Tag Archives: health and social care committee

8. Race, ethnicity, and the social determinants of health

The beginning of this section comes from: Coronavirus and the ‘social determinants’ of health inequalities: lessons from ‘Health in All Policies’ initiatives

A ‘social determinants’ focus shows that the most profound impacts on population health can come from (a) environments largely outside of an individual’s control (e.g. in relation to threats from others, such as pollution or violence), (b) access to high quality education and employment, and (c) economic inequality, influencing access to warm and safe housing, high quality water and nutrition, choices on transport, and access to safe and healthy environments.

In that context, the coronavirus also provides stark examples of major inequalities in relation to self-isolation and social distancing: some people have access to food, private spaces to self-isolate, and open places to exercise away from others; many people have insufficient access to food, no private space, and few places to go outside.

Corburn et al’s (2014) study of Richmond, California’s, focusing on ‘coproducing health equity in all policies’ highlights the strong connection between health and income and wealth, which differs markedly according to race and immigration status. It reports on a series of community discussions to identify key obstacles to health:

emerging from the workshops and health equity discussions was that one of the underlying causes of the multiple stressors experienced in Richmond was structural racism. By structural racism we meant that seemingly neutral policies and practices can function in racist ways by disempowering communities of color and perpetuating unequal historic conditions” (2014: 627-8).

In the UK, there has been some political attention devoted on the impact of coronavirus according to race and ethnicity, albeit generally described with the problematic catch-all term BAME (Black, Asian, and minority ethnic) to refer to all non-white populations.

Most notably, the PHE report Disparities in the risk and outcomes of COVID-19 highlights the unequal impact of coronavirus, with an action plan delayed, but expected to follow.

PHE ethnicity 2020

This inequality is discussed somewhat in committee proceedings, including in relation to:

  • Walton (1.5.20: q3) on concerns for BAME pregnant women and NHS staff
  • Owen (5.5.20: q424) on the social determinants of health inequalities
  • Owen (14.5.20: q95, q100) on the poor fit of PPE for women and BAME women
  • Owatemi (14.5.20: q99):

‘In a survey of over 2,000 BAME NHS staff, 50% stated that there was a culture of discrimination within the NHS. They felt that they were unable to speak up due to the lack of BAME representation in leadership roles. Currently, only 6% of NHS leadership positions are BAME staff’

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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7. Lower profile changes to policy and practice

A future series of posts will describe the many ways in which policy will (or should) change in practice, as public sector and other organizations change the way they do things in response to crisis. Current examples include the relaxation or postponement of high-political-stakes issues such as NHS targets and testing in schools, and as-important but lower stakes issues such as mental health self-management and the local authority obligation to provide social care.

In relation to oral evidence, examples include:

  • Stevens (17.3.20: q150-3) discusses relaxations on rules for GP prescribing, paying GPs upfront in relation to contracts, reducing the regularity of Care Quality Commission checks, and taking a more flexible approach to A&E and other targets to avoid their inevitable unintended consequences. The changes take place in the context of a reduced-capacity NHS and growing waiting list for services not met during the lockdown (see Hopson, Dixon (Chief Executive The Health Foundation), and Edwards (Chief Executive The Nuffield Trust) 14.5.20: q75-84).
  • Taiwo Owatemi MP (17.4.20: q371) on medicinal cannabis for children.
  • Hancock (17.4.20: q373) on the availability and operation of cancer services (compare with Rosie Cooper MP, 17.4.20: q380; Palmer, National Cancer Director NHS England, 1.5.20: q21-35; Murray, Chief Executive The King’s Fund, 14.5.20: q73)
  • Dean Russell MP (17.4.20: q386):

‘Last November, the Committee [Joint Committee on Human Rights] identified that human rights were being abused for people with learning disabilities and/or autism in mental health hospitals. As part of that, one of the concerns is that with coronavirus, family visits are currently being restricted and routine inspections have been suspended, which in turn potentially increases the young people’s isolation and also makes them more vulnerable to abuse of their rights.’

  • Walton (Chief Executive, Royal College of Midwives) (1.5.20: q11) on ‘domestic abuse increases during pregnancy’ and ‘it appears that during lockdown domestic abuse and control issues have increased’.
  • Murdoch (National Mental Health Director, NHS England) (1.5.20: q47-51) on the temporary reduction in referrals to child and adult mental health services, followed by a general consensus (MPs and witnesses, 14.5.20: q87-90) that adult and child mental health services were poorly funded anyway, with too few staff, dealing mostly with emergencies, so the post-pandemic provision is a major worry since there will be the latent demand plus new causes of mental health problems.

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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6. The relationship between science, science advice, and policy

There is a lot written in general about the extent to which UK policy is evidence-based (go to EBPM and this article and I’ll see you in a few days).

This issue was initially a big feature of the UK government rhetoric in March, in which the idea of ministers ‘following the science’ (or the advice of advisers and bodies such as Royal Colleges – Hancock, 17.4.20: q312) can be used to project a certain form of authority and control (see Weible et al).

It prompted regular debate on the extent to which scientific advisory bodies were subject to group-think and drawn from too-narrow pools of expertise (see for example Dingwall, Today programme 10.6.20, from 838am), and Vallance’s (17.3.20: q96) response:

‘If you thought SAGE and the way SAGE works was a cosy consensus of agreeing scientists, you would be very mistaken. It is a lively, robust discussion, with multiple inputs. We do not try to get everybody saying exactly the same thing. The idea is to look at the evidence and come up with the answers as best we can. There are sub-groups that work and feed into SAGE. The membership of SAGE changes, depending on what we are discussing. It is not as though it is the same group of people who always discuss all the topics; there are members who come for specific items’.

