Inquiry Recommendations

The governments of the UK, Scotland, Wales and Northern Ireland should each simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil emergencies.

The core structures should be:

• a single Cabinet-level or equivalent ministerial committee (including the senior minister responsible for health and social care) responsible for whole-system civil emergency preparedness and resilience for each government, which meets regularly and is chaired by the leader or deputy leader of the relevant government; and
• a single cross-departmental group of senior officials in each government (which reports regularly to the Cabinet-level or equivalent ministerial committee) to oversee and implement policy on civil emergency preparedness and resilience.

This should be put in place within 12 months of the publication of this Report.

Within 6 months of the creation of the group of senior officials, it should complete a review to simplify and reduce the number of structures responsible for whole- system civil emergency preparedness and resilience.

Subsequently, within 24 months of the publication of this Report, the ministerial committee should rationalise and streamline subordinate or supporting groups and committees responsible for whole-system civil emergency preparedness and resilience. Any groups and committees retained or created to support this core structure should have a clear purpose and should report regularly about progress with, and completion of, tasks assigned to them.

The UK government and devolved administrations should work together on developing a new approach to risk assessment that moves away from a reliance on single reasonable worst-case scenarios towards an approach that:

• assesses a wider range of scenarios representative of the different risks and the range of each kind of risk;
• considers the prevention and mitigation of an emergency in addition to dealing with its consequences;
• provides a full analysis of the ways in which the combined impacts of different risks may complicate or worsen an emergency;
• assesses long-term risks in addition to short-term risks and considers how they may interact with each other;
• undertakes an assessment of the impact of each risk on vulnerable people; and
• takes into account the capacity and capabilities of the UK.

In doing so, the UK government and devolved administrations should perform risk assessments that reflect the circumstances and characteristics particular to England, Wales, Scotland, Northern Ireland and the UK as a whole.

The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects.

As a minimum, the strategy should:

• be adaptable;
• include sections dedicated to each potential whole-system civil emergency – for example, one on pandemics with a clear explanation of the roles and responsibilities of the UK government, devolved administrations and their departments/directorates as well as local responders;
• consider a wide range of potential scenarios for each type of emergency;
• identify the key issues and set out a range of potential responses;
• identify how the strategy is to be applied to ensure that any potential responses are proportionate to the particular circumstances of the emergency;
• include an assessment in the short, medium and long term, based on published modelling, of the potential health, social and economic impacts of the emergency and of potential responses to the emergency on the population and, in particular, on vulnerable people; and
• include an assessment of the infrastructure, technology and skills the UK needs to respond effectively to the emergency and how those needs might change for different scenarios.

The strategy should be subject to a substantive reassessment at least every three years to ensure that it is up to date and effective, incorporating lessons learned between reassessments.

The UK government, working with the devolved administrations, should establish mechanisms for the timely collection, analysis, secure sharing and use of reliable data for informing emergency responses, in advance of future pandemics. Data systems should be tested in pandemic exercises.

The UK government should also commission a wider range of research projects ready to commence in the event of a future pandemic. These could be ‘hibernated’ studies or existing studies that are designed to be rapidly adapted to a new outbreak. Better working with international partners should be encouraged. This should include projects to:

• understand the prevalence of a new virus;
• measure the effectiveness of a range of different public health measures; and
• identify which groups of vulnerable people are hardest hit by the pandemic and why.

The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years.

The exercise should:

• test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak to multiple waves over a number of years;
• include a broad range of those involved in pandemic preparedness and response; and
• consider how a broad range of vulnerable people will be helped in the event of a pandemic.

For all civil emergency exercises, the governments of the UK, Scotland, Wales and Northern Ireland should each (unless there are reasons of national security for not doing so):

• publish an exercise report summarising the findings, lessons and recommendations, within three months of the conclusion of the exercise;
• publish an action plan setting out the specific steps that will be taken in response to the report’s findings, and by which entity, within six months of the conclusion of the exercise; and
• keep exercise reports, action plans, and emergency plans and guidance from across the UK in a single, UK-wide online archive, accessible to all involved in emergency preparedness, resilience and response.

