Transcript of Module 1 Public Hearing on 26 June 2023

(10.29 am)

Lady Hallett: Mr Keith.

Mr Keith: Good morning, my Lady. May I please call Emma Reed.

Ms Emma Reed

MS EMMA REED (sworn).

Questions From Lead Counsel to the Inquiry

Mr Keith: Could you please commence by providing your name.

Ms Emma Reed: My name is Emma Victoria Reed.

Lead Inquiry: Ms Reed, whilst you give evidence, could I remind you to keep your voice up – I don’t think there will be a problem – and also to make sure you speak clearly into the microphone so that your evidence may be properly recorded.

Have you kindly agreed to provide a statement to this Inquiry?

Ms Emma Reed: Yes, I have.

Lead Inquiry: May we have, please, INQ000195847 up, please.

Does that appear to be your statement?

Ms Emma Reed: It does.

Lead Inquiry: If we have the last page, you provided a signature and a statement of truth.

Ms Emma Reed: I did.

Lead Inquiry: My Lady, may that be published, please?

Lady Hallett: Certainly.

Mr Keith: Ms Reed, you have been a civil servant I think since April of 2003, and you’ve held a number of posts, not just in the Department of Health and Social Care but also the Cabinet Office and the Government Equalities Office; is that correct?

Ms Emma Reed: Yes, it is.

Lead Inquiry: Were you appointed to the senior civil service in April of 2013?

Ms Emma Reed: Yes, I was.

Lead Inquiry: From November 2014 until June 2015, were you one of the two deputy directors in the Department of Health and Social Care, leading on the response to the Ebola outbreak?

Ms Emma Reed: Yes, I was.

Lead Inquiry: Most significantly, are you currently director of the directorate in the Department of Health and Social Care which is the directorate of Emergency Preparedness and Health Protection?

Ms Emma Reed: Yes, I am.

Lead Inquiry: Have you been in that post since February of 2018?

Ms Emma Reed: Yes.

Lead Inquiry: Could you assist us, please, in broad terms, with the nature of the functions discharged within that directorate? We’ve heard a considerable amount of evidence about the various functions in the Department of Health and Social Care, and I therefore want to ask you what that particular directorate is concerned with. Is it, by way of commencement, the directorate that discharges or plays its part in discharging the duty on the Secretary of State for Health and Social Care by virtue of being a Category 1 responder under the Civil Contingencies Act 2004?

Ms Emma Reed: Yes, but allow me to set out broadly where my responsibilities in the directorate fall, and they broadly fall into two different areas. I have responsibility for health protection and health security policy –

Lead Inquiry: Can I come back to that, Ms Reed?

Ms Emma Reed: Of course.

Lead Inquiry: There is a method to my madness, I wanted you to set out generically the functions of the directorate before we look at health protection and health security.

So one of the major functions of the directorate is to discharge the duty on the Secretary of State by virtue of being a Category 1 responder under the CCA; is that correct?

Ms Emma Reed: It is, yes.

Lead Inquiry: Is another responsibility to discharge whatever functions are imposed on the DHSC by virtue of being the lead government department when it comes to health emergencies?

Ms Emma Reed: Yes, it is.

Lead Inquiry: Is it also part of your directorate’s functions to be concerned in that risk assessment process –

Ms Emma Reed: Yes, it is.

Lead Inquiry: – of which we have heard? And is it also your directorate which liaises with bodies such as the United Kingdom Health Security Agency and NHS England and the Department for Levelling Up, Housing and Communities, when it comes to assessing risk, managing risk, preparing for health emergencies?

Ms Emma Reed: Yes, it is.

Lead Inquiry: Importantly, given the extent of the burdens on you, is that why your directorate, the Emergency Preparedness and Health Protection Directorate, has led the DHSC’s response to all the major incidents to which you speak in your statement, monkeypox, the Novichok poisoning, the heatwave of 2022, and so on and so forth?

Ms Emma Reed: Yes, it is.

Lead Inquiry: All right.

So you’ve referred to health protection, and also to health security. What are they and what is the difference between them?

Ms Emma Reed: 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.

Lead Inquiry: So that’s all under health protection?

Ms Emma Reed: And health security.

Lead Inquiry: Ah, they’re together?

Ms Emma Reed: Yes, they are.

Lead Inquiry: 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?

Ms Emma Reed: They are very closely related to each other, and sit very closely adjoined.

Lead Inquiry: So which branch does the topic of pandemic preparedness fall under?

Ms Emma Reed: Predominantly under health protection.

Lead Inquiry: Right.

Is there, in your directorate, a third branch called the operational response centre?

Ms Emma Reed: Yes.

Lead Inquiry: What does that do?

Ms Emma Reed: So that covers the responsibilities you set out at the beginning of the questions which relate to the discharge of the Category 1 responder capability and is about how we prepare for threats and hazards that impact on public health, and how we respond also to those threats.

Lead Inquiry: So is it an emergency management centre? Does it deal with crisis management?

Ms Emma Reed: It does. It delivers emergency preparedness, resilience and response.

Lead Inquiry: Is the history, the etymology of the operational response centre, that it was first created within Health and Social Care to deal with the necessary preparations for the no-deal EU exit, but latterly it is now the crisis management centre in the Department of Health and Social Care that deals with all emergency preparedness, response and resilience issues?

Ms Emma Reed: That’s not quite right. The department has had a long-standing function that deals with emergency preparedness, resilience and response, and that was always part of the responsibility of this directorate and was part of my responsibility when I took the post in 2018.

In preparation for a no-deal exit we also developed an operational response centre that was focused on those particular capabilities for that threat, and following the exit from the European Union we merged both of those functions together to form what was then called the operational response centre, that brings in EPRR responsibility as well.

Lead Inquiry: I’m going to have to task you about your use of the word “function”. It’s a word that –

Ms Emma Reed: I apologise.

Lead Inquiry: No, no, there is no apology required. What do you mean when you say it had different functions? Do you mean there were different rooms, different operational response centres, different groups of people, or it was the same group of people just doing two different jobs?

Ms Emma Reed: It was – so by “functions” I mean a set of capabilities of – of – ways of working that we use a manage an emergency. In emergency response we had ones that dealt with broader threats, and in the operational response centre these were particular sets of products and ways of working that were specifically focused on no-deal exit.

Lead Inquiry: All right, so different jobs, but they were the same people, they were just dealing with, at different times, no-deal exit preparations or general EPRR responses?

Ms Emma Reed: No, they were different people. We maintained a capability to make sure that we were ready for any type of emergency as separate from the work we did to prepare for a no-deal exit.

Lead Inquiry: All right.

Ms Emma Reed: They were under – in the same part of my directorate, but they were different sets of people.

Lead Inquiry: Right, that’s clear, thank you.

My Lady’s heard evidence about the high level risk register that was held in the Department of Health and Social Care, and a departmental board meeting which held what was called a risk deep dive into major infectious diseases within the department, how the department would respond.

Could we please have INQ000022738 on the screen. This is a document, Ms Reed, dated 28 September 2016, so it’s before your time, because, as you’ve told us, you have been in post since February 2018.

If we look at page 2, please, would you just read the middle bullet point within the red box.


Ms Emma Reed: Thank you.

Lead Inquiry: At the time that you took up your position as director of the relevant directorate, to what extent did you understand that steps had been taken to address that plainly very serious and real concern? Were you told what had been done to raise awareness of the risk and to plan for the immediate mobilisation of a large number of staff in the directorate?

Ms Emma Reed: I was not made aware of that particular commitment or issue raised in 2016.

Lead Inquiry: Were you not told by anybody, “Ms Reed, congratulations, you’re the director of the directorate, you need to be aware that the main departmental board for the entire department, the DHSC, stated two years before there was a very real concern that the entire directorate would be rapidly overwhelmed in the event of a major pandemic, and this is what we’re doing about it”?

Ms Emma Reed: At the point that I took over the post, we did think about the resourcing models and methods for escalating and scaling up our resource if it was needed, but that was never aligned to this discussion in 2016. It was part of our regular resourcing considerations.

Lead Inquiry: Could we have the minutes of that departmental board meeting at INQ000057271, please, page 6.

Again, I emphasise, before your time, but there are, on page 6 – I’m just going to refer you to them and then give you time to read them – paragraphs 25 and 26, these words:

“It was more likely than not that even a moderate pandemic would overrun the system.”

So not the department, in fact, but the system, the government.

“At the extreme, there would be significant issues if it became necessary to track or quarantine thousands of people.”

Then, at 26, concerns are expressed about how resilient the “somewhat fragmented system” would be, that is to say the government system for preparedness.

So would you just like to just reflect on those two paragraphs and then I’ll ask you some questions.


Ms Emma Reed: Thank you.

Lead Inquiry: 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?

Ms Emma Reed: There was no discussion with me about quarantining.

Lead Inquiry: What about track and trace, any discussion about that?

Ms Emma Reed: There was no discussion with me about track and trace.

Lead Inquiry: 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”?

Ms Emma Reed: 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.

Lead Inquiry: In essence, these concerns were being addressed because there were boards and systems and procedures otherwise in place to try to make sure the system was better prepared?

Ms Emma Reed: Yes.

Lead Inquiry: We’ll look then at those boards in a moment.

An important part of your directorate’s preparedness arrangements was its – and I’m now going to slip into the terminology – ownership of a 2011 pandemic influenza strategy, was it not?

Ms Emma Reed: Yes. Yes.

Lead Inquiry: Because that was a strategy dealing with influenza pandemic, a health emergency, and therefore, by definition, something within the reach of the Department of Health and Social Care?

Ms Emma Reed: Yes.

Lead Inquiry: Or the Department of Health, as it was then known.

Can you recall what you understood when you took up your post about the efficacy, the appropriateness, the adequacy of that strategy, whether it was a good strategy, whether confidence was placed in it, whether it needed refreshing, whether it needed updating or wholesale revision? Can you recall what the state of play was?

Ms Emma Reed: As I recall, the view was that the strategy included important component parts that would be used for a pandemic influenza, that it had been tested through Exercise Cygnus and there were elements of that that needed to be enhanced, and that there was a work programme under way through the Pandemic Flu Readiness Board to deliver that.

Lead Inquiry: Were you concerned by the fact that Exercise Cygnus itself had concluded that the UK’s plans, policies and capability for preparedness were not sufficient to cope with the extreme demands of a severe pandemic?

So you’ve referred to Cygnus and your answer is essentially, “Well, I understand that Cygnus, [which had taken place before your time] had addressed elements of the strategy”, but the Exercise Cygnus conclusion was rather more serious than that, wasn’t it?

Ms Emma Reed: It was very clear that there was a lot of work that the department needed to do to improve its readiness for a pandemic influenza. If the question you’re asking is: was I concerned about that? Yes, I was concerned about that, but I was also aware that by the time I’d started in my post in 2018, a programme of work had been established to address those concerns.

Lead Inquiry: It was therefore of central concern to you that those programmes should continue, because they were put into place for a good reason, namely to meet the serious concerns of this – of the departmental board’s observations, the outcome of Exercise Cygnus, and a clear understanding that the 2011 strategy needed at the least some work doing on it?

Ms Emma Reed: Yes.

Lead Inquiry: All right.

That 2011 strategy was the only pandemic-scale strategy, wasn’t it?

Ms Emma Reed: It’s the only one that was centrally run by the Department of Health, yes.

Lead Inquiry: Well, pandemic is a health emergency, it goes to the heart of your department’s functions. Who else would have an overarching health emergency-related strategy for pandemic influenza?

Ms Emma Reed: I would expect that key organisations responsible for delivering pandemic influenza response would also have thought through and have plans in place on how they would respond, so that would include NHS England, Public Health England and local delivery partners.

Lead Inquiry: In the event of a national crisis, in the event of, as it turns out, a catastrophic health emergency, the Department of Health and Social Care is the lead government department which drives forward what is required to be done to prepare for and, initially at any rate, respond to that crisis?

Ms Emma Reed: That’s correct.

Lead Inquiry: So what other strategies for dealing with a pandemic-scale catastrophe were there than this single document?

Ms Emma Reed: The Department of Health owned the single document for the strategy for pandemic influenza preparedness.

Lead Inquiry: Right. It was the only strategy document, was it not?

Ms Emma Reed: Yes.

Lead Inquiry: There was no strategy document for anything other than an influenza pandemic?

Ms Emma Reed: That’s correct.

Lead Inquiry: Could we have INQ000022708, page 14.

Three bullet points from the bottom, in paragraph 2.21, there is a reference to the intrinsic unpredictability of influenza pandemics.

Ms Reed, could you just have a read of that bullet point, please.


Ms Emma Reed: Thank you.

Lead Inquiry: You are not by training an epidemiologist?

Ms Emma Reed: No.

Lead Inquiry: 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?

Ms Emma Reed: 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.

Lead Inquiry: But those very same risk assessment processes referred, of course, to the possibility or the risk of a non-influenza pandemic, and those same processes stated in terms that there were inherent variabilities, that the next pandemic might or might not be influenza, it might have the same characteristics, it could be just as deadly or more so, it could have higher transmission or less transmission, it could be just as severe or less severe.

Where were the plans for dealing with those eventualities?

Ms Emma Reed: Well, the plans that we developed and the mitigations we built were based on the risk that we had been informed was the most likely risk, that experts advised me and colleagues that was the highest risk, and that was of an influenza pandemic.

Alongside the influenza pandemic is a risk that relates to emerging infectious disease, and in that risk scenario we had prepared messages and responses that would respond to that risk should that risk materialise.

Lead Inquiry: But you know very well, of course, that that risk, the emerging infectious disease risk, was predicated upon and assumed confinement to health setting outbreak, that is to say it wouldn’t extend probably beyond health settings, and that there would be a very small, relatively speaking, number of casualties and an even smaller number of fatalities?

Ms Emma Reed: Yes, that’s correct.

Lead Inquiry: Yes.

Could we look at page 57 in this document, please. The 2011 strategy assumed – and we can see at paragraph 7.5 – that “staff absence is likely to be significantly higher than normal across all sectors”, levels of absence may vary due to the size, and then if you could scroll back out, please, and in the middle of the page, 7.4:

“… the Government will encourage those who are well to carry on with their normal daily lives … The UK Government does not plan to close borders, stop mass gatherings or impose controls on public transport during any pandemic.”

Any pandemic.

Between 2011, when this strategy was first made, Ms Reed, and 2020, when the non-influenza pandemic struck, are you aware in the Department of Health and Social Care of any person at any time questioning that statement, “the UK Government does not plan to close borders, stop mass gatherings or impose controls”? Was there any debate about the possible necessity of border closings, self-isolation, quarantine, mass quarantine, mandatory quarantine, or anything of that sort?

Ms Emma Reed: I’m not aware of any conversations on those areas of mitigation, no.

Lead Inquiry: Could we have INQ000023131, please.

This is a pandemic preparedness meeting dated November 2019, so on the eve of the pandemic, Ms Reed, but about a year and a half after you had taken up your post.

It’s a meeting of a – well, of, in fact, the Department of Health and Social Care, so it’s not, I think, a – it wasn’t a PIPP meeting or a PFRB meeting, we’ll come back to those in a moment, it’s just a departmental meeting.

Page 5, I’ll read out the relevant bit and then give you a moment to find the part on the screen.

On the right-hand side – don’t, please, scroll in, because I’ll lose my way – but on the right-hand side there is a heading “Areas of Work not Prioritised for the Next 6 Months:

“Adult Social Care – The briefing paper which outlined plans to augment adult social and community care during a pandemic, was agreed by the former CMO [Professor Dame Sally Davies], CSA and CNO in July 2018. DHSC policy and social care team to work with [National Health Service England and Improvement] to agree next steps.

“Pandemic Influenza Public Health Communications Strategy – The content was signed off … but needs further work … a Concept of Operations … document to outline the … command structure and the responsibilities of Departments … needs to be developed.

“Refresh of UK Pandemic Influenza Strategy – Update the content of the … Strategy to ensure that UK Pandemic Influenza preparedness and response policy is accurate and up to date.”

Ms Emma Reed: Thank you.

Lead Inquiry: These areas of xwork which were not prioritised were of fundamental importance, were they not, to the United Kingdom and the Department of Health and Social Care’s ability to be properly prepared for a pandemic?

Ms Emma Reed: They were important pieces of work in the pandemic flu readiness programme, yes. They were not the areas of priority.

Lead Inquiry: Are you suggesting, Ms Reed, that the bringing up to date and making accurate of the United Kingdom’s sole strategy for influenza preparedness was not a matter of very considerable importance?

Ms Emma Reed: No, sorry, allow me to clarify. These pieces of work were important as part of the pan flu readiness programme and they were important pieces within that programme. However, as I am happy to expand, at that period of time, in readiness for the potential disruption of a no-deal exit, my view at that time was preparing for a no-deal exit took precedent(sic) over completion of some of these pieces of work for a short period of time.

Lead Inquiry: Did you or anybody else when confronted with – and it was a Cabinet direction, wasn’t it?

Ms Emma Reed: Yes.

Lead Inquiry: Work must be – to use the etymology, the terminology, work must be prioritised, the euphemism for the cessation or interruption or complete stopping of other workstreams in order to be able to focus on preparations for a no-deal EU exit, that came from the highest level, did it not?

Ms Emma Reed: It did, yes.

Lead Inquiry: It did.

Did anybody in the Department of Health and Social Care, which bore the primary responsibility for getting the country ready for a health emergency, say, “These important” – you used the word vital, “These vital parts of pandemic preparedness cannot afford to be stopped”?

Ms Emma Reed: If I recall the process at that time, I was asked to look at which areas of work we would prioritise and de-prioritise in order to prepare for a no-deal exit, and in thinking through which areas of work I would de-prioritise and prioritise, I recall a submission going to ministers to set out which areas of work I would recommend that we prioritised and deprioritised.

On the case of adult social care particularly, I think it may be helpful to add that my concern about the impact of adult social care as a result of a no-deal exit, a real and credible threat to that sector, was that that sector needed to prepare for and ready itself for a no-deal exit over the risk of a pandemic preparedness.

Lead Inquiry: The concern that flowed from not being ready for a no-deal EU exit in the adult social care sector –

Ms Emma Reed: Yes.

Lead Inquiry: – was that there would be an interruption of services, that’s to say the availability of staff to work in the sector, because of problems with employment and the ability of individual members of the workforce to work in the United Kingdom after an abrupt and traumatic no-deal exit; also the supply of medicines probably?

Ms Emma Reed: That’s correct.

Lead Inquiry: So the two areas were workforce availability and supply chains?

Ms Emma Reed: I would say they’re two of the areas of concerns.

Lead Inquiry: What were the others?

Ms Emma Reed: I think financial stability of that sector was a particular concern before a no-deal exit, and at that time we weren’t certain what additional financial would be on the sector as a result of a no-deal exit, so that was an additional concern.

Lead Inquiry: Was it ever seriously considered by anybody in your department that one of the consequences of an unprepared no-deal EU exit would be the deaths of very large numbers of inhabitants of care homes?

Ms Emma Reed: I think that the human aspect and risks associated with that relating to a no-deal exit were considered. I don’t have the details of what the risk assessment said of a no-deal exit, but the risk of harm to the public was absolutely a consideration.

Lead Inquiry: In the risk assessment process, and the procedure was updated, as you know, in 2016 and then 2019, what was the assumed outcome of a severe influenza pandemic on the United Kingdom in terms of fatalities?

Ms Emma Reed: If I recall, I believe the number to be about 8 – 800,000, I think, but I’m recalling, I might have that number incorrect.

Lead Inquiry: Around 800,000 deaths?

Ms Emma Reed: (Witness nods)

Lead Inquiry: Of which, if the pandemic were to be particularly dangerous to the elderly, a significant proportion of those deaths would be in the care home sector, would they not?

Ms Emma Reed: I would believe so, yes.

Lead Inquiry: Yes. So let me put the question again: in terms of the balance between the possible outcomes of an unprepared no-deal EU exit and the appalling loss of life attendant upon a pandemic for which no preparedness had been carried out, why did no one say “We cannot afford to stop the pandemic preparedness”?

Ms Emma Reed: I think in response to your question, there’s a couple of points I think are important to make.

The first one is that the adult social care sector had done some work in pandemic preparedness prior to the pausate of the work.

Secondly, I think the work that was done for Operation Yellowhammer was of benefit to our preparedness for a pandemic influenza.

Then the third point I’d make is that, in considering where to allocate resources, what I consider is: what is a real and present and credible threat versus the risk of a threat? And to try to strike the balance of where resources are allocated, I retained teamwork on pandemic preparedness, but I also allocated resources to deal with the real risk of a disruption through a no-deal exit.

Lead Inquiry: All right. May we then look briefly at the NSRA process to which you’ve referred.

Can you recall what role you had in the republication of, the re-issue of the NSRA process in 2019?

Ms Emma Reed: The National Risk Register’s reassessment comes to my team to lead the process for reviewing whether the risk is still the same risk. One of my team led the work on developing that risk assessment. I was aware of the work at the time, that was led within my team.

Lead Inquiry: Not all the risks, indeed only a very small number of the risks, fall within the reach of the Department of Health and Social Care. Of course, disease is one of them, perhaps the main one.

Ms Emma Reed: The department has a number of risks on the risk register. Not all of the department’s risks are – fall within the confines of my directorate’s work. We deal with emerging infectious disease risk and we deal with pandemic risks, but there are risks that sit outside my team in the other parts of the department.

Lead Inquiry: Do you accept, as Ms Hammond on behalf of the Cabinet Office – and of course the Cabinet Office and the DHSC co-chair the Pandemic Flu Readiness Board – would you accept in relation to the DHSC, as Ms Hammond accepted in relation to the Cabinet Office, that the DHSC would have been better prepared for a pandemic if – had the reasonable worst-case scenario been closer, a lot closer to the realities of Covid than it was?

Ms Emma Reed: Yes, I think it stands to reason that we would have built a different set of responses and plans had the risk that we were dealing with been a Covid risk.

Lead Inquiry: There is evidence before my Lady that Dame Deirdre Hine in her review of the swine flu pandemic in 2009 had expressed some concerns about the adequacy of the RWCS, the reasonable worst-case scenario model.

Within the DHSC, as far as you’re aware, were there concerns ever expressed about the adequacy of the RWCS model, and in particular the risk that by focusing on the assumed worst-case scenario it could lead to a tendency to stop thinking about how to prevent that worst-case scenario from actually happening?

Ms Emma Reed: In the way in which you ask, nobody had raised with me a concern about the process for developing the reasonable worst-case scenario or that risk that we don’t do work on the lead-up to that risk occurring, and I believe that with the emerging infectious disease risk, we had complementary capabilities in two different sets of scenarios which would have – which would have addressed where those risks would have taken us.

Lead Inquiry: But of course, as you now accept, the scenario for new infectious disease was predicated on a very limited outbreak with relatively very limited consequences?

Ms Emma Reed: Indeed, and the mitigations that we had in place for managing that had been adequate for the outbreaks of those emerging infectious diseases I experienced over the five years of my appointment.

Lead Inquiry: Putting it another way, because the reasonable worst-case scenario for a non-influenza outbreak was described in such very limited terms, confined to health settings, relatively small number of casualties, an even smaller number – tragic though they are – of deaths, much less was required of the department to mitigate for that risk, because the risk, of course, had none of the terrible catastrophic consequences that the Covid pandemic resulted in?

Ms Emma Reed: Sorry, I –

Lead Inquiry: Yes. You didn’t have to do very much by way of mitigating the new and emerging infectious disease risk, because the risk was described in a very limited way. It didn’t have the catastrophic or national consequences that a severe influenza pandemic would have or as Covid had.

Ms Emma Reed: I wouldn’t agree with the statement that there was less for us to be concerned with, with relation to a high-consequence infectious disease risk. They are extremely serious, and we worked very closely with NHS England and Public Health England to ensure that the plans were in place for managing that risk.

Lead Inquiry: I didn’t suggest that you were less concerned. I said what you had to do practically by way of mitigating the risk was a great deal less than what you would have had to have done had you been mitigating for a severe national pandemic?

Ms Emma Reed: I think it’s true to say that our work on pandemic influenza was a greater responsibility for the department, yes.

Lead Inquiry: That work was framed by that 2011 strategy which said in terms: you don’t need to worry about things like borders or quarantining or self-isolation or mass test and trace. Because none of it was envisaged, was it?

Ms Emma Reed: I would say that – I wouldn’t necessarily say that it was framed by that. It was – the work that we did on pandemic influenza was framed by a series of documents, by Exercise Cygnus, by the risk registers across that period of time. So it was a number of different documents, including the 2011 strategy.

