Perils of Dunning-Kruger in health reform

A commentator recently decided to write an article in a regional newspaper about Northern Ireland’s Health Transformation. The article, unfortunately, was demonstrative of two fundamentally problematic aspects of human psychology – firstly, the huge bias towards existing systems even when they are clearly no longer functioning properly; and secondly, the now oft cited but itself frequently misunderstood “Dunning-Kruger” syndrome.

Let us start with the second. The article referred to stroke services, and specifically to the commonly advertised warning factors outlined as “FAST” – face, arm, speech, time. The article focused on “time”, complaining that someone who has had a stroke, under Northern Ireland’s proposals for reshaping stroke services, might have to travel further – thus losing precious “time”.

This, unfortunately, was a classic case of “Dunning-Kruger” as it actually is. Dunning-Kruger is not about ignorance, nor about stupidity; it is quite specifically about people who know something about a subject but, precisely because they do know something, they think they know more than they do.

In this case, the “time” referred to in “FAST” refers to the symptoms for any one of us to look for before calling the emergency services and declaring a suspected stroke – the “time” refers to calling 999 (or the relevant emergency number) immediately upon identifying them. It does not, however, refer to the time taken transferring a patient to a hospital from the site of the stroke; in fact, the evidence has been clear since 2006 (and was reinforced by a consultation document published in Northern Ireland in 2019) that what is important is initial stabilisation followed by a transfer to the right hospital, i.e. one with a highly specialist stroke unit.

The problem at the moment is that those highly specialised units do not exist in Northern Ireland; furthermore, the key specialist treatment which can overcome almost absolutely the impact of any stroke (known as “thrombectomy”) is available only during work hours five days a week. I know a little about this, because a year ago my own mother had a severe stroke – and its impact was made more severe by the fact she had the misfortune to have it late on a Friday, the worst possible time to have one as there were no specialists available anywhere until the Monday. This, self-evidently, is complete nonsense – the system should obviously be replaced by hyperacute units with specialist staff operating 24/7, and that is the proposal in the reconfiguration put forward in 2019. Yet, in 2023, it is still not agreed – precisely because too many politicians (and commentators) cannot get their heads around it because they think they understand modern stroke treatment better than they do. Precisely, because of Dunning-Kruger, in other words.

This brings us to the first point, which is perhaps linked. Let us disappear back in time and across the Atlantic to understand it. In 2000, Blockbuster Video stores were everywhere – the logo was as evident in high streets as Starbuck’s (anywhere) or Greggs (in the northern UK) now. That year, the all-conquering chain had the opportunity to buy a fledging competitor for just $50m. Seeing no benefit from doing so given that any competition would surely be crushed anyway, the option was declined. That fledging competitor nobody had ever heard of was Netflix.

In 2023, Netflix actually does the precise same thing Blockbuster did a quarter of a century ago; it enables you to watch things you want to watch when you want to watch them in your own living room. However, it does it in a completely different way. Blockbuster’s determination to stick not only to the same outcome but to the same process proved to be its undoing, so that a competitor that was once so small it was not worth buying ended up not just overhauling it but taking over its once dominant market position. The same will happen to Netflix in due course.

We have the same fundamental issue with health services. Increasingly, in the 21st century, “health” will be provided at home – via telemedicine (essentially technology), domiciliary care (with carers gradually trained up to be front-line medics), district nursing and so on. Artificial Intelligence will replace (actually, is replacing) scanners meaning that health professionals visiting your home – or even you yourself – will be able to take scans and, for example, identify clots or tumours immediately before you have even travelled to any sort of clinic or treatment centre. This is not some distant future, by the way – it is already happening. When asked at a recent conference why Denmark had shown the best improvement for cancer survival of 17 comparative countries since 1995 (Northern Ireland was bottom of the list), the Danish delegate said that his country had been the quickest to embrace healthcare in the home (and it is fair to add that Northern Ireland has been the least quick, with far too many people in hospital for far too long even compared to neighbouring jurisdictions). Healthcare in the home with “hospitals” providing regional specialist services is not just the future, it is in any successful system already the present. The thing is that those of us brought up an an era where “health” meant “hospitals” cannot quite get our heads around it – in the same way Blockbuster executives couldn’t get their heads around the point of Netflix.

This comfort with the status quo even when it is plainly outdated is itself, perhaps, a form of Dunning-Kruger – that notion that knowing something about a subject means knowing more or less everything about it. We should beware, however, that asking a commentator to write about health systems is as likely to lead to sensible commentary as, for example, asking me to carry out a Polish translation because I wrote a book about Western European languages. Polish may be a language, but it is not Western European and, in any case, translation is a specialised skill so I could not actually do it even in a language I speak relatively well.

By maintaining our health services as they were more or less in the 20th century, we are causing serious harm. Reshaping stoke services is just one example of the huge transformation ahead – perhaps we should use the word “modernisation” rather than “transformation” to help communicate this. Most of all, however, beware Dunning-Kruger…

“The Traitors” was compelling because it was real life…

The UK has not been doing much right recently, but I suspect it did produce the best version of “The Traitors“, which aired on the BBC over Christmas. By ignoring the original Dutch version’s selection of celebrities as contestants, and also by avoiding the trap the Americans fell into of intentionally ratcheting up tensions by using contestants from previous reality TV game shows, the UK version gave us a direct and compelling insight into human psychology. All versions were correct to identify the traitors from the outset – this in fact added to the drama, in a similar way to the famous detective series Columbo became extremely popular precisely because the viewer knew who the perpetrator was from the outset. Revealing the outcome is not the point; watching others work it out is the entertainment.

Put more simply: it was a superb demonstration of exactly what is right, and wrong, with human civilisation! Let us look at how…

Spoiler alert: I do not intend to name winners and losers here (for those still wishing to watch the UK version, be it on BBC iPlayer in the UK or elsewhere), but inevitably some of the points I raise will require reference to the actual show outcome.

Delusions of ability

One of the most obvious early factors in the game was the assumption by some contestants that they were good at a certain thing because of who they were – for example, that they could identify liars because they themselves were actors, or some similar sentiment.