The governments of the UK, Scotland, Wales and Northern Ireland should each produce and publish reports to their respective legislatures at least every three years on whole-system civil emergency preparedness and resilience.

The reports should include as a minimum:

• the risks that each government has identified are likely to result in whole-system civil emergencies;
• the recommendations that have been made to each government to mitigate those risks, and whether these recommendations have been accepted or rejected;
• a cost–benefit analysis setting out the economic and social costs of accepting the risks as against taking action to mitigate the risks;
• who may be vulnerable to the risks and what steps are being taken to mitigate those risks;
• a plan setting out the timescales for implementing the recommendations that have been accepted; and
• an update on the progress that has been made on implementing previously accepted recommendations.

The governments of the UK, Scotland, Wales and Northern Ireland should each introduce the use of red teams in the Civil Service to scrutinise and challenge the principles, evidence, policies and advice relating to preparedness for and resilience to whole-system civil emergencies. The red teams should be brought in from outside of government and the Civil Service.

The UK government should, in consultation with the devolved administrations, create a statutory independent body for whole-system civil emergency preparedness and resilience.

The new body should be given responsibility for:

• providing independent, strategic advice to the UK government and devolved administrations on their planning for, preparedness for and building resilience to whole-system civil emergencies;
• consulting with the voluntary, community and social enterprise sector at a national and local level and directors of public health on the protection of vulnerable people in whole-system civil emergencies;
• assessing the state of planning for, preparedness for and resilience to whole-system civil emergencies across the UK; and
• making recommendations on the capacity and capabilities that will be required to prepare for and build resilience to whole-system civil emergencies.

As an interim measure, the new body should be established on a non-statutory basis within 12 months of this Report, so that it may begin its work in advance of legislation being passed.

The Department of Health (Northern Ireland) should reconstitute the role of the Chief Medical Officer for Northern Ireland as an independent advisory role. The Chief Medical Officer for Northern Ireland should not have managerial responsibilities within the Department of Health (Northern Ireland).

The Government Office for Science (GO-Science) should develop and maintain a register of experts across the four nations of the UK who would be willing to participate in scientific advisory groups, covering a broad range of potential civil emergencies.

During a whole-system civil emergency, the UK government and devolved administrations should each routinely publish technical advice on scientific, economic and social matters at the earliest opportunity, as well as the minutes of expert advisory groups – except where there are good reasons that prevent publication, such as commercial confidentiality, personal safety or national security, or because legal advice privilege applies.

The Government Office for Science (GO-Science), the Scottish Government, the Welsh Government and the Department of Health (Northern Ireland) should each develop standard terms of appointment for all participants in scientific advisory groups. These terms should include:

• clarity around the nature of an individual’s role and the extent of their responsibility, as well as the likely time commitment;
• payment where their time commitment means that they have to spend time away from their substantive role;
• access to support services; and access to advice on personal and online security, with procedures for escalating specific concerns.

The UK government should bring into force in England section 1 of the Equality Act 2010, implementing the socio-economic duty.

The Northern Ireland Assembly and Northern Ireland Executive should consider an equivalent provision within section 75 of the Northern Ireland Act 1998.

The UK government should introduce legislation to place child rights impact assessments on a statutory footing in England.

The Northern Ireland Executive should consider an equivalent provision.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should each agree a framework that identifies people who would be most at risk of becoming infected by and dying from a disease and those who are most likely to be negatively impacted by any steps taken to respond to a future pandemic. The framework should set out the specific steps that could be taken to mitigate the risks to these people.

Equality impact assessments should form part of this framework. Where they cannot be undertaken in a national crisis, they should be reinstated as soon as possible.

Each government should agree and publish in its response to this Report how it will ensure that this framework is embedded into emergency decision-making and who will be responsible for ensuring these issues remain under consideration throughout a national crisis.

