48 hours in September when ministers and scientists split over Covid lockdown
In its latest investigation into the government’s handling of the pandemic, Insight asks whether the PM’s decision to prioritise the economy over ‘following the science’ led him to repeat the errors of the spring
The medical and scientific experts had been summoned the previous day and warned to keep their Sunday evening rendezvous with the prime minister a secret. When they dialled into the Zoom call at 6pm they found Boris Johnson and Rishi Sunak, the chancellor, at the end of the long mahogany cabinet room table in Downing Street.
The presence of the chancellor with no sign of other ministers was a little odd, because the experts had been invited to deliver presentations on the coronavirus pandemic rather than the economy. But the government was in a crisis that weekend in September and Sunak had been kicking up a fuss.
Two days earlier, Johnson had been forced to confirm the grim news that a second wave was “coming in”. His chief scientific and medical advisers were pressing him to bring in a short “circuit-breaker” lockdown that would save lives and arguably prevent the need for lengthy, economically damaging restrictions at a later date.
Johnson had reluctantly sided with the scientists and was preparing for a quick lockdown in the week of Monday, September 21, backed by his then chief adviser, Dominic Cummings. Two key members of his cabinet —Matt Hancock, the health secretary, and Michael Gove, the Cabinet Office minister — were also supporting tougher restrictions.
But Sunak wanted a different strategy. Faced with dire predictions that half a million people could be made redundant in the autumn, he strongly opposed a second lockdown, which some economists were saying would wreak further havoc on Britain’s already limping economy.
Which is why three of the four academics who had been invited to speak by No 10 that Sunday evening advocated a less restrictive approach, which avoided lockdowns.
The strategy of allowing the virus to take its course and build up “herd immunity” in the population had been dropped by the government at the start of the first wave because of evidence that it would lead to an unacceptable death toll and potentially overwhelm the NHS.
The speakers that night included Professor Sunetra Gupta and her Oxford University colleague, Professor Carl Heneghan. Gupta says they were each given 15 minutes in which they argued that a lockdown was unnecessary at that point: the virus could be allowed to spread with lighter controls if those most vulnerable to serious illness were protected. Gupta says herd immunity could be achieved “in the order of three to six months”.
They were joined by Anders Tegnell, Sweden’s leading epidemiologist, who had masterminded his country’s controversial policy of avoiding a lockdown to build up immunity from the virus in the hope it would reduce the impact of any second wave. Tegnell refuses to disclose what he said at the meeting.
At the end, Professor John Edmunds, of the London School of Hygiene and Tropical Medicine, presented the view of the government’s Sage advisory group, which wanted a two week circuit-breaker lockdown. Edmunds has also declined to reveal what he said to Johnson and Sunak that evening.
But his firm view on the necessity for an immediate lockdown was clear in a paper he co-authored with other Sage members that weekend. “Not acting now to reduce cases will result in a very large epidemic with catastrophic consequences in terms of direct Covid-related deaths and the ability of the health service to meet needs,” they wrote.
It was a huge call for the prime minister, but on that evening — Sunday, September 20 — he decided to side with the opponents of an immediate lockdown.
Just as in the first wave in March, Johnson would delay the lockdown and ignore warnings that the consequences would be disastrous for both the economy and people’s lives. “I don’t have sympathy for the government making the same mistake twice,” said a source on the Sage committee. “We told them quite clearly what they need to do for it to work. They don’t do that ... It’s been wishful thinking all the way through.”
The same mistake
Our investigation charts how the government increasingly diverged from the advice of its own scientists in the run-up to the second wave of the outbreak.
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Britain’s first 11-week lockdown was one of the longest in Europe because so many people had been infected in the early weeks of March. But the measures had been necessary. A total of 56,100 people died from the virus by the end of the first wave, but a paper commissioned by the government in the summer estimated 470,000 lives were saved by the lockdown despite its late introduction.
The cost of the longer lockdown was one of the biggest crashes in the nation’s wealth. Keen to reactivate the economy in the summer, the prime minister began relaxing social-distancing measures when the number of infections was higher than they had been in other European countries when they lifted their lockdowns.
The government’s plan from then on was to keep the reproduction rate — which is known as R and denotes the average number of infections produced by a single infected person — either at or below one, so that infections would not increase again. It was a delicate balancing act because, as restrictions were loosened to allow economic activity, the R number might creep up again, creating a new exponential growth in infections.