This is a version of an old classic – 90% of drivers think they are of above-average ability at driving. Clearly, this cannot be so.

More specifically, we tend to think of ourselves as less likely to be the victim of plots or scams. Those are things which happen to gullible people – but none of us likes to think of ourselves as gullible.

Yet we all are – as the contestants soon found!

These delusions of ability, in real life, can be quite stark. They cause significant problems in all walks of life, and explain why completely deluded charlatans like Liz Truss end up as Prime Minister (and don’t even realise how terrible they are at it when they attain the position they should never have attained).

Herd mentality

One of the most remarkable psychological aspects of the show happened towards the end when, with three men and three women left in, literally all of the contestants agreed that the/a remaining traitor must be male – which was, in fact, entirely sound logic.

Yet, when it came to the round table, all six voted for women!

They knew, and had indeed discussed, that if there were one remaining traitor it would be a man – regardless of whether they were “traitor” or “faithful”, they all recognised this would have to be the assumption and that they would have to vote accordingly. Yet none did.

Ultimately, this came down to herd mentality, which was common throughout – one name got mentioned early in the round table discussion, and then other contestants could not remove that name from their consideration even if they had never previously considered that name. Indeed, this also occurred at the start of the show, when they almost all voted for the same contestant (with no evidence and, of course, wrongly, as she was a “faithful”) on the basis simply that her name was mentioned.

This is a problem in everyday life too; most notably, perhaps, it is why meetings and committees fundamentally do not work. Ultimately, far too much relies on who speaks first and on which idea the group gets stuck on. It is very hard to get an idea out of a committee’s collective heads, even if the idea is in fact nonsense; indeed, studies show just how common it is for committees to end up making decisions that no individual on the committee really agreed with (despite having put their hands up to vote for it).

Recency bias

Another issue with that bizarre “banishment” of a female contestant when they had all agreed to go for a male was that she was consistently singled out simply for having added some information about herself later in the series.

This became a sort of “recency bias”; contestants could not get it out of their heads that she had added the information and thus homed in on the idea that she must be some kind of liar. The fact she had added information did not make her a liar – she had never lied; indeed, she had gone out of her way to add information about herself. Yet, far from being rewarded from this, she was ultimately banished (wrongly, as she too was a “faithful”) simply because other contestants could not let this irrelevant and in fact erroneous notion that she had “lied” out of their heads.

Again, “recency bias” is a massive problem in society, perhaps most obviously in the news cycle in the social media age. Shorn by 280-character tweets or 10-second tiktok clips of any sense of long-termism, our entire discussion – both in terms of how we pick our priorities and in terms of what we say about them – is incredibly short-termist. This means we are probably more inclined than ever to get recent ideas into our heads that we just cannot shake, even when it would become apparent if we gave them any actual thought that they are plainly irrelevant or clearly erroneous.

“Knowing” someone

One constant feature of the series was the sense in contestants that they “knew” each other. In fact, they had only met each other a few days beforehand (a key reason, in my view, that the UK version was so well done – in the US version, this was not the case).

Yet, despite the obvious fact that in fact they did not know each other at all, they came to believe that they did. Viewers were constantly treated to statements of certainty that so-and-so was “100% faithful” from other contestants – yet this was as likely to be said about a “traitor” as it was about a “faithful”.

This is also what underlay the sense of “betrayal” when contestants added extra information about themselves; there was this underlying idea that they all “knew” each other so well already (despite only having actually met a few days earlier) that any added information had been someone “kept secret” and therefore constituted a “lie”. Essentially, three contestants ended up “banished” on this entirely illogical and nonsensical basis – all three were “faithful” and none had, by any reasonable definition, lied. In fact, they were probably the three contestants who had been most open about their personal lives. (Did we know the relationship status and full career path of the other contestants? No we did not…)

The notion of “knowing” someone is in fact a well known bias in everything from choosing (or indeed rejecting) a romantic partner to voting for a particular candidate at elections. If we feel we “know” someone, we tend to be biased about them: often, this works in their favour – who doesn’t want their child’s teacher’s cousin’s mate in elected office so that when they appear on the news we can claim we “know” them? Sometimes, it works less well – for example, we may reject a romantic advance from someone on the basis that we put too much store on one particular thing we know about them (say, that they prefer dogs to cats when we prefer cats to dogs) even though there is a lot we do not know about them (say, their favourite holiday destinations or preferences in household financial management, which are probably more important in the long run and may be entirely aligned). We get obsessed by small pieces of information thinking they are large pieces of information ultimately because we think we “know” someone, when in reality they are no more familiar to us than the person standing behind us in the shopping queue.

Trust

Similar to this is the human desire to seek out love and trust (which most would probably see as interlinked).

Remarkably, contestants were very liberal with the phrase “I love you” (one I would use only with my immediate family and very specific close friends of decades-long standing), even when “banishing”. They spoke with considerable certainty about how much they “trusted” fellow contestants – even though those fellow contestants were in fact practically unknown to them and were actually opponents for a prize amounting ultimately to a six-figure sum. This was a clever aspect of the challenges built into the series – the challenges did, in fact, require a degree of trust and teamwork – leaving contestants to rely on people who could be “banishing” or “murdering” them just hours later.

The desire to seek love and trust is often an uplifting aspect of human nature, but it can also be extremely dangerous. For example, it plays a key part in scams, where (typically lonely but by no means stupid) people are brought into a stranger’s trust and then deceived – almost exactly, in fact, as on the show (this is in fact something one of the “Traitors” was open about in the media after the series ended and even in interviews during the episodes). We cannot go through life without trusting people, but knowing when we can and when we cannot is the key – and it is not easy, as the contestants found out!

Words don’t matter

Interestingly, contestants also said of themselves that they were “100% a faithful” – this was the specific term adopted. It did not seem to occur to them that this phrase was meaningless – every contestant was going to say it, whether they were or they weren’t. Words, to some extent at least, simply do not matter – actions do (or should).

