Scottish Government COVID-19 Advisory Group minutes: 5 October 2020

Attendees and apologies

Advisory group members

• Andrew Morris
• Harry Burns
• Dave Caesar
• David Crossman
• Tom Evans
•  Roger Halliday
• Angela Leitch
• Jim McMenamin
• Jill Pell
• Stephen Reicher
• Jacqui Reilly
• Chris Robertson
• Sheila Rowan
• Aziz Sheikh
• Devi Sridhar
• Mark Woolhouse

Invited attendees

• Mary Black
• Cat Carver

Scottish Government

• Richard Foggo
• Daniel Kleinberg
• [Redacted]
• John Nicholson
• Niamh O’Connor
• [Redacted]

Secretariat

• [Redacted]

Items and actions

• minutes
• annex
• summary notes

Minutes

Welcome and apologies

The Chair welcomed group members, invited guests and those attending.

Apologies – [Redacted] noted they would be arriving late. A number of group members had to leave before the end of the meeting to attend to other urgent business.

Minutes and actions

Action:group members to provide secretariat with any comments on the minutes of the previous meeting.

Actions from previous meeting: letters of thanks have now been sent to group members’ institutions by the Cabinet Secretary

Proposed measures

The Chair expressed thanks for the very quick responses to the request for views on SG proposals for additional measures to reduce R. AG advice based on science and evidence would be one of the inputs to Ministers’ decisions alongside e.g. advice from Directors of Public Health.

The background to the request made to the AG was summarised and the main issues covered in the group’s advice was outlined. A note of the group’s views, drawing on commentary on Slack prior to the meeting and discussion at the meeting, is attached.

Data and analytics

The question for the group was where can data be most useful over next 6 months. The Scottish Covid Data and Intelligence Network has been established to enable collaboration and shared insights, improve geospatial data and the conditions for collaborative research. The paper tabled for discussion highlighted current work and future priorities for the Network.

The Chair noted that work was underway across the UK to look at the enabling infrastructure & expertise that will underpin the next few years. Priority topics have been identified and will be funded, with Health Data Research UK leading on cross cutting work on how to develop data in a cross sectoral way. (The conflict of the Chair was noted). The formation of the Scottish Covid Data and Intelligence Network was prescient in anticipating the focus of that work.

The group noted that data on NHS performance was important, not just the Covid response but also indirect health impacts. It was noted that test & protect was crucially reliant on compliance with self-isolation. More robust & granular data on compliance would be helpful. This will be taken into account in conversations with JBC analysts and the group will be updated on any developments.

Action: the Chair will circulate a paper on National Core Studies now that Treasury has agreed on funding

Action: Secretariat to arrange a future session on National Core Studies.

Action: the Chief Statistician will post 4 harms data info on health and other impacts on Slack.

Briefing on post-lockdown mortality

The Chair had to leave the meeting temporarily and the Deputy Chair took over for this agenda item.

The paper for this item was introduced. It was driven by a concern that the history of first wave, when the impact of the virus on care homes and other vulnerable people was not fully understood, should not be repeated. Analysis indicated that a substantial proportion of those infected happened after lockdown. The implication was that, potentially, substantive mortality was still to arise the second wave. A strategy to protect the vulnerable was needed which addressed that risk.

Latest data shows that people in late 40s to early 60s are now being infected. A number are vulnerable and there is an opportunity to have a clear strategy to protect them. We didn’t have as much data on first wave at the time. We have more now and should be able to do better. What have we learnt about what works and where can we draw on best practice?

The situation in hospitals and care homes was much better than in the first wave but others are vulnerable too. This could be addressed through testing. Protection for the vulnerable should not be confined to shielding, which could be a very blunt instrument. Impact of shielding suggests participation should be a choice. Cost of isolation is massive – individuals should have the right to choose. Messaging is part of the response but exhortation doesn’t work. Improve awareness of risks and effective mitigations. Personalised advice could help people make choices. Need to enable as well as encourage.

In summary the group noted that community wide interventions may reduce the overall risk but do not directly protect the vulnerable. Similarly, we cannot only rely on protection of the vulnerable. Reducing R/restricting growth of the virus was necessary but insufficient.