In the late summer, relaxing the restrictions required cool heads and wise judgment. But the distance between the scientists’ advice and the government’s action widened and widened.
Our investigation found that the road to the second lockdown was littered with a series of ministerial decisions to help the economy, which were taken without consultation with key scientific advisory committees.
The decisions also flew in the face of advice from the World Bank, cross-party groups of politicians and leading international public health experts that, in the era of Covid, the virus had to be kept under control before the economy could thrive. Failing to do so would leave the country in the worst of all worlds.
After the Sunday evening meeting in Downing Street, Johnson continued with a series of weaker measures to contain the virus for six more weeks until — as the scientists predicted — the number of infections rose so high that his hand was finally forced into bringing in a national lockdown because the NHS was again in danger of being overrun.
As a result, more than 1.3 million extra infections are estimated to have spread across the country. We heard evidence that one intensive care ward in Manchester became so overwhelmed that patients were left to die without the life-saving care they needed.
The longer national lockdown was imposed last month and Britain would see more than 20,000 further deaths from the virus, adding to a tally that was already one of the worst in Europe.
Super Saturday
The journey towards the second lockdown began on July 4, or “Super Saturday”, as it had become known. It was the day when the prime minister lifted a whole raft of restrictions in England, with the reopening of pubs, restaurants, theatres, cinemas, museums and, finally, for those with pudding-bowl fringes, hairdressers. The move was bold.
NHS bosses had written to hospitals warning them to prepare for New Year’s Eve-level surges in demand for emergency services as people hit the pubs, and the government’s chief medical officer, Chris Whitty, was anxious about the outcome of relaxing so many restrictions at the same time. “None of us believe ... this is a risk-free next step,” he told a press briefing the day before.
On the evening of Super Saturday there was little self-restraint as people — especially the young — were released from more than three months of hibernation. Scenes of crowded city centres terrified those who understood the history of pandemics. Watching events that day, Professor Devi Sridhar, a member of Scotland’s Covid-19 advisory group, who has been critical of the UK government’s approach, was reminded of celebrations in 1918, when people thought the last great pandemic, the Spanish flu, was over after the first wave. “The messaging was wrong,” she said. “The idea that you’re celebrating the end of the pandemic, instead of preparing for a hard winter.”
The scientists were right to be concerned. That week the seven-day average of coronavirus cases fell to just below 600 a day, the lowest figure for the UK since the first wave had begun in earnest in March. From then on, infections began to rise again and would increase through July and August — at first little by little and then faster and faster.
“The second wave started on July 5 ... The nadir of the epidemic was that week,” said the senior Sage adviser, who has asked not to be named. He believes that Super Saturday was a big mistake and contradicted all the scientific advice.
Sage had advised the government on June 23 to relax the strictest measures incrementally so that it could gauge the effect each one had on infection rates and prevent infections from “accelerating”. The rush to open everything up, therefore, meant the scientists were unable to read which of the measures caused the spike that began in July.
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No consultation
Yet neither Johnson nor Sunak were in any mood to take things gradually. This was supposed to be the year of new prosperity with the exit from the EU, and yet Britain had lost close to 20% of its gross domestic product (GDP) in the three months to June.
The lockdown shrinkage of the economy was greater than any other G7 country in the first half of the year. [...]
That day the chancellor cheerfully served tables in a branch of Wagamama to advertise one of his new big initiatives: Eat Out to Help Out. [...]
The initiative was never put before the scientific advisers on Sage. Nor were members of Sage consulted on a sudden reversal of a key policy to control the virus announced by the prime minister in an online forum with the public two days later. He said it was time to replace the “stay at home if you can” with “go back to work if you can”’
As part of the drive to return life to normal, international travel was opened up on the same day as Johnson’s online forum. A new “traffic light” system of “travel corridors” was introduced that allowed people to travel to 59 countries with no requirement to quarantine for 14 days on return to England.
The policy was questionable, given that British tourists were travelling to countries such as Spain with higher rates of infection. In the penultimate week of July, when the air travel corridor was still open, Britain had 6.8 cases per 100,000 people, whereas Spain had 25.9 cases per 100,000. Many people brought the virus back into Britain from their travels.
