We’re starting to get the sense we’ll be moving away from groupthink: No one wants to own up to the bad karma of being associated with the group: Instead, consensus is on the menu.
Harries Answer: I’m smiling because there are a number of words which keep repeating through the Inquiry. I don’t hold with the groupthink agenda, I think people spoke very freely, they may not all have thought the same thing, and at the end of a meeting you have to come to a consensus statement and position to support progressing whatever the topic in charge is.
Does the UKHSA have spies on our TTE posts? Last week we reported groupthink as the word of the week, and Dame Harries now agrees. However, the plan was to end up with one view. Consensus it is then – well, it is for this week.
Emma Victoria Reed, one of the two former deputy directors in the Department of Health and Social Care, was on the stand on Monday. We may have been reading this wrong so far. The KCs (Mr Keith) strategy is making everyone look clueless regarding pandemic preparedness.
Question: You are not by training an epidemiologist?
Was this deliberate? Did he want to highlight the lack of formal training as a forerunner to the lack of preparedness? It would likely unnerve you if you were on the stand. The question that followed then set out the KCs position:
Question: Why did no one in the directorate, with an eye to that bullet point, ask himself or herself, “We have a strategy for dealing with influenza pandemic, but because influenza pandemics are intrinsically unpredictable, and because we may be struck by a pandemic that is not influenza but is another viral respiratory outbreak that is equally as unpredictable as influenza and therefore equally catastrophic, we need to have plans for that eventuality’? Why was that question not asked?
Answer: The preparedness we developed for pandemic influenza was based on the reasonable worst-case scenario, so effectively every renewal of that risk assessment did ask whether – what the scenario would be that we ought to prepare for, and on successive risk assessments the risk assessment was the pandemic we should prepare for was a pandemic influenza.
Like last week, we only knew about the F word, and no one told us about the other 30-odd pathogens circulating in the community. We were none the wiser because I’m no expert.
Furthermore, the KC highlights that everything was so complicated:
Question: In his report to the Inquiry, Dr Claas Kirchelle has said: “What sounded complicated on paper proved complicated in practice. The blurred statutory overlap between the local authority, Secretary of State, and Civil Contingencies Act duties could create significant operational confusion over prime protection responsibility during emergencies…” Dame Jenny, do you agree that there was some confusion perhaps over roles in emergency preparedness, resilience and response arising out of what is described as a complicated overlapping or blurred state of statutory responsibilities?
Answer: Yes, but I don’t think it was a perfect system before either…
Some of the initial exchanges between Mr. Keith KC and Ms. Reed are worth noting:
Mr Keith kicks off: So you’ve referred to health protection, and also to health security. What are they and what is the difference between them?
Answer: So health protection and health security policies form part of half of my responsibility. The types of policies that we have responsibility for in that area includes pandemic preparedness, emerging infectious disease, antimicrobial resistance. They are essentially about how the public health is protected but also what threats, under infectious diseases, emerging diseases and pandemics, may well be a risk to public health.
Question: So that’s all under health protection?
Answer: And health security.
Question:Ah, they’re together?
Answer: Yes, they are.
Question: All right. Your statement refers to the directorate having three branches, and you distinguish between health protection and health security, but are they in fact the same area?
Answer: They are very closely related to each other, and sit very closely adjoined.
Question: So which branch does the topic of pandemic preparedness fall under?
Answer: Predominantly under health protection.
We think the deceptively debonaire Mr. Keith is highlighting the complete confusion in the Department.
What is the difference between health protection and health security? We are also confused.
Later on, it gets worse.
Question: Do you recall when you took up post anybody briefing you about the serious concerns expressed by the Department of Health and Social Care’s own departmental board about whether or not there were systems in place to track or quarantine thousands of people in the event of even a moderate pandemic?
Answer: There was no discussion with me about quarantining.
Question: What about track and trace, any discussion about that?
Answer: There was no discussion with me about track and trace.
KC Question: “All right. Then, in relation to paragraph 26, did anybody at your very senior level in the Department say, “Ms Reed, we’ve got concerns about how fragmented the system for preparedness in the United Kingdom has become, this is something that your directorate is going to have to grapple with”?
Reed’s Answer: In the terms in which you set out, no. But the process for how the system would respond to a pandemic – and by the system I mean organisations in health and social care – was both a factor of our pandemic flu readiness programme but also one of the learnings from Exercise Cygnus, so the intent of that paragraph and the issue relating to system overload was something that I was aware of, yes.