The ability to comply was more important than motivation and we should enable people to comply with measures to reduce risk. Testing contacts, prioritise diagnostic testing if symptomatic, access to effective pharmacological interventions, vaccinations (flu and in due course COVID-19) would all be important for high-risk individuals. There was agreement that some form of choice for the vulnerable was essential.

Mass testing

The Chair had re-joined the meeting and resumed the chair for this agenda item, referring to the paper tabled for the meeting and the preceding SAGE paper.

Mass testing needs a clear aim, capacity to match & quick results. It also needs to be integrated with other systems, including test & protect – we need to be able to cope with and support a significant increase in the number of people isolating as a result of mass testing. We don’t have capacity for current priorities but there is hope that POC tests will be online soon and could underpin the way forward. Test on request could guide decisions. There are options for systems to support mass testing – a lower sensitivity test that’s repeatable may be better. Testing should be prioritised by likelihood of gain: SAGE has identified five groups. There may be a need to test students before they return home for Christmas.

A number of members of the group were concerned that the testing strategy had not yet been fully implemented and there was a need to address that before looking at further expansion. The immediate need was to focus on testing priorities and, beyond that, to implement strategies for HCW in all settings before expanding beyond that.

There was agreement that implementing the testing strategy is the priority. Though progress is not going as fast as we would have wished, progress has been made on all fronts compared to the position before the strategy was in place and extensive work is ongoing.

There may be tensions but delivering current strategy and thinking about developments are not mutually exclusive. It would be interesting to discuss frequency of testing/sensitivity further and acceptability for different populations, as well as the need to link back to supporting isolation.

Action: add to agenda for next meeting – to be considered in the context of recent ECDC recommendations.

AOB

Action:Secretariat to be in touch about finalising written comments on Proposed Measures (see Annex).

Annex

Agenda item three: proposed measures

On Monday, the C-19 Advisory Group was asked for comments on the material provided to Ministers late on Sunday by Ken Thomson; having previously commented on a set of proposals for further restrictions at its meeting on 21 September. Much of that discussion still holds.

The pressure of time meant the group has had only limited time to consider to discuss the material and for a short discussion in plenary. This therefore represents the views of the Group within the time available rather than settled advice and records where there are different views. An earlier version of this note was circulated to CMO and the Covid-19 Director prior to the group’s meeting on Monday.  

State of the epidemic

• number of cases/day is growing, but do not agree that growth rate is accelerating

• a substantial fraction of recent cases is associated with outbreaks in University residences, though there are concerns these are masking increases in working age adults.

• projections of exponential growth implicitly assume:

  • Measures introduced in past one to two weeks, including those to control university outbreaks, will have no effect

  • There will be no behavioural changes in response to the increase in cases other than those mandated by Government

• notwithstanding these points, the Group heard about the high pressure on public health teams caused by the numbers of cases in the central parts of Scotland in particular

Rationale and evidence

• the group was strongly supportive of a ‘level two’ approach which was sustainable, and did not agree with what they saw as a less well-evidenced harder level three approach, which appeared to be premised on current restrictions not working well enough

• a majority of group members did not support the introduction of level three ‘circuit breaker’ measures. Group members did not see a clear rationale for these measures, rather than more sustainable measures which would also allow for a reset of expectations around a contract with the public

Key points were:

• • what is the exit strategy which means such circuit breakers wouldn’t be needed repeatedly?

  • the full impact of braking measures might not be apparent until after the measures have ended?

  • what is the rationale for a national rather than local/regional approach

  • assuming NHS capacity and test and protect capability are in place, what will have changed at the end of a brake period?

  • why introduce new tougher measures without taking action to address lack of compliance with current measures?

  • need to acknowledge there is a risk of perverse incentives for commercial operators if all are penalised. The response should be focussed both geographically and on those causing the problem

• if we have a short period of strict restrictions, what will be different at the end? Unless something changes we will (as we have often discussed) simply yo-yo in and out of restrictions. Frequent changing of restrictions is likely to lead to increased public confusion and may burn up public goodwill

Any plan to go to ‘level three’ must address that question and provide answers. I think There are four areas which need to be addressed:

• • testing: will we use the time to ensure we can improve capacity and ensure we can do both backwards and forwards tracing to deal with clusters

  • support: can we get the structures and funding in place to help people self-isolate

  • regulation and enforcement: can we develop the regulation and inspection of hospitality venues and other public spaces to ensure that COVID-19 safety is strictly observed

