Written evidence submitted by The Nuffield Trust (CLL0087) Overview The experience of coronavirus over the last nine months has imposed an almost unprecedented stress test on the NHS and the UK’s broader abilities to protect the health of its citizens. This submission pulls together all the lessons we believe must be learnt for any future comparable disease outbreak, for other health emergencies and indeed for the smooth running of these vital services in normal times. It draws on both our research and analysis, and our tracking of data and research produced by other bodies, Government and the NHS. Key points Social care was overlooked at the start of the crisis with disastrous results despite warnings from preparatory exercises that it would face serious strain. The sector needs both a higher priority both in future emergencies and a wide-ranging reform programme which addresses its severe problems in access, coverage, and financial sustainability. 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. There was disagreement about which of the bodies leading on public health was actually responsible for key tasks. At times they did not operate in a joined up manner, within the centre or in relations with local services. The Test and Trace initiative shows examples of serious optimism bias and poor articulation of goals and priorities, both of which are well known issues in the UK health sector. Clarity of communication is vital and has a clear effect on public behaviour. The deterrent effect of early messaging on patients seeking healthcare for non-Covid conditions was an error, as is now widely recognised. Messaging later in the pandemic suffered from a lack of clarity as restrictions grew more complex, clearly demonstrated in surveys. Data and forecasts about the progression of the virus, Test and Trace, and other areas of the response, has often not been published or has been published with a lack of clarity about what it represents. This makes it difficult to assess some of the most expensive healthcare initiatives ever undertaken in the UK. It may have contributed to trust in government and official communications being below that of some other countries. A strategy suited to pandemic flu, and not a new coronavirus, was followed to some extent well into the crisis. Greater flexibility and responsiveness is important. 1. The UK’s prior preparedness for a pandemic 1.1. Readiness to protect public health The UK’s health protection efforts in the first wave of Covid-19 did not perform as well as those of several comparable countries. In hindsight, there are several lessons about how to plan for any comparable situation in future. 1.1.1. Having a strategy that reflects what is known The Government and arms-length bodies such as PHE based their initial response on the 2014 Pandemic Influenza Response plan1 and National Incident Emergency Response Plan. Neither was 1 fully suited to Covid-19 which had no known effective antivirals, and a higher mortality rate more biased to older age groups. This may have been linked to limited initial efforts to contain the virus through steps like travel controls and widespread testing. It is unclear whether Government had heeded lessons identified in Exercise Cygnus, a pandemic flu response test in 2016. This highlighted the exposure of social care and the lack of data available, and called for work on better understanding the public response. However, Exercise Cygnus again focused on lessons relevant to pandemic flu, assuming the disease should be allowed to spread widely and not anticipating care homes as centres of infection. 2 Other internal reports of major incidents such as Zika and MERS also existed: it is unclear whether lessons were learnt from these. 1.1.2. Clarity of roles We understand PHE believed that it had never been given the task of expanding testing capacity, only identifying and pioneering a test. Other parts of Government, and NHS England, however, expected them to lead on this. This may have contributed to a remarkable failure, compared to the UK’s peers, to dramatically increase testing during March and early April by drawing on NHS and private laboratories. There were similar tensions over guidance for personal protective equipment for NHS staff. NHS England and the DHSC were responsible for providing equipment and often faced shortages: PHE for issuing guidance saying what was required. This guidance was often highly contentious and frequently revised. 1.1.3. Information sharing and internal processes PHE created incident cells to deal with aspects of the crisis. These were at times poorly updated and coordinated, unevenly linked into central Government and SAGE, and occasionally notified of strategic decisions after they had already taken place, for example around the end of contact tracing. PHE, DHSC and the Cabinet Office relied on secondment internally and from the rest of Government for key positions. This risked exacerbating lack of cohesion, with individuals sometimes using their own contacts instead of processes. There remains a longstanding concern about the UK civil service’s reliance on high turnover, and generalists in highly specialised fields.3 Another serious issue was the cumbersome clearance model for guidance and announcements inherited by PHE. It is not clear that PHE had the capacity or the autonomy to play a leading role communicating with the public. 1.2. Readiness in NHS resources and capacity Relative to comparable countries, the UK broadly has fewer key staff and less bed capacity.4 The NHS had consistently failed to train and retain sufficient numbers of staff to keep pace with demand, with hospitals in England facing a 10% vacancy rate for nurses.5 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/344695/ PI_Response_Plan_13_Aug.pdf 2 https://www.gov.uk/government/publications/uk-pandemic-preparedness/annex-a-about-exercise-cygnus 3 https://www.instituteforgovernment.org.uk/blog/government-right-want-reduce-civil-service-turnover-how- do-it 4 https://www.nuffieldtrust.org.uk/files/2020-07/resuming-health-services-web.pdf 5 https://www.nuffieldtrust.org.uk/nhs-staffing-tracker/hospital-services/ In spite of efforts to quickly re-enlist inactive personnel, these shortages threatened preparedness and mean staff are now even more stretched as they try to address the additional demand built up during the pandemic. High acute care beds occupancy rates meant the NHS had less flexibility than other health systems to deal with a surge of demand. While the system acted quickly to bring in more capacity from Nightingale hospitals and the private sector, how much more these can offer both in dealing with Covid-19 and in recovering from its aftermath will be limited by staffing shortages. 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. Many facilities lack single occupancy rooms. Shared areas like corridors, lifts and waiting rooms are often not large enough to separate patients and maintain segregated flows.6 2. NHS Test and Trace From May, the UK moved to a model of trying to contain the virus through testing, tracing, tracking and isolating. Experiences with NHS Test and Trace present a number of important lessons, many which should perhaps be heard across the public sector. 2.1 Need for realism and optimism bias Government intended that NHS Test and Trace service in England would “play a vital role” in controlling the pandemic, and ended the first lockdown under this assumption.7 In reality, even at the time of writing, fewer than one in four recent close contacts were advised to isolate.8 This falls well below the level – at least 80% of contacts isolating – that SAGE suggested in May would be needed for an “effective” system.9 The planning fallacy also extended to the NHS app which was delayed by four months.10 The difficulties which caused these delays are real: other countries have also struggled.11 However, as we have previously pointed out, optimism bias is a very familiar cause of underperformance by the NHS so it is frustrating that this tendency remains.12 2.2. Need to articulate clear aims Policymakers failed to articulate a clear, shared purpose for the test and trace functions. On testing, while there were stated ambitions in terms of numbers of tests, the purpose of these was not well articulated creating a risk of waste, or resources pulled away from where they were needed. With a clear aim, it might have been easier to prioritise which aspects of performance to focus on. In the event, priorities lurched reactively, in turn, from testing numbers, to testing timeliness, tracing numbers and timeliness of tracing. 6 www.nuffieldtrust.org.uk/files/2020-06/ nhs-returning-to-normal-nigeledwards-nuffield-trust.pdf. 7 https://www.gov.uk/guidance/nhs-test-and-trace-how-it-works 8 https://covid.i-sense.org.uk/ accessed on 26 November 2020 9 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/888807/ S0402_Thirty-second_SAGE_meeting_on_Covid-19_.pdf 10 https://www.ft.com/content/c0c42341-4dda-4c89-9a28-8d14d129c8b2 11 https://www.wsj.com/articles/contact-tracing-the-wests-big-hope-for-suppressing-covid-19-is-in-disarray- 11600337670 12 https://www.nuffieldtrust.org.uk/files/2018-10/learning-from-history-web.pdf Equally, clearer aims may well have uncovered what role other arms of government could have played to support the goals.