In March 2022, the UK government launched an independent public inquiry to “examine the UK’s preparedness and response to the COVID-19 pandemic.” For several weeks, the Inquiry held a public consultation to determine what its terms of reference ought to be for the investigation moving forward, consulting with affected families, charities, and healthcare institutions. As one such institution, Collateral Global submitted its own response to the Inquiry’s Terms of Reference, which we have reprinted below.
1. What organisation are you submitting feedback on behalf of?
Response: Collateral Global, Charity No. 1195125, www.collateralglobal.org
2. Do the Inquiry’s draft Terms of Reference cover all the areas that you think should be covered by the Inquiry? (Yes/No answer)
Response: No
3. Please explain why you think the draft Terms of Reference do not cover all the areas that the Inquiry should address.
Response:
There are three key reasons:
- The stated purpose of the inquiry is vague: “produce a factual narrative account” risks delivering a description of what happened, rather than examining the underlying causes. The purpose of an inquiry should be to ask ‘why’, and not merely to describe the ‘what’ and the ‘how’.
- The inquiry needs to make a clear distinction between the pathology of the pandemic – i.e. the transmission of SARS-CoV-2 and the harm caused to those who suffered from the disease – and the responses to the pandemic that were put in place by the Government, and other institutions.
- The scope of the TOR is not broad enough: alongside economic, health and care sector responses and the public health response, the inquiry must address the entire range of impacts from the government’s policies.
4. Which issues or topics do you think the Inquiry should look at first?
Response:
There are two critical questions to be answered:
- Have the responses been effective in meeting their stated objectives, namely reducing mortality and morbidity from COVID-19?
Mandated Non-Pharmaceutical Interventions (MNPIs)
- What evidence was there available before and during the pandemic for effectiveness of the MNPIs that were implemented? How was this evidence incorporated into decision making?
- What conceptual frameworks were considered? On what basis were they selected? How was the uncertainty in prediction assessed?
- Did the interventions result in a reduction in mortality and morbidity from COVID-19?
- Could better results have been achieved using these MNPIs differently, or at different times? Could better results have been achieved without these specific MNPIs?
Vaccination rollout
- What evidence or frameworks were used for the vaccination strategy, and what alternatives were considered? To what extent did the rollout of the vaccine result in a reduction in mortality and morbidity from COVID-19?
- How can we ensure that more/better evidence is available in future? How can we ensure that it is properly incorporated into future decisions?
- How can we quantify the short, medium and long-term collateral effects of these interventions?
While the effectiveness of the splash of intervention can be measured more clearly as the scope of the policy was clear, some of the ripple effects have only become apparent over time (and this includes both positive and negative effects).
We should consider the following questions when assessing each ripple effect:
- What evidence was there available for this issue?
- Was that evidence incorporated into decision making?
- If so, how was it incorporated into decision making?
- How can we ensure that more/better evidence is available in future?
- How can we ensure that it is properly incorporated into future decisions?
A comprehensive list of collateral effects (both positive and negative) along with supporting research can be provided by Collateral Global – the spreadsheet is too long to include in this submission. They include but are not limited to:
Physical health:
- Changes in life expectancy
- Missed non-emergency surgical procedures, medical appointments, and routine treatments including screening and vaccinations (for example, due to “stay at home” messages or fear of contracting the virus)
- Physical health effects (for example obesity)
Mental health:
- Mental health problems (including addiction, depression, anxiety, OCD, eating disorders, self-harm, suicide)
- Impacts of fear (of catching COVID-19, health concerns, job losses and other economic concerns)
- Rates of neurodevelopmental disorders (for example ADHD, tics, ASD)
- Loneliness and isolation
Societal impacts:
- Divorce rates, foster care referrals, and relationship problems
- Welfare, including domestic abuse
- Changes in civic participation (for example voting, volunteering, community support)
- Infant, child and elderly welfare, including end-of-life care
- Effects of changes in life experiences, including missing out on life events such as weddings or funerals
- Reduced access to community facilities, such as sport, culture and religion
- Widening social inequalities (for example in income, educational attainment)
Educational impacts and other impacts on young people:
- Impact on education standards, not just attendances
- Impacts on speech and language development
- Neglect, referrals to social services and number of children taken into care, as well as those now ‘missing’ from the system following school absences
Workforce and economic impacts:
- Changes in time use (for example commuting)
- Loss of employment and changes in economic activity
- Impact on economic sectors (e.g., leisure, hospitality, sport, the arts) as well as impact on future GDP from initiatives such as the furlough scheme
- Impact on levels of support for employed, self-employed and unemployed
- Impact on areas of differing socio-economic status
- International responsibilities, and impacts of UK policy choices on international partners, including increased migration pressure
Environmental impacts:
- Environmental changes (e.g., air pollution levels, wildlife)
- Increase or decrease in road accidents
To account for all the ripple effects of policy decisions in future, the following ten steps ought to be taken to both minimise harms caused and allocate resources most efficiently.
- Determine reason for action (e.g., COVID-19)
- Propose intervention (e.g., MNPIs)
- Define expected outcome (e.g., change in mortality rate)
- Identify ripple effects in each sector (e.g., child welfare, loneliness, etc.)
- Quantify effects in each sector (e.g., expected effects of loneliness)
- Aggregate across sectors into a set of metrics (i.e., QALYs, WELLBYs)
- Monetise benefits and harms (note: could skip this stage)
- Compare to costs (i.e., cost-benefit analysis or cost-effectiveness analysis)
- Account for distributional concerns (equity weighted CBA or CEA)
- Make decision based on expected effects (compared to counterfactual)
The process of going through each step – especially steps 4 and 5 – ensures that the important downstream effects of policy are properly accounted for. These consequences might affect a population group that is largely ignored (such as young adults who do not go to university), a dimension of wellbeing that falls between the cracks of government departments (such as loneliness), or that will occur sometime into the future (such as the effects of childhood development on later life).
During the COVID-19 pandemic, step 3 – the expected splash – dominated decision-making, whilst steps 4-9 – properly accounting for the ripple effects – were largely bypassed. One reason for this is that these effects could not be quantified in the same, relatively easy, way as mortality risks. It does not follow, however, that they cannot be quantified at all.
While it is not our role to pre-empt the conclusions of the inquiry, we would like to see a framework developed that will ensure that future policy decisions account for their full effects and set an independent benchmark against which the public inquiry can be evaluated.
5. Do you think the Inquiry should set a planned end-date for its public hearings, so as to help ensure timely findings and recommendations? (Yes/No answer)
Response: Yes.
6. How should the Inquiry be designed and run to ensure that bereaved people or those who have suffered serious harm or hardship as a result of the pandemic have their voices heard?
Response:
The Inquiry should make a clear distinction between those who have suffered as a result of the SARS-CoV-2 infection, and those who have suffered as a consequence of the medical and non-medical interventions and policy responses. The inquiry should ensure that representative voices from those who suffered hardship or harm during the pandemic are listened to, whether that harm was physical, social, mental, or economic.