Support Bubbles and Extended Households: A Dog’s Breakfast?

For what is (hopefully) the final part of this campaign, read It’s an ill wind…, which described the English Government’s low-key statement, on 9 September 2020, that ‘established relationships’ would henceforth be exempted from social distancing.

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Two months ago I condemned the UK’s failure to introduce household bubbles to reunite non-cohabiting couples. This post reviews subsequent progress across the four home countries up to mid-August 2020.

On 10 June – the day immediately following publication of my previous post – Prime Minister Johnson announced the introduction of ‘support bubbles’ in England. Northern Ireland immediately followed suit, albeit with a variant of the English model.

Two days later the UK Government published papers revealing SAGE’s attitude to support bubbles and the nature of its advice.

Unfortunately there has been no further progress in England or Northern Ireland, other than to extend support bubbles to the ‘clinically extremely vulnerable’ who were then shielding.

But, meanwhile, both Scotland and Wales have introduced more liberal ‘extended households’ – support bubbles by another name – while the Scottish guidance enables all non-cohabiting couples to reunite.

As the political narrative veers back and forth between relaxing national lockdown and imposing restrictions to control more localised outbreaks, neither England nor Northern Ireland seems poised to rectify this anomaly.

And, short of a second national lockdown, it seems equally unlikely that the more relaxed regimes in Scotland and Wales will be reined back.

Thus far at least, these arrangements have been protected under localised lockdown arrangements, even when other social interaction has been sharply curtailed.

The overall picture is unnecessarily complex, with different interpretations in each country. The relationship between legislation and guidance in each country changes frequently as regulations are revoked and revised so it is exceptionally hard for us to distinguish what is permissible from what is prohibited.

One thing is clear: the former inequity – treating non-cohabiting couples differently to those cohabiting – is now compounded by a second: treating non-cohabiting couples differently, not for any obvious defensible reason, but ostensibly because of where they happen to live.  

This needs to change, and fast.

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A brief recapitulation

Those seeking chapter and verse are referred to my earlier post: what follows is a concise restatement of the core argument it set out.

Household bubbles (as they were then called) are small, exclusive groups of people who, though they might not live together, will have close contact with each other while remaining socially distanced from everyone else. If one has symptoms, all must quarantine.

There are many overlapping reasons why governments might want to introduce such bubbles, whether unifying households that do not occupy the same physical space; linking households to facilitate personal and family relationships; enabling caring and childcare arrangements; or supporting the lonely and vulnerable. I am concerned entirely with bubbles as a means of reuniting non-cohabiting couples.

In the UK almost one in ten adults pursues a relationship with someone they do not live with: about four million people – roughly two million couples – are affected. A 2012 study found roughly a quarter were aged over 45, a third aged 25-44 and the remaining 40% aged 16-24.

These relationships are fairly evenly distributed across ethnic and socio-economic groups. Many are longstanding: in the 2012 sample, over 40% had been together for more than three years; almost half of those for more than six years.

On 24 March, the day immediately following lockdown, Deputy Chief Medical Officer Harries told couples living apart to contemplate moving in together or else remain isolated in their separate ‘household units’ (the relevant section is about 21 minutes into this recording).

I believe this was discriminatory. The justification for permitting physical contact (and so increased risk of infection) between couples who share a home while denying it to those who live apart was flimsy, relying on two questionable assumptions: that cohabiting couples would invariably infect each other anyway; and that linking non-cohabiting couples would inevitably extend chains of transmission and increase infection rates by an unacceptably large margin.

Moreover it was wrong for the Government to infer that the relationships of non-cohabiting couples are invariably less permanent or less stable; and for it not to understand that many have to live apart, for sound financial, practical and logistical reasons.

The Scottish Government was first to float the formation of household bubbles, following the New Zealand model, in its framework for decision-making published on 5 May. But bubbles were not mentioned in the Scottish route map published on 21 May.

The UK Government’s plan to rebuild, published on 11 May, mooted New Zealand-style bubbles too:

‘…the Government has asked SAGE to examine whether, when and how it can safely change the regulations to allow people to expand their household group to include one other household in the same exclusive group.

The intention of this change would be to allow those who are isolated some more social contact, and to reduce the most harmful effects of the current social restrictions, while continuing to limit the risk of chains of transmission….’

