Coronavirus - how has the UK done? (Part 1)

          If you are a conservative politician, particularly PM or a cabinet member, then today must feel like a victory. Finally, managed to hit a target in relation to Coronavirus. One set only a month ago. Surely this shows that this government means what it says and now Boris Johnson PM is back in charge everything will turn out alright? As a voter who wanted them in power, who thinks that a Labour government would have been far worse, this must feel like vindication.

          Well, if you believe that, then I have a genuine Picasso to sell you, guvnor. Honest. Boner Fidey it is. What we have seen during this crisis is some masterful propaganda. Genuinely a masterclass in managing the public perception. Because, based on what information we have at the moment, we have fared worse than almost any other country in terms of our response to the challenges of Coronavirus. This is not just based on opinion or preference or political leanings. We, as a country and as a society, have lost far more people, suffered more death than we ever should have done according to the latest death tolls.

          That may seem like a bold statement, but it is based on the available statistics. Ultimately if we are going to compare countries, then this needs to be based on the outcomes – how fatal or damaging this virus has been. That is a really difficult thing to measure, but the consensus appears to be to use fatalities from Coronavirus (whilst we wait for the data to be considered in more detail over a longer period). The obvious comparisons against the UK are other European states. Proximity, similar socialist outlooks (i.e. healthcare, schools, sick pay etc.), access to world travel, genetically, social / ethnic mix, etc.It is worth saying up front - the data is not complete yet. Nor is it all directly comparable. In fact no two countries are the same in their demography or how they collect and report statistics. In time, there will be long statistical and research studies performed that will produce that information. But by then it will be ignored. The only limited defence that I can use is this - if we compare against 4 other countries that the OECD (and others) regularly compare us against as being similar, this should mitigate some bias. The changes of all 4 being incorrectly reported IN THE SAME DIRECTION are vanishingly small. 

          What do the available statistics tell us? Well in the UK in the first 5 weeks of Coronavirus impacting us (i.e. since we started recording 10+ deaths per day) there have been 26,097 reported deaths. From a population of 68 million. That means we have seen 0.38 fatalities from Coronavirus per 1,000 population. In Italy, over the equivalent first 5 weeks, that was 15,887 deaths against 60m (gives 0.26 per 1,000 population). In fact, if we look at number of deaths for similar size European countries, they are easily to tabulate. Simply put, we have seen a greater number of deaths than any country in Europe on that basis.

Country	Deaths per 1,000 population in first 5 weeks
UK	0.38
Spain	0.37
France	0.29
Italy	0.26
Germany	0.05

Based on information collated by Statista.com

         
          So, we can’t argue otherwise – we have the worst outcomes in the early stages of any comparable European country. Yes, statistics are tricky, and there may be under-reporting or other issues. But there is no reason to believe that these issues would unfairly treat us compared to 4 other countries all with the same challenges. Why? Why have we done so badly compared to other countries? Particularly given when we have, according to international comparisons one of the best healthcare systems in the world?

          There are lots of news articles calling out specific activities that did or didn’t happen that, frankly, I am going to dismiss. Whether your feeling is that Dominic Cummings should not have sat in on meetings of the Scientific Advisory Group for Emergencies (SAGE), or that Boris Johnson should have been present for the 5 Cobra meetings that he missed, whilst these may show the method of operation of this government, they really can’t account for the difference in death rates. In fact, many people would argue keeping Boris Johnson away from making decisions is probably helpful rather than a detriment. I instead think we should be focussing on 4 key areas that do seem to have made a difference to the success of different countries in reducing the death toll. They are:

• 1.    Speed and scope of social distancing measures;

• 2.    Ability to increase capacity of health services;

• 3.    Provision of Personal Protective Equipment (PPE); and

• 4   Testing for Coronavirus.

I don’t want to spend time going in to why each of these is important in the fight. After all, since the start of this crisis the people who were previously constitutional experts on Facebook have re-trained as virologists it turns out. But the world over these 4 tools or levers (along with track and trace as a fifth in some countries) have been the available actions open to governments to use. I am going to consider the first two in this blog (part 1), and then look at the second two and the media management in part 2.

Speed and scope of social distancing measures

In the UK, by the 5^th March we had breached the figure of 100 confirmed Coronavirus cases (it was 114 on that day). It seems a reasonable starting point for comparisons to be taken against other countries. To put some context around it, by then we had seen Italy (which reached that milestone on the 23^rd February) in clear trouble with an explosion in number of cases that was already threatening to overwhelm their health service – by the 5^th March this had turned in to 4,000 confirmed cases. By the 10^th March, this had turned in to 10,000 confirmed cases in Italy (along with 631 deaths). Our government knew that this was a problem, and one that required urgent action.

It is both surprising and appalling then that we did not initiate the social distancing measures we now see until the 23^rd March. That is 18 days when the government failed to take action to implement social distancing that had been seen to work in other countries and that scientists were saying was our best action at that point in time. 18 days. In that time period alone over 3,000 more people had been CONFIRMED as having been infected in the UK – when the rate of infection was doubling every 2 days. 359 people died from it in that period. Quite simply our government acted too late.

