Intended for healthcare professionals


Collective action may be the missing link in the UK’s pandemic performance

BMJ 2022; 379 doi: (Published 01 November 2022) Cite this as: BMJ 2022;379:o2620
  1. Cam Donaldson, Yunus chair and distinguished professor of health economics
  1. Glasgow Caledonian University
  1. cam.donaldson{at}

As the UK lurched from lockdowns to restrictions throughout 2020-21, many people will have felt as though little progress was being made in the fight against covid-19. We kept returning to the basic public health interventions that had saved lives—encouraging handwashing, physical distancing, and mask wearing.

The successes of new treatments for covid-19 and the ongoing vaccination programme point to a key factor missed by successive UK governments in combating the pandemic: the need for collective action. New treatments can be evaluated in robust trials only through the collective efforts of physicians, researchers, research funders, the NHS, and research participants. Vaccinations, too, are best delivered within the collective framework of the NHS.

Beyond that, the UK government seemed incapable of transferring these lessons to other aspects of tackling the pandemic. This even extends to ministers’ apparent inability to utter the phrase “collective action” when interviewed about the pandemic. This could be ideological, resulting in a failure to recognise that collective threats require such collective action. Even in encouraging and praising the efforts of the UK population for essentially individualistic actions such as handwashing, distancing, and mask wearing, the government failed to encourage this with clear messaging.

The UK’s poor international performance regarding covid related mortality is due to many factors, including health inequalities exacerbated by the pandemic that are likely to widen further in the light of public spending cuts, which also require collective action to ameliorate. Beyond these there seems to be nothing in our demography, relative to other countries, to explain our poor position. So, how else might a lack of collective action have contributed?

Local knowledge

The most obvious thing is preparation. Better prepared countries tend to be high spenders on publicly funded health systems, with a significant proportion of that spending allocated to public health. Such systems have the capacity to fight pandemics on multiple, integrated fronts. Successive UK governments have been responsible for eroding total healthcare spending, particularly expenditure on public health, with administrations over the past 12 years being more culpable.

More fundamentally, the UK government has seemed incapable of acting on proven collective approaches to public health, such as the test and trace programme in 2020-21. Such expertise already existed in collectively funded settings of the NHS and environmental health departments in local authorities. The expertise is set up in this way because testing and tracing is very much an activity based on local knowledge and the ability to integrate with other local services. Establishing private contracts at a national level, through providers that lack such expertise and are disconnected from local services and communities, has been nothing short of disastrous, especially when such expertise in the more collective existing entities could simply have been expanded. There have been other examples, too, such as early challenges in procuring personal protective equipment (PPE). How many times did we hear private companies lauded in press conferences, as opposed to the collective efforts of less glamorous and more sustainable options?1

In essence this would seem to indicate that, in policy dealings regarding the pandemic, the UK government has as far as possible privatised the response to the virus. This could, of course, be based on a genuine belief among the government, but it is not evidence based. The latter point is best illustrated by a call way back in March 2020 by Andrew Cuomo, governor of New York, for all parts of the US healthcare system to come together to tackle the pandemic. Despite the US being the world’s highest spender on healthcare its system lacks the potential for integration, and thus collective action, that comes with public funding.

Private insurance, being focused on the care of individuals when they become ill, does not cope well with major public health threats. While failure to recognise this has already cost lives in the US and the UK, the adoption of collective action could yet save many people facing the ongoing challenges of covid-19 or other post-pandemic threats to health.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

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