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In late January the UK reached the tragic milestone of 100,000 COVID-19 deaths and sadly there will be more to come. The pandemic is responsible for over 2 million deaths worldwide and few countries have escaped its impact. While this is a global phenomenon, it’s clear that the UK has been one of the hardest hit countries. This is a tragedy but also not what we might have expected; the UK is one of the world’s richest nations, it has a national health service and long tradition of public health, with a world class research infrastructure. A full national inquiry to learn the lessons of the pandemic is essential.  The experience so far points to three critical areas that have contributed to the heavy toll in the UK.

The first is the legacy of poor health and inequalities that left much of the population more vulnerable to the disease. Obesity and diabetes are key risk factors for severe COVID-19 and overall mortality from the virus has been higher for those with pre-existing health conditions. Since 2011, gains in life expectancy have stalled while the amount of time spent in poor health has increased. For some deprived groups, life expectancy has actually declined. The levels of disability and poor health for deprived and disadvantaged groups are high and have left them considerably more vulnerable to COVID-19. The scene for the current crisis was set long before the virus arrived.

The post pandemic reckoning needs to consider the extent to which existing health and economic inequalities, coupled with a lack of capacity and resilience in critical public services, made our experience far worse

This underlying vulnerability has been compounded by social conditions which allowed the virus to spread, with overcrowded housing, poverty and insecure work that have made it hard for people to self- isolate. COVID-19 prevalence data between 6 and 22 January from Imperial’s REACT study, confirms that large household size, living in a deprived neighbourhood, and black and Asian ethnicity were all associated with higher levels of infections compared to smaller households, less deprived neighbourhoods and other ethnicities.

The second is underlying weaknesses in the key public services that were at the forefront of managing the disease: the NHS, social care and the national public health infrastructure. Under-investment in public services is at the heart of the staffing shortages in the NHS which saw the health service short of over 100,000 staff at the start of the pandemic. Successive governments have run the health service at the edge of capacity with over 90% bed occupancy rates pre-COVID and numbers of ICU beds, doctors, nurses and diagnostic equipment (MRI and CT scanners) well below comparator countries. Managing a surge in demand in this context is incredibly difficult. Delays in the delivery of non-COVID care are worrying and likely to be storing up longer-term health impacts. It will take years and billions of pounds to clear the backlog and reduce long waiting times.

COVID-19 has shone a harsh light on the obviously inadequate system for social care where spending in 2018/19 was still less than a decade earlier in real terms. Cuts to the public health grant have seen spending per person fall by 22% in real terms since 2013/14. These cuts have left public health teams with fewer staff and less capacity to meet the sudden surge in demand that COVID-19 entailed.

The third area is policy failure; decisions and action to protect people in care homes were late and inadequate. Over a fifth of deaths took place in care homes. There was poor appreciation of the skills available in local authorities to help develop a strong test and trace system. Instead, the government relied heavily on private contractors, many selected quickly without normal due diligence to cost or value, and the system has struggled to meet its own targets. And there has been a lack of long-term planning and horizon scanning – a bias in decision-making towards the short term, has meant the country was not prepared and has struggled to find the capacity needed to deal with a crisis of this magnitude.

The pandemic has severely tested governments around the world, but the UK’s high death toll rightly raises huge questions as to how the pandemic was managed. Crucially, the post pandemic reckoning needs to extend beyond the immediate management of the COVID-19 crisis to consider the extent to which existing health and economic inequalities, coupled with a lack of capacity and resilience in critical public services, made our experience far worse. Tackling health and economic inequalities, building capacity and resilience across public services is likely to involve major and sustained increases in public spending. The current eyewatering bill for COVID-19 is just the start, not the end.

While the immediate cost of the pandemic has rightly been met by borrowing, sustained increases in spending to address the underlying fundamentals will require a once in a generation debate about the level of taxation in the UK.

This blog was originally published in Public Finance on 29 January 2021.

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