Lead Inquiry: When Mr Hancock MP became Secretary of State for your department in July 2018, that was after you had been appointed to your post as director of the EPHP directorate. He was provided with a document.

INQ000181825, please.

Ah, I’ve got the wrong reference, that’s his witness statement.

Could we have INQ000184105, instead, please. “Introduction to Emergency preparedness, resilience and response”. So this was a paper which was prepared for him, I think at his request, he wanted some more information, about the – well, England’s emergency preparedness, resilience and response.

Could we go down, please, to paragraph 12:

“Following a national-level exercise in 2016 and a subsequent National Security Council (Threats, Hazards, Resilience and Contingencies) meeting in February 2017, a cross-Government Pandemic Flu Readiness Board … was established to develop and manage the UK’s preparedness for a flu pandemic … The first year of the programme included the following work streams …”

Then over the page, please:

“- Response of the adult social care and community healthcare system.

“- Coping with excess deaths …

“- Communicating legal, moral and ethical considerations.”

That led to the MEAG committee being set up.

“- Keeping different sectors working with reduced staff numbers.”

If that could be shrunk, please.

Then, at paragraph 13, reference to “‘mass casualty’ planning”.

Do you recall assisting in the process by which Mr Hancock was briefed in relation to the general state of preparedness?

Ms Emma Reed: I am not familiar and cannot recall specifically adding to this briefing. I can say, and can recall, that when new ministers arrive I do support Clara Swinson in producing an assessment of the very current situation of risks and threats that the department faces as part of new ministerial briefing, but I can’t specifically recall contributing to this particular one.

Lead Inquiry: At paragraph 12, the first few words are:

“Following a national-level exercise in 2016 …”

Would that have been a reference to Exercise Cygnus, do you think?

Ms Emma Reed: Looking at the reference to the Pandemic Flu Readiness Board, I would assume it was in relation to Exercise Cygnus and not Exercise Alice.

Lead Inquiry: Yes, because it was as a direct result of Exercise Cygnus that the then Prime Minister directed in the NSC(THRC) meeting that a board be set up and a programme of work devised for the Pandemic Flu Readiness Board?

Ms Emma Reed: That’s correct.

Lead Inquiry: Looking back, are you surprised that there is no reference in this paragraph to the conclusions of Exercise Cygnus, which you described earlier yourself as being concerning, to the effect that the UK’s preparedness and response in terms of its plans, policies and capability were not sufficient?

Ms Emma Reed: No, I wouldn’t say that I was surprised that it didn’t go into more detail in this note. From my brief reading of this note, my assessment is that this was a very early briefing given to our Secretary of State to set out the range of threats and hazards that the department faced.

In 2018 there had been a series of challenging incidents over the last five years of my role, 32 major incidents, not including anything relating to Covid. So it’s very important at the very start of a secretary of state’s tenure that they’re clear about our risk assessment and their Category 1 responder requirements. I would have expected reference to the high-level risks on pandemic influenza and emerging disease, but in the context of the wider threat landscape.

Lead Inquiry: What was the highest risk in the entirety of the government’s risk assessment procedures?

Ms Emma Reed: When it came to hazards, it was pandemic influenza.

Lead Inquiry: What was the lead government department for pandemic influenza?

Ms Emma Reed: The Department of Health and Social Care.

Lead Inquiry: So are you not, therefore, somewhat surprised that there was no reference to the fact that the greatest hazard risk in the entirety of the government’s book of risks was a pandemic influenza and that the national level exercise of Exercise Cygnus, which dealt with the possibility of an influenza pandemic, had reached the conclusions that it did in such serious terms?

Ms Emma Reed: I would not have expected that document at that time to have included more information on that risk than it did. It is also useful to recognise that there had been a poisoning in Salisbury, there had been breast cancer screening incidents, so it was in a context of a number of different incidents that had occurred. I would expect the risk register to have been referred to, as it was in this document.

Lead Inquiry: May we then discuss in a little more detail some of the exercises. You were concerned, because you were one of the two deputy directors within the department leading on the response to the Ebola outbreak, so you were concerned very much with how the country – the department did respond?

Ms Emma Reed: Yes.

Lead Inquiry: To what extent – and I should say that – was that outbreak 2014/15, so not when you were director of the EPHP, you weren’t appointed to that post until February 2018, it was whilst you were in a different post?

Ms Emma Reed: That is correct.

Lead Inquiry: All right.

To what extent were you concerned with taking on the recommendations in the report on the Ebola outbreak once the outbreak was over?

Ms Emma Reed: Are you talking about at the immediate time or in my current post?

Lead Inquiry: No, at the immediate time. So following the outbreak obviously there was a certain amount of learning and reports were produced dealing with the outbreak and what could be learned from them, and making recommendations as to the future. To what extent were you concerned with that process?

Ms Emma Reed: I was involved in the lessons learned processes, there were a number of different lessons learned processes post the Ebola outbreak, and I moved to different roles that were unconnected in this area in the intervening period. So the work was continued by my colleagues.

Lead Inquiry: So you were involved in the lessons learned processes but only for a while?

Ms Emma Reed: Some of the lessons learned processes. There was a number of lessons learned processes.

Lead Inquiry: Right. You said the work was continued by your colleagues because you moved to different roles. To what extent were you concerned? For how long were you involved in the lessons learning process?

Ms Emma Reed: I’m recalling that some of the lessons learned processes were operational lessons learned, and some of them were more detailed lessons learned, a series of sessions. I was not involved in the more formal lessons learned processes, if I can recall.

Lead Inquiry: The reason I ask, Ms Reed, is that, as you will no doubt recall, one of the lessons, lesson 8, from the Ebola report was that appropriate levels of PPE should be maintained for ongoing infectious disease preparedness. A second lesson, lesson 16, was that consideration needed to be given to the development of the relevant powers to allow stepped interventions from port through to community, so, in a sense, social restrictions or closing of borders or management of people and gatherings.

Can you recall what steps were taken to pursue those issues, to draw up further papers or develop the thinking on PPE and social interventions?

Ms Emma Reed: So thinking about the PPE aspect of your question, PPE and appropriate levels of PPE were part of the mitigations that were recommended on the back of the emerging infectious disease risk. Ebola is an emerging infectious disease, it’s a high-consequence infectious disease, and would therefore have been dealt with under the mitigations for that particular risk.

Lead Inquiry: Can I just pause you there?

Ms Emma Reed: Yes, of course.

Lead Inquiry: Is that a reference back to what you said earlier, which is that of the two risks, health or disease-related risks in the risk assessment process, you’ve got influenza pandemic, with its assumed catastrophic consequences, and then you’ve got the much narrower new and emerging infectious disease risk, with the assumed much narrower consequences, and therefore reference to PPE would be a reference to the PPE required in a health setting or in a much narrower way?

Ms Emma Reed: That is correct. Ebola would have been classed as an emerging infectious disease and would have been treated as an emerging disease with the mitigations that would be appropriate for the management of high-consequence infectious disease. And with that, your question around PPE, is that PPE advice that would be given to us would be based on how you have that intensive treatment regime for a high-consequence infectious disease and what would be the appropriate PPE required to manage those diseases.

Lead Inquiry: What about lesson 16 and the consideration of powers that might be required to adopt interventions in the community, so restrictions on movement or public gatherings or border controls and so on? Do you recall what work was done on those issues?

Ms Emma Reed: I don’t recall the work that was done on those issues. I am aware that there was a view that border restrictions wouldn’t be the appropriate response for an emerging infectious disease or pandemic influenza.

Lead Inquiry: Of course, that’s why it was the lesson in the report. But was this not something that, at least subsequently, as the director of the directorate, you would have seen the outcome of the work done to put that recommendation into place?

Ms Emma Reed: I’m aware of work that Public Health England and latterly Health Security Agency have been doing around border measures. I’m not aware of any work that was done to restrict border access.

Lead Inquiry: Exercise Alice was in 2016, wasn’t it, and it was an assumed large-scale outbreak of MERS coronavirus?

Ms Emma Reed: Yes.

Lead Inquiry: That’s correct. Was that an exercise in which the Department of Health and Social Care was a participant, an organiser, or just an observer?

Ms Emma Reed: The exercise was run by Public Health England and the Department of Health and Social Care participated in that. I wasn’t in post at the time.

Lead Inquiry: But there were a number of recommendations made as a result of the report following on that exercise, were there not?

Ms Emma Reed: That’s correct.

Lead Inquiry: Those recommendations included issues such as developing plans for or at least considering the need for quarantine, self-isolation, the collection of data from contacts, an enlarged process of community sampling – of course, again, this was regarded as a high-consequence infectious disease, it was a more limited outbreak – do you know what happened with those lessons and the putting into place of practical measures to give effect to them?

Ms Emma Reed: Yes. There were two piece – bodies of work that were set up to lead pieces of work on how to respond to those actions. One was developed by NHS England, they set up a high-consequence infectious diseases programme. The Department of Health was a participant to that piece of work. And Public Health England set up a programme of work to also respond to the recommendations and the work on high-consequence infectious disease.

As I understand it, NHS England’s board continues, and we still play an active role on that, and PHE’s commitments have been embedded within their programme of work at UKHSA.

Lead Inquiry: Both those workstreams, Ms Reed, were clinically related, weren’t they? They were to do with how the NHS clinically would deal with the impact of a high-consequence infectious disease outbreak and how Public Health England would deal, I suppose, semi-clinically, with the outcome of an outbreak.

Where was the work done by the DHSC by way of plans for quarantine, self-isolation, enhanced community sampling and collection of data?

Ms Emma Reed: I would say that the recommendations were both clinical and operational, and that the clinical and operational elements of them were led by NHS England and Public Health England, with bodies that we were on to support. In your – answer to your question about where the work on contact tracing was led, that was within Public Health England.

Lead Inquiry: Did the DHSC, as far as you are aware, take forward, produce papers or policies or guidance or spend time thinking about any of those issues within its own department?

Ms Emma Reed: So the advice on clinical and operational matters would be the responsibility of NHS England and Public Health England, so we would look to those bodies to provide us with advice. I am not a clinician and I’m not well placed to write those papers. I would seek advice from colleagues across the health and social care organisations that can.

We were very aware of the level of readiness in the health and social care system to deal with an emerging infectious disease. There were, at – off memory, approximately eight or nine in the five years of my appointment, and so I was very aware of the response capability to high-consequence infectious disease and had run a number of incidents to see how that operated in practice.

Lead Inquiry: Those recommendations were not formulated by way of directions to NHS England or Improvement or to Public Health England, they were generic recommendations or lessons: X, Y or Z must be done.

So, given that it wasn’t the NHS England or the PHE who were told to respond in their own way, within the limits of their own functions, to these areas of concern, why wasn’t the DHSC itself responding, doing what it could to improve the overall system of preparedness for a health emergency by addressing these particular issues?

Ms Emma Reed: I would say that it is within the remit of those organisations to lead the response that was required to those recommendations. That is set in the remit letters and the responsibilities that those organisations hold to deliver adequate preparedness to an outbreak of an infectious disease and a response to public health. That is enshrined within the responsibility of those two bodies to do.

Lead Inquiry: Exercise Cygnus.

Ms Emma Reed: Yes.

Lead Inquiry: You’re aware, because we’ve been debating it, that the overall outcome of Exercise Cygnus was that the UK’s plans, policies and capability were not sufficient to cope with the extreme demands of a severe pandemic. How often, as far as you’re aware, was that conclusion considered within your department once you took up post

Ms Emma Reed: Sorry, could you repeat the question?

Lead Inquiry: Yes. How often was active consideration given to whether or not that general conclusion from Exercise Cygnus was being dealt with? How often were meetings held where employees in the department would say, “Right, well, that was the serious conclusion from the exercise. How well are we doing in terms of

addressing those concerns, of making sure that the plans

and the policies and the capability are now sufficient”?

How often was active consideration given to making sure

that that worrying feature was being adequately


Ms Emma Reed: I would say on a regular number of occasions in

different ways. That – the concern that was raised in

Cygnus was a feature of our risk and our risk register.

That was discussed at every level of the department on

a quarterly basis. We had boards that were looking at

the readiness of the health and social care system to

respond to that, that was chaired by my Director

General, Clara Swinson. We had quarterly conversations

to look at cross-government readiness and whether we

were addressing the recommendations of that report.

So – and also regular meetings with our

permanent secretary. So I think the question about how months later? 18 we were responding to our state of readiness was asked

on a regular occasion.

Lead Inquiry: How many recommendations came out of Exercise Cygnus?

Ms Emma Reed: 22, and four learning recommendations.

Lead Inquiry: By June 2020, how many of those recommendations did the

DHSC itself identify had not been fully completed?

Ms Emma Reed: Off my recollection, I would say that eight of them had

not been fully completed – had been partially completed, and about six of them had not been completed at all.

Lead Inquiry: That was, you’re quite right, the conclusion of a DHSC meeting, workstream, another workstream, to consider to what degree the department or to what degree the recommendations from Exercise Cygnus had not been completed, and that was a conclusion reached in June 2020, was it not, Ms Reed?

Ms Emma Reed: That sounds about the right date, yes.

Lead Inquiry: All right, take it from me then.

Lady Hallett: Can I just ask what you mean by not fully completed, not completed at all?

Completed means done, completed. So I would have thought not fully completed means work had started but it hadn’t finished. Not completed at all, I don’t understand.

Ms Emma Reed: Okay, allow me to expand. Some of the recommendations had different component parts to them, and so there may be an element of a part that had been completed. So, for example, we had completed some work on surge guidance, and that had been completed, but the second half of that, around socialising that with – or testing that with health and social care organisations, that part of it was not completed.

Lady Hallett: But that would come under the category of not completed.

Ms Emma Reed: I think that’s a fair conclusion to reach, yes, my Lady.

Lady Hallett: So what do we mean by six were not completed at all? Do we mean no work had started?

Ms Emma Reed: No, I wouldn’t say that no work had started. Work had started on all of the recommendations, but there were some elements of those that had been completed.

So I would agree with your conclusion that they weren’t completed, but work had begun on all of them.

Lady Hallett: Or they hadn’t got very far?

Ms Emma Reed: It varies across the recommendations, my Lady.

Lady Hallett: If you have a recommendation that says “We must get more PPE, this is a highly infectious disease, it’s got terrible consequences, we must get” – whose responsibility is it to get the PPE?

Ms Emma Reed: I would suggest that that would be my responsibility.

Lady Hallett: Who would ensure that your responsibility was carried through, apart from you?

Ms Emma Reed: That would be the responsibility of my permanent secretary and the departmental board.

Lady Hallett: So after Ebola you had a recommendation for more PPE, was it?

Ms Emma Reed: I can’t recall the recommendation from Ebola, my Lady.

Lady Hallett: I think there was one in relation to PPE.

Ms Emma Reed: If there was a recommendation that related to PPE being acquired for an emerging infectious disease, as I understand it the PPE stockpiles for emerging infectious disease have been adequately built, I haven’t had anything to tell me to the contrary. So I’m not – it’s – unfortunately before my time I can’t confirm whether or not and how the recommendations for Ebola’s PPE were delivered, but I can say that that hasn’t been raised to me as an issue, that there isn’t adequate PPE for an emerging infectious disease.

Lady Hallett: Thank you.

Mr Keith: Can I assist you, Ms Reed?

Lesson 8 from Ebola was that further work would be required between the Department of Health, NHS England and Public Health England to determine the most appropriate levels of PPE that should be maintained for ongoing infectious disease preparedness.

But for the reasons that we have been debating, namely that the assumed consequences of infectious non-influenza disease were set so low, were so narrow, in terms of being confined to healthcare settings, and very low levels of casualties and fatalities, not very much PPE was required to meet what was thought to be necessary for a high-consequence infectious disease. But no consideration was given at all to the need for PPE for a non-influenza pandemic.

That’s the sum of it, isn’t it?

Ms Emma Reed: The risk assessment we were building our mitigations for were a pandemic influenza and emerging infectious disease, and in both of those cases, with advice from experts and specialists, we were advised what PPE we needed for both of those risks. If you start from the premise of the risk you’re mitigating, you build the appropriate mitigation for those risks. So it is the case that we had appropriate PPE for those two scenarios, but not for a Covid pandemic, which was not the risk we were managing.

Lead Inquiry: Going back to the recommendations, the recommendations from Cygnus, 14 of which had not been fully completed, whatever that means, eight partially, perhaps six not fully, fully completed, that was not a situation in June 2020 which took anybody by surprise, was it?

Ms Emma Reed: No. The recommendations that hadn’t been completed were part of our ongoing programme of work, and, as I mentioned earlier, some elements of our programme needed to be paused, and so there were elements of those programmes that hadn’t been completed.

I would also say that there are a number of recommendations in Cygnus that it’s not really conceivable for us to say that we have ever fully completed. So the first recommendation is that our emergency preparedness must follow best practice. Well, by definition we never complete that, because the process is about continuous learning. So I’d never feel comfortable being at the point of saying that we’ve absolutely completed that activity. The way that some of the recommendations were phrased were such that they were about ongoing work and continuous development. So I think it would be difficult for us ever to get to the point that we’d say all 22 of those had been completed.

Lead Inquiry: The point, Ms Reed, though, is this, isn’t it: as at June 2020, the body that was looking at how many of the recommendations were implemented couldn’t have been taken by surprise, it must have been apparent to everybody who was responsible for implementing the implementations, from 2016 through to 2020, that the recommendations were not being implemented; it just was not being done, for a variety of reasons, which you’ve attempted to explain? It just wasn’t done.

Ms Emma Reed: There were a number of recommendations that weren’t completed, that’s absolutely correct.

Lead Inquiry: You knew that the recommendations were not being implemented. 2016 was four years before this committee reported as to the number which weren’t being implemented.

Ms Emma Reed: That’s correct.

Lead Inquiry: If we could have, please, on the screen INQ000022792, which is the report into Exercise Cygnus, page 6. At 1, amongst the recommendations which were never implemented in full was this one:

“The development of a Pandemic Concept of Operations …”


Ms Emma Reed: That’s correct.

Lead Inquiry: Page 8, at 3, work to be done on how the public would respond to a pandemic, that is to say whether it would self-isolate, whether it would cope with the demands of mandatory quarantining, how it would respond to social restrictions; correct?

Ms Emma Reed: I can’t say with certainty whether any of the work was done on this particular recommendation. I don’t think it is concluded.

Lead Inquiry: Now, the only thing that was done, Ms Reed, wasn’t it, was that a committee was set up called MEAG, of which my Lady has heard, the Moral and Ethical Advisory Group, which would give advice in the event of a pandemic on some of the moral and ethical questions that might arise?

Ms Emma Reed: Yes.

Lead Inquiry: But the work done, the behavioural work done as to how the public would deal with social restrictions and non-pharmaceutical interventions and how in practice the country would be enabled to deal with the consequences of a catastrophic pandemic were not addressed at all, were they?

Ms Emma Reed: No.

Lead Inquiry: Page 9:

“An effective response to pandemic influenza requires the capability and capacity to surge resources into key areas, which in some areas is currently lacking.”

The NHS did put into place, at your department’s urging, plans for surge capacity, and we saw that of course when the pandemic struck, but very little work was done in relation to how the adult social care sector would cope with a mass influx of patients in a pandemic.

Ms Emma Reed: I wouldn’t agree that there was no work done in that space. There was a lot of engagement with LRFs and some guidance was issued to adult social care providers in May of 2018 that addressed the question of surge. I would not say that that work was completed, and I would be very clear to say that there was more that we needed to do about community surge. But it was not the case that no work was done.

Lead Inquiry: Page 11, there was some feedback in the course of Exercise Cygnus from local resilience forums to the effect that there are just “too many plans” and “there is a question about how up to date all the plans are and whether there are contradictions between [them]”.

What was done in order to rewrite the plans? To produce something, perhaps in a single document, something that was coherent and clear to the LRFs? Was that ever done?

Ms Emma Reed: No, it wasn’t completed.

Lead Inquiry: Page 12, some of the feedback was to the effect that LRFs, the local resilience forums, “would have difficulty operating their plans and capabilities at this scale [of response]”.

“More focus and co-ordination on pan flu preparedness [is] needed nationally, departmentally and within Resilience and Emergencies Division Operations Centre itself.”

Now, of course you don’t speak for the Resilience and Emergencies Division of the Department for Levelling Up, Housing and Communities, nor for the Cabinet Office, but was that focus and co-ordination carried out, as far as you were aware?

Ms Emma Reed: I am aware that the Ministry for Housing engaged extensively with local resilience forum around their readiness in pandemic influenza. I’m aware the Cabinet Office engaged extensively with local resilience forums on their resilience standard and their level of preparedness.

Of course it’s also important to note that NHS England and Public Health England are represented on the local resilience forum, so I also engaged with the health system that sits on local resilience forum. It was not co-ordinated and that was definitely one of the recommendations that we were – we didn’t deliver, which I regret, around that co-ordination and the bringing together of advice. But we did engage with local resilience forums and at the local level.

Mr Keith: My Lady, is that a convenient moment?

Lady Hallett: Certainly. I shall return at 12 o’clock.

(11.45 am)

(A short break)

(12.00 pm)

Mr Keith: Ms Reed, what are health sector security and resilience plans?

Ms Emma Reed: They would be plans that organisations who are Category 1 responders and have responsibility under the Civil Contingencies Act need to have in place to ensure that they can discharge that duty.

Lead Inquiry: So they are plans which you put into place to make sure that everyone can know or you can be assured that your preparedness and continuity arrangements are in order, as they are obliged to be under the Civil Contingencies Act 2004, as a Category 1 responder?

Ms Emma Reed: Yes.

Lead Inquiry: Can we have INQ000187694, please, which is the 2016 plan, page 3, paragraph 1:

“Within the health sector, there are generally good levels of resilience, with good preparedness and business continuity arrangements in place.”

Ms Emma Reed: Yes.

Lead Inquiry: At paragraph 5:

“The health sector can be impacted by the majority of risks in the National Risk Assessment … it is essential that within the health sector, national planners are … planning against the common consequences … Given the diversity and interconnectedness within the health sector, and the extent to which it needs to respond to the consequences of emergencies in other sectors, emergency preparedness, resilience and response planning … adopts an ‘All Risks’ approach.”

So this is the DHSC saying “We have measured ourselves against a security and resilience assurance, these are our plans for preparedness and continuity, we [going back to paragraph 1] think there are generally good levels of resilience, with good preparedness and business continuity arrangements in place”, it’s you signing off on how you’re doing, paragraph 1?

Ms Emma Reed: Yes, but this is not a – this is not a static status, it is something that we continually look at, the health and social care sector’s resilience for emergency preparedness.

Lead Inquiry: Of course, so this is just for 2016?

Ms Emma Reed: Yes, I’m not familiar with this document.

Lead Inquiry: All right.

So every year or every two years these plans are put into place or these documents are prepared, and they’re not static, are they, they take account of whether or not there is good resilience and whether there has been an outbreak or whether there has been an exercise and whether you’ve responded to an exercise or whatever it might be. They’re not fixed, set in place. They take account of the reality of how well the department is doing.

Ms Emma Reed: The department and its delivery organisations.

Lead Inquiry: Arm’s length –

Ms Emma Reed: Yes.

Lead Inquiry: And its arm’s length bodies?

Ms Emma Reed: Yes.

Lead Inquiry: Could we then, please, have 2017/18 health sector resilience plan, INQ000105273. Page 3.

So, Ms Reed, this health sector security and resilience plan was after Exercise Cygnus. The first one I showed you was before the report in Exercise Cygnus.

Could you go, please, down to the bottom of the page – or, rather, halfway down the page. There we are, stop there.

So this plan, a year and a half later, from the earlier plan, is after Cygnus has reported in the terms that it did about the systemic insufficiency of the plans, policies and capability in the health sector, amongst others, to cope with the extreme demands of a severe pandemic, but the wording in this plan is identical:

“… there are generally good levels of resilience, with good preparedness and business continuity arrangements in place.”

The identical words to the plan 18 months before. So it wasn’t static – sorry, it was static. The plan uses the identical wording from the earlier plan. So how could it possibly have taken account of that severe conclusion from Exercise Cygnus, and the fact that the workstreams which came from Cygnus were not by and large being pursued through to their fruition?