A senior civil servant takes over a key post, and no one briefs her; there was no overlap with the previous post holder, and any institutional knowledge was lost. That cannot be so.
Also, note the abuse of the F word. What does it mean? Influenza? RSV? Rhinovirus? Countless known and unknown agents could cause acute respiratory infections.
If senior civil servants use vague terms betraying abysmal ignorance of basic microbiology, no wonder they and us are confused and public monies are wasted in useless ventures like mass testing.
Day 2 saw the much-awaited appearance of Matt Hancock. As Paymaster General and Minister for the Cabinet Office between May 2015 and July 2016, he was responsible ministerially for the National Security Risk Assessment process.
The KC was at pains to stress that the interview was only concerned with the issues of emergency planning and preparedness and wouldn’t be discussing pandemic measures and whether they worked or not – all is not lost; they’re up for discussion in module 2.
Hancock was keen to pass on that “on antivirals, we had a stockpile of antivirals for a flu, but not for a coronavirus”. In the preparedness, though, someone could have looked at the evidence; they don’t prevent transmission nor deal with serious complications.
Oh, and by the way, how can you not have a stockpile of coronavirus antivirals if they do not exist? This is a former Health Secretary giving evidence; you’d expect him to know this or someone to have briefed him.
Hancock’s position was clear: we need to lock down harder and faster next time: “but it is not nearly as important as getting the doctrine right so in future we’re ready to suppress a pandemic, unless the costs of lockdown are greater than the costs that the pandemic would bring.”
The KC returned to the dominant narrative of module 1. There was only one plan for influenza: “That single strategy document identified no strategy for a non-influenza pandemic other than the hope that the plan for an influenza pandemic could be modified to deal with a high-consequence infectious disease that was not influenza?”
We did find something we agree with Matt on: “It would be far better to have a respiratory disease plan and a blood-borne pandemic disease plan and a vector, i.e., touch-borne – or touch-borne disease plan, that was non-specific about the virology of the pathogen….”
We pointed this out so many times over the years, even citing Moltke the Elder: the unexpected always happens (“No plan of operations extends with any certainty beyond the first contact with the main hostile force”).
The KCs questioning further demonstrated how clueless everyone was: “Are you surprised now that you were not informed that the strategy was deemed to be, and I quote a document from your own department, ‘out of date, unfit for purpose’?”
The line of questioning continued in this vein: “How many of those overarching meetings, NSC (THRC) meetings, did you go to in order to inform them of those regular progress updates?“
Hancock Answer: Personally?
Answer: None that I can remember. I attended the National Security Council from time to time when the agenda included areas that I was responsible for. I was not a standing attendee. But I don’t recall ever being asked to attend to report on this.”
Question: Did you know of the existence of the NSC (THRC), the ministerial – overarching ministerial committee to which you were expected to report?
Answer: Yes, I attended it. That’s essentially the National Security Council.
Question: No, the NSC (THRC), the threats, hazards, resilience and contingencies committee.
Answer: Yes, that‘s a subcommittee. That one is a subcommittee of the National Security Council.
Question: How many of those subcommittee meetings did you attend?
Answer: I can’t recall.
Question: Did you attend any?
Answer: I may well have attended none, but I can’t recall.
Q: Have you seen any piece of paper that suggests you did attend?
Q: Why not?
Answer. I’ve no idea.
We also learnt of the lack of preparedness in social care – an easy dodge though for Matt – it was nothing to do with the Government as the responsibility lay with local authorities.
The KC revealed his latest thinking: “There was a bias within the Department of Health and Social Care in favour of influenza,” and as a consequence there was “a failure to think through properly the risks of a non-influenza pandemic… and the risk assessment was cause agnostic, it failed to identify a sufficiently broad range of scenarios.”
Module 1 isn’t about whether measures worked but whether measures were considered in the context of respiratory pathogens. The direction of travel is clear. Due to the focus on a single pathogen, plans were narrow, and government machinery was overly complicated and confused. Broadly speaking, the plans weren’t worth the paper they were printed on.
In response to Hancock’s answer, the day’s quote was from the KC on those who worked in healthcare.
“Lions led by structural donkeys, Mr Hancock; personally everyone gave their all but the system was not fit for purpose, was it?” said the KC.
