We’ve started week four with the Approved judgment for the Cabinet Office versus the Chair of the U.K. Covid Inquiry, which is now in.
The judgment granted permission to the Cabinet Office to apply for judicial review about the correct interpretation of section 21 of the Inquiries Act. Section 21 gives powers to the Chair of the Inquiry to require the production of evidence.
All did not go the Cabinet Office’s way; the review found the section 21 notice issued to the Cabinet Office was valid and that the Inquiry Chair acted rationally in issuing section 21(2)(b) of the notice “to provide any documents in his custody or under his control that relate to a matter in question at the inquiry.”
The claim for judicial review was dismissed. The Cabinet Office has until 4pm Monday to get its act together and send in the information – the unredacted versions of “various WhatsApp messages between 2020 and 2022 exchanged between the second interested party, the former Prime Minister, The Right Honourable Boris Johnson (“Mr. Johnson”), and his advisers including a senior adviser to Mr. Johnson, the first interested party, Henry Cook (“Mr. Cook”). The notice also sought Mr. Johnson’s diaries and notebooks.”
According to section 21(4) of the Act, the Cabinet Office may deem some of the information unreasonable and unrelated to the inquiry. However, it will be the Chair of the Inquiry who makes the decision on whether this is the case. Any application under 21 (4) must also be made by Monday 4pm, providing both clean and redacted copies of the documents to the Inquiry.
To say this Government is distracted is an understatement: There’ll be a lot of overtime this weekend in Downing St., but Monday it is.
The Inquiry also released Practical Tips for Witnesses Giving Oral Evidence in the Inquiry this week. Speak slowly and clearly, listen carefully and answer the question that’s been asked; if you do not know the answer, then say so. Politicians have ignored the latter so far as it isn’t their DNA to admit they don’t know.
On Monday, it was the Welsh who were up on the stand. Dr. Sir Frank Atherton, the Chief Medical Officer for Wales, went first. The horrendously complex organogram raised its head again.
Question: It’s a diagram, Sir Frank, which is difficult to take stock of at first, but you will see your position, Chief Medical Officer, halfway down the left-hand side of the large blue box in the middle: Population Health Directorate Chief Medical Officer.
Joining England and Scotland, the KC showed that Wales was equally unprepared – what a Union we have.
KC Question: So to draw the threads together, the two frameworks, the Wales Framework for Managing Major Infectious Disease and the Wales Health and Social care Influenza Pandemic Preparedness and Response Guidance, both of 2014 were never updated, they were based upon or at least consistent with the U.K. 2011 strategy?
Atherton Answer: Mm.
Question: Whilst there was some debate at some levels of the Welsh Government about these planning assumptions and the possibility that they might require being challenged, that they might not necessarily hold true, neither the guidance nor the challenge to those planning assumptions were ever taken forward in a significant sense prior to the pandemic hitting Wales; that’s the position, is it not?
Answer: Well, as I read what’s in front of me, it’s not a challenge to the – it’s stating that the role had very little – the role of these countermeasures had very little evidence.
Mm isn’t a great answer – it’s not in the practical tips.
However, we’ve found something we agree on with Sir Frank – there was very little evidence. The question is, why didn’t anyone develop any in the intervening years?
Ah, because we have those models – we can trot out when we need them – we can hear you say.
Towards the end of the interview, we have again the reason for the lack of preparedness – the B-word: if only Brexit were a virus, we might have a reasonable excuse to be as unprepared as we were – variants and all. Perhaps equally interesting alternatives to blame would be tsunamis, a plague of locusts, earthquakes and so on.
Answer: I agree with all of those points, and of course the reasoning behind that was that – the reason for that and for progress then to stall was that resources were moved to other issues.
Question: Yes. Is that a euphemistic reference to the impact of the necessary preparations for a no-deal EU exit?
Answer: Or Operation Yellowhammer, if you like, yes.
Question: Yes. So not only were no resources developed, not only did no work continue on the guidance, not only did the main committee dealing with this issue not sit again, but whatever work streams were being pursued were then interfered with by Operation Yellowhammer; is that a fair summary?
Answer: The work all stalled.
Question: So it stalled for additional reasons?
Answer: Yes.
The issue of antivirals raises its head again; they highlight the lack of focus on an evidence-based approach.
Question: …expressed concerns [about] the preparedness of care homes and in particular the arrangements for antivirals.” This was in the context of seasonal flu, was it not?
Answer: It was, yes.
Question: So in relation to seasonal flu, for which there is necessarily antiviral in existence and vaccines and a national flu service, you were expressing concerns about the ability of care homes and the arrangements for antivirals in that limited context?
The care home issue arises from service agreements from organisations such as NHS England, whose guidance provides antivirals for the treatment and post-exposure prophylaxis of influenza-like illness (ILI) in at-risk patients, including care home residents. The guidance has been adopted by the UKHSA to provide antivirals when circulation levels of “flu” are high. It is interesting to note that in this document, the terms “influenza” and “flu” seem to be synonymous. So the confusion can happily continue.
So, is it an evidence-based approach or not that we want? Here’s what we wrote about prophylaxis in our Cochrane review:
In prophylaxis there is no evidence that oseltamivir reduces symptomatic influenza‐like illness. Oseltamivir reduces the number of prophylaxis participants testing positive (based on antibody rise and/or culture test). However, this finding is weakened by oseltamivir’s interference with the viral replication on the swab and effect on antibody production. In addition oseltamivir does not affect asymptomatic influenza and there is no evidence that it interferes with person‐to‐person spread.
