The writer is a professor of economics and behavioural science at Warwick Business School
The Labour administration in Wales has declared a 16-day “fire break” — their version of the Covid-19 “circuit breaker” which opposition politicians in England are calling for. Boris Johnson’s government is resisting that call in England, trying instead to operate a system of putting different areas into different tiers of restrictions.
But does either course of action suggest a sustainable medium- or long-term strategy? The uncomfortable truth is that, in the absence of an effective and widely-available vaccine, the best we can do is try to maintain some target level of illness and death — and at a level where the health outcomes are proportionate to the costs inflicted on us.
Identifying the right value to place on preventing illnesses and deaths is the cornerstone on which such a strategy must rest. Unfortunately, all signs indicate that politicians on every side are unwilling to engage with this central idea. Instead, in their various ways, they shelter behind the claim that they are “following the science”. But there is no unified “science”: only a wide range of models and projections, from which different politicians can pick their preferred cherries.
The much-cited recommendations of the Scientific Advisory Group for Emergencies appear blind in one eye. They look primarily at the epidemiology, leavened by some health psychology, but pay only token attention to the price being paid in terms of jobs, incomes, business failures, damage to education and training, disruption of communities and infringement of personal and civil liberties.
So we find ourselves in an unsatisfactory situation. On one side, we have a government with a whack-a-mole approach, flailing about as infection rates pop up here and there, but without any clear or consistently applied criteria for moving areas into higher tiers — and still less for moving them out again.
On the other, we have an opposition uncritically grasping at lopsided advice from Sage, which is already a month out of date and lacks a rigorous estimate of the harms another lockdown will inflict on the population — not least the young, the poor and ethnic communities.
It is time for politicians to be upfront about the economic value to be placed on health, and to build a strategy accordingly. There is an obvious place to start. For many years, government departments and agencies have been required to weigh the health and safety impacts of proposed policies against other costs and benefits. And there is a well-established system for doing this.
It is set out in the UK Treasury Green Book. Applied to Covid-19, it would involve expressing the net health benefits of extra restrictions in terms of “quality-adjusted life years” — a measure that weights life years (gained or lost) by the quality of life experienced in those years — and balancing them against the economic costs.
The Department of Health judges that each Qaly is worth £60,000. Politicians may wrangle about whether that is an appropriate figure, but some figure is needed because by considering the implications of new restrictions in these terms, we can bring some focus to the analysis.
For example, a circuit breaker now would almost certainly require at least four to six-weeks’ lockdown to get the R number anywhere close to one. Forget the two to three weeks recommended by Sage — that was a month ago, when prevalence was substantially lower.
It is uncertain how much extra economic loss this would cause, but we might use the last lockdown as a reference. Office of Budget Responsibility and National Audit Office figures indicate that three months of lockdown between March and June could have cost 10 per cent of annual gross domestic product. If an additional circuit-breaker month, or more, were to push that up to 12 per cent, the extra economic cost could exceed £24bn. How many Qalys would need to be saved to meet the Green Book criteria to justify the extra cost?
Given the age distribution and health profiles of victims, each prevented Covid-related death is unlikely, on average, to represent more than 10 Qalys saved. At £60,000 per Qaly, the circuit breaker would have to prevent another 40,000 deaths to match the extra £24bn cost. However, if a best estimate suggested that the circuit breaker would be unlikely to prevent more than, say, 10,000 deaths, the costs would be deemed seriously excessive.
The £60,000 figure may, of course, be considered misguided. But if that is the case, politicians must make the case for a different value — and undertake to use it consistently. The same goes for the proponents of the tier system. When another million people are moved into a higher tier, we must be able to weigh the Qalys gained against the price they will be asked to pay and how those costs will be distributed.
However we make such calculations, we need clearly stated values, systematically applied, to underpin a stable strategy informed by up-to-date evidence and models that incorporate all of the benefits and harms. Nothing less will do.