Coronavirus: lessons learned to date Contents

2Pandemic preparedness

10.When the World Health Organisation announced on 4 January 2020 that a cluster of pneumonia cases had been reported in Wuhan, China, SARS-CoV-2 had not yet been identified as the cause, still less was it known to the UK public health authorities. Yet the UK has had, for many years, policies and procedures in place to be able to respond to new outbreaks of infectious diseases should they occur. Among these preparations were constructing a National Risk Register; preparing plans for responding to outbreaks of infectious diseases; and a set of institutional arrangements—including COBR, SAGE and the Civil Contingencies Secretariat—established to facilitate an effective response in emergencies.

11.It is worth noting that as of October 2019, the Johns Hopkins Global Health Security Index, the most comprehensive global study into pandemic preparedness, had the UK and the US as the best prepared in the world. Yet we know that covid has had a significantly bigger impact on these two countries compared to many others who ranked lower.13 Our inquiry found that the UK’s preparedness for responding to covid-19 had important deficiencies. The most important was that much of our preparation was for an influenza-like pandemic—notably one that was not characterised by asymptomatic transmission (and for which testing was therefore not so important). As well as this, witnesses told us that aspects of the structure of decision-making proved dysfunctional, and during the early stages of the pandemic the exchange of important information between public bodies was inadequate. That said, it is the nature of preparing to face future risks that there will be much that must be unknown about them. Perfect foresight, and therefore a perfect response, is not available.

12.Nevertheless, important lessons can be drawn and this Chapter considers the following elements of preparedness:

The National Risk Register

13.The National Risk Register (NRR) captures the Government’s assessment of the likelihood and potential impact of a range of different civil emergency risks which might occur over the next five years.

14.Since 2019, the National Risk Register has been based on the National Security Risk Assessment (NSRA), which is a classified document. The NSRA is prepared by the Civil Contingencies Secretariat which sits within the Cabinet Office. The latest version of the National Risk Register was published in December 2020. Given that our inquiry and the covid-19 pandemic occurred before the latest version of the National Risk Register, our focus will be on an earlier version of the National Risk Register, which was published in 2017.14

15.The risks identified in the National Risk Register are grouped into the following categories: natural hazards; diseases; major accidents; societal risks; and malicious attacks. The National Risk Register analysed risks through a three-stage process: identification of risks; assessment of the likelihood of the risks occurring and their impact if they do; and comparison of the risks in the National Risk Register. In identifying risks, the Register said that it consulted a wide range of experts both within and outside of Government.15

16.The 2017 National Risk Register said that “the likelihood of an emerging infectious disease spreading within the UK is assessed to be lower than that of a pandemic flu.”16 It also said that the consequences for emerging infectious diseases may be “several thousand people experiencing symptoms, potentially leading to up to 100 fatalities”.17 In the 2020 National Risk Register, this has been revised to say that a pandemic may potentially lead to “hundreds of thousands of deaths across the UK”.18 It is clear from the covid-19 pandemic that the 2017 version of the National Risk Register underestimated the impact of a non-influenza infectious disease. This appears to have been rectified in the 2020 version of the National Risk Register.

17.There have been a number of international human disease outbreaks in recent years which have been relevant to anticipating future disease threats:

18.What—in the light of covid-19—was an overreliance on pandemic influenza as the most important infectious disease threat clearly had consequences. It meant that the emphasis of detailed preparations was for what turned out to be the wrong type of disease—although, as we will see, some elements of preparing for pandemic flu did have some use in responding to covid-19.

19.The former Chief Medical Officer for England, Professor Dame Sally Davies, told us:

we all, in the UK, US and Europe, as experts and in policy, had a bias to flu, and planning for flu and diseases that had already occurred. As I look back, going back to Winter Willow, which was well before my time, and the national risk assessment, we underestimated the impact of novel and particularly zoonotic diseases.28

Preparations for a pandemic

20.Following the Swine flu outbreak of 2009, the then Government set up an independent review of the UK’s response to the 2009 influenza pandemic, which reported in July 2010. The review, led by Dame Deirdre Hine, found that pandemic preparedness was, generally, “impressive”.29 The review recommended that the pandemic preparedness framework be updated in light of the recommendations.

