Today Charlie discusses how Exercise Cygnus, the UK's pandemic exercise in 2016, holds up against the ongoing outbreak of COVID-19.
The UK government has had a lot of criticism in the press about them being unprepared to respond to COVID-19, despite the 2019 Global Health Security Index Report in which we were rated as one of the ‘most prepared countries’. There has also been criticism in the press that the lessons of Exercise Cygnus, an exercise which explored the issues of the UK’s pandemic response, had not been learned from and this contributed to our poor response. I thought for this week’s bulletin I would read the report and share some of what I have learnt from reading it, and with 20/20 vision to see if the issues explored and lessons identified align to coronavirus.
Exercise Cygnus was a command post exercise carried out by NHS England in October 2016 in order to estimate the impact of a hypothetical H2N2 influenza pandemic on the United Kingdom. It was conducted over three days and involved 34 different organisations, taking place at national, NHS England, Public Heath England and eight Local Resilience Forums level. It is important to note that the devolved administrations didn’t take part.
I think we have to note that the presumed scenario was very different to the real live incident we have with COVID-19. The scenario was as follows:
- The pandemic has H2M2 which is a flu pandemic, rather than a COVID type pandemic.
- The excess death was presumed to be 430,000 very different to our 33,000+ at the moment.
- For a flu pandemic there are drugs which can be used to treat patients, such as ‘Tamiflu’, which are not available in this situation.
- The rate of staff off sick was set at 30-35%, but it was presumed that once they were well, they would come back to work and there was no assumption of any prolonged lockdown.
- Not including the devolved administrations in the exercise, has led to different messaging in different parts of the UK.
My first observation is that the government were looking at a pandemic during this exercise, but it was fundamentally a different type of pandemic to the one we have now, with a whole set of different issues. When we run exercises, we run the scenario in an exercise and occasionally a similar real incident occurs, but more often than not the scenario and real-life incident are quite different. I don’t think we should be too critical of the government, at least they did an exercise, but I think they can’t be blamed for not guessing the scenario exactly.
There are two issues with COVID-19 which were not mentioned in the Exercise Cygnus report, and they have been major issues in the UK’s response; the first is that of PPE. When resource shortages were mentioned in the report, this was associated with excess deaths and the provision of burials and body bags, the amount of antiviral drugs available and perhaps having to use the army to maintain order, as the police might be depleted and struggle to manage with public unrest. The resources which the exercise concentrated on have not been an issue in COVID-19, there have been no riots, death numbers have been managed, we have not had to resort to mass burials, and antiviral drugs do not work on coronavirus. As far as I could see there was no substantial mention of PPE and the large amounts needed within the report.
The second issue completely missing in the report is the issues associated with reducing the infection rate and all the problems associated with social distancing, protecting the elderly and vulnerable, care homes, and lockdown measures to present the disease spreading. In the document there is mention of using the social care system and care homes to support the NHS if their capacity was overwhelmed, but there is no mention of the consequence of this and the impact of putting people who are still infectious into a setting where they could infect vulnerable people. It seems the strategy was to let the disease run its course and then just to deal with the consequences.
One of the main lessons identified from the report that there was a lack of ‘concept of operations’ (plan) to coordinate the response and that many turned up to the exercise unprepared and having not read their plan or it had only recently been updated. As an outsider, it is difficult to say whether there was enough planning conducted beforehand and if a better coordinated concept of operations was in place, whether the response would have been better. Personally, I think I would give the response 7 out of 10, but I think only a public enquiry after the event will be able to critically comment on how the level of preparedness affected the response.
There were lots of good comments and actions in the report, which have been reasonably well managed. These vary from using the army and volunteers, to bringing back retired doctors and nurses and people working from home. There were lots of recommendations on working with the devolved administrations, structures for managing the incident, information management and reporting and communication messages.
My conclusion is that Exercise Cygnus should not be used as a stick to beat the government’s response. I think it is better to have done an exercise on a slightly different scenario than not to exercise at all. Some of the big issues, such as COVID-19 in care homes, lack of PPE and infection control were not considered big problems in this exercise because they were less relevant to the scenario. These are my thoughts, but the final word will come in the inquiry after this is all over.