‘Without that framework, it feels like the virus is instructing us’

Back in May, our Editor Dr Jon Sutton spoke with Dr Rowena Hill, Psychologist and 'embedded scientist' within the cross-governmental Covid-19 Foresight Group. Following the release of a range of outputs from the group – and while awaiting the latest governmental announcement, on a localised and tiered response to the virus – they spoke again, on 12 October via Zoom.

What has changed since we last spoke? 

I'm still seconded full-time to the role. Last time we spoke, we were finding the most effective ways to operate with the group. Since then, we have produced over 40 reports, including three interim operational reviews – on 22 April, on 17 June, and the last one on 16 September. As with any emergency or major incident, it's about what we can learn, what are the lessons that we need to take forward? Those reports rest on empirical data collection, using a debrief platform purpose-built by the Hydra Foundation. We got all of the different people who were involved in emergency response – emergency managers, emergency services, throughout the country, at local level – to say, 'Okay, so what's going well, what isn't going so well? What do you think you need further support on?' Just to get a sense of how the country was doing, not only with regards to the communities which they serve, but also how they thought the response was going. 

For the first one, we collected the data at what was the top of the first national wave – we know some areas of the country haven't experienced a wave yet. And the second one was just as all of our structures around response were about to be stood down and the focus moved to recovery. And the last one we have just published, as it was announced that England had 'the rule of six', and just as we entered the foothills of a second wave. 

How come those reports have been made public now?

Well, our group is about integration, holistic understanding, and a focus on learning the lessons and preventing further harm. So our publication strategy was clear to be July 2021, or the second wave, whichever came first. And unfortunately the second wave has started, so we've released our reports.

We're privileged on that group to work with a whole range of excellent senior civil servants. They're fantastic. What we are trying to do with the release of those reports is break the ministerial ceiling, because we don't think that's happened yet. And also to encourage those conversations around the foresight that we've generated, and share lessons at community level, so that we can be better prepared going into the second wave, and whatever measures we might be facing in the coming weeks and months.

I saw Shaun West, who's Chair of the Foresight Group, was reasonably critical in terms of that breaking of the ministerial ceiling. He said that your output has to a certain extent been met with 'a pedestrian and perfunctory response'. Why do you think that's been? Do you think there's an increasing schism between the national level strategy and the local response?

I think there are a couple of different ways to think about that. From speaking to the local and strategic decision makers, they will be interacting with the regional structures such as the Joint Biosecurity Centre – a new development since we spoke last – and also incident management teams from public health agencies. When there's a local outbreak, they will come together and support that local strategic team. Certainly all of our different evidence from a range of different sources is suggesting that the national decision makers are very much asking for lots of data, lots of information, and lots of intelligence, from what's going on around the country with regards to Covid-19 and its management. They aren't necessarily engaging in a dialogue about that. The government departments responsible, particularly for communicating with the local levels, have put things in place. They've tried to create that dialogue, from what I can see, with varying success. But the ministerial engagement with that hasn't been widespread. It hasn't been enough. 

The other view is that ministerial officers have had our information – we've certainly sent it there and made sure that they're aware of it – but what they do with that is something different. We've seen from some of the discussions from SAGE, and also Independent SAGE, that there doesn't seem to be a consistent reliable engagement by ministers with the information and collective evidence from such groups. 

Which, when you think about it, is a bit bizarre, given that (with the exception of Independent SAGE), they set these bodies up? 

We were set up by DCC Paul Netherton, who is the most senior police officer for civil contingencies, to be a cross-governmental foresight group, rather than by government itself. But yes, the advisory bodies are really important at every level of managing an emergency, and although we have had lots of senior civil servants' engagement, and they have been very supportive of us, they sit on our group and they're very active, they engage with these groups and link them together. However, the ministerial layer putting all of that advice together is where that becomes fuzzy for me. How and where and who is putting all of that together, outside of silos, is not clear. However I would say that since our reports have been released, we have had a good supportive position taken by government, which I've seen as a really positive step. 

What about your relationship between the Foresight Group and SAGE, for example? As you are the only embedded psychologist, the only embedded scientist in the group, how have you viewed your relationship with them and indeed any other route by which psychologists are contributing to the discussion around Covid?