Ms Emma Reed: I’m not familiar with this document and this document was produced before my time in the organisation, so I cannot – I cannot make an assessment of the decision to draft that sentence as it is. Looking at this document for – for what I can see it to do, is it is looking across the totality of the threats and hazards landscape, so all of the threats that are captured in the National Security Risk Assessment, I think that my perception would be that at that time the concern of pandemic influenza was in a state of readiness, but this is looking at general levels of resilience and preparedness across all the risks in the National Risk Register.

Lead Inquiry: Ms Reed, in the field of health emergency, in the field of the Tier 1 risk faced by the United Kingdom, there had been since the earlier sector resilience plan, Exercise Cygnus, which had concluded in the way with which you are very familiar. How could a proper, adequate sector resilience plan conclude in this way using the identical wording that its earlier plan had used before Exercise Cygnus had reported?

Ms Emma Reed: I can’t comment on the drafting of this paper –

Lead Inquiry: Because this was before your time?

Ms Emma Reed: – it was not – before my time. I would not say that in the specific risk of pandemic influenza we were fully prepared or that there was good levels of resilience. I would say generally across the threat and hazards landscape there is a good level of resilience and a good degree of preparedness.

Lead Inquiry: Was there a sector resilience plan prepared by you, however, after you were in post?

Ms Emma Reed: I don’t believe there was, no. I don’t recall producing one, no.

Lead Inquiry: All right.

My Lady, there’s a document which we have on our system which hasn’t in fact been disclosed for a variety of reasons, I’m not quite sure why, to core participants and to the witness, and therefore I’m not in a position to be able to bring it up on the screen, and it’s not right that I should because it will take everyone by surprise.

But I want to ask you, Ms Reed, do you recall a sector resilience plan for 2018 and 2019 being prepared whilst you were and remain in post?

Ms Emma Reed: I don’t recall a plan being produced, no.

Lead Inquiry: All right.

If that plan were to use these words “there are generally good preparedness and business continuity arrangements in place”, that would seem to indicate that the wording had still not been materially altered, even by 2018/19, when you were in post?

Ms Emma Reed: I can’t comment on the text, I’m not familiar with the document. If the text is the same as the previous versions, that would imply that it hadn’t been changed. That would not be my view of the pandemic risk, but it would be my overarching view of our state of readiness for wider threats and hazards.

Lead Inquiry: All right.

The Pandemic Flu Readiness Board, we’ve covered the workstreams which were meant to be addressed by the Pandemic Flu Readiness Board. Bringing those threads together, the board was established in –

Ms Emma Reed: 2017.

Lead Inquiry: – in March, following Exercise Cygnus. It was established by order of the National Security Council Threats, Hazards, Resilience and Contingencies committee in the order of the then Prime Minister?

Ms Emma Reed: Yes.

Lead Inquiry: It had a number of workstreams, some of which were completed?

Ms Emma Reed: Yes.

Lead Inquiry: Some were part completed, some were not completed at all. We needn’t go into the detail of it. But that Pandemic Flu Readiness Board, which was a board chaired jointly by your department and the Cabinet Office, didn’t sit at all, did it, between November 2018 and November 2019?

Ms Emma Reed: That’s correct.

Lead Inquiry: You’ve already explained and other witnesses have explained that that was because of the necessary preparations for a no-deal exit, Operation Yellowhammer interfered in this process. But why did the fact that the particular workstreams were in some places being paused or not completed mean that the board itself didn’t have to meet between November 2018 and November 2019? Why was Operation Yellowhammer a sufficient explanation for why the board didn’t meet as opposed to why some of its workstreams were not being seen through to their conclusion?

Ms Emma Reed: I would say that the reason for that is that our prioritisation of resources in working on pandemic flu were prioritised at the delivery of key elements of the programme rather than in the secretariating of a board. So I prioritised our work on the Bill and on work to do with excess deaths and MEAG rather than board secretariating functions. So the work continued but we didn’t run a board.

Lead Inquiry: You were the prime civil servant, along with Ms Hammond, on that board?

Ms Emma Reed: Yes.

Lead Inquiry: You effectively co-chaired it?

Ms Emma Reed: Yes.

Lead Inquiry: You knew the board was not sitting and did not sit for a whole year.

Ms Emma Reed: That’s correct.

Lead Inquiry: Did you not think to yourself, “The risk of a pandemic has never gone away, these are important workstreams which the Prime Minister ordered to be done, they are things that matter, they reflect the conclusions of Exercise Cygnus, they are important aspects of getting this country ready for the Tier 1 risk, the greatest risk in the entire risk assessment process, I think we should be sitting”?

Ms Emma Reed: I – no, I don’t. I think that what I took as a judgment was, firstly, that resources were needed to support the response to the real threat of disruption from a no-deal exit and, secondly, that I prioritised work that needed to be completed on capabilities that actually were used in the Covid situation, which included the Pandemic Flu Bill. Those pieces of work could continue outwith a board structure.

Lead Inquiry: Now, there are a number of things that the board did see through to fruition. There was the drafting of a Bill –

Ms Emma Reed: Yes.

Lead Inquiry: – which was the draft pandemic Bill, which became the Coronavirus Act.

Ms Emma Reed: Yes.

Lead Inquiry: Only in relation to the emergency regulations in England was that Act used, was it not, when Covid struck, because Scotland, Wales, Northern Ireland all used earlier emanations of the Public Health Act, did they not?

Ms Emma Reed: I would have to check my records to see which piece of legislation –

Lead Inquiry: All right.

Ms Emma Reed: That would be an issue for the devolved administrations.

Lead Inquiry: MEAG –

Ms Emma Reed: Yes.

Lead Inquiry: – was put in place, the Moral and Ethical Advisory Group, and that gave valuable assistance, of course, during the pandemic on the moral and ethical issues.

Another piece of work that was done was the board authorised, drafted and prepared and published something called the National Resilience Standards. That was a standard, a test, a check, if you like, for local resilience forums, so that they knew to what standard their own preparedness plans had to be judged by?

Ms Emma Reed: Yes.

Lead Inquiry: I put it to Ms Hammond, but I ought to put it to you because I think the National Resilience Standards for Local Resilience Forums came, at least in part, from the Department of Health and Social Care, did they not?

Ms Emma Reed: If I recall, it was a piece of work that was led by the Cabinet Office working in partnership with the department responsible for local government, but we will have supported that work.

Lead Inquiry: All right. Are you aware that until 14 November 2019, just before the pandemic struck, the National Resilience Standards for Local Resilience Forums across the entirety of England and Wales made no reference to any need to judge their work by reference to the plans that might be required for an influenza pandemic?

Ms Emma Reed: That would be a matter for the Cabinet Office and the department for housing and local government.

Lead Inquiry: All right.

The PIPP board or the PIPP programme, what was that?

Ms Emma Reed: That was a programme that was led by my Director General, Clara Swinson. The responsibility of that body was to look at the delivery of the health and social care elements of pandemic preparedness. So it was a more internal health and social care-focused programme.

Lead Inquiry: Was there a long period during which it did not meet, or at least the board for the Pandemic Influenza Preparedness Programme did not meet?

Ms Emma Reed: As I recall, it also did not meet during the period of end 2018 to 2019.

Lead Inquiry: Again, because of Operation Yellowhammer?

Ms Emma Reed: As I understand it, yes.

Lead Inquiry: Do you agree that no pre-pandemic exercise in which your department was either an observer or a participant and no outbreak report and no DHSC policy or guidance paper considered the issue of the vulnerabilities and inequalities of parts of the community and how they might be affected by the plans that you were drawing up for a pandemic influenza?

Ms Emma Reed: No, I wouldn’t agree with that statement. I think there was consideration taken for the impact to vulnerable people of a pandemic influenza.

Lead Inquiry: Clinical vulnerability, Ms Reed, it was clinical vulnerability, it was obviously, in the event of a pandemic, the pandemic and our responses to the pandemic will have an impact clinically on those who are at greatest risk from the disease. Was there any consideration of anything other than clinical vulnerability?

Ms Emma Reed: I believe that there were considerations of wider inequalities of – for those individuals who would potentially find it difficult to access health and social care systems.

You mentioned earlier also the moral and ethical committee that considered issues around concerns from different faith groups about the approach to vaccination and shielding, so there were areas where thinking about protected characteristics were a consideration in our planning and preparing.

There was no systemic assessment of protected characteristics impact, but individual work programmes were considering impacts on vulnerable people.

Lead Inquiry: The work programmes to which I now understand you may be referring, was that the work done to ensure that if individuals want treatment, clinical treatment, steps needed to be taken to mitigate differential impact by ensuring that health communications will be available in a range of languages?

Ms Emma Reed: There was work undertaken to think about how we reach communities where English is not the first language. I would say that it is writ within the principles of how we deliver our work that we consider health inequalities at a national and local level and so communications would, in themselves, think about people who may not be able to access information where English isn’t their first language.

Lead Inquiry: Ms Reed, other than the obvious point that some people may be more clinically vulnerable to a pandemic, the only consideration in this whole ten-year period given to the position given to members of ethnic minority groups or vulnerable sectors of society, by way of your pandemic planning, was making sure that health information would be available in a range of languages; is that the sum of it?

Ms Emma Reed: I don’t believe that to be true, we considered equality impact assessment as part of the – as the 2011 strategy, we considered an impact assessment as part of the pandemic Bill preparedness that you mentioned earlier. In guidance that went to local resilience forums they talked about people who would struggle to access mainstream healthcare, which included those who were homeless and disenfranchised. So there was work to do that. It wasn’t systemic – systematic, I apologise, but there was work to consider vulnerable people.

Lead Inquiry: The work that was done, and you’ve just referred to it, was a consideration – there was a paper called the Equality Duty paper, which came out around about the same time as the 2011 strategy, there was nothing thereafter, which considered the legal obligation imposed on the government generally under the Equality Act 2010, known as The public sector Equality Duty. Is that the duty to which you’re referring?

Ms Emma Reed: Yes.

Lead Inquiry: Right. That was a broad omnibus consideration of the power or the duties of the government under the Equality Act. Where was a single paper referring to what the impact would be on the particular parts of society to which I’ve made reference of either a pandemic or your planning?

Ms Emma Reed: There was no single piece of paper with that on it.

Lead Inquiry: Right. Do you accept from me, evidence through me, evidence from the government’s own Equality Hub, and its director, Mr Bell, who has given a witness statement to my Lady, which says:

“Reasonable and proportionate searches have been conducted … I can confirm that this department was involved in no work related to the United … government’s response to civil emergencies, including a pandemic. There was no contribution to the design or preparation of any policy response on behalf of the United Kingdom government in the event of a pandemic.”

Just no work was done on this topic at all, was it?

Ms Emma Reed: There was no overarching assessment of the impact of the pandemic preparedness strategy on inequalities since the publication of the strategy in 2011.

Lead Inquiry: Thank you.

Ms Emma Reed: Had there been a revision, we would have done that.

Mr Keith: All right. Those are all my questions, thank you.

My Lady, that concludes the evidence of Ms Reed.

Lady Hallett: So no Rule 10?


Mr Keith: There were applications but permission has been denied.

Lady Hallett: Thank you very much.

Thank you, Ms Reed, thank you for your help.

The Witness: Thank you.

(The witness withdrew)

Ms Blackwell: My Lady, good morning. The next witness is Rosemary Gallagher MBE. May she be sworn, please.

Mrs Rosemary Gallagher


Questions From Counsel to the Inquiry

Ms Blackwell: Is it Ms or Mrs Gallagher?

Mrs Rosemary Gallagher: It’s Mrs.

Counsel Inquiry: Thank you.

Mrs Gallagher, thank you for the assistance that you have so far given to the Inquiry and thank you for coming to give evidence today.

Please keep your voice up, speak into the microphones so that the stenographer can hear you for the transcript. If I ask you a question that isn’t clear, please ask me to repeat it and I will.

If you need a break before our usual time of breaking – which I think will be 1 o’clock today, my Lady?

Lady Hallett: Or maybe 1.15, depending on how we go.

Ms Blackwell: Or maybe 1.15 – thank you – then please just say so.

Is it correct, Mrs Gallagher, that you are the professional lead for Infection Prevention and Control, or IPC, and nursing sustainability lead at the Royal College of Nursing, a role that you have held since 2009?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: Thank you. In terms of your professional career to date, you were a senior nurse in infection control at Stoke Mandeville Hospital from 2002 to 2008. In 2009 you represented the Royal College of Nursing as a member of the Pandemic Influenza Clinical and Operational Advisory Group, dealing with the H1N1 swine flu pandemic, and from June to October of 2015 you assisted the World Health Organisation on behalf of the RCN with the MERS outbreak in Saudi Arabia. Between 2014 and 2016 you led the RCN response to the Ebola viruses disease outbreak in West Africa, and in November 2018 you joined the emergency preparedness, resilience and response (EPRR) clinical reference group of NHS England at the request of its director, Stephen Groves.

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: You have provided two witness statements. May we put up first, please, INQ000177809. Can you confirm that that’s your first witness statement, Mrs Gallagher?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: Thank you. Now INQ000183414.

Thank you. Is that the second statement that you’ve provided?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: Thank you very much.

My Lady, could we have permission for those to be published?

Lady Hallett: You have.

Ms Blackwell: Thank you. We can take that down.

I’m going to begin, please, by asking you to describe to us the role and function that you hold at the Royal College of Nursing.

Mrs Rosemary Gallagher: So I am a registered nurse –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – and I provide strategic leadership on behalf of the Royal College of Nursing on matters relating to infection prevention and control. I provide specialist infection prevention and control advice to the college, to our members and our stakeholder organisations that we work with. My role is a UK-wide role, and I’m one of a team of about 13 professional leads that work together to cover many areas of nursing practice.

Counsel Inquiry: Right, and it being a UK-wide role, how do you ensure a tailored approach to the particular needs of each of the devolved nations, for instance?

Mrs Rosemary Gallagher: So the RCN has – covers the four regions of the United Kingdom, and my role often involves both proactive and reactive work. With the proactive work, we engage with the four countries, the four regions of the Royal College of Nursing, and as far as possible with our relevant organisations in the countries as well. For reactive work, we would respond according to the need and what it was that I could support them with.

Counsel Inquiry: Thank you.

Moving then to your role with the EPRR clinical reference group, a role that, as we’ve established, you’ve held since November of 2019. Could you provide us with an overview of what that group does, and in particular what your role is within that group?

Mrs Rosemary Gallagher: I was asked to be on the group as a nurse.

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: Not specifically in relation to my experience with infection prevention and control, though that was thought to be advantageous in terms of some of the discussions that took place in the meetings, and I shared that role with a colleague who represented public health nursing.

As a member of the EPRR we were there to represent our discipline of nursing and to provide nursing input and advice on discussions that were on the agenda at that time.

Counsel Inquiry: Right, thank you.

At paragraph 17 in your witness statement, you tell us that:

“Pandemic preparedness [with the group] focused only on influenza and was not a significant regular agenda item at meetings of [the group] …”

And that:

“The need to consider other potential infections with pandemic potential was made public by the Chief Medical Officer … for England in July of 2019 and this position was supported by the RCN due to the experience that it had gained through its planning to support Saudi Arabia with [the] MERS CoV [outbreak].”

You also say, Mrs Gallagher, that, additionally, Disease X was added as a new category to the World Health Organisation’s emergency priority list in 2019, but that the UK continued to focus on influenza, despite the experience of MERS in the Middle East, and Severe Acute Respiratory Syndrome, SARS, and the potential for a new coronavirus to emerge.

So the Chief Medical Officer had given advice in July 2019, the World Health Organisation had made Disease X – given it a place on the emergency priority list in the same year, and yet the group upon which you sat was giving pandemic influenza only a priority in its discussions, and even that wasn’t a regular agenda item.

Were you concerned about that?

Mrs Rosemary Gallagher: The overarching pandemic planning did not feel as if it reached into the EPRR group, whose agenda focused on much more recent incidents, and our response and our learning from those. So it was an ad hoc agenda item but not a regular item, and I’m unsure exactly how the EPRR group fed directly into the governance systems for pandemic planning.

Counsel Inquiry: Did you personally have any concerns prior to January of 2020 that the focus within the group was too narrow, given as it only appeared to consider pandemic influenza?

Mrs Rosemary Gallagher: The RCN had raised concerns regarding the opportunities for other organisms with pandemic potential that we needed to consider. The – if I recall the discussions, it was more of an agenda item rather than an opportunity to feed back, it was more feedback on where the pandemic planning was going.

Counsel Inquiry: The Inquiry has heard an explanation or justification from those who were focused, perhaps too narrowly, on pandemic influenza that in fact plans could be and should be adapted?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: So the fact that pandemic influenza led to a certain level of planning was able to be seized upon and used during the course of the Covid pandemic.

Do you agree that clinical preparedness plans are capable of being adapted for different infectious diseases?

Mrs Rosemary Gallagher: I believe that if you have the principles right in relation to pandemic planning, that you can use those as a platform to adapt as situations evolve. It won’t – you cannot have a specific plan for every specific organism, but it’s important that we get the foundation structures right.

Counsel Inquiry: Thank you.

The Inquiry has heard from Professor Dame Sally Davies, former Chief Medical Officer, and in her witness statement to the Inquiry she has said:

“I have previously expressed the view that whilst the [World Health Organisation] has said the UK was well prepared for a pandemic, those preparations assumed a pandemic of influenza. This reflected a longstanding bias in our preparations in favour of influenza and diseases that had already occurred, with, we now know, an underestimation of the impact of novel and particularly zoonotic diseases.”

Do you agree with that?

Mrs Rosemary Gallagher: I do.

Counsel Inquiry: Yes.

In his evidence to this Inquiry, Jeremy Hunt has said that in his view there was a groupthink that the United Kingdom knew that this stuff, as he described it, the best, and that we had no need to look further afield to other countries in order to try and learn from their experience.

In particular, he said:

“… I don’t think people were really registering particularly Korea as a place that we could learn from.”

Did you observe this type of groupthink as described?

Mrs Rosemary Gallagher: I did.

Counsel Inquiry: Yes, and did you raise your concerns in relation to that with anybody or any organisation?

Mrs Rosemary Gallagher: In response to the work that we did with Saudi Arabia, and also in relation to the work we did on Ebola, we raised significant concerns around the different needs, for example, for personal protective equipment that may differ from influenza. So the concerns that we raised came out of our experience supporting other incidents and were fed directly back to those involved.

Counsel Inquiry: Right, well, I want to ask you about your personal involvement with incidents representing the Royal College of Nursing.

In your witness statement, you tell us that the Royal College of Nursing was invited to be part of the Pandemic Influenza Clinical and Operational Advisory Group, or PICO, and that was as part of the response to the H1N1 swine flu –

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: – in 2009. Tell us about your experience in that group, please.

Mrs Rosemary Gallagher: So as part of the pandemic response in 2009, the college was approached to provide representation to the PICO. It was a clinical subgroup that I understand provided advice to SAGE at the time. Other members of the PICO included other medical royal colleges and those with other relevant areas of expertise.

We discussed situations or drafts of guidance that were being developed, and we met weekly. I shared that role with two colleagues within the Royal College of Nursing to ensure that we provided the correct level of representation, that included my colleague who led on health and safety, and the professional lead for community and primary care at that time, so we considered all care settings.

I found the PICO an excellent group. It allowed for multi-professional discussion and scrutiny of proposed guidance. The end result of that discussion would be agreement on a specific position, or to approve the guidance moving forward.

Counsel Inquiry: So you would describe this as an example of clinical stakeholder engagement working well?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: What you tell us, Mrs Gallagher, at paragraph 40 in your witness statement is that:

“We were able to feed in our expertise and intelligence and represent the needs of the [Royal College of Nursing’s] membership to inform the development of clinical guidance and guidelines concerning the response to pandemic flu.”

Then you go on to say:

“This was a very different experience to the approach taken by the [United Kingdom] government during the Covid-19 pandemic.”

How so?

Mrs Rosemary Gallagher: My experience in the early stages for Module 1 is that the opportunities for engagement of stakeholders from my position, from the Royal College of Nursing, was extremely limited, so this was a very – it had the perception of a very hierarchical response. Given that it was a command and control situation, however, we had the experience of knowing that stakeholder engagement could be implemented and worked very well in previous pandemics.

Counsel Inquiry: Well, indeed, Dame Deirdre Hine in her review following the swine flu outbreak, at paragraph 6.60 in her report, says:

“Further engagement is needed between health departments, professional bodies and employers to further develop clinical advice and provide support to staff during a pandemic.”

Is it your experience, Mrs Gallagher, that that lesson was or wasn’t carried forward and incorporated into preparedness planning for the Covid-19 outbreak?

Mrs Rosemary Gallagher: So the Royal College wasn’t specifically involved in pandemic planning. Our experience does not reflect stakeholder engagement. And I would just like to add that it’s not just the development of clinical guidance or guidelines that requires stakeholders to be involved. Nursing is the largest part of the healthcare worker workforce, and actually we have a key role in implementing guidance and guidelines. So it’s absolutely vital that we are around the table to be able to identify opportunities or risks to that proposed guidance.

Counsel Inquiry: But that didn’t happen?

Mrs Rosemary Gallagher: No.

Lady Hallett: Sorry, when didn’t it happen?

I’ve got a feeling that you were moving on to when the pandemic really was acknowledged as having hit, so in other words response rather than –

Mrs Rosemary Gallagher: So I was referring to the very early days, up until the middle of January, because I’m aware Module 1 only covers that short time period.

Ms Blackwell: All right, but in relation to pandemic planning –

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: – there was a lack of engagement with the Royal College of Nursing?

Mrs Rosemary Gallagher: That’s correct, yes.

Counsel Inquiry: You tell us in your witness statement about playing a clinical advisory role during the Ebola viruses disease outbreak?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: Can you tell us what that involved, please.

Mrs Rosemary Gallagher: So the Ebola epidemic in West Africa was extremely challenging, and a request was made for UK nurses to go out and support the delivery and action in West Africa. This request, from a nursing perspective, was led by the public health – by Public Health England.

Counsel Inquiry: Yes?

Mrs Rosemary Gallagher: – and I was asked to provide professional support to the nurses that were leading that response.

This was really about where the RCN could add value, as somebody put it, at a time when everybody was running towards the fire. We are able to sit back and reflect on what is needed from a professional and regulatory and indemnity perspective, and to support those nurses who may be interested in going to West Africa under those conditions to really understand what it is that they need to do and the level of competency and capability that is needed to do that sort of role.

Counsel Inquiry: Was it possible, in your experience, for lessons to be learned by the government in pandemic planning from the time of the Ebola viruses outbreak until Covid-19 hit at the beginning of January 2020?

Mrs Rosemary Gallagher: Yes, one of the most useful lessons for us, unfortunately, occurred when a healthcare worker in Spain acquired Ebola virus disease as a result pf caring for a patient in hospital in Madrid. Now, that healthcare worker was not involved in providing direct care. There were many, many lessons that were identified as a result of a European nursing summit with – through our relationship with the European Federation of Nurses, to identify lessons around how we can best protect healthcare workers from what we call high-consequence infectious diseases now, such as Ebola.

Now, we were not preparing for a pandemic of Ebola, this was very much a local situation, but it highlighted significant lessons around how infection control policies were written and the need to engage with clinical staff. It identified lessons around what – not just what type of personal protective equipment was needed but how we support staff to be educated on how to put these on and take these off safely. It also highlighted many lessons around confidence and communication and transparency that was needed by the healthcare workers.

Counsel Inquiry: I wanted to ask you about the culture of transparency and learning. What do you say, in relation to that, should have been carried forwards and perhaps wasn’t?

Mrs Rosemary Gallagher: We fed the lessons back from the experience of that meeting in Madrid directly. At the time I was part of a Department of Health communications group that actually worked very well, again with other stakeholders around the table, where we were able to feed in both intelligence from within the UK around how some vulnerable groups were feeling stigmatised, as cases started to be imported into the United Kingdom, but, on this occasion, more importantly, about the lessons we learnt from Madrid.

So that worked very well. However, I have no knowledge of what happened with those recommendations and that report after it was delivered.

Counsel Inquiry: All right, thank you.

Moving forward to MERS CoV, could you outline your role, please, during the outbreak in the Middle East in 2015.

Mrs Rosemary Gallagher: Yes. A request came in to Public Health England through the global – through GOARN, which was a global network, requesting support in Saudi Arabia, particularly in relation to the spread of MERS CoV within hospitals. There was real concern that healthcare workers were becoming infected with MERS, and MERS did have some sustained transmission between people at that time. We were asked to effectively identify nurses that would go – that would be willing to go to Saudi Arabia to support education and training on infection prevention and control.

