In order to exit lockdown safely, the UK will need to be able to identify virus hotspots and have a robust track and trace process in place to ensure that people who might be infected know that they need to self-isolate.
The new NHS Contact Tracing app is one critical component in the Government’s armoury for doing this.
The privacy of the individuals using the app and the security of their data are obviously critical for the success of the app and keeping the public safe. However, unless you are a privacy and security expert, this is not the thing to worry about; there are lots of people both inside and outside the NHS spending lots of time and ink on this problem.
What we need are more people worrying about wider challenges related to easing the lockdown and how we involve the public in helping to resolve them.
we can’t afford to ignore the public in the planning involved in easing the lockdown. To do so risks losing the precious trust of the public.
The Covid-19 pandemic hit countries around the world in the blink of an eye. Governments had to respond at unprecedented speed to limit the damage the virus could cause. The priority was, quite rightly, to protect citizens’ health and the integrity of their health systems. Arguably, particularly for those governments which were slow off the mark, there was no time for public engagement on whether this was the right response or how the lockdown should be implemented.
This is no longer true. As Katherine Wright said in her recent post, ‘In recent conversations I’ve been dismayed to hear the argument that “there isn’t time to do engagement” in the UK given the urgency of much Covid-19 research.‘
Any action we take as a country needs the vast majority of us to follow the rules laid out by the Government or we risk seeing the virus spread further and faster, killing more people and overwhelming the health service.
The public’s adherence to lockdown has been remarkable but has been born from people’s understanding of the need for, and trust in, the short term crisis response. However, this is likely to come under increased strain over time. Maintaining a coherent national strategy that is adhered to by the public depends, at least in part, on the extent to which the Government can maintain this public trust. The evidence that is used to make the decisions, and the processes to make the decisions, will all need to be seen as trustworthy.
At the very least, this will require greater transparency than we have seen up until now But the decisions about how to adapt lockdown as circumstances change will require the government to trade-off a set of factors which are, by their nature, nearly impossible to trade-off effectively: the health of individuals with very different risk profiles; the integrity of the health and care system; variable geographic impact; individual financial health; regional and national economic health; and a wider set of social impacts. And all of this in a country which is riven by very different perspectives about its future direction and relationship with the wider world.
The Government cannot hope to maintain trust without taking account of the widely different perspectives that the population has about these moral and ethical considerations.
Without trust, people are much more likely to ignore the rules as they come out of lockdown, pushing the country into a cycle of easing, reinfection and hard lockdown. This is too awful to contemplate.
Greater transparency from Government will help to ensure a better-informed public debate, but we need to go well beyond this; the traditional media and newer social media provide no space for wider and deeper reflection on the challenging trade-offs laid out above.
This means, therefore, that the Government needs to start engaging widely as a matter of real urgency. It needs to use all the public engagement tools in the box, including, but not limited to:
- Polls and surveys to get top of mind perspectives about the rapidly changing situation;
- Stakeholder consultation to ensure it is properly informed about the impact of its decisions on specific industries and communities; and
- Engaging community and voluntary organisations on the ground to understand the differential impact that both the virus and the Government’s response is having on different groups.
These tools will help the Government have a better evidence base about the impact of its decisions on the country, but they won’t help it to make informed decisions about the trade-offs that it needs to make.
It therefore urgently needs to start using deliberative mini-publics such as citizens’ juries, citizens’ assemblies and public dialogue. These deliberative tools will provide a robust evidence base about how the public view the trade-offs that need to be made, how they make them, and what values and perspectives they prioritise as they do so.
The Scottish Government has just announced a process for gathering the public’s views on transitioning out of the current lockdown arrangements. While this falls far short of deliberative engagement, it is a good start.
There are a number of different ways in which deliberative engagement could do this. By way of illustration, the three different options below give some idea of the range of decisions which deliberation could feed into.
Deliberation to support the development of iterations of the contact tracing app
The public has not been involved, as far as publicly available information suggests, in the initial development and implementation of the contact tracing app which is already being rolled out in the Isle of Wight.
However, engagement could feed into future iterations of the app as it is rolled out and its effectiveness monitored. Specifically, deliberative engagement could generate robust evidence about public perspectives on, for example, the:
- Trade-offs between benefits, risks and wider social harms and the impact these are having on the uptake and use;1
- Trustworthiness of the app and the evidence it generates to inform policy and the extent to which these are changing over time;
- Design and implementation of governance and accountability systems necessary to support trustworthiness;
- Identification of unintended consequences; and
- The app itself (including how user friendly it is) to inform future iterations.
With a large enough sample size, it will be possible to gain insights into: the extent to which the perspectives of different communities differ; and the impact of the app on inequality.
This app will be the first of its kind in the UK. Technology of this kind clearly could be of immense value, saving public money and generating evidence which will help the country to build a better health service. It is therefore critical that the Government gets it right; it must ensure that it is responsive to what the public thinks about it and the extent to which it is trusted. If it doesn’t do this it risks undermining its ability to use this technology in the future.
Dialogue to feed into wider policy decisions
Assuming take-up is high enough, the app will provide one element of the evidence base which the Government needs as it makes decisions about where and when to ease the lockdown.
But it isn’t a magic technological machine which will actually make the decisions for the Government; it just provides data.
And these decisions are difficult. How do the public balance the risk to health against the risk to their own finances and the wider economy? Who should be prioritised for immunity certificates? How should this work? Should work start times, and hence public transport use, be staggered? How? What should the sanctions be for people misreporting their symptoms on the contact tracing app, not self-isolating or deliberately infecting others?
As these questions show, and as I’ve said above, any decisions to move out of lockdown require a series of nearly impossible trade-offs. These will have differential effects across different communities, geographies and age groups, for example. The public acceptability of such decisions will depend not only on making the basis of these decisions transparent but ensuring that they take account of public perspectives on how to balance these impacts.
One-off or ongoing deliberative engagement will generate robust evidence about public perspectives on the range of topics illustrated in the bullets above.
Dialogue to support future pandemic (or other crisis) planning
The UK ran a planning exercise to test its ability to deal with a pandemic back in 2016. It didn’t involve the public in this, and possibly even worse, kept the results secret.
There really was no need for the Government to have to make the initial decisions about when to move into lockdown without engaging the public. Sure, for this virus, in February, there was no time to involve the public. However, during a pandemic planning exercise, many of the trade-offs highlighted above could have been explored by a deliberative mini-public. If the UK had done this back in 2016, we would have been much better prepared for Covid-19. We can’t afford to be in this position ever again.
And, right now, we can’t afford to ignore the public in the planning involved in easing the lockdown. To do so risks losing the precious trust of the public. And without trust, people are much more likely to ignore the rules as they come out of lockdown, pushing the country into a cycle of easing, reinfection and hard lockdown. This is too awful to contemplate.
This post has been cross-posted on the Nuffield Council for Bioethics blog.
- 1. I said above, unless you are an expert, you shouldn’t spend your time thinking about privacy and security. I stand by this (though of course, you should worry about what the experts are saying about this). However, the Government and experts should worry about how the public trade-off privacy and security against the app’s effectiveness and the robustness of the data generated, for example. And it should worry about how the public perspectives of this trade-off vary over time.