The response to the Covid-19 pandemic: lessons in governance and leadership
The Covid-19 pandemic has shone a light on how the UK functions: how decisions are made and by whom; the interlocking – or isolated – roles of health care, local government and the private sector – and the ‘heroic’ mindset dominating central government. In this long-read, Sir Prof Chris Ham analyses what the response to Covid tells us about how our systems work – and why this needs to change.
Responding to a pandemic like Covid-19 is a real-life stress test of decision making under conditions of major uncertainty. It raises many questions about how and where decisions are made, including the balance between centralised and decentralised decision making, the degree of collaboration between health and care agencies, the role of clinical teams in determining how services are organised and patients are treated, and the involvement of the private sector.
This long read discusses the role of the many institutions and actors involved at different levels with a particular focus on the NHS. It outlines how decision making was centralised in government and notes the extensive involvement of the private sector in the response. Collaboration both within the NHS and between the NHS and other agencies was enhanced, and clinical teams supported by managers were instrumental in shaping how services were delivered to patients.
The government’s decisions were informed by the advice of scientists on the Scientific Advisory Group for Emergencies (SAGE) and its sub-groups channelled through the chief scientific adviser and the chief medical officer. The expertise of the devolved administrations, regional and local government did not receive the same attention.
Covid-19 will continue to present major challenges for the foreseeable future and it is therefore important to learn lessons from experience to date. The process of lesson learning needs to acknowledge the huge challenges presented by the pandemic, the uncertainties it created both in government and the scientific community, and the pace at which decisions were taken.
Centralised decision making is necessary but insufficient in responding to a challenge like Covid-19. Much more needs to be done to draw on expertise and intelligence from all levels of government and from within the NHS. More work is also needed to strengthen partnership working through local resilience forums, integrated care systems and other mechanisms focused on places and communities.
Leaders must create teams across different professions and organisations if these partnerships are to be effective. They must also empower agile execution in uncertain environments where experimentation and learning are essential. Collective and distributed leadership rather than heroic leadership are needed to avoid repeating the mistakes of the past recognising the vital role of teams in the forefront of the response.
In this long-read, I conclude that a constitutional reset is required to avoid central government overreaching itself in future. Decisions should be taken at the appropriate level by leaders who understand the places and communities they serve. Public services need to be rebuilt to tackle the fragilities exposed by the pandemic recognising also the valuable contribution of voluntary and community sector organisations.
Centralised decision making
The combination of a centralised system of government in England and a publicly funded national health service (NHS) means, not surprisingly, that decision making has been highly centralised throughout the pandemic. Examples include:
- Decisions on the timing and nature of full or partial lockdowns to help manage rising infections rates and their impact on hospitals
- Decisions on how the NHS should respond including the declaration of a Level 4 national incident on 30 January
- Detailed guidance, amounting to instructions, on specific actions that should be taken e.g. letter on 17 March asking NHS trusts to postpone all non-urgent elective operations for at least three months and to discharge all hospital medical inpatients who were medically fit to leave, the latter supported by national guidance specifying that the discharge to assess model should be implemented across England
- Centralised procurement of ventilators, PPE and private sector hospitals for use by the NHS
- Establishment of NHS Test and Trace including the centralised procurement of additional laboratory and contact-tracing capacity
- Decisions to set up NHS Nightingale Hospitals in several areas to create additional critical care capacity for Covid-19 patients
- Decisions on the Covid-19 vaccination programme, including how this should be delivered and the groups in the population who should have priority
The declaration of a level 4 national incident led to the standing up of gold and silver command centres within the NHS working closely with local resilience forums to provide leadership and coordination of the pandemic response across the public sector. The chain of command put in place served a vital purpose in enabling leaders in different public services to work within an agreed framework. Centralised decision making did not, however, always produce the desired results.
valuable time was lost before local authorities were given responsibilities and resources to contribute to contact tracing
The procurement and distribution of PPE during the first wave was particularly problematic with widespread reports of shortages in supplies for NHS staff and staff working in residential and domiciliary care at a time of rising global demand. Procurement was controlled by the government who appointed Lord Deighton in April to help break the logjam of supply. This eventually led to improvements in the availability of PPE after several weeks in which staff at the forefront of the response expressed concerns at the risks they faced.
