The UK has not performed well in its response to the covid-19 pandemic. As a nation we were slow to appreciate the urgency of the worst public health emergency in 100 years and have been on the back foot from the beginning.
There has been a multiplicity of cascading and converging causes and failures to act effectively. As we enter a second period of lockdown, lessons need to be learned now to mend a badly damaged ship in the middle of the storm, and to stem the second wave. [1]
Throughout the crisis, recurrent features have been:
- the failure to get a timely grip
- too narrow a range of professional advice
- doing too little too late
- overpromising and underdelivering
- poor communications based on inadequate intelligence and over-centralisation.
There has also been an over-dependence on looking for private sector solutions while ignoring the “oven ready” expertise of more than 130 local public health teams with a track record of success in fighting pandemics and epidemics for over 170 years.
As the pandemic enters its second phase, new cases, hospital admissions and transfers to intensive care are escalating by the day. Learning lessons from the first wave has become urgent if we are not to witness tens of thousands more avoidable deaths, perhaps exceeding those of March and April.
In some ways the UK is in a better position to fight this re-energised wave of the virus, because it is benefiting from the multiple experiences of thousands of health and social care workers who have reacted to the pandemic with outstanding commitment. They have done so despite the stresses brought about by inadequate planning, flawed central interventions and inadequate support. Let nobody forget how the lack of personal protective equipment led to the deaths of NHS staff and contributed to the second, parallel epidemic in care homes that resulted in the premature demise of probably 30,000 residents.
Since the spring, many of the logistical issues concerning personal protective equipment and the management of bio secure beds have been addressed, but at the heart of the failure to halt the virus was the neglect of the local and regional public health system. This intensified after the disastrous Lansley reforms of the NHS in 2012 and the creation of Public Health England, a flawed national public health agency modelled on the American Centers of Disease Control.
It is now clear that appointing London-based, private companies to run test, trace and isolate has been disastrous and a waste of money. This should surely be the focus of any subsequent legal investigation.
Rebuilding local public health capacity is an urgent priority as we go into the winter, but the English government, driven by its infatuation with private sector solutions and hostility to public services, remains reluctant to embark on the U-turn that is so essential.
The conflict between an over-centralising administration operating in association with a tight cabal of London and Oxbridge advisers and the legitimate aspirations of local people to control their own destinies has been most acute in the confrontation between Boris Johnson, prime minister and former mayor of London, and Andy Burnham, mayor of Greater Manchester and former health secretary.
Their stand-off typified much of what is wrong with the current UK political settlement. Regional authorities struggle to take back control from the seat of power inside the M25, while Boris Johnson and his ministers—who share similar social, geographic and educational backgrounds—seek to gather more power and resources while delegating responsibility.
The losers will be the people who have most to lose—the poor and disadvantaged from the north of England and long-neglected coastal margins. The first wave of the pandemic was brought back to the Home Counties from the ski slopes of Italy and Austria after the February half-term holiday. It initially affected a healthy and well-nourished segment of the population who were well-placed to survive a set-to with the virus, before spreading to poorer communities. The same is unlikely to be the case for the large numbers of older northerners with long-term conditions as we go into winter.
One result of the numbers game that the government has played since the beginning of the pandemic has been a breakdown of public trust. Initially it only counted confirmed deaths in hospital and ignored equal numbers in care homes. Later it redacted 5000 deaths occurring after 28 days from infection and ignored untested covid cases at home. This disaster was consolidated by Dominic Cummings’ trip to Durham in May during lockdown and the poor example set by other prominent MPs during the pandemic.
Sadly, government advisers failed to challenge these sleights of hand, exacerbating the loss of trust which is so central to the effective handling of public health emergencies. Forsyth has recently argued for more robust public health advice. [2] Together with other weaknesses in the arrangements for professional advice to government on public health matters, this demonstrates the need not only to strengthen governance and structures to ensure a fit for purpose system, but also to look seriously at the case for a National Director of Public Health rather than a Chief Medical Officer (CMO), whose main focus is on the NHS. At the beginning of the pandemic, only one of the four national CMOs was fully trained in public health.
Faced with the necessity of another lockdown to retrieve some semblance of control while the testing and tracing fiasco is sorted out, chaos over the number of covid cases continues to be an important issue. Dido Harding, head of NHS Test and Trace, has admitted that the agency rowed back on the timeliness of testing results to avoid being overwhelmed. Around the country, tests are now being prioritised in variable ways that have implications for the accuracy of the daily published figures. It is quite possible that test and trace will grind to a halt again, as it did in March.
Although there have been steep rises in positive tests over the past few weeks, this is almost certainly not the full picture. A better indication is the numbers of hospital admissions and transfers to intensive care. As hospitals in the north west and elsewhere reach occupancy levels of over 90%, becoming essentially full, it is likely that the burden on the NHS will pass that experienced in April within the next week or two.
An apparent puzzle at the moment is that although the number of daily deaths has been rising steadily in recent weeks, this does not appear to be reflected the steep rise in cases in the community and people being admitted to hospital. A likely explanation is the imposition of the 28-day cut-off in the reporting of covid-19 deaths, coupled with improved survival rates, longer hospital stays and possibly in deaths occurring after 28 days in this phase of the pandemic. Perhaps the most accurate estimate of covid-19 deaths will be data assembled from the nation’s funeral directors.
The net effect of these trends will be even greater pressure on the NHS than in the spring. This means we will need to renew even further efforts to squash the circulation of the virus, and strengthen primary care and community services which will likely bear the brunt of the dark days to come.
John Ashton is the Public Health Adviser to the Crown Prince of Bahrain COVID Task Force. He was formerly regional director of public health for the North West of England and president of the UK Faculty of Public Health. He has written a new book, Blinded By Corona, How The Pandemic Ruined Britain’s Health And Wealth. Gibson Square Press, 2020.
Conflicts of interest: None declared.
References.
- Ashton, J. Blinded By Corona, How The Pandemic Ruined Britain’s Health And Wealth. Gibson Square Press, 2020.
- Forsyth, S. Is it time to rein in the public health experts? British Medical Journal,17 October 2020, p113.