Transcript of Module 2B Public Hearing on 01 March 2024.
(9.59 am)
Lady Hallett: Good morning on a rather damp St David’s Day
here in Cardiff.
Mr Poole: Can I call Dr Chris Williams, please.
Dr Chris Williams
DR CHRIS WILLIAMS (sworn).
Questions From Lead Counsel to the Inquiry for Module 2B
Mr Poole: Could you please start by giving us your full
name.
Dr Chris Williams: Christopher Julian Williams.
Lead 2B: Dr Williams, thank you for attending the Inquiry today
to give your evidence. Can I just remind you to please
keep your voice up so that we can hear you but also so
that your evidence can be recorded. If I ask you
a question you don’t understand, please do ask me to
rephrase it. There will be breaks, but if you do need
one, let us know.
Your witness statement to this module is at
INQ000251938. That was signed and dated on 17 August,
and is that statement true to the best of your knowledge
and belief?
Dr Chris Williams: It is.
Lead 2B: Now, Dr Williams, in terms of your professional
background, I understand that you have worked as
a consultant epidemiologist in Public Health Wales Communicable Disease Surveillance Centre, the CDSC, since 2013, and you have been involved in public health responses to communicable diseases since 2001; is that right?
Dr Chris Williams: Yes.
Lead 2B: You are a medical doctor, you completed your medical training and trained as a medical registrar with NHS England, following which you trained in the European fellowship for intervention epidemiology in Germany; is that right?
Dr Chris Williams: Roughly, there’s – some of the organisations have changed names, but yeah.
Lead 2B: Between 2008 and 2013 you worked as a consultant in communicable disease control, with responsibilities for outbreak control and surveillance, and you had involvement I think in the 2009 swine flu pandemic, and in addition you’ve worked for the World Health Organisation as an epidemiology consultant; is that also correct?
Dr Chris Williams: That’s correct, yes.
Lead 2B: Now, Dr Williams, going back to January 2020, and setting the scene, at the time you were one of only three consultants in the Communicable Disease Surveillance Centre; is that right?
Dr Chris Williams: Yes.
Lead 2B: Can you briefly tell us what the CDSC was and perhaps
explain its importance and significance in that period
January to March 2020.
Dr Chris Williams: So we have a responsibility for surveillance of
infectious diseases, also advising on outbreak
management and research, teaching, those kind of
activities.
In the early part of the pandemic we moved from
hearing about the first case from the WHO at the end of
2019 to starting to get briefings, mainly through
colleagues in Public Health England, about this new
infection, new disease that was affecting people in
China, and there were a series of meetings on that,
which in general Public Health England led, and we were
just – we were picking up on what was going and I was
disseminating it through my organisation.
Lead 2B: We will come to look at that in a bit more detail and
break that period down in a moment, but I understand
that in March 2020 you became one of three incident
directors to Public Health Wales. What did that role
involve?
Dr Chris Williams: So that was more day-to-day decision-making, attending
particular groups with respect to the response within
Public Health Wales, and, you know, monitoring the
situation. So there was quite a few tasks associated with that, but essentially it was the tactical response on the day. I was one, as you say, of three, and then I think there were four later.
Lead 2B: I’m right in saying that you were also involved with the Technical Advisory Cell and the Technical Advisory Group that we heard a bit about from Dr Hoyle yesterday; is that right?
Dr Chris Williams: That’s right, yeah.
Lead 2B: What was your primary contribution to the Technical Advisory Group?
Dr Chris Williams: So at the beginning I was involved with my role as an epidemiologist and passing on some of the information I was getting through the briefings and other mechanisms. I think the majority of the time I was there to give reports on the surveillance and the unfolding epidemiology of the infection in Wales.
Lead 2B: Would it be a fair summary to say that you were fairly heavily involved, then, with Public Health Wales and the Technical Advisory Group’s pandemic response in that early period, January, February, March 2020?
Dr Chris Williams: I think that’s fair to say, yes. Probably more Public Health Wales because that was my main role, but I was also involved in TAG and worked with the Chief Scientific Adviser for Health.
Lead 2B: So you were working closely with Dr Orford. Were you also working closely with Dr Atherton, the Chief Medical Officer?
Dr Chris Williams: Less so with Dr Atherton, it was more Dr Orford.
Lead 2B: Of the group of scientists at that time that were working and advising, was it only you that had an academic background in epidemiology and communicable diseases?
Dr Chris Williams: I can’t recall all of the qualifications of everyone in TAG, but certainly Welsh Government colleagues were more health and health policy and other aspects of science. There aren’t a huge number of infectious disease epidemiologists in general and in the UK.
Lead 2B: And am I right in saying that you undertook this work in an independent capacity insofar as you were not employed by the Welsh Government; that’s right, isn’t it?
Dr Chris Williams: Yes.
Lead 2B: Now, when did you first become aware of the pandemic?
Dr Chris Williams: So I can’t recall exactly, but I think I would have seen news reports of the WHO report at the end of 2019. I think it was 7 January when there was a briefing just after the Christmas period from Public Health England about a new pneumonia syndrome coming out in Wuhan in China, and there was sketchy information at that time, but there were continual meetings, repeated meetings, and then we started to learn more.
Lead 2B: Following that 7 January Public Health England meeting, what role did you assume regarding the outbreak?
Dr Chris Williams: Within CDSC, we tended to get involved when there was a briefing or some kind of communication about something that came through nationally, so I wrote a briefing note, I think it was the next day, based on the initial briefing, I informed other colleagues, and I think there were further briefing notes that came out from England that we then read and adapted and added to.
Lead 2B: Now, the Inquiry understands that there was a devolved administration update on 15 January that was also hosted by Public Health England. Did you attend that meeting, can you recall?
Dr Chris Williams: I’d have to check my evidence pack. Probably I would have done.
Lead 2B: What was your perception of the risk posed by Covid-19 at that time, so we’re talking mid-January 2020?
Dr Chris Williams: I honestly can’t recall what my perception is. What I do remember was that, towards the latter half of January, as there were reports of more and more cases coming from China, I was attempting to work out how fast the infection was spreading using some very rough, you know, mathematical techniques, so I must have had – been aware that there was a possibility of much wider spread.
Lead 2B: At this point in time, so still in sort of mid to late January, what body was responsible for providing expert epidemiology and scientific advice to the Welsh Government in a sort of day-to-day de facto sense?
Dr Chris Williams: That would have been Public Health Wales. Public Health England, because of their – they had a larger respiratory department and international department and other links, they tended to get information, you know, earlier or from different sources to us. Obviously we could access the media and other published sources, but a lot of the time we were taking information that was given to us by them, interpreting it, seeing what the context was for Wales and then disseminating it within our organisation and also to Welsh Government.
Lead 2B: Now, on 23 January 2020, there was a Public Health Wales briefing entitled “Update on Wuhan novel coronavirus”, I don’t intend to bring it up on the screen, but I just want to understand, did you play a role in authoring that briefing?
Dr Chris Williams: Yes, I would – I would have written that, but, again, adapted, probably, from a Public Health England briefing.
Lead 2B: Understood.
Now, that briefing note confirmed the likelihood of human-to-human transmission, and just to read a passage from it, it says:
“Due to the enlarging geographic area affected, and evidence of human to human transmission, it is increasingly likely that suspected cases (those with an appropriate clinical picture and travel or contact exposure) will be identified in the UK, including Wales.”
Did that 23 January briefing change the pandemic response in any way in Wales?
Dr Chris Williams: Once again, I can’t remember the exact sequence of events regarding the stepping up of various emergency response activities within Public Health Wales, but we were – certainly that briefing will have gone to key individuals within Public Health Wales and we made sure that people were aware of the risk.
Lead 2B: Can you tell us how Public Health Wales was monitoring and advising the Welsh Government on the spread of Covid-19 at this time, so we’re still at the back end of January 2020.
Dr Chris Williams: Again, my recollection is not strong from this time, but where we would have had information from the England briefings and the – by that time – daily meetings regarding the situation, I would have sent – I and sometimes colleagues would have sent out an email that also included, I believe, Welsh Government colleagues at the time. If it wasn’t directly to Welsh Government colleagues, then someone more senior to me would have disseminated that.
Lead 2B: Was there an understanding amongst your colleagues and those advising the Welsh Government at this time that this had pandemic potential?
Dr Chris Williams: I think we were – we were beginning to realise it had pandemic potential once – particularly once there were more widespread cases in China. You don’t necessarily get to hear about all of the cases and all of the transmission, so you can probably assume that if there are actual official reports from a country such as China that there’s probably quite a lot of transmission going on, and there was still international travel.
Lead 2B: Did you or any of your colleagues at this point think it worthwhile to review the Wales pan flu response plans and look whether they would be sufficient for a coronavirus pandemic?
Dr Chris Williams: I can’t recall whether we looked particularly at the pandemic flu plans. We were – we would have been aware of them. As I said, I was involved in the 2009 pandemic, so I’m sure I’d have looked at them at the time. But the plans tend to – you have to adapt based on the circumstances that are coming, and I think this needed a different response.
Lead 2B: Just on that point, then, were you given, can you recall, any instructions at any point at this period of time to perhaps begin reviewing population-wide NPIs to deal with a virus spreading such as this, as was instituted in China?
Dr Chris Williams: So we had the example of China. I don’t recall considering those for – for the UK. The climate of thinking was not necessarily to start with NPIs, because they’d never really been done at that level. That took a bit longer for that thinking to come through, I think.
Lead 2B: What about scaling up surveillance and contact tracing capacity, was that something that was – thought was given to at this point in time?
Dr Chris Williams: We were certainly scaling up surveillance activity. There were the First Few 100 epidemiology forms that we would sign to complete where we’d got suspected cases. And in terms of contact tracing I think I did – it might have been February by that time – I think I did write something on that.
Contact tracing per se isn’t necessarily the responsibility of CDSC, but we would have been involved in the surveillance, and maybe advising on that kind of response.
Lead 2B: To your recollection, was there any work being done to prepare care homes and hospitals for numerous cases and the risk of nosocomial infection?
Dr Chris Williams: I can’t recall any – any particular preparations along those lines, but we did make sure that all of our briefings went to the health service in Wales. And nosocomial spread of infections, respiratory infections is always a risk and … yeah.
Lead 2B: Now, Dr Sandifer has told the Inquiry in his written evidence that, with the exception of the CMO and his staff, he did not see the same awareness of and urgency about Covid across the rest of the Welsh Government. He has said what he thinks was missing in these first few weeks, namely 8 January, when he first became aware of Covid, to 20 February, which was the first meeting of the Welsh Government HSSG Coronavirus Planning and Response Group, he says what was lacking was national strategic leadership and co-ordination from the Welsh Government.
Do you have any comments on those observations of Dr Sandifer?
Dr Chris Williams: Between sort of mid-January up to sort of late February, early March, I didn’t have an awful lot of direct working with the Welsh Government, so I’m not really able to comment on their level of preparedness.
Lead 2B: Now, the Inquiry’s heard in Module 2 that the approach to the pandemic response in accordance with the UK influenza pandemic strategy was one of containment. What did you understand by “containment” and how was that implemented by Public Health Wales?
Dr Chris Williams: The idea behind containment is that you would identify every single case that came into the country, you would trace their contacts, gather some information about them and their contacts, and put into place isolation and quarantine of those contacts to ensure that there were no secondary or further cases. That was – that had been the response also in 2009, as – “containment phase”, as they called it.
Lead 2B: Now, the Inquiry also understands that in January 2020 there were several direct flights each week to Wuhan City from London Heathrow and other indirect flight routes. We know also that the common symptoms of Covid-19 were fever and a cold, so the kind of symptoms that might mirror a common cold might not give cause for concern.
Knowing all of that, what was your view on the likely success of a containment strategy?
Dr Chris Williams: Again, I don’t know exactly what my thoughts would have been at the time, but I had my experience of the 2009 pandemic of influenza which showed that containment really isn’t very feasible in a country with lots of international connections, with infections that are highly contagious, rapidly spread, and, you know, spread through multiple mechanisms.
Lead 2B: Was it your view, then, with that prior experience, that Wales needed to really start preparing for mass community transmission?
Dr Chris Williams: I suppose that’s the implication, yes, that that was probably on the way, when we were doing – as I say, I wasn’t directly doing the contact tracing, but when we were responding to that surveillance-wise, I think we were aware that it wasn’t going to be successful.
Lead 2B: And perhaps with the benefit of hindsight, do you think that containment was the right approach for Wales in February 2020?
Dr Chris Williams: I think it was, because even if you think you’re eventually not going to succeed, it’s worth trying the best you can. It will at least slow – especially in the first – first few cases, you can genuinely slow the infection. But as more and more people travel, you get, you know, cases that you’re not aware of, that are then transmitting, then that’s when it becomes untenable.
Lead 2B: As we move into late February, how did the epidemiological picture in Wales develop?
Dr Chris Williams: So I checked my notes before. The first case I think we reported was on 28 February in somebody that had returned from northern Italy, and then – we should also remember that before that there were a number of suspected cases reported, so people with appropriate symptoms and who had travelled to China or the changing list of countries, who were then identified, isolated, tested and found to be negative. But this was our first positive case, and from then on, you know, the case numbers did increase through March.
Lead 2B: A week or so before that first case, there was a SAGE meeting on 20 February. Were you and your colleagues at Public Health Wales appraised of what was discussed at that SAGE meeting, can you recall?
Dr Chris Williams: I don’t recall that particular one. I don’t think I was able to have any contact through SAGE meetings until either late February or early March via Welsh Government colleagues.
Lead 2B: So after that SAGE meeting of 20 February, Dr Orford emailed Dr Atherton and some other senior figures in HSSG about those SAGE discussions. Now, you aren’t copied in to that email. It says:
“From cruise ship – 30-50% asymptomatic-mild;
“Likely that UK testing has missed 40% of positives, due to delay in testing versus detectability of virus.”
Are those figures, and especially that point about testing missing 40% of positives, something that you were made aware of at that time?
Dr Chris Williams: I think I would have heard about the results of the cruise ship testing through some of the other professional briefings and, yeah, the fact of there being some asymptomatic cases probably wouldn’t have been a huge surprise.
Lead 2B: If 40% of positive cases had been missed, does it not follow that containment measures would effectively be obsolete?
Dr Chris Williams: That is the difficulty with containment. You just – I remember writing things at the time saying if we’re not catching all the cases then you’re only getting whatever effectiveness you get from the cases that you do know about.
Lead 2B: So being aware of this figure of 40% of – 40% being missed of positives, did you or any of your colleagues advise the Welsh Government of the difficulty that this presented with a containment strategy?
Dr Chris Williams: I don’t recall any advice I gave on that respect. The containment strategy, in my recollection, was a kind of UK-led strategy, so we were following the UK strategy, which started with containment.
Lead 2B: But if by 20 February you’ve got Dr Orford emailing Dr Atherton and noting in particular this worrying data about missed 40% of positives, should Wales have still been following the UK Government’s containment strategy, if effectively it was a doomed strategy by this point in time?
Dr Chris Williams: I would say that if you take the counterfactual, if Wales had decided that we would stop contact tracing, stop trying to identify new cases whilst that activity continued in the other nations of the UK, I don’t think that would have been particularly helpful to the response. I think you have to try, even though it’s very difficult and essentially impossible after a while.
Lead 2B: Can we, please, have a look at INQ000309714.
This was a presentation that was delivered, as we can see on the screen, by Dr Sandifer to the HSSG planning and response group on 28 February. It provided an update as to the progression of Covid-19 in Wales.
Did you have any input into that presentation, Dr Williams?
Dr Chris Williams: I don’t recall, but it’s likely that I would have done through some of the update slides that we’d send round.
Lead 2B: If we could please have page 16 of this presentation. The second – sorry, the third and fourth bullet points read:
“• Estimated 10 fold increased demand with further widening of geographical area within Europe.
“• Estimated 100 fold increased demand to account for historic cases that will then meet possible case definition.”
In this case what does “demand” refer to? Is this the demand on Public Health Wales to conduct surveillance and containment on all likely Covid-19 cases?
Dr Chris Williams: I can’t recall exactly, but I think there was discussion about resources needed for contact tracing around this time and that may have been playing into this. The contact tracing is very resource-intensive and with a sort of exponential increase in cases, it becomes quite difficult.
Lead 2B: Did you agree that there was likely to be a tenfold and then a hundredfold increase in cases that needed to be contained?
Dr Chris Williams: I can’t recall this exactly. This – the second statement seems to be about changes to the – retrospective changes to the case definition, so yeah, I’m not sure that – I can’t remember the implication of this.
Lead 2B: At this point would it be fair to say it was almost certain that community transmission would become widespread, in the event it wasn’t already?
Dr Chris Williams: Yeah, I think that’s fair to say. And, as I say, through my experience from 2009, I didn’t think that containment and contact tracing was some – was a possible early means of containing an infection like this, particularly in a country such as the UK, and when we had continued travel and, you know, continued movement within the country.
Lead 2B: We can, please, look at the next page, page 17. So on this following slide it reads:
“Healthcare providers response.
“Future challenges.
“• Step change in magnitude of response required.”
So did you see the need for a step change in the magnitude of response once it was clear that containment would not last?
Dr Chris Williams: Yes. It was going to be a huge demand on the NHS, regardless of the impact on individuals, also just – just the isolation, testing, those kind of demands.
Lead 2B: Could we, please, have INQ000252365. Thank you.
This is an email thread on 29 February, so the day after the presentation we’ve just been looking at, regarding Public Health England modelling work. We can see that from the subject title.
Now, it’s an email chain between yourself, Andrew Jones, Deputy CMO, Quentin Sandifer, and Dr Orford.
Can we please look at page 2, and the bottom email is from Andrew Jones, who worked for Public Health Wales, to Dr Orford, and it says:
“Dear Rob,
“We have just come off the PHE IMT.
“PHE have reported, through Yvonne Doyle MD, that work on the modelling to inform scenario planning, ‘next stage guidance’ including on containment strategy, has been accelerated and will commence today.”
Then if we can just go up to the next email in the chain, so it starts at the bottom of page 1, it’s an email from Dr Orford in response:
“Thanks Andrew, this is very helpful. Please let me know if there is anything that you need from me in the interim. Happy to call if this is easier?
“We will continue stetting up a STAC and work on better sharing of intel. We will write to SAGE early next week informing them as such, including those involved. Once we have the secure shared drive and mailbox in place we will forward details.
“Have not received read-out from Thursday’s SAGE yet which concerns me!”
Then the next email in the chain, the next one above, is from Dr Sandifer, in the middle of that page:
“We should avoid calling it a STAC – it isn’t – and what we need is the same level of urgency as it seems is happening in PHE/DHSC.”
Now, do you agree, Dr Williams, that parts of Public Health Wales, HSSG, were not responding to the Covid pandemic with the same level of urgency as in Public Health England?
Dr Chris Williams: I don’t think that was necessarily the case. You say Public Health Wales, HSSG, so HSSG is a subgroup of the Welsh Government is my understanding. But, yeah, we were working certainly in the CDSC with a lot of urgency, and a lot of our work was directed towards – towards this.
Lead 2B: As we move into March, there was a COBR meeting on 2 March in which it was announced that contact tracing for the source of the last two cases of Covid in the UK had been unsuccessful and that there was sustained community transmission in France and Germany. So at that point was it not guaranteed that containment had failed?
Dr Chris Williams: Yes, I imagine so.
Lead 2B: Now, there’s nothing of this in the TAC minutes of 2 March. Does that suggest that TAC had either not been made aware by its counterpart scientists on SAGE before that was announced in COBR?
Dr Chris Williams: I don’t recall the discussions in TAC. My recollection from the time is that particularly up until the first lockdown we were really, as a UK, including Scotland, Northern Ireland, following a sort of UK Government and PHE-led response, so contain was part of the overall response. We could have had debate about – internally about whether it was working, whether the contact tracing was working, but there wasn’t really a sense that that was something amenable to change. This was the response. And even – you know, even now, I think that was fair. I think a UK response was the right thing at the time.
Lead 2B: So just going back to one of my earlier questions, when I think I asked you from your experience on the ground who had overall ownership of pandemic response in this early period, and I think you answered Public Health Wales, in light of what you’ve just said, would it not be fair to say that effectively ownership of pandemic response was being led by Public Health England, with the devolved administrations – we’re obviously focusing on Wales and Public Health Wales – sort of effectively following suit; is that fair?
Dr Chris Williams: For most of the major decisions I think that was fair, but of course we had to plan within the context of a Welsh NHS and our own systems, and I know my colleagues in the laboratory, for example, were working on testing, et cetera. So there were elements that were Wales-specific, but the overarching plan I think was a UK one.
Lead 2B: I now want to turn to a SAGE report. It’s INQ000224070. It’s entitled, as we can see on the screen:
“Low critical care capacity and high severity of Covid-19 mean there is little functional difference between successful ‘flattening the curve’ and ongoing containment.”
This was presented to SPI-M and SAGE. It’s, I think, first produced 9 March but then updated on 16 March.
If I can, please, ask for page 6, final paragraph, to be brought up.
I’m going to start reading from the end of the second line:
“The model results here do no more than reinforce the findings of the WHO China Mission and validate the strategy adopted by Chinese health authorities in or around the 23rd of January 2020; and then subsequently by Hong Kong, Singapore, Japan, and South Korea. We suggest that they are strong evidence with which to abandon mitigation strategies, justified in any way by the possibility of a short epidemic. Governments need to devote the entirety of their attention and resources to creating viable ongoing solutions to the presence of this virus. We suggest that the first step is to adopt stringent fixed-term social distancing so as to give time for detailed planning the rapid development and any accompanying technology.”
Were you made aware of this SPI-M paper, and if so when were you aware?
Dr Chris Williams: I don’t recall exactly when I was aware of it, but I can recall it was within a few days or maybe even the same day. My recollection is this represented a kind of shift in thinking in terms of the academic papers being brought to SPI-M from a strategy of mitigation, which was the flattening the curve, to a recognition that mitigation would actually be an untenable and catastrophic situation, and actually would probably result in the same sort of social distancing that a planned extreme social distancing by mandate would have done.
So I think this was – this Riley paper was the first one that really – in my recollection, that said we had to lock down, essentially, and soon, and that mitigation wasn’t really a viable strategy.
Lead 2B: So this was significant in shifting the opinions within TAG; is that right?
Dr Chris Williams: I think – I don’t – I can’t say for, within TAG as a whole group, but I think within – I had some indirect access to what was going on in SAGE and, I think, SPI-M at the time, and this shifted the viewpoints there.
Lead 2B: If we can, please, have INQ000251994 on the screen, please.
This is a TAC document titled “Covid – Technical Advisory Cell: Briefing on Behavioural and Social Interventions”. It was circulated on 11 March 2020. Looking at the second paragraph, first, please:
“There are a range of behavioural and social interventions that are evidenced as having been effective in responding to past epidemics. These interventions are well understood by the public and have been enacted in other countries.”
Then in the third paragraph:
“Applying behavioural interventions could be helpful in containing an epidemic to some degree or changing the shape of the epidemiological curve …”
Just pausing there, why “could be”?
Dr Chris Williams: Yeah, I have reviewed this document, it does come a few days after the Riley paper, although before the 16 March update. I don’t think the sentence is entirely clear. I don’t recall to what extent I would have had any contribution to that, but it’s …
Lead 2B: But you would agree “could” seems slightly odd in this paragraph?
Dr Chris Williams: Yes.
Lead 2B: If we can skip down to the sixth paragraph, please, at the bottom of this page:
“SAGE considered that measures relating to individual isolation will likely need to be enacted within the next 10 to 14 days to be fully effective, and those concerning household quarantining and social distancing of the elderly and vulnerable 2-3 weeks after this. However, the triggers for individual and household isolation could be met earlier depending on the progress of the outbreak in the UK.”
Then if we can go over the page, please, to paragraph 9:
“Modelling suggests that the stringent interventions introduced in Wuhan from 23 January … may have reduced the reproduction number to below one. However, there are differing views across the scientific community about whether other factors were involved in this.”