In fact, on another version of the show, the lone winner was a contestant who had started out as a “faithful” but switched to be a “traitor”. She made the point, in media afterwards, that she never once said in as many words that she was not a “traitor” or that she was a “faithful” after the switch – but she noted that everyone believed she was still a “faithful” without her needing to confirm it (albeit mendaciously) in words.

We all know the lesson here. Words are a very low share of communication. Testing someone by making them say something is close to pointless. Put another way, demanding everyone makes the same commitment openly while knowing some are not committed behind closed doors renders the making of the commitment pointless. There are lessons there for every walk of life, from work to politics.

Refusal to shift viewpoint even when evidence shifts

At the roundtable discussions, the brutal truth is that contestants were utterly hopeless at identifying “traitors”. Some of the reasons are outlined above – they were deluded about their ability to pick them, they followed the first thing that was said without properly analysing it, they went with the most recent point made regardless of its relevance, they felt they knew and trusted people that they did not know and should not have trusted. Another reason, simply, is that our instinct for such things can be very poor.

Notably, on all versions of the show bar one it has taken at least six episodes for a single “traitor” to be identified (and banished) – and in fact the norm is for a “traitor” (or even “traitors”, plural) to win.

In other words, the ability of contestants to pick a “traitor” at the roundtable has been zero – on all versions of the show, when they did get a traitor, it was either pure chance (the odds are that they will get one sometimes even if selecting purely at random, after all) or because another “traitor” voted for a contestant (knowing that they were a “traitor”) and managed to persuade others to do likewise.

Spoiler alert: now I am about to write a couple of paragraphs which, while not identifying the winners, do hint at what happened in the last couple of episodes of the UK version.

In fact, even on the UK version, the only reason a “traitor” did not win was that another “traitor” cryptically warned the remaining contestants about him in the knowledge that he himself was about to be “banished”; and even at that, one of the winning contestants still refused to believe that a contestant who was a “traitor” actually was and thus did not act on this information despite the risk analysis being 100% in favour of acting on it; that contestant would not have been among the winners (and indeed would have ceded all the prize money to a single “traitor”) but for two fellow contestants heeding the warning.

In other words, one contestant was so committed to a narrative that had another contestant as a “faithful”, that there was no shifting of this narrative even when the evidence clearly shifted and the risk was entirely with sticking with the (obviously false) narrative. What this shows primarily is our bias towards building a story of things in our heads and refusing to shift from this story even when it is plainly in our interests (and probable based on the evidence) that we should do so. If you want to know why politics is such a mess, now you know…

If I can’t have it, nor can you…

Of course, the UK version also had a contestant, realising his hopes of victory had gone thanks to the deception of another contestant, then throwing that contestant under the bus for no reason other than that he could do so. He gained nothing from doing so himself, but felt it necessary to even up the score – or, more to the point, to ensure he and the other contestant ended up scoreless.

This is again human instinct, and it shows how everything from politics to competing for promotion in a bureaucracy can turn into a zero-sum game.

Don’t get ahead of yourself…

Of course, one other obvious problem with human society demonstrated on the show was that contestants who did show some aptitude for identifying the “traitors” were then “murdered” by them, precisely because of that aptitude. In fact, one of the “skills” required to win the game, particularly by a “faithful”, was not to show any discernible ability at picking “traitors”. “Faithfuls” presenting themselves as fairly clueless tended to survive both “banishment” (as they drew few rivals and created little attention) and “murder” (as they were no danger to the “traitors”).

This is the classic problem with bureaucracies. Those down the ranks who show any discernible talent are not promoted for it, but rather ganged up on – precisely because they are a danger to those further up. Rather than competing on aptitude, those further up may simply choose to ensure they are, well, maybe not “murdered” but quite possibly “banished”. In the long run, this ends up with those not demonstrating aptitude being promoted… (look up “Peter Principle” for more on this…)

Teamwork and tribalism

For all that, teamwork (cooperation in general) is an essential aspect of humanity, and indeed central to the success of the species going right back to the Bronze Age and well before it. The challenges were an essential part of the show because they created bonding towards a common goal – it was in all contestants’ interests to add money to the prize pot.

Successful societies are those which have a lot of “challenges” but very few “roundtables”!

Nevertheless, teams can also be funny things. Contestants ended up identifying strongly with their status either as “faithful” or “traitor” (to the extent that one, given the chance to switch and with it clearly in her interests to do so, simply could not). This is, and I am using the term in its original rather than in any cynical sense, “tribalism” in its basic form. In fact, the assignment one way or another was fairly random (albeit based a little on personality profile), so whether someone was a “faithful” or a “traitor” was very little to do with any talent or ability that they had. Yet it did create a sense of belonging – contestants were genuinely agitated by other contestants accusing them of not being “faithful” when they were, not just because it could see them eliminated from the game but also because of a genuine sense of attack on their game identity and affiliation; and, as noted above, they wanted to believe fellow contestants that they liked were of the same (“faithful”) identity even when they were not.

Again, we see this in so many walks of life – from partisan politics to celebrations of patriotism to the selection of sports teams to support. We feel insulted if our loyalty to the group is called into question; yet in fact this can reach the stage that loyalty requires such a performance that those who are disloyal cannot be meaningfully distinguished from those who are genuinely loyal.

Past success bias

When the “faithfuls” finally did get a “traitor”, they thought they had cracked it. They then, of course, became complacent or even arrogant. Believing they now knew how to identify “traitors”, they in fact missed that the runner-up in the vote which saw the first “traitor” eliminated was also in fact a “traitor”, to the extent that he received no votes at the next roundtable and in fact only one contestant ever subsequently voted for him to be “banished” until the end! They had also missed that the only reason they got the first “traitor” was that one of the other “traitors” guided them towards her for his own ends.

Here we have almost all the previous biases in action, plus another. Human beings, psychologically, believe all their past decisions were better than they actually were; they then base future decisions on those past decisions. This causes a skew; decisions which are not as good as we think they are piled upon other decisions which are not as good as we think they are – a kind of psychological entropy as our decision-making becomes ever more disorderly over time. We saw an admission of this towards the end as some contestants admitted that it was become more difficult, not less so, to identify “traitors” – one reason was that they had been thrown by the circumstances of the first (and for a long time only) occasion on which they had (apparently) identified one.

