key: cord-0919693-wwtpkinj authors: Atkinson, P.; Gobat, N.; Lant, S.; Mableson, H.; Pilbeam, C.; Solomon, T.; Tonkin-Crine, S.; Sheard, S. title: Understanding the policy dynamics of COVID-19 in the UK: early findings from interviews with policy makers and health care professionals date: 2020-10-07 journal: Soc Sci Med DOI: 10.1016/j.socscimed.2020.113423 sha: e06e3e978ba8b0c57c51416c3b6fa40568a75957 doc_id: 919693 cord_uid: wwtpkinj The UK government response to COVID-19 has been heavily criticised. We report witnesses’ perceptions of what has shaped UK policies and how these policies have been received by healthcare workers. Such studies are usually affected by hindsight. Here we deploy a novel prospective approach to capture real-time information. We are historians, social scientists and biomedical researchers who study how societies cope with infectious disease. In February 2020 we began regular semi-structured calls with prominent members of policy communities, and health care professionals, to elicit their roles in, and reactions to, the pandemic response. We report witnesses’ perceptions that personal protective equipment (PPE) stocks were too small, early warnings have not led to sufficiently rapid policy decisions, and a lack of transparency is sapping public trust. Significant successes include research mobilisation. The early experiences and reactions of our witnesses suggest important issues for investigation, notably a perception of delay in decision making. During public health emergencies policymakers are under unparalleled pressures, including from the media, public, healthcare workers, and politicians. We consider the dynamics of the UK policy response to the current COVID-19 pandemic, through the lens of 'policy sciences' literature, including its analysis of disaster response. This lens offers a valuable corrective to a positivist, linear view of the links between scientific knowledge and policy. Berridge reviews this linear view and its more realistic alternatives, drawing on the sociology of scientific knowledge and science policy studies. 1, 2 Berridge's paper on the UK response to the 2009 influenza pandemic highlights the utility of using contemporary oral history in shaping effective health policy. 3 The work of Jasanoff and others in establishing the discipline of science and technology studies (STS) calls attention to 'the untidy, uneven processes through which the production of science and technology becomes entangled with social norms and hierarchies.' 4 Black and Donald's account of the pitfalls of 'evidence-based policy' is an accessible summary of much other work. 5 Policy science work on how policymakers use evidence also helps interpret policy responses to coronavirus. A recent body of work by Paul Cairney and others discusses how they select which evidence they have time to use, sometimes starting from emotions, belief and habits rather than rational processes. Cairney and Oliver note the attractiveness, for Ministers, of framing strategies based on appeal to the emotions and the familiar, in contrast to the exercise of rationality. As we discuss, this is a good lens for understanding ambitious coronavirus testing targets set without reference to how the results would be used. Cairney and others also note J o u r n a l P r e -p r o o f how policymakers can only pay attention to a tiny proportion of their potential responsibilities. 6, 7, 8 Chris Whitty, the Chief Medical Officer for the UK government, has made a strong case for including more social science expertise in policymaking, since '[m]any policy decisions do not turn out the way they were intended because people do not behave in the way policymakers … thought they would.' 9 Weible et al, in an important contribution which was the first policy sciences paper on COVID-19, review how policy sciences can illuminate the interplay between scientific and technical expertise and policy choices in the COVID-19 crisis. 10 Their discussion of the interaction of policy with science, and of ways to assess policy success and failure, shaped our analysis of our transcribed calls with witnesses. Another valuable lens was Black and Donald's account of research as one of several contestable knowledge sources (which include public opinion, political insight, and managerial understanding). None of these, unaided, can dictate what policy should be. On 28 February 2020 we began interviewing two panels of witnesses, from UK policy communities and front-line health care professionals, for the purpose of capturing events and their immediate reactions to them. Interviews were semi-structured, beginning from a general question about what coronavirus-related work the witness had recently done: interviewers did not suggest particular themes. Ethics approval was secured from Research Ethics Committees of our two Universities. Recruitment was pragmatic, via personal contact, and, for the health care professionals, benefited from a 'snowball' approach. Our witnesses from policy communities were selected J o u r n a l P r e -p r o o f for their closeness to UK central government