18 September 2024
(10.00 am)
Lady Hallett: Mr Scott.
Mr Scott: Good morning, my Lady. Please may we call Professor Charlotte McArdle.
Professor Charlotte McArdle
PROFESSOR CHARLOTTE McARDLE (sworn).
Questions From Counsel to the Inquiry
Mr Scott: Good morning, Professor McArdle. Would you please give your full name.
Professor Charlotte McArdle: Charlotte McArdle.
Counsel Inquiry: And you are the former Chief Nursing Officer of Northern Ireland?
Professor Charlotte McArdle: That’s correct.
Counsel Inquiry: I would just like to go through your personal background, which is set out at paragraph 20(a) of your statement. You are a registered nurse and have been since 1991. You moved to Northern Ireland in 1993, and have been working in the Belfast Trust, rising up the ranks until in 2003 you became Deputy Director of Nursing for the Royal Hospitals group?
Professor Charlotte McArdle: That’s correct.
Counsel Inquiry: In 2007 you were appointed Director of Nursing, Primary Care and Older People in the South Eastern Health and Social Care Trust?
Professor Charlotte McArdle: Correct.
Counsel Inquiry: Then you were appointed as Chief Nursing Officer for Northern Ireland on 5 April 2013, and remained in post until 31 October 2021?
Professor Charlotte McArdle: Correct.
Counsel Inquiry: And you’re currently employed at NHS England as Deputy Chief Nursing Officer?
Professor Charlotte McArdle: Correct.
Counsel Inquiry: You are a visiting professor at the Ulster University, a trustee and vice chair of the Royal College of Nursing Foundation, and a board member of the Faculty of Nursing and Midwifery in the Royal College of Surgeons in Ireland?
Professor Charlotte McArdle: Correct.
Counsel Inquiry: I would like to start with your role as CNO in Northern Ireland. You say that you are – have the lead departmental policy on patient experience, amongst other aspects of your role. How much did your role change when the pandemic started?
Professor Charlotte McArdle: It changed quite significantly. At the start of the pandemic, I suppose in the early days, we tried to keep everything going as normal, but it became clear relatively quickly that that would not be sustainable and, as the department moved into both its emergency planning plan and we instigated the business continuity plan in the department, a lot of my normal functions, in terms of policy and normal business, would have reduced considerably in order to enable me to focus on work on the pandemic, for which I had lead responsibility and for which, as a member of the strategic planning cell, I would have undertaken.
Counsel Inquiry: Like a lot of people from Northern Ireland, you speak quite quickly.
Professor Charlotte McArdle: Okay.
Counsel Inquiry: I will ask you just to make sure you’re not going too fast.
Professor Charlotte McArdle: Apologies.
Counsel Inquiry: Believe me, I’ve been caught out by this many times before, so –
Lady Hallett: I just live in Northern Ireland, so …
Mr Scott: I just want to talk about some specific features of your role during the pandemic.
So you didn’t have any operational role in the design or delivery of care to patients; is that right?
Professor Charlotte McArdle: No, in the devolved administrations, which is different from the role in England, the Chief Nursing Officer sits in the Department of Health, and its primary function is to advise ministers, senior civil servants and across government on matters that affect nursing and midwifery and also to lead areas of policy development. So the operational responsibility for the delivery of care sits with the five integrated health and social care trusts in Northern Ireland and their executive teams.
Counsel Inquiry: So if you’re then in the department, did you have any opportunity to be on the front line, as it were, during the pandemic?
Professor Charlotte McArdle: Well, as part of my role I took a lead responsibility for the development of the Nightingale hospitals, both facilities, and the reason that I undertook that role primarily was because I had worked in the health service for a considerable period of time and had strong connections with the teams of the five health and social care trusts and indeed the wider health system in Northern Ireland.
You will understand that Northern Ireland is a small community and in that small team you are required to do many things, and I would have strong connections and strong operational experience as being an executive director of nursing, and therefore undertook that role, and in doing so, in taking the lead role for the development of the Nightingale hospitals and a fairly important leadership function on the surge planning element, I was out in the system quite a lot. I visited facilities, I visited the Nightingale facilities with the minister, I visited other facilities in our health system. I was in touch regularly with frontline nursing staff, and I met daily with the executive directors of nursing and the wider nursing community in Northern Ireland, and often on occasions more than daily.
And when it came to the vaccination programme, I undertook shifts in the vaccination team over the Christmas and New Year period when the first vaccination became available.
Counsel Inquiry: So you were fairly well plugged into what the experiences were of those who were actually delivering –
Professor Charlotte McArdle: Absolutely, and indeed at the time I – 2020 was the Year of the Nurse and the Midwife global campaign, and in recognition of that the minister had agreed to me delivering a leadership programme for nurses and midwives under the age of 35, so they would have been early career nurses, and that programme wasn’t able to be developed in the way in which we planned because of the pandemic and most of it was online, so I met regularly with a group of nurses who really described for me in detail the changes that they’d had to make in their practice and how they’d had to change location, change rotas, the impact of having their family, young children, et cetera, so a lot of that intelligence and information was very much in my thinking in decision-making at the department.
Counsel Inquiry: So it’s fair to say that you were fully aware of all of the concerns of nurses –
Professor Charlotte McArdle: Yes.
Counsel Inquiry: – of all ages and in all areas of speciality?
Professor Charlotte McArdle: I think so.
Counsel Inquiry: Sometimes it’s not that easy for someone, particularly maybe a junior nurse, to say exactly how they’re feeling to the Chief Nursing Officer. Do you think you did receive the unvarnished truth from those who were working?
Professor Charlotte McArdle: I mean, I think there’s a natural anxiety maybe about – and outside of the pandemic I would have experienced that in regular visits to organisations and to talk to frontline staff, but because I had done quite a lot of that and had a very strong connection, both with nurses on the front line and through the RCN, the Royal College of Nursing, as an example, I was very familiar with many of the staff who were working in our system and I was also quite communicative with them through social media, so they had plenty of opportunities to contact me, either directly or indirectly, to raise their concerns, and indeed I had representation from ICU nurses on particular issues from – that I had met and had spoken to previously, and because they had that connection they felt able to do so.
Counsel Inquiry: I just want to confirm your responsibility for some areas during the pandemic. It’s right that you were responsible for leading the development of visiting guidance in Northern Ireland?
Professor Charlotte McArdle: That’s correct, yes.
Counsel Inquiry: That was a role that you were given in the pandemic, it wasn’t one that you’d had prior to the pandemic; is that correct?
Professor Charlotte McArdle: Well, we didn’t – we didn’t have a national guidance on visiting that would have been for –
Counsel Inquiry: Sorry, just to interrupt, when you say “national” there?
Professor Charlotte McArdle: Sorry, I mean Northern Ireland regional. Each individual organisation would have their own visiting policy. But in the pandemic, both in terms of my communications with directors of nursing, which I said was very frequent, and our collective concern about safety of patients, staff and the population of Northern Ireland, we recognised there needed to be a policy position on visiting because –
Counsel Inquiry: I’m going to come back to the specifics of it, it’s just at the moment about what your responsibility was –
Professor Charlotte McArdle: Okay.
Counsel Inquiry: – and when it was given to you.
Just in terms of the infection prevention and control, so it’s right that there was an IPC cell set up in Northern Ireland, I think it was called the regional IPC cell; is that correct?
Professor Charlotte McArdle: That’s correct.
Counsel Inquiry: That had been established by the department. Do you remember when that was established?
Professor Charlotte McArdle: It was established as part of gold command and its structure, so I can’t remember exactly the date, but it would have been March time 2020.
Counsel Inquiry: You weren’t a member of that regional IPC cell?
Professor Charlotte McArdle: No, I wasn’t.
Counsel Inquiry: What oversight did you have of that regional IPC cell?
Professor Charlotte McArdle: The IPC cell was chaired by the executive director of nursing in the Public Health Agency and the Public Health Agency in Northern Ireland had responsibility for public health and essentially everything to do with outbreaks, infection, et cetera.
The IPC cell reported through the command structures we had in place at the time, and my oversight was a professional oversight, because I’m not an IPC nurse or specialist by background, and my oversight was to support the chair in his role as the chair of the group and to provide professional leadership and support. So effectively that meant regular communication, usually by telephone, about issues that had arisen, to take a second opinion on things, to seek assurance that the direction of travel was consistent, and to think about any complex challenges that might be for the system and how we might overcome them.
Counsel Inquiry: So given that you didn’t have any IPC particular expertise, I think you were just saying, it wouldn’t have been your role to review the guidance and point out areas that you thought were wrong; is that right?
Professor Charlotte McArdle: I certainly would have reviewed the guidance, but from a general nursing leadership perspective as opposed to a scientific specific infection control perspective.
Counsel Inquiry: So routes of transmission, for example, would have been completely outside of –
Professor Charlotte McArdle: Absolutely. It would have been –
Lady Hallett: Sorry to interrupt, when you mentioned getting a second opinion, what did you mean by that?
Professor Charlotte McArdle: So, for example, one of the examples I’ve provided in my statement is at a point in time there was an issue raised with the IPC cell in relation to fluid shield masks and a poor fit, and they had come up with kind of interim solutions to overcome that problem until a new mask could be found, and the chair of the IPC cell asked my opinion on that, whether I thought that was a viable option or whether it was something we could support nurses with.
And similarly when we were trying to outline different pathways and risks, so we had red (high-level risks), amber (medium) and (low-level) green on a traffic light system, the IPC cell produced a draft document which they asked me to look at from an operational sort of management senior nurse perspective and whether I thought it was feasible or workable, whether the language was correct, whether, you know, things were clear. It would have been that kind of second opinion role.
Mr Scott: The relationship between the regional IPC cell and the UK IPC cell, is that realistically that the UK IPC cell would be providing – obviously there was a Northern Ireland representative on the UK IPC cell – but was it effectively any guidance or direction, in the broadest possible sense of the word, that came from the UK IPC cell was adopted by the regional IPC cell?
Professor Charlotte McArdle: Effectively a member of the regional IPC cell was at the national cell. The national cell was very much a working group, a consensus group, bringing together experts in the four countries. Whatever was decided then at that national cell was taken back to our IPC regional cell for sign-off and agreement and then the guidance was issued by Public Health England.
Counsel Inquiry: But at any point in time did the regional IPC cell go against any guidance?
Professor Charlotte McArdle: No, I’m not aware, we implemented the PHE guidance, or UKHSA guidance as it became.
Counsel Inquiry: Thank you.
The Inquiry’s heard on a number of occasions about the fact that the healthcare system in Northern Ireland is different to the others in terms of its level of integration. Integration means that the health and social care trusts are responsible both for social care and also provision of healthcare; that’s right?
Professor Charlotte McArdle: Yes, that’s correct.
Counsel Inquiry: Did that structure help or hurt the provision of healthcare in Northern Ireland during the pandemic?
Professor Charlotte McArdle: In my opinion, it definitely helped. From my own perspective, my thought processes were always about health and social care, and how a patient or service user or a client manages their way through that pathway in an integrated and joined-up way.
At the time we supported the independent healthcare sector to deliver care, more acute care, out-of-hospital care, and we were able to do that by the provision of more IPC trained nurses from the trusts into the independent sector, we were able to open up training and provide extra training through our clinical education centre free of charge for primary care in the independent sector, and we shared PPE and provided PPE for the independent sector. It moved. I mean, obviously there were concerns about the availability of PPE, but we were able to share the supplies and make sure that everybody in a catchment area under the responsibility of the trust, because they are the commissioners of the care of patients in the independent sector, so it worked very effectively as a system approach.
And it also meant that, you know, I worked very closely with my chief professional colleagues, Chief Medical Officer, Chief Social Worker, in the policy guidance and directions that were given to the whole community.
Counsel Inquiry: It sounded to me like all of your examples there were about moving from the healthcare sector into the independent or the care sector. Did that cause a difficulty in accessing resources in the healthcare sector during the pandemic?
Professor Charlotte McArdle: Well, it certainly meant that from the acute hospital acute trust provision they had to provide more staffing out into independent sector to support care homes, their local care homes, but there was recognition that it was the right thing to do, and (b) it smoothed the pathway for patients, and (c) it meant that we could free up and keep the flow going through hospitals.
So for a very sick patient coming into hospital the beds need to continuously move and circulate in order to be able to admit people, to admit them to ICU, to come out of ICU, to recover back out into the community. So to make that process work well there was recognition that wider resources needed to be provided, so it was difficult. There is no getting away from the fact that there was limited capacity and a limited amount of staff, but the system working together in that way had a greater benefit.
Counsel Inquiry: I think you say in your statement that in Northern Ireland there are about 27,000 nurses and about 1,200 midwives; is that right?
Professor Charlotte McArdle: That’s correct.
Counsel Inquiry: Is that the system at its maximum capacity or is that the actual number of staff members that there were?
Professor Charlotte McArdle: That’s the actual number of – so the Department of Health doesn’t record the number of nurses working in the independent sector, we’ve very good data on nurses and other healthcare staff working in the HSC sector, but that number that you refer to, the 27,000, is the number of registrants on the NMC, a list working – in Northern Ireland – registered as working in Northern Ireland.
Counsel Inquiry: Let’s just think about the staffing within the healthcare sector, as opposed to the independent care sector at the moment. At the start of the pandemic, roughly how many vacancies were there, ideally in terms of the percentage of roles, as opposed to raw numbers?
Professor Charlotte McArdle: So, the workforce data in 2019, the vacancy rate for nursing, registered nursing and midwifery was 11% in 2019. That is, I recall, the highest vacancy rate during those pre-pandemic years, and it stemmed back to previous workforce planning. In 2009 to 2012, where the commissions are set by the Department for the Undergraduate and paid for by the Department for Undergraduate Nursing and Midwifery Places and, at that time, in 2009, the commissions were around 790, and over that period –
Counsel Inquiry: Sorry, I don’t want to go too far down the road about that but you’re saying that those high vacancy rates stemmed from decisions that were taken –
Professor Charlotte McArdle: Much earlier.
Counsel Inquiry: Yes.
What did that 11% vacancy rate mean in terms of the number of nurses that there were available to work in hospitals in primary care and other healthcare settings?
Professor Charlotte McArdle: Well, that would be a significant level of vacancy. It’s probably – in ideal terms, you would like vacancy rate, in my opinion, of around 4%, which allows for natural turnover, retirements, moving, et cetera. So it was significantly higher. That, coupled with the impact of sickness and self-isolation, really meant, in reality, the availability of the nursing workforce would have been closer to 20%, 25% non-availability of work. So that was very stretching.
Counsel Inquiry: At what time, just to pick up that 20/25% non-availability, at what point?
Professor Charlotte McArdle: Well, if the vacancy rate is 11 at March, or at the end of December and we know that the sickness absence, I think, in the first wave was around 8%, and then if you add on a bit more for self-isolation – so in that early first wave, March/April time of 2020.
Counsel Inquiry: That 11% figure, that’s smoothed out over all roles, all areas; is that right?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: So there would be areas where there are peaks, so there are higher vacancy rates; is that fair?
Professor Charlotte McArdle: That’s true, and there are traditionally areas in the health service that, when vacancy rates become an issue, it’s more prevalent in certain areas, and they would be medical unscheduled care – the pathway through the emergency department, for example, theatres would also be a high turnover rate – and they’re the areas that would emerge first, and I think it’s also fair to say that the profile of the nursing workforce in Northern Ireland, 50% of that workforce are on band 5, which is the entry level grade into nursing.
So 50% of those would be frontline care delivery nurses that you would meet in any ward or department or outpatient area in the hospital.
Counsel Inquiry: I’m going to come back to some of those specifics later on when we talk about ratios.
Professor Charlotte McArdle: Okay.
Counsel Inquiry: But is it an effective summary that the Northern Irish healthcare system didn’t really have any capacity that it could afford to lose during the pandemic?
Professor Charlotte McArdle: It didn’t have any spare capacity, it was very stretched at the time.
Counsel Inquiry: So while you say that the systemic benefits as a system operate between health and social care, is it not problematic to the provision of healthcare if you then have to lose nurses to the provision of the independent sector?
Professor Charlotte McArdle: Well, it means you’re diluting your workforce further, but it’s a balance of risk and it’s about how we enable the system to work effectively because there would be no point in keeping the staff in healthcare if we’re unable to discharge anybody out of the system.
Counsel Inquiry: Those were conscious choices, I presume, that were taken to provide nurses to the independent sector?
Professor Charlotte McArdle: Absolutely, by each of the organisations.
Counsel Inquiry: Do you think that they were decisions that were taken with the intention of trying to provide the best level of care for people in all different sectors?
Professor Charlotte McArdle: Absolutely, and in terms of providing support to smaller providers, to independent sector and to environments where there were actually less nursing staff, qualified nursing staff, dealing with much more acute care. In nursing homes, primarily, they wouldn’t normally provide. They needed a higher level of both nursing and a slightly different skill set in terms of their expertise.
Counsel Inquiry: On reflection, do you think that those decisions were the right ones or should have been taken in a different way?
Professor Charlotte McArdle: It’s the way the system works and I think it was the right thing to do and I really don’t know how we would have done it differently.
Counsel Inquiry: I want to move now to visiting restrictions. You say in your statement that Northern Ireland led the way in ensuring restrictions were applied in a person-centred way. What do you mean by that?
Professor Charlotte McArdle: So at the start of the pandemic, obviously we made a decision to restrict visiting, which is a normal protocol, in terms of infection prevention and control. So you would see that happening across hospital systems where there’s an outbreak of an infection, where visiting is limited and restricted. It would normally be for a number of days or a week and at the start of the pandemic we made that decision, that we needed to restrict visiting to protect very vulnerable patients, to protect our healthcare staff and to protect the public.
And those guidance – we didn’t at that time think the pandemic would be as long as it was. So as we became more familiar with the virus, its transmission, the impact that visiting was having on families, and we heard many, many stories about the impact of that, indeed there were lots of communications, both to the minister’s office and my office, and my small team worked to try and provide a solution to many of the queries that had been raised with them. But that was all fed into our decision-making around our flexibility with the guidance as we moved forward, which is probably why we had so many iterations of the guidance, because at every point possible we tried to flex them and be flexible, taking into account the feedback that we were getting from families and service users.
Counsel Inquiry: I’m going to go through some of the iterations.
Professor Charlotte McArdle: Okay.
Counsel Inquiry: But if you’re saying that you didn’t expect it to last as long, does that mean that the intention, when the initial visiting restrictions were brought in on 26 March, that they were effectively intended to be short term and that the intention was to keep people out, in order to protect them and healthcare workers?
Professor Charlotte McArdle: That would have been the normal thing to do in an infection control emergency, that you restrict visiting. So we used what we knew to be the best evidence base and to work well. But, as I say, we had no indication that we were going to have a pandemic for the length of time that we had.
Counsel Inquiry: Yes, but in terms of the original intention, was it that there was meant to be quite a firm separation, in the sense that you were trying to keep visitors out because you didn’t think the restrictions would be in place for that long?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: Is it right then that, effectively, the ground moved under your feet and so you had to change the approach to allow people in?
Professor Charlotte McArdle: Well, we were learning about the virus, we had a number of different variants of the virus, we didn’t have a vaccine until the end of 2020, testing was being developed. So, yes, the ground was shifting on a very frequent basis, in terms of the virus, the evidence we had, what we were learning, and what strategies we could put in place to protect people.
Counsel Inquiry: But right back at the very beginning there must have come a point in time where you thought “Our initial approach has to change because we have to let people in”. Was that something that you then realised changes had to be made?
Professor Charlotte McArdle: We did that very early on, we tried to make exceptions for palliative patients, for women who were pregnant, for children, for people with additional needs, very early on, as best we could in the environment that we had at the time, and also understanding that the non-pharmaceutical interventions, the distancing, the wearing of masks, the hands, were having an impact.
Counsel Inquiry: But there wasn’t a pre-pandemic plan for how to manage visiting in the event of a pandemic, was there?
Professor Charlotte McArdle: No, other than the IPC manual.
Counsel Inquiry: Well, the IPC manual didn’t provide for how you might approach visiting in the context of a pandemic, did it?
Professor Charlotte McArdle: No, as I say, only in a normal outbreak situation.
Counsel Inquiry: Yes. If we can just go, please, to INQ000376875, this is a document dated 21 April 2020 and it’s created by the Critical Care Network Northern Ireland. Can you just explain who they are, please?
Professor Charlotte McArdle: The Critical Care Network is a network which connects all of the intensive care units across Northern Ireland, they’re funded by the Health and Social Care Board, which is – which was at that time the Commissioner for Health and Social Care in Northern Ireland. They’re overseen by a clinical leadership team and a manager and they co-ordinate and deliver best practice and really network all of the intensive care units in Northern Ireland.
Counsel Inquiry: Seven intensive care units in Northern Ireland?
Professor Charlotte McArdle: Seven?
Counsel Inquiry: Are there seven?
Professor Charlotte McArdle: I would have to –
Counsel Inquiry: Okay, we’ll go over the page and please tell me if there are any that are missing here. This is dated 21 April 2020. If we could just please go to page 2, thank you, so this provides in terms of the background a brief overview. So on 26 March, all general hospital visiting was stopped. Is that the initial decision that you were talking about where you realised there needed to be a brake on visiting applied.
Professor Charlotte McArdle: Yes. All general visiting.
Counsel Inquiry: Yes.
Professor Charlotte McArdle: There were exceptions at that point.
Counsel Inquiry: Yes, and the exceptions were critical care areas where one visitor was permitted, and another exception was those in established labour; is that right?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: To what extent was the department monitoring how those exceptions were being applied by the trusts?
Professor Charlotte McArdle: Well, I met, as I say, regularly with our – we had our director of nursing huddle meeting. In the early days of the pandemic sometimes it was three times a day but, in the main, we met regularly at midday and all of those issues were discussed and how those restrictions were being implemented, any issues that were being identified with them, and any possible changes that we could implement because each of the directors of nursing and, indeed, the nursing staff were very conscious of the impact that this was having on families.
Counsel Inquiry: So you were being informed by the trusts about how they were applying these –
Professor Charlotte McArdle: Yes, and then as we moved through the process, and you maybe want to come to this later, when we changed the guidance to have local ability to deviate through risk assessment, but at that point that was reported on a weekly basis to the minister.
Counsel Inquiry: Again, just in terms of the timeline, on 9 April there was an update:
“With immediate effect all intensive care and general hospital visiting across Northern Ireland has now stopped.”
Professor Charlotte McArdle: Yes.
Counsel Inquiry: Then:
“Although palliative … care outside of Intensive Care was listed as an exception, there was no exception for those patients receiving end-of-life care within Intensive Care Units.”
Professor Charlotte McArdle: Yeah.
Counsel Inquiry: Why was that decision taken on 9 April to stop all intensive care visiting?
Professor Charlotte McArdle: I deeply regret that we had to make that decision but we were in the peak of the first wave, we were expanding our capacity for ICU, we had additional ICU beds in most intensive care units, some of which had limited space, and you will appreciate that an intensive care bed comes with both a lot of kit and a lot of staffing requirements, and it wasn’t possible in a high-risk area with aerosol-generating procedures and the implications of donning and doffing to enable staff to allow visitors in through the donning and doffing process, to be extra people in an already very confined space and when our staff were extremely stretched at that point in order to provide direct care. So we, for that period of time during that first wave, we had to further restrict visiting and we reverted to virtual visiting at that point.
Counsel Inquiry: How long did you expect those restrictions to have to be in place for?
Professor Charlotte McArdle: Only during the peak of the wave and they actually –
Counsel Inquiry: If I can push you a little harder, how long roughly was that: one week?
Professor Charlotte McArdle: A couple of weeks.
Counsel Inquiry: A couple of weeks? Did that view influence your decision about needing to go so far to prevent any intensive care visiting?
Professor Charlotte McArdle: My view that it would be relaxed within a couple of weeks?
Counsel Inquiry: Yes.
Professor Charlotte McArdle: I felt at the time we were between a rock and a hard place, there was nowhere else to go with this. It wasn’t a decision that I either wanted to make or would want anybody’s family to have experienced but it was a balance of risk between protecting patients, staff and the public, and I really do understand the implications of making that decision. I’ve had very personal experience not being able to visit my own mother when she died in hospital, so I do understand.
Counsel Inquiry: In the middle of April, there was a review conducted. Was that because you realised the toll that it was taking on people?
Professor Charlotte McArdle: Say that again, sorry?
Counsel Inquiry: In the middle of April, there was a review conducted about visiting at the end of life in intensive care.
Professor Charlotte McArdle: Yes.
Counsel Inquiry: Was that because you realised the toll that it was taking?
Professor Charlotte McArdle: Absolutely, yes.
Counsel Inquiry: If we can please just go over to page 3 because I want to see how that end of life in intensive care was being applied. So we have there at the top, there’s a list of – this is where the number seven came from –
Professor Charlotte McArdle: Yes.
Counsel Inquiry: – intensive care units. There’s no more missing there, is there?
Professor Charlotte McArdle: I don’t think so.
Counsel Inquiry: Okay. Then if we can just go down to question 1, it says:
“Does your unit recognise end of life as a special circumstance and allow loved one(s) to visit, where possible?”
So this is 21 April, this document, end of life visiting was permitted at that time; is that right?
Professor Charlotte McArdle: 21 April?
Counsel Inquiry: April. Well, it wasn’t expressly forbidden; that’s right, isn’t it?
Professor Charlotte McArdle: Yes. So even in this extremist part of the wave, if staff could have facilitated a visit in any way, they would have done so, of that I’m pretty certain.
Counsel Inquiry: Because the reports you were receiving back was that only two units out of the seven facilitated end-of-life visits and one of those was non-Covid and the other did have Covid-19. What was your view about the difference that was being applied by the different trusts?
Professor Charlotte McArdle: I think there are a number of different circumstances to be considered here and I am absolutely certain that, where possible, staff – nurse in charge and nursing staff – tried to accommodate even a short visit where they knew a patient was at the end of life. It depended a lot on the environment and the estate, I suppose, of the intensive care units, and they had expanded out into outside intensive care units. So they would have had patients potentially in theatre recovery in other areas and – so depending on that environment, the availability of space, the availability of staff, the sickness of the patients, all of that needed to be in context of supporting people to come in at the end of life, and so I do understand that some areas were better able to facilitate than others.
Counsel Inquiry: Did you think at this point – well, I’ll ask a slightly different question, I’ll come back to that one.
If we can have up, please, INQ000475219.
Lady Hallett: While the document’s coming up, Professor McArdle, can I just check: at this stage, the document to which Mr Scott has just taken you was dealing with intensive care units, and so all general hospital visits had been stopped.
Professor Charlotte McArdle: Yes.
Lady Hallett: So the only hospital visits that were taking place were some hospitals were letting families go in for end-of-life –
Professor Charlotte McArdle: Yes.
Lady Hallett: – visits, and two units were letting people in for end-of-life visits to intensive care. So things like maternity wards, there were no visits at all there; is that right?
Professor Charlotte McArdle: So for maternity, at all points a pregnant lady was allowed to have a birthing partner in active labour.
Lady Hallett: That’s throughout?
Professor Charlotte McArdle: Yes.
Mr Scott: But not around.
Professor Charlotte McArdle: Sorry?
Counsel Inquiry: But not around active labour, simply in active labour, at that point?
Professor Charlotte McArdle: Yes.
Lady Hallett: So birthing partner during active labour?
Professor Charlotte McArdle: Yes.
Lady Hallett: Is that the only other category of visit that was permitted?
Professor Charlotte McArdle: Yes. We did also make exception for children to have one parent with them, very soon after that period.
Lady Hallett: What about people who had particular needs, like somebody who was used to a carer or somebody who had dementia.
Professor Charlotte McArdle: Yes, and, again, that was down to discretion of the nurse in charge, and for people – it was in the guidance, people with additional needs should be discussed with the nurse in charge to accommodate that arrangement.
