When the coronavirus struck, the British government repeatedly said it was among the best-prepared countries in the world – with some justification. As recently as October, an international review of pandemic planning ranked the UK the second best prepared country in the world (behind the US).
Two months on, any breezy confidence has evaporated. The government is facing growing complaints over a series of policy missteps that critics say are responsible for the worst death toll in Europe.
How did a country that supposedly had one of the best pandemic plans in the world end up suffering one of the worst outbreaks?
A review of official documents and interviews with politicians, national security advisers and experts in risk management suggests one answer may be that ministers stuck closely to the recommendations of a well-honed plan for a different disease: the flu.
The origin of the UK’s strategy for a catastrophic influenza pandemic was a tractor blockade at a Cheshire oil refinery in September 2000. Several dozen farmers, angry about the cost of fuel, blockaded the Stanlow oil refinery and refused to leave until the Labour government agreed to a reduction in duty.
The blockade began on a Friday. By Wednesday, the UK was on the brink of collapse. Copycat groups obstructed other fuel depots. Enormous tailbacks of panic-buying motorists stretched out of petrol stations and down motorways. Fire engines and ambulances were days away from running dry, and NHS trusts faced cancelling elective surgeries. One supermarket started rationing.
The protests ended and ministers later agreed to freeze fuel duty. But according to politicians and civil servants in government at that time, the shock of the fuel crisis sparked a realisation at the highest levels of Whitehall that civil emergencies could bring down a country.
“For a few days, a few hundred protesting people outside fuel depots brought the country to a halt,” said Sir Peter Ricketts, a diplomat and later David Cameron’s national security adviser. “The shock of suddenly finding the country stopped because of a few fuel depots being blockaded was a real wake-up call.”
Within just the following year, the UK suffered more fuel protests, floods, foot-and-mouth disease, and the aftermath of September 11. Tony Blair’s government decided a completely new approach to civil emergencies was required, and established a revised and expanded civil contingencies secretariat in the Cabinet Office, backed by new legislation.
The ambition was “to create something which was better suited to the way in which the UK is run”, said Bruce Mann, the director of the unit from 2004 to 2010. Civil contingency planning would cascade downwards through tiers of government, he said, all the way from Whitehall to networks of local emergency response groups.
Mann’s unit dealt with a “relentless” series of civil emergencies during his six years in charge, including periodic outbreaks of infectious disease, endless fuel supply crises including the explosion at the Buncefield fuel refinery, bird flu scares, and the aftermath of terrorist atrocities both domestic and overseas, including the 7 July 2005 bombings.
But the team also had a second responsibility: predicting entirely new risks and anticipating how the government might respond. Within its first year the unit drew up the national risk register, a comprehensive catalogue of all the civil emergencies that could conceivably strike the UK, which continues to be updated annually. At the top of the list – then and now – was an influenza pandemic.
Early versions of the register now read as eerily prescient. “In addition to the severe health effects, a pandemic is also likely to cause significant wider social and economic damage and disruption,” stated the 2008 register. “Normal life is likely to face wider social and economic disruption, significant threats to the continuity of essential services, lower production levels, shortages and distribution difficulties.” Deaths would range from 50,000 to 750,000.
“Pandemic influenza has been one of the top risks in the risk register for a long time,” said Miles Elsden, a mathematician and former government scientist who specialises in contingency planning. Elsden helped coordinate meetings of the government’s Scientific Advisory Group for Emergencies (Sage) during the 2009 swine flu outbreak. “Everybody had been expecting something to come along,” he said. “The reasonable worst-case scenario that was the basis for most of the planning was Spanish influenza,” he added, referring to the 1918 flu pandemic that killed between 50 million and 100 million people worldwide.
Prof Lindsey Davies, a public health doctor, was brought in as the UK’s first national director of pandemic influenza preparedness in 2006. Having been handed the “fairly skeletal” existing plan, Davies began battling for additional resources. To get them, she would need to force ministers to realise the potential scale of a pandemic crisis. Together with Mann she coordinated the first major nationwide simulation of a flu pandemic in 2007, codenamed Winter Willow.
One question surrounding the government’s handling of the coronavirus is whether it implemented recommendations from a second, 2016 flu pandemic simulation, codenamed Exercise Cygnus. The report, which was leaked to the Guardian, made several recommendations that appear to have been overlooked.
But Winter Willow was the far larger exercise. Where Cygnus involved 950 people, Winter Willow marshalled more than 5,000 people, including government ministers, civil servants, emergency planners, NHS staff, and emergency services personnel to coordinate the first real attempt to test how the UK would hold up under the strain of a pandemic.
The result was transformative. “That was absolutely a turning point for us, because people at that stage realised what [a flu pandemic] could do,” Davies said. “We didn’t exaggerate it at all; if anything we underplayed it. We had a sort of moderate pandemic scenario, rather than the worst-case one. But even then,” she added, “we ran out of face masks.”
