It’s the last week of Module One before the long summer break. Up on Monday was Ms. Kate Bell, Assistant General Secretary to the Trades Union Congress (TUC), who took questions on budget cuts and workforce fragmentation: manna from heaven for a trade union representative to preach on the problems with cuts to services.
Ms. Bell: I think, you know, there is clear evidence of the workforce shortages on the ability to respond. I think, you know, even in 2019, Unison was saying half of NHS workers on the frontline of patient care say there are not enough staff on their shift to ensure patients are treated safely and with compassion, and I think you can see those impacts going through to the pandemic.
We also heard more about austerity as the cause, and all along it was the TUC leading the way in pointing this out.
Ms. Bell: Absolutely. I think, you know, the Inquiry has heard widespread evidence about the impact of austerity on the health service, and I think it’s important to note that the TUC was warning about this continuously throughout this period.
Also up was Gerry Murphy, Assistant General Secretary to the Irish Congress of Trade Unions, who was asked what he adds to the issue of infection control. Not much, it seems.
Ms. Blackwell: Is there anything that you would like to add in terms of infection control and prevention and how that was being manifested within the care sector in Northern Ireland, in the run-up to the pandemic?
Mr. Murphy: I have no evidence to offer in respect to that. I simply don’t have – we have nothing from our trade – from our affiliated trade unions and nothing from our interactions with the Northern Ireland Executive at that time either.
Also up was Philip James Banfield, the British Medical Association U.K. Council Chair. Mr. Keith highlighted the peripheral role of the BMA.
Question: But was the BMA aware of the growing debate about whether or not that was a strategy that was suitable for a coronavirus pandemic, for example MERS or SARS? Was that a debate with which you engaged?
Banfield Answer: As far as I’m aware, there was no specific debate.
With the hindsight of time, it’s becoming increasingly apparent that many organisations weren’t that interested in pandemic preparedness. However, they are now.
Question: Having been approached, was any consideration given to formalising the involvement of the BMA, in particular requiring it to become an observer or participant in future exercises?
Answer: No, that invitation wasn’t forthcoming.
Question: Did you ask, though, Professor?
Answer: Well, I wasn’t there at the time, so I
Question: Did the BMA ask?
Answer: Not as far as I know.
Question: All right. So if it was an invitation that was not forthcoming, it certainly wasn’t one that had been sought?
Answer: I can’t comment on that.
Question: All right.
The perplexing answer – it’s not me, guv – asks why the right people aren’t being invited. If you want to know what happened in 2011 or 2015, why not invite the chair from that period? The BMA apathy is concerning, given that acute respiratory infections are dealt with mainly in primary care. By the way, where was the Royal College of General Practitioners?
Dr. Dixon, the Chief Executive of the Health Foundation, also took the stand and provided some numbers on health spending.
Answer: Core NHS spending was protected relative to other public services, but over that decade the NHS received about half or slightly less than half than it would have normally expected to receive per annum compared to a long-run average.
Question: That’s an average of spending, annual spending in the United Kingdom, is it?
Answer: Yes, real terms growth on average, long run, is 3.6%. The NHS grew 1.4% over that decade.
Question: When you say it grew, you mean the spending grew as opposed to the NHS growing in size?
Answer: The spending grew, yes, by 1.4% real terms per year.
Monday whisked through the witnesses. Also fitted in was Michael Adamson from the British Red Cross. He wants a Minister for Resilience, he’s not the only one.
“We would like to see a Minister for Resilience, because at the moment those responsibilities fall to the Paymaster General, and we don’t – whatever the qualities of the Paymaster General – we don’t think that signals a serious commitment to national resilience, particularly when the Paymaster General has a range of other responsibilities.”
More ministers and more committees will only give rise to more complexity and, inevitably, more confusion. TTE thinks we need a Minister for Ministers to ensure they are doing their jobs.
Tuesday saw the morning spent listening to people who have suffered bereavement during the pandemic. The stories are harrowing and worth reading.
Representing the Covid Bereaved Families for Justice was Mr. Weatherby KC. Several points made were noteworthy.
“The experts expressly discounted any suggestion of Covid being a black swan event. The evidence shows that it was not only foreseeable but actually foreseen.”
Weatherby didn’t mince his words.
“The ship had no captain, the central agency with all the responsibilities had no organisational role, and to make matters worse, there was no plan B.
“So the Inquiry might conclude that there was no lack of effort expended in this area, but efforts which resulted in this woefully inadequate level of preparedness.
“So what was missing?
“Firstly, although there were ministers involved, there was no single point of responsibility in central Government for civil emergencies or resilience or preparedness. The captain wasn’t so much missing from the wheelhouse as there simply was no captain.
“Secondly, what appears to have been the hub of central Government preparedness, the Civil Contingencies Secretariat, had no actual responsibilities and no actual organisational role or powers. It operated on an ad hoc basis, in a liaison role between disparate parts of Government.
“Thirdly, there appears to have been a reliance on both the U.K. threat assessments and the pandemic flu plan in all the devolved jurisdictions rather than a critical consideration of them. The planning assumptions were not challenged, there was no plan B on flu, and what planning there was related to consequences, not prevention.”
Representing the bereaved Families in Northern Ireland was Justice Mr. Lavery KC. He told the Inquiry about the problems with the Department of Health’s inefficacies in the absence of ministers.
“My Lady, I’ve said this previously, the scale of the waiting list problem in Northern Ireland is mammoth, and one talks about waiting lists in Northern Ireland being longer than they are in other parts of the U.K., but in some instances they are 50 times longer. This is a combination, I suppose, of U.K.-imposed austerity measures and a dysfunctional Government in Northern Ireland.”
