How UK’s 'best prepared' healthcare system failed to gauge COVID-19

The UK is proud of their public health system and it’s unlike any other country as around 90 percent of British public supports the founding principles of National Health Service. But without accurate data being available to stakeholders in a timely manner, even the most sophisticated health systems can collapse in the globalized world of today.

Just a little over 2 months before the first case of to-be-named COVID-19 was detected, an index called 'Global Health Security Index' ranked the United Kingdom on the second position, trailing only behind the United States, in dealing with a serious outbreak by assessing over 80 factors across six main categories. Several indicators of the index even ranked the UK as the 'best prepared' nation on the planet. Enters COVID-19 and the UK has suffered more than 44,000 deaths and almost 3,00,000 people have been infected by the contagious disease. These developments raise obvious questions on the evaluation criteria of the GHS Index but the failure of the UK in combating the pandemic has also brought to limelight the flaws in its healthcare system.

UK’s first official advice regarding COVID-19 came on January 25 when Foreign and Commonwealth Office advised citizens against traveling to China’s Hubei province which was the original epicenter of the pandemic. The advice came just a day after France reported first cases of COVID-19 in Europe and on the same day as the World Health Organization (WHO) Regional Director for Europe outlined the importance of being prepared to detect and treat infected patients at local as well as national levels.

What followed was a series of debacles as authorities publically undermined the outbreak for several weeks, which lead to a worsening situation in the country. UK had taken a different approach from the beginning when authorities defined COVID-19 symptoms as only a sharp new cough, fever, or shortness of breath instead of eight symptoms listed by the World Health Organization (WHO) in early February. This definition was not updated until May 18 when Britain added a loss of taste and smell to the list of COVID-19 symptoms.

Restricted information flow and lack of testing to communities were other factors that contributed to worsening COVID-19 situation in the UK. Some reports have claimed that Public Health England, one of the agencies that led the country's COVID-19 response, was not allowed to share its surveillance reports with local partners until April and limited information was shared with public health directors.

Instead of utilizing an automated and integrated system for a real-time flow of information, the government also restricted the power of local authorities to inform their communities about the spread of the virus. Health directors of few cities have said that local governments were not allowed to proactively communicate about COVID-19 in the initial stages and everything was being controlled centrally.

A regular flow of accurate information is critical in the context of COVID-19 to prevent misunderstandings about the virus taking hold and more so in remote or small areas within a country where distinct languages prevail.

Authorities have also resisted calls to implement globally-acknowledged “track and trace” efforts on a large scale to combat COVID-19. On March 26, Dr. Jenny Harries, the deputy chief medical officer for England, boasted that not every advice by WHO is applicable to the UK because of its “extremely well-developed public health system in this country.” While addressing a press briefing she said, “we need to realize that the clue with the WHO is in its title – it’s a World Health Organization … And it is addressing all countries across the world, with entirely different health infrastructures … We have an extremely well-developed public health system in this country.”

In mid-March, the UK pivoted the majority of its testing capacity to test people in hospitals with symptoms and contact tracing was reportedly over except in few special cases such as outbreaks in prisons or immigration centers.

Authorities were heavily criticized for lack of progress in expanding COVID-19 testing capacity and senior officials later conceded that the UK hasn’t tested enough. Coronavirus tests were dramatically ramped up from mid-April and the UK recruited thousands of contact tracers to control outbreaks. The country is also developing an app to help contact tracing efforts with the help of smartphones although it has been mired in controversies ever since its announcement.

Initially, the app was supposed to be ready by mid-May but it did not materialize particularly because it was only able to register about 4% of nearby Apple iPhones. In mid-June, the government took a major U-turn saying that it would ditch its home-grown system for making the app that had been in works for several weeks and shift to Apple-Google technology. The app is now expected to be ready by the autumn or winter.

Health information system

An IT-enabled, integrated health information system is critical in the context of a highly contagious disease like COVID-19 because misunderstandings fueled by the 'infodemic' about the disease can have drastic consequences on a country's ability to respond to a pandemic.

The UK has been among the first countries to promote digitization of the healthcare system and its successive governments have launched one initiative after another hoping to build a digital records system that will improve the efficiency of its famed National Health Service. But despite spending nearly 20 years and billions of dollars, weak governance of Health Management Information System has restricted the distribution of critical data to the general public, clinicians, and even policymakers across different levels of government.

NHS Digital is at the center of the UK's health information system and is tasked to standardize, collect, and publish a wide range of health and social care data. Previously called the Health and Social Care Information Centre (HSCIC) until 2016, NHS Digital provides data to NHS and other authorities along with developing information standards that improve the way different parts of the system communicate. The institution is also responsible for setting up new information systems for specific datasets when requested by a pre-defined list of authorities which include NHS, the Secretary of State for Health and Social Care among a few others.

NHS Digital collects data from administrative and management systems but also relies on statistical surveys for specific datasets. On the surface, NHS Digital seems to be managing the country's health data in a seamless manner but as evident during the pandemic, timely distribution of data to stakeholders, including policymakers, remains a painful issue. Legal implications including the strict privacy standards adopted by the country restrict policymakers' ability to access critical health-related information. For instance, a 2015 direction by NHS England requires NHS Digital to provide health data to commissioners of healthcare services but the purpose of the direction also states that "commissioners do not provide direct patient care, they have no legal basis for accessing personal confidential patient information. Therefore, commissioners require an intermediary service that specializes in processing." Apart from the legal implications, several other factors contribute to disruptions in the timely flow of information.

