Browse
The UK Government had substantial warning about the new coronavirus and, in broad outline, what they might expect. The first death in China was announced on 11 January 2020, and the first confirmed cases appeared in Italy and the UK at the end of January. The first death occurred in England on 5 March. The World Health Organization (WHO) declared a public health emergency of international concern on 30 January and confirmed the existence of a pandemic on 12 March. By the end of January, it was clear that the virus was being transmitted from person to person, that it had a serious effect on those contracting it, and that there was the potential for it to become a pandemic. Commentators have broadly agreed that the UK Government was nevertheless slow to acknowledge the seriousness of the situation and to respond; the editor-in-chief of the British Medical Journal recorded the verdict of their editorial writers as: ‘Too little, too late, too flawed’ (Godlee, 21 May 2020). However, not all contributions from academics have agreed (for example, Cairney, 020).
The Government considered that it was well prepared for the pandemic. Prime Minister Johnson made this clear after he chaired his first COBRA meeting on 2 March – in fact the fifth that had been held on the new coronavirus – when he said: ‘…let me be absolutely clear that for the overwhelming majority of people who contract the virus, this will be a mild disease from which they will speedily and fully recover … Our country remains extremely well prepared, as it has been since the outbreak began in Wuhan several months ago’ (Johnson, 3 March 2020).
The majority of people in residential and nursing homes for older people are over 80 years old and particularly vulnerable to the ravages of COVID-19. Almost half – 46 per cent – of all excess deaths in England and Wales from the beginning of the pandemic to early August took place in care homes. In addition, the excess death rate for recipients of domiciliary care was similar to that for care home residents (Glynn, 13 July 2020). The UK was not alone in experiencing a high death rate among care home residents: Spain, Belgium, Canada and the US were all hit particularly badly in this regard, together with Sweden, albeit that a higher proportion of over 65s live in care homes there (Grabowski, 2020). Care homes in England recorded a 79 per cent increase in excess deaths from the week ending 13 March to the week ending 26 June (the figure for Wales was 66 per cent, for Scotland 62 per cent and for Northern Ireland 46 per cent). In England, 44 per cent of homes reported at least one case of suspected or confirmed COVID-19; the highest figure for UK countries was 65 per cent for Scotland (Bell et al, 2020). Unsurprisingly, nursing homes registered more cases and more deaths than residential homes. But other factors due to structural changes in provision, such as higher death rates in larger homes, beg additional explanation (as the total number of care homes has fallen, the number of large homes – with 45 beds or more – has increased.
Providing an account of the policy response to COVID-19 in England, this book analyses the political and long-term systemic factors associated with the failures to control the first wave of the pandemic during 2020.
It explores the part played by key policy actors, particularly politicians and scientists, and focuses on two difficult policy issues during the first wave: the establishment of a ‘test, trace and isolate’ system and responses to the high death rate in care homes for older people.
Drawing on a wide range of documentary evidence, including parliamentary papers and SAGE minutes, this book draws attention to the importance of longstanding structural problems in public health and the care sector, especially the impact of outsourcing and privatisation.
The lockdown in late March 2020 rendered the first wave of COVID-19 manageable: the NHS was hugely stretched, but not overwhelmed, and after late April the number of deaths fell. The Government did not have to face the kind of horror experienced in Northern Italy slightly earlier, with pictures from Bergamo of very ill patients in hospital corridors and full morgues. But exercising control over the pandemic has proved elusive in western liberal democracies and England has suffered badly in terms of high numbers of hospitalisations, high morbidity, high death rates and severe economic disruption. This Rapid Response has explored the relationship between politicians and scientists and some of the dilemmas this has entailed. It then highlighted and documented what is so far known about two key areas in the effort to control COVID-19: first, the position of public health and the need to establish an effective test and trace and isolate (TTI) system, historically central to any response by the public health authorities, and second, social care, in the form of care homes for older people, where residents and staff both suffered very high rates of infections and deaths.
While success has been claimed for policies to control the virus, particularly for the TTI system, the claims are difficult to justify. Attributing responsibility for the problems and assessing what should or could have been done is primarily a matter for a future public inquiry.
COVID-19 has proved an altogether more threatening and deadly disease than the new strain of influenza that had been expected at some point and for which plans, if not adequate preparations, had been made. Better understanding of the way in which COVID-19 behaves has rapidly emerged, but many questions have been difficult to answer: for example, why the virus is so highly transmissible, how far being infected will give immunity, and why some individuals are more vulnerable to infection and death. This makes control difficult. But public health structures and expertise are longstanding in the UK and the control of epidemics has long been recognised to come within the purview of government, requiring a coordinated response between central and local government, and between public health and clinical doctors, healthcare managers and government officials.
The pandemic has laid bare socioeconomic fault lines and exposed major divisions in western societies. In the UK, it became clear early on that older people, those on low incomes and black and minority ethnic communities suffered the highest rates of sickness and death, while young people have suffered major disruption to their education and many of those of working age, especially the self-employed, face high levels of unemployment and/or debt.
The interests of different groups as to how the virus should be controlled – by strict rules about individual behaviour or a more laissez-faire approach – have often been perceived to be in conflict by commentators and politicians, many of whom also tend to take a strong position on the vexed issue of freedom versus responsibility.
David Nabarro, a World Health Organization (WHO) Special Envoy responding to COVID-19 and Professor of Global Health at Imperial College, has remarked that when dealing with a lethal and unknown virus the traditional public health methods of test, trace and quarantine/isolate are likely to be the main or only tools available (Nabarro, 4 August 2020, BBC Radio 4 Today interview). Public health practitioners have historically adhered to the ‘precautionary principle’ (Greenhalgh et al, 9 April 2020), which enables the adoption of precautionary measures when scientific evidence is uncertain, and the stakes are high. In the absence of either effective treatment for a disease or the ready means to prevent it, the principle also suggests the need to combine as many methods of control for which there is an evidence-base, even if the beneficial effect is judged to be relatively mild. However, SAGE set a high evidence bar for a positive recommendation (for example, on the wearing of face masks, Meeting 27, Minutes 21 April 2020) before it would make a positive recommendation. Some economists are unconvinced about the precautionary principle, believing that it results in extreme caution and, in the case of COVID-19, lockdowns which are economically damaging and have adverse health impacts of their own (for example, Le Grand, 2 July 2020, BBC Radio 4 World at One interview).
Above all, an effective test, trace and isolate (TTI) system was essential to enable first an understanding of the spread of the virus via testing and, second, control of the virus via tracing the contacts of those testing positive and requiring them also to self-isolate.