Lady Hallett: Sorry to interrupt. You might have been coming to it, Mr Scott.
Mr Scott: What guidance did you give nurses in charge about how they should apply their judgement at that time?
Professor Charlotte McArdle: Well, their guidance was set out in the region guidance, which then would have been supplemented by trust guidance and support for them through their senior line manager.
So, again, this is down to circumstances on the day and we encouraged people to use a risk based approach to accommodate people where possible and, at all times in the guidance, we iterated the need for people to have their family as part of their wellness pathway or an end of life, and we recognised the importance of that being person centred and thinking about individuals, rather than a bland approach.
Counsel Inquiry: Is that right on 26 March or did that come later on?
Professor Charlotte McArdle: That came slightly later on, as I said, as we became more familiar with – at that point, in March, it was really a decision-based on safety.
Counsel Inquiry: But you – and when I say “you”, those within the Department of Health – had taken the decision from the Department of Health to prevent visiting, what guidance was the Department of Health giving trusts about how they should apply those exceptions?
Professor Charlotte McArdle: So they should apply the guidance in its totality.
Counsel Inquiry: This document that we have up on screen, it’s the PHA and CNO Covid-19 regional huddle, and it’s held on 17 April 2020, so it’s a couple of days before that CCaNNI document that we were just looking at.
This is a section of visiting policies in that meeting, those top three paragraphs – I presume you have had a chance to have a look over the document?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: It doesn’t appear from those paragraphs that the decision to allow visiting was being driven from within Northern Ireland. It looks like Northern Ireland was responding to views that were arising in England and in Scotland; is that right?
Professor Charlotte McArdle: Well, as stated there, the Secretary of State at the time had said that no one should die alone. We were very aware of that, and we were coming down from the peak of wave 1 at that time anyway and, as I said, the measures that were put in place were done so purely during the peak of wave 1 where we were seeing – maximum numbers of intensive care patients for wave 1, I think, was at 57, increased medical admissions, et cetera, so – and the peak was the middle two weeks of April, so we would have been considering how we could flex and reduce the very tight restrictions that we had anyway, and we were very conscious of the need to have people, particularly for end of life, for maternity and for children.
Counsel Inquiry: Hesitant to apply too literal a reading to a note of a meeting but, again, it doesn’t seem like there’s a real driver from those present at that meeting that visiting is something that absolutely had to happen at that point in time; is that fair or not?
Professor Charlotte McArdle: I can assure the Inquiry that visiting was – if you look at the minutes of the huddle meetings and other nursing meetings, it was a regular feature, it was at the forefront of everybody’s mind, it was an issue that we spent considerable time on.
Counsel Inquiry: It may have been something you spent time on but there’s a difference between spending time on discussing the topic and people saying in a meeting “This is absolutely something that has to happen now”. Was anybody making that point in the middle of April 2020?
Professor Charlotte McArdle: Yes, I think all of the directors of nursing, myself, were working to expand and reduce the rigidness of the guidance, and we were reviewing that on a daily basis, that was my point about the meeting is, while it may not be documented in your minute here, the purpose of us having that discussion was to be as flexible as we could and extend the opportunities for people to visit.
Counsel Inquiry: If that can come down now, please, if we can go to the arrangements of visiting patients who were approaching their end of life, that was published on 11 May 2020.
That’s at INQ000120721.
Lady Hallett: While that document’s coming up, and I apologise for keeping interrupting, you said at the beginning, when Mr Scott started asking you questions about visiting restrictions, that Northern Ireland led the way to ensure that the restrictions were applied in a person-centred way. What did you mean by you led the way?
Professor Charlotte McArdle: So, my Lady, further on in the pandemic we developed two specific pathways, one for hospital and hospice care and one for care homes, and while this module is not looking at care homes obviously in an integrated system we devised policy guidance for both, and we developed a Care Partner scheme, which we implemented from – effectively the guidance went out in September 2020, which recognised the need for families to be with people in long-term care, for families to be present with people who had additional needs in hospitals.
And that Care Partner policy was the first of its kind. It was evidenced from Canada. And in terms of the four countries we were the only country at that point to have such a policy. And indeed in my current role and – I have been working in NHS England to develop a Care Partner policy for NHS England with patients, families and advocates like John’s Campaign and the Patients Association.
Mr Scott: Those features that you’re relying on came later on in the pandemic. Would you say that you led the way at the start of the pandemic in terms of visiting?
Professor Charlotte McArdle: No, I think we were doing what other countries were having to do and make very difficult decisions.
Counsel Inquiry: So the document we have up on screen is 11 May. This is what followed on from a review. At this point in time you’re well past the initial period of time you thought the visiting restrictions would be in force, is that right?
Professor Charlotte McArdle: Sorry, which –
Counsel Inquiry: Sorry, let’s go to page 1 of that document, just so you can see it. It’s 11 May –
Professor Charlotte McArdle: Okay, 11 May, yes.
Counsel Inquiry: Yes, there you go.
Thank you. If we can just go back to page 7, please.
In this document, this is where you set out fairly strident principles in terms of what’s expected, so we see at paragraph 3.3.1:
“People have the right to be with a loved one … at the time of death and this should be respected and accommodated where possible.”
That’s the starting point, was it, that people should be applying when considering visiting restrictions?
Professor Charlotte McArdle: Sorry, I’m having trouble hearing you.
Counsel Inquiry: That was the starting point that should be applied when people were considering applying visiting restrictions; is that right?
Professor Charlotte McArdle: That people should have a right to visit.
Counsel Inquiry: People have the right –
Professor Charlotte McArdle: Yes, yes.
Counsel Inquiry: Then if we can just look at paragraph 3.3.5, that:
“Only in extreme cases should family members/loved ones next of kin be denied the possibility to be with a patient at the time leading to or of death … reasons should be clearly outlined to the patient and his/her family members and/or loved ones.”
Then if we can also look at 3.3.8, please, that:
“Infection prevention and control requirements should not be so rigid as to prevent family members/loved ones from saying goodbye in as humanely a way as possible – this includes the ability for them to hold hands and touch the dying person.”
Do you think those fundamental principles were being followed by trusts in Northern Ireland in the summer of 2020?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: Were you receiving any complaints, comments, suggestions, thoughts by family members that those weren’t being followed?
Professor Charlotte McArdle: I had several complaints from families about restrictions on visiting and access to services. I’m not aware of any particular case that was in relation to a person dying. I am aware of a number of cases where people have travelled from other countries to come to visit and when they arrived to see a dying relative, usually a parent, they were unable to visit, and in those circumstances, where that was known, a solution was found to accommodate them.
Counsel Inquiry: How did you ensure that these principles were being complied with by trusts?
Professor Charlotte McArdle: Because I was in daily contact with directors of nursing, who have responsibility for the provision of patient experience and services in those trusts, and I was assured by them. I was also in contact with staff, and I wasn’t hearing that they were unable to accommodate visiting. I was hearing their concern, absolutely, about having to find ways round issues to support people to visit.
Counsel Inquiry: Are you satisfied, then, that in every reasonable instance, let’s not say every instance, but in every reasonable instance that people were able to be with their loved one at the point of their death?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: Is there anything more that you think you could have done or should have done to make sure that any of these principles were being complied with?
Professor Charlotte McArdle: I think that we did our best in the circumstances. We tried to be flexible with the iterations of the guidance as new evidence became available, as we became aware of particular difficulties, and I’m not sure that I could have personally done any more or my team. It was a very difficult time and decisions were the least worst option.
Counsel Inquiry: Just in terms of the timing of the dissemination of this guidance on 11 May, isn’t it right that you’d actually provided a briefing paper on 6 May that enclosed this guidance?
Professor Charlotte McArdle: To the minister?
Counsel Inquiry: Yes.
Professor Charlotte McArdle: Yes.
Counsel Inquiry: Why did it take five days to come in?
Professor Charlotte McArdle: The minister – obviously I produced the paper to the minister, the minister was receiving a lot of papers from different policy areas, there was a lot going on in the department, and him and I potentially, although I don’t remember for certain, on this occasion would have discussed the issues before he signed off the paper, and it may have come back with queries from the minister before the final paper was agreed.
Counsel Inquiry: Well, if I can just take you then to INQ000103665, just on that point of queries, so that you have that, that’s gone to the permanent secretary and the minister, dated 6 May.
Professor Charlotte McArdle: Yeah.
Counsel Inquiry: If we just go, please, to page 3, those are responses from the minister –
Professor Charlotte McArdle: Yeah.
Counsel Inquiry: – on 4 May. Are you aware of the reason why it took five days for that guidance to come in, or is this a question better put to the minister?
Professor Charlotte McArdle: Or is this question about?
Counsel Inquiry: Better put to the minister.
Professor Charlotte McArdle: I think that’s a reasonable timeframe, given the work that was going on in the department, the fact that we were in a pandemic response, the fact that the minister and his team had questions that required answers before he signed it off. I think that’s appropriate challenge on the minister’s behalf.
Counsel Inquiry: There was then the next iteration of guidance was on 30 June 2020, which was the regional principles for visiting.
If I can please take us to INQ000103667, at page 11.
So this was the advice that had been given at the end of June, so it’s another step beyond the end of life guidance that had been on 11 May; that’s right?
Professor Charlotte McArdle: Yes. So –
Counsel Inquiry: It appears – sorry. It appears from this grid that, depending on the surge level, that actually there were times when the end of life guidance was being watered down; is that fair or not?
Professor Charlotte McArdle: Depending on the level of – as set by the UK CMOs. So it was clear from March to June that there were a number of instances where people were confused by the number in of iterations of the guidance. We set it out in this format so that the public would be clear, based on the alert level, what they could expect in times of visiting.
So in high surge – and I think the only other period that we had alert level 5 during the pandemic was the third wave in January 2021, where again, if you look at the guidance, there were restrictions on ICU visiting for a limited period of time during the alert level 5, but it was in an effort to try to make clear to people, so they could go to the website and link our visiting guidance to the alert level and also to provide clearer guidance for staff so that they could plan more effectively on the alert level.
Counsel Inquiry: But why did the principles that we’ve been looking at at 11 May, why would they not have been able to apply during the higher extreme surge period?
Professor Charlotte McArdle: Because we said in extreme circumstances it may be that visitors could not be accommodated and that was an extreme circumstance in UK level 5 –
Counsel Inquiry: But –
Professor Charlotte McArdle: – with a new variant in January 2021.
Counsel Inquiry: But then again, wouldn’t that only have applied to Covid settings rather than non-Covid settings, because at that point in time you had different pathways?
Professor Charlotte McArdle: We did have different pathways, but the nature of the virus, it was very hard to maintain pathways, and we do – as part of the visiting guidance we did a review of the evidence around the impact of visiting on the – on nosocomial transmission in particular, and in the studies we looked at, the Covid study, which you’ll appreciate at that time was early evidence, suggested that patients had a role in – or visitors definitely had a role in the spread of infection. We looked at a SARS paper and we looked at a MERS paper, and both of those indicated – the MERS paper indicated that 12% of infection spread in hospital was due to visiting and the SARS paper had no nosocomial spread but they had really restricted – no visiting at all, even in a paediatric unit.
So I think we were aware of the evidence and we knew that in high surge, where the virus was in a lot of circulation in communities, and the transmission routes coming from communities into hospital, that it was too big of a risk to take in the peak of the surge. And they were the only two times during the whole pandemic that ICU – restrictions on visiting to that extent.
Counsel Inquiry: But this applies to non-Covid general wards as well. Surely you haven’t got the same considerations in a non-Covid general ward in 2021 or 2022 that you would have in ICU?
Professor Charlotte McArdle: But given the spread of the virus from community transmission, the risk is bringing that virus into the hospital and then spreading it among vulnerable, susceptible patients who are acutely ill with medical conditions, many of which are respiratory anyway.
Counsel Inquiry: So what use did you make of testing to make sure that you knew they were negative at that point?
Professor Charlotte McArdle: For patients, for relatives –
Counsel Inquiry: Of the visitors.
Professor Charlotte McArdle: At which point?
Counsel Inquiry: 2021 or 2022.
Professor Charlotte McArdle: In 2021, our testing capacity was being developed. We had lateral flow testings. They were, as you may know, a high false positive or false negative rate. We had other measures, IPC measures, in place to – non-pharmaceutical interventions – to support the reduction of nosocomial spread. But even at all of that, the risk to vulnerable populations and people in hospital is significant and also to the healthcare worker workforce. The vaccine only began to be rolled out at the start of 2021, so at that point, in January, we didn’t really have widespread vaccine, we only were starting to protect the most vulnerable in our society.
Counsel Inquiry: I’ll move on. Were you aware of concerns being raised about the inappropriate use of DNACPRs in Northern Ireland?
Professor Charlotte McArdle: No, I wasn’t, and I think if you’re referring to inappropriate decisions being made, in my professional opinion, that would be totally unacceptable and outwith any code of conduct of any healthcare professional.
Counsel Inquiry: I’m more interested about whether you were actually informed that –
Professor Charlotte McArdle: No, I wasn’t. I wasn’t. And the department developed an ethical framework to support clinicians to make those decisions in very difficult times, recognising that they are decisions that unfortunately are made on a day in daily basis by our clinicians in hospital, so the guidance was to support them in this extra challenging time to do that. And that then followed with it subsequent bereavement support guidance for staff and for people who had been affected by the pandemic.
Counsel Inquiry: Staffing numbers and particularly nursing ratios in the surge times. So it’s right, isn’t it, on 1 March 2020 there were 88 critical care beds in Northern Ireland?
Professor Charlotte McArdle: That’s correct.
Counsel Inquiry: The first wave surge plan, the final version was dated 17 April; does that sound about right to you?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: And that indicated a need for 140 Covid and 35 non-Covid critical care beds, so effectively doubling the number of critical care beds; is that right?
Professor Charlotte McArdle: Yes, but we did also develop a surge plan that took us past that to –
Counsel Inquiry: Yes.
Professor Charlotte McArdle: Okay.
Counsel Inquiry: But that’s what was intended –
Professor Charlotte McArdle: Yes.
Counsel Inquiry: – that you were looking at effectively doubling the number of critical care beds.
Was there ever the nursing capacity that would have been able to deal with the number of critical care beds that were anticipated?
Professor Charlotte McArdle: It would have been extremely challenging. It would have meant reducing the ratios significantly, it would have meant taking further action to reduce other services and to bring additional staff into work in ICU, as most countries did have to do anyway, to support the critical care nursing team to deliver that care. So in normal times a 1:1 ratio for a ventilated patient was not going to be possible.
Counsel Inquiry: Can we please have up INQ000377063.
This is feedback from nursing staff about the workforce, and it’s noting a conversation on 23 April 2020. That conversation didn’t involve you.
Professor Charlotte McArdle: No, but it involved one of my senior nursing advisers, which I’d brought in to support me in the pandemic.
Counsel Inquiry: So you would have been aware of the discussions that were going on?
Professor Charlotte McArdle: Yes.
Counsel Inquiry: If we could please go down to paragraph 3.4, and it’s talking there about the modelling, and it’s talking about effectively going up through the ratios. This is 23 April.
Can I please take you to INQ000438043. This is the letter that you sent to the executive directors of nursing across the five trusts in Northern Ireland, and it’s dated 22 April, so the day before that conversation. Then effectively this letter says:
“Delivering Care staffing should be adhered to as far as possible … At this point suspension of Delivering Care … Nursing or midwifery staff should exercise professional judgement in determining safe staffing requirements that maximises the knowledge and skills within their teams and if necessary adopting a more task based approach to the delivery of care.”
There seems a disconnect between that letter on 22 April, where you’re effectively saying to the trusts “You need to look after the staffing numbers based on the information capacity you have available” and then the discussion the next day that’s talking about nursing ratios.
Professor Charlotte McArdle: So we had a safe staffing policy in Northern Ireland from 2014 which covers broadly medical, surgical and other specialities. The ICU module of that safe staffing policy hadn’t yet been signed off prior to the pandemic, so we’re talking about slightly different things here.
The ICU guidance was from the critical care society which – and they’re very well known and – as standard nurse staff ratios for critical care for levels 1, 2 and 3. The letter was a broader letter, recognising that, in order to accommodate ICU expansion, we would have to move staff from other places and other wards, and in order to do that we could no longer meet the safe staffing requirements of the policy in 2014. And indeed it was on the back of a conversation with the directors of nursing, who were looking for my support to share the workload and move people around and they needed me to stand down that policy in order to do that safely.
Counsel Inquiry: Was that effectively what happened, that it was just moving people to wherever they were required across Northern Ireland?
Professor Charlotte McArdle: It was moving people, yes.
Counsel Inquiry: Were you actually capable of setting staffing ratios or was it simply going to be: we have capacity issues here, we’re just going to have to put people in those places?
Professor Charlotte McArdle: We tried to maintain staffing ratios as best that we could in order to maintain safety. I think there were limits on what we were prepared to do and not do. We all recognised that it was extremely challenging and we would have to dilute the staff, but that we could not have a situation where there would be no nurse in charge and no nurses with skills to care for patients in – in any unit, and certainly in intensive care. It was agreed with the network and you see the – in that evidence paper, the proposal to stay at 1:1 for as long as possible and then move to 1:2 and 1:4, and I don’t believe that during the pandemic we ever moved past 1:4 in any ICU situation.
Counsel Inquiry: Was the fundamental problem a lack of nurses?
Professor Charlotte McArdle: Yes, we didn’t have capacity to do what we needed to do.
Counsel Inquiry: Because in October 2020 isn’t it right that you asked chief nursing officers in England, Wales, Scotland and the Republic of Ireland if they would provide you with extra staff?
Professor Charlotte McArdle: Yes, that’s correct.
Counsel Inquiry: And no one was able to help you?
Professor Charlotte McArdle: Correct.
Counsel Inquiry: How bad was the situation in October 2020 that you needed to ask the other nations of the UK to provide staff?
Professor Charlotte McArdle: At that time we had particular challenges in – particularly in relation to intensive care, and our ability to flex up, so we were monitoring the ICU bed usage through the critical care network on a – I would say a twice daily benefit basis, and I was in regular contact with the ICU hub on a regular contact, and I knew that we had a small number of beds that we could still staff at that – at the required level in October, but if we had a sudden surge or an event that – where a number of ICU beds would be required, for example in a non-Covid situation, that would be very challenging for us, so this was an attempt to plan for the worst-case scenario. And in fact the agreement with the Republic of Ireland was that while they couldn’t transfer staff, they would be able to take a number of patients for us if we needed to.
Counsel Inquiry: Did the numbers available impact upon patient care in the first wave, second wave or third wave?
Professor Charlotte McArdle: I think that it certainly impacted on our staff’s ability to deliver the care and I am quite sure that that impact on staff had an impact on patient experience, at least. I don’t think we have the evidence to say that it impacted on someone’s outcome, but it certainly impacted on experience of both staff and patients.
Counsel Inquiry: You had the workforce appeal. I think it’s right that actually there weren’t a huge number of people who returned in terms of nursing staff, through the workforce appeal?
Professor Charlotte McArdle: Correct.
Counsel Inquiry: Why were the numbers so low about who was able to actually then rejoin, or have you set that out in your statement because I’m just conscious of the time?
Professor Charlotte McArdle: We ended up with 447 nurses from the workforce appeal. The numbers did drop significantly from those who had applied to those who ended up, that’s correct, and there were a number of reasons for that. Many, many, I think, felt an emotive response to the call for action and I certainly was very vocal and visible in that call to action, but they didn’t necessarily either want to work in frontline services, didn’t necessarily have the skills, the particular skills that we needed, or they had very rigid rotas that we couldn’t facilitate. Others wanted permanent jobs that weren’t going to be provided through this workforce appeal. So there were a number of different reasons and, in some ways, I think we had better success with the vaccination programme.
Counsel Inquiry: But in terms of the workforce appeal for numbers, particularly when you’re going through that second wave, was there anyone who had expressed an interest or made an application through the workforce appeal who you think may have been able to provide the skills but, actually, the way that the workforce appeal was structured meant that they weren’t then able to be deployed? I’m not asking for individuals, I’m just – in terms of did you make available use of everybody who expressed an interest?
Professor Charlotte McArdle: I can’t answer that question because I wasn’t directly involved in the workforce appeal, and the trusts would be better placed to answer that.
Counsel Inquiry: Again, this is one thing that we hear frequently, that the trusts are better placed to answer that in terms of the Nightingale, the workforce appeal. Is there not a lack of control from the Department of Health when these issues are then passed on to the trusts?
Professor Charlotte McArdle: I don’t believe so. I think that the Department of Health have a very specific role in overseeing the health and social care system. During the pandemic we became closer to that system in a number – I was very involved operationally but, in terms of the response to the workforce appeal, it was managed through HR and the workforce policy director at the department and what I’m saying to you is I’m not close enough to know the detail of that.
Counsel Inquiry: Just a few very minor questions left – sorry, not minor questions, just a small number, that’s what I meant to say.
The RQIA suspension, I’m going to ask the CMO about the reasons for that. Were you asked what view you had about the impact of suspending the inspection of the hospitals by the RQIA would have upon the protection of healthcare workers?
Professor Charlotte McArdle: I don’t recall being directly asked, but I would have been aware of the conversations between the chief executive and the CMO at the time, and I understood that the direction that was issued from the department was on the back of a conversation with the chief executive of the RQIA at the time, who had a professional background, she was a nurse, and saw the opportunity for RQIA staff to be more helpful –
Counsel Inquiry: Yes, sorry to cut across you, but in terms of is there a benefit of a regulator, such as the RQIA, maintaining inspections of IPC provision in hospitals; is that beneficial during a pandemic?
Professor Charlotte McArdle: I think that we – the flexibility allowed them to inspect if they needed to inspect. I think that, during the pandemic, their staff provided a more beneficial role in the work that they undertook in terms of supporting particularly independent sector and working with the Public Health Agency in particular around communication and management of outbreaks, and supporting healthcare staff.
I think the trusts have an IPC team, a very skilled and expert IPC team, there are processes in place in organisations to oversee IPC and I would also note I think the RQIA report, when they did visit hospitals, suggested that, in the main, with a couple of recommendations, there was a high standard of adherence to the IPC guidance.
Counsel Inquiry: Yes.
Finally, the impact upon nurses. Did you come to learn about any concerns or issues that were being faced by ethnic minority nursing staff?
Professor Charlotte McArdle: I was aware of the information from the other countries, in terms of the mix of healthcare staff. I think it’s fair to say in Northern Ireland we have a different population mix, probably, than the other three countries and, because we have a smaller ethnic minority mix, I think – and again we would have discussed this through both IPC cell and the nursing huddles – the nurse directors and the senior nursing teams were very aware of where those staff were located, and I understood that all of the same level of support and – was provided to them as to all other members of staff.
Counsel Inquiry: Then finally, was there sufficient provision being made for nurses who were suffering from Long Covid?
Professor Charlotte McArdle: Again, that’s something that I wasn’t directly involved in from a policy perspective, but I do know that there was a group at the minister’s request set up to examine the impact of Long Covid and the provision of services, which were set up in Northern Ireland through a clinic. I myself became aware of the work of Dr Elaine Maxwell and the work that she’d done reviewing the international evidence around sequelae –
Counsel Inquiry: I think you’ve set that out in your statement.
Professor Charlotte McArdle: Yes, okay, thank you.
Mr Scott: Thank you.
My Lady, I have no more questions.
Questions From the Chair
Lady Hallett: Thank you.
Some more questions, Professor McArdle, on visiting restrictions. First of all, one of the core participants has asked: when you mentioned additional needs for the purposes of making individualised exceptions to visiting suspensions, what was the guidance on additional needs?
Professor Charlotte McArdle: It was simply additional needs, so it’s broad enough to cover anyone who has a specific set of circumstances, should that be a learning disability, a mental health issue, dementia, a child with additional needs, any patient or service user who has a requirement to have another person with them, either to act as an advocate or to communicate on their behalf.
Lady Hallett: The other question they’ve asked is: you said that you felt the principles about family visits at the time of death or about the time of death were applied in Northern Ireland. The suggestion is that there is evidence that exceptions to the visiting restrictions were not always subject to an individual risk assessment and that patients with additional needs or at the end of life were not permitted to have visitors or family/carers with them. Now, you’ve said you relied on your directors of nurses and contact you had with frontline staff. Were there any other steps you had to take to monitor whether what you were being told was actually happening?
Professor Charlotte McArdle: Well, my Lady, as I said, whenever we moved the guidance on to provide more flexibility and to take account of local transmission – so in one area of Northern Ireland you might have had a population with a high transmission rate present and in another lower transmission, so the flexibility for organisations would depend on that as well. But, in the case where organisations moved away from any of the regional guidance, they reported that on a weekly basis through me to the minister, so that was the assurance that organisations were adhering to the guidance.
Lady Hallett: So if they didn’t allow or didn’t conduct risk assessments because they had a high number of cases, that would be reported to you, and are you saying you didn’t get any such reports?
Professor Charlotte McArdle: I’m saying that where they deviated from the guidance, so say, for example, they didn’t allow an end of life visit –
Lady Hallett: Yes.
Professor Charlotte McArdle: – they had to document why that was so.
Lady Hallett: Did you get such reports?
Professor Charlotte McArdle: We did. We got a very small number but they were exceptional circumstances and, whenever we went back to the individual organisations, they were able to explain why specifically on that occasion the guidance wasn’t adhered to.
Lady Hallett: Thank you.
Right, I think, Ms Waddoup, you’ve got a question or two. You’ve over there. Can you see?
The Witness: Yes, thank you.
Questions From Ms Waddoup
Ms Waddoup: Good morning, Professor. I ask questions on behalf of 13 Pregnancy, Baby and Parent Organisations and we’d like to focus on restrictions on parents and families being with their babies in neonatal units.
Would you agree, Professor, that parents, and in particular both parents, being with their babies on the neonatal unit is a positive thing not just for parents but also for babies, for the health and development of those babies?
Professor Charlotte McArdle: Yes, I would agree.
Ms Waddoup: Could you perhaps explain some of the ways in which that’s important?
Professor Charlotte McArdle: It’s important for bonding, it’s important for family interventions, it’s important to ensure the growth and development of the baby and to have that support network around them from parents, it’s also an important opportunity for staff to talk to both parents in a neonatal unit, where obviously there is a very sick child and to prepare them for whatever the outcome is going to be, hopefully positive, and to educate and support them at the time.
Ms Waddoup: Thank you, that’s helpful. Is it right that it wasn’t until the 7 May 2021 iteration of the visiting guidance, the pathway to enhanced visiting guidance that you were speaking about, that, as a general rule, both parents were permitted to be with their babies on the neonatal unit at all times?
Professor Charlotte McArdle: Yes, that would be correct, there was provision for one parent.
Ms Waddoup: Prior to that guidance?
Professor Charlotte McArdle: Yes.
Ms Waddoup: So it wasn’t until May 2021 that, as a general rule, both parents could be there at all times?
Professor Charlotte McArdle: As a general rule but, as I say, at that point local risk assessment was in place, so where that could have been facilitated it would have been facilitated.
Ms Waddoup: So, given what you have said about the importance of family care to these, by definition, very vulnerable babies, and given what we also know about the very severe and distressing impact of restrictions in this distinct context, do you agree, as your Welsh counterpart said she did yesterday, that parents should always have been considered as one unit for the purposes of so-called visitor guidance in this context, ie that both should have been allowed to visit?
Professor Charlotte McArdle: I think that that will be down to individual circumstance. I think it will depend on the mix of – the babies in the neonatal unit, as you said, are very vulnerable, they’re immunosuppressed, immunocompromised, and a risk assessment should be made based on the environment, the babies, the staff and the parents and, where possible, I think of course, yes, both should be accommodated.
At the start of the pandemic, when we did not understand a lot about the virus, we were learning as we went along, that would not have been possible, and I think, on reflection, it would be – which is why we amended the guidance so many times, to support people, to be more flexible. But, as I’ve said previously, these were very difficult decisions that nobody wanted to make, and they were made in the best interest of protecting young babies, families and the public.
