A health emergency of this scale requires a strategic and systems-based approach
As we embark on what may be the very early stages of Lockdown 3.0, our fears for the future are made darker both by a real uncertainty about the course of the next few months and by the knowledge that it did not have to be like this. It is tempting to attribute such comment to hindsight, but in fact we have been led by a government which has egregiously disregarded what is actually little more than common sense. A health emergency of this potential scale required a strategic and systems-based approach from the start. This approach should have led early on to the production of a coherent plan with clear purpose. It should throughout have shown itself nimble to adapt in real time to new circumstances and to new knowledge. It should have forged a genuine partnership with civil society, devolving power and decision making as far as possible. Two way communication and transparency should have been its touchstones. The public should at all times have been able to base its confidence in the government precisely because it was leading well, demonstrably on the front foot, and whatever the situation, unwilling to be shaken from its prime purpose.
What we have experienced is very different. The potential scale of the health emergency was not understood at Cabinet level for some time. There was no clarity of purpose. The “herd immunity/control/suppression” debate remains unsettled in some quarters. There was little sign that early identification of pandemic danger spots in the nation’s fabric, such as social care, social and health inequalities, and poverty, led to the kind of policy attention required. Since May less than half the public have thought the Government was handling the pandemic well, in contrast with Germany and Nordic countries. [1]
Public opinion has consistently been ahead of the government’s willingness to take a decision. Each of the three national lockdowns have been widely criticised for being too late, causing unnecessary loss of life, economic and social harm, and a long haul back to gaining control of the virus. Before each, while government was agonising at the prospect of the inevitable, a huge majority of the public was expressing support for a lockdown. [2] In neither of the first two lockdowns was proper use made of the opportunity created to attend to the danger spots outlined above, or to ensuring that the basic instruments for regaining control were fit for purpose, especially the Find, Test, Trace, Isolate, and Support system (FTTIS).
Instead of a strategic approach, we have experienced, with some notable exceptions, a reactive firefighting response, in part shaped by an apparent presumption that the private sector will do a better job than the public sector. The exceptions are mainly those where scientists have been most able to lead, often in public/private partnerships, such as the vaccine development programme, and the NIHR initiatives, especially the Recovery trial. But the main thrust of government policy may fit uncomfortably with the characterisation offered by the prime minister himself, in describing the government’s approach to the control of outbreaks as “whack-a-mole.” This is an amusement arcade game in which players use a mallet to hit toy moles, which appear at random, back into their holes. The metaphor well captures two glaring deficiencies in the government’s approach. The first is the conception of pandemic response as comprising a series of discrete skirmishes, rather than as a feedback-informed campaign, itself based on a systems approach. The second is the idea that the pandemic’s course is no more or less than the playing out of random events. Neither are true.
There are several examples of the lack of systems thinking. The social care sector was early on identifiable as a danger spot, given the age and frailty of many of those in receipt of social care. Its reform has been part of several recent governments’ agendas, but instead of conceiving of the pandemic as a trigger to getting on with what was necessary, reform has been pushed back further. Instead of spending the required sums of public money to adequately protect those with limited political voice, including in obvious and easily implemented ways, such as proper pay and employment contracts for social care workers, the government chose to preserve, and spend large sums of public money in other sectors. If the main purpose was to control and suppress the virus, truly reforming investment in social care would surely rank higher than “Eat out to help out.”
The fact that schools have become a political football also reflects a lack of systems thinking. “Mass testing” has been introduced into schools, as a way of making them “safe,” but as a standalone intervention, despite their being intimately and porously connected to the communities they serve. Attention has not simultaneously been paid to strengthening the other weak components of the covid control system. Support for those needing to self-isolate, the key intervention to break transmission, remains poor, especially when compared with other examples of compensation for performing a civic duty, such as jury service, and with the approach taken by other countries. Even if the performance of the tests being relied on was “adequate,” their introduction looks likely to lead to harm. Government support for the other measures recommended by Independent Sage [3], including ventilation, making use of alternative venues, class size reduction, and changing teachers’ position on the vaccination priority list, may be more effective in controlling the virus and reducing disruption to kids’ education. This must be investigated, and use made of the lockdown to evaluate the contribution these tests might make among those who are now attending school.
The fact that covid’s effects are not distributed randomly, but felt disproportionately among those already vulnerable to ill health on account of their income, housing, occupation, or ethnicity, should have been a major spur to applying systems thinking to how best to control the virus across all sections of society. Instead while the pandemic has done so much to expose and amplify inequalities [4], and despite the “levelling up” rhetoric of the government after the December 2019 election, policies to address the widening social and health inequalities remain unformulated and unimplemented. The proposed end to the £20 a week Universal Credit supplement in April is a case in point, despite a majority of the public wanting it to be maintained [5]. If the overriding purpose is to control and suppress covid, this is fundamental: self-isolation remains regressive. Those most likely to be exposed to the disease, and to experience worst outcomes, are those least likely to be able to afford to self-isolate, or to self-isolate from their family members successfully. Household transmission remains a major component of all transmission [6] [7].
The current public and political focus is understandably on whether the NHS can continue to meet growing demand in the immediate term, whether current restrictions will be sufficient to reduce transmission, and whether the vaccination programme can roll out fast enough to help to reduce demands on the NHS. But we also need to be pressing for the best possible use to be made of the space bought by a national lockdown, and to generate consensus on what conditions need to be obtained before restrictions begin to be lifted. We need to see policies and action designed to avoid a repeat of what happened after the last two lockdowns. At a minimum these should include radical upgrading of the FTTIS system, including appropriate financial, physical, and psychological support for those self-isolating, a better designed social safety net, for example by maintaining the Universal Credit uplift, but also by ensuring that the families of all those deemed essential workers do not experience poverty in work. Apart from a brief period in the summer, presumably related to the prospect of a summer holiday, a majority of the public has supported quarantine for arrivals [8]. And yet, in contrast to elsewhere, we have allowed ourselves to sink under our travel hub status, not float on our island nation status. With the risk of variants likely to increase, border controls that apply to everybody need to be introduced.
In addition attention must now turn not just to how we “win the war against covid,” but to the development of a coherent strategy for how we win the peace. In order to maintain zero community transmission, all the factors that drive it need to be addressed as part of an integrated covid suppression strategy. This requires the same coherent approach across all of government that the UK promotes around the world in its development programmes, but seems not to apply at home. Without it, it will be hard for the UK to demonstrate the leadership required in its role as chair of the globally critical COP26 conference in Glasgow in November.
Mike Gill, former Regional Director of Public Health, South East England.
Hilde Rapp, Director of the Centre for International Peace Building.
Competing interests: None declared.
References:
[1] https://yougov.co.uk/topics/international/articles-reports/2020/03/17/perception-government-handling-covid-19
[3] Independent Sage An urgent plan for safer schools https://www.independentsage.org/wp-content/uploads/2020/11/Safe-schools-v4b1.pdf
[4] http://www.instituteofhealthequity.org/about-our-work/latest-updates-from-the-institute/build-back-fairer
[6] Zachary J et al Household Transmission of SARS-CoV-2A Systematic Review and Meta-analysis https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774102
[7] Thomson H et al Report 38 – SARS-CoV-2 setting-specific transmission rates: a systematic review and meta-analysis https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-38-transmission/
[8] https://yougov.co.uk/topics/international/articles-reports/2020/03/17/level-support-actions-governments-could-take