🤦 The Machinery of Hope in Crisis: What the UK Inquiry Teaches Us About Building Better Systems

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There is a moment, inevitable in any prolonged crisis, when you realize that the structures holding everything together were not built for this. They were built for normal times—for the manageable friction of everyday governance, the predictable choreography of departmental silos, the comfortable assumption that someone, somewhere, has a plan.

The UK’s COVID-19 Inquiry reveals something more unsettling: sometimes there is no plan. Or rather, there is a plan—several, actually—but they’re tucked away in different filing cabinets, written in different languages, and most crucially, never speak to each other until the moment when silence becomes catastrophic.

This is not a story of malice. It’s a story of structures that failed precisely because they were designed for peace, not for plague. And that distinction matters.

Core decision-making and political governance: COVID-19 Public inquiry UK M2 V2 

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Transcript

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the debates, the friction between the four nations. That is precisely what we're diving into today. Our sources take us deep inside that engine room. We are moving beyond the public story to look at the inner workings, the institutional stresses, and critically, the fractures of the UK's four nations' response. And the sources for this deep dive are just incredibly detailed. We're working primarily with volume two of the UK COVID-19 inquiry, which pulled together evidence from, well, everywhere, the UK government, Scotland, Wales, and Northern Ireland. And this isn't just about listing what happened. It's about looking at the institutional anatomy, you know, exposing the reality of governance when it's under that kind of extreme stress. Exactly. So our mission here is a really detailed exploration of the friction points the inquiry found. Things like how scientific consensus was built or maybe forced. where the push for centralization didn't work and how these massive data gaps and a real failure of foresight led to so much disproportionate suffering for vulnerable people. We're basically uncovering the chaotic structural flaws that the whole crisis laid bare. So let's start at the very top of that scientific advice structure in the And crucially, it's a UK-wide role. He reports directly to the cabinet secretary, and his job was very clearly defined, provide scientific advice to the prime minister and the cabinet. So not telling them what to do, but making sure they understood the science behind the choices. Precisely. It's science for policy, not science policy itself. He wasn't advising on, say, research funding. He was the expert translator, making sure the people at the top understood the risks and the certainties. And a big part of that, according to the inquiry, was his relationship with the chief medical officer for England. A huge part. The relationship between him and Professor Sir Chris Witte was exceptionally close. The inquiry said their bond was built on considerable mutual trust. They were reportedly speaking several times each day. Wow. Yeah. And they were aligned on the vast majority of the advice. So that mutual confidence at the top meant that coherent, unified scientific advice could get to ministers very quickly. That kind of alignment seems absolutely critical in a crisis. I remember even the former prime minister, Boris Johnson, praised them. He said they did an excellent job of presenting the science. They did. And that was a major functional strength for the UK government. But yeah, and this is a huge but the inquiry found immediately. That this clarity just did not extend smoothly to the devolved nations. GDAs. Exactly. Their advisory structures were often fragmented or, well, just misunderstood by London. Okay, so let's get into that fragmentation. Where did things start to go wrong with identifying the right people in the devolved nations? Wales is a perfect example of this. This institutional confusion. The formal chief scientific advisor for Wales was a professor Peter Halligan. Okay. However, it was Dr. Rob Orford who was the chief scientific advisor for health who was actually leading the vital scientific work for the Welsh government. Ah, so a classic case of mistaken identity at an institutional level. Completely. The UK government mistakenly invited Professor Halligan to the first SAGE meetings, just assuming he was the main health lead. And this lack of clarity about who did what structurally fed directly into the UK government's assumption that Welsh health advice was, you know, sorted. That feels like a pretty fundamental failure from the start, just not understanding how the other nations are set up. What about Northern Ireland? Was it a similar story? Northern Ireland had an even bigger structural problem. It didn't have a cross-government chief scientific advisor at all. Really? None? None. Professor Ian Young was the CSA for the Department of Health, but his actual remit for the pandemic, and I'm quoting here, was not recorded or specified in writing at the outset. And all of this structural