This is an issue across huge areas of human society. One such area mentioned before on this blog and elsewhere is “coaching” on social media – on any subject, from fitness to language learning to financial advice. In many instances, a self-styled “coach” may have had apparent success once – but they may also have misconstrued the nature of that success, and misinterpreted the lessons to learn from it. In other words, even when we have success, we often fail to understand why…

Humility

To finish on an optimistic note, if I were to identify a common characteristic among the winners of the show, it is that they were humble. They were not, in fact, the ones who tended to claim they were especially brilliant at anything; you never heard them saying they were “two or three steps ahead”, nor even particularly “strategising” about how to win the game. One quite openly just wanted the prize money to help his mum out!

Perhaps, therefore, if there is a lesson to take from all of this, it is that humility is not given sufficient priority. None of us knows anything like as much as we like to think we know, least of all the authors of blog posts like this one! It is perhaps worth reflecting on that more often than we do.

Instead of “cuts”, how about “improvements”?

Northern Ireland’s public finances are something of a mess, with Departments, Agencies and Trusts constantly having to over-budget and then find “savings” (or, often, outright “cuts”). This is particularly true of Northern Ireland within the UK, for complex reasons we need not go into here, but it is also true of the UK as a whole; and in fact it is true of much of the Western World.

One area where this draws particular interest, not least currently, is “Health” (however defined). This is an extraordinarily difficult area to get right, because of its extreme complexity, and therefore it defies rational debate on Twitter or radio phone-ins.

What underlies most quick responses, however, is the implicit suggestion that just doing one thing (whatever it may be) would fix the problem. Unfortunately, this is absolutely untrue (this is known as “causal reductionism” – see number 6 here); to deliver a Health Service that meets the reasonable needs and expectations of the population in 2030 will take more than a single change.

Quick thinking

A survey was carried out in the United States pre-Covid which asked people to rate their position on a scale of 1-10 on issues such as immigration, abortion and taxation (from strongly agree to strongly disagree). People were invited into a room to fill out the survey under exam conditions.

Some were given all the time they wanted to consider their answers in silence. However, others were not. In some instances, they were suddenly told they had just a few minutes to complete the survey (having previously been unaware of any time limit). In others, sounds were deliberately played to distract them.

What was found was that people’s views when distracted – by a time limit or by a noise or whatever – clearly shifted to those most commonly deemed conservative (in every sense); this was even more marked among those who had higher levels of education (who also, in turn, were more likely to self-identify as “Democrat”).

In other words, in this world of social media and constant information bombardment, views shift towards the more instinctive and away from those which may evolve through study – and this applies to everyone, even those lucky enough to have had years of study (in fact, there is some evidence that they are even worse afflicted, as they are better at using their study to justify instinctive positions on social media or on the air waves – “just better at being wrong” as G.S. Bhogal puts it).

“NHS model cannot work”

We see this applied both ways if someone suggests that the UK should replace its Health Service model with a “social insurance model” or some such.

On the “left”, people go mad at the “Americanisation” of the system, even though most large countries in Europe use the “social insurance model” and have better outcomes.

On the “right”, people suggest this would magically fix a lot of problems even though all you are really doing is replacing tax with compulsory insurance – it’s the same money, fundamentally.

Give it some thought, and the “model” is not really the problem (nor would changing it particularly cause a problem – it just wouldn’t solve one either).

“People should pay to see GPs”

Similarly, the idea of people paying to see GPs is met with squeals of “Americanisation” by the “left” (even though everywhere from Ireland to Germany has paying to see GPs in some way) and of “Great Solution” by some on the “right” (even though if you set the payments too low they make no difference and if you make them too high they just deny access to the greater long-term detriment of the population’s health).

Again, we spend a lot of time talking about something which is fundamentally irrelevant to solving the actual problems that exist.

“Bloated administrators”

“Bloated administration” is a bit of a problem in Northern Ireland, for historical reasons. However, the underlying idea that you can do savings and cuts “without affecting the front line”, as often suggested, simply does not follow logically; in fact, if you ask GPs what their main problem is currently, they will cite the “non-clinical administration” they have to do – if anything, that would suggest that we need more administrators, not fewer.

In other words, there is no “front line” without the “back line” – the supposed distinction between them is of limited to no practical relevance.

Improvement

So how do you begin providing some actual solutions to some actual problems? Well, you know a word that never gets mentioned when discussing the issues in the Health Service? Improve(ment).

When is the last time you heard it?

Is that not incredible?

Unfortunately, this is the classic social media debate – we are so busy proving we are ideologically right that we do not actually take time to think of the things which are practically right. Like, how we actually improve things.

25 years ago, British cycling was a joke. The Tour de France was confined to marginal TV channels (and almost no one in the UK had ever heard of the Giro d’Italia or Vuelta a Espana) and cycling rarely featured on “Team GB” medal targets. Cycling was something hardcore fitness freaks did, but the idea that it was a competitive sport was rarely if ever considered by the broad population.

Then there was a fundamental change of direction among the authorities, who instead of seeking some single big change they could make to push cycling into the public consciousness and consider it an elite sport instead pursued a “1% strategy” – they sought a 1% improvement in every area they could – be it facilities, nutrition, education, equipment, coaching, marketing or whatever. By nudging every area up just a little, they nudged the whole thing up a lot – and, at elite level where margins are extraordinarily tight, this jump saw cycling in UK go from barely considered backwater to genuinely world leading. Team GB now wins as many Olympic medals in cycling alone as it did in the entire Olympics in 1996; and British cyclists have won or finished very high up in several Tours, Giros and Vueltas ahead of cyclists from countries where cycling has always been higher priority as a competitive sport. (Whisper it quietly, but a similar process is why Arsenal are top the Premier League currently.)

In the end, if we want to solve problems like an over-capacity Health Service, or indeed any others, what we have to do is look for 1% improvements right across the board; and if we asked another question: what can each and every one of us do to assist that 1%? It’s only 1%, we should all be able to find that?