Then, when things began to go very wrong, commentators speculated about the extent to which ministers would blame their advisers for their policy and its timing. The latter problem became a regular feature in oral evidence. For example:

  • Vallance (5.5.20: 392-6) states that (a) ‘SAGE does not make decisions. SAGE gives advice; it is an advisory body and Ministers of course have to make decisions’, and (b) they need some confidentiality to make sure that ministers get the information to make choices first (‘to be allowed time to make those decisions’).
  • Vallance (5.5.20: q406) is heavy on the line that scientists only give advice, not make policy: ‘we give science advice and then Ministers have to make their decisions. All I can say is that the advice that we have given has been heard and has been taken by the Government. Clearly, what we do not give advice on is absolutely precise policy decisions or absolute timings on things. Those are decisions that Ministers must take on the basis of the science. The correct way of saying it is that the decisions are informed by science. They are not led by science, as you said in opening the question’.
  • Vallance (5.5.20: Q407) describes how that advice may be presented when the scientists do not agree: ‘… our output is very much in the form of options, in the form of uncertainty and in the form of what could be done and what the potential consequences might be, not, “Here is the answer. Get on and do this.” That is not how it works.’

The UK’s nascent blame-game problem makes Costello’s (17.4.20: q298) suggestion of ‘a no-blame audit’ (‘where were the system errors that led us to have probably the highest death rates in Europe?’), to inform planning for the second wave, seem unrealistic. Open debates may be common in some scientific conferences (albeit not the ones I attend), but such learning is competitive and contested in adversarial political systems (see Dunlop, and Dunlop & Radaelli). I think this limitation helps explain Vallance’s (5.5.20: q390) reluctance to reflect openly on what he would do differently if he had better data on the doubling time of the virus in March (see also Harries, 5.5.20: q414-7 on excess deaths).

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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5. Confusion about the language of intervention and stages of intervention

The Health and Social Care Committee sessions highlight two types of confusion about how best to describe stages of government policy. In particular, the difference between mitigate/suppress represents either a profound change in UK government policy or trivial semantics.

The distinction between contain and delay measures.

The Committee probes the idea of a shift in early March from contain to delay, which taps into wider debates in which critics suggest that the UK gave up on containment too soon (discussed in post 1 in relation to testing). In two sessions, Whitty (5.3.20: q2-4 and q55; 16.3.20) emphasizes that the measures to contain and delay are very similar, so the distinction is misleading:

‘At this point in the early stage of delay, the actions are primarily ones of case finding and isolating cases that come from high-risk areas, which is to try to reduce the possibility of seeding into the community and therefore slow down the initiation of an epidemic, then try to pick up cases early and isolate them in hospital environments so we minimise the chance of transmission within hospitals’ (5.3.20: q55).

Vallance (5.5.20: q41) states that the initial plan was to isolate and track to contain the virus. Then, the UK had a ‘massive influx of cases, not from China but from all sorts of other places, partly because of the huge connectivity of the UK … once it went beyond that to being a pandemic you didn’t know where it was going to come from, and we got a very large number of cases coming in right the way across the country from multiple European sources somewhere around late February and detected in early March’.

The distinction between mitigation and suppression measures

It is common for UK media and social media discussions to highlight a U-turn from mitigation to suppression measures in mid-March, summed up to some extent by the Prime Minister’s exhortation to stay home (16.3.20) and then obligation to stay home (23.3.20).

During this time, the Imperial College COVID-19 Response Team report dated 16.3.20 described (a) ‘mitigation’ measures as likely to reduce UK deaths only from 500000 to 250000, and therefore not viable, prompting (b) the need for ‘suppression’ measures to reduce deaths to 5,600-48,000 over two years.

In contrast, Vallance (17.3.20: q67) describes the distinction as mere semantics:

‘It is a semantic difference, whether you call it suppression, delay or mitigation. The aim is exactly the same, which is, how do you keep this thing down, how do you keep it below the level at which you want to keep it, and how do you keep it down for long enough to ensure that you have managed to achieve suppression?’

Vallance suggests that the UK took suppression measures from 16.3.20 without using the word suppress (17.3.20: q84; see also 5.5.20: q432 ‘we are definitely in “mitigate” now’, which suggests that he says ‘mitigation’ when most might say ‘suppression’). Similarly, Hunt (17.3.20: q69) describes ‘the very dramatic social distancing measures that have now been announced’. Whitty is also keen in the 5.3.20 sessions to downplay the idea that there are distinct categories of action associated with different terms.

For me, these discussions highlight two main issues.

First, initial UK government policy was often confusing because its communication was poor. In this case, it seems that the meaning of each term was not agreed from the outset, contributing to some confusion among adviser, advisee, and commentator.

Second, and more importantly, they betray a lack of appreciation of the difference between measures in relation to their likely levels of implementation. Most notably, several discussions (17.3.20: q84-5) equate UK policy from 16.3.20 as the kinds of suppression measures associated with China or South Korea, despite a huge gulf in their level of enforcement (see also Harries, 5.5.20: q440: ‘People seem to think there was a lockdown moment, whereas in fact a series of interventions based on science were recommended’). In contrast, Costello (17.4.20: q298) favours a more compulsory form of isolation associated with ‘a lot of the Asian states’: ‘Just asking people to self-isolate will not achieve the quarantine that you want’.