confusion, it leads directly to that big, well-known failing with SAGE attendants, right? The scientific advisory group for emergencies. It does. It's shocking, really. Representatives from the devolved administrations were just not invited to the first SAGE meeting in January 2020. Not at all. Not at all. Dr. Orford in Wales actually had to proactively chase them up about it. The inquiry was very clear on this. It led to recommendation two that DA representatives have to be invited from the very outset of any future emergency. It seems obvious in hindsight. It does. But the whole process of them eventually getting a seat at the table lacked clarity and created these huge disparities in who knew what and when. It just fundamentally undermined the idea of a coordinated UK wide response from day one. So how did the inquiry rate these local groups? Were they just duplicating the work of SAGE? No, not at all. They were providing essential local translation. Scotland's group, the C-19 AG, was described as a reliable and effective source of advice for These parallel structures ended up being essential for them to make adaptive decisions on the ground. Okay, so moving from the science to the political decision-making machine in Westminster, the inquiry paints a picture of a system that wasn't just under stress, but was fundamentally unsuited for a crisis list. That's a key takeaway. Absolutely. The first big structural problem was relying on the lead government department model. Which put the Department of Health and Social Care, the DHSC, in charge. Right. And the inquiry found this model was, their words, fatally flawed for a whole system civil emergency. like a pandemic. Oh, I fatally flawed. I mean, you can see the logic. It's a health crisis, so the health department leads. What was so wrong with that? Because a pandemic isn't just a health crisis. It's an everything crisis. It is the economy, education, housing, transport, welfare. Yeah. Everything. The DHSC is good at clinical policy, but it just didn't have the legal power or the expertise to coordinate huge rapid changes across all those other departments. So the response needed to be whole of government, but the structure was still stuck in its silo. Precisely. And that model inevitably just fell apart when the prime minister took over strategic decisions in early March 2020. But even then, the chaos continued. Oh, yes. Even within the central structure run by the Cabinet Office, the performance up to May 2020 was described by one senior witness as just chaotic. And that wasn't just messiness. It was a failure to coordinate, to delegate, to maintain any kind of strategic focus. And the attempt to fix this with these ministerial implementation groups, the MIGs, that's That didn't work either, did it? It seems like it actually made things worse. They were, you could say, structurally doomed from the start. Two main reasons. First, their remits overlapped badly, so time was wasted just figuring out who was in charge of what. And the second reason? This is a classic governance problem. The inquiry concluded that, you know, accountability works much better when the scrutiny comes from outside. On the leadership front, the inquiry really zeroed in on this problem of delay and indecisiveness at the very top. We heard a lot about the prime minister's tendencies, especially that term trolleying. Yes, and this is so critical because of the nature of exponential growth. Dominic Cummings described the prime minister's tendency to trolley, to just constantly bounce back and forth, changing strategic direction every day, according to who he spoke to last. So policy was essentially being decided on the fly. Right. Not based on a consistent, clear strategy. And that instability has devastating consequences when time is your most precious resource. How did the inquiry actually quantify the cost of that delay? Well, the most glaring example was the decision on the second lockdown. It was delayed until October 31st, 2020. Experts had first advised restrictions six weeks earlier. Six weeks? Six weeks. In a pandemic where cases are doubling every few days, that delay meant millions of extra infections and thousands of avoidable deaths. The inquiry made the point very clearly. Not acting quickly is a decision, and it's often a decision with far greater harms. So if the internal UK government was chaotic, the report shows that adding the devolutionary strain on top just made it all so much more politically complex. The strain was pervasive, and it was almost entirely political. Leaders of the devolved administrations, Nicholas Sturgeon in Scotland, Mark Drakeford in Wales, they consistently felt that the COBIR meetings were just performative. TOBR being the National Crisis Management Committee. Right. They felt it was just there to formally approve decisions the UK government had already made. The dysfunction in Northern Ireland was extreme because of the power sharing arrangements in these very siloed departments. Ministers had never clarified what the executive committee's role would even be in a pandemic before it happened. So they were figuring out who was in charge weeks into the first lockdown. Exactly. Basic questions about where the political center