Transcript of Module 3 Public Hearing on 26 September 2024.
(10.00 am)
Lady Hallett: Ms Carey, I understand the next witness is
Professor Fong. Some details of his evidence may well
be distressing, not only probably to the witness himself
but also to those who are following our proceedings. We
expect it to contain descriptions of end-of-life care
and the management of those who died. So those in the
hearing room who feel they will be too distressed, please leave now, and those who are watching online, if you wish to do so, please pause the live stream.
Ms Carey: Yes, thank you very much, my Lady. May I invite now, please, Professor Fong to be sworn.
Professor Fong
PROFESSOR FONG (sworn).
Questions From Lead Counsel to the Inquiry for Module 3
Ms Carey: Professor Fong, your full name, please.
Professor Fong: I am Kevin Fong.
Lead 3: You are a doctor employed by University College London Hospitals NHS trust as a consultant anaesthetist, is that right?
Professor Fong: That is correct.
Lead 3: You also work as a helicopter emergency medical service doctor for the air ambulance charity in Kent, Surrey and Sussex?
Professor Fong: That is correct.
Lead 3: I think you have a dual specialist accreditation in anaesthesia and intensive care medicine, and you have been in practice now for some 26 years?
Professor Fong: That is correct.
Lead 3: During the pandemic, is this right, you were seconded to NHS England as a national clinical adviser to the emergency preparedness resilience and response core, EPRR as we have been referring to it, and it is about that that I would like to ask you some questions.
I think also though, as well as working in the EPRR capacity, you took on clinical roles, including clinical shifts at UCLH and indeed in critical care transfer, so one hospital to another, throughout the southeast of England; was that by road and air?
Professor Fong: By road and air, yes.
Lead 3: The questions I want to ask you this morning really focus on your role in what are called peer support visits for intensive care units, and I think you say in your statement that you were responsible for organising and leading a programme of visits into hospitals that were experiencing severe pressure during the pandemic. This was across England, is that right?
Professor Fong: That is correct, yes.
Lead 3: And how long did the visits programme last?
Professor Fong: So formally the programme ran from around the summer
2020 all the way through until July 2021, when
administrative support was ceased. They continued in
other forms after that but that was the formal
programme.
Lead 3: Over the course of that period how many visits did you
personally undertake?
Professor Fong: I personally led and undertook more than 40. I lost
count.
Lead 3: All right. I think the visits had their genesis, is this right, when you received a message in March 2020 from a colleague at a general hospital – district general hospital that was experiencing a significant surge. So can we start there, please, Professor. Just tell me, what did the clinician tell you about what was going on in their hospital?
Professor Fong: So at that time I was aware that they were experiencing pressure when I contacted one of the clinicians working on the shop floor. They told me that their ICU was full, that they were overflowing with patients, that they were running out of staff, that they were running out of basic consumable items, and that included drugs, equipment, that they were raiding their resuscitation trolleys, which are the trolleys that you usually keep for cardiopulmonary resuscitation if someone has a cardiac arrest, for things like – very basic items like bougies –
Lead 3: What’s a bougie?
Professor Fong: A bougie is a kind of flexible stick that you use to help intubate a patient to place a tube into their windpipe to help them breathe and establish them on a ventilator. They were raiding the trolleys for those items. They are very basic items. And – and for endotracheal tubes, tubes that you would place in the windpipe to establish them on a ventilator.
Lead 3: Were you surprised to learn that they were running out of such basic equipment?
Professor Fong: It was very early in the pandemic, it was quite a shocking account. They – I was surprised at the scale of the pressure they were facing and that the data had not captured that.
Lead 3: No, well, I was going to ask you that, and I ought to have introduced your statement, which ends 474327. I think you have a copy in front of you, Professor, if you need it.
You said there that what you had learnt appeared to be, your words, at odds with the data reports. What was the data telling you that was such at odds with what this hospital was telling you?
