Written evidence submitted by Bristol Care Homes (CLL0015)

In politics, academia, and public debate, there is much contention over the best strategy to counter Covid-19. In this note, I seek to develop the case for a targeted strategy.

The main options for a counteractive strategy are

a targeted protection strategy
a blanket lockdown strategy

It must be the case a priori, that i) if a limited typology of more vulnerable groups exists and ii) if it is possible to adequately protect those groups, then a targeted strategy is best.

Contrarily, iii) if the virus strikes at random or iv) if there are high vulnerability groups, but they can’t be adequately protected or v) if a target strategy has not been implemented and infections, hospitalisations and deaths are rising or vi) if there is low compliance to a target strategy, then a blanket strategy is needed.

A targeted strategy would also need to include general population risk reduction through proper infection control including disciplined use of masks, hand sanitisation, and social distancing. These have been inadequate in UK practice eg crowded summer beaches, late night city revelling, only recent widespread use of masks etc, so that a targeted strategy has not been fully trialled.

I try to set the above scenarios out in this table.

	A limited number of vulnerable groups can be identified	The virus strikes at random
Vulnerable groups can be well protected This is done ahead of infections/deaths	Target strategy is best	Blanket strategy is needed
Vulnerable groups cannot be adequately protected	Blanket strategy is needed
A target strategy has not been implemented and infections, hospitalisations and deaths are rising	Blanket strategy is needed
A target strategy meets with low compliance	Blanket strategy is needed

Yellow highlighting shows the conditions under which a targeted strategy is best.

Blue highlighting shows the current UK position, where a lockdown may once again be inevitable, but could have been avoided.

Do the conditions for a target strategy exist? It does seem possible that a limited typology of more vulnerable groups can be identified.

The latest ONS data shows

Total all cause excess mortality	59,275	As %age Covid excess deaths
Less deaths with comorbidity*	5,000
Less non-Covid deaths	13,299
Total Covid caused excess deaths	40,976
Excess deaths in care homes	21,239	52%
Excess deaths >80s	10,149	25%
Deaths in other groups	9,588	23%

*this figure is estimated as a percentage of care home deaths

Care home residents and people >80 in the general population thus account for 77% of excess deaths due to Covid. Analysis of the same data shows that availability of full PPE plus rigorous infection control procedures have reduced infection rates and excess care home mortality to zero, indicating that these two groups can be properly protected by targeted strategies. I have no typology classification for the 9,588 deaths beyond these two groups. This would be necessary to reach any complete analysis sufficiently reliable for policy formulation, but is presumably available within government data. If these deaths are random and don’t fit any typology, then blanket lockdown becomes necessary.

The choice between blanket and target strategies arises with regard to i) whether to impose total lockdown, but also ii) whether to quarantine whole groups rather than identified individuals when lockdown is not in place. The current practice of quarantining all school years, university students, people returning to the UK, and individuals having contact with positive cases, quarantines whole groups, over 90% of whom are uninfected. Testing of all such groups, and quarantining only positive cases, must surely be a better solution. More importantly it would increase compliance, which is running dangerously low under the current strategy.

In summary

A limited typology of vulnerable groups can be identified
These groups can be adequately protected
Type analysis of the remaining 23% of Covid deaths is needed to be more certain
Compliance would be higher under a targeted strategy
A blanket strategy causes much wider social harm than a targeted strategy
A blanket lockdown strategy cannot be a permanent solution, and as an on/off strategy has worse total outcomes than a fully implemented target strategy
There is a danger of civil disobedience and even unrest from repeat lockdowns
The WHO envoy on Covid, David Nabarro, supports a targeted strategy.

We are, however, where we are. Government failure to implement a targeted strategy by having no PPE available in March, and no adequate trace, test, and isolate system developed since March, may leave us no choice but to enter the very much second best of a second lockdown. Government and their scientific and medical advisers need to account for these failures, and to demonstrate a pathway to a fully specified target protection strategy which has never so far been properly implemented.

Geoff Crocker

Chair

Bristol Care Homes

Nov 2020