  • messaging: can we reset the overall messaging to make it clear, coherent and address informal socialising

• the group heard about the pressures on the contact tracing and public health systems in the central belt in particular, and the view that there was a short term need to relieve the pressure on teams. Increasing the contact tracing workforce is one option. This is difficult to do under current pressures but a circuit breaker would make that more feasible. However, it is unclear what substantive changes would be achieved in a short circuit break

Protect the vulnerable

• several group members saw these measures as aimed solely at reducing R rather than targeting the harms of the disease explicitly

• group members wished to see more reference to measures to protect those who are most vulnerable in care homes and long term care settings, inclusive of community hospitals and those receiving care at home.

• measures in place to protect care homes should reduce the death toll, but will not protect vulnerable persons in the wider community

Compliance to existing advice/restrictions

• dwells too much on limitation rather than regulation. Our two major problems are in pubs and in homes, where people are mingling too closely and in excessive numbers. Our response is to close down pubs and close down home visits but once we lift restrictions we go back to unregulated behaviours

• an alternative approach is to focus more on robust systems of regulation whereby pubs must be safe with COVID-19 secure measures to stay open. And if we have a clear message of ‘keep your distance’ in pubs and restaurants and other public spaces, it makes it much easier to have a consistent overall message which applies to the home as well

• moreover, such a message can be couched much more positively (what we are doing must  be done to keep things open rather than what we are closing down) and hence more likely to be observed. In sum we need a coherence of policy as well as a coherence of messaging to crack the hard nut of socialising in the home

• a number of group members noted the lack of compelling data on current levels of compliance:

  • how well aware are the public of FACTS?

  • can we focus efforts on non-compliant organisations and individuals, with proper monitoring and enforcement

• one group member commented that simplicity was important and that it wasn’t clear how greater compliance could be achieved without simplification

• several group members commented on the risks to compliance if new rules were seen as irrational or unfair to those who are compliant

Individual Measures (though see compliance)

• One group member offered the following views:

• • i think there needs to be strong imperative against any international travel (except for essential reasons) and asking for people to stay within 50 to 100 miles of home (basically staycations and short visits are fine but not travelling long distances around the country)

  • i think all children’s activities should be left out of the restrictions so that children can be protected from the impact of these restrictions. Children under 15 haven’t been drivers of this epidemic (unlike those aged 15 to 24 years old). That’s also a good message to send- that children are being put first

  • outdoor contact sports should be ok as well. I think the message of getting outside as much as possible should be held. and differentiating between inside and outside.

  • another offered the view that ventilation needs to be added to the list of key behaviours around FACTS

Summary notes

1. The group discussed Scottish Government proposals for additional measures to reduce R. The Group’s views on the science and evidence would be one of the inputs to Ministers’ decisions. 

2. The group considered the role of data and where it could be most useful over next 6 months. The group heard about the Scottish Covid Data and Intelligence Network, which has been established to enable collaboration and shared insights, improve geospatial data and the conditions for collaborative research. The group noted the current work and future priorities for the Network. The group heard that work was underway across the UK to look at the enabling infrastructure & expertise that will underpin work on Covid over the next few years. The group noted that data on NHS performance was important, not just the Covid response but also indirect health impacts. 

3. The group considered learnings from the first wave on the significance of post-lockdown mortality. The situation in hospitals and care homes was now much better than in the first wave but others are vulnerable too. Community wide interventions may reduce the overall risk but do not directly protect the vulnerable. The learning from the first wave should inform a strategy to protect the vulnerable which addressed that risk. And encouraged and enabled people to comply with measures to reduce risk.

4. The group considered issues relating to mass testing. Increasing testing capacity to enable mass testing could add to current options. It needs a clear aim, quick results and should be integrated with other systems, including Test & Protect – needs to be able to cope with mass isolation. Technology is opening up options for systems to support mass testing – a lower sensitivity test that’s repeatable may be better. Testing should be prioritised by likelihood of gain: SAGE has identified 5 groups. 

5. There was agreement that – pending capacity and resources to conduct mass testing - implementing the testing strategy should be the current priority. It was noted that progress has been made on all fronts compared to the position before the strategy was in place and extensive work is ongoing. There was insufficient time to conclude discussion, which would be resumed at the next meeting.