The Development of Pandemic Influenza Preparedness Policy Frameworks in England (1988-2019)

Background: Responsibilities for the control of infectious disease in the UK have changed since the 19th Century, shifting between local and national authorities. Since the Civil Contingencies Act in 2004, public health agencies, the wider NHS and local authorities have a legal responsibility to plan for pandemics, with the Department of Health as designated lead government department. Despite three pandemics of influenza during the 20th Century, it took until 1997 for the UK to publish its first national plan. Since then, there have been four further iterations, and pandemic influenza remains high on the National Risk Assessment. Aim and objectives: To critically analyse the development of pandemic influenza preparedness policy frameworks in England and identify what conditions led to policy change between 1988 and 2019. 1.) To understand what policy frameworks were developed and how they changed. 2.) To understand why the policy frameworks were developed and why they changed. 3.) To identify who was involved in developing the policy frameworks and understand how they affected policy outcomes. 4.) To explore how actors and their role in policy framework development has changed. Methodology: This research takes a qualitative interpretative approach, combining methodologies from history and social science, and applying policy theories to answer the objectives. Oral history interviews (n=24 experts and civil servants) were combined with primary and secondary written sources, and a witness seminar (n=9 experts and civil servants). Thematic Narrative Analysis and inductive-deductive thematic analysis was conducted. The Multiple Streams Approach and policy learning have been utilised to understand reasons for policy change. Findings: Specific epistemic communities, policy entrepreneurs, and different crises, have been important in raising government attention on the need for pandemic influenzas preparedness. Pandemic influenza was reframed from a health problem to a security problem in the early 2000s, requiring an all-hazards/whole-society approach. Nationally and globally, new institutions and instruments were established for this. Between 2004 and 2009 large-scale change took place to the policy environment. The introduction of new actors with expertise across modelling, emergency management, ethics, communication, and (to a limited degree) animal health and behavioural science, supported alternative policy options to be considered. Nonetheless these largely remained grounded in biomedical understandings and technologies. A pandemic influenza preparedness programme was agreed and received funding from the treasury in 2007. As part of this, building blocks were established which included clinical countermeasures and Public Health and Social Measures. The programme was rapidly adapted and implemented in response to a novel H1N1-09 virus. During the ‘Swine Flu’ pandemic, biomedical/ science-based epistemic learning supported the response and identified gaps in surveillance and research but there were missed opportunities for further community engagement and reflexive learning. There was also greater recognition of the need to embed flexibility into national plans to accommodate a range of pandemic scenarios and variation across the country. However, following the pandemic, only incremental change occurred, despite opportunities for more transformative change between 2010 and 2019. Health systems reform challenged the bandwidth of policy actors and led to attention being diverted away from pandemic preparedness. Advisory networks largely remained limited to specific experts from biomedical disciplines The ambition for whole society/whole government and all-hazards approaches remained but was not adequately embedded in policy design and implementation. Conclusion: Changes have occurred in the problem, policy and politics streams for pandemic influenza preparedness. Epistemic communities consisting of biomedical scientists, clinicians and medically trained civil servants have played an essential role in this, alongside windows of opportunity created through crises. However, large-scale change has been limited by continuous health system reform, at times a shortage of political will, reduced resources, multiple crises and conflicting political priorities. In the future a greater plurality of knowledge within advisory systems could increase the diversity of policy options and bring new perspectives to the transboundary challenges of pandemic influenza preparedness.