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Prior to 2020, the 1918 influenza pandemic was the worst in recent history. However, the next major pandemic is unlikely to wait another century.  

There is an urgent need to understand how the UK can prevent another human, social and economic disaster on the scale of that caused by COVID-19. Better national responses and international cooperation will be critical to preventing and responding to future threats to health and society.  

So the launch of a statutory public inquiry into the UK’s pandemic response is welcome, but the inquiry team face a daunting task. The UK COVID-19 Inquiry will likely become the most wide-ranging and complex investigation ever undertaken by a public inquiry. 

As Tim Gardner recently wrote, the inquiry should focus on two critical areas: the preparations made prior to COVID-19 and the decisions made by government during the pandemic. However, it’s important that these issues aren’t looked at in isolation. A number of important factors created the context for COVID-19 in the UK, and shaped and interacted with the choices made by government when developing the policy response.  

Here are the ten contextual factors that the inquiry will need to consider during its investigation:  

1. A decade of austerity 

The decade before the pandemic saw the longest sustained squeeze on public spending on record, with day-to-day spending on public services falling in real terms by 13% per person and, outside of health, by 25% per person. Reductions in spending affected the resilience of public services and influenced the social and economic conditions that impact people’s health in the short and long-term. There was considerable disinvestment in preventative public services, and while NHS spending was protected in real terms, funding increases did not keep pace with growing demand.   

2. Pre-existing inequalities 

Income and wealth inequalities had also widened over the previous decade, leaving people in lower socio-economic groups more vulnerable to the effects of the pandemic. The impact of austerity was most significant in areas with the greatest need: the least deprived local authorities saw a 16% decrease in net spending per person, while expenditure fell by 31% in the most deprived areas. This was accompanied by a rise in the prevalence of multiple long-term conditions since the early 2000s, disproportionately affecting those in more deprived areas and from some ethnic minority groups.  

3. Gaps in pandemic planning 

The UK had every opportunity to prepare for a pandemic. Emerging infectious disease and pandemic influenza were classed as significant risks, with ample opportunity to develop and test response plans. However, the UK government was underprepared. Learning from previous incidents and exercises was not consistently applied, emergency stockpiles of PPE were inadequate, and preparations for Brexit diverted resources from other contingency planning. More generally, government policymaking is undermined by a lack of capability to adequately plan for the future and address long-running issues.    

4. Public health cuts 

Austerity extended deep into the public health system in England, with Public Health England’s budget falling by 17% in real terms between 2015-16 and 2019-20 and local spending on public health per person 22% lower. The public health grant allows local authorities to provide services that are vital to improving people’s health, such as obesity, drug and alcohol, and sexual health services. It also helps steer how wider local policies and services, such as housing, planning and children’s services, can support improvements in health.  

5. Constrained NHS capacity  

Before COVID-19, the health service was already under growing pressure. While protected from real-terms cuts, funding growth over the previous decade was severely constrained. The limited capacity of the NHS to absorb demand shocks was noted before COVID-19, and the UK entered the pandemic with fewer doctors, nurses, hospital beds, and equipment per capita than most comparable countries. Hospitals regularly operated with high rates of bed occupancy and growing staff shortages. Performance against key indicators – including access to general practice and hospital waiting times – was the worst on record.  

6. Political neglect of social care 

England's system of adult social care is underfunded, understaffed, and undervalued. The system is a threadbare safety-net, with publicly funded services only available to people with the highest needs and lowest means. Real terms funding per person fell considerably over the decade prior to the pandemic, and fewer people were receiving support from local authorities, despite rising needs. Workforce shortages were huge, with many social care staff working for low pay and under poor terms and conditions. Many care homes relied on agency staff working across several different sites, adding to the risk of COVID-19 transmission.  

7. Fragmentation and disruption of the health and care system 

The health and care system that entered the pandemic was complex and fragmented, still adapting to the sweeping structural changes to the NHS in England made by the 2012 Health and Social Care Act. The Health Protection Agency (previously responsible for managing infectious diseases) was replaced by Public Health England (combining health protection and health promotion). Adult social care in England is also fragmented, with the system comprising a complex web of national and local organisations, with more limited national oversight and coordination of policy than in the NHS.  

8. Centralised decision making 

In contrast to the fragmentation of the health and care system, the UK political system is highly centralised by international standards. Top-down approaches to planning and decision making are also pervasive in the NHS. This influenced the response to the pandemic, meaning the NHS was able to respond rapidly in March 2020 with widespread changes to services, directed by national bodies. By contrast, England’s centralised testing and tracing system faced major challenges and increasingly shifted to a more locally-driven approach over time.  

9. Political upheaval 

In the five years that preceded the pandemic, the political agenda was consumed by the UK’s departure from the European Union. During this period, the UK government was led by three different prime ministers, through periods of majority and minority governments, and three general elections. While negotiations over the UK's relationship with the EU continue, the UK formally left on January 31 2020 – the day that the first known cases of COVID-19 in the UK were reported. 

10. Shortcomings in data and the data infrastructure 

While data enabled some of the more successful aspects of the pandemic response, much of the infrastructure that allowed more efficient information sharing was only developed in response to the crisis. Data quality was a significant barrier to the response in certain areas, including the lack of a care home register and the difficulties identifying care home residents in routine data. Lack of data on care home staff also hampered understanding of why care home outbreaks were occurring. The lack of reliable data also caused difficulties for local authorities working to prioritise vaccinations for unpaid carers or provide support to vulnerable individuals. 

Find out more 

Explore our long read: How can the UK COVID-19 Inquiry bring about meaningful change?  


This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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