Difficulties were also encountered in making full and effective use of the Nightingale Hospitals set up very rapidly by NHS England when the nature of the pandemic became clear. These hospitals were intended to provide headroom to enable the NHS to cope with rising demand but their use was limited by staffing constraints. Action taken within the NHS to expand intensive care capacity in existing hospitals was more effective, illustrating the value of local leaders and their teams being able to decide how to respond to changing circumstances.
Contact tracing presented even greater challenges. Here the government established a national contact tracing system making use of the private sector and Public Health England, seemingly unaware of expertise available in local authorities. Despite repeated representations from local government leaders and public health directors, valuable time was lost before local authorities were given responsibilities and resources to contribute to contact tracing and to support people to self-isolate.
National guidance from NHS England on hospital discharge was effective in releasing beds for use by Covid-19 patients and was enabled by close collaboration between NHS organisations, local authorities and other partners. However, this approach was criticised for unintentionally spreading the virus into care homes when patients were not tested before discharge. The government’s neglect of care homes contributed to the high rate of deaths from Covid-19 and was accentuated by delays in implementing testing of staff and residents.
Throughout the pandemic communication between central and local government was often weak or non-existent with council leaders learning of the government’s decisions through the media rather than direct contact from ministers and officials. Elected mayors in some of England’s regions were particularly vocal in their criticism. First ministers in the devolved administrations of Northern Ireland, Scotland and Wales also felt their contribution had been marginalised.
Government ministers adopted an heroic leadership style in which they sought to demonstrate their grip of the crisis to the public. This was exemplified by over optimistic promises to develop ‘world class’ and ‘world beating’ responses, deliver ambitious targets, such as carrying out 100,000 tests by the end of April 2020, and appoint high-profile leaders on issues like PPE. It was also evident in the decision to replace Public Health England with a new body, the National Institute for Health Protection, because of what ministers perceived as failings in PHE’s response, without a plan for how this would be achieved.
Failure to work closely with local authorities became problematic in the light of the differential impact of the pandemic in different areas. Centralised decisions affecting the whole of England were not always sensitive to regional and local variations in infection rates and the pressures placed on the NHS. The government’s decision to relax the national lockdown in May when infections rates had fallen further in London and the south of England than in the north was a prime example. Relaxation contributed to a resurgence of the virus which could have been avoided had regional and local leaders been involved in decision making.
Collaboration between health and care agencies and with the voluntary sector
Collaboration between health and care agencies took a number of forms including multiagency partnerships known as local resilience forums bringing together local authorities, NHS organisations, the emergency services and other agencies to provide leadership and coordination of the local response to the pandemic across public services. These partnerships drew on different sources of expertise around defined places and communities and made a valuable contribution in many areas.
Within the NHS collaboration between hospitals in the first wave helped to ensure that sufficient intensive care capacity was available to meet rapidly rising demand. This involved integrated care systems – systems that evolved from sustainability and transformation partnerships established in 2016 – facilitating agreements between hospitals to assist each other by sharing capacity if one hospital was working to its limits. Mutual aid operated between areas if pressures on hospitals meant that there was spare capacity in some areas when others had reached their limits.
communication between central and local government was often weak or non-existent with council leaders learning of the government’s decisions through the media
Collaboration was also evident in closer working between hospitals, community health services, primary care and social care. This was particularly important in enabling hospital inpatients who were medically fit to leave hospital to do so in order to release beds for Covid-19 patients. It also helped in enabling patients to be supported in their own homes instead of being admitted to hospital. Local authorities worked closely with care providers on the provision of PPE and testing albeit with delays in delivery.
Another area of closer collaboration was support for people who were shielding and those who were clinically extremely vulnerable. The voluntary sector was involved with NHS organisations and local authorities in providing this support and in many other aspects of the pandemic response. The expertise of the voluntary sector was invaluable in enabling public services to respond to the challenges they were facing, making use of volunteers and the distinctive expertise of the sector.
