Tag Archives: UK Government

The UK Government’s COVID-19 policy: assessing evidence-informed policy analysis in real time

abstract 25k words

On the 23rd March 2020, the UK Government’s Prime Minister Boris Johnson declared: ‘From this evening I must give the British people a very simple instruction – you must stay at home’. He announced measures to help limit the impact of COVID-19 , including new regulations on behaviour, police powers to support public health, budgetary measures to support businesses and workers during their economic inactivity, the almost-complete closure of schools, and the major expansion of healthcare capacity via investment in technology, discharge to care homes, and a consolidation of national, private, and new health service capacity (note that many of these measures relate only to England, with devolved governments responsible for public health in Northern Ireland, Scotland, and Wales). Overall, the coronavirus prompted almost-unprecedented policy change, towards state intervention, at a speed and magnitude that seemed unimaginable before 2020.

Yet, many have criticised the UK government’s response as slow and insufficient. Criticisms include that UK ministers and their advisors did not:

  • take the coronavirus seriously enough in relation to existing evidence (when its devastating effect was increasingly apparent in China in January and Italy from February)
  • act as quickly as some countries to test for infection to limit its spread, and/ or introduce swift measures to close schools, businesses, and major social events, and regulate social behaviour (such as in Taiwan, South Korea, or New Zealand)
  • introduce strict-enough measures to stop people coming into contact with each other at events and in public transport.

They blame UK ministers for pursuing a ‘mitigation’ strategy, allegedly based on reducing the rate of infection and impact of COVID-19 until the population developed ‘herd immunity’, rather than an elimination strategy to minimise its spread until a vaccine or antiviral could be developed. Or, they criticise the over-reliance on specific models, which underestimated the R (rate of transmission) and ‘doubling time’ of cases and contributed to a 2-week delay of lockdown.

Many cite this delay, compounded by insufficient personal protective equipment (PPE) in hospitals and fatal errors in the treatment of care homes, as the biggest contributor to the UK’s unusually high number of excess deaths (Campbell et al, 2020; Burn-Murdoch and Giles, 2020; Scally et al, 2020; Mason, 2020; Ball, 2020; compare with Freedman, 2020a; 2020b and Snowden, 2020).

In contrast, scientific advisers to UK ministers have emphasised the need to gather evidence continuously to model the epidemic and identify key points at which to intervene, to reduce the size of the peak of population illness initially, then manage the spread of the virus over the longer term (e.g. Vallance). Throughout, they emphasised the need for individual behavioural change (hand washing and social distancing), supplemented by government action, in a liberal democracy in which direct imposition is unusual and, according to UK ministers, unsustainable in the long term.

We can relate these debates to the general limits to policymaking identified in policy studies (summarised in Cairney, 2016; 2020a; Cairney et al, 2019) and underpinning the ‘governance thesis’ that dominates the study of British policymaking (Kerr and Kettell, 2006: 11; Jordan and Cairney, 2013: 234).

First, policymakers must ignore almost all evidence. Individuals combine cognition and emotion to help them make choices efficiently, and governments have equivalent rules to prioritise only some information.

Second, policymakers have a limited understanding, and even less control, of their policymaking environments. No single centre of government has the power to control policy outcomes. Rather, there are many policymakers and influencers spread across a political system, and most choices in government are made in subsystems, with their own rules and networks, over which ministers have limited knowledge and influence. Further, the social and economic context, and events such as a pandemic, often appear to be largely out of their control.

Third, even though they lack full knowledge and control, governments must still make choices. Therefore, their choices are necessarily flawed.

Fourth, their choices produce unequal impacts on different social groups.

Overall, the idea that policy is controlled by a small number of UK government ministers, with the power to solve major policy problems, is still popular in media and public debate, but dismissed in policy research .

Hold the UK government to account via systematic analysis, not trials by social media

To make more sense of current developments in the UK, we need to understand how UK policymakers address these limitations in practice, and widen the scope of debate to consider the impact of policy on inequalities.

A policy theory-informed and real-time account helps us avoid after-the-fact wisdom and bad-faith trials by social media.

UK government action has been deficient in important ways, but we need careful and systematic analysis to help us separate (a) well-informed criticism to foster policy learning and hold ministers to account, from (a) a naïve and partisan rush to judgement that undermines learning and helps let ministers off the hook.

To that end, I combine insights from policy analysis guides, policy theories, and critical policy analysis to analyse the UK government’s initial coronavirus policy. I use the lens of 5-step policy analysis models to identify what analysts and policymakers need to do, the limits to their ability to do it, and the distributional consequences of their choices.

I focus on sources in the public record, including oral evidence to the House of Commons Health and Social Care committee, and the minutes and meeting papers of the UK Government’s Scientific Advisory Group for Emergencies (SAGE) (and NERVTAG), transcripts of TV press conferences and radio interviews, and reports by professional bodies and think tanks.

The short version is here. The long version – containing a huge list of sources and ongoing debates – is here. Both are on the COVID-19 page.

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COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

This post is part 8 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The table is too big to reproduce here, so you have the following options:

Table 2 in PDF

Table 2 as a word document

Or, if you prefer not to read the posts individually:

The whole thing in PDF

The whole thing as a Word document

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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Filed under COVID-19, Evidence Based Policymaking (EBPM), Prevention policy, Public health, UK politics and policy

COVID-19 policy in the UK: SAGE Theme 3. Communicating to the public

This post is part 7 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

SAGE’s emphasis on uncertainty and limited knowledge extended to the evidence on how to influence behaviour via communication:

‘there is limited evidence on the best phrasing of messages, the barriers and stressors that people will encounter when trying to follow guidance, the attitudes of the public to the interventions, or the best strategies to promote adherence in the long-term’ (SPI-B Meeting paper 3.3.20: 2)

Early on, SAGE minutes described continuously the potential problems of communicating risk and encouraging behavioural change through communication (in other words, based on low expectations for the types of quarantine measures associated with China and South Korea).

  • It sought ‘behavioural science input on public communication’ and ‘agreed on the importance of behavioural science informing policy – and on the importance of public trust in HMG’s approach’ (28.1.20: 2).
  • It worried about how the public might interpret ‘case fatality rate’, given the different ways to describe and interpret frequencies and risks (4.2.20: 3).
  • It stated that ‘Epidemiological terms need to be made clearer in the planning documents to avoid ambiguity’ (11.2.20: 3).
  • Its extensive discussion of behavioural science (13.2.20: 2-3) includes: there will be public scepticism and inaction until first deaths are confirmed; the main aim is to motivate people by relating behavioural change to their lives; messaging should stress ‘personal responsibility and responsibility to others’ and be clear on which measures are effective’, and ‘National messaging should be clear and definitive: if such messaging is presented as both precautionary and sufficient, it will reduce the likelihood of the public adopting further unnecessary or contradictory behaviours’ (13.2.20: 2-3)
  • Banning large public events could signal the need to change behaviour more generally, but evidence for its likely impact is unavailable (SPI-M-O, 11.2.20: 1).

Generally speaking, the assumption underpinning communication is that behavioural change will come largely from communication (encouragement and exhortation) rather than imposition. Hence, for example, the SPI-B (25.2.20: 2) recommendation on limiting the ‘risk of public disorder’:

  • ‘Provide clear and transparent reasons for different strategies: The public need to understand the purpose of the Government’s policy, why the UK approach differs to other countries and how resources are being allocated. SPI-B agreed that government should prioritise messaging that explains clearly why certain actions are being taken, ahead of messaging designed solely for reassuring the public.
  • This should also set clear expectations on how the response will develop, g. ensuring the public understands what they can expect as the outbreak evolves and what will happen when large numbers of people present at hospitals. The use of early messaging will help, as a) individuals are likely to be more receptive to messages before an issue becomes controversial and b) it will promote a sense the Government is following a plan.
  • Promote a sense of collectivism: All messaging should reinforce a sense of community, that “we are all in this together.” This will avoid increasing tensions between different groups (including between responding agencies and the public); promote social norms around behaviours; and lead to self-policing within communities around important behaviours’.

The underpinning assumption is that the government should treat people as ‘rational actors’: explain risk and how to reduce it, support existing measures by the public to socially distance, be transparent, explain if UK is doing things differently to other countries, and recognise that these measures are easier for some more than others (13.3.20: 3).

In that context, SPI-B Meeting paper 22.3.20 describes how to enable social distancing with reference to the ‘behaviour change wheel’ (Michie et al, 2011): ‘There are nine broad ways of achieving behaviour change: Education, Persuasion, Incentivisation, Coercion, Enablement, Training, Restriction, Environmental restructuring, and Modelling’ and many could reinforce each other (22.3.20: 1). The paper comments on current policy in relation to 5 elements:

  1. Education – clarify guidance (generally, and for shielding), e.g. through interactive website, tailored to many audiences
  2. Persuasion – increase perceived threat among ‘those who are complacent, using hard-hitting emotional messaging’ while providing clarity and positive messaging (tailored to your audience’s motivation) on what action to take (22.3.20: 1-2).
  3. Incentivisation – emphasise social approval as a reward for behaviour change
  4. Coercion – ‘Consideration should be given to enacting legislation, with community involvement, to compel key social distancing measures’ (combined with encouraging ‘social disapproval but with a strong caveat around unwanted negative consequences’ (22.3.20: 2)
  5. Enablement – make sure that people have alternative access to social contact, food, and other resources for people feeling the unequal impact of lockdown (particularly for vulnerable people shielding, aided by community support).

Apparently, section 3 of SPI-B’s meeting paper (1.4.20b: 2) had been redacted because it was critical of a UK Government ‘Framework; with 4 new proposals for greater compliance: ‘17) increasing the financial penalties imposed; 18) introducing self-validation for movements; 19) reducing exercise and/or shopping; 20) reducing non-home working’. On 17, it suggests that the evidence base for (e.g.) fining someone exercising more than 1km from their home could contribute to lower support for policy overall. On 17-19, it suggests that most people are already complying, so there is no evidence to support more targeted measures. It is more positive about 20, since it could reduce non-home working (especially if financially supported). Generally, it suggests that ministers should ‘also consider the role of rewards and facilitations in improving adherence’ and use organisational changes, such as staggered work hours and new use of space, rather than simply focusing on individuals.

Communication after the lockdown

SAGE suggests that communication problems are more complicated during the release of lockdown measures (in other words, without the ability to present the relatively-low-ambiguity message ‘stay at home’). Examples (mostly from SPI-B and its contributors) include:

  • Address potential confusion, causing false concern or reassurance, regarding antigen and antibody tests (meeting papers 1.4.20c: 3; 13.4.20b: 1-4; 22.4.20b: 1-5; 29.4.20a: 1-4)
  • When notifying people about the need to self-isolate, address the trade-offs between symptom versus positive test based notifications (meeting paper 29.4.20a: 1-4; 5.5.20: 1-8)
  • If you are worried about public ‘disorder’, focus on clear, effective, tailored communication, using local influencers, appealing to sympathetic groups (like NHS staff), and co-producing messages between the police and public (in other words, police via consent, and do not exacerbate grievances) (meeting papers 19.4.20: 1-4; 21.4.20: 1-3; 4.5.20: 1-11)
  • Be wary of lockdowns specific to very small areas, which undermine the ‘all in it together’ message (REDACTED and Clifford Stott, no date: 1). If you must to it, clarify precisely who is affected and what they should do, support the people most vulnerable and impacted (e.g. financially), and redesign physical spaces (meeting paper SPI-B 22.4.20a)
  • When reopening schools (fully or partly), communication is key to the inevitably complex and unpredictable behavioural consequences (so, for example, work with parents, teachers, and other stakeholders to co-produce clear guidance) (29.4.20d: 1-10)
  • On the introduction of Alert Levels, as part of the Joint Biosecurity Centre work on local outbreaks (described in meeting paper 20.5.20a: 1-9): build public trust and understanding regarding JBC alert levels, and relate them very clearly to expected behaviour (SAGE 28.5.20). Each Alert Level should relate clearly to a required response in that area, and ‘public communications on Alert Levels needs many trusted messengers giving the same advice, many times’ (meeting paper 27.5.20b: 3).
  • On transmission between social networks, ‘Communicate two key principles: 1. People whose work involves large numbers of contacts with different people should avoid close, prolonged, indoor contact with anyone as far as possible … 2. People with different workplace networks should avoid meeting or sharing the same spaces’ (meeting paper 27.5.20b: 1).
  • On outbreaks in ‘forgotten institutional settings’ (including Prisons, Homeless Hostels, Migrant dormitories, and Long stay mental health): address the unusually low levels of trust in (or awareness of) government messaging among so-called ‘hard to reach groups’ (meeting paper 28.5.20a: 1).

