Recovery vs resilience: long-term thinking needed to withstand future health shocks

A ‘clear and present danger’ 

In July, the first COVID-19 inquiry report called for ‘radical reform’ to ensure that ‘so many deaths and so much suffering’ never happen again. The moving voices of those bereaved remind us to think not only about when the next pandemic could hit but the very ‘clear and present danger’ COVID-19 continues to present. 

‘It’s very important that we remember the human cost, because there are too many people out there now that think COVID has gone away.’  COVID-19 Inquiry 

Over 4 years on from the start of the pandemic, data suggest COVID-19 has not ‘gone away’. As of 13 December 2024, the ZOE health study reported 97,904 new daily (self-reported) symptomatic cases of COVID-19 in the UK.  

Early in the pandemic, future planning focused on ‘recovery’ and what was needed to re-establish ‘normality’. ‘Recovery’ suggests the COVID-19 cloud has ceased to cast its shadow. But, as Health Foundation work has reported, particular groups have been left with a legacy of a disproportionately unequal impact.  

‘Being better prepared’ 

The Health Foundation has recognised the importance of building resilience against future shocks to the health and care system. To do this well, we need research that will help the health system learn from our pandemic response to date and tell us how to be better prepared. 

‘Had the UK been better prepared for and more resilient to the pandemic, some of that financial and human cost may have been avoided.’  COVID-19 Inquiry 

In October 2020, we commissioned Ipsos and RAND Europe to explore what this research agenda should look like. Their deliberative work heard not only from those leading responses but also those affected, including those disproportionately impacted and typically underrepresented. This deliberative approach identified two important questions the research should answer: 

• How can we mitigate the long-term effects of COVID-19? 
• How can we build resilience into the health system?  

While these questions are not easily answered, six features – discussed in the next section – emerged as vital for an effective ‘resilience’ research agenda.  

We also realised we needed to hear from a mix of experts to help policymakers and researchers designing and commissioning this research determine priority topics and how the research should be conducted. These experts came together to publish a collection of articles under the convening umbrella of the BMJ. 

Here, we summarise the recommendations from the BMJ collection against the five research agenda features identified by Ipsos and RAND. The sixth feature – embedding learning into practice – echoes throughout.  

Recommendations for a ‘resilience’ research agenda  

Collaboration and interdisciplinarity  

Collaboration and interdisciplinarity are essential for research to contribute effectively to a front-line pandemic response. For COVID-19, this has involved both developing our ability to deal with the disease through effective treatments and collaborative efforts around data, including standardisation, real-time reporting, linkage and the creation of cross-country cohorts.  

Collaboration demands ‘ongoing investment’ to realise the benefits of working with international colleagues to evaluate public health interventions and build infrastructure that can overcome siloed research cultures. 

‘It isn’t just about cross-governmental working on promoting healthy lives… It is about working together across all agencies... we saw fantastic examples of collaborations through COVID-19, would love to bottle some of that alignment to make a real change going forward.’  Research stakeholder, Developing a long-term research agenda 

Public services and continuity 

In addition to examples of research contributing to effective responses during the pandemic, the BMJ collection also highlights less than effective responses where research was absent. While some industries – like retail grocery and construction – used research to maintain continuity of services and focused on infrastructure issues like workforce, the health and social care research agenda neglected continuity and instead largely explored a biomedical agenda. One example is the 2023 UKRI COVID-19 research programme. Of the £327.8m spent, just £7.2m (2.2%) funded health care workforce research projects.  

However, which health services should be maintained was a live debate throughout the early days of the pandemic. Research has shown the need for continuity in the face of system shocks. We now know that the ‘stepping down’ and deprioritising of non-COVID-19 care contributed to sharp rises in waiting lists. Likewise, although the reported deterioration in children’s mental health predates the pandemic, the closure of schools has potentially worsened a generation’s mental health. Health systems cannot be treated in isolation: 

‘In my mind, the most important aspect cuts across the two ‘social’ categories – which is, essentially, how to keep society going in times of crisis. All the research in the world on bolstering health systems is essentially worthless without thinking about how we ensure people can go to work, trust their governments, send their children to school, receive necessary social care, not fall prey to mis- or disinformation.’  Policy stakeholder, Developing a long-term research agenda 

Continuity is an important research topic not only for service delivery but also for public trust, as the above quote indicates. The BMJ collection highlights the clear relationship between trust in policy and compliance with public health measures, such as masking or vaccines, and the negative consequences for resilience when policy is not trusted. 

Evidence and policy 

Too often, policy is made in the absence of evidence, or insights from evidence are not ‘translated’ effectively into ‘resilient policymaking’. 

‘We need to be asking, ‘What is the knowledge that is required to generate an answer that will support effective policymaking?’  Funder stakeholder, Developing a long-term research agenda

Resilient policymaking also demands a move away from what is often short-term thinking driven by political concerns to longer term horizons that enable ‘the sweet spot’ of relevance and influence. 

‘5–10 years is probably the sweet spot where the research agenda is both influenceable and relevant at the current time.’  Policy stakeholder, Developing a long-term research agenda  

To really understand how we can be more resilient, only a long-term lens can tell us first, if it is the health shock that is ‘causing harm’, and second, how we should respond to not only the acute impact but the chronic. 

‘There needs to be a longitudinal aspect that follows up communities . . . to see what the short-, medium- and long-term impact is and how resilient they are for the next shock.’  Research stakeholder, Developing a long-term research agenda 

For policy that is itself resilient, the main question should be how to look to the future rather than be influenced only by the ‘vagaries’ of current political agendas. This need becomes even more acute in the context of the ongoing disproportionate impact generated by inequalities during the pandemic. We need longer term horizons to see if these inequalities are likely to persist. 

Inequalities 

We are only now seeing the unintended consequences of decisions made during the pandemic. For example, school closures exacerbated a ‘digital divide’, with some students having no or unsuitable access to the predominantly online learning. We need to ensure policymaking is informed by potentially differing effects and work to reduce rather than exacerbate inequalities. Equity considerations need to run throughout a research agenda for resilience, shaped by insights from diverse stakeholders. The COVID-19 Inquiry highlighted this was absent during the pandemic. 

‘[There was a] failure to engage appropriately with those who know their communities best, such as local authorities, the voluntary sector and community groups.’  COVID-19 Inquiry 

Trajectory for resilience  

Not all of the BMJ collection’s recommendations for policymakers and researchers are new or unknown. The government’s health mission recognises widening inequalities. But we still have some way to go to establish an effective public health system. We cannot simply aim to recover. We must use this opportunity to learn from our pandemic response and do better in future.  

‘My question is, are we recovering to what we had before, or do we want to recover to something that is a better trajectory than we had before?’  Policy stakeholder, Developing a long-term research agenda  

We don’t know when or what the next shock will be, but we know how we responded last time. And through research we are beginning to know how far that response was effective.  

There are efforts to build more resilience into the health and care research ecosystem. The National Institute for Health and Care Research have recently announced £80m for research and established 13 Health Protection Units across the UK. This is welcome and their priority areas chime with many of the transdisciplinary topics discussed here, including behavioural science and emergency preparedness. It is hoped the lessons from this work inform a national research agenda for that infrastructure. Resilience research needs to be built on collaboration around data, adopt longer term lenses, link to effective policymaking and avoid the costs and unintended consequences in both real time and the future.  

This body of work gives policymakers and researchers the chance to design a research agenda that ensures the health and care system will not simply recover but be more resilient for both present and future shocks.