Picture the scene. We are in Downing Street and the news media are awaiting another coronavirus press conference. Professor Chris Whitty, the Chief Medical Officer for England is ready. Sir Patrick Vallance the Chief Scientific Advisor is ready. Where is the Prime Minister (PM)? Late again.
I have this vision of our PM frantically scurrying around like the White Rabbit in Alice in Wonderland humming “I’m late I’m late for very important date”. We might all smile at this vision but I’m afraid the analogy of being late is not a laughing matter when it is applied as the major theme for the UK governments management of what I described in a previous blog as the worst public health crisis in my lifetime. I also recall the PM famously using the phrase “A stitch in time saves nine” which is indeed true however in a pandemic being late or not sewing that stitch in time can and has cost thousands of lives.
In the week that has seen the UK pass 100,000 deaths it is right to reflect on the tragic loss of life. The call from government saying this is not the time to analyse why the UK has done so badly is in my view the wrong line to take. The government could learn a thing or two from the UK health care professions who for years have developed themselves as reflective practitioners. Donald Schon (1983) wrote extensively about reflection in terms of the creation of learning organisations who can both reflect in and on action. It is the former that has been sadly lacking in the UKs response to the coronavirus crisis. Reflection needs to be on the table throughout the pandemic and had it been, we may not have repeated the same mistakes. The management of pandemics is well documented in the medical literature. Professor Chris Whitty the Chief Medical Officer for England outlines how to manage a pandemic in this useful lecture at Gresham College.
Indeed it is also important to remind us of the words of Sir Patrick Vallance who when recommending the urgency of action in a pandemic implored that we “go earlier than you think you want to, go a bit harder than you think you want to and go broader than you think you want to in terms of restrictions.” My observation of the UK pandemic response leads me to conclude that we failed to do any of these. However, for this blog let’s focus on timing. Going early in terms of restrictions and other actions can have an enormous beneficial impact.
The last year has been to coin an overstated phrase “unprecedented” with many arguing that any government would have been overwhelmed and struggled to manage the crisis. Is this fair? One can look at other countries who have managed the situation better and as such have had better outcomes. New Zealand, Australia, Korea for example. Others will point to the differences between countries in terms of geography, population, culture, transport, relative poverty, healthcare systems, reporting mechanisms and living conditions which make comparisons inherently complex.
With the current death toll in the UK so high and continuing to rise, and many scientists telling us that things will inevitably get worse before they get better the question everyone is asking is : What has gone wrong? In this blog I’m going to argue that in large part our problems are based on a lack of urgency in acting. I’m arguing that we have not followed Sir Patrick Vallance’s recommendation and in particular we have been late to act throughout. Below I will set out the evidence for this and propose some tentative reasons as to why this has been the case.
Firstly, despite a pandemic being recognised as the largest threat to any country (it will always be top of any country’s risk register) the UK was slow to recognise the impending crisis and late to recognise the implications of a virus of this nature and how quickly it can spread globally. History informs us of how quickly Spanish flu spread in 1918. The UK was never going to be immune. Late recognition and poor pandemic preparedness meant we were late to get in place the critical infrastructure required to mount a response. Despite several warnings and meetings of the civil contingencies committee (COBR) the health secretary Matt Hancock was dismissive of the threat playing it down. Indeed, the PM failed to attend several early meetings giving the impression that the UK were not taking this as seriously as they should.
When faced with a looming medical/public health emergency it is important that the scientific advisors are in place early (which they were) and that their advice is acted upon. The evidence clearly points to a slow response to this advice which manifested itself in several critical late decisions early in the pandemic. The UK did not close its borders and implement quarantine measures allowing the virus to seed extensively in all parts of the community. Once community transmission had been established it was too late. It did not have in place a substantive testing regime, largely because we were unprepared. It very quickly became clear when we switched from community testing to testing only those in hospital with Covid symptoms that we lacked critical mass testing capacity and hence spent months trying to catch up. Evidence from previous outbreaks of SARS and MERS demonstrated how important mass testing was in controlling the spread, a position advocated by the World Health Organization (WHO). The UK saw case numbers grow rapidly and was slow to get the important public health messages out. Consequently, hospital admissions increased, and the death toll leapt. We were in serious danger of the NHS becoming overwhelmed with critically ill Covid patients.