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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4. Uncertainty and hesitancy during initial UK coronavirus responses

Vallance (17.3.20: q114) ‘I do not think any of us have seen anything like this. It is a first in not just a generation but potentially the first for 100 years. None of us has seen this. … This is a daily changing and unique situation where we are learning as we go along’.

Early UK discussions are characterized by the expression of uncertainty about what was happening (based on limited data and the questionable accuracy of the most-used model), and hesitancy about how quickly and substantively to respond. This combination of uncertainty and hesitancy informs continuous discussions about why the UK appeared to pursue a lockdown too late, contributing to an unusually high number of excess deaths.

However, it is worth keeping them separate – analytically – to compare uncertainty about (a) what is happening, and (b) what ministers and the public are willing to do about it (as described in the previous post, in relation to problem definition), which inform hesitancy in different ways. Either way, the wider context is that the UK government eventually introduced measures on social regulation that would have seemed unthinkable in the UK before 2020.

The NERVTAG notes show how much uncertainty there was in January 2020, with initial assessments of low risk before the virus spread to other countries and then the UK. Even by the early stages, and still in March, there was some hesitancy about recommending quarantine-style measures, and a tendency to focus on low impact or low social compliance as a way to reject new measures.

  • Compare with Freedman 7.6.20 (‘Where the science went wrong. Sage minutes show that scientific caution, rather than a strategy of “herd immunity”, drove the UK’s slow response to the Covid-19 pandemic).

The oral evidence to the Health and Social Care committee

In the first oral evidence session in March, Whitty (5.3.20: q1) was still describing the virus in relation to China and only providing an initial mild warning that the chances of containment in China (followed by minimal global spread) are ‘slim to zero’ since it is ‘highly likely that there is some level of community transmission of this virus in the UK now’.

Similarly, Willett (Director for Acute Care, NHS England) (17.3.20: q175) described the sense that there was no perceived emergency (in WHO and UK statements) by the end of January, followed by the sense that information, advice, and policy was changing ‘literally every few days’.

The initial oral evidence shows that the science advice was primarily about how to inform and persuade people to change their behavior, focusing heavily on regular handwashing, followed by exhortations to self-isolate at home if feeling symptoms.

Whitty (5.3.20: 2-4) describes delaying the peak of the epidemic via ‘changes to society’ to (a) avoid it coinciding with ‘winter pressures on the NHS’ and boost the capacity to respond, (b) understand the virus better, and (c) hope that it ‘if you move into spring and summer, the natural rate of transmission may go down’ (as with respiratory viruses ‘like flu, colds and coughs’, in which people are less often in small enclosed spaces).

These early discussions emphasise the need for parliamentary and public discussion on more impositional measures, but with no strong push for anything like a lockdown (and, for example, some concern about the measures in South Korea not being acceptable in the UK – Whitty, 5.3.20: q5).

Even on 17.3.20, Vallance (q72) was describing waiting 2-3 weeks to find out the effect of the Prime Minister’s 16.3.20 message, hoping that it could keep the number of ‘excess deaths’ down to 20000 (and Vallance and Whitty had been describing pre-lockdown measures as quite extreme). The same day, Stevens (and Powis, National Medical Director, NHS England) described the PM’s hope that people would act according to the ‘good judgment and altruistic instincts of the British people’ without the need to impose social distancing (17.3.20: q176).

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

6 Comments

Filed under COVID-19, Uncategorized

3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19

Frankly, the widespread and intense focus on ‘herd immunity’ was a needless distraction, sparked initially by government advisors but then nitrous-turbo-boosted, gold-plated, and covered in neon lights during a series of ridiculous media and social media representations of ill-worded statements.

This initial focus took attention away from a much more profound discussion of what the UK government thinks is feasible, which informs a very stark choice: to define the COVID-19 problem as (a) a short term pandemic to be eradicated (as in countries like South Korea) or (b) a long term pandemic to be expected and managed every year (the definition in countries like the UK).

There is no ‘herd immunity strategy’

The key thing to note is that ministers and their advisors:

  • Did talk in general terms about the idea of ‘herd immunity’ in March (best summed up as: herd immunity is only possible if there is a vaccine or enough people are infected and recover)
  • Did not recommend an extreme non-intervention policy in which most of the population would be infected quickly to achieve herd immunity (in February, advisers described this outcome as the Reasonable Worst Case Scenario; see also Whitty, 5.3.20: q15-17)

Rather, describing the idea of herd immunity as an inevitability (not determined by choice) is key to understanding the UK approach. It helps us question the idea that there was a big policy U-turn in mid-March. Policy did change in the short term, but a sole focus on the short term distracts from the profound implications of its long-term strategy (in the absence of a vaccine) associated with phrases such as ‘flatten the curve’ (rather than ‘eradicate the virus’).

Examples of UK government representatives talking about herd immunity

1.      Wilful misrepresentation, often put to music

Full Fact’s challenge to the wilful misrepresentation of Prime Minister Boris Johnson’s appearance on the ITV programme This Morning (10.3.20): Here is the transcript of what Boris Johnson said on This Morning about the new coronavirus

These video stinkers, in which people (a) cut quotes so that you don’t hear the context, and provide a misleading headline, or (b) put a bunch of cut interviews in sequence and combine them with a tune that sounds like a knock-off version of the end credits to the TV Series The Hulk (in other words, people design these messages to get an emotional reaction).