Hancock’s Answer: “That’s absolutely right…”
Later that day, the former director of Public Health England from 2012 to 2020, Mr. Duncan Selbie, gave evidence. The KC’s tactic put him immediately on the back foot.
Question: It’s right, Mr. Selbie, that you don’t hold any medical or scientific qualifications, do you? Do you feel in any way that that hampered you in carrying out your role as Chief Executive of Public Health England?
Answer: Well, I’ve thought deeply about this, and, you know, with all genuine humility, no.
Question: All right. Thank you very much for that answer. Indeed, we have been through the extensive experience that you had of acting as a chief executive before taking up that post at Public Health England. But I suspect that you may have been asked a similar question when you gave an interview in 2013 to the Lancet, because, asked about your experience in public health, your answer appears to have been: “You can fit my public health credentials on a postage stamp…” Is that right?
A postage stamp, it is, then.
Day Three saw the Scots up. There’s not much to report apart from the fact that they were as unprepared as the English: For once, there’s unification in the Union.
However, there was a change to Kate Blackwell asking the questions. The Inquiry has appointed eleven King’s Counsels (KCs) to support Hugo, the Lead Counsel. The inquiry cost was reportedly £85 million by August last year; the Telegraph reported costs had hit £114 million before the hearings had begun. It’s anyone’s guess how much it will end up costing; some contracts are reported to run for up to seven years.
Up on Thursday was Sir Jeremy Farrar (see here for a bit of background). However, you wouldn’t have known from the news, as his testimony went largely unnoticed.
However, we detected a shift in his thinking as he mentioned the need for red teams to challenge SAGE thinking. “The second thing I would suggest, and I was part of this in a U.S. group, is that there is outside the SAGE system, but linked to it in a constructive way, if you like, a red team. A red team that would have access to other – the same information but would be able to constructively challenge the thinking from the outside and wouldn’t be within the room at the same time.”
He must have been listening to our soundings, as in our plan to the PM in October 2020; we said, “Red teaming policy decisions should be the norm by adopting a practice that rigorously challenges plans, policies and any assumptions.”
We also detected little reference to evidence in his testimony, but with his recent move to the WHO in Geneva, he seems to have taken a penchant for their cheese: “In public health there’s rarely a magic bullet. Public health – the analogy of the Swiss cheese model of having multiple interventions is crucial.” Farrar’s strategy is to throw the kitchen sink at a respiratory virus and hope for the best.
The big act of Thursday Saw Nicola Sturgeon take to the soapbox – Ooops, no, Nicola, the witness box: “Ms Sturgeon, I’m so sorry, that is a witness box not a soapbox, and we cannot allow.”
The Deputy First Minister in the Scottish Government, John Swinney, followed her. Ms. Blackwell wanted to know why the Cabinet Sub-Committee on Scottish Government Resilience, which met to prepare for special contingencies such as pandemic influenza, had last met on April 14th 2010.
Backwell question: Do you agree that, as far as this meeting was concerned, it very much looked as if the committee was going to be busy?
Swinney Answer: Yes, and the work that flowed from that over a number of years, I think, demonstrates exactly that point.
Question: So why was this the last occasion upon which this committee met?
It’s starting to look like the Counsels to the inquiry have done their homework. Slowly they are unpicking the complicated, confused mess of government decision-making structures. Too many people coming and going, too many committees, no one keeping an eye on the overall strategy and a “sluggishness” within the system.
Blackwell Question: Can I suggest, in addition to that, though, there appears to have been a sluggishness within the Scottish Government to implement aspects of not only the Exercise Cygnus recommendations but also those that had come from Exercise Silver Swan in 2016 and Exercise Iris in 2018?
We’ll leave the final word for this week to Lady Hallett, who’s had enough of acronyms.
Lady Hallett: I think we have all had enough acronyms for one day.
The Witness: I’m sorry about that.”
Lady Hallett: It”s not your fault, I’m afraid it’s systemic.
The Witness: Yes.
Lady Hallett: If only it was enough acronyms for a lifetime, but I fear it’s not.
We think it may be more gobbledygook next week, particularly if this week’s performance is anything to go by. However, let’s hope it’s not systemic.
Dr. Carl Heneghan is the Oxford Professor of Evidence Based Medicine and Dr. Tom Jefferson is an epidemiologist based in Rome who works with Professor Heneghan on the Cochrane Collaboration. This article was first published on their Substack blog, Trust The Evidence, which you can subscribe to here.