21.As a result the UK Influenza Preparedness Strategy was published in 2011. The 2011 Strategy updated the previous preparedness plan of 2007.30 The Strategy set out five phases: detection; assessment; treatment; escalation; and recovery. The current Government’s Coronavirus action plan acknowledged the role of the Strategy in informing its response to covid-19.31

22.The prospective national response to an influenza pandemic was tested in an exercise which took place from 18–20 October 2016. Exercise Cygnus was led by Public Health England. As part of the exercise, participants considered their capacity and capability to operate at the peak of a pandemic affecting 50% of the population which could cause between 200,000 and 400,000 excess deaths in the UK. It is important to note that Exercise Cygnus focused on the treatment and escalation phases of the pandemic response. It did not simulate the detection and assessment phases. The then Secretary of State for Health and Social Care acknowledged this in his evidence to our inquiry in November 2020:

The problem with Project Cygnus was […] that it started from the assumption that we were going to have a pandemic flu that was already rampant and widespread. It was an exercise in what you would do in the period at which lots of people were already dying. What it did not ask were the prior questions, “What type of pandemic is most likely? What are the different characteristics of different pandemics”—flu or coronavirus being two obvious examples—“and can we act to stop getting into the position at which Project Cygnus started off?” Those are the prior questions that I think it is very important for everyone around the world to be asking as part of the lessons from this.32

23.Another pandemic exercise, Winter Willow, was carried out in 2007. Exercise Winter Willow was five times larger than Exercise Cygnus with 5,000 participants. Winter Willow was more comprehensive than Exercise Cygnus in that its starting point was an announcement of a pandemic by the WHO, whereas Exercise Cygnus only simulated the treatment and escalation phases. Winter Willow identified four broad areas of improvement, under which lessons were identified: crisis management and coordination; public advice and communication; further policy development; and business continuity.

24.Despite carrying out simulation exercises, we heard that the UK did not adequately learn the lessons of previous pandemics.33 In particular, the SARS and MERS outbreaks contained lessons that the UK could have learnt at an earlier stage. The handling of the covid-19 pandemic in Asia illustrates the value of learning those lessons from SARS and MERS. For example, Professor David Heymann, Professor of Infectious Disease Epidemiology at the London School of Hygiene and Tropical Medicine (LSHTM), told us:

One of the issues in Asia, as you said, was that they had SARS and also a MERS coronavirus outbreak in South Korea, which killed 38 people from one importation of disease. They were well prepared. They learnt lessons and they applied those lessons between the current pandemic and SARS. They developed excess beds for hospitalisation and isolation. In all of those countries, those rooms have renal dialysis capacity and ventilation capacity. They learned and applied the lessons. By 20 January [2020], they were already detecting cases and responding to outbreaks that were occurring.34

25.However, it was not just Asia that learnt from its previous experiences. Professor Devi Sridhar, Chair of Global Public Health at the University of Edinburgh, told us that Europe and the United States had been complacent in their reaction compared to west Africa:

One of the interesting things in February [2020] was the complacency across all rich countries, including the United States, about this virus. The worst thing people could think of was the flu, and the flu kills a lot of people. That is why we got the whole idea and obsession that it was just like a bad flu, whereas in places like west Africa they redeployed their post-Ebola structures towards Covid structures because they knew that an infectious disease can run through society, shut down your schools and hospitals, stop vaccination campaigns and paralyse society for months. There is a sense of complacency because in European countries or in North America we have not seen infectious diseases cause destruction in the way they have been doing on an ongoing basis in poorer countries, who reacted much faster.35

26.While Asia and west Africa used their learnings from more recent diseases, the UK deployed its Influenza Preparedness Strategy 2011 as the basis of its early response to covid-19. The former Cabinet Secretary, Lord Sedwill, confirmed this:

Essentially, we took the pandemic flu plan and tried to adapt it for Covid-19. Obviously, the adaptation of that plan continued as we learnt more about the disease. […] for several months the scientists did not know about asymptomatic transmission, and therefore the focus in the early stages was on measures—social controls, social interventions—to try to impede transmission between people who were symptomatic and to identify early those who were symptomatic.36

There were also other aspects of the UK’s preparations that helped. Lord Sedwill pointed out that the Coronavirus Act 202037 had its genesis in a draft influenza Bill which had been recommended by Exercise Cygnus.38

27.The former Chief Medical Officer for England, Professor Dame Sally Davies, told our inquiry:

Quite simply, we were in groupthink. Our infectious disease experts really did not believe that SARS, or another SARS, would get from Asia to us. It is a form of British exceptionalism.39

Dame Sally went on to tell us that more challenge was needed in the thinking of future risks:

We need to open up and get some more challenge into our thinking about what we are planning for […] In thinking through what could happen, it would be well worth bringing in people from Asia and Africa to think about that as well, to broaden our experience and the voices in the room.40

The machinery of decision-making

28.COBR—named after the Cabinet Office Briefing Rooms—is the high-level body that coordinates the central Government response to national emergencies. COBR brings together Ministers and senior officials from relevant UK Government departments and agencies along with representatives from other relevant organisations. SAGE, via its co-chairs, feeds into COBR.41 On 29 June 2020, the Government updated its list of Cabinet Committees.42 Cabinet Committees are sub-groups of the Cabinet. Covid-19 Strategy (Covid-S), a Cabinet Committee chaired by the Prime Minister, looked at the strategic response and the recovery strategy. Covid-19 Operations (Covid-O), a Cabinet Committee chaired by the then Chancellor of the Duchy of Lancaster and Minister for the Cabinet Office, Rt Hon Michael Gove MP, focussed on the delivery and operational response to covid-19.