This would later show up in research on the second wave of the virus. A study from Basel University in Switzerland shows a new variant of the virus appears to have emerged in Spain in early summer and then spread to the UK by the middle of July. Remarkably, by September the variant was estimated to be responsible for 50% of virus cases in England and 80% of those in Wales and Scotland.
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As if to emphasise the scale of the risk being taken, a report commissioned by Sir Patrick Vallance, the government’s chief scientific adviser, was published on July 14 setting out what could happen if there was a second wave of the virus in winter.
The report — produced by the UK’s Academy of Medical Sciences with the help of several Sage members — drew attention to how Australia and New Zealand had acted swiftly to stem the spread of the virus in winter and had managed to keep the virus transmission at very low levels. “Assuming that they maintain control, their winter season will be very different from that which is likely in the UK,” said the report. The two countries’ death figures have remained small: New Zealand has had just 25 fatalities while Australia has recorded 908.
The report went on to outline a “reasonable worst-case scenario” with almost 120,000 deaths by the middle of 2021 if the R number was to reach 1.7 in September. However, it warned that hospital capacity was “likely” to be stretched even if R went between 1.1 and 1.5.
It meant that the government would have to take great care with any policies that might increase the infection rate. But the R number was already on the rise.
Sage committee minutes show that it was recognised at the end of July that infections may no longer be below the crucial “one” threshold for R and by early August the scientists were advising that “strong measures introduced early for short periods are likely to be more effective in reducing transmission than less stringent measures which would need to be implemented for longer”.
This was also the view of the 58 MPs on the Commons all-party coronavirus group, which had been taking evidence about how to deal with the pandemic from scientists, public health experts and frontline medical workers. By mid-August, with infections having risen to more than 1,000 a day, they wrote directly to the prime minister. “It is already clear that to minimise the risk of a second wave occurring and therefore to save lives, an urgent change in government approach is required,” the letter said.
The group wanted the government to introduce a “zero-Covid” strategy, which would mean bringing in measures to restrict the virus to less than 70 cases a day. This would not only save lives — it would benefit the economy, the group argued. “The truth was then as it is now, that minimising community transmission allows a faster and stronger economic recovery,” said Dan Poulter, the Conservative MP who is a vice-chairman of the parliamentary group, as well as being a doctor who works part-time in the NHS. The group received no response from ministers to its letter.
Many scientists also favoured a strategy that was aimed at cutting infection to near zero. Professor Steven Riley, a member of the government’s scientific pandemic influenza group on modelling (SPI-M), which reports to Sage, said the UK must adopt such an approach if the country faced the same situation again. “From the experience of this pandemic, some countries have had much, much better outcomes by pursuing that [approach]. Even if we didn’t achieve it, we should have it as an objective,” he said. “I don’t think that will be controversial. In fact, it’s almost silly to suggest otherwise.”
Indeed, in May, economists at the World Bank had published a report entitled “The Sooner, the Better”, which concluded that countries in Europe and central Asia that had acted earlier to stem the virus’s spread had suffered less damage to their economies and fewer deaths. Locking down early was a win-win strategy. It was advice that many scientists believed should be applied to avoid further economic damage from a second wave.
Break our fear
However, elsewhere in Westminster, it was almost as if the lurking menace of the virus had been forgotten in the late summer months. As September approached, the government was imploring people to return to working life after the school holidays.
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By the beginning of September, the Eat Out to Help Out initiative had been a huge triumph for the chancellor. More than 78,000 restaurants and pubs had participated in the scheme and at least 160 million meals had been served before it ended on August 31.
But it was too good, according to researchers from Warwick University, who found that the initiative may have been responsible for between 8% and 17% of new Covid-19 clusters in August and early September. Encouraging many different households to share enclosed indoor spaces, regardless of “Covid-secure” measures, had allowed the virus to proliferate dangerously fast.
The report’s author, Professor Thiemo Fetzer, concluded: “Eat Out to Help Out may in the end have been a false economy: one that subsidised the spread of the pandemic into autumn and contributed to the start of the second wave.”
They were strong words, but he was not alone in taking that position. “If you look at the use of restaurants in July, it’s pretty low,” the Sage source explained. “It took a bribe from the chancellor to make us go. It wasn’t about support for restaurants — otherwise, it would have counted for takeaways. It was to break our fear, and it worked.”
