Coronavirus: lessons learned to date
Introduction
The House of Commons and Science and Technology Committee and Health and Social Care Committee have published their Report, Coronavirus: lessons learned to date, examining the initial UK response to the covid pandemic.
The 150-page Report, published on 12 October 2021, contains 38 recommendations to the Government and public bodies, and draws on evidence from over 50 witnesses—including Rt Hon Matt Hancock MP, Professor Chris Whitty, Sir Patrick Vallance, Sir Simon Stevens, Dame Kate Bingham, Baroness Harding of Winscombe and Dominic Cummings—as well as over 400 written submissions.
The Report was agreed unanimously by members of both Select Committees, which consist of 22 MPs from three political parties—Conservative, Labour and SNP.
The joint inquiry, which began in October 2020, examined six key areas of the response to covid-19: the country's preparedness for a pandemic; the use of non-pharmaceutical interventions such as border controls, social distancing and lockdowns to control the pandemic; the use of test, trace and isolate strategies; the impact of the pandemic on social care; the impact of the pandemic on specific communities; and the procurement and roll-out of covid-19 vaccines.
The inquiry concluded that some initiatives were examples of global best practice but others represented mistakes. Both must be reflected on to ensure that lessons are applied to better inform future responses to emergencies.
Executive Summary
Covid-19 has been the biggest crisis our country has faced in generations, and the greatest peacetime challenge in a century. It has disrupted our lives to an extent few predicted; separated friends and families; closed businesses and damaged livelihoods; and, most tragically of all, it has been associated with the deaths of over 150,000 people in the UK and nearly 5 million people worldwide to date.
The United Kingdom is not alone in having suffered badly because of covid-19 and the pandemic is far from over. Comparing the experience of different countries is not straightforward: covid-related deaths are recorded in varying ways. The effect of the pandemic on particular countries has been different at different times—for example some countries that fared better than others in the early months of the pandemic have subsequently experienced more fatalities. But in 2020 the UK did significantly worse in terms of covid deaths than many countries—especially compared to those in East Asia even though they were much closer geographically to where the virus first appeared. The scale of this early loss requires us to ask why the UK was affected worse than others.
Conversely the success of the vaccine programme—one of the most effective in Europe and, for a country of our size one of the most effective in the world—shows that positive as well as negative lessons should be taken from our handling of the pandemic. All learning needs to happen rapidly because of the likelihood of future pandemics which is why we are producing this Report now. Its purpose is not to point fingers of blame but ensure an accurate understanding of both successes and failures to date so that crucial lessons can be learned for the future.
Our inquiry looked in detail at six key areas of the response to covid-19, which are outlined in more detail in this Report’s first Chapter: the country’s preparedness for a pandemic; the use of non-pharmaceutical interventions such as border controls, social distancing and lockdowns to control the pandemic; the use of test, trace and isolate strategies; the impact of the pandemic on social care; the impact of the pandemic on specific communities; and the procurement and roll-out of covid-19 vaccines. Across these areas we have identified several key issues which have had a major impact on the UK response to covid-19, and should be a key focus for the Government as it seeks to learn the lessons from the pandemic. This Report, and the evidence we gathered, are principally around the experience and the response to the pandemic in England although we refer to aspects elsewhere in the United Kingdom where relevant.
1.The UK’s pandemic planning was too narrowly and inflexibly based on a flu model which failed to learn the lessons from SARS, MERS and Ebola. The result was that whilst our pandemic planning had been globally acclaimed, it performed less well than other countries when it was needed most.
2.In the first three months the strategy reflected official scientific advice to the Government which was accepted and implemented. When the Government moved from the ‘contain’ stage to the ‘delay’ stage, that approach involved trying to manage the spread of covid through the population rather than to stop it spreading altogether. This amounted in practice to accepting that herd immunity by infection was the inevitable outcome, given that the United Kingdom had no firm prospect of a vaccine, limited testing capacity and there was a widespread view that the public would not accept a lockdown for a significant period. The UK, along with many other countries in Europe and North America made a serious early error in adopting this fatalistic approach and not considering a more emphatic and rigorous approach to stopping the spread of the virus as adopted by many East and South East Asian countries. The fact that the UK approach reflected a consensus between official scientific advisers and the Government indicates a degree of groupthink that was present at the time which meant we were not as open to approaches being taken elsewhere as we should have been.