The spontaneous emergence of mutual aid groups during the pandemic testifies to the resilience of community engagement. These groups have provided practical support, such as help with shopping and the collection of medicines, and they have offered social support to combat loneliness. The government’s furlough scheme enabled people of working age to contribute to these groups and research by New Local suggests that they thrived where there were high levels of social capital.
Many charities experienced reductions in income and funding in the face of rising need and demand for their support. This meant that some had to cut back on staff and focus their resources on people in greatest need. The fragility of the voluntary sector was recognised by the government which provided additional financial support, for example to hospices, and this was supplemented by support from local authorities and the NHS in many areas.
As the first wave abated, collaboration focused on restoring services for non-Covid-19 patients. This included ensuring effective use of private sector hospitals for the treatment of NHS patients and using mutual aid to work towards national targets on waiting times. The emphasis placed on the role of integrated care systems in leading restoration was both a stimulus to and an enabler of this kind of cooperation.
These systems are now being asked to lead work in the NHS and with partner organisations in dealing with the backlog of diagnosis and treatment for non-Covid-19 patients that has built up. They will also be expected to give priority to tackling health inequalities by working with local authorities and voluntary and community sector organisations on the root causes of inequalities. Proposals from NHS England and Improvement to establish integrated care systems as statutory bodies indicates the direction of travel.
The expertise of the voluntary sector was invaluable in enabling public services to respond to the challenges they were facing
The army played a critical role in setting up the Nightingale hospitals and supporting the distribution of PPE within the NHS and the establishment of testing sites. Army personnel were also involved in supporting local authorities in dealing with local outbreaks during the summer and in mobilising mass testing as new types of tests became available. At the time of writing, the army has been asked to support the delivery of Covid-19 vaccines in England and to provide staff to help hard pressed hospitals in London and the Midlands.
The role of clinical teams
While NHS England exercised tight control of the NHS response to the pandemic, clinical teams were instrumental in shaping how services were delivered to patients. National and international networks supported teams in this work through active sharing of information and intelligence. China played a part in the first stages followed by Italy and other countries in Europe which were in the forefront of the response.
An early example was work on a breathing aid known as Continuous Positive Airway Pressure (CPAP) which enables patients to breathe more easily when oxygen alone is insufficient. For some patients, CPAP proved to be an effective alternative to mechanical ventilation which was in short supply and in any case carried risks for patients. Work at UCLH demonstrated the possibility of manufacturing CPAP devices at scale and the benefits of so doing.
Another example was learning about the most effective way of proning patients. In the early stages of the pandemic, clinical teams in a number of countries tested the benefits of patients being placed flat on their stomachs with their face and chest down rather than on their backs. Gold standard trial data on proning are not yet available, particularly for awake patients, although small scale and observational studies have shown benefits.
Clinical teams worked with managers to increase intensive care capacity within hospitals at speed. This entailed converting space on wards and in operating theatres for use by critically ill patients making use of additional ventilators and other equipment acquired by the NHS. After the first wave, clinical teams and managers established green and blue pathways within hospitals to separate the care of Covid-19 and non-Covid-19 patients to ensure the safe restoration of services.
General practices also innovated by working together to separate the care of patients with suspected Covid-19 from the care of other patients. Surgeries were designated as red, amber or green according to the work undertaken and much greater use was made of telephone and digital consultations. General practices were also central to the Covid-19 vaccination programme under the leadership of clinical commissioning groups, making use of primary care networks.
Clinical teams have been supported by researchers who took the initiative in establishing trials into the effectiveness of different treatments. A landmark example is the Recovery Trial led by researchers at Oxford University. This has enlisted many thousands of patients into clinical trials to evaluate the effectiveness of treatments such as dexamethasone, hydroxychloroquine and lopinavir-ritonavir. Positive findings on dexamethasone are estimated to have saved 1.4 million lives worldwide.
