Intended for healthcare professionals


England’s health policy response to covid-19

BMJ 2020; 369 doi: (Published 15 May 2020) Cite this as: BMJ 2020;369:m1937

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  1. Hugh Alderwick, assistant director,
  2. Phoebe Dunn, research fellow,
  3. Jennifer Dixon, chief executive
  1. Health Foundation, London, UK
  1. Correspondence to: Hugh.Alderwick{at}

Government prioritised the NHS but was slow to protect social care

The UK prime minister, Boris Johnson, announced plans for the next phase of the government’s response to covid-19 on 10 May. This included some changes to social distancing rules, including asking people to return to work if they cannot work from home, and a new system for ranking the country’s threat from covid-19 (50 days after a similar system was introduced in New Zealand). The message “stay home” shifted to the vague “stay alert.” A lack of clear guidance and inconsistent messages have caused confusion about what the new rules mean.

The number of excess deaths in the UK during the pandemic has now reached 50 000.123 While it is too early to assess how the government’s handling of the pandemic has shaped its impact, the policy response in England has been decidedly mixed so far.

After a slow start, the scale and reach of policy change since March 2020 has been dizzying.4 Extraordinary measures—emergency laws, lockdown, the job retention scheme—have been accompanied by a heavy flow of policy announcements, plans, and guidance documents. The result is a complex combination of changes interacting with the health system and society.

The NHS entered the outbreak with fewer doctors, nurses, hospital beds, and equipment per capita than most comparable countries.5 The NHS was promised “whatever it needs” to deal with covid-19,6 and it responded with widespread service changes. In mid-March, NHS leaders introduced measures to postpone all non-urgent elective operations, shift to remote general practice appointments, block buy independent sector capacity, and more. Policy changes included cancelling routine quality inspections, suspending or replacing payment systems such as the Quality and Outcomes Framework, and centralising commissioning. These changes may have unintended consequences—including showing barriers caused by “usual” NHS policy.

Other aspects of the government’s approach have been less clear or consistent. Early talk of herd immunity quickly disappeared.7 And policies on testing have been confusing and constrained by lack of capacity. The World Health Organization told countries to “test, test, test.”8 The government stopped community testing on 12 March.9 Testing has since expanded and government has set various targets—initially for 250 000 tests a day (with no date for when it will be delivered), then 100 000 a day by the end of April.

On 1 May, the health secretary said the 100 000 target had been met, though this included tests that had been sent out but not necessarily completed. The target has been missed almost every day since.10 And detail is lacking on the government’s test, track, and trace programme. Guidance on personal protective equipment has been revised several times, alongside major shortages reported for health and care staff.11

Inadequate support for social care

Government support for social care came too late. A covid-19 “action plan” for social care was published on 15 April12—nearly a month after country-wide social distancing measures had been introduced. The plan promised greater support for social care staff, expanded testing, and a plan to recruit 20 000 more workers. But implementing it across a fragmented system of around 18 500 organisations will be a challenge.

Meanwhile, social care leaders report that staff and service users have not been adequately protected.13 Extra funding for councils has come in stages—first in March (£1.6bn (€1.8bn $2bn) for all local authority services plus £1.3bn for care packages for people leaving hospital), then a further £1.6bn in April. So far there have been 8312 deaths related to covid-19 in care homes in England and Wales,14 and social care staff—mostly women—have been around twice as likely to die from covid-19 as other adults.15

No action plan could undo decades of political neglect. The social care system was in crisis before covid-19 arrived. Government investment has long been inadequate, staff shortages are widespread, and care providers are at risk of collapse.16 The failure of successive governments to reform social care is being laid bare. Government must now give the same priority to protecting the social care system as it has done to the NHS.

Politicians have repeatedly claimed that they are “following the science.” But are they following or hiding? The science is neither singular nor simple. Policy decisions are choices with trade-offs—shaped by data, values, biases, and more. The chancellor has said “it’s not a case of choosing between the economy and public health.”17 But greater clarity is needed on the values guiding political decisions as social distancing measures are eased.

This must include a commitment to health equity. Deaths from covid-19 in the most deprived areas are more than double those in the least,18 and death rates are higher among black and other ethnic minority groups than the white population.19 Social distancing policies could also worsen health inequalities in the short and long term.20

Government has introduced unprecedented measures to protect people’s incomes during the crisis. But enhanced social protections and action to address structural inequalities must be part of the long term strategy to protect population health as the country moves out of lockdown and into the “new normal.”


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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