2.      Headlines stoking the idea of herd immunity during a time when everyone should have been careful about how explain and interpret early discussions

British government wants UK to acquire coronavirus ‘herd immunity’, writes Robert Peston (12.3.20)

3.      The accentuation of a message not being emphasised by government spokespeople, at the expense of a message that requires more attention.

This interview is described by Sky News (13.3.20) as: ‘The government’s chief scientific adviser Sir Patrick Vallance has told Sky News that about 60% of people will need to become infected with coronavirus in order for the UK to enjoy “herd immunity”’. You might be forgiven for thinking that he was on Sky extolling the virtues of a strategy to that end. This was certainly the write-up in respected papers like the FT (UK’s chief scientific adviser defends ‘herd immunity’ strategy for coronavirus). Yet, he was saying nothing of the sort. Rather, when prompted, he discussed herd immunity in relation to the belief that COVID-19 will endure long enough to become as common as seasonal flu.

See Vallance’s interview on the same day (13.3.20) during Radio 4’s Today programme (transcribed by the Spectator and headlined as “How ‘herd immunity’ can help fight coronavirus” as if it is his main message). The Today Programme also tweeted only 30 seconds to single out that brief exchange. Yet, clearly his overall message – in this and other interviews – was that some interventions (e.g. staying at home; self-isolating with symptoms) would have bigger effects than others (e.g. school closures; prohibiting mass gatherings) during the ‘flattening of the peak’ strategy (‘What we don’t want is everybody to end up getting it in a short period of time so that we swamp and overwhelm NHS services’). Rather than describing ‘herd immunity’ as a strategy, he is really describing how to deal with its inevitability.

[PAC: Note that these examples are increasingly difficult to track, because people take the herd immunity argument for granted or cite reference to it misleadingly. For example, Scalley et al state “To widespread criticism, he floated an approach to “build up some degree of herd immunity” founded on an erroneous view that the vast majority of cases would be mild, like influenza”. Their citation takes you here, in which there is no reference to herd immunity or the quotation]

In oral evidence, Vallance (17.3.20: q70) compares these measures as follows (while describing the ‘confidence intervals’ as ‘quite wide’, q77):

‘The interventions we have made have all been modelled out – it is just modelling; we need to be aware of that – to say what effect they would have on the peak. In the first one we introduced, case isolation, you would expect to bring the peak down by about 20%. In the second one, whole household quarantine, you would expect to bring it down by about 25%. The social shielding of the elderly has less of an effect on the peak but a much bigger effect on the mortality, where you might expect it to be between 20% and 30%. General social distancing measures—as you said, quite extreme ones have now been introduced—would be expected to reduce the peak by about 50%. They are not necessarily all completely additive, but it tells you that together we should expect those to have a very significant effect on the peak, and we should start to see the rates come down in two or three weeks’ time. The ambition in any outbreak is to try to get the R0 value down below one. That is the value, on average, of what one person would do in infecting others. At the moment, the R0 value is somewhere between two and three, and the aim is to get it below one, at which time things start to decrease’

Further discussion of herd immunity in oral evidence

Throughout the evidence sessions, some MPs raise the herd immunity idea, but not energetically, and perhaps largely to allow government advisers to clarify their initial statements (e.g. 17.3.20: q112; 17.4.20: q303).

In May, Vallance (5.5.20: q389 and q404) makes it extra-clear that he was not advocating the ‘herd immunity’ idea associated with no intervention:

‘Q389 Chair: It sounds like there is still a degree of uncertainty as to whether an antibody leads to an immune response. Back on 13 March, you said the aim was to build up some kind of herd immunity where lots of people in the country had had the virus so that they could not catch it again. When you said that, which was nearly two months ago, what was your evidence then for the existence of that kind of immunity?

Sir Patrick Vallance: I should be clear about what I was trying to say, and, if I did not say it clearly enough, I apologise. What I was trying to say was that, in the absence of a therapeutic, the way in which you can stop a community becoming susceptible to this is through immunity. Immunity can be obtained either by vaccination or by people who have had the infection. We don’t know, as I said, exactly what degree of protection you get from natural infection, and we don’t yet have a vaccine. The second thing is that the higher the proportion of people in the community with immunity, the easier it is to control the disease and, ultimately, the easier it is to release measures. So vaccination becomes an important part of how you end up with protection, assuming you can get a decent immune response with vaccines, which we also do not know yet, but you would expect there to be some degree of immunity. The expectation is that antibody responses will correlate with immunity to some degree—maybe very high or maybe not so high. As to the degree of protection, whether it is to reduce the severity of the disease or to reduce the overall effect of the disease and the ability to catch the disease, we still have some work to do to find out about that.

Q404 ‘To reiterate, as I said at the beginning to Jeremy Hunt, my points about immunity were not actually about getting immunity through that route. My point has been clear from the outset that we need to suppress the peak, and keep the peak down flat below the level at which the NHS can cope, to protect the NHS and to make sure that we reduce deaths. That has been the strategy.’

See also:

Government emails on herd immunity

[Update 15.10.20] The BBC used a Freedom of Information request to secure ‘every email sent by Sir Patrick [Vallance] and chief medical officer for England, Professor Chris Whitty, from the start of February to the start of June, containing the words “herd immunity”‘.