The Northern Ireland Executive and UK government (in consultation with the Irish government where necessary) should review the structures and delegated powers of government in Northern Ireland to consider:

• the empowerment of the First Minister and deputy First Minister jointly to direct the work of other ministers and departments during an emergency;

• the empowerment of the Head of the Northern Ireland Civil Service in relation to the allocation of civil servants to departments or to civil contingency structures during an emergency; and

• how decisions that would usually be subject to ministerial approval would be taken should an emergency occur during the suspension of power-sharing arrangements.

The UK government and devolved administrations should set out in future pandemic preparedness strategies (see the Inquiry’s Module 1 Report, Recommendation 4) how decision-making will work in a future pandemic.

This should include provision for COBR to be used as the initial response structure and set out how the UK government and devolved administrations will transition from managing a pandemic through COBR to managing it through separate arrangements in each nation when it becomes clear that the  emergency will be longer-term.

It should include provision for longer-term decision-making structures in the UK government which consist of:

• a strategy group to set the overall approach to each stage of the pandemic and take decisions on major interventions (eg entering and exiting lockdown); and

• an operational group to take decisions on the implementation of the agreed strategy throughout the pandemic.

The design of these structures should include an outline of decision-making procedures for each group.

The strategy should make express provision for the involvement of the UK Cabinet in the decision-making of the strategy and operational groups.

It should also provide that longer-term decision-making should be conducted primarily by the UK, Scottish and Welsh Cabinets and the Northern Ireland

Executive.

Decision-making groups in each nation should include a minister with responsibility for representing the interests of vulnerable groups. In the UK government, the Minister for Women and Equalities may be the most appropriate minister in this regard.

The UK government and the devolved administrations should each establish formal arrangements for covering the roles of Prime Minister and First Minister (and in Northern Ireland, deputy First Minister) as applicable during a whole-system civil emergency, should the incumbent be unable to undertake their duties for any reason.

The response to a future whole-system civil emergency should be coordinated via central taskforces in each of the UK, Scotland, Wales and Northern Ireland, with responsibility for the commissioning and synthesis of advice, coordination of a single data picture and facilitation of decision-making processes. In preparation, the UK government and the devolved administrations should each design the operating procedures for these taskforces, including, but not limited to, identifying the key roles needed to run the taskforces and how those roles would be appointed.

The UK government should also identify the role of its taskforce in supporting decision-making procedures within the strategy and operational decision-making structures.

These arrangements should be incorporated into future pandemic preparedness strategies (see the Inquiry’s Module 1 Report, Recommendation 4).

The Executive Office should amend the Ministerial Code to impose a duty of confidentiality on ministers that prohibits the disclosure of the individual views of ministers expressed during meetings of the Northern Ireland Executive Committee.

The UK government and the devolved administrations should each develop action plans for how government communications will be made more accessible during a pandemic.

As a minimum, these should include making provision for the translation of government press conferences into British Sign Language (and Irish Sign Language in Northern Ireland) and the translation of key announcements into the most frequently spoken languages in the UK.

The UK government and devolved administrations should ensure that the draft affirmative procedure is the standard process for enacting substantial and wide- ranging powers in a civil emergency, such as a pandemic, under primary public health legislation.

Any departure from this procedure should be the exception, with clear criteria and safeguards in place to prevent the bypassing of parliamentary scrutiny. These safeguards should include:

• ‘sunset clauses’ for regulations made using the made affirmative procedure, specifying a clear expiration date, typically within two months; and

• a duty on ministers to report to their respective legislatures every two months on the exercise of emergency powers.

The UK government should undertake a review of the Civil Contingencies Act 2004 to assess its potential role in managing future civil emergencies, including pandemics, and whether it could be employed as an interim emergency framework until more specific legislation with appropriate parliamentary safeguards is passed.

The review should:

• examine the conditions under which the Civil Contingencies Act 2004 may be invoked in a public health emergency;

• consider any adjustments to the Act’s safeguards, such as the triple lock test or time limits, that would make it more adaptable to pandemics; and

• produce clear guidance on the Act’s application for use in civil emergencies, including pandemics, to support its use as an emergency measure in advance of specific legislation – such as a dedicated pandemic bill – being passed.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should develop an online portal for use in future civil emergencies, where members of the public can access information on the legal restrictions that apply in their area and any associated guidance.

