Two years on: how can a COVID-19 public inquiry help the UK learn the right lessons?

Two years on: how can a COVID-19 public inquiry help the UK learn the right lessons?

The pandemic has been a traumatic shock in so many ways.  A public inquiry could be used to address the UK’s more deep-seated problems, as well as failings in our institutions – or it could be a great wasted opportunity. The next few months will decide

Geoff Mulgan

Before Christmas, Boris Johnson announced that Baroness Heather Hallett had been appointed to lead the UK’s COVID-19 Public Inquiry. The inquiry will start work in spring 2022 with full powers, including the power to compel the production of documents and to summon witnesses to give evidence on oath. Its aim is to examine the UK’s pandemic response and ensure that we learn the right lessons for the future. The terms of reference are promised – in draft form – shortly.

To help inform the process, the International Public Policy Observatory (IPPO) and Prospect magazine held a joint event at the end of January, examining how such an inquiry should be run. It featured an extraordinary range of speakers with experience of past inquiries, ideas on future ones, and experience of the harms caused by the pandemic (see video recording below, and full line-up at the end of this piece).

This also seemed a good moment to redraft a paper I put out a few months ago on the goals and design of the inquiry, having added more thoughts on the design that were prompted by our speakers’ comments.

Seven steps to ensure the UK learns from a COVID-19 Public Inquiry

People at every level have worked incredibly hard over the last two years. Yet what is not in doubt is that the UK has performed badly, exhibiting among the highest levels of excess mortality and economic harm, as well as the largest debt and tax burden in living memory. Hopefully we can perform better in the way we learn lessons from the pandemic..

The key points I want to make are therefore all about ensuring the inquiry really helps the UK learn:

  1. We need multiple inquiries rather than a single one. The complexity of the issues in health, education, the economy and society are far beyond the capacity of a single inquiry.
  2. This is even more obvious if the UK inquiry is to reach reasonably rapid conclusions, with, perhaps, an interim report in 2022 and a final one before the end of 2023. There is no plausible way for a single inquiry to be both broad enough and fast enough. This implies the need for a core inquiry on decisions that were made at the heart of the UK Government, but with encouragement for a network of parallel inquiries that are focused on particular sectors: hospitals, schools, the economy. This is partly a matter of logic: although some issues cut across these fields, most of the lessons they need to address are specific and distinct.
  3. The inquiry process needs to include opportunities for airing peoples’ experiences: what it was like to be locked down, in care homes, fearful, on the frontline in hospitals. This cathartic aspect of the inquiry will be vital.
  4. The (multiple) inquiries need to commission evidence in the way research does: i.e. syntheses of evidence and findings around issues such as behaviour, compliance, modelling or mental health.
  5. The inquiries need to be designed with a clear focus on implementation. Past inquiries were disbanded when they reported, leaving the job of implementation and monitoring to the government. This cannot be acceptable in the case of a COVID inquiry.
  6. The space for the inquiry needs to reflect its ethos – a physical space that signals a willingness to learn rather than a confrontational courtroom, with hearings being held around the country in order to engage with those who were worst affected by the pandemic (such as some minority communities, disabled people, and care home residents).
  7. While a core part of the inquiry will need to be formal and judicial, with sworn testimony, most of it doesn’t need to be and will benefit from gathering of evidence, insights and experiences in a less rigid and formal way.

A brief history of UK inquiries

There is a long tradition of inquiries after big public disasters or crises. In the UK, these have included the Chilcot Report into the Iraq War, the Hutton Inquiry prompted by the death of Dr David Kelly, the Grenfell Tower InquirySir Brian Leveson’s Inquiry on abuses by the media, and the Bloody Sunday Inquiry.

There are many other types of inquiry: parliamentary, royal commissions, audits that try to get to the truth, as well as internal civil service inquiries. And there are more localised inquiries, including the various ones conducted on individual hospitals after crises such as the Mid-Staffordshire hospital deaths. There are also many UK parliamentary inquiries – one estimate suggests there have already been around 60 COVID-related inquiries carried out by different select committees.

The UK’s COVID-19 Public Inquiry will take place under legislation passed in 2005, which tried to standardise inquiry formats and grants formal powers to demand witnesses and documents.