See also:

SPI-M (Meeting paper 17.3.20b: 4) list of how to describe probabilities. This is more important than it looks, since there is a potentially major gap between the public and advisory group understanding of words like ‘probably’ (compare with the CIA’s Words of Estimative Probability).

SAGE language of probability 17.3.20b p4

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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Filed under COVID-19, Evidence Based Policymaking (EBPM), Prevention policy, Public health, UK politics and policy

COVID-19 policy in the UK: SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

This post is part 6 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

Limited testing

Oral evidence to the Health and Social Care committee highlights the now-well-documented limits to UK testing capacity and PPE stocks (see also NERVTAG on PPE). SAGE does not discuss testing capacity much in the beginning, although on 10.3.20 it lists as an action point: ‘Plans for how PHE can move from 1,000 serology tests to 10,000 tests per week’ and by 16.3.20 it describes the urgent need to scale up testing – perhaps with commercial involvement and to test at home (if can ensure accuracy) – and to secure sufficient data to track the epidemic well enough to inform operational decisions. From April, it highlights the need for a ‘national testing strategy’ to cover NHS patients, staff, an epidemiological survey, and the community (2.4.20), and the need for far more testing is a feature of almost every meeting from then.

Limited contact tracing

Initially, SAGE describes a quite-low contact tracing capacity: ‘Currently, PHE can cope with five new cases a week (requiring isolation of 800 contacts). Modelling suggests this capacity could be increased to 50 new cases a week (8,000 contact isolations)’ (18.2.20: 1).

Previously, it had noted that the point would come when transmission was too high to make contact tracing worthwhile, particularly since many (e.g. asymptomatic) cases may already have been missed (20.2.20: 2) and the necessary testing capacity was not in place (16.4.20): ‘PHE to work with SPI-M to develop criteria for when contact tracing is no longer worthwhile. This should include consideration of any limiting factors on testing and alternative methods of identifying epidemic evolution and characteristics’ (11.2.20: 3; see also Testing and contact tracing).

It returned to the feasibility question after the lockdown, with:

  • SPI-M (meeting paper 4.20d: 1-3) estimating that effective contact tracing (80% of non-household cases, in 2 days) could reduce the R by 30-60% if you could quarantine many people, multiple times; and,
  • SPI-B (meeting paper 4.20a: 1-3) advising on the need to clarify to people how it would work and what they should do, redesign physical spaces, and conduct new qualitative research and stakeholder engagement to ‘help us to understand more clearly the specific drivers, enablers and barriers for new behavioural recommendations’ to address an unprecedented problem in the UK (22.4.20a: 2). SPI-B also describes the trade-offs between app-informed systems (notification based on symptoms would suit people seeking to be precautionary, but could reduce compliance among people who believe the risk to be low) (see meeting papers 29.4.20: 3 and 5.5.20: 1-8)
  • SAGE noting ongoing work on clusters and super-spreading events, which necessitate cluster-based contact tracing (11.6.20: 3)
  • A more general message that contact tracing will be overwhelmed if lockdown measures are released too soon, raising R well above 1 and causing incidence to rise too quickly (e.g. 14.5.20)

Low capacity to achieve high levels of information necessary for forecasting

This type of discussion exemplifies a general and continuous focus on the lack of data to inform advice:

‘24. Real-time forecasting models rely on deriving information on the epidemic from surveillance. If transmission is established in the UK there will necessarily be a delay before sufficiently accurate forecasts in the UK are available. 25. Decisions being made on whether to modify or lift non-pharmaceutical interventions require accurate understanding of the state of the epidemic. Large-scale serological data would be ideal, especially combined with direct monitoring of contact behaviour. 26. Preliminary forecasts and accurate estimates of epidemiological parameters will likely be available in the order of weeks and not days following widespread outbreaks in the UK (or a similar country). While some estimates may be available before this time their accuracy will be much more limited. 27. The UK hospitalisation rate and CFR will be very important for operational planning and will be estimated over a similar timeframe. They may take longer depending on the availability of data’ (Meeting paper 2.3.20: 3-4).

A limited capacity to reach a relatively cautious consensus?

These limitations to information contributed to the difference between SAGE’s estimate on UK transmission (such as in comparison with Italy) and the UK’s much faster rate of transmission:

‘the UK likely has thousands of cases – as many as 5,000 to 10,000 – which are geographically spread nationally … The UK is considered to be 4-5 weeks behind Italy but on a similar curve (6-8 weeks behind if interventions are applied)’ (10.3.20: 1)

‘Based on limited available evidence, SAGE considers that the UK is 2 to 4 weeks behind Italy in terms of the epidemic curve’ (18.3.20: 1)

Rather, the UK was under 2 weeks behind Italy on the 10th March, suggesting that its lockdown measures were put in place too late.

At the heart of this estimate was the under-estimated doubling time of infection (‘the time it takes for the number of cases to double in size’, Meeting paper 3.2.20a):

  • although described as 3-4 days (28.1.20: 1) then 4-6 days (Meeting paper 2.3.20) based on Wuhan, and 3-5 days based on Hubei (Meeting paper 3.2.20a),
  • SAGE estimates ‘every 5-6 days’ (16.3.20: 1) and states that ‘Assuming a doubling time of around 5-7 days continues to be reasonable’ (18.3.20: 1).
  • Only by meeting 18 does SAGE estimate the doubling time (ICU patients) at 3-4 days (23.3.20). By meeting 19, it describes the doubling time in hospitals as 3.3 days (26.3.20: 1).

Kit Yates suggests that (a) the UK exhibited a 3-day doubling time during this period (Huffington Post), and (b) although many members of SAGE and SPI-M would have preferred to model on the assumption of 3-days:

Having spoken to some of the modellers on SPI-M, not all of them were missing this. Many of the groups had fitted models to data and come up with shorter and more realistic doubling times, maybe around the 3-day mark, but their estimates never found consensus within the group, so some members of SPI-M have communicated their concerns to me that some of the modelling groups had more influence over the consensus decision than others, which meant that some opinions or estimates which might have been valid, didn’t get heard, and consequently weren’t passed on up the line to SAGE, and then further towards the government, so an over-reliance on certain models or modelling groups might have been costly in this situation (interview, Kit Yates, More or Less, 10.6.20: 4m47s-5m27s)

Yates then suggests that the most listened-to model – led by Neil Ferguson, published 16.3.20 –  estimates a doubling time of 5-days, based on early data from Wuhan, using estimate of R2.4 (and generation time of 6.5 days), ‘which we now know to be way too low’ when we look at the UK data:

If they had just plotted the early trajectory of the epidemics against the current UK data at that point, they would have seen [by 14.3.20] that their model was starting to underestimate the number of cases and then the number of deaths which were occurring in the UK’ (interview, Kit Yates, More or Less, 10.6.20: 7m2s-7m15s)

Yates’ account highlights not only

  1. the effect of uncertainty and limited capacity to generate more information, but also
  2. the wider effect of path dependence, in which the (a) written and unwritten rules and norms of organisations, and (b) enduring ways of thinking (in individuals and groups, and political systems) place limits on new action. These limits are often necessary and beneficial, and often unnecessary and harmful.

Compare with Vallance’s oral evidence to the Health and Social Care committee (17.3.20: q96):

‘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 full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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Filed under COVID-19, Evidence Based Policymaking (EBPM), Prevention policy, Public health, UK politics and policy

COVID-19 policy in the UK: SAGE Theme 1. The language of intervention

This post is part 5 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

There is often a clear distinction between a strategy designed to (a) eliminate a virus/ the spread of disease quickly, and (b) manage the spread of infection over the long term (see The overall narrative).

However, generally, the language of virus management is confusing. We need to be careful with interpreting the language used in these minutes, and other sources such as oral evidence to House of Commons committees, particularly when comparing the language at the beginning (when people were also unsure what to call SARS-CoV-2 and COVID-19) to present day debates.

For example, in January, it is tempting to contrast ‘slow down the spread of the outbreak domestically’ (28.1.20: 2) with a strategy towards ‘extinction’, but the proposed actions may be the same even if the expectations of impact are different. Some people interpret these differences as indicative of a profoundly different approach (delay versus eradicate); some describe the semantic differences as semantics.

By February, SAGE’s expectation is of an inevitable epidemic and inability to contain COVID-19, prompting it to describe the inevitable series of stages:

‘Priorities will shift during a potential outbreak from containment and isolation on to delay and, finally, to case management … When there is sustained transmission in the UK, contact tracing will no longer be useful’ (18.2.20: 1; its discussion on 20.2.20: 2 also concludes that ‘individual cases could already have been missed – including individuals advised that they are not infectious’).

Mitigation versus suppression

On the face of it, it looks like there is a major difference in the ways on which (a) the Imperial College COVID-19 Response Team and (b) SAGE describe possible policy responses. The Imperial paper makes a distinction between mitigation and suppression:

  1. Its ‘mitigation strategy scenarios’ highlight the relative effects of partly-voluntary measures on mortality and demand for ‘critical care beds’ in hospitals: (voluntary) ‘case isolation in the home’ (people with symptoms stay at home for 7 days), ‘voluntary home quarantine’ (all members of the household stay at home for 14 days if one member has symptoms), (government enforced) ‘social distancing of those over 70’ or ‘social distancing of entire population’ (while still going to work, school or University), and closure of most schools and universities. It omits ‘stopping mass gatherings’ because ‘the contact-time at such events is relatively small compared to the time spent at home, in schools or workplaces and in other community locations such as bars and restaurants’ (2020a: 8). Assuming 70-75% compliance, it describes the combination of ‘case isolation, home quarantine and social distancing of those aged over 70’ as the most impactful, but predicts that ‘mitigation is unlikely to be a viable option without overwhelming healthcare systems’ (2020a: 8-10). These measures would only ‘reduce peak critical care demand by two-thirds and halve the number of deaths’ (to approximately 250,000).
  2. Its ‘suppression strategy scenarios’ describe what it would take to reduce the rate of infection (R) from the estimated 2.0-2.6 to 1 or below (in other words, the game-changing point at which one person would infect no more than one other person) and reduce ‘critical care requirements’ to manageable levels. It predicts that a combination of four options – ‘case isolation’, ‘social distancing of the entire population’ (the measure with the largest impact), ‘household quarantine’ and ‘school and university closure’ – would reduce critical care demand from its peak ‘approximately 3 weeks after the interventions are introduced’, and contribute to a range of 5,600-48,000 deaths over two years (depending on the current R and the ‘trigger’ for action in relation to the number of occupied critical care beds) (2020a: 13-14).

In comparison, the SAGE meeting paper (26.2.20b: 1-3), produced 2-3 weeks earlier, pretty much assumes away the possible distinction between mitigation versus suppression measures (which Vallance has described as semantic rather than substantive – scroll down to The distinction between mitigation and suppression measures). In other words, it assumes ‘high levels of compliance over long periods of time’ (26.2.20b: 1). As such, we can interpret SAGE’s discussion as (a) requiring high levels of compliance for these measures to work (the equivalent of Imperial’s description of suppression), while (b) not describing how to use (more or less voluntary versus impositional) government policy to secure compliance. In comparison, Imperial equates suppression with the relatively-short-term measures associated with China and South Korea (while noting uncertainty about how to maintain such measures until a vaccine is produced).