29.We heard evidence that during the pandemic, COBR was not functioning as effectively as it should have been. Dominic Cummings, former assistant to the Prime Minister, told us that there were leaks from COBR meetings.43 Mr Cummings also told us that the meetings were not conducive for situations that required technology and data:

The Cobra system, as some people will know, is what is called a STRAP environment. That means that it is an environment where you don’t have phones. You cannot just take in laptops. It is kept in a certain way, so that the intelligence services know that Russia, China, North Korea or whoever cannot smuggle things in. That kind of system is completely hopeless for a pandemic. This is why we all moved out of Cobra. We had to end up doing it literally in the Cabinet Room and just gerrymander iPads, TV screens and stuff in there, because you could not get the people with the laptops, the internet connections and the data that we needed to look at into the Cobra room, because the Cobra room is a STRAP 3 and above environment, which does not allow such things in. The whole wiring of how the Cabinet Office is set up to deal with this kind of crisis just fundamentally didn’t work.44

Mr Cummings went on to tell us that “we stopped doing the meetings in Cobra and from the week of the 9th [March 2020], the daily covid meetings were all in the Cabinet Room.”45

30.Our inquiry heard that the organisation of preparedness for future emergencies was too thin at the top of Government and constantly prone to being sacrificed to the short-term demands that predominate in Government.46

31.The designated body within the Government to manage the National Security Risk Assessment and the National Risk Register is the Civil Contingencies Secretariat (CCS) which assigns risks to lead Departments. We heard evidence that this approach to risk planning was not satisfactory. Alex Thomas, programme director at the Institute for Government and a former civil servant, told us that the plans do not reach into individual Government departments:

Risk planning was in a box marked “Civil Contingencies” in the centre of Government and did not reach into other Government Departments strongly or clearly enough. For example, that meant that the Department for Education was underprepared for even a flu pandemic and what might happen in schools, because foresight, anticipation and contingency planning capability was too low.47

We also heard that there were a range of other time pressures on Ministers and officials which limited their ability to prepare “insurance policies”.48 Sir Oliver Letwin told us:

Particularly in a democracy, government—politicians, administrators, civil servants and so on—is completely preoccupied with trying to deal with things that are actually happening […] The pressure to deal with real problems that are current is overwhelming. The result is that too little attention is paid, in every area, to building appropriate insurance policies against things that are uncertain, and working hard enough to identify all the things that might hit us and all the flexibilities and resilience we need to deal with them.49

32.Sir Oliver also told us that during his time in Government, he had set up a new group comprised of officials tasked with identifying potential viruses that may impact the UK. Sir Oliver told us that these resources were redeployed elsewhere:

those people or their successors have been absorbed back into the generality of the CCS [Civil Contingencies Secretariat], and there was no scanning unit of that kind in place at the time this virus first came into partial view. That is quite an interesting, tiny example of the extent to which the mechanisms of government, even including the civil contingencies secretariat and the Cabinet Office itself, are inclined not to invest in long-term insurance and are more inclined to focus on the here and now. No doubt the people who were absorbed were absorbed into some important activity—just then—but that meant they were not available to do what could have been useful when we got there some years later.50

33.To counter the issues of lack of time and resources for pandemic preparedness, Sir Oliver proposed setting up an external agency to survey potential threats and prepare for them:

I do not believe that we are anything like as well prepared for future problems as we could be if we were, as a nation, to have some external body that is not subject to the pressures that are on Whitehall’s Ministers and civil servants, that has its funding somehow enshrined in law, and has the sole task of looking at what is not happening but might happen, and to which we could respond better if we were better prepared to do so. At the moment, we do not have that sort of body, in common with very many other countries, and I think we lack it.51

Data sharing

34.One of the lessons from Exercise Cygnus (Lesson 17) was that: “The process and timelines for providing and best presenting data on which responders will make strategic decisions during an influenza pandemic should be clarified”.52 That lesson was in response to an issue identified in the build up to Exercise Cygnus relating to epidemiological data:

The way in which epidemiological data is produced and disseminated to responding organisations required clarification. PHE was requested to produce a report listing the steps they would go through to provide information about the disease and the timelines for producing this information. They should also consider how these timelines can be reduced to provide the most rapid situation assessment to the response.53

35.Exercise Winter Willow in 2007 also highlighted issues relating to data. The Winter Willow report said that “there is a need to improve linkages between established local and regional resilience structures and their equivalents in the National Health Service”.54 The report continued:

The Exercise highlighted the need for the process for the collection of regular data and information at the local level, and its collation into reports to the centre, to be reviewed. There were several possible communication routes between local responders and the centre with the potential to lead to confusion.55

36.We note that issues with data sharing arose early on in the covid-19 pandemic. In written evidence to the Science and Technology Committee, Sir Patrick Vallance, the Government Chief Scientific Adviser, highlighted these issues, including availability of data needed to inform advice to Ministers:

Sir Patrick also summarised:

One lesson that is very important to learn from this pandemic, and for emergencies in general, is that data flows and data systems are incredibly important. You need the information in order to be able to make the decisions. Therefore, for any emergency situation those data systems need to be in place up front to be able to give the information to make the analysis and make the decisions.57

37.Evidence taken by the Public Administration and Constitutional Affairs Committee (PACAC) also highlighted the issue of data flows between national and local organisations. Jeanelle de Gruchy, then President of the Association of Directors of Public Health, said:

[…] in the early days what happened is that a number of systems were set up outwith either the emergency planning system or the public health systems. What you had is, for instance, a testing system set up outside that and there was no way in which those test results could easily flow into the public health system. Because different systems were being set up in silos outwith the public health or emergency response systems that we had, there were technical issues of different data systems that were not speaking to each other. That was certainly a problem.

Secondly, there was definitely a sense of, “You do not really need that data at a local level,” and use of information governance where you had to justify. You had to make a case for why you needed the data. There was a lot of energy going into why we needed that data and having to make a case for it, when in the middle of an epidemic that should have been clear. The case should have been that local directors of public health needed that data and local systems needed that data to be effective in our response. I think it is a combination of both.58

The Greater London Authority also said that local authorities were an afterthought in the designs for data sharing:

Throughout the crisis, there has been a strong sense that local authorities and other local public services have consistently been omitted from central Government’s initial thinking on designs for data sharing.

This has manifested itself in challenges related to shielding lists, volunteering, testing data and tracing of complex cases, plus difficulties in accessing relevant data about people who are furloughed or economically vulnerable. And also the need for bodies such as the GLA to publish a wide range of regional reporting to provide greater transparency to stakeholders such as the media, civil society and the public.59

38.The lack of data flows between national and local organisations was most acutely brought to the fore early in the pandemic with Test and Trace. Speaking in November 2020, Jeanelle de Gruchy told the PACAC:

I think directors of public health would say that if we had had all the data we have now in July or earlier, we would have had a stronger response to the epidemic. They would not, in some ways, share the nationally held data with us, even though there was lots of agitation about wanting to get the data. That was very slow. When it did start to come through, again it was only certain types of data that were coming through. This was on test and trace. We started to get more of that kind of data in June and early July, but it was only from early August that we had patient-identifiable data. In other words, names or ways in which we could understand who was getting infected and where and whether there were links between people.

It was into later August that we were getting the datasets we had been asking for, the negative testing data. We were just getting positive cases rather than how many people were being tested and coming up negative so that we could understand how many negative tests there were.

In all of that time, a lot of energy and effort was having to be put in to ask for the data, to make a case for the data and to try to improve the data flows.60

Further, local directors of public health were not given access to NHS Test and Trace’s central repository of positive cases. Greg Fell, Director of Public Health, Sheffield City Council, told the Science and Technology Committee about access to the Contact Tracing and Advice Service (CTAS):

From April/May when it [NHS Test and Trace] was established to approximately September/October. Basically, when we stood up our local contact tracing service, which from memory was in early October, we had access to CTAS. Most of us have been asking for it for quite a considerable time. The problem in the main was technical rather than a political block.61

The National Audit Office has said that “timely sharing of data has not always occurred” and highlighted the early issues around Test and Trace and shielding.62

39.On 10 May 2020, months after the pandemic hit the UK, the Prime Minister announced the creation of the Joint Biosecurity Centre (JBC).63 The JBC’s stated aim was to “provide evidence-based, objective analysis, assessment and advice to inform local and national decision-making in response to covid-19 outbreaks.”64 It does this by bringing together different datasets, including cases by local authority, testing data by geography, number of outbreaks reported to PHE from local settings such as schools, hospitals or prisons, and the international situation. Dr Clare Gardiner, then Director of the Joint Biosecurity Centre, told us in October 2020 that work had been undertaken to improve data sharing, including its timeliness, with local authorities:

