Prof Carl Heneghan & Tom Jefferson

Boris Johnson needs to bin the rule of six

Professor Carl Heneghan talks to Andrew Neil on Spectator TV
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When Boris Johnson returned to work in April after his brush with coronavirus, he warned that lockdown restrictions must remain to prevent a second wave. Ever since, beset by anxieties, doubts and fear, and surrounded by a platoon of advisors, the PM has made one cautious, catastrophic error after another.

Last week’s roll of the dice with the ‘rule of six’ could well be the policy that tips the British public over the edge. For it is a disturbing decision that has no scientific evidence to back it up, and may well end up having major social consequences.

The government has decided to blame young people for the latest restrictions, having spent August asking them to revive the economy. What was the purpose of Chancellor Rishi Sunak’s ‘eat out to help out’ scheme if at the first sign of a rise in cases the PM’s hasty response is to lockdown again? We were told to get back to work, what did the government expect? Increased activity at the end of summer leads to an increase in acute respiratory infections, as it does every year. This is not rocket science.

Last week Mr Johnson and his team, as they have done many times, acted too hastily. There is no evidence to inform the rule of six – its impact will be minimal.

At Oxford University’s Centre for Evidence Based Medicine, we have spent years trawling through the scientific evidence on the effects of measures such as distancing on respiratory viral spread. We are not aware of any study pointing to the number six. If it’s made up, why not five or seven?

The lack of evidence reflects the inconsistency in the devolved nations’ implementation of the rule. In England, gatherings of more than six people will be illegal. In Wales and Scotland, children under 12 are exempt; people in Wales will also be able to meet in groups of up to 30 outdoors. Northern Ireland has taken a more measured approach and not announced any changes to how many people can meet. These disagreements in policy reveal how decisions are being made without evidence. It seems that somebody in government sat in a cabinet office room and said six is a good idea and nobody disagreed.

At its core, the decision to restrict gatherings belies a fundamental misunderstanding of what is happening with coronavirus in Britain.

Professor Carl Heneghan spoke to Andrew Neil on Spectator TV about Covid-19

Admissions for Covid, critical care bed occupancies and deaths are now at an all-time low. There are currently 600 patients in hospital with Covid compared to over 17,000 at the height of the epidemic. An average of ten patients a day die with Covid registered on their death certificate, compared to over 1,000 at the peak.

The current shift in focus away from the impact of the disease is a worrying development. For months the severity of the pandemic was monitored by numbers of cases, numbers of admissions, and deaths. All three measures are open to misinterpretation if their definitions are not standardised.

Cases are being over-diagnosed by a test that can pick up dead viral load; hospital admissions are subjective decisions made by physicians which can vary from hospital to hospital. Even deaths have been misattributed.

Intervening with restrictive measures at the first sign of an upturn in cases means we are in for a long hard winter. The government’s modelling predicts catastrophe. Yet this is wide of the mark. Cases will rise, as they will in winter for all acute respiratory pathogens, but this will not necessarily translate into excess deaths.

In times of crisis, soothsayers are all the craze. Despite their consistently poor results, the government keeps turning to models to inform its policymaking. When it does this, it ignores the vast expertise of our clinicians and public health experts who could provide a more robust approach based on their real-world healthcare experiences.

The problems with policy stem from the current cabinet’s vast inexperience: the Health Secretary has been in post for just over two years now; the PM and the Chief Medical Officer a year. The Joint Biosecurity Centre is overseen by a senior spy who monitors the spread of coronavirus and suppresses new outbreaks. Add to this mix the new chair of the National Institute for Health Protection, who similarly has little or no background in healthcare. Our leaders amount to little more than a Dad’s Army of highly paid individuals with little or no experience of the job at hand.

This inexperience leads to rash decisions and arbitrary policies.

One example is that entire areas can be locked down if they have 50 cases per 100,000 people. Yet the recognised alert threshold for ‘regular’ acute respiratory infections is 400 cases per 100,000.

Epidemics are nonlinear; they tend to be chaotic with few certainties. Leaders cannot foresee the future; they need flexibility in their planning. In fact, epidemics are like war: foggy, unpredictable and never go the way you think.

As the situation has worsened, Britain’s mental health has deteriorated. During lockdown, a fifth of vulnerable people considered self-harming, routine healthcare came to a standstill, operations were cancelled, and cancer care put on hold.

Through all this, the health secretary transformed himself into the Covid secretary as these wider healthcare issues were disregarded.

Covid caught us with our pants down despite 20 years of pandemic preparedness rhetoric and expense. The most glaring initial blunder was not observing what was going on in other European nations and learning from their mistakes. When we asked a senior Italian health official in Lombardy if he had had any British observers or requests for information during the initial phases of the pandemic, he replied: ‘no’.

So, what should we do to address the situation? First the governments must set a clear aim for containing all acute respiratory infections – not just Covid – and formulate a plan for the short, medium and long term

In the short term, we have a choice: contain the spread – which is unrealistic – or shelter the vulnerable and get on with life.

We need to also urgently reinforce the primary care surveillance system, which gathers intelligence of what is actually happening in the community.

It is also vital that we review the accuracy of the tests currently being deployed. Our studies show that many Covid tests are picking up virus traces long after an infection has gone. An overly simplistic testing approach has, therefore, resulted in large numbers of people being incorrectly labelled as a threat to public health.

We must ensure that we have adequate supplies of PPE equipment and our frontline staff are supported physically and mentally.

Most important of all, life should return to as close as possible to normality. Drugs and vaccines may very well help us in the long term, but the short-term strategy should be based on the lessons learned in these chaotic few months.

In these pressing times, we need thoughtful, analytical policy that refrains from intervening when the uncertainties are significant, and the evidence is lacking.

We need to simplify the messaging around social distancing. And remove the plethora of non-evidence-based policies.

For starters, the rule of six policy should be binned. We must also address the failings that meant we were wholly unprepared to begin with. We need advice that isn’t too narrow in its focus.

Most of all, Mr Johnson, we need you not to panic.

Written byProf Carl Heneghan & Tom Jefferson

Carl Heneghan is professor of evidence-based medicine at the University of Oxford and director of the Centre for Evidence-Based Medicine Tom Jefferson is a senior associate tutor and honorary research fellow at the Centre for Evidence-Based Medicine, University of Oxford

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