One reason for SAGE to assume compliance in its scenario building is to focus on the contribution of each measure, generally taking place over 13 weeks, to delaying the peak of infection (while stating that ‘It will likely not be feasible to provide estimates of the effectiveness of individual control measures, just the overall effectiveness of them all’, 26.2.20b: 1), while taking into account their behavioural implications (26.2.20b: 2-3).

  • School closures could contribute to a 3-week delay, especially if combined with FE/ HE closures (but with an unequal impact on ‘Those in lower socio-economic groups … more reliant on free school meals or unable to rearrange work to provide childcare’).
  • Home isolation (65% of symptomatic cases stay at home for 7 days) could contribute to a 2-3 week delay (and is the ‘Easiest measure to explain and justify to the public’).
  • ‘Voluntary household quarantine’ (all member of the household isolate for 14 days) would have a similar effect – assuming 50% compliance – but with far more implications for behavioural public policy:

‘Resistance & non-compliance will be greater if impacts of this policy are inequitable. For those on low incomes, loss of income means inability to pay for food, heating, lighting, internet. This can be addressed by guaranteeing supplies during quarantine periods.

Variable compliance, due to variable capacity to comply, may lead to dissatisfaction.

Ensuring supplies flow to households is essential. A desire to help among the wider community (e.g. taking on chores, delivering supplies) could be encouraged and scaffolded to support quarantined households.

There is a risk of stigma, so ‘voluntary quarantine’ should be portrayed as an act of altruistic civic duty’.

  • ‘Social distancing’ (‘enacted early’), in which people restrict themselves to essential activity (work and school) could produce a 3-5 week delay (and likely to be supported in relation to mass leisure events, albeit less so when work activities involve a lot of contact.

[Note that it is not until May that it addresses this issue of feasibility directly (and, even then, it does not distinguish between technical and political feasibility: ‘It was noted that a useful addition to control measures SAGE considers (in addition to scientific uncertainty) would be the feasibility of monitoring/ enforcement’ (7.5.20: 3)]

As theme 2 suggests, there is a growing recognition that these measures should have been introduced by early March (such as via the Coronavirus Act 2020 not passed until 25.3.20), and likely would if the UK government and SAGE had more information (or interpreted its information in a different way). However, by mid-March, SAGE expresses a mixture of (a) growing urgency, but also (b) the need to stick to the plan, to reduce the peak and avoid a second peak of infection). On 13th March, it states:

‘There are no strong scientific grounds to hasten or delay implementation of either household isolation or social distancing of the elderly or the vulnerable in order to manage the epidemiological curve compared to previous advice. However, there will be some minor gains from going early and potentially useful reinforcement of the importance of taking personal action if symptomatic. Household isolation is modelled to have the biggest effect of the three interventions currently planned, but with some risks. SAGE therefore thinks there is scientific evidence to support household isolation being implemented as soon as practically possible’ (13.3.20: 1)

‘SAGE further agreed that one purpose of behavioural and social interventions is to enable the NHS to meet demand and therefore reduce indirect mortality and morbidity. There is a risk that current proposed measures (individual and household isolation and social distancing) will not reduce demand enough: they may need to be coupled with more intensive actions to enable the NHS to cope, whether regionally or nationally’ (13.3.20: 2)

On 16th March, it states:

‘On the basis of accumulating data, including on NHS critical care capacity, the advice from SAGE has changed regarding the speed of implementation of additional interventions. SAGE advises that there is clear evidence to support additional social distancing measures be introduced as soon as possible’ (16.3.20: 1)

Overall, we can conclude two things about the language of intervention:

  1. There is now a clear difference between the ways in which SAGE and its critics describe policy: to manage an inevitably long-term epidemic, versus to try to eliminate it within national borders.
  2. There is a less clear difference between terms such as suppress and mitigate, largely because SAGE focused primarily on a comparison of different measures (and their combination) rather than the question of compliance.

See also: There is no ‘herd immunity strategy’, which argues that this focus on each intervention was lost in radio and TV interviews with Vallance.

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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Filed under COVID-19, Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy, UK politics and policy

COVID-19 policy in the UK: SAGE meetings from January-June 2020

This post is part 4 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

SAGE began a series of extraordinary meetings from 22nd January 2020. The first was described as ‘precautionary’ (22.1.20: 1) and includes updates from NERVTAG which met from 13th January. Its minutes state that ‘SAGE is unable to say at this stage whether it might be required to reconvene’ (22.1.20: 2). The second meeting notes that SAGE will meet regularly (e.g. 2-3 times per week in February) and coordinate all relevant science advice to inform domestic policy, including from NERVTAG and SPI-M (Scientific Pandemic Influenza Group on Modelling) which became a ‘formal sub-group of SAGE for the duration of this outbreak’ (SPI-M-O) (28.1.20: 1). It also convened an additional Scientific Pandemic Influenza subgroup (SPI-B) in February. I summarise these developments by month, but you can see that, by March, it is worth summarising each meeting. The main theme is uncertainty.

January 2020

The first meeting highlights immense uncertainty. Its description of WN-CoV (Wuhan Coronavirus), and statements such as ‘There is evidence of person-to-person transmission. It is unknown whether transmission is sustainable’, sum up the profound lack of information on what is to come (22.1.20: 1-2). It notes high uncertainty on how to identify cases, rates of infection, infectiousness in the absence of symptoms, and which previous experience (such as MERS) offers the most useful guidance. Only 6 days later, it estimates an R between 2-3, doubling rate of 3-4 days, incubation period of around 5 days, 14-day window of infectivity, varied symptoms such as coughing and fever, and a respiratory transmission route (different from SARS and MERS) (28.1.20: 1). These estimates are fairly constant from then, albeit qualified with reference to uncertainty (e.g. about asymptomatic transmission), some key outliers (e.g. the duration of illness in one case was 41 days – 4.2.20: 1), and some new estimates (e.g. of a 6-day ‘serial interval’, or ‘time between successive cases in a chain of transmission’, 11.2.20: 1). By now, it is preparing a response: modelling a ‘reasonable worst case scenario’ (RWC) based on the assumption of an R of 2.5 and no known treatment or vaccine, considering how to slow the spread, and considering how behavioural insights can be used to encourage self-isolation.

February 2020

SAGE began to focus on what measures might delay or reduce the impact of the epidemic. It described travel restrictions from China as low value, since a 95% reduction would have to be draconian to achieve and only secure a one month delay, which might be better achieved with other measures (3.2.20: 1-2). It, and supporting papers, suggested that the evidence was so limited that they could draw ‘no meaningful conclusions … as to whether it is possible to achieve a delay of a month’ by using one or a combination of these measures: international travel restrictions, domestic travel restrictions, quarantine people coming from infected areas, close schools, close FE/ HE, cancel large public events, contact tracing, voluntary home isolation, facemasks, hand washing. Further, some could undermine each other (e.g. school closures impact on older people or people in self-isolation) and have major societal or opportunity costs (SPI-M-O, 3.2.20b: 1-4). For example, the ‘SPI-M-O: Consensus view on public gatherings’ (11.2.20: 1) notes the aim to reduce duration and closeness of (particularly indoor) contact. Large outdoor gatherings are not worse than small, and stopping large events could prompt people to go to pubs (worse).

Throughout February, the minutes emphasize high uncertainty:

  • if there will be an epidemic outside of China (4.2.20: 2)
  • if it spreads through ‘air conditioning systems’ (4.2.20: 3)
  • the spread from, and impact on, children and therefore the impact of closing schools (4.2.20: 3; discussed in a separate paper by SPI-M-O, 10.2.20c: 1-2)
  • ‘SAGE heard that NERVTAG advises that there is limited to no evidence of the benefits of the general public wearing facemasks as a preventative measure’ (while ‘symptomatic people should be encouraged to wear a surgical face mask, providing that it can be tolerated’ (4.2.20: 3)

At the same time, its meeting papers emphasized a delay in accurate figures during an initial outbreak: ‘Preliminary forecasts and accurate estimates of epidemiological parameters will likely be available in the order of weeks and not days following widespread outbreaks in the UK’ (SPI-M-O, 3.2.20a: 3).

This problem proved to be crucial to the timing of government intervention. A key learning point will be the disconnect between the following statement and the subsequent realisation (3-4 weeks later) that the lockdown measures from mid-to-late March came too late to prevent an unanticipated number of excess deaths:

‘SAGE advises that surveillance measures, which commenced this week, will provide

actionable data to inform HMG efforts to contain and mitigate spread of Covid-19’ … PHE’s surveillance approach provides sufficient sensitivity to detect an outbreak in its early stages. This should provide evidence of an epidemic around 9- 11 weeks before its peak … increasing surveillance coverage beyond the current approach would not significantly improve our understanding of incidence’ (25.2.20: 1)

It also seems clear from the minutes and papers that SAGE highlighted a reasonable worst case scenario on 26.2.20. It was as worrying as the Imperial College COVID-19 Response Team report dated 16.3.20 that allegedly changed the UK Government’s mind on the 16th March. Meeting paper 26.2.20a described the assumption of an 80% infection attack rate and 50% clinical attack rate (i.e. 50% of the UK population would experience symptoms), which underpins the assumption of 3.6 million requiring hospital care of at least 8 days (11% of symptomatic), and 541,200 requiring ventilation (1.65% of symptomatic) for 16 days. While it lists excess deaths as unknown, its 1% infection mortality rate suggests 524,800 deaths. This RWC replaces a previous projection (in Meeting paper 10.2.20a: 1-3, based on pandemic flu assumptions) of 820,000 excess deaths (27.2.20: 1).

As such, the more important difference could come from SAGE’s discussion of ‘non-pharmaceutical interventions (NPIs)’ if it recommends ‘mitigation’ while the Imperial team recommends ‘suppression’. However, the language to describe each approach is too unclear to tell (see Theme 1. The language of intervention; also note that NPIs were often described from March as ‘behavioural and social interventions’ following an SPI-B recommendation, Meeting paper 3.2.20: 1, but the language of NPI seems to have stuck).

March 2020

In March, SAGE focused initially (Meetings 12-14) on preparing for the peak of infection on the assumption that it had time to transition towards a series of isolation and social distancing measures that would be sustainable (and therefore unlikely to contribute to a second peak if lifted too soon). Early meetings and meeting papers express caution about the limited evidence for intervention and the potential for their unintended consequences. This approach began to change somewhat from mid-March (Meeting 15), and accelerate from Meetings 16-18, when it became clear that incidence and virus transmission were much larger than expected, before a new phase began from Meeting 19 (after the UK lockdown was announced on the 23rd).

Meeting 12 (3.3.18) describes preparations to gather and consolidate information on the epidemic and the likely relative effect of each intervention, while its meeting papers emphasise:

  • ‘It is highly likely that there is sustained transmission of COVID-19 in the UK at present’, and a peak of infection ‘might be expected approximately 3-5 months after the establishment of widespread sustained transmission’ (SPI-M Meeting paper 2.3.20: 1)
  • the need the prepare the public while giving ‘clear and transparent reasons for different strategies’ and reducing ambiguity whenever giving guidance (SPI-B Meeting paper 3.2.20: 1-2)
  • The need to combine different measures (e.g. school closure, self-isolation, household isolation, isolating over-65s) at the right time; ‘implementing a subset of measures would be ideal. Whilst this would have a more moderate impact it would be much less likely to result in a second wave’ (Meeting paper 4.3.20a: 3).

