Written evidence from James Tudor-White1 (RCC 07)

Public Administration and Constitutional Affairs Committee Responding to Covid-19 and the Coronavirus Act inquiry

SUMMARISATION The Covid-19 pandemic caught the world by surprise in early 2020, and we are still by no means close to having found a solution to the pandemic. While the "situation in Europe is improving, globally it is worsening" (World Health Organisation, 2020, p.1). The Coronavirus Act 2020 was implemented to provide the government with the powers necessary to be able to tackle and handle the pandemic. In April, the government outlined its 5 tests for determining when lockdown measures could and should be lifted. These measures will also play an important determinant on whether to end the temporary provisions of the Coronavirus Act of 2020.

The ultimate goal is that Covid-19 will no longer pose a threat to the population of the . Once this is the case, there would be no reason for the government to possess any of the temporary powers it was given as a result of this piece of legislation. Each test the government laid out will have its own advantages and caveats when determining the duration of the lockdown and when the temporary provisions of the Coronavirus Act 2020 can be repealed.

The being overwhelmed by the coronavirus outbreak was a major concern, and still is a concern for any future planning. This test is a good benchmark for determining whether the United Kingdom could handle another significant outbreak of Covid-19. It is widely accepted that this is likely to be the case, and it should be viewed as a case of when, not if. The capacity of the NHS will be instrumental in determining the response to any further outbreaks of Covid-19, and this will be determined by ensuring there is sufficient PPE, critical care capacity, and low staff sickness levels.

Relieving of lockdown measures and the rescinding of the Coronavirus Act 2020 should also be determined by the Ro rate and the rate of infection. It will also require a global outlook however, because of the nature that pandemics often occur over several waves, thus increases in the rate of infections in other countries which have already been affected by the pandemic could act as a lead indicator of what the UK should expect.

As part of devolution the nations of , and Wales all have the powers to determine healthcare policy. Therefore, there is definitely the capabilities and scope for divergence in policies between the four nations. This report goes on to further state that localised responses to

1 James Tudor-White Esq. is an International Relations major from the University of Birmingham. Since March, James has been following the coronavirus pandemic engaging with a variety of experts from a variety of organisations, as well as reading relevant academic literature on the subject. coronavirus will be the best approach, and if not localised then certainly the devolved powers should be able to decide the best approach. do suggest that despite a localised approach being the best response there should be some central authoritative oversight when it comes to collating data and setting the standards and overall numbers of testing required. It will then be down to each nation to determine which regions need the most testing.

To what extent should the Government's five tests for easing lockdown also inform whether to end the temporary provisions of the Coronavirus Act 2020?

How should the 5 tests be evidenced? In April, it was announced the lockdown of the United Kingdom would end when 5 criterions were met, to ensure a handle had been reached on the coronavirus crisis. It is imperative that the easing of lockdown measures should be slow and transitional. The Ro rate must be the clear determinant of easing lockdown measures and any relieving of measures which could increase the Ro rate above one must not proceed despite any public or media pressure. It is essential scientific evidence prevails. At the time of writing this evidence, the UK is beginning to 'open up' and non- essential retail shops are expected to open on the 15th of June. It is very easy to be hasty when making amendments or considering the ending of the temporary provisions bestowed on the government by the Coronavirus Act of 2020, but concern and preparedness should be focused on making sure there are sufficient measures in place if there is to be a second peak epidemic. Any delay in the response could ultimately lead to unnecessary loss of life, and therefore it may be in the best interests, to ensure that the ability to implement the temporary measures at short notice is still easily possible.

Test 1 - THE NATIONAL HEALTH SERVICE MUST NOT BE OVERWHELMED During the previous months of the coronavirus crisis there were serious and very valid concerns that the National Health Service could be overwhelmed. This led to the rapid establishment of NHS Nightingale hospitals, designed to increase capacity either for the treatment of Covid-19 patients or as 'step-down' facilities for recuperation and those not requiring treatment using ventilators. Thankfully, many of these facilities accepted none or fewer than anticipated patients, and therefore these facilities were not overwhelmed. However, it would be wrong to categorically say that the NHS was not at stages overwhelmed, and this must be considered on a local and regional level. It was well publicised and documented the strains the NHS staff were under, and the pressures on hospitals, especially in regard to Personal Protective Equipment (PPE). Northwick Park hospital in North London declared a critical emergency where it had to ask local hospitals to take some of their patients, for they were lacking spaces to provide critical and intensive care as a result of the increasing number of Covid-19 patients (Dunhill, 2020).