As well as pinpointing holes in the planning, Winter Willow galvanised ministers into taking the threat of a pandemic seriously. “Ministers, when they were faced with the reality of it, suddenly realised that this actually could be disastrous,” Davies added.
Several changes of government later, and after a decade of austerity, pandemic planning appears to have slowly dropped off the radar. The value of the UK’s pandemic influenza stockpile, estimated at £831m in 2013, declined by 40% over six years. Ricketts says that while the government had a faultless record anticipating pandemic influenza as a risk, “somewhere along the line that didn’t get translated into decisions on funding, preparedness stocks, the in-case stocks of vital equipment to make it real”.
But a second consensus has also emerged: that one of the UK’s big mistakes, rather than failing to plan, was planning for the wrong illness.
Whole tracts of the UK’s comprehensive pandemic strategy turn upon any pandemic being flu – a different type of disease to a coronavirus. The emergency pandemic stockpile contains millions of doses of Tamiflu and Relenza to help alleviate the worst of the symptoms for anyone catching the new flu disease, and a National Flu Pandemic Service would distribute them. Stockpiles of existing flu vaccines that might be effective against the new strain would be distributed to inoculate health workers, while contingency contracts with pharmaceutical companies would be spun up to manufacture more flu drugs.
The government’s most recent national security risk assessment, compiled last year, predicted a potential catastrophe in the event of a flu pandemic: trillions of pounds in damages, deaths in the five figures, disruption lasting for months.
However, the risk assessment’s prediction for the potential impact of a new disease like a coronavirus was staggeringly off target. The worst-case scenario for a novel infectious disease in the UK, the government’s risk assessment said, “could be on the scale of the Sars outbreak in Toronto, Canada”, which involved 438 probable and suspected cases and 44 deaths. Economic damage would be limited to a few billion pounds, mostly from nervous tourists staying away.
The British government’s focus on flu, and the failure to look at how Asian countries were responding to the coronavirus, was recently described by the former health secretary Jeremy Hunt as “one of the biggest failures of scientific advice to ministers in our lifetimes”. “It is now clear that a major blind spot in the approach taken in Europe and America was our focus on pandemic flu rather than pandemic coronaviruses, such as Sars or Mers,” he told parliament.
The extent to which Boris Johnson’s government stuck to a protocol laid out in its flu pandemic plans is made clear by reviewing the 2011 strategy for responding to a flu pandemic (the most recent published version available). It reads like an extraordinarily precise description of the steps the UK government did (and did not) take in its initial response to Covid-19.
Mass gatherings such as football matches and live music events would continue, in part to “help maintain public morale”. There would be no quarantining of international arrivals at airports, though passengers would be encouraged to report any symptoms upon arrival. Face masks would not be recommended for use by the public. There is no mention whatsoever of healthy people being confined to their homes in an attempt to prevent transmission.
Perhaps most striking is that the decision to wind down contact tracing on 12 March, widely viewed as an error that has hamstrung the UK’s ability to fight back against the coronavirus, is also alluded to in the government’s flu pandemic strategy.
Its first “detection and assessment” phase ( seemingly an analogue for the “contain” phase of the coronavirus response) describes how the focus would shift away from “actively finding” and isolating confirmed and suspected cases, and instead turn to treatment of the disease once there was “evidence of sustained community transmission of the virus”. It even anticipates that detection and assessment could itself be a “relatively short” phase, depending on the circumstances.
The flu strategy bluntly concludes: “It will not be possible to halt the spread of a new pandemic influenza virus, and it would be a waste of public health resources and capacity to attempt to do so.”
There is one obvious but important reason why the UK may have focused its attention so much on planning for influenza: following Spanish flu in 1918, subsequent pandemics included Asian flu in 1957, Hong Kong flu in 1967, and swine flu in 2009. Barring HIV/Aids, almost every significant disease outbreak for the past hundred years has been some form of flu.
A Department of Health spokesperson acknowledged that several steps taken by the government resemble those set out in the strategy, but cautioned against interpreting this as the result of some blinkered focus on the document. While useful, they stressed, the strategy would have been only one of several elements considered by government scientific advisers, alongside emerging data from Wuhan as well as new research into the nature of the virus.
They added that contact tracing did not stop when Britain moved to the delay phase, but was instead focused on specific settings at risk of infection such as residential care homes. “This is an unprecedented global pandemic and we have taken the right steps at the right time to combat it, guided at all times by the best scientific advice,” they said.
Prof David Tuckett, an expert in decision-making under uncertainty who runs a research group called CRUISSE at University College London exploring how organisations can respond to “radical uncertainty”, has some sympathy for ministers. It would be natural for ministers to turn to their flu pandemic plan, he said, because it was the only one they had – but that can be precisely the peril of placing assumptions into the core of your plan.
“You have a model based on your central case, and you have a whole set of useful things you’ve learned from some exercise or other,” Tuckett said. But if the crisis being dealt with is substantially different from the one a government has planned for “then a central case will distract you from thinking. That is, in a way, what happened.”