As readers of our antivirals series will find out, when we finally got all the regulatory data for Oseltamivir/Tamiflu, we could only analyse one transmission trial (known as WV 15799). It had a very weak design and enrolled 962 people aged from one to 75 years. Only 18 included individuals who were aged 65 or more. There were clear signs of gastric and renal toxicity, which could not be attributed to influenza as the purpose was prophylaxis, not treatment of people with influenza. The number treated to harm was 94. None of these or later analyses made their way into the UKHSA document. We will explain why in the last portion of the antivirals series.
We also saw the introduction of Ms. Heaven, who pointed to the problems of hospital infections:“So we can see there that in the basic introduction: “Healthcare associated infections continue to cause substantial patient morbidity and cost to the health service.”
Monday’s conclusions are quite straightforward – “All hospitals need to establish ways of caring for large numbers of infectious patients on a scale outside their normal experience, including those requiring high dependency care.”
On Tuesday, the First Minister of Wales, Mark Drakeford, told us the Government had no process for assessing the risk of its people.
Question: My point, though, Mr. Drakeford, was concerned with the system of risk assessment. There is no process by which, formally, the Welsh Government gets to analyse the risks which its country faces – which may have to be responded to not just by local resilience forums but by the Welsh Government itself – in the way that there is for Scotland and for England?
Answer: No, for those purposes, we used the U.K.-wide risk assessment process.
Drakeford confirmed what we have learnt so far: the Welsh, like the English and the Scots, were all equally unprepared.
Question: But the fact that it was able to respond is neither here nor there in terms of the consideration of whether or not structurally the system of preparedness, in advance of the pandemic, was simply not as good as it should have been and therefore the Welsh Government was not as prepared as it could have been. Would you agree?
Drakeford Answer: Put like that, I would agree, yes.
On Wednesday, Catherine Calderwood was up on the stand. She’s the former Scottish CMO who resigned due to breaking lockdown rules – she thought it might be a good idea to take trips to her second home in the midst of restrictions.
However, we learnt a new reason why there was such poor decision-making. The quality of the line was so bad when we dialled into SAGE meetings, we couldn’t hear anything. Well, it beats Brexit for a reason.
Question: You attended, therefore, some of the SAGE meetings as the pandemic struck?
Calderwood Answer: Correct.
Question: Did you find that an easy form of communication? Were there difficulties in, literally in hearing what was being said and in understanding the flow of the information which was being fed into that committee and then being relayed out of it?
Answer: Yes, very much so. Unfortunately there were a large number of people dialled in to meetings. Of course, our infrastructure for remote working was nothing like it is now, and so we would – I would have attended or my deputy attended or – with several other people from Scotland. But very often the quality of the line was poor, it dropped out very frequently, and there was often not really a fully fluent read-out from some of those very important meetings in the early days of the pandemic.
Calderwood also agreed with the point that SAGE was inadequate for the purposes of the Scottish Government.
Question: All right. Did there come a point in March of 2020 when you appreciated that the source of scientific and medical advice from SAGE – or particularly, I should say, scientific advice from SAGE was inadequate for the purposes of the Scottish Government, in part for the practical reasons which you’ve identified, and therefore you set up, together with a colleague, Professor Andrew Morris, the Chief Scientific Adviser, a new group, the COVID-19 Advisory Group?
Answer: Yes. So just to be clear, Professor Andrew Morris had been my Chief Scientist prior to the current Chief Scientist at the time, so I went back to my colleague, Andrew Morris, and asked him to set up a COVID-19 Advisory Group for Scotland, that’s correct, in March 2020.
This raises serious questions about how governments function and cooperate. They cannot mount a decent line of communication – but more importantly, it raises questions about the inadequacies of SAGE. So much so that the Scots had to set up their own rival group.
Also up was Professor Mark Woolhouse, who was at pains to stress the fear factor surrounding respiratory outbreaks. This time was just a warm-up: “And the other point I would make, and I hope this doesn’t sound too shocking, but it’s: on the scale of potential pandemics, COVID-19 was not at the top and it was possibly quite far from the top. It may be that next time – and there will be a next time, I don’t know when, it may be quite some time in the future, but I don’t know when – but there will be a next time, and it’s possible that next time we are dealing with a virus that is much more deadly and is also much more transmissible, in which case actually the things we did to control COVID-19 wouldn’t have worked anyway, at least not without society completely falling apart.”
Next time it’ll be much more deadly, and you know what you need to be prepared for it.
Woolhouse: Now, I’m not sitting here as a doom-monger saying “This is going to happen” or “This is going to happen soon”, but I am confident enough to tell Government that this is something you should be concerned about, you should be prepared for. The next pandemic could be far more difficult to handle than COVID-19 was, and we all saw the damage that that pandemic caused us.
Defensiveness, though, is one of the most destructive ways to affect communication – I’m not a doom monger, but hey, here comes the doom.
There are three more weeks of module 1 to go. The media are tiring as it drops off the headlines. We’re also losing the will to follow some of the excuses. We think we’ve already hit data saturation. The conclusion is clear. It was complicated, and governments were unprepared; no one knew very much while everyone was preparing for an influenza outbreak, but don’t worry, this was just the warm-up – next time, we’ll be much better prepared.
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, Trust The Evidence, which you can subscribe to here.
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