

As highlighted this week by the Covid Clinically Vulnerable Families group, far too little effort has been made to improve indoor air quality in hospitals since 2020. Those in hospital are (obviously!) sicker, older, and more vulnerable to Covid infection than the general population. It is frankly scandalous that we have done so little to make at least these spaces safer for patients (and, by the way, staff).

Meanwhile, the autumn booster campaign started this month - please do get boosted if you are eligible! It remains the best protection to severe illness if infected.

For more detailed analysis of latest data, including the other home nations, please read Bob Hawkins’ latest substack post!

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The UK Covid-19 inquiry’s module 1 report on the resilience and preparedness of the UK had “no hesitation in concluding that the processes, planning and policy of the civil contingency structures within the UK government and devolved administrations and civil services failed their citizens.” It calls for a “fundamental reform” of the way in which the UK plans for future emergencies.

Heather Hallett had specific recommendations for how the structure of emergency planning could be improved: she suggested a single cabinet level committee for whole system preparedness and resilience; a single group for emergency preparedness oversight; a new whole system civil emergency strategy; and the creation of an independent statutory body for whole system emergency preparedness, resilience, and response.

The report’s emphasis on whole systems thinking and a move away from siloed, disjointed planning within separate government departments is very welcome but I don’t think it goes far enough. A more ambitious approach would be to move emergency planning away from its own silo of “an emergency” to the whole system of everyday policy making.

The covid-19 pandemic has shown us how environmental and sociodemographic factors can put people at increased risk of exposure to infection and of severe disease once infected. But Hallett highlights how previous emergency planning overlooked the disproportionate impact that both a pandemic disease and pandemic measures would have on more disadvantaged or sicker communities. The UK government failed to work at local as well as national levels to ensure that plans were feasible and appropriate; and the range of emergency scenarios they considered was too narrow—in this case, only planning for a flu pandemic and not considering any sort of mitigation or prevention measures.

I would argue that many of the policy options to tackle these pandemic failures should be part of everyday planning.

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For any potential pandemic disease, mitigation has to include improving housing quality, improving access to safe green spaces, improving indoor and outdoor air quality, and improving sick pay provision. The benefits of these mitigation measures are twofold: they improve population health (and so reduce the severity of illness when people become infected) and they improve the ability of people to respond to pandemic measures, such as isolation or social distancing, that reduce exposure to infectious aerosols (so that people can avoid infection altogether).

Additionally, strengthening overall public health and prevention, improving nutrition, and increasing access to physical and mental health services would also reduce our vulnerability to a future pandemic by improving population health. We saw only too clearly in the covid-19 pandemic how morbidities such as obesity, cardiovascular diseases, or kidney disease greatly increased people’s risk of severe illness, death, and long covid.

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All of those strategies for resilience align with the new government’s stated priorities for housing, urban environments, public health, and healthcare delivery. For example, Labour’s king’s speech in July 2024 placed great emphasis on providing high quality housing, building new towns, and improving the NHS. These are not quick fixes and must be part of long term, integrated, policy making. The additional benefit in the event of an emergency of better population health and reduced health inequality shouldn’t be treated separately as part of “emergency planning.” Incorporating consideration of those additional benefits within everyday policy making and treasury evaluations of department spending plans will help to ensure that these policies are realised.

Similarly, Hallett’s recommendations for an independent statutory body to “consult with the voluntary, community and social enterprise sector at a national and local level” is relevant beyond emergency planning, especially as the Labour government has made explicit commitments to devolve more policy to local communities. A wider whole systems approach would incorporate emergency planning into existing plans for greater devolution.

Of course, we need to make emergency plans across several areas that are specific to future pandemics, such as testing, contact tracing, social distancing, NHS response, vaccine development and deployment, and national and international surveillance. But, fundamentally, we can start mitigating the impact of future pandemics right now by further prioritising efforts to reduce sociodemographic inequalities and improve population health and wellbeing.

Health in all policies is also emergency preparedness in all policies. Once we recognise this, it makes the economic case for policies that enhance long term population resilience even stronger because while the timing of a future pandemic is uncertain, the fact of it is not.