We undertook an assessment of the situation and were actually very concerned about potentially just going out to seek nurses to respond to this, and we asked if it would be possible to undertake an assessment in person so that we could identify whether it was appropriate for nurses to be – to go there, number one, but also to identify what risks might be present, both culturally, clinically, you know, a holistic view, and it was on that basis that we were asked to visit – when I say “we”, myself and a colleague in Public Health England – to visit and undertake that assessment, and the subsequent ask, given our expertise, was then to look more widely at potential transmission of MERS CoV and how infection prevention and control might support that.

Counsel Inquiry: Right, and you tell us at paragraph 36 in your witness statement that you believe, in your extensive experience of that outbreak:

“… significant lessons should have been learnt from the experience with MERS CoV. For example, the Gulf Co-operation Council’s IPC guidance specifically addressed the airborne spread of MERS CoV and the requirement for the use of RPE.”

Mrs Rosemary Gallagher: Yes, that’s correct.

Counsel Inquiry: You go on to say in a following paragraph:

“The Covid-19 pandemic has shown that there was too much of a focus on preparing for a flu pandemic and not enough consideration was given to how such plans would need to be adapted to deal with a respiratory infection pandemic, where the primary mode of transmission was not necessarily via ‘traditional’ droplet transmission.”


“… that airborne transmission needed to be properly factored into IPC Guidance concerning the level of PPE required for health and care workers exposed to patients with Covid-19.”

Mrs Rosemary Gallagher: That’s correct. We had the experience of MERS CoV in Saudi Arabia and we additionally had the South Korean experience as well, both of which showed that transmission within healthcare facilities was entirely possible in addition to community spread of infection.

Counsel Inquiry: What is the difference between PPE and RPE?

Mrs Rosemary Gallagher: So RPE stands for respiratory protective equipment, and it is one form of personal protective equipment. Personal protective equipment is a broad term that in healthcare would cover items such as gloves, aprons, respiratory protective equipment, for example.

PPE is designed to protect the wearer from a hazard, so in the case of a pandemic of whatever cause, that would be the infectious agent or the biological hazard that is present at that moment in time.

Counsel Inquiry: Are there lessons that you believe could have been learned from countries dealing with MERS CoV regarding the stockpiling and use of RPE?

Mrs Rosemary Gallagher: Yes. To – when you’re – in my view, if you are planning for a pandemic, we need to consider all eventualities. So we need to consider both potentially the use of surgical masks, but they are not personal protective equipment, and consider the need for respiratory protective equipment for an infection that is spread through the respiratory route predominantly. Not exclusively but predominantly.

It’s my view that there was inadequate consideration given to not just the use of respiratory protective equipment for a prolonged period of time but exactly which elements of the health and care system would need to use respiratory protective equipment if we had widespread infection.

Counsel Inquiry: Right. So not just for hospital settings?

Mrs Rosemary Gallagher: No, the NHS is more than buildings, so the NHS considers – the NHS has hospitals and healthcare facilities but also community teams, community nurses, district nurses, GP practice nurses, for example; all make up part of the NHS. So NHS care goes beyond hospitals.

Counsel Inquiry: Right, thank you.

I want to ask you now about the level of engagement that the RCN had in the preparation of Exercise Cygnus, which we know began to be prepared in 2014 but in fact didn’t take place until 2016.

Was the RCN involved in any sense in either the preparation or the carrying out of that exercise?

Mrs Rosemary Gallagher: Not to the best of my knowledge.

Counsel Inquiry: Do you know whether or not the RCN was invited to be involved in the preparation or carrying out of the exercise?

Mrs Rosemary Gallagher: No.

Counsel Inquiry: Corporate memory. You tell us in paragraph 34 of your witness statement that you have concerns about the loss of corporate memory.

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: You say:

“There was … a palpable change in culture, in the years immediately preceding the Covid-19 pandemic, brought about by the successive administrations. This seemed to manifest in an attitude where engagement with stakeholder organisations seemed to be less of a priority.”

Can you expand upon that, please. What did you mean by a “palpable change in culture”?

Mrs Rosemary Gallagher: So as I’ve described, our experience supporting the incidents of MERS and Ebola were very positive experiences in terms of the engagement and the value that professional nursing was held in, so far as we could support that. At the time, around 2017, we were also part of an antimicrobial resistance programme board that was managed by Public Health England, that, again, had a variety of stakeholders, including the RCGP, the Royal Pharmaceutical Society, around the table.

Once that was disestablished, about a year later, stakeholder engagement was significantly reduced and really remained that way until the pre-pandemic period.

Counsel Inquiry: All right. Just taking that into account and moving back for a moment to Exercise Cygnus, do you believe it was a mistake for the Royal College of Nursing not to be involved in that exercise?

Mrs Rosemary Gallagher: Yes, but I would go further and say it was a mistake not to involve other professional organisations alongside ourselves as well.

Counsel Inquiry: Thank you.

May we put up, please, a paragraph of the report that’s been provided to the Inquiry by Dr Claas Kirchelle. Thank you.

It’s at INQ000205178, and we’re looking at paragraph 112.

I want to seek your opinion on this paragraph, please, Mrs Gallagher:

“There were also ongoing concerns about [Public Health England’s] ability to act as an independent advocate for public health from within the Department of Health (from 2018 Department of Health and Social Care …). In 2014, the British Medical Association … warned that ‘the requirement to adhere to civil service rules and regulations is having an impact on [PHE staff’s] ability to do their work. Particular concerns have been raised about ( … ) the ability to publicly discuss or criticise public health policies’. In surveys, local authorities noted that PHE could do more to ‘acknowledge the pressures and constraints facing Local Authorities in its work with them’ and ‘be more vocal around issues such as welfare reform and austerity and what this means for the health of our nation’. A later witness seminar also highlighted that the increasingly rapid turnaround of civil servants across government departments had created a lack of specialist interlocutors and understanding in Whitehall.”

In your view, Mrs Gallagher, did Public Health England become less able to effectively advocate for public health and public health budgets in the period preceding January 2020? Are you able to give us your opinion on that?

Mrs Rosemary Gallagher: What I can say is that the Royal College of Nursing was very concerned around the reduced funding for Public Health England and the impact that that was having on local authorities and local health protection teams to support population health initiatives in that time.

From my perspective, obviously from an infection prevention and control position, the conversations continued in terms of business as usual, but not necessarily in relation to how we could move – work forward to increase population health and respond to incidents at pace.

Counsel Inquiry: All right, thank you. We can take that down now.

Finally on the issue of stakeholder engagement, before we leave this topic, please could we display INQ000148405, and it’s page 5, paragraph 15 of Professor Kevin Fenton’s witness statement, he being the president of the Faculty of Public Health.

If we could look over the page, please – in fact let’s look at paragraph 15 on page 5. Thank you. Could we highlight that, please:

“Generalist specialists in public health, particularly those working in health protection at regional and local levels, have been under-represented in the development of national pandemic policy, strategy and guidance and there is opportunity for this to be addressed in the future through the UKHSA-hosted Centre for Pandemic Preparedness. There was a significant missed opportunity for broader engagement in planning across local resilience forums and local health resilience partnerships which require closer working and mainstreaming of planning, training and exercising of pandemic response arrangements.”

From your viewpoint, working within the Royal College of Nursing, do you agree with those sentiments?

Mrs Rosemary Gallagher: I do.

Counsel Inquiry: Thank you very much. We can take that down, please.

By early 2019, is it your view, Mrs Gallagher, that there were sufficient structures in place for raising, escalating and addressing concerns on behalf of frontline staff amongst the UK preparedness bodies?

Mrs Rosemary Gallagher: I don’t think I can answer that question, because we weren’t specifically involved in preparedness.

Counsel Inquiry: All right. So because of your lack of involvement at all, it’s not possible for you to comment on that question?

Mrs Rosemary Gallagher: No. Could you repeat the question again for me, please.

Counsel Inquiry: Yes. It was whether or not you considered that there were sufficient structures in place for escalating and addressing concerns on behalf of your frontline staff, with the United Kingdom preparedness bodies.

Mrs Rosemary Gallagher: No, that wasn’t in place, we weren’t able to contribute to that.

Counsel Inquiry: All right, and indeed, as you’ve already said, there was a complete lack of engagement with the Royal College of Nursing in terms of preparedness, so there was no option or potential for –

Mrs Rosemary Gallagher: No.

Counsel Inquiry: – raising those issues on behalf of your frontline staff?

Mrs Rosemary Gallagher: No.

Counsel Inquiry: You tell us in your witness statement that, in terms of your role at the Royal College of Nursing – and indeed you’ve confirmed this this morning – that it was as part of a UK-wide organisation.

Did you have any concerns in relation to how EPRR had been dealt with in any of the devolved nations in terms of the frontline staff there?

Mrs Rosemary Gallagher: No. I – I only attended the EPRR group which was based in England.

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: However, we did, if it was available at the time, take intelligence or feedback from our members in relation to what was relevant to feed in to the EPRR group. To the best of my knowledge, the agenda items that were discussed, the lessons there would have been learnt, would have been shared with the four countries.

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: But I wasn’t party to those discussions.

Counsel Inquiry: All right.

I want to come on to discuss workforce resilience issues which are crucial to a pandemic. What is the relationship, Mrs Gallagher, between the resilience of health systems and the resilience of the workforce within healthcare and social care?

Mrs Rosemary Gallagher: So the resilience of the health and care workforce is absolutely essential in order to be able to deliver healthcare services that meet the public’s needs. We know that we went into the pandemic with a significant shortage, we were about 50,000 nurses short before we went into the pandemic, and therefore that immediately put us at risk when we needed to surge capacity to support patients who were infected, either at home or in hospitals.

Counsel Inquiry: Had the RCN, in your view, consistently highlighted over a number of years the absence of effective workforce planning for nursing?

Mrs Rosemary Gallagher: They had.

Counsel Inquiry: What was the reaction of the government to that being highlighted?

Mrs Rosemary Gallagher: The RCN has campaigned and lobbied for many, many years around what we now call staff safe – safe staffing for effective care. The RCN has participated in significant research with our European counterparts around the impact of insufficient numbers of registered nurses, for example, on patient care and the implications for patient safety. The RCN has responded to all the consultations and also comprehensive spending reviews highlighting the importance of investment in the nursing workforce.

Counsel Inquiry: Has this been handled differently across the different nations? What I’m coming to is asking you about the fact that the Welsh Government have implemented the Nurse Staffing Levels (Wales) Act, which was passed in March of 2016, and does that mean that health boards and NHS trusts in Wales must have regard to the importance of providing appropriate numbers of nurses in all settings?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: In Scotland, the Health and Care (Staffing) (Scotland) Act of 2019 has been passed, setting out requirements for safe staffing across both health and care services, but the implementation of that, in fact, was delayed due to Covid-19?

Mrs Rosemary Gallagher: That’s correct.

Counsel Inquiry: So is that still pending, as far as you’re aware?

Mrs Rosemary Gallagher: As far as I’m aware, but I’m not leading that piece of work, so –

Counsel Inquiry: All right.

You also tell us in your witness statement that in Northern Ireland members took industrial action in December 2019 and January 2020 over safe staffing and pay.

Mrs Rosemary Gallagher: Yes, they did.

Counsel Inquiry: So just immediately going into the pandemic?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: All right.

So does this still remain a concern of high priority for the RCN across the four nations?

Mrs Rosemary Gallagher: Yes, absolutely. I mean, there are clearly differences across the UK in terms of how workforce and the need for an appropriate workforce level is implemented across the UK.

Counsel Inquiry: Right, thank you.

I’d like to display, please, the witness statement of Jeremy Hunt, please, just to underline this point, page 15, paragraph 66. Could we highlight this, please.

“As I have written elsewhere, one of the things I learned in my time as Health Secretary and wish I had understood better at the outset was the importance of workforce planning. This was not something I implemented while Secretary of State because it took me some time to appreciate the full picture. I was also not advised to place more emphasis on this because the NHS had a longstanding habit of relying on immigration to fill any gaps. However, with a two million shortage of doctors globally according to the World Health Organisation, this was not a sustainable position in the long term.”

Now, the former Secretary of State for Health and Social Care doesn’t mention nursing there –

Mrs Rosemary Gallagher: No.

Counsel Inquiry: – he uses the shortage of doctors as an example, but would you say, Mrs Gallagher, that the issue was just as important in relation to nursing and workforce planning?

Mrs Rosemary Gallagher: Absolutely. We know we have a global shortage of nurses, as identified in the triple impact report, so this is a global problem, and the reliance on overseas nurses is a real cause of concern for the Royal College of Nursing.

Counsel Inquiry: Thank you.

Lady Hallett: I think, Ms Blackwell, we are going to pause there, because we have a strange noise that I know –

Ms Blackwell: Oh dear.

Lady Hallett: – may need fixing. I don’t know if you are conscious of it. Initially I thought it was thunder, but …

Ms Blackwell: Right.

Lady Hallett: Forgive us, you’re going to have to come back this afternoon, Mrs Gallagher. I hope it’s not too inconvenient for you. I shall return at, I’m being told, 1.45.

Ms Blackwell: Fingers crossed. Thank you.

(1.03 pm)

(The short adjournment)

(1.45 pm)

Lady Hallett: I’m assured the problem has been resolved.

Ms Blackwell: I do hope so. Thank you, my Lady.

Mrs Gallagher, just before we broke, we were discussing workforce resilience issues and the importance of workforce planning, and I’d like to turn now to look at public health and local infection control.

At paragraph 65 in your witness statement, you tell us that:

“Funding for public health services and interventions (ie the frontline public health services funded by local authorities) in England has not been consistent and has suffered under austerity measures.”

And you say that:

“The public health grant has been cut by more than a fifth (22% [in fact]), since 2015/16. Consequently, this has meant that local authorities are unable to provide vital functions that promote well-being and prevent ill health and the reductions in outreach services such as smoking cessation [and other health matters] which impacts population health and chances.

You go on to say that:

“It is the [Royal College of Nursing’s] contention that this historic underfunding of public health [has] undermined the capacity of local public health teams to effectively improve health and reduce inequalities and respond to the Covid-19 pandemic.”

From a nursing perspective, then, how does a reduction to the public health grant and public health spending affect pandemic preparedness at the local level? Is it just a matter of resilience, or are there other effects to the cutting in the budgets?

Mrs Rosemary Gallagher: In terms of population health and having a population that is as well as it can be to not suffer unnecessarily from the impact of an infectious disease, population health is absolutely vital, and throughout the life course. So, for example, we know we have far fewer health visitors at the moment that support mothers and also support young children, and that is vital in terms of local communities.

In terms of operational management of the pandemic, that’s – that, at a local or regional level, would be supported by the health protection teams, and they are absolutely vital in having good relationships, collaborative relationships with provider organisations such as NHS trusts, but also in supporting care homes.

Now, health protection teams came under Public Health England, they’re now under the UKHSA, and their roles have continued but, with the changes in the landscape, those roles and relationships have changed over time. So it’s a bit of both, if you like.

Counsel Inquiry: All right, thank you.

Professor Philip Banfield from the British Medical Association has provided a witness statement to the Inquiry in which he says that reforms to the public health system in England in particular led to a fragmented system and that the 2012 Health and Social Care Act fractured in many places the links between public health specialists and NHS colleagues, which in turn impacted upon pandemic response.

Do you agree with that?

Mrs Rosemary Gallagher: I do.

Counsel Inquiry: All right.

What role does community infection prevention and control have to play in pandemic planning and emergency response?

Mrs Rosemary Gallagher: So the role of community infection control teams has changed over time. When I was in clinical practice we provided support from the acute trust to our community partners and provided them with an infection control service, but in other areas they have dedicated infection control teams. So there is variation across the system on how advice is provided.

We know that when the Lansley reforms, the changes to the NHS – the Health and Social Care Act was implemented, that we lost many community infection control teams as staff moved under the umbrella of local authorities away from their original employers, and that gap, if you like, placed increased pressure on health protection teams, but also had an effect on local relationships and resilience locally.

Counsel Inquiry: May we put up, please, the statement of Professor Kevin Fenton at paragraph 11, pages 3 to 4, and highlight that, please. Thank you.

Here he says:

“Health protection teams, which moved from the Health Protection Agency … to [Public Health England] … saw successive reductions in funding and capacity over the pre-pandemic years and lack of investment in regional emergency preparedness, response and resilience … teams. A direct result of these changes was a reduction in the amount of professional exposure that the public health specialist generalist workforce had to health protection duties and continuing professional development outside of PHE. There was also a reduction in the exposure that NHS staff in general had to important public health issues associated with health protection, especially in community settings. This is likely to have contributed to a poor understanding of the role of the wider public health agenda around pandemic preparedness, and more specifically the role of local authority public health teams and wider system partners in pandemic preparedness and response. Community infection prevention and control … is a key element of pandemic planning and local health protection more generally, but guidance is unclear on commissioning responsibilities, funding streams, and standards for high-performing local integrated services. It is largely understood that provision for community IPC was a significant casualty of the 2012 reforms and the Faculty considers the creation of Integrated Care Systems, with local authority Directors of Public Health and UKHSA as key partners, an opportunity to rectify the current problems. The use of Contain Outbreak Management Funding … during the pandemic to temporarily increase IPC capacity in many systems provides proof of concept of what can be achieved through concerted effort and funding enhancements.”

Do you agree with Professor Fenton’s suggestion that guidance on commissioning responsibilities, funding streams and standards for high-performing local integrated services is unclear?

Mrs Rosemary Gallagher: From my experience, yes.

Counsel Inquiry: Do you also consider that the provision for community IPC was a significant casualty of the reforms? I think as you’ve just referred to.

Mrs Rosemary Gallagher: Yes, I do.

Counsel Inquiry: All right.

Towards the end of that paragraph, Professor Fenton suggests that the use of the COMF during the pandemic to temporary increase IPC capacity demonstrates the concept of what can be achieved; do you agree with him in that regard?

Mrs Rosemary Gallagher: I do. In order to sustain the benefits that have been achieved through this, however, I would also focus on a need for standardised training as a foundation, a cornerstone for health protection teams, because there is no standardised education currently for health protection practitioners.

Counsel Inquiry: How would that best be achieved?

Mrs Rosemary Gallagher: There are a number of ways in which education can be commissioned and delivered. For me, the starting point would be to identify the needs of health protection practitioners, who are not all nurses at all, many do not have a nursing background, and to support them to identify what is needed in order for them to deliver their role in practice.

Counsel Inquiry: Thank you.

Lady Hallett: Just before you go on, may I interrupt.

Can you explain, I appreciate it’s not your expression, Mrs Gallagher, “specialist generalists” sounds a bit contradictory to me.

Mrs Rosemary Gallagher: Sorry, that’s me.

Lady Hallett: Is it? Oh, no, I think it’s in this report as well.

Mrs Rosemary Gallagher: Oh, I see.

Lady Hallett: What is a specialist generalist?

Mrs Rosemary Gallagher: I’m not quite sure actually.

Lady Hallett: Right.

Ms Blackwell: We will provide a definition for my Lady.

Lady Hallett: Thank you. I hope it makes sense. At the moment it doesn’t.

Mrs Rosemary Gallagher: I think I know what it means, but I wouldn’t like to say.

Counsel Inquiry: Right.

In terms of the problems created in public health provision, the Inquiry has heard from Professors Marmot and Bambra that those difficulties that arose, those highlighting of inequalities that developed, hit certain areas of the country hardest and hit people who were suffering from particular inequalities even harder, living in those areas.

Is that something that you recognise, and if so, is the difficulty with inequalities, and that caused by funding or lack of workforce planning or some of the issues that we’ve looked at, is that something that the Royal College of nurse was alive to prior to the onset of the pandemic?

Mrs Rosemary Gallagher: Certainly in relation to the impact of the pandemic, we’re very aware of the effect of inequalities both on our nursing workforce but also on those that required care or were most affected by the pandemic.

The second part of your question, in relation to workforce –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – could you just repeat that for me, please.

Counsel Inquiry: Yes, what I’m asking is whether or not the fact that inequalities hit in particular areas, as Professors Marmot and Bambra have told the Inquiry, and whether or not that was exacerbated by either workforce issues or public health funding cuts or a combination of both, and if that is something which the Royal College of Nursing recognises, was that something that was apparent prior to the onset of the pandemic in 2020?

Mrs Rosemary Gallagher: Certainly the Royal College is very aware of the impact of inequalities, from a public health perspective. Then, obviously, whatever impacts on our public health ultimately affects our hospitals and the demand for hospital services, so the two are very closely related.

The issue of black and ethnic minority staff in terms of their experience in the workforce is well documented by the Royal College of Nursing.

Counsel Inquiry: Is that something to which the Royal College of Nursing was alive prior to the pandemic?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: The onset of the pandemic.

Mrs Rosemary Gallagher: I would – yes.

Counsel Inquiry: All right.

Moving on to social care, please, you describe in your statement at paragraph 48 that there was not a whole systems approach to pandemic planning, particularly with regard to social care, and you say that from your perspective:

“This was evident at the start of the pandemic, during efforts to rapidly scale up acute capacity, when some community staff were being redeployed into the acute sector without sufficient thought being given to the services that needed to continue in the community. For example [and this is an example that you give in your statement], the [Royal College of Nursing] heard reports that community nursing staff were being asked to go and work in hospitals when community services needed to be augmented at the same time to ensure essential services such as child protection and end of life care, could continue.”

You identified this as a problem. Was this a problem that had persisted prior to the pandemic or was this something that came to light only when the pandemic hit and the staff, as you say, were being pulled from hospitals into the care sector and back again and vice versa?

Mrs Rosemary Gallagher: Certainly you would expect to need to move staff in a case of need –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – in the case of a national incident. The pandemic highlighted, really, the impact of doing such actions, and there was real concern regarding how we would maintain care for our patients in the community, and we have many more patients in community settings than we do in hospital settings, for example.

The RCN has raised concerns over a number of years around a reduction in the community nursing workforce and the implications for that, not just in terms of community care but the knock-on effect of care in hospitals.

Counsel Inquiry: Right. As far as you are aware, was there any planning in terms of the movement of staff from hospitals into adult social care and workforce planning in any of the pandemic planning that was undertaken?

Mrs Rosemary Gallagher: As I recall, as we took place – part in Operation Pica around 2018, the need to consider the movement of staff and the different demands in different care sectors at different times was on that agenda.

To the best of my memory, I don’t recall in-depth discussions on what the real impact of that might mean, particularly from a nursing perspective.

Counsel Inquiry: In your view, was there adequate operational guidance in place for managing a pandemic within the social care sector prior to Covid-19 hitting?

Mrs Rosemary Gallagher: I’m not aware of any, but we weren’t involved in the pandemic planning.

Counsel Inquiry: Yes, of course.

Mrs Rosemary Gallagher: Yeah.

Counsel Inquiry: Certainly none was brought to the attention of the RCN –

Mrs Rosemary Gallagher: Not that I recall.

Counsel Inquiry: – nor was there any invitation given to the RCN to involve itself in any such guidance being prepared?

Mrs Rosemary Gallagher: Not that I recall.

Counsel Inquiry: All right.

I’d like to ask you now, please, about the value of healthcare-acquired infection operational guidance, which you deal with at paragraph 53 in your witness statement.

Now, there was the publication in 2012 by the Health Protection Agency of certain guidance, and you recall that the guidance was updated in 2016, I think, as an internal document but that that update wasn’t published; is that right?

Mrs Rosemary Gallagher: Yes, that’s a verbal report that I had. I’ve not seen the 2016 updated guidance.

Counsel Inquiry: Right.

You say in your witness statement that the fact that this operational guidance wasn’t published, that’s the 2016 update, I think:

“… meant that NHS teams, as well as care homes and community settings, did not have up-to-date information on the roles and responsibilities of Health Protection teams, and this would have impacted directly on local, regional and national incidents, including responding to HCIDs such as Covid-19.”

Mrs Rosemary Gallagher: Yes. The – as I recall, the operational guidance was a recommendation that came out of the Stoke Mandeville report in 2016 – 2006, apologies, where there was criticism around the role of the Health Protection Agency local team at that time and how they intervened to support the NHS trusts.

The guidance is around roles and responsibilities, and relationships between health protection teams, acute trusts and community providers is really important for dealing with local or regional issues, and therefore, when it comes to a national incident, it’s absolutely essential.

The 2012 guidance focuses on healthcare-acquired infection because Stoke Mandeville was predominantly around clostridioides difficile healthcare-acquired infection.

However, for me this represents good governance and essentially having your house in order to have operational guidance in place that can be referred to and is already in place.