So instead of looking for savings, or cuts, or even “efficiencies” (usually code for “savings” or “cuts”, frankly), why not instead look for “improvements”?

There’s a thought. We should have more thoughts…

Coronavirus – closedown must have a purpose

If I were anywhere in the UK and Ireland currently, I think I would probably be most comfortable in Wales. Even though I am not entirely clear what it is, the Government there seems to have a “reset” strategy, planning to take two weeks of outright lockdown to fix things and then move back to easing restrictions, all from a lower case rate (per capita) than other places.

The worry everywhere, however, is that Covid responses are being reported solely in terms of social and economic restrictions. Up to a point, that is understandable – those are what most people notice. These are known as non-pharmaceutical interventions – interventions beyond the health system which can help intervene to stop the virus (and specifically stop it causing illness and death).

However, there is absolutely no point in having the restrictions – and the severe damage they cause to mental well-being, economic livelihoods and indeed the Health Service itself – without also considering the public health interventions also required. These are rarely reported, but they are vital – otherwise we ultimately face a choice of permanent closedown or the virus running rampant.

So what should we use the next few weeks to do?

Strategy

Firstly, as written here many times, we need a strategy. Restrictions are a tactic, not a strategy. Having tactics without a strategy is like having a mask without the straps – you may have the main bit people see in place, but it is ultimately fundamentally useless. The straps are essential for masks – and so is strategy for public policy.

We have to determine how we are going to live with the virus. With retail and schools open, the scientific evidence is we can ensure the case rate does not spiral out of control. Once we allow students to travel and hospitality to open, however, the famous R-number goes above one; so the only way we can do this is by further specific interventions which enable us to break chains of infection.

Contact Tracing

The first thing we do to break chains of infection is identify to origin. However, all over Europe, the contact tracing model is failing to do this. In Northern Ireland, more than half of cases for some time have been “community transmission” – which, effectively, means we do not know the origin. However, even in countries which have handled the pandemic well and are better resourced, there is a serious struggle to identify the origin because the tracers do not ask where you were at time of infection but rather merely at time of infectiousness and are then running out of time to do the forward tracing bit to find out the origin at time of infection. In parts of Germany, where Contact Tracing is effectively considered part of primary care, tracers admit they are struggling to find the origin in the majority of cases in urban areas because they simply lack to time to go through, for example, every restaurant’s guest list.

Here in Northern Ireland, we need to reform and resource urgently (we have given ourselves 4-6 weeks in practice):

• change the questioning so it goes to point of infection;
• change the phone notifications so they are immediate (not a week late) and refer clearly to the time of positive test of the contact (so the 14 days start from there, not from the time of notification);
• maintain a public record of the locations of infection – by sector, geography and age group at least;
• provide constantly updated information and advice on superspreading incidents; and
• feed in this information and advice to any future restrictions so the reasoning is transparent.

This would all help to identify to origins of infection and to impede behaviour likely to cause infection.

Self-isolation

People asked to self-isolate are, for the most part, not doing so. This is hardly surprising – it is a big ask, meaning loss of social contact, loss of income and an element even of stigma. Also, a lot of people are confused as to why (or even if) it is 10 days for those testing positive but 14 for contacts.

Here there needs to be an element of carrot and stick. A means-tested payment of up to £500 could compensate for the loss of income and even social contact; conversely, that would also mean there would need to be enforcement (by spot checks etc). We may also need to consider improved support for carers and even potentially support for businesses and organisations (if they lose workers for a period).

As a minor personal view, I do wonder if it should be so strict as to disallow any exercise during the period. A walk outdoors alone at a time which is not busy, perhaps within a certain distance of home, should probably be allowed – and may in fact encourage compliance.

Self-isolation is vital to breaking the chains of infection; without it functioning properly, we are frankly doomed to permanent closedown.

Community Comms

The other aspect of this is that communications to guide responsible behaviour is often best delivered by people respected locally – sometimes very locally.

Having the Chief Medical Officer telling people to “wise up” is a bit like Hillary Clinton calling people “deplorable” – it is completely the wrong level.

Local civic leaders or even celebrities are much better placed to deliver key messages.

Ultimately this is about behaviour change. This takes more than the odd YouTube video pleading for compliance.

Transparency

All of the above requires greater transparency.

With more information and improved advice, we can then communicate better why self-isolation is important, why behaviour change is vital, and therefore why and not just what restrictions are in place. That will vastly improve compliance in itself.

From there we can begin, carefully, to re-open close contact services, hospitality (at least certain aspects) and the arts – with every step providing data and information to enable us to look after ourselves and each other.

And, by the way, let’s focus on this vital work – and not attention seekers just seeking headlines. This matters. They don’t.

Coronavirus – blog review

As I will no doubt be reducing my writing on the subject next month, I thought it worthwhile to summarise some of the points made on this blog so far with regard to the new Coronavirus; I also made some of them in a podcast in late May.

I re-emphasise that I have no expertise in biology and medicine, but I do have some in public policy (and I happen to speak German, thus enabling the comparison between the English-speaking world and the German-speaking world upon which I intend to build in the coming days and weeks). These are analysis pieces for information and interest; they do not constitute formal research, far less government policy.

If, like me, you are in Northern Ireland, remember the core government advice currently remains stay safe, save lives – wash your hands, keep your distance, do not engage in gatherings indoors of more than six or outdoors of more than ten.

Remember also to avoid the three ‘C’s – contact, crowds, and closed spaces!

In summary, the most important thing right now is that there must always be room for doubt. We still do not understand this virus, so we cannot say anything about public policy responses with absolute confidence (so those who do are making it up).

We must be aware that in our own response to this, it is as much about managing and perceiving risk as anything else. Also, the objectives are not quite as obvious as we might at first think. Even when we establish what they are and judge performance thus far, we must also be aware that our own intuition may be deceiving us fundamentally and always apply the plausibility and relevance test.