Oxford University researchers also led the development of a vaccine for Covid-19 which came into use in England in January 2021. This involved collaboration between vaccine experts and those involved in running large-scale clinical trials who came together rapidly to undertake research into a vaccine and carry out tests into its efficacy and safety. In this case partnership with pharmaceutical company Astrazeneca was important in ensuring that there was capacity to manufacture the vaccine and to make it available at an affordable price.
Other innovations included greater use of digital technologies in hospitals and mental health services to support remote and virtual consultations with patients, more flexible working by staff to support intensive care teams in hospitals at the forefront of the emergency response and the use of virtual wards to care for patients in their own homes. These innovations were propelled by the uncertainty surrounding the virus, the limitations of centralised and regional planning in these circumstances, and the need for agility in the delivery of front-line care.
The role of the private sector
The government has relied extensively on the private sector, most obviously in the procurement of PPE and mechanical ventilators and most obviously in NHS Test and Trace.
Large contracts were placed with Serco and Sitel in April to establish a national contact tracing service from scratch. In the event, staff employed to work in the service were under utilised and their success in reaching people who tested positive and following up contacts was well below that required for the service to be effective. It was also much lower than those of public health teams in local authorities whose expertise was recognised only belatedly by the government and who now lead work on local outbreaks.
Private sector companies were used to support other aspects of NHS Test and Trace. A review by the National Audit Office found that 407 contracts worth £7bn with 217 public and private organisations had been signed with many being assigned by direct award without competition under emergency measures introduced during the pandemic. Most of the funding was for testing and encompassed setting up testing sites and laboratories, providing supplies, and bringing in logistics expertise.
Local resilience forums and integrated care systems demonstrated what was possible but there were also programmes that suffered from fragmented roles and responsibilities and poor communication.
The involvement of the private sector resulted in a rapid growth of testing capacity using NHS and Public Health England laboratories as well as the commissioning of new capacity in the Lighthouse Laboratories. These so-called mega laboratories involve various organisations including private sector companies, universities, research institutes and the NHS. In its assessment, the NAO recognized the achievement in expanding testing but noted that that the target for providing test results within 24 hours had not been met and also that NHS Test and Trace had not planned adequately for the sharp rise in demand for testing when schools and universities reopened in the autumn.
The way in which the government involved private sector companies proved controversial. The most serious concerns related to the high cost of using management consultants and the way in which they were hired, under performance on some contracts, and challenges in companies collecting, reporting and sharing data with public sector partners. Data sharing was particularly problematic on testing and contact tracing where local authorities did not receive detailed information on people testing positive in their areas until the end of June.
Private sector companies have been involved in many other ways, including in partnership with the public sector. An example was the development of CPAP (see above) involving collaboration between clinicians at UCLH, researchers at UCL, and engineers at Mercedes AMG High Performance Powertrains. Similar partnerships have led to innovations in testing and in the ventilator challenge where many companies worked with clinical teams to increase capacity. These partnerships appear to have been more effective in using private sector skills than simply contracting with companies to deliver specific programmes.
Heroic leadership vs mesh governance
The governance of the pandemic response in England has been characterised by centralised decision making supported by extensive use of the private sector. Partnership working both within the NHS and between the NHS and other agencies was increasingly evident and clinical teams were able to determine how services should be delivered and patients treated with the support of managers and researchers. The army played a valuable supporting role in ensuring the effective delivery of specific work programmes.
Regional and local government contributed to the response in many ways, working with local communities, but could have done more if the government had been willing to make use of their expertise. Instead, Ministers chose to take direct responsibility using the agencies at their disposal. On public health, for example, the Secretary of State for Health and Social Care worked through the Department of Health and Social Care and Public Health England, who in turn contracted with a wide range of companies to deliver political commitments.
