This article originally appeared as a chapter in “The Pandemic: Where Did We Go Wrong? A Very Public Inquiry”, edited by John Muir. The book is available for purchase here.
Whatever it takes
“Whatever extra resources our NHS needs to cope with coronavirus – it will get.”
Chancellor Rishi Sunak, Budget Speech, 11th March 2020
In March 2020, whilst millions of people across England went into lockdown, the NHS embarked on its biggest liberation in a generation.
After years of focus on national plans, re-organisations and deficits, all routine inspections were cancelled; national and local planning processes suspended; income protected; laws flexed; and additional funding made available for whatever staff, facilities, equipment, discharge packages, training, elective care, “or any other relevant category” of spend the NHS deemed required.
Within a month the Treasury had allocated £6.6bn of additional funding to the NHS, whilst the Secretary of State for Health & Social Care had committed to writing off £13.4bn of historic NHS debt. The NHS, never far from people’s hearts, was at the heart of a national struggle, one we could not afford to lose.
Failure is not an option
“Last night the Government announced additional measures to seek to reduce the spread across the country. It is essential these measures succeed…. This letter therefore sets out important actions we are now asking every part of the NHS to put in place….”
Sir Simon Stevens, NHS Chief Executive, Amanda Pritchard, NHS Chief Operating Officer, Next Steps On NHS Response to COVID-19, 17th March 2020
Debate continues about potential missed opportunities pre-COVID, not least from the 2016 Exercise Cygnus which simulated the impact of a H2N2 pandemic on the NHS.
Yet in seven decades since it’s foundation, never had the NHS faced a challenge of this enormity. Its response was, similarly, un-precedented.
Haunted by images of overwhelmed hospitals in northern Italy, NHS “Gold”, “Silver” and “Bronze” commands mobilised across the country with a mission to free-up in-patient and critical care capacity. In parallel, retired clinical staff were re-registered, final-year students mobilised, existing hospitals reconfigured, new facilities constructed, and ways of working transformed, all in timescales unimaginable under any other circumstances. The rapid construction of the Nightingale temporary hospitals was just a part of a nationwide response in which frontline professionals came together to support each other and those impacted by the pandemic. A senior NHS manager, with decades of experience, described “the greatest sense of professional purpose I ever felt”.
By June 2020, whilst the pandemic was far from over, the initial 'battle' in the UK was effectively declared won; the reward, a gradual easing of the lockdown measures that had brought almost every aspect of daily life to a standstill. And yet, as the first weekend in July witnessed pubs re-open, and the NHS’ 72nd birthday, it did not necessarily feel like a time for celebration.
Even as our health service was being celebrated in rainbow portraits and weekly applause, across England and Wales over 170 NHS staff had died alongside some 50,000 of their fellow citizens.
Pride and sorrow
Whilst international comparisons remain difficult, and the full story of the pandemic far from written, how can we reconcile the rightful pride we feel in the NHS, the huge resources mobilised, and the many sacrifices made; with the terrible death toll nonetheless experienced?
Was the NHS incorrect in its assessment of what was needed; were the deaths (and their hugely unequal impact) an inevitable consequence of the broader environment; or are there deeper lessons that need to be understood, both in manage any further waves of COVID-19, and for the long-term good of our health and care systems?
Rising to the challenge
By the end of June 2020, there were over 300,000 lab-confirmed cases of COVID-19 in the UK. And yet whilst NHS staff and hospitals were severely tested, they were not overwhelmed.
That so very few people were treated in the Nightingale in London, at the epicentre and height of the outbreak, was no small tribute to how existing NHS services responded. In many ways the NHS was able to harness the extra funding it received: vital critical care capacity was created and the lightening-fast “digital revolution” in areas such as Primary Care will likely form part of a lasting legacy.
In the widespread collaboration between primary, community and social services, many areas saw more progress in transforming relationships and ways of working in three months, than the previous decade. Staff received much-deserved support, recognition and, not least, professional autonomy; and responded with outstanding levels of professionalism and dedication. Those who received treatment in this period, including the Prime Minister, brought back stories of the care they had received and the profound difference it made to them.
The limits of command-and-control?
And yet, even at the time, questions were being raised: around the daily increases in COVID-19 cases and fatalities, the pressures on services, and whether resources were always being appropriately directed.
It is easy to look back with even limited hindsight, but many NHS staff voiced concerns around the extent to which physical and mental health services deemed “non-urgent” were effectively shut-down, and the potential long-term effects of these centralised decisions. And whilst frontline staff and NHS organisations were being explicitly freed from routine planning, financial controls, inspections and regulation, the response to COVID-19 in many ways continued to reflect a deeply entrenched and top-down approach to service management.