Test and Trace colleagues and Public Health England colleagues have been working incredibly hard over the summer, particularly since May and June, to get as much data in as timely a fashion as they can to local colleagues.65

40.It is evident that the sharing of granular data is critical to an effective response to an emergency. We heard evidence that this did not materialise in the covid-19 pandemic and instead, early efforts to analyse the pandemic were “hampered”.66

The use of the Armed Forces and volunteers

41.Our inquiry found that many of the deficiencies of the UK’s response to covid were operational and logistical rather than scientific—such as in the repeated inadequacies of the testing system. Witnesses to our inquiry were clear about the value of the Armed Forces in supporting emergency responses. For example, Sir Oliver Letwin told us:

My view is that the armed forces are the place in Britain that is
overwhelmingly best equipped to deal with logistical problems of the kind you are almost certain to face when unknown things happen to you on a major scale [… ..] I strongly believe that the lesson of all this is that, rather than relying on Serco—I do not mean to besmirch a particular firm—or other private sector providers, or just local authorities, or just Ministries, we need systems in place that mean that flexible responses, where they involve complex rapid logistics in the face of uncertainty, typically bring the Army in, and in a way that we have pre-co-ordinated. I do not believe we have done enough of that kind of planning yet.67

Similarly, Lord Sedwill also explained that the Government “sent an awful lot of Army planners into DHSC to help it in the early days of this, for exactly the reasons [Sir Oliver] said”.68 Sir Simon Stevens, then Chief Executive Officer of NHS England (now Lord Stevens of Birmingham), also highlighted the role of the Armed Forces in supporting the NHS’s response to covid-19:

[The Armed Forces] have played a fantastic role alongside our NHS staff […] we have selectively been able to benefit from some of the logistics expertise of the armed forces […] At the moment, we have about 1,800 people from the armed forces working alongside [NHS staff].69

42.In particular, the Armed Forces have supported the Government’s mass testing programme and the roll-out of covid-19 vaccines. For example, 2,000 Armed Forces personnel were deployed to Liverpool to support mass testing in November 2020, and 320 Armed Forces personnel were deployed to Kent to support the mass testing of hauliers over Christmas 2020.70 To support the vaccination programme, military planners were deployed to the Vaccine Taskforce, while other Armed Forces personnel have been deployed to support the logistics of vaccine deployment.71

43.Sir Oliver Letwin suggested that there should be better “pre-coordinated” plans so that the use of the Armed Forces in emergency situations was better planned for in resource terms.72

44.Many members of the public have also played an important role as volunteers. During the first wave of the pandemic, for example, over 750,000 people signed up to the NHS’s call for volunteers, against an initial target of 250,000.73 Sir Simon Stevens highlighted the role of volunteers supporting the roll-out of covid-19 vaccines and supporting NHS community care during the pandemic:

Because of the particular handling properties of the Pfizer-BioNTech vaccine, we could not have just distributed it to all 7,000 GP practices or 9,000 pharmacies in England and said, “Off you go.” […] We have supplies nationally; fair distribution across the country; local mobilisation, including of volunteers, such as the St John’s Ambulance […]

Fortunately, not just friends and neighbours but volunteers, and the role of local authorities through the Local Resilience Forums, have played a big part in helping people at home.74

45.However, witnesses also emphasised the administrative burden involved in rapidly vetting large numbers of volunteers. For example, Emily Holzhausen, Director of Policy at Carers UK, stated:

Of course things have to work quite quickly and there needs to be a proportionate response, making sure that the people we have operating are bona fide, but at the same time making sure that we get those volunteers out quite quickly.75

The preparedness of the NHS

46.The NHS went to extraordinary lengths to ensure that there was enough critical care capacity for people hospitalised with covid-19. In evidence to the Health and Social Care Committee in March 2020, Sir Simon Stevens set out some of the steps the NHS was taking to increase that capacity:

We have 3,700 critical care beds in play for adults at the moment and, obviously, as part of our readiness for the likely influx of more coronavirus patients, we are going to be taking concerted action across the whole of the NHS to free up to a third of the general and acute beds. We want to enable perhaps 30,000 of the 100,000 general and acute beds to be available for coronavirus patients.76

47.Beginning in March 2020, the Government and the NHS increased capacity with the opening of Nightingale hospitals across the country, the return of thousands of former NHS staff, and the re-deployment of nearly 20% of existing NHS staff during the pandemic.77 This latter point was signalled as particularly important by the then Secretary of State for Health and Social Care who acknowledged that the physical capacity built up through the Nightingales relied on the availability of staff.78 As the Nightingale hospitals were not extensively used it is difficult to evaluate their true effectiveness. Nonetheless, the speed at which they were created is remarkable.

