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Last week the UK officially reported over 100,000 COVID deaths, and one of the worst per capita death rates in the world. This is despite the NHS—a health service that is frequently rated one of the top in the world, and that is sufficiently coordinated and integrated that in a national crises it can move patients and resources all around the country to meet needs. It is even able to deliver 2 million doses a week of a new vaccine. So why does it have one of the worst COVID mortality rates in the world? And what can other countries learn from this example? The answer may lie in what public health professionals have argued for a long time—that the health service needs to be seen as our last line of defence against disease. The wider health system, society, and economy is what produces and protects health, both in a pandemic and in normal times.
The NHS—a strong health service in need of a new, healthier society
Whilst we await the results of the inevitable range of inquiries, it is clear that four major components of an unhealthy society were present in the UK's COVID response:
Poor governance. The number one cause of the UK's COVID death rate is surely poor decision making and poor governance. At its core, this means insufficient and late uses of lockdown and social distancing measures (particularly in late 2020), politically tolerating a high rate of COVID cases which left no resilience for shocks like the new variant, ever-changing and over-complex communication messages, lack of transparency over scientific advice, and leaders who flouted their own lockdown policies. As Professor Michael Marmot puts it, this has “damaged social cohesion and inclusiveness, undermined trust, de-emphasised the importance of the common good, and failed to take the political decisions that would have recognised health and well-being of the population as priority.” A good health system requires good governance and the resulting public trust in the government.
The UK has high degrees of income inequality and job insecurity (often exacerbated by racial inequality). There have been concerns about the impact of this on health since the 1980s, but it became much more apparent in 2020—with those in lower paid and manual occupations more at risk of infection and death, and many lower paid workers feeling compelled to go back to work, and unable to safely isolate. Good interventions by the government such as the furlough scheme should be acknowledged, but this was not enough to mitigate the structural economic problems underlying our health system, and limited mandatory sick pay.
Underfunded public health system. Over the last five years the NHS has been partially protected from budget cuts, but has still faced unprecedented pressures, falling performance and escalating waiting times, a false economy, leaving little space to increase capacity during a crisis. The UK's public health service has fared a lot worse. It’s critical aim to protect and improve health in the country, has faced much tougher cuts of up to 22 percent. This limited the UK’s pandemic preparedness, track and trace capability, advice to local and national government, and our ability to engage and communicate with local communities to ensure buy-in with public health measures and vaccines.
The UK example has some key lessons for all countries (including the UK itself) who are considering how to improve their current response, and how to “build back better” and prepare for future pandemics:
Make clear public communication, transparency, and trustworthy leadership a greater priority
Ensure short term labour market interventions, and social protection programmes are sufficient to enable insecure workers to follow Covid guidance
In the longer term, cuts to public health and social care budgets should be routinely assessed in terms of their impact on health system performance
Health and social care services are more likely to be resilient to shocks if integrated and coordinated, and this must include their procurement systems
Pandemic preparedness plans must include mechanisms to re-prioritise and maintain the most essential health services, and must expand beyond traditional areas to include plans for the social care sector, social protection policies and the labour market.
Health impact assessments of economic policies should become routine—e.g., assessments of social protection mechanisms and labour market policies.
Decision makers should adequately fund locally led but nationally coordinated public health systems, to ensure communities are appropriately engaged and involved in health services, and that they trust public health advice provided. Pandemic preparedness plans must build off the strengths of these systems.
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.