Finding evidence for this test should be one of the easiest. Evidence can be gathered directly from hospital trusts and from a regional health authority level. This would be the most appropriate way of identifying strains on the NHS. Another determinant of ensuring whether the NHS could become overwhelmed would be to establish what the Ro rate is currently at and make any forecasts

1 as to predict how it could change. If it is likely to increase significantly above 1, then assurances should be sort that the expected number of those infected with Covid-19 requiring hospitalisation would not be greater than the current capacity, i.e. social shielding of the most vulnerable is in place so severity of Covid-19 infections is minimised as much as possible. If it were to be greater, then measures such as reintroducing some aspects of the lockdown measures should be considered, so as to reduce the Ro rate below 1 to stop the spread of the virus accelerating.

I personally believe and will repeat this assertion, that a regional approach will be the most effective means of managing the relief of lockdown measures, gathering evidence necessary for the monitoring of the Covid-19 outbreak, and ultimately on determining whether there should be any reintroduction of lockdown measures. Hospital trusts and regional health authorities will have the best understanding of the current situation in their hospitals and health care facilities (including care homes and hospices) and will be best to realise any challenges or shortcomings these facilities may face, that a centralised governmental response could overlook.

TEST 2 - A 'SUSTAINED AND CONSISTENT' DECREASE IN THE DAILY DEATH RATE It is imperative that any 'sustained and consistent' decrease in the daily death rate is not just relative to the infection rate. Logic dictates that if the number of confirmed active cases falls, then the death rate will also decrease. What the government needs to ensure is happening, especially as further research is conducted on potential treatments and alleviants, is that the death rate is falling compared to previous months. i.e. the number of people who die from Covid-19 in July is less than in June even if the number of people infected remains the same. Otherwise, [with the evidence and knowledge of Covid-19 we have at the time - in which there is no definitive answer as to whether immunity exists] we could enter a new second peak epidemic, in which there could be a significant number of fatalities. What needs to be ensured is that should the rate of infection rises, as it very well could when all social distancing measures are reversed, sufficient and adequate healthcare should be available to ensure the death rate remains low and does not rise. Dexamethasone is a significant leap forward in this direction.

This test I believe is one of the easiest to measure, the data can be collated from death certificates. I believe an important aspect of this would be that there should be greater consideration on deaths which can also be attributed to Covid-19. Another aspect of data which should be considered is the excess mortality rate, this will help provide a detailed understanding of what the death rate is like across the country, in which demographics are suffering from the greatest excess mortalities.

TEST 3 -RATE OF INFECTION HAS DECREASED TO 'MANAGEABLE LEVELS' This also appears to be a test which can be easily met, when test and trace has been fully implemented. The rate of infection will naturally decrease as people remain isolated from one another during the lockdown and the mode of transmission of the virus reduces. What needs to be ensured is that the rate of infection is at a low level but also the number of confirmed and suspected cases are at low levels. This is because once lockdown measures are relieved and social interaction

2 resumes to normal levels, the Ro rate will naturally increase. It is, therefore, important that there are as few cases as possible so that the chance of transmission is reduced as much as possible. This test proves the essentiality of having an effective test and trace mechanism is in place. With the evidence as it currently is there is a very real risk of pre-symptomatic transmission, it is likely the case that people are most infectious in the pre-symptomatic stage, with viral loads and shedding2 increasing from 2.5 days before the emergence of symptoms and peaking at 0.6 days before a patient becomes symptomatic (Heneghan, Brassey and Jefferson, 2020).