48.As well as the establishment of the Nightingale hospitals, the NHS acted quickly to increase ventilator capacity, supported by the Government’s ventilator challenge to the manufacturing and medical devices industries to produce new ventilators.79 Sir Simon Stevens stated that the NHS began the pandemic with 8,175 ventilators (including those repurposed from the private sector and elsewhere) and procured an additional 3,799, which were supplemented by 14,000 additional machines produced through the Ventilator Challenge.80

49.This meant the UK largely avoided scenes seen elsewhere around the world of hospitals running out of intensive care beds, albeit with clinicians having to make difficult decisions under intense pressure about who would benefit from intensive care. Initial guidance to clinicians based on the Clinical Frailty Scale was insufficient and had serious consequences, such as for people with learning disabilities discussed later in this Report. However, this guidance was quickly updated and Sir Simon Stevens stated again in January 2021 that no one who would clinically benefit was being denied intensive care or ventilator support.81 The NHS’s ability to respond in this manner demonstrated some aspects of effective preparation. For example, former Chief Medical Officer Professor Dame Sally Davies told us that as a result of Exercise Cygnus the UK “had already prepared for asking staff who had just retired to come back and for how that would work”.82 This was echoed by former Cabinet Secretary Lord Sedwill.83

50.Sir Simon Stevens praised the flexibility of NHS staff in responding in this manner:

[P]eople, under the most difficult circumstances, have all pitched in with incredible esprit de corps while recognising, frankly, that people across the health service are tired, stressed and frustrated.84

However, while Sir Simon stated there were generally few barriers to redeploying staff in this fashion, he did highlight that in normal times it is difficult for NHS staff to develop an adjunct clinical discipline, or to switch specialties or sub-specialties mid-career, despite this being beneficial both for flexible staffing in the NHS and the professional and personal development of staff.85

51.The rapid response of the NHS required a significant amount of resources to be repurposed from elsewhere in the system. As the Health and Social Care Committee found in its Report on Delivering core NHS and care services during the pandemic and beyond, there has been a “a substantial increase in the number of missed, delayed and cancelled appointments across essential non-COVID related services.”86 That Report also found that some areas of care, such as dentistry, were particularly badly affected because of the prevalence of aerosol-generating procedures during routine care.87

52.Lord Sedwill and Professor Dame Sally Davies both argued that although the NHS responded well, there was a need to scale back radically usual activity because of the norm for the NHS to run “hot”. For example, Dame Sally told us:

Everyone in the room was used to and aware of the fact that the NHS runs, as I call it, hot in the winter […] because of winter infections, particularly with a bad seasonal flu, and can almost fall over […] [If] you look at Europe, we are in the bottom half dozen for number of doctors per head of population, number of hospital beds per head of population and number of ITU beds per head of population. We clearly had a less resilient system.88

53.This was echoed in written evidence from organisations including the Royal College of Midwives (RCM), who suggested that the NHS was short of over 3,000 midwives and that 40% of RCM members worked three or more hours of unpaid overtime every week, suggesting that the NHS had been “reliant upon the goodwill of those who staff the system.”89 These pressures in midwifery were seen in the disruption to some maternity services including freestanding midwifery units, acknowledged by Sir Simon Stevens.90

54.The Nuffield Trust, similarly, stated:

The NHS entered the pandemic in a more fragile state than some other countries’ healthcare systems, running near the limit of bed capacity and with serious staffing shortages. This long term lack of a buffer in resources means coping with and recovering from shocks is more difficult.91

55.Moreover, the Nuffield Trust also highlighted the impact of low levels of capital investment on the NHS’s ability to respond to the pandemic, particularly in terms of infection prevention and control:

The fact that the UK trails most other countries in capital investment means many parts of the NHS are working with outdated buildings, and will be challenged to take steps such as separate Covid and non-Covid wards which could allow expanded activity while maintaining infection control.92

This challenge was also highlighted in written evidence, including by the Healthcare Infection Society, who stated:

Ventilation, spacing and isolation facilities in most areas of hospitals were not compliant with recommendations in Health Building Notes (HBN) and Health Technical Memoranda (HTM). No practical solutions were available to address this.93