Just, again, pausing there, what was your view about the efficacy of the measures that had been implemented in Wuhan?
Dr Chris Williams: So I think measures in Wuhan and, to an extent, in northern Italy showed that it was possible to enact extreme social distancing to drive the reproduction number below 1 and actually suppress the wave, so I think it was empirically possible.
The debate that I can recall was around the modelling and scenario planning as to what might be possible within the UK, and, as I say, the thinking moved on from flattening the curve to realising that actually it was not only possible to enact a lockdown but actually it was necessary, to avoid terrible loss of life and an impact on wider society.
My impression of this document is it was – it was – it’s maybe a few days behind some of the – that SAGE thinking, but I couldn’t give you a day-by-day account of how those things went on.
Lead 2B: Just have a look at a couple more paragraphs, if we may, in this document. Paragraph 10 next, please:
“Hong Kong and Singapore are undertaking extensive contact tracing as well as a raft of social distancing measures such as school closures and self-isolation, but not to the same level of stringency as seen in Wuhan. There is also anecdotal evidence of extensive self-isolation by the general population. The roughly linear increase in the number of cases in Hong Kong and Singapore suggest that this approach has held the reproduction number around one.”
Then if we can, please, go over the page, to page 3, and look at the second bullet point:
“Home and work based distancing interventions have a greater individual impact. When combined self-isolation, household quarantine and social distancing of vulnerable groups and over 70s is predicted to lead to a 37% reduction in infection related deaths.”
Then finally, please, paragraph 13 at the bottom of this page:
“A combination of these measures is expected to have a greater impact: implementing a subset of measures would be ideal. Whilst this would have a more moderate impact it would be much less likely to result in a second wave. In comparison, combining stringent social distancing measures, school closures and quarantining cases, as a long-term policy, may have a similar impact to that seen in Hong Kong or Singapore but this could result in a large second epidemic wave once the measures were lifted.”
Just, again, pausing there, it’s right, isn’t it, that Hong Kong and Singapore had experienced their own coronavirus pandemic in the last 20 years, so they had experience of multiple waves; yes?
Dr Chris Williams: The SARS-CoV-1 – I suppose it was a pandemic but not in the same sense as, say, the 2009 pandemic, but they had experience of having to step up contact tracing and, you know, those sorts of interventions rapidly.
Lead 2B: Had they not modelled the impacts of second and third waves as well?
Dr Chris Williams: I don’t know what modelling they’d done at the time.
Lead 2B: Going back to this document we’ve just been looking at, over the page, page 4, paragraph 14, please:
“The timing of interventions would be critical.”
Then paragraph 16, please:
“These interventions assume compliance levels of 50% or more long periods of time. This may be unachievable in the UK population and uptake of these measures is likely to vary across groups, possibly leading to variation in outbreak intensities across different communities.”
Can you help us, where did that assumption come from, namely that a compliance level of 50% may be unachievable in the UK population?
Dr Chris Williams: I don’t know where that would have come from. As I say, the arguments you presented here in this paper are sort of a mixture of the pre-Riley paper about flattening the curve, there’s the point about not putting in too many interventions, otherwise you’ll get a second wave, but then the one above that you presented shows about the ICU surveillance figures, which was actually part of the mechanism for the repeated lockdowns that Riley was advocating and then Ferguson’s paper after that.
Lead 2B: As a summary, by 11 March 2020, would it be fair to say the following things: the timing of an NPI would be critical, as is stated in this paper; you would agree?
Dr Chris Williams: Yes.
Lead 2B: Early intervention led to quicker results?
I’m afraid if you nod, we can’t pick up your answer.
Dr Chris Williams: Yes.
Lead 2B: Thank you. A combination of stringent NPIs, so home and work-based distancing interventions, self-isolation, household quarantine, social distancing of vulnerable groups, was likely to result in a 37% reduction in deaths?
Dr Chris Williams: Again, that came from the pre-Riley assumptions. I think that was not sufficient actually to suppress the epidemic, so this isn’t suppression, that’s a flattening the curve statistic in my recollection.
Lead 2B: I understand. Lockdown in Wuhan was effective?
Dr Chris Williams: Yes.
Lead 2B: Stringent NPIs in Hong Kong and Singapore also were effective?
Dr Chris Williams: Yes.
Lead 2B: The ideal outcome would have been to flatten the curve and push the epidemic into the summer months?
Dr Chris Williams: I’m not sure. Are you asking whether I think that now or whether that’s an implication of the paper?
Lead 2B: Whether at the time that would be – that would have been something that could have been safely assumed or thought.
Dr Chris Williams: I’m sorry, I can’t – I can’t really answer that.
Lead 2B: Bearing this in mind, and what we can see from this paper, why was lockdown not recommended by TAC at this point? So this is 11 March 2020.
Dr Chris Williams: So, again, this is on my recollection, but I have gone back and read some of the papers and done some further thinking, so it is with the benefit of that. My recollection, as I’ve said before, is that the overall strategy that we were following was a UK strategy, that the chief medical officers had made an agreement that they were going to attempt to do the same thing at the same time, except where there were specific reasons for a different response, because of differences in the NHS structure or whatever. So we were following a UK response.
My recollection – and TAG would have reflected the discussion and the thinking within SAGE. My recollection that the 13 March SAGE meeting, there was a consensus that lockdown was necessary. There may be need for repeated lockdowns, et cetera, but actually that there needed to be extreme social distancing to suppress the epidemic and prevent really severe impacts on the population.
And my recollection that after the previous papers about flattening the curve, that certainly by that 13 March meeting, that there was a consensus within SAGE, albeit although I wasn’t a member, so you maybe better ask people within SAGE, but that’s what they were recommending at that time, and I would have thought that TAG and the Chief Scientific Adviser would have echoed those views because that’s the way that we were operating.
Lead 2B: Now, I’ll – we’ll come on to that 13 March meeting in a moment. Just, though, hearing what you’ve said, that effectively it would have been impossible to have locked down without UK Government co-operation; is that fair?
Dr Chris Williams: I mean, I can’t say exactly how it would have gone, but I don’t think it would have been feasible.
Lead 2B: Do you not still think TAC should have at least considered locking down and advised the Welsh Government on locking down, leaving aside the practicalities or the relationship with the UK Government and what had been agreed at CMO level?
Dr Chris Williams: I suppose we could have considered doing that as a group, but recalling that the change in the thinking within the SAGE and modelling groups that we were relying on was only happening around this time.
Lead 2B: Could we please have INQ000271443 displayed. Thank you.
This is TAC’s briefing on behavioural and social interventions. We understand this to be dated 11 March.
If we have a look at point 4, please:
“The objectives of these interventions could be to:
“• Contain the outbreak so that it does not become an epidemic (note – this is [likely] to be [unachievable]).”
Was considering the possibility then of containment completely unrealistically about this date, namely 11 March?
Dr Chris Williams: Yes, I think that’s – that’s how it would be.
Lead 2B: Looking then at the next paragraph, paragraph 5, please:
“Any intervention would need to be Government policy for a significant duration (2-3 months) in order to see the benefit, as removing and/or relaxing the intervention too early could result in a new outbreak and potentially extend transmission of the virus into Winter 2020.”
Am I right in thinking that what this is saying is: go too early and the peak of infections might simply be displaced to a worse time of year?
Dr Chris Williams: So the first part of the sentence is correct, that any serious intervention would need to be done for significant duration. It’s also true that removing, relaxing it could result in a new outbreak. Reading it now, it looks like a mixture of the two forms of thought at the time, but essentially for a lockdown to work you have to implement it for a sufficient amount of time so that you know you’ve suppressed the virus and then you can then be sure that the levels are low once you’ve finished. What then happened after that is something that modelling might predict, but you don’t really know at the time.
Lead 2B: I understand. But does –
Lady Hallett: Mr Poole, just before you go on, I’m really sorry.
You said – am I right in thinking your question was: am I right in thinking that what this is saying is “go too early and the peak of infections may simply be displaced to a worse time of year”?
That’s not how I read it. I read it: because any intervention has to be two to three months long, then you don’t want to go too late because otherwise you risk going into the winter months.
That’s how I read it. So I read it the opposite way from you.
Mr Poole: Well, my Lady, perhaps we can put that to Dr Williams.
Lady Hallett: Which is the correct reading?
Dr Chris Williams: I have to confess I’m slightly confused by this paragraph, because it seems to be a mixture of flattening the curve and suppression, which was then moved on to.
The problem with the – was thought at the time was that suppression would work, so you put in interventions for two to three months, you would stop the epidemic for that time, but then after a while you would get a second infection and then you would either have to lock down again or you would get a further wave.
My also recollection is from the Riley paper and others that they predicted that it would come back every two to three months, actually even more frequently than that, which wasn’t actually the case in summer of 2020, so it took a longer time for the second wave to come around than they predicted.
Mr Poole: Is it right that this is predicated on the fact of there being sort of, effectively, only one lockdown? It doesn’t contemplate, does it, two or three successive lockdowns at specific intervals?
Dr Chris Williams: So as I’ve said, the Riley paper from the 9th was starting to contemplate the idea of repeated lockdowns or at least the first lockdowns. I can’t remember when the second paper came out but it actually did model repeated lockdowns. But this was around the time that that thinking was changing, so that might be the reason that this document is maybe a mixture of those views and was still reflecting the ideas of kind of flattening the peak, and also being concerned about not suppressing the peak because then you would get another peak but it would come in winter, when we would have the flu and other things at the time. I think the idea of lockdowns was quite far from practice in people’s minds and the idea of repeated lockdowns was even – even further away. So maybe that’s why the thinking was along those lines.
Lead 2B: If we can, please, have a look at, I think it’s page 6 of the document we’ve got in front of us, we can see there some of the modelling that was done, and I want to look – it’s not – certainly if you’re colour blind you won’t be able to follow this but I think you can just about see it, it’s – I’m looking at the grey dashed line.
Dr Chris Williams: Yeah.
Lead 2B: Is it right that that represents, looking at the key, school closures, case isolation, household quarantine and social distancing of the entire population?
Dr Chris Williams: Yes.
Lead 2B: So it is the scenario most like what we saw enacted over a week later, which we’re coming on to in a moment. Yes?
Dr Chris Williams: That’s right, yes. So the SD is the additional social isolation.
Lead 2B: Yes.
Dr Chris Williams: And it shows a flatten – it’s suppressed the first peak completely, but then you get a much larger peak, it predicts, actually into the summer.
Lead 2B: Is that because, as you’ve just described, a sort of reduction in case rates by mid-May and then suddenly a number of cases sharply increasing, is that because the model assumed that the set of restrictions would be lifted effectively all at once and then case numbers would increase in the population at that point?
Dr Chris Williams: I can’t remember the exact assumptions but there would have been something relatively simple like that, but yes, we assumed that – restrictions in place for X amount of time and then either gradually or immediately removed.
Lead 2B: Can you recall, did anyone ask about – going back to my previous question – multiple lockdowns or the staggered releasing of restrictions, or were those questions that were not being asked at this time?
Dr Chris Williams: I think the staggered release of restrictions – I can’t recall exactly what the modellers did, but they would have probably tried to put simple on/off things within the models, at this stage certainly. They – I think they were modelled later with staggered restrictions. And the idea of repeated lockdowns was I think the paper after this, when – again, I can’t recall exactly but I’m sure there were papers from Riley and papers from Ferguson, probably Edmunds’ group as well, showing what would happen if you lock down for a period and then you used good surveillance to watch until there were a certain number of cases emerging, I think in intensive care, and then you locked down again based on that number. So those were the models they were starting to run a little bit after this paper.
Lead 2B: Now, on 12 March the UK Government announced that from the following day, 13 March, those with coronavirus symptoms, either a new continuous cough, high temperature, should stay at home for at least seven days, and all those over 70 and those with serious medical conditions also advised against going on cruises.
Now, obviously that announcement fell short of a mandated lockdown. What warning were you given, Public Health Wales given or yourself or TAC given, ahead of that announcement by the UK Government?
Dr Chris Williams: I beg your pardon, is that 13 March?
Lead 2B: This is the announcement on 12 March, with the restrictions coming into effect the following day. What warning, if any, were you given about that announcement?
Dr Chris Williams: I don’t recall being given any warning.
Lead 2B: Were you surprised that an announcement like that would be made without your input and without any prior warning?
Dr Chris Williams: I can’t recall if I was surprised or not. I think I was surprised that it wasn’t a more – a more complete lockdown.
Lead 2B: At this point, so we’re now 12 March, was the scientific consensus in Wales in favour of restrictions being imposed only and no further, or in favour of an immediate lockdown, to your recollection?
Dr Chris Williams: My recollection, as far as it goes, was that we’d thought that – given all of the preceding papers, that by that 12 March that there would be a UK-wide mandated full lockdown, given the sorts of warnings that were given in the Riley and the Ferguson papers.
Lead 2B: Given that that was your view and, I think I’m right in saying, a sort of scientific consensus view by 12 March, and you were surprised that the 12 March announcement hadn’t gone further, did you speak to anyone about this? What did you do?
Dr Chris Williams: I can’t recall exactly my verbal or written communications at the time. As I say, my – my understanding at the time was that we were working as a four nations, as a UK-wide response, and it would have been very difficult to lock down in Wales and not lock down in England, and certainly we found subsequently – you know, there’s a lot of movement across the border – it only really works properly if there’s a UK-wide intervention.
Lead 2B: You’ve said earlier that you worked quite closely with Dr Orford, the Chief Scientific Adviser for Health in Wales, I mean, at this stage, did you raise your concerns with Dr Orford, can you recall?
Dr Chris Williams: I don’t recall whether I raised them in a written format. I think it’s probable that if we’d had any telephone meetings or similar at the time that I would have expressed surprise that that was the response.
Lead 2B: I think it would be fair summary to say that between this date, 12 March, and 20 March, those on TAC were becoming increasingly concerned about the approach being taken in Wales to the pandemic. If I can just anchor that in perhaps a point in time, on 15 March TAC authored a paper for the SAGE meeting that was to take place the following day – I don’t want that paper pulled up, please – it’s TAC’s recommendations for the Welsh Government, and the executive summary reads:
“TAC group recommends that unless the requisite resources [resources for the NHS to prevent it becoming overwhelmed] are identified in the next seven days, with a clearly defined plan to implement them in a timely manner a policy of more stringent interventions should be considered for Wales.”
Why was that your advice or TAC’s advice at that time?
Dr Chris Williams: I think that was to do with the NHS capacity, that it would need to be greatly augmented if we were going to have a big wave.
Lead 2B: So was there a concern that unless more stringent interventions were immediately put in place, then the NHS in Wales risked being overwhelmed?
Dr Chris Williams: Yes, that was a concern at the time.
Lead 2B: Do you think, looking back, that that advice was – went far enough?
Dr Chris Williams: I suppose even after – even at the time I did wonder whether we, including myself, could have done more to argue for an earlier lockdown, given that the UK-wide lockdown didn’t happen when we thought it might have done. The only other thing I would say is that we were ever so slightly behind the epidemiology in England, so actually the case numbers were maybe a week or something behind the numbers in England, and there was – you know, there was rationales for timings of lockdowns, but yes, I was – I have wondered about whether we – I should have argued harder for something to be done, but I’m not sure it would have made an awful lot of difference.
Lead 2B: Doesn’t being, epidemiologically, a week behind, doesn’t that, in fact, give Wales sort of effectively a head start, it would allow Wales to get ahead of the curve?
Dr Chris Williams: You need to time the lockdown so that you don’t – I think – I recall, you know, John Edmunds’ testimony is you don’t go into lockdown when there’s just only one case, because that’s clearly too early, but then when there are too many cases that’s too late, so somewhere between one and the other. And the papers were arguing for earlier lockdowns. I don’t know exactly how that timing would have worked for Wales, but, as I say, at the time, it – just wasn’t aware that it was an option.
Lead 2B: Now, five days later on 20 March TAC was asked to commission a paper on lockdown measures and then a TAC advisory paper was published on 23 March, which again advised on – it was entitled “Lockdown and release strategy”. So that appears to be the first formal interrogation by TAC into national lockdowns; is that right? Is that your recollection?
Dr Chris Williams: I would have thought, given that there was the feedback between SAGE meetings and TAC, that some of the other papers and repeated lockdown papers would have been discussed within TAC but maybe that’s the first time it was formally put down on paper.
Lead 2B: Was TAG and TAC consulted on the ultimate decision to lock down on 23 March?
Dr Chris Williams: I don’t recall the discussions being of that variety, but yeah, I just – I don’t recall, you’d have to ask them about the minutes.
Lead 2B: In your view, should Wales have locked down earlier in March 2020?
Dr Chris Williams: So my view is that the UK should have locked down earlier, and ideally, you know, on 12 March or possibly even earlier than that, because of – partly because of what the modelling was saying in terms of the timing of a lockdown in relation to the impact, and also partly because we had evidence that it would work, from, you know, Wuhan and Italy.
Lead 2B: What would the impact of an earlier lockdown have been on later waves?
Dr Chris Williams: It’s very difficult to answer that. I think it would have reduced the impact on the first wave in terms of hospitalisations and deaths. However, it might have been that there would have been a rebound effect over the second wave, and we did see that to an extent, that we were actually slightly less impacted relative to population in the first wave but then slightly more in the second wave. This is from some of my subsequent reading of the figures from the time. So there was an extent to which what you don’t get in one wave you do get later on, unless it’s a very well enacted and early suppression the second time.
Lead 2B: Now, Dr Williams, I just want to change topic, if I may, and ask you some questions about asymptomatic transmission of Covid-19. Again, I want to try to take this chronologically, if I can.
What did you know about asymptomatic transmission in early January 2020?
Dr Chris Williams: So, again, I’m not sure it would have been something that I thought about greatly, but I can say that professionally I would have assumed that there was likely to have been asymptomatic infection, and this is just from my experience of other respiratory viruses. I know SARS-CoV-1 didn’t generally have asymptomatic infections but SARS-CoV-2 does and influenza certainly does. Whether those asymptomatic infections were detectable by testing and whether they were transmissible is a separate question.
Lead 2B: I think on 29 January you and your colleagues at Public Health Wales received an email from Public Health England attaching a paper on asymptomatic transmission. Again, I’m not going to ask for it to be displayed, but that paper, if you recall it, outlined early credible evidence of asymptomatic transmission from an individual in Germany who appeared to have been infected through her asymptomatic parents. Do you recall this paper that I’m talking about?
Dr Chris Williams: Yes.
Lead 2B: And the paper concluded that “The currently available data is not adequate to provide evidence for major asymptomatic/subclinical transmission of 2019-nCoV”, but that there was evidence of small-scale anecdotal asymptomatic transmission.
Was it your view as an epidemiologist that it is better to keep an open mind about transmission possibilities?
Dr Chris Williams: I think in general, it is. What you don’t know is to what extent they play a role in terms of the transmission of the infection, so something may be possible but not a major factor or it may be possible and a major factor, and it’s hard to tell, particularly early in the phases.
Lead 2B: Was it your view that the best approach would be to assume that asymptomatic transmission was taking place?
Dr Chris Williams: I can’t really answer that. You have to think about also the implications of assuming asymptomatic transmission, which would – given the case definition at the time was “travel from China or Wuhan with symptoms”, you’d then quite quickly shift that to “anyone who’s travelled from China”, which I don’t think would have been very feasible in terms of follow-up, and probably you would have then had to think about, you know, what would the next step be. So maybe that’s the light in which it was considered.
But yes, it’s always worth considering on the precautionary basis what might be transmission routes.
Lead 2B: Moving forward chronologically, then, so that was a paper that was shared with you on 29 January. On 17 February 2020, the Diamond Princess asymptomatic cases were discussed in a SAGE meeting. Do you recall discussing the evidence of asymptomatic cases on the Diamond Princess in TAC?
Dr Chris Williams: I don’t recall those discussions in TAC. I’m sure there would have been – we’d got reports from the Diamond Princess through the PHE meetings, I’m sure there would have been some at least information on that, but I don’t recall discussions in TAC.
Lead 2B: If we can, please, have INQ000119469 on screen.
This is minutes of a NERVTAG meeting of 21 February 2020.
If we could, please, have page 6, at paragraph 3.4. Thank you.
“NF noted that there were a few modelling groups estimating a higher infection rate when comparing case populations in Singapore, South Korea and Japan, this suggests that at least a third have been missed. JE commented on this after the meeting taking into account the issue of asymptomatic cases, where the evidence suggests that 40% of virologically confirmed cases are asymptomatic.”
Do you recall being informed of this?
Dr Chris Williams: I don’t recall that particular – I wasn’t on NERVTAG or received the minutes from NERVTAG, but I’m sure the figure of the – from what was happening in the Diamond Princess was probably reported elsewhere.
Lead 2B: So by late February, were you and your colleagues aware that asymptomatic transmission was taking place, and the extent of asymptomatic transmission could be as great as 40%?
Dr Chris Williams: As I say, I can’t recall, but I’m sure it would have been part of the thinking.
Lead 2B: Did TAG or TAC formally advise the Welsh Government at this point, in late February, about the potentially very high rates of asymptomatic transmission?
Dr Chris Williams: Again, I can’t – TAG – as I’ve mentioned earlier in my statement, TAG was one of the things that I was involved in. My role was mainly to give epidemiological updates, and my main role was within Public Health Wales, so I don’t recall absolutely all the discussions in TAG at the time unfortunately.
Lead 2B: Dr Williams, I’m going to change topic again and talk to you next about, first, discharge of patients from hospitals to care homes and also then testing of care home staff.
Now, as I’m sure or you may be aware, there is a later module of this Inquiry that is going to be looking at the care sector, but within this module we are looking at high level core Welsh Government decisions that might have impacted on the care sector.
Were you involved in providing any advice about discharging patients from hospitals to care homes in February to April 2020?
Dr Chris Williams: February to April … not … not that I can recall between February and end of March, no.
Lead 2B: Is it right that you have subsequently worked with colleagues to address the question of transmission to care homes from these discharges, so namely discharges from hospitals to care homes?
Dr Chris Williams: Yes.
Lead 2B: That work, am I right in saying, has largely confirmed that transmission to care home residents was driven by their exposure to the community through staff rather than from hospital discharges; is that right?
Dr Chris Williams: That’s the broad conclusion. I just want to caveat that by saying that of course it’s possible for care home residents from discharges, particularly early in the pandemic, to have then gone on to cause transmission within those homes, I’m not arguing at any point that that wasn’t a possibility. We just felt that there was a bigger risk, and an ongoing risk, from the community to staff to the care home, and that was something that was potentially amenable to change, and that’s why we did this work.
Lead 2B: So from the point of view of care home outbreaks, the testing regime of care home staff and residents was important in terms of saving lives, possibly more important than the policies around discharge from hospitals; is that fair?
Dr Chris Williams: I think it was – I think it’s the whole package of what you would do around care homes, how you would support the staff, how you would support the work within – the infection control and things like that within the care home, rather than simply the testing policy versus – within staff versus the testing policy on discharges.
Lead 2B: Can we, please, have INQ000228309 displayed. Thank you.
Now, this is an email chain, it covers 31 March through to 1 April. It’s between Dr Thomas Connor, yourself, Dr Orford and other members of TAC.
Just by way of context, Dr Connor has circulated a paper on nosocomial outbreaks and, given the spread of outbreaks observed in a hospital in late March 2020, the issue was raised as to how effectively you could test healthcare workers to ensure that positive cases of Covid were caught.
So just with that context, if we can go, please, to page 2 of this email chain – I’m grateful – at the bottom email.