The text implied that bubbles would be introduced in stage two of the plan, for implementation no earlier than 1 June. Meanwhile, with effect from 13 May, non-cohabiting couples were allowed to arrange to meet while remaining two metres apart.

But, as in Scotland, Johnson’s follow-up announcement of stage 2 components on 28 May made no reference to bubbles. Even though, as we now know, the relevant discussions had taken place within SAGE two weeks beforehand.

Rubbing salt into the wound, new regulations were brought into force on 1 June making it illegal for two partners not living in the same household to be indoors together. At a stroke, all non-cohabiting couples had their intimacy criminalised.

Then, after a further two weeks, everything began to change.

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Support bubbles are introduced in England

On 10 June, Johnson announced in relation to England:

‘From this weekend, we will allow single adult households – so adults living alone or single parents with children under 18 – to form a “support bubble” with one other household.

All those in a support bubble will be able to act as if they live in the same household – meaning they can spend time together inside each other’s homes and do not need to stay 2 metres apart.

I want to stress that support bubbles must be exclusive – meaning you cannot switch the household you are in a bubble with or connect with multiple households. And if any member of the support bubble develops symptoms, all members of the bubble will need to follow the normal advice on household isolation.

We are making this change to support those who are particularly lonely as a result of lockdown measures. It is a targeted intervention to limit the most harmful effects of the current social restrictions. It is emphatically not designed for people who don’t qualify to start meeting inside other people’s homes – that remains against the law.’

So countering the effect of social isolation on single-adult households was the justification for restricting this entitlement. No mention was made of non-cohabiting couples.

The concession was not confined solely to those in single-adult households, but neither was it extended those who both live in households containing two or more adults. It too substituted one inequitable position for another.

I cannot reliably estimate the impact on the cohort of non-cohabiting couples. Those most likely not to benefit include older couples whose young adult children still live with each of them, those caring for elderly or disabled relatives and those living with siblings or in multi-generational households.

My best guess is that at least half the cohort was kept in purdah – up to two million people with the misfortune not to live in a one-adult household and partnered with someone in the same boat.

Guidance published on 23 June clarified that the second household could be of any size; that single parents with children who turn 18 could remain in their bubble; and that, while no limit had been imposed on the distance between paired households, local arrangements were preferred.

Those deemed clinically vulnerable were advised to bear this in mind when deciding to form a bubble (though entitlement was extended to the clinically extremely vulnerable – those shielding – just a few weeks later).

People ‘at a higher risk of exposure to those with coronavirus’ were also advised to take particular care when deciding whether to form a support bubble.

Regulations were introduced which exempted from prohibited gatherings of two or more people indoors those comprising members of the same household ‘or members of two households which are linked households in relation to each other’.

Linked households were defined as follows:

‘(1) Where a household comprises one adult, or one adult and one or more persons who are under the age of 18 on 12 June 2020 (“the first household”), the adult may choose to be linked with one other household (“the second household”) provided that –

the second household is not linked with any other household; and

all the adult members of the second household agree.

(2) There is no limit on the number of adults or children which may be in the second household.

(3) The first and second households are “linked households” in relation to each other.

(4) The first and second households cease to be linked households if neither household satisfies the condition in the opening words of paragraph (1).

(5) Once the first and second households have ceased being linked households, neither the first household nor the second household may be linked with any other household.’

The implications of the second sub-paragraph are worth reflecting on.

A support bubble can be formed between a single person with a school-age child and a multi-generational household of, say, 12 people including grandparents, several people of working age and several children. Fourteen people would be linked together, each with their own potential chains of transmission.  

Conversely, two single people, each with one resident adult child – so four people in all – are unable to form a bubble.

Yet, other things being equal, the risk of increased covid transmission is substantially greater in the first pairing than in the second.

The penultimate sub-paragraph makes it clear that, if the adult population of the single-adult household increases (other than through children attaining adulthood, as clarified by the guidance), the bubble will burst. 

The final sub-paragraph is not fully explained in the guidance: it means that, if a support bubble bursts for any reason, neither household can establish a new and different support bubble. There is no time limit on this prohibition. So households that form bubbles have only one chance to get it right, and must then stick with their decision or revert to solitude.

