Today is the 4th anniversary of my blog, and it is usual at such times to comment on unexpected market changes. Indeed over the past 4 years there have been some genuinely surprising developments in the British energy market…the introduction of a price cap by a Conservative Government springs to mind.
Yet this time, I feel that the past 3 months have seen something so unprecedented in most people’s lifetimes, that it renders any such commentary obsolete, not just in this anniversary post, put in any future ones. The current situation is one of significant human tragedy, and I send good wishes to everyone who has been sick or bereaved as a result of this pandemic.
Data-driven policy is a good thing: if the right data are analysed in the right way
One of the things that strikes me about the current situation is that policymakers around the globe emphasise on a daily basis how their actions are “guided by the science”. I find this interesting: I have for many years, as my regular readers will know, bemoaned the lack of data behind policy decisions – the infamous price cap being a case in point. Now governments are taking great pains to stress how data and science are guiding their actions, so of course I ought to be pleased.
“I am an epidemiologist and I worry that the response is based too much on epidemiology alone,”
– Mark Woolhouse, professor of infectious disease epidemiology, Edinburgh University
Yet somehow I am not. Because it’s important not only to be driven by data and analysis, but by the right data and the right analysis, and here I fear mistakes are being made. There has been an understandable bias on behalf of the British Government to err on the side of caution and listen to the most pessimistic forecasts, those of Professor Neil Ferguson at Imperial College. Imperial College is a well respected institution, known for scientific excellence, yet Professor Fergusson has a track record of modelling worst-case outcomes that have led policy-makers to some disastrous decisions.
Many rural communities still feel the effects of the foot-and-mouth crisis which devastated many livelihoods. Professor Michael Thrusfield of Edinburgh University has claimed Professor Ferguson’s “severely flawed’’ errors led to the cull of more than 6 million animals that did not need to die. Professor Ferguson was also responsible for the modelling in the 2009 outbreak of swine flu, when he predicted there would be 65,000 deaths. In the event, only 457 people died and the Government wasted £1.2 billion on treatments that were not needed.
Alternative analyses from the University of Oxford, another highly respected institution, takes an altogether less apocalyptic tone. Somehow, ministers with limited experience of mathematical modelling need to make sense of this, against a backdrop of economic stagnation, the like of which has never been seen. It is worrying that critical debate on the subject of disease modelling in the UK has been muted, and much of the detailed analysis can be found in non-UK publications.
Poor understanding of risk guides public response
It is also interesting to note the extent to which the Government has been surprised by public compliance with the lockdown measures. I find this rather inexplicable, since we have recent experience of the British public accepting the prospect of direct hardship without fuss – when the Coalition Government came to office in 2010 and announced that a period of austerity would be required in order to stabilise the economy following the 2008 banking crash and its aftermath, the public accepted the argument largely without protest. That the actual level of austerity was less than advertised does not take away from the willingness of the public to both understand and accept the need for personal sacrifice for the greater good.
There is also some interesting analysis around the extent to which the public response is due to a widespread inability to analyse risk effectively. As someone whose job is largely about understanding and managing risk, this is something I come across quite often – people generally tend to over-estimate the effects of low risk but high impact occurrences, as illustrated by the larger numbers of people that fear air travel over road travel despite road travel being many times more dangerous.
What will be interesting to see in the coming months will be the extent to which people with other health conditions whose treatment is suspended will put pressure on the Government, or even seek to use the courts, to require the NHS to either re-start their treatment or to compensate them from damage they suffer as a result of the withdrawal of treatment, particularly as evidence emerges of empty hospitals and idle medics – some 42% of acute care beds are now unoccupied. Being too slow to open this spare capacity to non-Covid-19 use may give rise to claims of negligence either on the part of individual hospitals or by Public Health England or the Department of Health and Social Care.
It will also be important to find ways to re-open dental treatment which has effectively been sent back to medieval times with extractions being the only treatment options currently available to many people. Indeed, people are reportedly pulling out their own teeth in preference to living with dental pain which can be literally unbearable.