It’s an email from Dr Connor, yes, on 31 March, 22.41. Then over the page, it goes to page 3, paragraph 4, I’m grateful, yes:
“Just thinking in terms of timescales the potential for routine testing to have picked this up is very contingent on how that testing regimen is designed. In this case we have a cluster of 50-70 cases who all flagged positive within 7 days of the suspected index case. That to me suggests that one implemented something like weekly testing would be critical in catching something like this early. I would think that if a portion of staff tested every day then detection that there is a problem on a ward might be possible. But, say, testing everyone once a week could conceivably have missed basically all of the transmission here. So to me the message is to design routine testing well, taking into account the observed timescales in AB and understanding that such testing has to be rapid to be useful.”
AB being the hospital that I referred to when giving context to this email chain.
Then if we can, please, go at page 2, to the top email.
This is your reply of – on 1 April. I’m looking at the second paragraph, five lines down, starting:
“On regular testing I was thinking of a different scenario, whereby healthcare workers could be infected at home rather than the ward. Agree that only daily testing would be secure, but weekly testing would help to give routine reassurance and also set up a rhythm and acceptance of testing and self-consideration of symptoms. Of course you can be unlucky with this too and miss a whole week, but I think it could work and I think have seen that it’s been used elsewhere (will check).”
Now, you say there “self-consideration of symptoms”. Did you consider the role of asymptomatic transmission when considering this advice, Dr Williams?
Dr Chris Williams: I believe so, yes. So this was the email – the outbreak that Tom refers to was one in Aneurin Bevan that actually my team had investigated initially and we found this number of cases and then Tom had added on to that with a genomic analysis to try to work out what the chains of transmission were, and this was then leading into a discussion about how healthcare worker testing might help mitigate the transmission in hospitals both between staff and patients, patients to staff, but also to staff at home. So we started to discuss the timing of that, and how you would optimise it.
You also have to remember about the performance of tests and things like that.
Lead 2B: Would it have been more prudent to advocate for testing more frequently than once every seven days, as Dr Connor has done?
Dr Chris Williams: I think we were both arguing – I think we were both discussing whether weekly testing would work and how many it would miss and what pattern you would use, rather than that he was arguing for daily testing and I was arguing for weekly.
Again, the – because – I think it was in the understanding of the asymptomatic cases, and the fact that healthcare workers do tend to carry on working even if they’ve got mild symptoms, or sometimes with severe symptoms, and actually I think what I was trying to say here was that giving people the test and then it turned out to be positive maybe before symptoms would at least give them the rationale that they would not then go to work whilst infectious. So there’s quite a lot of things going on here.
Lead 2B: Was it your view that there needed to be some routine testing, then, of healthcare workers at least once every seven days?
Dr Chris Williams: That’s my recollection, is these email chains would allow me(?) time to argue for that.
Lead 2B: On the same day, about two hours later, you email Dr Orford.
If we could, please, have INQ000224062 on the screen. Thank you.
You emailed Dr Orford – this was a CDC study about the high proportion of healthcare workers testing positive for Covid-19, and care homes, who were asymptomatic.
As we see there, the email at the top of this page:
“Will try to discuss this offline with Robin. Whilst it is true that the NPV of the test is low, it is also true that potentially a high proportion of those testing positive (and therefore likely shedding) are asymptomatic (see below in context of care homes). It is also true that HCW will continue to work whilst symptomatic despite guidance.”
Then email from Dr Orford slightly above that one, please, says:
“It would be good to understand if there is more data out there on higher intensity testing of HCWs. Also it is a risk based approach to mitigate nosocomial outbreaks – whilst it may have a low pick-up it might have a ‘marginal gain’ and also a psychological barrier for HCWs.”
What did you understand by Dr Orford’s response? What did you understand that to mean?
Dr Chris Williams: I think I was – I think I was arguing for routine testing of healthcare workers so you could pick up both pre-symptomatic, mild symptom and asymptomatic infections, and Rob is just asking if there’s more evidence on this. I don’t know about the “marginal gain”. The negative predictive value point is that, when there’s little infection around – well, there’s a lot of infection around, that negative tests might not necessarily mean that that person is negative, so it might provide false reassurance, but I don’t know exactly what he means in that second sentence.
Lead 2B: Perhaps to summarise then what was known, what you knew by 1 April, you knew it was essential to routinely test healthcare workers to avoid transmission to patients; yes?
Dr Chris Williams: I wouldn’t say I knew it was essential but I was suggesting that might be a means of preventing transmission, yes.
Lead 2B: I understand. Symptom-based screening alone would fail to identify Covid-19 cases?
Dr Chris Williams: That’s what I thought, yes.
Lead 2B: So routine screening of everyone, so symptomatic and asymptomatic, was really the only effective way to avoid transmission of Covid-19 from staff bringing community infections into a care home; is that right?
Dr Chris Williams: I think that was part of my thinking. I mean, it’s a very complex area, but yes, to pick up those asymptomatic infections you needed a test.
Lead 2B: If asymptomatic transmission accounted for up to 40% of Covid cases, testing symptomatic individuals only could miss up to 40% of outbreaks on any one day; is that –
Dr Chris Williams: Yes.
Lead 2B: And if some healthcare workers would continue to work whilst symptomatic, even more infections would obviously be missed; is that right?
Dr Chris Williams: If they were symptomatic they wouldn’t necessarily be missed, someone would know about them. But, yeah.
Mr Poole: I’m grateful.
My Lady, I’m not going to quite finish this topic, so this might be an appropriate time for a break.
Lady Hallett: Certainly. 11.30.
(11.13 am)
(A short break)
(11.30 am)
Lady Hallett: Mr Poole.
Mr Poole: Dr Williams, we were just talking about the position as at 1 April. I just want to move forward a few weeks to 17 April, and there was a Public Health Wales Strategic Coordinating Support Group meeting on that date.
You provided an update on the situation in care homes. You said 300 care homes are reporting Covid-19 activity, roughly 25% of care homes in Wales. Then your colleague from Public Health Wales provided some further information and said:
“To date 322 of 1,302 registered care homes in Wales have reported Covid-19 activity. A total of 153 cases have been confirmed. Since 9th of April, Public Health Wales have been offering testing of symptomatic and asymptomatic staff. There is a 62% positive iterate of staff tested.”
Was this a policy that had been rolled out across all care homes in Wales, to your knowledge, with mandatory testing, or was it being offered – provided only to care homes as and when outbreaks emerged?
Dr Chris Williams: My recollection, it was for outbreaks.
Lead 2B: A 62% positivity rate for staff tested must have been very concerning?
Dr Chris Williams: That is a high rate, yes.
Lead 2B: Of those tested, more care home staff than not were positive for Covid, 62%?
Dr Chris Williams: It’s over 50%, yeah.
Lead 2B: Given the number of outbreaks in care homes across Wales at that time, coupled with what we’ve just discussed about your knowledge of asymptomatic spread, did you think that roll-out of mandatory testing of all staff and residents should take place at that time?
Dr Chris Williams: I don’t recall what my views were at the time. I think there was a meeting the following day that moved things on a little bit, but no, I don’t recall.
Lead 2B: Taking a look at what was happening in England, on 14 April the UK Chief Medical Officer’s advice was that testing within care home settings was a priority, following concern highlighted by a study of 29 care homes by Public Health England, and then on 28 April in England the Department of Health announced extending testing to all residents in care homes irrespective of symptoms.
There was a ministerial advice on the scaling up of testing in care homes that was provided to Vaughan Gething on 30 April.
It’s INQ000116607. Which is up on display, thank you.
Did you contribute to that ministerial advice?
Dr Chris Williams: I don’t recall that I did, no.
Lead 2B: Perhaps we can just have a look, then, at page 4, paragraph 16, under the “Impact of asymptomatic care home residents” reads, first bullet point:
“A pilot study recently undertaken by PHE in six care homes in London that reported an outbreak tested all residents and staff groups. Preliminary results from one care home with over 100 residents investigated at an early stage of the outbreak in the home, 75% of residents were positive for COVID-19 but only 25% were symptomatic. 50% of staff were positive but only 29% of these were symptomatic …”
Then if we can, please, go to page 5, paragraph 21. Paragraph 21, thank you.
“Discussions with colleagues in Welsh Government and PHW indicate that testing of asymptomatic (or reportedly so) care workers would help to prevent introductions into care homes, and also provide an estimate of community incidence of COVID.”
Then, please, paragraph 23, bottom of the page, thank you.
Under “The Options”:
“There are limited options. Do nothing is not [an] option. Expanding into asymptomatic individuals still lacks the evidence base to support this being the best use of testing capacity.”
So by this point, there was peer reviewed evidence in favour of routine testing in care homes from that CDC study one month prior. Do you agree with the statement that there wasn’t an evidence base to support mass testing that we see in this document?
Dr Chris Williams: I don’t think that’s – I don’t think that’s correct in this – (inaudible) the question. So the CDC paper found that there was asymptomatic infection but it didn’t necessarily advocate for routine testing of asymptomatic staff. I think a follow-up paper and then editorial in the New England Journal later in April, I think, before this but after the previous ones, started to advocate for regular testing. However, there wasn’t evidence, ie trial evidence, showing that if you took X number of care homes and tested all of the staff and residents and then you took some care homes and didn’t, that actually this would improve outcomes. So I wouldn’t say that there was strong evidence but on the precautionary basis I think I was advocating for some kind of routine testing of staff, through my sighting of the paper on 1 April and also some documents on the 18th.
Lead 2B: I understand.
Is it a fair interpretation that the reference here to the “best use of testing capacity” that there were capacity issues with testing and so the advice was perhaps to prioritise their use elsewhere, so in hospitals and for symptomatic key workers?
Dr Chris Williams: Having reviewed this document, which I don’t recall seeing at the time, but having reviewed this document, it does seem to make mention of capacity. I think there’s also a reference to 25,000 tests or something like that, in relation to residents and capacity.
Lead 2B: Just finally on this topic, annexed to this ministerial advice is a document titled “Summary of discussion on prioritising tests for care homes” – sorry, INQ000116607, if that could be displayed, please, page 10.
This document proposed prioritising blanket testing of symptomatic and asymptomatic staff in certain care homes, those with an outbreak, Covid-free homes, struggling homes. And in this annex it is noted, I think it’s page 11, paragraph 2 – if we can see that, please.
“FA [this is Dr Atherton] indicated that it would have been helpful to have this information earlier as it had caused enormous issues in Wales. Proved very difficult situation as the media had picked this up as a very significant divergent of policy.
“There was a 4 nations group on testing but Wales did not seem to be fully plugged in.”
In your view, insofar as you can answer, as you weren’t sighted on this paper at the time, was Dr Atherton fair when he said that Wales was not fully plugged in on this issue?
Dr Chris Williams: I wasn’t a member of the four nations testing group, so I can’t really comment on that.
Lead 2B: Dr Williams, changing topic and briefly touching on the question of face masks, face coverings, that was obviously one area where there was a difference of opinion between the four nations. I’d just like to ask you a few questions about this.
On 11 May the UK Government advised the public to consider wearing face masks in enclosed public spaces. And in terms of what we know happened in England (on 5 June, face coverings were required in hospital settings, on 15 June they were required on public transport, and then 24 June they were mandatory in shops and supermarkets), on the other hand face masks only became mandatory on public transport in Wales on 27 July and in shops and other public spaces on 14 September.
Now, there is a TAG advice dated 8 June 2020, I don’t need to go to it, but it did not explicitly advise that masks be mandated in public, and on that same date Dr Atherton advised the First Minister on this topic and he said:
“I remain of the view that the evidence of benefits does not justify a mandatory or legislative process and I still see dangers in taking such an approach in Wales.”
Did you agree with that advice?
Dr Chris Williams: I can’t recall at the time but not necessarily, no. I think I put in my witness statement that I thought that it might be worth a try, masks, even in the absence of good evidence, knowing that it’s very hard to get definitive evidence for an intervention such as face coverings.
Lead 2B: As you say, I think you say in your witness statement, on face coverings:
“… I can recall arguing verbally (in TAG) in favour of their use, even in the absence of evidence …”
That’s right?
Dr Chris Williams: That’s correct, yes.
Lead 2B: Moving then to another topic, again fairly briefly, just superspreader events.
The Six Nations men’s rugby match between Wales and Scotland, as we’ve heard earlier, was due to take place on Saturday 14 March 2020. Welsh ministers declined to intervene to stop that match and the Welsh Rugby Union ultimately took the decision to postpone the match at lunchtime on the day before, but by which time 20,000 Scotland fans had already arrived in Cardiff. There were also two Stereophonics concerts on 14 and 15 March held in Cardiff.
Now, your views, expressed in a briefing to TAC around 10 March, was that the modelling evidence did not show a major impact of mass events on overall transmission.
Do you stand by that advice?
Dr Chris Williams: I think that’s certainly what the modelling was showing at the time. I still think that mass events don’t generally have a huge impact on transmission, because there’s a lot of transmission going on elsewhere. But of course it doesn’t mean to say, as with my previous answer, that transmission can’t or doesn’t happen at mass events.
Lead 2B: Now, one of the reasons the Wales and Scotland match was not cancelled was, as I understand it, due to a concern about socialising displacement, so people going to more pubs and restaurants if the match was cancelled.
Now, in light of what we know about voluntary reductions in contacts and socialising in mid-March, do you think those concerns were well-founded?
Dr Chris Williams: I think the concern that transmission could happen better in closed environments like, you know, pubs and restaurants was correct.
Lead 2B: Are you able to assist at all with what might have happened to Covid-19 community caseload progression in Wales in March 2020 had those events not proceeded?
Dr Chris Williams: I couldn’t – couldn’t say how it would have changed things. I think evidence from some – some evidence of low effects from mass events and some evidence – I think there was one in Scotland where there was quite a large impact on transmission, but you have to look at the circumstances in the particular events.
Lady Hallett: There’s also the impact on public behaviour, isn’t there?
Dr Chris Williams: You could see it as part of a wider –
Lady Hallett: You allow a mass event to go ahead, it gives the public the message “Everything’s fine”.
Dr Chris Williams: I agree, and, yes, that should be a consideration.
Mr Poole: Dr Williams, finally, and again a slightly different topic, about school closures, if I may.
You briefly mentioned school closures in your evidence, and in your witness statement at paragraph 118 you say:
“Regarding schools I thought it was important to set the risks here in context given the relatively low severity and burden in children and the negative effects of school closures.”
What, in your view, were the risks to children in schools?
Dr Chris Williams: I think the risk of infection, severe outcomes in children was low, and that was reasonably well recognised at the time. I have children of my own and I know that the effect of them not going to school might have been damaging to their education and other parts of their social development, and I also knew that there were a lot of concerns about transmission in schools, both driving the epidemic and also within – across the workforce.
Lead 2B: In the passage I think we’ve got on the screen, in paragraph 118 of your statement, what do you mean by setting the risk in context?
Dr Chris Williams: I think in the context of what the risk was in the rest of the population, that I think I was concerned that maybe schools were seen as a sort of magic bullet to – you close the schools you can really nip some of the transmission in the bud, and that’s partly based on the experience of flu, where we know that children play a large role in transmission of influenza, and with other infectious diseases. But I think – I thought it ought to be balanced with the knowledge that the outcomes were generally pretty good in children.
Lead 2B: And how were the risks assessed for schoolchildren in Wales?
Dr Chris Williams: As I say, we set up a report to try to report on the numbers of cases in both schoolchildren and also in staff, to try to say what they were, and also compare them to the incidence and the indicators in the local authority population at the time, just to make that comparison.
Lead 2B: Again, looking at this paragraph of your witness statement, what do you mean by the “negative effects of school closures”?
Dr Chris Williams: So, in addition to the effects on the students themselves, I think there was also a recognition that closing schools has a big impact on parents, particularly there was concern about healthcare worker parents and other sort of staff that then wouldn’t be able to go to work because the school was closed, so I think that was part of the wider considerations, but … yeah.
Mr Poole: Dr Williams, those are all the questions I have for you.
I think there are some Rule 10 questions, my Lady.
Lady Hallett: I think, Ms Heaven, you’re asking some questions.
Ms Heaven: Yes.
Questions From Ms Heaven
Ms Heaven: Good morning, Dr Williams, I represent the Covid-19 Bereaved Families for Justice Cymru.
Just two topics, please. I want to come back very briefly to face coverings and then the autumn firebreak.
So, my Lady, for your reference, I’m swapping round the two questions on which I’ve been granted permission.
CTI has just covered with you what you say in your statement, but can I just read it back to you and ask some targeted questions. So it’s 119 of your statement, don’t worry, you say :
“On face coverings I can recall arguing verbally (in TAG) in favour of their use, even in the absence of evidence, as I knew that there was evidence from SARS-CoV-1 that surgical face coverings had a protective effect in hospitals and also that they were likely empirically to be effective; and that a measure with low effectiveness deployed very widely can have a significant effect.”
So two things firstly, can I just check here, you’re obviously talking here about advocating for surgical face coverings. Are we talking here about fluid-repellant surgical masks? To give it its technical term.
Dr Chris Williams: I think so, yes. I mean, I just meant face coverings in general.
Ms Heaven: Okay, that’s helpful, because my next question was going to be: it seems that you are also talking about advocating for face coverings in the community, in TAG?
Dr Chris Williams: That’s my recollection.
Ms Heaven: Okay, now, you’re saying in your witness here – your statement – you’re “arguing verbally”, and that’s obviously your word, in favour of face coverings, and it would seem to be that you’re suggesting that, as an infectious disease epidemiologist, you were facing some opposition in TAG to your views. So is this correct, were you facing some opposition? If so, from whom?
Dr Chris Williams: I can recall there were arguments about other negative impacts of using face coverings in different groups. I can’t recall who in particular might have made them. Also on the case of things like face coverings and – you mentioned surgical face masks, that tends to be the purview of people with infection prevention and control expertise, and microbiologists, and that’s not my – generally my area of expertise –
Ms Heaven: Well, can I just prompt you, were you facing some push-back from Frank Atherton, CMO, on face coverings? Because we obviously know from the evidence that he was not in favour of them in the community for quite some time.
Dr Chris Williams: Frank Atherton wasn’t a regulator attender at TAG meetings so I don’t think that it would have been him.
Ms Heaven: Okay.
Second question then, please, is just generally you have given some views but I want to be absolutely clear on your view on the approach taken by the Welsh Government to face coverings. CTI has taken you through the dates. We know that on every measure the Welsh Government diverged and was later than all the other four nations in their approach to recommending and mandating masks.
Robert Hoyle, who was from a TAG subgroup, told the Inquiry yesterday the Welsh Government should have mandated masks much earlier. To be absolutely clear, do you agree with his view?
Dr Chris Williams: I think that would have been a reasonable approach.
Ms Heaven: You’ve also just been asked by CTI about the approach Frank Atherton took in May and I know you didn’t see the document. We know that Frank Atherton was giving advice in May that face coverings were essentially a matter of personal choice, directly contrary to the evidence we heard in Module 2 was being given by Chris Whitty to the UK Government.
Do you have a view on the Welsh Government’s approach in May 2020 to face coverings?
Dr Chris Williams: I don’t really have a view, no, not beyond what we’ve just discussed.
Ms Heaven: Okay.
Next topic then, firebreak, and again I’m going to read to you. It’s paragraph 117 of your statement you say:
“I was an advocate for lockdowns when rates were rising, given my experience from March 2020. In autumn 2020 surveillance data was used to guide local and regional levels of restriction, and I was involved in explaining these data to groups advising on these. On the firebreak, I recall verbally advocating for a long enough period to be significant, but I was aware that there were constraints in feasibility and also that an intervention not mirrored across the border would have more limited effects.”
So the first topic is on the timing of the introduction. Were you advocating for the firebreak to be introduced earlier, and if so to whom?
And if I can just ask the next one, because you can answer it together, please. Should the firebreak have been implemented sooner?
So did you want it at the time to be coming in sooner, and now, thinking back, should it have come in sooner?
Dr Chris Williams: I don’t recall that in particular. I know there’s other evidence from Public Health Wales advice on the firebreak intervention. All I can recall at the time is advocating for some kind of national restriction because the rates were rising, and also for a significant length of time because we knew it wouldn’t have much effect if we did it for a short period of time.
Ms Heaven: It doesn’t say in your witness statement when were you advocating. So when were you advocating for national restrictions?
Dr Chris Williams: Again, I don’t have records to – I have to say I don’t have records to say exactly what I was saying at the time. I feel that a prolonged firebreak at the time might have actually pushed the larger wave more towards when we had vaccinations, but I don’t think that was really a feasible option at the time unfortunately.
Ms Heaven: Okay, that was going to be my second question, is: should the firebreak have been longer? And I think you’ve sort of answered that, haven’t you, by saying you thought it probably should but that probably wasn’t feasible, to push the firebreak longer into when the more vulnerable groups had been vaccinated?
Dr Chris Williams: Yeah, you’d have to ask Welsh Government colleagues the reasons for feasibility. But you can still see the firebreak as a notch in the data, so it had some effect.
Ms Heaven: What about a four-week firebreak, was that something that you think perhaps would have been sensible? So not right into the December period but just four weeks.
Dr Chris Williams: I really can’t say what the difference was – would have been, I would have probably thought that would just have given a bigger notch.
In the event we had quite a prolonged period of lockdown after the December restrictions, that were actually a lot longer than any period that was advocated in the autumn. That’s just a reflection with hindsight.
Ms Heaven: Yes, okay. Thank you very much.
Thank you, my Lady, those are my questions.
Lady Hallett: Thank you, Ms Heaven.
Ms Foubister. Sorry, have I pronounced that correctly?
Questions From Ms Foubister
Ms Foubister: Good morning, Dr Williams. I represent John’s Campaign and Care Rights UK.
I’m going to ask a few short questions about your role regarding non-pharmaceutical interventions, I’ll refer to them as NPIs.
At paragraph 116 of your witness statement you note that your role in relation to NPIs was mainly to provide information to assist with decision-making. Was it within your role to provide information not just about harm caused by Covid but also to provide information about all relevant harms to health, in particular indirect harms resulting from NPIs?
Dr Chris Williams: So I do recognise that there are a number of indirect harms from NPIs, but I work in the infectious disease surveillance department, I felt it was my role to give the information about the epidemiology of infectious disease and that others were better placed to give data and advice on other harms.
Ms Foubister: I refer next to a document which I hope can be brought up, which is INQ000183846.
While I just wait for it to come up, this is a statement from Professor John Watkins, also a consultant epidemiologist, who worked, amongst other roles, for the policy modelling group feeding into TAG and the Social Care Working Group feeding into SAGE.
Yes, this is the document. And within that if we could go to page 16.
And under the heading “Wider Non-COVID-19 related harms to [NPIs]” there’s a paragraph under that heading, and about halfway down the paragraph Professor Watkins says that he:
“… highlighted, early on, that people with mental health issues may be harmed by lack of social contact, people with early stage cancer and CVD may not get the diagnosis and treatment they needed, children’s education and social development was being impact etc. Despite raising these issues I saw no attempt to quantify, or consider, these when restrictions were being imposed.”
Were you also aware of concerns of this nature?
Dr Chris Williams: I don’t recall what the discussions were in TAG, but I think the immediate problem was to avoid a huge health impact from a large wave of Covid-19, and I still don’t think that could have been avoided in any other way than a lockdown, despite the negative aspects to it.
Ms Foubister: And in 2020, was there an attempt to quantify or collect data or even consider the more indirect harms resulting from NPIs?
Dr Chris Williams: I don’t recall that from my own work or – it might be in other people’s evidence, but remember I’m a specialist – it’s in infectious disease
epidemiology.
Ms Foubister: You may not be able to answer this, given what you’ve
just said, but my final question is: to what extent were
the adverse impacts of NPIs on people in care or those
needing care analysed? To what extent was data or
expert input obtained for the benefit of core
decision-makers in order to be weighed against the
benefits?
Dr Chris Williams: I can’t answer that, I’m afraid. I’m not part of that
evidence.
Ms Foubister: Thank you.
The Witness: Thanks.
Lady Hallett: Thank you very much.
Thank you very much, Dr Williams. Thank you for
your help.
The Witness: Thank you.