Therefore, never has the truth been more important. Almost anything said with absolute certainty does not merit attention – it is invariably said to appeal to prejudice rather than truth. We even need to consider that the reverse of what we view to be instinctive may end up being true, and that what we regard as “safer” may not be. There is also considerable risk in simple, apparently clear claims which are in fact profoundly misleading, even to the extent of missing key points in their favour. If we must make comparisons… well, we probably shouldn’t too often. We also should not overstate the significance of apparently simple numbers like R.

“Lockdown” always was a profoundly good idea, provided it was properly prepared for. However, it is a long way from the “safe” option it is sometimes presented as, and it cannot last forever. Even right now, you can legitimately argue for or against “raising lockdown”, but make sure you are asking the right question. When it is raised, however, other countries can be taken into account and it must not be done piecemeal, but rather via a phased or staged approach, and based on the Regulations which set out what we are trying to achieve.

For all the discussion about “lockdown, however (understandable because it is what most obviously affects most of us), the difference between good and bad outcomes is predominantly to do not with “lockdown” but with early diagnostics. This truth may be boring but that does not make it less true – indeed, we should always be seeking solutions, not headlines. It is also legitimate to attack the UK Governent for its early inaction, but such attacks must be specific to where it actually erred otherwise they serve no purpose.

It is also important to report what actually matters to us. Targets and personalities are meaningless; actions and delivery are what count. We should probably also define our terms. “Social distancing” does not mean “lockdown”, for example – saying the former must remain for months or years does not mean the latter must.

One of the difficulties in dramatic here-and-now news is it misses the broader analysis, such as the awkward truth that the difference in outcomes between the UK and Germany is not narrowly in the two countries’ response to the new coronavirus (regardless of the UK Government’s very evident failings in that regard), but in the fundamental basis of their health services. The UK is always fire-fighting whereas German-speaking Europe puts in the early preparation in a targeted way – this reveals itself further in the two countries’ testing strategies. Yet, for all that, things in Germany are (and were, when the linked piece was written) nothing like as smooth or simple as they are reported in the English-speaking world (and they are still not even post-lockdown); its lockdown was fundamentally less strict. The UK continues to miss the point on testing that the virus can often be asymptomatic; and also that it needs a better informed public of active citizens taking responsibility. Yet one UK territory has done rather well.

There are also differences within the UK just as there are within Germany – Northern Ireland is going its own route in some significant areas and has its own recovery plan, maintaining rightly or wrongly a later lockdown, which is not perfect but is an improvement on the UK Government’s. We have also not paid enough attention to the immense challenges of re-opening the Health Service. To some degree, this is what devolution is all about.

Also, if you get it wrong as the UK Government has done, it is better and safer to admit your errors (and likewise in Sweden) and stop defending the indefensible otherwise you end up looking (and being) dangerously clueless with your global standing diminished and daft policy decisions mocked for being made with no purpose.

There is a concern that politicians in Northern Ireland were too focused on the worst case while the authorities in Northern Ireland are not publishing the science, which makes the public feel they are being treated like idiots and actually causes more confusion, leaving also bewilderment over why there are no checks at ports of entry and why meat factories are still operating. It may also be useful, later in the pandemic, to think of lanes more often than bubbles.

There are some quirks, too, such as why planes are still in the air and why we need the return of sport. There is also always the chance that we are closer to the end of this than we think – but that really is not very likely. We are probably over-thinking apps, and there are also always just random questions.

We also need to consider our own personal well-being, not least how we think our way through living during the virus and after it and how we imagine the future while making sure not to write humans out of it.

Where does all of this end? Maybe somewhat differently from what we had initially understood. But we can learn from others, particularly around things like restaurant re-openings. There will surely be some good to come out of it; we just do not know when.

I have also included some Facebook posts, for example on how we ourselves can balance probabilities in terms of virus transmission; the meaning of “Step 1” in Northern Ireland; on the practicalities of shopping with the virus about; and on that ever present danger of comparisons.

More recently, I have considered how we apply our knowledge, what the statistics tell us (both at home and abroad), what we are learning (and how we continue to learn from global outbreaks), how to focus on the right issues, and how we deal with complex problems. There have also been testing queries, general confusion and outright nonsense…

I also reckon this external article from Unherd is essential reading for anyone genuinely wanting to understand the public policy and scientific challenges around all of this.

In the meantime, here is some outline practical guidance primarily for people in Northern Ireland.

Coronavirus – podcast

Was good to join Slugger O’Toole for a podcast on the Coronavirus, the Northern Ireland Executive’s response and some international comparisons on YouTube.

Coronavirus – Keep it simple on Cummings

One of the reasons Left Liberals lose a lot is that they don’t know how to keep things simple.

It was made very clear, by the Prime Minister himself, that everyone had a civic responsibility not to break the rules or people would “suffer”.

It was made clear from his Twitter account as he lay in intensive care that there were no exceptions.

It was also clarified a few days later that the “rules” are not guidance, they are the law. And understandably, since everyone could “suffer” and they “include you”.

On 31 March prominent adviser to the UK Government Professor Neil Ferguson received a female guest at his home in London. The same day, prominent adviser to the UK Government Dominic Cummings drove from London to Durham.

These were the Regulations as they applied in England on that day.


In Mr Cummings’ case, there is a further problem with his having left home, namely that both he and his wife (who was also in the car) had symptoms. The guidance for people with symptoms across the UK was, is, and for some time will be:

It was clear that Professor Ferguson had to resign; the law does not permit people to “leave the place where they are living” to visit friends, but he had encouraged someone to do so to visit him.

It is obviously equally clear the Mr Cummings has to resign. The law does not permit people to “leave the place where they are living” to deposit their children with grandparents or indeed anyone else, whether 260 yards or 260 miles away. In his case, the Guidelines are also clear that neither he nor his wife were allowed to “leave home for any reason”.

Let us not complicate it, therefore. As the Prime Minister’s own account put it, if one person breaks the rules we all suffer; the rules apply to everyone including Mr Cummings; Mr Cummings and his wife broke the rules and therefore broke the law; and Mr Cummings and his wife acted clearly contrary to the Guidelines.

“Common sense”, for the record, would dictate that if there was any issue with childcare, someone else should have come to the house to deal with it. But many people with symptoms not requiring hospital care have managed childcare perfectly well.