Counsel Inquiry: Has the RCN been vocal in expressing its concern about a lack of guidance in this area?

Mrs Rosemary Gallagher: I don’t believe we’ve written anything formally, but certainly questions have been asked over the years since it was developed and at a time when it would have been reasonable to update it.

Counsel Inquiry: Yes. One of the aspects that you bring to the forefront in your witness statement is the concern that has been regularly raised by the RCN at national fora, including the Care Quality Commission’s stakeholder group for non-hospital organisations, that the CQC had not delivered on its regulatory responsibilities in relation to IPC, to the extent of ensuring effective systems.

Is that something which has regularly been raised by the RCN over the years?

Mrs Rosemary Gallagher: So when I attended the CQC meetings on behalf of the Royal College of Nursing I did raise this at those meetings, and I also took the opportunity, I can’t recall which meeting specifically, but to raise this as part of concerted efforts to support the reduction in healthcare-associated infections that didn’t just focus on hospitals.

Counsel Inquiry: Right. In particular, I think, one of the concerns of the RCN was that a focused inspection was requested of the CQC in adult social care and to strengthen non-hospital-based IPC provisions. You say in your witness statement that:

“Despite [that], the RCN is not aware of consideration being given to providers, such as care homes, being assessed in pandemic planning with regard to meeting the fundamental requirements of the Code of Practice or their ability to escalate issues if required.”

Is that right?

Mrs Rosemary Gallagher: That’s correct. The theory behind our ask is that if care homes are well prepared for business as usual, then when it comes to an incident they are much better prepared to respond and consider how they will manage, should that occur.

Counsel Inquiry: Was social care non-compliance something that you’d raised with the Department of Health and Social Care before 2020?

Mrs Rosemary Gallagher: Non-compliance with regard to the code of practice –

Counsel Inquiry: Yes?

Mrs Rosemary Gallagher: – do you mean?

We raised concerns around the level of compliance, I would say, rather than non-compliance with the code of practice, which every provider of health and care has to meet in a proportionate way to their role. So there is a different expectation for care homes than there is, for example, to a large acute hospital.

The essential expectations around having good policies and procedures and education in place would be fundamental to their response in a pandemic.

Counsel Inquiry: Right, thank you.

We’ve touched upon PPE and RPE, and you tell us in your witness statement that, as far as the RCN is concerned, there was a lack of – or insufficient stockpiling of RPE that was needed. That’s also a reference, is it not, to FFP-3 face masks, which I think you’ve already described to us, the critical nature of those?

You say that without a sufficient stockpile of that equipment, not only for hospital settings but also for community nursing, nursing staff are putting their own lives and the lives of their families and patients at risk.

But in addition to the availability of such PPE, is it also necessary for those who are going to be utilising it to know how to fit it properly?

Mrs Rosemary Gallagher: Yes.

Counsel Inquiry: That involves staff training in fit testing.

From an RCN perspective, is there or indeed was there at the onset of the pandemic sufficient capability within staff who might need that PPE to be able to fit it properly? Had the training been in force and in place?

Mrs Rosemary Gallagher: If I might go back a little step –

Counsel Inquiry: Certainly.

Mrs Rosemary Gallagher: – briefly. The failure to consider a pathogen that had pandemic potential that would require the extended use of respiratory protective equipment was not duly considered, and it is my view that that had an effect on how large the stockpile was of respiratory protective equipment as opposed to face masks.

If you take that to the next degree, then I would have expected consideration of the need to cascade fit testing to be in place as part of pandemic preparedness.

When a pandemic or an incident first starts, it’s absolutely critical that we also take a precautionary approach to what it is we are dealing with until the science tells us otherwise, and that would also have implications for how much respiratory protective equipment we would need. It’s clear now that those systems for escalating fit testing, and also the system for having standardised respiratory protective equipment, was not in place, and by that I mean the demand for respiratory protective equipment resulted in many different types of masks being available, and masks fit people differently. So whilst your face may fit one type of mask, it may not fit the other. So this then necessitated multiple attempts or multiple – the multiple – multiple requirements to fit test staff on numerous occasions because of the numerous types of masks that were required.

So I don’t believe that the system was well set up to consider this as part of pandemic planning.

Counsel Inquiry: All right. So just to summarise your evidence, a lack of foresight in terms of the requirement for RPE, a lack of stockpiling for RPE, and then a lack of fit testing for the various RPE facilities?

Mrs Rosemary Gallagher: Yes, or having systems in place to cascade fit testing. You can, for example, introduce a train the trainer system, where you can cascade to staff. Most trusts would not routinely – well, I can’t think of any trust, actually, that would routinely educate or train all its staff to be fit tested all the time in RPE. However, we did learn from H1N1 and Ebola that there would be a need to expand and escalate fit testing and the use of RPE as part of those experiences.

Counsel Inquiry: In your witness statement, you discuss framing vulnerability as a clinical category in pandemic plans and guidance. In your view, were structural health inequalities factored into the government’s pandemic planning?

Mrs Rosemary Gallagher: No. I don’t believe so.

Counsel Inquiry: Why do you say that?

Mrs Rosemary Gallagher: So the structural health inequalities that I would consider of key importance to take into account would have included inequalities within the healthcare workforce, as well as the vulnerabilities and inequalities experienced by our population, and that has undoubtedly changed since the last pandemic.

Counsel Inquiry: How has that changed?

Mrs Rosemary Gallagher: So we know that our levels of non-communicable diseases have increased, so diseases such as diabetes, obesity, for example, those have really escalated since the 2009 pandemic, therefore there have been shifts in our populations that we would need to keep considering as part of our pandemic planning.

Counsel Inquiry: All right.

Frontline workforce and planning for minority ethnic members of the workforce. Paragraph 63 of your report, you say that:

“In its written submission to the … Treasury Comprehensive Spending Review … [in] (September 2020) … the [Royal College of Nursing] highlighted the overrepresentation of BAME staff at bands four to six, which represent those professionals providing care on the frontline, warning that they may be at increased risk of exposure to the viral load of Covid-19.”

And you also highlighted the fact that:

“… as the pay bands increase, data shows larger increases in the number of white staff at each pay grade compared to the increase of in ethnic minority staff.”

Was the risk of a disproportionate impact on minority ethnic staff mitigated against within pandemic planning as far as the Royal College of Nursing is concerned?

Mrs Rosemary Gallagher: In my opinion, no, but as I’ve stated before, we weren’t involved in pandemic planning.

Counsel Inquiry: But you haven’t seen anything or had anything brought to your attention in your position to indicate that it was so considered?

Mrs Rosemary Gallagher: Not that I recall. The language used in most strategic documents tends to refer to at-risk groups –

Counsel Inquiry: Yes.

Mrs Rosemary Gallagher: – or, as you’ve said, other clinical vulnerabilities linked to medical conditions, but not inequalities as described by Professor Marmot, for example.

Counsel Inquiry: Thank you.

Finally, Mrs Gallagher, turning to lessons learned for future pandemics. You’ve mentioned stakeholder engagement earlier in your evidence this morning. What do you say is missing and what needs to be done in order to better ensure a level of preparedness, certainly so far as your organisation is concerned, with stakeholder engagement going forwards?

Mrs Rosemary Gallagher: I would say that we need to revisit what we think stakeholder engagement means. There may be assumptions that stakeholder engagement could be something as simple as sending out a draft document to review and comment on, but the view of the Royal College of Nursing is that meaningful stakeholder engagement would entail involvement at the beginning rather than being a recipient at the end of a long process.

We would also consider stakeholder engagement to be absolutely vital to allow us to really consider the impact of what we have learnt now in terms of vulnerabilities. So, for example, by engaging with other royal colleges or other organisations, which has been such a valuable lesson for us during the pandemic. So, for example, the inclusion of organisations such as the British Occupational Hygiene Society or speech and language therapists or others that can bring a combined view together with ours on how we operationalise or manage specific incidents or view guidance.

Counsel Inquiry: Thank you.

Finally, is there any recommendation that you would like to bring to the attention of the Inquiry so far as transparency is concerned?

Mrs Rosemary Gallagher: Transparency is absolutely vital to support communication. In my experience, I have found that healthcare professionals and the general public are very understanding that guidance and advice changes as an incident or a pandemic evolves, and they are very forgiving of changes in guidance and advice. But they need to understand why. So we are able to bring people with us if we can do that, and bringing in the public and our healthcare workers with us at a time of national crisis is absolutely vital.

Counsel Inquiry: So transparency and information provision?

Mrs Rosemary Gallagher: Yes.

Ms Blackwell: Yes, thank you.

My Lady, those are all the questions that I have. You have provisionally provided permission for Covid-19 Bereaved Families for Justice to ask a specific question around a meeting of the Chief Nursing Officers back in 2014, according to the sheet that I have.

May they ask those questions now, please?

Lady Hallett: They may. Ms Munroe.

Questions From Ms Munroe KC

Ms Munroe: Thank you, my Lady.

Good afternoon, Mrs Gallagher.

Mrs Rosemary Gallagher: Good afternoon.

Ms Munroe KC: In your witness statement at paragraph 29 – I should have said, my name is Allison Munroe and I ask questions on behalf of Covid-19 Bereaved Families for Justice.

In your statement at paragraph 29 – we don’t need to bring it up – you make reference to a meeting on 22 October 2014 between the Chief Nursing Officer and regional CNO nursing teams. It’s a meeting you yourself did not attend.

Mrs Rosemary Gallagher: That’s correct.

Ms Munroe KC: But you say that from discussions that flowed from that meeting, there were concerns about whether or not the voices of nurses were being heard, and that issue of stakeholder engagement that you’ve spoken about at length this afternoon and earlier this morning.

Can you assist us, please, were there wider concerns about the engagement with the Chief Nursing Officer and the RCN, and did you see any improvements following on from that meeting in 2014?

Mrs Rosemary Gallagher: The feedback I had as a result of that meeting, which I wasn’t present at, was that the information that was provided, and this was in relation to the Ebola outbreak, had been positively received and that there was … that it had been taken on board around the need for nursing to be engaged in this response.

I don’t – I don’t recall any issues in relation to relationships, there were good professional working relationships at that time, but clearly because this was in response to an incident that was occurring at a moment in time, the meeting was called at quite short notice, to the best of my memory.

Ms Munroe KC: You’ve said there were good working relationships. You have been referred to paragraph 34 of your statement again earlier, before the luncheon adjournment, where you speak about certain significant changes that happened in the healthcare system and the culture around about the time 2018 to 2019.

Now, with regards to the Chief Nursing Officer, Dame Ruth May succeeded Jane Cummings in January of 2019. To what extent did that change have an impact, if at all, on the pan professional working and communications between the CNO and the RCN?

Mrs Rosemary Gallagher: To the best of my knowledge, there was no detrimental effect at all when Dame Ruth May took over her position of CNO. Most of the – my experience before that had been to work to the Deputy Chief Nurse in Public Health England, who then held a strategic relationship with the Chief Nursing Officers team in the NHS. From my perspective, the change in CNO leadership didn’t cause any issues at all.

Ms Munroe: Thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Ms Munroe.

Ms Blackwell: That concludes Mrs Gallagher’s evidence.

Lady Hallett: Thank you very much indeed for your help, Mrs Gallagher.

The Witness: Thank you.

(The witness withdrew)

Ms Blackwell: My Lord, may I please call Professor Dame Jenny Harries. Would you take the oath, please.

Dame Harries


Questions From Counsel to the Inquiry

Ms Blackwell: May I begin by thanking you for the assistance that you’ve so far given to the Inquiry. You have produced an extensive witness statement.

May we have it on the screen, please. It’s INQ000148429. Can you confirm that that’s your witness statement, please, Dame Jenny.

Dame Harries: It is.

Counsel Inquiry: Thank you. We can take that down.

We have also had two witness statements from Professor Isabel Oliver, who is the Interim Chief Scientific Officer. The first statement on 17 May 2023, which is at INQ000194054, and then a supplementary statement at 12 June 2023, at INQ000212902. May we have permission, please, to publish Dame Jenny’s witness statement and the second of Professor Isabel Oliver’s statements, please, today?

I can inform my Lady that the first witness statement of Professor Oliver will be published at a slightly later date.

Lady Hallett: Thank you.

Ms Blackwell: Thank you.

Please keep your voice up during questions, Dame Jenny. If I ask anything that you don’t understand, please ask me to repeat it and I will.

I’m going to begin by taking you through your professional qualifications and previous roles and relevant experience so far as it is relevant to our Inquiry.

So you are now chief executive of the United Kingdom Health Security Agency, since its formation in April of 2021, and head of the NHS Test and Trace since May of 2021.

You, prior to joining the UKHSA, were the Deputy Chief Medical Officer for England between 2019 and 2021, and prior to that you were the regional director of the south of England at Public Health England from 2013 to 2019, and prior to that you were the Interim Deputy National Medical Director between 2016 and 2017.

You have also worked as a director of public health. You are a medical physician with specialist training in public health medicine. You have formal qualifications in medicine and pharmacology, a Master’s degree in public health and also one in business administration. You have a postgraduate diploma in health economics evaluation and a postgraduate certificate in strategic planning and commissioning.

You are a fellow of the Chartered Management Institute, a visiting professor of public health at the University of Chester, and honorary fellow of both the Faculty of Occupational Medicine and the Royal College of Paediatrics and Child Health.

You are a member of the Joint Committee on Vaccination and Immunisation, national advisory committee on the NHS Constitution, NHS England Clinical Priorities Advisory Group and Women’s Health Taskforce.

In particular you were the national programme director for Ebola screening and the UK returning workers programme in 2014 to 2016, and you were the SRO of the subsequent development of the High Consequence Infectious Disease Programme, and prior to the Covid-19 pandemic you contributed to various significant health protection incidents, including Zika in 2016, the Hurricane Irma response in 2017, the Novichok poisonings in 2018 and the first cases of monkeypox in the United Kingdom in 2018.

During the Covid pandemic, you chaired the SAGE Social Care Working Group, led clinical work on the initial shielding programme, and acted for SRO for co-ordination of the subsequent Enhanced Protection Programme for those who remain more clinically vulnerable to serious outcomes from Covid-19:

Dame Harries: Broadly, yes. Can I just clarify a couple of points?

So the roles where you said I – it started with membership of the JCVI, those are previous roles, they’re not current, and that’s important, I think.

The most important qualification, which you probably didn’t read out, was a fellowship of the Faculty of Public Health. That’s probably the most important one for now.

Then I would also just like to flag, just for clarity, I am a Welsh resident, and I realise there might be conversations around UK countries, and I trained in Wales, and to flag actually that I’ve spent more of my time professionally working in local – as you’ve said, as a director of public health in the regions than I have nationally. So where that is relevant I’m assuming it will be okay for me to add that commentary.

Counsel Inquiry: Thank you.

Let’s deal first, please, with the background and history of public health bodies in England, starting with the Health Protection Agency, which was established in April of 2003. To help put things in historical context, is it right that the HPA was the public health body in operation in England during the SARS outbreak in late 2002, but that outbreak, of course, was not contained until July of 2003, the swine flu outbreak in 2009 and 2010, and the MERS outbreak in the Kingdom of Saudi Arabia in June of 2012?

Dame Harries: Yes.

Counsel Inquiry: The HPA was an executive non-departmental arm’s length public body sponsored by the Department of Health which was accountable to the Secretary of State for Health and the Minister of State for Public Health, but which was operated separately to the Department of Health?

Dame Harries: Yes.

Counsel Inquiry: Could we display, please, INQ000187830, which is in fact a sheet which helpfully description the different organisational models of national statutory bodies.

At page 1, paragraph 2, we see described an “Executive non-departmental public body”:

“[Those] bodies are normally established [by] primary legislation. They carry out a wide range of administrative, commercial, executive and regulatory or technical functions which are considered to be better delivered at arm’s length from ministers.”

Existing examples given there are the Care Quality Commission and the independent regulator of NHS foundation trusts.

We’ll just leave that on screen for the moment, please.

You set out in your witness statement the five main roles of the HPA, which were: advising government on public health protection policies and programmes; delivering services and supporting the NHS and other agencies to protect people from infectious diseases, poisons, chemicals, radiological hazards; providing an impartial and authoritative source of information and advice for professionals and the public; responding to new threats of public health; and providing a rapid response to health protection emergencies, including the deliberate release of biological, chemical, poison or radioactive substances.

So can we see, Dame Jenny, that the HPA’s principal role was related to health protection?

Dame Harries: (Witness nods)

Counsel Inquiry: There are three core strands of public health, are there not: health protection, health improvement and healthcare, public health?

The change that took place when HPA was replaced by Public Health England in 2013 to 2021 was brought about in part to make a cohesive change to the three core strands in public health; is that right?

Dame Harries: It is. My understanding – I wasn’t actually in the Health Protection Agency myself.

Counsel Inquiry: Yes.

Dame Harries: My understanding was, along with a number of other public bodies at the time, that the intention was to try and, as you say, streamline this, I think partly or if not mainly for efficiency reasons. But actually in the – for Public Health England there was a wider remit as well, which I think as you have been speaking through the Inquiry were very aware around inequalities and the importance of people’s lives, their work, how they live on a daily basis and how important that is for health protection. So actually bringing together the health improvement elements alongside the health protection gave a potential opportunity to protect on all of those fronts in one organisation.

Counsel Inquiry: To help put things again in a historical context, Public Health England was in operation during the global outbreak of Ebola from 2013 to 2016, the MERS outbreak in South Korea in 2015, and of course the start of the Covid pandemic in January 2020.

Dame Harries: Yes.

Counsel Inquiry: Public Health England was established as an executive agency of the Department of Health. So returning to our fact sheet, and if we look, please, at paragraph 4 of page 1, we can see that an executive agency is:

“A national body created administratively, not legally distinct from its ‘home’ Department. Examples including the Medicines and Healthcare products Regulatory Agency (MHRA).”

And of course Public Health England.

So it was operationally independent but legally part of the Department of Health, the Department of Health and Social Care?

Dame Harries: It was, but actually in looking at your – at that statement, of course I think the description of the non-departmental public body uses regulatory as a distinctive element, and in fact we say – we can see here that MHRA is a regulatory agency. So I think what that probably signals is that, in theory, there is a lot of difference and in practice there potentially isn’t.

Counsel Inquiry: Well, one of the differences between the way in which the HPA was created and run and Public Health England is created and run is that there was a direct link, wasn’t there, there was a direct legal link between Public Health England and its home department, the Department of Health?

Dame Harries: Yes, that’s correct, but the HPA also eventually will have reported back up to Parliament, I think, for its use of public money. So, as I say, I think the distinctions are there. They’re clearly not entirely distinguished, even in this statement, and in practice I think they are less differential than perhaps is assumed from this.

Counsel Inquiry: As far as PHE’s functions were concerned, they were wide-ranging and, as you have already told us, one intention was to bring together the three strands of public health. Its key functions, set out in your statement at paragraph 80, include:

“… fulfilling the Secretary of State’s duty to protect the public’s health from infectious diseases and other public health hazards.

“b. Improving the public’s health and wellbeing.

“c. Improving population health through sustainable health and care services.

“d. Building the capability and capacity of the public health system.

“e. Developing and publishing the evidence base for public health …”

Is that right?

Dame Harries: It is. I think probably in all of those it says somewhere “in partnership”, because clearly one organisation can’t do all of that, and that was a key component of PHE’s work.

Counsel Inquiry: All right. Well, in relation to pandemic preparedness and resilience, is it correct that PHE’s functions included but were not limited to surveillance, the rapid assessment of the first cases and early alerting, testing and contact tracing, providing guidance on border and infection control, the exchange of information with international contacts, designing and running simulation exercises, and managing the pandemic flu stockpile?

Dame Harries: Yes. I think just – on two of those points, which I’m sure we’ll come on to, on testing and contact tracing I think it’s – we should not assume that is mass testing and mass contact tracing, which I think we will come on to.

Counsel Inquiry: Yes.

Dame Harries: And in managing the stockpile, it is very definitely management and procurement rather than decision on.

Counsel Inquiry: All right, thank you. We will be turning to look at that later on in your evidence.

Then bringing public health agencies up to date, we now know that the Public Health England organisation was replaced by the UK Health Security Agency, that change took place in 2021, and it became operational towards the end of that year, October 2021.

It’s right, isn’t it, that during the Covid-19 pandemic the government decided to separate out again the national health improvement, healthcare public health and health protection functions?

Dame Harries: Yes.

Counsel Inquiry: Yes, so the health improvement functions of Public Health England moved into a new structure called the Office for Health Improvement and Disparities, or the OHID, which sits within the DHSC?

Dame Harries: Yes.

Counsel Inquiry: The healthcare public health functions of Public Health England transferred to the OHID, NHS England, NHS Improvement and NHS Digital, and the health protection capabilities of Public Health England and NHS Test and Trace were combined into the new UKHSA, a pandemic preparedness and response super-body which has a permanent standing capacity to prepare for, prevent and respond to infectious diseases and other threats to health?

Dame Harries: That’s right.

Counsel Inquiry: Thank you.

So the UKHSA is an executive agency of the DHSC –

Dame Harries: Yes.

Counsel Inquiry: – is that right? Thank you. We can take that down, please, now.

I want to look in a little bit more detail, please, at the changes made to England’s public health structures by the Health and Social Care Act of 2012.

Would you agree that in 2012 there was a complex restructuring of health and public health services in England, including the – abolishing the HPA and transferring its functions to the PHE, which involved the merging of 5,000 staff from over 120 different organisations. I mean, that in itself is quite a task.

Dame Harries: Yes. I mean, I think there’s a series of different organisational moves which have involved very large numbers of staff and very complex systems working, including the last one.

Counsel Inquiry: Thank you. Also the abolition of strategic health authorities and primary care trusts, which were replaced with a number of clinical commissioning groups.

Dame Harries: Yes.

Counsel Inquiry: The creation of a new arm’s length commissioning body, NHS England, which came into force?

Dame Harries: Yes.

Counsel Inquiry: Also the Secretary of State for Health was given a statutory duty to take steps to protect the health of the people of England, meaning that at a national level accountability for health protection would rest with central government?

Dame Harries: Yes.

Counsel Inquiry: And importantly, giving local authorities responsibility for improving the health of their local populations, which was previously, I think, the responsibility of the primary care trusts?

Dame Harries: Yes.

Counsel Inquiry: The government’s rationale for that change was that many of the wider determinants of health, for example housing, economic development, transport, could be more easily impacted by local authorities who had overall responsibility for improving the local area for their populations and who were well placed to take a very broad view of what services would impact positively on the health of their local populations and maximise benefits?

Dame Harries: Yes, I mean, it returned to the sort of 1970s model, a medical officer for health for the community, which I think was important, and if you look at where the evidence is now, after a little bit of a sticky start, I think that’s where most people think a director of public health should be: in the local authority.

Counsel Inquiry: Yes, the directors of public health in England were also given a new ringfenced budget and a duty to publish annual reports, I think, that could chart local progress. They were intended to be strategic leaders for public health, and health inequalities, in local communities, working with the local NHS across the public, private and voluntary sectors, and new proposed local statutory health and well-being boards.

In your view, Dame Jenny, that has been a successful implementation?

Dame Harries: It was a painful birth, I think, and I say that having taken my own team, when I was a director of public health in Norfolk & Waveney, over to the local authority and worked as chief officer in local authority and PCT. It wasn’t welcomed by all and there were some losses, which we might come on to. But I think broadly now, and particularly actually since the last three years, it’s been very clear that many of those public health director colleagues have really risen to the challenge and are very respected senior leaders in their communities.

Counsel Inquiry: Would you agree that the 2012 reforms across the board relating to mainly the creation of Public Health England but the other matters that we’ve touched upon received mixed reviews from the public health community?

Dame Harries: I think that’s a fair comment.

Counsel Inquiry: Okay. The Inquiry has heard from Professor David Heymann, who was a non-executive chair of both the HPA and PHE, and also from Professor Whitworth, the biosecurity expert, who were both of the view that it was beneficial to have health protection and health improvement under one roof, the one roof of one organisation, because of the cross-learning to be had between those areas, and the synergy, as they described it, that was created between them as a result. But on the other hand, others have raised concerns about the structural reforms and problems that have arisen, which we’re going to look at now, if we may.

Dame Harries: If I might just add, though, I think whichever way you divide public health it goes in multiple different directions, so there is no straight line which works perfectly, and what perhaps you haven’t mentioned is the potential advantage of the organisation we have now, which is actually to build up on the science side, which I think has been a little bit suppressed in the last year, so totally supportive of the directors of public health but actually, when we get to what can we do to prevent a pandemic –

Counsel Inquiry: Yes.

