Blog post

The COVID-19 inquiry terms of reference: what next?

As the much needed inquiry into COVID-19 begins, what can we do to make it as productive as possible? 
Dr Layla McCay

21 April 2022

To help inform the COVID-19 inquiry, Dr Layla McCay sets out some key principles for it to follow and pointers for us to help make it as pertinent as possible. 


In May 2021, the government confirmed there would be an independent public inquiry into the COVID-19 pandemic in the United Kingdom. The inquiry team now begins the monumental task of scoping what could be the biggest statutory inquiry this country has ever seen. As NHS leaders and organisations could be expected to present written and oral evidence to the inquiry, it will be a key focus for the NHS Confederation and our members across the healthcare system in England, Wales and Northern Ireland, as well as many of our partners.

Bringing forth timely, practical lessons will be the most valuable contribution of the inquiry

Last month the inquiry team published its much-anticipated draft terms of reference, setting out the inquiry’s aims and scope. Those involved in decision-making and delivery of health and social care services may have received this broad and far-reaching document with some trepidation. It will be important to reflect their priorities and concerns in the inquiry. On balance, however, an overly prescriptive terms of reference could delay the implementation of recommendations to improve health system preparedness and resilience. As well as hearing from the experiences of those most impacted by the pandemic, I believe that bringing forth timely, practical lessons will be the most valuable contribution of the inquiry.

Broad goals and timelines may be wise in theory, but in practice, there is a very real concern that this inquiry could go on ad infinitum. This would be counterproductive. The inquiry team should be mindful of  the seven-year-long inquiry into the Iraq war, the length of which was found to have reduced the impact of recommendations. Recommendations made three, four or even five years in the future will simply be too late, especially considering the huge challenges facing the healthcare system. Given the wider economic climate, the government can also ill afford to rack up a huge bill for taxpayers.

The terms of reference in practice

The terms of reference set the scope of the inquiry, but much will depend on how the inquiry team conducts its work. Some inquiries break the process down into segments or modules, which could be useful here to establish the facts and extract timely lessons learned. They will need to decide how to engage with a broad set of stakeholders and whether to set an end date for its public hearings. We believe some key principles should guide the inquiry process:

The inquiry should be based on collaboration with the devolved nations. It will be important to consider devolution, the different health systems in each UK nation, inter-governmental relations and different decisions and policies enacted by each nation. It should closely engage and communicate with partners in the devolved governments throughout the inquiry.

There should be a focus on accountability at the highest level. The inquiry should focus on decisions which were made at the highest level and were the most influential in shaping the pandemic response – starting with government decisions – rather than looking at the actions of individual doctors, nurses and other staff who were operating within that challenging national framework.

The inquiry should aim to contextualise the response, including the circumstances facing the healthcare system as it entered the pandemic, which should be central to the inquiry. As the first COVID-19 cases emerged, the NHS was in a more difficult position than many health systems in comparable countries, with higher hospital occupancy rates but fewer doctors, nurses and capital assets to meet levels of demand.

In recognition of ongoing pressures, there should be an emphasis on proportionality. System leaders are still operating under a level four incident and along with a huge elective care backlog are facing the double emergency of unprecedented demand and high COVID-19-related staff absences. We therefore think the inquiry team should take a proportionate approach to requesting information by, for example, aggregating information requests via NHS England and NHS Improvement rather than asking individual organisations.

Even if an end date for the inquiry is not set, in recognition of the huge emotional strain the inquiry will place on witnesses – especially frontline staff – they should be given as much detail as possible about the focus and longevity of investigations.

The inquiry process should be conducted with as much openness and transparency as possible. This will be crucial as the inquiry is expected to extend beyond the next election and NHS leaders will be concerned about potential implications or liability.

What is the NHS Confederation doing?

I look forward to working with the inquiry team to ensure all experiences from within our complex health and social care landscape are meaningfully represented – not just acute and care home settings but those working hard to deliver primary, community, mental health and ambulance services. System leaders innovated at scale throughout the pandemic and their experiences should be central to any assessment of best practice and lessons learned – as should the healthcare system’s move towards integration.

We will continue to support and advocate for our members throughout the inquiry process by offering information and briefings, providing a narrative account of key developments and by intervening and providing public comment where necessary. We will also support the timely implementation of recommendations – a notoriously challenging but vital task.

If you have any questions or would like to discuss the inquiry process, please contact Annie Bliss.