It will take a long time for actuaries to analyse the data from this period to understand whether the decisions made were the correct ones. They will unpick the mortality data and try to understand how many of those recorded as dying of Covid-19, simply died with it, and would have likely died over the next year anyway. They will set against this the growing number of excess deaths resulting from the near complete cessation of other medical treatments and a reluctance on the part of the pubic to either add to the perceived burden on the NHS or to expose themselves to potential infection in a hospital environment by seeking treatment for other medical emergencies in a timely manner.
They will also need to examine the long-term effects of the near-cessation of economic activity on health outcomes. That poor health and premature death is linked with poverty is not news, nor is the understanding that with economic contraction less funding is available for investments in health provision. The Government will need to think carefully about how and when the current lockdown is lifted in order to balance the fears of new waves of infection against the need to defend the economy.
Hopes are pinned on a vaccine but doubts are emerging
It is also far from clear that a true exit from the current situation is available. On the one hand there is optimism about a potential vaccine – the University of Oxford, whose clinical trials began last week, has already begun production of the vaccine in anticipation of a positive outcome, while on the other hand, there is some evidence that the protection from the disease afforded by antibodies as a result of previous infection may be temporary, but even this is proving controversial. The reality is that as SARS-CoV-2, the virus strain that causes Covid-19 is still relatively new, comparatively little is known about its behaviour.
“There are too many rapid mutations to neatly trace a COVID-19 family tree,”
– Dr Peter Forster, geneticist, University of Cambridge.
There are also signs that the coronavirus is mutating, suggesting the threat may be similar to that of seasonal flu where the composition of each year’s vaccine is effectively a guess at which strain will be prevalent. The US CDC estimates that flu vaccines are typically only about 60% effective and in some years the effectiveness can be as low as 36%. Mechanisms such as immunological imprinting are still poorly understood, so it may be years before an effective vaccine is developed, if ever.
If the disease does follow this path, healthcare systems around the world will need to be re-structured in order to separate Covid-19 patients from other patients. In the UK this will be hugely challenging since the NHS, or as politicians nauseatingly put it “our” NHS is the equivalent of a national religion. The NHS is effectively mythologised, and any potential reform is shot down by the argument that we must avoid a US-style system, an argument that wilfully ignores the many other models around the world. Politicians and other public commentators refer to the NHS as “the envy of the world” – this is not only false but ridiculous: no other country has modelled its health system on the NHS.
Currently, healthcare workers are being treated as heroes, and while there are indeed many examples of personal heroism, a narrative is emerging that healthcare workers are losing their lives as result of treating victims of the disease. However, early analysis of the available data suggests healthcare workers are not dying at a higher rate than the population as a whole, and that those working in the highest risk areas of intensive care, are also not more affected.
The NHS has long been dysfunctional – a good outcome of the current crisis would be a proper debate about how it can be restructured, to better meet the needs of the population reflecting current medical and social realities. Exploring appropriate means of co-operation with the private sector, which is happening with mixed success during this pandemic, and the extent to which some services should no longer be free at the point of use, would be hugely beneficial.
Re-setting attitudes to illness and death
The possibility that we may have to live with Covid-19 in the long term and that it may routinely claim lives is one that currently strikes fear into society. But I would challenge this view. In recent years, healthcare systems in the developed world have become much more adept at extending life, and increasing numbers of people live to an advanced age. Life expectancy at birth in Britain has increased from 40 years for men and 43 years for women in 1908 when the state pension was first introduced, to 79.3 and 82.9 years respectively in 2018.
However, long life does not mean good health, with many of those living to an advanced age doing so with multiple conditions requiring varying levels of care. The need to provide support to this population either in-home, or in care settings is placing an increasing strain on local authorities, with lack of funding a growing problem – according the thinktank The Kings’ Fund, in 2018/19, 841,850 adults received publicly funded long-term social care, primarily in care/nursing homes or in their own homes while there were 1.9 million requests for new support of which only a quarter were actually deemed eligible for long-term care. Age UK estimates that 1.5 million people in England that need some help with day-to-day life, but do not receive it. This is not just an issue for older people with increasing numbers of working age people also requiring support.