Professor Fong: The data – it was more that the data did not paint the picture of that severity of pressure: out of basic equipment, out of staff, insufficient staff, to staff transfers out to decompress your facility. And I felt that there was a gap between what we could understand by seeing numbers on screens and what was actually happening when you spoke to the people on the ground.
Lead 3: I think you said that that clinician told you that they had insufficient intensive care and anaesthetic medical staff to be able to transfer patients out?
Professor Fong: That is correct.
Lead 3: Given that you had been involved in transfers, how many doctors and nurses does it take to conduct a transfer from one ICU to another?
Professor Fong: So it is a specialist skill, you usually require at least one specialist intensive care nurse and an intensive care doctor or anaesthetist who is specially trained to conduct these. They are not without risk, they are difficult to do, there’s risk to the patient, there’s risk to the staff.
Lead 3: In short, were you invited then to come and see what it was like in the hospital?
Professor Fong: At that time, no. At that time it was just the realisation that perhaps there was a gap between the data and the information and the insight. You know, data isn’t information, information isn’t insight, and I – given that so much of this depended upon understanding how much capacity there was in the system, I identified that as a problem.
Lead 3: Can I ask you about your first visit, please, and I think you deal with this starting at your paragraph 15 in your statement.
I think you talk there about visiting what you describe as:
“… one of [the] UK’s hardest hit hospitals for ICU COVID-19 Covid admissions, relative to baseline critical care capacity.”
Can you put that into layman’s speak for us.
Professor Fong: Yes. So on this occasion I was aware that this hospital was already under pressure. I had contacted them and they said – and I said “Please tell me what’s going on”. And in the end the clinical lead, who I knew personally, said “It’s much easier if you come and see it.”
When I talk about baseline capacity, that is the number of beds that that unit would have had pre-Covid. And that’s important because it determines the number of staff available to run that bed. An ICU bed is not a piece of furniture, it requires a specialist staff around it of many people.
Lead 3: And so this was an informal visit as a result of the offer, effectively, from the clinician you knew, is that correct?
Professor Fong: It was. It occurred to me that it might be useful for me to see that myself. And so I did indeed, I think one Sunday afternoon, visit that unit.
Lead 3: You say this was a hospital where a catchment area featured pockets of significant social deprivation, as well as black, Asian and minority ethnic communities, who we know were at increased risk of severe Covid if infected.
So could you tell us, please, what you saw on that first visit.
Professor Fong: Yeah, it was very memorable. I was greeted at the entrance by one of the intensive care registrars. I asked him immediately what things had been like. He replied – I will never forget, he replied “It’s been like a terrorist attack every day since this started and we don’t know when the attacks are going to stop.”
And I remember thinking that’s – you know, for them, that was not a hyperbolic statement, they’d admitted an average of eight intensive care patients per day during the whole of that period.
We went into the hospital. Their oxygen panel alarms, so the panels that show you the state of their oxygen supply, were alarming constantly. They led me down to an ad hoc intensive care area. Their intensive care areas were already full. So their baseline was already full and they had spilt out into their operating theatres.
Lead 3: This is, I think, April 2020?
Professor Fong: That is correct.
Lead 3: Can you give us an idea of what’s the noise like in an ICU when the oxygen is under stress – there are obviously other pieces of equipment – I just want to try and get a sense of what it was actually like.
Professor Fong: It is difficult to remember precisely what I was hearing. Intensive care units are noisy at the best of times but – they led me through this – I guess this plastic air lock that they had assembled with a zip and – you know, between the clean areas and the Covid areas. The operating theatres’ recovery was just – like nothing I had ever seen. An intensive care bed is supposed to have about 20 to 25 square metres. It’s the size of a very large living room.
Lead 3: Pick something in our hearing centre to give us an idea.
Professor Fong: It would probably be from here to that desk, to my Lady’s desk, and about that width. That’s about – 5m by 5m should be what it should be.