These regulations were revoked on 4 July, although variants have subsequently reappeared in the regulations governing local lockdowns, to exempt support bubbles from the restrictions imposed.

It follows that, except under local lockdown regulations, differently constituted household bubbles are no longer illegal.  

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Northern Ireland follows suit

Northern Ireland promptly decided to permit:

‘People who live alone to form a small support unit with one other household, enabling the person to visit, stay over and spend more time with their support network….’

This came into effect on 13 June, simultaneously with England.

But the associated guidance made it clear that one of the two households had to be a one-person household in the strict sense, containing no children:

‘People who live alone are permitted to visit one other household indoors to form a small support unit (a ‘bubble’).

The bubble would therefore contain two households forming a single unit, that is the person living on their own and members of the other household, where social distancing between them would no longer be required.

This enables the person who lives alone to visit, stay over and spend more time with the second household. The second household can be of any size.’

This is far less generous than the corresponding provision in England and unfairly penalises single parents.

The guidance further states:

‘…members of the two households within a bubble will not be permitted to visit or have visitors from a third household’.

This runs counter to arrangements in the other home countries, where the pairing of households enables the resulting unit to be treated as a single household for the purposes of interaction with another.

I have been unable to track down any clear definition of these ‘support units’ in the Northern Irish legislation, beyond the removal of a restriction on movement:

‘…in the case of a person who lives alone, to visit another person’s private dwelling, including staying one or more nights in that person’s dwelling’.

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Little has changed since in England and Northern Ireland

On 22 June both the UK Government – in relation to England – and the Northern Ireland Executive announced that, with effect from 6 July, those shielding could also form a support bubble. The same distinctions between the rules in the two countries continued to apply.

The limits on household size in England and Northern Ireland remain unchanged since they were first introduced two months ago.

On 24 July, the UK Government published ‘the next chapter in our plan to rebuild’, an extension of the original plan published on 10 May. It gives no commitment to extend or expand support bubbles, merely offering a vague general statement:

‘We all need to continue to minimise close contact with people we don’t live with, only meet small groups at any one time (just the members of two households, or six people from multiple households if outdoors) and limit how frequently we meet different people socially over a short period of time to avoid spreading the virus to multiple groups of people. It is vital that people continue to follow the social distancing guidelines to help keep everyone safe as the risk of a wide outbreak remains.

There is a careful balance to strike; safely reopening society and the economy is only possible because the restrictions on social contact remain in place. We will keep these guidelines under review and look to allow ever more contact between family and friends when we can.’

This is completely unhelpful. It is unclear whether the constitution of support bubbles is subject to review and there is no timetable for any further relaxation.

Most of us are resigned to limiting social contact and keeping our distance from the vast majority of our acquaintance, but we also recognise that non-cohabiting couples are a special case, deserving to be treated as such, in much the same way that separated parents with children are deemed a special case.

The present arrangements are such that, theoretically at least, many non-cohabiting couples are still supposed to be maintaining a distance of two metres from each other, having been kept physically apart for almost five months.

I say ‘theoretically’ because I imagine that most will by now have decided to bypass this unreasonable and unfair restriction. But it is insufficient for governments simply to turn a blind eye towards behaviour that they themselves have previously criminalised.

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Extended Household Groups in Scotland

One week on from Johnson’s announcement, on 19 June, First Minister Sturgeon introduced essentially identical arrangements, except that Scotland decided to call these new units ‘extended household groups’.

Unlike Johnson, Sturgeon made explicit reference to non-cohabiting couples:

‘For example, it will allow…a non-cohabiting couple, where at least one of them lives alone, to be reunited indoors without the need for physical distancing.’ 

She added: 

‘I hope very much we might be able to expand this ‘extended household group’ idea in the not too distant future so it benefits more people and I will keep you updated on that.’

The Scottish regulations took a much more straightforward approach than their English counterparts, specifying simply that:

‘“extended household” means two households which have chosen to be treated as a single household, where one of those households is a qualifying household…’

and

‘“qualifying household” means—

(a) a person who lives alone, or

(b) a household where only one person in the household is 18 years or over,”.

Other aspects of the announcement – such as the exclusivity of extended households – were confined to the guidance.