3.Whether because of inadequate capacity or deliberate policy, it was also a serious mistake to get to the point where community testing was stopped early in the pandemic. A country with a world-class expertise in data analysis should not have faced the biggest health crisis in a hundred years with virtually no data to analyse. This problem was compounded by a failure of national public bodies involved in the response to share such data as was available with each other, including between national and local government.
4.Even if the decision to stop community testing was taken purely for capacity reasons, it is clear that there should have been more challenge to Public Health England to increase testing capacity right at the outset by Ministers, scientific advisers and the Department of Health and Social Care. Instead testing capacity appeared to be accepted for too long as a fait accompli.
5.The initial response to the crisis also exposed some major deficiencies in the machinery of Government. The structures for offering scientific advice lacked transparency, international representation and structured challenge. Protocols to share vital information between public bodies were absent. The Civil Contingencies Secretariat was inadequately resourced, including with specialist expertise which had been removed. Scientific accomplishment was hampered by operational inadequacy.
6.Accountability in a democracy depends on elected decision-makers not just taking advice, but examining, questioning and challenging it before making their own decisions. Although it was a rapidly changing situation, given the large number of deaths predicted it was surprising that the initially fatalistic assumptions about the impossibility of suppressing the virus were not challenged until it became clear the NHS could be overwhelmed. Even when the UK strategy did change dramatically in March 2020, it was because of domestic concern about the NHS being overwhelmed rather than a serious decision to follow emerging international best practice.
7.There was a desire to avoid a lockdown because of the immense harm it would entail to the economy, normal health services and society. In the absence of other strategies such as rigorous case isolation, a meaningful test and trace operation, and robust border controls, a full lockdown was inevitable and should have come sooner.
8.Although some criticised the then Secretary of State for announcing it unilaterally, and with little public support from elsewhere in Government and the NHS, the testing target of 100,000 tests a day was important to galvanise the system to drive the massive increase in testing capacity that was required. However it was a significant failing that such a personal initiative was needed in the first place.
9.It was, however, a remarkable achievement for the NHS to expand ventilator and intensive care capacity, including through the establishment of Nightingale hospitals and the ventilator challenge. Overall, the majority of covid-19 patients with a clinical need for hospital care received it. However, the price paid to deliver this was significant interruption to NHS core services including in areas like cancer which are time critical.
10.Despite being one of the first countries in the world to develop a test for covid in January 2020, the United Kingdom failed to translate that scientific leadership into operational success in establishing an effective test and trace system during the first year of the pandemic. The slow, uncertain, and often chaotic performance of the test, trace and isolate system severely hampered the UK’s response to the pandemic. This was partly because NHS Test and Trace was only established when daily infections had risen to 2,000. The result was that the Test and Trace operation ultimately failed in its stated objective to prevent future lockdowns despite vast quantities of taxpayers’ money being directed to it.
11.The test and trace operation followed a centralised model initially, meaning assistance from laboratories outside PHE—particularly university laboratories—was rebuffed. The same was true for contact tracing, where the established capabilities of local Directors of Public Health and their teams were not effectively harnessed during the initial response to the pandemic, despite local approaches proving effective in places where they were pursued. It is now clear that the optimal structure for test and trace is one that is locally driven with the ability to draw on central surge capacity but it took the best part of a year to get to that point.
12.The UK does now appear to have sufficient testing and tracing capacity, indeed one of the largest such capabilities in Europe. However, the problem of compliance with isolation instructions remains a challenge. We heard evidence that inadequate financial support was a barrier for some people, and that—until recently—the inability of contacts to be released from isolation if they tested negative contributed to lower compliance.
13.The Government and the NHS both failed adequately to recognise the significant risks to the social care sector at the beginning of the pandemic. Until the social care working group was established in May 2020, SAGE either did not have sufficient representation from social care or did not give enough weight to the impact on the social care sector. Without such input and broader expertise, Ministers lacked important advice when making crucial decisions. This, coupled with staff shortages, a lack of sufficient testing and PPE, and the design of care settings to enable communal living hampered isolation and infection control, meant that some care providers were unable to respond to risks as effectively as they should. This had devastating and preventable repercussions for people receiving care and their families and put staff providing social care at risk.