It is therefore legitimate to question whether it is preferable for people to live longer (or longer that would otherwise be the case for them), but less independent lives, or whether dying earlier from a short illness might be “better”, particularly if a level of care can be arranged where the individual is comfortable, able to be with family, and suffering minimised.
I am not immediately facing the challenges of old age, but whenever I do think about it, I am reminded of the words of the young Jane Eyre in Charlotte Brontë’s famous novel. When asked what she must do to avoid the fires of hell, she replied: “I must keep in good health, and not die.” I have no wish to live forever, but neither would I want to spend years unable to meet my own most basic physical needs.
Of course my preferences may not be shared by others – it will be the job of the Government to try to establish an approach that reflects the preferences of the wider population, and provides the appropriate balance between maintaining personal health autonomy and the protection of the wider public. This may require reverting to 19th century approaches to managing contagious diseases, and possibly also returning to more Victorian perpectives on death, which was approached in a more open way than is the case today where death has become almost taboo and people are uncomfortable speaking about death and loss.
“From our modern point of view, it is easy to make fun of these rituals, but Victorian culture recognised death as an integral part of life and they maintained an honest understanding of loss and grief,”
– Carol Christ, executive vice chancellor and provost, University of California, Berkeley
Of course, some of the Victorian death rituals were bizarre and even distasteful, but death was not hidden the way it is today with our many euphemisms for death. A proper public consideration over end of life care, and whether prevention of death should be the primary objective of the healthcare system in all cases would be welcome. That is not to say any lives should be written down as being of less value, or that end of life should be actively hastened, but a wider consideration of the goals of the healthcare system and more discussion over desirable outcomes in individual cases, and before a crisis occurs, would be welcome.
Whatever happens with the lifting of the lock-down, there is a growing realisation that life is unlikely to return to “normal”, and in fact, this provides many opportunities. There is likely to be some requirement in the near term to maintain some form of social distancing, and this could provide the impetus businesses need to change how workplaces operate. Rather than returning to a 1950s style of cubicle working, there is an opportunity to provide greater levels of flexible working – investment in communications infrastructure would help here.
Allowing flexibility in time as well as geography has the potential to also break down remaining gender barriers in the workplace. Although there has been evidence during the lock-down of women being disproportionally expected to take responsibility for childcare and supervising home schooling, parents need to resist this and businesses need to be challenged on any perceptions that men require less flexibility than women. Allowing staff to work non-standard hours as well as being away from the office will make family life easier to manage.
The business landscape will change in other ways. Businesses will likely strengthen their online offerings and potentially diversify into areas that could continue should further lockdowns occur. Many are already doing this, with restaurants beginning to offer takeaway services. Businesses that cannot do this will develop ways of continuing to operate safely despite the risk of pandemics, for example through the use of appropriate PPE, and virus testing – the development of tests that give results in minutes will enable businesses and healthcare providers alike to deal appropriately with those who have the virus but are without symptoms. It could, for example, become routine to be tested ahead of a hair-cut, visit to the dentist, or plane trip.
Automated testing could be a game changer – imagine a skin test being performed by railway ticket barriers that denies entry to anyone testing positive. Such technology, if safe, would be preferable to phone apps that would be open to abuse.
The economy will change in other ways. Some businesses will not survive this crisis, but that is also not necessarily a bad thing – poor businesses lock up capital that could more usefully be used elsewhere. Allowing them to fail allows that capital to be re-cycled and invested in more viable enterprises. This is true in energy, where some new entrant suppliers arguably do not have sufficiently robust business models or operations to merit continued trading, and could also lead to some re-evaluation of the pursuit of increased competition as being an end in its own right.
It will be interesting to look back next year and see what happens…probably it will be a mixture of good and bad developments, amazing innovations and missed opportunities. It is said that adversity is the mother of invention, and I believe this to be true – like many people I’m exploring how I can expand my own businesses to adapt to new ways of working. My plan to launch a training offering is now going digital, and I’m currently researching and writing my first courses which I hope to launch in the coming days once I figure out the tech part. Watch this space…
“One cannot plan for the unexpected”
– Aaron Klug