Representing Welsh bereaved families was Ms. Heaven. She pointed to the woeful inadequacies in the Welsh health infrastructure that meant there wasn’t a single high-consequence infectious disease bed.
“Wales could not even deal with one high-consequence infectious disease when the pandemic hit. Since 2006 NHS Wales has surveyed and produced annual reports on all airborne isolation rooms in major hospitals across Wales. Every year the reports concluded that many of these isolation rooms were inadequate.
“In 2017 the Airborne Isolation Rooms Review Working Group produced a report to inform policy on airborne isolation rooms in major acute hospitals.”
She also mentioned the problem of hospital-acquired infection, which wasn’t a priority.
“Now, a matter of real significance to the Cymru group is hospital-acquired COVID-19. Many people in Wales died because they caught COVID-19 in Welsh hospitals with inadequate ventilation and poor infection control. It has been deeply concerning and upsetting to learn about the extent to which this issue was simply not a priority for the Welsh Government and NHS Wales.”
Ms. Heaven makes a vital point, but let’s be clear, prevention of hospital viral infection wasn’t a priority in any of the devolved nations’ plans for preparedness.
Mr. Ford KC represented the Association of Directors of Public Health. While we understand the need for KCs to represent bereaved families, we don’t understand why the directors of public health need one. Can’t they speak for themselves, and more importantly, how much is all this costing? Oh, and who’s paying?
While the public health directors want more money and more of a role next time, it’s still unclear what evidence-based interventions they will undertake to make a difference. While there’s a host of actions, everyone wants to instigate changes for the next time. However, anything that might be perceived as evidence-based only emerged twice in Tuesday’s discussion.
Mr. Weatherby: Assurance means an evidence-based scheme whereby minimum standards and consistency and compliance can be audited and proven.
Mr Weatherby: The default position should be that national risk assessments, together with their methodology and the evidence base behind them, and all civil emergency plans, should be published unless there are clear national security reasons why they must remain closed.
Most of the 63 referrals to evidence on Tuesday was opinion, the vast majority arising after the event. If only we had done xxxxxxx please, fill in the blank.
On the final day, we heard closing statements from the British Medical Association, the TUC, and the Government Office for Science, formerly headed up by Sir Patrick. The Office for Science thinks fundamental structural change is needed in at least two respects.
“First, the focus should be on capabilities and scenarios, and not specific plans for specific types of pandemic. The response to the emergency that eventuates will inevitably need to be targeted, but the preparation needs to be broad. Predicting the next pandemic with any sort of precision is impossible. There are too many variables. There is little value, we would suggest, in asking whether previous iterations of the NSRA foresaw the right sort of pandemic.”
But, finally, we found an evidence-based statement that reflects the reality of uncertainty:
“Similarly, there were some suggestions floated during the course of evidence apparently predicated on a belief that it is our powers of prediction that need to be improved. One is that drugs and vaccines effective against COVID-19 should have been stockpiled and would have been with a little more imagination. Yet nobody knew which drugs worked until extensive clinical trials had taken place, and you cannot stockpile a drug or vaccine which does not yet exist.”
The Office for Science considers we need to build the capability to do research.
“But what you can do is to assess and build your capability to research, trial, and roll out existing treatments when faced with a new hazard.”
We agree, but it shouldn’t just be for drugs and vaccines, where all the profits are. It should be for the non-pharmaceutical interventions that make a difference to society. Yet we haven’t done a single trial of masks before, during the pandemic, or have any plans to do one after.
Their second point is we need a more integrated cross-government response. Hmm, doesn’t that mean more money and more complexity for next time.
“Pandemics require an integrated cross and intergovernmental response. They present funding challenges which cannot be met by a single department, with a single budget from which to meet all of its day-to-day requirements.”
The Office also thinks we need to keep with the SAGE advice.
“The SAGE model allows for flexibility and a tailored response to the emergency that is being faced. It enables the right people to be assembled from the appropriate disciplines.”
There’s no need for an evaluation or reflection; it’ll be more of the same SAGE advice next time.
As the Inquiry breaks up for its summer break, we’ll also sign off from the Health Inquiry.
We’ve had six weeks so far, making it 69 witness statements in total.
Wednesday was the last day of Module One; the good news is Boris has finally cracked the code for his phone. Handy, though, that it’s on the day the inquiry breaks up.
The first phase of the Covid Inquiry has heard from its final witness. The interim report is expected in 2024. So, what have we learnt so far:
The plan was based on the F word and mainly on a 2011 document for an influenza pandemic.
Groupthink meant that other viruses weren’t considered. We didn’t need any plans because we have effective antivirals and a seasonal vaccine. However, while many thought the plans were dire, Dame Jenny of the UKHSA said they were “actually pretty good”.
Hancock thought we should have locked down harder and faster, while Hunt figured we should all move to South Korea. Also, when we did our one mock-up training day in a decade, most recommendations were ignored – it seemed it was Brexit that got in the way. However, this wasn’t the only excuse; it was the acronyms for Arlene, the lines of communication for the Scots, the lack of funding for the TUC, and for the public health directors; it was because they had to learn about what to do on the BBC. For the Inquiry team, it was that complicated organogram that was supposed to – but didn’t – guide the decision-making. But for everyone, apart from George Osborne, it was austerity that did it.
We also learnt that some experts can fit their knowledge of infection control on a postage stamp. Finally, we now know that a lockdown wasn’t planned for despite it being the extraordinary policy of our time. We also think it’ll be more of the same next time! But if we learnt one thing: the ship certainly had no captain.
We’ll return when Module Two Core U.K. decision-making and political governance kick off in the Autumn.
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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