There is still insufficient evidence of the possibility of asymptomatic transmission of Covid-19, but as it would appear at this moment in time asymptomatic transmission of SARS-Co V-2 is possible but appears to be a rare phenomenon. The real issue is pre-symptomatic transmission of SARS- CoV-2, and this is when patients are infected but yet to develop symptoms. Research in China shows that pre-symptomatic transmission of Covid-19 is likely and happens frequently, with one study [albeit a small sample] finding over 44% of transmissions happened through pre- symptomatic individuals, with peak transmission occurring 0.7 days before symptom onset (Slifka, Messer & Amanna, 2020, p.1). Further research was also conducted by (Casey, et al., 2020), in which it is found that the proportion of presymptomatic transmission ranged from 42.8% to 80.6% (p.2). This shows that the only way of evidencing whether the rate of infection is at manageable levels will be through testing and tracing. Once a patient becomes symptomatic it is essential all they have come into contact with are removed from the general population, as is anyone these people may have come into contact within the days preceding the initial patient becoming symptomatic. We must have sufficient capacity so all these persons can be checked.

To understand whether the rate of infection has fallen to manageable levels, we have a plethora of options available to undertake this task. I shall, however, make the recommendation for regional approaches when it comes to understanding whether the rate of infection is at a 'manageable level'. Determining what is a 'manageable level' will most likely depend on local hospital capacities and availability of PPE. Shortages of either beds or PPE will ultimately have to result in reducing the infection rate to a point where there will be no risk of the number of patients exceeding the surge critical care bed capacity. Therefore, determining that the rate of infection is at manageable levels will require several datasets to be used, to establish a regional, national (The Four Nations) and country level approach. The rate of infection can be gathered by calculating the Ro rate. This also goes to emphasise the importance and necessity of a widespread and effective testing mechanism. Data can be gathered from the number of positive tests each day, the number of hospital admissions for those with Covid-19 or suspected Covid-19 patients.

TEST 4- ENSURING THE SUPPLY OF TESTS AND PPE CAN MEET FUTURE DEMAND I have not conducted much research into this area so it would be hard for me to give an evidential judgement. But personally, it should be expected that there will be a second peak epidemic of

2 Viral load is the quantity of viral particles present in an individual. Viral shedding refers to the process of the expulsion of viral progeny after replication in a host-cell infection into the environment.

3 Covid-19, the extent to which could very well be determined by whether a vaccine has been developed and if there is a vaccination programme in place. Therefore, the NHS must ensure it has enough PPE to handle a second peak based on what the current modelling would suggest it to be like. Second peaks can in some cases be more serious than the initial first wave, such as the 1918 HlNl Spanish Flu, where most of the deaths could be attributed to the second wave. The 2009 HlNl Swine Flu initial outbreak was also followed by a second wave, in this instance it was not as serious as the first, but was still undoubtedly a significant rise in infections, fortunately in this case it was presumed that most of those infected would have mild symptoms.

I personally believe it would be in the best of interests if stores of PPE were made in time for October, to account for a second wave being at least equal to the initial outbreak. This would at least put the NHS in a strong position if the outbreak was to be more severe, or in an exemplary position should the outbreak be milder.

TEST 5 - BEING CONFIDENT ANY ADJUSTMENTS WOULD NOT RISK A SECOND PEAK (THAT COULD OVERWHELM THE NHS) The term adjustments refer to the relieving of lockdown measures and there is a very real and incredibly significant risk of the possibility of a second peak should these measures not be done in a transitory and controlled manner. The World Health Organisation has been explicit that countries must not be hasty when it comes to the relaxation of lockdown measures, and that just because the infection rate is falling it could not rise again, leading to an immediate second peak. Pandemics and epidemics can be shown to follow a standard path, in which a second peak can often follow. Professor Neil Ferguson illustrated the threat that this posed in his work in March (Ferguson, et al., 2020), and it seems to fit general pandemic epidemiology to suggest that there will be a second peak. What needs to be achieved is not counting on if, but when and thus delaying the second peak as much as possible to allow the restoration of PPE supplies, and hopefully enable development of the SARS-Co V-2 vaccine to be further down the line. Much like the other tests outlined before, evidencing this will ultimately depend on modelling, and calculating the infection rate. There will inevitably be a delay between the relieving of lockdown measures and whether there will be any increase in the infection rate. Ultimately, this emphasises the necessity of an efficient, large scale and widespread testing system in place, to identify possible cases while the patients are still presymptomatic. Calculating the Ro rate using both theoretical and data led approaches will be able to determine the risks of relieving certain measures and how they could lead to increased transmission of Covid-19, and increase in the rate of infection.