56.These impediments to effective infection prevention and control made it more difficult for the NHS not only to see patients physically, but also led to widespread restrictions on people accompanying patients, like birth partners or, as we note elsewhere, advocates for people with learning disabilities.94 The Healthcare Infection Society also highlighted the issue of bed capacity and staff levels on infection prevention and control (IPC) grounds, not just the delivery of critical care:

Bed occupancy was chronically high with relatively low staffing ratios of qualified staff and an inadequate number of side rooms in most hospitals. These are undesirable in IPC terms. Not only are infections more likely to spread and be more difficult to control, but the deficiencies hinder the ability to respond to unusual IPC challenges.95

57.Sir Simon Stevens summed up the broader issue of managing NHS capacity during a health crisis in his evidence to us in January 2021:

Should we try to build more resilience into public services rather than running everything to the optimum just-in-time efficiency? I think that is one of the big lessons from the pandemic. We talked a bit about it earlier in respect of extended supply chains versus domestic manufacturing capacity, but that is just one instance of the broader point, which is that resilience requires buffer, and buffer can look wasteful until the moment when it is not.96

Conclusions and recommendations


58.The UK has established procedures and structures to prepare for the nation’s major future risks, including a National Risk Register, the Civil Contingencies Secretariat and the Scientific Advisory Group for Emergencies (SAGE). However, the anticipated future risk of pandemic disease focused too closely on influenza rather than diseases like SARS and MERS that had in recent years appeared in Asian countries.

59.Previous exercises to test the national response capability, namely Exercises Cygnus and Winter Willow, did not squarely address a disease with the characteristics of covid-19. Nevertheless, some useful lessons were learned and applied, such as the drafting of legislative measures that might be needed.

60.The operation of COBR was not well-suited to the modern demands of a pandemic response. It is especially concerning that its culture of confidentiality was considered by some to be so unreliable that alternative meetings were arranged that could command greater confidentiality among participants.

61.The Civil Contingencies Secretariat did not have adequate resources to maintain a substantial standing capability to survey the development of potential threats, and it had a limited reach into the range of Government departments required to respond to a pandemic. The experience has been that this investment in resilience is at risk of being trumped by the day-to-day pressures of Government.

62.Protocols to share data between public bodies involved in the response were too slow to establish and to become functional. This was especially true in the data flows from national to local government.

63.The NHS responded quickly and strongly to the demands of the pandemic, but compared to other health systems it “runs hot”—with little spare capacity built in to cope with sudden and unexpected surges of demand such as in a pandemic.

Recommendations and lessons learned

64.A greater diversity of expertise and challenge—including from practitioners from other countries and a wider range of disciplines—should be included in the framing of the National Risk Register and the plans that emanate from it. Plans for the future should include a substantial and systematic method of learning from international practice during the course of an emergency.

65.A standing capability should be established in Government, or reporting to it, to scan the horizon for future threats, with adequate resource and counting on specialists with an independence from short-term political and administrative pressures.

66.The Government should ensure comprehensive plans are made for future risks and emergencies. The UK should aim to be a world leader in co-ordinating international resilience planning, including reform of the World Health Organisation to ensure that it is able to play a more effective role in future pandemics.

67.The resourcing and capabilities of the Civil Contingencies Secretariat should be improved. The Civil Contingencies Secretariat should be empowered to ‘stress test’ plans and to ensure that Departments are able to carry out a contingency plan if required. The details and results of these stress tests should be included in the Cabinet Office’s annual report.

68.Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.

69.The Armed Forces should have a more central and standing role in preparing for and responding to emergencies like pandemics, given the depth of capability and experience they have in planning, logistics and rapid mobilisation. The Civil Contingencies Secretariat should work with the Armed Forces to improve operational expertise in emergencies in public bodies.

70.The Government and the NHS should consider establishing a volunteer reserve database so that volunteers who have had appropriate checks can be rapidly called up and deployed in an emergency rather than needing to begin from scratch.

71.The experience of the demands placed on the NHS during the covid-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS.

72.The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients such as advocates for people with learning disabilities and birthing partners.

73.Comprehensive analysis should be carried out to assess the safety of running the NHS with the limited latent capacity that it currently has, particularly in Intensive Care Units, critical care units and high dependency units.

74.Building on the experience of staff working more flexibly during the pandemic and to enable more flexible staffing in the NHS, NHS England and Health Education England should develop proposals to better enable NHS staff to change clinical specialty mid-career and train in sub-specialties.

