Mind the gap: From recommendation to practice in crisis management. Exploring the gap between the “lessons identified” during exercise cygnus and the UK government response to COVID-19
DOI:
https://doi.org/10.5055/jem.0596Keywords:
crisis management, learning, COVID-19, exercisesAbstract
The failure to learn lessons from crises is a common observation. The UK Government has been criticized for its response to the COVID-19 crisis. Many critics have highlighted the Government’s apparent failure to learn the lessons from Exercise Cygnus, which made recommendations to improve the UK’s response to a pandemic. This article compares and contrasts the UK Government’s response with the exercise recommendations. It critiques the gaps using current crisis management literature and argues that to avoid future failings, more emphasis is needed on the effectiveness of recommendations from exercises. If this is not done, exercise lessons identified, and their recommendations will not be operationalized. This article argues that the successful transition from policy recommendation to practice requires recommendations to be contextualized, so they are feasible and practical, before they can be institutionalized. It introduces a practical framework and organizational actions on how future exercises can close the gap from lessons identified to be learned and shape practice.
References
Turner BA: The organizational and interorganizational development of disasters. Adm Sci Q. 1976; 21(3): 378-397. DOI: 10.2307/2391850.
Elliott D: The failure of organizational learning from crisis—A matter of life and death? J Contingen Crisis Manag. 2009; 17(3): 157-168.
Fischbacher-Smith D, Fischbacher-Smith M: Barriers to organizational learning. In Seel NM (ed.): Encyclopedia of the Sciences of Learning. Boston, MA: Springer, 2012: 407-409.
Pollock K: Review of persistent lessons identified relating to interoperability from emergencies and major incidents since 1986. Emergency Planning College Occasional Paper New Series Number 6. 2013. Available at www.epcresilience.com. Accessed September
, 2020.
Coles E: Learning the lessons from major incidents: A short review of the literature. Emergency Planning College, Occasional Papers No 10. 2014. Available at www.epcresilience.com. Accessed September 9, 2020.
Borodzicz EP: Risk, Crisis & Security Management. Chichester: John Wiley, 2005.
Smith D, Elliot D: Exploring the barriers to learning from crisis: Organisational learning and crisis. Manag Learn. 2007; 38(5): 519-538.
May P: Policy learning and failure. J Pub Pol. 1992; 12(4): 331-354.
Birkland TA: Disasters, lessons learned, and fantasy documents. J Contingen Crisis Manag. 2009; 17(3): 146-156. DOI: 10.1111/j.1468-5973.2009.00575.x.
Stark A: Public Inquiries, Policy Learning, and the Threat of Future Crises. USA: Oxford University Press, 2019.
Scally G, Jacobson B, Abbasi K: The UK’s public health response to COVID-19. BMJ. 2020; 369: M1932.
Griffin S: COVID-19: Former civil service head criticises government’s response to crisis. BMJ. 2020; 370: M2992. DOI: 10.1136/bmj.m2992.
UK Parliament Public Accounts Committee: Whole of Government Response to COVID-19. London: House of Commons. 2020: HC 404.
Goddard NL, Delpech VC, Watson JM, et al.: Lessons learned from SARS: The experience of the health protection agency, England. Public Health. 2006; 120(1): 27-32. DOI: 10.1016/j.puhe.2005.10.003.
Public Health England: Treatment of MERS-CoV: Information for Clinicians. Public Health England, 2017.
House of Commons Science and Technology Committee: Science in Emergencies: UK Lessons from Ebola. London: The Stationery Office, 2016: HC469.
Wise J: UK response to H1N1 pandemic was highly satisfactory, independent review says. BMJ. 2010; 341: C3569-C3569. DOI: 10.1136/bmj.c3569.
Public Health England: Exercise Cygnus report: Tier one command post exercise, pandemic influenza—18 to 20 October 2016. 2017.
Levac D, Colquhoun H, O’Brian KK: Scoping studies: Advancing the methodology. Implement Sci. 2010; 5(1): 1-9.
