Joe’s View: Educated fools, marshmallows and the NHS Covid tracing app

In a column for Digital Health, Joe McDonald, stresses why the public needs to get behind the NHS Covid-19 app in order to beat the virus.

Listening to Rob Newman (remember comedians Newman and Baddiel?) on BBC radio 4 recently I was reminded of a phrase my late father often used to describe me, “Educated Fool” he’d say whenever we disagreed.

In Newman’s Half-Full Philosophy Hour, he recounted how, as a child his life was changed by hearing a First World War veteran interviewed in a live broadcast. Asked what he remembered with affection about his time in the trenches, the octogenarian soldier replied “the camaraderie”. Then when asked to give an example, he recounted how he and his comrades in arms were horrified by the arrival of a posh, educated fool of a commanding officer who, keen to make a name for himself, decided that the veteran and his young friends should make a suicidal full frontal assault on the German lines. He then described how “camaraderie” saved their lives.

The veteran explained to the interviewer “Just as he was about to blow his whistle to launch the attack, we shot him. Camaraderie, see?”

Shocked by this revelation, Newman asked his grandfather if such a tale could be true and got the reply “bayonetting was better -shooting caused too many questions”. Newman mused on the need to be on the “right side of history”.

Wait and win double

Which side of history will Boris Johnson find himself on? There is little doubt about the quality of our Prime Minister’s education, Eton and Oxford, the finest education that money can buy but of course leadership isn’t just about education is it? It’s about character. There is a famous test of character beloved of developmental psychologists, the Marshmallow Test.

The test was developed in the 1960’s by Walter Mischel, a Stanford psychologist. It measures the ability of a small child to defer gratification by placing the child in front of a single marshmallow and then telling the child they can have two marshmallows if they can be left alone with it for 15 minutes without eating it. So there are two types of character, those who eat the marshmallow and miss out on the deferred reward and those who wait and win double. Mischel then followed up the children for over 20 years and reported that those who got two marshmallows fared much better in later life than those who went for instant gratification.

Now, I don’t think you need to be a consultant psychiatrist to figure out which group Boris Johnson is in. I’m pretty sure he’s a one marshmallow guy. Lock down late, open up too early and obsessed with keeping the pubs open. 60,000 dead already, a second wave gathering momentum and “the science” no longer followed but roundly ignored. So just when we need a leader of two marshmallow calibre, let’s say a Marcus Rashford kind of guy, we have Boris.

The three U’s

So it all looks pretty grim, right?

Wrong. We can solve the problem ourselves. The means of our deliverance has been handed to us by the clever people at NHSX in the shape of the NHS Covid Tracing App. OK, it’s a little bit later than we might have liked and OK we did all tell them that the first iteration wouldn’t fly.

I have downloaded the app and submitted it to the 3 U’s test. To be considered a success any application has to be: useful, useable and most importantly in this case, used. And used in massive numbers, not just downloaded in massive numbers but actually USED in massive numbers.

Because our app is a little later than some others, it is actually somewhat better in my opinion than some others around the world but the problem with similar apps is that they haven’t achieved the mass adoption required to be effective. Even in Germany (well led by Angela “two marshmallows” Merkhel), only 20% of the population have downloaded the equivalent app and who knows how many actually use it? Ireland and Scotland have also topped out at about 20% well below the required level of use to make a significant difference. Useful and usable but not used.

Delivering useable tech

In Newcastle’s town centre today I spent an hour watching people. I didn’t see anyone open the app and check-in using the QR code functionality and worse still only about 10% of establishments had a QR code displayed. On closer examination some of the QR codes weren’t for the NHS Covid App, Weatherspoons, for example have their own check-in QR code scheme and they are not alone.

Those of us who remember the National Programme for IT will recall that the delivery of an application is the start, not the end of the project. This project has delivered useful , usable tech but is likely to fail without addressing the human factors, “the soft stuff” that will drive the massive use we need to set ourselves free.

We will need national treasures (Rashford, Ant and Dec, Shirley Bassey, Billy Connolly etc.)  to sell the use of the app to a nation whose trust wilted under the dead weight of the Barnard Castle Eye Test and died when it was decided to share healthcare information with the police.

We will need to incentivise establishments to display a QR code and to make them insist on people checking in. We will need to hold prime time TV tutorials to explain to the public when to turn the app off to avoid overwhelming our fragile Test and Trace infrastructure with false positives.

We need to incentivise citizens to download and USE the app. A free lottery ticket with every download? Check-in at The Earl of Pitt Street, win a free pint? Ideas on a postcard or better still on this twitter thread:

Congratulations @MattHancock and @matthewsgould Great technical work by @NHSX to deliver @NHSCOVID19app . Here are some suggestions around the 'soft stuff' of getting massive buy in required to make it a success. pic.twitter.com/kUtHaky1vb

— Prof Joe McDonald, NHS Digital Reform Specialist (@CompareSoftware) September 27, 2020

Way out of the nightmare

During The Black Death, a red cross was painted on the door of infected buildings to warn people off, maybe we could start a social movement which would view the absence of an NHS Covid App QR code at a doorway with the same horror and would make you take your business to an establishment that cared enough to get involved.

There is a way out of this nightmare. It is down to us though. Download the app, use it, tell everyone you know to use it, check-in religiously, don’t go to places with no QR code. Don’t be like Boris, be a two marshmallow person and we might just save Christmas, get the pubs open and prevent another 60,000 deaths.