The Independent Scientific Advisory Group for Emergencies (SAGE) – Covid-19: what are the options for the UK?
This report, which we have the “Executive Summary” of below (Report published in full here), gives a really good overview of current scientific thinking on how the UK might continue and win the fight against COVID-19. It doesn’t hold back from identifying where it disagrees with or questions Government policy, but remains balanced and realistic about how we might win this vital battle. The report “Summary” below is probably detailed enough for most people, but the full report gives far more detail, should you want it.
The report focuses on the priorities for measures to support a gradual release from social distancing measures through a sustainable public health response to Covid-19. It draws on the policy considerations proposed by the World Health Organization and makes recommendations to the government on ways to suppress the virus until the delivery of an effective vaccine.
On 4 May 2020 a 13-strong committee convened by former UK government Chief Scientific Adviser Sir David King discussed some aspects of the science behind the UK strategy in a two and a half hour meeting. Leading experts in public health, epidemiology, primary care, virology, mathematical modelling, and social and health policy, raised ideas and issues for consideration which we are pleased to share. We recognise the enormous efforts of many in the development of new vaccines and therapies, which may be critical to long term control of this pandemic. Our report does not aim to critique such work. Rather, we recognise that such solutions will take time and will still require an appropriate public health infrastructure to maximise their benefit. This is the focus of our first report and the meeting aimed to offer some constructive ideas to the governments of the UK and the devolved nations about how best to tackle this crisis, to save lives, suppress the coronavirus and get the economy moving again.
Our Independent SAGE report focuses on the priorities for measures to be taken to support a gradual release from social distancing measures through a sustainable public health response to COVID-19. This will be essential in suppressing the virus until the delivery of an effective vaccine with universal uptake. We do not address, except as it is directly relevant, the clear structural and procedural weaknesses that contributed to the current situation as we expect these to be addressed in a future inquiry. We draw extensively on the policy considerations proposed by the World Health Organization, which provide a clear structure on which an effective policy should be based given the inevitability that the virus will continue to cross borders. Our main recommendations are:
1. The government should take all necessary measures to control the virus through suppression and not simply managing its spread. Evidence must show that COVID-19 transmission is controlled before measures are relaxed. We detect ambivalence in the government’s strategic response, with some advisers promoting the idea of simply ‘flattening the curve’ or ensuring the NHS is not overwhelmed. We find this attitude counter-productive and potentially dangerous. Without suppression, we shall inevitably see a more rapid return of local epidemics resulting in more deaths and potentially further partial or national lockdowns, with the economic costs that will incur.
2. The government should refocus its ambition on ensuring sufficient public health and health system capacities to ensure that we can identify, isolate, test and treat all cases, and to trace and quarantine contacts. Quarantine should be for 14 days and not seven. The government must develop a clear quarantine and messaging policy which takes account of the diversity of experiences of our population, variations in household structures, and with appropriate quarantine facilities in the community. This should be accompanied by real time high quality detailed data about the epidemic in each local authority and ward area.
3. Government ministers, NHS bodies and their officials should adhere to the Code of Practice for Statistics and the UK Statistics Authority should reports breaches of the code. There is concern about inaccurate, incomplete and selective data presented by government officials at the daily PM press briefings. We recommend the involvement of statisticians responsible for analyses, and the Office for Statistics Regulation should publish further assessments of these data. The UK Statistics Authority, an independent body responsible for oversight of the statistics produced by the Office for National Statistics and other government departments and public bodies has a Code of Practice.
The Code requires
i) trustworthiness: confidence in the people and organisations that produce statistics and data,
ii) quality: data and methods that produce assured statistics and
iii) value: statistics that support society’s needs for information. It is vital the public has trust in the integrity and independence of statistics and that those data are accurate, timely and meaningful.
4. The government evaluates alternatives to complement conventional epidemiological modelling, such as dynamic causal modelling—e.g., via the expertise established by the RAMP initiative. Dynamic causal modelling (DCM) enables real-time assimilation of data quickly and efficiently to estimate the current levels of infection and ensuing reproduction rates (R). The computational efficiency of DCM may allow pressing questions to be answered; for example, would a devolved social distancing and surveillance policy—based on local prevalence estimates—be more efficacious than a centralised approach? In short, there is a pressing need to evaluate alternative approaches (and hypotheses) that may support real-time policy-making.
5. Recognising the centrality of human behaviour in virus transmission, the government should ensure that as social distance measures are eased, measures are taken to enable population-wide habit development for hand and surface disinfection, using and disposing of tissues for coughs and sneezes and not touching the T-zone (eyes, nose and mouth).
6. Outbreak risks must be minimised in high vulnerability and institutional settings. No-one should be discharged from hospital to another high-risk setting such as a care home without having been tested and found to be non-infectious. The government should rapidly invest in the elimination of transmission in the currently recognised “high risk” settings, including but not limited to social care and health service facilities, prisons and migrant detention facilities, homes with multiple occupancy, and households that are overcrowded or contain multiple generations. This includes staffing, testing, protective equipment and guidance for effective household isolation. Community facilities and requisitioned hotels are likely to be needed to house a significant proportion of infected people and their contacts.