What should be the triggers for re-introducing the lockdown? The most obvious measure for the reintroduction of 'lockdown' measures to me, would be if there was any of the following events: The Ro rate climbs above 1 - this is the base number, above which we know the rate of infection of the virus will increase. But it could be safe to assume, that once the Ro rate rises above this number,

4 certain measures may need to be introduced to bring the rate beneath 1. (It may be decided that a number higher than 1 would be acceptable, but that would need to be determined by epidemiologists.) If a vaccine is developed and a vaccine programme implemented, or should new research suggest that it is possible to develop an immunity to SARS-CoV-2 then instead of 3 consulting the Ro value, modelling would need to be based around the RE value • If the RE value starts to rise, it would be indicative of an increase in the rate of infection and hence there could be new outbreak and second peak epidemic. The death rate begins to rise - this would be dependent on the rate infection. If the rate of infection was falling but the fatality rate of Covid-19 was increasing, then action must be taken. This could indicate mutations to the virus which make it more lethal, or that our health system in its current form is being overwhelmed or unable to provide the healthcare facilities necessary. There is a shortage of PPE available or the supply lines of PPE are significantly disrupted. The nature of this would be dependent on when this metric is used. For example, if during a second peak there was a shortage of PPE it would be safe to assume that the country would already have lockdown measures in place. For this metric to be used, it would be if there was either no available PPE stores left to replenish medical facilities or if the rate of infection is increasing and it can be determined that the demands for PPE would outweigh current stores. Hospital Occupancy Rates - this metric would be useful when combined with infection rates and the Ro rate. This would be a measure best applied during the winter flu period. If hospitals were already having high occupancy rates as a result of the flu season, then measure may need to be considered to reduce the strain on the NHS. I have already asserted that I believe the best approach could be that of a local or regional nature and thus this would work effectively alongside monitoring the bed occupancy rates in hospitals. Staff Sickness Levels - this metric is similar to the aforementioned 2. If staff sickness levels (regarding Covid-19) are high, then it can be understood that the capabilities of the hospitals to handle an outbreak would be severely strained. Outbreaks in other states could act as a lead indicator of whether a lockdown in the United Kingdom would be necessary. To the extent that this will determine a lockdown being necessary will depend on several factors. For example; Does the UK still have a quarantine policy in place? Does the UK receive a large number of visitors from the affected country? Is the UK following any trends that affected countries had shown? Are we tracking similarly? Has this country locked down and how severely will this impact our PPE supply lines?

What data is available to make these decisions? Is that data sufficiently robust? I am not sufficiently versed in this area to make an informed argument. If I was to choose data, I believe the data used should come from hospital trusts and local health authorities. These are the "frontline" in the fight against Coronavirus and are best able to provide essential data needed. Hospitals and care homes will best be able to keep track of their demand for PPE, as well as the bed

3 The RE value is the effective reproduction rate - average number of new infections caused by a single infected individual in a partially susceptible population. The Ro rate considers the whole population to be susceptible.

5 occupancy rate and staff sickness levels, so it will be easiest to determine their capabilities. Data can also be gathered from hospital trusts and local health authorities to determine rates of infections as well as the Covid-19 death rate in hospitals or the locale.

From my understanding there are issues with the accuracy of the Ro rate when infections have dropped to low levels. In my opinion, it would be best suited to have a widespread track and tracing system to determine the Ro rate rather than using solely mathematical models. Mathematical models and simulations while useful are also prone to errors should the data or numbers used be incorrect. But that is not to say that both approaches data and theoretical should not be used together, as this will help act as a means of ensuring consistency in the Ro/RE rate and improving the accuracy.