Dame Harries: – it wasn’t well placed.

Counsel Inquiry: No. Well, we’re going to look at the scientific side and how that has been perhaps improved by the UKHSA.

But remaining for a moment, please, with Public Health England, because that’s the organisation that was in force in the run-up to the pandemic, and really throughout the majority of the timescale that Module 1 is looking at.

I want to look at five potential drawbacks: confusion over EPRR responsibilities, independence from government, funding issues, capacity issues, and fragmentation of public health services.

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 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?

Dame Harries: Yes, but I don’t think it was a perfect system before either, and so I think what you’re potentially getting is a central view out rather than an outside view in, but I do – I agree in principle that it was confused, partly because of a number of different new changes, people have to get used to them, partly because of the movement, which, we’ve just said, I think, everybody supports, of the director of public health into the local authority.

Counsel Inquiry: Thank you.

Dr Claas Kirchelle also has told the Inquiry in his report:

“Although it absorbed many pre-existing structures, PHE also differed from its predecessors in key ways. In addition to its combination of health protection and promotion functions, PHE broke with the post-1950s English tradition of statutory non-departmental public health bodies that were set up by Parliament by being integrated as an executive body within the Department of Health. This not only resulted in far greater political control over PHE activities by ministers, but also meant that all employees were civil servants and subject to the Official Secrets Act – a cause of concern amongst public health workers …”

Do you agree with that as a description, and do you agree that the very close political connection between the organisation and government was a cause of concern amongst public health workers?

Dame Harries: I recognise the cause of concern and I recognise the perception, I don’t necessarily agree with the content.

Counsel Inquiry: All right. Why not?

Dame Harries: Well, I mean, I myself at times have been accused of going to the dark side. This is the standard thing. And it’s very difficult because, as I pointed out when I did, I was a director of public health one day in a community and then, on the other side, the next, I’m just the same person with exactly the same professional skills and ambitions. There is a different way, necessarily, of working in government to try and achieve the outcomes, and I think the most important thing, as we’ll probably see with other systems, is you need the trust of the people you’re working with, and those relationships, and I think that is important to organisational change.

Counsel Inquiry: To what extent did being an executive agency of Public Health England affect its ability to act as an independent advocate for public health and decide its own public health priorities?

Dame Harries: So I think there are two answers to that. One is in reality and one is in perception, as I’ve said. So there was very definitely a strong perception. I can remember when I joined the organisation from – you know, having not been in this area of work at all, was that government was trying to stop everything being published. So the minute you stopped to try to align comments so it didn’t confuse the public, it was perceived as “government won’t let us publish science”, and it was entirely incorrect, and in fact there was a very specific clause inserted in the rule that said there is a right for Public Health England – and we’ve retained it in the UK Health Security Agency – to speak the truth about the science.

But there’s also how you use that to enable good public health outcomes and sometimes it’s better for the public, for the political context, you’ll get better outcomes if you manage that type of relationship, and you almost have to be in it to understand it, and I think that’s one of the problems.

Counsel Inquiry: So is it important in your view for public health advisers to be independent of the government, or at least appear to be independent of the government?

Dame Harries: So I like to think – I am a civil servant – this is where I have to throw whichever hat I’m wearing up in the air – but I’m also bound by General Medical Council regulations, and I stick to them very firmly, but at the end of the day I’m bound by my moral compass, which is very definitely set on delivering public health outcomes.

So I – there is a debate here about, if you are away from government, whether you can achieve good outcomes or whether it’s better to be closer. But I think the key point is you need both, that’s the really important thing, and you need the connections between them.

Counsel Inquiry: How important is it for an organisation such as Public Health England to be able to set its own strategic priorities, and is that possible with such a close connection with government?

Dame Harries: I think it is important, because I’m sure, you know, a lot of the conversations that have been happening so far in this Inquiry are very much about who is raising which issues, are they being heard, and that is part of that strategic direction, and in most cases they are the experts in the topic and need to do that. Nevertheless, the point you make is they will be to some extent moved by whatever the departmental initiatives and priorities are, and they are part of that machinery. So there is a balancing act.

Counsel Inquiry: Thank you.

Moving on to funding, please, could we display INQ000 – ah, we have it already, paragraph 108. You’re ahead of me, thank you very much.

This is, again, from Dr Kirchhelle’s report and I just want to focus for a moment on the public health budget, please:

“Functioning of the new local and national English public health structures was compromised by austerity politics [in his view]. At the local level, the abolition of PCTs [primary care trusts] meant that overall public health performance was strongly dependent on local authority capabilities to commission and deliver effective services. Ministers had promised to ringfence the public health budget for local authorities. However, an in-year cut of £200 million in 2015 was followed by further reductions over the next 5 years. According to the Local Government Association, this amounted to a real term reduction of the public health grant from over £3.5 billion in 2015-16 to just over £3 billion in 2020-21.”

That’s a difference of 14%.

“Other estimates by the Institute for Public Policy Research spoke of an even more dramatic reduction of £850 million in net expenditure between 2014/2015 and 2019/2020 with the poorest areas in England experiencing disproportionately high cuts of almost 15 percent. Resulting pressures on local public health were exacerbated by an overall 49 percent real term cut in central government funding for local authorities between 2010/11 and 2016/17 and a resulting practice of ‘top slicing’ whereby authorities reallocated ringfenced public health budgets to other services broadly impacting health and well-being such as trading standards or parks and green spaces. In 2010, Healthy Lives, Healthy People had promised to give ‘local government the freedom, responsibility and funding to innovate and develop their own ways of improving public health in their area’. Freedom and responsibility had been granted – but funding was often lacking.”

Thank you, we can take that down.

Dame Jenny, do you agree that the ringfenced public health budget reduced over time due to austerity?

Dame Harries: Yes. I mean, those figures – and, I mean, I recognise some of them, obviously I’ve read the report, but I think they just need to be taken in context. If there are 152 top tier local authorities and a 200 million cut in a year, we just need to think that’s just about a million, and we’re – so it’s an important million for that local population –

Counsel Inquiry: Yes.

Dame Harries: – but just to put that in context and hold that tight.

Nevertheless I do agree with you and I know that directors of public health were under significant pressure. Local authorities were actually often much more efficient at commissioning services, so they could almost generate savings from that and get just the same public health outcomes, but nevertheless they were significantly under pressure.

Counsel Inquiry: But as well as having the opportunity to generate income themselves, the public health budget was reduced even further, wasn’t it, by local authorities dipping into it due to cuts to their overall funding from central government, as set out in the piece that we’ve just seen?

Dame Harries: Yes, and rather than use the word “generate”, I might just say that there was a lesser – a lower loss, if you like, rather than – it wasn’t a generation –

Counsel Inquiry: Yes –

Dame Harries: – it was just –

Counsel Inquiry: – all right.

Dame Harries: – (inaudible) more efficiently, just for clarity.

So I think the way the public health grant was managed, it went through Public Health England effectively, it came out as a top figure from local authorities. It wasn’t possible, often, to see – and we can – I think may acknowledge that for health protection – exactly the detail of what was being spent where.

Counsel Inquiry: Yes.

Dame Harries: And it was a very sensitive area for obvious reasons. But I think it’s fairly reasonable to assume that local authorities were translating where lives were being protected through the lens which they had at that time.

Counsel Inquiry: Do you agree that the poorest areas in England experienced disproportionately high cuts?

Dame Harries: I can’t comment on that objectively without seeing the numbers, but my understanding is that that’s the case.

Counsel Inquiry: How did the funding cuts impact on the work of the directors of public health and local authorities generally when it came to EPRR functions, do you think?

Dame Harries: So I think it’s fair to say, I mean, even at the start, before any of the budgetary changes, whether because of perceptions of people, for example, in clinical roles not wanting to move to local authorities, or whether for other reasons, the changes, people – actually lots of staff were lost in that move, so there was some skill loss, and then increasingly, as people went across, some of the – initially, not now, but some of the directors of public health roles started to move down the hierarchy within the local authority and some of the more, if you like, the expensive roles, so some of the ones – perhaps the clinical roles, would be lost. So I think it is fair to say, and I’m pretty confident it’s evidenced, that some of the health protection skills were denuded from – particularly from the smaller local authorities, where you would perhaps have one director of public health, one consultant and one other. Really quite small.

Counsel Inquiry: Yes. In fact your colleague Professor Oliver tells us at paragraph 93 in her witness statement that:

“Over the period from 2009 to 2013, regional EPRR resourcing in terms of whole time equivalent capacity and relative seniority and that of other teams supporting EPRR functions reduced.”

She says that consequently this impacted on the ability of regional teams to undertake EPRR functions including engaging in multi-agency pandemic preparedness work, and that reductions in funding also impacted on the HPT workforce which would have had a further impact on EPRR capacity.

Dame Harries: Yes, just for clarity, though, those comments relate to the Health Protection Agency EPRR capacity, not the local authority, which is what I was referring to before.

Counsel Inquiry: Right. But do you agree –

Dame Harries: But I agree.

Counsel Inquiry: – with what she says in terms of the –

Dame Harries: Yes.

Counsel Inquiry: – reduction in capacity.


Lady Hallett: If you’re moving on – actually you have one more, haven’t you, for the five?

Ms Blackwell: Yes, sorry, that was dealing with capacity issues and I’m just going to deal, if I may – were you inviting me to take a break, my Lady?

Lady Hallett: When you’re ready.

Ms Blackwell: Thank you.

Fragmentation of the public health system. I’ll just deal with this briefly if I may.

Professor Philip Banfield of the BMA has told the Inquiry that reforms of the public health system in England in particular led to a fragmented system, with the 2012 Health and Social Care Act fracturing in many places the links between public health specialists and NHS colleagues.

Is that something that you recognise, Dame Jenny?

Dame Harries: I recognise it as a recurrent theme every time there is a change in the system, and it happens always when there’s an NHS change as well, so it’s almost if you’re working on the front line, you have to throw your rope out to the person you knew last week and see which organisation they’ve landed in. So I do recognise it but it’s not that uncommon. I think it was particularly difficult over that period.

Counsel Inquiry: Do you agree that community infection prevention and control suffered as a result of the fragmentation?

Dame Harries: So that was some of the clinical capacity that I was mentioning. It was a declining resource anyway, I think, so IPC nursing – I know I personally persuaded two of my nurses to come across to the council with me. Most places were not that lucky, they mostly stayed in the NHS, and actually there was – there is and was a strong need for them in the community.

Counsel Inquiry: Finally, do you have any comments on how the structural changes might have impacted on staff morale and working conditions, including pay, based on your own experience as regional director of the south of England PHE?

Dame Harries: So within the PHE at the time?

Counsel Inquiry: Yes.

Dame Harries: So I think pay – pay was a standard terms and conditions, so to speak, for different multidisciplinary, but that was not the issue, with one exception, I think, which was for EPRR staff, where the regional layer went, then people were – then people were – there was a reconstruction, if you like, and a formal consultation, and several people moved down a rank rather than stayed in their existing roles. So I think that did prove demoralising for many of them.

But I think the uncertainty around it, and, as I say, just trying to find out whether the other end of your rope needed to land is unsettling. People generally want to get on and do the job that they are trained to do.

Counsel Inquiry: And it created its own pressure?

Dame Harries: Yes.

Ms Blackwell: Thank you.

My Lady, is that a convenient point?

Lady Hallett: Thank you very much. I shall be back at 3.15.

(3.00 pm)

(A short break)

(3.15 pm)

Lady Hallett: Yes, Ms Blackwell.

Ms Blackwell: Thank you, my Lady.

At paragraph 139 in your statement, Dame Jenny, you explain that the PHE centres and regional teams worked with the NHS and local authorities as well as with other agencies involved in local public health systems across all of the three domains of public health.

What did the health protection teams do? What were their functions?

Dame Harries: So the health protection teams were part of each PHE centre, and it’s actually the same teams we use now. They would have a lead CCDC, a communicable disease consultant, who would work and link with the director of public health in a local authority. So if, for example, you had some sort of health protection incident, then usually the director public health – one would alert the other, depending on how the situation had arisen, and they would work out between them how they needed to go about it. If there was a longstanding health protection issue, I can think – smelly quarries or something like that, then they would call on resource from the centre of Public Health England to get specialist input.

Counsel Inquiry: You also say that regional directors played an important role in providing a local perspective in PHE’s work at a national level. Can you provide an example of how that might have worked?

Lady Hallett: Before you do, could you speak more slowly? Like many of us, and I’m also guilty, you speak very quickly, and I know it’s been a very long day for our wonderful stenographer, so …

Dame Harries: My apologies.

Lady Hallett: Not at all, please don’t apologise.

Dame Harries: I will try and speak more slowly.

So in response to your question, as a regional director for the south of England, I had two centre directors who would report to me, each of whom had several health protection teams, and if, for example, let’s say it was a capacity issue, they were having problems with recruitment, we would be reporting that back in to the executive management team, nationally, to alert to the fact that there may be some risk in a health protection provision. Alternatively, if they were doing good work and had had some success in a particular issue, then that was an opportunity to be sharing that work.

But obviously it also gave an opportunity to feed back on the local political side as well and how different directors of public health were working in their patches.

Ms Blackwell: Thank you.

There were a number of changes to the structures of the regions and therefore to the management and delivery of EPRR functions over the course of our module time period. What was the impact of those structural changes to the PHE regions and to the regional teams?

Dame Harries: So this started with the Health Protection Agency problems, and I think there were something like 28 strategic health authorities when it started off and gradually they all got removed and then we went into PHE regions.

The difficulties of coterminosity, or lack of it, was a major problem, and therefore, as numbers went down, with resource cuts across, obviously, local areas but Public Health England teams as well, then those individuals were trying to support more local resilience fora, directors of public health and local health resilience partnerships.

So generally it meant you were less able perhaps to put the same amount of input as you would have done, and support, into those different areas.

Counsel Inquiry: Professor Fenton, from the UK Faculty of Public Health, who we have already looked at, said:

“Health protection teams, which moved from the Health Protection Agency … to [Public Health England] … saw successive reductions in funding and capacity over the pre-pandemic years and a lack of investment in regional emergency preparedness, response and resilience … teams.”

He says:

“A direct result of these changes was a reduction in the amount of professional exposure that the public health specialist generalist workforce had to health protection duties and continuing professional development outside of PHE.”

Now, first of all, could you help both my Lady and myself by explaining what a specialist generalist workforce might be?

Dame Harries: I will try very hard.

So the Faculty of Public Health and the Royal Society of Public Health, but the Faculty sets the standards for public health training. As people go through their training programme, they could become a health protection specialist, I mentioned a CCDC, a consultant in communicable disease control, who is very focused on health protection, or they could become a specialist generalist, meaning that they were general across all those three areas of public health.

But we would expect a generalist still to have basic health protection training and exposure, so that if you have something like a pandemic they also would turn to support that.

So I think what he’s suggesting is that if the teams in health protection were getting smaller and perhaps a little bit more fraught and overworked, they would potentially have less time to support that training as the generalists came through.

Counsel Inquiry: Is that something that you recognise?

Dame Harries: It works both ways, because actually if you have less capacity in your health protection teams, it’s great way to learn, because you get given a whole load of things because there’s nobody else there to pick it up. But I think his point is he would be wanting to ensure those people were receiving on-the-job training, and there might be less capacity to do that.

Counsel Inquiry: All right, thank you.

I want to touch briefly upon the developments in the infrastructure of public laboratories and in the generation of microbiological data, because there will be other witnesses who will be helping the Inquiry with this, but we have received a report from the then CMO, Sir Liam Donaldson, called Getting Ahead of the Curve, which the Inquiry has read, and it was a report which proposed the creation, I think, of the HPA.

Within that report, there is reference to structural reforms that brought about the creation of the HPA in 2003. Is it right that during the creation of HPA that the public health laboratory service, PHLS, was disbanded and merged into the HPA, and that control over all the local PHLS laboratories was transferred into the NHS?

Dame Harries: I wasn’t around at the time so I’m only able to give you the information as I understand it, but I think what happened is that there were 30 – broadly the public health laboratory service grew up after the war and had quite a wide reach. At the 2002 reforms, when HPA was formed, around 32 laboratories went into the NHS, and the rest, if you like, the specialist laboratories and reference – public health reference laboratories, went to Health Protection Agency, and those are the ones which we retain in the UK Health Security Agency and, previously, Public Health England.

Counsel Inquiry: How did that work in practice?

Dame Harries: Well, it meant that the local – the NHS trusts, the hospitals, had their own laboratories attached, and so I presume what Liam Donaldson is referring to is there would – he would perceive a fracture, if you like, between the NHS laboratories, now, and the specialist laboratories, and sometimes you need an alerting system to see where there are cases being diagnosed and then, if you like, send them on to the reference laboratories to check them out in detail.

I think in around 2010, again before I came into the English system, the – there was a change in data flows, and therefore actually the reporting of data almost automatically then caught up, I suspect, with the concerns of 2002. So in general that work flows through.

We have different issues now, which is around staff retention and training and differential pay issues across the two divides, but I think the data flow issue is predominantly resolved.

Counsel Inquiry: Right, thank you.

Does the microbiological testing of virus samples require laboratory facilities and laboratory scientists who are specially trained or is it something that all scientists working within the service can deal with, and can it be dealt with at any of the laboratory sites?

Dame Harries: No. So I think for many of the viruses that we will be talking about – and they’re very rare, you know, before I draw everybody’s anxiety levels up. The Public Health England, at the time UKHSA now, deals with the very highest level pathogens. So we talk about containment level 4, the highest level laboratories, and those are only situated with – on two sites for what was then Public Health England and another one, which was the government’s scientific laboratory at Porton Down, and so none of the – if we have a case of the high-consequence infectious disease case or pathogen X, whatever it might be, that we’re uncertain about, they will be managed in a way which goes almost always to Porton Down or respiratory to Colindale labs, and they will be dealt with in those high containment facilities for safety.

Counsel Inquiry: What about the infrastructure of those two laboratory settings, in Porton Down and Colindale, and the requirement obviously to keep that infrastructure updated and safe?

Dame Harries: Yeah, so these are major undertakings. They’re part, if you like, of the national – well, they are part of the national security infrastructure, and therefore it’s absolutely vital that the country retains them. In fact, as we’ve discussed, I think, through the early part of the Inquiry, we can see that the risks of these new emerging diseases developing and potential for needing to do more research and to use them for vaccine evaluation as well is growing.

Meanwhile, they take an awful long time to build, so it’s very important that when decisions are being made about health protection, those sorts of decisions in funding and maintenance of laboratories absolutely factors in the timeframe for safe refurbishment and building.

Counsel Inquiry: Looking back now, do you have any reflections on whether all of the structural reforms had an impact on pandemic preparedness in England leading up to January 2020?

Dame Harries: It’s very difficult to look back because the comments you’ve made about fractured lines and the potential – there definitely was uncertainty after 2013 when Public Health England started. We know, in fact we’ve submitted a number of papers, where different parts of the system have tried to work, directors of public health, with Public Health England proactively to recognise different roles and responsibilities.

That said, we’ve also put forward in the evidence a survey which suggests actually that people do understand them. So my feeling is that the overall issue is more to do with capacity rather than roles and responsibilities.

Counsel Inquiry: Thank you.

You also deal with the funding situation of PHE in your witness statement and you tell us at paragraph 91 that:

“Over the lifetime of PHE, its funding from central Government was reduced by over 40% in real terms (ie taking into account inflation and unfunded pay pressures). Thus, the organisation had to implement the cost savings that this required so it met its duty to operate within its budget. In addition, there were budget reductions on the level of funding in PHE’s predecessor bodies for the functions that came into PHE in 2013.”

I’d like to display INQ000090350, which is an absolutely of yearly funding for PHE received from the DHSC that UKHSA has produced for the Inquiry.

We can see the year in the left-hand column, and the funding in levels of millions on the right-hand column.

So we can see that the core grant in aid funding that PHE received from the DHSC in 2019/20 – thank you – was 287.1 million.

If we move further up the chart and further back in time, in 2013/14 the amount was 392.5 million.

Is that the 40% reduction that you were referring to?

Dame Harries: It is, but it’s in real terms, and I think we’ve explained in the submission, in the statement how that is derived.

But yes, effectively what was happening, not only was the grant in aid dropping, but the costs were going up, so maintenance of these very expensive laboratories which you have to retain. But also the organisation therefore, in order to sustain itself, became very dependent on its earnt income. It has absolutely brilliant scientists and it can generate some income. But by the end of this period my view would be that, rather than having a system that was a critical system for the UK, founded on a substantial grant that could maintain it, it was trying to pedal fast to keep up, generating income, and often using its scientists to do that rather than perhaps strengthen the wider health protection system.

Counsel Inquiry: Just so we understand, although it appears that there is a big rise in funding in the years 2012/13 to 2013/14, that’s because Public Health England was a much larger organisation than PHA, wasn’t it, and it had to take on many more functions when it was created?

Dame Harries: It was, and also there’s a change in the middle, and again I think explained in the statement, because it took on child – some of the child public health programmes –

Counsel Inquiry: Yes.

Dame Harries: – which actually – you know, the overall system went down but the – there was an additional grant in aid for that.

Counsel Inquiry: Apart from the way in which you’ve described in your answers just now, are there any other ways in which those funding cuts which ran in parallel to workforce issues and structural changes that we’ve just looked at impacted on PHE’s pandemic preparedness functions?

Dame Harries: I mean, you know, I wouldn’t like to make a particular case for this in the sense that I recognise at that time almost all public sector organisations were – had budget decreases, but of course the combined effect of that meant that if the local authority also had insufficient and the NHS had also dropped their numbers of staff, what happened was, when you met round the local resilience forum table, you may not see the person you saw last week because they’d gone to another one. There weren’t as many people there to staff.

So I think the overall impact was quite significant –


Counsel Inquiry: Just pause, please, Dame Jenny, sorry. I’m afraid this is a recurring theme in the afternoon. And it’s usually when I’m on my feet.

Lady Hallett: Don’t get paranoid, Ms Blackwell.

Ms Blackwell: I’m sorry, I won’t.

Sorry, Dame Jenny, you were explaining about perhaps not seeing the same face around the table?

Dame Harries: Well, concurrent efficiencies in relevant partner organisations is really important to meant a system-wide health protection response.

Counsel Inquiry: Thank you.

I’d like to turn now to discuss the interaction and involvement between PHE and the national risk assessment and how PHE works to create and provide the important facts and figures and calculations.

So could we have on the screen, please, INQ000206659, which is a document entitled “Risk assessment template cross-government risk assessment of 2018 emerging infectious diseases”.

Is this the document that PHE would have produced and provided to DHSC in relation to the NRSA assessment for the risk pertaining to emerging infectious diseases?

Dame Harries: I’m unable personally to answer that directly. I would imagine so.

Counsel Inquiry: All right.

Dame Harries: Yes.

Counsel Inquiry: Because it’s dated 2018, from your general knowledge of the system, could we assume that this was in preparation for the 2019 NSRA?

Dame Harries: I’m making that assumption.

Counsel Inquiry: All right. Who would have produced this document, Dame Jenny?

Dame Harries: This is difficult, and I think it would be better to check. The general principle was that DHSC would feed into the national risk assessment, but they absolutely would consult with the specialists in Public Health England to ensure that the right information was fed back.

Counsel Inquiry: So does that suggest that the first stage of collating the information and performing the assessment happens at DHSC, and that that information is then provided to PHE for their comments and additions?

Dame Harries: Yes, I think with most of these processes you have a starting point and the first question is: is this still correct?

Counsel Inquiry: Right.

Dame Harries: I mean, it’s a practical issue, which, if you’ve got something on a piece of paper, people will comment no. If you put it open, they’re less likely to. So I think you start off with: this is the position as it was last year or two years ago, does this still look right, are there new risks or should this change?

Counsel Inquiry: I’d like to look at the last two paragraphs on this page, please, and just remind ourselves of the reasonable worst-case scenario risk description, or indeed to see how it is in this template document.

Over the past 30 years, more than 30 new or newly recognised diseases have been identified. Most of these have been zoonoses, ie diseases that are naturally transmissible, directly or indirectly, from animals to humans. The reasonable worst-case scenario … is an outbreak of a high-consequence infectious disease … which is airborne. An airborne disease is more likely to spread rapidly from person to person, and can make contact tracing more difficult compared to other diseases which have a different route of transmission. Other emerging infectious diseases which are spread through different routes of transmission are explored in the three variations below.

