Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Covid-19 has highlighted the NHS’s strengths and weaknesses

BMJ 2020; 369 doi: (Published 03 June 2020) Cite this as: BMJ 2020;369:m2124

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  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
  2. Follow David on Twitter: @mancunianmedic

Those of us involved daily in NHS machinations and policy have long been aware of the service’s strengths and weaknesses, well before they were stress tested to new levels by the covid-19 pandemic. But issues that were hiding in plain sight are now in the spotlight, front and centre.

Covid-19 has held up a mirror to our culture, structure, and system resilience. The selflessness and commitment on show among NHS staff have been astonishing. We don’t work in war zones, and although our physical and mental wellbeing are often at long term risk from the job under normal circumstances, this is the first time in my career that staff have been in immediate personal danger of a potentially critical condition, just from turning up to work.

All around me I’ve seen people coming to work despite the fear and risk to themselves or their families—out of fierce loyalty to professional values, patients, and the teams they work with. Beyond patient facing staff, the operational managers and executives are working flat out to prepare for and respond to the tidal wave of demand. Clinical leaders and managers are reorganising service models, changing roles, and increasing capacity at speed. The clinical academic community has mobilised to develop the evidence base and technology.

A further strength is that because we’re a genuinely national health service, with fairly centralised leadership in national statutory agencies and leading figures closely linked to the legislature and executive, we’ve been able to put out national positions and good practice guidance, as well as getting key legislation in place very quickly, in the form of the emergency Coronavirus Act.1

We’ve seen a suite of good practice guidelines and rapid clinical guidelines from the National Institute for Health and Care Excellence.2 Public Health England and NHS England have updated online guidance, information sheets, and campaigns.3 And senior medics in government departments and agencies have become well known public presences.

NHS England has also issued operational guidance to trusts. An emergency budget has given more resources to the NHS and to central planning around logistical responses, and local health and social care service leaders have been given new service permissions and powers from the NHS chief executive and chief operating officer.4

Sadly, there have been well documented failings in this central policy and communications operation and in our pandemic preparedness and logistical supplies. Technical experts working in the civil service or non-departmental, arm’s length groups have had their reputations and political independence compromised. Some official guidance has seemed weakened by realpolitik.

It’s started to look like an overly centralised and controlling bureaucracy, not least within Public Health England, and has stifled more local planning across individual localities rather than focusing on what individual organisations have done in the pandemic response to deal with their own challenges.

Next week I want to discuss some of the underlying structural weaknesses now cruelly exposed by the pandemic, which I hope has now given us the impetus to challenge them.



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