Public health, medical and scientific experts suggested through their modelling exercises that the death toll, if we didn’t act quickly, could exceed 500,000; a situation socially and politically unpalatable. Therefore, in the absence of no known treatments and no vaccine we would have to resort to the tried and tested traditional methods for the suppression of a respiratory borne virus. Robust hand hygiene, respiratory/cough etiquette and maintaining social distance to reduce close social interaction. The logical conclusion was that to radically reduce social contacts we needed to lockdown. It is widely acknowledged now that the UK was at least a week late in introducing the first lockdown in March 2020.
In the meantime, the virus was sweeping through vulnerable elderly groups in care homes. We were again late to recognise this threat and late to protect them despite Hancock’s claims of throwing a ring of protection around them. The death toll continued to mount. At this stage both the Health (NHS) and care sectors were under enormous pressure and ill equipped to manage. The greatest worry at that stage was lack of adequate Personal Protective Equipment (PPE). Due to our ill preparedness we were late to provide appropriate PPE to both the NHS and the care home sector, exposing healthcare workers to undue risk. The death toll of healthcare workers in any pandemic is high and we were now starting to see this rise in the UK.
Another major criticism during the earlier months was how slow we were in ramping up testing capacity, tracking, tracing cases and ensuring isolation measures were in place. Indeed, concerns about test, trace and isolation continue today. However, lockdown and other public health measures did reduce the case numbers through the summer but inevitably the virus, which thrives in cold damp conditions started to cause further problems as we approached autumn and winter. Combined with this the UK saw a new variant of the virus emerge in the autumn with greater transmissibility. Cases started to rise again along with the inevitable hospital admissions and deaths. It appeared despite warnings from all scientists and health professionals that a second wave was highly possible we were late to recognise the emergence of a second wave of infections. The signs of which were there in September 2020. This led to a second lockdown in November when the advice from the scientific advisors was to lockdown in mid-October or earlier. This decision was compounded by a complex tiered restrictions arrangement to manage outbreaks locally aimed at the avoidance of unnecessary restrictions. Meanwhile the death toll continued to mount.
Notwithstanding the emergence of a new variant of the virus during the second lockdown everyone’s attention was switched to Christmas. The advice offered from government that restrictions would be relaxed for five days was met with incredulity by health professions who argued that this would simply allow the virus to be spread exponentially through greater household mixing. All the evidence at this stage pointed to household mixing as the primary source of transmission. As the situation worsened following the release of lockdown in early December it became obvious that the Christmas guidance had to change. To no ones surprise the advice was changed at the last-minute meaning everyone would have to rearrange their plans. The late change to the Xmas guidance probably meant more family mixing than would have happened had the advice been robust and communicated to the public earlier. Very quickly after Christmas we saw rapid changes to the tier management despite calls for a further lockdown. Cases rose rapidly, hospital admissions were now worse than in the first wave and scientists called for a lockdown. Consequently, we were late implementing Lockdown 3.
Throughout the pandemic the government has provided detailed guidance on restrictions, care homes, travel arrangements and education. It’s difficult to get this right all the time but the issuing of guidance was at times so late it became difficult to interpret the issues with clarity. Probably one the best examples of this relates to the advice provided to schools. Should they stay open or close? What should the Covid secure measures be? How do you construct bubbles of students to reduce social contact? Covid testing of pupils and staff? examinations and assessment guidance? However, the final straw was surely when schools opened in January after the Christmas break to only be told they had to close the very next day as we moved into Lockdown 3.
In conclusion it is said that to manage a pandemic you need a clear, robust strategic plan. The evidence presented here would suggest a lack of strategic planning with crisis decision making on the hoof. Some have argued that we have a PM who struggles to take the big decisions required, who procrastinates and inevitably is left with Hobson’s choice. If you couple this with a group of key ministers who appear to lack the competence to carry their portfolios we have the recipe for a disaster. The consequence of which means the UK has experienced a terrible outcome across a whole set of health, education and economic indicators.
Schon, D. (1983) The reflective practitioner: how professionals think in action Basic Books, New York
Whitty, C. (2018) How to Control an Epidemic https://www.youtube.com/watch?v=rn55z95L1h8