'Command-and-control' is one way to mobilise resources around a clearly defined task, but it does not leave much space for multiple perspectives and reflection. During the early stages of a complex and evolving outbreak, there was never going to be a singular and clear objective, as much as we might have wanted one. Interpreted through the command structures, it became too easy for messages around “saving lives” and “protecting the NHS” to become about “protecting and building hospital capacity”.
Collateral damage in the care sector
Whilst pace was important in responding to COVID-19, it was never an end in itself; being able to do things quickly is helpful only if they are the right things, and if the opportunity cost of doing them does not outweigh the benefits.
Whatever the rights and wrongs of discharging patients of uncertain COVID-19 status into care homes, there is no doubt it happened, it happened rapidly and in many different places, and it had severe consequences for those living and working in those environments.
The NHS’ ability to organise itself, to attract resources and political support, and ultimately to command, put executives at the centre of a response which often seemed to lack an understanding of the impact of decisions for those outside of the service. Even as the crisis and deaths in care homes escalated, PPE and testing capacity continued to be prioritised towards hospital staff and patients; with primary and community care also often struggling to get access to the resources they needed. Local authority Directors of Adult and Children’s Social Services and Public Health were co-opted into command structures, but with limited roles in the overall national and regional agendas.
The complexities of infection control in care settings, the peripatetic nature of the care workforce (driven by the low-paid and insecure nature of care work) and the dangers of care workers becoming both victims and vectors for the virus: were all well known within and outside of the caring professions. And yet the evidence suggests that if such concerns were heard, they nonetheless struggled to be prioritised in the context of crisis management as a whole.
Longer term consequences for communities
Whilst an immediate priority of creating capacity to treat the most seriously infected was understandable, such a singular focus left little room for responding to wider needs. Only time will tell how many more lives will be lost as a result of the suspension of routine diagnostic and treatment services during lockdown, and the extent to which it might have been possible to mitigate further. But arguably one of the reasons why GPs were able to innovate and continue to provide primary care services is because they have always operated largely as separate entities, grounded in local communities and outside of centralised NHS control. For core NHS staff, as for the many ordinary people who responded to the NHS call for a volunteer army - “Your NHS Needs You” - the experience of the pandemic proved highly variable; with critical care units on the constant point of being overwhelmed, whilst people in other areas found themselves with comparatively little to do.
A crisis yes, a war no
For many NHS staff COVID-19 was a brutal and traumatising experience. Important questions need to be asked about the extent to which military metaphors were helpful, or appropriate, in supporting them.
As pointed out by commentators at the time, doctors, nurses and other healthcare professionals are not soldiers; they do not enlist in the knowledge that they might be asked to lay down their lives. Despite the pandemic being one of the highest probability and highest impact events on the National Risk Register in the UK for well over a decade, as initial PPE shortages and associated confusion demonstrated, the NHS was underprepared. Resources made available in March could not compensate for historic underinvestment; and in their place, the idea of the NHS staff as heroes created the potential for a sense of exceptionalism, where both clinical and support staff were expected to make-do and carry on, whilst being exposed to risks which were very far from normal or acceptable.
The result was a high level of infection amongst NHS workers, some hospitals becoming repositories of infection, perhaps most dangerously, a sense amongst the broader population that the “war” was happening elsewhere; that all they had to do was to applaud the NHS, and it was the NHS’s fight to “win”.
The pandemic was not a chance confluence of broader global circumstances, nor a political choice, but an event which was waiting to happen; seeing the NHS and its staff as an army to be thrown into the breach, should such events occur, is risking their lives and ours.
So, how did the NHS perform overall?
In some areas it succeeded, in others mistakes were made which were often a product of an environment and culture established long before March 2020. The NHS never has, and cannot in the time of COVID-19, operate in a vacuum: it is as much a part of our society as social care, housing, and any number of other public services and no more or less critical to the health and wellbeing of our communities as a whole.
There are many potential lessons to take from the experience; about how to manage investment in health and care strategically over the longer-term; how to build more effective and connected relationships and understanding between professionals across our health and care system; and the risks of simplistic, top-down solutions in a situation that is complex and evolving.
Perhaps most important of all though is the lesson that no single institution can save us – no single perspective, no single solution – and that the NHS, those who work in it and those who lead it, are only human. That we have the NHS, and that we hold it in such regard, is something to be proud of; but recognising its limitations and our own personal responsibilities will remain critical to its, and our, survival.