The BBC narrative is that some people think that the government was in favour of pursuing ‘herd immunity’ via high infection rates in the population (60%) that would contribute to hundreds of thousands of deaths.

For me, this is a misleading story.

The emails largely show that these advisors regret ever using the term ‘herd immunity’ because it allows people to jump to wild conclusions based on patching together minimal evidence (and ignoring more convincing evidence that advisors pushed strongly for suppression measures).

Defining the COVID-19 problem in the UK

If so, this clarity allows us to think more about the implications of the UK government’s problem definition. In a much larger paper (that’s right – its completion is on the to-do list), I suggest that these elements inform the UK government’s definition of the policy problem by mid-March 2020:

  1. We are responding to an epidemic that cannot be eradicated. Herd immunity is only possible if there is a vaccine or enough people are infected and recover.
  2. We need to use a suppression strategy to reduce infection enough to avoid overwhelming health service capacity, and shield the people most vulnerable to major illness or death caused by COVID-19, to minimize deaths during at least one peak of infection.
  3. We need to maintain suppression for a period of time that is difficult to predict, subject to compliance levels that are difficult to predict and monitor.
  4. We need to avoid panicking the public in the lead up to suppression, avoid too-draconian enforcement, and maintain wide public trust in the government.
  5. We need to avoid (a) excessive and (b) insufficient suppression measures, either of which could contribute to a second wave of the epidemic of the same magnitude as the first.
  6. We need to transition safely from suppression measures to foster economic activity, find safe ways for people to return to work and education, and reinstate the full use of NHS capacity for non-COVID-19 illness. In the absence of a vaccine, this strategy will likely involve social distancing and (voluntary) track-and-trace measures to isolate people with COVID-19.
  7. Any action or inaction has a profoundly unequal impact on social groups.

In other words, UK government policy is about reducing or moving the initial peak of infection, followed by longer term management to ensure that the NHS always has capacity to treat. The short-term focus emphasized the need to get the timing right in relation to the balance between public health benefits and social and economic cost (rather than to adopt a precautionary principle):

‘There is also timing. There will be quite a long period between knowing that we have an epidemic running at a reasonable rate and the actual peak. We are keen not to intervene until the point when we absolutely have to, so as to minimise the economic and social disruption on people, and then to stop it again as soon as we can afterwards. It is both the combination of what we need to do—in later questions we might want to go into some details about the things we can do—and the timing. The timing is critical. It is important that we minimise the social disruption while doing what we can to make sure we maximise the public health impact’ (Whitty, 5.3.20: q18)

[See also q39 on the unresolved difficulties of isolating vulnerable people physically without producing too high costs socially, and

q59 on ‘no need at this stage to be stocking up on anything. … this is going to be a marathon not a sprint. This is going to be a long period. There is going to be a lead time before the serious take-off of this comes, which we will be able to indicate … There is nothing in the current environment that would rationally lead someone to want to go out and stock up on stuff’.]

It is difficult to tell exactly what ministers and advisors expect to happen long-term in the absence of a vaccine (although Vallance 17.3.20: q102 is clear that the initial suppression measures will take an indeterminate number of months, not a few weeks). For example, are they managing infections and expecting regular deaths (assuming a mortality rate at approximately 1%) or expecting a high NHS capacity to reduce that mortality rate? Most discussions in public refer generally to the peak and NHS capacity but not the specifics:

‘Overall, the goal is clearly to bend the curve down and to make sure that the NHS capacity is there, and at the same time to do the work to try to improve our ability as a society to cope with this disease, with the goal of lifting some of the incredibly restrictive methods that we have had to place on the population in order to get the disease under control’ (Hancock, 17.4.20: q306)

The long-term implications of ‘flatten the curve’

In that context, Costello (17.4.20: q303) sums up my niggling concerns about the ‘flatten the curve’ message. This phrase suggests that we

  • keep transmission low enough to make sure that the number of relevant cases does not overwhelm the NHS (an approach with high support), and
  • accept that transmission will remain at a lower but significant rate until a vaccine is found (an approach that is not discussed as much, but it implies the continuation of deaths at a lower but regular rate):

‘The recent estimates, even from the chief scientific officer, are that after this wave, where we could see 40,000 deaths by the time it is over, we could have maybe only 10% to 15% of the population infected or covered, so the idea of herd immunity would mean maybe another five or six more waves to get to 60%. I do not think we should be using phrases such as “flatten the curve” because it implies continuing. We have to suppress this right down.’ (Costello, 17.4.20: q303)

The other side of this coin is that government advisers were initially working on the assumption that they could keep the initial number of deaths to 20000, which suggests a population infection rate well below 10% of the population (2/60m people, assuming the 1% mortality rate described by Whitty, 5.3.20: q11) and no expectation of herd immunity in the short term.

Comparing the UK definition with approaches in South Korea and China

The oral evidence sessions, probing the UK government’s longer term vision, help make key aspects of this definition somewhat clearer in two main ways.