The beds were stacked in here so tightly that I had to squeeze between them. The patients were close enough that they would have been able to hold hands. The equipment was wedged between them. This looked like a unit that was in real trouble. It had already taken on its full intensive care unit capacity. It was in the ad hoc areas. It was in its theatre’s recovery, and the nurses were nursing at a ratio as low as 1:6 actually, at that time; one specialist care nurse to six intubated ventilated patients.
Lead 3: Can you help us: how long did you spend at this hospital, and then we will widen it to the other visits that you conducted. How long were you there for?
Professor Fong: So this was an afternoon’s visit where I had a look around at all of the different areas. And I think this – I talked to the staff on the shop floor, many of whom were already in tears, and I realised at this point that perhaps it would be better if we were able to do this ourselves and see these areas to understand what they were going through.
Lead 3: What were the nurses telling you?
Professor Fong: They were telling us that they couldn’t operate at this level, they – these diluted ratios, with one specialist ICU nurse covering four or six patients at a time.
I remember in another hospital the nurses telling me that all you have time to do is to manage the alarms; you’re not managing the patients. The alarms are going off constantly – the syringe drivers, the ventilators, the beds, whatever you’ve got, the oxygen, and you’re putting out fires, rather than caring for the patient.
Lead 3: When you came away from that visit, what did you resolve or decide to do?
Professor Fong: I think it reinforced my sense that there was a gap between what the data could tell us and what we could understand by talking to people or actually being there. I think the data were important and necessary, but they weren’t sufficient alone to give us a good picture of what the state of compensation or decompensation of these units was, and so after that, I felt that we had to have mechanisms that would better inform us, to give us the information, to give us the insight.
Lead 3: I think you say in your statement that acute hospitals have to complete a return on a daily basis with their data, and you say that’s an onerous task, and you make this observation: that the quality and completeness of the data return reduced when the hospital, the unit, was under severe operational stress, and presumably therefore you had the best data from those hospitals that weren’t under that degree of pressure?
Professor Fong: That’s correct. The data collection forms at first were incredibly onerous, so much so that the nursing staff who were already pressured were coming in, in their spare time to complete them and return them. And it was clear – we plotted the data. It was clear that those units under the most stress provided the poorest data returns, and indeed until the point that they became so operationally stressed that they provided no returns at all. So those that you wanted to know the most about were least likely to return in first wave.
Lead 3: Can we be clear, the data return, is that a requirement placed on them by NHSE?
We have also heard about ICNARC data, and I just want to be clear about who requires this data to be provided.
Professor Fong: So those data sets are separate, but there was a requirement centrally from NHS England and/or the regions in addition to the ICNARC data which is routinely collected for, I think, all the units now.
Lead 3: Okay. You decided then that there needed to be this programme set up, and I think you say that:
“The visiting team [either you and/or the rest of your colleagues going on them] would comprise up to four doctor and nurses drawn from a unit of a similar size and scope in another region.”
And just tell us now, over the course of your 40-plus visits, how long were you at the ICUs for?
Professor Fong: So, each visit, we would turn up, depending on geographically where they were, as well as you could in the morning, that was usually, practically speaking, nine or ten o’clock in the morning. We would stay for a full day. It was important that this wouldn’t be a cursory flyby of a visit. It was important that we had time to embed with them, to put on PPE, to get onto the shop floor with their people on their units, and then to spend the back half of the day in conversation, so that would be all five hours of conversation afterwards with whoever would talk to us.
Lead 3: And when you spoke to the staff, what kind of roles were they were performing? What levels of staff did you speak to?
Professor Fong: So, we made the offer open to the unit we were visiting. Sometimes we would only talk to the doctors and nurses; sometimes they would give us everybody. They would – we would talk to the doctors, the nurses, the allied healthcare professionals as well, the occupational therapists, the dietitians, the physiotherapists, all of these people who are required to run an intensive care unit, healthcare assistants. It was really up to the unit how they wanted to use us as a resource.