Arfskey H, O’Malley L: Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005; 8(1): 19-32.
Haddon-Cave C: The Nimrod Review. An Independent Review into the Broader Issues Surrounding the Loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006. London: The Stationary Office, 2009.
Department of Health: UK Influenza Pandemic Preparedness Strategy 2011. London: UK Government, 2011.
UK Legislation: Coronavirus Act 2020. UK Public General Acts 2020. Legislation.gov.uk. Available at http://www.legislation.gov.uk/ukpga/2020/7/contents/enacted. Accessed June 5, 2020.
Blick A, Walker C: Why did government not use the civil contingencies act? The Law Society Gazette. April 2, 2020. Available at https://www.lawgazette.co.uk/legal-updates/why-did-governmentnot-use-the-civil-contingencies-act/5103742.article. Accessed June 5, 2020.
Department of Health: UK Pandemic Influenza Communications Strategy 2012. London: UK Government, 2012.
Department of Health: Principles of Effective Communication: Scientific Evidence Base Review. London: UK Government, 2011.
Home Office: Planning for a Possible Influenza Pandemic – A Framework for Planners Preparing to Manage Deaths. London: UK Government Cabinet Office, 2008.
Cabinet Office: National Planning Assumptions Assessments Tool. London: UK Government, 2011.
Public Health England: Pandemic Influenza Strategic Framework. London: Phe, 2014.
Public Health England: Pandemic Influenza Response Plan 2014. London: Phe, 2014.
Kruger HM, Meton J, Williams A: Pandemic continuity planning: Will coronavirus test local authority business continuity plans? A case study of a local authority in the North of England. Emerg Manag Rev. 2020; 4(1): 4-27.
Public Health England: Exercise Cygnus report: Tier one command post exercise, pandemic influenza – 18 to 20 October 2016. 2017: 6.
Macpherson A, Elliott D, Antonacopoulou E: The impact of learning on policy development in response to crisis. In Organization Learning Knowledge Capabilities International Conference, Boston, MA, 2010.
Argyris C, Schon DA: Organisational Learning II: Theory, Method, and Practice. Reading, MA: Addison-Wesley Ashgate, 1996.
Paraskevas A: Crisis management or crisis response system? A complexity science approach to organizational crises. Manag Decis. 2006; 44(7): 892-907. DOI: 10.1108/00251740610680587.
Clarke LB: Mission Improbable: Using Fantasy Documents to Tame Disaster. Chicago: University of Chicago Press, 1999.
Fenwick T, Seville E, Brunsdon D: Reducing the Impact of Organisational Silos on Resilience: A Report on the Impact of Silos on Resilience and How the Impacts Might Be Reduced. Christchurch: Resilient Organisations Research Programme, 2009.
Guelke C: A strategic approach to disaster preparedness. In Paper Presented at the Engineering Management Conference, 2005. Proceedings IEEE International, 2005.
Powers V: Creating a collaborative government. KM World. 2004; 13(4): 12.
Endsley MR: Toward a theory of situation awareness in dynamic systems. Hum Factors. 1995; 37(1): 32-64. DOI: 10.1518/001872095779049543.
Woods DD: Creating foresight: Lessons for resilience from Columbia. In Farjoun M, Starbuck WH (eds.): Organisation at the Limit: NASA and the Columbia Disaster. Blackwell, 2005.
Cabinet Office: National Risk Register of Civil Emergencies: Updating the Public on the Government’s Current Assessment of the Potential Impact of a Range of Different Civil Emergency Risks. London: UK Government, 2008. Available at https://www.gov.uk/government/publications/national-risk-register-of-civil-emergencies. Accessed May 10, 2020.
Cabinet Office: National Risk Register of Civil Emergencies: The National Risk Register 2017 Explains the Risks of Major Emergencies that Could Affect the UK in the Next Five Years and Provides Resilience Advice and Guidance. London: UK Government, 2017. Available at https://www.gov.uk/government/publications/nationalrisk-register-of-civil-emergencies-2017-edition. Accessed May 10, 2020.
