Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: The structural problems highlighted by covid-19

BMJ 2020; 369 doi: (Published 11 June 2020) Cite this as: BMJ 2020;369:m2214

Read our latest coverage of the coronavirus pandemic

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

There’s been much to celebrate in the extraordinary, professional, and brave response of NHS staff to covid-19. But the crisis has also brought to wider attention a host of structural problems that those in the know had already recognised. As we consider settling back into business as usual, it’s important that we focus on solutions.

Acres of newsprint and hours of broadcasting have been devoted to our country’s failure to enact adequate pandemic preparedness after the 2016 Cygnus exercise, which was based on a future novel virus or strain.1 There’s now a court challenge asking for the full Cygnus report details to be released.2 Recommendations for capacity in testing, contact tracing, personal protective equipment (PPE), ventilators, and intensive care bed capacity—among the lowest in the developed world—were not heeded.

Even if we’d responded a few weeks earlier to the World Health Organization’s declarations of coronavirus as a public health emergency and then a pandemic,3 those gaps in capacity, stocks, and the ability to scale up quickly would always have been exposed. South East Asian nations and Germany already had the necessary infrastructure, or flexible links with the biotechnology sector, that enabled them to react more quickly.45

In England, since the 2010 election we’ve also seen sustained cuts to funding of local government (where directors of public health and their teams have sat since the 2012 Health and Social Care Act), to the public health grant, budgets, and staffing, impairing local capacity to respond to a pandemic with case identification and contact tracing.67

Arguably, Public Health England (also legislated into existence in 2012) is now heavily centralised and has at times during the pandemic proved too rigid and controlling, sometimes reactive and slow off the mark—for instance, over guidance on transfers from hospital to care homes or on PPE. Its credibility has been harmed by this and by seeming too close to politicians in government communications.

Furthermore, England’s hospital bed base is among the lowest per 1000 population among OECD nations, and hospitals were already running far too close to capacity—with endemic overcrowding, long waits in emergency departments, and increasing numbers of beds put out of action by delayed care transfers due to poor capacity in social and community health services.8

Funding and workforce

Social care has been subjected to a sustained attack on funding since 2010. The care home service has struggled for viability and funding. And home care has lacked staff, with immigration policy worsening the situation and around one in eight vacancies unfilled. We have no more care home places now than in 2010, and 400 000 fewer people receive home care.910

Although many models of enhanced NHS support for care homes have been successful and independent evaluations are showing their benefits, residents have consistently faced problems in accessing input from community health services, and wrangles persist over unrealistic expectations in the GP contract for input from primary care.1112

Meanwhile, before we’d even heard of covid-19, the NHS was struggling with big workforce shortages. One in eight nursing posts and one in 12 medical posts were unfilled, and this was more pressing still in some specialties or regions. Burnout and attrition were becoming endemic. Key groups, such as community nurses and health visitors, had been subjected to sustained cuts.13

Although a hostile immigration policy and an unsettling atmosphere from Brexit have increasingly deterred staff from coming to the UK, one in seven clinical staff trained overseas. During the pandemic these staff have paid for their service in blood—just look at the body count.14

Despite the many success stories of the frontline NHS and social care response to the pandemic, so many of the problems we’ve witnessed have their roots in the structural problems that those of us who work in services, and who watch health policy closely, knew were hiding in plain sight. The pandemic has put them centre stage, and once it’s over they need to be tackled with effective and sustained action, to avoid a repeat when pandemic time comes around again.



View Abstract