Covid-19: value-based policy making

By Jonathan Michaels.

While claiming to be ‘following the science’ politicians in many countries have implemented a range of widely differing policies in relation to Covid-19. This week, the UK government has reopened various parts of the economy in England, including pubs and restaurants, hairdressers and cinemas. Evidence-based decision making is not value-free. In framing the question, we identify options that we consider politically acceptable and the outcomes that concern us. In identifying credible and relevant evidence, the many contradictions and uncertainties provide ample opportunities to select the evidence that confirms our prejudices. Finally, we must make trade-offs in deciding which combination of outcomes is preferred, considering all the competing, and inevitably uncertain, risks, benefits and costs.

It is clear that any relaxation in current measures to address Covid-19 will result in a slowing of the elimination of the virus, if not a resurgence. Much of the focus has been on keeping the R0 below 1. However, even without exceeding this number, and thus instigating a second wave, allowing it to rise to 1 is to accept continuation of the current rate of infections and deaths (about 700 per week in the UK at the time of writing). Even letting it drift from 0.8 to 0.9 will nearly double the number of expected deaths over the coming months. Whether we attempt to minimise this loss of life, or trade these lives for the freedom to visit pubs and watch football or to reopen schools and reconnect with family, is a value choice. Such preferences are likely to differ significantly between those who are vulnerable and shielding, working single mothers, and the macho Eton alumni.

The UK government’s response to Covid-19 does not make explicit where and how such judgements have been made.  However, the underlying principles upon which such decisions are made are most clearly laid out in the Treasury’s Green Book, which states its aim as “transparent, objective, evidence-based appraisal and evaluation of proposals to inform decision making”. With policy changing so rapidly it seems unlikely that the government has carried out any formal Social Cost Benefit or Cost Effectiveness Analysis, as described in the book.

It has been argued by Donald Trump and others that the cure may be worse than the disease. It seems quite possible that a formal cost benefit analysis, in line with the Green Book methodology, would show that the effects on mental and physical health related to unemployment, poverty and social isolation may outweigh the direct losses due to the pandemic.  However, the idea that our failure, in a wealthy country, to deal with poverty, deprivation and health inequalities, should be seen as justification for a failure to address the health implications of the pandemic, seems abhorrent.

The economic effects of the pandemic are likely to be severe throughout the world and it is well established that previous austerity measures have had a profound effect on poverty and health, but austerity is not the only possible response to the crisis.  Boris Johnson has recently discounted austerity and suggested that investment in infrastructure will aid economic recovery.  However, building roads and high-speed rail links and expediting repairs to schools and hospitals, will do little to address the excess deaths that result from socio-economic deprivation and health inequalities. To address these will require a different set of priorities for new infrastructure, such as better social housing and investment in a social care system that has been shown to be failing by recent events.

If the pandemic has taught us anything, it is that the vital infrastructure upon which we have relied so much over the past few months is not the primarily male occupations in construction and manufacturing that the suggested projects might provide. Rather, it is the low paid, predominantly female or immigrant workers in the care sector, the unpaid domestic work and childcare, and the voluntary sector, that are vital to the health of the nation.

At the height of the second world war the coalition government commissioned the Beveridge Report, which recommended “Comprehensive health and rehabilitation services for prevention and cure of disease and restoration of capacity for work, available to all members of the community”. Despite the huge economic impact of the war, the post-war establishment of the National Health Service (NHS) resulted in a universal healthcare system that remains highly valued by the public.

Before the Covid-19 pandemic struck there had been many years of reports and debates regarding the difficulties in the social care system in the UK, which was suffering from numerous shortcomings. The pandemic has highlighted the inadequacies of the current social care system, the lack of coordination with the NHS, and the failure of the profit motive to deliver high quality, sustainable provision. Perhaps the most effective and valuable legacy of the pandemic could be a series of measures to address poverty and health inequalities, including the establishment of a National Social Care System that parallels the establishment of the NHS after the second world war.


Author: Jonathan Michaels

Affiliations: School of Health and Related Research, University of Sheffield

Competing interests: None

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