Bussey K: Coronavirus in Scotland: Pandemic planning ‘should fall to NHS not ministers’. The Times, May 9, 2020. Available at https://www.thetimes.co.uk/article/coronavirus-in-scotlandpandemic-planning-should-fall-to-nhs-not-ministers-bwmd3nfm2. Accessed May 9, 2020.
BBC: Coronavirus PPE: Gowns Ordered from Turkey Fail to Meet Safety Standards. BBC May 7, 2020. Available at https://www.bbc.co.uk/news/uk-52569364. Accessed May 11, 2020.
Alexander D: Britain is in a state of emergency. So where are its emergency planners? Guardian, May 5, 2020. Available at https://www.theguardian.com/commentisfree/2020/may/05/britainemergency-planners-pandemic-government. Accessed May 2020.
Bryce C, Ring P, Ashby S, et al.: Resilience in the face of uncertainty: Early lessons from the COVID-19 pandemic. J Risk Res. 2020; 23: 880-888. DOI: 10.1080/13669877.2020.1756379.
Mersey Care NHS Foundation Trust: Plan for the management of pandemic influenza. 2020: 41. Available at https://www.merseycare.nhs.uk/media/7091/irp03-v2-plan-for-the-management-of-pandemic-influenza-up9mar20-rev-mar2023.pdf. Accessed September 1, 2020.
Swinford S, Smyth C, Wright O, et al.: Cracks widen as fatigue takes its toll at Downing Street. The Times, May 23, 2020.
Kuenssberg L: Coronavirus: A Government under Great Strain. BBC, May 14, 2020. Available at https://www.bbc.co.uk/news/ukpolitics-52670086. Accessed May 15, 2020.
DeWolf F, Mejri M: Crisis communication failures: The BP case study. Int J Adv Manag Econ. 2013; 2(2): 48-56.
Hale J, Dulek R, Hale D: Crisis response communication challenges: Building theory from qualitative data. J Bus Commun. 2005; 42: 112-134. DOI: 10.1177/0021943605274751.
Prime Minister: PM letter to nation on coronavirus. Prime Minister’s Office, 10 Downing Street and The Rt Hon Boris Johnson MP. March 28, 2020. Available at https://www.gov.uk/government/publications/pm-letter-to-nation-on-coronavirus#history. Accessed May 11, 2020.
Wright O, Elliott F, Andrews K: PM sets out lock down plan. The Times, May 11, 2020. Available at https://www.thetimes.co.uk/article/boris-johnson-announces-lockdown-exit-plan-27xxlf6dr. Accessed May 11, 2020.
Boin A, ‘t Hart P, Stern E, et al. (eds.): The Politics of Crisis Management (2nd ed.). Cambridge: Cambridge University Press. 2017.
McLaughlin M: Coronavirus in Scotland: Boris Johnson told to make clear he is ‘only leading England’s lockdown’. The Times, May 29, 2020. Available at https://www.thetimes.co.uk/article/coronavirus-in-scotland-boris-johnson-told-to-make-clear-he-is-onlyleading-englands-lockdown-gldmb209v. Accessed May 29, 2020.
Webster L: Lockdown: Welsh FM reminds reporters PM speaks for England only. The National, May 8, 2020. Available at https://www.thenational.scot/news/18436531.lockdown-welsh-fm-remindsreporters-pm-.speaks-.england/. Accessed May 8, 2020.
Cushion S, Soo N, Kyriakidou M, et al.: Different lockdown rules in the four nations are confusing the public. LSE COVID-19 Blog, May 22, 2020. Available at https://blogs.lse.ac.uk/covid19/. Accessed May 23, 2020.
Department of Health: Impact of School Closures on an Influenza Pandemic: Scientific Evidence Base Review. London: UK Government, 2014.
