Do you remember when we were told that the British Government was ‘following the science’, or ‘led by the science’? Science, in the definite article (for Conservatives there is only The Science), was leading the Government: but not any more. Now the British Government is ‘guided by the science’. The selection of the word, with the quiet elision of significance in the move from the passive ‘follow’ to the more positive but still usefully ambiguous ‘guided’, we may assume was the centre of much of the Government’s internal PR attention; attention which is – after all – where Downing Street concentrates almost all its executive effort these days, for that theatre of all our nightmares, the daily press briefing in Downing Street, on the COVID-19 crisis. What is less clear is whether this represents a new Government acceptance of the fact that leadership is expected to come from Government in a crisis, and not handled as another exercise in Conservative buck-passing; or represents a new understanding in Government of the enduring uncertainty intrinsic to science: particularly in the case of a new virus, in which ‘science’ is quite obviously not yet in any position fully to understand many of the implications of the COVID-19 virus, still less produce a solution, whether in the form of a vaccine or cure, or both. It may be that Government will simply have to resign itself to adopting the unaccustomed role of political leadership, out there in the lonely spotlight; which includes embracing the entire responsibility for everything that goes with it. So far, however taking responsibility for leadership has not been high on the Johnson Government COVID-19 agenda.
Professor Devi Sridhar, Professor of Global Public Health at the University of Edinburgh, interviewed by the Guardian (23rd April), said this: “As a scientist, I hope I never again hear the phrase ‘based on the best science and evidence’ spoken by a politician …. This phrase has become basically meaningless and used to explain anything and everything”. Which is to say it explains nothing at all. Sridhar went on to argue that a real diversity of scientific views was observable in March, at which time: “World Health Organization advice, and what we’ve learned from lots of previous outbreaks in low- and middle-income countries, is that the faster you move at the start, the better”. Hence to institute a policy of test, trace and isolate would be the starting point for most public health professionals faced with coronavirus.
Sridhar suggested the government policy seemed to be based on a choice betweeneliminating the virus, or it becoming endemic; a choice analysed for effectiveness by using computer models. In the Guardian article both Srrdhar and Professor Mark Woolhouse, who is an epidemiologist specialising in infectious disease, also of Edinburgh University argued that epidemiology, at the expense of other scientific advice, may have played too large a role in decision making. Woolhouse thought the advice had been too much driven by epidemiology, with too much influence given to modelling.
For a political perspective on all this the Guardian turned to Professor Christina Boswell, an Edinburgh University political scientist, who provided this opinion: “The government isn’t using expertise simply to validate claims, it also appears to be using it as an insurance policy, …. If things go wrong – and the curve gets too steep – it will be the scientific advice that is to blame”.
This analysis is part of the discussion which follows the fine grain of the unfolding crisis. In such circumstances, a Government may fairly look for respite in the argument that we all make mistakes, especially in a crisis and in the short term, but what matters is the long term, the bigger picture, and the final destination. The mistakes can be reviewed ex-post, when the dust has settled. All that has merit, though it is not mere carping to point out that in that ex-post world the Government are offering to avoid too close scrutiny by public, media and political opposition now, this would look more credible if Britain’s long established experience of high profile public enquiries were not fairly routinely to be better described as exercises in whitewashing than as exemplars of retributive justice.
Nevertheless, let us set justice to one side, and move on to more productive territory. Here, unfortunately the Government defence is confronted by a twofold problem. First, both the PM and Government continually used hospital deaths, solely of those who have tested positive for COVID-19 as the appropriate measure of deaths, and cumulatively signalling the progress of the now famous steep, or flatter ‘curve’ on the graph, as a test of Government success in its fight against the virus. Stephen Powis, the Medical Director, National Health Service England gave this opinion at the Daily Press Briefing in Downing Street on 28th March: “If it [the death toll] is less than 20,000… that would be a good result though every death is a tragedy, but we should not be complacent about that” (Reuters). What if the Government is not in fact delivering a “good result”?
On 30th April Boris Johnson, now back in post presented the Government measurement of tested deaths: 26,711: only four weeks after the Powis judgement, and we already have gone far above his ‘good result’, an increase of no less than 6,711, or +33.6%. The deaths are already a third higher than hoped. Unfortunately that is not the only problem with the chosen statistic. It only registers a death at this national press briefing, if someone has been tested, and died. It does not measure those who have not been tested. It therefore deliberately leaves out almost all the population of care homes, to say nothing of those languishing at home, neither in hospital nor in a care home, whether in ‘care’ at home or not. The principal focus throughout has exclusively been on hospitals, and later only, those who have tested positive (originally it was only those tested, hospitalised and who died who were counted in the daily death figures, until that measure’s credibility wilted) not because all the deaths could possible be only there, but because that is where the critical pressure on the NHS falls, or that is where the Government chooses to look.