14.The lack of priority attached to social care during the initial phase of the pandemic was illustrative of a longstanding failure to afford social care the same attention as the NHS. The rapid discharge of people from hospitals into care homes without adequate testing or rigorous isolation was indicative of the disparity. It is understandable that the Government should move quickly to avoid hospitals being overwhelmed but it was a mistake to allow patients to be transferred to care homes without the rigour shown in places like Germany and Hong Kong. This, combined with untested staff bringing infection into homes from the community, led to many thousands of deaths which could have been avoided.
15.It is impossible to know whether a circuit breaker in the early autumn of 2020 would have had a material effect in preventing a second lockdown given that the Kent (or Alpha) variant may already have been prevalent. Indeed such an approach was pursued in Wales, which still ended up having further restrictions in December 2020. In this decision not to have a circuit breaker, the UK Government did not follow the official scientific advice. Ministers were clearly over-optimistic in their assumption that the worst was behind us during the summer months of 2020.
16.At the same time there were important areas where the UK’s pandemic performance outperformed other countries. Unlike many governments, UK Ministers were correct to identify that a vaccine would be the long-term route out of the pandemic and presciently supported the research and development of a number of covid-19 vaccines, including the Oxford/AstraZeneca vaccine. A significant part of the success of the Oxford/AstraZeneca vaccine was due to the Government’s early investment in research and development which originally started with the UK Vaccines Network set up in 2016. That investment and support through successive governments has clearly paid off.
17.The result has been a UK vaccination programme encompassing discovery, purchase and full vaccination of over 80% of the adult population by September 2021 which has been one of the most effective initiatives in the history of UK science and public administration and which was delivered by the NHS. Millions of lives will ultimately be saved as a result of the global vaccine effort in which the UK has played a leading part. In the UK alone, the successful deployment of effective vaccines has, as at September 2021, allowed a resumption of much of normal life with incalculable benefits to people’s lives, livelihoods and to society.
18.Treatments for covid are another area where the UK’s response was genuinely world-leading. The RECOVERY Trial had, by mid-August 2021, recruited just over 42,000 volunteers worldwide to mount randomised trials of covid-19 treatments. Establishing the effectiveness of dexamethasone and the ineffectiveness of hydrochloroquine were vital contributions to the worldwide battle against covid-19 and estimated to have saved over a million lives globally.
19.The UK regulatory authorities—principally the MHRA and the JCVI—approached their crucial remit with authority and creativity. Allowing the results of clinical trials to be submitted on a rolling basis made the UK the first Western country in the world to approve a vaccine. The bold decision to extend the interval between doses allowed more people to be vaccinated more quickly and so protected the population.
20.The establishment—following the suggestion of Sir Patrick Vallance—of the Vaccine Taskforce outside of the Department of Health and Social Care, and comprising a portfolio of experienced individuals from industry, healthcare, science and Government was vital to its success, as was the bold, authoritative leadership of Kate Bingham. The Government was right to act to accelerate the delivery of institutions like the Vaccines Manufacturing Innovation Centre proposed in the Industrial Strategy, and to have invested further in manufacturing capacity.
21.However, existing social, economic and health inequalities were exacerbated by the pandemic and combined with possible biological factors contributed to unequal outcomes including unacceptably high death rates amongst people from Black, Asian and Minority Ethnic communities. Increased exposure to covid as a result of people’s housing and working conditions played a significant role. We also heard that Black, Asian and minority ethnic staff in the NHS, who are underrepresented in leadership and management roles, faced greater difficulty in accessing the appropriate and useable Personal Protective Equipment. The experience of the covid pandemic underlines the need for an urgent and long term strategy to tackle health inequalities and to address the working conditions which have put staff from Black, Asian and minority ethnic communities at greater risk.
22.Likewise the disproportionately high mortality rates that people with learning disabilities and autistic people have suffered throughout the pandemic has highlighted the health inequalities faced by this group. While pre-existing health conditions undoubtedly contributed to the increased mortality risk, they were compounded by inadequate access to the care people with learning disabilities needed at a time of crisis. This was a result of restrictions on non-covid hospital activity, and, significantly, because of access restrictions which prevented family members and other carers accompanying people with learning disabilities in hospital to perform their expected advocacy role. “Do not attempt CPR” notices were issued inappropriately for some people with learning disabilities, which was completely unacceptable. Plans for future emergencies should recognise that blanket access restrictions to hospital may not be appropriate for patients who rely on an advocate to express their requirements.