Ms Waddoup: Thank you.
Finally this: you’ve spoken about the guidance being kept under continuous review, about Northern Ireland leading the way in this respect, the charity Bliss, which advocates for sick and premature babies, have received reports, including from neonatal staff at one trust in Northern Ireland, of restrictions on wider family access, so by siblings and grandparents, continuing all the way into May 2023 with Covid-19 being given as the justification.
Are you aware of that happening?
Professor Charlotte McArdle: I’m not aware – I’m aware of it happening in line with the guidance during the pandemic of 2020 and up until, as you say, 2021, when we made that change. I left my post in October 2021, so I can’t really comment on what happened after that period.
Ms Waddoup: You’re not able to assist us, if that was happening, in fact, all the way into 2023, why that might have been happening?
Professor Charlotte McArdle: I would only – I would understand from my experience that that would be down to local circumstances in the neonatal unit at the time, potentially the number of cots, the number of staff and the physical environment of the unit.
Ms Waddoup: Thank you, that’s helpful.
Thank you, my Lady.
Lady Hallett: Thank you.
Mr Wilcock?
Questions From Mr Wilcock KC
Mr Wilcock: Professor, I represent Northern Ireland Covid Bereaved Families for Justice, and Mr Scott has helpfully already asked you most of the questions we wished to ask you but her Ladyship has given us permission to ask you two relatively short questions in relation to visiting restrictions.
Before I do that, can I just confirm, you’ve told us, haven’t you, that you’ve had lots of communications about the impact these restrictions were having on people in hospitals and care homes during the course of the pandemic?
Professor Charlotte McArdle: Yes, that’s correct.
Mr Wilcock KC: Just for the record, can I say that I’m not asking you about care homes, for the very simple reason that, as you pointed out earlier, the Inquiry has made clear to us that that would not be within the scope of this module, and it may be that her Ladyship will consider recalling you to give evidence on this topic in a later module on care homes. So I’m really only asking about hospitals at this minute.
Many of the families I represent have reported what they see as inconsistent implementation of the visiting restrictions that were in place in different hospitals at any given time. In that context, can I ask you these questions:
First of all, do you agree that any impression that visiting restrictions were being inconsistently implemented was inevitably confusing and distressing?
Professor Charlotte McArdle: I agree, it was confusing and distressing. But I think it’s a complex area, and I think it’s subject to the virus, the local arrangements, as I’ve described, local transmission, hospital estate, availability of staff, risk assessment of the patients. There are a number of complex factors to be considered and I appreciate that that is not easily understood for people from a non-healthcare background and, in that context, yes, it was somewhat confusing and indeed frustrating for the public.
Mr Wilcock KC: So, given the balance between, we accept, the complexity of the situation you were dealing with and the distress that would be caused to individuals affected, apart from your decision whether or not to answer the complaints you directly received, what was the formal review or complaint mechanism in place for someone directly affected by what they saw as an inconsistent application of the visiting guidance, so that they could register their view and receive from the healthcare system the explanation for what was happening; what was the formal system in place?
Professor Charlotte McArdle: Well, there were two systems in place, firstly through the trust caring for the patient in the normal complaints procedure, contacts through the nurse in charge and on up through their organisation and a formal complaint if necessary, and also the Patient and Client council, as a route to advocate on their behalf and, indeed, the Patient and Client Council did work very closely with us, and I accept your point about care homes, but they were engaged in that process through with other patient association groups, patients who’d come to them, and they were a very good source and, indeed, they carried out a survey for us which was very helpful in feeding back people’s experience of visiting policy.
Mr Wilcock: My Lady, two questions occur to me, they’re very short and they’ve probably already occurred to you; may I ask them?
Lady Hallett: You may, Mr Wilcock.
Mr Wilcock: Thank you.
So there was no individual system, there was no system specific to the pandemic: it’s just what existed before?
Professor Charlotte McArdle: It would have been normal governance processes in the health system.
Mr Wilcock KC: Was that sufficient, given the distress the inconsistent application would cause?
Professor Charlotte McArdle: I would be of the opinion that, if anybody raised a concern with the nurse in charge or with the trust and the organisation, they would have made best efforts to
rectify that situation, as did happen in the number of
cases that I was aware of.
Mr Wilcock: Well, comment may be made on the phrasing of
that answer, but I’ve no further questions.
Thank you, my Lady.
Lady Hallett: Thank you, Mr Wilcock.
Thank you very much Professor McArdle. Those are
the questions we have for you. As Mr Wilcock has
presaged, there is a possibility we will have to ask you to come back, and I’m sorry about the impositions we make but thank you for your help so far.
The Witness: Thank you.
(The witness withdrew)
Lady Hallett: I shall return at 11.35.
(11.21 am)
(A short break)
(11.35 am)
Lady Hallett: Ms Carey.
Ms Carey: Thank you. May I call, please, Professor Susan Hopkins, and may she be sworn.
Professor Susan Hopkins
PROFESSOR SUSAN HOPKINS (affirmed).
Questions From Lead Counsel to the Inquiry for Module 3
Ms Carey: Professor, your full name, please.
Professor Susan Hopkins: My name is Susan Hopkins.
Lead 3: Thank you. You have made a statement to Module 3 dated 31 January with the INQ000410867, and I think you have a copy in front of you.
Professor Susan Hopkins: I do.
Lead 3: Professor, I have a number of topics to deal with you over the course of today. Can I just start, please, with your personal background. Is this right, you are a professor of infectious diseases and health security at University College London?
Professor Susan Hopkins: Correct.
Lead 3: You maintain what is described as an active research portfolio and you continue to work clinically as a consultant at the Royal Free Hospital?
Professor Susan Hopkins: I do.
Lead 3: You, in 2021, in October, became the interim Chief Medical Adviser to UKHSA –
Professor Susan Hopkins: I did.
Lead 3: – UK Health and Safety Agency, but we’re calling it UKHSA for short – and then was formally appointed to the post in June 2022. Prior to joining UKHSA, is this right, you were the deputy director of the National Infection Service at Public Health England from 2018 to 2020?
Professor Susan Hopkins: Correct.
Lead 3: I know there is various other responsibilities you have, but that will probably do for our purposes.
Can I ask you, please, we have heard a little about
the WHO, World Health Organisation, guidelines, and
I just want to establish at the start: is it the
position that the UK is bound to follow WHO guidance
and/or advice?
Professor Susan Hopkins: Absolutely not. I think, first of all, the consensus
that WHO will come to will actually be a consensus
bringing in lots of different countries, and UK will
usually be a member of those advisory groups that help inform WHO advice. It is really important to recognise that each country develops advice for their own situation, but that the evidence base that we are using tends to be very, very similar, and the knowledge that we are sharing, both nationally and internationally, tends to be from the same evidence base.
Lead 3: But the WHO doesn’t mandate action in any given country; is that right?
Professor Susan Hopkins: Correct.
Lead 3: If the WHO advice is not followed, presumably there’s no sanction or anything like that?
Professor Susan Hopkins: Similarly to guidance in this country, likewise.
Lead 3: We’re going to come on to the UK guidance, right.
Can I deal with, firstly, Public Health England and a little bit about their roles and structures, and then do the same with UKHSA just so that we’re clear about the two different bodies. I think, is this right, Public Health England or PHE was set up in 2013 –
Professor Susan Hopkins: Correct.
Lead 3: – with the aim of protecting and improving the nation’s health and wellbeing and reduce health inequalities, and they are to carry out the Secretary of State’s statutory duties and functions to promote the health and wellbeing of the nation?
Professor Susan Hopkins: Correct.
Lead 3: All right. During Covid, did Public Health England have the following two roles: they were to provide scientific advice and guidance to the Chief Medical Officer?
Professor Susan Hopkins: Correct.
Lead 3: Translate SAGE’s advice into guidance for clinical settings and audiences?
Professor Susan Hopkins: To all settings and audiences, not just clinical settings.
Lead 3: Thank you. And they were to undertake specific scientific tasks, for example, testing and contact tracing?
Professor Susan Hopkins: Those were some of the tasks, yes.
Lead 3: Quite, yes, there’s a lot more. Right. Is this the position, that Public Health England acted as advisers to the UK IPC cell?
Professor Susan Hopkins: So UK – PHE and subsequently UKHSA were one of the teams of advisers to the IPC cell. It was all of the public health agencies and the NHS coming together, and therefore had a role in advice, but as did the advice coming from SAGE or the expert groups from SAGE as well, or other advisory groups from government. All of that came together within the IPC cell.
Lead 3: Yes, it wasn’t to the exclusion of the other public health agencies, but –
Professor Susan Hopkins: Absolutely not.
Lead 3: – we’ll look at the IPC cell a little later, and if anyone wishes to know more about PHE’s engagement with other bodies, it is set out in full in the statement and I’m not going to go through it with you now.
UKHSA came on 18 August 2020, the Secretary of State announced the new body. It went through various names, which I won’t trouble you with, but is it right that the name changed to UKHSA on 24 March 2021 and UKHSA formally launched on 1 April that year?
Professor Susan Hopkins: So it formally launched with the chief exec and the chair on 1 April but actually it came into formal action on 1 October of 2021.
Lead 3: Right. Their responsibilities and roles included preventing and anticipating threats to health and help building the nation’s readiness, defences and health security. They had detection functions, an analysis function, a responsive function and to what’s called “lead strong and sustainable global, national, regional and local partnerships designed to save lives [and] protect the nation from public health threats, and reduce inequalities”?
Professor Susan Hopkins: Correct.
Lady Hallett: So what was the real difference between that and Public Health England?
Professor Susan Hopkins: So Public Health England included infectious diseases, external health threats, health improvement through non-communicable diseases, so things like obesity, smoking. Public Health England also held the public health grant that was given to local authorities on behalf of the department. UKHSA does not do non-communicable diseases, health improvement such as obesity, smoking, alcohol, and the lead role for health disparities or health inequalities sits with the department as part of the Office for Health Improvement and Disparities, the other half of what PHE was.
Ms Carey: So in the event of a future pandemic, the burden is going to fall on UKHSA?
Professor Susan Hopkins: So I think the operational burden will fall on UKHSA. It will require the whole of government. And it will also require the department, in its role with health improvement and disparities, to work with us very closely on those elements.
Lead 3: Can I ask you about one other group that we’ve heard of, it’s the Senior Clinicians Group, is that the same thing as the senior clinical leads, do you know?
Professor Susan Hopkins: Well, I presume it is, I’ve seen both used. I think we called it Senior Clinicians Group because it wasn’t necessarily just leads from organisations, and individuals were invited to that to provide views or opinions so that a range of people from a range of organisations across the four nations could come together.
Lead 3: And I think in your statement you say that the Senior Clinicians Group was convened by the Chief Medical Officer’s office, it included the Chief Medical Officer, the deputies, the NHSE medical director – was that Sir Stephen Powis predominantly for the time –
Professor Susan Hopkins: It was, yes.
Lead 3: The NHSE director of emergency planning – who was that, please?
Professor Susan Hopkins: That was Professor Keith Willett.
Lead 3: Thank you. The PHE medical director?
Professor Susan Hopkins: That was Yvonne Doyle.
Lead 3: Thank you. And then there was various – there was a PHE incident director?
Professor Susan Hopkins: That was me and Professor Nick Phin, who – we shared that role for the first nine months of the pandemic.
Lead 3: And the Senior Clinicians Group first met on 16 March 2020, and the membership gradually widened to include the four nations’ chief nursing officers, the CMOs and relevant DCMOs, and with various experts invited to attend individual meetings; is that –
Professor Susan Hopkins: And that was very rapid, I think within a week it was a four nations group.
Lead 3: Professor, can I ask some overview questions at the beginning, predominantly about transmission.
Do you agree that determining the mode or modes of transmission has consequences for the IPC measures that are recommended?
Professor Susan Hopkins: I do agree, and – but I would also highlight that when we determine the mode of transmission and the measures that are going to be done, we use a lot of information that has developed over many years and evidence that’s developed over many years in the literature, for both the mode of transmission but also the evidence for what we will do.
Lead 3: All right. I think are you aware that we are familiar with three main routes relevant to respiratory viruses: the droplet route, the aerosol route – do you agree that “airborne” and “aerosol” are used synonymously?
Professor Susan Hopkins: So I think – can I just put this in a really simple way? I think that in traditional terms there has been dichotomies, simple binary dichotomies that I think the pandemic has shown are not helpful.
Lead 3: Pause there, please, because we’re going to come on to that.
Professor Susan Hopkins: Yes.
Lead 3: I just want you to understand that we’re aware of the three main routes. We’ll look at whether they are good one, bad ones or perhaps ought to change in a moment. But to go back to my question, do you agree that generally “airborne” and “aerosol” are used synonymously?
Professor Susan Hopkins: “Airborne” and “aerosol” are – I don’t know if it’s used synonymously, I think “aerosol” is meant – to me is a component. “Airborne” I think more aligns with respiratory route of transmission.
Lead 3: Well, for these purposes and the Covid-19, yes. And obviously we are familiar with contact, both direct and indirect, or fomite, however you want. So they’re the three routes we are going to be concentrating on.
In your statement, when you refer to droplets, what particle size are you referring to?
Professor Susan Hopkins: So I think if we look at traditional measures of droplets that were used throughout the early days of the pandemic, droplets were regarded to be larger particle sizes that would fall close to where the patient is or where individuals are in the public. I think that there were dichotomies and measures that are taken, and we can discuss those, but I think that, again, this was about simplifying complex matters into terms that people could understand.
Lead 3: So in the vein of simplicity, in your statement, what droplet size are you referring to when you say droplets?
Professor Susan Hopkins: So I think in the statement I think what it’s referring to is that the traditional infection prevention and control measures that were used were droplets – were large particle sizes, usually in the order of multiple microns to hundreds of microns wide.
Lead 3: Can you give us a figure? We’re going to come on and look at the 100 dividing line, but I just want to understand what your position is so that people know at the outset when they see in the statement of Professor Hopkins referring to a droplet, she is talking about a particle size of what?
Professor Susan Hopkins: So I’m afraid I think that I would say that the traditional particle size of droplets and aerosols that have been used throughout the pandemic have been based on evidence that was built on for many years. The aerosol droplet size has traditionally been measured as a sort of 5-micron, things that get into the narrow parts of the lung, but I would also highlight that what we have done and the evidence that has emerged during the pandemic means that that dichotomy is no longer useful or helpful.
Lead 3: I follow that and we will look at it, but I just want to understand some basic parameters at the outset.
So when you are talking about aerosols you are referring to particle sizes of 5 microns or smaller; is that correct?
Professor Susan Hopkins: That’s the traditional –
Lead 3: All right, and can we take it that if it’s above 5 microns, that is potentially you referring to it as a droplet?
Professor Susan Hopkins: Correct.
Lead 3: Right, thank you.
Are you aware that Professor Beggs’ evidence was that particles of 100 microns or larger behave ballistically?
Professor Susan Hopkins: I am aware from –
Lead 3: You’ve read his statement?
Professor Susan Hopkins: I have.
Lead 3: He says that particles of 100 microns or under behave like aerosols, ie they float and travel larger distances?
Professor Susan Hopkins: So I recognise that that is the particle physics that he describes.
Lead 3: Do you agree with that dividing line?
Professor Susan Hopkins: So I agree that, again, the dichotomy of 5 microns versus 100 microns is not helpful and that we should recognise a range of particle sizes that come through. I think that what we’ve seen emerge throughout the pandemic is that these simple dichotomies are not helpful in understanding how transmission occurs and the interventions that could control transmission.
Lead 3: All right. Do you think that the 100-micron dividing line is about right?
Professor Susan Hopkins: I again think we should be thinking about respiratory transmission in general and about the range of particles that people emit through a range of procedures, and that actually what we are seeing from all of the evidence accumulated in the pandemic and a review of a lot of the evidence before, that we should be talking more in general of respiratory transmission and what we can do to reduce it rather than talking about particle size per se.
Lead 3: I follow that, but it would be helpful to have on the record whether you agree the 100-micron dividing line is a sensible one. You may say 110, you may say 90, but give us a ballpark figure.
Professor Susan Hopkins: I mean, you know, I think the problem is that if we develop into a new number as a dividing line then we don’t actually overarchingly think about what are the measures that we can do to reduce respiratory transmission and what are the interventions that are helpful in doing that. So in my way of thinking, what we have is a continuum of particle sizes that go from very small to much larger, some that are visible by the eye and the majority that are not visible by the eye, and things that we can’t measure routinely in practice, and therefore what I think is really important in thinking about that is: what are the interventions that will help us reduce the risk of respiratory transmission in a wide variety of settings to prevent people getting infected.
Lead 3: All right.
Do you think in future there needs to be a more multidisciplinary approach to the formulation of IPC guidance?
Professor Susan Hopkins: So –
Lead 3: Not just clinicians but with physicists, engineers and the like?
Professor Susan Hopkins: I agree that the multidisciplinarity is important. Multidisciplinarity occurs in hospitals with hospital engineers contributing to IPC teams. I think, again, the feeds into the IPC cell who are writing the ultimate guidance for operationalisation in the NHS were multidisciplinary, through the advisory groups, which are multidisciplinary, to government, and specifically the SAGE Environmental Modelling Group which had multidisciplinarity. So I think the feeds in need to be multidiscipline, because they will bring in all of those aspects, and then I think that in developing the guidance that needs to be thought about the range of individuals who will be using that guidance and whether it’s understood by them and can be practised by them.
Lady Hallett: Sorry, just going back to your answer, Professor, how can we reduce the risk of respiratory infection in a wide range of settings, that sounds as if you don’t think there’s any purpose whatsoever in deciding whether it’s aerosol or droplet transmission because circumstances can vary and you ought to be catering for every possibility?
Professor Susan Hopkins: So I think –
Lady Hallett: Every reasonable possibility.
Professor Susan Hopkins: Yeah, I agree. So I think what we’ve learnt through the pandemic is that respiratory transmission occurs in a wide variety of different ways and that when we’re looking at the ways of controlling it we need to look at a wide variety of ways of controlling it: knowing who is infected, knowing the risks of the person who may be about to see somebody who is infected, knowing how we can improve the ventilation in the environments, whether that be through temporary measures or more permanent measures, thinking about how we isolate individuals and quarantine them, having widespread testing available. I’m happy to go into this in more detail. But I think it’s really important to recognise that a golden bullet or a silver bullet won’t work if we just think about it in binary terms, and I’m really keen, coming out of the pandemic, that we understand the multidisciplinarity that’s important but also the multiple different interventions that we need to use at once as complex interventions to reduce infection transmission.
Ms Carey: All understood, Professor, but the bottom line is that early on in the pandemic droplet transmission was deemed to be the main route of transmission.
Professor Susan Hopkins: Agreed.
Lead 3: So it may well be now, in 2024, our understanding has evolved, if not changed, but I do need to deal with what was known back in 2020 and onwards.
So in that vein, as at January 2020, I think it was Public Health England that published the first Covid-19 IPC guidance on 10 January, and that’s paragraph 290(c) if you want to look.
As at 10 January, what was Public Health England’s understanding about the mode or modes of transmission?
Professor Susan Hopkins: Well, the emerging information that was essentially shared with us from WHO was that the main route of transmission was close contact transmission and likely, therefore, to be related to droplet transmission, as that close contact was the predominant route.
Lead 3: Right. So that accorded with Public Health England’s understanding?
Professor Susan Hopkins: So that was the best information. We had no information in country at the time.
Lead 3: Right. Then at that time, in January, we know that shortly after that guidance Covid became an HCID, a high-consequence infectious disease, and that accordingly, therefore, various precautions were needed, including the use of FFP3 respirators when dealing with an HCID; is that correct?
Professor Susan Hopkins: Correct.
Lead 3: It was declassified in due course on 19 March.
I’m not going to ask you about the classification and declassification decisions, but is this the position, that the January 2020 guidance was based on MERS guidance?
Professor Susan Hopkins: So we had established guidance for MERS and for SARS and for diseases that were neither endemic, epidemic or pandemic, so these were all very rare infections that were not circulating in the community and so the only exposures that we would see in the UK were imported cases that were then being managed in healthcare settings, and therefore it was very clear about that what we wanted to do was reduce the risk of any transmission when we are trying to find out more information.
Lead 3: Now, putting aside the fact that MERS was designated as a high-consequence infectious disease, the MERS guidance said that MERS was transmitted by large respiratory droplets, direct or indirect contact, it may also have been detected in blood, faeces and other bodily fluids, and, under certain circumstances, airborne transmission was thought to have occurred, particularly from aerolised respiratory secretions. So a number of routes of transmission for MERS there. And MERS guidance recommended FFP3; is that right?
Professor Susan Hopkins: Correct.
Lead 3: Now, of course it was an HCID as well, so that may add a complication into it. You mentioned, I think, SARS. Do you agree that SARS was transmitted by the airborne and droplet route as well?
Professor Susan Hopkins: So again the majority of evidence from the SARS epidemic from 2003 was that the majority transmission was through droplet and, actually, it was from the SARS epidemic that occurred that the idea of aerosolise – generating procedures actually came to the fore, predominantly because the people who had not – had just worn no face masks or only fluid-resistant surgical masks were transmitted in healthcare, having performed a procedure, an aerosol-generating procedure. If those people were in – doing other forms of healthcare, so normal healthcare routine delivery, without FFP3s, we didn’t see transmissions. Transmissions occurred at those AGP moments.
Lead 3: Right.
Professor Susan Hopkins: So a lot of the evidence that we used for MERS subsequently is based on what we learnt from those hundreds of cases that were then transmitted in other countries during SARS.
Lead 3: Right.
Lady Hallett: You’re like me, you speak very quickly, could you slow down. It’s just that some of the words you’re using, I’m watching the transcription – it’s not easy.
Ms Carey: So you have MERS transmitted via number of routes, you’ve got SARS transmitted via airborne and droplet but the majority is considered to be droplet transmission.
Professor Susan Hopkins: Correct.
Lead 3: You have the WHO considering that Covid was droplet and/or contact transmission but, obviously, there is some reference to airborne, and I’m trying to understand why at the outset airborne seems to have dropped off the radar, if I can put it like that.
Professor Susan Hopkins: Yeah, I think that when we look and when we consider airborne – and we’ve got a number of diseases that we consider airborne – we often think about transmission at long distance, rather than short distance, and what we saw during the early cases that were identified for SARS-CoV-2, as it’s now known, or Covid-19, that the cases that were being identified were very close contact and that those were predominantly within a metre but definitely within 2 metres.
When we have looked at airborne transmission for other infections – and I think the two classic examples that are often used are TB and measles, where actually transmission often occurs in the next door room or in another environment where you can see that it’s transmitting, has to transmit through the air because it’s not been in the same room. And we see that in healthcare as well, particularly for things like TB and measles, where we know that these can jump from room to room and that’s where the traditional component of transmitting through the air for these infections has occurred, whereas for infections that are transmitting to people within the same close confined space has been traditionally used as droplet.
Lead 3: Right, so in relation to Covid, it was considered to be droplet and, therefore, the risk was greater the nearer you were to the infectious person?
Professor Susan Hopkins: Correct.
Lead 3: Can I ask you this: when did Public Health England first consider there was evidence to suggest that Covid-19 was transmitted via the airborne route?
Professor Susan Hopkins: So I think that was an accumulation of evidence over time, I don’t think I could put at a single moment, there’s – this was not just Public Health England’s evidence but other evidence from other teams globally, where we regularly reviewed the evidence. A lot of that evidence came together at advisory groups where Public Health England was one of many providing evidence, either through SAGE subgroups or to NERVTAG, and I would say that by 2021 – we were pretty clear in 2021 that there was some element that was happening through the air but that, even then, there was thought to be lots of other circumstances around why this might happen.
For example, PHE was doing studies all the way along on – in hospital rooms and collecting air samples, and collecting it from the environment, so the touch surfaces that people touched and, in doing those studies, we were reviewing the analysis at each point and, in those, we only found two samples where it was through the air, one in a room that an AGP had been performed and another in a room where lots of people had merged into that room to provide healthcare and there was thought to be disturbance in the air. And those things were all sort of saying: it is definitely possible but it’s not dominating because these are rare events, rather than finding it in the air at all times.
Lead 3: Can you help us with when the UK IPC guidance first mentioned that Covid could be transmitted by the airborne route?
Professor Susan Hopkins: Well, I think it mentioned it for aerosol-generating procedures from the start –
Lead 3: Put those to one side because that’s specific. Just generally.
Professor Susan Hopkins: So I cannot recollect when it particularly mentioned it. I do recall that in UK – PHE, as it was then, brought together independent experts to do a Respiratory Evidence Panel in spring of 2021. In that spring of 2021, along with experts from SAGE Environmental Modelling Group, there was a consensus that there was at least some airborne component, and that that should be started to be reflected in the guidelines. It was probably later than that when –
Lead 3: Yes.
Professor Susan Hopkins: – it was full on that there is clearly airborne. I think that was probably 2022 –
Lead 3: Yeah, we think it’s either the end of 2021 or certainly by January 2022, when there is reference to either wholly or it became predominantly airborne transmission and we’ll look at the terminology later, all right.
So spring 2021, I think you said you, among with other groups, there was a consensus by that stage that it was capable of being transmitted via the airborne route?
Professor Susan Hopkins: There was definitely a consensus that there was some components of transmission where – covering through the airborne route, but that the dominant mode was still close contact through droplet.
Lead 3: Do you agree that where there is an accepted risk of aerosol transmission, FFP3 masks should be recommended?
Professor Susan Hopkins: So I think this is, again, quite a complex area and I think that, if I may, I would say that, when we look at the components of fluid-resistant surgical masks versus FFP3 masks, we look at the evidence that we have available and their effectiveness of use. Both the laboratory evidence, which is one element, but then the evidence in clinical practice.
And where we looked at it, and repeatedly looked at it and are still looking at it, the evidence is weak that they actually – FFP3s protected more than fluid-resistant surgical masks. And the judgements from many of the consensus groups that were being discussed is that there is a whole host of interventions that we needed to do, that FFP3 – and I’m sure you’ve heard mention before of the hierarchy of controls – is at the very bottom of the hierarchy, rather than at the top and that the other elements were more important to be introduced rather than a binary, fluid-resistant surgical mask versus –
Lead 3: Pause there, please, because you’re right: FFP3 is part of the PPE which is at the bottom of the hierarchy of controls. But I just want to come back to what you were saying. I had understood the position that respirators offer a higher degree of protection to those wearing them than those wearing an FRSM mask; do you agree or disagree with that?
Professor Susan Hopkins: So they offer a higher degree of protection that’s been studied in laboratory procedures. When we look at it in clinical trials of various different types, it is very mixed, actually, and, in some studies, there is no difference between them.
Lead 3: If that was the case, why bother putting them on then for AGPs at all?
Professor Susan Hopkins: So again AGPs are pushing out – what was thought and what is considered to be thinking is that AGPs are pushing out a large volume of aerosols and you’re in very close proximity to the individual and that that higher level of protection therefore may help.
When we’re looking at wider airborne, what we’re trying to do is a variety of different components of control and we are looking at all of the different elements of practice to try and reduce any elements of respiratory transmission.
I would say that, if we were to look at the evidence and use and require FFP3s, then, given people are coming to hospital with respiratory viral infections all the time, then we would be asking people to wear them all the time, but we don’t, we ask people to wear them at very specific moments, using all of the other elements as a priority.
Lead 3: Professor, can I just ask you this: I understand that you’re drawing a distinction between the level of protection that is deemed as a result of a lab-based experiment and you said it was different in a clinical context but, if, in reality, in a clinical context it makes no difference, why on earth is there all this controversy about whether you should wear an FRSM and an FFP3 if, in reality, it makes no difference?