In the early days, I was very much engaged with them and other mechanisms of science getting in to Westminister and Whitehall, so they knew what we were and were not doing. Our purpose was never to be SAGE, they are a hard working group tasked with doing very specific things. We've got different priorities so I wanted to make sure what we were doing was clear and didn't duplicate. More recently, we've had more contact again. It isn't so dependent on us, as scientists and academics to reach out to each other and say, 'I'm doing this, I'm doing that', it is a little bit more connected now by the architecture of Government and the networks of science and academia in Government.

You said about reports focusing on what's going well, what's not going so well… I know your most downloaded paper from the group is on communication, and that seems to be a consistent theme?

Very much so I think. And there's a couple of different aspects to that. There's the communication with the public; what are the current restrictions, what can we do, what can't we do, what is mitigating, what's the latest science advising, it is clear and do people understand what has changed and why? And then there's communication between the central government and those local strategic decision makers. And that's also been something that we've been looking at by the very nature of the people that we've been researching and collaborating with. They are very clear that there hasn't been a two-way dialogue in the course of C-19. It's been pretty much broadcasting or announcement led policy. It's been quite reactionary. 

The latest communications paper was very clear – the voice across the UK was 'Tell us what we're strategically aiming for'. Because if that is known, so we know that we're trying to achieve, somebody who's currently in charge of a local authority, who has been tasked with Covid marshals, with local outbreak management plans, and other C-19 related initiatives, they are able to design those in a way that fits with that strategy much better if they know about it. Currently, I think other nations may have said what they are aiming for, but England hasn't necessarily said what the overarching strategy is, to know what the direction of travel will be, or what we are aiming for is essential I think. Those local strategic decision makers need to know what they are aligning to. 

Trying to get their voices heard in to government, and not necessarily feeling they have achieved this, that has been another clear finding that we've established across a range of different outputs and evidence. Certainly they have lots of valuable experience managing major incidents at 'local' levels, such as within Local Resilience Forums. These are multiagency community partnerships and structures, and they absolutely know most about how to connect, manage, and understand their local complexities. You could have one local resilience forum with five different health protection boards. And all of that has to come together when there's increased viral transmission in that area, or when a new initiative or directive comes out from the centre. All of that has to co-align and make sense. So there's a lot of energy that's being used to align all of those structures with the direction of travel. If they know what the strategy is that we're moving towards, that energy can be much more streamlined.

The biggest thing I worry about is the fatigue and burnout of those strategic decision makers. Not only key worker – and we mostly think of the NHS when we say that – but also the people who are running the structures that are managing all of the different facets of Covid-19 at a local level. We're talking about local authority staff, blue light staff, emergency planners, people in health agencies… these people have been stood up now, since the beginning of March, maybe in February… before that, they had a lot of spring flooding, before that it was planning for the EU transition. So these people have been flat out working now for almost a year. And we're now going into the pressured months of seasonal influenza, winter flooding, severe weather aspects, a second wave of Covid-19 and EU Transition. The same people manage all of those. I'm pretty worried about them. 

We risk losing their energy and their expertise. Those people who are leading at a local level seem to me to be far more thoughtful, practical, intelligent, than the MPs… of any party, this isn't a party political thing. Those people seem to really know where they're at, what's needed. Their care for their communities comes across in media interviews, because they're embedded in those communities, which MPs aren't always. There are other aspects to it as well – the job of an MP is not necessarily an appealing one that that attracts the most capable, but at the local level these leaders are used to controlling big budgets, working with a wide range of people… they've got the know how, and it just seems such a shame that doesn't seem to be used to its full potential at the moment.

I think it is used to its full potential at local level, I just don't think it's necessarily used to its full potential at central level. Those who are elected to represent people in our democratic processes, should be listening and talking with those local strategic decision makers – directors of public health, local authority chief executives, local health agency decision-makers, gold commanders of emergency service personnel, emergency planners. Really experienced, highly skilled, strategic individuals whose job it is to design, plan and deliver local response. Their expertise and their skill set, absolutely should be reaching those national decision-makers. They are quite frustrated by this. We risk losing these people because they don't want to feel as though they have the energy or the role identification anymore. I think we're further towards that than most people would acknowledge.

There's lots of discussion about families being affected, people's children not liking their mobile phone ringing anymore. 'This has impacted and fundamentally affected my life, my public role, my service role, and it is now hurting my relationships and those around me.' We're significantly dependent on that cohort of people across the UK, who are now experiencing significant impacts across all the domains of their life, that worries me – for them as individuals and for society.

