From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

England’s Response to the Coronavirus Pandemic – the August update (2020)

Michael Calnan

 Policies over the last three months have predominantly focused on easing the stringent restrictions which were put in place in March 2020.These policies or the’ road map’, have been in the main tied, although not always, to the five tests for the easing of the restrictions which were set out previously and were to be linked to the Covid-19 system of alert levels which was downgraded from 4 to 3 on June 19^th.  There have been a number of policies introduced gradually over this period but perhaps the most significant were the reduction in the social distancing rule from 2 to I metre plus; the introduction, relaxation and then tightening of quarantine laws for travellers from selected countries to this country; the compulsory wearing of face coverings on public transport, in hospitals and in shops; the re-opening of non -essential shops and the hospitality sector and some parts of the sports/entertainment industry; the permission for two households of any size to meet indoors and outside; and for the vulnerable no longer needing to shield. One policy, which has been the focus of a continuing debate, is when to open schools. The plan for all primary school years to go back to school before the end of the summer term proved to be inoperable. Schools will not now fully open until September at the earliest.

Achieving each of the five tests has also proved problematic not least ensuring the supply of tests. There was political rhetoric about the potential of the test and trace system, but the bespoke mobile app was abandoned and there were communication problems between the centralised system being run by an outsourced company and the local public health agencies who have considerable experience in this field. It has been reported that £10bn has been spent on this outsourced system reflecting the governments’ support for a public-private partnership. One of the five tests included the need not to risk a second peak but there has been evidence of second peaks in some local areas such as Leicester and Northern England where restrictive measures have been reintroduced. Poor relationships between national agencies and local public health teams were also claimed to be one reason for the slow response to the outbreak in Leicester as after initially denying access it was agreed to provide local authorities with the data required for test and trace. The government has now given local authorities ‘lightning’ lock down powers. However, at the national level the relaxation of measures has recently been postponed with a rise in infection rates.

Medical scientists have argued for the need to be prepared for a second wave of Covid-19 in the coming winter with further significant loss of life. The government has pledged an extra £3bn to ease winter pressures on the NHS in England. The isolation period for those with symptoms has been increased to ten days. Covid-19 appears also to have been a catalyst for a national, apparently more interventionist, anti-obesity strategy.

The government ceased their daily televised media briefings which now take place when they have significant developments to report with government accountability reverting back to reliance primarily on parliamentary scrutiny.

Assessing the policy response
The government policy response was previously described as one which was characterised as reactive, lacked a coherent and consistent communication strategy and has been tied to medical science. While the first two appear still relevant the link with science appears to be looser in recent policy which is illustrated by the drop in the alert levels coming, in some instances, after the decisions to ease restrictions. The needs of the economy have recently appeared to have taken a higher priority with a strategy for a ‘new deal’ and a plethora of policies aimed at resuscitating the economy. Certainly, the government has made explicit that the role of medical scientists is to provide advice and the government to make political decisions so the level of scientific support for recent government policy for lifting the restrictions is difficult to judge. Survey evidence shows public support for government policy has declined significantly, not least in the light of media criticism about the lack of leadership, U-turns in policy, expanding testing for essential workers and patients, problems implementing the track and trace system, and with the provision of PPE for frontline staff. Public trust was further dented by the controversy about the government’s senior advisor breaking the rules associated with the lockdown.

The government have committed to an independent inquiry into their management of the pandemic but how will it be judged? Probably unfavourably at present in that despite both the reduction in the overall infection rate and in the number of Covid-19 related deaths, England has the highest excess mortality rate in Europe combined with marked social inequalities in the risk of death.

England’s response to the coronavirus pandemic – Update (May 2020)
Michael Calnan

The stringent restrictions associated with the governments suppression of transmission policy were required by law to be reviewed three weeks after their implementation. The cabinet agreed, in the absence of the Prime Minister due to illness from Covid-19, to a further extension for three weeks. The government have set out five tests before easing of the restrictions can take place which are: Making sure the NHS could cope; A “sustained and consistent” fall in the daily death rate; reliable data showing the rate of infection was decreasing to “manageable levels”; ensuring the supply of tests and Personal Protective Equipment (PPE) could meet future demand and being confident any adjustments would not risk a second peak .It is suggested that relaxation of social distancing measures will depend on the reproductive rate (R) being and staying below one. This R rate has informed the  three step conditional plan for gradually easing the restrictions with a non- specific timetable set out in the most recent review, although social distancing rules are still in place. The government changed its public message to “stay alert, control the virus, save lives” from “stay at home’ which is still being used by the other UK devolved governments. A Covid-19 alert system is to be introduced to track the virus, which ranks the threat level on a scale of one-five with England currently at stage four but moving towards stage three. Face coverings have been recommended for use by the public in enclosed places, which is a policy shift.

