Civil servants, experts and ministers were responsible for a degree of "groupthink" about the nature of threats to the UK that hampered the response to the coronavirus pandemic, the Covid Inquiry has concluded.
The inquiry's first report on its investigations into the handling of Covid 19 said that on balance it believed groupthink – which is the phenomenon of people in a group thinking about things in the same way – was a "systemic flaw" in the UK's pandemic response.
The panel, chaired by former Court of Appeal judge Baroness Heather Hallett, also said that churn among civil servants and ministers in government caused a loss of institutional memory about civil contingency exercises that was a further hindrance.
Hallett's module 1 report said the team had "no hesitation in concluding that the processes, planning and policy of the civil contingency structures within the UK government and devolved administrations and civil services failed their citizens".
The report said there had been a failure to treat the emergence Covid-19 as a "whole-system" emergency and that the "wrong" pandemic had been prepared for.
Hallett's principal recommendation was the creation of a single, independent statutory body responsible for whole-system preparedness and response.
The module 1 report acknowledged that while some former senior figures in government – including ex-PM David Cameron, former chancellor George Osborne and former Cabinet Office minister Oliver Letwin – had referenced groupthink in government as part of the problem, others had not. The report identified UK Health Security Agency chief executive Prof Dame Jenny Harries among those who had rejected the idea.
Nevertheless, the panel concluded that groupthink had played a part in the "wrong" consensus being reached between the Cabinet Office, the Department of Health and Social Care and devolved administrations on key points. Those points were the view that the UK was "well prepared for a pandemic", that preparing for pandemic influenza would be "sufficient", and that advance consideration of non-pharmaceutical interventions to mitigate the effects of a pandemic was not necessary.
In particular, the report singled out evidence from Duncan Selbie, former chief executive of the now-abolished Public Health England, who said the organisation had only ever planned for pandemic testing for "numbers in the few hundreds", rather than mass testing.
The report said: "This was notwithstanding that it was Public Health England’s stated remit to be the expert national public health agency whose first function was to fulfil the secretary of state for health and social care’s duty to protect the public from infectious diseases and to be responsible for providing the national infrastructure for health protection, including the investigation and management of outbreaks of infectious diseases."
The report said the failure to consider such issues adequately appeared to be "at least in part, the result of groupthink".
"Either no one had thought about them, or no one was able to cause a sufficient number of others within the system to think and do something about them – a combination of groupthink and a failure to challenge the consensus proactively," the report said.
The report added that its concerns about groupthink were not limited to the expert groups that advised the UK government on preparedness.
"This was a systemic flaw," the report said. " That is not to say that no one bears responsibility: It applied to officials, experts and ministers alike. Everyone involved with pandemic preparedness bears some responsibility, but it is principally those who led the organisations responsible for emergency preparedness, resilience and response who were at fault."
The module 1 report's recommendations include calling for increase use of so-called "red teams", with Hallett calling for the civil service required to regularly bring in external experts to "scrutinise and challenge" its emergency-planning resilience.
Combatting institutional memory loss
The report said a block to pandemic-time action was the loss of institutional memory – among both officials and ministers – that was caused by churn.
It said that understanding lessons from the past and retaining knowledge about previous failures contributed to more effective decision-making and helped to prevent the repetition of similar mistakes – as well as fostering innovation and continuous improvement.
A further recommendation is the creation of a central online "repository" of information related to civil-emergency exercises, "including all exercise reports and emergency guidance".
The proposal is designed to give civil servants with an interest in pandemic preparedness and response quick, open access to preserved institutional information – removing the need to embark on "wasteful parallel processes".
"This repository should be accessible to, among others, the devolved administrations, local and regional tiers of government, and those in the voluntary and community sectors," the report said.
The recommendation requires the UK and devolved governments to produce a report summarising the findings, lessons and recommendations of relevant exercises within three months of their conclusion – unless there are national security reasons not to do so.
Relevant organisations should also publish action plans setting out specific steps that will be taken in response to each report's findings within six months.