The public health response by UK governments to COVID-19

The fourth of five BMA reports, each with a particular focus on the pandemic response.

Location: UK
Audience: All doctors Patients and public
Updated: Thursday 28 July 2022
COVID virus illustration

About this report

This report examines the approaches and key decisions taken by UK governments during the pandemic and the public health measures they introduced. It assesses whether these choices were timely, appropriate, and proportionate to deal with the threat and impact of COVID-19.

How prepared was the UK for a pandemic?

The UK’s pandemic preparation was inadequate, focusing entirely on an influenza-style pandemic and ignoring recommendations from previous planning exercises that would have ensured the UK was better prepared to respond to COVID-19.

Major reforms to the UK’s public health structures, alongside a decade of underfunding, meant public health systems across the UK entered the pandemic without the resources, workforce, capacity, structures, or voice they needed to shape and influence governments’ responses to COVID-19.

The running down of public health funding progressively over last decade left the public health service understaffed and under-resourced and this inevitably reduced their ability to manage the pandemic.
SAS doctor, England

Key recommendations

  • All UK governments should review its public health structures to ensure expertise is located where it is needed and is included as part of government decision making – particularly at times of national crisis.
  • All UK governments should adequately fund public health services wherever they are located to enable the nation to better respond at a rapid pace during future emergencies.
  • All UK governments should urgently increase the numbers of public health staff at a local and national level and increase the number of public health training places provided.
Questions for the inquiries
  • Why did the UK’s pandemic preparation focus entirely on an influenza-style pandemic? What impact did this approach have on the UK’s initial response to COVID-19?
  • Why were recommendations from pre-pandemic planning exercises not acted on and included in COVID-19 plans?
  • How, if at all, could local public health expertise (e.g. health promotion or protection) have been used more effectively in the response to COVID-19?
  • What was the impact of public health structures, long-term public health funding and public health staffing levels on government responses to COVID-19? How could these be improved to ensure the UK is better prepared for a future pandemic?

First wave (Feb 2020 - Sept 2020)

The UK failed to act quickly in response to the emergence of COVID-19. There was no clear policy approach at the start of the pandemic, with initial contract tracing abandoned in mid-March and a significant delay before population-wide distancing strategies were introduced.

Delays continued throughout 2020. For example, there was a gap of two to three months between face coverings being recommended by global health agencies and this advice being implemented by UK governments.

During summer 2020, the UK failed to prepare for a second wave. Public health messaging became mixed and confusing, and the dominant political narrative focused on ending restrictions rather than caution and preparation for an expected increase in infections in the autumn. The UK Government failed to use this time to build effective systems for testing and contact tracing, leading to significant UK-wide testing backlogs and, in England, outsourced contact tracing, which turned out to be a critical and costly failure.

Did they not see what was happening in China, Hong Kong, Singapore, Italy? It was like they thought it would not come here.
Consultant, Scotland
Too little too late. These measures work but they seemed always to be deployed only when it was absolutely obvious that something had to be done. They would have been so much more effective – so much less disruption and harm would have been caused – if they had been deployed earlier and followed more assiduously.
Consultant, England

 

Key recommendations

  • The UK Government must assess the impact of the Eat out to Help Out scheme on both the economy and COVID-19 transmission – to guide similar decisions and debates in any future pandemic.
Questions for the inquiries
  • How and to what extent did the UK Government assess the situation in China in early 2020 as a potential threat to the UK? To what extent did the UK Government apply precautionary principles as a consequence?
  • What information did PHE (Public Health England) use to inform its advice that scaling up capacity for testing was not possible? Given that this course of action would be implemented just weeks later, was this advice from PHE challenged sufficiently?
  • Following the decision to shift capacity away from contact tracing on 12 March 2020, why did it take 11 days for the UK Government to introduce population-wide distancing measures when it was already known community transmission of COVID-19 would likely overwhelm the system?
  • What role did behavioural science play in the UK Government’s decision not to quickly impose a package of NPIs (non-pharmaceutical interventions) against COVID-19? Was this driven by an incorrect assumption that adherence would quickly wane?
  • Why did the UK Government spend the seven days from 16 – 23 March 2020 advising voluntary behaviour change rather than introducing lockdown?
  • What was the impact of high-profile failures to adhere to lockdown rules on public support and adherence, and on trust in COVID-19 interventions?
  • Why was the decision to require mask-wearing in public taken as late as it was? What role did the shortages of PPE play, caused by a lack of adequate stockpiling and maintaining of national stockpiles?
  • Why were UK governments not more cautious during the summer of 2020 and how effectively did they use this time to prepare for a second wave?
  • Why did the UK Government choose to outsource extensive testing and opt not to use existing, public capacity? Could better value for money and effectiveness have been achieved by using existing public sector laboratories?
  • What was the structure, value for money, and performance of the various contact tracing systems deployed across the UK throughout the pandemic?

Second wave (Sept 2020 - Apr 2021)

As a result of ending the first lockdown with no coherent plan for keeping COVID-19 at bay, infection rates rose rapidly. Local lockdowns and localised restrictions were introduced from summer 2020 but these failed to sufficiently contain the spread of infections. Communication and information-sharing between national and local government was poor and undermined the implementation of local restrictions.

Public communication became even less clear during the second wave, limiting people’s understanding of local measures. Last minute changes to restrictions during Christmas 2020 created confusion and frustration, severely damaging trust in public messaging.

