Tony O’Sullivan, co-chair of the campaign Keep Our NHS Public, welcomed viewers to the first session of the People’s Covid Inquiry (PCI). He said that the aim of the inquiry was to learn lessons quickly, given that the UK (at that time) had the worst pro-rata death rate from covid-19 in the world. Evidence would be heard from witnesses including experts in their field and citizen witnesses.

He then handed over to the panel chair, Michael Mansfield QC. Mansfield explained that it could take years for a full-blown public inquiry to report. The PCI was the only inquiry currently looking into the pandemic and would report after listening to the evidence over a number of sessions.

The first witness was Joanna Goodman of Covid-19 Bereaved Families for Justice Group. Goodman had helped set up the group after her father died of covid-19 in April 2020. His medical history meant that he was clinically vulnerable, but he had been given a hospital appointment where he had to wait in a crowded room for an hour with no particular precautions in place. It was felt that he had caught covid there, and he died nine days before his shielding letter arrived. Goodman felt his death had been preventable.

The group now had 2600 members and a recurring theme was that of failures involving NHS 111. An investigative journalist had established that at the outset of the pandemic the covid response service was outsourced. There was very limited training, with inflexible scripted questions which didn’t take account of the very varied symptoms of covid. Many who needed hospital treatment were told to stay at home and take paracetamol, and as a result got to hospital too late, or died at home. 

40% of group members believed their loved ones had contracted covid in hospital.

“I thought (my Dad’s) death was preventable. It’s really heart-breaking to see many of the same mistakes being made time and time again.”

The next witness was Michael Marmot, Professor of Epidemiology and Public Health at UCL, and author of reviews including “Fair Society, Healthy Lives” (2010) and “Build Back Fairer” (2020).

His report “Health Equity in England, the Marmot Review 10 years on” showed that we had lost a decade with regard to health equity. This was important going into a pandemic as health equity is a good marker for the state of a society. He noted that there had been a change of government in 2010, and that the new government’s ambition was “to roll back the state.” And indeed from 2010 – 2019 public spending fell from 42% of GDP to 35%, most marked in areas of the greatest deprivation. In addition, tax and benefit changes had hit the poorest hardest. Health inequalities had become bigger and health stopped improving. For example, improvements in life expectancy slowed down and all but stopped, and the health of the poorest outside London got worse.

Marmot said that the inequalities in mortality from covid reflected social gradients and health inequalities in general, particularly in minority ethnic groups. He noted that the UK had the highest excess mortality rate—worse even than the US—due to several factors including the prevailing quality of governance and political culture, prior disinvestment in public services, social and economic inequalities, and pre-pandemic poor health. He criticised the “miserable failure” of test, trace, and isolate, with contracts given to “buddies” instead of to the NHS and public health, and noted that people needed financial support to stay at home, which had not been easily available.

Going forward, Marmot wanted the government to put equity of health and wellbeing at the heart of government policy. This would include reducing child poverty, ending the gig economy, and not taking money away from the poorest. He felt that “right now” is the time to be dealing with poverty.

He was critical of the government’s attempt to trade off health against the economy during the pandemic.

“The trade-off between the economy and public health is a false one. The smaller the mortality from covid the smaller the hit to the economy.”

The third witness was Holly Turner, a learning disability nurse in child and adolescent mental health services (CAMHS).

Turner said that working in CAMHS had always been stressful because of long term problems, with staffing shortages and lack of resources leading to difficult working conditions. However “things had definitely gone downhill” during the decade before the pandemic. Children were suffering extreme deprivation, for instance due to poor housing, and there had been difficulty in getting respite (care). Children were being referred to acute mental health services, many of whose problems were due, at least in part, to environmental factors. The pandemic exacerbated all of these problems, with special needs schools being closed and respite care withdrawn.

Turner talked about challenges to her own family life. “It’s been incredibly difficult to manage.” Both she and her husband (also a nurse) had had covid, and they had been unable to get a school place for one of their young children, despite both being front line workers.

She confirmed that she knew of no discussions with CAMHS staff about how to manage the service at the beginning of the pandemic. 

“We’ve been crying out for support for a really, really long time. And we’ve been dealing with short staffing for a really, really long time. And I think a lot of NHS workers have felt that nobody really listens to us.”  

The fourth witness was Gabriel Scally, professor, public health doctor and academic, who had personal experience of emergency and pandemic planning.

Scally said the country was unprepared for a pandemic, partly due to the abolition of many of the organisations and structures responsible for planning relevant services. He noted that public health structures were decimated after the Lansley reforms of 2010, when the new public health structure, Public Health England (PHE) was introduced. At the same time he felt that the abolition of PHE in the middle of the pandemic was “an ill judged move.” It should have been done in a planned and structured way. 

He echoed the comments of Michael Marmot, that there was “a plethora of evidence” that public health had been in decline over the last decade, and that there had been a “significant shift away from public health, unprecedented in the last 100 to 150 years.” Scally said that this was because we have had governments that have no real interest in the health of the population.

Scally noted that in the past there had been a number of planning exercises for emergencies, such as a pandemic, but that all such contingency planning had been stripped out after 2010, with local agencies being left to make their own arrangements. He regretted the fact that the public and communities had not been mobilised to take more control of the situation once the pandemic struck, but rather had just been told what to do. He cited in particular the major failing of the centralised test, trace, isolate, and support system, which should have been run locally by public health directors.

“Public health in general became a lesser interest of the government. If the system had been operating well and run by public health people ….we would have coped much better.”

The final witness was  John Lister, professional health policy analyst and researcher for 37 years. He said that after a decade of investment in the NHS (2000-2010) the following decade had seen the policy of “austerity” drag down the service. As a result, targets were routinely missed, waiting lists had risen, and by 2019 the NHS was short of 100,000 staff. The number of hospital beds had fallen drastically, with mental health and learning disability particularly hard hit. At the same time social care was also in crisis. 

“A government that doesn’t care about inequalities and the poor has no incentive to invest in the NHS.”  

Lister described how the marketisation of the NHS had exacerbated the effects of underfunding because it had squandered scarce financial and clinical resources. He described the effects of the outsourcing of hospital cleaning which had led to falling hospital hygiene standards and a rise in hospital acquired infections. 

Lister said that going forward the government needed to invest seriously in the NHS, in particular hospitals and bed numbers, and to restore staff numbers. The sums required would be trivial compared to the many billions spent during the pandemic. He was critical of the government’s plan to spend £10 billion contracting NHS work out to private hospitals instead of investing that to build up capacity in NHS hospitals.

“The last decade has seen funding stripped from public health, local government and the NHS, leading to increasing levels of ill health. The end result has placed an impossible burden on the NHS.” 

Several themes ran through the evidence. Public health had been “in decline” in the decade prior to the pandemic which had resulted in increased health inequalities, which were reflected in the unequal distribution of covid deaths across the population, particularly the minority ethnic population. At the same time the running down of public health had weakened structures which should have been in place to deal with a pandemic. 

The chronic underfunding of the NHS meant it was already in crisis and unprepared for a pandemic.  

Witnesses were very critical of the “miserable failure” of the outsourced test, trace, and isolate system which could, and should, have been run by local public health and the NHS.

Going forward the government needed to urgently correct health inequalities and to invest in the NHS rather than continuing to divert money to the private sector.

Jacky Davis, consultant radiologist, founder member of Keep our NHS Public, panel member of the People’s Covid inquiry.

Competing interests: none declared.