Professor Susan Hopkins: Well, I think that we can ask lots of people that question. I think that there’s benefits that are seen where you can eliminate the risk of an infection. However, when you’re in the middle of a pandemic, you can’t eliminate the risk of infection. What we know is that healthcare workers and the community were suffering infection rates at the same, roughly the same rate in the population, because the infection was transmitting around us in all places. Therefore what you’re trying to do in healthcare is really, where the risk is considered the greatest, provide the greatest level of protection to bring that risk down to where the level of protection is for everyone else that is circulating.
Lead 3: Quite. There is a load of infected people in a Covid ward and nurses having to deal with them day in, day out, there’s going to be a higher level of viral load and therefore you want to protect the healthcare workers from contracting Covid, and the way to do that is FFP3?
Professor Susan Hopkins: So that would suggest that all of the transmissions in healthcare occurred from a patient to a nurse. We know that’s not the case. The transmissions were occurring from healthcare worker to healthcare worker, from healthcare worker in the community, and I think that what we – it’s really important to be able to reduce the infection transmission risk to the level that is circulating in – at all levels in the community at the time.
Lead 3: Forget who brings in the infection, whether it’s the healthcare worker, a visitor, when they were allowed, or the patient. If there’s lots of people in a ward with Covid, there’s going to be a higher viral load in the room, is there not?
Professor Susan Hopkins: If they are in the early course of disease, yes.
Lead 3: Yes, quite. In those circumstances, I just want to understand why, if there’s no real difference between the protective measures provided by FFP3 and FRSM, there has been such widespread controversy, why it dominates the IPC guidance if, as you say, there isn’t any real difference in a clinical setting?
Professor Susan Hopkins: Well, I mean, I think that’s one of the challenges that we have and one of the things that we need to learn from post-pandemic and understand better because, actually, there were harms from wearing FFP3s as well: there was blistering on faces, and there were significant harms. I think that, from my point of view, that having these discussions in the middle of a pandemic is very challenging, that we need to have an ongoing discussion and ongoing evidence about whether these masks actually do protect people better in real life settings in wards.
Lead 3: So if there were a pandemic in a year’s time and we’re back in the position we were at the beginning of 2020, what would your recommendation be for healthcare workers on a general ward; what level of mask should they wear?
Professor Susan Hopkins: So, again, I think it would take the level of risk that’s on the ward that’s there, I think the level of ventilation that’s there, and I think that it would also take the views of the healthcare workers and the views of the evidence. I think that it’s really important that, if the evidence was strong that FFP3s really protected people from it, and we saw a definitive reductions in it, it would have been recommended.
Even at the end of the pandemic, this was low quality evidence and it may have reduced infection, and those words are really important, I think, when we’re thinking about future evidence. I think that we need to bring this, actually, as a learning point for the future about how do we develop pandemic guidance before the pandemic occurs, so that people are actually able to input into it and be able to provide that rationale and discussion at that point.
Lead 3: Well, whether it’s right scientifically in a lab or in the clinical context, clearly we need to look at the fact that there were distinctions drawn between FRSM and FFP3.
Can I ask you this: what was the evidence base for deeming Covid to be transmitted via the droplet contact route at the start of the pandemic?
Professor Susan Hopkins: So that was based on the studies that were performed in China and then in other countries about how many people were infected and what the proximity to individuals were that were being infected. It was based in this country when we started to see cases on looking at where the infections occurred and how the infections occurred in the community and in other settings.
It included collecting specimens from the environment where the individuals were with infection, both in the home environment but in the healthcare environment and in other workplaces as well, from samples taken from surfaces, samples taken from air and samples taken from contacts.
Lead 3: Do I take it, therefore, that PHE considered the evidence base sufficiently strong for that to be then the cornerstone of the IPC guidance, it’s droplet and contact mainly?
Professor Susan Hopkins: So I think that the evidence was sufficient for us to have that knowledge, both from our organisation but from all other public health organisations and health organisations and evidence organisations globally.
Lead 3: Does it follow that PHE did not consider there was sufficient evidence of aerosol transmission at the start of the pandemic?
Professor Susan Hopkins: Correct.
Lead 3: If there was no evidence to include it, was there evidence to exclude aerosol transmission at the start of the pandemic?
Professor Susan Hopkins: It’s very difficult to exclude elements.
Lead 3: If it couldn’t be excluded, why wasn’t the guidance based around the fact that, well, we don’t know, so we’re going to take a precautionary approach and recommend IPC guidance that covers droplet, aerosol and contact transmission?
Professor Susan Hopkins: So I think it’s important that IPC guidance is built on the years of evidence that have gone before and the evidence that we’ve had from other respiratory viruses, influenza, MERS, SARS, and the evidence that we’ve used in previous pandemics and in other studies as well. So the evidence is not just based on the precise information we have but multiple documents that people are constantly reviewing, new evidence that’s emerging, and that when we think about the approach to IPC, the aim for infection prevention and control that is taken nationally and internationally is very much about reducing the risk.
It was not possible in a pandemic to eliminate the risk because we were all having events happening to us in the community, on travel to work, in our households, that were causing transmission. So this was not an event where you can eliminate risk in healthcare because the risk will be there outside healthcare as well.
Lead 3: Of course, there’s nothing to stop the healthcare worker getting on the bus and catching it on the way to work and then going into the hospital and infecting other people, I follow that, but why doesn’t the guidance say at the start: we think it’s droplet and contact, we can’t exclude aerosol and, therefore, at the moment, we are recommending the highest level of protection until we know more about the route of transmission?
Professor Susan Hopkins: So my understanding is that the pandemic Covid-19 guidance was based on the pandemic flu guidance, which again is a respiratory virus, and, while there are differences, I think that in Professor Beggs’ report he highlights the similarities as well. I think that the important point here is that IPC guidance is there to facilitate the use of a wide range of interventions to reduce transmission in healthcare, and that is based on the evidence that is available to us at the time or that is evolving.
We would rarely say all of these other things need to be done as a precaution because that is – has risks and benefits and, in medicine, we use risks and benefits in looking at the various different elements at all times. At the very outset, so in March 2020, the risks were that we had never asked people to wear FFP3 masks for prolonged periods. Actually, when we saw that we saw them get ulcers on their faces and having challenges in breathing and challenges in being dehydrated. That was clearly important. The second point was that FFP3s were not routinely used in healthcare, apart from specialist teams, such as teams I’ve worked on, because we manage infectious diseases regularly and, therefore, that healthcare workers weren’t fit tested and therefore could not have been rolled out at speed or at scale.
It would have taken many, many, many months to do that everywhere and, actually, what that may have done is taken the use of FFP3 to places which were considered at lower risk at the time, rather than places that were considered at highest risk.
Lead 3: I follow that but that comes down to whether we’ve got enough FFP3, which –
Professor Susan Hopkins: Not just enough FFP3, enough people to train people, enough people to test people, enough different types of masks and also whether that risk was proportionate to the benefit of doing it. And it was considered, as it is for much IPC, that the risk balance here was in favour of fluid-resistant surgical masks for the majority and FFP3s for those with the highest risk procedures, based on what was known already.
Lead 3: All right. So does it come to this, that at the start of the pandemic, let’s call it March 2020, although there was no evidence to exclude aerosol transmission, one of the reasons or the reasons why it wasn’t recommended is because there’s a comfort issue, a fit-testing issue, it’s not routinely used and there was a need to prioritise it for those areas deemed to be at highest risk?
Professor Susan Hopkins: And the evidence wasn’t there for their use.
Lead 3: Right. Can I ask you this: there are many who think that, rather than being led by the science, it was the lack of FFP3 that drove that early IPC guidance and caused it to not recommend FFP3. What do you say that that, Professor?
Professor Susan Hopkins: I do not recall that that was the decision-making process.
Lead 3: Now, in 2024, what is UKHSA’s position about the routes of transmission for Covid-19?
Professor Susan Hopkins: So I think Covid-19 is a respiratory virus and, as with many other respiratory viruses that there is a route of transmission that is through the air and that is not just big droplets that are close but smaller droplets that may be within 1 to 2 metres, and that there’s some components of those droplets that can stay in the air, of which some of those may be infectious and infect other people.
So a range of droplets – a range of sizes of respiratory particles that comes out of the mouth and a range of those respiratory particles that may be infectious.
Lead 3: Yes, and presumably contact?
Professor Susan Hopkins: And I think that contact is still potentially a role, as for many other viruses. I think that, you know, the idea that we are going to throw hand washing out in managing infection would be a wrong thing to do. Not only does it manage this but it manages many others.
Lead 3: So, although the language would be different now in 2024, in reality, you’re saying all three routes of transmission are considered to be the routes for Covid-19?
Professor Susan Hopkins: I think all three routes but I think it’s important to recognise that the closer you are to somebody and the longer you spend with somebody, especially in a confined space, is most likely to result in transmission.
Lead 3: Okay, now, you’ve alluded a number of times to the fact that you don’t consider the dichotomy between droplet and airborne to be useful any longer and, indeed, you’ve written as such in letters, I think, indeed, one to Mr Jones from CATA.
If that distinction is no longer useful, what does that actually mean now for IPC guidance; what is it going to say, Professor?
Professor Susan Hopkins: Well, I mean, again this is – I can give you my view, I can give you some of the view from my organisation but I think this needs to be a consensus exercise across multiple scientific disciplines to bring this together. I think we need to separate out what we think is the route of transmission and how we think that route of transmission goes to the strength of evidence for the interventions that we need to do to reduce that mode of transmission. If I may, I would say that, in healthcare, one of the biggest things that we can do to reduce respiratory infections that happen every single day and transmission of respiratory infections is to improve the ventilation in healthcare and also consider the – where patients are placed in delivery of healthcare, whether we have enough single rooms, how we can use those rooms effectively.
I then think that we need to think about ensuring that we can test people regularly so we know what they have, and that we think about the individual level risk mitigations that people have, including vaccination. So vaccination very much changes people’s level of risk and their perception of their own level of risk but, of course, many healthcare workers vote with their feet and decide that they no longer need vaccination for Covid or flu, or many other things.
I then think that there’s the final element then – and there’s many other elements I could go into – but the final element is in relation to masks. Personally, I think that we should have an enabling situation with FFP3s, and I call it enabling, rather than mandating, and that means that people are able to judge their own personal level of risk better, that they are able to get fit tested regularly, that there’s a range of masks available to fit them. For example, I know that I only fit one or two masks and lots of other masks don’t work for me. So that means that organisations need to be able to have all of those skills in place in order for people to be able to take their view on the risk and the risk on the procedure that they may be doing.
I then think that in terms of evidence I think what we’ve seen in terms of the evidence that has developed throughout is that FFP3 masks may – and I think all of it says “may”, provide a higher level of protection than fluid-resistant surgical masks. I think we need to look at that better, I think we need to provide and perform studies better in the NHS to allow us to understand this better in between pandemics, so that we are ready for pandemics. Then I think that, when we are considering how we work with healthcare workers to inform their level of risk, that that is very much informed about the environment they’re working in, the organisation they’re working in, and how – that we need all of those things to come together to improve our IPC guidance from where it is now, which is still in the dichotomy mode, into much more a patient level and a healthcare worker level of risk.
Lead 3: Do you think, therefore, that the terminology – the dichotomy, to use your words – needs to be clarified and/or changed?
Professor Susan Hopkins: Yes.
Lead 3: Do you know if there’s any work ongoing – but the WHO to one side – in the UK to try and reach agreement about the terminology that should be used for a respiratory virus?
Professor Susan Hopkins: So we are working within our organisation to develop the better evidence base. I think one of the things that we need to do and which we are doing is working with wide variety of different scientists and looking –
Lady Hallett: Please slow down.
Professor Susan Hopkins: Sorry.
Lady Hallett: It’s an awful lot of substance.
Professor Susan Hopkins: Sorry! We are working with a wide variety of scientists of multiple different disciplines to try and come up with consensus statements, which is one of the things that we tried to do during the pandemic in difficult scenarios because, I think, each organisation may have different views on the practicability of it, the operationalisation of it, the feasibility of delivery, but I believe that we need to have that sort of consensus statement in the UK ready for the next pandemic but also ready for the day-to-day management of respiratory infections in the NHS.
Ms Carey: Is that, do I understand it, work being done within UKHSA?
Professor Susan Hopkins: Within UKHSA but also with our advisory committees, NERVTAG advisory committee for dangerous pathogens, et cetera.
Lead 3: What about across the UK with the public health agencies in the devolved nations, has that work started?
Professor Susan Hopkins: So I think again, within the public health agencies, we have forums within the four public health agencies to come together, we have a health protection committee and a health protection oversight group, we share regularly our views within the public health agencies. I think it’s important that there is a public health agency evidence but I also think it’s important that the operationalisation of this evidence is considered by the NHS.
Lead 3: Her Ladyship heard, I think, in earlier evidence in another module the suggestion that UKHSA appeared reluctant to admit airborne transmission outside of AGPs; do you agree or disagree with that statement?
Professor Susan Hopkins: I think that as it changed over time and as the evidence evolved I think that we did acknowledge this, and actually it’s acknowledged on our website, so – but I think that we were cautious in the early days because of the lack of evidence, and as an organisation we needed to ensure that we were taking views from many different parts of our organisation, with many different views in it, but also the evidence that was collected not just by our scientists but by scientists from other organisations, in delivering statements on government websites.
Lady Hallett: Can I just ask, I don’t know if you read the Module 1 report in which I spoke about groupthink, a lot of the evidence base you’re talking about seems to have come from a group of scientists, you say around the world, and the WHO then uses that expertise. How do you ensure that there isn’t just an element of “Well, we all think this is droplet, the WHO says it’s droplet, so we’re all going to go along that path” and you just end up confirming each other’s – is it called confirmatory bias? I can’t remember what it’s called in scientific terms. But how do you stop that kind of groupthink developing? Whether it’s right or wrong, how do you stop a bunch of scientists all saying basically the same thing, and nobody is saying “But wait a minute, the emperor’s got no clothes”?
Professor Susan Hopkins: So, first of all, I think systematic reviews are one of the big things that we do in medicine and in health delivery in general, and so that’s about independent ex – individuals who have got expertise in gathering together from a wide variety of different sources, weighing up the strength of evidence in it and summarising what it says into whether things are low-quality or high-quality evidence and the range of outcomes that it’s looking at.
Those evidence reviews were often done rapidly in the pandemic because they needed to be done in days or weeks rather than a prolonged period of time. In normal time we would normally take one year to do an evidence review, it would have lots of different meetings, bringing people together to hear a wide range of opinions. And I think it’s really important that a wide range of opinions are viewed and in many cases, in internal conversations or in conversations across organisations, those are. But then at the end of the day we have to reach scientific or health consensus, and that is where everyone’s views are heard, that people are able to provide the evidence for their view, and then where that evidence is not robust that we’re thinking about what science do we need to do next to improve the evidence there in order to base the consensus on the decision of most.
It’s really important though that consensus decisions in health are not one and done. They’re decisions that are – change over time. Which is I think what we saw during Covid-19. Lots of things changed over time.
So new information, new evidence was constantly being reviewed and that allowed people to change opinions, but it doesn’t change fast, because if it would change fast then we wouldn’t have an evidence to do that, but if something big came about then that’s what would happen.
I mean, I can give you the example. For example Mpox, that we dealt with recently, in 2022 started out as a high-consequence infectious disease. We learnt quite rapidly it wasn’t airborne, it was mainly close contact, and therefore we de-escalated the high-consequence infectious disease. And that’s the way that we do it. And it wasn’t – so it’s not about rigidity of thinking, it’s about having an open mind, learning from everything that we see, bringing that together from a wide variety of different angles to then share that in summary.
And I think in – the Environmental Modelling Group did that really well for the environmental stuff, because they brought together such a wide range of opinions, to then summarise where the evidence was and where things were weak or low and where further work needed to be done.
Lady Hallett: Can I just – I’m sorry to interrupt, Ms Carey, can I just challenge.
You say the evidence base in the early days of the pandemic was such that the consensus became that it was droplet and close contact, but did you really have that much evidence in the early days? I mean, so you’re relying on some research carried out in China, and no doubt because you couldn’t really examine that in maybe the ways you’d like to, there may have been problems with that. Other than that you knew about cases which had been exported. But how did you then know that it was close contact? I mean, what was the evidence base at that stage to come to the consensus that it was close contact and droplet?
Professor Susan Hopkins: So, I mean, I can give you lots of different examples on that. So each country as they – as individuals were identified in a country were doing very detailed investigations around cases. So if I can give you the examples here, for the first two cases we identified in late January 2020 we tested lots of people around them to try and understand. We looked at all of the different elements that they had done in their infectious periods, and we called the infectious period two days before they developed symptoms, until they were isolated, and we could only find transmission in those very close contact individuals. We didn’t find transmissions in taxis, we didn’t find transmission in a dorm room, we didn’t find transmission in restaurants.
Equally, what became known as the cluster related to skiing in Brighton, which again had quite a number of cases involved, we did a detailed investigation internally but then also, with all of the other countries where cases were, to look at what their contact was, what their route of transmission was, and there was no infections identified in people who had transient contact. We tested and looked at and followed up for symptoms a variety of different households, a variety of different workplace settings, and that’s where – all of that slowly emerging evidence. That’s just two examples but I could – you know, every single case in those first hundreds had a detailed investigation around it where we were following people on a daily basis to see if they developed any symptoms, and testing them very regularly if they did.
So it was all of that that brought us to the understanding of how it was transmitted, in the best way that we could over time. And we continued to do that.
Lady Hallett: I’m no scientist, as you obviously will know, but there were limitations on the work you carried out. I mean, for example, you said two days – you were tracking them for two days before their symptoms showed. You didn’t know how long people were infectious at that stage, did you?
Professor Susan Hopkins: No, we didn’t, and again that is an approach that we take from any respiratory viruses, where we recognised that people often have very mild symptoms they wouldn’t recognise in the day or two before, and so we always went back two days prior to where those symptoms – what I’m saying is that even in those two days prior we would not find people who they had transmitted to outside people who had been in very close contact with them.
Lady Hallett: Ms Carey.
Ms Carey: One final question because I’d like to move on, Professor. You said a moment ago that you think that PHE were cautious in the early days. There are many in the room who think PHE were not just cautious but slow to accept airborne transmission and in particular the possibility of far-field transmission. Now, some years on, do you agree or disagree that PHE were slow?
Professor Susan Hopkins: I mean, I think developing evidence is slow. Making statements as a national organisation requires evidence. It’s therefore our job to ensure that the statements that we make are fully evidenced, and I think that we tried to do that, and showed a variation in approach in doing that over time, as the evidence consensus built.
Lead 3: Is that a no?
Professor Susan Hopkins: So I think it’s a no.
Lead 3: Can I turn, please, to the UK IPC cell. I think you are aware, we’ve heard quite a lot of evidence in the last few days about the cell and indeed about how the guidelines were drafted, what level of sign-off – my words, not anyone else’s – before ultimate publication, and I just want to be clear what – PHE and in due course UKHSA’s stance on it. Do you agree that it was the IPC cell that drafted the guidance?
Professor Susan Hopkins: Correct.
Lead 3: That it then went to the Senior Clinicians Group?
Professor Susan Hopkins: No.
Lead 3: Right. Help us then, what happens after it’s drafted by the UK IPC cell?
Professor Susan Hopkins: So I think – first of all, it varied at different times during the pandemic. And so that’s really important, because it was not one size fits all. The first IPC guidance that PHE released was emergency guidance.
Lead 3: Yes.
Professor Susan Hopkins: That was done by PHE. The second IPC guidance was guidance that the Deputy Chief Medical Officer, Professor Jonathan Van-Tam, commissioned from NERVTAG members as the pandemic Covid-19 guidance. That was cleared –
Lead 3: Was that the March?
Professor Susan Hopkins: That was the March guidance.
Lead 3: Thank you.
Professor Susan Hopkins: That was cleared by NERVTAG at advisory committees, was reviewed by public health agencies and the NHS, but was essentially signed off by NERVTAG.
Lead 3: And the UK IPC guidance?
Professor Susan Hopkins: The UK IPC guidance, so the UK IPC guidance really became as a routine from thereafter.
Lead 3: So from the April guidance onwards?
Professor Susan Hopkins: April guidance onwards.
Lead 3: All right, fine, okay. Put the pre-UK IPC cell guidance to one side.
Professor Susan Hopkins: Yeah.
Lead 3: It is drafted, I think you agreed, by the UK IPC cell, and then once we’re in April 2020 was it then that it went to the Senior Clinicians Group?
Professor Susan Hopkins: No, it was – it would – so the IPC cell was the operational cell led by the NHS, and this guidance was for the NHS, and had four public health agencies inputting into it as well as the IPC nurses and leaders, doctors from NHS England. The IPC cell guidance was then ratified by the IPC and by their senior responsible officer –
Lead 3: It’s my fault, you’re right, I missed out that stage, you’re right, we heard that it had to be ratified by each of the public health agencies and then went to the Senior Clinicians Group?
Professor Susan Hopkins: The Senior Clinicians Group was not a sign-off group on this. The Senior Clinicians Group had moments where there was differences – sufficient differences of opinion that the chief nursing officers could not come to an agreement on, and then it was escalated to the Senior Clinicians Group.
I can only recall a few occasions that happened. One was the guidance that we released in early April wearing face masks for all, because that was outwith traditional IPC guidance. One was the shortages guidance, which went to the Senior Clinicians Group for discussion. And then at various points the Senior Clinicians Group discussed components of it but never ratified it and it was not ratified by the Senior Clinicians Group.
Lead 3: So to use your words, who had sign-off?
Professor Susan Hopkins: So the sign-off was the IPC cell.
Lead 3: If we have heard evidence that said that PHE signed off, I assume from that answer you would disagree with that?
Professor Susan Hopkins: The IPC cell was there to create the four nations IPC guidance for operationalisation into the NHS. UKHSA published it on behalf of the four nations, and that was really important, and one of our roles was to ensure that it was consistent with other guidance that was on gov.uk and other guidance that was being published, and that it had those same principles in it that were sitting across government as a cross-government document. From our point of view that was not us saying “You are wrong, IPC cell”; if we thought there was some consideration where we thought it needed to be reconsidered, that was asked for the IPC cell to reconsider it and gain consensus.
Lead 3: I see the distinction that is drawn, but we heard yesterday from the Chief Nursing Officer that PHE could effectively say no. I think indeed Dr Ritchie said, I’m paraphrasing, effectively the same thing.
Can I ask you this, because there may be some confusion, it may not help now to go through the rights and wrongs of it. Was it set out anywhere: you draft it, we approve it, you publish it?
Professor Susan Hopkins: We – I mean, you shared an email that – earlier on that you might want to bring up, which I think was – highlighted the sort of sign-off for publishing, but I think it also highlights in that email that you shared, that was from early February 2020, that it went back to the IPC cell if there was disagreement.
I think I just – can I just come as a doctor and as a healthcare professional –
Lead 3: Please do.
Professor Susan Hopkins: – and somebody who has worked in healthcare in this country in lots of different ways.
Firstly, and in Public Health England in lots of different ways over time, there is no situation where Public Health England has had a veto about something that’s happening in the NHS and for any guidance that’s delivered into the NHS. That is not our role, we are advisers, we try to bring together scientific evidence, we try to support organisations in their delivery, but there is literally on nothing that the NHS delivers is – we would have a veto. Quite rightly, because we are one part of it.
Equally, and something that was for a four nations approach, Public Health England is one of four public health bodies, and health and public health is devolved, and there is no occasion that one organisation could therefore overrule other organisations, nor would it be expected.
Equally in things like Senior Clinicians Group or advisory groups, the idea is always to try to drive a scientific or health consensus rather than a single component driving our decisions, because that’s not helpful in delivering a system-level approach to anything in healthcare.
Lead 3: So no one has the right of veto, Public Health England want to ensure there is consistency before it’s published with other agencies, departments who have put out things on the website and the like, but that’s not the same thing as you saying: no, that’s the wrong guidance. Am I understanding that correctly?
Professor Susan Hopkins: Correct.
Lead 3: Does it come to this, then, that once the IPC cell reach a consensus, effectively no one is going to overrule it unless it diverges from something that you see another government agency or department has put out?
Professor Susan Hopkins: Another government agency, another government, another organisation. If it disagreed with SAGE recommendations, for example, it would be reconsidered. Really important that the IPC cell took advice from various subgroups of SAGE, various advisory bodies for SAGE, various government advisory bodies like NERVTAG, and that it was about taking all of that in and translating what was scientific advice to government into an operational guidance that could be delivered in healthcare settings.
Lead 3: So once the UK IPC cell come up with the guidance and it is seen by the public health agencies in the respective four nations, there may be some toing and froing, some changes, once it’s been through that process effectively, therefore, it becomes the guidance unless someone else says something different about it and PHE need to align that with another body or another agency; is that it?
Professor Susan Hopkins: Correct.
Lead 3: Right, now that we’ve got to that position, do you think it would have been helpful for that to have been set out anywhere?
Professor Susan Hopkins: I think clearly with hindsight and with people’s views that can change over time and, you know, it feels like it may be necessary to, but I think it’s really important that this is a well established mechanism for both working together collaboratively as organisations and thinking about things as we go forward.
I would say that we did recognise this to some extent and have developed a memorandum of understanding with the department and NHS England, so I think we need to go wider and think about it as a four nations approach.
Lead 3: Can I turn, please, to some of the guidance, and we’re not going to go through it all, Professor, but you have helpfully in your statement set out different tranches of time when guidance changed and there were perhaps some of the more significant changes. That’s not to belittle the other changes.
January to March 2020, can I ask you this: by the time that Covid-19 was declassified, was there in fact enough FFP3 to supply all healthcare workers in patient-facing roles?
Professor Susan Hopkins: I – my understanding was that there were – I was never told the exact number at the time – I do know the number now in retrospect – but the role I had – I was told at the time and I was told in the guidance that I wrote, was involved in writing, and for the wider mask wearing and FFP3 wearing in the health system, that I shouldn’t be considering guidance for what supply was available, I should be considering guidance –
Lead 3: That’s a different question.
Professor Susan Hopkins: But I think that’s really important because I did not know in March 2020 what the supply of masks were, that was not –
Lead 3: Right.
Professor Susan Hopkins: – part of my role and I think that was not part of – the organisation was not told at any time and I don’t recall anything saying at any time that we must change this guidance because there won’t be enough FFP3 masks.
Lead 3: So you didn’t know then whether there was or wasn’t enough FFP3. I think you said that you now know –
Professor Susan Hopkins: Well –
Lead 3: – there wasn’t?
Professor Susan Hopkins: Well, I know that there were in the order of 26 million FFP3 masks and that there were more being purchased all the time. It then would depend on how much you used an FFP3 mask and whether you used it once per patient, which would mean 30 or 40 masks per day, or even up to 100 if you were doing lots of interactions, versus one per session, which could mean two or three masks a day. So it really would depend on the use of the masks and how they were used.
Lead 3: Can I put it another way you told us in due course there was a need to prioritise which AGPs and areas, hotspots, call it what you will, for FFP3. Doesn’t it follow that they were prioritised for a reason, because there wasn’t enough FFP3 at that time?
Professor Susan Hopkins: I think they were prioritised to prioritise the greatest risk areas that were considered at the time to the protection that was available to protect people.
Lead 3: Can I ask you about the extent to which the lack of supply or supply difficulties affected the early guidance, and can we look on screen, please, at INQ000398198_2. It’s an IPC cell meeting from 4 March. Now, you’re not in the cell, are you, Professor, I want to make that clear. But just to look through you, if I may, can we see the supply chain update as at 4 March?
Can we highlight that, thank you very much.
One of the contributors there is talking about noting that there’s a healthy supply of FFP3 but there is concern around demand for swabbing patients:
“Model being looked at is that 10,000 patients will be swabbed a day from next week …
“[Someone else] noted that supply chain are looking at releasing stock from the pandemic stockpile [but] the model … may not fit with people’s current usage …”
Then this, another contributor:
“… noted that pragmatic approach may differ. For [healthcare workers] looking after patients who are confirmed, they should be the priority for wearing FFP3 rather than those in minimal/short contact.”