decision making. We did not attempt to interview politicians or their political advisers ('Special Advisers') at this stage, but the witnesses we did choose were sufficient to understand the pattern of developing events. Witnesses spoke on condition of anonymity, enabling them to speak more frankly. We do not disclose the organisations where they work, which include key sources of UK scientific advice on the outbreak. The anonymity of the witnesses is problematic, as it does not allow the reader to see the overall pattern of each witness' contributions. We had no alternative: our complete anonymity approach was the only one under which the policy witnesses would permit their evidence to be used. They felt they were a very small group, from which individuals could too easily be identified. The same constraint did not apply to the health care workers, drawn from a more numerous group. Here we can describe someone, for example, as 'a clinical director'. In the initial phase of our data collection it would be unethical and impractical to distract witnesses from their outbreak response duties for full-length interviews. Semi-structured telephone and online calls, typically of 15 minutes, are recorded and transcribed, contacting each witness weekly or fortnightly. Analysis at this stage focusses on any rapid learning which emerges. This prospective approach is novel, though some of the early oral history work on AIDS policy had a similar style and has been called 'history in the making'. 11 The project continues until August 2021: during its second phase we will conduct longer interviews and more formal data analyses, seeking broader findings valuable for longer term policy making, for example improving government readiness for future epidemics. The funders have played no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The themes we discuss below are selected for their salience in the interviews. As mentioned, we did not guide witnesses to particular topics. The transcripts were not coded: instead we searched them for emergent themes. We now consider in turn the themes of early warning systems, clarity of communication, contingency planning, research readiness, delays, scientific advice, central-local tensions and visibility. [Text box about here: 'Early warning of emerging diseases The International Health Regulations require WHO Member States to detect and report specific diseases. Resulting intelligence is shared. A range of different international networks have been set up to meet specific needs, for example the US CDC's Morbidity and Mortality Weekly Report. 12, 13 The Emerging Infections and Zoonoses section of Public Health England (PHE) is responsible for early warning. It conducts horizon scanning of nearly a hundred sources for rumours of diseases and incidents around the world. Sources include the WHO and Ministries of Health, media, and social media, which are used because first news about infectious disease events now often comes from unofficial sources. 14 ] J o u r n a l P r e -p r o o f . Global -particularly WHO-based -early warning systems served their purpose well according to our witnesses. These systems triggered UK responses at the beginning of January 2020. As the concern of specialists at Public Health England (PHE) mounted, the issue was escalated on 13 January to the government's New and 15 We asked our witnesses how well this machinery worked in early 2020. One said the processes had been: 'extremely confused to begin with … people were being on-boarded into [Whitehall (central government) teams] at a rate of knots, so there was a certain amount of confusion: messages were being misunderstood, passed to the wrong people and so on. … now [26 March], … the civil service is actually performing, but it took a few weeks.' 16 Concern mounted. We heard that: we're going to do now, but as soon as we have got this, we will do the next thing." The uncertainty of PPE is a nightmare.' 18 Communication, to health and social care staff and the public, has to be timely, accurate, and reconcile the pressure for simple messages with the need to justify changes of direction. However, a GP partner in the Liverpool area described the stream of information they receive daily and the lack of nuance of these messages, which they felt were not sufficiently or appropriately targeted to healthcare professionals. Association] as well. And a lot of it is just the same stuff re-cooked. … And … it hasn't really changed what we have done … Four emails a day to read is just bonkers really. Especially when you're still trying to do your full-time job. … That kind of sensationalisation, we don't need that sent to us by government. ' 19 Some communication to the public has been exemplary in its clarity. Health care professionals in our study, however, have often been left confused and frustrated by the particularly poor communication of changes in PPE policies, which appears to be related to the unclear allocation of responsibilities between NHSE and PHE discussed below. 