With the introduction of phase three of the Scottish route map, which took effect from 10 July, Sturgeon announced that those who were shielding might now form an extended household. She continued:

‘The other changes that come into effect today don’t apply to people who are shielding, unfortunately. But they do apply to everyone else.

From today, if you are part of a non-cohabiting couple, regardless of your living arrangements, you don’t need to stay physically distant from each other, indoors or outdoors.’

So, since 10 July, all non-cohabiting partners in Scotland other than those shielding have been reunited.

And, since shielding was paused on 1 August, their exemption lasted no more than three weeks, though it remains to be seen whether this freedom will disappear if and when shielding resumes later in the year.

The Regulations giving effect to these changes simply redefined an extended household:

‘“extended household” means two households—

(a) which have chosen to be treated as a single household, and

(b) do not already form part of another extended household,”’

This legislation remains in force, but though the legal position is that any two households can form an exclusive extended household, regardless of size or composition, the present guidance advocates extended households only if one of the households contains one adult.

But that restriction is omitted if the purpose is to reunite non-cohabiting couples:

‘Forming an extended household

The regulations have been changed to allow 2 households to be able to form an extended household group.

In Phase 3, our advice is that extended household groups may be appropriate for people who live alone and/or people who are in a relationship, but don’t live with their partner….’ 

The guidance continues:

‘Couples who do not live together

If two adults are in a relationship and they do not live together they, and any children they each live with, can agree to form an ‘extended household group’. 

Everyone in the extended household will be able to act, and will be treated, as if they live in one household – meaning they can spend time together inside each other’s homes and not need to stay at least 2 metres apart.

However, we know that if one member of a household gets coronavirus, there is a strong likelihood that other members of that household will also catch it. For this reason, there are some important rules that extended households should follow to remain as safe as possible:

a household should not form an extended household with more than one other household

households can end the arrangement at any time, but should not then form an extended household with a new household

We would also encourage parents or guardians to discuss extended household arrangements with any children in their household. This is an important decision that should be properly discussed and agreed beforehand…

…Members of an extended household are considered to be one household for the legal requirements on meeting other households and going outside, and for the guidance in this document about seeing friends and family and about exercise and leisure activity….’

This wording could be clearer as it relates to households containing two or more adults. If one half of a non-cohabiting couple lives with their sister, say, or a parent, or any other adult who is not a child of that person, this implies that those adults don’t have to be consulted or agree to the formation of the extended household.

Still, this is carping. Although Scotland’s exit from lockdown has generally been slower and far more cautious than England’s, in this case they have moved one significant step further.

Why England has not followed their lead remains a mystery. One can only surmise that non-cohabiting couples are a higher priority in Scotland than they are south of the border.

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Extended Household Groups in Wales

Wales was late to the party but, when it introduced extended households, it was without any restriction on the size of the households forming them.

First Minister Drakeford announced them on 29 June, with effect from 6 July, so some three weeks later than in England and Northern Ireland.

The regulations defining an extended household in Wales did so as follows:

‘(6) If two households agree to be treated as a single (extended) household for the purposes of these Regulations, any reference in these Regulations (other than in paragraphs (7) and (8)) to a “household” is to be read as including both households.

(7) To agree to be treated as a single household all of the adults of the two households must agree.

(8) But—

(a) a household may only agree to be treated as a single household with one other household, and

(b) if two households cease to agree to be treated as a single household, neither household may agree to be treated as a single household under paragraph (6) with any other household.’

So in Wales all the adults must agree to the arrangement and there is a similar provision to that in the English regulations forbidding the formation of a second extended household should the first collapse.

However these regulations seem also to have been revoked.

The Welsh guidance does not distinguish non-cohabiting couples as Scotland does. Although clear that there is no limit on the size of either household, it does make a distinction in respect of houses of multiple occupation (HMOs):

‘Houses of multiple occupation (HMOs) are made up of separate households which will have their own tenancy agreements, but share facilities, such as bathrooms, living rooms or kitchens. Each household within an HMO can enter into separate extended households, but because of the higher potential that coronavirus could be spread throughout the house, these households should be aware that they are potentially putting themselves and others at increased risk and they should think carefully about forming an extended household with people not living in their house.’

And, in Wales, the guidance for those shielding is that, even in extended households – which are designed to eliminate the need for social distancing – they should:

‘Aim to keep 2 metres (3 steps) away from others, and sleep in a separate bed where possible.’

