Will Boris Johnson’s “Moonshot” become lost in space? – The BMJ

Martin McKee is professor of European Public Health at the London School of Hygiene & Tropical Medicine and a member of the Independent SAGE convened by Sir David King. He writes in a personal capacity.

blogs.bmj.com 

Improved testing and new technologies must be part of a well thought out strategy, says Martin McKee
Boris Johnson does not do detail. Somehow he failed to read, or perhaps understand, the text of the EU Withdrawal Agreement that he presented as a “fantastic moment” for the country when he signed it in January 2020. As a consequence, he now finds himself in what is an unprecedented position for a British prime minister of declaring his intention not just to breach international law, but to reject provisions of a treaty he signed only a few months earlier. Sources in Whitehall have noted his preference for papers that are brief and avoid complexity, a preference apparently enforced by his special adviser Dominic Cummings. Nor does he seem to have a sense of curiosity, demonstrated by his repeated failure to attend COBRA meetings at the start of the pandemic. It was therefore unsurprising that his announcement of what has been termed a “Moonshot” project to vastly increase testing for coronavirus lacked any detail other than that it “will require a giant, collaborative effort from government, business, public health professionals, scientists, logistics experts and many, many more.”

Fortunately, some details have become available, in the form of a leaked description of the project and a Powerpoint presentation. They are not reassuring.

The concept is based on testing on a massive scale, up to 10 million tests each day. This will be achieved by widespread use of new, and not yet evaluated tests. These would be, as Johnson predicted in March, “as simple as a pregnancy test”.  Unfortunately, it soon became clear that the tests that the government purchased, for an estimated £17 million, did not actually work. Undeterred, his government now seems, if the documents are to be believed, to be willing to spend up to £100 billion in the hope that any technical problems can be overcome. This would be the equivalent of 70% of the annual NHS budget, prompting several of us who have read it to wonder if it could be a typo, although it is impossible to check as the government does not comment on leaked documents and has failed to provide any meaningful information to Parliament.

To the extent that there are any details, we must look to the Powerpoint presentation, prepared by the Boston Consulting Group. This exemplifies the problems inherent in many management consultancy presentations. First, it draws on an analogy that seems designed to appeal to the more gullible customers, in this case invoking a mission to the moon. Yet a few moment’s reflection reveals the problems with this analogy. When Nasa was programming the guidance in its Saturn V rockets, it knew exactly where the moon would be on 16th July 1969, when Apollo 11 would land. In the centuries since Galileo, astronomers had charted its path with ever greater accuracy. In marked contrast, as has become all too apparent, our ability to predict where the pandemic will be even a few days in advance is far from perfect.

Second, it seems to convey a great deal of information until you look closely. For example, a diagram of a system for scaling up testing in Greater Manchester contains a series of circles labelled, for example, data or validation. Yet these are floating in space, rather like cosmic bodies, with no indication of data flows or lines of accountability. Worse, there is at best lip service paid to existing structures, such as local government and its public health departments. Yet, in other places there is great detail. For example, it sets out a daily schedule for oversight of the project. Every day there will be a “Public Health, Clinical, Scientific Oversight forum” from 11.30-12.00, followed immediately by a daily leadership update. The possibility that a crisis might intervene, disrupting the timetable, does not seem to have been considered. Yet, at the same time there is no information about what these meetings will actually do.

There are many other problems, commented on elsewhere, such as how to deal with false negatives and false positives that will likely be much greater using the new tests. In comments to The BMJ, Jon Deeks, leader of the Cochrane Collaboration’s covid-19 test evaluation activities, said “These are plans from the world of management consultants and show complete ignorance of many essential basic principles of testing, public health, and screening.”

Above all, these proposals show no self-awareness of the problems that have beset England’s highly problematic covid-19 response so far. They portray a government whose ambition far exceeds its ability to deliver, and which sees governing as the practice of launching grandiose initiatives detached from any clear strategy. Many aspects seem totally detached from reality. The timetable presented in the documents envisage that it would be rolled out in early 2021. Given that this is being promised in a country where successive governments have spectacularly failed in almost every major information technology project they have undertaken in recent years, with the proposed system for post-Brexit trading nowhere near ready, this timetable seems, to say the least, rather optimistic. Even if it was delivered on time, by then hopefully we will be beginning to see a vaccine coming on stream.

Once again we see a preoccupation with numbers of tests. It lists target groups, with no indication of how they will be identified and by whom and what might happen once they have been identified. Those involved in the current response know that only a small proportion of people asked to self-isolate actually do so, although once again, Johnson seems unaware, as indicated by his answer to Keir Starmer at Prime Minister’s Questions on 9th September. There is no evidence of any understanding of the importance of a joined up Find, Test, Trace, Isolate and Support system.

One of the most concerning aspects of the Moonshot project is that it continues England’s obsession with standalone initiatives, developed without any apparent involvement of those on the ground or acknowledgement of existing structures. It transmits unbounded optimism, disregarding the enormous problems with the existing testing and tracing programmes.

Another is that this will distract from fixing the problems with the existing system, especially as public health staff are struggling with the abolition of Public Health England. Colleagues report that the consultants involved in developing the proposals have already taken up much of their valuable time.

There is a need to improve testing and new technologies could play an important role. However this must be part of a well thought out strategy, drawing, for example, on thinking in Germany with its focus on in-depth investigation of emerging clusters.

On the basis of what is presented here, this looks less like Apollo 11, which took Neill Armstrong to the moon successfully, and more like Apollo 13.

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