There has been lots of speculation and accusation as to why that is. Certainly, interviews given in the early to middle part of March by ministers and officials suggest that at that point the government was working to a “herd immunity” strategy. This changed very suddenly around March 18^th – when this was dismissed by (amongst others) Matt Hancock MP – the Secretary of State for Health. But why the sudden (apparent) change? Because the whole concept of herd immunity was rubbished by the science. It wasn’t something you could aim for; it was something that might be a side effect of not acting enough and letting lots of people die. But this wasn’t new scientific thinking – this was always the case. 

A fair challenge then, is why are there no members of SAGE coming out to say that the government ignored their advice? Every government minister who has given press conferences or updates, from the very outset, has stuck to the line - "we are being led by the science" or "we are following the advice of the scientists". Surely we should be raging at SAGE for giving such bad advice? 

This ignores a fundamental and very important aspect of scientific advice. Scientists provide answers. What they don't do, in this setting, is ask the questions. It is quite simple really to use the questions to lead your response. If you ask "What is the best way to reduce deaths and keep people safe from Coronavirus?" to a group of scientists you will get one set of answers. If you ask "What is the best route to take to manage Coronavirus whilst protecting the economy?" or "What steps will we be able to implement quickly on Coronavirus without worrying the public?" or many other, well you get very different answers. It is a very clever way of deflecting the blame from yourself as a government. We are being led by the science. What you never add is that the science is being led by you. 

What questions the scientists were being asked to opine on can be guessed at. But we don’t know, and right at this moment that isn’t important. What does matter is that because Boris Johnson’s government left it so long more people have been infected, and more people have died.

Ability to increase capacity of health services

One of the most worrying things for anyone following the news during the early days of this crisis was watching the health services of European countries struggle and collapse under the pressure. Countries worst hit by this phenomenon were Italy, Spain, and Portugal. There are a number of connecting themes for these countries – that are shared with the UK. The specifics of the Coronavirus mean that to reduce death tolls (amongst patients) requires 3 things – ventilators (along with the specialist spaces in hospitals); doctors; and nurses to run those beds. It is really that simple. Because we don’t yet have a really effective treatment regime or a vaccine the only thing that health services can do is treat the symptoms. Beds, doctors and nurses.

The common thread that runs through those 3 countries is that they were all hit hard during the last financial crisis, and that they all suffered from long, drawn out austerity plans that reduced the capacity and capability of their health services. They are 3 of the 5 “PIIGS” economies that were most impacted (the other 2 were Ireland and Greece) and faced the deepest cuts. Quite simply government spending on healthcare had been slashed in those countries in the run up to the current crisis. In fact, spending had fallen in Portugal and Spain and kept flat in Italy.

Why then didn’t we see the NHS facing the same catastrophe? This is a mixture of a number of factors, some historic and some based on government actions. The NHS has seen – over the years of Tory austerity – a marked reduction in growth of spending on it. The statistics and budgets make it very clear that since 2009 the NHS has not had the same level of government support it had previously enjoyed. This is not a point that can be argued. Certainly, we now spend more than we previously have, and this rises every year. But it is not rising in line with the historic trend. Our government is constantly tightening what is spent on health services.

Thankfully, historically we have invested in health services more than other countries. This has meant that because of a higher starting point even though we have faced similar or greater cuts due to austerity our health service is still amongst the best in the world. And you get it for free – at the time of writing this. We haven’t yet been dragged down to the level of care that the government appears to be heading towards over the last 11 years. 

Additionally, one thing that the NHS did very quickly that other countries hadn't gotten right was to immediately limit the scope of all other services provided. In particular "elective" procedures. To give an example of an elective procedure, these include knee and hip replacements, removal of cataracts or fitting of leg-braces. I am not a clinician, and these decisions must be led by what is needed. What can be mentioned is that this decision has one other helpful effect. The government hasn't met it's target for elective procedures for the last 8 years (having previously met it or been close since the introduction). At least this time next year they have a reasonable explanation for it. Is it too much to expect that this will be the end of that measure?

In addition, the government was able to, at very short notice, set up additional centres to help deal with any overspill by utilising NHS and military (along with civilian contractor) resources. The speed at which these were made ready and operational is a testament to the excellence of our armed forces and the NHS. Thankfully the planning for this sort of threat had been done well in advance. In 2016 there was a 3-day exercise on how the UK would cope with a flu pandemic. The findings from that exercise were stark. And unfortunately, many were not listened to. We have known for a number of years that we needed a stockpile of ventilators and PPE. But the government never spent the money to acquire them.

We did have the plans drawn up to increase the number of available beds. In fact, these plans were immediately put in place. The army and NHS managed to set up the Nightingale centre in an unbelievable amount of time due to their hard work. It has so far treated 51 patients in it’s 4000 beds. It wasn’t needed in the end, because the NHS in London worked brilliantly to manage the surge in numbers. Time may yet tell, and this may be a prescient decision. We may face a second surge in cases. Or we may face a double crisis when the flu season starts if we haven’t gotten a vaccine. As a much wiser man than I said “I would rather be looking at it, than looking for it”.

In addition, it made excellent news when it was opened, and really, isn’t that all that matters? Again, what was needed, much more than the beds themselves, was a good media story to placate the media. When this is over, hopefully there will be an enquiry – one aim should be to understand how the NHS pulled off the seemingly impossible, and another should be to work out why the hell we didn’t implement the learnings of our disaster planning exercise.

That doesn’t finish this blog – in fact this is only halfway. In part 2 I want to cover PPE, testing and media management. Because it seems that a lot more time has been spent considering media management than any other aspect.