But shielding in Wales is paused from 16 August.

Moreover, on 13 August, Drakeford announced that, if conditions remain stable, up to four households may constitute a single extended household from 22 August.

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Summarising these distinctions

In a nutshell then, a non-cohabiting couple:

Or, at least, that’s my very best effort to make sense of a tangled web of different regulations and guidance. If you think I’ve missed anything, or have a different interpretation, do please let me know!

Incidentally, since early August, the French have operated a ‘laissez-passer’ system enabling the partners of French citizens stranded elsewhere in the world to apply to join them in France. But then the French have a long history of indulging love and lovers, while we in the UK are hypocritically straight-laced.

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Deliberations in SAGE

My earlier post drew attention to research evidence then in the public domain, as well as the outcomes of deliberations in Scotland and England, including a summary in the Minutes of the 34th SAGE meeting, which took place on 7 May 2020 and were published on 29 May.

Since then, four further SAGE papers have entered the public domain, all of them published on 12 June:

This commentary summarises the arguments set out, drawing out the most salient points and the emerging consensus position.

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What the Minutes say

The minutes of the 34^th meeting were extremely cautious about the introduction of bubbles, despite evidence of their effective deployment in New Zealand.

Having acknowledged two potential benefits, they list a series of risks and problems:

They conclude that ‘introduction of bubbles is not straightforward and carries potential unforeseen risks’. Further work is necessary to inform a decision.

This ‘can’t do; not invented here; people are not to be trusted’ mentality set the tone for much of SAGE’s subsequent engagement with the issue, helping to explain why the introduction of bubbles was delayed, and why England and Northern Ireland still have such tightly prescribed arrangements. 

The Minutes of the 36^th Meeting are similar in tone. The summary at the head of them says (my emphasis):

‘SAGE advised that social bubbles have the potential to create significant unwanted effects and advised against their introduction in the short term, when other distancing measures have only just been lifted, or in conjunction with release of other measures.’

The main treatment is quoted verbatim below (emphases are mine):

‘SAGE advised strong caution concerning the introduction of social bubbling – particularly in the short term, when other distancing measures have only just been lifted, or in conjunction with release of other measures. SAGE has advised previously against making too many changes at once.

While SAGE noted the impact of lockdown on wellbeing and theoretical benefits of bubbling for some people (e.g. those experiencing loneliness, stress, economic hardship), it cannot be regarded as a universal good; for some people bubbling is impossible, too complicated or there may be no other household for them to link to.

Any bubbling will increase infection risk. If introduced, bubbling should only happen when it is safe to do so from an epidemiological perspective and on a very modest basis initially.

Currently incidence is too high and R close to 1. Active contact tracing should be a pre-condition of introducing bubbling.

Modelling of risk to date has assumed that schools remain closed and that R is 0.8 or lower. Risk would be amplified if schools are open and if workplaces are busier.

For bubbling itself, risk can be minimised if participating households are small, i.e. two one-person households interacting (1+1) or (slightly more risky) a one-person household interacting with a larger household (1+n). Bubbles of larger households with multiple individual connections provide a significant potential risk.

Consideration is needed, however, of bubbling involving multi-generational families including older people, of families which include vulnerable individuals or which include a healthcare worker.

SAGE also noted significant challenges to operationalising bubbling and setting out unambiguous guidelines. Isolation on contact with an index case would have to involve the whole bubble.

Messaging needs to be clear prior to launch to prevent/reduce non-adherence.

SAGE advised that non-adherence with guidelines could lead to spread of the infection and that non-adherence was likely, especially if larger households are bubbled together.

SAGE noted a paucity of evidence from the adoption of bubbling in other countries – but that there is already some evidence of potentially significant non-adherence with bubbling guidelines.

Other unintended consequences are possible.

SAGE concluded that bubbling may be appropriate in limited circumstances – and that policy development in the area would benefit from being able to quantify and compare its impacts with other measures, though quantification is challenging and data sparse.

DHSC polling could in future ask about interactions among households to determine whether bubbling is already happening.’

The only action was to prepare ‘a covering summary note on social bubbling, setting out SAGE’s advice and caveats’. This has not yet been published.