I just want to understand what PHE’s position is. Is this pragmatism driving the guidance, rather than the science, if I can put it like that?
Professor Susan Hopkins: Well, I think what you can see also is that – on the line above is that it’s about fit testing so there a degree of how things can be operationalised, I think, which is often called pragmatic in the NHS. So can you actually get out whole new types of masks that all need to be fit tested with different people and how do you prioritise the masks that people are used to wearing and are appropriate for individuals, recognising that there can be ten different FFP3 masks but only one is suitable for an individual, and how those are therefore prioritised for use. And I think again about prioritising it for where the highest risk is, is coming through at this point.
Lead 3: Now, in fairness, as at 4 March it’s still an HCID, so we always need to keep that in mind, which may have slightly altered the way in which people are talking about these things. Come 6 March though, there was updated guidance, and I’m at your paragraph 295 if it helps you, Professor. There was an updated version of IPC guidance and, in short, the guidance advised that FFP3 for use by workers conducting AGPs or in confirmed – sorry, contact with confirmed cases, and FRSMs should be used for close patient contact of a possible case.
So that was where we were just before we went into lockdown, effectively. Is that right, that that stayed the position then for most of 2020?
Professor Susan Hopkins: Well, I think, actually, the position changed in the sense that traditional infection prevention and control is only used for where infections are suspected or confirmed and, actually, what we did was we changed that to all patient contact required fluid-resistant surgical masks or any contact in areas that AGPs were being performed, not necessarily in confirmed, and then, more widely in June, that all staff in hospitals wore fluid-resistant surgical masks to prevent the spread to each other and to patients.
Lead 3: Okay, we’ll come onto that. Can I ask you this, though, 6 March, Covid is still an HCID. Why at that time were you requiring the use of FRSM, unless carrying out an AGP, when it was still classified as an HCID and therefore should have been FFP3 for at least another week?
Professor Susan Hopkins: Well, I think that, again this, was about operational – I’m just reflecting. I’ll just be clear that this is a moment in time, I don’t recall the exact decision-making. As I said, I wasn’t sitting in the IPC cell. The components that I think would have been considered at that time are things like the – whether individuals who were being possible cases, of which that is many individuals coming into hospital with a fever or with a cough or with a wide variety of symptoms, and the probability that they might have Covid-19, at which point, at this stage in early March, it was still relatively low probability.
So if you think that there are many thousands of people coming into the NHS each day through emergency departments and through elective procedures, and that actually it would be still – it was still at this point for this guidance very rare that individuals were being detected as positive. And so it was to allow people to have some level of protection for those cases that might go on to develop or be Covid but recognising that the vast majority were not.
Lead 3: My Lady, can I just deal with the position in early April 2020 and then perhaps break for lunch.
Professor, can I ask you, please, if you turn in your bundle to paragraph 308 and on 2 April, on behalf of the UK IPC cell, PHE published updated Covid-19 guidance and can we look, please, at INQ000348325_0004. This made a number of changes to IPC guidance but it’s the sessional use that I’d like to ask you about, please, Professor.
Now, let me ask you this: was this change to requiring sessional use of PPE driven in reality by lack of PPE or supply chain issues?
Professor Susan Hopkins: It was driven for two reasons. So one is that we had never used PPE in this way in the NHS before. So I’ve been working in the NHS for more than 20 years but, throughout my time here and actually at any time before that, through people who have worked here for longer than me, I have – we have never asked everyone in the NHS to wear some form of PPE all the time. It’s always been a rare event. So maybe one in 20 patients at most that you would see in hospital would you wear personal protective equipment. Therefore, the supply chain was not resilient to this amount of PPE being used.
The trade-off, therefore, in the views of a number of us who were developing this guidance was to provide – use things sessionally, so that they would provide protection for both the wearer and the – to others, was to – was an effective way of mitigating this, which would be extraordinary use if we were taking it on and off for every patient.
That was discussed with Health and Safety Executive, who said that they would expect fluid-resistant surgical masks to last a few hours and FFP3 masks to last at least a day.
Lead 3: I follow that, Professor. Is the short answer: yes, it was driven by –
Professor Susan Hopkins: So it was driven by extraordinary demand in an extraordinary setting, that was never – was not preconceived pre the pandemic to be the way we would use personal protective equipment, so this was an unprecedented piece of guidance.
Lead 3: All right. Aprons and gloves still single use but respirators, surgical masks, eye protection and the long sleeve disposable fluid gowns can be subject to single sessional use in various circumstances. Can I ask you this: how long would a session be?
Professor Susan Hopkins: I mean, it would vary, so we typically in – when we’re doing, say, for example, a ward round, you would typically start your ward round and go to the end but you might take a break if it was particularly long at the time. I suppose a bit like our day here today. It would never last less than two hours a session, at the same time – you would be expected to work at least two hours, and frequently people would be expected to work four hours often without a break or for a very short toilet break if necessary. Hospitals are very busy places and we are required to see a lot of people in a short space of time.
In some parts of the organisation that might be shorter, so if you were doing a very high intensity task that required a lot of concentration, you might break after half an hour or an hour to have a break, but then in other situations, like in some complex surgery, you might keep going for 12 hours.
So I don’t think it was – it was allowing people to break down those sessions into how they worked rather than saying one hour, two hours, three hours. And again that was based on the overarching evidence from HSC that these masks would be able to tolerate this.
Lead 3: Well, it goes on to say, as we can see there on page 5, it’s on our screen:
“While generally considered good practice, there is no evidence to show that discarding disposable respirators, facemasks or eye protection in between … reduces the risk of infection transmission … Indeed, frequent handling of this equipment to discard and replace it could theoretically increase risk of exposure … The rationale for recommending sessional use in certain circumstances is therefore to reduce the risk of inadvertent indirect transmission, as well as to facilitate delivery of efficient clinical care.”
And should it say “and also because we don’t have enough at the moment”?
Professor Susan Hopkins: Well, I don’t think that was the – that was what we based the guidance on. As I said, when I was involved in writing this guidance, this was probably the piece of guidance that I was involved in because it was such a seismic shift from infection control guidance to say “We’ll only use it if somebody has a confirmed infection” to “We’ll use it at every interaction in the NHS that we’re going to do from now on”. And that required – this was one of the pieces of guidance that had robust discussion at the Senior Clinical Group, as you can imagine, because of that seismic shift for the unprecedented moment that we were in.
And I would say that when I was involved in this I was never told “You must do this because there’s not enough PPE”, but it was – it made sense that we tried to deliver it in an effective way.
Again, I’ll come back that if you are delivering care to 30 patients on a ward and you’re going to see each one of them and after each one of them you’ve to take off all of this equipment, wash your hands, then go and find new equipment, that slows you down too, so it was really to think about how we provide care to both protect patients and to protect healthcare workers.
Ms Carey: My Lady, would that be a convenient moment?
Lady Hallett: I’m going to be incredibly generous and give an extra two minutes for our hour of lunch, otherwise I might be facing a rebellion. 1.55.
Ms Carey: Thank you very much.
(12.53 pm)
(The short adjournment)
(1.55 pm)
Lady Hallett: Lesson to self, slowly.
The Witness: Exactly.
Lady Hallett: Ms Carey.
Ms Carey: Thank you, my Lady.
Professor, can we turn to April to November 2020, and that timeframe. Can I – we just looked before lunch at sessional use, that was on 4 April, but a week later there was actually quite a large change, wasn’t there, in relation to the IPC guidance?
Can we put up on screen, please, INQ000408929, and.
Whilst that’s being done, notwithstanding the sessional use guidance the week before, there was now, by 11 April, a shortage of disposable fluid-resistant gowns; is that correct?
Professor Susan Hopkins: Correct.
Lead 3: The recommendation ended up being to prioritise gowns for AGPs, and I want to look at how this came to the IPC cell’s attention. You were involved in the email chain.
Can we go to page 5. Thank you very much.
Here we are, 10 April, an email from you saying:
“1. The supplies of gowns have not arrived into the country as expected.
“2. HSE have assessed gowns that have arrived as not suitable – apparently 23,000 – to confirm that these were not usable in any scenario.
“3. If there are no gowns over the weekend, will HSE support the use of aprons instead of gowns?”
Aprons, my word, are far flimsier, if I can put it like that, than the gowns that you were relying on; is that correct?
Professor Susan Hopkins: Correct.
Lead 3: All right. Do you remember now how many gowns we were expecting to arrive that didn’t turn up?
Professor Susan Hopkins: Well, I think, according to here, it was 23,000. I –
Lead 3: Ah, I thought that was 23,000 had arrived that weren’t suitable?
Professor Susan Hopkins: Oh, right, okay, sorry, I don’t know how many gowns had not arrived.
Lead 3: All right.
Professor Susan Hopkins: I will recall that around this time Keith Willett, who led the operational response in NHS England, called me and said “We need help and support from you to try to develop risk mitigation if these things don’t arrive.”
I will also recall that many countries were not exporting even things that were paid for because they were holding them for their own, and we were not a make country for equipment at this point, it happened later, and therefore we were at the behest of what was managing to get into the country.
Lead 3: I follow that.
Lady Hallett: By a “make country”, you mean what, a country that manufactured their own?
Professor Susan Hopkins: A country that manufactures their own.
Ms Carey: Although can we just look now, please, at page 4, as we go backwards, as it were, through the email. You receive an email saying:
“1. I’ve had an update … a consignment has arrived …
“2. HSE has not assessed any gowns as unsuitable.”
So querying what was said in the earlier email.
“We have spoken to Burberry about the gowns they are proposing to produce and are waiting for tests …
“3. The coveralls piece in a separate chain is relevant here, these are more likely to be appropriate than aprons particularly if AGPs are involved. If you are able to identify what communication was received from HSE and when on those we can look to join the two things together.”
Can you just – where are we going with this email chain?
Professor Susan Hopkins: So I think this was NHS England saying to me that we’re short of stuff.
Lead 3: Yes.
Professor Susan Hopkins: Me asking for support from HSE to identify what is the best alternatives, as the incident directors are co-ordinating components of it. Subsequently there were worries about lots of different supplies happening over this weekend and I was subsequently asked to lead a piece of work, working with HSE, NHS England to develop shortages guidance.
Lead 3: Fine. And if we go up to the next one, you’re basically trying to understand what HSE’s position is going to be, is that it, in the event that we run out of the fluid-resistant gowns and potentially have to consider reverting to aprons, hence why you say there:
“… if there are no gowns or coveralls, what is your view … of aprons.”
And can I ask you this, Professor, are we literally talking about we’ve got a day’s supply left? Do you know how low supplies were?
Professor Susan Hopkins: So, again, this was through verbal communications that we were down to days, and if – you know, if supplies didn’t come into country on Wednesday, it would be – there would be no supply to deliver at the weekend. So at that point in time it was – they were managing supplies into country and then delivering out to not just only hospitals but also care homes and primary care services on a day-to-day basis, depending on demand and supply.
Lead 3: It was clearly – if we put that down and just look up page 3, middle of the top of the page, you’re saying:
“I need an answer … today in case there are no gowns.
“Keith is on the email trail.”
It was pretty urgent, wasn’t it, that this got resolved?
Professor Susan Hopkins: It felt pretty urgent at the time.
Lead 3: If we go then to page 2 in the email, you are engaged then in, I think, some email traffic with the HSE. If we look at the bottom email, they say to you:
“Susan,
“We have received some testing data on 200k coveralls at the Daventry … although a view on this won’t be available today, hopefully tomorrow. Emily Lawson …”
Is she at the DHSC?
Professor Susan Hopkins: So Emily Lawson, she had a variety of roles, she was at Cabinet Office, DHSC and NHS England, and she led a lot of supply chain co-ordination across those multiple organisations. I can’t say what her particular role was at that –
Lead 3: Fine, don’t worry, we can find it out.
And:
“On aprons all we can offer today is the gowns v aprons document published on our website earlier … Any further more specific answer would be dependent on the whole proposed ensemble ie the type of apron, single use or resuable and what was worn underneath and again we would not be able to turn around an answer on that this evening. If there is a more specific …”
Questions effectively.
Can I just ask you this: did you consider that the HSE were being helpful here in their response?
Professor Susan Hopkins: I think HSE were considering all of the components that they had available to them. I think that – I think that the HSE very much go by the regulations and the things that they’ve laid down. That often doesn’t work in practice –
Lead 3: That’s what I was going to ask you. I’m not suggesting this was a deliberate attempt by them to be difficult, but if it is urgent, as we are going to run out in a day or days, did you think they got the urgency?
Professor Susan Hopkins: I think they got the urgency but I think they were staying within their lane and saying what was approved. And, you know, I think this, again, is about how organisations come together in emergency response, bringing their own specific expertise but also recognising the challenges of the system.
Lead 3: All right. And if we just go back to the top of page 2 Mr Willett from NHSE says – thanks HSE for their input. He says:
“… we are … not going to [get] … DHSC supply chain sufficient gowns this weekend to equip staff in multiple hospitals …
“We now need to offer an agreed position to all NHS organisations and staff the default PPE that should be adopted to substitute for a gown …”
And then he sets that out.
“Is it to follow the WHO guidance on this to default to a single disposable apron as per the Standard Infection Control Precautions?
“I’m sorry to press but I currently have staff across the NHS caring for 17,000 confirmed COVID 19 positive patients.”
How did this play out, Professor? What was the upshot of this exchange?
Professor Susan Hopkins: So the upshot of this exchange was that myself, other individuals in PHE, individuals in NHS England and across the public health agencies worked with HSE to develop, first of all, a – what we would call a straw man. So using the guidance that was available internationally for shortages, which was available from CDC, which was also available from World Health Organisation, and evidence that we were able to glean from the literature, which was pretty scanty I would say at this point, to come up with a proposal for how we would manage to use, reuse or wear for a prolonged period elements of the personal protective equipment.
That was subsequently discussed again because it was out of standard practice with the senior clinicians and I would say that there was considerable amount of differing views at that point that were expressed, and I think, if I recall, Ruth May may have even mentioned it in her statement. But this was an emergency situation where, as a last resort, we wanted to ensure that the elements of protection that we could provide were the best we could do within the confines of the situation.
Lead 3: Right. And I think the position was so out of the ordinary that the Secretary of State was informed about this shortage, and indeed is it right that he effectively approved the guidance that came out on 17 April, I think it was?
Professor Susan Hopkins: The guidance was shared across all of the organisations that I’ve mentioned. It was agreed at the Senior Clinicians Group that this was in extremis guidance but we should release it rather than doing it for each individual item as they came along, and that it was so unusual a situation that the Secretary of State was informed and asked for his approval. But I think I would say that the Secretary of State is not going to disagree with the consensus health view at that time, he was there to really purvey that political viewpoint –
Lead 3: I wasn’t suggesting that he was going to veto this, but you don’t normally run all the guidance past the Secretary of State, do you?
Professor Susan Hopkins: No, it was because it was so exceptional and out of kilter.
Lead 3: And what happened, did we run out of gowns that weekend; do you know?
Professor Susan Hopkins: Well, I think what we know from the stories with my colleagues and peers and also from many other stories that we’ve heard throughout is that there was moments where people did not have the right thing at the right time. I think that there was never zero in the stocks, there was never zero going out, but there were moments that the right place did not quite have the right amount of equipment for them at that moment.
Lead 3: So –
Professor Susan Hopkins: And that improved quite rapidly over the course of the next six weeks.
Lady Hallett: Was the reason why we ran out of things in the right place at the right time, however we’re going to describe it, because we hadn’t got sufficiently large stockpiles?
Professor Susan Hopkins: So I think – well, I think one is that the stockpiles were insufficient for the scale of the pandemic and the scale of the personal protective equipment that was being used. The second was that some elements in the stockpile had been there for many years and, whilst they had been validated that they were still fit for purpose, when people used them they fell apart. So whilst they may have had the right filtration efficiency, the plastic had denatured, so some of the stuff in the stockpile just was not fit.
And the final bit I think is that the unprecedented delivery of PPE to all of the care homes, which was not considered pre-pandemic, all of the GP surgeries, as well as the hospitals, had not been considered previously, in my understanding, and so the stockpile was there predominantly for hospital use but, given what we understood about this virus, we were trying to ensure that there was wider protection in the health and care system.
Ms Carey: The guidance, I think, was published on 17 April. I don’t need to take you to it, but can I ask, please, that we put on screen INQ000106357. My Lady, this is a central alerting – a CAS document.
It doesn’t come from you, I appreciate, Professor, but effectively it’s how the 17 April guidance was sent out, as I understand it, across NHS England and, if you note, my Lady, it was originally issued at 17 April, it was a Friday, at 16.43 in the afternoon and I raise it because, of course, you’ve heard evidence about things coming out late on a Friday.
If you turn over – sorry, go to page 2, you can see this alert aims to highlight the sessional use and reuse of personal protective equipment and there are severe shortages of supplies. The considerations are to ensure that health and care workers are appropriately protected from Covid, where items of PPE are unavailable. The reuse of PPE should be implemented until confirmation of adequate resupply is in place.
I’m using this as a vehicle, Professor, to ask you: do you think that when there were changes to the guidance like this at short notice, it caused a degree of fear and upset amongst the healthcare workers when they were told they had to do something different this time?
Professor Susan Hopkins: I completely agree and I think that, you know, the emergency release of these types of guidance on a Friday evening was something that really happened at those early months, when things were rapidly developing. Later, and I couldn’t give you the exact date, there was an agreement that the guidance could not be released after Thursday and, ideally, on a Monday or Tuesday, where people had plenty of time to do it.
I would highlight this was emergency release, we were worried that people were not going to have supply at the weekend and I would particularly highlight that the big thing we were talking about here was sessional use first and reuse second. Again, having already talked about sessional use but having heard from people in organisations who were calling me saying that people still don’t feel comfortable with sessional use, so it was really to try and prioritise sessional but, if we needed to, to reuse in an emergency situation to ensure that there was a level of protection.
Lead 3: Do I take it from everything that you’ve said that you do agree that this change to IPC guidance was driven purely by a lack of stock?
Professor Susan Hopkins: I – yes.
Lead 3: Okay.
Professor Susan Hopkins: Both a lack of stock now but also potential lacks of stock in coming weeks.
Lead 3: All right.
I want to move on to December 2020 but can I just help you to this extent. On 4 June, EMG produced a paper to SAGE saying droplet and indirect are still the most important routes of transmission; there was weak evidence in June of aerosol transmission.
Can I turn now to December 2020 and, if it helps you, Professor, paragraph 325 in your statement. We are now in the Alpha variant era, and I think you say that Alpha variant was more transmissible than the Wuhan variant, or call it what you will, from March 2020; is that the position?
Professor Susan Hopkins: Yes. So, to be clear, the Alpha variant was the first major variant that we were able to detect and study. We believe, looking back, there were other variants previous to that but that was when genomic sequencing was at sufficient level that we could really understand this, and that we had sufficient testing and surveillance that was allowing us to make an improved understanding about what the virus was doing, and what we could see was that the transmission rate was increased.
The thought – there was two reasons considered for that and, over time, that developed better. The first was that people were getting infected with a shorter incubation period or faster, so, from one person to the next, it was jumping really fast; and the second was that the number of people who were infected by a single individual seemed to be greater than it was on the earlier stages.
Lead 3: Against that background, I think it’s right that the IPC cell were asked to review the IPC guidance and effectively said no change to the IPC guidance but can I ask you please about some of the minutes and can we put up on screen please INQ000398244.
This is the IPC cell minutes for 22 December 2020 and I would like, please, to go to page 3 of that document.
My Lady, we looked at this briefly with Dr Ritchie but can we go to the middle of the page with the entry saying “CB”. CB was a representative of Public Health England?
Professor Susan Hopkins: Correct.
Lead 3: In that meeting, he said that:
“Our understanding [ie PHE’s understanding] of aerosol transmission has changed. A precautionary approach to move to FFP3 masks whilst we are awaiting evidence should be advised.”
What was the change?
Professor Susan Hopkins: Well, what was – so, first of all, I’d say that the guidance at the time had FFP3 masks in AGP hotspots, et cetera. We – through our regular contact with our peers in hospitals and through people working in hospitals, and including CB, I think, at this time, we were noting that some hospitals were going further and they were making the decision based on transmission that was happening in their hospital or ventilation that they were seeing in their hospital to moving to more wide use of FFP3 for patients with Covid. I would say that, at this point, there were no shortages and there were plenty of supply of all types of masks. So there was clearly an ability to go more widely, if it was considered that that was the approach.
Lead 3: Pause there. I’m not suggesting that it’s anything to do with supply at the moment. I just want to know what it was that led to the phrase going in there “our understanding”; what in PHE’s understanding had changed?
Professor Susan Hopkins: Well, I think, you know, you’ve mentioned the EMG evidence of low risk, we had seen that there were outbreaks occurring in hospitals, that those outbreaks were bigger than what we had seen in the wave 1 outbreaks in particular, and that there was some increasing understanding that aerosol was a mode of transmission.
Lead 3: When it says “a precautionary approach to move to FFP3 whilst we are awaiting evidence should be advised”, what evidence was it that you were waiting for?
Professor Susan Hopkins: Well, I think that, at the time, we were worried more about was this something that was just happening in some places, rather than more generally and was this evidence that FFP3s were going to be more effective or less effective for this. I would say that I don’t know exactly what CB was thinking in this meeting and I don’t know what it was.
I think that there had – there was an increasing view that, where people were risk assessing that there was a risk assessment locally in hospitals, that they should be at least enabled to wear FFP3 masks, because they were available and that individual hospital situations and circumstances differed very greatly across the country, and so I think this was part of that approach.
Lead 3: I want to be clear whether PHE was recommending a precautionary approach at this stage because Alpha was more transmissible or because the evidence have aerosol transmission had changed or both?
Professor Susan Hopkins: I think it was probably both, though it’s – only one thing is mentioned here.
Lead 3: Yes.
Professor Susan Hopkins: But my recollection is that we were – PHE through its evidence of and the study Alpha, had recognised its increasing transmissibility. I think that was the first thing that we recognised about it. We did not know and understand why that increasing transmissibility was there at this time but, obviously, alongside the emerging evidence on at least some aerosol transmission, this was one of the components that was being discussed.
Lead 3: Can I ask you this, why was PHE recommending a precautionary approach at this stage of the pandemic, when it didn’t do so in March 2020?
Professor Susan Hopkins: So I think this was an individual recommending it. I think it’s really important that individuals come to meetings and raise a wide variety of components. I think there was a view and remains a view in PHE and UKHSA that there needs to be a more enabling approach to use of FFP3 where the risk to patients or individuals healthcare workers is warranted, and I think this was part of that developing evidence.
Lead 3: Okay, can I ask you this then: why were you recommending FFP3 when, as you told us earlier, there was only weak evidence that FFP3 was more protective than a mask?
Professor Susan Hopkins: Well, I think you can see here in this – this is again the discussion at the IPC cell, as one part of the discussion to bring it to discuss and to bring to the consensus view of the IPC cell.
I have discussed, after this, with various members of the team and there were various discussions within Public Health England at the time and, actually, one of the discussions was did we have strong enough evidence that we would say that this must be done and, actually, at the time, though evidence was very weak, there were lots of discussions with the environmental modelling group about the other elements of control that were in place, and that FFP3 was only one, and I think the general view at this time and the consensus statement that came through after this, from both the IPC cell, which PHE contributed to, was that FFP3s were only one measure and that the overarching components of the virus had not changed and, therefore, that what we would do in PHE was look at the evidence in a way, which is what we subsequently did by convening a Respiratory Evidence Panel.
Lady Hallett: Could you ask your question again?
Ms Carey: Yes, certainly.
I understand that but you told us this morning that the evidence was weak that FFP3s protected more than FRSMs and, I’ll be frank with you, it’s caused a great degree of consternation amongst many in this room. If that position is right, what you set out this morning, why here is a representative of PHE recommending FFP3?
Professor Susan Hopkins: Well, because I think that the appropriate thing is to discuss things in IPC cells, where it is discussed and then agreed as a consensus opinion. Again, this is the sort of contrary to groupthink, where everyone comes in and says the same thing. It’s coming in with different opinions and views –
Lead 3: I’m going to interrupt you there; that’s not an answer to the question I asked. If you genuinely think that FFP3 is less protective, why on earth is your representative in December recommending it on a precautionary basis?
Professor Susan Hopkins: So I’ve never said it’s less protective. I said it may be more –
Lead 3: You said the evidence is weak that actually FFP3 is protective more than fluid-resistant masks and goes on to explain that lab conditions were not the same as the clinical context.
Professor Susan Hopkins: Correct, but that is not the same as that they are less protective.
Lead 3: All right. Well, given your answer this morning, can you see a disconnect between what you said to us and what is being said here in December 2020?
Professor Susan Hopkins: And I think again what I would highlight from this is this is views being expressed to bring consensus to discussion. It is also views that were then brought back into PHE to discuss further, and the decision at that was to go and further review the evidence to decide whether the evidence was strong enough to do that.
Lead 3: I think you have seen Professor Beggs’ statement and he said at paragraph 211, for anyone who is following it:
“Historically medical professionals have placed much emphasis on randomised control trials and effectively have tended to downplay evidence from observational laboratory and modelling studies.”
What do you say to his observation about that?
Professor Susan Hopkins: So I would say that medical evidence is graded and that it comes in a variety of ways, that laboratory studies are one element but, for example, when we take drugs, for every hundred drugs that are developed, only five get licensed because what happens in the laboratory doesn’t work in practice. And so we have a gradation of evidence, the evidence is not just randomised control trials, it’s also case theories, other studies that are performed and, from the point of view of looking at respiratory evidence, we looked at all of the different types of evidence that were there and available.
Lead 3: So do you agree or disagree with him?
Professor Susan Hopkins: So I agree that the randomised control trials – actually, meta analysis of randomised control trials is the highest evidence; I disagree that we only look at one type of evidence.
Lead 3: Are you expecting there to be randomised control trials in relation to whether FFP3 is better than FFP2 when it comes to protection against Covid?
Professor Susan Hopkins: So I think that those trials have not been conducted but there have been trials looking at FFP3s versus fluid-resistant surgical masks in Covid and also prior to Covid.
Lead 3: Is your view that evidence on the effectiveness of masks will continue to be weak if there are no positive results from randomised control trials?
Professor Susan Hopkins: So in the terms of how we grade our evidence that’s true but I think that what that means is that we need to do those trials properly to allow us to look at this, not just for Covid but for other respiratory viruses that circulate because, otherwise, we are not advancing knowledge in the way that science advances knowledge.
Lead 3: Do you agree with the advice being tendered by your colleague there?
Professor Susan Hopkins: So I think that my view at the time, and my view remains now, is that the FFP3s were one part of the control measures that, in this scenario, that it was a reasonable thing to propose but it was not the only view that was expressed, either in PHE or in other organisations.
Lead 3: All right can we look please at the following day’s IPC cell minutes, INQ000398242, and can we go to – I think it’s page 2. Again, Professor, not a minute that you were in but, if we look on page 2, essentially what happened there was, following what had been said the day before, all of the four nations were asked for their position to try and reach the consensus, as you told us. I’m not going to go through Scotland Wales and Northern Ireland but that’s the thread.
Can we go to page 3 please, at the top of the page, there was an agreement with a consensus. There are concerns from one of the participants that the use of FFP3 – due to availability and capacity for fit testing. There is evidence that other IPC measures are not being adhered to:
“What is the process if PHE make a different statement to the IPC cell?”
We assume that’s a reference to the fact that the day before they were recommending the precautionary approach and yet that wasn’t meeting favour with the rest of the cell. Dr Ritchie said the IPC cell was requested to provide a position statement on whether any change is required to IPC PPE guidance, in relation to what became, I think it was, Alpha:
“If higher levels of PPE of Parliament recommended at the time, in the absence of evidence, it would be difficult to go back on this. We need to look more closely at healthcare worker to healthcare worker transmission.”
