Coronavirus: thick as mince

31/05/2020

The one thing for which we can thank Dominic Cummings is his popularising the phrase "thick as mince". Even though it's had currency since 2006, few had heard of it before he so spectacularly applied it to David Davis in 2017.

Giving it an airing again, it is particularly apt to apply it to the witless hacks of The Sunday Telegraph who today really excel themselves in their pursuit of "secret squirrel" reporting, thereby completely missing the point.

In the breathless style so typical of the legacy media, their (online) headline declares: "Revealed", as the hacks, Laura Donnelly, the health editor, and Tom Morgan, then tell us that: "test and trace was abandoned because system 'could only cope with five coronavirus cases a week'". This has been translated into a suitably lurid headline for the front page of the print edition.

Here, they are relying on the newly-released Sage papers as their source, and in particular the minutes of the meeting on 18 February where it is "revealed" that Public Health England (PHE) "can cope with five new cases a week", which will require the isolation of 800 contacts.

This Donnelly and Morgan wrongly interpret as the reason why Britain’s disastrous decision to abandon testing for coronavirus occurred, asserting that because PHE's Covid systems "were struggling so badly", routine testing and tracing of contacts was stopped.

Had the pair understood what they were reading in the next few lines, they might have come to a different conclusion. There, we see that Sage agreed that there was a need to feed into trigger points for decisions "on when the current monitoring and contact tracing approach is no longer working", with the committee noting that, "when there is sustained transmission in the UK, contact tracing will no longer be useful".

It was thus expected that, at the following meeting, PHE would present a paper proposing trigger points "for when the current approach to monitoring and contact tracing should be reviewed, revised or stopped".

For anyone familiar with the 2011 Flu Pandemic Strategy, which was being followed at the time, this "trigger point" concept is used to signal when the first two phases of the pandemic response are to be concluded.

These are the "detection" and "assessment" phases, where PHE take the lead, collecting and analysing detailed clinical and epidemiological information on early cases. But, as set out in the plan, once evidence of sustained community transmission of the virus is detected, i.e. cases not linked to any known or previously identified cases, these two phases are ended.

The plan then moves on to the "treatment" and "escalation" phases, where the management authority is handed to the NHS. The PHE local contact tracing teams end their community work and revert to providing support services to the NHS.

Thus we see at the next Sage meeting on 20 February, the comment that PHE's proposed triggers for reviewing whether to discontinue contact tracing "are sensible", with the comment that, "any decision to discontinue contact tracing will generate a public reaction – which requires consideration with input from behavioural scientists".

The "any decision" phrasing is somewhat weasel wording, because the decision trigger point has already been decided. The previous Sage meeting had said that "when there is sustained transmission in the UK, contact tracing will no longer be useful", at which point it was to be stopped.

On 25 February, therefore, we see Sage agreeing that PHE's surveillance approach provides sufficient sensitivity to detect an outbreak in its early stages, with further agreement that "increasing surveillance coverage beyond the current approach would not significantly improve our understanding of incidence".

Again, this requires an understanding of the 2011 plan, where it has already been decided as a matter of policy that "it will not be possible to halt the spread of a new pandemic influenza virus, and it would be a waste of public health resources and capacity to attempt to do so". The committee members, therefore, are simply watching for the point when surveillance activity (i.e., testing and tracing) is to be discontinued.

This point is identified on 5 March when, under the heading "situation update" it is noted that UK surveillance of intensive care units has identified Covid-19 cases. Not all of these, the committee is told, "have had overseas travel or contacts, suggesting sustained community transmission is underway in the UK".

Although not explicitly stated (because everybody on the committee will understand the implications), this signals that community contact tracing can now be brought to a halt, as the response moves to the next stage. We get the confirmation of this on 13 March, where we see the laconic remark that "community testing is ending today".

In their reporting, Donnelly and Morgan simply haven't understood this sequence and the reasons for it. Presumably in an attempt to stoke up indignation, they then report that Jenny Harries, deputy chief medical officer for England, later claimed abandoning testing was a policy choice because "there comes a point in a pandemic where that is not an appropriate intervention".

The Government's consistent position at the time, the pair write, "was that they were following scientific advice" – which is precisely the case, as the 2011 plan represents the cumulative scientific wisdom, distilled into one document. The pity was, of course, that it was directed at the wrong disease.

Nevertheless, Donnelly and Morgan have their narrative. Citing former health secretary Jeremy Hunt, who has said the decision to abandon testing and tracing will rank as one of the "biggest failures of scientific advice to ministers in our lifetimes", they move on to explore the PHE capacity issues.

Had they read the current edition of the New Statesman and this in the BMJ, they might have learnt that cutting back on the public health system was a matter of deliberate policy.

But what they don't even begin to understand is that the contraction of the system was considered acceptable because, in the pandemic planning, it was never anticipated that extensive contact testing would be required.

This is a chicken and egg situation. PHE didn't have the capacity to carry out extensive contact tracing and testing (for control purposes), because there was no intention to control the pandemic, when the infection arrived in the UK. Thus, testing and contact tracing wasn't stopped because of lack of capacity. There was a lack of capacity because it was always expected that testing and contact tracing would be stopped.

Where the errors come, therefore, are at the planning stage, in not preparing a contingency plan for a SARS-like disease and then, as this pandemic took hold in the UK, the response wasn't flexible enough (or quick enough) to realise that the flu plan was no longer viable.

It is true though that, had the scientists and assembled "experts" at Sage realised the game was up, there was nothing immediately that could have been done, because of capacity issues. But, at least, they could have sounded the alarm, and got an expansion programme underway.

As it is, it was some weeks before a decision was made to reinstate the test and trace operation, on a flawed basis that has little chance of working effectively. But that is another story.

Given that the media seems to be incapable of understanding the failures at the initial stages of the response, we do not need to hold our breath in the expectation that they will be able to follow the developments. We seem to be suffering the perfect storm of an incompetent government scrutinised by an incompetent media, obsessed with "secret squirrel" reporting.

Also published on Turbulent Times.