To what extent should there be alignment throughout the UK on the response to Covid-19, and ending lockdown restrictions? To what extent is there scope for divergence in policy for devolved administrations and local authorities, in particular in relation to easing lockdown restrictions and Covid-19 testing capacity? In principle, there is a significant rationale and justification for there to be a reduction in centralisation when it comes to handling the relaxation of lockdown restrictions and testing capacity. I will say this firstly, I am by no means qualified from a constitutional and legal perspective to provide any answers or opinion on how best devolution and local authorities can best handle testing capacity, so my comments on this area will be sparse and lacking. The nations of Northern Ireland, Scotland and Wales all have devolved powers under the remit of healthcare, and I personally believe the handling of Covid-19, the relaxation oflockdown and any re-introduction of measures or responses deemed necessary will be best managed and implemented at the local level. The devolved nations are I believe in the best position to determine the scale of testing necessary, and when it comes to releasing lockdown measures.

Data has already shown there are significant discrepancies and variations in the Ro rate of coronavirus across the country, and the notion of a 'one size fits all' policy to me seems illogical. There is a consensus amongst all that the response by German authorities to Covid-19 was phenomenally successful. The response was led by the federal nature of Germany, in which the 16 states have devolved powers regarding healthcare. It is therefore, of my opinion, that the United Kingdom, has the ability and possibility to learn significantly from the response of the German authorities especially under the context of devolution. I would argue that the United Kingdom for the short term needs to grant greater autonomy to regions in the UK, and not have the four nations with devolved power deciding policy, or worse still centrally enacted legislation.

There is definitely scope for divergence in policy among the devolved powers, all having remits under healthcare, and any healthcare policies chosen would not conflict with any reserved areas. Therefore, I believe strongly that the four nations (if a local or regional approach is not feasible) should be able to determine the necessary measures need to supress the spread of Covid-19, ensure

6 their healthcare facilities are capable for any resurgence of Covid-19 and ultimately ensure the necessary testing is carried and determining [if applicable] which areas should be of priority for testing. However, an important caveat should be that there is central government oversight of the devolved regions and there should be an accepted level of standards which needs to be maintained to ensure consistency across all of the United Kingdom, i.e. levels of testing and commonality on the reporting of figures. In regard to testing there should be a central collative body who will ensure data is distributed to the appropriate authorities and determining rates of infection. But in general regional and local teams will have full responsibility over testing. David McCoy wrote in that countries which adopted decentralised approaches worked best such as in Germany where there were 400 decentralised teams and in Kerala which maintains a decentralised health system (McCoy, 2020).

We have seen the devolved powers already acting with a degree of independence during the coronavirus crisis, for example Scotland delaying the relaxation of lockdown measures compared to England. This approach I believe is necessary to handling the Covid-19 outbreak. While this has demonstrated the capabilities for devolved powers, I believe that further divestment would be in the interest of all parties for handling the relaxation and the need for implementation of new measures.

I am not well versed in the area of capacity testing in terms of knowing the regional capacities as they stand presently. I don't believe in my opinion that there are any areas where there should be a divergence in policy when it comes to basic testing practices, that is test as many people as possible. The concept of 'test, test, test' was explicated clearly by Dr. Tedros on many occasions and it still stands that there is a consensus that the most effective way of combatting any new outbreaks of Covid-19 is through a thorough and effective test and tracing mechanism. There should be no divergence in this among the devolved nations as this has been shown to be the most effective way of handling Covid-19. As discussed at Chatham House on the Weekly Covid-19 Pandemic Briefing, there needs to be a stronger focus on epidemiological responses such as testing, tracing and containment. National lockdowns will soon become a disproportionate response to outbreaks and instead focus should be on removing individuals with Covid-19 from the general population. That is not to say that national lockdowns should no longer be considered as an approach as it could still be an essential response needed if there was to be a second peak epidemic, sporadic4 cases of Covid-19, or the Ro rate rising too high above 1 across the entire country.