Then one of the contributors asked if PHE had evidence of increased aerosol transmission, and the person said:
“There may be an increased risk of aerosol transmission following evidence re singing, shouting and enclosed spaces.”
We’ve heard from Dr Beggs about a particular choral study/trial – I’m sure the Skagit, I think that’s how you pronounce it – which spoke about these things. Then, effectively, the meeting came to a close and the paper was put forward, I think, to the Senior Clinicians Group.
Do you or were you informed there was any resistance to PHE’s proposal by other cell members?
Professor Susan Hopkins: So I don’t recall that. I do know that the PHE staff came back and it was discussed within PHE. I know that there were further discussions in PHE about what the evidence base looked like, and rapid evidence reviews that had already been conducted were looked at and reviewed again, with a variety of different senior medical advisers, senior clinicians and scientists in PHE at the time.
I know that we subsequently brought this and wider face masks, face coverings and FFP3 discussions back to senior clinicians groups, to have further discussion, again, because this was about making sure that we all understood what the evidence was that was available at the time and thought about the decisions in healthcare, in hospitals, in care homes and in the wider system.
Lead 3: Did you ever see the minutes that we’ve now got?
Professor Susan Hopkins: I did not see them until I was displayed them for the Inquiry.
Lead 3: For the Inquiry, all right. Did anyone ever say to you there was a concern that if higher levels of PPE were recommended at this time, in the absence of evidence, it would be difficult to go back on this?
Professor Susan Hopkins: I don’t recall that.
Lead 3: I mean, do you read that as them wanting to save face, in short?
Professor Susan Hopkins: It could be read as that but I think that we also need to recognise that – you know, that the components here were worried more, I think, about how they were going to explain the decision. In what I can see from reading this, not having been in the meeting, I think that, you know, the really important component moving forward, for us as an organisation, is to provide the best evidence and the best recommendations we can to enable the NHS to do their work.
Lead 3: We know, in due course, that the IPC guidance didn’t change in light of the Alpha variant but the reference to PHE having increased understanding of aerosol transmission, it appears to have got lost; would you agree with that?
Professor Susan Hopkins: Well, I think it was increasing, I think that when we released the Respiratory Evidence Panel review, which I believe was in May but, of course, would have been discussed internally and seen drafts of it before that, it was highlighted that there was an increasing understanding from aerosol transmission. So I think it was gradually coming through, slowly but surely, and I think that the important point was that we were looking not just at how it was transmitted but the overall mitigations to prevent transmission.
Lead 3: Can I ask you this: you can’t speak for the member, obviously, in the cell, but why didn’t PHE stand their ground and say “No, we’ve now got some evidence of aerosol transmission, the IPC guidance needs to change and offer a higher degree of protection”?
Professor Susan Hopkins: I’m afraid I don’t know that.
Lead 3: Can you answer why PHE didn’t say, “Well, in addition this variant’s more transmissible, so, in fact, there’s two good reasons now for having a higher level of PPE”?
Professor Susan Hopkins: I don’t know. But I would have expected that the start of the meeting, which I think the piece that you showed us the day before talked about PHE providing a situational update, which is what would have usually happened. I don’t know actually what was said.
Lead 3: It may be thought by many that PHE were right here about aerosol transmission but ought to have stood their ground and fought their corner. Do you think this is an example perhaps of groupthink?
Professor Susan Hopkins: Well, I think the fact that PHE was giving and airing a different view is an example of not being involved in groupthink. That I think, you know, it does come back to scientific consensus about the evidence that’s there, the evidence that’s available, and the majority view and how that’s done. I don’t think this was the only group, I would highlight, so there was – this group would have been taking input from the hospital onset Covid-19 group, the Environmental Modelling Group, SAGE, NERVTAG , as I’ve said, and would have had the option, and did on this occasion, and, as I recall, discussed it at the Senior Clinicians Group, which would have had the four nations’ CMOs, chief nursing officers and also a wide variety of senior medical and health individuals.
So I think it would have been challenged and questioned and about whether this was the right thing to do at the time.
Lead 3: Do you think PHE capitulated too easily here and should have said “No, come on, this is a really serious development, it can affect our IPC measures, we need to reconsider the evidence about aerosol transmission now by December 2020”?
Professor Susan Hopkins: So with the risk of sounding like this is going back into, you know, a long time ago, I think this was a really challenging moment in the pandemic. We were almost at Christmas Eve and you will recall the societal components that were happening at the same time. This came back and was discussed again in the – in January, in great detail, and kept getting discussed, and we kept reviewing the evidence.
I think the – again coming back to how organisations work in pandemics, I think it’s really important that people put forward their views, that they have the evidence, that they get a wide variety of views to bring this forward, and I think that, you know, given the moment in the pandemic that the IPC consensus and the consensus from other groups that were sought at the time has to be considered the moment – that moment, that view at that point in time.
Lead 3: Do you think, upon reflection, the IPC cell were asking the wrong question and, rather than concentrating on the transmissibility of the variant, they should have gone back and considered the route of transmission at the outset?
Professor Susan Hopkins: I think they did consider that the route of transmission was in a similar way to previous and that’s probably true actually, and I don’t think we’ve got evidence that the route of transmission for Covid-19/SARS-CoV-2 has changed at any point.
But there is evidence that it became more transmissible and invaded the immune system more progressively over time. I think, again, this is really difficult to look at this moment in time at this point here. I do know that there was a lot of robust discussion happening and a lot of robust discussion continued to happen about what were the right interventions to reduce respiratory transmission in hospitals, in communities, in schools, in workplaces, and PHE was involved in many of those different discussions with many different actors across the time period.
Lead 3: Okay, that can come down, thank you.
Can I move on in time, please, to February 2021, and you were aware, I think, Professor, that the Royal College of Nursing commissioned an independent review of IPC measures and we’re going to hear from various parties over the next few weeks dealing with it but, in short, did the review from the RCN amount to they wanted nurses to be assured that face masks were effective and that quality of ventilation would be investigated.
Professor Susan Hopkins: I believe so. This is the HSSIB report; is that correct?
Lead 3: No, this is the RCN’s independent review conducted by Professor Dinah Gould, which is a slightly different matter, and it’s at paragraph 330, if it helps you, in your witness statement. I’m sorry I jumped –
Professor Susan Hopkins: Apologies.
Lead 3: No, it’s all right. Take a moment. 330, RCN published their independent review.
(Pause)
Lead 3: I think it led, correct me if I’m wrong, that there was a Respiratory Evidence Panel convened by PHE. Have I got that right?
Professor Susan Hopkins: That’s correct.
Lead 3: Was that result of the RCN’s independent review?
Professor Susan Hopkins: No.
Lead 3: Okay. Pause there then, please. In relation to the RCN independent review, in short they wanted the assurance about the protection provided by face mask and the quality of ventilation, and I just want to ask you about ventilation. We haven’t dealt with that very much but do you think that issues around ventilation got lost by the concentration on this being a droplet contact borne virus, as opposed to also having the route of aerosol transmission?
Professor Susan Hopkins: I think perhaps it did but I also believe that – well, when I work in hospitals, the hospital teams work very closely with the engineering departments who understand the air changes that happen in different parts of the organisation, and ventilation is considered an important part of the hospital infrastructure and delivery, and I think – sometimes I think that what got lost is that we were too involved in looking at, you know, whether it was fluid-resistant surgical masks, whether it was FFP3s, whether it was droplet or versus aerosol, rather than going to the principles of things that we know are really helpful to reduce infection in healthcare settings, not just Covid-19 but a wide variety of other bacteria and viruses.
And I think that, actually, you know, trying to – some of the components here is about trying to get us to understand these things better and to ensure that the multidisciplinary way of working is bringing all that together to reduce infection.
Lead 3: So help us, please, then, why was it that the Respiratory Evidence Panel were commissioned or convened to look at the role of face coverings in – I think it was May – or before May but it was published in May?
Professor Susan Hopkins: So actually this came from some of the discussions we’ve just had about December 2020.
Lead 3: Tell us about that, please?
Professor Susan Hopkins: And so, essentially, we brought a variety of papers looking at the rapid evidence reviews that PHE were doing at the time and the role of face masks and face coverings in a wide variety of settings because recognising that Public Health England’s role, the NHS was well known component but we were also talking about schools and workplaces, supermarkets, the environment and the general public, and we were trying to ensure that the evidence was looked at across all of those settings, rather than just one area.
And in January 2021 at the discussions at the Senior Clinicians Group we asked whether the Senior Clinicians Group would endorse us setting up a Respiratory Evidence Panel, an independent panel where we would invite a range of experts to come and give their views and to allow us to move the debate forward, if you like, so that it was not seen as PHE as an organisation asking for things to happen. But we were really trying to bring together a group of experts.
1 April was when it started and it reported in May so I think it’s just important to get the timeline. So these things take time to get the people in, to ask them whether they’re willing to give up their time and then to provide the evidence.
Lead 3: Can we look at the findings of the REP and it might be easiest to call up on screen your statement. Could we have INQ000410867_0134 and paragraph 335 in your statement, Professor.
Thank you. Could we highlight paragraph 335:
“At the meeting on 17 May [2021] the REP assessed review-level evidence to consider the potential effectiveness of face masks … The findings presented included:
“a. Airborne transmission beyond two metres was possible and contributory factors include poorly ventilated indoor settings, prolonged exposure and activities that may generate more aerosols.
“b. Certain [variants of concern] are likely to have increased transmissibility …
“c. Evidence to date suggested modes of transmission of [variants] had not changed so it was likely that the IPC measures should be adequate.
“d. The evidence suggests all types of face mask are, to some extent, effective in reducing transmission of [Covid] in both healthcare and public, community settings. N95 respirators are likely to be most effective.”
Is that an equivalent of FFP3?
Professor Susan Hopkins: So it’s equivalent to FFP2 –
Lead 3: Thank you.
Professor Susan Hopkins: – and I think that was used because there was more evidence for N95 but very little evidence for FFP3 in the literature.
Lead 3: All right, fine. We’ll come back to FFP2 later, if we may, but FFP2 respirators are:
“… likely to be the most effective, followed by surgical masks, and then non-medical masks, although non-medical masks (such as cloth masks) made of 2 or 3 layers may have similar filtration efficiency.”
So there was, was there not, another piece of evidence supporting airborne transmission, albeit making the obvious point that, if it’s a poorly ventilated area, it makes aerosol transmission worse, prolonged exposure makes it worse and there may be some activities that generate aerosols.
As a result of these findings, I think is it right that you asked the IPC – or the IPC cell were asked to review the position and didn’t change?
Professor Susan Hopkins: Can I just actually –
Lead 3: Yes.
Professor Susan Hopkins: – highlight that the next (e) point on that –
Lead 3: Oh, right. Yes, certainly.
Professor Susan Hopkins: – I just think to make sure that we give the full evidence review summary – highlights that might be more effective, so it was still rather uncertain and I just think that that also comes into an important part of consideration of evidence.
So, in essence, what we’re looking at is what are the sort of biological laboratory-based experiment and then looking actually in healthcare about the evidence that was available.
Lead 3: You still say evidence of low or very low certainty from SARS and other respiratory viruses suggest in healthcare FFP2 respirators or equivalent might be more effective. All right, I understand that point but I actually want to concentrate on the airborne transmission point, as this was another piece of evidence to put into the mix suggesting that airborne transmission had been overlooked at the start of the pandemic and, as a result, I think you said, in your paragraph 339, Professor, that the IPC cell met to discuss the findings of the REP evidence and the IPC cell majority view was that there was no need to change the approach to RPE, based on the findings of the Respiratory Evidence Panel; have I got that right?
Professor Susan Hopkins: I believe that was because they had also added and recently changed the guidance to have a more risk assessed approach to do it.
Lead 3: Yes, they did.
Professor Susan Hopkins: So that, in a way, because some of this had already happened, to allow what I think PHE was calling for, which is more ability for organisations to use FFP3s in areas –
Lead 3: Let me ask you this then: how do you risk assess properly, if you are risk assessing for a droplet-borne virus, when in fact you are dealing with an airborne one?
Professor Susan Hopkins: So I think what you’re asking is about the ventilation, so you’re actually saying – what he is saying here is airborne PPE are likely when working with a cohort of Covid positive patients and that means that what we’re asking hospitals to do is to consider that there is a risk of aerosol in certain areas and to look at a multiple range of components, including ventilation and considering where that needs to be done to what other measures that need to be considered, again recognising that some hospitals had made those decisions, that the guidance was there, as I think Health and Safety Executive put it, as the minimum standard, but there was nothing at this point stopping people to go further, if they decided there was an issue, an outbreak, an incident on the ward, ventilation failure or a very high density of infection patients.
Lead 3: Well, forgive me, Professor, but you have told us that IPC measures shouldn’t be seen in isolation. So ventilation is clearly one of the matters to be considered in a risk assessment, I take that point, but my point is: how on earth are the healthcare workers and indeed those risk assessing going to be risk assessing properly if they don’t know what the route of transmission is?
Professor Susan Hopkins: I think what we’re saying here is that we’re increasing evidence of some airborne – airborne PPE, there was also evidence in the statements that there was increasing statements coming out and I think, at this point, we had released publicly our REP findings about the potential risk for aerosol. So Public Health England had released this into the public domain and shared it with people.
We were talking about it, about let air in, about ventilating on, as part of our general public health advice. So we were talking about letting air in, opening windows, ventilating well, as components, and hospitals understand their own environment where they may have areas that ventilation was poor, with their experts in each of the hospital infection control infectious diseases, engineers and environment.
Lead 3: So if they’re in an old estate with poor ventilation, how are they going to conduct a risk assessment that catered for an airborne transmitted virus?
Professor Susan Hopkins: I mean, I think this is underestimating what hospitals and hospital staff are capable of doing. There are many experts sitting in hospitals working on this on a day-to-day basis. They were reviewing the evidence and were reviewing the papers that came out, and they provide risk assessments for all variety of infections that come into hospital and risk assessments on how patients are managed and how – and the precautions in healthcare workers for a variety of components of infectious diseases, and other health and safety measures all the time.
Lead 3: Do you think it would be helpful though, for those risk assessing, to know categorically now that there was evidence suggesting there was airborne transmission; would it not help them in their task?
Professor Susan Hopkins: I mean, I can’t recall what was exactly written in the guidance at this point but I do think that there was increasing public information about ventilation, letting air in, opening windows, so that this was being discussed openly to the whole population about the measures to reduce the spread of Covid-19.
Lead 3: Okay. I’m going to canter through December 2021 to June 2022 because there was, I think this is right, no changes to the IPC guidance when Omicron variant emerged. I think the IPC cell were asked to consider whether mask guidance should be reviewed and, as I understand it, PHE maintained their view they wanted greater use of FFP3.
Professor, if it helps you, I’m at paragraph 350 in your statement.
8 December, there was a meeting of the IPC cell, or UKHSA. UKHSA, as you now are flagged their opinions based on the output of the REP and the limited evidence regarding the emergence of Omicron variant highlighting a greater need for FFP3 mask use, and they say this:
“This is a rapidly evolving situation in the absence of scientific certainty, as previously recommended by PHE for Alpha. A more precautionary approach, including the wider use of FFP3 respirators should be considered by the IPC cell.”
So not dissimilar to the position in December 2020, if I can put it like that; do you agree?
Professor Susan Hopkins: I agree.
Lead 3: Right. I suppose the same questions again, really, there was no change to the guidance, do you think now – what are we – a year on, PHE ought to have been more forceful in saying “Hold on, come on now” –
Professor Susan Hopkins: So –
Lead 3: – “FFP3 please, FFP3 please. Put it in the guidance”.
Professor Susan Hopkins: Well, I think, you know, it’s a similar situation to where we are right now, not just for Covid-19 but for a wide range of respiratory viruses and I think that we need to think about transmission of respiratory viruses in three ways in healthcare settings: what is the risk from the environment; what is the risk from patient to patient and healthcare worker; and what is the risk between healthcare worker and healthcare worker and to patient?
All of those require slightly different elements but I would come back and say that FFP3 is one element only and that my belief in coming out of this pandemic is that we need to look at the wider elements of reducing infection, rather than just the dichotomy of fluid-resistant surgical masks and FFP3, and that we need to improve the evidence base on which we make decisions, which we can do because respiratory viral infections are going to continue to spread.
Lead 3: That brings me on to I think January 2022, when the IPC guidance wasn’t Covid-19-specific but was published for seasonal respiratory viruses, so presumably flu, RSV and the like. All right.
Can we have a look, please, on screen, at INQ000348433_20.
And this is from that guidance and you will see there that RPE or FFP3 or powered air purifying respirator hoods, it says:
“A respirator with an assigned protection factor (APF) 20, that is, an FFP2 respirator (or equivalent), must be worn by staff when:
“• caring for patients with a suspected or confirmed infection spread by the airborne route (during the infectious period)”
And:
“• when … [AGPs are being done] on a patient with a suspected or confirmed infection spread by the droplet or airborne route.”
So no reference there to Covid, because it’s wider than that, but can I ask you this: reading that, does it sound like RPE should now be used for all encounters with patients with Covid or suspected of having Covid?
Professor Susan Hopkins: So I think it could be read like that, yes.
Lead 3: Yes. And does it now sound like healthcare workers have got to now work out whether the infection is being spread by the droplet or airborne route?
Professor Susan Hopkins: Well, I think that that is true to some extent but I think there was also – information would have been provided in this guidance about what infections were spread by which route.
Lead 3: Ah, because we looked to see if there was a list that set out that neatly and we couldn’t find one and maybe we’ve – we’re at cross purposes, one or other of us will be correct, and we’ll check it out, but do you think, even just standing back for a second, that’s not particularly helpful guidance to the healthcare worker?
Professor Susan Hopkins: I agree.
Lead 3: At this time I think it was asked that the word “wholly” and “predominantly” were being discussed in the IPC cell. Can I just deal with it in a nutshell: do you think that guidance that refers to “wholly airborne” or “predominantly airborne” is helpful to the healthcare worker?
Professor Susan Hopkins: No.
Lead 3: No, all right.
Finishing the IPC guidance, if I may, we come to April 2022, when the Covid-19 IPC guidance was withdrawn and the National Infection Prevention and Control Manual was published, I think on 14 April that year. Does that bring us roughly to the end of the guidance in most of our relevant period?
Professor Susan Hopkins: I think so.
Lead 3: All right, can I ask you this though please: about the impact of the withdrawal of the Covid-19 IPC guidance on clinically vulnerable and clinically extremely vulnerable people, do you know whether any consideration was given to the vulnerabilities of those groups when determining that no future Covid-19 guidance was required?
Professor Susan Hopkins: So when any guidance was done it was looked at as – in a sort of public sector equality duty, which would have included this to – as part of it.
From my point of view, in hospitals, in particular, there are usually wards where these individuals are cared for more than others, so a haematology ward or an oncology ward, where you’re getting cancer treatment, for example. And there, hospitals would define what the precautions are to be used in those wards. For example, I know that lateral flow testing continued to happen on those wards much after others, and actually in some of those wards, routinely in the winter or when there’s lots of viruses circulating, that staff routinely wear fluid-resistant surgical masks to reduce spread of infections.
So – sorry.
Lady Hallett: I’m getting messages.
Professor Susan Hopkins: So staff routinely would use fluid-resistant surgical masks to prevent the spread of infections on those types of wards, so I think that is the normal course of events within healthcare, to consider the individual factors of the patient as well as the infections that are circulating.
Ms Carey: Can I ask you in a similar vein: do you think that air filtration, for example the use of HEPA filters, was given sufficient priority in the IPC guidance?
Professor Susan Hopkins: I don’t believe it was.
Lead 3: No. Do you think that IPC guidance in future should look to the use of portable air cleaning equipment like that?
Professor Susan Hopkins: So I think – and I will say that this is one of the reasons why I think we need to have a wider discussion about some of this, I think a lot of the ventilation components are dealt with by building memoranda and technical memoranda that are done by the technical estates, facilities and engineering teams in hospitals.
However, where the – bringing ventilation, particularly where you talk about portable ventilation, UV HEPA filters, into the front and foremost consideration of hospitals, so that they’re not just redesigning a building or rebuilding a building but actually thinking how they can improve ventilation, is an important thing that should be brought into the guidance in the future for infection prevention and control teams to consider.
Can I just finally, there was and there remains that Health and Social Care Act, and there remains in that Health and Social Care Act the components of infection control that need to be considered to reduce the risk of nosocomial infections. That includes things like ventilation in estates. And I think that IPC guidance needs to reflect that in a greater way going forward.
Lead 3: I was going to ask you about nosocomial infections as the next topic, so let’s deal with that now, please, and it’s at paragraph 160 in your statement please.
And I just would like briefly if you could, please, Professor, to help us with the establishment of the Nosocomial Transmission Group, which I think was established by SAGE as a subgroup. It had PHE’s Director of National Infection Service on it.
Is this right, it was focused only on hospitals?
Professor Susan Hopkins: Correct.
Lead 3: In due course it became the Hospital-Onset COVID-19 Working Group, HOCI?
Professor Susan Hopkins: HOCI I think it was named.
Lead 3: And various pieces of data then from HOCI were added in and the data came to sitreps and they were verified by Public Health England. And if anyone wants to know more detail undertaken by PHE in this area, it is set out at pages 77 to 86.
Can I explain why I’m cantering over it? Because tomorrow we’re going to hear from Dr Warne, who is one of the IPC trio who is going to take us through some of the challenges in determining the extent of nosocomial infections. And so, with your Ladyship’s permission, I’m going to leave it to him, if I may, and I mean you no disrespect, Professor.
It does, though, bring into play, does it not, the ability to test symptomatic, asymptomatic and presymptomatic patients and healthcare workers, would you agree?
Professor Susan Hopkins: I absolutely agree and think that the – I don’t know, I can’t recall off the top of my head right now, but I think the changing in testing, both in patients and healthcare workers, made dramatic shifts in that first year, both due to testing availability in the health services and otherwise, the capacity to do that, the turnaround time. And I think this remarkable shift also happened when we started to be able to use the rapid tests that we then all became used to using, which PHE was really part of, the development of and validating of, of those tests.
Lead 3: Can I just ask you about asymptomatic transmission, which is not the same as asymptomatic infection, we understand that difference, just so that you’re aware, but – and clearly there was an evolution in understanding about how much asymptomatic transmission there was; would you agree with that?
Professor Susan Hopkins: Absolutely.
Lead 3: When do you think PHE came to the view that there was evidence of asymptomatic transmission?
Professor Susan Hopkins: Again, I don’t think this was a moment where there was an electric light bulb that went on. I think there was gradually increasing, slowly-but-surely evidence that we were seeing people who at first that we thought – were testing positive but would go on to develop symptoms, because, again, it was quite common for people to have that presymptomatic phase. But then when we did studies looking at individuals over time we recognised that 30/40% of individuals never developed symptoms but that some of their households became infected.
So in the studies that we did in households or in organisations where we would find one of these individuals and then follow their household, we could see that they were transmitting particularly through their household.
And that’s good evidence because they would have all been staying at home, hopefully, following the guidance to stay at home with those symptoms.
Lead 3: If it helps you, certainly by 1 April 2020 Public Health England said that there was the possibility of asymptomatic transmission but other analysis would provide the best evidence.
The reason I mention that is this: we have in our evidence a statement from Matt Hancock, the Secretary of State, who says this, that:
[As read] “During January until 3 April 2020 I repeatedly raised my concerns about the potential for asymptomatic individuals to infect others with those advising me. However, up to that point I was repeatedly advised by PHE both that we should not assume asymptomatic transmission …”
And I would like to know, did you – not you personally, but did PHE advise Mr Hancock in the way he sets out?
Professor Susan Hopkins: So I don’t know what – and I can’t recall. I presume this was in individual discussions with Mr Hancock, which I was not in the room with Mr Hancock until late May 2020.
Lead 3: Okay.
Professor Susan Hopkins: So I would say that that may have been the perception of people communicating.
I think if you look at the science advisory papers to NERVTAG and to SAGE, it was much more nuanced and there was uncertainty, and I – I personally would, I think as you’ve realised, don’t believe that we can be so clear-cut for some of this, and that would not be my way of explaining things to ministers.
Lead 3: Can you help us if it wasn’t you in the room with him or in the rooms with him who was it likely to have been that was advising him?
Professor Susan Hopkins: So my understanding from the early meetings were the director of the national infection service, the medical director and the emergencies(?) medical director and the chief exec – of Public Health England –
Lady Hallett: Sorry to interrupt again, there’s also quite a difference, isn’t there, between you shouldn’t assume that something’s happening and there’s some evidence it may be happening. I mean, they’re not the same thing, are they?
Professor Susan Hopkins: Agreed. And I think that the whole point of scientific exploration is that you say what you know at the time, because you have to be clear and communicate what you know, but that you also continue to study it to see if you are wrong.
Lady Hallett: We’re not assuming it’s happening, but it may be?
Professor Susan Hopkins: And it may be and we don’t –
Lady Hallett: That’s why we’re going to look further?
Professor Susan Hopkins: Exactly.
Ms Carey: I diverted briefly –
Professor Susan Hopkins: Apologies.
Lead 3: – to deal with asymptomatic, but can I return to nosocomial transmission, and I think a study conducted by UKHSA into the efficacy of interventions to prevent nosocomial transmission.
And could we have up on screen INQ000348244, please.
It’s at your paragraph 188, Professor, if you need to look at it, but it might be easier to use the document.
Can you just give us a background as to why UKHSA commissioned this piece of work?
Professor Susan Hopkins: So this was part of our modelling work, so UKHSA, and Public Health England beforehand, had a healthcare-associated or nosocomial modelling team. So these are teams that take assumptions that we understand, with things that we know about the virus, and then work them into large-scale models that the computer will one run hundreds of thousands and millions of times to provide estimates of what might happen in real life and allow those variations to be seen.
For example, in looking at masking, it was not a study that said masking only around –
“… only around patients prevents 56% of infections …”
This would have been a number that they would have put into the model about how effective masking was, and then they would have let the model run for thousands or millions of iterations and then it would have come out saying: this – doing this, in this model, looks like it reduces these amount of infections.
Does that –
Lead 3: Yes.
Professor Susan Hopkins: It’s just – it’s the complexity of models, which I think is important to do. This was not a real life study, it was not conducted in a hospital.
Lead 3: No, I follow that, but the key messages from the study we’ve got up on screen there, and in relation to “Patient infections”:
“Interventions in place over the course of the pandemic have prevented up to 1.2 million patient infections compared to a scenario where no interventions were ever implemented.”
And if people want to know what the interventions were, I’m not going to suggest we call it up on screen but there is a timeline of them at page 3 in the study. It includes mask wearing for patients, mask wearing being universal in hospitals, testing of all people on admission, and I think, of course, vaccinations through it. So there is a number of different ways that interventions are looked at, but in short there that is an endorsement, isn’t it, for the interventions that we came to live with at helping prevent transmission –
Professor Susan Hopkins: Absolutely. But recognising this was masking, not FFP3s, just –
Lead 3: Yes.
Professor Susan Hopkins: – make this point, and that universal masking by healthcare workers was extremely effective for preventing healthcare worker to healthcare worker transmission, again as fluid-resistant surgical masks, helping us to try to understand it.
Lady Hallett: The transcriber, I’m afraid, is missing an awful lot of what you’re saying.
Ms Carey: She’s not the only one.
I’m sorry, it’s my fault, Professor, because I should tell you to slow down, and I know we’ve got a lot to gather but these are important findings.
So clearly, there, there is interventions that have prevented potentially up to 1.2 million patient infections, compared to the scenario where there are no interventions. All right?
It is:
“• Isolation of symptomatic [healthcare workers], and masking by [healthcare workers] …”
Brackets, any mask not FFP3, I understand that.
“… around patients (or universally) are important strategies for preventing patient infections and when used in combination …”
With the other interventions I assume that means.