The government’s approach revealed its lack of trust in councils being able to deliver key aspects of the pandemic response at a time of national emergency. This appears to have been because of concerns that councils vary in their performance and in their ability to collaborate with partners. Ministers also seem to have been concerned that local leadership would result in a postcode lottery when national consistency was required. It was this and a desire to see a rapid scaling up of capacity that led the government to rely heavily on the private sector.
collective leadership drawing on all the talents and resources available is preferable to heroic leadership of the kind that prevailed during the pandemic response.
NHS England led the NHS response to Covid-19 in association with government ministers. Detailed guidance on how NHS organisations should respond at different stages of the pandemic set out the expectations of national leaders and was underpinned by additional funding to cover the costs. Local NHS leaders had some scope to implement national guidance taking account of the pressures they faced and clinical teams played a major part in reshaping how services were delivered and in the delivery of the Covid-19 vaccine programme.
The government’s use of the private sector attracted much analysis and some criticism. Concerns focused on the way in which contracts were let, allegations of favoritism and cronyism in the award of some contracts, and lack of transparency in the release of information about contracts. In its assessment, the National Audit Office criticised inadequate documentation in some procurements to give assurance that the risks associated with them had been mitigated and lack of transparency.
The complex challenges presented by the pandemic and the many public and private agencies involved required an unprecedented level of collaboration to be effective. Local resilience forums and integrated care systems demonstrated what was possible but there were also programmes that suffered from fragmented roles and responsibilities and poor communication. An example was testing where there was confusion about the respective roles of the Department of Health and Social Care and Public Health England.
The establishment of NHS Test and Trace as a new agency (actually not part of the NHS despite its name), initially reporting directly to the Prime Minister, came to symbolise the government’s preference for centralised control and heroic leadership. The agency brought together work already underway on the expansion of testing and the development of contact tracing with the addition of a new unit known as the Joint Biosecurity Centre. It oversees the delivery of work contracted out to the private sector and over time it gave local authorities more information and support to enable them to control local outbreaks.
The head of NHS Test and Trace, Baroness Harding, referred on more than one occasion to her ambition to create a ‘team of teams’ to deliver the complex programme she led. In doing so, Harding was channeling the work of General Stanley McChrystal whose book of the same name outlines lessons from the United States military in dealing with new terrorist threats. McChrystal argues that the fight against al-Qaeda could only be won by breaking down silos, drawing together different sources of expertise, and shortening lines of communication in a significant departure from traditional command-and-control systems.
In the case of NHS test and Trace, the team of teams was made up of civil servants, management consultants, leaders seconded from the NHS and local government, and the army. The challenge it faced was how to make a reality of McChrystal’s lessons in the midst of an unprecedented national crisis and in a context where expertise from different agencies and backgrounds was assembled rapidly. This context did not allow time and space for the investment in organisational development usually needed, creating challenges in making a reality of Harding’s aspiration.
McChrystal’s ideas are developed further by Amy Edmondson who argues that complex challenges in the public and private sectors require unprecedented levels of collaboration between teams that come together from different professions and organisations This is because of the explosion of specialised knowledge together with the multifaceted nature of the problems facing societies.
Edmondson uses the term ‘extreme teaming’ to describe these collaborations and she identifies four key characteristics of leadership needed in effective teams. They include building an engaging vision to motivate team members, cultivating psychological safety to overcome personal challenges, developing shared mental models to facilitate communication and collaboration, and empowering agile execution. Edmondson argues that leaders need to be ambidextrous, addressing both interpersonal and technical challenges and moving between facilitation and motivation-oriented practices.
Geoff Mulgan addresses these ideas from a different perspective in arguing that government responses to Covid-19 should avoid binary choices between centralisation and decentralisation, public and private, and the like. Instead he makes the case for new governance models based on partnerships and networks capable of bringing together different sources of expertise. Mulgan uses the phrase ‘mesh governance’ to describe how collaborative working is best suited to dealing with complex challenges, recognising that this needs to be worked on consciously and continuously to be effective.
Examples of mesh governance in England are found at the local and regional levels in the form of integrated care systems, local resilience forums, and combined authorities in local government. As discussed earlier, these multiagency partnerships played a prominent part in supporting collaboration in the pandemic response and in so doing lay down a challenge to central government where silo-working and command and control were much more in evidence. Even so, regional and local partnerships varied in their effectiveness and were not always recognised by central government for the contribution they could make.
if any good can come out of the last year it would be a willingness to learn lessons on governance and leadership for the future.
