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Planning for post-event lesson learning

Posted on 17th April 2020 at 13:51pm

It is being widely reported that we were warned about the threat of a global pandemic. Yet on most fronts, we were still arguably behind the curve and caught unprepared. We will need to understand why this was the case, and what we need to do to prepare for the next pandemic, says Roger Gomm.

When the crisis eases there will be a need to plan for local debriefs to identify organisational learning and the inevitable public inquiry.

Over the past 25 years more than 30 new, or newly recognised, emerging infectious diseases have been identified around the world, such as Ebola, Zika and Middle East Respiratory Syndrome (MERS). The latter emerged recently in 2012 and still poses a global health threat.

In 2003, the Harvard Business Review published an article entitled Predictable Surprises: The Disasters You Should Have Seen Coming. The authors, Max Bazerman and Michael Watkins, both business school professors, argued that while the world is an unpredictable place, unpredictability is often not the problem. The problem is that faced with clear risks, we still fail to act. For Watkins, the coronavirus pandemic is the ultimate predictable surprise.  

I have some sympathy for the current crisis leaders and feel I should acknowledge that even foreseeable problems can be inherently hard to prepare for. But we need an honest appraisal of why we couldn’t grasp the scale of the threat.

Understand the context: Integrated emergency management

The management of the health emergency should be viewed in the wider context of integrated emergency management (IEM), the concept on which civil protection in the UK is based. IEM is a holistic approach to preventing and managing emergencies that entails six key steps: anticipation; assessment; prevention; preparation; response; and recovery. Emergency preparedness covers the first four of these steps while emergency response and recovery covers the last two steps.

Under IEM, the preparation for, response to and recovery from emergencies focuses on the consequences and wider impacts of events rather than their causes. The underlying aim of IEM is to develop flexible and adaptable arrangements that will enable an effective joint response to, and recovery from, any emergency.

The UK Cabinet Office publishes the National Risk Register (NRR) of Civil Emergencies and the ‘local’ Risk Registers are produced by the Local Resilience Forums every two years. These documents provide an assessment of the likelihood and potential impact of a range of different civil emergency risks – including naturally and accidentally occurring hazards and malicious threats – that may directly affect the UK over the next five years. It often surprises people that the highest risk (likelihood and impact) is not terrorism, but pandemic influenza. 

Flu pandemics are natural events that happen when a unique flu virus evolves to which few people, if any, are immune. There are important differences between ‘ordinary’ seasonal flu of the kind that happens in winter, and pandemic flu. In a pandemic, the new virus will spread quickly and cause more serious illness in a large proportion of the population, owing to the lack of immunity.

The 2017 NRR reported that there is a high probability of a flu pandemic occurring, but it is impossible to predict when or exactly what it would be like. The most recent pandemic flu outbreak was an H1N1 strain known as swine flu in 2009 which caused more than 18,500 deaths worldwide.

In 1918 another variant of the same H1N1 strain called Spanish flu killed more than 50 million people globally. However, other flu strains exist with pandemic potential, such as H5N1 – avian or bird flu. This strain caused several hundred human deaths in South East Asia in 1996. 

The consequences were catastrophic for the UK. In response to this risk, the UK Influenza Pandemic Preparedness Strategy covers strategic planning, response and scientific evidence and links to the World Health Organisation and global influenza preparedness plans.

The pandemic flu risk has been in both national and local risk registers for several years. We need to understand, why when faced with a clear risk, we failed to prepare sufficiently; our capability and capacity have not been enough.

Learning the lessons

The UK Emergency Response and Recovery provides guidance for all agencies in Chapter 4.6: Identifying and learning lessons. The key themes are: 

4.6.1: Keep records to facilitate operational debriefs and evidence for enquiries. Capture information while memories are fresh

4.6.2: Comprehensive record of events, decisions, reasoning behind key decisions and actions taken

4.6.3 Identify lessons and make more widely available for those who might be involved in future emergencies.

4.6.4: Debriefing should be open and honest

Individual and local debriefs

To support the public inquiry and facilitate learning, I believe there needs to be an agreed structure to the individual agencies and local resilience forums debrief. This will require some planning and, in my view, central guidance. The methodology will be important for us to identify ‘what went well’ and ‘what did not go well’ and how we can use this information to improve our future preparedness, response and recovery.

The process normally starts with a summary of the event – accepting that the debrief may well reveal more information about the event, an opportunity for individual reflection on their role in the event, an opportunity for open discussion and a facilitated plenary discussion, perhaps on key issues emerging.

In order to identify the post-event organisational learning, the facilitator needs to create a single debrief report, an analysis of where the response was effective and where it was not. They should consider whether any general or specific review activity is required, identify ways in which the response could have been improved and develop action plans.

However, it is easy to identify lessons but for organisations to learn the lessons, they need to change plans, training and exercising. Dr Kevin Pollock, in a report commissioned by the Cabinet Office Civil Contingencies Secretariat consistently found the same or similar issues raised by the 32 inquiries and events he examined from 1986 to 2010.

He identified this as a “cause for concern”.  He suggests that “lessons identified” from the events are not being learned to the extent that there is sufficient change in both policy and procedure to prevent repetition.

How can we ensure the lessons identified become lessons learned? It will require a commitment central government and politicians, monitoring and auditing the process to ensure that the resilience programme is being followed; and all recommendations pursued to conclusion.

The public inquiry

It has been widely reported in the media that owing to the scale of the coronavirus outbreak and the response it has required from government, a large-scale public inquiry is now inevitable, as suggested by former head of the civil service, Sir Bob Kerslake. He says that the scope of the decision-making undertaken by politicians and officials has been vast, and, as some of it has already been challenged, there would need to be a chance to reflect upon the UK’s response in case of another pandemic.

“There will need to be some sort of inquiry after we get through this to learn lessons,” says Lord Kerslake, who is a crossbench peer. “This is one where we might face the same situation again.”

The current public health emergency, with multiple deaths and a significant economic impact predicted is an issue of serious public concern. The public will want an inquiry to scrutinise past decisions and events and to set out a clear plan to tackle future pandemics.

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