There has also been a recognition of the need for systematic testing, although abandoned initially. This led the Minister for Health to set a very ‘audacious’ target  that 100,000 tests would be carried out per day, by the end of April’, with the next target being 200,000 a day, by the end of this month. By April 30^th the number of tests reported to have been carried out reached that figure (122,347), although testing levels have continued to vary since then. The government aims to renew community contact tracing alongside a mobile app in mid-May, mobilising 18,000 contact tracers including 3,000 health professionals.

An increasing number of infections and deaths in care homes and in the wider community became apparent and the daily reported statistics on numbers of deaths were revised to accommodate this although these may be still an underestimate. There has been a call for more extensive testing in care homes as social care workers and their clients did not appear to be a priority for testing and for PPE. The government appears to have responded to the latter concern in their published guidelines on the use of PPE (April 10th 2020). The importance of social care provision may now have begun to have some recognition as its workers have been given a distinctive ‘brand’, which is similar to NHS staff.

Finally, there is emerging evidence of social inequalities in the experience of people infected with Covid-19 with BAME groups being more at risk of dying than other ethnic groups (as do people from deprived areas). The government states that they are supporting research to explain these inequalities, which should inform policy.

Assessing the policy response in England 

The government policy response might be described to date as one that was characterised as reactive, which significantly shifted its direction early on, was slower to develop than in other countries, lacks a clear communication strategy particularly about exit plans and has been tied to medical science. This crisis has highlighted the difference between the NHS and Social Care in terms of funding and priorities. The devolved and fragmented nature of social care based mainly in the private sector raises questions about the extent of government’s/local authorities’ financial responsibility for this sector.

The enduring difficulties in supplying adequate PPE to front line staff and deficiencies in testing capacity continues to raise questions about how prepared the NHS was to meet the challenges of this type of pandemic. There are conflicting accounts, but recent reports suggest that the NHS was under prepared – e.g. recommendations for epidemic preparedness from Exercise Cygnus (2016) were not made public or implemented by the government due to a lack of available funding.

Have these policies been successful? The infection transmission rate has declined,  at least in the community, and while the number of deaths from Covid-19 appears to have peaked they are running at the second highest in the world. However, the key evidence to assess success, or relative success compared with other countries, will be excess mortality data which should be available in the longer term. Survey evidence suggests there is still a small majority of the public who have trust in government policy but it is waning with a lack of public approval for its testing policy in particular.

England’s response to the coronavirus pandemic – Original post (April 2020)

Michael Calnan, Professor of Medical Sociology
University of Kent

The government response to Covid-19 in England was originally described in terms of three phases, which were: containment (e.g. contact tracing, education for effective hand washing), delay (which aims to flatten the peak of the outbreak to protect the NHS and provide time for research to develop effective tests, treatments and vaccines) and mitigation (based on the idea of ‘herd immunity’ where the epidemic should be allowed to run its course to allow the population to build up resistance to it. Mitigation would be introduced to limit the number of deaths through protecting the most vulnerable, but the government would not need to totally eradicate the disease). The general approach was, and has continued to be, presented as evidence-based, with the Scientific Advisory Group for Emergencies (SAGE) appearing to actively provide advice. An emphasis was placed on the timing of the introduction of policies to maximise their effectiveness based on the scientific evidence.

Containment was the initial policy but on March 12^th the government announced it was moving from the containment to the delay phase – but this policy would not as be as ‘draconian’ as adopted in other countries. The prime minister (PM) raised his profile and, in the first of the televised daily media briefings/updates, was flanked by two medical / public health and scientific experts. The PM gave the ‘honest’ message that people might lose their loved ones, suggesting it should be taken seriously as it was the ‘worst public health crisis for a generation’.

