Covid inquiry: the flaws that led to system failure
BMJ 2024; 386 doi: https://doi.org/10.1136/bmj.q1865 (Published 29 August 2024) Cite this as: BMJ 2024;386:q1865
- Gabriel Scally, visiting professor of public health
- gabriel.scally{at}btinternet.com
The first report from the UK’s covid-19 inquiry, chaired by Heather Hallett, delivered a scathing critique of the country’s system of planning for and reacting to health emergencies.1 Module 1 of the inquiry examined the structures and processes in place for pandemic preparedness, resilience, and response across the UK. In just over 200 pages, the report paints a clear picture of the serious inadequacies that left the UK unprepared for the covid pandemic. Failings identified include a fatally flawed risk assessment process, an outdated and narrow pandemic strategy, not learning from past outbreaks, and a lack of focus on pandemic preparedness. In essence, the report exposes “a lack of adequate leadership, coordination and oversight” in the years before the pandemic.
Perhaps the report’s most telling criticism is that, even now, the structures and organisations we rely on to protect us as a country are blind to their inherent fundamental flaws and failings. This dearth of insight, added to the abundant failures of foresight, led the inquiry to make 10 radical and far reaching recommendations. This small number of focused recommendations speaks volumes about the need for precision and clarity in state responsibility, where labyrinthine structures, groupthink, absence of accountability, and the wilful neglect of public health and prevention all contributed to the devastating outcomes of covid-19.
The report’s recommendations centre on the UK government, together with the devolved administrations, creating an independent statutory organisation responsible for advice on civil emergency preparedness, resilience, and response. Developing new mechanisms for whole system preparedness would also involve constructing a UK-wide civil emergency strategy that would be tested regularly and refreshed at least every three years.
In examining pandemic preparedness, the report identifies many failings in obtaining and using expert advice. The inquiry’s suggested solution to the dominant closeted and corralled approach is to use “red teams,” an approach developed in military and cybersecurity realms but now applied more widely.2 It involves creating groups of critical thinkers to identify blind spots and vulnerabilities, challenge orthodoxy, and probe flaws and vulnerabilities.
Neglect of public health
Unfortunately for the UK population, little or no attention was paid in advance, or during the early phase of the pandemic, to the public health measures that might have prevented or at least delayed the rapid spread of an infectious disease. The report noted the contrast between the approach in the UK and that adopted in (for example) Taiwan and South Korea, where it was understood that the spread of a dangerous infectious disease should and could be stopped. This failure to consider public health measures in the UK is entirely in keeping with the steady marginalisation and diminution of public health in England since 2010.
Although the inquiry catalogued the multiple failures in planning and preparedness, it did not delve into the undoubtedly more complex and perhaps ideological reasons why they occurred. A little recognised culture war has been waged on public health as part of a broader ideological programme of “state retreat”3 in England since 2010. This has included the abolition of government offices for the regions, regional development agencies, strategic health authorities, regional resilience forums, and primary care trusts, and the abandonment of conterminous boundaries between NHS and top tier local authorities. It is little surprise that emergency preparedness was so deficient in the absence of any integrating, coordinating, or management function at a regional level in England operating between Whitehall departments and the multiple bodies, often very local, that are charged with implementing government policy.
The hollowing out of England’s public health capacity and influence of public health was accompanied by attempts to reinvent the language used. The replacement of “public health” with “health security” in the title of the government’s English public health body (from Public Health England to UK Health Security Agency) is just the most prominent example. A further example is the, thankfully unsuccessful, attempts by the Department of Health in Westminster to mandate use of the terms “health variations” and “health disparities” instead of the clearly understood term “health inequalities.” The most recent assault on public health discourse is the growing use of the term “non-pharmaceutical interventions” instead of “public health measures.” This redefining of public health in terms of its relation to pharmaceutical products displays a biomedical bias and is lazy and inaccurate.
Hallett and the inquiry team delivered a report that is an indictment of the system in Westminster and the devolved administrations. As she states in the introduction, “There must be radical reform.”1 Never again can a disease be permitted to lead to so many deaths and so much suffering. The report lays out what needs to be done, and the UK has a new government. There is no time to waste. Another pandemic could emerge at any time, and the World Health Organization’s recent declaration of mpox as a public health emergency of international concern is a timely reminder.4 Until the inquiry recommendations are implemented, we remain vulnerable and unprotected.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Commissioned; not externally peer reviewed.