(Note the Regulations allow only childcare carried out by a public service.)

That’s it. And any Cabinet Minister or MP claiming otherwise (or indeed any journalist reporting otherwise) is embarrassing themselves. Remember, the Government itself has explained why these rules and guidelines exist:

So Mr Cummings, on the Government’s own terms, must go. It is probably time the Prime Minister went too. A crisis of this scale is no time for Downing Street to be occupied but a convalescent, far less one as obviously hypocritical and incompetent as the current occupant.

Coronavirus – better an admission of failure than a pathetic cover-up

“It’s the cover-up that gets you, not the issue” said Nixon, about his resignation. Politicians seem very unwilling to learn the lesson half a century on, however.

The UK was in fact quite well prepared for a pandemic. It had run simulations; it had stockpiled PPE; it had prepared modelling; it had drafted emergency legislation. The problem was that it had prepared for an influenza pandemic; the UK Government’s risk register had an influenza pandemic very high, above nuclear fall-out; but any other sort of pandemic was felt almost impossible.

On the basis of the simulations and the stockpiles, the UK began modelling in January, drafted emergency legislation on 10 February; and was already preparing administratively from mid February. The Government asked the scientists what the value of R was in this case, allowing for reasonable modifications in people’s behaviour; the response going into March was “2.3”.

This was an error. It was in fact 2.8.

This does not sound much different, but in early March it was the difference between hitting peak of infections around ten weeks later (i.e. about now) or hitting them five weeks later (i.e. at Easter). The Government thus prepared to introduce gradual lockdown measures.

This was also an error, and not just of timing. The modelling was all about protecting the NHS from an influenza pandemic which would affect the broad population and be spread primarily by children. But in fact this is a coronavirus pandemic which disproportionately affects older people and is primarily spread by people of working age.

Even though it was beginning to be obvious to amateurs just watching the graphs comparing the UK and Italy, it was not until 12 March that the Government received further modelling saying it was 2.8, not 2.3; meaning that from that stage, the UK was four weeks, not nine weeks, from peak of infections. To protect the NHS, which was always the main aim, lockdown would have to be introduced faster.

This article is not about the peculiarities of why the Government relied so much on one set of modelling rather than on what was going on around it. In Scotland in late February a Nike event had already proven a “super-spreader”; somehow, this was not revealed, even to neighbouring businesses, until May. In other words, there was evidence right before their eyes, even without a cursory look at the comparison graphs with Italy, that spread was much faster within parts of the UK than the modelling was suggesting. The reliance on modelling (which is not even forecasting and is only as good as the data you put into it – and the data from China was at best patchy) is a debate for another day, albeit an extremely important one.

There ensued a degree of panic as a Prime Minister, who knew little about the virus because he had taken much of February off on holiday and does not seem a big fan of hard work anyway (has anyone seen him recently?), returned on 2 March to tell everyone he was washing his hands but also still shaking them. Only 10 days later he was faced with the reality that to protect the NHS he would have to lockdown.

And there is that phrase again – “protect the NHS”. Still not having adjusted from an influenza pandemic, the focus was mainly on protecting the Health Service (likely, during an influenza pandemic like 1918, to become overburdened with people of working age) and also contemplating school closures (a standard response to an influenza outbreak).

It is worth emphasising here that almost every Western country struggled with this adjustment. The emphasis across Western Europe was on ensuring that there were enough ICU beds essentially for an influenza pandemic. Ireland and German state authorities even closed their schools, as a standard response to an influenza outbreak. Only the German Health authorities and some other smaller countries recognised quickly that this was not, in fact, an influenza pandemic but a coronavirus and therefore the rules were slightly different: national governments and public health authorities in countries such as Germany, Austria, Norway and Iceland therefore focused resources early on trying to understand the virus rather than assuming it was just like influenza. They have been a month ahead of everyone else in Western Europe and North America ever since, saving initially at least tens of thousands of lives as a result.

The result in March was an intentional policy of pushing people out of hospitals as quickly as possible (as well as building new ones), to create space for the victims of the pandemic. One of the places they pushed them into was residential care. In other words, as we approached peak infections from a virus to which older people were most vulnerable, the UK Government intentionally pushed people out of hospital and into care homes where many of those older people live.

This looks in retrospect like a truly shocking error of public policy. At the time, however, it was not totally unreasonable – it was based on all the plans prepared for an influenza outbreak. In such a case, it would have been the correct policy.

But it was not the correct policy. The fundamental error was the failure to grasp quickly enough the difference between the expected influenza pandemic and the actual coronavirus pandemic. (This failure also led to the UK throwing away its initial testing advantage in the belief it did not really need to understand the virus – summed up on 27 March by one of its senior advisers in a media briefing with the line “Testing is something of a sideshow“.)

UK Government Ministers now have two options. They can either admit the error: “Yes, we were following detailed pandemic plans set out by scientists with world-leading credentials in this area, but although this was also the case in other countries we now realise that in some of the detail those plans led to errors, for which we apologise and from which we intend to learn“; or they can, well, lie: “No, but really we were protecting care homes, and we never pushed people into them, and really no one could have foreseen all of this and it was all just a bit of bad luck“.

If they were to go for the former, the public would probably be quite understanding. The policy was well intentioned and well researched – it just turns out the research was skewed to the wrong type of virus.

However, just lying about it is callous and destructive. It shows an inability to accept responsibility and to learn from fundamental errors. No one is expecting any government to manage a crisis of this scale without making mistakes; but people do expect them to be honest about them in order to learn from them. The Government needs to learn, fast, that this is not an unreasonable expectation.

Worst thing Brexit demonstrates? Rampant “classism”

I still intend to make very little political comment on this blog, as there is very little more about it to say. Any rational person can see that the English-speaking world has succumbed to crazed populism, and every further issue – from what to do about mobile roaming charges to how to restore the Northern Ireland Executive, derives from that basic problem.

However, for me the most appalling thing brought home by all of this in the UK has been the British media’s rampant classism (is that a word? It is now).

