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23 May 2020

Who or what is essential?

Tag(s): Politics & Economics, Current Affairs, Leadership & Management
The coronavirus is undoubtedly a major crisis and all nations are struggling to find the right balance between protecting their citizens’ health and indeed lives while also protecting their way of life. However, the British government seems to have got this very wrong with one of the highest rates of death combined with possibly one of the deepest recessions. On the latter point I recognise that technically we will not have been in recession until the end of the second quarter but it is crystal clear that the second quarter will see the biggest fall in one quarter since records began. Whole sectors of the economy are all but closed; public transport is down by over 80%; and JCB, a world-class family owned business, is forecasting that its sales this year will be barely 50% of those in 2019.  But in all this chaos there seems to be a tremendous lack of logic in applying the test as to what is essential.

Take the dental profession. Most dental practices are a mixture of NHS and private practice. Some are exclusively private and they are under instructions to keep closed while getting no public funding support. They still have to pay rates and rent. They might be next to a bookmaker who might be getting some public funding. So it would seem that the dental profession is an unnecessary luxury while the betting business is judged as more important.

This will have grave consequences including deaths because dentists are expert at diagnosing mouth cancers and every six weeks or so about 1,000 cases of cancer are diagnosed in this way. Dental surgeries have very high standards of hygiene and dentists and other staff routinely wear masks and gloves. If this continues for much longer many of these practices will go bust with devastating consequences not only for the workers but also for the oral hygiene of British citizens. This does not just mean ugly molars and bad breath - gum disease, if not treated, can lead to other serious health conditions.

Similar arguments apply to physiotherapists. These people pay a vital role in restoring physical well-being after people have had accidents or strains but particularly after reconstructive or replacement surgery. As many such operations have been mistakenly postponed when these operations eventually do take place the convalescents may find that there are no physiotherapists to be found as many will have shut up shop.

The government has found that by delaying the lockdown and dithering over strategy for some weeks it will be very much harder to open up. The messages seem clear and simple but on analysis they are found to be confusing. How is it that I am now allowed to have a cleaner or decorator come to my house to work but not a relative or friend to have a glass of wine in our garden keeping easily 2 metres apart? People all over the country are asking questions like this.

The government constantly defend themselves by saying all their decisions are based on “the science.” But this is not the case. I don’t think anyone in the cabinet is a scientist and I don’t think they know what science is.[i] Science starts with hypothesis. Then there is experimentation to test the hypothesis. There is a clear scientific method which is followed. Once the results are in the scientist and his colleagues would publish their findings and invite peer review to allow critical appraisal and therefore the elimination of error. The Scientific Advisory Group for Emergencies (Sage) has apparently produced over 120 reports but only published a quarter of them and I am not sure how many of those have been peer reviewed. “The science” is therefore not science.

We are told that the lockdown was decided upon after an Imperial College report suggested that if it was not conducted there would be 250,000 deaths. But this same source had made similar dark forecasts in the past and often been proved hopelessly wrong. Indeed their methodology has been seriously criticised. Sweden, under this scenario, would have had about 60,000 deaths. But following a much more permissive strategy it has only had fewer than 4,000 reported deaths.

Then again the number of deaths from the disease is difficult to compare by country. Belgium has the highest rate per head of population but apparently they count in a different way. While the UK counts only those who have died after a positive test Belgium includes suspected deaths. The only true way to see what has happened is to consider the number of extra deaths compared with an average period of time. By this count the UK has had about 60,000 extra deaths so far in 2020. This will include both those who have died of the COVID-19 disease while not having been tested and those who have died from some other cause that was not dealt with because the NHS has been prioritising coronavirus cases and so delaying other important operations. There may also be people who though feeling ill have stayed away from GPs and hospitals because of the relentless message to stay at home. So they stayed at home and didn’t get treatment for a stroke or heart attack and so died.

On 5th March in a blog called “Wash Your Hands” I warned of this problem saying:

“The NHS is overstretched as we all know. I have demonstrated on these pages several times that it always will be by definition. If you design a service to be free at the point of use then since you cannot control demand you can only limit supply by rationing which means waiting lists and queues.  So by heaping a whole load of extra pressure on the NHS other regular patients will suffer. Operations will be delayed. Queues will get longer. And the media and the opposition will complain about that even though they created the problem.”

On 28th March in a blog called “What Will Happen?” I touched on the key worker problem.  I said:

“I was disappointed that the government didn’t class farmers and their employees as key workers. If it is recognised that we must be allowed to leave our homes to buy food and therefore food retailers must stay open, surely the same applies to food producers, both farmers and processors. One muppet close to the government recently suggested that we didn’t need our farmers at all. I would think we should prioritise reducing imports of food to below 20%.”

Even Prince Charles is now calling for a new Land Army[ii]. On 11th April in a blog called “Intensive care” I touched on the problem of counting deaths:

“Every day journalists solemnly read out the number of new cases and the number of deaths and report them as if they are facts. But they are only the number of reported cases and the number of deaths where the death certificate states that the cause of death was Covid-19 and only those that occurred in hospital. They exclude deaths in care homes or at home. Noone can possibly know how many have already had the disease without knowing and recovered from it. That is because there is as yet no test anywhere in the world that can verify this. Similarly, a doctor may diagnose the cause of death as Covid-19 when in fact it may have been some pre-existing condition that became aggravated by the new infection.”
And on the 25th April in a blog entitled “Metabolic Syndrome” I reported how badly the UK compared with other European countries in preparedness:
The … analysis has been updated to include “Covid-19 safety ranking”. This attempts to assess how fast different healthcare systems can mobilise additional resources, and how efficient they are at testing and diagnosis, etc. Germany, Switzerland and Austria top the European ranking, all of which have systems of multiple health insurers, and competing healthcare providers. The UK is ranked No 30 below Romania and Bulgaria.  There is one ranking where the UK is listed in the top 3: the “Covid-19 risk ranking”.

I have never served in political office and can only imagine what the pressures must be like.  But I have served on many boards.   On all of these we would hold a regular, usually annual, review of risks. We would assess these by probability and then by impact. In other words we would ask how likely was an event to occur, and then, if it did, what would be its likely effect. Then we would discuss how we might mitigate those risks which were both likely to occur and would have a severe rather than a marginal impact. In this case a pandemic was likely to occur. This is the fourth this century after SARS, bird flu and swine flu. Bill Gates warned of it in a TED talk over five years ago. One cannot know when it will happen but we could be certain that it was just a matter of time.

Its impact was likely to be severe but clearly would be much more severe if we were not well-prepared to deal with it. And being well-prepared did not just mean having front line staff in hospitals and care homes properly resourced and trained. It also meant preparing for the question I have asked in this blog. Who and what is essential. The civil service should have had all of that worked out in documents to be reviewed on a routine and regular basis.

[i] There are only 26 MPs with a degree in science.  Margaret Thatcher would often say that she was surprised when she was introduced as Britain’s first female Prime Minister. She thought it more interesting that she was Britain’s first Prime Minister who was a trained scientist.
[ii] My mother used to pick potatoes during the War.

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