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According to Google tracking data — a source used by the government — the number of people attending workplaces was now just 35% below normal levels, whereas it had been down 70% during the first lockdown. [...]
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The effects of the government’s strategy were becoming increasingly evident in the figures for new infections. By September 1, the average daily figures over a week had passed 2,000 for the first time since the first wave. They had almost quadrupled since Super Saturday.
The largest Covid-19 testing study of virus infection, undertaken by Imperial College London, has shown that between August 22 and September 7, the R number was estimated to be 1.7. In other words, it had hit the benchmark for the “worst-case scenario” the government’s scientists had set six weeks earlier.
With the R rate at 1.7 — and schools and universities set to return after a summer of pressure from parents and students — many of the scientists believed a second lockdown was inevitable from this point onwards. The only question was when.
Worst-case scenario
The rapid rise in infections over the first week of September meant Johnson was forced to take the threat more seriously. On Wednesday, September 9, he announced the introduction of a new law limiting gatherings of people to six.
The new “rule of six” came as a surprise to some of the government’s own scientists. Assistant professor Nicholas Davies, who sits on the government’s SPI-M committee, said his colleagues had not been consulted. “They seemed to be making decisions, and it wasn’t really clear what the rationale for them was,” he said. That day his modelling committee informed the government that the “the current situation is in line with the latest reasonable worst-case scenario”. But another week went by.
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... on Wednesday, September 16, with infections rising to more than 4,000, Johnson was still firmly against tougher measures. “I don’t want a second national lockdown,” he told a parliamentary committee. “I think it would be completely wrong for this country, and we are going to do everything in our power to prevent it.”
That evening, he received a visit from two tall men in black suits who would later be maligned as “Professor Gloom and Dr Doom”. The chief scientific adviser Vallance and the chief medical officer Whitty and gave a sobering assessment of the virus’s progression.
Hospital admissions for Covid-19 had doubled since the beginning of the month, they said, and the country was on track for 200 to 500 deaths a day by early November. The two experts urged the prime minister to impose a two-week circuit-breaker lockdown to bring the R number back under control.
Johnson is said to have initially sided with the two scientists. “There’s no question,” he said as he toured a new vaccine factory two days later on Friday, September 18, in his hard hat, “[we] are now seeing a second wave coming in”.
The proposal for the two-week lockdown went before the Cabinet Office’s Covid-19 operation committee, where it is said to have been accepted by Hancock and Gove. Plans were started to announce the circuit-breaker.
However, Sunak was the dissenting voice. On Friday evening, the chancellor met Johnson to express his concern about how damaging the quick lockdown could be to the economy.
The meeting resulted in invitations being sent out to the four academics — Gupta, Heneghan, Edmunds and Tegnell — to speak at Downing Street on Sunday, September 20. The presence of Tegnell, Sweden’s leading epidemiologist, was particularly controversial because his country had suffered a high death rate during the first wave. To date, Sweden has suffered 7,354 deaths from the virus compared with 442 and 918 in neighbouring Finland and Denmark respectively.
Many thought then his policies might have achieved some herd immunity, but infections would begin to rocket upwards again not long after he spoke at No 10. Tegnell now says a herd immunity approach is “highly unethical”.
The meeting seemed to convince Johnson. Afterwards, he called in his team and ruled out a lockdown. In doing so, he dismissed the arguments of Sage expert Edmunds, who was warning of a “catastrophe” if it was not introduced.
The split with his chief scientific advisers had never been more apparent. The next morning, Whitty and Vallance took the unprecedented step of holding their own press conference. “As we see it,” Vallance said, “cases are increasing, hospitalisations are following, deaths unfortunately will follow that. And there is the potential for this to move very fast.”
He estimated that there would be 50,000 cases a day by mid-October leading to 200-plus daily deaths a month later, based on a doubling rate of around a week. It was a prediction that led to scathing criticism in some newspapers. Whitty and Vallance were accused of “scaremongering” and one newspaper quoted an unnamed Tory MP describing them as “Witless and Unbalanced”.
However, the infection estimate would later prove to be mostly accurate in terms of the true number of infections, and the death figures were in fact a large underestimation. According to Imperial College London, which has drawn together official statistics and the results of mass population sampling, infections reached about 45,000 in mid-October. By mid-November the official daily death toll averaged around 430 a day.