Meeting 13 (5.3.20) describes staying in the ‘containment’ phase (which, I think, means isolating people with positive tests at home or in hospital) , and introducing: a 12-week period of individual and household isolation measures in 1-2 weeks, on the assumption of 50% compliance; and a longer period of shielding over-65s 2 weeks later. It describes ‘no evidence to suggest that banning very large gatherings would reduce transmission’, while closing bars and restaurants ‘would have an effect, but would be very difficult to implement’, and ‘school closures would have smaller effects on the epidemic curve than other options’ (5.3.20: 1). Its SPI-B Meeting paper (4.3.20b) expresses caution about limited evidence and reliance on expert opinion, while identifying:

  • potential displacement problems (e.g. school closures prompt people to congregate elsewhere, or be looked after by vulnerable older people, while parents to lose the chance to work)
  • the visibility of groups not complying
  • the unequal impact on poorer and single parent families of school closure and loss of school meals, lost income, lower internet access, and isolation
  • how to reduce discontent about only isolating at-risk groups (the view that ‘explaining that members of the community are building some immunity will make this acceptable’ is not unanimous) (4.3.20b: 2).

Meeting 14 (10.3.20) states that the UK may have 5-10000 cases and ‘10-14 weeks from the epidemic peak if no mitigations are introduced’ (10.3.20: 2). It restates the focus on isolation first, followed by additional measures in April, and emphasizes the need to transition to measures that are acceptable and sustainable for the long term:

‘SAGE agreed that a balance needs to be struck between interventions that theoretically have significant impacts and interventions which the public can feasibly and safely adopt in sufficient numbers over long periods’ …’the public will face considerable challenges in seeking to comply with these measures, (e.g. poorer households, those relying on grandparents for childcare)’ (10.3.20: 2)

Meeting 15 (13.3.20: 1) describes an update to its data, suggesting ‘more cases in the UK than SAGE previously expected at this point, and we may therefore be further ahead on the epidemic curve, but the UK remains on broadly the same epidemic trajectory and time to peak’. It states that ‘household isolation and social distancing of the elderly and vulnerable should be implemented soon, provided they can be done well and equitably’, noting that there are ‘no strong scientific grounds’ to accelerate key measures but ‘there will be some minor gains from going early and potentially useful reinforcement of the importance of taking personal action if symptomatic’ (13.3.20: 1) and ‘more intensive actions’ will be required to maintain NHS capacity (13.3.20: 2).

*******

On the 16th March, the UK Prime Minister Boris Johnson describes an ‘emergency’ (one week before declaring a ‘national emergency’ and UK-wide lockdown)

*******

Meeting 16 (16.3.20) describes the possibility that there are 5-10000 new cases in the UK (there is great uncertainty on the estimate’), doubling every 5-6 days. Therefore, to stay within NHS capacity, ‘the advice from SAGE has changed regarding the speed of implementation of additional interventions. SAGE advises that there is clear evidence to support additional social distancing measures be introduced as soon as possible’ (16.3.20: 1). SPI-M Meeting paper (16.3.20: 1) describes:

‘a combination of case isolation, household isolation and social distancing of vulnerable groups is very unlikely to prevent critical care facilities being overwhelmed … it is unclear whether or not the addition of general social distancing measures to case isolation, household isolation and social distancing of vulnerable groups would curtail the epidemic by reducing the reproduction number to less than 1 … the addition of both general social distancing and school closures to case isolation, household isolation and social distancing of vulnerable groups would be likely to control the epidemic when kept in place for a long period. SPI-M-O agreed that this strategy should be followed as soon as practical’

Meeting 17 (18.3.20) marks a major acceleration of plans, and a de-emphasis of the low-certainty/ beware-the-unintended-consequences approach of previous meetings (on the assumption that it was now 2-4 weeks behind Italy). It recommends school closures as soon as possible (and it, and SPIM Meeting paper 17.3.20b, now downplays the likely displacement effect). It focuses particularly on London, as the place with the largest initial numbers:

‘Measures with the strongest support, in terms of effect, were closure of a) schools, b) places of leisure (restaurants, bars, entertainment and indoor public spaces) and c) indoor workplaces. … Transport measures such as restricting public transport, taxis and private hire facilities would have minimal impact on reducing transmission’ (18.3.20: 2)

Meeting 18 (23.3.20) states that the R is higher than expected (2.6-2.8), requiring ‘high rates of compliance for social distancing’ to get it below 1 and stay under NHS capacity (23.3.20: 1). There is an urgent need for more community testing/ surveillance (and to address the global shortage of test supplies). In the meantime, it needs a ‘clear rationale for prioritising testing for patients and health workers’ (the latter ‘should take priority’) (23.3.20: 3) Closing UK borders ‘would have a negligible effect on spread’ (23.3.20: 2).

*******

The lockdown. On the 23rd March 2020, the UK Prime Minister Boris Johnson declared: ‘From this evening I must give the British people a very simple instruction – you must stay at home’. He announced measures to help limit the impact of coronavirus, including police powers to support public health, such as to disperse gatherings of more than two people (unless they live together), close events and shops, and limit outdoor exercise to once per day (at a distance of two metres from others).

*******

Meeting 19 (26.3.20) follows the lockdown. SAGE describes its priorities if the R goes below 1 and NHS capacity remains under 100%: ‘monitoring, maintenance and release’ (based on higher testing); public messaging on mass testing and varying interventions; understanding nosocomial transmission and immunology; clinical trials (avoiding hasty decisions’ on new drug treatment in absence of good data) and ‘how to minimise potential harms from the interventions, including those arising from postponement of normal services, mental ill health and reduced ability to exercise. It needs to consider in particular health impacts on poorer people’ (26.3.20: 1-2). The optimistic scenario is 10,000 deaths from the first wave (SPIM-O Meeting paper 25.3.20: 4).

Meeting 20 Confirms RWC and optimistic scenarios (Meeting paper 25.3.20), but it needs a ‘clearer narrative, clarifying areas subject to uncertainty and sensitivities’ and to clarify that scenarios (with different assumptions on, for example, the R, which should be explained more) are not predictions (29.3.20).

Meeting 21 seeks to establish SAGE ‘scientific priorities’ (e.g. long term health impacts of COVID-19, including socioeconomic impact on health (including mental health), community testing, international work (‘comorbidities such as malaria and malnutrition) (31.3.20: 1-2). NHS to set up an interdisciplinary group (including science and engineering) to ‘understand and tackle nosocomial transmission’ in the context of its growth and urgent need to define/ track it (31.3.20: 1-2). SAGE to focus on testing requirements, not operational issues. It notes the need to identify a single source of information on deaths.

April 2020

The meetings in April highlight four recurring themes.

First, it stresses that it will not know the impact of lockdown measures for some time, that it is too soon to understand the impact of releasing them, and there is high risk of failure: ‘There is a danger that lifting measures too early could cause a second wave of exponential epidemic growth – requiring measures to be re-imposed’ (2.4.20: 1; see also 14.4.20: 1-2). This problem remains even if a reliable testing and contact tracing system is in place, and if there are environmental improvements to reduce transmission (by keeping people apart).

Second, it notes signals from multiple sources (including CO-CIN and the RCGP) on the higher risk of major illness and death among black people, the ongoing investigation of higher risk to ‘BAME’ health workers (16.4.20), and further (high priority) work on ‘ethnicity, deprivation, and mortality’ (21.4.20: 1) (see also: Race, ethnicity, and the social determinants of health).

Third, it highlights the need for a ‘national testing strategy’ to cover NHS patients, staff, an epidemiological survey, and the community (2.4.20). The need for far more testing is a feature of almost every meeting (see also The need to ramp up testing).

Fourth, SAGE describes the need for more short and long-term research, identifying nosocomial infection as a short term priority, and long term priorities in areas such as the long term health impacts of COVID-19 (including socioeconomic impacts on physical and mental health), community testing, and international work (31.3.20: 1-2).

Finally, it reflects shifting advice on the precautionary use of face masks. Previously, advisory bodies emphasized limited evidence of a clear benefit to the wearer, and worried that public mask use would reduce the supply to healthcare professionals and generate a false sense of security (compare with this Greenhalgh et al article on the precautionary principle, the subsequent debate, and work by the Royal Society). Even by April: ‘NERVTAG concluded that the increased use of masks would have minimal effect’ on general population infection (7.4.20: 1), while the WHO described limited evidence that facemasks are beneficial for community use (9.4.20). Still, general face mask use but could have small positive effect, particularly in ‘enclosed environments with poor ventilation, and around vulnerable people’ (14.4.20: 2) and ‘on balance, there is enough evidence to support recommendation of community use of cloth face masks, for short periods in enclosed spaces where social distancing is not possible’ (partly because people can be infectious with no symptoms), as long as people know that it is no substitute for social distancing and handwashing (21.4.20)

May 2020

In May, SAGE continues to discuss high uncertainty on relaxing lockdown measures, the details of testing systems, and the need for research.

Generally, it advises that relaxations should not happen before there is more understanding of transmission in hospitals and care homes, and ‘until effective outbreak surveillance and test and trace systems are up and running’ (14.5.20). It advises specifically ‘against reopening personal care services, as they typically rely on highly connected workers who may accelerate transmission’ (5.5.20: 3) and warns against the too-quick introduction of social bubbles. Relaxation runs the risk of diminishing public adherence to social distancing, and to overwhelm any contact tracing system put in place:

‘SAGE participants reaffirmed their recent advice that numbers of Covid-19 cases remain high (around 10,000 cases per day with wide confidence intervals); that R is 0.7-0.9 and could be very close to 1 in places across the UK; and that there is very little room for manoeuvre especially before a test, trace and isolate system is up and running effectively. It is not yet possible to assess the effect of the first set of changes which were made on easing restrictions to lockdown’ (28.5.20: 3).

It recommends extensive testing in hospitals and care homes (12.5.20: 3) and ‘remains of the view that a monitoring and test, trace & isolate system needs to be put in place’ (12.5.20: 1)

June 2020

In June, SAGE identifies the importance of clusters of infection (super-spreading events) and the importance of a contact tracing system that focuses on clusters (rather than simply individuals) (11.6.20: 3). It reaffirms the value of a 2-metre distance rule. It also notes that the research on immunology remains unclear, which makes immunity passports a bad idea (4.6.20).

It describes the result of multiple meeting papers on the unequal impact of COVID-19:

‘There is an increased risk from Covid-19 to BAME groups, which should be urgently investigated through social science research and biomedical research, and mitigated by policy makers’ … ‘SAGE also noted the importance of involving BAME groups in framing research questions, participating in research projects, sharing findings and implementing recommendations’ (4.6.20: 1-3)

See also: Race, ethnicity, and the social determinants of health

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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COVID-19 policy in the UK: The overall narrative underpinning SAGE advice and UK government policy

This post is part 3 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

I discuss the UK government’s definition of the COVID-19 policy problem in some other posts (1. in a now-dated post on early developments, and 2. in relation to oral evidence to the Health and Social Care committee). It includes the following elements:

  • 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.
  • 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.
  • 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.
  • 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.
  • 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.

This understanding in the UK, informed strongly by SAGE, also informs the ways in which SAGE (a) deals with uncertainty, and (b) describes the likely impact of each stage of action.

Manage suppression during the first peak to avoid a second peak

Most importantly, it stresses continuously the need to avoid excessive suppressive measures on the first peak that would contribute to a second peak [my emphasis added]:

  • ‘Any combination of [non-pharmaceutical] measures would slow but not halt an epidemic’, 25.2.20: 1).
  • ‘Mitigations can be expected to change the shape of the epidemic curve or the timing of a first or second peak, but are not likely to reduce the overall number of total infections’. Therefore, identify whose priorities matter (such as NHS England) on the assumption that, ‘The optimal shape of the epidemic curve will differ according to sectoral or organisational priorities’ (27.2.20: 2).
  • ‘A combination of these measures [school closures, household isolation, social distancing] is expected to have a greater impact: implementing a subset of measures would be ideal. Whilst this would have a more moderate impact it would be much less likely to result in a second wave. In comparison combining stringent social distancing measures, school closures and quarantining cases, as a long-term policy, may have a similar impact to that seen in Hong Kong or Singapore, but this could result in a large second epidemic wave once the measures were lifted’ (Meeting paper 4.3.20a: 3).
  • SAGE was unanimous that measures seeking to completely suppress spread of Covid-19 will cause a second peak. SAGE advises that it is a near certainty that countries such as China, where heavy suppression is underway, will experience a second peak once measures are relaxed’ (also: ‘It was noted that Singapore had had an effective “contain phase” but that now new cases had appeared) (13.3.20: 2)
  • Its visual of each possible peak of infection emphasises the risk of a second peak (Meeting paper 4.3.20: 2).