Foreign & Commonwealth Office: Guidance on Pandemic Flu. Fact Sheet for British Nationals Overseas. London: UK Government, 2017.
Ministry of Defence: COVID support force: The MOD’s contribution to the coronavirus response. 2020. Available at https://www.gov.uk/guidance/covid-support-force-the-mods-contribution-to-thecoronavirus-response. Accessed May 12, 2020.
Pearson CM, Clair JA: Reframing crisis management. AMR. 1998; 23(1): 59-76.
Smith D: Beyond contingency planning: Towards a model of crisis management. In Smith D, Elliot D (eds.): Key Readings in Crisis Management, Systems and Structures for Prevention and Recovery. New York: Routledge, 2006: 147-158.
Janis IL: Groupthink. Boston: Houghton Mifflin, 1982.
Swinford S, Smyth C, Wright O, et al.: Cracks widen as fatigue takes its toll at Downing Street. The Times, May 23, 2020.
McLaughlin M, Andrews K: Sturgeon’s demand at number ten. The Times, May 8, 2020. Available at https://www.thetimes.co.uk/article/lockdown-nicola-sturgeons-demand-to-no-10-p2kkhq6fr. Accessed May 8, 2020.
Astbury-Ward E: NHS nightingale hospitals: Agile response to COVID-19 or a white elephant? Medscape, May 1, 2020. Available at https://www.medscape.com/viewarticle/929778. Accessed May 8, 2020.
UK Parliament Public Accounts Committee: Whole of Government Response to COVID-19. London: House of Commons, 2020: 11, HC 404.
Smith M: Approval of government handling of coronavirus sinks to lowest level. YouGov. June 3, 2020. Available at https://yougov.co.uk/topics/politics/articles-reports/2020/06/03/approval-government-handling-coronavirus-sinks-low. Accessed June 27, 2020.
Ghosh P: Coronavirus: Some scientists say UK virus strategy is ‘risking lives’. BBC, March 14, 2020. Available at https://www.bbc.co.uk/news/science-environment-51892402. Accessed May 11, 2020.
Symth C: Coronavirus: Lockdown delay cost lives, says sage member. The Times, May 22, 2020. Available at https://www.thetimes.co.uk/article/coronavirus-lockdown-delay-cost-lives-says-sagemember-dkgp2pwd8. Accessed May 22, 2020.
O’Neill S: Boris Johnson ‘failed to take coronavirus threat seriously’. The Times. June 3, 2020. Available at https://www.thetimes.co.uk/article/boris-johnson-failed-to-take-coronavirus-threatseriously-rs2n7vd0w. Accessed June 3, 2020.
Sunday Times: UK’s lockdown dithering led to worst death toll in Europe. Revealed: insight. Sunday Times, May 24, 2020. Available at https://www.thetimes.co.uk/article/revealed-uk-slockdown-dithering-led-to-worst-death-toll-in-europe-w86pt3hh5. Accessed May 24, 2020.
Whipple T: Coronavirus: Stop passing the buck, top scientist tells politicians. The Times, May 19, 2020. Available at https://www.thetimes.co.uk/article/coronavirus-stop-passing-the-buck-topscientist-tells-politicians-d6292nbrg. Accessed May 20, 2020.
Swinford S, Smyth C: Make lockdown science public. Jeremy Hunt urges as minister shifts blame. The Times, May 20, 2020. Available at https://www.thetimes.co.uk/article/scientists-and-mps-urge-no-10-topublish-its-advice-hmhzd99nm. Accessed May 20, 2020.
BBC: Coronavirus: Acting earlier would have saved lives. Says Sage member. BBC, 2020. Available at https://www.bbc.co.uk/news/uk-52764645. Accessed May 22, 2020.
Ramakrishnan V: President of the royal society, addresses trust in science during the coronavirus (COVID-19) pandemic. 2020. Available at https://royalsociety.org/blog/2020/05/following-the-science/. Accessed June 20, 2020.