(The witness withdrew)
Mr Poole: If I can – I’ll wait.
Lady Hallett: Mr Poole, Ms Whitaker, don’t worry, the
question wasn’t asked, so we’re moving on.
Mr Poole: Exactly, my Lady.
Can I call Dr Roland Salmon, please.
Dr Roland Salmon
DR ROLAND SALMON (sworn).
Questions From Lead Counsel to the Inquiry for Module 2B
Lady Hallett: I hope we haven’t kept you waiting too long.
The Witness: No.
Mr Poole: Dr Salmon, could you please start by giving us your full name.
Dr Roland Salmon: Yes, I’m Roland Laurence Salmon.
Lead 2B: Dr Salmon, thank you very much for attending today and giving your evidence. If I can just ask you to keep your voice up so that we can hear you, also so your evidence can be recorded. And if I ask you anything that isn’t clear, please do ask me to rephrase it.
Now, you have kindly given a witness statement to this Inquiry, INQ000224354. We can see that on the screen. We don’t need to go to it, but at page 16 you’ve signed and dated this statement on 14 July last year, are the contents of that statement true to the best of your knowledge and belief?
Dr Roland Salmon: Yes, they are.
Lead 2B: Dr Salmon, in terms of your professional background and career, between 1990 and your retirement in 2013, is it right that you worked as a regional epidemiologist for the Communicable Disease Surveillance Centre Wales, and from 1998 you were its director?
Dr Roland Salmon: Yes, that’s correct.
Lead 2B: You spent eight years, up to 2019, as a member of the Department of Health’s Advisory Committee on Dangerous Pathogens, including two years as acting chair and
eight years as chair of its transmissible spongiform
encephalopathy working group; is that right?
Dr Roland Salmon: Yes, that’s correct, I was succeeded by one
Chris Whitty.
Lead 2B: The Inquiry knows him well.
From 2003 to 2013 you were a member of the
Scientific Advisory Committee (Conseil Scientifique) of
the French National Institute for Public Health
Surveillance and subsequently, until 2016, a member of
its management board; is that right?
Dr Roland Salmon: That’s correct.
Lead 2B: I think you have been a senior crematorium medical
referee for Cardiff Council Crematorium since 1999; is
that also right?
Dr Roland Salmon: That’s also correct.
Lead 2B: In terms of your role in the Welsh Government’s response
to the pandemic is it right you never sat on TAG or TAC
or any of their subgroups?
Dr Roland Salmon: I had no formal role at all.
Lead 2B: And is it right you had no formal communication at any
level with the Welsh Government or its advisory groups
throughout the pandemic?
Dr Roland Salmon: Yes, that’s also correct.
Lead 2B: Now, I plan to ask you some questions in a moment about
the overall notion of population immunity and shielding, but first, if I may, I want to address some comments you have made concerning the pre-eminence of modelling and modellers in the pandemic and the figures that those modellers used.
Now, in your witness statement you have commented that in TAC it was, your words, “mathematical modellers that dominated the agenda”.
Now, you have obviously confirmed you were not a member of TAG or TAC. The Inquiry has heard evidence from a member of TAG and TAC a moment ago, Dr Chris Williams, who was a consultant epidemiologist. The Inquiry has also received written evidence from other members of TAG, so Jonathan Price, he is the chief economist, Dr Catherine Moore is a microbiologist, Dr Brendan Collins is the head of health economics, and later on this afternoon we will hear from Professor Ann John, who is an expert in public health and psychiatry. So on the face of it the membership of TAG appears broad. I just want to understand the basis for your comment in your statement that it was mathematical modellers that dominated the agenda.
Dr Roland Salmon: Yes, certainly. I mean, you’ll be the first to point out, Mr Poole, that that is, of course, hearsay, and I would be the first to concede that point, and to recognise that there were – as I think I put in my statement, there are a number of other individuals with other skills particularly relevant to communicable disease.
However, the outputs and the emphasis that was put on particularly the R number and on social distancing suggested to me that the particular discipline of mathematical modelling was rather more dominant. And I also drew on my own experience of being on these sorts of committees, and we had of course had interaction with mathematical modellers on the Advisory Committee on Dangerous Pathogens, on the committee in France.
And one of the things which you will find with any group of scientists in the room is that there will be a number of opinions, or at least two or three opinions. They have to be synthesised in some way. And then of course along come the mathematical modellers with some very neat numerical constructions, and there’s always a little bit of a tendency to heave a sigh of relief and to follow the way that that guides.
And in many ways that can be very helpful, but you do have to detach yourself a little bit from that and ask: well, how do these models, in my own qualitative assessment, relate to the infectious disease problem as I see it? And I didn’t get a sense of that happening. Particularly from the public commentaries from TAC and particularly on one of two of their online published outputs.
Lead 2B: So is the problem you describe perhaps less a TAG and TAC issue, is it more a political one? Might it be said that – so one of the roles of, say, a Welsh minister, a non-expert in the field, is to receive the technical, the scientific advice, the modelling advice and weigh that up against other kinds of impacts and harms; would that be fair?
Dr Roland Salmon: I think that’s fair, and I think it’s very fair to say that: does the problem exist with the construction of the advice, its communication or its reception? And I think, frankly, problems can occur at any one of those stages.
Lead 2B: We are going to hear later on this afternoon from Professor Michael Gravenor. He was one of the modellers with TAG and TAC. He explains in his witness statement that the problem wasn’t with too little modelling per se but with the fact that there was insufficient data and capacity to build sophisticated models accounting for, say, economic impact, social harms, indirect health harms and so on, to be able to fully model the impact of NPIs. Have you got any comment on that statement?
Dr Roland Salmon: I mean, only to say that that is true and that is a common complaint that you hear.
Lead 2B: Changing topic, then, and moving to population immunity or, as some refer to it, herd immunity. You have said in your statement at paragraph 16, just to sort of orientate you, you say:
“Herd immunity is not a strategy but rather a time honoured epidemiological term that is used to characterise the resistance of a community to an infectious disease.”
Now, that statement is uncontentious, but perhaps you can explain to those following the evidence what you mean by that.
Dr Roland Salmon: Yes. I think I mean to – I mean, I think that the quote that I’ve put in there describes it very clearly and I’m not entirely sure how I can improve upon that, but I think it describes the circumstance where sufficient people have been exposed to a disease previously that new introductions of an infection can’t hold and spread – can’t get a hold and spread to any appreciable degree.
Lead 2B: Now, as a perhaps important caveat, it’s right, isn’t it, that the notion of population immunity was built into modelling work that was done by SPI-M and SAGE? So it’s not as though they ignored it altogether, they accounted for the fact that as community transmission figures grow, at some point people will develop immunity, so the virus peaks and case rates fall?
Dr Roland Salmon: Yes, I mean, that is one of the ordinary underlying assumptions of what’s called SIR modelling, which I think was the predominant form of modelling used both by SAGE and with TAG. Though, as you point out, I wasn’t there, so I can’t say that with any certainty.
Lead 2B: Likewise, by late February 2020, so when containment had ended in the UK, the scientific and policy approach was not that Covid could be suppressed indefinitely, which – the knock-on effect of that is that almost every conceivable long-term strategy for tackling the pandemic would involve some form of herd immunity, really would you agree the issue for the politicians and the decision-makers was: what is the best way to get there?
Dr Roland Salmon: Yes, I mean, I would go further than that, I think that was always the issue right from the outset. I mean, you provided me with Professor Whitty’s statement to read as part of the evidence bundle and he does a briefing note for the special adviser at Number 10 Downing Street on the – I think it’s 28 February 2020, and when I look at that his summary of the situation and the possibilities I have to say is almost exactly the same kind of parameters of any summary that, had I had to write one, I would have come up with.
Lead 2B: Moving on then. Am I right in summarising your position in the following way: that the epidemiological notion of acquiring population immunity can be part of a policy of managing Covid-19 in a population as an alternative to the imposition of stringent population wide NPIs? So that policy would be one of, I think you used the phrase, “focussed protection” of the most vulnerable to Covid-19?
Dr Roland Salmon: Yes, I mean, I suppose the problem I have is that I consider the policy to represent what you would do either as a politician or a public health agency, and you don’t “do” herd immunity; herd immunity or population immunity is where you might get to, dependent on what the actual actions you take are.
Now, the actions that were taken were rather stringent lockdown measures. My own view was that measures more focused on the individual would deliver a similar position eventually. But I think you’re right to say that in both of them the state of population immunity features is an important end point.
Lead 2B: You say in your statement that acquiring population immunity is more of a beneficial byproduct of the strategy of focused protection?
Dr Roland Salmon: Yes.
Lead 2B: Is it perhaps not more accurate to say that population immunity and focused protection are really two sides of the same coin? So, for those who are vulnerable, for them to return to a semblance of a normal life, the population around them needs to acquire a degree of immunity, thus enabling vulnerable individuals – we’re obviously talking in a pre-vaccine world here – to receive healthcare, receive visitors, go into their communities and so on; is that right?
Dr Roland Salmon: I mean, I’m – I suppose I’d say you’re welcome to make that distinction. It’s not one I would feel particularly necessary to make. I think – or the way I’ve described it as a byproduct probably has sufficient clarity for everybody’s understanding.
Lead 2B: Now, I just want to go through some of the concerns that have been expressed about this general approach, just to –
Dr Roland Salmon: Yeah.
Lead 2B: – get your comments on them, please, Dr Salmon.
First, Professor Woolhouse, professor of infectious disease epidemiology at the University of Edinburgh, also a member of SPI-M, he has said in his statement to the Inquiry in Module 2 that it was not known in the early stages of the pandemic whether the immunological resistance acquired from catching and recovering from Covid would be 100% effective in preventing reinfection.
So just pausing there, this means that allowing the disease to move through the population in, say, March and April 2020 without any guarantee that previous infections would ensure immunity would be a highly risky strategy. Do you agree with that?
Dr Roland Salmon: Well, actually I don’t. I mean – and interestingly I think there are some contradictions in Professor Woolhouse’s own witness statements in this.
I mean, he makes the point that if you had taken more modest interventions somewhat earlier than they were – I mean, he uses it – calls it cocooning, I call it focused protection – then it would have been possible to detach the epidemics that were taking place among vulnerable populations in places like hospital and care homes from the wider transmission in the community. I think that’s correct, and I think that transmission in the community might reasonably have been expected to bring with it a measure of protection.
Now, you wouldn’t have known how much until the epidemic had progressed, but I think you would have felt reasonably confident that you would have – while that was happening, be protecting the most vulnerable elements of society.
Lead 2B: So do you take exception with me describing it as a highly risky strategy? Would you accept that it was a risky strategy then?
Dr Roland Salmon: I mean, I think it would have been a relatively straightforward and safe strategy and I think many of Professor Woolhouse’s own comments tend in that direction.
Lead 2B: Another concern, and do correct me if I’m wrong, with the approach of a protect vulnerable individuals while allowing population immunity for everyone else, is that does it not assume that population immunity could be reached within a matter of months or within a short period of time?
Dr Roland Salmon: Well, no, it doesn’t. I mean, it will take as long as it will take. I mean, I think the question you have to ask yourself are: what are your alternatives given the disruption that other approaches will take?
Yes, ideally you would hope it would arrive relatively quickly. I mean, there is an interesting historical example that I think Professor Heymann introduced at the very beginning of the proceedings of the Inquiry, and that’s the coronavirus OC43, which was almost certainly a pandemic virus at the end of the 19th century, yet, certainly by the time we’re able to identify it and study it, we think of it as a common cold virus and it seems quite likely it transitioned to that stage in a relatively short space of time. So there were reasonable biological grounds for a degree of optimism about what would happen here.
Lead 2B: Related to the point I just made about the population immunity might take a significant period of time is a point that Sir Chris Whitty makes in his evidence in Module 2. His witness statement is at INQ000248853, and we’re looking at paragraph 6.23.
Sir Chris says:
“The biggest scientific weakness is that it starts from the thesis that inevitably herd immunity will be acquired if you leave things long enough. That is not the case for a very large proportion of the most important diseases in the world. For most of the major disease I have worked on, you never acquire full herd immunity. Basing a policy on the assumption that eventually immunity in the less at risk population will protect the others is not a safe starting point.”
What do you say in response to –
Dr Roland Salmon: Well, this is very like –
Lead 2B: – so –
Dr Roland Salmon: This is very like a comment he made in the BM – British Medical Journal, and I frankly thought it was bizarre, because your jumping-off point – and the examples he used in the British Medical Journal were the Ebola virus and the human immunodeficiency virus, HIV. Now, of course your jumping-off point for any consideration of your strategy is the biology of the virus that you’re dealing with, and those viruses are so fundamentally different in their properties that, yes, of course you wouldn’t adopt a herd immunity strategy for them, but my point is that the underlying virology of the coronavirus is such that that becomes a reasonable option and, in my view, one that – about which you could have made relatively optimistic predictions from a fairly early date.
Lead 2B: There are a few other concerns that have been expressed with a focused protection policy. If I just outline a few of them so we can know your response –
Dr Roland Salmon: Please.
Lead 2B: – Dr Salmon.
Dr Roland Salmon: I’d be keen to respond, to be –
Lead 2B: First, people who are not in the vulnerable group will contract Covid-19 and die, so this would happen at greater numbers due to a greater rate of transmission before – obviously we’re talking before vaccine development. I mean, do you agree with that?
Dr Roland Salmon: I’m not convinced about that either. I mean, what you’re talking about is how do these different strategies work out in practice. Now, the strategies that we did adopt, with the rather extensive lockdowns, also – because, I would argue, of the loss of focus, also resulted in rather large casualty rates among the vulnerable in care homes and hospitals.
Now, it’s quite true that you have to craft your focused protection rather carefully and it’s also true that you might modify that as it goes along. But I don’t see that intrinsically that would necessarily lead to more infection in a wider population, and indeed it might lead to less infection of vulnerable people due to, a point that I also make in my witness statement, that the number of severe cases is not merely, as John Edmunds erroneously said, a function of the number of cases, it’s also a function of the time over which the virus circulates. The longer it circulates, the more opportunity it has to go into those risky situations, like care homes, like prisons, like meat factories, like hospitals, where it will infect vulnerable people with, you know, the sorts of consequences that we’ve seen.
So, as I say, I don’t accept actually the point that Professor Whitty is making here.
Lead 2B: Now, it may be that you will give the same answer to this next concern that you’ve just given, because another concern about focused protection is that hospitals would exceed capacity and not be able to provide other required forms of urgent care, let alone treating those that require assistance with Covid-19. Do you agree or disagree?
Dr Roland Salmon: I mean, as I say, I think my previous answer substantially addresses that point.
Lead 2B: What about, finally, the effect of focused protection on Long Covid? That’s entirely unknown and could be severe and significant?
Dr Roland Salmon: Yes, I mean, Long Covid is one of the unknowns in all of this. I mean, it’s less unknown now than it was, and I … I can’t claim I’ve looked at this in a lot of detail but there were papers in The Lancet from an Oxford-based group, based on millions of health records in the United States, and the takeaway message from that is not that Long Covid is trivial or that we can discount it, not at all, but that it’s very similar in both its frequency and in the range of symptoms to long forms of other viral and infectious diseases, which we know exist and which we co-exist with.
I have some knowledge of this because in the late ’90s, with Dr Sharon Parry of Cardiff University, we did a long paper for the Health and Safety Executive on the chronic sequelae, the chronic consequences of infectious diseases.
So whilst I, as I say, fully acknowledge the uncertainties around Long Covid and I fully acknowledge its seriousness, it seems to me it’s of a piece with consequences from other infectious diseases about which we don’t take similar protective measures.
Now we need to understand all of these a lot better and if Covid gives a stimulus to research into this sort of thing, I feel that can only be a good thing, but what I don’t think it calls for is particular extra preventive measures over and above those that are used for acute Covid, because the final point is that the very – the worst, the most serious sequelae of Long Covid appear to be proportional to the seriousness of the initial illness. So inasmuch as we control that initial illness and control its serious forms, whether by vaccination, whether by letting the vaccine(sic) circulate among people when they were younger and safer, rather than letting them get to being old and vulnerable, we will also be preventing the worst aspects of Long Covid.
Lead 2B: Dr Salmon –
Lady Hallett: Are you moving on?
Mr Poole: I am, my Lady.
Lady Hallett: Can I just ask, I don’t know how easy it is to do in a few sentences, but could you give me some practical information on how focused protection would work? In other words, supposing my mother was still alive and living alone – I mean, how do you find the vulnerable – what place – what measures do you put in place? How does it work?
Dr Roland Salmon: Yes. Sure. This was the kind of thing that I was trying to address when I wrote to a number of politicians here in Wales. And I might commend the correspondence I have with Rhun ap lorwerth to you.
I mean, essentially for the vulnerable population it doesn’t look terribly different from the lockdown that they had already. What is rather easier for them, however, is that services around them should be working rather better.
I feel that on top of that shielding of those high-risk individuals, like your mother, for example, would be particular attention to the locations which we rapidly identified were a risk for spreading the disease – we’ve talked about these a lot – hospitals, care homes, prisons, meat factories. That is where I would have used test and trace, particularly when the numbers of tests available were rather limited.
And there is a very simple reason for that. I mean, I’ve done my share – not as much as the environmental health officers – of chasing people around the community and trying to actually manage a system of contact tracing in a wider community. It’s extremely difficult and resource-intensive. Whereas if you have a population for which you have a convenient register and you know who they are and you wish to stop the spread among them, whether that’s staff of a care home, staff in a hospital, that is much easier to organise in an efficient and effective way, and actually eliminates the largest part of the problem.
The final thing I would have done, and again I mention this in my letter, is promoted the use of protective equipment in at-risk occupations. And again, in the first two or three months of the epidemic we were pretty clear what those occupations were. I mean, it is an abiding scandal that the PPE stocks had been depleted between 2009 and 2020.
So I hope that gives you a feeling for how I see this would work out in practice. And this was the suggestion, as I say, I made to several Welsh politicians, I mean, largely on the ground that they were contemplating the firebreak, which struck me as a thoroughly bad idea, but Mr Poole may well wish to come on to that.
Mr Poole: Dr Salmon, let’s just explore this then a bit further with you, because I think the letter you’re referring to is the letter of 18 October 2020.
Dr Roland Salmon: Yes.
Lead 2B: So we’ve got that displayed, INQ000130868.
Who did you send this letter to? I think you’ve said –
Dr Roland Salmon: Oh, gosh.
Lead 2B: – Welsh ministers?
Dr Roland Salmon: Yeah, it’s – do you want me to run through –
Lead 2B: I don’t need an entire distribution list, but just give me a sense of who was in the –
Dr Roland Salmon: I essentially sent it to politicians – I’ve had a long career in Wales, and Wales is not a big place, so I essentially sent it to politicians I had met under some other heading in the past.
That was two Plaid Cymru politicians, Dai Lloyd and Rhun ap Iorwerth, the Conservative leader, Andrew RT Davies, and three Welsh ministers, Mark Drakeford, Vaughan Gething and Julie Morgan.
Lead 2B: Thank you. If we have a look, please, at the second paragraph, you list the matters that the letter concerns.
Number 4:
“Workable approaches centred on the person (‘targeted shielding’, ‘focussed protection’).”
Which is what you’ve just been –
Dr Roland Salmon: Yeah, I –
Lead 2B: – my Lady.
If we go to that section then of the letter, I think it’s page 2, you describe here how the framework would work in practice, and you suggest at (i) at-risk people, at-risk locations and – thank you – and then, over the page, to – the next page – at-risk occupations, which you’ve just alluded to.
In terms of at-risk persons, you say:
“Effectively shield vulnerable people by a combination of advice to (to wear masks, avoid situations where they couldn’t control their personal space) and the necessary social support to make this do-able.”
Then in terms of at-risk locations, the next bullet point, you say:
“Ramp up infection control and bring in regular screening and exclusion of infected/symptomatic persons from locations where spread occurs readily. This would include:
“• Hospitals
“• Care Homes
“• Meat Factories
“• Prisons
“• Universities”
And I just want to focus, in the time we’ve got, on those two in particular, because it is known that the vast majority of deaths from Covid-19 in Wales occurred in hospitals and care homes.
Some of those deaths in hospitals were of course contracted in the community but we also know that rates of nosocomial infection were high throughout the pandemic.
Professor Woolhouse has said about this, he says it wasn’t made clear how well the vulnerable segment could be protected from infection in practice.
Now, the Inquiry understands from February to March 2020 Public Health Wales and NHS Wales were devoting considerable effort to infection control measures, testing staff and patients, attempting cohort infectious and non-infectious patients and care home residents, and so on, and yet still Wales had a significant number of deaths amongst those who were being shielded, and that was a pattern that was seen across the whole of the UK.
Now, against that backdrop, Professor Woolhouse’s comments might seem like an understatement. I mean, what effective practical protections could have been provided to those who needed to shield from March 2020, that were available in March 2020, that were not provided to vulnerable people in hospitals and care homes in Wales?
Dr Roland Salmon: I mean, okay. I think shielding of vulnerable people at home just to dispose of that first was precisely the sorts of things that people were doing on their own initiative before the lockdowns were brought into place, a point, again, that I think Professor Woolhouse rightly makes.
In terms of protection in the location, like hospitals and care homes, I’m not going to sit here and pretend there are any very easy solutions to this. I just I think would make the point that it didn’t become any easier to do this because the whole of the population was locked down. In fact, quite the reverse. A degree of lack of focus, in my view, made spread in those particular locations occur more readily. I mean, the sort of things that you have to do, having adequate personal protective equipment and having adequate capacity to test and trace, probably should have been anticipated on the basis of the pandemic flu plans and yet apparently hadn’t been, and – yes, I think that I’ll conclude there perhaps.
Lead 2B: Would you agree that targeted shielding for social care workers in March would have been extremely difficult, would it not? You have a finite number of care workers, you have care homes that were not set up to enable isolation rooms and cohorting, and on top of that you have a business model predicated on social care workers moving between sites.
Dr Roland Salmon: I mean, all the above is true but, I mean, I think the question the Inquiry might wish to ask itself is: did the introduction of lockdowns actually make that any easier to manage? And I would argue no, it didn’t.
And that reminds me of the other point that, with advancing age, I’d forgotten, the other problem that we have is the lack of capacity in our acute hospital sector. Our hospitals run often at 85% to 90% occupancy all the time. With that you really don’t have the space and resilience for efficient and effective infection control.
One way around that might have been to have used the Nightingale hospitals for step-down care rather than imagine that they would have been used for acute care. But as far as I can see that never happened either.
Lead 2B: There is one other matter I just want to ask you before we move on. Targeted shielding assumes that people who are vulnerable can be protected by virtue of their vulnerability, defined, presumably, as a health vulnerability. However, obviously the Inquiry understands that those with pre-existing health vulnerabilities who are on the shielding list compared with vulnerabilities of whole communities are not necessarily one and the same thing. So, for example, we heard earlier this week from Professor Ogbonna and the findings of his socioeconomic subgroup that reported in June 2020, and they concluded that the risk of Covid-related death in males and females of black ethnicity was 1.9 times higher than those with white ethnicity, and that the risk of Covid-related death from men of Bangladeshi and Pakistani ethnicity was 1.8 times higher than white males.
Now, I assume you are not proposing that Wales should or could lock down and shield communities that are already minoritised within society?
Dr Roland Salmon: No, not at all. And I think a bit of context is quite helpful here, if you’ll allow me.
Easily the biggest driver of vulnerability is age. I mean, a point that Professor Woolhouse makes, and I endorse, and comes from the original OpenSAFELY study available on 7 May – as a pre-print – in 2020 is that the risk to an 80-year old is 10,000 times the risk to a 20-year old, the risk of death.
Now, if you slightly – what’s the word? – cheating slightly put that into a “what is your year-on-year rising risk?” it’s about – your risk goes up about 1.16 per year. So that means, of course, that someone from a black and minority ethnic group has the same risk as a white person about five years older than them, when you sit and do the sums.