SAGE image of 1st 2nd peaks 4.3.20

  • ‘The objective is to avoid critical cases exceeding NHS intensive care and other respiratory support bed capacity’ … SAGE ‘advice on interventions should be based on what the NHS needs’ (16.3.20: 1)
  • The fewer cases that happen as a result of the policies enacted, the larger subsequent waves are expected to be when policies are lifted (SPI-M-O Meeting paper 25.3.20: 1)
  • ‘There is a danger that lifting measures too early could cause a second wave of exponential epidemic growth – requiring measures to be re-imposed’ (2.4.20: 1)

Avoid the unintended consequences of epidemic suppression

This understanding intersects with (c) an emphasis of the loss of benefits caused by certain interventions (such as schools closures).

  • SPI-B (Meeting paper 4.3.20b: 1-4) expresses reluctance to close schools, partly to avoid the unintended consequences, including: displacement problems (e.g. school closures prompt children to be looked after by vulnerable older people, or parents to lose the chance to work); and, the unequal impact on poorer and single parent families (loss of school meals, lost income, lower internet access, exacerbating isolation and mental ill health). It then states that: ‘The importance of schools during a crisis should not be overlooked. This includes: Acting as a source of emotional support for children; Providing education (e.g. on hand hygiene) which is conveyed back to families; Provision of social service (e.g. free school meals, monitoring wellbeing); Acting as a point of leadership and communication within communities’ (4.3.20b: 4).
  • ‘Long periods of social isolation may have significant risks for vulnerable people … SAGE agreed that a balance needs to be struck between interventions that theoretically have significant impacts and interventions which the public can feasibly and safely adopt in sufficient numbers over long periods. Input from behavioural scientists is essential to policy development of cocooning measures, to increase public practicability and likelihood of compliance … the public will face considerable challenges in seeking to comply with these measures, (e.g. poorer households, those relying on grandparents for childcare)’ (10.3.20: 2).
  • After the lockdown (23.3.20), SAGE describes a priority regarding: ‘how to minimise potential harms from the interventions, including those arising from postponement of normal services, mental ill health and reduced ability to exercise. It needs to consider in particular health impacts on poorer people’ (26.3.20: 1-2).

Exhort and encourage, rather than impose

It also intersects with (d) a primary focus on exhortation and encouragement rather than the imposition of behavioural change (Table 1), largely based on the belief that the UK government would be unwilling or unable to enforce behavioural change in ways associated with China. In that context, the government’s willingness and ability to enforce social distancing and business closure from the 23rd March is striking.

Examples include:

  • when recommending ‘individual home isolation (symptomatic individuals to stay at home for 14 days) and whole family isolation (fellow household members of symptomatic individuals to stay at home for 14 days after last family member becomes unwell)’, it assumes a 50% compliance rate, and notes that ‘closing bars and restaurants ‘would have an effect, but would be very difficult to implement’ (5.3.20: 1).

See also: oral evidence to the Health and Social Care committee, which suggests that the UK government and SAGE’s problem definition contrasts with approaches in countries such as South Korea (described by Kim et al, and Kim).

It also contrasts with the approach described by several of the UK’s (expert) critics, including Professor Devi Sridhar (Professor of Global Public Health), who is critical of SAGE specifically, and more generally of the UK government’s rejection of an ‘elimination’ strategy:

Table 1 sets out one way to describe the distinction between these approaches:

  • The UK government is addressing a chronic problem, being cautious about policy change without supportive evidence, identifying trigger points to new approaches (based on incidence), and assuming initially that the approach is based largely on exhortation.
  • One alternative is to pursue elimination aggressively, adopting a precautionary principle before there is supportive evidence of a major problem and the effectiveness of solutions, backed by measures such as contact tracing and quarantine, and assuming that the imposition of behaviour should be a continuous expectation.

One approach highlights the lack of evidence to support major policy change, and therefore gives primacy to the status quo. The other is more preventive, giving primacy to the precautionary principle until there is more clarity or certainty on the available evidence.

Table 1

In that context, note (in Table 2) how frequently the SAGE minutes state that there is limited evidence to support policy change, and that an epidemic is inevitable (in other words, elimination without a vaccine is near-impossible). Both statements tend to support a UK government policy that was, until mid-March, based on reluctance to enforce a profound lockdown to impose social distancing.

As the next post describes, the chronology of Table 2 is instructive, since it demonstrates a degree of path dependence based on initial uncertainty and hesitancy. This approach was understandable at first (particularly when connected to an argument about reducing the peak of infection then avoiding a second wave), before being so heavily criticised only two months later.

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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COVID-19 policy in the UK: The role of SAGE and science advice to government

This post is part 2 of COVID-19 policy in the UK: Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The issue of science advice to government, and the role of SAGE in particular, became unusually high profile in the UK, particularly in relation to four factors:

  1. Ministers described ‘following the science’ to project a certain form of authority and control.
  2. The SAGE minutes and papers – including a record of SAGE members and attendees – were initially unpublished, in line with the previous convention of government to publish after, rather than during, a crisis.

‘SAGE is keen to make the modelling and other inputs underpinning its advice available to the public and fellow scientists’ (13.3.20: 1)

When it agrees to publish SAGE papers/ documents, it stresses: ‘It is important to demonstrate the uncertainties scientists have faced, how understanding of Covid-19 has developed over time, and the science behind the advice at each stage’ (16.3.20: 2)

‘SAGE discussed plans to release the academic models underpinning SAGE and SPI-M discussions and judgements. Modellers agreed that code would become public but emphasised that the effort to do this immediately would distract from other analyses. It was agreed that code should become public as soon as practical, and SPI-M would return to SAGE with a proposal on how this would be achieved. ACTION: SPI-M to advise on how to make public the source code for academic models, working with relevant partners’ (18.3.20: 2).

SAGE welcomes releasing names of SAGE participants (if willing) and notes role of Ian Boyd as ‘independent challenge function’ (28.4.20: 1)

SAGE also describes the need for a better system to allow SAGE participants to function effectively and with proper support (given the immense pressure/ strain on their time and mental health) (7.5.20: 1)

  1. There were growing concerns that ministers would blame their advisers for poor choices (compare Freedman and Snowdon) or at least use science advice as ‘an insurance policy’, and
  2. There was some debate about the appropriateness of Dominic Cummings (Prime Minister Boris Johnson’s special adviser) attending some meetings.

Therefore, its official description reflects its initial role plus a degree of clarification on the role of science advice mechanisms during the COVID-19 pandemic. The SAGE webpage on the gov.uk sites describes its role as:

provides scientific and technical advice to support government decision makers during emergencies … SAGE is responsible for ensuring that timely and coordinated scientific advice is made available to decision makers to support UK cross-government decisions in the Cabinet Office Briefing Room (COBR). The advice provided by SAGE does not represent official government policy’.

Its more detailed explainer describes:

‘SAGE’s role is to provide unified scientific advice on all the key issues, based on the body of scientific evidence presented by its expert participants. This includes everything from latest knowledge of the virus to modelling the disease course, understanding the clinical picture, and effects of and compliance with interventions. This advice together with a descriptor of uncertainties is then passed onto government ministers. The advice is used by Ministers to allow them to make decisions and inform the government’s response to the COVID-19 outbreak …

The government, naturally, also considers a range of other evidence including economic, social, and broader environmental factors when making its decisions…

SAGE is comprised of leading lights in their representative fields from across the worlds of academia and practice. They do not operate under government instruction and expert participation changes for each meeting, based on the expertise needed to address the crisis the country is faced with …

SAGE is also attended by official representatives from relevant parts of government. There are roughly 20 such officials involved in each meeting and they do not frequently contribute to discussions, but can play an important role in highlighting considerations such as key questions or concerns for policymakers that science needs to help answer or understanding Civil Service structures. They may also ask for clarification on a scientific point’ (emphasis added by yours truly).

Note that the number of participants can be around 60 people, which is more like an assembly with presentations and a modest amount of discussion, than a decision-making function (the Zoom meeting on 4.6.20 lists 76 participants). Even a Cabinet meeting is about 20 and that is too much for coherent discussion/ action (hence separate, smaller, committees).

Further, each set of now-published minutes contains an ‘addendum’ to clarify its operation. For example, its first minutes in 2020 seek to clarify the role of participants. Note that the participants change somewhat at each meeting (see the full list of members/ attendees), and some names are redacted. Dominic Cummings’ name only appears (I think) on 5.3.20, 14.4.20, and two meetings on 1.5.20 (although, as Freedman notes, ‘his colleague Ben Warner was a more regular presence’).

SAGE minutes 1 addendum 22.1.20

More importantly, the minutes from late February begin to distinguish between three types of potential science advice:

  1. to describe the size of the problem (e.g. surveillance of cases and trends, estimating a reasonable worst case scenario)
  2. to estimate the relative impact of many possible interventions (e.g. restrictions on travel, school closures, self-isolation, household quarantine, and social distancing measures)
  3. to recommend the level and timing of state action to achieve compliance in relation to those interventions.

SAGE focused primarily on roles 1 and 2, arguing against role 3 on the basis that state intervention is a political choice to be taken by ministers. Ministers are responsible for weighing up the potential public health benefits of each measure in relation to their social and economic costs (see also: The relationship between science, science advice, and policy).

Example 1: setting boundaries between advice and strategy

  • ‘It is a political decision to consider whether it is preferable to enact stricter measures at first, lifting them gradually as required, or to start with fewer measures and add further measures if required. Surveillance data streams will allow real-time monitoring of epidemic growth rates and thus allow approximate evaluation of the impact of whatever package of interventions is implemented’ (Meeting paper 26.2.20b: 1)

This example highlights a limitation in performing role 2 to inform 3: SAGE would not be able to compare the relative impact of measures without knowing their level of imposition and its impact on compliance. Further, the way in which it addressed this problem is crucial to our interpretation and evaluation of the timing and substance of the UK government’s response.

In short, it simultaneously assumed away and maintained attention to this problem by stating:

  • ‘The measures outlined below assume high levels of compliance over long periods of time. This may be unachievable in the UK population’ (26.2.20b: 1).
  • ‘advice on interventions should be based on what the NHS needs and what modelling of those interventions suggests, not on the (limited) evidence on whether the public will comply with the interventions in sufficient numbers and over time’ (16.3.20: 1)

The assumption of high compliance reduces the need for SAGE to make distinctions between terms such as mitigation versus suppression (see also: Confusion about the language of intervention and stages of intervention). However, it contributes to confusion within wider debates on UK action (see Theme 1. The language of intervention).

Example 2: setting boundaries between advice and value judgements

  • ‘SAGE has not provided a recommendation of which interventions, or package of interventions, that Government may choose to apply. Any decision must consider the impacts these interventions may have on society, on individuals, the workforce and businesses, and the operation of Government and public services’ (Meeting paper 4.3.20a: 1).

To all intents and purposes, SAGE is noting that governments need to make value-based choices to:

  1. Weigh up the costs and benefits of any action (as described by Layard et al, with reference to wellbeing measures and the assumed price of a life), and
  2. Decide whose wellbeing, and lives, matter the most (because any action or inaction will have unequal consequences across a population).

In other words, policy analysis is one part evidence and one part value judgement. Both elements are contested in different ways, and different questions inform political choices (e.g. whose knowledge counts versus whose wellbeing counts?).