was were still being asked in late March 2020. And this structural division just boiled over when they had to make tough calls on restrictions. It really did. The most extreme example was the vote on restrictions in November 2020. The Department of Health proposed extending them based on CMO advice, and the whole thing just devolved into a political vote straight down party lines. So the science was overridden by politics. Completely. Democratic Unionist Party ministers blocked a two-week extension using a cross-community vote. And this incident was, according to multiple witnesses, almost universally regarded as one of the lowest points of the entire pandemic response in Northern Ireland. The inquiry was unequivocal. That level of dysfunction can never be allowed to happen again. Let's circle back to the scientific structure for a moment and Sage's approach to consensus. The goal was admirable, you know, present in the United Front, but the inquiry found it came at a pretty significant cost. It did. Sage's formal goal was always to find a single integrated view of the science. The idea was to avoid confusing ministers with lots of competing opinions. Which makes sense in a crisis. Decision makers want a clear line. Of course. And Professor Medley estimated the delay this caused, getting different experts to agree, was... The risk, as Professor Woolhouse pointed out, was that just reporting the majority view could give an impression of groupthink to the political leaders. So they weren't getting the full picture. No. He confirmed that minority views were not always communicated to officials and ministers. So the decision makers were often shielded from the very real debate and uncertainty the scientists themselves were grappling with. So what's the recommendation to fix that for next time? The inquiry says future SAGE Minutes have to clearly state the level of confidence in the advice and explicitly highlight any uncertainties or minority views. It's about transparency. Now, once that advice was handed over to the government, it seems it just vanished into what the scientists called an advisory black hole. This was a major, major point of frustration for them. The information flow was strictly one way. This was deliberate. Professors Vallance and Witte were, quote, scrupulous about not reporting back discussions held within central government to SAGE. Why? To protect the science from political influence. That was the idea. To protect the integrity of the process. But it created this operational vacuum. The advisors would submit their work and then nothing. So they had no idea if it was being used or maybe ignored or misunderstood? Correct. As Professor Rubin put it, the advice often appeared to disappear into a black hole. Yeah. Became a matter of guesswork as to what decisions have been affected by sage advice. That must have been incredibly difficult. Professor Valance himself admitted it was a failure on their part. He said they could have been better at feeding back because without that feedback, the scientists couldn't provide useful, targeted advice. They didn't know what the government's policy constraints were. They were just operating in a vacuum. Speaking of missing information, one of the most glaring issues the inquiry highlighted was the total failure to properly model the economic consequences of the interventions. Right. Claire Lombardelli, the Treasury's chief economic advisor, confirmed it simply was not possible to meaningfully model the overall economic cost of lockdown. That's just astonishing. If you can't model the economic costs, then the strategic decisions become, well, they become polarized. Almost ideological. That is exactly what happened. Because the data was missing, decision-making became this zero-sum tug-of-war, as one witness put it, between health protection, championed by Matt Hancock, and economy protection, championed by Rishi Sunak. So instead of being presented with nuanced tradeoffs like option A saves X lives and costs Y billion, they were just presented with two extremes. Right. And if we connect that back to the trolling problem we talked about, it means the prime minister wasn't just bouncing between people. He was bouncing between these two poles. Because the lack of integrated modeling forced that polarization. The government's own structure amplified the leadership problem. Wow. And finally, on this, we have to talk about how a lot of these key decisions were actually made, which was way outside the formal record, the whole government by WhatsApp issue. Yes. Despite the former prime minister denying it, the evidence was overwhelming. Key strategic discussions from new interventions to a circuit breaker lockdown. They all happened on instant messaging platforms. WhatsApp, iMessages. Even Twitter DMs. And this is happening across all four nations. And while that's how people communicate in a crisis, it's a disaster for accountability, right? It completely bypasses the formal recording system. It creates huge problems for the public record. In Wales, for example, the policy was that you were supposed to save those messages. But concerns are made that people were using private channels specifically to get around that, to keep things off the