So what that also tells us is that younger members of those communities, although they may be at more risk than their white equivalents – and this is quite wrong and shouldn’t be the case, I entirely concede that – though they be at more risk are not at substantial enough a risk that they need to change their behaviour patterns at all, it’s just that the levels at which vulnerability kick in are at a younger age group in those communities, as I say by about some five years, based on some fairly crude maths.
Lead 2B: Dr Salmon, I want to change topic now, and you’ve anticipated that I might have wanted to ask you some questions about the firebreak, which I’m going to do now.
Dr Roland Salmon: Sure.
Lead 2B: You described in your letter to the Welsh Government that we looked at a moment ago.
And perhaps we can have it back up, it’s INQ000130868. If we can have a look at page 2, please, the first bullet point on that page.
You say:
“• ‘Good adherence to measures’ is required.”
In the second bullet point:
“• The incubation period of Covid-19 (2-14 days) combined with high asymptomatic carriage rates (c30% in youg adults) ensures that the virus will be reintroduced into the community as soon as the circuit breaker is finished.”
Then finally the third bullet point:
“• ‘If regulations and behaviour then return to pre-circuit break levels, there would be a return to exponential growth’ meaning any respite is a very small number of weeks, too short to remedy problems with track and trace systems and too soon for a vaccine to be available.”
I assume you stand by the concerns that you expressed at that time in that letter?
Dr Roland Salmon: Yes, I do, and, I mean, within the inverted commas are quotes from SAGE minutes that I’d taken from the time, so in a sense these are quotes from the proponents of this scheme that seem to me to suggest that it won’t work rather than anything that I may have introduced into the debate.
Lead 2B: You say in your witness statement:
“… from a simple eyeballing of the observed COVID incidence, it would be difficult to conclude other than any effect was marginal at best.”
So do you think that the matters that you’ve identified already, so especially – we’ve still got it on the screen – especially the second and third bullet points of the letter, prove to be borne out?
Dr Roland Salmon: Yes.
Lead 2B: Would those issues have appeared had the firebreak been implemented for longer, in your view?
Dr Roland Salmon: No, I don’t think there would have been, because I think there would have been sufficient circulation in the community or sufficient opportunity for reintroduction that yes, possibly we might have had a slightly longer pause, but exactly the same situation would have re-established itself very quickly.
I understand the enthusiasm for some clinicians for the firebreak. I mean, I am a doctor, I have worked, admittedly many years ago, in busy clinical settings when almost any respite is so welcome, but I do think this one was particularly expensively bought, and really is hard to justify on broader social grounds.
Lead 2B: Changing topic again slightly, talking about NPIs. At paragraph 24 of your statement, you say that you consider many decisions regarding NPIs that were made by the Welsh Government were, your words, “inappropriate and lacking justification”. You identify as two examples the Welsh Government’s decision to close selected supermarket aisles and pubs being prohibited from selling alcohol. Can you just briefly explain why you considered those two examples to be inappropriate and unjustified?
Dr Roland Salmon: Yes, because I can think of no basis on why you might think they would work. If we consider supermarket aisles, I mean, case control studies in France, the ComCor study at the Institut Pasteur showed that large supermarkets and large department stores were not a setting where increased risk took place. So whether you leave the aisles open or you leave them shut really doesn’t matter. And actually if people are going into the supermarket why do you want to shut one aisle and not the other one? It seemed quite – I mean, I think one of your witnesses yesterday was talking about a lack of lived experience, but that seemed to suggest a lack of lived experience of even going to the supermarket.
And also the pub with no beer. I mean, the problem with any setting – and yes, restaurant and pub settings are an issue – are when people congregate in them, and that those people who are vulnerable are best avoiding them and advised to do so. But sort of opening it up and not have beer seems to me perhaps an overly enduring legacy of the chapel heritage, I don’t know.
Lead 2B: Dr Salmon, finally, you wrote a blog post titled “The … View from Wales”.
We have it at INQ000130866.
Perhaps we can just look at that together, if we can –
Dr Roland Salmon: Yes, of course.
Lead 2B: – please have a look at page 2, the third paragraph, please, that starts “Finally”, I’m grateful:
“Finally, the Wellbeing of Future Generations Act, some of Wales most forward thinking legislation singularly failed to translate into any sort of systematic evaluation of the downsides of global ‘lockdown’ approaches; downsides most likely to impact on just those future generations whose interests the Act seeks to protect.”
Please can you just briefly expand on your views there on lockdowns in the context of the Wellbeing of Future Generations Act.
Dr Roland Salmon: Yes, I mean, what I had in mind here was the loss of educational and employment opportunities to younger cohorts, I mean children, students, young adults in work, who bore a disproportionate share of the economic and social burden. And it’s easy to think that, “Well, that’s economics and on the other hand we’re saving lives”, but what I think we lose sight of unless we take a whole-life view of public health is that those losses of opportunities and that economic loss will translate into – and there are plenty of examples of this – ill health and loss of life expectancy. It may not be as immediate, but it will certainly be there.
Now, how we level those up, we’re starting to stray into where people’s values are, and I think where the politicians are reasonably expected to come in, but I did feel that this particular dimension wasn’t even considered.
And when I say “I”, I mean we, and if you’ll forgive me I might draw attention to who my fellow authors are. I mean, Meirion Evans received the OBE for his work on SARS in Hong Kong in 2003 with the World Health Organisation; Stephen Palmer had worked in Atlanta and set up the Communicable Disease Surveillance Centre in Wales; and John Watkins has spent his – who I think has submitted written evidence to this Inquiry – has spent his life working on influenza and respiratory disease epidemiology. So these are not lightweight opinions, whatever view you may take of mine.
Lead 2B: Would you have supported a full lockdown if it permitted schools to remain open?
Dr Roland Salmon: No, I don’t think I would because I don’t, frank – it has always been my view that the purpose of epidemiology is to target attention on those people who are vulnerable, who are at risk, in the terminology, and those behaviours that constitute a risk. That is why you do it. And you do it in such a way as to keep the restrictions that you impose as targeted as possible and to allow as much of the ordinary life that people want to lead – whether you approve of it, whether you disapprove of it – to go on as much as possible. That is the whole scientific not to say ethical basis of the discipline. So just to sort of think “Well, this is hard work, let’s just shut everything down and that will spare us any further thought on the matter” seems to me quite the wrong way to approach it. And I don’t always agree with Professor Woolhouse, who I know distantly, but the title of his book “The Year the World Went Mad” is one I’m entirely in tune with.
Mr Poole: Dr Salmon, I have no further questions for you.
The Witness: Thank you.
Lady Hallett: I don’t think there are any Rule 10 questions.
Mr Poole: No, my Lady.
Lady Hallett: Thank you very much indeed for your help, Dr Salmon, I’m very grateful.
The Witness: My pleasure.
(The witness withdrew)
Lady Hallett: Right, well, so that everyone can make their plans, we have to finish by 4.15 at the latest. So shall we break now for lunch?
Mr Poole: I think if we can, my Lady, yes.
Lady Hallett: And then return at 1.30?
Mr Poole: That’s fine.
(12.34 pm)
(The short adjournment)
(1.29 pm)
Lady Hallett: Yes, Ms Spector.
Ms Spector: My Lady, please can I call Professor Ann John.
Professor Ann John
PROFESSOR ANN JOHN (affirmed).
Questions From Counsel to the Inquiry
Ms Spector: Could you please start by giving us your full name.
Professor Ann John: Ann John.
Counsel Inquiry: Thank you for attending today and assisting the Inquiry. As we go through your evidence, please remember to keep your voice up and speak into the microphone so the stenographers can pick up everything that you say. Please do ask me to repeat if anything isn’t clear.
Your witness statement that you provided for this module of the Inquiry is at INQ000286066, and it was signed on 2 October 2023. Are the contents of that statement true to the best of your knowledge and belief?
Professor Ann John: Yes.
Counsel Inquiry: Professor John, in terms of your professional background, is it correct that you are a clinical academic with a background in primary care and public health?
Professor Ann John: Yes.
Counsel Inquiry: As a brief overview of your career, such as is relevant to the Inquiry, you are clinical professor of public health and psychiatry at Swansea University and an honorary consultant in public health medicine, a role you have held since 2017?
Professor Ann John: Yes, at a professorial level.
Counsel Inquiry: You are a strategic lead for mental health research and national-led suicide prevention at Public Health Wales, and you co-chair the cross-government group for suicide prevention?
Professor Ann John: Yes.
Counsel Inquiry: Prior to 2017, you were the deputy head of Swansea University Medical School?
Professor Ann John: Yes.
Counsel Inquiry: Before which point you held various senior posts in public and mental health at Swansea University?
Professor Ann John: Yes.
Counsel Inquiry: With regard to your involvement in specific groups tasked with Covid-19 pandemic response, you were a member of the Technical Advisory Group, or TAG, from 27 June 2020?
Professor Ann John: Yeah.
Counsel Inquiry: Within TAG, you were chair of the Risk Communication and Behavioural Insights (RCBI) subgroup?
Professor Ann John: Yes.
Counsel Inquiry: You were a member also of the children and education TAG subgroup?
Professor Ann John: Yeah.
Counsel Inquiry: And in addition to all of those roles you sat on what’s called SPI-B, the independent Scientific Pandemic Insights Group on Behaviours advising SAGE and the UK Government in the summer of 2020?
Professor Ann John: Yes.
Counsel Inquiry: Which you became co-chair of in June 2021?
Professor Ann John: Yes.
Counsel Inquiry: Professor, what was the Risk Communication and Behavioural Insights (RCBI) subgroup and what was its work?
Professor Ann John: So the RCBI subgroup was a group that was set up as a subgroup of TAG, so it was to – it was basically to provide scientific insights and support to policymakers around behavioural science.
Counsel Inquiry: Is it right that you were approached to set up the group by Fliss Bennee, the co-chair of TAG, in early June of 2020?
Professor Ann John: Yes.
Counsel Inquiry: And you held your first meeting on 22 July of 2020?
Professor Ann John: Absolutely.
Counsel Inquiry: In terms of SPI-B, that group provided expert social and behavioural scientific advice as a subgroup of SAGE.
Professor Ann John: Yes.
Counsel Inquiry: How did you come to be involved with SPI-B?
Professor Ann John: So initially I was invited by James Rubin to sit on the group. Then when SPI-B developed a co-ordination group, so that was sort of a smaller group of scientists, and then a wider group that we would draw on, I was on the co-ordinating group. And then when James Rubin and Lucy Yardley stepped down as co-chairs, I was invited by Brooke Rogers, Professor Brooke Rogers, to be co-chair of SPI-B.
Counsel Inquiry: To ask you about the timings, you have told us that you were approached to chair RCBI in Wales on 2 June 2020 and the first meeting of that group, as we’ve heard, was held on 22 July 2020. On the other hand, the Inquiry understands that SPI-B, as a general group, was stood up on 13 February of 2020. Although I appreciate that you might not have been a member in that initial formation of SPI-B.
After becoming the chair of RCBI were you able to gain any understanding all about why the RCBI had not been set up earlier in the course of the pandemic?
Professor Ann John: It’s very difficult for me to comment, because that was also very close to the time that I’d become involved with TAG as well, so I’m not sure what the thinking was before that, but I guess what I would say is that as soon as I was invited and we’d pulled all the members from diverse disciplines together for RCBI, we had a very active role in feeding into TAG.
Counsel Inquiry: You might not be able to answer, but do you know whether anything was being done prior to June 2020 to obtain specialised Welsh-specific advice about behavioural science?
Professor Ann John: So I can’t really answer that, I know there were people on the sort of civil servant side with some expertise in behavioural science.
Counsel Inquiry: Do you think that it might have helped had RCBI been set up earlier than it was?
Professor Ann John: I think one of the things that the pandemic has really highlighted, you know, and it was absolutely pivotal prior to the advent of vaccination, is how important behavioural science is. So understanding – so this idea that you can tell people what to do and they’ll do it is naive and antiquated, and I think, you know, the importance of behavioural science has been absolutely highlighted during the pandemic. You know, understanding people’s, you know, motivations, their capabilities, their understanding, and awareness about risk, you know, the limitations in their lives to enable them to follow rules, and the impacts of inequalities, was absolutely highlighted. And so, I guess, from my perspective, and for going forward, you absolutely want behavioural science input during any pandemic from the beginning, but also that that capacity is being built up currently.
Counsel Inquiry: You touched on it already, but can I ask you to provide an overview of what the term “behavioural science” means and what its methodology is.
Professor Ann John: So it’s that understanding – I guess in some ways I would repeat what I’ve just said, it’s understanding human behaviour, you know, that people will have motivations about why they might follow rules or behaviour in a certain way, that there are limitations. You know, staying in a one-bedroom flat during a stay-at-home order is very different to staying in a house with a garden. You know, people might have front facing frontline jobs with zero-hours contracts, so then when you’re asking people to isolate where there’s no financial assistance, then that’s really – that’s much more challenging for them than for someone who has the financial wherewithal.
So having that understanding of motivations, capabilities and opportunities is really important when you’re thinking about, you know, what are the – how do we encourage people to behave in certain ways. And I guess it also highlights that things like, you know, using “protecting others” rather than blame and fear and shame is always a much more ineffective way.
Counsel Inquiry: We might return to some of those themes in due course in your evidence, but as a summary is it correct to say that some of the things that RCBI advised on during the course of the pandemic were: examining behaviours towards restrictions in place such as physical distancing, you’ve touched on that; examining differential uptake of vaccines; understanding drivers of behaviours in young people regarding NPIs (non-pharmaceutical interventions); and focusing on protective strategies for under-served groups?
Professor Ann John: Absolutely.
Counsel Inquiry: What empirical or observed evidence did RCBI rely on to formulate its advice?
Professor Ann John: So for the most part, in a pandemic where lots of the things that – the science that we were relying on was being generated and evolving as time went on, the sorts of things that we were relying on were mainly surveys. Some of those surveys were what we call panel surveys, so they try to be as representative as they can be, but it’s all self-report. And the issues around self-report is that – you know, it’s not that people lie, it’s that sometimes – you know, when I was a GP, if I was asking someone “How much do you drink?”, those answers can be very different to what someone’s actual consumption is, for all sorts of reasons. So self-report was absolutely – so those sorts of surveys were absolutely important in a situation where we didn’t have the evidence, but I guess we know that they’re quite biased. And going forward, it would be really good to have what we call empirical evidence, so also being able to see what people actually do rather than what they say they’ll do.
Counsel Inquiry: You describe in your witness statement that both the RCBI and SPI-B preferred what you call a facilitative and/or enabling approach rather than a directive approach. Are you able to explain the differences between those two approaches?
Professor Ann John: A directive approach is – would be much more: you make a rule and you enforce a punishment if people don’t follow those rules. An enabling approach is really, you know, I would say, fundamental to behavioural science. It’s understanding all those different factors that sort of encroach upon why someone might behave in the way that they do.
So the vast majority of people adhered to the restrictions that were in place. And where they didn’t, it was for the reasons that I outlined before, you know, it was things like, you know, not having access to financial support to self-isolate, it was, you know, being in – not having the support to go and get a food shop or walk their dog. So I guess it really is about understanding those sorts of issues.
Counsel Inquiry: Moving to RCBI and how the commissioning process worked for that group, how did that process work? Did commissions come from TAG or did they come elsewhere in the Welsh Government?
Professor Ann John: So for the most part, we either received commissions during discussions in TAG, so I do remember – you know, in a particular incident I remember about moral injury in healthcare workers, that was a discussion that happened in TAG. Other times we would hear from the secretariat what had – what questions were being asked.
Counsel Inquiry: Were you able to set your own priorities as a group or did these always come through TAG or through the secretariat?
Professor Ann John: I think I would say that we were in some ways able to set our own priorities because we were such active members of TAG, so we were able to bring issues up.
Counsel Inquiry: Did you at times provide advice on issues that, where advice hadn’t been requested but you felt that that advice was necessary?
Professor Ann John: I think that where we were – you know, so a good example is young people, that where – them – you know, something might be touched upon in TAG, we would be able to say “We’ll go away and do some work on this”.
Lady Hallett: Sorry, Professor, you used the expression “moral injury”, I don’t think everybody knows what moral injury means, could you just give a short explanation.
Professor Ann John: So I think the thing about moral injury – so we talk a lot about burn-out, and people really link burn-out to workload, but actually it’s much more complicated than that. You know, burn-out is much more common in what we call a moral injury, so where people are working in a situation where they can’t do what they have been trained to do, where they’re doing things that they feel are against the ethos of their profession.
So we did a piece of work predominantly on healthcare workers who were working, you know, at high capacity but also in a situation where people were sometimes, you know, dying without loved ones, that might be in conflict with how they would want to practice. So we were highlighting that it was not just – and most of the evidence on this issue comes from combat zones. So we were looking at the evidence that existed to apply it to the sort of morale in the healthcare and social care sector.
Lady Hallett: Thank you.
Ms Spector: Was the RCBI a multidisciplinary group? What kinds of expertise did the group have access to?
Professor Ann John: So for the most part, so there were public health people there, there was myself and Ashley Gould, who was going to be my – who was my co-chair after about a year. There was – there were various psychologists, so there was Professor Nick Pidgeon, who has a lot of expertise in risk communication, predominantly in relation to climate change, and does a lot of UK Government advice. There was Professor John Parkinson, there was Tony Manstead. We also had – we had evidence synthesis experts, Adrian Edwards, we had people from social sciences.
So I think behavioural science really is multidisciplinary, and we also invited officials from – we had a member of the Welsh Government sort of communications team, which I think meant that they were hearing a lot of behavioural science in terms of how communications were done. And someone from the police as well.
Counsel Inquiry: Do you think that there was sufficient representation on TAG and on RCBI of people from ethnic minorities and from socially deprived backgrounds or minoritised groups?
Professor Ann John: In a word, no. I think that reflects society as a whole. So if you look at the composition of professors around the country in every university, representation from, you know, people from ethnic minorities or more socially deprived backgrounds, even representation in university of people from deprived backgrounds is not great. So I do think – we had the best people round the table, and the way that looked and was – the composition of it reflects society as a whole. So I think there’s something to do about widening access and participation in science and education.
But knowing that to be the case – you know, having a diverse range of voices round the table is really important. Knowing that to be the case, it really highlighted how important it was to have co-production, be going to groups of people from, you know, ethnic minorities, from more deprived communities, to really understand how they felt about interventions being discussed. So that sort of focus group work, which was going on to to some extent, but also that co-production and co-development of interventions is really important.
Counsel Inquiry: I now want to ask you about co-ordination and divergence of policies between the UK and Wales.
Please can we have displayed on the screen INQ000384805, and can we see the email that was sent on 12 May 2020 from Professor John Watkins, who is a professor of epidemiology at Cardiff University and was a member of the policy modelling subgroup of TAG.
Email sent at 12.17, second paragraph down:
“… I find it quite alarming that the four home nations are not marching in step in addressing the challenge of exiting ‘lockdown’.
“From a scientific point of view, the epidemiology of this disease does not warrant this differential approach and therefore I am a concerned that opinion is diverging. Wales, with its extended land border with England, crossed daily by citizens for work, with differing rules backed by law, puts people in a particularly difficult position. If all policy in this matter is based on Science and I am not aware of any difference in the scientific advice given to Welsh Government compared to England, then why have ministers chosen a different course?”
Professor Watkins’ concern was that rules were putting people in a difficult position.
Now, I am not going to ask you about the rights and wrongs of those policies, I want to ask you about the impacts of those kinds of divergences between the four nations and especially between Wales and England on population behaviour.
Are you able to assist with what the impact that divergences like the speed of exiting lockdowns is likely to have had on people’s understanding of and compliance with restrictions in Wales?
Professor Ann John: So one of the basic principles of behavioural science and communication is having clear messages that – where you explain why you’ve come to that policy decision. I think for people, this divergence across nations – now, there’s always going to be some because the composition in different regions is different. You know, as we’ve heard, Wales has an older, more deprived composition in terms of population. So there are some reasons to be different.
However, it would have been very confusing to people that – you know, there was one point where you had to wear a mask on the train till you got to Newport and then you could take it off. Now, there is no doubt in my mind that that – you know, that idea, that if we’re following the science why are we coming to different conclusions, was difficult for people, and that would have had an impact on trust, and we know how much trust in government and in the decisions being made impacts behaviours in these situations.
So while I think we do need to acknowledge that sometimes rules will be different, the responsibility is to communicate why, and I think that sometimes was missing.
Counsel Inquiry: I think you’ve answered my next question, but I’ll put it anyway. Is it possible that divergences of policy like the ones you’ve described weakened a belief amongst the population in the science and could those divergences have caused a fall in confidence in government policies that were being led by the science?
Professor Ann John: So, yes, I think for – you know, unless you gave a very clear explanation for that divergence, it would have affected some segments of the population. So, you know, if you trust in your government, if you feel that a policy is being done, is being enacted to keep you safe, it may not impact adherence, but in general, for other parts of the population, it would. So I think clear, consistent messaging is really important.
And I guess going forward it would – and I do think this is – my understanding is this is happening, is I think it’s – working together, you know, recognising that part of that leadership role across the four nations is coming to some kind of consensus, in the way we did as scientists in terms of policy, is really important going forward.
Counsel Inquiry: Professor, I now want to ask a you few questions about the formulation of assumptions about population compliance around NPIs, especially in the first wave of the pandemic. I caveat these questions in that it is fully appreciated that RCBI was not set up at that point in time.
Please can we have on screen INQ000049647.
This is a document from Imperial College titled “Impact of non-pharmaceutical interventions … to reduce COVID-19 mortality and healthcare demand” dated 16 March 2020.
If we turn to page 6, please, there’s a table titled “Summary of NPI interventions considered”. Under “Case isolation in the home”, top row, if you look at the final sentence, it says:
“Assume 70% of household comply with the policy.”
Then second one down, “Voluntary home quarantine”, final sentence:
“Assume 50% of household comply with the policy.”
Then, moving two rows down, “Social distancing of entire population”, first sentence:
“All households reduce contact outside household, school or workplace by 75%.”
Could we now, please, turn to a different document, INQ000349161.
This is a TAC briefing for the Welsh Government titled “Briefing from SAGE outputs on Behavioural and Social Interventions”.
And then on page 3, at paragraph 16:
“These interventions assume compliance level of 50% or more over long periods of time. This may be unachievable in the UK population and uptake of these measures is likely to vary across groups, possibly leading to variation in outbreak intensities across different communities.”
If I just ask you some questions about that.
In terms of actual compliance figures, it’s of course difficult to obtain concrete – a concrete single metric of whole population compliance across the pandemic. That said, in late March and April 2020, are you able to comment on what population compliance was like, whether it was in excess or under the estimates that we’ve just seen in those documents?
Professor Ann John: So I guess firstly I really don’t like the word “compliant”, because – I think “adherence” is a much better word. I think we – I think the vast majority of – I think these are probably underestimates at the time. Now, I think when you’re – for the sort of modelling that was being undertaken then, they’re actually being more conservative, so they’re basing their assumptions on lower levels of adherence than I think actually we found. I think the issue around that is that it sort of – I think we didn’t make the most of, and absolutely underplayed, the public’s, you know, wanting to both protect themselves but also those around them. That – I think in Wales we did understand that sort of collective responsibility, and that talking about all those things was much better than thinking about – thinking about it from a sort of people will break the rules perspective.
So I think there’s two issues here, I think these are very conservative assumptions, and normally when we do – when we make assumptions, when we’re doing modelling, you tend to be on the conservative side because there are many more risks with being on – looking at them the other way.
But I think we do – we fail to recognise sometimes how much the public and communities pull together.
Counsel Inquiry: On 14 April 2020, one of your colleagues from SPI-B, Professor Lucy Yardley, said in an email to Professor Mark Woolhouse, a professor – as we’ve heard earlier today – of infectious disease epidemiology:
“I find epidemiologists tend to underestimate the extent to which what people do is malleable and can be influenced by how things are introduced and supported.”