But Vallance and Whitty had lost the battle over the circuit-breaker lockdown and they were publicly at odds with their political masters. That day, the Sage meeting — which they jointly chair — endorsed the alarming report from Edmunds and his colleagues that warned of dire consequences if the government failed to act quickly. “The more rapidly these interventions are put in place the greater the reduction in Covid-related deaths and the quicker they can be eased,” the report stated.
Johnson, however, was not swayed. The next day, Tuesday, September 22, he announced minor extensions to the rules banning more than six people from meeting and a new 10pm curfew on pubs and restaurants. There was also a request that people work from home if they could. That was it.
The new curfew turned out to be a symbolic gesture and Google tracking data shows that the number of people attending workplaces continued to rise.
The Sage member says the announcement ignored advice that a tougher package of interventions was needed. “Just picking one [intervention] and saying we’re going to try and get people to work from home a bit in some half-hearted way isn’t going to be enough,” he said.
Thomas House, a SPI-M member from Manchester University, recalled his reaction to Johnson’s decision. “It was a bit like, ‘Oh God, haven’t we learnt the message of March?’, which is that, when this starts, you want to act early,” he said. “By September, we’d had months and months of accumulated evidence.”
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Zero-Covid strategy
Britain and Europe’s failure to emerge from the first lockdown successfully was the subject of international academic interest. On Thursday, September 24, a study entitled “Lessons learnt from easing Covid-19 restrictions” was published in the Lancet medical journal by academics from seven universities across the world with input from the London School of Hygiene and Tropical Medicine, King’s College London, Edinburgh University and the World Health Organisation.
The study compared the health and economic outcomes of Japan, Singapore, South Korea, New Zealand and Hong Kong — which had all sought to eradicate infections — with countries in Europe where virus cases had been allowed to build up in a second wave. “At the time of writing, Spain, Germany and the UK have offered a reminder of the enormous potential for resurgence if comprehensive safeguards are not in place,” the study warned.
By controlling the virus at very low levels with strict measures such as border controls and rapid lockdowns, the Asia Pacific countries had suffered less damage to their economies and far lower death tolls than Britain. Indeed by October, the Sydney Opera House announced that it would be reopening.
The academics in the study concluded: “The argument is strong for countries adopting a so-called zero-Covid strategy, which aims to eliminate domestic transmission.” There was still hope that Europe could regain some control over the virus. “It is not too late for the ... lessons to be learnt and applied now.”
It had appeared that Scotland was following this approach in the summer by maintaining restrictions for longer than the rest of the UK. It is one of the reasons the country has a slightly lower death rate than England — 103 deaths per 100,000 compared with 111 per 100,000. But by September a second wave was emerging that was blamed on the Scottish government’s failure to control its borders, as shown by the prevalence of the virus’s Spanish strain in new infections. The problem would be exacerbated by the reopening of universities.
The optimal time: now
In the middle of September, hundreds of thousands of students criss-crossed Britain to start the new term at universities and colleges. It was another step too far for the government’s scientific advisers.
“We were concerned that, in particular with the opening of the universities, things could escalate very, very rapidly,” said Professor Daniela De Angelis, a SPI-M committee member. Her fellow SPI-M member House describes the “remixing” of households at universities as a “high risk” to take. “I just thought, ‘Why didn’t we try and get the first semester online?” he said.
It did not take long for students to pass on the virus. By Monday, September 28, thousands of students had been ordered to isolate themselves after outbreaks at Manchester, Exeter, Oxford Brookes, Glasgow, Aberdeen, Dundee and St Andrews universities.
As the days passed, it was becoming obvious that Johnson’s control measures were having little effect. On October 8, Sage received evidence that infections and hospital admissions were exceeding the reasonable worst-case scenario.
Four days later, 19,445 positive tests were recorded, which was close to a 50% rise since the beginning of the month. This was well beyond even the newly geared-up test-and-trace capability.
That afternoon, Johnson addressed the nation once again to provide some alarming news. “There are already more Covid patients in UK hospitals today than there were on March 23 when the whole country went into lockdown and deaths, alas, are also rising once again,” he announced. “These figures are flashing at us like dashboard warnings in a passenger jet. And we must act now.”
But he was still holding out against bringing in a circuit-breaker lockdown. Instead, the prime minister announced that he was “simplifying” and “standardising” local rules that had been used in England to damp down infections in towns and cities by introducing three tiers of restrictions.