First, they help confirm that UK policy is built on the assumption that COVID-19 will be a regular or seasonal problem (in the absence of a vaccine and culture change). For example, Hunt (17.3.20: q105) suggests that some country leaders think there will be (a) a peak of infection, then (b) containment, followed by (c) fizzling out:

‘China has officially announced that it thinks it is past the peak. The South Korean Foreign Minister was on TV at the weekend saying that she thinks South Korea has passed the peak, and it seems to think it has passed the peak with less than 1% of the population being infected. It is very realistic that there could be second or third waves, but it does not seem to be expecting it as much as you do … The Chinese and Korean view seems to be that it could be something like SARS, for example, which just burns itself out when the reproduction rate gets below one. Why is it that you are, unfortunately, so certain that it will come back?’

In contrast, Vallance (e.g. 17.3.20: q104-5) suggests strongly that COVID-19’s properties indicate high transmissibility and continuous recurrence (we may have to plan for a ‘spike every year’). This definition of the problem underpins the UK government’s expectation of long term management and, I think, is one of several reasons that ministers and advisers describe evaluation as premature.

Second, they suggest that this approach is built on a further assumption of what it feasible in the UK in relation to social behaviour.

A key element of international comparison relates to very different assumptions about social behaviour in each country. For example, the committee heard from respondents about experiences in South Korea, Hong Kong, Taiwan, and Singapore, in which previous pandemics – such as SARS – had a profound effect on government preparation and public behaviour (e.g. Comas-Herrera, 19.5.20: q446; Lum (Professor of Social Work and Social Administration, Hong Kong University) 19.5.20: q450, 456, 463; Chen (Former Vice-President of the Republic of China (Taiwan), 3.6.20: 492-504).

As a result, in many countries, you can expect widespread mask use and routine temperature checks, relatively invasive test and tracing measures, and obligatory isolation, to form part of a government’s response (such as to act quickly on regional ‘hotspots’ to prevent nationwide spread; compare with Hancock, 17.4.20: q318 on the connection of a UK lockdown to national unity, and Vallance, 5.5.20: q410-11 lukewarm on regional approaches, but also Harries, 5.5.20; q416 on the UK addressing hotspots in the earliest phase).

All of these measures and behaviours can contain the transmission of coronavirus in a way that seems to be far less feasible in the UK. For example, Doyle (26.3.20: q199-202) suggests that the South Korean system involves a degree of personal invasion not expected in UK, including giving bank details to government and being tested in public places like restaurants.

Further, even if these measures are possible, there is scepticism about their long-term impact: ‘the Chinese state and people are still doing some pretty extraordinary things’, with the potential that ‘when they take their foot off the brake the epidemic will surge back again’ (Whitty, 5.3.20: q13-4).

Instead, the emphasis from UK government respondents is initially (from March) about recommending the measures with the highest positive public health impact and lowest negative social and economic impact (handwashing). For example, Whitty (5.3.20: q18, see also q25, and Vallance 17.3.20: q92) compares measures:

‘ranging from those with almost no economic impact and high efficacy – top of the range being washing your hands and second being covering your mouth with a tissue when you cough – all the way down to those that have major societal impact, such as closing schools, which obviously affects children but also parents, potentially employment and particular sectors of the economy. It is very easy to choose a package of measures that is quite dramatic but has relatively little impact on the epidemic. We are very keen to avoid that, so we are modelling out all the combinations that we can because people’s livelihoods depend on it’.

Throughout, there is an emphasis on what might work in a UK-style liberal democracy characterised by relatively low social regulation, reinforced with reference to behavioural public policy:

‘All the behavioural science would suggest that we have to get the transparency right. We have to get the communication right. We have to trust that people want to know things, they want to know about this and they want to be able to be empowered to make their own decisions’ (Vallance, 17.3.20: 98).

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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2. The inadequate supply of personal protective equipment (PPE)

The inadequate supply of PPE is a feature of almost every evidence session (more so than the focus on adequate numbers of ventilators and ICU capacity – 17.3.20: q67, q124, q139-44; 26.3.20: q194; 14.4.20: q306; 17.4.20: q296).

Initial sessions focused on who should have access to PPE (for example, perhaps not GPs since people are advised not to attend surgeries – Harries, 5.3.20: q51) and the limited training on how to wear or dispose of it safely (Whitty, Chief Medical Officer, 5.3.20: q53).

The remaining sessions exposed a gulf in feedback between: (a) people giving oral evidence to the committee on behalf of government bodies, and (b) most other people responding to requests for information by MPs.

This disconnect prompts several MPs to describe PPE as a policy ‘fiasco’, note its impact on already decreasing trust in government, and connect this problem of trust to issues such as

  • PPE standards that seemed out of step with WHO guidance (for example, 26.3.20: q237-48), and
  • the reclassification of COVID-19 as no longer a ‘high-consequences infectious disease’ (note: it relates to the individual, not the population) (17.3.20: q170; 26.3.20: q258-9).

In other words, UK bodies denied – with only moderate success – that changes to PPE advice related to shortages of the right equipment.

Examples of specific PPE discussions include:

Pritchard (Chief Operating Officer, NHS England) and Stevens describe sufficient stockpiles but temporary distributional issues and a need to ramp up supply in the future, perhaps solved in a week (17.3.20: q129-31; 137). The Chair, Jeremy Hunt MP suggests that this answer is at odds with feedback from NHS staff describing access only to paper masks and aprons (17.3.20: q132).