official record. It's fast, but it completely jeopardizes transparency. This next chapter is, I think, arguably the most sobering part of the inquiry's findings. They had to make space and quickly. But the policy was fundamentally undermined, not by bad intentions, but by a total lack of capacity and poor planning. It was the testing, wasn't it? Yes. The failure was inadequate planning and just a severe lack of testing capacity in those early months. Former First Minister Nicola Sturgeon later conceded it was a profound mistake. Michelle O'Neill in Northern Ireland said the lack of testing did not serve those residents of care homes well. So in the rush to save the hospitals, they inadvertently ceded the virus into the most vulnerable settings imaginable. That's what happened. The policy eventually shifted in April 2020 across all four nations to mandate pre-discharge testing. But that was only once the testing capacity had finally been built up. In Wales, for instance, the new rule was confirmed on April 22nd. It was a reactive change, triggered by tragedy, not by foresight. And beyond the care homes, the inquiry uncovered a systemic failure to protect disabled people. Yes, a group who are already more likely to be in poverty, in poor housing, and at greater risk of isolation. And the timeline here is just one of the most damning details in the entire report. When did they finally get considered at a high level? It took until May 21st, 2020, for the position of disabled people to be formally considered at an interministerial level. May 21st. That's two months into the first lockdown, after the first wave had already peaked. Exactly. Two months before, the specific critical risks to this huge part of the population were finally being formally addressed. And the consequence, according to groups like Disability Wales, was that disabled people felt that society was changing without them. Reasonable adjustments were few and far between. It seems like a complete failure of institutional imagination. The inquiry said ministers should have had access to expert advice informed by disabled people themselves right from January 2020. The problems with data collection also meant that the disproportionate impact on ethnic minority groups was known early on, but it wasn't acted on quickly. This was made so much worse by systemic data gaps. Ethnicity data was often poorly or confusingly captured. And a huge failure was in death registration. At the time, only Scotland collected ethnicity data on death certificates. Really? So the other nations couldn't even accurately track the deaths in different communities? Not quickly or accurately, no. Which delayed the necessary targeted policy responses. And even when the early signs of disproportionate risk did emerge in April 2020, the action was still too slow. Why was that? Well, the inquiry notes that part of the problem was that those most at risk were often key workers in jobs upon which communities depended. They couldn't just shield or work from home. The response was reactive, not proactive. Finally, let's talk about the indirect harms, the things that weren't showing up on the daily dashboards. This points to a really severe systemic focus on only what you can measure immediately. Decision makers were fixated on the daily epidemiological data, and they neglected the longer-term, non-quantifiable societal impacts. And children were a huge part of that. A huge part. Michael Gove himself accepted that the UK government did not pay enough attention to the impact particularly on children. The decision to close schools, for example, which has profound consequences, was made in Wales without any formal impact assessment. And then there was the Rule of Six. Right. England didn't grant exemptions for children, unlike Wales and Scotland. And the reason given for England's choice was for clarity and simplicity in the rules. So simplicity was prioritized over child welfare. Even when Sage was pushing for the exemption, it's a stark example of priorities. And what about the risk of domestic abuse, something that was obviously going to increase during a lockdown? Ellen McNamara, the deputy cabinet secretary, gave powerful evidence on this. She said it was far too difficult to get people to pay attention to domestic violence because it was not showing up in the data that senior decision makers were looking at. The dashboard was silent. It was. And it took, her words, relentless pushing by a female private secretary in number 10 to even get the Hidden Harm Summit on the agenda in May 2020. That is just a damning indictment of what the system was set up to see and what it was blind. to. It shows that obvious foreseeable human costs that weren't in the clinical data were just ignored until one person fought to get them seen. It is a complete failure to apply a whole system perspective. Okay, let's move on to communication. This is the interface between the science, the policy, and all of us. Early on, the government had a clear success with its messaging, didn't it? But it came with a sting in the tail. It did. The initial Stay Home, Protect our NHS, Save Lives campaign was brilliant. It was simple, precise, and it worked. It maximized compliance. However, the Protect the