“Specifically, the current RWCS is based on an outbreak of a respiratory infection in the United Kingdom … which is similar to the outbreak of … (MERS) seen in South Korea in the 2015. This has been chosen due to the current risk of this disease and the historical precedent of imported MERS cases leading to outbreaks. However, it should be noted that due to the nature of an emerging infectious disease there is some uncertainty as to whether a different emerging pathogen, including one which was airborne, would lead to an outbreak similar to the scenario described.”

We can see, moving back to paragraph 4, that the “overall confidence assessment”, the likelihood or plausibility, is assessed as being low.

Was the reference to infection control procedures a reference to IPC within the healthcare setting or community IPC or both?

Dame Harries: Sorry, where is the reference to IPC?

Counsel Inquiry: If we look at, in fact, over the page at page 2, I think it’s clearer here. If we look at the first two paragraphs here:

“The RWCS is predicated on a novel or emerging infection (ie one that is either globally unknown or unknown/very rare in the UK) arising in another country and then arriving in the UK before it is identified. It is possible that a novel infection could arise in the UK first but this is less likely.

“Based upon the experience of recent international outbreaks of MERS, the likely impact of such an outbreak originating outside the UK would be cases occurring amongst returning travellers and their families and close contacts, with potential spread to health care workers, and other patients within a hospital setting. The resulting cluster of individuals with a similar illness should lead to infection control within health care settings and other public health measures being instigated which can control the spread of the disease. For MERS, sustained human-to-human transmission outside of close contacts and healthcare workers has been limited so far … and therefore there is currently a low risk of this disease presenting a wider threat to the UK. However, sustained human-to-human transmission in emerging airborne diseases is possible, which is why infection control procedures are critical to the mitigation of this risk.”

Dame Harries: Sorry, and could you repeat the actual question?

Counsel Inquiry: Yes. So the reference in the middle of that paragraph, if we can highlight it:

“The resulting cluster of individuals with a similar illness should lead to infection control within health care settings and other public health measures being instigated which can control the spread of the disease.”

So is the reference to infection control procedures a reference to IPC within healthcare settings or within community IPC or both, do you think?

Dame Harries: So, I mean, as I say, I’m slightly – we just need to take this carefully because I’m not clear of the absolute origin of the document, but I can see a peer reviewed reference there, of 2017, so it’s going to be 2017 or later, which – and the reference to infection control will be, it says, within healthcare settings. But we always have infection control measures within healthcare settings. This will refer to, potentially, bolstered healthcare settings controls, and I think this work actually was taken forward in the HCID pathway work which resulted in the commissioning of five new airborne HCID transmission control centres, if you like, which were not in the UK prior to this.

Counsel Inquiry: Right. When were those created or where were they created?

Dame Harries: So the names are actually in the statement, but the HCID work which started after Ebola, which is obviously a contact transmission, but looked at the potential for high-consequence airborne and touch transmission, and at the time there were just two contact transmission centres, which was the Royal Free and Newcastle, so, working with DHSC and with NHSE, new airborne transmission control centres, if you like, were created, so this is a direct result of the HCID pathway. And in fact in 2018, of course, we had a MERS case; appropriate IPC in healthcare settings was put in place, and there was no transmission.

Counsel Inquiry: All right, thank you.

Is it right that, certainly looking at this document, which appears to have been based on the MERS outbreak, that SARS and MERS were considered to be primarily transmitted via droplets rather than aerosols?

Dame Harries: No, I mean, I think Professor David Heymann put it –

Counsel Inquiry: Sliding –

Dame Harries: – I thought expressed it very well in his – the evidence prior to this was that mostly people were infectious when they were symptomatic, and the aerosol generating procedures, so these are procedures where you are, if you like, it’s not quite right, but actively pushing air up from the bottom of the lungs, which is different, for example, to having a virus sitting in your nose and it just popping out if you sneeze or are passing somebody.

So these were – that is how the transmission had occurred, and if we go to the Korea case, for example, as soon as they had put in good infection control measures in the healthcare setting, then they got on top of the transmission.

Counsel Inquiry: All right. And you’ve referred to the evidence that Professor Heymann gave to the Inquiry. He described, didn’t he, that really the difference between droplets and aerosols is best described by a sliding scale –

Dame Harries: Yes.

Counsel Inquiry: – droplets being the heavier, larger particles and aerosols being smaller, so the bottom of the scale.

Dame Harries: But there is also a generational thing, it depends about how forcefully they come out, which is why we have these distinctions about singing or shouting.

Counsel Inquiry: Yes.

If we can go to paragraph 15, please, at page 9 of this document. Now, we can see that according to this risk assessment, it states that the total number of estimated fatalities – there we are, at the top of the page – is between 40 and 70.

If we go to the last paragraph on page 10, please, thank you, and highlight the bottom paragraph, we can see that:

“The number of casualties is based on the MERS outbreak in South Korea.”

Which we have already established. And:

“Given this number of casualties, the number of fatalities could range from 40 to 70. Approximately 40 people died in the MERS outbreak, but with a case fatality rate of 34.9% it is possible that up to 70 people could have died. Both figures could be higher or lower than this, depending on how communicable the disease is, as well as how quickly the disease is recognised and prevented from spreading further using infection control measures.”

Let’s just look for a moment, please, also at paragraph 16, which is on the previous page. We can see that the number of physical casualties is assessed here as being 200.

Do you know, Dame Jenny, why that figure was assessed at that level, taking into account that the number of cases in Korea was 186?

Dame Harries: Well, I don’t, and I think I would need to look at this. I’m very happy to do that outside the court and provide written feedback. It’s quite difficult to just look at the numbers and make that decision.

But clearly, you know, Korea is one setting. I think all of these suggestions or scenarios around reasonable worst-case scenarios are based on what we know and the context at the time, and that’s as good as we have. So we know case fatality rate around 35%, and the rest of it is a very sensible but, in many ways, a slightly educated guess unless you’ve got other parameters.

Counsel Inquiry: Thank you. Can we take that down, please, and replace it with INQ000185135, which is part of the 2019 National Security Risk Assessment, which this information fed into. Could we go straight to page 8, please. Thank you.

Now, if we look at – without highlighting, if we look at the two main paragraphs under “Human welfare”, going further down to “Casualties”, first of all, the total number of casualties here, in the document itself, is 2,000, and if we move up the page, the total number of fatalities is 200.

Now, again, I appreciate, Dame Jenny, that you weren’t personally involved in creating this risk assessment, nor indeed in providing the figures that we’ve just looked at that appear on the template, but in your experience of these matters are you able to assist as to why, having been provided with the figures of between 40 and 70 fatalities and 200 casualties, those figures could have been expanded to 200 fatalities and 2,000 casualties, as we see in the actual document?

Dame Harries: So as I’ve said before, I mean, I would need to look at the whole document. On this sheet that you’re showing me it doesn’t actually mention which disease we’re looking at, so case fatality rate for MERS was around 35% but I think for SARS in the early days it was around 10%, so that would immediately answer your question, but I don’t have the rest of the information to do that. I’m very happy to take it away and look in more detail.

Counsel Inquiry: I think that would be helpful to the Inquiry.

On that point, let’s just look at page 9, please, and the section entitled “Human welfare – confidence assessment”. Can we highlight that paragraph, please, because what it makes clear is that:

“For the number of casualties and fatalities, the lower bound is based on the MERS outbreak in South Korea. However, there’s the potential for this to be much higher. During the SARS outbreak in 2003, there were approximately 350 reported deaths in China although this was where the outbreak [was] originating. Both figures could be higher or lower than this depending on how communicable the disease is [which is a phrase that we’ve also seen in the template], as well as how quickly the disease is recognised and prevented from spreading further using infection control measures. There is considerable uncertainty regarding the impact of the outbreak on British Nationals Overseas. This scenario has not been modelled by the FCO or Department of Health. The number of non-British fatalities and casualties abroad will depend on the country where the outbreak occurs and the response of the responding health system. For MERS there have been 2,102 casualties; 733 deaths from 2012-2017 but for SARS there were 8,096 casualties and 774 deaths from November 2002-July 2003. The figures presented are therefore based on the SARS outbreak in 2003.”

Dame Harries: Which aligns with what I’ve just suggested.

Counsel Inquiry: Yes. So the figures are provided by PHE, and then they’re not simply taken at face value, they will be worked on or adapted or perhaps even given a slightly different scenario in the preparation of this final document; is that right?

Dame Harries: I don’t think I would translate it that way.

Counsel Inquiry: All right.

Dame Harries: In the sense that the information – I don’t disagree with anything which is on the screen in front of me now, it’s just we’re talking about estimates.

Counsel Inquiry: Yes.

Dame Harries: We have no cases to go on. So it’s extremely difficult. All it’s looking at is the totality of cases and other outbreaks and the case fatality rates. And even that, actually, could be over or underestimated depending on how many people were tested at the time.

So, I mean – if I may, my Lady, there is a general point here about the way we’re trying to fit viruses backwards, I suspect, either into legal arguments or the pockets of differentials in the risk assessment when they don’t fit neatly in each. It’s not possible often, in civil service terms, to actually say “unknown” in a box because it needs a number in a box in order to generate the next bit of the logic and the money that goes with it, and I think it drives some of these conversations into differentials which are not realistic. We just don’t know, this is as good as we get.

Counsel Inquiry: All right. There is a high level of uncertainty within that paragraph, isn’t there?

Dame Harries: Yes.

Counsel Inquiry: Lots of variables?

Dame Harries: Yes.

Counsel Inquiry: And I suppose to a certain extent, you know, the figures are the best that can be achieved at the present time that the document is created?

Dame Harries: But I wouldn’t like to suggest – or at least I have no evidence to suggest that somebody has taken some figures in one place and then moved them around in the others. What is stated here looks reasonable.

Counsel Inquiry: Right.

Dame Harries: It’s just very uncertain.

Counsel Inquiry: Thank you, we can take that down.

The provision of expert scientific advice and contribution to expert advisory groups. We know that PHE contributed to a number of the scientific committees that advised central government and often provided a secretariat for them.

As far as you’re aware, to what extent were experts provided by PHE able to challenge the views of experts on those panels?

Dame Harries: So usually if colleagues in PHE were attending any of those groups they were there as individual experts. It depends what group it was. And in fact for UKHSA we’ve just done a review and we’ve identified 19 different government – I mean, just to make the spaghetti even worse – different advisory committees. And then there are a whole load beyond that which are not government ones, are technical advisory groups.

So if they’re on a government – there is a government advisory committee, there are rules about how you – and I think you’ve had those as well. They will be there offering their independent professional advice and they will be receiving that from other colleagues around the room.

If you looked now, for example, we run technical advisory groups and UKHSA will chair them, and so they would be there as a UKHSA representative. But actually there are a number of places where people will get external advice, including, for example, from the advisory boards both of PHE and UKHSA.

Counsel Inquiry: You will be aware, I think, Dame Jenny, that the Inquiry has heard about the need to avoid groupthink, particularly in these advisory groups. Do you have any reflections on whether or not the PHE scientific experts may have contributed to groupthink or suffered from that as a principle?

Dame Harries: 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. But on the whole, scientists are quite outspoken. And I think it was Sir Patrick Vallance who said they actually quite like to be challenged and have to change their mind. It’s quite exciting if you’re a scientist. So I don’t really hold with that.

I do recognise that particularly during the pandemic, and actually through lots of incidents, there is a feeling of people being left out of the room. Everybody wants to be in the room offering views, and there has to be a practical limit to that. It should be representative, it should be challenging, you should have the right skills, but you can’t have everybody or the whole response stops.

Counsel Inquiry: So perhaps the composition of the groups is important to –

Dame Harries: Yes.

Counsel Inquiry: – make sure that there is a range of experience and viewpoints?

Dame Harries: Absolutely.

Counsel Inquiry: Yes.

Simulation exercises. We’ve received information about several exercises through the course of our preparation for the Inquiry. I want to concentrate, please, Dame Jenny, with you on Exercise Alice.

Could we have up on screen, please, the report, which is at INQ000090431. Thank you.

I think it’s possible also to display at the same time a freedom of information request which was made by a member of the public in relation to actions implemented as a result of this exercise, which is at INQ000191910, if we could put that up on the right-hand side of the screen, please. Thank you.

This, as the Inquiry has already heard, was a tabletop exercise conducted on 16 February 2016 in London to explore the challenges that a large-scale outbreak of MERS CoV could present nationally to health partners in England, and participating in the exercise were representatives from NHS England, Public Health England and the Department of Health, as it then was, and also observers from the Cabinet Office, the devolved administrations and GO-Science.

If we look at page 5 of the report, please, we can see the objectives of the exercise at paragraph 2.2:

“1. To explore and confirm the health capabilities, capacities, protocols and resources, including surge arrangements.

“2. To explore and confirm national command, control, communication and co-ordination arrangements.

“3. To explore the capability for contact tracing and quarantining of possible MERS CoV cases.

“4. To explore and confirm co-ordination of public messaging associated with a large number of MERS CoV cases.”

If we just remind ourselves of the scenario, it was where a group of people from London and Birmingham had travelled to the Middle East and ten days after they returned three of them presented at three different hospitals with flu like symptoms. After their histories had been analysed MERS CoV was suspected and a process of contact tracing was initiated, and after two days two of the cases were lab confirmed and a further case, at St Thomas’ Hospital was strongly suspected. Prior to arriving at the hospitals, two of the patients had been part of a large gathering, and the scenario then developed with 50 lab confirmed cases and 650 possible contacts, and various elements of the NHS were under pressure from the cases and the media had taken a keen interest.

There was a general consensus on the need to identify capacity and capability of assets within the health system, and the level and use of PPE was central and considered of crucial importance for frontline staff. It was noted that the learning from Ebola on infection control understanding, although improved, was still not embedded with staff. And also considered important were access to sufficient levels of appropriate PPE and pandemic stockpiles to ensure sufficient quantities of PPE were available.

If we can look at some of the lessons and actions identified, and go to page 10, please, and look at action 4. Action 4 was to develop a MERS CoV serology assay procedure to include a plan for a process to scale-up capacity.

Now, is that relating to an antibody test?

Dame Harries: Well, it’s a detection test, yes, a diagnostic test, and that was completed by PHE, and in fact they’d been working on them since 2011. It’s why we had such good early access during the Covid pandemic.

Counsel Inquiry: Thank you.

In relation to this action 4, if we look to the document on the right-hand side, please, which if we go to page 2, fortuitously is set out in the same order, and we highlight number 4, we can see that the answer to this question was that the procedure was developed and used during the management of the imported case in August of 2018 – that’s the imported case of MERS, isn’t it? – and that:

“Laboratory procedures for scaling up capacity have been well rehearsed across a range of outbreaks.”

Can you explain what range of outbreaks that capacity would have been rehearsed in relation to?

Dame Harries: So if you have a new infection, it would be PHE’s role to create the assay, the diagnostic test, and be able to scale that, and initially you would usually go out to Public Health England laboratories, then out to NHS laboratories, depending on the risk associated with the pathogen itself.

So, I mean, when – once you have an assay for something, it’s – I mean, I’m not an expert in serology assays, that’s why we have them. Once you have them, there’s a – you’ve usually got your skill there, although you do need to ensure that they are – remain quality assured.

So in terms of rehearsed across a range of outbreaks, I’m trying to think what else would have happened in that intervening period.

So I can’t offhand think what happened between 2015 and August 2018 save to say that obviously this is an example that it had been rolled out and was available.

Counsel Inquiry: Right. All right, thank you.

Can we go to action 5, please, which is on the following page of the report, on the left-hand side. Thank you.

Now, this is an action to:

“Produce a briefing paper on the South Korea outbreak with details on the cases and response and [to] consider the direct application to the UK including port of entry screening.”

In relation to this point, can we now go to the freedom of information request and have a look at whether or not this was an action that had been taken up by the time that this response was provided.

The response is that:

“… port of entry screening has been found to be of minimal use across a number of outbreaks and has been widely studied. The details of individual cases have not been released apart from the index case. The protocols developed following Exercise Alice were tested in the response to the importation of a case in 2018 which was successfully managed.”

But in terms of whether or not the briefing paper was ever prepared on the South Korea outbreak with the intention of taking on board the manner in which South Korea reacted to their outbreak of MERS and attempting to learn for the United Kingdom, do you know, Dame Jenny, whether or not that briefing paper was ever prepared?

Dame Harries: So I think what I’m reading here is – and I wasn’t at Exercise Alice myself, but what I understand has happened is that the lessons that were learned from it, in terms of the importation of this case and the learning from South Korea, was moved into what I would call practical utilisation. So we may well come on to the National Incident and Emergency Response Plan, the NIERP, gets updated regularly, now on an annual basis, proactively reviewed, and learning from this will get fed into it. But I think importantly there will have been discussion, and I think it was in our pack that we sent in, around the clinical management of cases.

Counsel Inquiry: Yes.

Dame Harries: That actually went into the doctors’ packs, for example, for those people who were on call, it went out to the NHS, so there was a clear pathway for managing cases.

So depending on whether you – I think there are two issues here: there’s management of the case, and I think we have submitted some evidence that PHE did that. I think the port of entry screening evidence base, about whether it works, is a separate issue, and I’m happy to talk about that. Then, though, I think there are then port health, which is a completely different issue, and I’m very happy to talk about that as well.

Counsel Inquiry: I was particularly interested in the management of cases, but it’s –

Dame Harries: So there was – I think we’ve submitted a document, I think it was 2017, which went through the normal review process in the EPRR delivery group that was included in the pack. I think it was temporarily held up, not from the doctors’ packs but in order to make sure that it aligned with the HCID pathway that was under development. And that’s now out on the website for everybody to use.

Counsel Inquiry: So once that was affirmed, then the guidance was given, thank you.

Can we look at action 7, please, which is on the following page of the report. Page 13, thank you.


“Produce an options plan using extant evidence and cost benefits for quarantine versus self-isolation for a range of contact types including symptomatic, asymptomatic and high risk groups.”

Is it right that there was a lot of discussion around the issue of restriction of movement of symptomatic and asymptomatic patients and whether this should be voluntary, that’s self-isolation, or through enforced isolation, which is quarantine?

Dame Harries: Not just for this, but for Ebola as well.

Counsel Inquiry: Right.

Dame Harries: And I was personally involved with some – many of the Ebola discussions. So I would classify action identified 7 as a wicked issue and one that we might want to return to.

One of the problems with this is it’s not something, I think, that PHE can resolve independently, and I think there is submitted with the statement a document from 2019, after quite a long piece of work, about port entry screening, and the two link together, because obviously if somebody’s coming in you need to grab them when they come in if you’re going to do this.

These are very, very difficult decisions for individuals to make. The law needs to support them, and there are costs involved. And the evidence base is often in a completely different direction to political will, and so they’re very difficult issues to deal with.

So I think PHE, as far as I understand it, had done quite a lot of work on port health. This was one of the areas that they had identified that they needed support from the lead department. It requires buy-in from the Department for Transport, Border Force, almost everybody, and I think it hasn’t progressed beyond that.

Counsel Inquiry: This issue in particular has a number of possible options, doesn’t it? I think in South Korea there was the use of hotels, but then there is also the option of using specific locations as sites for quarantine, and also the legal rights of the restriction of movement of people, and all of that is brought to bear, isn’t it, during this discussion? So it’s not a simple matter by any means?

Dame Harries: It’s not at all, although we – you know, the country has used a managed quarantine service during Covid, but many of those difficult issues have surfaced through that utilisation.

Counsel Inquiry: Thank you.

If we just look, please, over to the other document and see what response was given by PHE, it says:

“This background research has been used to develop the current guidance. Any decisions about making this enforceable were outside the remit of PHE.”

Which is –

Dame Harries: Which is more or less what I’m saying, and it does link very closely with the port health discussion.

Counsel Inquiry: Thank you.

Actions 8 and 9 are to:

“Develop a plan for the process of community sampling in a MERS-CoV outbreak …”

And also to:

“Develop a live tool or system to collect data from MERS-CoV contacts …”

If we look over to the FOI document, dealing with 8 first, we can see:

“Develop a plan for the process of community sampling.”

PHE confirm that “guidance has been produced and is available at”, the following place, and:

“Sample processing will take place in the routine manner, adjusted for scale. As part of any incident response, this scale will be determined and then appropriately resourced in conjunction with other responding agencies.”

And that:

“This is also contained in the first few hundred (FF100) Enhanced Case and Contact Protocol which is also available at the above link.”

Then we see the answer to number 9, to develop a live tool or system, is that:

“… There are a range of systems that were employed by PHE and continue to be employed by UKHSA for gathering data from contacts across a range of outbreaks and are chosen based on the scale of the outbreak. They are causative organism agnostic to avoid duplication or processes.”

Can you explain to us, please, what causative organism agnostic means?

Dame Harries: I was going to say, both of those are quite Mr Humphrey.

So basically what it’s saying is there are ways of collecting data depending on the sides of the outbreak and the type that it is, and you do need to fit it to that. For example, in fact, if it was not this organism but a food-borne one, for example, we might be working and looking at local authority systems and environmental health officers.

So I think there are two issues in both of those examples. One is, my other wicked issue for the Inquiry would actually be community sampling. So UKHSA has actually put in a sort of mini rapid response team to enable that in some cases, but it is not mass testing. So I think this move from large-scale contact tracing or large-scale community testing to mass testing is one that is not resolved.

There are – I think our data systems are much better, but actually it requires infrastructure as well, and we’re still continuing to try and build the systems that we had, which were excellent towards the latter phases of the Covid pandemic, but still need both infrastructure support, if you like, and operational utilisation.

Counsel Inquiry: Right, thank you.

We can put those documents off the screen now.

Do you agree, Dame Jenny, using what we’ve just looked at as examples, that Exercise Alice presented us with the opportunity of conducting important research which should feed into emergency plans not only for a future MERS CoV outbreak but also any other type of emerging infectious disease?

Dame Harries: Yeah, I think actually I looked at these with interest because I worked directly on the airport screening for Ebola, and a number of these discussions and problems arose, and then we had this. But at the time that Exercise Alice happened, we were developing proactively the HCID pathway –

Counsel Inquiry: Already?

Dame Harries: Yes. So I think to some extent, whereas you might think this would be a stop point to say, “Let’s do something”, in fact a lot of the activity was already happening. What we do now in UKHSA is if we have an outbreak we immediately put in a research programme at the start that says: what are the questions we’re finding that we don’t know the answer to? So that we try and kick that off immediately so it supports, you know, outbreak management later.

Counsel Inquiry: Yes. It’s fair to say, though, that looking at Exercise Alice and some of the actions or lessons learned that were highlighted, and from the evidence that you’ve given and what we’ve seen from the freedom of information request, that some of the actions were implemented by Public Health England even though that was not the commissioning organisation for the exercise. Why would that be? Would Public Health England have taken on actions that were ordinarily outwith their own work areas?

Dame Harries: They will always try and do the right thing, and that’s often not recognised. So this is a great opportunity to do so. And I tell staff to run towards things if it’s important for health protection. But those two issues around port health – and I think we can see that in the work frame there – were there from Ebola, and community sampling is a long-standing issue, so those are two issues which I think the organisation has felt unable to resolve on its own, and it needs wider than DHSC. That’s also my point.

Counsel Inquiry: Thank you.

There was an exercise that took place in 2016 called Exercise Northern Light. I don’t want to go to the details with you, but just to say that one of the matters identified during the course of the exercise was that current arrangements with supporting surge centres and partner organisations would benefit from future development in preparation for multiple HCID cases; and I just raise that because I’d like to move on to Exercise Cygnus which took place in October of 2016.

Again I don’t want to go to the documentation, but simply to confirm that one of the lessons identified in Operation Cygnus was that an effective response to pandemic influenza – because that was the subject matter of this exercise – requires the capability and capacity to surge resources into key areas which in some areas were lacking.

Then Exercise Broad Street in January of 2018, which had as its subject matter an HCID outbreak, also touched upon the need for surge capacity.

Do you accept, Dame Jenny, that by the time we reached the outbreak of Covid-19 in January of 2020, that there had been lessons identified, warnings given, however you want to describe it, that come a pandemic, whether it be influenza or another type of disease, there needed to be within the health systems of the United Kingdom public health and also general health the capacity for a surge in terms of within hospitals, within workforces, and within a capacity in order to try and deal with a significant outbreak?

Dame Harries: I do, but I think all of those three things are quite different surge mechanisms, and I’m wildly trying to remember – it’s a bit like variants for Covid – which one the Northern Lights exercise was, I think it was Lassa fever and H7N9, which was to try and see if two HCIDs, an airborne and a touch, could be handled at the same time.