Meanwhile, here is the unconscious ‘danse macabre’ accompanying that Government choice. On 24th April, the Telegraph reported the effect of Government policy under this headline ‘Care homes’ soaring death rate blamed on ‘reckless’ order to take back Covid-19 patients’. The article referred to two ‘policy documents’ published on 19th March and 2nd April to the effect that “officials told NHS hospitals to transfer any patients who no longer required hospital level treatment, and set out a blueprint for care homes to accept patients with Covid-19 or who had not even been tested”. This was at the same time the Telegraph was reporting that, “coronavirus deaths accelerated more than twice as fast in care homes than in hospitals”. Whatever the intent of the policy, whether or not intended to ease the pressure on hospitals when it was feared they would be overwhelmed, or the merit of such proposals notwithstanding, it is worth reflecting that it should actually be considered by Government most appropriate even for purposes of recording deaths from COVID-19, to focus on hospital testing as the critical measurement criterion, over the actual trend in deaths, because of the scrupulous precision offered by following only the highly selective data. Then to present to the nation a narrowly defined and partially recorded figure to somehow, day-and-daily ‘stand for’ the nation’s total deaths from COVID-19, which has dutifully been reported by the media, and carried forward by almost everyone as the authentic daily figures on deaths from COVID-19. They are authentic, but they are neither accurate representations of total daily deaths, nor give the full picture of deaths from deaths linked to COVID-19. We now know that.
Scotland announced a change in the reporting of deaths outside those tested and hospitalised on 2nd April, with additional weekly reporting, from the following week of deaths “where coronavirus or COVID-19 are mentioned on the death certificate”; from data held by the National Records of Scotland. It was acknowledged that this would increase the total number of deaths being reported. In fact by the end of April it was acknowledged that, particularly through a rise in deaths in care homes, this meant that deaths were higher in care homes than in hospital. The Telegraph (29th April), reported that “National Records of Scotland (NRS) statistics showed that care homes accounted for 338 of the 656 cases recorded on death certificates last week”. This represents 51.5% of total deaths for the week (which total will also include deaths at home, provided the death certificate reports COVID-19 as a cause). Neither deaths in hospital nor deaths of those tested therefore provide anything like the full picture.
This was recognised by the British Government, which also began providing ONS figures on non-hospitalised patient deaths. Boris Johnson’s latest figure of 26,711 deaths was no longer solely the hospitalised and tested patient deaths, but incorporated those “tested positive for coronavirus across all settings”. Whether that figure is co-terminus with the total deaths of all those whose death on the death certificate is partially or wholly ascribed to COVID-19, I do not know.
This does not, however mean we can be confident we now know the total, cumulative deaths from COVID-19. The FT undertook an independent analysis of the ONS statistics now being presented, and linked this data to “all cause excess mortality” and “using the latest trends in the daily hospital deaths assuming the relationship between these and total excess deaths remained stable, as it has so far over the course of the pandemic. Using this calculation, a conservative estimate of UK excess deaths by April 21 was 41,102” (FT, 22nd April). Thus a week before Johnson’s figure of 26,711 is announced as total deaths of those testing positive, the FT proposes the figure (excluding one week compared to Johnson) is 41,102 or 14,391 (53.9%) higher than Johnson’s figure. So the reported figures look low and the analysis to explain them is becoming Byzantine for the non-specialist to comprehend
Evidence for the importance of the FT approach is provided by the work of the eminent statistician, David Spiegelhalter, Winton Professor of the Public Understanding of Risk, in the Statistical Laboratory at the University of Cambridge. He wrote this in the Guardian, 30th April: “I have stopped taking much notice of the number given out at the daily press conferences, as it is only based on reports from hospitals, oscillates wildly around weekends, and recently included deaths that occurred a month ago. And this week the number of UK deaths jumped up by nearly 5,000 to 26,097 in one day – rather close to Starmer’s count – by retrospectively including non-hospital deaths that had tested positive for the virus”.
Spiegelhalter notes that there is no consistency in the statistics across different countries. This is not solely because of the data selected for inclusion by the health authorities and Governments. It also depends on the complex underlying demographics of each country (an older population profile in Italy, younger in Ireland, giving a ten year difference in population median age between them, which will affect the data measured, where deaths are age-related).
Spiegelhalter determines an important issue: “Many feel that excess deaths give a truer picture of the impact of an epidemic”. the problem is that on this measure, the performance of the British response to the crisis stands out as a great deal less than satisfactory, not just by the measure of its own 20,000 deaths ‘good result’, but by any measure at all that would carry conviction.