Recommendation: I believe an approach for the releasing oflockdown measures should be like that of a county-level administration. Under this model hospital trusts would report Covid-19 infection rates to the local health authorities, who in turn would discuss with the local councils the best approach for the area, whether this be a full and total relaxation of all lockdown measures, or implementing new

4 Sporadic here referring to clusters of cases emerging in various areas with no common links between the outbreaks.

7 lockdown measures. This approach to me would enable quicker and more localised responses which could increase the effectiveness of reducing the spread and transmission of the coronavirus. At the very least regional approaches to Covid-19 should be considered, as this could prove to be the most effective way of reducing transmission from region to region and ensuring that necessary specific precautions can be taken to keep the Ro, infection and death rate at manageable levels.

I make a further recommendation or suggestion for consideration regarding the alleviation of lockdown measures and the possibility these measures may need to be reinstated. There is no doubt, that there are significant costs associated with Covid-19 and certain industries have been directly affected more so than others. Should the evidence suggest the United Kingdom is approaching a second peak epidemic, the evidence could come from second peaks occurring in other states, especially those which were first affected by the coronavirus outbreak, or an increase in the number of people becoming infected from Covid-19. Dr Mike Ryan from the WHO stated that despite coronavirus infections falling a too sudden relaxation in measures could lead to an 'immediate second peak' and that there is a very reasonable expectation of a second peak'... there will be a first wave... and then it recurs months later... that may be a reality for many countries' (Reuters, 2020). Then the course of action the United Kingdom could take [dependent on the circumstances and the severity] the approach of a discriminatory lockdown. The gist of this is, people would be categorised and banded based on the risk Covid-19 posed to them based on arbitrary generalisations. For example, a 70-year-old male patient with heart disease and COPD would be in a higher band, than an 18-year-old female with no underlying health risks. These bandings would however be determined for an entire household/bubble, with the highest banding being the determinant of all individuals. By adopting a banding/categorisation method to the lockdown, the United Kingdom could enable individuals to meet with social distancing requirements in place, and also allow some more businesses to operate, reducing the economic cost to the country, and granting greater freedoms to individuals. Ultimately, there is the very real possibility that the second peak epidemic could be significantly worse than the initial outbreak of Covid-19 in the UK. This would be especially true if combined with a 'bad' flu season. This categorisation method for a new lockdown would build off the existing social shielding measures but in a more dynamic and fluid manner.

June 2020

References: Casey, M., et al., (2020) 'Pre-symptomatic transmission of SARS-CoV-2 infection: a secondary analysis using published data', medRxiv, doi: https:// doi.org/10.1101/2020.05.08.20094870

Dunhill, L. (2020) 'Exclusive: Critical care unit overwhelmed by coronavirus patients', https://www.hsj.co.uk/news/exclusive-critical-care-unit-overwhelmed-by-coronavirus- patients/7027189.article, Date Accessed: 11th June 2020

8 Ferguson, N., et al., (2020) 'Impact of non-pharmaceutical interventions (NPis) to reduce COVID- 19 mortality and healthcare demand,' Imperial College London, doi: https:/Idoi.org/10.25561/77482

Heneghan, C., Brassey, J., & Jefferson, T. (2020) 'SARS-CoV-2 viral load and the severity of COVID-19', https://www.cebm.net/covid-19/sars-cov-2-viral-load-and-the-severity-of-covid-19/, Date Accessed: 8th June 2020

McCoy, D. (2020) 'Countries from Germany to Vietnam got test and trace right, so why didn't England?', https://www.theguardian.com/commentisfree/2020/jun/16/germany-vietnam-test- trace-england-coronavirus, Date Accessed: 17th June 2020

Reuters (2020) 'WHO warms of 'second peak' in areas where COVID-19 declining', https://www.reuters.com/article/us-health-coronavirus-who-peak/who-warns-of-second-peak- in-areas-where-covid-19-declining-idUSKBN2311VJ, Date Accessed: 3rd June 2020

Slifka, M.K., Messer, W.B., & Amanna, I.J. (2020) 'Analysis of Covid-19 transmission: Low risk of presymptomatic spread?' College of American Pathologists, doi: 10.5858/arpa.2020-0255-LE

World Health Organisation (2020) 'Coronavirus Disease (COVID-19) Situation Report - 141', https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200609-covid-19- sitrep-141.pdf?sfvrsn=72falb16 2,

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