Counsel Inquiry: Yes.

Dame Harries: Which is – as long as they’re small case numbers, it’s a different type of surge. Whereas pan flu is obviously a very large national one, and the Broad Street I think was checking –

Counsel Inquiry: Yes.

Dame Harries: – effectively the pathway that we were just putting in on the HCID pathway. So – and they’re checking different parts of the system. There’s an NHS surge, there’s a whole population public health surge.

So I do broadly agree, but I think two of those worked reasonably well. It’s the Cygnus pan flu one where the capacity obviously was stretched, and there are mutual support arrangements. So each Public Health England centre would support the other one, it would divert calls or you could have whole regions working, and the emergency response plan outlines that work and allows resource to be flexed, and we can work across with NHSE as well. But I think the pan flu one is the one – is more like the Covid that we’ve just experienced, and says “Actually when really stressed the resources are very, very low”.

Counsel Inquiry: Yes.

At paragraph 106 in your witness statement, you say this, that:

“PHE had identified a gap in national strategy across government focusing on infectious diseases since the 2002 Getting Ahead of the Curve document, thus in 2018 it started work on an infectious diseases strategy which was published in autumn 2019 through a joint launch with the Chief Medical Officer.”

You go on to say:

“This identified ten strategic priorities including infectious disease surveillance, whole genome sequencing, major emergency response, and health inequalities.”

For how long had that gap existed?

Dame Harries: So I don’t think it was a gap in action, it’s a gap in focus.

Counsel Inquiry: Right.

Dame Harries: So the initial Liam Donaldson document from 2002, Getting Ahead of the Curve, was a CMO document setting out a strategic direction and actually forecasting almost the creation of the Health Protection Agency.

This one was actually very much more about – it was actually an internal strategy. It wasn’t so much a national one, but it had very wide consultation, and it was designed to put some focus and also recognise that there were new developing techniques. So the whole genome sequencing activity is moving us into a completely different realm of health protection with new opportunities in how we manage outbreaks and get on top of them more quickly.

So I wouldn’t like it to be thought that the – those streams of work were not ongoing and, in fact, you know, we’re just about to publish our own UKHSA strategy for the next three years and the topics will be pretty familiar because that’s what we need to focus on.

So I would not read an absence into that, I would just say it was far more of, after an internal reorganisation, getting a focus on the topics that were already being worked on.

Counsel Inquiry: So is it possible to say whether that gap in infectious disease strategy had any impact on the UK’s preparedness for a pandemic?

Dame Harries: I don’t – I mean, apart from the general capacity issues and the financial background, I don’t think it did, and in fact what you can see during that time is, for example, the way that we started diagnosing and treating TB – which is done at the Birmingham PHE, now UKHSA, laboratory using whole genome sequencing – actually progressed very rapidly and moved from around a month in detection to coming to a week, and knowing whether you had a multidrug-resistant TB case. So these were actually advances, not going backwards, so I don’t think I would accept that.

Counsel Inquiry: Before we leave this subject, I just want to ask you: to what extent did PHE seek learning from other countries that dealt first-hand with outbreaks including SARS and MERS?

Dame Harries: So that happens at a number of levels. It works – it used to work, we continue to work with DHSC who have the prime relationship with WHO, for example, but actually the previous health protection and medical director Sir Paul Cosford was on whatever the board level was for European Centre for Disease … Control and contributed to that regularly. There are individual groups across, we have experts supporting – in fact in many ways leading – WHO laboratory – reference laboratories.

So there’s a lot of different individual professional levels. And again, I know it’s a recurrent theme, but I think people are unfamiliar with the level of interconnectivity on an international basis, both on an individual level and organisational.

I mean, I might say as well that PHE was part of IANPHI, which is the institute – association of national public health – International Association of National Public Health Institutes, yet another acronym, and would regularly exchange information, and that happened through Covid and continues to.

Counsel Inquiry: Thank you.

I’d like to ask you now about the Public Health England emergency planning documents, and two in particular, the ConOps document and also the NIERP, did you call it?

Dame Harries: I call it the NIERP, it’s the national planning document.

Counsel Inquiry: Yes, all right.

So the ConOps document, was this updated after 2013?

Dame Harries: It’s updated regularly and annually and it had a very big update, I think it was after Ebola, it was around 2016/17.

Counsel Inquiry: Right, okay, and this is the document that details PHE’s response to incidents. Yes. And is it intended to be used alongside the NIERP and also deal with threat specific plans?

Dame Harries: So it’s progressed. So it started life well before I was involved within it but, as I say, it’s almost come together as a single plan, so an operating process in the background framework, and is, yes, is agnostic to the threat. But the people who might be involved in it will be decided by the nature of the threat.

So, for example, it would manage a business continuity issue. When all the steam valves go supporting one of the laboratories, it’s more likely to be somebody on the corporate management side, a senior leader; whereas if it was a high-consequence infectious disease, the strategic response director would almost certainly be a medical professional.

Counsel Inquiry: All right, thank you.

I would like to look at the pandemic influenza response plan 2014, please, and we can see this at INQ000178938. In fact, these are the minutes of a board meeting of the Pandemic Influenza Co-ordination Group of July 2019, and we can see that if we move down the page, please, and move to page 2 and look at the first paragraph, we can see that there has been prepared a paper on outline specific functions:

“… as this is a draft, the divisions listed in the document are in no particular order. GD thanked those who have already contributed; GD still waiting for a few more sections of PHE to contribute.”

Then this:

“Noted that the challenge is that some PHE structures have changed significantly since the last PHE pandemic flu plan was published so we have to reorganise the document in that respect (eg NIS was formed since the last plan was published).”

All right, just pausing there, please, do you know, Dame Jenny, whether or not the pandemic influenza response plan was updated post-2014 in order to reflect the fact that there had been a change in PHE structures?

Dame Harries: I think it wasn’t, because the plan was – and I think you may have heard earlier – that Department of Health were due to upgrade their plan and therefore the idea is that these cascade and follow and link with each other. That said, the national infection service was formed of recognised groupings within PHE, professional groupings. So I think it wouldn’t be that the plan would be inoperable, and in actual fact the way that the NIERP – if you’ll excuse the acronyms – works is that you have that as the backbone of emergency responses and then your plan runs alongside it. So the operational response would still have happened, but you are right, there wasn’t a follow-up plan from this. We were – I think PHE was waiting for the DHSC one to come through.

Counsel Inquiry: Right, so no update between 2014 and the outbreak of the pandemic in January 2020?

Dame Harries: Yes.

Ms Blackwell: I’m being told that our brave stenographer would like a break in about five minutes.

Lady Hallett: How much longer have we got to go?

Ms Blackwell: I’ve probably got about 15 minutes left, so …

Lady Hallett: Right.

Ms Blackwell: Then I think there’s about five minutes of questioning from another of the CPs, so –

Lady Hallett: Let’s break now.

Ms Blackwell: – it’s convenient to do so. Thank you.

Lady Hallett: Five minutes.

(4.26 pm)

(A short break)

(4.31 pm)

Ms Blackwell: Thank you, my Lady.

So we’d established, Dame Jenny, that in relation to the pandemic influenza response plan of 2014 it was not subsequently updated between its implementation and the pandemic hitting to update in terms of a change in organisational structures.

Could we go to page 67 of the plan, please – thank you – the first paragraph, which states:

“During a pandemic NSC(THRC) will co-ordinate central government activities, make key strategic decisions such as the countermeasures required and determine UK priorities.”

Do you agree, Dame Jenny, that that appears to be a misunderstanding of that body’s role, that in fact the NSC(THRC) was a body that enabled ministers to spot major emerging diseases and understand the risks and receive expert advice on response and mitigation?

Dame Harries: I read it as a co-ordination role. I realise that’s not exactly – it does say “co-ordinate”, it’s not exactly what it says. How I read that and in fact what happens in practice –

Counsel Inquiry: Yes.

Dame Harries: – is that CCS will ensure that everybody is in the right place and obviously all the ministerial decisions finally get agreed at COBR –

Counsel Inquiry: All right.

Dame Harries: – for something like this. So, you know, I cannot foresee that we would have a pandemic without some COBR decision-making.

Counsel Inquiry: No, but this sentence, as I’ve just read it out, and the description that it provides about the practical level at which this group would be involved in a pandemic is misleading, isn’t it?

Dame Harries: I think it could be phrased better, let’s put it that way.

Counsel Inquiry: All right.

Dame Harries: I mean, it pre-dates – well, no, it must have been started when I joined, around the time that I joined PHE, and I wouldn’t necessarily have personally been responsible; and sometimes you do look back at documents and you think that was not entirely well articulated. So I think it could be better articulated.

I think people will have – those people involved in the response will have known where the wheels were turning and in fact will have been invited, for something like this, to contribute either directly to COBR or through CMO.

Counsel Inquiry: But the benefit of a document like this being accurate – not only in terms of its description of the health bodies but also of the role of a CCS, Cabinet Office body like this – is that whoever reads the document is clear about roles and responsibilities and this, in the two aspects that we’ve just looked at, could have been clearer and on one level could be described as misleading?

Dame Harries: I think I would agree with you. I mean, there are two things I would say: one is I notice the date is 2014, and I now have the same problem at UKHSA, every time an organisation changes you’re having to go back and work through documents to try and make them work with the ones before. And it’s not just your own organisation, it’s the other pieces of the machinery that have changed at the same time, and they’re sometimes changing as you’re trying to update your document. So I agree with you. I am less concerned in practice that that sentence would have affected how individuals responded. They would have worked to the NIERP and the systems in place.

Counsel Inquiry: Because, as you may or may not be aware, the NSC(THRC) was retired in 2018 and became completely disbanded by 2019. So in fact, as we get towards the time that the pandemic hit, that organisation was no longer in existence.

Dame Harries: I agree with you, I think it’s unhelpful. We’re probably – I should suspect PHE is not the only organisation with outdated documents and it’s why, for things like the NIERP particularly – which is the backbone of response, and I think you can see that through the evidence that’s there – it is proactively updated after each incident.

Counsel Inquiry: I want to move away from this document now – we can take that down, please, thank you – and just ask you about a plan, a UKHSA plan for MERS. Is there one in force other than a draft interim response plan that was created some time ago? Do you know whether there’s a final plan in force?

Dame Harries: There is guidance and it would be handled along an HCID pathway, so effectively the practical application is there.

Counsel Inquiry: How is it viewed in terms of the level of concern that MERS poses?

Dame Harries: So MERS is on the HCID list. So, I mean, in practice, what that means is if we have ten cases of something else, we say: is this a cluster? Does it look unusual? If there’s one case of MERS, somebody’s on the phone to me immediately and the CMO knows and the HCID pathway goes in and the HCID network is activated. So – and we have seen that happen. We’ve had a Lassa fever case recently, we’ve had MERS.

So I’m very confident – I mean, you can’t – you will never secure 100% confidence, but it has been rehearsed, and the 2018 example of that is that that case was managed well.

Counsel Inquiry: All right, thank you.

In terms of planning for an HCID or Disease X pandemic, Professor Oliver in her witness statement to us has confirmed that Public Health England was not involved in any programmes of work related to specific planning for a pandemic caused by any pathogen other than influenza – and indeed that accords with other evidence that the Inquiry has received – or indeed any pathogen agnostic planning.

Dame Harries: Yes. Can I be invited to continue?

Counsel Inquiry: Yes, please do.

Dame Harries: So, yes, strictly to – you said, that’s my understanding. But it does go back a little bit to trying to fit what we have – the way I see what we have, from a clinical perspective – and I think in many ways probably reflecting what Sir Patrick and Sir Chris Whitty said – is that we have a respiratory virus plan, currently, I think, because the national strategic risk assessment says you have to use an example, and that is geared to flu, and then we have an HCID pathway which is smaller but has very high protection. And I’m probably pre-empting some further questions.

My view is that the flu plan is actually a pretty good one. I turned round and thought I’d ask the question the other way round: if I was going to choose an example, because that’s what the risk assessment says I must do, what other example of a respiratory virus with pandemic potential would I use? And there wouldn’t – I would still use flu because that’s the history to date. But what it doesn’t have is what I would call a sensitivity analysis. It doesn’t do the bits that says: well, what if this flu virus had a longer incubation period or this flu virus transmitted asymptomatically for 50% of cases?

So the actual sort of structures of the pathways, whether it’s a new virus or not, feel okay to me, but that’s the bit that’s missing at a national level and that would have got us to a consideration of, you know, what’s – what is – had we planned for more asymptomatic transmission or a containment phase, as the Hine report suggested.

Counsel Inquiry: Yes, but also doesn’t it have an effect on decisions in terms of pandemic stockpiles and clinical countermeasures?

Dame Harries: Yes.

Counsel Inquiry: Because there was only a pandemic influenza plan, the planning, the practical planning for pandemic stockpiles and clinical countermeasures followed that plan and so in terms of antivirals they were entirely suitable for an influenza pandemic but, as it happened, not for the pandemic that hit us?

Dame Harries: To an extent, yes, but, I mean, if we did a sensitivity analysis that said, “We’re going to have a new virus that’s got 100% asymptomatic transmission, we’ll only know if we go into it”, we’d all be walking around in PPE every day of our lives. So there is a limit to what that stockpile might ever do, and it’s not an unreasonable assumption to put it somewhere around the boundaries that I think it was. But I do think this, however you call it – as I say, I call it a sensitivity analysis – we didn’t think – it should have been flexed to potential characteristics of the virus. The underlying plan is fine, but that isn’t of course – this is the problem, that’s not what the NSRA, I think, allows PHE or the Department of Health to do. It gets very specific on – it wants to know how many cases, and we have the same thing with Covid where I will be asked, you know, what is your trigger point? But if you have a virus that is behaving – is a new virus or you don’t know how it’s going to behave, specifying a trigger point is not the right thing to do; you need to leave your mind open to what it might do.

Counsel Inquiry: What are PHE’s responsibilities in terms of stockpiling clinical countermeasures and PPE?

Dame Harries: So – what were they?

Counsel Inquiry: Yes, of course.

Dame Harries: Sorry, because I’m sort of jumping between organisations and actually I wasn’t responsible personally for PHE.

Counsel Inquiry: No, of course. And, sorry, just to remind ourselves that we are dealing with the period of time running up to –

Dame Harries: Exactly.

Counsel Inquiry: – the pandemic, so that’s why I’d counted the question in terms of –

Dame Harries: Yes, exactly.

Counsel Inquiry: – PHE.

Dame Harries: So PHE had a VCR team, it was a vaccine and countermeasures response team –

Counsel Inquiry: Yes.

Dame Harries: – which was not there to set the parameters of the stockpile, it was there to do the procurement and manage the processing of it and make sure it was stored effectively and that it turned over effectively. And it’s quite a complex procurement and management system which – I realise you have a very, very long chapter on that, but important because there is another part in Department of Health which links with it, and the actual parameters of the stockpile are set through the Department of Health and with input from groups such as NERVTAG.

Counsel Inquiry: All right.

I have two topics left. One is the health of the population prior to Covid-19 and the extent to which pre-existing inequalities and vulnerabilities were considered and accounted for in pandemic planning and preparations.

Was it part of PHE’s functions to assess the nation’s health from time to time and also to seek to improve it?

Dame Harries: Yes.

Counsel Inquiry: Right, and what assessment would you give to the Inquiry about the state of the nation’s health in the months running up to the Covid pandemic hitting?

Dame Harries: I’ve read Sir Michael Marmot’s report and I would agree with the broad headline. I’ll put some caveats. The principle, which I think many people have established and we know, is that infectious disease will follow those areas of vulnerability, and that’s – and I don’t just mean clinical vulnerability, although that is important separately. It will be the vulnerability, combined vulnerability of socio-economic deprivation and things like housing and, you know, whether people have got good jobs. These are all protective measures for good health outcomes.

So I broadly agree. I – and he says himself – I don’t agree necessarily that the causative element, the link between the timeframe for austerity and the burden of disease in the population, it’s very difficult to draw that conclusion directly. It’s possible, but even he acknowledges that.

Counsel Inquiry: Right, okay. So as a principle?

Dame Harries: But as a principle, people who are in the more deprived areas will suffer from – they’re more adversely affected by infectious diseases but also by underlying health conditions as well, which combined then creates a major problem.

Counsel Inquiry: Right. Although you question the timescale, do you accept what Professors Marmot and Bambra said about the decline in the ten years running up to the Covid pandemic?

Dame Harries: I think what I’m saying is the object of evidence of decline you can measure, health and socio-economic deprivation and burden of disease. The bit that’s not so easy to do is draw the direct link. They were making a link directly between austerity and (inaudible) –

Counsel Inquiry: Yes. No, no.

Dame Harries: – and some people will and others won’t, and I’m just saying it’s difficult to draw that. But definitely the shape of the curve, if you like –

Counsel Inquiry: Yes.

Dame Harries: – is clear, it’s evidential.

Counsel Inquiry: Over the ten years leading up to the pandemic?

Dame Harries: Yes.

Counsel Inquiry: Thank you.

May we put up on the screen, please, the report from the Institute of Government which is entitled “How fit were public services for the coronavirus?” Thank you very much. If we go immediately, please, to page 11, I would just like to look with you, please, Dame Jenny, at the chart at the top of the page.

This is a piece of work that has been prepared by the institute and they have through various pieces of evidence received, sought to draw conclusions in relation to how prepared and resilient public services were at the start of the crisis, providing red for a level of organisational preparedness that was below par or failed, amber for something that was acceptable, and green for good.

We can see that on the left-hand side the categories are split into “Preparedness” and “Resilience”, and each of those into “Quality of plans”, “Ability to implement plans”, “Performance going into the crisis”, “Staff”, “Buildings” and “Equipment”.

Then along the horizontal axis and in the columns coming down from the top, we see “The NHS”: “Hospitals” and “General practice”; “Local government”: “Local emergency support services”, “Adult social care”, “Children’s social care”; “Education”: “Schools”. And then “The criminal justice system”, on the right-hand side, separated into “Police”, “Criminal courts” and “Prisons”.

The resilience of hospitals wasn’t good, but if we look further to the middle of the graph we can see that, both in relation to preparedness and resilience, adult social care appears to have failed.

Are those concerns reflected in your experience of these organisations running up to the time that the pandemic hit?

Dame Harries: I think I will have to refrain from comment, I’m a scientist, this looks completely subjective and I have absolutely no idea on how the ratings have been derived.

I mean, I can make a few comments, but just looking at it, for example, hospitals, ability to implement plans if you have no staff, or we’ve said that the EPRR arrangements are low, feels a slightly strange conclusion.

I think in adult social care as well. I mean, it is one of the big problems for social care – and I might add I have personal family experience of this and used to support commissioning in local authorities – so I think, notwithstanding what’s on there, I would agree that social care was a high-risk area and one of the difficulties – and this goes to buildings and equipment and what have you – is it is a largely privately provided service, so the difficulties of ensuring that there are plans that are fit or that people who are running those services, their responsibility at the start of the pandemic to understand infection control and have PPE ready for their staff is really challenging, and I think that has come out through the pandemic.

What I do know is they are an extremely vulnerable group of individuals and I think, you know, recognise – and I personally always see this as a continuum for medical care, you can’t just exclude one side of it. But I would – I’m afraid would have to refrain from comment on the rest, because it’s not very evidential.

Counsel Inquiry: Well, I had understood that you’d been provided with the report provided by the Institute of Government prior to today, and you would have understood that the findings are based on extensive desk research, analysis of government data, interviews with civil servants, frontline staff, representative bodies and other experts.

Dame Harries: But it still has a subjective element to it. I mean, things that I could comment on: for example, prisons actually in the first wave of the pandemic had excellent outcomes, and in fact PHE is a WHO collaborating centre for prison health, and you can see a marked contrast between the outcomes there in the first wave and the US. But, you know, I still think by the time you put those together somebody has to knit them. So I agree with you in the overarching. The red column in the middle absolutely stands out and I would agree with it.

Counsel Inquiry: Thank you.

Finally I want to give you the opportunity, Dame Jenny, to provide us with your experience and knowledge in terms of what we have been through, your evidence today, but also any aspects that we haven’t touched upon and allow you to assist the Chair in terms of any recommendations that she may want to consider in terms of lessons learned.

I know that in particular you were impressed with evidence that has been given to the Inquiry about the possibility of recommending the appointment of a resilience minister.

Dame Harries: Yes, thank you. It wasn’t an idea that I thought I would warm to when somebody first suggested it, but actually when I look back through my experience and when you look at what I’m calling the wicked issues, one of the difficulties is that these – for example, infrastructure for maintaining very high containment level laboratories, or social care agenda – cannot be tackled even by a very willing – and I might add Department of Health have worked very hard with us – individual department. It needs somebody, and you see it happening in incident response, which is why Sir Oliver Letwin’s contribution was very interesting. I don’t say that with a political slant at all. It was very evident that he understood what happened and how you needed to make things work.

So I tend to agree. I would add a note of caution, which is: just like the rest of the system, churn in the system is a major problem, we lose understanding, we lose connections, and I’ve had four different ministers in the Department of Health, and you can start to see the difference of people who understand the problems and then clearly it turns to other things, which we – you know, is inevitable.

So I think that minister almost needs to stay with it for the whole of the Parliamentary session, almost, for it to maintain the infrastructure for the country.

The second point I would make is to do with the science. Again, Sir Patrick Vallance said this, but I think we are – and I think David Heymann said it, we’re missing what the opportunities are. This all sounds very depressing and where everything may or may not have gone wrong, but for UKHSA, one of the positive things about having a science – more science-focused organisation is to work upstream. So in contrast to perhaps where we have been, it’s allowing me to put in more systematic horizon scanning and surveillance, we’re already starting to work with industry and we’ve taken in – so somebody I think mentioned: where has the vaccine taskforce gone? The answer is: I’ve got it and I’m working with it upfront, because we have the opportunity with new vaccine products, new diagnostic tests, to actually do one was things which was missing here, which was put equal focus on prevention for the next pandemic. And we have new tools.

Ms Blackwell: Thank you.

My Lady, that completes my questions. I know that provisional permission has been given to Ms Claire Mitchell King’s Counsel on behalf of the Scottish Covid Bereaved to ask a question, I think one or two questions on the topic of Dame Jenny Harries’ role as DCMO for England, and may she do that now?

Lady Hallett: Of course.

Ms Mitchell.

Questions From Ms Mitchell KC

Ms Mitchell: I’m obliged.

Dame Jenny, we have heard that you were Deputy Chief Medical Officer for England 2019 to 2021, and in your evidence today you’ve spoken about connections between governments and organisations and also the interconnectivity and the benefits of interconnectivity.

I’d like to ask you, please, about the connections between individuals in the roles of the four nations, and particularly your role when you were Deputy Chief Medical Officer.

During your time as Deputy Chief Medical Officer, did you have meetings or discussions with the other Deputy Chief Medical Officers in their roles in the four nations?

Dame Harries: Yes.

Ms Mitchell KC: Can you tell me, was any of the work that was done in those discussions and meetings related to pandemic planning or pandemic preparedness?

Dame Harries: So during the Covid pandemic, most of it is obviously – I mean, we’re moving on to the next phase, almost, so I’m just looking for a signal as to how I should answer this.

Lady Hallett: No, we’re asking about – I think Ms Mitchell is asking about what was the work done in collaboration with the devolved administrations in relation to planning and preparedness, not response.

Dame Harries: In that case, I might decline slightly, because – just to explain, my – although it may not appear that to the nation, my Deputy – there are usually two Deputy Chief Medical Officers supporting the English CMO. One of them did the health protection role, which was Professor Jonathan Van-Tam, and the other one is the health improvement role. So actually when I joined the department it was to support work on tobacco control, obesity, physical exercise and that sort of agenda. So I would not have expected to be involved in the planning for pandemics. It would be more with the health protection DCMO.

Ms Mitchell: I see, but one of your colleagues would be the person that we posed that question to then?

Dame Harries: Yes.

Ms Mitchell: I’m obliged.

Lady Hallett: Thank you very much, Ms Mitchell.

Thank you very much, Dame Jenny, I think that concludes the questions – thank you very much to our stenographer for keeping going – I’m very grateful to you for all your help and for your interesting thoughts.

The Witness: Thank you.

(The witness withdrew)

Lady Hallett: Thank you, and 10 o’clock tomorrow morning, please.

Ms Blackwell: Thank you, my Lady.

(5.00 pm)

(The hearing adjourned until 10 am on Tuesday, 27 June 2023)