Feedback from representatives of staff seeking PPE describe something more akin to a shortage crisis (for example, Nagpaul, 26.3.20: q239; Bullion, 26.3.20: q264; Green, 26.3.20: q266 and 289; Pittard, 17.4.20: q296; Kinnair, 17.4.20: q297 and 305). Again, Sarah Owen MP (26.3.20: q249) sums up the major gulf between oral evidence on PPE (from PHE and others) and the wider feedback from NHS and other care workers on the inadequacy of supply of the right protective equipment.

Hancock (17.4.20: q306) describes the supply of PPE (and ventilators) as the third element of his ‘battle plan’ (compare with Taiwo Owatemi MP, 17.4.20: q316 and Yvette Cooper MP, 17.4.20: q319 and a series of questions q348-58). However, Hopson (Chief Executive, NHS Providers, 14.5.20: q92-95) describes continued uncertainty (particularly with gowns), making it difficult to plan surgery or find the right PPE for women and ethnic minority staff, while Green (19.5.20: q470) describes the situation as far worse outside of NHS settings (on the assumption that the NHS was prioritised).

By June, Deighton, as ‘Adviser to the Secretary of State on PPE’, describes overcoming supply problems and taking the ‘kinks’ out of logistics (3.6.20: q553-4) and improvement by the day, while most questions suggest that this image of hope is still at odds with other feedback to MPs.

COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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1. The need to ramp up testing (for many purposes)

The need to ramp up testing is a recurring theme, in which respondents describe low capacity in the beginning, and continuous problems with ‘ramping up’ capacity, then reflect on the difference it could have made in key areas (during more reflective discussions in June).

The figures reported in oral evidence were 2000 per day (Harries, Deputy Chief Medical Officer, 5.3.20: q54), 4000 (Vallance, Chief Scientific Advisor, 17.3.20: q78-84), 7000 (Doyle, Medical Director, Public Health England, 26.3.20: q196), and 50000 (Hancock, Secretary of State, 17.4.20: q312), but increasingly in the absence of a definition of testing, which became important when the UK government began to treat all tests sent out as part of meeting its 100000 per day target.

In March, Vallance (17.3.20: q78-84) described capacity as 4000 reliable tests per day, and noted the lack of accuracy of the larger-scale of tests available in the market, to argue that the UK was one of the most frequent testers at the time. Such arguments dated very quickly. Hancock (17.4.20: q306) then describes ‘ramp-up testing’ as the fourth element of the government’s ‘battle plan’ but often with low clarity on how, and who would be responsible. This confusion is apparent when Doyle (26.3.20: q196) describes separate responsibilities, in which PHE would be responsible for testing NHS staff and patients (target 25000 tests per day), while the Office for Life Sciences would take forward the 100000 tests per day pledge.

In most cases, there is broad agreement on the negative impact of the limited testing capacity, including:

Surveillance and modelling

Vallance (17.3.20 and 5.5.20: q435) reflects on the need for more testing to aid initial surveillance, suggesting that they could have acted very differently if the testing capacity was higher. This issue will run and run. The absence of data affected the ability of advisory bodies to model the estimated ‘peak’ of infection (based partly on its doubling-rate) that became so central to the UK government’s initial lockdown strategy. Further, there is much debate on the adequacy of UK modelling. For example, listen to the Radio 4 series More or Less (10.6.20, ‘Antibody tests, early lockdown advice and European deaths’), which argues that, during the 1st press UK government conference (12th March), Vallance misjudged the UK as being 4- rather than 2-weeks behind Italy. Compare with Vallance (5.5.20: q390).

NHS staff and services

NHS bodies describe their reduced ability to operate effectively (throughout the session on 17.3.20 which included Stevens, chief executive of NHS England). Nagpaul (British Medical Association) (26.3.20: q203-4) describes the combination of (a) advice to self-isolate with symptoms, and (b) an absence of testing, as a potential cause of a 10% shortage of NHS staff during the crisis, and this problem is a continuous theme in this day’s evidence. Green (Care England) (26.3.20: q267) and Bullion (Vice-President, Association of Directors of Adult Social Services) (26.3.20: q279) make the same case for a social care sector already at low capacity. Kinnair (Royal College of Nursing) and Pittard (Faculty of Intensive Care Medicine) describe low testing (and limited PPE) as major worries for staff (17.4.20: q297)

Discharges to care homes

One key example – still to be explored fully – is the absence of routine testing of NHS patients during the push to discharge 15000 people from hospital to social care beds in England (Stevens, 17.3.20: q122-3; Green, 26.3.20: q274). Green (19.5.20: q470 and q478) notes that the UK Government prioritised the NHS at the expense of social care, prompting NHS discharges to care homes before proper testing was in place, while knowing that care homes are ill-suited to isolation measures. Note that the NHS was already under capacity pressure before the crisis (Stevens, 17.3.20: q165), and redeploying medical and nursing care from care homes, while Willet (Director for Acute Care, NHS England 17.3.20: q165) describes an already fragmented system of 12500 care homes in England.

Overall, the absence of sufficient information – from routine testing for the virus, and proper analysis of care home capacity – combined with a huge drive to favour NHS care and move people to care homes, contributed to a disproportionately large coronavirus problem in care homes.

This experience compares with many other countries that addressed care homes more effectively. In Germany, patients were not discharged to care homes unless they could quarantine (Halletz, Chief Executive Officer, AGVP (Employers’ Association – Care Homes) 19.5.20: q455). In South Korea, people were taken from care homes to be quarantined (Comas-Herrera, Assistant Professorial Research Fellow, Care Policy and Evaluation Centre, LSE, 19.5.20: q447).