• Political decision-making

While adapting policy response according to the problem in hand is necessary to effectively tackle a problem, excessive room for political decision-making in flow of healthcare data could undermine the effectiveness of Health Management Information Systems during emergencies and lead to uninformed decision-making at national as well as local levels.

Excessive room for political decision-making and the government’s ability to restrict the flow of information to their local counterparts are being termed as one of the biggest pitfalls in the UK’s COVID-19 response. For many weeks during the initial stages of the outbreak, local officials were provided little more information than what the government released for the general public, according to several media reports filed over the past few months.

Public health director from Sandwell, Lisa McNally, said that local officials weren’t provided information like the details of people calling NHS helpline with COVID-19 symptoms that could have helped them undertake special efforts at a local level to contain the spread. A report quoted her saying that the government didn’t even share the models being used by its scientific advisers for COVID-19 and the data that fed them.

British PM Johnson recently announced that the country is moving to “more localized responses” but even then public health directors had complained that they didn’t have access to critical data required to materialize such responses.

Councils at the local level have been asking for real-time information about positive cases, down to the names and contact details of individuals, and failing that by street, postcode, or catchment area of 1,500 people. However, most have only received a daily feed of aggregate community test results for the entire upper tier local authority.

• Interoperability challenges

Interoperability is the ability of computer systems to seamlessly share data in a way that everyone involved understands it in the same way. The interoperability of data is extremely useful for public health professionals to understand the information and make decisions that can improve the efficiency of the healthcare system.

Achieving interoperability of data and IT systems is a longstanding aim in the UK and is essential to achieve current goals for digital transformation, but it will be very challenging to fully achieve because of few counterproductive initiatives. For nearly two decades, the British government has launched one initiative after another to digitize NHS hoping that will improve care. But its clinicians still struggle in digitally accessing medical records of their patients, leading to prolonged waiting times, confused patients, and needlessly repetition of tests and procedures.

While there has been some progress towards achieving interoperability in the UK’s health system, much uncertainty remains. Almost all general practitioners who are independent contractors with the NHS have been using computerized records for many years and they now mainly rely upon one of two popular software systems. But computerizing hospitals in the country has been a rough road which is still far from over. The country has cycled through a series of plans over the past two decades which included repeatedly setting and delaying deadlines for going paperless: 2010, 2020, and most recently 2023.

In a recent strategy to digitalize hospitals, authorities encouraged hospitals to buy their own EHRs, without necessarily focusing on how well those software systems would communicate with others.

• Complex governance arrangement

UK’s health system is divided across several bodies including the NHS, PHE in a complex governance arrangement which is a major reason for the delay in policy response. One such instance that hampered the country’s fight against COVID-19 was the delay in accepting commercially made testing kits.

The government has acknowledged that the UK hadn’t tested enough. Matt Hancock, the health minister, blamed a shortage of lab capacity. But several private kit makers argue that it wasn’t the case. Mark Reed, general manager of a company called Pro-Lab Diagnostics, has said that the government didn’t engage enough with the private companies that were ready to help. Reed and officials from two other diagnostic firms – Novacyt and GeneFirst Ltd – said that PHE evaluations of their testing kits were only completed in mid-to-late March and thus their kits couldn’t have been deployed when the UK needed it the most.

Public Health England, on the other hand, has reportedly said that it wasn’t its job to approve or recommend tests and NHS labs were free to order and validate test kits made by private companies. Heads of three NHS labs have, however, said that they waited for PHE’s evaluation of such kits before using them.

• Maintaining public trust

Maintaining public trust for using their data is essential to achieving the UK's ambitions to digitize its healthcare system. Health information is used both to inform the direct care the patient receives and for planning and policymaking by the government officials. Most developed countries allow the public to opt-out of having their data stored in centralized medical records but the opt-out rate has been low. However, increasing risks and missteps by governments could raise concerns among people and more people could choose to opt-out.

A related risk arises from cybersecurity. The use of aged IT systems makes healthcare data vulnerable to cyber-attack and loss of data. NHS has already been targetted with a widespread cyberattack called WannaCry in 2017 and several trusts under the agency were using outdated IT systems at the time of the attack, including Windows XP - a 17-year-old operating system that was no longer receiving patches from Microsoft. The chaos surrounding the UK’s contact-tracing app could further impact public sentiment.

Conclusion and agenda for discussion

The British are proud of their public health system and it’s unlike any other country as around 90 percent of UK public supports the founding principles of NHS. But without accurate data being available to stakeholders in a timely manner, even the most sophisticated health systems can collapse in the globalized world of today.

Modernizing the NHS has been a headache for the British government despite spending billions of dollars on consecutive initiatives over the past 2 decades. Even though there has been some progress, much uncertainty remains because policymakers and health professionals are still not getting accurate data in a timely manner. The problems are partly because of the complex governance structure and politicization of public healthcare in the UK, which impacts the ability to make quick and informed decisions.

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.