The more general point here, standing back from Covid-19, is that many of the most intractable challenges in contemporary societies are best addressed by systems and these take time to develop and mature. As Atul Gawande argued in the 2014 Reith lectures, we live in ‘the century of the system’ and must design new ways in which people can work together to make best use of different knowledge and skills. This means recognising that collective leadership drawing on all the talents and resources available is preferable to heroic leadership of the kind that prevailed during the pandemic response.
With Covid-19 likely to present major challenges for the foreseeable future, now is the time to redouble efforts to build effective partnerships, and to invest in the development of leaders able to work in this way. This will be particularly important as England embarks on economic and social recovery where collaboration between the public and private sectors holds the best hope for the future. Centralised direction and support have a role but there needs to be much greater emphasis on leadership that is collective and distributed to teams at the forefront of the response.
Equally important is the need for there to be shorter lines of communication between central government and leaders in care homes, general practices, hospitals and public health teams. The failure of Ministers to learn rapidly about the impact of their decisions and to adjust course accordingly undoubtedly contributed to the United Kingdom’s poor performance on Covid-19. Strengthening capabilities for policy learning in government is an urgent priority.
The pandemic has shone a harsh light on governance in the United Kingdom and demonstrated the need for greater clarity about the relationship between the Westminster government and the devolved administrations. Complexity is also evident in England in the relationship between central government, local government, combined authorities and elected regional mayors. The delayed white paper on devolution in England provides an opportunity to review these arrangements and to clarify the roles and powers of different tiers of government.
Nowhere has public sector fragility been more evident than in the NHS where chronic shortages of staff and intensive care capacity have been exposed for all to see
At the core of a constitutional reset should be recognition of the need for there to be properly resourced and well led public sector agencies at all levels able to deal with crises on the scale of the pandemic. Covid-19 will not be the last national emergency of the twenty first century and if any good can come out of the last year it would be a willingness to learn lessons on governance and leadership for the future.
The government’s default to the private sector reflects the fragility of the public sector after a decade of austerity as well as an ideological preference for private sector solutions. Nowhere has public sector fragility been more evident than in the NHS where chronic shortages of staff and intensive care capacity have been exposed for all to see and have at times threatened to overwhelm services. Public health, social care and other services run by local authorities have also suffered from cuts in public funding and this has weakened their resilience when these services were most needed. Now is the time to begin addressing these weaknesses as part of a multi-year rebuilding programme to ensure that public services are better prepared to deal with future challenges.
A programme of this kind must use all the assets that are available including in the voluntary and community sectors. Local authorities and other public sector agencies must share power and be open to different ways of responding to people’s needs, drawing on the experience of areas already working in this way. This means embracing the community paradigm by empowering communities, resourcing them, and creating a culture of community collaboration.
Hilary Cottam’s work shows why there is urgency in adopting this approach. Her essential insight is that people and communities need to be active agents of change and not passive recipients of care and support. The focus should be on people’s lives and developing capabilities that enable them to make changes that can be sustained. Wigan in Greater Manchester is a case study in how this kind of thinking has been applied in the form of a deal with citizens and it has delivered impressive results.
Rebuilding public services should not entail going back to what existed before the pandemic. The recommendations of the joint voluntary, community and social enterprise review should be revisited to ensure that voluntary sector organisations are fully engaged in partnership working and properly resourced. Rather than taking on functions better undertaken by the public sector, the private sector should be engaged as a partner where additional capacity and distinctive capabilities are needed.
Chris Ham is Chair of the Coventry and Warwickshire Health and Care Partnership, Co-Chair of the NHS Assembly and Non-Executive Director of the Royal Free London Hospitals NHS Foundation Trust. He was Chief Executive of The King’s Fund between 2010 and 2018. He also sits on the Board of New Local.