We seem to be at a crossroads in our COVID response in England. It's different to March. Everyone understands the implications of social distancing and also of higher prevalence of the virus. Everyone seems to agree there are no easy choices. (1/n)

We have reliably measured levels of infection rising since the end of August (at least). We know this will cause hospitalizations and deaths, but we are choosing not to make strong changes to our behaviour because of the associated economic and other harms (2/n).

This isn't unreasonable in many ways, because those harms are real and they affect the most vulnerable in our society. But levels of the virus keep going up. We must be assuming that somehow numbers of infections will plateau before hospitals + nightingales are overwhelmed? (3/n)

I don't think we can be sure this will happen. Although growth rates are lower than March, they are not flat. Are we all assuming that most _other_ people will reduce their mixing so it will all be OK? (4/n)

But -- and this is the bit I'm struggling with today -- even under optimistic scenarios, are we just assuming hospitals will get half full and we will roll on like that to April? (5/n)

I don't think we want that. We all clapped the NHS once a week, which was OK when events were unforseen. We surely can't sleep walk into this. I think the current debate should have 2 parts. (6/n)

We need to decide if we want a low or a high prevalence winter of COVID. Local and national leaders from left and right need to say if they prefer we run at high levels of infection or not. If we decide to run high, someone has to explain that to NHS staff. (7/n)

If we aim for low prevalence, everyone needs to sign up to that and then make it happen. There is a lot of chat about how country x or country y is managing so well. Whatever technical success they have, they have all decided not to accept high numbers of infections. (8/n)