‘t Hart P, Sundelius B: Crisis management revisited: A new agenda for research, training and capacity building within Europe. Cooperation Conflict. 2013; 48(3): 444-461. DOI: 10.1177/0010836713485711.
UK Parliament Public Accounts Committee: Whole of Government Response to COVID-19. London: House of Commons, 2020: 14, HC 404.
Campbell D: Millions in UK miss cancer screenings, tests and treatments due to COVID-19. The Guardian. June 1, 2020. Available at https://www.theguardian.com/society/2020/jun/01/millions-in-uk-miss-cancer-screenings-tests-and-treatments-due-tocovid-19. Accessed June 5, 2020.
Prentice D: Care home death figures a ‘national scandal’ says UNISON. April 14, 2020. Available at https://www.unison.org.uk/news/press-release/2020/04/care-home-death-figures-national-scandal-says-unison. Accessed April 15, 2020.
Smyth C: Leaders accused of making the NHS a scapegoat over coronavirus. The Times, May 23, 2020. Available at https://www.thetimes.co.uk/article/leaders-accused-of-making-the-nhs-a-scapegoatover-coronavirus-sv59qv68x. Accessed May 23, 2020.
Twigg J, Mosel I: Emergent groups and spontaneous volunteers in urban disaster response. Environ Urbaniz. 2017; 29(2): 443-458. DOI: 10.1177/0956247817721413.
Lowe S, Fothergill A: A need to help: Emergent volunteer behavior after September 11. Beyond September 11th: An Account of Post-Disaster Research, 2003. Institute of Behavioral Science, Natural Hazards Research and Applications Information Center, University of Colorado.
Kendra JM, Wachtendorf T: Elements of resilience after the world trade center disaster: Reconstituting New York city’s emergency operations center. Disasters. 2003; 27(1): 37-53.
Lynch P, Khoo A: Coronavirus: Volunteers flock to join community support groups. BBC. Available at https://www.bbc.co.uk/news/uk-england-51978388. Accessed June 20, 2020.
Moritz J: Coronavirus: Volunteers ‘not being called upon’ to help NHS. BBC. Available at https://www.bbc.co.uk/news/uk-52418946. Accessed July 20, 2020.
Tidball-Binz M: Managing the dead in catastrophes: Guiding principles and practical recommendations for first responders. Int Rev Red Cross. 2007; 89(866): 421-442.
Booth R: Temporary morgues being set up across UK amid rising covid-19 deaths. The Guardian, March 19, 2020. Available at https://www.theguardian.com/world/2020/mar/19/temporarymorgues-being-set-up-across-uk-amid-rising-covid-19-deaths. Accessed May 20, 2020.
Raleigh VS: Tackling UK’s mortality problem: COVID-19 and other causes. BMJ. 2020; 369: M2295. DOI: 10.1136/bmj.m2295.
Elliott F, Fisher L: Coronavirus monitoring centre has changing role and leadership. The Times, June 3, 2020. Available at https://www.thetimes.co.uk/article/coronavirus-monitoring-centre-haschanging-role-and-leadership-c7jw8rldt. Accessed June 4, 2020.
Hewson T, Shepherd A, Hard J, et al.: Effects of the COVID-19 pandemic on the mental health of prisoners. Lancet Psychiatry. 2020; 7: 568-570. DOI: 10.1016/S2215-0366(20)30241-8.
Ministry of Justice and Public Health: Preventing and controlling outbreaks of COVID-19 in prisons and places of detention. London, UK Government, 2020. Available at https://www.gov.uk/government/publications/covid-19-prisons-and-other-prescribed-places-of-detention-guidance/covid-19-prisons-and-otherprescribed-places-of-detention-guidance. Accessed August 20, 2020.
Shaw D: Coronavirus: More than 140 released prisoners housed in hotels during lockdown. BBC. 2020. Available at https://www.bbc.co.uk/news/uk-53452050. Accessed July 20, 2020.