[see also:

  • ‘Determining a tolerable level of risk from imported cases requires consideration of a number of non-science factors and is a policy question’ (28.4.20: 3)
  • ‘SAGE reemphasises that its own focus should always be on providing clear scientific advice to government and the principles behind that advice’ (7.5.20: 1)]

Future reflections

Any future inquiry will be heavily contested, since policy learning and evaluation are political acts (and the best way to gather and use evidence during a pandemic is highly contested).  Still, hopefully, it will promote reflection on how, in practice, governments and advisory bodies negotiate the blurry boundary between scientific advice and political choice when they are so interdependent and rely so heavily on judgement in the face of ambiguity and uncertainty (or ‘radical uncertainty’). I discuss this issue in the next post, which highlights the ways in which UK ministers relied on SAGE (and advisers) to define the policy problem.

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

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Filed under COVID-19, Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy, UK politics and policy

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

In this post, ‘following the science’ describes UK ministers taking the advice of their scientific advisers and SAGE (the Scientific Advisory Group for Emergencies).

If so, were UK ministers ‘guided by the expert recommendations of the 4 UK Chief Medical Officers and the Scientific Advisory Group for Emergencies’?

The short answer is yes.

They followed advice in two profoundly important ways:

  1. Defining coronavirus as a policy problem.

My reading of the SAGE minutes and meeting papers identifies the consistency of the overall narrative underpinning SAGE advice and UK government policy. It can be summed up as follows:

  1. coronavirus represents a long term problem with no immediate solution (such as a vaccine) and minimal prospect of extinction/ eradication
  2. use policy measures – on isolation and social distancing – to flatten the first peak of infection and avoid overwhelming health service capacity
  3. don’t impose or relax measures too quickly (which will cause a second peak of infection)
  4. reflect on the balance between (a) the positive impact of lockdown (on the incidence and rate of transmission), (b) the negative impact of lockdown (on freedom, physical and mental health, and the immediate economic consequences).

If you examine UK ministerial speeches and SAGE minutes, you will find very similar messages: a coronavirus epidemic is inevitable, we need to ease gradually into suppression measures to avoid a second peak of infection as big as the first, and our focus is exhortation and encouragement over imposition.

  1. The timing and substance of interventions before lockdown

I describe a long chronological story of SAGE minutes and papers. Its main theme is unusually high levels of uncertainty from the beginning. The lack of solid evidence, available to SAGE at each stage, should not be dismissed.

In January, SAGE discusses uncertainty about human-to-human transmission and associates coronavirus strongly with Wuhan in China. In February, it had more data on transmission but described high uncertainty on what measures might delay or reduce the impact of the epidemic. In March, it focused on preparing for the peak of infection on the assumption that it had time to transition gradually towards a series of isolation and social distancing measures. This approach began to change from mid-March when it became clear that the number of people infected, and the rate of transmission, was much larger and faster than expected.

Therefore, the Prime Minister’s declarations – of emergency on 16.3.20 and of lockdown on 23.3.20 – did not lag behind SAGE advice. It would not be outrageous to argue that it went ahead of that advice, at least as recorded in SAGE minutes and meeting papers (compare with Freedman, Snowden, More or Less).

The long answer

If you would like the long answer, I can offer you 35280 words, including a 22380-word table summarizing the SAGE minutes and meeting papers (meetings 1-41, 22.1.20-11.6.20).

It includes:

The full list of SAGE posts:

COVID-19 policy in the UK: yes, the UK Government did ‘follow the science’

Did the UK Government ‘follow the science’? Reflections on SAGE meetings

The role of SAGE and science advice to government

The overall narrative underpinning SAGE advice and UK government policy

SAGE meetings from January-June 2020

SAGE Theme 1. The language of intervention

SAGE Theme 2. Limited capacity for testing, forecasting, and challenging assumptions

SAGE Theme 3. Communicating to the public

COVID-19 policy in the UK: Table 2: Summary of SAGE minutes, January-June 2020

Further reading

So far, the wider project includes:

  • The early minutes from NERVTAG (the New and Emerging Respiratory Virus Threats Advisory Group)
  • Oral evidence to House of Commons committees, beginning with Health and Social Care

I am also writing a paper based on this post, but don’t hold your breath.

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Filed under COVID-19, Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy

Here’s why there is always an expectations gap in prevention policy

Prevention is the most important social policy agenda of our time. Many governments make a sincere commitment to it, backed up by new policy strategies and resources. Yet, they also make limited progress before giving up or changing tack. Then, a new government arrives, producing the same cycle of enthusiasm and despair. This fundamental agenda never seems to get off the ground. We aim to explain this ‘prevention puzzle’, or the continuous gap between policymaker expectations and actual outcomes.

What is prevention policy and policymaking?

When engaged in ‘prevention’, governments seek to:

  1. Reform policy. To move from reactive to preventive public services, intervening earlier in people’s lives to ward off social problems and their costs when they seem avoidable.
  2. Reform policymaking. To (a) ‘join up’ government departments and services to solve ‘wicked problems’ that transcend one area, (b) give more responsibility for service design to local public bodies, stakeholders, ‘communities’ and service users, and (c) produce long term aims for outcomes, and reduce short term performance targets.
  3. Ensure that policy is ‘evidence based’.

Three reasons why they never seem to succeed

We use well established policy theories/ studies to explain the prevention puzzle.

  1. They don’t know what prevention means. They express a commitment to something before defining it. When they start to make sense of it, they find out how difficult it is to pursue, and how many controversial choices it involves.
  2. They engage in a policy process that is too complex to control. They try to share responsibility with many actors and coordinate action to direct policy outcomes, without the ability to design those relationships and control policy outcomes. Yet, they need to demonstrate to the electorate that they are in control. When they make sense of policymaking, they find out how difficult it is to localise and centralise.
  3. They are unable and unwilling to produce ‘evidence based policymaking’. Policymakers seek ‘rational’ and ‘irrational’ shortcuts to gather enough information to make ‘good enough’ decisions. When they seek evidence on preventing problems before they arise, they find that it is patchy, inconclusive, often counter to their beliefs, and unable to provide a ‘magic bullet’ to help make and justify choices.

Who knows what happens when they address these problems at the same time?

We draw on empirical and comparative UK and devolved government analysis to show in detail how policymaking differs according to the (a) type of government, (b) issue, and (c) era in which they operate.

Although it is reasonable to expect policymaking to be very different in, for example, the UK versus Scottish, or Labour versus Conservative governments, and in eras of boom versus austerity, a key part of our research is to show that the same basic ‘prevention puzzle’ exists at all times. You can’t simply solve it with a change of venue or government.

Our book – Why Isn’t Government Policy More Preventive? – is in press (Oxford University Press) and will be out in January 2020, with sample chapters appearing here. Our longer term agenda – via IMAJINE – is to examine how policymakers try to address ‘spatial justice’ and reduce territorial inequalities across Europe partly by pursuing prevention and reforming public services.

 

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No one will understand British politics and policymaking after Brexit

Let’s be optimistic for a few seconds, and focus on the idea that a vote for the UK to leave the European Union was a vote for UK sovereignty and ‘taking back control’ of policy and policymaking. The comparison is between an EU process that is distant and undemocratic and a UK process we can all understand and influence, following the simple phrase ‘if you know who is in charge, you know who to blame’.

The down side is that we don’t know who is in charge, and it’s often futile to try to find a named individual or role to blame. The EU certainly complicates the picture, but don’t be fooled into thinking that we will eventually produce a UK political system that anyone understands.

If giving a lecture, this is the point at which I’d pause for effect and restate the idea that no-one understands the UK policymaking system as a whole [insert meaningful looks here]. Many people know about many parts of the system, but it’s not like a jigsaw puzzle that we’ve completed by working together. At best, it’s like that Dalmatian jigsaw that we started at Christmas before getting drunk and falling out.

Top-10-Almost-Unsolvable-Worlds-Hardest-Jigsaw-Puzzles-9

Instead, policymakers and commentators tell simple stories about British politics

The dominant story of British politics relates initially to the idea of parliamentary sovereignty: we vote in constituencies to elect MPs as our representatives, and MPs as a whole represent the final arbiters on policy in the UK. This idea connects strongly to elements of the ‘Westminster model’ (WM), a shorthand phrase to describe key ways in which the UK political system is perhaps designed to work. Perhaps policymaking should reflect strongly the wishes of the public. In representative democracies, political parties engage each other in a battle of ideas, to attract the attention and support of the voting public; the public votes every 4-5 years; the winner forms a government; the government turns its manifesto into policy; and, policy choices are carried out by civil servants and other bodies. In other words, there should be a clear link between public preferences, the strategies and ideas of parties and the final result.

The WM serves this purpose in a particular way: the UK has a plurality (‘first past the post’) voting system which tends to exaggerate support for, and give a majority in Parliament to, the winning party. It has an adversarial (and majoritarian?) style of politics and a ‘winner takes all’ mentality which tends to exclude opposition parties. The executive resides in the legislature and power tends to be concentrated within government – in ministers that head government departments and the Prime Minister who heads (and determines the members of) Cabinet. The government is responsible for the vast majority of public policy and it uses its governing majority, combined with a strong party ‘whip’, to make sure that its legislation is passed by Parliament.

In other words, the ‘take home message’ of this story is that the UK policy process is centralised and that the arrangement reflects a ‘British political tradition’: the government is accountable to public on the assumption that it is powerful and responsible. So, you know who is in charge and therefore who to praise or blame, and elections every 4-5 years are supplemented by parliamentary scrutiny built on holding ministers directly to account.

These stories are more useful for our entertainment than enlightenment

Consider these five factors which challenge the ability of elected policymakers to control the policy process.

  1. Bounded rationality. Ministers only have the ability to pay attention to a tiny proportion of the issues over which have formal responsibility. So, how can they control issues if they have to ignore almost all of them?
  2. Policy communities. Ministers delegate responsibility to civil servants at a quite-low level of government. Civil servants make policy in consultation with interest groups and other participants with the ability to trade resources (such as information) for access or influence. Such relationships can endure long after particular ministers or elected governments have come and gone.
  3. Multi-level governance. The UK government shares policymaking ‘vertically’ (with international, EU, devolved, and local governments) and ‘horizontally’ (with non-governmental and quasi-non-governmental organisations).
  4. Complex government. Policymaking ‘emerges’ from the interaction between many actors, institutions, and regulations. In complex policymaking systems, people act without full knowledge of how other people act elsewhere in the system.
  5. Policy environments. Many policy conditions and events are out of policymakers’ control (including demographic, technological, and economic change)

So, for example, the UK government has to juggle two stories of British politics – on the need to be pragmatic in the face of these five challenges to their power and sense of control, versus the need to construct a strong image of governing competence with reference to control – in the knowledge that one of them is a tall tale.

Brexit will change only one part of that story

None of these factors should prompt us to minimise the influence of the EU on the UK. Rather, they should prompt us to think harder about the impact of Brexit on ‘parliamentary sovereignty’ and ministerial accountability via UK central government control. The phrase ‘you know who is in charge, and who to blame’ will become a more important rallying cry in British politics (when we can no longer blame the EU for British policy), but let’s focus on what actually happens in British politics and recognise how little of it we understand before we decide who to blame.

This post is an amended version of the introductory post for the course POLU9UK: Policy and Policymaking in the UK which draws on this ‘1000 Words’ series on public policy.

 

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What happens when UK Governments try to control and delegate policymaking? #POLU9UK

To celebrate Andy Murray becoming number 1, I have recorded the podcast in the style of him giving an interview:

 

British politics looks weird because UK governments have contradictory incentives: to look like they are in control, but delegate most, of policymaking; to take but shuffle off responsibility for policy outcomes; to hold on and let go.