7. Ensure preventive measures are established in workplaces, with physical distancing and support to enable personal protective behaviours. Health and safety regulations appropriate for COVID -19 suppression and adequate surveillance should be agreed with trade unions and other staff representatives, with sanctions that are large enough to deter unsafe practices. There should also be a facility for workers to report unsafe working conditions, with no victimisation for those using it.
8. There must be reform of the process of procurement of goods and services to ensure responsive and timely supply for primary and secondary care, and community infection control, in anticipation of a second wave of infection. This reform must take account of the documented challenges and failures of procurement over the last three months.
9. Managing the risk of importing cases from other countries, with consequent high-risk of transmission, is vital. This should be introduced as soon as possible, treating Great Britain and the island of Ireland as distinct health territories. We welcome the government’s recent commitment to establish a port control and quarantine strategy as an adjunct to other control measures. Managing the testing, thermal assessment, collection of contact details and quarantine facilities, such as requisitioned hotels, will be essential to stop imported cases.
10. Communities and civil society organisations should have a voice, be informed, engaged and participatory in the exit from lockdown. This pandemic starts and ends within communities. Full participation and engagement of those communities on issues such as childcare and public transport will assist with enabling control measures. Conversely, a top-down approach risks losing their support and trust. We are deeply concerned about the effects of the infection and the lockdown on BAME, marginalised, and low-income groups. There is an urgent need for government to demonstrate such active participation from communities from around the country.
11. The government should take steps to ensure all children, irrespective of their backgrounds, have access to technology and internet at home, and where required additional learning support which does not rely on parents at home. The government should also ensure that resources are available for schools to conduct remote learning. The closure of schools due to the COVID-19 pandemic has caused unprecedented challenges for everyone involved – students, teachers and parents- but we are particularly concerned about the detrimental impact (and widening of educational inequalities) of long-term social distancing measures on learning for children from lower socioeconomic backgrounds. Education is a human right which should not be compromised in the context of COVID-19.
12. The government must ensure that health and social care services are planned, strengthened, and prepared for future waves of infection while continuing to provide the full range of services to all. For health services, this will require planning to ensure there are capacity and resources to meet need safely and to resume elective services including hospital, mental health and community health services. For social care this will require having accurate data on all staff and needs of residents; making good the serious shortages in staffing, increasing qualified staffing levels, and ensuring all staff terms and conditions of services include full sickness benefits when they fall ill.
13. The government should rapidly strengthen the social safety net, including addressing low income benefits and housing, thereby ensuring protection of the most vulnerable in our population. It is now clear that COVID-19 has disproportionately affected older people, low income groups living in deprived areas, BAME communities, and those who are otherwise marginalised. We also note the over-representation of BAME communities as low paid care workers in health and social care settings which makes them vulnerable to COVD-19-related infection and deaths.
14. The management of often multi-organ COVID-19 disease has been based in hospital and ICU settings. Hospitals have had to radically alter non-COVID patient flows in order to deal with these pressures, and Nightingale facilities have also needed to be developed. There is clear evidence of increasing non-COVID mortality in association with the pandemic. The government should work with the Royal Colleges and professional societies to ensure that capacity and treatment guidance is updated and disseminated as evidence emerges.
15. There should be a re-evaluation of current plans to reduce overall hospital beds in the NHS per head of population and consider ICU bed and staffing requirements to provide future surge capacity. We also recommend a rapid engagement with primary care and community health settings to support those recovering from COVID-19 disease, and the sequelae, including mental health problems, as well as support to rapidly identify and manage future local outbreaks.
16. The government should urgently review and improve co-ordination in the response to the pandemic across the multiple bodies tasked with pandemic planning, both within England, including different government departments, the NHS, PHE, and local authorities, and others, among the Westminster and devolved administrations.</div>
17. In order to underpin our recommendations, the future long-term management of the pandemic should be based on an integrated and sustainable public health infrastructure. The government has adopted a top-down approach with vertical structures for test and trace programmes. The overdependence on outsourcing of key operational functions limits the sustainability of this approach. A more appropriate infection control response will require adaptation for local needs. Leadership from local public health and primary care professionals is essential. We do not specify which organisations should be responsible for these roles and functions as this will vary in the four nations of the United Kingdom but, in each of them, there should be a clear system map setting out responsibilities, accountability, and lines of communication.
18. In the longer term we recommend that legislation to enable an integrated National Health and Social Care System for England is considered, along the lines of the NHS in Scotland and Wales and the integrated NHS and social care system of Northern Ireland.
19. The Independent SAGE will continue to meet to consider some of these specific recommendations and to offer constructive solutions to government to ensure that the coronavirus is suppressed, that lives are saved and that the economy is able to recover as rapidly as possible.