Like with any job, one of the keys to avoiding that kind of burnout is giving people some level of control and some vision of where they're going… that's basic insight from psychology research that we've known for a long time, that people require from their jobs.

Absolutely. And I know that there's some element of the virus being unpredictable. But we know enough about how we've managed it to date, that we can at least develop some form of strategy and framework, so that if the virus is at different levels in different communities, we know what we're aiming to do and what kind of things are going to be implemented in response. 

Part of the problem at the moment is that central government, local strategic decision makers, communities and the public don't necessarily know what's coming because we're not quite sure what interventions map on to levels of community transmission. I'm hoping the Prime Minister will be announcing this afternoon a much more predictable management framework… that we can actually see 'If this happens, then that will happen', so that there is at least some element of predictability and control, or that we know what consequences and causes are related. At the moment I don't think that mapping is transparent or evident to us.

When we spoke back in May, you talked a bit about how important the vaccine was in moving between stages of response and recovery. This, I guess, is the fundamental issue: none of us know whether a vaccine is going to come, and if it will only work with some people some of the time. None of us really know whether zero Covid is a realistic option, given the balance with the economy. None of us really know what lockdown does other than buy us a little bit of time. Some are still talking about herd immunity even though there seems to be a growing scientific consensus that it's not a practical strategy to pursue, certainly without a vaccine. The endpoint still seems a long way off and very uncertain. What do you think we should be aiming for?

My own personal point of view, is that as much as we can, we should be aiming for zero Covid. Then the swing between response and recovery, and the different measures that we're needing to take, can be more predictable if we have outbreaks. At the moment, we're nowhere near that. That's why it feels, to me, that we move very quickly from one direction of travel to another. We don't necessarily have that framework of small gradual steps that lead us to a place where as few people experience the virus as possible. Until we have an adequate test trace isolate, and other aspects of the management of Covid are linked up, I don't think we are going to move out of the current feeling that things are not totally aligned. Without that framework that we're moving towards, it feels more like the virus is managing us.

I have heard people say that the British public as a whole can cope with complete lockdown, or complete normality, but struggle with any kind of halfway house measure. If there is such a thing as 'behavioural fatigue' – and I know that was a controversial concept early on – that it's around mixed and localised messages? When we spoke in May, you did warn that the public were going to struggle more when messages inevitably became more nuanced and localised. And there does now seem to be an increasing mood of kind of pessimism and fatalism possibly, perhaps linked to those inequalities in strategy and restrictions. 

I believe we live in a world where people do have the capacity, the motivation, to exist in that space between lockdown and open. We are not comfortable in uncertainty, but we can exist there. We demonstrate that in our behaviour in every other realm of life and activity across society. It's not that we're not capable of managing that, or displaying the advised behaviours, it's that nobody has sufficiently told us the steps of that behaviour and why that would be good and beneficial, and what the consequences of doing that well would look like? 

When we think about the vast array of messaging evidence, from health psychology, around changing attitude and behaviours, it needs to be clear, it needs to be consistent. What I desperately hope for is an outline of explanation of what we are aiming for the medium to longer term, so that people can motivate themselves to keep within a shared framework to achieve that. If you can see what you are working within, so you see that the rate is going up, and you know that you're going to move from tier one to tier two, and that means certain restrictions, you can accommodate your life, and you can move with it. When that data isn't available, or it isn't widely public shared in an accessible way for people to understand, and we don't know where it's going, that's when people feel that their life opportunities are being randomly thwarted compared with a shared common understanding of what we're trying to achieve, how we're trying to achieve it, and what we can do individually to help achieve that. 

It worked for short term goals, like lockdown because we knew what we were all doing. But we now realise we're all in a mid-long term situation, that bit in the middle of the beginning and end of the pandemic. I don't think it necessarily needs to be that we're all doing the same thing. We can't: we need to be much more community-based than that. But if we're all within the same framework, with an understanding of the steps that escalate and de-escalate, and the trigger points, then we know our parameters for the next few seasons. We can prepare for that duration, rather than swinging from open to closed to open again. It isn't a mid-term plan, and that's what we need. A plan for the bit in the middle. Getting everyone vaccinated when that comes, then we can start an exit strategy from the pandemic. But the vaccine is not the gift of an ending, it's just a step towards an exit strategy, an exit strategy to stabilise and then transition us back to a free society and out of the health emergency.    