These incompatible incentives reflect our incompatible stories of British politics:

  • One stresses central control, the other stresses complexity and emergent outcomes despite central government intervention
  • One stresses the need for central control to ensure clear lines of accountability, the other stresses the need for pragmatism and how ridiculous it is to hold people to account for things over which they have minimal control.
  • One gets all the attention, despite being misleading, partly because it relates to a simple and comforting message on accountability and the exciting world of high politics. The other gets little attention, despite being more accurate, because its message is confusing and often boring.

So, when we discuss the big post-war developments in British politics, and their impact on policymaking and accountability, we should not expect to find a grand or consistent plan. Instead, post war government reforms reflect these contradictions, and prompt a tendency for elected policymakers to delegate or ‘shuffle off’ most responsibility but intervene in unpredictable and inconsistent ways.

What were these big changes? 1. A shift from state to market?

I say this not to diminish the argument that major changes from the 1970s, to alter the balance between the state and market in the UK, were often ideologically driven. Rather, don’t assume that the consistent/systematic application of that ideology is the main explanation. In some cases, governments:

  • diluted their reformist beliefs, preferring pragmatism and realistic aims
  • pursued reforms for simple aims such as to bolster their popularity
  • accepted or reinforced the actions of their predecessors (even if from another party)
  • pursued major reforms after key events and crises seemed to force their hand.

Overall, politics is often about telling a story about handling government or crises well, not actually controlling events and outcomes, and no single elected government can oversee a 10, 20, or 30-year plan to reform the state in the scale we witnessed.

Still, we can now see fundamental differences when we compare the UK state with that of the 1970s. Examples include:

  • A ‘paradigm’ shift in economic policy, from ‘Keynesian’ to ‘monetarist’ economics (see Hall), prompted by economic crisis in the 1970s under Labour and the election of a Conservative government in 1979. For example, governments no longer promise to achieve ‘full employment’ via measures such as capital investment (indeed, the Thatcher government appeared to accept high unemployment while favouring inflation controls).
  • Privatisation. The sale of public assets (including major nationalised utilities and local authority owned social housing), break up of state monopolies, injection of competition in the public sector, introduction of public–private partnerships for major capital projects, and charging for government services.

In both cases, you can see one form of this debate on central control playing out: for some advocates of economic reform and privatisation, this was about producing a ‘rejuvenated’ and ‘lean’ state, with ministers able to focus on core tasks – making strategic decisions and creating rules for others to follow – without having to pretend that they can control the economy or manage major industries. In this account, post-war developments were based on the idea of state planning and central control over the economy and most public services, while post-79 developments were driven by the belief that such planning had failed.

Although prompted by the Conservative government of 1979-97, the Labour government from 1997-2010 reinforced most measures (and privatised more services than Thatcher would have envisaged). It also extended the idea of limiting central government ministerial intervention in the economy by introducing Bank of England independence (making it primarily responsible for interest rates and strategies to manage inflation).

  1. A shift from ‘rowing’ to ‘steering’?

This ‘lean’ theme is summed up in the metaphor (made famous by management consultants Osborne and Gaebler) of ‘steering, not rowing’, in which governments decide to provide direction to public services/ public servants rather than managing them directly. Also look out for the phrase ‘new public management’ (NPM) which mostly describes the application of private business methods to the public sector. Examples include:

  • Civil service reforms to separate strategic ministerial/ operational decisions and make public servants more directly accountable for the latter.
  • Quasi-markets. Public bodies like hospitals and schools are given greater operational independence. One part of the public sector competes with another for (say) the business of commissioning agencies and/ or to compete in league tables of performance.
  • Quangos. The increased use of quasi-non-governmental bodies, sponsored by government departments but operating at ‘arms-length’ from elected policymakers.
  • Public sector reforms in which non-governmental bodies play an increasing role in service delivery while subject to regulation, inspection, and performance management.
  1. Constitutional

These reforms, often designed to give a sense of reinforced central control, are different from decisions by the UK government to shift power upwards, to the European Union, and downwards,(a) in 1999, to devolved governments in Scotland, Wales and Northern Ireland, and (b) through various experiments in regional government (in the early 2000s) and ‘localism’ (from 2010).

What is the overall effect of these reforms?

These reforms prompted several debates about the modern nature of the UK state, based on questions such as, Is it ‘hollowing’ or rejuvenated?

  • Is UK central government now less able to influence policy outcomes, and more reliant on persuasion and cooperation from many actors in policy networks? Do we talk about multi-level governance, not government, because no single government can control policy? Is this the great irony of reform: they were designed to reinforce central control but they actually exacerbated the UK’s governance problem?
  • Or, has central government shuffled off direct responsibility for the previously unmanageable parts of the public sector that took up a disproportionate amount of ministerial energy (major industries, local government, Scotland), and become more powerful via regulatory mechanisms or more able to shift blame?

When considering these questions, note how this UK-specific discussion can be supplemented by the ‘universal’ factors we discuss in POLU9UK and covered in the 1000 Words series, including: ministers are boundedly rational, operating in a policy environment with a huge number of actors, and apparently unable to control outcomes that ‘emerge’ from complex systems. In other words, the answer to the ‘hollowing’ question will not come only from an analysis of UK government policies.

What is the effect on ministerial accountability?

As in Scotland, the UK Government has experimented with many forms of accountability based on one of these two stories of central government:

  1. Westminster-style democratic accountability, through periodic elections and more regular reports by ministers to Westminster. This requires a strong sense of central government and ministerial control – if you know who is in charge, you know who to hold to account or reward or punish in the next election.
  2. Institutional accountability, through performance management measures applied to the chief executives of public bodies, such as elected local authorities and unelected agencies and quangos.
  3. Accountability via pluralist democracy, fostering the shared ‘ownership’ of policy with stakeholders to produce choices that both support.
  4. Localist democracy, encouraging a sense of collective responsibility between local authorities and their stakeholders.
  5. User based notions of accountability, when a public body considers its added value to (and responds to the wishes of) service users, or public bodies and users ‘co-produce’ and share responsibility for the outcomes.

Yet, 2-5 generally seem incompatible with, or overshadowed by, 1. Ministers think that the public expects Westminster-style accountability, so they try these other measures but also:

  • Try to show that they still control the direction of delegated services, often with reference to problematic proxies of their own success (see the example of Troubled Families)
  • Intervene in an ad hoc way in the decisions of public bodies that they’d otherwise like to run themselves (see Gains and Stoker)
  • Or, they seem to delegate power to public bodies but introduce so many regulations, budget limits, and performance measures that it is difficult for those bodies to exert their autonomy (see the example of ‘prevention policy’, in which central governments simultaneously support and scupper various forms of prevention and early intervention).

Group work

In groups we can discuss these major reforms and the extent to which they were driven by a grand plan or a series of unfortunate events.

We can discuss accountability and try to explain how and why ministers intervene in some areas but not others.

Since we focused on the two basic stories of (lack of) control in week 2, this week we can zoom in to discuss specific measures to demonstrate success in government or produce the appearance of control. What examples spring to mind?

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Policy networks and communities #POLU9UK

As we discussed in week 2, if you start your study of British politics by describing the Westminster model, you get something like this:

Key parts of the Westminster political system help concentrate power in the executive. Representative democracy is the basis for most participation and accountability. The UK is a unitary state built on parliamentary sovereignty and a fusion of executive and legislature, not a delegation or division of powers. The plurality electoral system exaggerates single party majorities, the whip helps maintain party control of Parliament, the government holds the whip, and the Prime Minister controls membership of the government. So, you get centralised government and you know who is in charge and therefore to blame.

Yet, if you read the recommended reading, you get this:

Most contemporary analysts dwell on the shortcomings of the Westminster account and compare it with a more realistic framework based on modern discussions of governance … Britain has moved away from a distinctive Westminster model.

And, if you read this post on the pervasiveness of policy networks and communities, you get something like this:

‘Policy networks’ or ‘policy communities’ represent the building blocks of policy studies. Most policy theories situate them at the heart of the policy process.

So, you may want to know: ‘How did we get from the one case of affairs to the other case of affairs?’ (source). Here are some possible explanations to discuss.

One account is wrong

In our grumpy account, we pretty much complain that the incorrect story still wins because it sounds so good. The uncool academics have all agreed that the ‘governance’ story best sums up British politics, but the media and public don’t pay attention to it, politicians act as if it doesn’t exist, and cool Lijphart gets all the attention with his ‘majoritarian’ model of the UK which accentuates the adversarial and top-down nature compared to the utopian consensus democracies in which all politicans hold hands and sing together before agreeing all their policies.

One account is wrong most of the time

When less grumpy, we suggest that our account is correct most of the time. People pay attention to the exciting world of elected politics and governing politicians, but it represents the tip of the iceberg. Most policy is processed below the surface, away from the public spotlight, and this process does not match the UK’s majoritarian image. Instead, policymakers tend to work routinely with other policy participants to share information and advice and come to collective understandings of problems and feasible solutions.

What explains the shift from one image to the other?

If we go for the latter explanation, we need to know how this process works: what prompts a tiny number of issues to receive the excitement and attention and a huge number to receive almost none? I’ll give you some ideas below, but note that you can find the same basic explanation of this agenda setting/ framing process in many theories of the policy process. You should read as many as possible and, in particular, those on framing, punctuated equilibrium, and power/ideas. Combined, you get the sense of two scenarios: one in which people simply can’t pay attention to many policy issues and have to ignore most; and, one in which people exploit this limitation to make sure that some issues are ignored (for example, by framing issues as ‘solved’ by policymakers, with only experts required to oversee the implementation of key choices).

The general explanation: powerful people have limited attention

You’ll find this general explanation squirrelled away somewhere in almost everything I’ve written. In this case, it’s in the networks 1000 words post:

  • The size and scope of the state is so large that it is in danger of becoming unmanageable. The same can be said of the crowded environment in which huge numbers of actors seek policy influence. Consequently, the state’s component parts are broken down into policy sectors and sub-sectors, with power spread across government.
  • Elected policymakers can only pay attention to a tiny proportion of issues for which they are responsible. So, they pay attention to a small number and ignore the rest. In effect, they delegate policymaking responsibility to other actors such as bureaucrats, often at low levels of government.
  • At this level of government and specialisation, bureaucrats rely on specialist organisations for information and advice.
  • Those organisations trade that information/advice and other resources for access to, and influence within, the government (other resources may relate to who groups represent – such as a large, paying membership, an important profession, or a high status donor or corporation).
  • Therefore, most public policy is conducted primarily through small and specialist policy communities that process issues at a level of government not particularly visible to the public, and with minimal senior policymaker involvement.

A specific explanation: even ‘majoriarian’ governments seek consensus even when issues become high profile

I like this story about Brent Spar as an example of ‘bureaucratic accommodation’. In a nutshell (from p577), they argue that we began with a high profile issue in which Greenpeace occupied a Shell oil rig that was due for disposal, got Shell to change its policy through high profile campaigning, but that they came to quieter agreement within government by agreeing on specific policies without shifting their basic principles. Many of us saw the conflict but few saw the consensus building that followed (and, in fact, preceded these events). There are many stories like this, in which relatively short periods of highly salient policymaking ‘punctuate’ much longer spells of humdrum activity.

brent-spar

Group activities

So, in our group work we can explore the key themes through examples. I’ll ask you to identify the conditions under which Westminster-model-style activity happens, and the conditions under which we’d expect policy communities to develop. I’ll ask you to compare issues in which there is high salience and conflict with issues that are low salience and/ or low conflict. I might even ask you to remember some high profile issues from the past then ask: where are they now?

 

 

 

 

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Policymaking in the UK: do you really know who is in charge and who to blame? #POLU9UK

This week, we continue with the idea of two stories of British politics. In one, the Westminster model-style story, the moral is that the centralisation of power produces clear lines of accountability: you know who is in charge and, therefore, the heroes or villains. In another, the complex government story, the world seems too messy and power too diffuse to know all the main characters.