The vaccination rollout signalled a turning point in governments’ pandemic responses. The NHS-led rollout of the vaccination programme was a vital success during this time and signalled a move away from lockdowns.

However, although the overall vaccination rollout was hugely successful, governments need to do more to address inequity in vaccine up-take and to combat anti-vaccination messaging.

LAs (local authorities) routinely had access to no, or very little data [sic], often well after the fact, such that they felt unable to truly understand the impact that COVID was having on their populations. This was not remedied until well over a year after the initial declaration of the pandemic.
Public Health Consultant, England

Key recommendations

  • All UK governments should review their approach to – or policy on – localised restrictions in the event of a future pandemic, to ensure that, if used again, these processes are clear, inspire confidence, and are enforceable.
Questions for the inquiries
  • What was the effectiveness of local lockdowns on case rates and their wider implications on the wellbeing of the populations affected?
  • How effective and consistent was communication and information-sharing between national and local government, particularly around the implementation of local lockdowns?
  • How effective were governments’ public communications, including cultural competence, and the impact of these communications on adherence to and understanding of restrictions?
  • Why did the UK, Northern Irish, and Welsh Governments, which had adopted circuit-breaker lockdowns, choose not to extend them, only to implement national lockdowns a month after they ended?

Third wave (May 2021 - Dec 2021)

Despite mass vaccinations, COVID-19 cases and hospitalisations remained high moving into the third wave. The rapid spread of the Delta variant put even greater pressure on the UK’s health services which were working at the limits of their capacity to deliver both COVID-19 and non-COVID-19 care.

The UK Government unnecessarily politicised public health measures by framing the removal of restrictions in the context of ‘freedom’. More balanced messaging was needed around actions that were advisable to maintain even without legal requirements, in order to control the spread of COVID-19 and protect the most vulnerable to severe disease.

 

Communication is key, and as with so much else, the government’s communication was woeful. Even now, the community are confused as to why the vaccine is not eradicating COVID. [The] end result being that people are not careful enough and we have ongoing problems in society and healthcare.
Junior Doctor, Northern Ireland
Questions for the inquiries
  • How effectively did UK governments support CEV (clinically extremely vulnerable) people as they shifted towards policies of relaxing restrictions that focused on limiting spread of the virus?
  • Were the clear public health advantages of lifting restrictions, particularly to the population’s mental health, appropriately balanced with serious concerns around the impact of this wave on healthcare services and workforce capacity?
  • How effectively did governments and relevant health agencies respond to the emergence of long COVID, and how have they continued to both treat and support those suffering from it?
  • Given the high levels of COVID-19 cases and hospitalisations, was the rate at which restrictions were lifted during the third wave appropriate?
  • To what extent was data on vaccination coverage balanced with other factors such as case rates, hospitalisations rates, and the impact of long COVID when making decisions about easing restrictions?

Fourth wave (Dec 2021 - present)

Omicron spread rapidly and caused widespread concern about the impact on the UK’s health services during winter, an already precarious time for the UK’s health services. To limit this threat and reduce rising staff absence rates, governments should have reintroduced measures far earlier than they eventually did.

In early 2022 all four UK governments published strategies for replacing legal restrictions with guidance. However, the removal of key public health measures, such as free testing, self-isolation support payments, and statutory sick pay provision in England, created a two-tier system where only those who could afford it could protect themselves.

Since these strategies were published, public health messaging has frequently failed to be widely disseminated. A lack of clear government guidance, gaps in vaccine coverage and limited consideration given to the prevalence and impact of long COVID all raise questions about how groups most at risk, like the clinically vulnerable or unvaccinated, are being adequately protected.

The dismantling of pandemic infrastructure – including the scaling back of public health services, testing capacity and prevalence monitoring – is premature and jeopardises the UK’s response to any future spikes of the virus or, critically, any new pandemic.

A critical lesson of the pandemic is that timely and decisive action saves lives, while inaction puts them at risk. The BMA has, therefore, responded to current worryingly high rates of COVID-19 cases and, tragically, increases in deaths from the virus, by calling for the reintroduction of mask wearing in health and care settings. Rapid action from all four UK governments is critical to protect patients and NHS staff.

Key recommendations

  • We call on all UK governments to focus resources on promoting the COVID-19 vaccine amongst at-risk and under-vaccinated groups.
  • All UK governments should take steps to ensure that the staffing, tools, and facilities needed to address any future pandemic can be scaled up quickly if necessary.
  • All governments must reintroduce or re-emphasise mask wearing in health and social care settings, to protect patients and staff.
Questions for the inquiries
  • Why were alternative approaches to managing high rates of infections – including the reintroduction of previously withdrawn measures – not adopted before December 2021?
  • To what extent was the prevalence of long COVID, which is associated with poorer health outcomes and increases demand upon NHS services, considered in decisions by UK governments to ease restrictions?
  • What was the basis for the UK Government removing remaining legal restrictions in England AND key public health measures such as free testing and self-isolation support payments when the Omicron variant, with its high transmissibility, had yet to peak?
  • Has the failure to accompany the removal of most COVID-19 protections with clear, consistent, and ongoing public health messaging, hindered the ability of UK governments and the public to realistically move to a sustainable strategy of “living with COVID”?
  • How are the UK governments maintaining or disposing of their pandemic assets – in the form of workforce or facilities in particular? Does this risk undermining any future pandemic response?