This stark message was difficult for the public to accept and their response in combination with new scientific evidence appears to have led, a few days later, to a shift in policy. This epidemiological modelling evidence was based on the experience in Italy / ChinaThe policy option recommended in this report was suppression if countries could manage it. This aims to reverse epidemic growth rather mitigation which according to the report would have led to the overwhelming of the health system and the loss of hundreds of thousands of lives. Thus, the government moved from its delay strategy towards a policy of suppression of the transmission, basically advising the public to adopt social distancing and curtail social activities such as use pubs/ restaurants, work from home with individual/ household isolation for 7 or 14 days for those with symptoms, although schools were still to be open. This policy put an emphasis on advising the public rather than instructing them as adopted in other countries and seems to reflect the influence of behavioural/psychological expertise. The government recognised the economic consequences of their policies so there was an emphasis in policy on protecting the health of both the public and the economy. The initial response was in the spring budget, which was followed by a  much stronger package of measures introduced to provide support for businesses, supporting wages of vulnerable staff, addressing workers’ rights and pay during the ‘crisis’, and support for the self-employed. This involved significant public expenditure and intervention in the market economy although it is now in recession.

Over recent weeks the government has taken increasingly stringent measures such as increasing control and limitations over foreign travel, shutdown of schools in England and banning the gatherings of more than two people (excluding people who live together). 27 million households are now to be sent letters highlighting the need to continue social distancing and should only leave the house for: shopping for basic necessities, exercise, any medical need and travelling to work if they cannot work from home. Emergency legal powers have been introduced to enforce these measures, suggesting that the public, or at least some sections of the public, could not be trusted to behave responsibly. The police have been given the power to fine people who are not adhering to these measures. Concern has been expressed about a lack of consistency in the exercise of these powers by the police. There is also the potential threat to civil rights if there is a further extension of such coercive policies, although these powers are required to be renewed every six months.

Policies also focused on trying to free up and repurpose capacity within the hospital acute sector. The NHS has negotiated block contracts with private hospitals who would treat non-urgent NHS patients. The building of temporary hospitals has expanded the number of intensive care beds and recruiting retired clinicians has begun to address the shortfall in staff. Policies aimed at increasing the supply of protective equipment for frontline staff and the availability of ventilators and the expansion of testing of staff and patients/public have proved more problematic to implement.

Assessing the policy response in England

The NHS appears to be as prepared as any other health care system to meet the challenges of the demands of this unexpected pandemic, but in some parts of the service, such as A and E, it has been performing at the limits of its capacity for some time. This raises questions about its resilience when under extreme pressure. The focus in government policy has been on hospital care but the pandemic has major consequences for both primary and social care. The latter will be caring for discharged patients, but the limited service has suffered from chronic underfunding. The policies have also led to a decline in the use of accident and emergency /primary care services which suggests a build -up of untreated physical and mental health problems.

The PM emphasised the salience of public trust for enhancing adherence to government policies. The daily media briefings might be seen as a strategy for building public trust through enhancing transparency about the risks and uncertainties as it displays honesty and integrity. However, it is an approach that might undermine confidence in competence – i.e. through shifts in policy or poor communication giving unclear, confusing and contradictory messages. Collective social action and social trust is also being called for in these policies which involves the public trusting in one another and having some responsibility for the vulnerable and older people – a form of social and altruistic trust. The success of this will depend on societal cohesion which has been illustrated by the recruitment of volunteers (750,000) to help the NHS.

The eventual emphasis on more stringent suppression policy measures appears to be justified by the evidence, but there has been much criticism of the slower response of the government and NHS management to the outbreak and specifically their inability to learn from the experiences of other countries. The lack of early intervention might have reflected the liberal values of a conservative government and their reluctance to intervene and that they were initially thinking of adopting a mitigation strategy, which may have avoided the need for some of the severe social distancing measures now having an impact on the country’s social and economic life and mental health. There is considerable uncertainty about how long these measures need to be in place and can be sustained, if the public will accept recurring social distancing, and what is the most effective strategy. Certainly, the hardest hit, both in the short and longer terms, will be the increasing number of people living in precarious social and economic circumstances.

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