The standard inquiry model

The UK’s more formal and serious inquiries generally aim to find out:

  • what happened;
  • why it happened;
  • who is to blame; and
  • how to prevent it happening again.

They take their models from the law and courtrooms, with witnesses, cross-examinations and written judgments. They happen in a physical place, usually in central London. As in a courtroom, they aim to establish the key facts, determine guilt, and then have an additional aim of recommending new rules or laws to prevent mistakes being repeated. They are usually created by the executive but have a degree of independence, and are typically advisory.

Many believe these characteristics mean the 2005 legislation is flawed – and that we need a framework for genuinely independent inquiries which can also play a part in the implementation of their findings. The results of an inquiry can reframe how an issue is seen; can lead to new rules, laws and institutions being introduced; and can prompt new procedures – for example, for professions such as the police or social workers. The default for any COVID inquiries will be very similar.

However, this is where the challenges really begin – because the breadth of the pandemic is far wider than the typical topic for a public inquiry.

The limitations of hierarchical models

One option may be to limit the public inquiry’s scope, and look only at top-level decisions – apportioning blame to some of the people in charge. This approach satisfies a deep human need for explanation and justice: if something has gone wrong, we want to see who is to blame and to see them shamed or punished (in the ancient past, kings who lost big battles were sometimes killed). Westminster-style parliamentary systems are particularly keen on ‘sacrificial accountability’, while the US has its own style of often quite partisan inquiries.

This will indeed have to be the core of the main inquiry. To be quick and lead to at least some rapid actions, the inquiry needs tightly circumscribed terms of reference.

However, this should not be the end of the matter. The main limitation of the traditional inquiry structure is that it’s not a particularly good way to change how a complex system works. Just as criminal courts are mainly designed to establish guilt, not promote learning, reconciliation and/or rehabilitation, the same is true of court-like public inquiries.

Possible additions: ‘whole of society’ approaches

There are many different options for inquiries, and this is a good moment to consider them. They range from ‘truth and reconciliation’ inquiries, to no-fault compensation processes, to the ways industries such as airlines deal with crashes, through to academic analyses of events such as the 2007/08 financial crash. They can involve representative or random samples of the public (e.g. citizens’ assemblies and juries), or just experts and officials.

Here are some of the key design issues to consider:

1. Single or multiple?

A first recommendation from the Chair should be that this cannot be a single inquiry – it is simply not plausible. No single Chair and no lone committee can be fully on top of the huge range of issues on which lessons need to be learned regarding the impacts of, and responses to, the pandemic across the UK. So the task needs to be disaggregated into a series of parallel inquiries – looking at issues from schooling and hospitals to the economy. While a core inquiry focused on central government can happen quite fast, it will not be sufficient.

2. Staged?

The traditional public inquiry format spends a lot of time gathering evidence before the Chair goes away to write a report. A better model is to organise the inquiry with distinct stages, although these can overlap:

  1. a stage to gather key facts and data;
  2. a stage to generate key hypotheses (e.g. that the UK should have locked down sooner on several occasions, or that it needed greater institutional capacity – for example, to integrate scientific, economic and other factors at the heart of government, or to coordinate national and local governance);
  3. a stage to explore these hypotheses with evidence and witnesses;
  4. a stage to look at blame or individual responsibility; and
  5. a stage to look at structural recommendations.

There are many other options – but the classic inquiry model can be too slow and disorganised, and risks going around in circles.

3. People or state, or both?

The Chair needs to recommend a way for people to express their experiences and hurt; an inquiry that solely consists of interviewing powerful people will not work in this sense. Any inquiry needs a cathartic dimension. This implies hearings around the UK and use of different platforms to gather testimony. One useful innovation might be to combine a chair with a citizens’ jury.

4. What kinds of evidence?

The traditional inquiry model depends on witness statements from high-status individual experts, a method long superseded in many fields. An alternative approach also seeks out multiple kinds of data and knowledge, and asks what would best help the relevant systems to learn the right lessons. It includes formal evidence synthesis of the kind that IPPO does, along with systematic learning from practitioners and professionals to tap into the kind of tacit knowledge that may not be apparent in formal evidence.