Ultimately, there used to be a basic deal with the media that they would report the words of senior MPs because it was reasonable to assume they carried some expert weight. Perhaps this deal was always an illusion. Now, it is obviously ridiculous.

Almost all of the Conservative back-bench MPs given prominence by the media on the subject of Brexit speak with upper-class accents. Not one has a single iota of expertise to offer on the subject. Nor will any suffer the consequences.

So why are they covered? At all?

Indeed, last week, a “research report” from a group of them was covered as lead story on the news. It is a basic fact that the report was complete rubbish. That fact was not reported.

In fact, it was reported rather ludicrously that “economists [plural, even though only one was cited] see benefits of Brexit” and that a “customs expert [one Dutch lad whose actual experience was never outlined” had been involved in some research about technology. Actually not a single economist believes Brexit will cause anything other than damage to the UK economy; indeed, not a single person with even an ounce of common sense (quite obviously if your main competitors can trade freely and you can’t, you will be at a disadvantage). Not a single customs expert believes customs frontiers can be managed solely through “technology”, and again anyone thinking about it can see why not and understands that not a single customs frontier works that way with good reason.

Why, therefore, are MPs with no expertise and no basic understanding of society wheeled out and given priority by the media for comment? The common link is that they all speak with upper-class accents.

Underlying this, therefore, is the notion that because someone speaks with an upper-class accent, they must have something expert to contribute (and conversely, that those who do not speak with such an accent should not be given priority and should therefore yield the air waves to those who do). This is plainly not the case. In fact, in the case of Brexit, those given such priority have not the first clue what they are talking about – zero experience, zero expertise, and actually zero interest (the outcome is of no concern to them after all).

They also tend to be men, by the way. Indeed, referendum coverage saw men given 84% of the air time. Is that not a scandal?

It would make for a much more interesting public debate if MPs you constantly hear of were not given priority media coverage, and instead others – with different accents, and a few women – actually were. You may then receive real expert input, and encourage a meaningful discussion.

As it is, the media continue to report this as an upper-class soap opera. We have Downton Abbey for that. The issues around Brexit are of profound concern to millions of people. We need a proper debate, involving people who actually know what they are talking about. Is that not what we pay the licence fee for?

Identity politics work – sadly

In the UK yesterday, many people from the “Remain” end of the spectrum expressed disbelief that UK passports will be blue from October 2019. Some, the current author included, noted that they were not blue in any case before they switched to their current burgundy; others suggested there were other priorities in national life; still more tried to pin a cost on the change (we will come to that…); and pollsters said people did not really care that much.

Meanwhile, in the US, the President was arguing for the term “Merry Christmas” in preference to “Happy Holidays”. There was a similarly disdainful reaction from Liberals; and pollsters again said people did not really care that much.

However, I suspect people do care. That is why the UK Prime Minister and US President are getting up to such antics around “identity politics”. As we know only too well in Northern Ireland, identity politics work.

A few years ago, at around this time of year, Sinn Fein decided to switch its stance on the Union Flag at City Hall, thus meaning that an Alliance amendment in line with its own policy would see it flown only on designated days. Very few people would have expressed much interest in the subject to pollsters, but Sinn Fein was deliberately pulling at emotions and identities; and the DUP responded. The result was economic chaos – and both parties improved their position at the subsequent elections. Having messed around for a year now while Health goes unreformed, Education becomes unsustainable and the economy fails to grow, the two parties should be being punished by the electorate for their callous unwillingness to get on with the job – yet both, in fact, are scoring record poll numbers. Identity politics work.

I was in the US last month and I did notice the preponderance of the word “holiday”, to an extent that it is now plainly ludicrous. A market outside the Smithsonian in Washington DC plays Christmas music, sells Christmas gifts, is based on German Weihnachtsmaerkte (“Christmas markets”), yet incredibly is referred to as a “Holiday Market”. This, to people of even slightly Conservative leanings, is surely an example of political uber-correctness, and a reaction is unsurprising. This notion that things which are obviously one thing cannot be referred to as that thing for fear of causing some kind of “offence” genuinely and often in fact legitimately annoys people, even though they overtly make little of it. So, when someone actually appeals to that covert annoyance, it is unsurprising that that appeal is successful. Identity politics work.

And so it was with the response to the blue passports. Firstly, there is the somewhat academic factual reaction (“Ah, but Croatia has its own colour and it is in the EU”); but for people like last week’s Question Time audience in Barnsley, that misses the point and just looks smug. Secondly, there is the (entirely legitimate) mockery of the notion that the colour is “iconic” for the simple reason that UK passports were never that shade of blue; but perhaps this too misses the point, which is presumably that at least they will not be burgundy like the Continentals. Thirdly, there is the notion that there are other priorities; but here we have the Remainers/Liberals engaging in fake news of their own. Although the new passport provision contract will indeed cost nearly £500m, the fact is it would cost that regardless of the colour – so the notion that not changing the colour would leave £500m over to tackle homelessness or to spend on the NHS is no more accurate than the infamous £350m claim on the Brexit bus.

In fact, we all get embroiled in identity politics – even those of us who claim to be above it get embroiled in it, even though we tell ourselves that we only do so to try to emphasise why we are above it. In fact, I do think it is worth making the point that having a big fuss over changing a passport colour does make the British themselves look rather insecure and their government look pathetic. If anything, however, even this is merely a representative symptom of the broader problem – that the British are fundamentally insecure and their government is pathetic. To be clear, I could not care what colour my passport is, which means it does not bother me to change it; what bothers me are the ludicrous fantasies of “bringing back”, “iconic colours” and “independence” when we should not be seeking to “bring back”, there is nothing “iconic” about the colour, and the fact the passports will be made abroad to standards set abroad rather demonstrates the absurdity of the notion of “independence” in an interdependent world.

For all that, in fact what has happened is the Prime Minister has successfully diverted attention from the real story, which is that David Davis’ impact assessments have now been shown beyond doubt not to, er, assess impact. Since one Cabinet Minister has gone for lying, there is a cast iron case for a second going. But we are not talking about that. Identity politics can be a lovely diversion when you want to shield some other story – which is why they work. Sadly.