I keep thinking of ways in which we're in that unusual inbetween space, and things that seem to become completely normalised… the other day on the app, I got one of those disappearing 'possible exposure' alerts. What's that all about?!

For me, there's the analogy of the Olympic cycling team. If you're going to introduce the system, try and make sure that all the links work, do as much as you can to get every inch of quality embedded in the baseline. If we see a chink missing here and a chink missing there, that's when the trust and integrity goes. It is about doing the basics and doing them well. 

I'm not saying they need to be perfect, we don't operate under that misapprehension in the C19 National Foresight Group. That isn't the reality of moving at pace within this pandemic. Sometimes things need to be good rather than perfect. For example, some of those reports that are now released and on NTU's website, we wrote in four days, because they needed to be written in four days. Some were written in 24 hours, because we needed an answer at that point in time. And very often the approach of 'enough of an answer now is better than a perfect answer too late'. I stand by that for knowing where we are, what kind of direction we're going in. But once you act on that advice, like the app, and develop a response, then it needs to be trustworthy, it needs to have integrity. It can't send mixed messages or conflicting advice into the public sphere. That's when that public trust erodes, and the integrity is questioned. You can have enough of an answer that we can do something, but once you decide to 'do something', you need to make sure that is robust. 

Makes sense. To end, could give me a bit of hope?

We've been tracking public mood, and it is very responsive to what's going on at the time. Mood is very different to things like fatigue, solidarity, togetherness and community cohesion. These latter things are the things that we sometimes take our eye off the ball with in the management of the pandemic, because we're talking about the public health aspects so much. Partly because of priorities, but also because it feels more actionable. But there have been some really great innovation and practice that people are committed to sticking with. That's one of the things that that gives me hope, human agility, ingenuity and kindness. 

The other thing that gives me a lot of hope is around the amazing work that continues to be done across different parts of society and organisations. For example the infrastructure that local strategic decision makers have helped build to manage the pandemic, all of that has been created, or completely redesigned, in a really agile way. That's similar to how everyone's different workspaces and ways of working have been redesigned. As we take learning from the first wave into the second wave, we don't know how the pandemic will behave, but we've got some people out there at local level who are really experienced and experts in planning and figuring this stuff out. That, with the agility I mentioned, is a pretty good safety net for us all. If we as communities continue to build our infrastructures of mutual aid and community hubs, and we have those experts at that local level who are guiding us, if we've got overall strategy from the centre, then hopefully we can feel that we're a little bit more aligned. It's not going to solve it, but it might feel more stable and steady. Rather than 'we're all in this together, because we're experiencing the same thing', it will be 'we're all in this together, because we're achieving the same thing'.

Fingers crossed. And psychology will remain central to that. Have you been proud of psychology's input and response to the crisis?

Hugely proud. Certainly in the UK, psychology has been really responsive, we've been really proactive, and we've understood ourselves, what we can offer, and put ourselves in a policy space that is really appropriate for us to be in. And we've owned those spaces that we absolutely should be in. But also because in my own experience, on that group, we touch so many different disciplines and subject areas and when you pull all of that together, the one thing that always has a really important view of the holistic outcome is psychology. All of those different things connecting together and being experienced is the fabric of what we seek to do. And psychology is always relevant, always helpful in those discussions. 

Back in May, you and I had quite a bit of discussion around whether we were a bit reticent as a discipline to be proactive and be in those spaces. I think we've become much more confident and vocal at demonstrating that we do have something of real value to offer. This is how people are going to experience this, how people are going to receive it, how we're going to respond. The wraparound of psychology isn't as 'surface' as the wraparound term suggests: it pervades all of it, it holds it together.

Postscript from Dr Hill: Since this interview the Prime Minister has announced a second national lockdown to bring the R rate down across England. Although challenging, this will hopefully be a short-term experience. The mid to longer term, and how we move ourselves out of managing Covid-19 when that time hopefully comes, will still remain. How we manage our activities, our connections, our society and ourselves in the difficult mid-term inbetween period is what we should be focusing on. Covid-19 is here for the immediate future, as is our need to manage it. How we adjust to restricted liberty, our individual role in the public health of our society, and the challenges of big uninvited change in how we chose to live our lives, is one of the greatest challenges of our lives.    

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