This may be particularly relevant in a complex story like that of COVID-19, with many layers (infection and epidemiology; economics; social dynamics; politics) and a lot of uncertainty. The Chair should work with research funders to commission evidence syntheses on these points as inputs to the inquiry/inquiries.

5. The right questions?

Any inquiry is defined by the questions that are thought to be important. Some are basic questions of competence and process (what right and wrong decisions were made about lockdowns?), and I expect this to be the core of the formal inquiry. But the process of learning also requires that attention is paid to deeper, underlying causes. These aspects may best be passed out to parallel inquiries and investigations – for example:

  • What has the crisis shown us about loneliness and isolation, and how these might be better addressed in future?
  • How can we create better machineries for coordination between the UK Government, devolved administrations and local government?
  • How should science advice be organised in future, particularly to make more use of social sciences that were fairly marginal within SAGE?
  • What lessons can be learned from the good and bad use of modelling during the crisis?
  • How can we help the residential care system improve its own use of knowledge and data – which is currently far behind the health system?
  • Given we now know the ‘stay home’ message fuelled a spike in domestic violence, what might we do differently in a future pandemic?

It soon becomes obvious that seeking answers to these very varied questions requires a number of different styles of inquiry.

6. Written reports or a platform?

The classic public inquiry ends with a report, usually a long one. Yet it’s not obvious that a large written report is a good way to help a system learn, whether in terms of sense-making or impacts. Indeed, there is vast evidence to suggest that an inquiry is unlikely to be effective as a way to get lessons learned unless these can be easily translated into rules and laws.

Instead, findings need to be tailored to multiple audiences, then organised in ways that help with their digestion, much of which is likely to happen through conversation and events rather than prose. One option is therefore to organise more of the inquiry as a ‘platform’ – giving space for people to express their experiences of the pandemic, reflections on what went wrong, and suggestions for answers.

A platform structure could also link multiple inquiries, including bodies of evidence, with easy searchability. This must be preferable to the classic format of a written report extending to several hundred pages.

7. How government responds

Much of government will be under intense scrutiny as COVID-19 inquiries proceed. Inevitably, parts of Whitehall are preparing themselves, with defence teams being set up and tactics considered to manage the flow of information. Where individuals are at risk of litigation, this may be understandable. But the Public Accounts Committee and National Audit Office should signal now that this would be a misuse of public money.

Government needs to see the public inquiry process as a valuable way for it to learn how to do better, including how it can learn from other countries that have been shown to have superior methods of organising – whether in terms of data and science advice, or national-local coordination.

How a ‘whole of society’ inquiry model could work

I suggested last September that we need a ‘Whole of Society’ approach to inquiries, not just a classic Whitehall/Westminster one. I am even more convinced of this now. A ‘whole of society’ approach would run more like a matrix of linked inquiries, covering, respectively:

  • the Prime Minister and the ‘centre’;
  • other UK Government departments;
  • schools;
  • hospitals;
  • local authorities;
  • central risk management capability in government;
  • public health;
  • social security;
  • parliament;
  • police;
  • science advice; and
  • universities.

The aim would be to ensure evidence-based deliberation on the key issues and lessons for each institution. So, for example, the lessons for schools are likely to be very different from those for the police or Whitehall, and they are most likely to be accepted by teachers if people they respect – including other teachers – are closely involved. The design challenge is to ensure there are proportionate inquiries within each sector or field, but with shared questions, facts and evidence.

A wasted opportunity?

Scotland is already consulting on the form its inquiry should take. The UK COVID-19 Public Inquiry has yet to publish its draft terms of reference, one of many symptoms of a rather distracted executive. It is highly likely the most traditional model will be adopted, just because it’s what people at the top are used to.

The pandemic has been a traumatic shock in so many ways. It could be used to address and fix more deep-seated problems, as well as failings in our institutions. Or it could be a great wasted opportunity. The next few months will decide.

Sir Geoff Mulgan is Professor of Collective Intelligence, Public Policy and Social Innovation at UCL STEaPP, and IPPO’s Co-investigator


The IPPO/Prospect inquiries event on 27 January was chaired by Geoff Mulgan and Alan Rusbridger, editor of Prospect. The speakers were: