22 Apr 2022

The consultation on the terms of reference for the UK’s independent inquiry into the Covid-19 pandemic is now closed. We look forward to seeing if our submission (see our blog last month) will result in Baroness Hallett making any changes before presenting the terms to the Prime Minister for approval. More importantly, we wait with interest for the call for submitting evidence to the inquiry, and what form that will take. Evidence will be at the heart of the inquiry, including how it was used, or not used, to inform policy and its implementation.

One of the guiding principles of evidence-based medicine (EBM) is that before doing new research the existing literature and evidence should be interrogated and synthesised, to see what is already known. That principle was established in the 1990s, nearly thirty years before Covid-19. Unfortunately, one of the features of the pandemic response in the UK, was that a very large amount of what was already known, and in some cases already synthesised into guidelines, was overlooked, ignored or deemed irrelevant. 

One of the arguments advanced in defence of the shift away from EBM, was that as this was such a major emergency, there was simply no time either to do new original studies (with some notable exceptions), nor engage in the often slow and painstaking processes of evidence syntheses and reviews. This was certainly true early on; but we are now more than two years into the pandemic, and clearly, a lot could have been done in two years – as advances in vaccines have demonstrated. That is not our main point. Our point is that there was already an extensive evidence base. This seems to have played little part in the way policy was developed and implemented.

Disproportionate impact of Covid-19 on people from ethnic minorities 

There are several examples when opportunities went begging. Early in the pandemic, it became apparent that people from some ethnic minorities, seemed to be in much greater danger from infection, hospitalisation, severe illness and death, than the rest of the population. This was perhaps initially most obvious in the daily TV news bulletins, when deaths among NHS staff were reported along with photographs of the deceased; the data soon bore this impression out. In fact, applied informatics researchers at the ARC were among the first researchers to identify a mortality increase by ethnic group in their analysis of data from mental health service users in south London. 

But what did we already know that might have helped? There are four sources of evidence, which could have been corralled, especially into the epidemiological models that were proliferating. 

First, there is an extensive evidence base about the disproportionate burden that some communities bear, in the patterning of health inequalities. The non-communicable diseases (NCDs) driving inequalities in health in these communities – or what the news bulletins referred to as ‘pre-existing medical conditions’ - are well known. There are guidelines about the most cost-effective methods of prevention in those communities, much of which is rich in background information about the communities. That evidence and those guidelines remain in place, in for example, the NICE public health guidelines on type 2 diabetes, coronary heart disease and obesity. But on the face of it, they were not used to any great effect in the response to Covid, certainly not in helping those communities.

As the pandemic progressed, the health inequalities in ethnic minority communities and beyond were recognised, and NHS England and others repeatedly described the problem and exhorted the NHS to do something about it. But what were NHS providers supposed to do, and how? Pulling together the existing evidence, and using it, appear to have been off the table.

Prof Michael P Kelly, Prof Peter Littlejohns, Dr Sarah Markham

Ignoring international evidence from SARS and MERS

Second, and staying with pre-existing medical conditions, earlier this century both SARS and MERS appeared. The learning in countries in east Asia that had dealt with SARS, had prepared them for the need for a rapid response to Covid. This preparedness in the East was ignored in the West. The oddest thing here is that SARS is a corona virus which interacted with pre-existing NCDs; precisely the ones of interest here, driving health inequalities. The scientific papers describing this are readily available. It is documented in textbooks. Hardly obscure stuff. Of course, it might be argued that not all corona viruses behave in the same way, and Covid-19 was clearly different. But surely it was worth a look? Surely the syndemic hypotheses that writers like Richard Horton, editor of The Lancet, had drawn attention to early on, deserved to be taken seriously, not least because the syndemic interaction involved social disadvantage.

To what extent did the predictive epidemiological models take account of the variegation in the population, the existing risk profiles in certain population groups and the likelihood of major mortality in well identified groups in the population? Again, from the outside, it looks like hardly at all, at least in the way they found their way into policy. 

Prof Michael P Kelly, Prof Peter Littlejohns, Dr Sarah Markham

Where we live: patterns of living, work, rest and play

Third, there is large and extensive evidence about the society we live in, and the people who make up our communities. Patterns of living, of work, rest and play, and how these change and evolve, are grist to the mill of history, sociology, anthropology, geography, community studies. As well as being found in the social scientific literature, this knowledge is held by local public health teams and by communities themselves. There is also a vast amount of data collected by commercial organisations about their customers and their habits. The sector providing care homes is another that accumulates lots of information about its clients, its staff, and families of residents in the homes. The latter are particularly important, as being elderly was a major risk for severe Covid-19 infection and death. Even a passing acquaintance with some of this material tells us several key things.

There are very high degrees of social variegation in the population. We are not all the same and we don’t all behave in the same way. These variations are not randomly chaotic and governed by chance. Within the highly granulated worlds of ordinary people, there are patterns.

Prof Michael P Kelly, Prof Peter Littlejohns, Dr Sarah Markham

Walk along almost any high street across the UK and the social variation is clear. But in the pandemic, it was as if it was hidden in plain sight. UK governments and their modellers, for example, seem to have been completely blind-sided as to the patterns of employment in care homes, and the possibilities of the spread of infection there. 

All in it together?

In spite of the evidence about social differences and accompanying risk, the government insisted that everyone was at equal risk, and that we were “all in it together”. However, recent revelations show that they did not even believe it themselves. The epidemiological models and predictions and policy seemed to show little awareness that actions like eating, shopping, family socialising, the ability to work from home, the capacity to use digital technologies, the availability of home connectivity and equipment, life in care homes, among many, were not similar for everyone. You might throw up your hands, respond and argue that it’s all too complicated. But complex as it may be, we already know a lot about these matters both in the social scientific literature, and in the local communities and their service providers. 

The arrival of infection in a globalised travel system, the seeding of infection by UK holidaymakers from ski resorts in the Alps, or from families in the UK visiting their relatives living in India, were not matters of chance; they were highly predictable. It was this failure to think in terms of the predictability of human conduct, which seems so woeful.

Prof Michael P Kelly, Prof Peter Littlejohns, Dr Sarah Markham

And even where predictions were made, about the unwillingness to comply with lockdown rules, for example, they proved to be wide of the mark. A quick look back at the history of compliance by the civilian population in the face of enemy bombing in World War II, should have led to questioning these non-compliance predictions immediately. But no. It appears that the historical record - the historical evidence - was ignored in favour of extrapolation from limited amount of psychological evidence, or worse, speculation. The idea that people respond well to threats and sanctions – which was the line that policy took at various times, is once again devoid of an historical or real-world understanding of compliance to everything from queuing, standing on the right-hand side of escalators on the London tube, to the voluntary compliance with smoke-free legislation when it was introduced.

Ignoring the evidence on health-related behaviour change

Fourth, it is remarkable that in the UK we have produced some of the most sophisticated research about health-related behaviour-change in the world. This would have been the obvious place to start, even if it would require interpretation and assessment in the light of the pandemic. Some of the scientists who have developed this evidence were on government advisory committees. But this was not the evidence used.

Instead, a series of the same old, same old, tried, tested and failed superficially common-sense solutions about human behaviour were rolled out, with a peppering of nudge-inspired ideas. This is extraordinary given that the scientific evidence supporting nudge and behavioural insights is so thin, compared to mainstream health-related behaviour change.  

Prof Michael P Kelly, Prof Peter Littlejohns, Dr Sarah Markham

At one point early on, the idea surfaced that the perceived level of personal threat needed to be increased among the population, who were apparently complacent. The plan was to use hard-hitting emotional messaging. Once again, key parts of the evidence seem to have been ignored. There is an extensive literature about the way that people respond to threats. One important model called the stress-coping paradigm, suggests a two-phase response. The first phase involves appraisal of threat – asking the question “To what degree is the stimulus benign or malign – a threat or not?” The second phase is concerned with working out what can be done about it. Such second phase actions may involve taking direct action, denial, worry or doing nothing and hoping for the best. Protection Motivation Theory uses similar ideas about appraisal and action. At the heart of both is an important precept - that the ability to act effectively in the face of threat involves using skills, and quite likely in the case of a new pandemic, skills which people didn’t already possess, or had never practised. To help people cope, we need to help them develop the necessary skills and capabilities. What we definitely should not do, is just let them deal with the threat de novo, and expect them to work it out from first principles. In the framework of another important model, we may have motivated people, but if they have neither the capabilities nor the opportunity, it won’t happen. 

But sadly, letting them work it out for themselves, seems to be exactly the approach adopted in the UK. So skills, capabilities and opportunities for home schooling, shopping, managing social distancing, wearing masks, surviving when the money runs out, accessing digital platforms, travel, going to the workplace when it is impossible to work from home, were pretty much left to members of the public. At best, support and advice was patchy. And of course, not everyone was starting from the same base. These skills, resources and capabilities are as variegated as the social differences in populations. Additionally, the business and commercial community, much of which had to stop or seriously curtail trading, were not offered much other than what appears to have been a cursory acknowledgement of the problem, some financial recompense and apparently very complex ways to access the cash. The understanding of how businesses are supposed to cope in a commercial world turned upside down, seems to have been driven by a belief that the market would sort it out. One might suppose that ‘the devil take the hindmost’ approach fits well with a free market economic ideology, but it lacks compassion. More importantly, perhaps, it is disconnected from the real lives of large swathes of the population, and all the evidence that was readily to hand.  

A new relationship between evidence and policy is required

So now we are all waiting for the news of the start of the inquiry to move the debate on to what can be done to mitigate and learn from past mistakes. This is essential as Covid-19 has not gone away and may remerge as a major public health crisis at any time. Nor is it the only potential threat to national wellbeing as current political and international events demonstrate. In the context of the risk of future large-scale disasters, we need to be better prepared to identify, evaluate and deploy evidence to inform decision-making and better protect public health.

Some of the ideas in this blog relating to changing health-related behaviour are covered in more detail here and those relating to social factors and Covid-19 here.  

The relationship between evidence and policy has always been a contested area, an issue we covered in an earlier blog and the difficulties of the relationship between scientists and politicians has always been a tricky one, particularly when so much is at stake.

However, things can be improved. You can even undertake research into how to improve the chances of evidence informing policy. An example of this is when 93 UK scientific advisors and government officials were asked in real time how they were interacting with policymakers during the Covid crisis (see What the Covid-19 experience has taught us about the limits of evidence-informed policy making and How did UK policymaking in the COVID-19 response use science? Evidence from scientific advisers).

The challenge for the inquiry then is not only to explore why evidence was used or not used, but also to identify and propose the best models for evidence informing policy in the future.

About the authors:

  • Professor Michael P Kelly. Michael is a senior visiting fellow in the Department of Public Health and Primary Care at the University of Cambridge and a member of St John’s College. Between 2005 and 2014 he was the Director of the Centre for Public Health at the National Institute of Health and Care Excellence (NICE)
  • Professor Peter Littlejohns. Peter is emeritus professor of public health, King’s College London, public health and multimorbidity theme lead, ARC South London. Between 1999 and 2013 he was the Clinical and Public Health Director at the National Institute of Health and Care Excellence (NICE)
  • Dr Sarah Markham. Sarah is a visiting researcher at the Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London