What have we learnt from the covid-19 inquiry so far? – The BMJ

Flaws in decision making and governance resulted in a chaotic response

The covid-19 inquiry is currently focusing on core UK decision making and governance. Recent witnesses have described how decision making was centred on Boris Johnson as prime minister who was slow to understand the significance of covid-19, dismissive of its likely impact, and largely absent from discussion of its implications in the first weeks of 2020. Johnsons vacillating stance on how best to respond to covid-19 was a source of immense frustration for the advisers and civil servants working with him and had measurable consequences for the publics health.1 The civil service through the Cabinet Office and Department of Health and Social Care was also ill-prepared for the biggest crisis facing the British state in decades.

So far so familiar in validating the findings of inquiries by parliamentary committees and accounts by scientists and journalists who have reported on these issues.234 The picture of highly centralised decision making, weak institutions in Whitehall, and ineffective checks and balances on the prime minister raise serious questions about what needs to be done to prepare for the next crisis on this scale. Public reporting may have emphasised toxic relationships and a macho and misogynistic culture at the heart of government, but the most important task for the inquiry is to draw out lessons to ensure this can never happen again.

A good place to start is Whitehall. The Cabinet Office and its Civil Contingencies Secretariat (CSC) have a key role in planning for and responding to crises. In the event, they lacked the people and capabilities needed to deal with covid-19 resulting in the absence of a plan on issues like shielding vulnerable people and managing the disruption of schools. As the National Audit Office reported in 2021, this meant that a playbook of responses had to be developed rapidly resulting in delays and missteps at a critical juncture.5 At a minimum, the Cabinet Office and CSC need the resources to undertake assurance of departmental plans and the authority to challenge plans that are inadequate.

The civil service must draw on people with experience of leading key public services at a local level to ensure that national plans reflect a deep understanding of how these services work. The governments abysmal management of social care in the first stages of covid-19 demonstrated what happened when this understanding was lacking. It was only when the Social Care Sector Covid-19 Support Taskforce was established, under the leadership of an experienced social care leader, that matters improved. The work of the taskforce enabled finance and support to be targeted where it was most needed based on a well informed appreciation of how social care was organised and delivered.6

The linked and more profound point is that central government should be more willing to trust and support local government in responding to crises. Examples during covid-19, such as shielding vulnerable people, test and trace, and schools policy, illustrate the folly of trying to run everything from Whitehall. In the case of test and trace, folly was compounded by the government favouring private sector companies over the public sector and weaknesses in procurement from the private sector.

Partnerships of public sector bodies, including local resilience forums and integrated care systems, played a valuable role in the pandemic response when the government was willing to recognise their contribution. The same was evident in the vaccination programme where collaboration between the NHS, local authorities, the army, and others delivered one of the most important and successful aspects of the response. Emily Lawson, programme director, has described how its success was based on assembling a team of teams with the range of talents needed to deliver vaccinations at speed and scale.7

A combination of collective leadership, partnership working, team working, and experience from the front line are more likely to succeed than heroic leadership by a prime minister widely acknowledged to have lacked the skills required during covid-19. Greater diversity among those working with the prime minister, as advocated in the evidence of deputy cabinet secretary, Helen McNamara, is also required. Very senior civil servants must also reflect on how they might have brought more stability and direction to a febrile working environment.

What then of the contribution of the chief scientific adviser and the chief medical officer? Notes released from Patrick Vallances personal diaries to the inquiry show that he shared the frustrations of others who were in the room with Boris Johnson when decisions were made. There is also an argument that Vallance and Chris Whitty were a shield behind which the prime minister sheltered when claiming that he was following the science. This has led to the contention that scientists may be better advised to work from the outside to avoid being compromised.8

Against this, it is important to recognise that both Vallance and Whitty may have moderated the more libertarian instincts of Johnson, even if their views were not always acted on. Vallance was also instrumental in setting up the Vaccine Task Force and helping to appoint Kate Bingham to lead its workanother successful part of the pandemic response. A plausible case can be made that he and Whitty were able to exert more influence by being inside the tent, exasperating as that may have been at times. Their future evidence to the inquiry will be particularly important in shedding light on this issue.

Boris Johnsons power in 2020 resulted from his hold over his party and the government after leading Britain out of the EU at the beginning of the pandemic and winning a majority at the 2019 general election. As well as appointing his supporters to the Cabinet, he preferred to inform the Cabinet of decisions rather than seek their views, and he was mindful of the libertarian views of Conservative MPs on the Covid Recovery Group.6 These considerations underline the need for effective checks and balances to avoid power being used recklessly. The inquiry will have performed a useful service if it can formulate recommendations on how to do so.

Competing interests: Chris Ham is co-chair of the NHS Assembly and emeritus professor of health and management at the University of Birmingham. He writes here in a personal capacity.

Provenance and peer review: not commissioned, not peer reviewed.

Health and Social Care and Science and Technology Committees (2021), Coronavirus: lessons learned to date

Farrar J. with Ahuja, A. (2021) Spike. London: Profile Books.

NAO (2021a) The governments preparedness for the COVID-19 pandemic: lessons for government on risk management.

Lawson, E. (2021) Coronavirus: How to vaccinate a nation - Science Museum Group

Sridhar D. (2023) Where should scientists have been: inside or outside No 10? The Guardian, 4 November.

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What have we learnt from the covid-19 inquiry so far? - The BMJ