Do you agree with Professor Yardley on that point?
Professor Ann John: Absolutely. I think, you know, it goes back to that issue around financial support for isolation. You know, for some people it was very challenging to isolate, you know, from a financial – from the point of view of, you know, feeding your family. If you’re on a zero-hours contract, if you’re working in a workplace where you’ll put loads of burden on others, if you’re in a front facing, frontline occupation, you need support to stay home. So absolutely, I agree with her.
Counsel Inquiry: Moving to a new topic, I will ask some brief questions about the notion of behavioural fatigue, which touches on, of course, some evidence that you’ve already given for us.
In your witness statement that you provided you reference the emerging debate on behavioural or pandemic fatigue in March of 2020 which was later addressed in RCBI. Are you able to briefly summarise what that debate was and what it referred to in the population?
Professor Ann John: So the idea of pandemic fatigue I think really fits in with sort of popular culture. You know, it sounds like, you know, Barack Obama and Mark Zuckerberg talking about decision fatigue. So it sort of feels like common sense, doesn’t it? People will get tired of it.
In actual fact there no evidence for that. I think as time went on from when that term was first mentioned, you know, more and more of us came out and said, well, actually, there’s no evidence for that.
I think if you – if you put forward clear consistent messaging, if you supported people in how to adopt certain behaviours like isolation, there was no idea that pandemic fatigue existed.
Lady Hallett: I think Professor Sir Chris Whitty, who used the expression, regretted it in his evidence before me.
Professor Ann John: And I think absolutely it’s because it’s sort of – you – you’re trying to communicate with the public and it sounds like common – you know, it sounds – it’s in popular discussion, isn’t it? So yeah, absolutely.
Ms Spector: What were some of the dangers of public discourse normalising a notion of behavioural fatigue?
Professor Ann John: I guess – I guess where – you know, if it – if people – it’s almost like a confirmation bias. So if you think that pandemic fatigue is something, then I think the risk for the public is that it might normalise, sort of, not adhering so carefully.
I think the risk in terms of policy and for scientific advice is that that would impact how you think we can continue with restrictions or what restrictions should happen after you come out of, say, a firebreak or a stay-at-home order. So I think that’s where the danger in the term lay.
Counsel Inquiry: In your view and from your experience working in TAG and on RCBI, were policymakers or ministers within the Welsh Government, were they making decisions based on notions of behavioural fatigue that you didn’t think, as you’ve said, there was evidence for?
Professor Ann John: No. I think as soon as – this was something that, within the sort of behavioural science groups I was in, we were very clear about it, and we communicated that every time it came up.
Counsel Inquiry: Moving to the summer of 2020, in his statement to this Inquiry, Dr Rob Orford has said that following the first wave too much of society was opened up all at once and in terms of hospitality it led it a feeling that “if it’s okay to go to the pub then it’s okay to mix with others” and that there was a lack of reasoned debate on the impact or harm of these measures.
Do you agree with Dr Orford’s comments about that?
Professor Ann John: So the way I think about this, so I’m assuming this is linking to Eat Out to Help Out, you know, you’ve heard before how we didn’t have input into that or its messaging. I can’t comment on the balances across different areas that policymakers were making. But I guess what I would say is that if you’re saying to people, you know, “We need to eat out to help out the economy”, now, when you’re thinking about people’s motivations, the economy might not be the most important thing to them, it might be the mental health of their grandmother, it might be their own sense of loneliness.
So if you can do things for one reason, then you can do it for others, so it absolutely would have affected people’s behaviours.
Counsel Inquiry: Moving forwards in time, just briefly, TAG published the paper “Behavioural insights to support a post fire break Wales” on 29 October 2020. Did you or the RCBI feed into that paper?
Professor Ann John: Yes.
Counsel Inquiry: What was the purpose of the paper? What was it designed to achieve or to support?
Professor Ann John: So the firebreak in October was a sort of a short two-week stay-at-home order, and, you know, when people are coming in and out of different restrictions, it really is about thinking about: how do we do that and maintain behaviours? And so it was really thinking about issues like the financial support, having – giving people …
So one of the things that we, you know, struggle with, everyone, is, like, risk, risk perception and risk communication. And your perception of risk feeds into your behaviours, but it’s really hard to communicate. You know, like the radiation from flying in an aeroplane is the same as having ten almonds in your pocket. You know, that’s the sort of way that you try to communicate risk. And I guess it was highlighting as well how people could, as restrictions eased, go forward into their own behaviours but understanding how they could maybe do that safely or how they might make another choice in your life.
So one of the things that really impacts on behaviour is education and awareness, and also I think – I think we could have been better – so I think for policymakers you like to – you like to give certainty, because giving people certainty, you sort of feel that that feels like a good leader and that feels like we’re keeping people safe. Whereas in actual fact, you know, being able to communicate uncertainty in a situation that was evolving, you know, rapidly, I think might have prevented those ideas about, you know, there were U turns or why have we got different policies in different places.
Counsel Inquiry: Going back to the summer of 2020, we know that RCBI wasn’t set up when restrictions began to ease in Wales in 2020 after that first wave, but do you think it would have helped if the kind of work that you did later on in October on risk awareness and communications in that TAG paper could have been done following the first wave? Would that have assisted in the manner in which Wales unlocked from lockdown?
Professor Ann John: I think, in keeping with what I said earlier, I absolutely believe, and I think it’s fully acknowledged now, having behavioural science and all those disciplines’ input into these sorts of changing restrictions was important, and would have been important.
Counsel Inquiry: Moving to my final topic: under-served groups and ethnic minorities and data on them and their representation.
You explain in your witness statement that the pandemic highlighted one of the underpinnings of public health that is often overlooked, and you go on to describe how usually groups who are under-served and vulnerable are largely hidden and unlikely to impact the health of others. But, you say, this changed during the pandemic.
Are you able to just expand on what you meant by that.
Professor Ann John: So when you – so we all think that things – things like the data collected by hospitals or the data collected in schools or even the census gives us true facts. If you work with data, you develop a healthy disrespect for it.
One of the things that really came out in the pandemic, and I think has been transformative, is that there were things that we could not count. So – and one of those things was about ethnicity. You know, ethnicity is so poorly recorded in routinely collected data. And that’s sort of for understandable reasons, you know, people often would say “Prefer not to say”. And that comes back to trust. But because those things aren’t recorded, we can’t count, and because we can’t count, we can’t see what the disproportionate impact in certain sectors of society are.
So if people aren’t accessing services, we can’t count them. If we don’t – if we’re not recording ethnicity, it’s very difficult – and there are lots of characteristics, at least with the impact of the pandemic on ethnic minority groups – you know, there was that sense, when you were on social media very early on in the pandemic, you know, lots of the photos of people who were dying were from ethnic minorities, but there are, equally, lots of characteristics where people might be vulnerable that aren’t so visible.
And I think one of the important lessons going forward, and I do – I do think it’s been recognised, is ensuring that we have timely, accurate data systems. We can’t just, you know, try to develop data systems in the middle of a pandemic. We really need to invest, and I think in many ways we have, in those systems being operational.
Counsel Inquiry: My final question is just about that. Are you able to provide slightly more information about what has been done already and what is still being done to increase the acquisition of the kind of data that you describe?
Professor Ann John: So there are UK-wide initiatives, both with NHS data, with recording of ethnicity status in hospitals, in healthcare. There’s the idea of recording ethnicity on death certificates, but recording on death certificates of things like occupancy and ethnicity can be quite poor.
So I guess what I’m saying is there’s a lot of work to be done with under-served populations, so I know that – you know, back in the day I always used to tick “Prefer not to say” because you have an inherent knowledge that it’s going to be a disadvantage to you. It’s not an advantage to be from an ethnic minority. So I think there are things that we need – we need to address education and awareness of people in terms of their suspicions about why we’re recording this data.
And we also need to think about, you know, how we
address those trust issues across our most, sort of,
unheard vulnerable populations. Because all those
things come down to trust.
Ms Spector: My Lady, I have no further questions, and
I don’t believe there are any Rule 10 applications.
Lady Hallett: No, there aren’t.
Thank you very much indeed, Professor. I do hope
being a clinical professor doesn’t mean you stopped
teaching, because I found it extremely interesting.
Thank you very much indeed.
The Witness: Thank you.
(The witness withdrew)
Mr Poole: If I can call Professor Michael Gravenor, please.
Professor Michael Gravenor
PROFESSOR MICHAEL GRAVENOR (affirmed).
Questions From Lead Counsel to the Inquiry for Module 2B
Lady Hallett: I hope we haven’t kept you waiting,
Professor.
Mr Poole: Please take a seat, Professor. If you could
start with giving us your full name, please.
Professor Michael Gravenor: My name is Michael Brynley Gravenor.
Lead 2B: Professor, whilst giving your evidence, if you can
please keep your voice up so we can hear you but also so
your evidence can be recorded. If I ask you a question
you don’t understand, please do ask me to rephrase it;
and thank you again for coming and assisting the Inquiry this afternoon.
The witness statement you’ve provided for this module is at INQ000347979. We don’t need to go to it but at page 35 you signed and dated that on 28 October of last year. Are the contents of that statement true to the best of your knowledge and belief?
Professor Michael Gravenor: Yes.
Lead 2B: Professor, by way of overview of your career, then, to date, you’re a professor of epidemiology and biostatistics at Swansea University; correct?
Professor Michael Gravenor: That’s right.
Lead 2B: Your academic career has been focused on infectious disease epidemiology and public health data analysis through mathematical modelling and statistics; is that also right?
Professor Michael Gravenor: That’s right.
Lead 2B: Although you have not previously worked with coronaviruses I think I’m right in saying you have professional experience in the practical application of mathematical models of infectious disease for policymakers; is that right?
Professor Michael Gravenor: That’s correct.
Lead 2B: In terms of your role during the pandemic, is it right that in May 2020 you joined TAG and the modelling subgroup which was co-chaired by Brendan Collins and Craiger Solomons?
Professor Michael Gravenor: That’s right.
Lead 2B: From April to May 2020 you and some colleagues from Swansea University, which we will call the Swansea modelling team, had been commissioned to provide a Welsh-specific epidemiological models to assist the Welsh Government respond to Covid-19; is that right?
Professor Michael Gravenor: That’s right, yes. I maybe wouldn’t say commissioned, but …
Lady Hallett: You volunteered.
Professor Michael Gravenor: Yes.
Mr Poole: Was the work that you did voluntary, unpaid work?
Professor Michael Gravenor: Yes. Up until much later in the day.
Lead 2B: To the best of your knowledge, Professor, were there any epidemiological models being developed and run in Wales for the Welsh population in February and March 2020?
Professor Michael Gravenor: I would say that some of the – or a good few of the SPI-M models would include Wales as an element. I wasn’t aware of any specific focus on Wales from any other models.
Lead 2B: So is it right in this period, February/March, Wales was heavily dependent on the modelling work that was being done by SPI-M, which was also being used to inform SAGE discussions?
Professor Michael Gravenor: Yes, that’s correct.
Lead 2B: Professor, when did you first become aware of Covid-19?
Professor Michael Gravenor: I think it would have been on the news in early January, I expect.
Lead 2B: What were your views about what was happening in Wuhan and the potential pandemic that was unfolding in the January 2020?
Professor Michael Gravenor: I think – I knew as colleagues several of the epidemiologists that were involved in the analysis of the outbreak in Wuhan and I read their reports as they were coming out in January, so I followed it quite closely because of my background and because of my links with some of the people working on it at that time. So I think I was fairly up to date with the evolving situation and the potential concerns, because I could see it being conveyed by colleagues.
Lead 2B: But obviously at this point you had no formal role in advising the Welsh Government, you were entirely independent?
Professor Michael Gravenor: That’s right.
Lead 2B: Did you raise the alarm with your professional colleagues? I think you say in your witness statement that very large numbers of infections in 2020 would be likely.
Professor Michael Gravenor: Well, within the medical school in Swansea, yes, in informal conversations, yes, it looked fairly obvious.
Lead 2B: What kind of interventions did you think would be required?
Professor Michael Gravenor: At that point, I – I really don’t know at that point. I think that’s going back quite a long time and a bit of hindsight involved there. I just expected a large epidemic.
Lead 2B: Could we, please, have INQ000374405 on screen.
This is an email that you sent on 24 February 2020, and it’s right you sent this to an individual who worked at Public Health Wales?
Professor Michael Gravenor: That’s right.
Lead 2B: I’m just going to pick it up from about four lines down:
“The other is corona related. I cornered Brendan the other day …”
Is that Brendan Mason, who worked for Public Health Wales?
Professor Michael Gravenor: That’s right, Brendan and I were lecturing together on that day in the medical school to medical students.
Lead 2B: So you say:
“I cornered Brendan the other day, he was measles outbreak lead, and I was asking him for data and information on MMR vaccination. He was looking pretty pale with 24/7 preparation for corona, and I briefly asked him if he needed any modelling support, might be a bit late in the day but Wales does represent a devolved and small public health response so potentially they can do things differently, university campus closures, that sort of thing, if they wanted. They may make some support on scenarios and if they do I wondered if you were interested.”
By doing things differently, what do you mean? Differently to England, differently to the rest of the UK?
Professor Michael Gravenor: I honestly can’t remember what I meant at that point. I really was at that point just reaching out to some colleagues to see if they would be interested in essentially some modelling analyses, because it might be provided. And it was through my contacts with Brendan that I was introduced to Public Health Wales and Dr Chris Williams and colleagues.
So at that stage I was following the modelling analysis quite closely, and I thought that some help may have been – in terms of interpreting perhaps the modelling output that was coming out. I was aware that these kind of reports might have been news to a lot of people. So I was just really fishing around at that stage for maybe something that we could do to help interpret what was happening in Wales. I was aware that the health response was devolved but I don’t think I was referring to any specific kind of activity at that point.
Lead 2B: No, you were obviously offering modelling support, and in that email we just looked at you said it might be a bit late in the day, so was it your view that, sort of, modelling should have really been put in place already by the – towards the end of February 2020?
Professor Michael Gravenor: Yeah, I guess that’s what I thought, yes. I – or that they would be relying on the, you know, well established groups in SPI-M and the large groups involved there, Imperial and the London School of Hygiene and Tropical Medicine. So I knew that a lot of modelling support was going to come from that area and that’s what might have been relied upon.
Lead 2B: Did you get a reply from that offer, did Public Health Wales take you up on your offer at this stage of providing modelling support?
Professor Michael Gravenor: On that day, no, but that is the – as I said, that was, I think, when – as I recall, that’s when, sort of, leave was cancelled, so to speak, for Public Health Wales and things got very, very busy indeed.
So I didn’t hear back immediately, but that is the route at which I was introduced to Public Health Wales and, ultimately, Welsh Government.
Lead 2B: And individuals like Dr Chris Williams who we heard from earlier?
Professor Michael Gravenor: Yes, so Dr Mason introduced me to Chris Williams and that’s really where the link started.
Lead 2B: On 14 March you sent an email, perhaps we can have it up, INQ000374409. You sent an email, and I think it was – you sent it to someone who I understand is a mathematical biologist, you say:
“All gone a bit bonkers here, control via natural herd immunity? I think they will backtrack on that. No evidence on duration of immunity, no evidence on long-term respiratory complications of survivors by age.
“Don’t understand why. Massive investment in the surveillance and testing of the obvious route into the country via half term ski trips. Shut down and have a substantial in % terms, it has to be (given it is at low end) effect on R0. Chase up cases like hell with all the resources going there, slow everything down in the summer, wait for better treatments for next winter.”
Do you stand by what you said then in this email of 14 March, that by locking down earlier, investing in surveillance and testing of those entering the country and chasing, in your words, cases up like hell would have been the best strategy for Wales in mid-March 2020?
Professor Michael Gravenor: It’s difficult looking back at these now, but parts of it, parts of it.
I think by the 14th – I think – we’d gone past the routes into the country, I think we’d gone well past that. So I think this is more of a comment that – as you know, herd immunity was discussed many, many times and the approach there means slightly different things to different people, but I think it well reflects my concerns that – I mean, there is a little bit of modelling there, which – the first thing that would come to my mind is that the idea that we reach a certain threshold and that’s it, that’s – as an epidemiologist, that never seemed like a very sensible conclusion, because viruses are extremely adept at changing and so there was always going to be concerns over immunity, and I think this is – this is before the term “Long Covid” was mentioned but systemic nasty respiratory viruses cause damage and we don’t know the problems there.
But in terms – and also, in terms of large scale emergency response, then shutting activities down and reducing contacts a lot has always been part of discussions of pandemic response in terms of things like influenza and – in worst-case type scenarios, then shutting down and waiting for vaccine improvements in terms of influenza is a discussed option. So it seemed that we were very much, very much at that point in mid-March.
Lead 2B: At this point in mid-March, I mean, it’s right, isn’t it, to say that there was no massive investment in surveillance and testing of those coming into the country, whether it be ski trips or otherwise. There was no shutdown, we know, for a further week. There was no contact tracing, let alone the rigorous contact tracing that you’re advocating for in this email.
I mean, would it be fair to say that this was a missed opportunity for Wales to have better controlled the first wave?
Professor Michael Gravenor: No, I think at this point there was not really – I – I don’t think this was applicable at that point in time, it just simply wasn’t. So this is not something that could have been done at that point in time, but it’s something that we had to move towards. And so I would slightly separate out the surveillance and the routes into the country: surveillance I meant within Wales, not in terms of international travel, which I think was long gone by then.
But no, I don’t think it’s something that could have been done at that moment. It’s something that would – that it seemed very apparent that we would have to invest in going forward.
Lady Hallett: You’re not saying it should have been done before?
Professor Michael Gravenor: I think there would – I think it’s apparent that there wouldn’t have been much time before to put that full surveillance and testing in place. I think, given the numbers of tests that were available at that time, that’s not something that could have just been done at that point.
So I’m not saying that it was an option that was missed, it’s just a comment that that’s where we’d got to head towards.
Mr Poole: This is mid-March 2020.
Professor Michael Gravenor: Yeah.
Lead 2B: And we’ve heard from various witnesses alarm bells ringing with them in early to mid-January, so it’s a two-month period.
Professor Michael Gravenor: And I think testing, bringing a testing system into place to deal with that is a huge challenge and, as it proved, took considerably more time. So I would not like to represent it as an option that was right there available at that time. That’s not correct.
Lead 2B: We’ve heard from Dr Roland Salmon earlier today about his views on the efficacy of lockdowns, and in your statement to the Inquiry you have said that it was clear that once the situation of late February, early March was reached, a first national lockdown was necessary.
Why do you describe it as being clear by late February, early March, that lockdown was necessary?
Professor Michael Gravenor: Well, there was very little – I think by late February, early March we – the reported seeding throughout the country was suggesting that the kind of things that had evolved around surveillance and testing and – were not sufficient to be able to control it UK-wide, and it was going to spread very, very rapidly.
So all we then have to – is to greatly reduce contacts, greatly reduce mixing between individuals, and at that point we had a pretty good estimate of the transmissibility, dealing with a very, very transmissible virus, and it seemed that there wasn’t really anything else in the short term, other than a substantial reduction in contacts.
Lead 2B: Do you think that the national lockdown should have been implemented earlier than 23 March?
Professor Michael Gravenor: In retrospect, I think it would have been helpful it was, yes.
Lead 2B: I’m right, aren’t I, that your modelling subgroup analysing an earlier lockdown in a July 2020 paper?
If we could, please, have INQ000302585 displayed. Excellent. Page 7, thank you.
I want to look at figure 9. This shows the effect of different timings of lockdown parameters on the potential course of the pandemic in Wales. Under the scenario of no mitigation measures at all, the pandemic would be expected to have reached a very high peak in mid-May. Yes?
Professor Michael Gravenor: Yes.
Lead 2B: If only pre-lockdown reduction levels of contact were maintained, so in other words no full lockdown, a peak of over 250 deaths per day may have been expected near the beginning of June; yes?
Professor Michael Gravenor: Yes.
Lead 2B: And if lockdown had been delayed by only five days the scenarios here suggest an additional 28% of deaths would have occurred. Am I reading that right?
Professor Michael Gravenor: Yes.
Lead 2B: And if lockdown had been introduced only five days earlier than 23 March, an expected 24% of deaths may have been prevented; is that also right?
Professor Michael Gravenor: Yes, that is the output from that model fit, yes. So moving all those reductions in contacts earlier would – can only really have the effect of slowing down the epidemic earlier, with a knock-on effect on the first peak. So I understand that there are debates about how we slowed down contacts prior to the mandated lockdown, and so this modelling exercise is an exercise in moving kind of all of those events earlier in time. But I think it’s – it’s an inevitable part of infectious disease dynamics that if you reduce contacts earlier, you reduce the peak. There are potential consequences of that later on, but in terms of the peak, yes. I think that that is – I think that that’s – there’s a strong, strong case for that.
Lead 2B: I was going to ask you, Professor, would an earlier first peak have led to a greater number of deaths in the second wave?
Professor Michael Gravenor: It is possible you have – it depends what you do in the second wave. There are – by suppressing it so hard, you have fewer people infected, and that means later on, when mixing increases, there are more people that can become infected in the second wave. You would technically have a slightly higher R value when the second wave would be initiated, which was inevitable.
So those things are important considerations, as I say, very, very important consideration, yes, but I guess it depends. I think the question of whether you’d have more in the second wave begs the question of what do you do differently in that second wave.
Lead 2B: Quite.
In your statement you describe other reasons, indirect reasons, why an earlier lockdown would have been preferable, and one of those reasons relates to care homes, and in your evidence you say care homes would have fared better from an earlier lockdown.
Just briefly, why do you say that?
Professor Michael Gravenor: It’s – that’s a tricky question, because we didn’t – we do not model care homes explicitly in our work. When – many of these models work better on a large scale, a large population scale. When it comes down to individual hospitals or individual care homes then there are local level effects that must be taken into account in terms of disease control that are going to be implemented and can never be captured by a broad scale modelling exercise.
I think that that comment would refer to the fact that the late lockdown meant we had a very high prevalence of infection throughout April and early May in the UK, and any effort to keep an infectious disease out of a risky environment, such as a hospital or a care home, is more difficult if the prevalence in the community is higher.
So we’ve since looked at the relationship between the prevalence in the community and risks in care homes, and there is a significant association between the two, in that clearly infection control is likely to be easier if the prevalence in the community is not so high.
So by keeping that prevalence – maybe it’s something we’ll come back to later – but by keeping that prevalence at a lower level, there are consequences of having a high – dealing with a high prevalence.
And I think the infection at the hospitals and the infection in the care homes, which don’t follow this epidemic curve exactly, they show different problems with infection spread in these environments, and I would say that one aspect of that link would be the high community prevalence.
Lead 2B: Professor, I just want to change topics, if I may, and talk to you about the Imperial influenza model.
The evidence heard in Module 2 confirmed that the earliest models created in the UK to deal with the Covid-19 pandemic were created by SPI-M using the Imperial model; that’s right, isn’t it?
Professor Michael Gravenor: Yes, amongst other models, yes.
Lead 2B: And you’ve described in your statement how the Imperial model had been developed for influenza.
It’s right, isn’t it, that there are advantages and disadvantages of relying on a model that has been developed for a different disease? So on the one hand you have the advantage that the model is available for use rapidly; on the other hand, the Imperial model being based on influenza has different epidemiological features that were less relevant to Covid. Is that a fair summary?
Professor Michael Gravenor: Possibly. I would put a lot more emphasis on the former. So I didn’t –
Lead 2B: On the advantages?
Professor Michael Gravenor: Yes.
Lead 2B: The positives?
Professor Michael Gravenor: I didn’t consider it a weakness really at all, because it was certainly very, very convenient that these issues had been thought about at a large scale and geographical scale and a lot of the impacts of disease spread had been built into them, and then changing those models to reflect, for example, the different incubation period or the different infectious period of a different virus is something that can be implemented by an expert team like Imperial very quickly.