This portal should be easily accessible and its content should be written in straightforward and unambiguous language.

The UK government should invite the devolved administrations, as a matter of standard practice, to nominate relevant ministers and officials to attend COBR meetings in the event of relevant whole-system civil emergencies that have the potential to have UK-wide effects.

While intergovernmental relations should be facilitated through COBR in the initial months of any future pandemic, the UK government and devolved administrations should ensure that a specific four-nations structure, concerning pandemic response, is stood up at the same time as the transition away from COBR to nation-specific decision-making structures. This should meet regularly during a pandemic and be attended by all heads of government.

Arrangements for these four-nations meetings should be incorporated into future pandemic preparedness strategies (see the Inquiry’s Module 1 Report, Recommendation 4).

The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control guidance
for healthcare settings. This body must:

• have clear lines of responsibility and a clear, pre-defined role and remit during a pandemic;
• have multidisciplinary membership, including experts in the science of viral transmission as well as those with clinical expertise;
• ensure that its guidance accounts for the risk of all plausible routes of transmission until sufficient evidence emerges to rule out specific routes; and
• ensure that guidance clearly explains the underlying rationale for the precautions recommended.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with employers, including health boards and trusts, to review the availability of qualified fit testers and take steps to increase the number of fit testers accordingly. Availability should be reviewed every three years in line with the Inquiry’s Module 1 Report (Recommendation 4).

The Health and Safety Executive and the Health and Safety Executive for Northern Ireland should update their guidance to employers to emphasise the need to ensure that sufficient fit-testing capacity is available.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by:

• improving patient data by enabling more granular diagnostic coding;
• ensuring that care records are compatible across primary and secondary care; and
• enabling secure data-sharing and linkage across multiple health datasets and systems for identifying individuals at high risk.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic.

Plans must ensure that there is sufficient workforce capacity and the ability to surge, including the number and type of staff required, recruitment and training provision.

This should be completed as part of the whole-system civil emergency strategy recommended in the Inquiry’s Module 1 Report (Recommendation 4). Plans should be published and subject to review every three years.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic plans include practical steps to rapidly scale up hospital capacity to treat acutely unwell patients. This should include critical care services that can deliver multiple levels and types of organ support. It should also cover necessary equipment, supplies, space and staff, including redeployment and training.

All trusts and health boards must keep an easily accessible, up-to-date record of the information needed to implement these plans in the hospital sites they operate. This should include technical aspects of critical care expansion such as power, ventilation, oxygen and waste management systems.

Plans for expanding capacity should be published, subject to review every three years and tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6).

The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic.

That framework must:

• be informed by comprehensive engagement with the public and developed in conjunction with professionals across healthcare, law and ethics, as well as with regulators of healthcare professionals;
• set out clearly established triggers for its use, based at least in part on a UK-wide system that measures critical care capacity strain and facilitates mutual aid (such as the CRITCON tool used in England);
• establish clinicians’ legal and professional duties in applying the framework, which should be clearly explained to clinicians through guidance; and
• be regularly reviewed with reference to contemporary patient data during a pandemic, and any future use of it must be evaluated and reported on publicly.

A plan and timeline for completing this work should be published within six months of this Report.

Application of the framework should be tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6).

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in the event of a pandemic outbreak.

The UK Statistics Authority should work with data providers to ensure that the data are comparable across the four nations of the UK.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients’ wishes and preferences for future care and treatment in order to inform individualised decision-making, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices.

The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should cover the nature and level of support that will be provided during and after a pandemic.

All four governments should develop a programme of peer support visits that can, from the outset of a pandemic, be targeted towards areas of acute hospitals under considerable strain. The purpose of the visits should be to support front-line staff, collect insights on the pressures that healthcare workers are facing and understand what further support they might need.