exercise cygnus exercise cygnus exercise cygnus was a three-day simulation exercise carried out by the uk government in october 2016 to estimate the impact of a hypothetical h2n2 influenza pandemic on the united kingdom. it aimed to identify strengths and weaknesses within the united kingdom health system and emergency response chain by putting it under significant strain, providing insight on the country's resilience and any future ameliorations required. it was conducted by public health england representing the department of health and social care, as part of a project led by the "emergency preparedness, resilience and response partnership group". twelve government departments across scotland, wales and northern ireland, as well as local resilience forums (lrfs) participated. more than 950 workers from those organisations, prisons and local or central government were involved during the three-day simulation, and their ability to cope under situations of high medical stress was tested. the exercise was named "cygnus" as the theoretical h2n2 virus was nicknamed "swan 'flu" and said to originate from swans, the latin name for which is cygnus. scenario in the scenario, the 950 participants from central and local government were placed in the seventh week of the pandemic – the peak of the crisis, when there is the greatest demand for healthcare. at this stage, an estimated 50% of the population had been infected, with close to 400,000 deaths. the hypothetical situation was that the vaccine had been made and purchased but not yet delivered to the united kingdom. hospital and social care officials were to come up with emergency plans managing resource strain, while government officials were exposed to situations requiring quick decision-making. to make the situation more realistic, cobra meetings were held between ministers and officials. simulated news outlets and social media such as "wnn" and "twister" were also employed to give fictitious updates. a government disclaimer on the uk pandemic preparedness website stated that exercise cygnus was not intended to manage future pandemics of different nature, or to pinpoint what measures to adopt to avoid widespread transmission. jeremy hunt, secretary of state for health and social care at the time, recounts how he was confronted with a decision to close all the intensive care units and switch off the ventilators because redeploying the staff would save more lives - not a decision he felt a minister should be asked to make. learning results from the exercise identified four main learning points and 22 further recommendations. in general, it showed that the pandemic would cause the country's health system to collapse from a lack of resources, with sally davies, the chief medical officer at the time, stating that a lack of medical ventilators and the logistics of disposal of dead bodies were serious issues. the full results of the exercise remained classified up till 23 october 2020 following public inquiry and pressure. in november 2020, the united kingdom government stated that all identified lessons have been discussed accordingly and appropriately taken into account for its pandemic preparedness plans. the daily telegraph reported in march 2020 one government source as saying that the results of the simulation were "too terrifying" to be revealed. according to the telegraph, the exercise led to assumptions that a "herd immunity" approach would be the best response to a similar epidemic. the new statesman had been first to report on the results of cygnus two weeks earlier. a partial report of findings was later released by british newspaper the guardian, leading to public dissatisfaction on how it was managed. in may 2020, when interviewed by the guardian, martin green, chief executive of care england, one of the united kingdom's biggest private care home companies, said that the government did not previously alert private health sectors to the lack of capacity should a pandemic arise. a number of news reports criticised the government's handling of the covid-19 pandemic in the light of the conclusions reached by exercise cygnus. there was criticism that no follow-up document was written detailing how to deal with an influenza pandemic after december 2016. in march 2020, the three government documents available for response to covid-19 were those published in 2011 ("influenza pandemic preparedness strategy"), 2012 ("health and social care influenza pandemic preparedness and response") and 2014 ("pandemic influenza response plan") respectively, with no revised report following exercise cygnus and no mention of ventilators. despite a lack of ventilators being previously identified in exercise cygnus, there was a shortage of them during covid-19 with the government stockpiles proving to be insufficient. in march 2020, six weeks following the first case of coronavirus in the united kingdom, matt hancock, acting health secretary of the united kingdom, turned to a range of corporations such as jcb and rolls-royce, stating, "if you produce a ventilator, we will buy it. no number is too high". results of exercise cygnus were leaked to the guardian newspaper in may 2020. a complete version was later released in october 2020 by the department of health and social care. four main areas of improvement as well as 22 other weaknesses were identified. develop a "concept of operations" during exercise cygnus, the strategy used was a combination of department of health and social care's uk influenza pandemic preparedness strategy 2011, as well as eight or more other scientific documents gleaned from the h1n1 pandemic in 2009. however, the exercise revealed that there was no overview or central management to coordinate all participants. as of october 2016, feedback showed that organisations varied in preparedness, with some relying on corporate memory of the 2009 h1n1 response, and others depending on individual pandemic protocols which may be outdated, missing or incomplete. there was also demonstration of silo planning between and within some corporations, however organisations had different levels of detail and structure that could not correspond well when used simultaneously. it was understood that up to half the population will be implicated should there be insufficient understanding of the severity of a pandemic during the response. exercise cygnus revealed the need to develop a "pandemic concept of operations" to bridge communication between organisations. this aims to manage collective response strategically by delegating specific roles to each organisation and directing their interactions during a pandemic. nhs england recognises that a variety of sectors are implicated, hence a central administration and unified