Lead 2B: Let me just put to you some of the comments that Professor Mark Woolhouse made about the disadvantages of the Imperial model and see what you agree with and what you disagree with.
Professor Woolhouse said influenza models explicitly represented schools rather than care homes and influenza models tend to focus on social distancing as the preferred method of intervention rather than alternative interventions. And he identified two reasons for that: first, contact tracing is not a useful intervention for influenza due to its short generation time and high numbers of asymptomatic cases, therefore is not incorporated into the models, but obviously is a key intervention for SARS-like infections like Covid; and then second, he makes the point that influenza has a lower R number than Covid, meaning that social distancing measures required to keep an epidemic manageable can be much less drastic than a full lockdown.
The first question is: as a point of principle, do you agree with those observations?
Professor Michael Gravenor: Yes, I think all those are valid observations, yes.
Lead 2B: As a consequence, then, of using the Imperial model, do you think that that adopted a trend or a bias in favour of lockdowns rather than focusing on the contribution of, say, case detection, contact tracing, self-isolation, shielding, and so forth?
Professor Michael Gravenor: I’m not sure how one follows from the other. I mean, the models can’t include all the important factors, they’re always a simplification of reality. So I think the major drawback would be not having explicit care homes and that route.
So that is a – that is a problem. So I agree with those issues. I think that they don’t necessarily flow from choosing that model as the starting point, because, of course, all these models were greatly developed over time, but choosing this model as a starting point I don’t think that that was problematic in that sense.
It’s – it was identified very quickly over time what needs to be changed and added. Contact tracing, for example, was analysed by several modelling groups very, very early and models and papers were published on that in, I think, late January, early February. So some of those issues were being addressed quite early on, some but not all.
Lead 2B: Now, although you were not involved with the Welsh pandemic response at this period of time, are you able to comment on any concerns that the models were London-centric or followed a pattern too closely pegged to London?
Professor Michael Gravenor: At this point I would not – I wasn’t privy to any data or models themselves, so it’s quite difficult to comment on that, I would say. Yeah, I just – I just – at that point I was not actively using the models or building them.
So I think – do you mean London-centric in terms of data and analysing the outbreak in London? Because they weren’t in any way confined to London.
Lead 2B: Let me just put to you some comments from one of your colleagues on TAC and the co-chair of the modelling subgroup, Craiger Solomons, who has commented that the approach of trying to use the material model crudely adjusted for Wales’ population size provided results, in his words, of poor quality. And that – his reasons, I’ll give you the three reasons and then ask for your – whether you agree with them.
He said that because models were seeded to Wales rather than England they could not account for differences in Welsh demographics, differences in Welsh geography, rurality, socioeconomic factors, population movement, and also different timings and durations of NPIs.
Professor Michael Gravenor: Okay, so there’s several points there and I do agree with some of them, I guess.
So I don’t think it’s a problem with the models. It’s more the kind of questions you’re asking from the models, and I think they would be a little bit less Welsh-focused by these groups, which is perhaps not surprising. So I think it’s not the models themselves, no. It would be perhaps your last point, in terms of if slightly different timings are involved, the seeding of the models is a reasonable – reasonable point. Wales getting infections slightly after large parts of England means that at any point in time you might be at a slightly different stage of the epidemic. So having the ability to use those same models but in the Welsh context gives you a little bit more insight, I suspect.
Lead 2B: Now, you say in your statement that it was clear by the end of March that a Wales-specific model would be required, and we’ll explore after the break in a moment the development of the Swansea model in the spring and the summer of 2020.
Did the lack of a Wales-specific model increase planning uncertainty in Wales?
Professor Michael Gravenor: I think what I meant by required was we’d been asked to do it, so I don’t think –
Lead 2B: So in your view not needed?
Professor Michael Gravenor: I don’t think I would have known at that point. So when I said “required” I meant we would – we were – we were required to do it because we’d been asked.
Mr Poole: I understand.
My Lady, if that’s an appropriate point to take a break.
Lady Hallett: Yes, certainly. I shall return at 3 o’clock.
(2.42 pm)
(A short break)
(2.59 pm)
Mr Poole: Professor, I’m going to ask you some questions briefly about the Swansea model next, we know that the Swansea model was not operational or used by policymakers during the first wave of Covid and you very helpfully in your witness statement set out the timeline of its development, which I’m not proposing to take you through now, save to note that modelling work using the Swansea model commenced around May to June 2020; is that right?
Professor Michael Gravenor: That’s right.
Lead 2B: And then modelling results were available around August 2020?
Professor Michael Gravenor: That’s right, yes.
Lead 2B: Now, could you just please provide a brief high level overview of how the Swansea model worked for us?
Professor Michael Gravenor: It’s probably worth saying that there’s not one model. In the intervening time before we developed the Swansea model we provided lots of small modelling analyses and questions and developed lots of different models over the period, probably ten or 15 different models. But the main model we used, which was labelled the “Swansea model”, not by me, it – we – these models, as you’ve mentioned, have been in development – are best if they’ve been in development for a long time, so we took the decision not to build it from scratch. I felt at first it would be too difficult to do that.
But by that time a lot of the SPI-M modelling groups had made modelling frameworks available to the public, and we explored a range of those, and used a framework that was provided by the London School of Hygiene and Tropical Medicine, and then that’s the model that we adapted for Wales.
On a broad level, it describes the transmission of an infectious disease within the 22 local authorities of Wales, so it’s what we call a local authority level model. So the demographics are relevant to those local authorities. And then the results are collated on a Wales level. And that was the level where it was probably most appropriately used.
But at the heart of it it’s a local authority SEIR-type infectious disease model.
Lead 2B: And in terms of the uses of the model, is it right that the Swansea model played a role in modelling a range of key policy decisions, so if I just run through a few of them: firebreak, social distancing, self-isolation requirements, the reasonable worst-case scenario in autumn and winter 2020, the potential effect of the firebreak lockdown in October/November 2020, and also the return of children to school in 2020 and also in 2021; is that right?
Professor Michael Gravenor: Yes, I would say so. I think isolation-type models were probably based around contact tracing models, which were done separately.
Lead 2B: I think you say in your evidence that the Rt estimate alone is not sufficiently robust to inform decisions. What other factors would you be expecting policymakers to consider?
Professor Michael Gravenor: I think I’m referring there to the R value is crucial in terms of the direction that the epidemic is taking and how fast, but it has to be put in the context of a time. I think I would be referring there to the prevalence. So if, for example, there was an R of – an Rt of around about 1.4, you might expect the doubling time over about ten days, which is useful, but the situation there has to be related to the prevalence.
So, for example, if there were 100 cases a day a Wales, which at times would have been a relatively small number, this would indicate that in a week or so you might expect 200 cases per day, but if you were in a situation where the prevalence is already 1,000 cases a day, then in a week or so there’ll be 2,000 cases a day, and in absolute terms the growth rate’s the same but in absolute terms it makes a very big difference to the impact of that. So the impact is not directly from Rt, it is combined with the overall prevalence.
Lead 2B: I understand.
I’m going to ask you about some of the modelling then that the Swansea model was used for. The first major event I want to touch on in the summer of 2020 is Eat Out to Help Out.
Now, we know Eat Out to Help Out, that was introduced between 3 August and 31 August 2020, so the Swansea model was up and running, could have advised policymakers on how Eat Out to Help Out would impact transmission and impact on hospitality and deaths. Were you consulted on the Eat Out to Help Out scheme or asked to model any of its effects?
Professor Michael Gravenor: No.
Lead 2B: Can you help us, what was the community caseload of Covid-19 in Wales immediately prior to 3 August 2020?
Professor Michael Gravenor: I couldn’t tell you exactly. It was very low.
Lead 2B: Very?
Professor Michael Gravenor: It was very low.
Lead 2B: Low.
How would the removal of many NPIs affect the position in June/July 2020, as restrictions eased?
Professor Michael Gravenor: Well, it would increase the Rt value and we would return to an exponential growth of the epidemic.
Lead 2B: In your opinion, did the Eat Out to Help Out scheme accelerate the arrival of the second wave in Wales?
Professor Michael Gravenor: I haven’t seen any analysis of that and we haven’t conducted any analysis of that ourselves, so I can’t really comment on that.
Lady Hallett: I think we –
Professor Michael Gravenor: Anything that – sorry.
Lady Hallett: I’m sorry to interrupt. You carry on.
Professor Michael Gravenor: I would just say that anything that increases the – anything that increases close contacts in a risky situation is going to increase. Mixing – anything that increases mixing is going to increase Rt and accelerate the arrival of the autumn wave. The extent to which it happened, I really don’t know.
Lady Hallett: I think that’s consistent with evidence I’ve heard in a previous module. And I should also say that Rishi Sunak, who introduced the policy, indicated that Eat Out to Help Out was meant to be conducted in a Covid-secure environment. So I don’t know how one can factor that into modelling calculations, but you hadn’t done them anyway, so …
Thank you.
Mr Poole: Moving on to the autumn 2020 and the firebreak, you describe in your statement that it was clear by 11 September 2020 that the R number in Wales was above 1. At this time a TAC report I think referenced a SAGE R number for Wales of between 0.7 and 1, and stated that the current R number was higher than this suggests. Why do you think it was higher than suggested?
Professor Michael Gravenor: Well, one thing to say is that the published R numbers were always lagged by – in the order of two to three weeks, depending on where you really look at it. This is because the signal that we observe for any changes to transmission, say an increase in transmission, are cases and hospitalisations and possibly deaths, and these do not occur at the time of infection, they occur after a delay. And that delay could be in the order of two weeks.
On top of that, you – there is a delay from the last data point that you had before you estimated Rt, which could add a few more days to that as well, and then there’s potentially a delay in communicating that advice. So it all adds up to the most – the most up-to-date R value really reflects the situation a couple of weeks prior.
So if you want to make a comment on today’s R value, then you really have to look at the trends that you’ve seen in the past and any other knowledge you have about mixing.
So if we were in a situation where we see the trends in R increasing, and on top of that perhaps some other areas of the country sitting on SPI-M would be reporting R values above 1, so you can see trends there. But on top of that, if in terms of behaviour the only thing that’s really happening in terms of there’s not controls on – not so many controls on social mixing and schools have gone back and other activity is going on, then it would be a very reasonable conclusion that the R value was above 1 at that point.
Lead 2B: So when SAGE on 11 September were reporting the R number for Wales as between 0.7 and 1, and you say likely to be higher, what do you think the R number was more likely to be at that point?
Professor Michael Gravenor: I possibly could have brought that information with me, but I think we were head – I think it was in the order of 1.2, 1.3.
Lead 2B: I think I’m right in saying, aren’t I, by this point in time you had modelled a new reasonable worst-case scenario which showed a potential for a large second wave?
Professor Michael Gravenor: Yes.
Lead 2B: Now, in the modelling work that you were doing in late August, September, am I right in thinking that while you modelled some NPIs being introduced to reduce contact and bring the R number down, the assumption was that there would not be a repeat of the March 2020 national lockdown? Is that right?
Professor Michael Gravenor: In the reasonable worst case?
Lead 2B: Yes.
Professor Michael Gravenor: Yes.
Lead 2B: Where did that assumption come from, that there wouldn’t be a repeat of a national lockdown?
Professor Michael Gravenor: I think that would come under the remit of the reasonable worst case that we were asked to model. So it would be, the situation in August or September, this amount of behaviour, where is this taking us? So it’s – I mean, there are various different uses of the models, and modelling explicit policy such as introducing restrictions in movement, et cetera, would be part of a scenario modelling. In terms of the reasonable worst case I think the remit would generally be: if things stay as they are where are we heading? And it can possibly take into account some changes over time.
Lead 2B: Modelling was conducted for the 11 September 2020 TAC advice that went to the Welsh Government – I don’t need to display that advice here – it was noted in that advice the pattern of increasing cases is similar to the situation in February, action should be taken to prevent significant harm arising from Covid-19 or another national – sorry, or another full lockdown.
Then again, that was 11 September.
On 18 September a TAC advice, if we could have that, please, displayed, INQ000222823, as we see there it’s 18 September 2020, if we could look at page 2, the first bullet point, please:
“The epidemic is evolving rapidly across Wales and the UK, meaning that estimates become out of date very quickly. There is consensus that the situation continues to be serious. This is highlighted by the sad news that we have begun again this week to have deaths from Covid-19 recorded in Wales.”
Then if we can please have a look at the fourth bullet point on that page:
“A package of … (NPIs) on local and national scale may be needed to bring R back below 1. Some NPIs may need to be in place for a significant length of time, though an earlier and more comprehensive response is likely to reduced the length of time for which they are required.”
What did you envisage by an “earlier and more comprehensive response”, Professor?
Professor Michael Gravenor: So, again, the earlier that you act, you’re acting at a lower prevalence, and the degree which you suppress it then takes you down to an even low prevalence. So in terms of buying time, from that sense, acting earlier suppresses it to a lower level and delays the next action. Waiting longer means you have to either act more severely to bring it down to very low levels or you are acting to bring it down to a somewhat lower prevalence from which it will return as well.
I think the important thing of this point in time is we estimated how many people had been infected in Wales during the first wave, and it’s not a very large number, it’s maybe 6, 7% of the population at most, and it just left a huge potential for growth which is reflected in the reasonable worst cases for the UK as well. The situation is not quite the same because the R value is generally much lower than it was in March, and that’s because of the understanding of isolation and test and trace and just general realisation that you shouldn’t be spreading a virus.
However, the R value is – it doesn’t need to be very far above 1 to be problematic, and I think – you know, this is sometimes difficult to communicate, but the – an R value of 1.2 doesn’t sound much different to an R value of 1.1, but very approximately, in terms of contacts, you have to reduce your contacts by 20% from 1.2 and 10% from 1.1 approximately. So it’s twice as much effort, so twice as much of a reduction in contacts required just for small changes in R. So the potential was very, very much still there.
Lead 2B: When you’re talking about an “earlier and more comprehensive response”, is “comprehensive response” alluding to potential for the need for a lockdown or a firebreak lockdown?
Professor Michael Gravenor: I am – I don’t know. I expect so. I didn’t write this, of course.
Lead 2B: If we could, sticking with the same document, please, page 5 and then the third bullet point on that page, please. Thank you.
“In mid-April mobility of Facebook users in Wales was 50% lower than the baseline, this is 1% lower than the baseline and is up slightly from last week. 22% of Facebook users in Wales are staying put, similar to the previous week. In early April around 45% were staying put – this was around 18% in early March.”
Does this mean that, in addition to the worsening indicators that we’ve just looked at, people in Wales were travelling more in September than they were in March, which was obviously likely to culminate in greater community transmission?
Professor Michael Gravenor: Yes, possibly. I find it difficult to comment on this, I never analysed this data at all.
Lead 2B: I understand.
If we could, please, have a look at some further modelling for a 2 October 2020 TAG advice – thank you, INQ000066408 – we can see that on the screen there.
It’s page 2, please, first bullet point.
It says:
“Some data streams indicate potential slowing in the growth rate of the epidemic, but it remains likely that infection incidence is growing overall in Wales.”
Then, please, the second bullet point:
“The latest estimate of R; from … (SAGE) for Wales is between 1.3 and 1.6.”
Then, please, the fifth bullet point on that page:
“Unless measures bring R back below 1, it is possible that infection incidence and hospital admissions may exceed scenario planning levels.”
So from your point of view, Professor, was it clear from early to mid-September 2020 that significant intervention would be required to reduce transmission, and then by early October, this being dated 2 October, there was concern that hospitals exceeding scenario planning levels, so in other words the NHS in Wales would risk being overwhelmed?
Professor Michael Gravenor: Yes, I would agree with that, yes.
Lead 2B: Do you think the tone of the TAC advice documents that we’ve just seen was sufficient to convey the seriousness of that message to the Welsh Government?
Professor Michael Gravenor: I think I’d have to see the full context for that.
Lead 2B: Well, were there occasions when you thought perhaps stronger warnings, stronger messaging might be warranted?
Professor Michael Gravenor: I don’t think so. I don’t – I don’t think so. I think the – I think there was some uncertainty there, perhaps, in terms of the estimates and perhaps because we’d come from the period where the R value was estimated as being under 1, even though that was out of date, so I think there was a growing realisation here across TAC that we were heading towards interventions.
Lady Hallett: Could you look at the first bullet point, Professor. I mean, if I were a politician reading this, “Some data streams indicate potential slowing in the growth rate …”, I’d think, “Oh, good, we’re going the right way”, and I may not even focus too much on what remains of that sentence.
Don’t you think that should have been much more of an alert rather than, “Oh, we may be getting better”? It doesn’t sound very strong to me.
Professor Michael Gravenor: Yes, I think the second bullet point should have gone first on that, because I think by that point we were fairly clear that R was greater than 1.
It’s hard to remember exactly when this was written. When it was written and when it was dated might be two different things. But … yeah –
Lady Hallett: Do you know who drew up the briefs and the reports?
Professor Michael Gravenor: Sorry?
Lady Hallett: Do you know who drew them up?
Professor Michael Gravenor: No. No. I knew that they could be circulated. Yeah, circulated for comments, yes.
Mr Poole: Professor, you describe in your statement that you were first asked to model a specific firebreak scenario of two to three weeks on 11 October. Were you surprised that that work was commissioned a whole month after you started raising concerns about transmission rates in Wales?
Professor Michael Gravenor: Not really. Once again, I’d say we weren’t commissioned to do it. There was no commissioning involved at this stage at all.
Lead 2B: You were asked to.
Professor Michael Gravenor: And the second thing to say is it’s true that we were asked to do the specific two and three-week model. At that point we’d previously modelled a range of scenarios, so it wasn’t the first time we’d looked at that. So I think we’d been looking at firebreak situations elsewhere, circuit-breakers were being actively discussed in SPI-M and in many places, so that was not the first time we were asked to do it and we had been preparing that before.
Lead 2B: I mean, did the fact that you were carrying out this modelling work entirely pro bono, I think, until August 2021, did that have an impact on the work that you were able to do?
Professor Michael Gravenor: Yes, yes. It – we would have been able to do a lot more. So everything we were doing – the team at this point, myself and Professor Lucini and Dr Dawson and Dr Bennett, we all had full-time commitments to our roles in the university, so if we could have been relieved of that we would have been able to run more scenarios, I think we were quite keen on running additional models alongside – it’s important to have an ensemble if you can, and we could’ve looked at more scenarios. We could’ve done more things. We could’ve possibly brought in more people as well, which would have been very, very useful. So I think a mechanism that could have enabled that would have been quite useful, I think.
I think it’s an important point to make that in an emergency situation there are certain expertise that does not necessarily sit in a standing capacity within government or within health services, and it exists in places like universities, and accessing that expertise is – I think it’s very important, not just from our point of view, but important – there’s expertise in all sorts of the response, the behavioural side, the genetics, and accessing that – a mechanism to access that expertise I think is an important lesson we’ve learnt and – yeah. So this was largely evening work, yeah.
Lead 2B: That 11 October modelling of a two to three-week firebreak, were you surprised that you were asked to model a two to three-week firebreak as opposed to, say, a four-week or even longer firebreak?
Professor Michael Gravenor: Yes, I’ve certainly considered this since. I wouldn’t say I was surprised. We – we just did it. This is late in – not – this is 15 October. We have a question, we do it. And so I think just delivering that to a – to a level of quality that we’d be happy with is what took our focus. I don’t think we – we had already run situations that were longer, and we know that a longer firebreak would have more of an impact. So at that point in time, I can – I can say that we just took it and we did it.
Lead 2B: I think I’m right in saying you did in fact model, though, a four-week firebreak, did you not?
Professor Michael Gravenor: Yes, we’ve looked at – we looked at all ranges, we could –
Lead 2B: What –
Professor Michael Gravenor: – our model and simulations over many different combinations and repeated … all sorts of situations.
Lead 2B: What did the modelling show about the impact of a four-week lockdown?
Professor Michael Gravenor: I think – I think we – well, it would have driven the prevalence lower and it would have given more time before prevalence returned to the pre-firebreak levels. That’s something we reported on in detail for the two and three-week scenarios. For the other scenarios we have – had those numbers, but at this point this was the remit of our – of our investigation, we focused on those two and provided that.
Lead 2B: Having sort of perhaps stepped outside the brief and modelled a four-week lockdown, and having made the findings that you did, did you advise TAG or TAC of those findings at the time?
Professor Michael Gravenor: At the time, no. I think they were shared – I think they were discussed in the modelling subgroup perhaps prior to that, but I think by the time we got to dates going over the school half term, so when we looked prior to that, we just set up a set of scenarios in which you can vary the length of the firebreak, and they may or may not have had school closures and they may have had different effects. So there would have been very many scenarios that we would have, and then we would focus then on the two to three-week – and then we were given a date. So they wouldn’t have been directly comparable anyway because we were running over the half term, and then after the half term of the firebreak
there was a mixed school – some – some return to
school.
So it was a very specific situation that we were
modelling in response to that email, which does not
directly correspond to the previous kind of
circuit-breaker experiments that were done before.
Lead 2B: From what you’ve just said, it sounds as though by the
time you were asked to model the firebreak it was pretty
advanced thinking on the part of the Welsh Government
that there was going to be a firebreak. I mean, did
modelling – in your view, did modelling work need to be
carried out in order for that decision to be made to
impose a firebreak?
Professor Michael Gravenor: I think possibly not, I think it’s going to perhaps October we – there was a fairly well set plan for 15 guide thinking in terms of the impact and maybe being
most useful in terms of the return time. So it’s
an important decision. So you’ve got to understand the
particular circumstances in which it’s going to work and
the uncertainty around that.
So within the remit of the two and three-week
firebreak we considered a combination of what the true
value R was when we headed into it. Now, that was
unknown, so we considered a range. Then we have to
consider a range of the impact, and so we considered
a range of those, because it may not reduce contact as much as it happened in March. So we can use that as a yardstick but it may not be as effective. Then finally we have to consider what is the likely R at the end of the firebreak. And there are certain things to consider there, it’s deeper into the winter, there might be a carry-over effect of the firebreak, whether it’s beneficial. Which is what largely transpired. So there are many different potential outcomes.
And I think the modelling is useful to sort of have those explicitly down – we don’t necessarily know which one of these is going to be followed so it’s not necessary to show that, but with that – with that analysis you can say that under the range of the assumptions – under the range of scenarios that we consider to be reasonable then this is going – this is a possible likely effect. And if that is a suppression for some extra time beyond the actual break, then it has – then it will have a big impact on prevalence, as it did.
Lead 2B: Professor, did you have any concerns that the Welsh Government on occasion were perhaps overly eager to obtain modelling outputs at perhaps the expense of timely decision-making?
Professor Michael Gravenor: It’s not my experience at all, no.
Lead 2B: The First Minister’s provided a statement to this module of the Inquiry in which he said that the firebreak produced the gains which had been expected but that the gains were, in his words, much more short-lived than the modelling available to the Welsh Government had anticipated. Now, we know that by early December in Wales indicators for clinical admissions and the Rt rate were nearing pre-firebreak levels, so is the First Minister right in that assessment?
Professor Michael Gravenor: I believe not. I think, as I’ve kind of described previously, the firebreak scenarios covered a very large range, but in reality the time bought was at the upper end of our optimistic scenarios. So while there were some scenarios in which it could possibly be lower, they were the very, very, very most optimistic.
The – what we – what we hoped was a baseline scenario was the current R and then it would have a large impact, because the – I believe the comms and the preparation was done very well and people were aware and they were – it looked as if they would be on board. So we set an impact that would be quite effective, not quite as effective as March, but a very effective one. And following that we assumed that the R would be exactly the same again. Using that model, we projected a return time to the pre-firebreak conditions of 38 days, and the data will show that the return time was in the area of 39, 40 days.
