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The fragility of the UK’s hospital and public laboratory systems

Academics from Alliance Manchester Business School have co-authored a hard-hitting report on what went wrong in the early stages of the COVID-19 pandemic and what lessons can now be learnt for the future.

The When Systems Fail report from the Foundational Economy Collective not only looks at the initial response of NHS acute hospitals and public laboratories to the crisis, but explores the deeper causes of failures in specific services which proliferated into unanticipated and uncontrolled large-scale breakdowns.

Report co-author Professor Karel Williams from Alliance MBS, said: “The media and opposition politicians have offered two kinds of explanations for what went wrong. Their analysis tends to centre on ‘we name the guilty men’ or ‘this arrow indicates the defective part’. Both are partly true because there were policy mistakes and systems like track and trace have not been working effectively.

“But our report engages in more fundamental issues, outlining how fragility was built into the UK’s hospital and public laboratory systems so that the COVID-19 crisis was an accident waiting to happen. What science and technology studies would call a ‘normal accident’ which is inevitable given system design.”


The report says the first reason for fragility was that the hospital system was already so tightly stretched that it did not have the buffer capacity needed to absorb a pandemic surge. Hence hospital beds had to be cleared by discharging untested patients into care homes and most non-COVID treatments had to be halted. Secondly, the public health laboratory system lacked the organisational capacity to respond to unexpected circumstances.

It says this double fragility was unintentionally caused by a combination of long-term funding shortages and a process that political scientists call ‘hyper-innovation’.
Added Professor Williams: “Austerity was important, but so too was a 30-year period of continuing organisational churn imposed on the NHS and public health in the name of public sector reform. Hyper-innovation hollowed out our health services and eroded their capacity to respond to emergencies in adaptable and resilient ways.”

Beyond this critique, the report addresses remedies and the question of how to rebuild so that we have more robust health systems, and more generally can re-skill the state so that it does not default onto distress outsourcing whenever it wants quick results.

Professor Williams says recovering from a condition of chronic incapacity will be very difficult. “The report shows that this will demand much greater funding than is recognised by any of the major political parties. It will also require a new approach which we term the ‘careful practice of policy’, which recognises the limits of the top-down approach to policymaking that has been dominant for three decades.”

Careful policymaking

The report concludes by exploring what such careful policymaking might look like in practice. It says the first pre-requisite is to broaden the frame of public political debate which has, for decades, been more or less exclusively concerned with the issue of NHS funding and questions about the role of private service providers within a publicly funded service. It adds that a fixation on the issue of funding and the role of private providers is crowding out discussion of other issues that are equally important to health and to other public services.

Adds Professor Williams: “Fundamentally, what this report criticises is not specific policies but a health policy process where it is assumed that effectiveness can be achieved through control and top-down redesign which specifies structures and mechanisms.

“What we need is an alternative model for thinking about how policy is made. This alternative is a careful process of policymaking that is modest, experimental, iterative, revisable and consultative as it crystallises concerns, specifies these as problems, and seeks possible solutions to those problems. COVID-19 gives us the motive and the opportunity to rethink the health system.”

*The report was based on independent research by academics in the first three months of the UK lockdown. Professors Julie Froud and Karel Williams from Alliance MBS worked on the report, alongside academics from Queen Mary University of London and the Open University. All academics are members of a European academic network, the Foundational Economy Collective.