protocol to oversee the whole strategy is required for organisations to work synonymously. devolved administrations have separate contingency plans which were not investigated during exercise cygnus. in this segment, wales was also excluded as it had previously investigated its response through "exercise cygnet" conducted in 2015. ease legislation during pandemic the proposition to roll back on legislation and regulatory restrictions, particularly within the health sector, is considered. this would aid in managing essential services and operationalising increased health care demands with fewer obstacles. greater flexibility is recommended especially in a pandemic when situations evolve quickly and decisions need to be made as soon as possible. key suggestions were for rules to be more malleable and easily adapted to the circumstance at hand. the choices as to which legislation will be amended is determined by pandemic influenza planning assumptions. previous findings from department of health and social care provide direction as to what type of corrections are appropriate for health legislation in the midst of a pandemic. devolved administrations were advised to adopt similar measures in fields of devolved competence. the need for future work to expand on the types of restrictions affected was noted. understand and manage public reaction exercise cygnus was centred around assumptions of public responses that have yet to be validated. expectations of how the public will react was postulated based on the magnitude of "swan flu". this may not have been entirely representative of what would have happened in real life. for example, exercise cygnus did not involve live broadcasting or widespread coverage which typically characterises an actual pandemic. hence, its reactions are based around theoretical public reaction. this was identified and understood as a possible limitation to exercise cygnus, and the role of public opinion on pandemic response still requires further investigation. it was stated that in reality, moral decisions, such as those involving mass burials or population triage, may differ in face of public reaction. further work is required to understand public reaction, so that it can be factored into significant decisions and communication strategies, particularly for ethically charged scenarios. research into how public perception and response to a pandemic will further aid the trajectory of emergency strategies and how they can be communicated. in 2019, the moral and ethical advisory group (meag) was established to give unbiased guidance to government regarding controversial health issues. meet demand for services a lack of resources and limited ability to increase supply in face of demand was identified in health disciplines. this affects how emergency plans can be operationalised at a local level, implicating the revision of the "pandemic concept of operations". little tactical coordination was observed when the need for services outweighed the capacity of local responders, particularly in communities with excess death, social care facilities and amongst national health service staff. the need for more precise protocols was identified to guide health care providers at an operational level should there be a need to drastically step up local response. a suggestion was to implement planning at a regional level as opposed to through local resilience forums for crucial aspects of pandemic influenza response (e.g., excess death). this improves coordination across multiple agencies locally. logistically, more health workers and resources such as ventilators, personal protective equipment (ppe) and hospital beds are required to face a large pandemic. investigation also showed that the reverse triage strategy proposed by the nhs, whereby patients are moved from hospitals to social care, may not be well supported by the current social care system. this requires a high level of teamwork across several corporations, which was detailed through a provided framework but may not be viable under the pressure and widespread impact of a pandemic. local resilience forums have announced that they depend on subject matter experts for more complicated aspects of pandemic response to implement responses. these professionals do not belong to lrf but give detailed technical support to enable colleagues to comprehend different elements of the response. the strategic coordinating group (srg) structure is used by experts for holistic contribution. doubts were raised if this method was sustainable in the case of a fast-moving pandemic, since experts would have to aid more than one srg. further recommendations the 22 further recommendations, listed per the report, include: corporations are required to update their "emergency preparedness resilience and response training and exercising" for optimum performance expert advice from all stakeholders should be readily presented to scgs for corresponding response. this should occur efficiently so multiple lrfs can benefit from this support. planning should occur on a national level, and take into account how local pandemic flu strategies can be operationalised in implementation. the health tripartite (dh, nhs england and phe) and chief medical officers (cmos) should have cobra meetings incorporated into flu response more research needs to be done to investigate if population-based triage is viable during a critical, widespread influenza pandemic more work is required to understand surge arrangements when the pandemic becomes overwhelming. nhs england should direct the operational side while dh should give management, guidance and policy direction with advice from the four nations cmo meeting. dh should collaborate with partners to understand how antivirals may be used in a pandemic. phe and nhs england must cooperate to improve current community guidelines and deliver antivirals within restrictions stipulated by nhs emergency preparedness staff. all corporations must be prepared for increased staff absence in the midst of a pandemic and make appropriate plans. pandemic plans need to be effectively communicated to public for reassurance, and the right amount of detail of disclosed information should be ascertained. steps to release information to public should be coordinated by dh, nhs england and phe national teams together with devolved administrations a variety of stakeholders needs to be involved during communication of the pandemic to public. special care is needed in the realm of social media. cross-government efforts need to be conducted to avoid repetition and redundancy across departments. department of education should investigate the impact of school closures on the wider community. british nationals residing overseas