It is with bewilderment and concern we watch as COVID-19 overwhelms the UK’s health and social systems. There are lessons to be learnt for Australia, too.
We learnt about public health and clinical medicine from British textbooks, and some of us worked in NHS hospitals and general practice and saw the NHS and primary health care as models for other countries.
In its report of 12 May, The Independent Scientific Advisory Group for Emergencies (SAGE) shares this concern, but not the bewilderment. SAGE was convened by the former UK Government Chief Scientific Advisor Sir David King and its membership included leading experts in public health, epidemiology, primary care, virology, mathematical modelling, and social and health policy. In its analysis – COVID-19: What are the options for the UK? – there are lessons for the UK and some for Australia.
The SAGE report anticipates a second wave of the pandemic to hit communities and vulnerable populations – care homes, prisons, health and care workers, lower socio-economic workers, overcrowded living environments and poor communities.
And the report acknowledges the important role of the WHO and relies heavily on WHO’s guidance for transitioning from lockdowns and closures to normalcy in giving their advice – decisions driven by public health and epidemiology, maintaining regular health services, effective and sensitive engagement with populations, and, social and economic support.
Re-orienting the health system
The SAGE recommendations aim to upend the UK approach. Top-down, centralised control should give way to local/regional management and the availability of locally relevant data. Where this is already happening – Scotland, Wales and Northern Ireland – the coronavirus has done less damage than in England.
The “top-down” approach, in the committee’s view, has led to fragmentation of public health and health care services with counter-productive separations between them and between primary health care and other local organisations. The integration and integrity of the overall health and social systems have been undermined by policies which have outsourced key operating functions. ‘GPs and primary care workers form the backbone of a future sustainable response.’
The capacity of the public health system was found to be inadequate to the demands of identifying, isolating, testing and treating all the cases and needs greater investment in human and material resources; and the availability of personal protective equipment (PPE) was seriously inadequate.
Most of the focus of the UK response was on the hospital system; the committee recommended the focus needed to be redirected to strengthening and linking the public health services to community health services, primary health care (GPs), local non-government organisations and the community.
While looking forward with the focus on local and regional integrated responses, the continuing political pressure to reduce overall hospital beds should be reviewed in light of the heavy demand placed on them in the management of critically ill patients.
The objective must be to suppress the coronavirus – to control infection – expose underlying causes – and not to focus solely on managing the spread – the plateau – and the hospital load of cases.
The Government’s Chief Scientific Adviser, Sir Patrick Vallance said on 13 March:
“Our aim is to try and reduce the peak, broaden the peak, not suppress it completely; also, because the vast majority of people get a mild illness, to build up some kind of herd immunity so more people are immune to this disease and we reduce the transmission, at the same time we protect those who are most vulnerable to it. Those are the key things we need to do”
The SAGE committee examined the data that should inform decision-making and management. It said,
“The data presented at daily press briefings are compelling but may not be useful indicators of the underlying causes of the pandemic—and might come to be regarded as politicised metrics of government performance. The data, in and of themselves, are useless: it is the underlying latent causes of the epidemiology that matter.”
The utility, timeliness and validity of data are crucial to informed decisions in a rapidly changing epidemic environment. Furthermore, traditional epidemiological models for monitoring should be supplemented by strategies such as dynamic causal modelling with real-time estimates of the actual infection and reproduction rates to enable rapid responses to local outbreaks. In the view of the SAGE committee, current reports of deaths and death rates are not a good indicator of actual mortality from the pandemic, and it recommended weekly estimates of mortality – over and above that normally expected, adjusted for age and seasonally – as better estimates of deaths due to COVID-19. (This approach is evident now in some of the formal COVID-19 news updates.)
Trust and community relationships
The SAGE committee was highly critical of the confused and vague messaging from Government, such as PM Johnson’s slogan to “Stay alert!”. And their report said a lot about taking the community into its confidence with clear communication and integrity.
The report said:
“Trust is too often undervalued. It is not encouraged by giving contracts to unproven commercial entities with uncertain reputations in the public eye. The least the government can do is to provide clarity on all the functions needed to implement a test, trace, and isolate strategy and then overlay it with every organisation necessary to make it happen, with clear lines of communication, performance management and accountability. If this does not include a strong role for local government and, especially, its public and environmental health departments, it will fail. “
The UK failures with COVID-19 which led to the SAGE expert committee’s recommendations, must not be sheeted home to Public Health England, the NHS, primary health care, or the people who staff these organisations or the many other front-line and caring organisations. It is the attrition, fragmentation and isolation of these organisations by relentless sallies from successive governments to corporatise and privatise key functions in these and related institutions.
Some lessons for Australia
· Be prepared to respond to a second wave and future community outbreaks, especially in high risk environments and populations.
· Aim to control the infection rate and suppress the coronavirus.
· Prepare for planned and early involvement of primary health care, community services and NGOs.
· Use real-time data modelling with the capability of focussing on regional and local populations.
· Prepare and rehearse national responses to future pandemics and other national emergencies.
· Above all, develop trust through the integrity, transparency and authenticity of political and public health policy and operations.
From the perspective of Australia, with our early responses and achievements to date, the response to the pandemic in United Kingdom was lackadaisical, almost Trumpian, and lacked a sense of urgency. We can only hope for a renewed commitment to the inherent value of the public health and social institutions in that country and our own as the uncertain future unfolds.