O’Moore E: Briefing paper-interim assessment of impact of various population management strategies in prisons in response to COVID-19 pandemic in England. April 24, 2020.
Broekema W, Porth J, Steen T, et al.: Public leaders’ organizational learning orientations in the wake of a crisis and the role of public service motivation. Saf Sci. 2019; 113: 200-209. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/882622/covid-19-population-management-strategy-prisons.pdf. Accessed September 9, 2020.
Milway K, Saxton A: The challenge of organisational learning. Stanford Soc Innov Rev. 2011; 5: 44-49.
Rashman L, Withers E, Hartley J: Organisational learning and knowledge in public service organisations: A systematic review of the literature. Int J Manag Rev. 2009; 11(4): 463-494.
Serrat O: A primer on organisational learning. Knowl Solut. 2009; 69: 1-6.
Carmeli A, Schaubroeck J: Organisational crisis-preparedness: The importance of learning from failures. Long Range Planning. 2008; 41: 177-196.
Moynihan DP: Learning under uncertainty: Networks in crisis management. Public Adm Rev. 2008; 68(2): 350-365. DOI: 10.1111/j.1540-6210.2007.00867.x.
Birkland TA: Lessons of Disaster: Policy Change after Catastrophic Events. Washington DC: Georgetown University Press, 2007.
Rosenthal U, Charles MT, ‘tHart P (eds.): Coping with Crises: The Management of Disasters, Riots and Terrorism. Springfield, IL: Charles Thomas, 1989.
Boin A, Ekengren M, Rhinard M: Hiding in plain sight: Conceptualizing the creeping crisis. Risks Hazards Crisis Public Policy. 2020; 11(2): 116-138. DOI: 10.1002/rhc3.12193.
Turner BA: Man-Made Disasters. London: Wykeham Science Press, 1978.
Perrow C; Normal Accidents—Living with High-Risk Technologies. New Jersey: Princeton University Press, 1999.
Boin A, Lodge M: Designing resilient institutions for transboundary crisis management: A time for public administration. Public Adm. 2016; 94(2): 289-298. DOI: 10.1111/padm.12264.
‘T Hart P: Symbols, rituals and power: The lost dimensions of crisis management. J Contingen Crisis Manag. 1993; 1(1): 36-50.
Blanchard PN, Thacker JW: Effective Training: Systems, Strategies, and Practices. Upper Saddle River, NJ: Prentice-Hall, 2013.
Renå H, Christensen J: Learning from crisis: The role of enquiry commissions. J Contingen Crisis Manag. 2020; 28(1): 41-49. DOI: 10.1111/1468-5973.12269.
Toft B, Reynolds S: Learning from Disasters: A Management Approach. 3rd ed. Leicester: Perpetuity Press, 2005.
Kletz T: Learning from Accidents. 3rd ed. Oxford: Butterworth-Heinemann, 2001: 313.
Toft B, Reynolds S: Learning from Disasters: A Management Approach. 3rd ed. Leicester: Perpetuity Press, 2005: 70.
Public Health England: Exercise cygnus report: Tier one command post exercise. Pandemic influenza – 18 to 20 October 2016, 2017: 3.
Pollock K: From lessons to learning: A practical framework. 2020. Available at www.researchgate.net/profile/Kevin_Pollock6.
Rolfe G, Freshwater D, Jasper M: Critical Reflection in Nursing and the Helping Professions: A User’s Guide. Basingstoke: Palgrave Macmillan, 2001.
Taylor: The Hillsborough Stadium Disaster 15 April 1989 Inquiry by Lord Justice Taylor. London: HMSO, 1990: Cm 962.
Pauchant T, Mitroff I: Transforming the Crisis-Prone Organisation: Preventing Individual, Organisational and Environmental Tragedies. San Francisco: Jossey-Bass, 1992: 52.
Published
How to Cite
Issue
Section
License
Copyright 2007-2023, Weston Medical Publishing, LLC and Journal of Emergency Management. All Rights Reserved