Richard North, 18/04/2020  
 


Although the grandstanding Richard Horton, editor-in-chief of the Lancet, has had a good epidemic – in the sense that people used to talk about having a good "war" – I actually prefer the more measured approach of the British Medical Journal. It seems to have a far better handle on where we stand in this developing crisis.

The crucial element currently on the table – as it always has been – was raised yesterday by Jeremy Hunt, chair of the Health and Social Care Committee. These are the plans for what is now called the "test, track and trace" programme, which health secretary Matt Hancock at last concedes is necessary if we are to lift the lockdown.

But what the BMJ has to say, through Mike Gill, former Regional Director of Public Health, South East England, is more than a little bit depressing. It suggests something that will come as little surprise to readers of this blog – that the government is on a collision course with reality.

In a piece headed, "Whitehall has locked down its own capacity for flexible thinking", Gill homes in on lifting the lockdown and, in so doing, questions the development and imminent launch of the mobile-based contact tracing "app" announced on Easter Sunday by Hancock.

In that respect, one of the "key questions" he poses is, "What steps are being taken now to build up the significant local resource required for effective case identification, contact tracing, quarantining", and then for "managed isolation on the scale needed to minimise the risk of a second and further waves, once lockdown begins to be eased?"

Specifically, he argues that the role of local public health teams needs reasserting, including environmental health officers, "apparently for some reason never involved in the early contact tracing". These teams, he says, are vital to our being able to exit lockdown. They need very active and urgent rebuilding.

By coincidence, one assumes, in yesterday's hearing of Jeremy Hunt's health committee, Clive Betts - chair of the communities and local government committee – was co-opted to question Hancock on precisely that issue. And the results were not encouraging.

Betts actually started off with the assumption that local authority environmental health departments were going to have "a major role to play" in contact tracing, "It isn't just going to be about apps", Betts said. "There's going to be a lot of physical hands-on work that local councils are going to be fully compensated for that".

But Hancock responded with some equivocation, leaving it open as to whether local authorities were to be used at all for contact tracing. Betts, however, asserted that "public health and environmental health officers are going to be absolutely key to getting that done". He thus asked: "It's going to be done at a local level isn't it, if we're going to get it right?"

It is there that the real Hancock emerged: "We haven't made that decision", he said, "not least because the interaction with the e-contact tracing". The app, he said, "is critical and whether it's done locally or whether it's done through phone banks that are national level, that decision is not yet made".

Betts was not at all happy with that. He asked Hancock to accept that, although apps were "clearly an important part of this as a way forward", many people, perhaps those who are most vulnerable – the elderly for example – are not always comfortable using new technology.

For them, Betts said, "physical contact tracking and tracing done at a local level may be in the end the only way you're going to get a comprehensive approach to it".

But, while Hancock conceded that "the role of people in contact tracing" was "very, very important", he thought that much of the work would be "done over the phone". Going round to somebody's house, he said, "isn't always necessary". He could "see the point about having a local angle to it" but given the scale of contact tracing that is likely to be needed, "doing this nationally over the phone has a lot of advantages".

And there we have it. Despite his claim not to have made up his mind, it is clear which way Hancock is moving. He believes that he can exploit mobile phone technology to track people's movements.

The point of the app, Hancock says is that it will "assist individuals to do contact tracing themselves". They can notify people with whom they have been in close contact, when they have downloaded the app. And then "of course", they can link that to testing, so people can get the tests.

This, we gather, is where the call centres come in. The infected persons notifies the centre of their contacts, and they are then contacted and invited to take a test. Presumably, if any of these contacts test positive, they too will be invited to ring in with a list of their contacts.

This assumes, of course, that people have their mobiles with them when they go out and that, knowing they are being tracked, that they will keep their phones on, and will then be prepared to disclose the results to a government-operated call-centre (assuming they can get through).

Gill, in the BMJ, however, questions the "further potential erosion of our civil liberties" through the introduction of this app "without as yet any proper parliamentary scrutiny, let alone public discussion, of its implications".

But that is only the beginning. It doesn't take much to work out the flaws in this system. There are many reasons why people would not want to take part in such an exercise, not least as they may be uncomfortable disclosing such information to the government, consenting to downloading an app which will give government untrammelled access to their every movement.

And then there is the Betts point, that many people, perhaps those who are most vulnerable – the elderly for example – are not always comfortable using new technology.

Hancock concedes that "we need to get the technology right". But, in what is an unproven system, the New Scientist is dubious.

A simulation of a city of one million people found that 80 percent of smartphone users in the UK would need to install a contact-tracing app in order for it to be effective in suppressing an epidemic: that is 56 percent of the national population. It would be a tall order to get that level of cooperation.

Then, because the system relies on Bluetooth low-energy (LE) technology to record when a phone has come into close proximity with anyone else using the app, many false contacts could be recorded. As the signals pass through walls, people behind screens and in different rooms could be unnecessarily flagged as contacts. And, because many apps being considered only record contacts every five minutes, some infectious contacts could be missed.

Having done this job, though, I suspect that even if the technical problems were resolved, the health secretary is still riding for a fall. What might work in Communist China, is unlikely to be accepted here.

People are reluctant to give out personal details at the best of times, and the crucial role of the home visit is to establish a bond of trust, against a personal guarantee of confidentiality. For that reason, the face-to-face interview will often yield details that an impersonal phone call cannot achieve.

One gets the impression from Hancock, though, that he is determined to avoid using local resources, and is intent on pursuing a national solution over which he has direct control.

In its own way, therefore, the issue of contact tracing is showing up the centralising, authoritarian tendencies in this government. Its insistence on micromanaging the epidemic, refusing to engage community resources, has been noted before, but here it is, naked in tooth and claw.

Gill, in the BMJ thinks that government has "a unique window of opportunity to make policy development much more inclusive and comprehensive". Unless this is seized, he warns, the British public's attitudes and behaviour, not to mention mental health, are likely to change for the worse.

But there is no sign of this in Hancock's approach to managing the epidemic. We are seeing a continuation of the "top down" trend which has characterised this government, and a death of localism.

This may well trigger serious resistance until this epidemic can be resolved and, since the course embarked by Hancock is unlikely to meet with success, he may be replicating the Market Garden disaster, this time with an app too far.






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