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On Monday, Scotland’s chief medical officer Caroline Calderwood predicted that up to 250,000 people might be hospitalised if a major Covid-19 or coronavirus scenario materialises in the country.

Under a worst-case scenario based on data sourced from other countries stricken by the virus, Calderwood’s forecast that 50 to 80 per cent of Scotland’s population might be infected; four per cent of them would require hospitalisation. That poses a numerical problem, as Scotland’s NHS only has 13,400 acute care beds. Needless to say, 250,000 does not go into 13,400.


As Scotland first minister Nicola Sturgeon underlined, Calderwood’s model assumed catastrophic circumstances which could well never transpire. And those 250,000 people might not necessarily all require urgent care at the same time. But this is by no means a uniquely Scottish issue. As the UK braces itself for a major coronavirus outbreak, questions are being raised about whether the NHS is ready to face down a massive rash of hospitalisations.

Susan Crossland, president of the Society for Acute Medicine, says that the government’s plan to manage Covid-19 “sounds very sensible” but that the main question now is how many people who catch the disease will actually have to be hospitalised.

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There is no official estimate for that, even if a Daily Telegraph article reported health officials calculating that up to 70 per cent of the UK population could catch the illness. The World Health Organisation says that one out of six (or 16 per cent) of people with the virus might become seriously ill. Combined, those estimates return a total of 7.4 million British residents potentially needing hospitalisation.

“If we do see a lot of serious cases it will of course put pressure on the NHS. And then we need to start thinking about how we’re going to use escalation beds [mothballed beds that aren’t used except during high-pressure periods], how we are going to cope with staff if they are catching illness,” says Crossland. “That’s going to put pressure on an already quite pressured system.”


The NHS has been haemorrhaging hospital beds for decades. In 2017, the King’s Fund, a think tank, found that the number of beds in England had plummeted from 299,000 in 1987 to 142,000 in 2017 – a 52 per cent slump. The number of beds in general and acute care in England fell by 43 per cent in the same period, even if heavier cuts on other types of beds – including those for maternity, mental illness, or learning disability patients – means that acute and general beds make up the majority of the total bed stock. As of December 2019, NHS figures show that England had 128,329 beds available – of which 101,598 in general and acute care. The UK as a whole had 167,589 hospital beds as of 2017, according to figures by the OECD, an international organisation.

This decrease has happened despite an increase in population – from 56.8 million 30 years ago to today’s 66 million. “In recent years, the UK has gone from having about four beds per thousand people in 2000 to two and a half beds per thousand people now,” says Mark Dayan, head of public affairs at Nuffield Trust, a charity focused on healthcare.

While the number of hospital beds – which should be thought of not only as actual linens and mattress, but also equipment and medical staff attending to them – has consistently gone down across the developed world, the UK’s axing has been much more radical than comparable countries’. According to OECD figures, in 2017 Germany had eight beds per thousand people, while France had 5.98 beds per thousand. On average, Dayan says, the number of beds per thousand people in similarly developed countries is almost twice that of the UK.

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The reduction in bed numbers, Dayan explains, is the outcome of a precise mindset that caught on in western countries, aimed at having people treated more quickly rather than staying in hospitals.


“Advances in surgery and anaesthetics mean that more people can be treated within one day and therefore you need fewer beds for those non-urgent patients. In many countries there’s also been a bit of a drive to try and reduce reliance on hospitals and increase the number of people who are cared for either at home or at out of hospital services like general practices in the UK,” he says.

However tempting it might be to lay the axe-wielding at the feet of austerity-pushing politicians, that is only part of the story. Yes, NHS beds fell from 183,831 in 2010 to 167,589 in 2017, but they had already been falling before that.

“Even in the 2000s [under New Labour] when a lot of money was going into the NHS – with really big increase in funding every year – the number of beds was still falling then as well,” Dayan says. “It’s been the policy of successive governments and NHS leaderships to try and reduce the reliance on hospitals and health services.”

To an extent, that effort has been successful, as treatments became more effective and swift. “You couldn’t have had that big bed reduction without some success in reducing the need for beds,” Dayan says. On the other hand, the UK likely overdid it, as NHS beds became routinely overcrowded in recent years and waiting lists targets were routinely missed.

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So where does this leave the UK when it comes to facing a coronavirus crisis?

According to Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, “a small shock can have major consequences, as happened in 2015” – a reference to a study he co-authored which chalked a spike in deaths across England and Wales in January that year to failures in healthcare including long waits and dearth of beds. The paper suggested that austerity might have played a role in it.

“On the other hand, the UK has a strong public health infrastructure compared to many other countries, which puts it in a better position to contain spread,” McKee says.

If the number of UK serious cases were to spiral out of control, the government will first of all ask patients who are currently hospitalised but can be treated at home to do just that. “Another option, which is something that the NHS uses to respond to more regular crises, like the winter flu, is to cancel or delay planned operations in order to free up beds and staff for urgent patients in this case patients with coronavirus,” Dayan says.

In his opinion, a dire scenario will mostly have to do with numbers combined with speed of contagion rather than quantity only. “The concern would be that coronavirus comes on a big scale very quickly, so that everybody is getting it at once,” he says. But that is far from a guaranteed outcome, especially if the government’s containment strategy is effective.

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Time might also be on our side. Come spring, Covid-19’s contagiousness might change. “The flu and the common cold are both much more common in cold, wet periods,” Crossland says. “We don’t know how coronavirus is going to behave in warmer weather.”

Gian Volpicelli is WIRED's politics editor. He tweets from @Gmvolpi

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