“… up to 88% of the total number of nosocomial patient infections that occur when no interventions are in place.
“• Masking only around patients prevent 56% of infections even when [healthcare workers] do not isolate …”
Is this really a ringing endorsement for, in the event of a pandemic, masks of some kind for both patients and healthcare workers?
Professor Susan Hopkins: Absolutely. And, you know, also a patient/healthcare worker isolation when they’ve got symptoms and lots of other components, but this particularly highlights the importance of any type of masking.
Lead 3: And does that –
Lady Hallett: So –
Ms Carey: I’m so sorry –
Lady Hallett: – said masking of patients and healthcare workers, but I can’t see in these key messages where the masking of patients comes; it’s just healthcare workers, isn’t it?
Professor Susan Hopkins: So this study would have included, and I know did, included it from June, it would have looked at the data from the intervention where patient – healthcare workers were all wearing masks but also potentially the intervention where patients were wearing masks as –
Lady Hallett: But these messages are all about masking by healthcare workers I think, or have I misread them?
Ms Carey: I thought they included universal masking, which was patients and healthcare workers.
Lady Hallett: By healthcare workers, universal masking by healthcare workers. I can’t find masking of patients in these messages.
Professor Susan Hopkins: I would have to go back and look at the modelling study in detail to go through that and –
Ms Carey: Can I tell you why I think it is? Can we just call up page 3 in case this answers it quickly, and if it doesn’t we’ll revert to …
Can we go to page 3:
“Timeline of interventions …”
Obviously one of the first interventions was to reduce anyone going into the hospital in the first place then prevent visitors going in.
“[Healthcare workers] masking around all patients”
That’s for the healthcare workers, obviously.
“[Healthcare workers] masking (universal)”
Lady Hallett: So that’s healthcare workers.
Ms Carey: Yes, still healthcare workers. But did they not bring in, I thought that patients were encouraged to wear –
Professor Susan Hopkins: Yes, the patients were encouraged –
Lead 3: If they could tolerate it?
Professor Susan Hopkins: Exactly. So I think they probably didn’t model it because it was so uncertain –
Lead 3: All right.
Professor Susan Hopkins: – and it would depend on how unwell the patient was, and if they required an oxygen mask they clearly couldn’t wear a face mask.
Lead 3: So let me rephrase my question: is this a ringing endorsement for the universal masking of healthcare workers, undoubtedly?
Professor Susan Hopkins: Yes, I believe that universal masking was a really important role in this pandemic.
Lead 3: Okay. And we might need to look to see whether this includes the universal masking of patients who could tolerate it.
Professor Susan Hopkins: Yes, I think that would have been more uncertain, so they –
Lead 3: It was a poor question by me –
Professor Susan Hopkins: Yeah.
Ms Carey: I’m going to move on, please, to a different topic.
I know it’s a bit early, my Lady, but would that be a convenient moment, because we’re moving –
Lady Hallett: Certainly I think I know somebody, from whom I am receiving messages, who would be really grateful. We really do – I mean, it’s important evidence you’re giving, Professor, so I know how difficult it is to change your speech pattern, but if you could this afternoon, afterwards, when we come back.
The Witness: I’ll try my best.
Ms Carey: Thank you, my Lady.
Lady Hallett: 20 past.
(3.02 pm)
(A short break)
(3.20 pm)
Lady Hallett: Ms Carey, I have asked for the temperature to be turned down.
Ms Carey: Thank you very much.
Professor, can I turn to a different subject, please, and the SIREN study. I’m at paragraph 189 in your statement, if it helps. Can you briefly summarise why it was set up, what was its aims and then we’ll look at some of the results?
Professor Susan Hopkins: Thank you. So the SIREN study, of which I was the chief investigator, was set up in May 2020 to understand infection prevalence in healthcare workers by regular testing, because there was no asymptomatic testing happening routinely, to understand the risk of reinfection in healthcare workers who had previously been infected, and the reason for this was that they were a cohort of people that we could test regularly over time and, subsequently, when the vaccines came, to determine the effectiveness of vaccines in healthcare workers.
Lead 3: Let’s call up on screen, please, INQ000320603, and page 2, please. There we have the findings, and I would like your help, Professor, just putting them into a plain language, if we may. I think the first one was:
“In January 2021 the SIREN study published its first analysis of protection following SARS-CoV-2 … Crucially the analysis showed that reinfection was possible and could occur, but that there was an over 80% reduction in infection among people who had previously contracted Covid-19 compared to those who had not.”
Is this it, that 80% of people didn’t get Covid at all where they had previously had it?
Professor Susan Hopkins: So at this point in time –
Lead 3: Yes.
Professor Susan Hopkins: – in January 2021, so this was after looking – we had recruited people from May to the autumn, and we followed people up, we understood their baseline immunity to Covid by blood tests and then we did two-weekly testing on them, so tests every other week by PCR, to determine whether they could become infected either asymptomatically or symptomatically, and we followed them up over that period of time.
In January 2021, due to the infections that were circulating widely, we were – that was our first moment that we were able to make an assessment of the level of what happened if you were immune to SARS-CoV-2.
At that point, what it showed, that if you had immunity defined by having a previous positive PCR test or having antibodies in your blood, that you did not get reinfected, and by “reinfected”, I don’t mean that you didn’t develop symptoms, you didn’t develop a PCR positive asymptomatically at all at that period of time.
Lead 3: Am I right, then, if you had had it before, 80% of people didn’t get it again; is that the wrong way of putting it?
Professor Susan Hopkins: No, if they had it before, so if they had had it any time between February 2020 and December 2020, then they did not get another infection episode in, by and large, November, December, January 2021, because that’s when infections were circulating at high levels.
Lead 3: “In spring 2021 when the Alpha variant was dominant in the UK, the SIREN study published its first analysis of the effectiveness of vaccines, focusing primarily on the Pfizer vaccine. The analysis showed that short-term vaccine effectiveness against infection 21 days after the first dose was 70% in the study population of healthcare workers and rose to 85%, 7 days after the second dose …”
So is that saying, effectively, that you’re less likely to get infected if you’re vaccinated, especially if you have had two doses?
Professor Susan Hopkins: Yes, it was saying that, even after one dose, only, if you took the people who got the vaccine and the people who did not, then the people who got the vaccine did not get a subsequent infection over the period under follow-up.
Lead 3: February 2022, help us there what was the main finding of SIREN in February 2022?
Professor Susan Hopkins: So, again, that looked at the short-term vaccine, which was what we looked at first because we were looking at this in real time. So vaccine was rolled out from December 2020. So in April/May 2021 when we produced our first analysis, we were only looking at the first 90 days after being delivered vaccine. In February 2022, we were looking at the longer duration after being delivered vaccine, and what we could see is that people who had been delivered vaccine at a longer period, so more than six months at this point, had less protection against immunity.
Can I also add that this was with the Omicron variant, so the variants were changing, and we know that Omicron evaded not only the natural immunity that we had but also the protective immunity from vaccines.
Lead 3: Thank you very much. All right, that can come down.
Can I ask you, please, about your paragraph 201. You say this:
“Using an individual based mathematical model to predict how large the burden of [I think this is healthcare acquired infections] would have been if vaccines had not been available from 8 December, it concluded that the vaccine roll-out averted infection in a large proportion of hospital healthcare workers in England. Without vaccines second wave infections in the patient-facing healthcare workers could have been 21.8%.”
Is that essentially championing the cause of vaccines in helping prevent infections within healthcare workers?
Professor Susan Hopkins: So vaccines as a mitigation measure were part of the mitigation measures we then had in play to reduce infections in healthcare workers and the general population.
Lead 3: But looking at your paragraph 202, please, Professor, I think you say there that the findings also highlighted occupational risk factors that persisted in healthcare workers, despite vaccine roll-out, and could you just summarise, please, paragraph 202.
Professor Susan Hopkins: Yes. Are what we are highlighting in this analysis is both – what we do, first of all, is we look at one thing compared to the other. The most important point on that one element compared to the other, on the simple analysis, were that healthcare assistants and bedside therapists were those who had occupational risk factors following vaccine roll-out, and that being of black or Asian ethnicity had an increased risk of infection during the second wave, compared to those of white ethnicity.
But, after adjusting from the time since people were vaccinated – so not just looking at it in terms of whether you were vaccinated or not but how long was it since the vaccination, that the significant factor was predominantly related to Asian ethnicity in this study.
Lead 3: So can I just ask you about that answer: you say that being of black or Asian ethnicity had an increased risk of infection during the second wave, compared to those of white ethnicity. Can you help at all as to why there is that increased risk in the second wave?
Professor Susan Hopkins: Well, I mean, there is lots of work that went on to look at disparities and particularly within ethnic groups. I think that when – and some of this is in the various disparity reports that people will have read during the course of this. And when we look at healthcare workers, one aspect is on what they do as healthcare workers, but other aspects are where they live, the amount of people who live in their house, the other people they’re mixing with outside work, and you can’t take all of those outside factors into control.
So in some of the studies that we tried to do in SIREN, which again were people answering survey questions for us, we tried to look and see: did the amount of people in the house contribute to it; did the age of people in the house contribute to infection; and there were lots of other factors that were colliding in the risks of infection and where – ethnicity was one of those risks that we could see.
Lead 3: I want to come on to disparities in just a moment but just finishing the SIREN study, paragraph 204. I think you said:
“The study found that both occupational and domestic exposures were associated with increased risk of infection, including increased household size and frequent exposure. Regarding occupational factors, it is likely that exposure to Covid differed by role, healthcare assistant, compared to doctor.”
Does that mean that the healthcare assistant was more likely to get Covid than the doctor was?
Professor Susan Hopkins: Correct.
Lead 3: Obviously, in a setting: inpatient wards with more risk of infection if you worked there, than compared to emergency departments.
Obviously then, including the time spent with individual patients and activities involved.
You say it was not possible to unpick these associations further but is any work being done to try and work out why differing roles had an increased risk of infections, different settings had increased risks of infections, and take ICU out of it for a moment because they’re in a slightly different category, the people, and those working in ICU?
Professor Susan Hopkins: Yeah, I mean, I think that – I mean, we can speculate. I think what we’ve tried to do in the SIREN study, all the way along, is use the data that individuals gave us as part of the study. They consented to give us this information. We have also done qualitative work so where we have done interviews with healthcare workers to try and understand things better and it’s always difficult to disentangle the environment that they work in, the environment that they socialise in and the environment that they live in at home from all of the factors because all of them interplay from each other.
So I don’t think we will be able to simply say, “Yes, this was it and that was not”. And what we have tried to do repeatedly is come up with highlighting that an increased household size was important, increased exposure to patients was important, increased – differences in roles and one of the reasons why we highlighted roles was we thought this might be about the potential education factors that differing roles have, but it’s, again, very difficult to disentangle this. What we try and do is use the study to provide the best understanding that we can based on what we have.
Lead 3: Can I ask you this, has any work been done in SIREN – and it may be that’s not the right study for it – to look at whether non-clinical workers have an increased risk of contracting Covid-19 at work?
Professor Susan Hopkins: So this varied over time, actually, and the – at some parts of the studies, particularly in the first wave, non-clinical workers and clinical workers had very similar rates of infection, and we think that was predominantly driven by healthcare worker to healthcare worker exposures at that point.
At later points in time, that risk changed and what we’re highlighting in this particular study – and again we can share with you all of the various studies published because we’ve repeatedly re-analysed – at this particular time there are lots of different factors relating to prior exposure, vaccination, the types of work they did.
But we can’t disentangle the training they did or how well they applied the infection control precautions because that’s not what you can do in a survey. You can only do that if you observe people or if you do detailed, qualitative interviews with a very small number rather than the almost 50,000 people who participated in this study.
Lead 3: Okay, can I come on to the disparities and I want to ask you, please, about PHE published, I think, a review of disparities and risk outcomes in June 2020, so relatively early on in the pandemic. It’s at your paragraph 439, please, and then I would like to overview and I want to look at one aspect of the study itself.
The review found that the largest disparity was age, so if you were 80 or over you were 70 more times likely to die than those under 40. The risk of dying amongst those with Covid-19 was higher in males than females, higher in those living in more deprived areas than those living in the least deprived, and higher in those in black, Asian and minority ethnic groups than in white ethnic groups.
Can I just pause you there. Will you correct me if this is too simplistic but, if you were a healthcare worker, who was a female, who was BAME, who lived in a lower deprived area, do all of those things add up to increased risks at each and every stage or is that too –
Professor Susan Hopkins: Well, the female would have been lower risk.
Lead 3: Oh, sorry, BAME, male, working in healthcare, from a deprived area: does that all add risk, upon risk, upon risk, is really what I’m asking you?
Professor Susan Hopkins: So it adds layers of risk, yes.
Lead 3: Presumably, take one of those away, slightly less risk each and every time you remove one of those factors?
Professor Susan Hopkins: Except a lot of them can’t be removed.
Lead 3: Quite. All right, so let’s look, please, then at the review itself and can I call up on screen, please, INQ000399820. I’m going to page 5. I want to actually just look at some geographic inequalities, which is not something we’ve really looked at, Professor. Obviously, this is just a study by Public Health England and therefore concentrates on English data; is that right?
Professor Susan Hopkins: Correct.
Lead 3: All right, okay. There we can see that geographical inequalities:
“The regional pattern in diagnoses rates and death rates in confirmed cases among males were similar. London had the highest rates followed by the North West, the North East and the West Midlands. The South West had the lowest. For females the North East and the North West had higher diagnosis rates than London, while London had the highest death rate.”
Then you can see there what is set out in relation to local authorities. Obviously, the data tells you what the position is but the question always becomes then why. Is any work being done to work out why there are these regional variations?
Professor Susan Hopkins: So, first of all, this is all people in the population, so it’s not just healthcare workers, and recognising that healthcare workers were a very small proportion of the total infections that were seen, though a very important part.
The second thing I would say is that, especially in this stage and if you look at over the pandemic, one of the things was that waves of infection would sweep through the community at different points, and we know that London and the North West, particularly the North West as links to Manchester and Liverpool as big urban conurbations, really drove a lot of the early waves that we saw. The North East, again predominantly at Newcastle, and the West Midlands driving. You can see that at each of these, the urban settings, where there are large numbers of people, are particularly where we saw large numbers of cases, especially in the first wave, though that consideration then played out at subsequent waves and at subsequent waves of infection, where you would see a different regional variation all of the time.
Lead 3: So there may be reasons really to do with the kind of concentration of people in an area, as an obvious reason as to why there are these perhaps variations in the South West, thinking about Cornwall and Devon, for example. That might be an explanation for why there is this variation?
Professor Susan Hopkins: So places that were rural, for example, often had lower amounts of infection but then, once the infection got into that community, it spread very rapidly and we saw that particularly between the waves, where waves of infection came into small areas, and we could see very high clusters of infections in areas as it spread in the community.
Lead 3: Can I take that down, please, and I take it that you would agree that we shouldn’t read into that that people in London got worse care than those did in the South West, that’s a far too simplistic analysis of the geographical variations?
Professor Susan Hopkins: I think that there’s far too much complexity to read into geographical –
Lead 3: Right. I say that just to make that clear, rather than anything else.
Professor Susan Hopkins: Yeah.
Lead 3: Obviously, I’ve concentrated there on the geographical variations but the ethnic and disproportionate effect on those in the BAME communities was a big part of that review and can I ask, following that review, do you think that there was action taken fast enough to address the disproportionate impacts on ethnic minorities?
Professor Susan Hopkins: So I think I would put it into two components. So first of all is that we, as a country, need to tackle the impact of – the health impacts on ethnic minorities, not simply for the pandemic but this is there well before the pandemic and has not been resolved after the pandemic, and that requires culturally appropriate messaging, involving black and minority ethnic groups and – into thinking about the messages that can be delivered for their groups and populations, and in thinking about the interventions that can work in those populations.
I think it’s important to note that, not just in healthcare but in many other service industries – taxis, shops in London – that black and Asian minority ethnic groups often couldn’t, for example, work from home in the same way as others, and I think that we need to recognise the structural issues in our societies to try and improve them in the future, not just for this but for everything else to do with health and wellbeing.
Lead 3: Now, the review obviously looked at geography, sex, age, deprivation, ethnicity, occupation, I think, and residence in a care home – I’m not going to ask you about that, that’s another module – but can I ask you this: how was it determined which disparities would be focused on in the review?
Professor Susan Hopkins: So my understanding is that the disparities that were focused on were the ones that we had, one, data for –
Lead 3: Right.
Professor Susan Hopkins: – because that’s important to be able to look at and – though I would say that the data also got better after the disparities review because of some of the discussions that were happening around that time.
Secondly, that it was important to recognise that the disparities were things that were included in the public sector equality duty and where there was at least some evidence from epidemiological studies that these were important factors. By epidemiological studies, I mean the data that we were looking at day in, day out to try and understand who was being affected by this pandemic.
Lead 3: Do you know why disability was not mentioned in the review?
Professor Susan Hopkins: So I would say that the reason why disability particularly wasn’t mentioned in the review is that there was no data available easily to link disability and the range of different disabilities with the results on Covid that we’ve seen. Subsequent studies did try and do that but, at this point in time, that was not available, and it was a challenge even to do it in real time, over the whole pandemic for other reasons.
Lead 3: Different topic, may I ask you about Long Covid, please, and PHE’s role, as it was, in relation to planning for and responding to the long-term consequences of Long Covid.
I think is this right: there wasn’t any kind of public health communications plan in relation to Long Covid; is that correct?
Professor Susan Hopkins: Yeah, so I think – I mean, just to reflect, so Long Covid was something that, first of all, was being reported by individuals, I think particularly started to be reported in May and June, as weeks had passed since they had had their infection potentially in late February and March and they were still not feeling better. I think that, at the time, and I would say even still, we don’t understand enough about Long Covid to be able to give the right messaging, and I know that the NIHR, so the National Institute for Health Research, has put a lot of funding to try and improve that.
From a public health point of view it is very difficult to give a message if we don’t know what we’re trying to do or reduce. I think what we were trying to do was reduce infections in whatever way we could and by reducing infections then we would therefore see less of an impact by Long Covid.
Finally, I would say that vaccination, when we looked at it, was clearly an important factor for reducing Long Covid as well.
Lead 3: May I ask you about death data, please. I think your colleague, Dame Jenny Harries, contributed to parts of your statement, or certainly parts of her Module 2 statement are in the Module 3 statement, and she indicates there that, when considering the risk to the UK, there were three triggers, one of which was healthcare workers dying because that indicated a new infection was severe and transmissible. Who and how were deaths of healthcare workers monitored by PHE, if at all?
Professor Susan Hopkins: So, again, first of all, there is no national registry of deaths that is delivered to PHE. The Office for National Statistics collects the death registrations, which includes occupation, and so we were reliant on information that was shared to us by the Office of National Statistics once the data was available and, in my recollection, they led on the reports for employment and occupation-associated mortality and produced reports regularly from April 2020.
Lead 3: Do you think there should be better reporting of healthcare worker deaths in the event of a future pandemic?
Professor Susan Hopkins: Yes, I mean, I would always like better reporting, I mean, you know, this is the challenge. I think this comes down to how we talk to people about how we use their data. So, for example, whether we can share more readily, even outside of a pandemic the – because if you’re trying to do it in a pandemic, then you’re doing it in – if you like, in haste, so how we can share what healthcare workers do, what their occupation is, and then how are they getting sick or not getting sick over the course of their healthcare experience.
I think that that would require healthcare workers to consent to share that data and that would, you know – has challenges within it or would require government to make a decision that that information was going to be shared with certain bodies. I think that there are ongoing debates about sharing information, including from GP records data, for example, and it’s not easy, but clearly as an organisation who’s trying to use data to better understand problems, we would like a greater discussion with the public and with healthcare workers on how we do that.
Lady Hallett: I’m not sure that’s going to work, is it? “Just in case you die, healthcare worker, please can we have more data?”
Professor Susan Hopkins: I mean, I think the challenge is that so, for example, in the SIREN study, people consent to share a lot of information with us about their health records and a consent for us to look at their health records but that involves discussions and conversations, and I think that the NHS, as an employer, has a conversation to have with their healthcare workers about whether they would be willing to do that to better understand the causes of ill health in healthcare workers.
Ms Carey: Can I broaden the data to an area where there is some data and ask you, please, about the estimates of how many patients in hospital caught hospital-acquired Covid-19.
Can we call up on screen, please, INQ000348633_0011.
My Lady, tomorrow Dr Warne will help deal with hospital-acquired infections but there is just some data I would like your help with, please, Professor.
I think, is this right, that UKHSA prepared a report in June 2021 looking at where there was hospital-acquired infection, how many people got it and of those how many people died.
Now, there’s a number of acronyms. Can you just help us with “HOHA”, please?
Professor Susan Hopkins: Hospital-onset hospital-acquired (sic). My understanding was that was day 14 or greater.
Lead 3: So if you are testing positive and you have been in hospital and it’s day 15, the chances are you got it in hospital. If you’re testing in days less than 14, then there’s suspected, which is “hospital-onset suspected hospital-acquired” – or “healthcare-acquired” infection, and it goes down, and the Cs deal with community-acquired infections.
I just want to look at the hospital one, and we’ll just take the top “HOHA”, because there there is a degree of certainty that at least they were tested on day 15 and therefore it was acquired in hospital. The whole time period, is this from March 2020 to April 2021, when the data was collected and produced into this report; is that right?
Professor Susan Hopkins: Yes.
Lead 3: All right. So between March 2020 and April 2021, is this England only?
Professor Susan Hopkins: Yes.
Lead 3: Okay. There were 29,950 hospital-acquired infections, of which 9,854 of those people died; is that correct?
Professor Susan Hopkins: Yes.
Lead 3: The proportion: so 9,854 is presumably 33% of the 29,950?
Professor Susan Hopkins: Correct.
Lead 3: “Mean age”, please, what is that telling us?
Professor Susan Hopkins: That’s the average age of the people who died, so the average age of the people who died in this category was 75 years of age.
Lead 3: Then if it’s wanted to, it’s broken down into the first and second wave. I won’t go through all of this. What was the purpose behind the production of this data?
Professor Susan Hopkins: So we looked at this data on an ongoing basis, we reviewed it to understand what was happening, I think that, what you can see, just to put some of the totality in there, is that these are the infections that were admitted to hospital –
Lead 3: Yes.
Professor Susan Hopkins: – and we were looking to see if that was changing over time across it. This will also then have been used to determine where the interventions should take place to reduce hospital transmission. They will have been using these in the modelling data that we talked about earlier about healthcare workers. So they will use that to then determine what intervention worked over time. So they’ll have summarised it here for ease, but they will have produced this data by week and by month as well, so that we can really understand a breakdown and then see how things changed or shifted when interventions were introduced.
Lead 3: Can I ask, please, for page 2 of this document to be put up on screen and, Professor, correct me if I understand this graph incorrectly. The figure 1b spans March 2020, you can see there the first wave and then the peak of the second wave, just to help people orientate themselves, so through to 2021. But is this right: it shows us the proportion of patients in hospital who acquired Covid in hospital?
Professor Susan Hopkins: Correct.
Lead 3: Go to the peak of wave 2, I just want to make sure we understand it, there were over 20,000 – thank you very much.
Professor Susan Hopkins: Can we have the –
Lead 3: Can we have it back again, actually.
Professor Susan Hopkins: It’s the 1a graph.
Lead 3: We’ll have to do it small. It’s over 20,000 patients are in hospital in, what, January 2021?
Professor Susan Hopkins: Yes, I believe it was about 25,000 at its peak.
Lead 3: Yes, all right. Of those, the red indicates those who acquired Covid in the community; is that right?
Professor Susan Hopkins: Correct.
Lead 3: Then suspected that they acquired in the community is the purple, and then up to a small – we probably can’t see it very clearly – a different way of working out whether they’re hospital acquired. But if you look at the top blue, is that those that, based on the date of testing, it is assumed that they acquired Covid in hospital at that time?
Professor Susan Hopkins: Correct.
Lead 3: That is – I can’t work it out, but it must be over –
Professor Susan Hopkins: I think it’s about 3,000 for the hospital-acquired hospital associated one because it’s the very light blue at the top. You can see that it’s not quite half of the section.
Lead 3: So in wave 2, about 3,000 people acquired Covid in the hospital?
Professor Susan Hopkins: In the worst week of wave 2.
Lead 3: In the worst week, yes.
Professor Susan Hopkins: Yes. More than that over the whole period.
Lead 3: Okay, thank you.
Professor Susan Hopkins: You might want to highlight that the nosocomial proportion – the two other facts – was lower in the wave 2b, which is what we’re looking at, at that peak, and – compared to the 2a wave, and that –
Lead 3: Where is the 2a wave?
Professor Susan Hopkins: The 2a wave was the one that came up and then went down a little bit, so that when we had the partial closures in November, in society, and then December was where we had the Alpha variant come through. I think that’s important.
Lead 3: Thank you very much, that can come down, thank you.
Final topic, please. I’d like to ask you, on behalf of UKHSA, about lessons learned and recommendations. Can you summarise what you think is the key lesson learnt, and I know there will be lots, but give her Ladyship, please, your key lesson from UKHSA’s perspective?
Professor Susan Hopkins: Well, I think – I mean, can I take this from an IPC, first of all, because we’ve had a lot of discussion on IPC today and then I’ll very happily go more widely on some of the other components.
So on IPC, I think that the first thing is that multidisciplinarity is important and we need to ensure that there’s a range of views feeding into any discussions; that we need to have well-circulated and agreed guidance prepared in advance of the next pandemic, with a range of scenarios that we’re considering, so people understand the thinking, that of course will be stressed and of course it will be thought through at the time of the next pandemic.
I think, as I’ve said repeatedly, that there are ways that we can improve ventilation to think about respiratory viruses more generally and there are political choices for ministers about how much money they want to spend on that, either temporary or permanent; that the evidence base for complex interventions, of which infection control is a very classic complex intervention, needs to be considered and thought through, and we need to take opportunities outside a pandemic period to develop that evidence, rather than waiting for a pandemic.
The final bit which I will come to which is about face masks and FFP3, so firstly I think that we need to have a discussion and agreement about how much extra value that we think FFP3s are, that if we think that they’re of extra value and we want to do that in a future pandemic, that we have a cadre of staff continually trained to be able to use them, knowing what type of FFP3s they can wear and that those are in supply and stock, and that – we need to consider other alternatives to using fit testing as a barrier that may also protect people, and I know that people have talked again about non-fit-tested FFP3 which would require a legislative or regulatory change.
Lead 3: I was just going to say, would that not involve the health and safety –
Professor Susan Hopkins: It would require a legislative or regulatory change but I think these are discussions that we should have outside the heat of a pandemic and be ready and prepared for the next one.
Lead 3: Can I ask you this: putting aside any agreement or disagreement about the protective effects of FRSM versus FFP3, Professor Beggs certainly opined that a middle ground, whether it be FFP2 or something else, should be explored. What’s UKHSA’s stance on a potential middle ground; do we need to look into that?
Professor Susan Hopkins: Yeah, well, first of all I would say that FFP2s need fit testing too, so it’s not that you can wear an FFP2 and not get fit testing. I think many of us – and I think there’s – some of the emails that have been presented during the course of this talked quite a lot to HSE and others about whether we absolutely need to do fit testing, would the filtration of a mask help. I think we need to discuss that and be clear about it and what’s different about a normal situation and an emergency situation, where changing from, you know – on average, I mean, I’ve used FFP3s to care for individuals with highly complex infections for 30 years almost but that’s a very small proportion of the hospital and, if we want to do this and we want to do this more generally, and that is the decision and the consensus that that’s the place to do then we have to have the place ready for that and it wasn’t ready and it still isn’t ready to fit test everyone and to have a variety of masks available for the range of faces that we thankfully have in our NHS.