The minutes of the 38^th meeting, on 21^st May added that:

‘SAGE advised that either social bubbling or opening both primary and secondary schools had the potential to recreate significant transmission networks, which would have a large effect on the epidemic.’

Essentially SAGE was looking for reasons not to endorse support bubbles and, if they had to be introduced, how to restrict them to the fewest possible households.

But they should have been asking themselves how bubbles might best help people to cope with social isolation; how to maximise their adoption within the headroom available; and how to extend and expand them as soon as feasibly practicable.

I can find no further reference in later Minutes which, at the time of writing, have been published for meetings up to and including 9 July.

This suggests there has been no further discussion, since mid-May, of the scope for expanding support bubbles to replicate extended households.

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What the two SPI-M-O papers say

Both SPI-M-O papers are much more balanced and hence noticeably more pro-bubble than the Minutes.

The first is little more than a ‘sighter’ on the broad principles. It argues that bubbles:

The second is more substantial but covers much of the same ground.

An initial summary acknowledges that social interaction under lockdown depended on single household bubbles. Allowing bubbles to ‘span across small households’ would not have a particularly large effect on R, even with very high take-up.

Pairing one-person households would increase R only marginally. Provided R is at 0.8 or less, pairing two-person households or a one-person household with another of any size would also be unlikely to raise R above 1.0. Pairing larger households would be more likely to increase R beyond 1.0. The effect could be reduced by restricting bubbles to households with primary-aged children.

The paper discusses the outcomes of three modelling studies, one of which was summarised in my earlier post.

Some of the more interesting points made in the main body include:

SPI-B’s Contribution

SPI-B’s paper consists of a three-page summary and a 15-page annex which includes five pages of footnotes. It is rambling, waffly and repetitive.

The essential points are:

According to this definition, England and Northern Ireland are stuck in phase 1, Scotland is in phase 2 and Wales will shortly move beyond phase 3.

It is unclear whether this is because it is thought that Scotland and Wales have household transmission better under control, while England and Northern Ireland have made insufficient progress.

There is no data in the public domain identifying the epidemiological impact of bubbles or extended households themselves, whether adverse or otherwise, but their retention in localised lockdowns to date suggests that they are not perceived to be particularly problematic.

It seems more likely that Scotland and Wales attach relatively higher priority to extended households than some other elements of the relaxation of lockdown.

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Conclusion

As with so much else in the response to covid-19, the devolution of responsibility for health matters has resulted in four subtly different sets of guidance.

If there are sound reasons for this – driven by the different epidemiological conditions in each of the four countries – it would be helpful to see the evidence for that.

We should also be told what markers Scotland and Wales have used to justify their decisions, so we can be assured that England and Northern Ireland continue to fall short on those measures.

If there is no data on the comparable epidemiological impact of bubbles and extended households, it should be collected. If there is data it should be published immediately.

As matters stand, the dearth of published evidence and markers suggest there is negligible justification for these distinctions, beyond the opportunities they provide for political points-scoring.

The consequence is undoubtedly a dog’s breakfast.

Having four sets of guidance backed up by an ever-changing legislative hotch-potch is not a recipe for success. It sows public confusion and disgruntlement, in circumstances where it would be far better for rules to be universal, fair and equitable, for messaging to be simple, clear and precise.

Throughout its course, the handling of this epidemic by the UK Government has left much to be desired. None of the devolved governments has been exempt from ineptitude. All might redeem themselves a little by eliminating these unnecessary variations.

They should adopt a unified common approach to support bubbles and extended households, aligning all four countries with the most liberal interpretation. Common terminology would also help.

As for non-cohabiting couples, the argument for prioritising the economy misses the point; the ‘schools versus pubs’ argument entirely misses the point: when there is limited headroom for relaxing lockdown, the restoration of long-term, loving human relationships must take priority.

There are sound ethical reasons for this and, indeed, for preventing the state from interfering in such matters in the first place. Moreover, the costs of doing otherwise – in the shape of social unrest, disinclination to follow official guidance, increased mental and physical ill-health – are considerable.

The cost of prohibiting relationships between non-cohabiting couples almost certainly outweighs significantly the very limited impact on controlling infection.

So I call on all four governments to confirm forthwith that all non-cohabiting couples resident in the UK can resume their relationships with immediate effect.

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TD

August 2020