Although some aspects of these stories are specific to the UK, they relate to some ‘universal’ questions and concepts that we can use to identify the limits to centralised power. Put simply, some rather unrealistic requirements for the Westminster story include:

  1. You know what policy is, and that it is made by a small number of actors at the heart of government.
  2. Those actors possess comprehensive knowledge about the problems and solutions they describe.
  3. They can turn policy intent into policy outcomes in a straightforward way.

If life were that simple, I wouldn’t be asking you to read the following blog posts (underlined) which complicate the hell out of our neat story:

You don’t know what policy is, and it is not only made by a small number of actors at the heart of government.

We don’t really know what government policy is. In fact, we don’t even know how to define ‘public policy’ that well. Instead, a definition like ‘the sum total of government action, from signals of intent to the final outcomes’ raises more issues than it settles: policy is remarkably difficult to identify and measure; it is made by many actors inside, outside, and sort of inside/outside government; the boundary between the people influencing and making policy is unclear; and, the study of policy is often about the things governments don’t do.

Actors don’t possess comprehensive knowledge about the problems and solutions they describe

It’s fairly obvious than no-one possesses all possible information about policy problems and the likely effects of proposed solutions. It’s not obvious what happens next. Classic discussions identified a tendency to produce ‘good enough’ decisions based on limited knowledge and cognitive ability, or to seek other measures of ‘good’ policy such as their ability to command widespread consensus (and no radical movement away from such policy settlements). Modern discussions offer us a wealth of discussions of the implications of ‘bounded rationality’, but three insights stand out:

  1. Policymakers pay disproportionate attention to a tiny proportion of the issues for which they are responsible. There is great potential for punctuations in policy/ policymaking when their attention lurches, but most policy is made in networks in the absence of such attention.
  2. Policymakers combine ‘rational’ and ‘irrational’ ways to make decisions with limited information. The way they frame problems limits their attention to a small number of possible solutions, and that framing can be driven by emotional/ moral choices backed up with a selective use of evidence.
  3. It is always difficult to describe this process as ‘evidence-based policymaking’ even when policymakers have sincere intentions.

Policymakers cannot turn policy intent into policy outcomes in a straightforward way

The classic way to describe straightforward policymaking is with reference to a policy cycle and its stages. This image of a cycle was cooked up by marketing companies trying to sell hula hoops to policymakers and interest groups in the 1960s. It is not an accurate description of policymaking (but spirographs are harder to sell).

Instead, for decades we have tried to explain the ‘gap’ between the high expectations of policymakers and the actual – often dispiriting- outcomes, or wonder if policymakers really have such high expectations for success in the first place (or if they prefer to focus on how to present any of their actions as successful). This was a key topic before the rise of ‘multi-level governance’ and the often-deliberate separation of central government action and expected outcomes.

The upshot: in Westminster systems do you really know who is in charge and who to blame?

These factors combine to generate a sense of complex government in which it is difficult to identify policy, link it to the ‘rational’ processes associated with a small number of powerful actors at the heart of government, and trace a direct line from their choices to outcomes.

Of course, we should not go too far to argue that governments don’t make a difference. Indeed, many ministers have demonstrated the amount of damage (or good) you can do in government. Still, let’s not assume that the policy process in the UK is anything like the story we tell about Westminster.

Seminar questions

In the seminar, I’ll ask you reflect on these limits and what they tell us about the ‘Westminster model’. We’ll start by me asking you to summarise the main points of this post. Then, we’ll get into some examples in British politics.

Try to think of some relevant examples of what happens when, for example, minsters seem to make quick and emotional (rather than ‘evidence based’) decisions: what happens next? Some obvious examples – based on our discussions so far – include the Iraq War and the ‘troubled families’ agenda, but please bring some examples that interest you.

In group work, I’ll invite you to answer these questions:

  1. What is UK government policy on X? Pick a topic and tell me what government policy is.
  2. How did the government choose policy? When you decide what government policy is, describe how it made its choices.
  3. What were the outcomes? When you identify government policy choices, describe their impact on policy outcomes.

I’ll also ask you to identify at least one blatant lie in this blog post.

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Scotland’s Future: A Summary of the White Paper in Slightly Fewer Words Than The White Paper’s Own Summary

Scotland’s Future is an unusual mix of the mundane and the meaningful. On the one hand, it doesn’t tell you much more than you already knew: the current Scottish Government supports independence and has its own ideas about how it should look. On the other, if you take a step back, you remember how unusual it is for a government to treat independence as a policy like any other, setting out a White Paper and using the civil service machinery to help turn its broad aims and manifesto into a whopping policy document. The choice of a White Paper is also interesting in terms of UK history. They are traditionally used as a way to consult. A Green Paper sets out broad aims and asks questions. A White Paper is a stronger statement of intent, set out in detail, and put to the public for its reaction. They know what they want to do, but they are willing to talk to you about it, to make sure they got it right.

I remember noticing this mix of mundane/ meaningful when hearing the White Paper described by a civil servant in an innocuous way (although this is only an impression you would get if you were there – not if you read about it in the Herald). I mostly spaced out when hearing some of the descriptions, only to remember that this is a Scottish Government civil servant describing the details of the policy of independence. So, I managed to catch the most important part: the White Paper is a mixture of 3 things:

(1)   What the Scottish Government wants and can safely say will happen if there is a Yes vote (Scottish independence, as described in the WP);

(2)   What the Scottish Government hopes to secure in negotiation with the UK Government if there is a Yes vote (for example, a currency union);

(3)   What the current Scottish Government would like to see happen if there is a Yes vote (for example, a particular kind of social democratic state and particular policies, or the removal of policies such as the ‘bedroom tax’).

Much has been made about the third type of aim, which can be described as the SNP using the Scottish Government to write its next manifesto (albeit on twitter, where people go to make their most succinct and outrageous claims), but remember that this is a consultation document, not something that binds a Scottish Government led by another party (and remember that the SNP had already written most of this stuff anyway, with the civil service there to minimise mistakes). Even without the hyperbole, it is an unusual document, setting out a policy for something the Scottish Government does not control. One might say that, in a complex world, the idea of a government being in control is silly anyway, but this WP is unusually candid about the things it only hopes to achieve and the often-party-political points it wants to make.

It is in this context that we should view the aims set out in the WP:

Alex Salmond’s preface has that big idea, mixed with pragmatism and values, feel: we will seek independence to pursue our own aims, work with the UK Government to secure them, and hope to build on the idea of Scottish ‘values’ to produce a particular kind of state and set of policies. This is a straightforward rhetorical device setting out his (now pragmatic) hopes and dreams.

The preface is followed by some bullet points which contain more details and mixes the governmental with the party political. This is the approach that has been described as the Scottish Government writing the SNP’s manifesto. Alongside the general desire for decisions about Scotland to be made by ‘those who live and work here’, is a broad statement about economic policy being conducive to business (including small business) and geared more to Scotland than the South East of England (a point used partly to justify a potentially-right-wing-looking drop in corporation tax (and air duty), ‘to counter the gravitational business pull of London’), a detailed account of current policy intentions and some strong criticism of current UK Government policy. The ‘social democratic’ feel is there, with a general commitment not to reform the welfare state in the way currently done by the UK Government, and to protect pensions and the minimum wage (while promoting, and paying its staff, the ‘living wage’).  There is a particular emphasis on childcare to allow women to return to work (prompting some commentary about the relative lack of support for independence by women). There is also a clear dig at the UK Government as a Conservative-led government, with a commitment to abolish the ‘bedroom tax’ (for social housing only?) and return the Scottish part of the Royal Mail to public ownership. The ‘bedroom tax’ is, I think, mentioned 38 times and linked to the ‘poll tax’ twice (it’s a bit like the roundabouts going through Dundee – they have a hypnotic effect and you lose count).

These aims are followed by the case for independence and some broad plans for an independent Scotland. It is this area in which the Scottish Government shows most strength, by presenting Scotland in a positive light, particularly in relation to its economy and its scope for growth through innovation, and by presenting broad aims which reinforce its Nordic-looking (‘social democratic’? progressive? corporatist?) credentials tied strongly to its aims on economic activity. There is a focus on: ‘fostering high levels of trust and reducing income inequality’; promoting more equal employee representation and, in particular, ‘greater female participation on company boards’; reducing corporation tax and air duty (perhaps the non-progressive outliers in this list) and perhaps National Insurance contributions for small business; fostering a corporatist approach to issues such as fair pay; and, removing tax incentives for marriage and a reduction in employment rights. The stand-out element is the commitment to increase ‘female and parental participation in the workforce through a transformational expansion in childcare provision’. 3 and 4 year olds (and ‘vulnerable’ 2 year olds) will be offered the hours equivalent to primary schooling. Early criticism focuses on the idea that this policy is only promised in an independent Scotland, not now. Yet, the plan is based on a five year lead-in, to produce a much larger trained workforce (five years seems ambitious enough to me).

There is also a broad commitment to: maintain Scotland’s key education policies (comprehensive schools, free higher education) but improve on the Scottish Government’s record on major inequalities in attainment (there is a similar mention of health inequalities); re-establish the link between the state pension (but not other social security) and average earnings or inflation if it is higher (a policy abolished by a pre-devolution Conservative Government) and slow down the increase of the pension age when it reaches 66 (partly because Scots live shorter and less expensive lives); and protect social protection: ‘support for people who work; a safety net for people who cannot work; and a climate of social solidarity’. Its justice aims are fairly vague.

This is accompanied by a discussion of shakier ground, which: (a) requires more UK Government cooperation, arguing (why not go for it completely if you go for it?) that ‘The pound is Scotland’s currency just as much as it is the rest of the UK’s’ and that it should form an influential part of a ‘Sterling Area’ (i.e. not just use the pound on the sly); and (b) engages in the difficult-to-control debate about Scotland’s finances and likely future tax rates: ‘As Scotland’s public finances are healthier than those of the UK as a whole, there will no requirement for an independent Scotland to raise the general rate of taxation to fund existing levels of spending’ (compare with recent coverage of the IFS report).

The focus on international affairs is fairly uneventful at times (given that this would be the biggest area of transferred powers), perhaps because the debates have been well aired: the Scottish Government budget for embassies would be lower than it (estimates it) pays for its share of the UK (and used to promote culture and trade); it would negotiate its entry to to the EU on the basis of already meeting most of its conditions, staying out of the Eurozone (OK, that argument is more interesting) and Schengen area; it would meet the ‘good global citizen’ test by giving 0.7% of Gross National Income to international development; and put up more of a fight in EU fishing and agriculture negotiations. It also promises a (less UK, less right wing?) points-based system on immigration and to reintroduce the old student visas system (removed by the UK Government, producing much teeth-gnashing and income reduction in Universities).

Defence and energy are the bigger bones of contention, requiring some degree of cooperation with the UK Government. The Scottish Government promises the removal of nuclear weapons from Scotland ‘within the first term of the Scottish Parliament following independence’ (while aiming to join NATO) and to use some of its £2.5bn budget to build ‘to a total of 15,000 regular and 5,000 reserve personnel’. It also seeks to maintain a GB-wide energy market to, for example, allow it to continue to export renewable electricity to England.

The Scottish Government describes the transitional arrangements (to begin as a new, elected Scottish Parliament in May 2016) on things like civil service transfers as straightforward, preferring to focus on the need to produce a written constitution, enshrining certain broad principles on equality and the right to healthcare and education (and a specific ban on nuclear weapons), and developed in partnership with a ‘constitutional convention’. Its commitment to ‘subsidiarity’ and the protection of local government appears later in the main document.

If only to reinforce the idea that this is no ordinary White Paper, and that the Scottish Government is engaging in unusually tense party political and yes/ no ground, it has printed a clear dig at the no campaign’s focus on the worst-case scenario: Scotland will still get access to the BBC network, ensuring that ‘the people of Scotland will still have access to all current programming, including EastEnders, Dr Who, and Strictly Come Dancing and to channels like CBeebies’. What other government document can say that?

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