Richard North, 04/04/2020  

A sunny weekend is forecast, with predictions of a pleasantly warm Sunday. As we run towards the end of the second week of lockdown, therefore, the temptation to ignore health secretary Hancock's "instruction" and make the most of the good weather must be overpowering.

That tension exists over the continuation of the lockdown policy is borne out by the Telegraph, as some ministers argue for the measures to be lifted "sooner rather than later".

One minister goes so far as to argue that government would come under "increased political pressure" to lift the lockdown when parliament reopens on 21 April, and that presupposes that it has not already been confronted by a mutiny led by stir-crazy parents at their wit's end after running out of ideas to deal with bored and fractious children.

But, there are troubles lying in store for us, according to Anthony Costello (our former WHO man).

He has been speaking to a senior international epidemic expert who tells him that: "You can stop contact tracing in the hotspots, but when you lift the lockdown, everywhere at the same time, you'll face a problem: the virus will come back. New hotspots will form".

Actually, I've been thinking about this very thing, all in the context of the more general predictions about this epidemic, where modelling estimates suggested that the UK could suffer 750,000 additional deaths over the course of a pandemic, with local planners having to cope with up to 210,000 to 315,000 additional deaths over a 15 week period and perhaps half of these over three weeks at the height of the epidemic.

On reflection, if you accept that we don't have a single outbreak but many, with foci all over the country and at different stages of development, I can't see this frightening timescale being realised.

For a start, because the case and mortality totals – currently standing at 38,168 cases and 3,605 hospital recorded deaths – are largely fuelled by just a few hotspots, the population at risk to exponential phase outbreaks is not the 60 million plus of the entire nation. It could be a very much smaller figure of around ten million.

That means we're not going to see the massive figures predicted – not yet, anyway, and even then not at the speed predicted. The hotspots, as long as the lockdown is maintained, will eventually burn out as the virus is robbed of fresh meat, rather in the manner of a wildfire which has been contained by firebreaks.

The "firebreak" equivalent is the lockdown, which has put a lid on much of the spread. Thus, the opportunity for infection to pass from the London hotspot to, say, York, is fairly limited. But once the lockdown is lifted - as it must be in the not too distant future - movement throughout the country will be resumed. New outbreaks will crop up and existing small-scale incidents will be refreshed.

If we have started to see a downturn in the rate of new cases, which the CMO predicts might happen within two to three weeks, it will not last. We will be looking at a newly-invigorated epidemic and we'll be back where we started.

Costello's man thus argues that, to stop the epidemic, we must have a community programme for case detection and contact tracing. Otherwise, he says, "you won’t find the virus until it's too late".

Enter, at this point, Richard Vize, who complains that local authority activities to tackle the epidemic are being hampered by "central micromanagement". Ministers, he says, persist in the fantasy that everything works best when it is run from the centre.

The tensions aren't about money, he adds, but about communication and coordination. There have been delays, confusion and aborted work, such as changes of policy about where central and local government responsibilities lie, while public health directors are frustrated at being excluded from key communications and the development of guidance by NHS England and government departments.

As the message is that much more should be done by local authorities, the timing of a letter from Steve Battersby, Vice-president of the Chartered Institute of Environmental Health, couldn't be better.

Despite the years of austerity, he writes, there are resources in local government that we have also failed to use. There have been environmental health officers (EHOs) up and down the country desperate to help their public health colleagues – for example, with tracing contacts after testing (if there had been any).

They would also have been more effective at getting messages out to the public, particularly those most vulnerable or living in multi-occupied houses. Many EHOs have been left twiddling their thumbs for too long when their whole reason to exist is to protect public health.

You read it here first, of course. And another interesting, if familiar view comes from Michael Waterson at Warwick University. He says that it is a common view that the British government moved too late to institute a policy of testing everyone who has had recent contact with known coronavirus cases.

However, he tells us, there are several English local authorities in which there are fewer than five known cases and case density in the local population is very low. Using the most recent current figures, these include Hull, Blackburn, Stoke-on-Trent, Telford, Gateshead, Middlesbrough, Redcar and Darlington.

Testing all those who have had contact with the known cases in these areas should be a strictly limited task. Once done, subject to movement restrictions in and out, productive activity in these areas can commence or recommence, engineering facilities put to use in producing items in critically short supply – and they can once again, after many years, become an engine of growth.

With that low incidence, the monitoring of cases is easily manageable, especially if known and under-used resources such as EHOs were used, which begs the question as to why the government did not embark on an extensive community testing programme, tracing and testing cases and contacts.

Typically, the media has turned the lack of testing into a political scandal, and the fringe media is luxuriating in ever-more lurid conspiracy theories, but I'm afraid we will have to be content with that reliable old workhorse for an explanation – government (and professional) incompetence.

So far, I have managed to review government pandemic planning documents going back to 2005, such as this and this, both under Labour health secretaries, respectively John Reid and Patricia Hewitt.

Then we had this interesting document in 2006 – still under Labour's Patricia Hewitt – which gave advice to businesses, retailing the "key planning assumption" that, "during a flu pandemic, the government's overall aim will be to encourage people to carry on as normal, as far as possible". When 15 years later, we say the Johnson administration initially attempt the same policy, few would have thought that he shared it with the Blair government.

And since then, we have had an international strategy and a national framework in 2007, framed under Gordon Brown, together with an analysis of the science base for an overarching government strategy, which spanned Blair's and Brown's tenures in office.

This then brings us to the 2011 Preparedness Strategy, brought into being under Cameron's coalition government, as was the 2014 response plan and strategic framework.

A common thread running through all these plans was the limited use of community testing. It is limited to monitoring the first stage of the epidemic to establish when community spread had occurred. There is no provision in any of the plans for an extensive "trace and test" programme. In all cases the government relies for the resolution of the epidemic on the development of a vaccine, using the hospital services to hold down the death rate (mitigation) until it comes available.

In other words, while many different governments have had an input into planning the pandemic response, the short straw has gone to the Johnson administration, which has found that standing back and allowing the casualties to mount - the "bring out your dead" policy, while awaiting the cavalry is not politically tenable.

Desperately trying to deflect the political flak from their favoured son, we have serial latter day experts like Jeremy Warner and the ever-pompous Charles Moore blaming the bureaucrats, but the fact is that we are suffering from decades of inadequate policy-making.

And sadly for Johnson and his fellow ministers, they are finding that changing policy on the hoof is no walk in the park - which perhaps explains why Hancock is so keen to deprive us of that pleasure this weekend.

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