Now, I think that’s coincidentally close, okay, that’s not something you expect from these kind of model exercises, they do not have that kind of precision, but it coincidentally shows that that baseline scenario was almost exactly the time bought. And I would say quite a substantial amount of time, if – so 39 days added on to the time of the firebreak, which is only two weeks long, is quite substantial and it shows the trajectory that the epidemic took within the firebreak.
And that’s been – there’s many independent corroborations of that. You can see in the ONS data that the prevalence in Wales is half that of England around about that time, and you can – and there are, I believe, published estimates from independent modelling groups, the London School published a paper on the circuit-breakers in England which analysed the effectiveness of the Wales firebreak and showed, I think, that it had a 45% reduction in Rt, which is quite considerable.
So I think the time bought is pretty much very, very close to what we suggested in the models.
Lead 2B: So when the First Minister said the gains were much more short-lived than the modelling available to the Welsh Government had anticipated, I understand your evidence to be the modelling was accurate. Would it therefore follow that the duration of effects had not been communicated to the Welsh Government?
Professor Michael Gravenor: I don’t think that’s true, I think we – I think we said for a two-week we would expect a three to five-week reset, and for a three-week we’d expect a five to seven-week reset.
Lead 2B: So the net effect of that is you say that statement from the First Minister, that’s just wrong?
Professor Michael Gravenor: Yes, I think it doesn’t reflect the post-firebreak period.
What we found post-firebreak is that there was a little bit of a period where growth was – one might imagine that the R number declines very, very rapidly, and as soon as everyone goes back to normal it goes right back to normal. The evidence is that there was a period after the firebreak where it was actually growing a little bit more slowly than prior to the firebreak, and then it picked up speed. Which might represent the conditions of transmission and going deeper into the winter, as we approached December, but also the arrival of the Alpha variant, which is circling that time, which is considerably more transmissible.
Lead 2B: Professor, just before we leave this topic of the firebreak, just two short questions, and we’ve still got quite a bit to cover, so if you could try and keep your answer as brief as you can to these questions.
First is: was the timing of the firebreak in your view reasonable or should it have come earlier? My second question: should it have been longer?
Professor Michael Gravenor: I think the timing was – earlier would have helped, as we have talked several times about the prevalence issue. I do believe that the timing including the preparation and the comms was about right. But having it at the lowest end means that it was always going to be the minimum impact in the shortest amount of time. So looking back on it now, we – I do think it should have been longer.
A longer firebreak could have – given how effective it was, given how effective it was in reducing Rt a longer firebreak would have set – if that, if those benefits had continued, it would have set the prevalence down to a very low level, and then we would have headed toward December.
I think a four-week firebreak would have put the reset time deep into December. At this point in time we’ve got a lot of knowledge from – about the transmission conditions deep in the winter, including knowledge of Alpha, the Alpha variant.
So I think a longer firebreak would have put us in a much, a much better position in December and potentially could have avoided some of the worst of that second wave.
Lead 2B: And the four-week firebreak, just to be clear, had been modelled but the results of that modelling exercise had not been passed on to TAG or TAC?
Professor Michael Gravenor: Not as part of the – not as part of that commission, because the instructions came to provide evidence on the two and three-week.
Lead 2B: I understand.
Professor Michael Gravenor: The work has been – the effects have been shared informally in the modelling subgroup and in terms of just general discussions about a longer firebreak has a bigger effect.
Lead 2B: Professor, I want to move on to the winter period 2020. On 2 December TAG published a statement regarding NPIs in the pre-Christmas period.
Could we, please, have INQ000350039. Thank you.
If we could have a look, please, at page 3. If I can go to the second paragraph, in fact, on the third line of that second paragraph, the – where it starts:
“The firebreak had the intended impact of a short sharp early intervention to push back the epidemic by three to four weeks. The benefits of this period of negative growth have nearly been lost, with case numbers and hospital admissions nearly reaching levels seen at the beginning of the firebreak.”
Then, please, if we can go to the same page, page 3, but the fourth paragraph, that starts:
“Deaths are currently as high as May, with the excess death rate in Wales higher than in England and Scotland over recent weeks, and tracking above our reasonable worst case.”
That was obviously a concerning picture epidemiologically; yes?
Professor Michael Gravenor: Yes, yes, I think that’s possibly around the worst point of the epidemic, I would say, in my experience.
Lead 2B: And in the same document, the policy modelling done by your team at Swansea University compared some different NPI interventions over December 2020 against some varying rates of background Rt.
If we can, please, have page 12. Thank you.
So the policy options being compared were: first, no intervention; then entering Tier 2 restriction; and then, the third one, entering Tier 3 restrictions.
Pausing there, why were those the three options that were modelled? Was that the commission that you had that received?
Professor Michael Gravenor: For that particular paper, yes. So they would be directly asked to use those conditions. I think prior to that we’d already started looking at the next point at which changes would need to be made, and we’d already considered various levels including Tier 4.
Lead 2B: Now, the advice of TAG that was summarised back in 2 December 2020 – I don’t need this to be displayed – but that summary was that policy modelling suggests that – I’m grateful – introducing the equivalent of Tier 3 restrictions, for example closure of hospitality and entertainment, reduction in mixing prior to the relaxation of restrictions before Christmas will reduce the number of hospital and ICU beds required for Covid-19 patients and subsequent deaths.
Is it right that the strongest, if I can put it that way, NPI option then being explored in early December were Tier 3 restrictions, or you’ve just alluded to you were in fact looking at Tier 4 or effectively lockdown restrictions as well?
Professor Michael Gravenor: We were looking at them, but that was the question that was being asked here.
Lead 2B: So you were effectively reporting only – and this is no criticism, because of the extent of your commission – but you were reporting only on the strongest NPI option, being Tier 3 restrictions?
Professor Michael Gravenor: Yes.
Lead 2B: Now, we looked previously at a TAG meeting on 13 October. It was noted in those minutes of that TAG meeting that, and I just read this to you:
“Yesterday there was a COBR meeting and announcement around the [three] tiers in England – a SAGE chairs group took place yesterday and no one felt that the highest tier was strong enough to bring R below 1.”
So my question is this: if Tier 3 restrictions had been seen as insufficient before the firebreak lockdown, and Wales was quickly approaching pre-firebreak levels, why was it assumed that Tier 3 restrictions would be sufficient this time around?
Professor Michael Gravenor: Sorry, what was the date of the SAGE?
Lead 2B: 13 October.
Professor Michael Gravenor: So there was a lot of – there was a lot of debate about the R values to use for different tiers and it did change a little bit over time, and I think there was a little bit of a difference between areas and between DAs. So we’d previously used a value where it just pushes it under 1, and I think that was appropriate, I think that was appropriate at the time. Again, we would explore sensitivity to that. But by the time we’ve got into December, I think it was just becoming clear that that was not the case.
So I think by this, by around about this point – which is why I think I mentioned that this point in the epidemic, it became clear that this was definitely not the point in Wales. So shortly after this, we start to realise that Tier 3 is nowhere near enough. But we’re now dealing with a much more transmissible situation than we had previously, and bringing that kind of Alpha advantage in transmissibility, which we didn’t have at this point in time, into it would show that it would not be close to enough with Tier 3.
Lead 2B: So it’s your view that Tier 3 restrictions would not be sufficient to bring the R value down?
Professor Michael Gravenor: Oh, it would bring the R value down.
Lead 2B: Sorry, to bring the R value down below 1?
Professor Michael Gravenor: No.
Lead 2B: Yet we see here in this TAG –
Professor Michael Gravenor: Sorry, I don’t mean – it was around about this time, it was – I couldn’t – I wouldn’t say that it was before this was written, no. No, sorry, I don’t want to give that impression at all. It was right about this time.
Lead 2B: But I would be right in saying that nowhere in this advice does it allude to any concerns that in fact Tier 3 restrictions would not have the effect of bringing the R value below 1?
Professor Michael Gravenor: No, I don’t think it mentions that. It certainly has an impact on R which is going to reduce the number of cases, it’s going to reduce the number of hospitalisations but … yeah, I think that there are – there were points at which that would be a reasonable assumption to make, but those turned out not to be true quite soon after this.
Lead 2B: Before we move off this document, I just want to ask you some final questions about the advice given about pre-Christmas NPIs, and in particular schools.
I’m grateful, page 13 of this document.
We can see there in the table that your team had modelled the difference in hospitalisations and deaths between schools staying open and closing between 14 to 18 December. Schools staying open for that period you estimated would result in between 120 and 150 deaths; that’s right, isn’t it?
Professor Michael Gravenor: Yes.
Lead 2B: I’m asking you this because in a TAG meeting two months earlier the picture looked different.
If I can just have those notes, please, INQ000313192 – I’m grateful – page 4, paragraph 1, right at the top:
“When asking people to self-isolate because they’re Covid positive, there are issues around what other members of the household do and this is a moral and public health discussion and may lie outside the remit of TAG. Worth highlighting the evidence of children transmitting to adults is so limited that it may be worth letting children out anyway.”
And then, reading on, please:
“Concern is around children in schools and what happens there. Agree immune suppressed children are a different situation, but the current evidence does not suggest transmission in the school context. Still quite a lot we don’t know about asymptomatics infection; the modelling originally done was based on flu where children are super spreaders and this has not been replicated with Covid.”
But my question is simply this: why were you then, in December, modelling deaths against school closures if you weren’t satisfied that children were meaningful spreaders of the virus?
Professor Michael Gravenor: I’m sorry, I didn’t. This is not my opinion.
Lead 2B: So is the answer that when we look at the 2 December TAG paper, this was something you had been asked or TAG had been asked –
Professor Michael Gravenor: Can you clarify the date of this?
Lead 2B: This is 9 October 2020.
Professor Michael Gravenor: Okay. So I think the exact role of transmission in schools was pretty much unknown, I think, by this point. So this is all assumption. I think we’d gone through a situation where schools closed pretty quickly in March, prevalence was driven down to very, very low levels and then there was the school holidays and then a couple of weeks back in school. None of that is sufficient to give you a good estimate of the importance of transmission in schools.
Lead 2B: Now, we know schools were closed early on 14 December; hospitality, however, remained open. Do you think you should have been asked to model the effects of keeping schools open and closing hospitality venues?
Professor Michael Gravenor: Sorry, for which dates?
Lead 2B: So 14 December is when schools were closed early in Wales, but hospitality remained open. So my question was simply: do you think you should have been asked to model the effect of in fact keeping schools open but closing hospitality?
Professor Michael Gravenor: Yes, I think we could have done that, it’s a blunt tool, whether you can distinguish things very easily, in terms – in terms of schools we relied heavily on what we would call the contact matrix between different age groups and this is obtained from surveys and empirical epidemiology, surveys such as CoMix, and they basically tell you how often a person of one age is in contact with a person of another age on a typical day.
So within those surveys, the contacts that take place within schools are to some degree recorded, so those are the contacts that we would remove from our model when schools are closed. So it was – it was not based on the observation – so our model was not based on the observational epidemiology of how often transmission occurs within schools, it was based on the typical contacts that are made within schools and between school-aged people and people outside of the schools.
So in some ways it’s a very easy thing to implement in the model, and you can remove those, which simulates school closures. It doesn’t capture all of the nuances of that, but at the end of the day those contacts exist, and reducing any contacts in the model across or within groups and across groups – because not all the contacts can be maintained within children – if you reduce any of those contacts, you are going to reduce infections and cases and hospitalisations, deaths. The extent to which they are changed is very, very difficult to do – but ultimately all we’re doing there is reducing the contacts of that age group – and a little bit harder to do under other circumstances.
Lead 2B: Can we just return to the chronology. We were working our way through December and the advice that was being given by TAC. On 11 December there was a further TAC advice that was published. I don’t need it to be displayed, I’ll just read you a few relevant passages from it:
“Cases of Covid-19 per 100,000 of the population in Wales, have increased by 54% since our last report.
“As of 9th December, test positivity for COVID-19 … is above the red circuit breaker indicator threshold, at 19.4%.
“As of 11th December, the number of people with confirmed COVID-19 in hospital, has increased by 9% since last week, remaining higher than the April peak and above the red circuit breaker indicator threshold.”
So as with the October firebreak, I think you were commissioned to provide some further modelling, but was it not obvious from 11 December that Tier 4 restrictions, namely a lockdown, would be needed to get a grip on transmission rates?
Professor Michael Gravenor: Yes.
Lead 2B: Do you think that a third lockdown should have been implemented earlier?
Professor Michael Gravenor: Yes, in retrospect, yes.
Lead 2B: Now, in December 2020 Professor John Edmunds stated, “this is the worst moment of the whole epidemic”, and in January 2021 that, in his words, “really major additional measures” were needed.
We now know that Wales fared particularly badly in the second wave and in December 2020. Do you think the same comment applies then to Wales? Was Wales caught in a very bad position?
Professor Michael Gravenor: Yes, I would say so. I think it’s – it doesn’t give much solace, but I think there is a – it was somewhat unfortunate to come out of a firebreak into the highest transmission period, December, with the emergence of the Alpha variant which went on to make up a very, very substantial part of the second wave. So whilst there was measures going on in early December, they clearly weren’t enough, and they came at a time of the return period from the firebreak.
So I think it is one of the worst situations in that point, in the sense that we dealt with – we had to deal with a very difficult situation, which was very high transmission rates, from the point of high prevalence.
So it comes back to the point again, is if you had a longer firebreak, for example, you deal with those situations from a lower prevalence, and so by that point you would be able to perhaps respond or consider the response a little bit – a little bit better, and certainly the – you know, the consequences of that period would have been – would have been reduced.
So whilst Alpha can’t be predicted, it kind of illustrates that importance of the overall prevalence, and so dealing with that already high was a – it was rather a sort of perfect storm and I think – I think that could have only been avoided by a longer firebreak before – beforehand.
Lead 2B: Professor, just two short topics before I finish.
Indirect effects of NPIs. Could more have been done by your team on indirect harms over 2020 and 2021, had the resources been made available to you?
Professor Michael Gravenor: Are you referring perhaps to economic type effects or –
Lead 2B: Indirect effects, NPIs, so social, economic, quality of life.
Professor Michael Gravenor: This is not our area of expertise in terms of social effects. No. And I – we set up the model very, very early to build in potential costs so that indirect effects and cost benefits could potentially be weighed up against each other. That was done in September.
So, however, I don’t think that the numbers to bring into the model were ever – ever provided, were ever made available. So I think the framework was there, but if we’d have been given more time, no, because there was nothing to – there was nothing to bring in. So we were, I think, frustrated by that and made a certain amount of progress on the costs sides for the health. That fed into every model run. But in terms of how the knock-on societal or economic effects, I felt that there was no information being provided to us at all that would allow us to bring that into the model.
Lead 2B: Finally – and I think you may have answered this question already in your evidence this afternoon – what, if any, modelling was done to reflect the elderly population in Wales? What specific considerations were given by TAG and TAC on preventing the spread of Covid amongst the elderly, particularly those in care homes?
Professor Michael Gravenor: Well, TAG would have a care home group which worked with the SAGE care home groups for very – mostly, that’s not something I was involved with. In terms of modelling, it is – it is something that was not part of – most, I think, almost all the models didn’t model care homes explicitly. So they were not – they were not tools that were well developed for that question. You can look at the questions of reducing contact in elderly and how much that would improve matters, but that’s – that’s not much help if you really don’t know what’s going on on the ground.
So I think that that is a – not so much of a modelling question, more of a disease management on the ground type of question. And if we understood that much better, then perhaps it could feed back to the models, but it’s not something we were involved with at all.
Mr Poole: Professor, thank you. Those are all my questions, but there are some questions from behind me.
Lady Hallett: Ms Heaven.
Questions From Ms Heaven
Ms Heaven: My Lady.
Good afternoon, Professor Gravenor, just a few short questions. I represent the Covid-19 Bereaved Families for Justice Cymru.
I want to start by asking you – so, sorry, it’s back to the firebreak, please. So this is a comment that was made to the Inquiry in the witness statement of Andrew Nelson – I don’t know if you know who he is or was at the time – chief executive information officer at Cym Taf Morgannwg University Health Board. Just so that we can be clear, part of his role in the pandemic was to model the impact of Covid on hospital flows, resources and healthcare systems.
I think you nodded when I asked you if you knew who he was; is that correct?
Professor Michael Gravenor: Yes, Andrew was a very valuable member of the modelling subgroup, TAG.
Ms Heaven: So he says this at paragraph 250, my Lady:
“In regard to the firebreak, it is apparent from emails and files [which he attaches, I’m not going to show them to you because we don’t have time] that I and others raised concerns that the two-week period was going to prove insufficient to allow Wales to avoid a pre-Christmas lockdown and that it would not reduce the prevalence of Covid to a level in line with the Swansea University model for Q3/4 2020/21 which had formed the basis of Welsh Government’s planning guidance to the NHS at that time.”
So we obviously know – and we can see the email that you received from Rob Orford on that Sunday evening on 11 October requesting you to look at the two to three-week period.
So my question is this: were you then made aware of these concerns that were being raised, we know it was on 16 October, by Andrew Nelson?
Professor Michael Gravenor: I don’t recall that, no, I don’t recall that being a major discussion. We were very – I think it could well be something that would have been commented on, that when the announcement came that it was going to be about two weeks, I think several people would have perhaps made the comments that they would like it to be longer. I don’t remember it being a major point of discussion within our modelling group.
Ms Heaven: Well, I can’t take you to any emails to show that you were aware, so I’ll move on from that point.
He also says this:
“With the benefit of hindsight, the modelling group maybe should have done more analysis of extending the autumn firebreak until the majority of the most vulnerable JCVI groups had been vaccinated.”
And he says 80% of the groups had received their first vaccination by 16 February, and he says “as this may have reduced fatality”.
So before I ask you for your comment on this statement, just so that we can understand your evidence just a moment ago on this issue, you said that if there had been a longer firebreak this would mean very low prevalence into December, you said four weeks would push deep into December, and you say in your statement – and indeed you’ve said it today – that this would have meant that Wales would have faced the period of high winter transmission plus the emergence of the Alpha variant from a starting point of much lower community prevalence than it had to face in December 2020.
So that’s your evidence.
Now, just before I ask you to comment on the vulnerable groups and the vaccine roll-out, presumably the Welsh Government knew at the time, in October 2020 and before the firebreak, what you’ve just said today because, as you confirmed, you had modelled a four-week firebreak and presumably you’d fed the results back into the Welsh Government; is that correct?
Professor Michael Gravenor: Sorry, I described that in a little bit of detail. I wasn’t asked specifically to model for that. We set up the model to contain firebreaks of any duration.
Ms Heaven: Yes. But you say in your witness statement that you modelled two to four weeks.
Professor Michael Gravenor: Yes.
Ms Heaven: That’s what you say in your statement. So presumably you fed the results of a four-week firebreak back into the Welsh Government?
Professor Michael Gravenor: It would have been discussed at some point, at some point perhaps at the policy modelling group, but –
Ms Heaven: So if you –
Professor Michael Gravenor: – I can’t point you to the exact –
Ms Heaven: No.
Professor Michael Gravenor: – exact time. As I say, those scenarios are not directly comparable to the commissioned two/three-week ones because they had specific dates and specific scenarios round school.
So the point being we considered a range of firebreaks and then, by then, it was narrowed down to two to three weeks.
Ms Heaven: Okay. But if three weeks buys a three to five-week delay, does it follow that four weeks buys a four to six-week delay?
Professor Michael Gravenor: So I would say three weeks buys a five to seven-week delay.
Ms Heaven: Okay, so what does four weeks buy?
Professor Michael Gravenor: Seven to nine.
Ms Heaven: Okay. And the Welsh Government knew that, did they?
Professor Michael Gravenor: I wouldn’t say that they knew that, that was not in the report. So the report for the five to seven weeks and the three to five weeks was in the report that went in for the two to three-week firebreaks. That did not include the four-week firebreaks.
Ms Heaven: Why not?
Professor Michael Gravenor: Because that was the report requested at that specific time for the two to three-week firebreaks. It didn’t reflect previous work, it reflected the questions that we were asked at that point in time, and we have to be very focused on those –
Ms Heaven: Okay.
Professor Michael Gravenor: – and all the scenarios – there are, as I mentioned, there are lots of scenarios around those, not – that don’t just involve the time of the firebreak.
Ms Heaven: Okay.
Professor Michael Gravenor: So once we were asked to do two and three weeks, we focus on that.
Ms Heaven: We don’t want to take an unfair point against the Welsh Government; they didn’t know about your results for the four-week modelling?
Professor Michael Gravenor: No, but I think we would – we would all know that we have the evidence from a two-week firebreak in terms of how much of an effect it has, and the three-week firebreak –
Ms Heaven: Yes.
Professor Michael Gravenor: – the extrapolation to a four-week firebreak is –
Ms Heaven: Common sense?
Professor Michael Gravenor: It’s common sense.
Ms Heaven: Okay.
So let me move on to the question, then, on the vulnerable groups and the roll-outs. You said you modelled many scenarios. We can’t see any evidence in the disclosure or in your witness statement to suggest that in autumn 2020 your modelling team was asked to or indeed modelled various scenarios relating to an extended lockdown – so this is the Andrew Nelson point – beyond four weeks, factoring in things like the proposed timing of the vaccine roll-out to vulnerable groups; and of course we know the vaccine arrived in Wales in December 2020 and I think the roll-out started in the January.
So is the Inquiry to understand that you were not asked and hence did not conduct modelling on this issue, so extended lockdown, linked to timing of vaccine roll-out?
Professor Michael Gravenor: Extended firebreak?
Ms Heaven: Yes, firebreak, thank you.
Professor Michael Gravenor: No.
Ms Heaven: No. So you were not asked and you didn’t model it?
Professor Michael Gravenor: I guess other than the four-week, no.
Ms Heaven: No. Okay.
Very finally, if I may, my Lady, 22 December 2021, First Minister for Wales, Mark Drakeford, announced restrictions that would come into force on Boxing Day, and this was obviously in response to Omicron. It includes, as I’m sure you remember, the rule of six, meeting in pubs and restaurants, cinemas, face coverings in restaurants but they could be taken off when you were sitting down, outdoor events limited to 50 with 30 indoors but no restrictions for smaller meetings in private homes.
So it’s just a very short question: were you asked to model these range of proposals that were announced on 22 December and, if not, do you accept you should have been asked? A.
Ms Heaven: 2021.
Professor Michael Gravenor: Erm –
Ms Heaven: So it’s the rule of six again.
Professor Michael Gravenor: So in 2021, at exactly that time, we modelled a lot of
scenarios for Omicron. At that point I think we were
largely modelling the range of scenarios that reflected
the uncertainty regarding the severity of Omicron. So
we’d had a very limited number of – a very limited
amount of data on the hospitalisations and deaths which
indicated the levels of severity. So we had to run sets
of scenarios that were all consistent with that and then
see what was happening next.
So I think – as I remember, we didn’t – we
certainly didn’t, in answer to your question, model
those very, very specific interventions because we never
do.
Ms Heaven: Okay.
Professor Michael Gravenor: It is more the broader reductions in transmission that
are accompanied by those interventions, and we certainly
modelled lots of scenarios of Tier 1, Tier 2, Tier 3 –
Ms Heaven: Okay.
Professor Michael Gravenor: – type interventions in the period from December and
going into January with Omicron, as we gradually learnt
more about its severity. But quite a lot of scenarios December …? 22 then, yes.
Ms Heaven: Well, thank you very much, those are my
questions.
Thank you, my Lady.
Lady Hallett: Thank you, Ms Heaven.
I think that completes the evidence for this week.
Mr Poole: My Lady, it does.
Lady Hallett: Thank you very much, Professor, and if by the sounds of it you had to fulfil your other full-time commitments as well as doing this work, please accept my gratitude, I’m sure the gratitude of people of Wales, to you and to your colleagues.
The Witness: Croeso.
(The witness withdrew)
Lady Hallett: Thank you. 10 o’clock Monday, please.
(4.05 pm)
(The hearing adjourned until 10 am on Monday, 4 March 2024)