Yesterday’s publication of the minutes of the government’s Scientific Advisory Group for Emergencies (SAGE) raises some interesting questions. An initial summary in yesterday’s Guardian has a timeline suggesting that it was the distinguished medics on SAGE rather than the Prime Minister who went from complacency in January and February to panic in March, and who ignored the risk to care homes until it was too late.
Is this a Machiavellian conspiracy by Dominic Cummings to blame the scientists, or is it business as usual? Having spent a dozen years on the university’s governing body and various of its subcommittees, I can absolutely get how this happened. Once a committee gets going, it can become very reluctant to change its opinion on anything. Committees can become sociopathic, worrying about their status, ducking liability, and finding reasons why problems are either somebody else’s or not practically soluble.
So I spent a couple of hours yesterday reading the minutes, and indeed we see the group worried about its power: on February 13th it wants the messaging to emphasise that official advice is both efficaceous and sufficient, to “reduce the likelihood of the public adopting unnecessary or contradictory behaviours”. Turf is defended: Public Health England (PHE) ruled on February 18th that it can cope with 5 new cases a week (meaning tracing 800 contacts) and hoped this might be increased to 50; they’d already decided the previous week that it wasn’t possible to accelerate diagnostic capacity. So far, so much as one might expect.
The big question, though, is why nobody thought of protecting people in care homes. The answer seems to be that SAGE dismissed the problem early on as “too hard” or “not our problem”. On March 5th they note that social distancing for over-65s could save a lot of lives and would be most effective for those living independently: but it would be “a challenge to implement this measure in communal settings such as care homes”. They appear more concerned that “Many of the proposed measures will be easier to implement for those on higher incomes” and the focus is on getting PHE to draft guidance. (This is the meeting at which Dominic Cummings makes his first appearance, so he cannot dump all the blame on the scientists.)
On March 10th, they decide to cocoon the over-70s and medically vulnerable, and advise 7/14 days isolation for people with symptoms / their families. They advise that “special policy consideration be given to care homes and various types of retirement communities” – but note the passive voice, and this doesn’t appear on the list of actions and trigger points on the following page. It’s still somebody else’s problem.
By March 13th, some care homes had already banned visitors without waiting for government advice to do so, and on the same day SAGE decided that the goal was to enable the NHS to meet demand. Two days later, the NHS started clearing 30,000 beds, sending hundreds of infected patients into care homes and causing thousands of deaths.
The next month is consumed with panic about whether the NHS will be swamped by the peak, and it’s only when this subsides that we read on April 14 that more and more cases are acquired in hospital, which have been masking the decline in the community, with a note “Care homes remain a concern. There are less data available from these” – but only as item 10 on the situation update. At last there’s a relevant action: to widen viral sampling in hospitals and care homes. However the committee’s effort is now tied up with the controversy about whether to advise public mask wearing. (It still resists expert advice on this as it doesn’t want to admit that its initial position was wrong.) The meetings on April 16 and 21 are also consumed by the mask debate (on which the early members of the committee, who blocked mask wearing to protect PPE supplies to the NHS, prevailed over the newer members, leaving the UK an outlier).
On April 23 we see “a small but significant proportion of deaths relate to deaths in care homes, rather than hospitals”, but the meeting mostly discussed testing, and they resolved that they needed more discussions to get a testing strategy for care homes, as well as someone to lead it.
On April 30 the penny is starting to drop. There is significant transmission in care homes “but numbers are plateauing”. This has now been taken under the heading of nosocomial (hospital) transmission, to which more attention is paid. The committee’s view is that we need lots of testing; the rate of asymptomatic infection among healthcare staff may be 5–6%. However, “Understanding the causes of transmission in care homes is more challenging.” Really? Anyway: at last there’s a SAGE subgroup on care homes.
Finally on May 5 the committee acknowledges that hospitals and care homes are driving the transmission. Without them R would be near 0.5. The policy focus should be on reducing transmission in health and social care, they realise: the epidemic is actually three separate but interacting epidemics. For hospitals it’s about infection control procedures. And what about care homes? No doubt the subgroup will report in due course.
My experience of university committees makes this all just too painfully familiar. What’s failed here is not the science, but the process of government. The committee started out full of NHS medics and bureaucrats, and lots of theoreticians – modelers aplenty – but there’s still nobody from the care sector. The members focus on the NHS they know and stay in their comfort zone. And now, we might ask, is there anybody with operational experience relevant to running a large testing and tracing programme? Or would it be a waste of time to try to create such a competence in the SAGE environment?