NHS part led to this unintended overcompliance. And the inquiry found this change immediately made the messaging less clear and more abstract. What does stay alert even mean in practice? Well, that's the point. It's subjective. It's hard to turn into a specific action, especially when you compare it to the hard command of stay home. An expert from the Scottish government noted that messaging works best when it's clear and precise. This was a major misstep. There was also that huge blind spot in the messaging around the science of transmission. Everyone remembers hands, face, space. But what crucial element was missing for so long? Ventilation. Ventilation. Sage had endorsed the importance of good ventilation by July 2020. It was becoming clear that airborne transmission was a massive risk, especially indoors. Yet the famous Hands Face Space campaign launched in September 2020 completely left it out. It feels like institutional inertia. They had a catchy slogan and just stuck with it. It seems so. And when did that vital piece of advice finally get added? Much, much later. March 2021. That's when the campaign was finally changed to include fresh air. That lag meant businesses, schools, everyone were not being properly advised on a crucial mitigation for the better part of a year. So beyond the messaging, the legislation itself was a mess. It created this confusing, often unjust environment for everyone. The whole legislative response relied on complex, constantly changing secondary legislation. It was often introduced with little advance notice, and sometimes it changed day to day. I remember the former Home Secretary, Dame Priti Patel, was very critical. She described the drafting process as suboptimal at every single level. She strongly advocated for a much simpler legislative approach for any future emergency. And that lack of legal clarity was made worse by ministers blurring the lines between what was just advice and what was actually the law. That was a huge problem. Ministers often failed to carefully distinguish between advice, guidance, and law. They used the word should, and the public naturally would hear must. It led to so much confusion. And this legal vagueness fed directly into serious problems with enforcement, particularly with fixed penalty notices. or FPNs. The complexity led to inconsistent enforcement and a really high error rate in the FPNs that were reviewed. The police themselves were struggling to interpret the rapid rule changes. Officers were charging people under the wrong regulations or under rules that had already been repealed. And these FPNs, crucially, were handed out disproportionately to certain groups. They were. The data showed clear disproportionality. In the early stages in England, people from ethnic minorities were 1.6 times more likely to get an FPN than white people. The data over the full period confirmed that FPNs were disproportionately issued to young people, men, and people from ethnic minorities. And there was no easy way to appeal them. Right. And given the high error rate, the inquiry said the lack of an established formal appeal process was unacceptable. The pandemic exposed a kind of structural chaos and a real lack of foresight. The UK's reliance on that centralized DHSC-led department model was, as the inquiry said, fatally flawed. And in Northern Ireland, it was just paralyzed by politics. Exactly. Well, the inquiry provided several vital lessons. Listen four is about establishing a framework for decisions that sets out clear, pre-agreed criteria for how you escalate or de-escalate interventions. So you're not making it up as you go along. Right. And that framework has to be based on explicit principles. Early action saves lives and, quote, may more generally reduce the financial, economic and societal costs of letting the emergency grow. Political hesitation is fiscally irresponsible and morally costly. The ultimate takeaway for me, though, is maybe the most unsettling fact in the whole volume. It speaks volumes about preparedness at the absolute highest level. You're talking about the leadership contingency planning or the lack of it. Exactly. When the prime minister got sick with COVID-19, the plan in place, which was basically that he had verbally told the first secretary of state to deputize for him. The key decision on the first lockdown had already been made. If the prime minister had been incapacitated a few weeks earlier before that decision was made, the implications would have been catastrophic. And that leads us to our final provocative thought for you to consider. The inquiry found that political leaders failed to ensure the most basic structures. A clear strategy, impact assessments, succession plans were in place before the crisis hit. So if our institutional leaders relied on fortune over foresight, what structures can you put in place now in your own life, your business, your community to ensure that foresight and not just dumb luck determines your readiness for the next unpredictable challenge? That requires deliberate planning, not just hoping for the best. And that's a deep dive for today. Thank you for joining us. We will be back soon with more deep dives into the evidence that shapes our understanding of the world.