This is not the end of the problems of the Government in the predicament in which it finds itself. The second problem to which I referred at the beginning, is the state of the NHS and related infrastructure after ten years of (at the very best), over-ripe, misdirected, exaggerated, austerity inflicted by Conservative Governments on vital NHS and local infrastructure to the real cost, and loss of the whole country; from which we are all now suffering. The difficulties the Government has faced with testing, with ventilators, with ICU, with PPE; with supply lines in the age of globalised ‘just-in-time’ processes; and with the NHS and local authority resilience structures of administration and operation that used to exist, but have been destroyed; has left the country and its people struggling against the odds (of the Government’s own making) to fight COVID-19 properly equipped to do so, and the Government itself now finds itself bereft of the executive levers to pull, that it once had in place, to fix the problem.
We are now building everything from scratch, in the middle of a lockdown, at the apex of the crisis: testing, PPE logistics, reconfiguring the NHS, and so on. It is not as if the Government did not know the problems that awaited a pandemic, or the risks that one could happen. Exercise Cygnus, a dry-run in 2016 provided an illumination of the problem, and what was required; especially investment. It didn’t happen. ‘Don’t get it done’ became the Conservative government’s alternative solution. The required investment was not made; desk exercise buck-passing was preferred. It was a Conservative Health Minister of the time who blew the whistle on that failure; he was astonished to discover four years later that nothing had been done to plug the gaping hole in our pandemic defences. Dr Philip Lee was a Conservative Health Minister who attended the Operation Cygnus dry-run in 2016. He understood the shortcomings that were revealed by the Cygnus operation, and is horrified at what has unfolded now, leading him to believe the real action and investment required of the Government by the failures exposed by Cygnus was never undertaken. He said as recently as 19th April that the government was advised to: “strengthen the surge capability and capacity in operational resources in certain areas. If demand outstrips local supply, there will be a need to scale up the response, for example to regional level. This was particularly true for excess deaths, social care and the NHS” (The Observer).
Where was the organisation and infrastructure to carry that out? Lee’s criticisms are part confirmed by Sir Ian Boyd, a past Chief Scientific Adviser at the Department for Environment, Food and Rural Affairs (DEFRA) and who is a professor of biology at the University of St Andrews. Boyd wrote this in Nature, on 30th March: “I took part in simulated exercises to prepare my country for the practical, economic and social shock waves from rare but devastating events..… I recall a practice run for an influenza pandemic in which about 200,000 people died. It left me shattered.” He goes on to argue that: “We learnt what would help, but did not necessarily implement those lessons”.
Professor Gabriel Scally, of Bristol University and a past Regional Director of Public Health, said in an interview on Newsnight (30th April), reported fully in the Belfast Telegraph (1st May), that on large scale testing “he was ‘very worried’ about the country’s ability to get to the levels of contact tracers needed, saying 10 years ago it would have been possible – but cuts have damaged this. Scally reacted angrily to the Conservative former Cabinet Minister David Gauke’s austerity cuts defence made in Newsnight, arguing back that: “The resilience has been stripped systematically out of the system, you cannot, when a big problem like this hits, you can’t just reinvent things and put them back the way you wish they were”.
In similar vein, the Belfast Telegraph adroitly sets Scally’s comments beside those of the Nobel Prize winner, Sir Paul Nurse, Chief Executive of the vast biomedical research centre the Francis Crick Institute, who labelled the Government’s target of 100,000 coronavirus tests per day “a PR stunt”. He added: “Where was the strategy under that? I haven’t seen a strategy under it. It just sounded good”. Nurse’s argument was close to Scally’s, emphasising local infrastructure and readiness: “If we had had local testing connected to local hospitals, we could have made hospitals a safe place” criticising the testing regime, the exposure of patients and health workers and concluding: “Testing was absolutely critical, it hasn’t been handled properly” (Belfast Telegraph).
This is no way to govern a country; short-term or long-term. It is a terrible indictment of Conservative Government and the ideology that drives it. The irony is, that whatever gains they thought they would make from austerity in reducing the national debt and eliminating the deficit simply never happened. The country remained in deficit, the debt spiralled, and because of austerity the economy failed adequately to recover; a triple whammy for the austerity blunder. Investment to protect the resilience infrastructure of the NHS and local authorities that is there to protect the country, just as much as the armed forces, against the threat of potential pandemics, was not only not made, or not maintained. The existing infrastructure was deliberately dismantled. The cost of obsessing on what the Conservative Governments of Cameron, May and Johnson wrongly claimed they couldn’t afford; simply now means that they have created an even bigger deficit and national debt than anyone ever could imagine, in part because their austerity policies (which ironically reflected poor understanding of monetary economics, anyway) undermined the country’s capacity to limit the damage to the economy of COVID-19.