It was the moment when the rift between the politicians and their scientists became public. When taking questions, Whitty, who was standing alongside Johnson, admitted he was “not confident — and nor is anybody confident” that even the third tier with the severest restrictions would be enough to curtail the spread of the virus.
The scientists say they were not consulted. Davies, the SPI-M member, describes the tiers decision as a “a moment of increasing concern and worry for a lot of us because it just felt like the decision making was disconnected from the science ... It does sometimes feel like shouting into the void.”
The impatience felt by the scientists was turning into rebellion. Sage rushed out the minutes of its meeting from three weeks earlier that had called for the immediate introduction of a circuit-breaker. It was an obvious attempt to influence public opinion, as the minutes were published ahead of schedule.
The release of the scientists’ views caused a furore. Until then, it had not been known how strongly the government’s scientific advisers had lobbied for a lockdown in September. The next day, Sir Keir Starmer, the Labour Party leader, backed the scientists and called for a shutdown across England.
But the government dug in. The next day in the Commons, Wednesday, October 14, Sunak hit back, accusing Labour of being “detached from reality” and being irresponsible for not acknowledging “the economic cost of a blunt national lockdown”. This was little more than two weeks before the government would perform a U-turn and announce a lockdown.
The scientists, meanwhile, were making another push to change the prime minister’s mind. Sage member Professor Graham Medley had teamed up with four Warwick University members of the government’s SPI-M committee to call for a two-week circuit-breaker lockdown during the October school half-term. “The optimal time for a break is always now; there are no good epidemiological reasons to delay the break as this will simply push back any benefits until later, leaving more time for additional cases to accumulate,” they wrote. The paper added: “A short lockdown period would limit the economic costs of such a measure.”
By Tuesday, October 20, reported deaths surpassed the 200-a-day threshold. Two days later, the SPI-M committee estimated there were up to 90,000 daily infections. “We knew that lockdown was coming,” said Dr Marc Baguelin, a member from Imperial College London. “The politicians are saying, ‘No, no, no, it’s not going to come.’ But we knew it would come. We were worried, obviously, that a lot of lives were going to be lost.”
Assistant professor Davies says he felt scared that Johnson appeared to be falling into the same delay pattern that had been so disastrous in the first wave. “It seemed like a repeat of the situation in March,” he said.
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Gloves off
On Wednesday, October 28, with reported deaths at more than 300 a day, the scientists on the SPI-M committee made a final appeal. It produced a report setting out the consequences of continued inaction. As if to emphasise the point, the front-page prominently featured a line stating “not government policy” in large red capital letters.
While the committee had previously avoided making economic projections, now the gloves were off. The scientists wanted to show that the delays were killing people and would ultimately do more damage to the economy.
They argued for a “rapid and decisive” lockdown to control infections at much lower levels which could more effectively be tackled with the test and trace system. This would allow more of the economy to safely open up.
That day both Germany and France announced national lockdowns to curb their own second waves of the virus.
The pressure on the government was becoming too much. On Friday, October 30, health officials delivered a presentation to the Downing Street operation committee with an unequivocal message: hospitals would be overrun in every part of England within weeks if nothing was done to stem the rate of infections.
The prime minister had no choice. After making clear for months that he would not countenance a lockdown, he caved in. But there would be one last twist. Fearing that Johnson might wobble again and change his mind, as he had done in September, someone in the prime minister’s close circle leaked the news to the press.
Cummings and the prime minister’s then communications director, Lee Cain, would emerge as suspects in the hunt for the leaker. Both men resigned two weeks later, ostensibly in a row over who should be Johnson’s chief of staff. But sources say the underlying reason was the simmering tension between Cummings and Johnson over the failure to bring in the circuit-breaker in September. This is denied by Downing Street.
The lockdown was announced on the evening of Halloween. The country would be closed for four weeks.
Christmas funeral
The government’s delay had a human cost. According to estimates from Imperial College London, 2.5 million people were infected between the day the prime minister ignored his expert calls for the circuit breaker on September 22 and the end of the lockdown on December 1.
The figures suggest that if Johnson had brought in measures to hold daily infections level, 1.3 million fewer people would have been infected. With the virus’s death rate typically estimated at between 0.5% and 1%, it suggests that between 7,000 and 13,000 people might not have died if stricter measures had been introduced earlier.