So I think it’s – and that’s where I think I would come down to operational evidence and an agreement about the way forward in this as really important, and I think that we see respiratory viruses every year, we see them every winter in the NHS. Just because the pandemic’s over doesn’t mean we cannot understand this better.
Ms Carey: My Lady, they’re all my questions. I know there are some core participant questions but there may be some matters your Ladyship –
Lady Hallett: Yes, there are, I’m afraid.
Questions From the Chair
Lady Hallett: I appreciate you saying we need a suite of interventions but I’m going to have to take you back to FFP3 masks, Professor. It’s just to check that you did say – I’ve got from the [draft] transcript, you said about FFP3 masks:
“The evidence is weak that FFP3 protected more than fluid-resistant surgical masks.”
Right?
Professor Susan Hopkins: Correct.
Lady Hallett: And you are saying that?
Professor Susan Hopkins: Correct.
Lady Hallett: As a layperson, I tried one of these on yesterday, so I could find out what people were saying.
Professor Susan Hopkins: Yes.
Lady Hallett: So that’s the FFP3 –
Professor Susan Hopkins: One of them, yeah.
Lady Hallett: – and that’s the fluid-resistant surgical mask.
As a layperson, just putting that on, there seems to be lots of gaps, it’s quite flimsy but, putting that on, I had to be shown how to do it, going back to the fit testing, surely just looking at it, that offers so much more protection; it must do, mustn’t it?
Professor Susan Hopkins: But can I just explain one of the challenges that we have is that, in hospitals, there was, and I’d have no doubt, there was transmission from people who – patients who had infection but I think, as you’ve seen in some of the studies, that the most transmission was from healthcare worker to healthcare worker, which would mean they needed to wear those all the time and then there was significant transmission –
Lady Hallett: That’s a different point. I’m sorry, Professor, I’m going to have to interrupt, that’s a completely different point. It may be associated, there may be disadvantages to wearing them all the time and you may get the ulcers. Some may say getting an ulcer isn’t as bad as getting Covid but there are all sorts of arguments. I just want to challenge that that article (indicated), basically, there’s weak evidence to say that the, apparently, much stronger-looking, closer-fitting, has to be fit tested article, there is weak evidence it offers better protection than that.
Professor Susan Hopkins: Correct.
Lady Hallett: You’re sticking to that?
Professor Susan Hopkins: I am. I’m a clinician and scientist and I can only go with what the evidence has done, from looking at it in hospitals, in healthcare facilities, and I think that – you know, that when we do something, when we talk about wearing something in – rather than just wearing it for five minutes or ten minutes and looking at it in that way, we have to talk about how it’s worn for a 12-hour shift, how it’s worn repeatedly, day after day, and that’s about operational interventions that are able to be applied for many days, weeks and months, and that’s where – they work really well in the lab, don’t get me wrong, the laboratory is really clear, but when you look at them in practice –
Lady Hallett: It’s the way people wear them. In other words, because they’re uncomfortable people may take them off?
Professor Susan Hopkins: There may be all of those things but that’s what matters when you try and do something in practice is: does what happens in the laboratory actually work in practice, in real life, in the scenario where you’re managing it? And that’s the challenge that we have.
Lady Hallett: Right. Another matter that a core participant asked me to explore, you talked about enabling practices, and I think what you meant was a practice whereby, if I’m a healthcare worker, I can choose the kind of mask that I want to wear.
I just wondered, and this core participant wondered, how does that work in practice, you know, if I’m a ward manager, or whatever they’re called these days – I’m sure people have changed the titles, they always do – how does that work, how is it organised so that, you know, I might have one nurse saying “I want to wear that”, I might have a doctor saying, “I want to wear that”; how do you arrange that if everybody is allowed just to choose their own mask?
Professor Susan Hopkins: So we make those decisions every day in normal times, so for example, if I’m working in a ward and I’m seeing patients in the emergency department or on the ward, before I go in and see an individual patient, I assess whether I think there is a risk and what that risk is.
I have a variety of personal protective equipment, from aprons and gloves to a range of masks available, and that that is – there’s standard guidance that’s there, but you can always change what you are considering wearing based on the risk assessment.
I think one of the things for me that really is important, and I think we need to again highlight, is that some people’s either perceptions of risks or their real risks for their underlying conditions that they may have, or the fact that they are pregnant, might mean that they want a higher level of protection at a certain point in time to others, and we know that because right now when we interview healthcare workers, their perception of risk right now when they’re seeing Covid patients is very difficult – different than it was, and individuals right now make those risk-based decisions on a day-to-day basis. What we need to do is determine how we use the information that people have acquired in the last few years in the best way possible to inform not just a pandemic but management of patients with infectious diseases in hospital every day.
Lady Hallett: Thank you.
I think, Ms Sen Gupta, you have a few questions. You’re over there.
Questions From Ms Sen Gupta KC
Ms Sen Gupta: Thank you, my Lady.
Professor Hopkins, I represent the Frontline Migrant Health Workers Group. Our clients’ members include two particular categories of worker. First, outsourced non-clinical workers, such as cleaners, medical couriers, porters, security guards and taxi drivers, who were in precarious employment, including zero-hours contracts, on low wages, and include ethnic minority and migrant workers. And second, migrant clinical workers, such as Filipino nurses, whose visas prevented recourse to public funds and whose leave to remain in the UK was contingent on their continued employment.
I’m going to provide some brief context by reference to your witness statement before asking you a few questions.
At page 57 you included a quotation from the Environmental Modelling Group paper produced on 11 February 2021 as follows:
“There is a clear interplay between occupational risk of SARS-CoV-2 transmission and socioeconomic [inequalities], which reflects the amplifying effects between the working environment, crowded housing, job insecurity and poverty.”
At paragraph 439 of your statement, and as just referred to by Ms Carey, you note that the PHE report published in August 2020 found a high risk of dying among those living in the more deprived areas than those living in the least deprived, and in black, Asian and minority ethnic groups than in white ethnic groups.
Now, against that context, when PHE and UKHSA were producing guidance during the pandemic, as described at section 3 of your statement, what specific consideration was given to the protection of outsourced non-clinical workers?
Professor Susan Hopkins: Thank you. So I think that, firstly, when we were providing guidance we were doing it for the public at large, so – as well as the individual in IPC guidance for healthcare workers that’s here. In developing our guidance for the public, we looked particularly at the public sector equality duties –
Ms Sen KC: I’m sorry to interrupt, we have very limited time, I’m not asking you about the public, I’m asking you specifically about outsourced non-clinical workers, and specific consideration that was given to that group.
Professor Susan Hopkins: So I think I would say that the – all of the workers that worked for the NHS or in the NHS, if that’s what you’re asking, were included in the guidance. There was no group that were excluded.
Ms Sen KC: What about specific consideration being given to the protection of migrant clinical workers?
Professor Susan Hopkins: So, again, that would have been included as part of the public sector equality duty rather than specific groups.
Ms Sen KC: So neither of those groups were given specific consideration; is that right?
Professor Susan Hopkins: I think they were included in general considerations.
Ms Sen KC: Thank you.
Is it right that the provision of PPE to outsourced non-clinical workers was not specifically considered by PHE, UKHSA?
Professor Susan Hopkins: So when the guidance was written, it included any staff that were employed or delivered care or worked in the NHS. It was not particularly for outsourced or insourced. So if they provided a care pathway for the NHS, then they were considered included in the guidance.
Lady Hallett: Ms Sen Gupta, you asked permission to swap a question, you have permission if you wish to do so.
Ms Sen Gupta: I’m very grateful, thank you, my Lady.
Professor Hopkins, was any specific consideration given by PHE/UKHSA to destitution and deportation as potential consequences of self-isolation for low-wage outsourced workers and migrant workers?
Professor Susan Hopkins: So we discussed with the government to ensure that people would be able to isolate, we discussed with the government the ability to create self-isolation payments, and we worked with the local authorities to support individuals who needed to isolate.
Ms Sen KC: Thank you. In relation to a question about disparities that CTI just asked you this afternoon, you used the phrase “culturally appropriate messaging, involving black and minority ethnic groups”. You appeared to suggest that it is for black and minority ethnic groups, rather than the healthcare system, to change their behaviour in order to reduce the risk of death.
What did you mean when you referred to “culturally appropriate messaging, involving black and minority ethnic groups”?
Professor Susan Hopkins: So I did not mean, if that’s what is perceived, that I thought that there was differing messaging or messaging about changing their behaviour. I think what I was recognising is that there are groups of individuals who live in multigenerational households, in different situations, and that therefore their risk in those households was different, so just to clarify that.
In terms of messaging, one of the things that we do as an organisation, and we did during the pandemic, is something called co-creation, so where we work with different groups and sectors for guidance to ensure that the guidance is understood, that the guidance works for them, that they can understand it and they can deliver it, and that they provide feedback on the words that we’re using to ensure that the language, the messaging is understood by very wide groups in the population.
Ms Sen Gupta: Thank you, my Lady.
Lady Hallett: Thank you, Ms Sen Gupta, I’m very grateful.
Mr Thomas.
Mr Thomas is also over there.
Questions From Professor Thomas KC
Professor Thomas: Good afternoon, Professor Hopkins. I hope I can be heard; yes?
Professor Susan Hopkins: Yes.
Professor Thomas KC: I represent FEMHO, the Federation of Ethnic Minority Healthcare Organisations, and just so you know, FEMHO is particularly focused on the unequal impact that Covid had on the black, Asian and minority ethnic healthcare workers.
As you know, and have given evidence this afternoon, these workers were disproportionately affected by the pandemic, facing higher infection rates, higher mortality rates, and greater challenges in accessing appropriate protective equipment.
My first question, I’ve got a handful of questions and I’ve got a short period of time to do it, so I’ll try to be focused. My first question is this: when did you first become aware that there was an issue of disproportionate infection and death amongst black, Asian and minority ethnic healthcare workers and patients?
Professor Susan Hopkins: So I think that was a gradually evolving situation from stories that were being told to us and the NHS throughout late March 2020 and into April 2020.
Professor Thomas KC: Okay. Given the known disparities in the Covid-19 outcomes amongst these ethnic minority populations, help me with this: what specific measures were taken to address these disparities early in the pandemic response?
Professor Susan Hopkins: So I think the first thing I would say is that one of the reasons why we were worried about some of the transmissions and the very sad deaths that we saw in those first weeks were that we believed that people needed to have more access to fluid-resistant surgical masks to prevent transmission in healthcare settings, which was the reason for the guidance in April 2020, because of hearing about healthcare worker to healthcare worker transmission, about hearing about clusters of infections. So that was very much the step change. That was unprecedented at the time that we would ask everyone to wear a face mask to reduce the risk of transmission.
Subsequently, the NHS, as the lead employer, worked with some of the team members in Public Health England to develop a risk assessment approach and to consider the approaches that needed to happen at individual organisations by the organisations who employed people.
Professor Thomas KC: I’m going to come on to that in a moment. Okay, thank you for that.
What, if any, were the lessons learned from observing and addressing this disparity, and how did these inform any adjustments or improvements in the ongoing pandemic response?
Professor Susan Hopkins: Well, I think the pandemic response changed at all times in many different ways. I think first of all talking and being clear about it, releasing the disparities report and being very open about the data was one of PHE’s central roles in this. Convening groups, talking to community groups, talking to groups of people who were affected, understanding how they were infected, improving the information that was being provided.
And finally I think, in relation to vaccination, very much working with community groups and organisations to – that had been affected by Covid-19 and – throughout 2020 to ensure that vaccine was available in different sites and centres in different ways that they would be enabled to receive the vaccine as soon as possible.
Professor Thomas KC: Let me move on. I want to now turn to the public sector equality duty and the health inequality assessment on PPE. Okay?
So, as regards the public sector equality duty and the health inequality assessments by Public Health England and the UKHSA on PPE – and for your information you discussed this in your witness statement at paragraph 376 – the first question is this: can you clarify what the health inequality assessment for PPE guidance included beyond the June 18, 2020 guidance?
Professor Susan Hopkins: So the public sector equality duty looks at the elements that we can look at for public – age, gender, sexuality, ethnicity, and equalities and disability. Where those were assessed by the teams performing and developing the guidance, they looked at the range that they could do and they assessed whether there was an inequality by the essence of the guidance or how that could be addressed in different ways. And so the issues were often that some elements of that could not be addressed because there was no evidence, but where there was evidence those were addressed by particular statements in the guidance.
Professor Thomas KC: Again, on the same page at – sorry, same paragraph, paragraph 378, you suggest that there was no unlawful discrimination based on factors such as race and ethnicity. Question: was there a specific health inequalities impact assessment on race, ethnicity, and if not, why wasn’t this done, especially given the known vulnerabilities of ethnic minority healthcare workers?
Professor Susan Hopkins: So race and ethnicity would be included in a standard assessment, so would have been included in all of the public sector equality duty assessments that were carried out, rather than performing it separately.
Professor Thomas KC: You mention at paragraph 378(b) and (c) that facial hair for religious or cultural reasons impeded the effectiveness of PPE. Question: do you think that just merely providing guidance on suitable facial hair was adequate, given how critical PPE fit is for those workers? Couldn’t more have been done to ensure that they were properly protected?
Professor Susan Hopkins: So there was, in the guidance, also reference to the respirators, but that required access to the respirators. I think the importance about some of the pictures that were there to help share with people what sort of facial hair was able to be worn with traditional FFP3s were there to assist people.
My understanding at the time was that individuals, if they were not able to be fit tested for certain roles, would then be supported to find alternative respirators that could be used or alternative roles where they would be able to deliver their clinical role in a different role not requiring the particular mask that they had tried on.
Professor Thomas KC: Just help me, so let me just step in here, I mean to say, when I say couldn’t more have been done, could I just suggest a few things and you can tell me whether they were considered.
So, for instance, active outreach, proactive communication with healthcare providers, training and fit testing, employer accountability in issuing clear guidance to employers about their legal duty to provide suitable and adequate PPE for their staff, stockpiling alternative PPE.
So when I say couldn’t more have been done, I’m talking about those sorts of measures. Would you agree?
Professor Susan Hopkins: So I think fit testing was done, and – for example, fit testing was done and performed on a range of different masks and a range of different respirators, depending on what was available. Guidance was really clear that there was an employer responsibility, and this is not an employer responsibility just for the pandemic, it’s a responsibility that exists today and a responsibility that existed beforehand.
And I do agree that when we’re planning for stockpiling, we need to plan for a range of masks and a range of respirators, if that’s what we wish to do, that will fit a variety of different faces, including a variety of different facial hair.
Professor Thomas KC: I’ve nearly finished, just a couple more questions.
Let me come on to the Public Health England disparity 2020 review. Question: do you accept the evidence presented by the experts to this Inquiry, that’s Professor James Nazroo and Laia Bécares, that the higher infection and mortality rates amongst black, Asian and minority ethnic healthcare workers were directly linked to their overrepresentation in high-risk roles and greater exposure to Covid-19 patients?
Professor Susan Hopkins: So I think that’s not just in healthcare but in many other settings as well. I think that it’s really important that healthcare workers in the UK are extremely diverse, come from many different countries to work here, and we need to recognise all of those different ethnicities and enable them to do their job well and safely.
I think that it’s also important to recognise that there are many other occupations, particularly in some urban centres, that are dominated by ethnic minorities and recent migrants, and we need to ensure that we look at that across the whole society.
Professor Thomas KC: Well, I’m grateful for that response and, whilst I accept what you say, Professor, this is my next question: given the clear data that there was very early on, as – late March, as you’ve just indicated, do you not agree that there was a delay in responding to these findings? It’s right, isn’t it, that more should have been done at an earlier stage to address the risks to these communities? Can we agree on that?
Professor Susan Hopkins: I would say yes, we can agree that more should have been done for lots of things, and should continue to be done.
Professor Thomas KC: Well, I’m not talking about lots of things, I’m being very specific, because we’re here in this Inquiry looking at healthcare.
Professor Susan Hopkins: Well, I think more could be done for healthcare workers then, but I also think it’s important that more can be done on an ongoing basis to improve health and care provision.
Professor Thomas KC: What do you make of the criticisms, how do you respond to the criticisms such as those made by Professor Khunti that the Public Health England report failed to offer clear actions or timeframes to address the greater risks faced by ethnic minority communities? Can we agree on this: this was a missed opportunity, wasn’t it?
Professor Susan Hopkins: So I think that the report that we commissioned at Public Health England was to provide a description of these disparities. There were separate – a working report and a separate report that looked a lot more about the engagement and the community engagement exercise that took place, and a lot of work that went on with organisations to improve and deliver actions related to the disparities. The report that was presented here is the report describing what those are, to define the way forward.
Lady Hallett: I’m afraid I’m going to have to ask you to stop, I’m really sorry, Mr Thomas.
Professor Thomas: I’m grateful, my Lady.
Lady Hallett: Ms Gowman.
Questions From Ms Gowman
Ms Gowman: Professor, I ask questions on behalf of Covid Bereaved Families for Justice Cymru, the Welsh bereaved.
You state at paragraph 93 of your statement on the issue of testing that:
“A UK-wide approach was agreed [as] the most effective way to manage epidemiological and response arrangements to break the chains of transmission”.
Just for some context, before I get to my questions, we know that in fact in Wales and England there was a divergence of approach in respect of the issue of testing, particularly in relation to testing of healthcare workers and patients during the pandemic.
I’ll provide one specific example where this was felt particularly acutely. In November 2020, the UK Government introduced twice-weekly routine testing of all healthcare workers in England. In contrast, the Welsh Government did not introduce routine testing of all healthcare workers until January 2021, with roll-out in fact not happening until much later, closer to March 2021.
So turning to my questions with your comment at paragraph 93 firmly in mind, do you consider that divergence between England and Wales on the approach to the testing of healthcare workers negatively impacted on the effectiveness of the UK-wide epidemiological and response arrangements?
Professor Susan Hopkins: Thank you. So I think, first of all, as you know, as we’ve said previously, health and public health are devolved but we try to maintain consensus as much as possible. We were very keen to roll it out in England and had been for some time. I think that Wales made a decision that they thought there were other interventions they wished to do before this, but agreed with the early evidence that we had that it was providing an effective route to reduce transmission from healthcare worker to healthcare worker.
I think that rapid diagnostic tests were new, there was a lot of controversy about them, as somebody who was very much involved in their roll-out and development and evaluation, and actually it took time for people to believe in them and that they were a useful intervention.
And I think that some delays in rolling them out were understandable because of the evidence that was emerging, but we also had – and I believe that the faster roll-out of them will definitely have prevented infections, though I would also recognise that people with symptoms who were healthcare workers or otherwise had widespread availability of PCR tests at that point, and so a lot of detections would have been through those methods.
Ms Gowman: I think you’ve answered my second question in respect of co-ordination as well, so I’ll move straight on to my final question on that topic.
Do you have a view on which of the two nations’ approaches to testing, particularly in relation to asymptomatic healthcare workers, would have been most effective in breaking the chains of transmission?
Professor Susan Hopkins: Well, I think the reason why we pushed so hard to develop rapid antigen testing, to develop them and evaluate them and then introduce them into practice, was we recognised that asymptomatic infection was occurring and asymptomatic transmission was occurring, and this was a major intervention to reduce people who were asymptomatic. About half the people at that point were asymptomatic, and at least half of those people were transmitting with asymptomatic infections, or that’s what we were seeing in the data, and therefore I believed that rapid antigen tests – and I still do – had an effective role in reducing transmission. And, therefore, if we had introduced them earlier, it would have had a greater impact, delaying them may have reduced the size of their impact, especially when we had such widespread transmission in December 2020.
Ms Gowman: So do I take it from that answer that the basic answer is that you think that the English approach was better than Wales?
Professor Susan Hopkins: I think that we may have disagreements in different countries. My view is that the English approach to testing widespread healthcare workers was the appropriate approach for us at that time.
Ms Gowman: At that time. Thank you, Professor.
Thank you.
Lady Hallett: Thank you, Ms Gowman.
Ms Hannett, where are you? You’re right over there.
Questions From Ms Hannett KC
Ms Hannett: Professor Hopkins, I act on behalf of the Long Covid groups, and I have a number of questions about data gathering and surveillance of Long Covid by both Public Health England and UKHSA.
Can I deal first with PHE. Did PHE gather data on Long Covid?
Professor Susan Hopkins: So we routinely did not gather data on Long Covid because it was very difficult to determine. We utilised two sources of the main data. One was the collection from ONS that looked at the individuals who had prolonged symptoms in the community, and the second was the SIREN study in healthcare workers where we did regular surveys to ask people how long their symptoms had lasted.
Ms Hannett KC: Could I just follow up on that, because in January 2021 Public Health England said in a note to the CMO that they had recruited staff to support the development of surveillance on post-acute Covid-19 syndromes; did that not come to be implemented?
Professor Susan Hopkins: So that was part of the studies we were doing with ONS or through the SIREN study in healthcare workers. We did also try and recruit individuals but that actually didn’t work out so well as the majority of individuals were already delivering – or attending hospitals, and the main role to understand Long Covid needed to be clearly delineated in hospitals.
Ms Hannett KC: Sorry, Professor, could I just clarify that. Are you saying you tried to recruit individuals through the SIREN study in healthcare workers to look specifically at Long Covid, but that that didn’t work out?
Professor Susan Hopkins: No, we only had survey data from them rather than anything else.
Ms Hannett KC: Right. Can I just ask, then, one further follow-up question on that. Why is it, then, that Public Health England didn’t collect data on Long Covid even though it collected data on Long Covid – sorry, let me start that question again.
Why didn’t Public Health England collect data on Covid – Long Covid even though ONS was collecting it, even though it collected Covid data when ONS was collecting it? In other words, collection by ONS wasn’t a prohibition to the collection of data in respect of Covid-19 itself?
Professor Susan Hopkins: No, but ONS study was at that point being funded by PHE and UKHSA and very much involved those teams. It was the largest study of its kind globally to look at individuals and follow them over time, and so that was – and a very important part of what we do is trying not to replicate it.
Secondly, the other major source of where we collect data from is routine data that is collected at either the primary care or the secondary care level and there was not routine coding that we would be able to analyse the data that was already being collected to understand who had Long Covid in those settings, and there still isn’t standardised coding to allow us to understand that.
Ms Hannett KC: Can I just follow this, so in terms of UKHSA, does the position remain the same in respect of the UKHSA collection of Long Covid data, ie that it doesn’t itself collect data on Long Covid?
Professor Susan Hopkins: So it doesn’t itself collect new data. What it’s doing is trying to ensure that any data that’s available in primary care records, in secondary care records, where people have consented for their sharing of the data, or from any studies, is brought together to understand the impact of Long Covid, but actually the predominant data collection for Long Covid is happening in the NHS, in the NHS-funded clinics.
Ms Hannett KC: Can I ask whether that’s satisfactory from UKHSA’s perspective, given that it’s not possible for you to effectively understand the extent of the disease burden without understanding how Long Covid is presenting in the community?
Professor Susan Hopkins: So I think it’s really important to understand that we require clear definitions of what to survey, clear ways of coding that data within the health system records in order for us to perform surveillance. Those studies, funded by the National Institute for Health Research, are still ongoing, and it’s those studies that will allow us to provide estimates in the population rather than needing to require to collect data from every single individual.
Ms Hannett KC: Professor Hopkins, can I just go back to the SIREN study and can I ask whether the SIREN study looked at all at the effects of Long Covid on healthcare workers?
Professor Susan Hopkins: Yes, it has, and we have a publication that will be coming out shortly, which I’m very happy to share with the Inquiry in due course, which is looking at the proportions of staff that had symptoms of more than 12 weeks for a wide range of symptoms and at each of the variants – at each of the times of different variants throughout the pandemic, and the time off work that people have had or the amount of people that have changed their job.
We’ve just finished the analysis and I’m very happy to share that.
Ms Hannett KC: Then my final set of questions, Professor Hopkins, concerns future pandemic planning by UKHSA. Have plans for monitoring and surveillance of any potential long-term sequelae for a novel virus been incorporated into future pandemic planning?
Professor Susan Hopkins: So, again, I would say that when we understand the effects of the longer term consequences and how we can measure those is considered, I think that again that what we really need to do is understand what the size of the study needs to be to understand the problem, like the ONS study or like the studies that are now being funded through NIHR.
UKHSA’s role will be to ensure that all of the data that’s being collected by other studies is available, if needed, to collect additional data but I think there are a range of studies that would depend on the infection and the consequences of the infection that would require research funding in the first instance to provide consent from individuals.
Ms Hannett KC: So is the answer presently no?
Professor Susan Hopkins: So there is presently a research framework to collect data and that research framework is funded by government. UKHSA is not a research funder but we would be contributing to that research framework to ensure that the studies are available.
Ms Hannett KC: So you agree that it’s important that they should be in due course?
Professor Susan Hopkins: It’s important that they are studied so that we understand them better.
Ms Hannett: I’m grateful.
Thank you, my Lady.
Lady Hallett: Thank you, Ms Hannett.
Right, I think we have Ms Jones.
Questions From Ms Jones
Ms Jones: Thank you, my Lady.
My Lady, there might be two Ms Joneses. Who were you expecting to hear from?
Ms Carey: It’s the John’s Campaign Ms Jones.
Lady Hallett: I thought that went without saying but anyway. Ms Jones?
Ms Jones: Thank you, my Lady.
Professor Hopkins, I represent Care Rights UK, the Patients Association and John’s Campaign, all of whom represent individuals drawing on health and social care and their loved ones.
Our question for you today is about the PPE guidance that was published in April 2020 and which you have referred to in your evidence as introducing enhanced PPE recommendations across different health and social care settings.
When this guidance was formulated, did Public Health England consider the needs of patients with particular disabilities or additional needs and what, if any, consideration was given to the potential detrimental impact on those patients of healthcare staff being required to wear certain forms of PPE?
Professor Susan Hopkins: Yes, we did discuss and consider it. At the time there’s the challenge of particularly communicating with people who are older, people who are hard of hearing, people who require lips to be able to read people, and the balance at the time was that that was really important and that we needed to continue to look and see what alternative approaches would be available in the future, but that the predominant reason to do it was to reduce transmission of the virus and that this was really important in those settings.
Over time, new masks became available with a see-through component in it and those were also then included as possibilities in – for organisations to consider.
Ms Jones: Thank you, Professor Hopkins. That’s my only question.
Lady Hallett: Thank you, Ms Jones.
Further Questions From the Chair
Lady Hallett: Right, I’ve got a couple of questions the Disability Charities Commission have asked me to put to you and, given the time, I’m going to do it and I’m going to do it quickly.
In June 2020, the ONS published its finding that a disproportionately high number of disabled people were dying of Covid-19 and Public Health England published its updated review in August 2020. The question is: you knew by then, because of the ONS study, that a disproportionately high number of disabled people were dying, why wasn’t disability recorded as one of the disparities?
Professor Susan Hopkins: As I said earlier, disability is not routinely recorded in notes that we could see and required detailed healthcare records and that was something that came through and then was utilised for things like the QCovid score later but was not available to us for routine daily analysis of data.
Lady Hallett: So it wasn’t available at the time –
Professor Susan Hopkins: And it’s still not available.
Lady Hallett: Right. Should it be?
Professor Susan Hopkins: Well, again, it comes back to what data should be made available and, personally, I think that, again, this will require individuals to consent that this data is made available and that we have a way of understanding what the disabilities are. The best way to do that would be through GP records made available to national organisations but that’s something that’s under discussion.
Lady Hallett: Thank you very much. I’m sorry, now I understand the confusion. I hadn’t realised it. I’ve got there. I may be being a bit slow at the end of the day.
Thank you very much indeed for your help, Professor Hopkins, I appreciate it’s been a long day for you and I’m sorry about the number of times we had to ask you to speak more slowly but it’s what happens, I’m afraid.
Thank you for your help and I shall sit again at 10.00 tomorrow.
(The witness withdrew)
(4.38 pm)
(The hearing adjourned until 10.00 am on Thursday, 19 September 2024)