20 One health care worker, commenting on the way PPE guidance changed, told us that it would have been better to tell the NHS that guidelines are J o u r n a l P r e -p r o o f "for now", based on availability of supplies, and would change. 21 However a person close to the process spoke to us of their concern that such experience could have been used better, and about the impact of resource constraints: [lessons] '"learnt" implies you have done something with the knowledge, which isn't necessarily the case … bear in mind that … NHS England and PHE … are much worse off in terms of staffing and funding compared to … 2009 … and … [the] Department of Health [and Social Care (DHSC)] as well. We are doing more with less, and it shows.' 23 One element of DHSC 'doing more with less' has been the progressive stripping away of in-house medical advice to the Chief Medical Officer (CMO), and a one-fifth reduction in its overall staffing since 2010. 24, 25, 26 Contingency plans dealt, among other things, with the governance of an epidemic response, including the co-ordination of different agencies. Faced with an unparalleled challenge in 2020, there was considerable improvisation over governance, as we discuss in the section on central-local tensions. Research is often neglected as an element of epidemic response, but is especially important when responding to a novel pathogen. Through our interviews we heard about the valuable UK science contribution to global readiness initiatives in novel viral pathogen research, which allowed the global scientific community to sequence the virus and gather patient data to pre-established protocols with unprecedented speed, accelerating the introduction of accurate diagnostics and the development of vaccines and treatments. 35 We conclude that the UK was particularly well prepared, in global terms, to respond rapidly with, for example, clinical trials. Research indicates the sheer difficulty of crisis decision-making, stressing problems collecting and comprehending the necessary information, ambiguity, complexity, pace and organizational barriers to agile decision-making, including shared responsibilities between multiple organisations. 36 In England, decisions -and, critically, implementation -were slow to follow the initial alert. We were told that 'six weeks of opportunity was wasted,' and that: 'from 20 th January, it was clear there was human transmission … that this was going to spread around the world. And that was a six week window [for] ramping up PPE, making sure there was supplies, beds, making sure we were prepared for what was likely.' 37 J o u r n a l P r e -p r o o f It is normal for health professionals and advisers to complain of delay when there is an urgent policy issue to be resolved. What is different about an epidemic is the need to react fast enough to start slowing its exponential growth, or as one witness put it: 'there is no point saying we are doing things quickly ... I have heard many times that ... [something] is going on at unprecedented speed. But ... until that speed is faster than the pace of the epidemic, you won't be able to mitigate ... or indeed bring the epidemic to an end. 38 'Inevitably as things get passed down from Committees, and this is in the Ministers, SAGE, the lag phase between … advice [from] SAGE … or a decision made by whoever, Minister or anybody else, there is a lag … until it gets through the system. And when you are in an epidemic which is very fast moving … it is no good to say we are going quicker than we usually go'. 39 Persuading government Ministers to make the challenging decisions needed has often been difficult, though some decisions were said to be rapid. The majority of our policy witnesses frequently expressed frustration about delayed decisions. Our health care professional witnesses noticed such lags in many places, notably in the redeployment and retraining of staff. We heard from the policy community of 'a couple of heated moments [in mid-March] where people were saying "you are not moving fast enough"'. The government's most senior advisers, we were told, responded that policy decisions were a process, that the politicians needed to be led through it. 40 Our evidence allows us to refine Weible et al's observation that the COVID-19 outbreak challenges scientific and technical advisers to simplify and communicate, and challenges policy makers to balance political judgement with the responsible use of expert advice. 41 Kogan et al studied the interaction between researchers and policy makers in DHSC's predecessor, the DHSS, concluding that it was productive when participants could translate policy problems into research questions and research findings into actionable briefings. 42 45 Politicians use scientific and technical experts as part of the rationale for policy decisions, but the attractions of this tactic have never been greater than during this epidemic. 