Committee update, 12th June 2020: Figures confirming discharges of hospital patients into care homes, responding to the National Audit Office report Readying the NHS and adult social care in England for COVID-19. The NAO press release states:

‘Patients discharged quickly from hospitals between mid-March and mid-April were sometimes placed in care homes without being tested for COVID-19. On 17 March, hospitals were advised to discharge urgently all in-patients medically fit to leave in order to increase capacity to support those with acute healthcare needs. Between 17 March and 15 April, around 25,000 people were discharged from hospitals into care homes, compared with around 35,000 people in the same period in 2019. Due to government policy at the time, not all patients were tested for COVID-19 before discharge, with priority given to patients with symptoms. On 15 April, the policy was changed to test all those being discharged into care homes. It is not known how many patients discharged to care homes had COVID-19 at the point they left hospital’

Testing and contact tracing

The issue of testing in relation to initial contact tracing is less straightforward. On several occasions, PHE and health department respondents note that there came a point when the number of infections, and rate of infection, ruled out the effectiveness of contact tracing and testing in favour of UK-wide lockdown measures: ‘several weeks ago that ship had begun to sail. Nevertheless, we kept going until mid-March, until we were absolutely sure that contact tracing in that way would not work’ (Doyle, 26.3.20: q198; see also q232 on testing representing only one of many necessary measures).

There is a continuous discussion in multiple sessions on why the UK stopped contact tracing after it became clear that the rate of transmission was very high (e.g. Harries 5.5.20: q415 on the shift from ‘contain’ to ‘delay’ on 12th March, q418 on using limited tests in hospitals where most needed, and q425-8).

Costello (Professor of Global Health and Sustainable Development, UCL, 17.4.20: q303-4) agrees with this approach in relation to London and several other cities where prevalence and transmission were unusually high, but argues that in many places there were very few cases (fewer than 10 cases in 50 local health areas until mid-March) and that they could have been contained. This issue will run and run too (see the discussion on contain/ delay in the run up to the first peak).

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COVID-19 policy in the UK: oral evidence to the Health and Social Care Committee (5th March- 3rd June 2020)

This series of posts describes the key themes and issues to arise from oral evidence to the House of Commons Health and Social Care Committee on COVID-19. It is the first committee on my to-do list.

When possible, I have (or will) connect them to some other sources of information, such as the minutes from NERVTAG, the not-yet-read-by-me minutes by SAGE, and the 8000-word paper that I am writing (which is currently 20000 words, and based initially on this unwieldy blog post). The result is a very long read, which I have broken down into a collection of 9 reads. One unintended consequence is that you may not see a respondent’s full title in some posts, because originally I only listed it the first time on the full document. Fortunately, there is a simple solution: read all the posts from 1-8.

Two issues often seem to dominate the oral evidence to the Health and Social Care Committee in multiple sessions from March to June 2020:

  1. Limited testing: antigen testing to detect the virus now, then antibody testing to detect if someone had COVID-19 in the past.
  2. Shortages of personal protective equipment (PPE), initially for NHS staff, followed by concerns about availability in social care and other sectors.

These issues connect to a series of knock-on issues, such as the discharge of patients from NHS hospitals to care homes without being tested.

They also intersect with broader policy themes which include how to:

  1. Define coronavirus as a policy problem, such as with reference to the oft-abused phrase ‘herd immunity.
  2. Act despite uncertainty, or a lack of information on which to give advice and make choices.
  3. Define different stages of intervention, including contain, delay, research, mitigate, and suppress.
  4. Describe the relationship between science advice and policy, to project the sense that policy is evidence-informed but that elected politicians are responsible for choice.
  5. Identify the many changes to policy and practice that would otherwise receive minimal attention (in other words, they are low salience but high importance).
  6. Address the links between health inequalities and race and ethnicity.

These sessions generally relate to activity for England, but with few indications that the actions or issues are markedly different in Northern Ireland, Scotland, or Wales. Indeed, (a) there is frequent reference to UK-wide cooperation and coordination, and (b) issues such as NHS hospital discharges to care homes without testing or quarantine measures seem UK-wide (albeit with variations in practice). A proper focus on devolved government is also on the to-do list.

PS I also left out some issues because they seemed unresolved by June:

  • Test, track, and trace (Hancock, 17.4.20: q325-7; Vallance and Harries, 5.5.20: q425-8; Chen, 3.6.20: 492-504; Fraser, Professor of Pathogen Dynamics, University of Oxford and Harding, Executive Chair of NHS Test and Trace programme, 3.6.20: 510-52)
  • When to have border restrictions (Cooper, 17.4.20: q344)
  • Testing for a vaccine (Van-Tam, Deputy Chief Medical Officer, 17.4.20: q366)
  • Who to learn from, in relation to comparability (Vallance, 5.5.20: q435; see also the dedicated session 19.5.20 on South Korea, Hong Kong, Germany).

The full series of posts:

  1. The need to ramp up testing (for many purposes)
  2. The inadequate supply of personal protective equipment (PPE)
  3. Defining the policy problem: ‘herd immunity’, long term management, and the containability of COVID-19
  4. Uncertainty and hesitancy during initial UK coronavirus responses
  5. Confusion about the language of intervention and stages of intervention
  6. The relationship between science, science advice, and policy
  7. Lower profile changes to policy and practice
  8. Race, ethnicity, and the social determinants of health

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