19 WHO, ‘Severe Acute Respiratory Syndrome (SARS)’, accessed 17 September 2021

20 WHO, ‘Summary of probable SARS cases’, accessed 17 September 2021

21 NHS, ‘Swine flu (H1N1)’, accessed 17 September 2021

22 WHO, ‘Swine flu illness in the United States and Mexico’, accessed 17 September 2021

23 US Centres for Disease Control and Prevention, ‘2009 H1N1 Pandemic’, accessed 17 September 2021

24 NHS, ‘Swine flu (H1N1)’, accessed 17 September 2021

25 WHO, ‘Middle East respiratory syndrome coronavirus (MERS-CoV)’, accessed 17 September 2021

26 WHO, ‘Worldwide reduction in MERS cases and deaths since 2016’, accessed 17 September 2021

27 NHS, ‘Middle East respiratory syndrome (MERS)’, accessed 17 September 2021

31 GOV.UK, Coronavirus: action plan, March 2020, paragraph 4.1

37 The Public Administration and Constitutional Affairs Committee has published a report on Parliamentary Scrutiny of the Government’s handling of Covid-19, which includes the Coronavirus Act 2020

41 There is no public record of how many times COBR met in response to covid-19. The Scottish government has published the COBR meetings it was invited to: Scottish Government, Written question, 12 May 2020

42 GOV.UK, ‘List of Cabinet Committees’, accessed 17 September 2021

52 GOV.UK, Exercise Cygnus report, July 2017, page 31

53 GOV.UK, Exercise Cygnus report, July 2017, page 32

54 Department of Health, Exercise Winter Willow: Lessons Identified, December 2007, page 11

55 Department of Health, Exercise Winter Willow: Lessons Identified, December 2007, page 12

56 Written evidence submitted to the Science and Technology Committee, Sir Patrick Vallance, UK Government Chief Scientific Adviser, (C190111)

57 Oral evidence taken before the Science and Technology Committee on 16 July 2020, HC (2019–21) 136, Q1043

58 Oral evidence taken before the Public Administration and Constitutional Affairs Committee on 5 November 2020, HC (2019–21) 803, Q56

59 Written evidence submitted to the Public Administration and Constitutional Affairs Committee, Greater London Authority and the London Office of Technology & Innovation at London Councils, (DTA24)

60 Oral evidence taken before the Public Administration and Constitutional Affairs Committee on 5 November 2020, HC (2019–21) 803, Q55

61 Oral evidence taken before the Science and Technology Committee on 27 January 2021, HC (2019–21) 136, Q1819

63 GOV.UK, ‘Prime Minister’s statement on coronavirus’, accessed 17 September 2021

64 GOV.UK, ‘Joint Biosecurity Centre’, accessed 17 September 2021

70 Department of Health and Social Care, ‘Liverpool to be regularly tested for coronavirus in first whole city testing pilot’, accessed 17 September 2021; Ministry of Defence, ‘COVID Support Force: the MOD’s continued contribution to the coronavirus response’, accessed 17 September 2021

75 Oral evidence taken before the Health and Social Care Committee on 26 March 2020, HC (2019–21) 36, Q278

76 Oral evidence taken before the Health and Social Care Committee on 17 March 2020, HC 36 (2019–21), Qq.119–124

77 NHS England, ‘NHS steps up coronavirus fight with two more Nightingale Hospitals’, accessed 17 September 2021; NHS England, ‘Thousands of former NHS staff are back on the front line in the NHS fight against coronavirus’, accessed September 2021, Survey Coordination Centre, NHS Staff Survey 2020, March 2020

78 Oral evidence taken before the Health and Social Care Committee on 7 January 2021, HC 1121 (2019–21), Q18

80 Oral evidence taken before the Health and Social Care Committee on 17 March 2020, HC 36 (2019–21), Qq.124; GOV.UK, ‘Ventilator Challenge hailed a success as UK production finishes’, accessed 17 September 2021

81 Q867; Letter from the Minister of State for Care to the Chair of the Health and Social Care Committee, 27 November 2020; Sir Simon Steven’s claim has been rebutted by Jonathan Calvert and George Arbuthnott in a March 2021 investigation in the Sunday Times.

86 Health and Social Care Committee, Second Report of Session 2019–21, Delivering core NHS and care services during the pandemic and beyond, HC 320, para 23

87 Health and Social Care Committee, Second Report of Session 2019–21, Delivering core NHS and care services during the pandemic and beyond, HC 320, para 56

89 Royal College of Midwives (CLL0073)

91 The Nuffield Trust (CLL0087)

92 The Nuffield Trust (CLL0087)

93 Healthcare Infection Society (CLL0071)

94 Q872; Paragraphs 318–19

95 Healthcare Infection Society (CLL0071)

Published: 12 October 2021 Site information    Accessibility statement