46 Scientific expertise is a comfort as well an intellectually valuable input to decisions: it can also comfort the public, as when scientific advisors such as Whitty and Vallance flank a senior Minister in press briefings. But the 'what should we do' question made witnesses concerned that Ministers were shifting the accountability for hard decisions onto them. 47 This was emphasised by a public rhetoric of 'following the science', for example to justify the lockdown decision at the end of March: this rhetoric lasted until late April. Ministers have met challenges such as testing, and the supply of ventilators, with promises that appear unsupported by evidence to demonstrate that delivery was feasible or explanation of how the test results would be used. This is an example of policymakers taking the 'shortcuts' that Cairney described, where decisions are based on emotions, beliefs and habits: not, in these cases, following the science. 48 Disasters pose co-ordination problems, and these affected how scientific advice was Once the top-level decision is made, the speed and quality of implementation is critical in disaster response. There is no obvious demarcation between decisions about policy and implementation. In the last ten years, government Ministers have aimed to devolve decision-making from DHSC (and its predecessor, DH), setting the direction but leaving some important decisions to NHSE. 52 This approach was never going to apply in a major crisis such as COVID-19, where political pressure on the government for solutions was, inevitably, intense. The existing 'peacetime' model, which devolved responsibility, and effective public accountability, for many NHS matters to NHSE and the NHS itself, was transformed by the pandemic. If such an ethically fraught policy needed to be considered, that needed to be done in public and not in private -a good reason for the UK authorities' decision against relying on the population acquiring immunity. These early findings are presented now because of the value of rapid feedback. There are inevitable methodological limitations to meeting this objective. There are availability biases in the witnesses: whilst all witnesses' time is at a premium during this phase of the outbreak, this may have been felt most acutely in key organisations such as DHSC, NHSE and PHE. Policy dynamics vary between the four countries of the UK: while we do include health care professionals in Scotland and Wales, to date we have only included key informants from policy communities in England. We now draw out some conclusions about the interaction of policy with scientific and technical experts and information, and then conclude with the issue of policy success or failure. In relation to science and policy, we note the essential role of boundaryspanning individuals who can translate policy problems into research questions, and research results into advice. This is particularly necessary where governance is complex and fragmented, as in central government and the NHS, if knowledge which can be used is to reach decision-makers who could use it. Without the efforts of these boundary-spanning individuals, we heard how dialogue can 'go round in circles.' UK government has been eager to use science to legitimise its choices -to the concern of several scientific advisers who told us policy makers were trying to pass responsibility for decisions to them. Whatever the reluctance of politicians to J o u r n a l P r e -p r o o f make unpopular choices, there are now signs in the UK that scientists are emphasising the doctrine that 'advisers advise and Ministers decide'. Turning finally to the assessment of success and failure, as Brändström and Kuipers observe, policy decisions (and non-decisions) are heavily scrutinized and politicized through framing strategies and blame-games. 60 Our witnesses mostly felt that blame games had started by March, while framing contests, such as 'invisible foreign enemy' versus 'inevitable result of austerity/cuts in preparedness investment' are definitely evident. 61 Blame games about coronavirus response take place in a setting of media speculation about the newly-elected government's dissatisfaction with the general performance of the civil service, and about how to interpret the departure of its head, Mark Sedwill. 62 The uncertain outcomes of blame games and framing contests serve as a reminder of the emergent and contingent element in the policy dynamics of coronavirus. Richard Horton wrote in a Lancet editorial on 28 March: 'The NHS has been wholly unprepared for this pandemic. It's impossible to understand why. … It is, indeed, as one health worker wrote … "a national scandal".' 63 How far does our evidence support this? Weible et al identify three fields of success (or failure). 64 First, successful decisions 'contain threats, minimize damage, and restore order and stability'. UK planning anticipated that the initial 'containment' strategy would be overwhelmed by a sufficiently infectious pathogen: up to that point it appears to have done its job relatively well, though questions remain. 65 The succeeding 'delay' and 'mitigation' phases have had much more mixed results: much better than nothing, but so far not nearly as effective as policies adopted, for example, in Germany and South Korea, as evidenced by the UK's 'R' trend. 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