Lead 3: Did you ever speak to any non-clinical staff during your visits?
Professor Fong: So, if by “non-clinical staff” you mean neither doctors nor nurses, then yes. As I mentioned, the allied healthcare professionals who are also clinically active. Healthcare assistants. I think at one or two hospitals, we did speak to some of the porters and some of the cleaning staff.
Lead 3: May I ask you this: what was the sort of purpose of going in and visiting these hospitals? What was the aim?
Professor Fong: It was twofold. First and foremost, it was to provide support for these people. We designed them very carefully. It took effort to design these visits. They were informal. They were peers, so we would take doctors and nurses from similarly sized hospitals from another region in to see a mirror image of themselves elsewhere so that it would encourage discussion and sharing of information.
So the first, foremost was to provide support for these people, to allow them to spend some time reflecting and – with us, and learning, you know, if there were different ways to do things.
And then, secondarily, it was to try and close this information – this gap between information data information and insight so that I could go back to the emergency preparedness resilience and response team and report in and give an accurate picture of what we were dealing with.
Lady Hallett: Sorry to interrupt. Can I just go back to the data gap, Professor Fong.
Presumably, if you have that gap, what you were hearing and seeing is dismissed as anecdotal because the data is not showing it? “Dismissed” may be too pejorative a word.
Professor Fong: Yes. There is understandably, you know, this value that we attribute to stuff that you can count. But, you know, in their famous words, not everything that counts can be counted. And for me, if we were talking about the capacity available in these units, then we had to understand this anecdotal picture. This picture is a complex assessment of a complex system, and that’s why I was taking the teams in.
The doctors and nurses who came with me are system experts. They are able to see with their own eyes and have an assessment of what is happening.
Ms Carey: I think you said you spent more than 400 hours during the course of your visits in conversation with the frontline teams.
Are you aware whether there’s any – there were any similar visits or programmes run in Scotland, Wales and Northern Ireland?
Professor Fong: I was contacted by representatives from several of the other nations. We were NHS England, and so my role was an NHS England role, and the programme was an NHS England programme.
We were unable to offer visits outside of England at that time. We discussed with the four nations what we were doing. We had requests, but we didn’t have the resource to fulfil them, and I am not aware of any similar programme in the other nations.
Lead 3: And can I ask you this: you’re going into ICUs, as I understand it, that are under the most extreme pressure. Is there any sense that you, by visiting, might have added to the burden that the unit was under?
Professor Fong: So this is one of the things that we thought about really carefully, that we must not add to the pressure they were already under. And that was part of the crafting of this product, was to make sure that they didn’t feel like this was some surprise inspection by NHS England, that we were going in to support and give them time to share, and it was why it was important that it was peer support, that it was people who understood the pressures that they might be under. And, you know, it was very carefully crafted so that we would not add to the burden, and it was designed so that it should have been a positive experience for them as a unit.
Lead 3: In your statement, you have set out in particular 14 visits out of the 40-plus that you conducted. I’m not going to ask about all of them, but I would like to ask a little detail about some of them, ideally across the waves, if I can put it like that.
Can I start, please, with what you experienced and saw when you went to hospital 2, which was December 2020.
I think you said there that it was a large teaching hospital, had 32 critical care beds, normally run at a capacity of 30, and you went there I think that autumn; is that right?
Professor Fong: That is correct.
Lead 3: And how many beds were they running during the first wave that they told you?
Professor Fong: So this was a large teaching hospital that usually ran at 30 beds. At the peak of the first wave, they’d got to 55. So those numbers don’t mean very much, do they? But what it means is that the resources they would have to run 30 beds were stretched to nearly 200 per cent, nearly twice their capacity, and because it’s not about the physical bed space, because it’s about the people who are trained to deliver that critical care, that’s a massive stretch for them, and they had certainly felt it.
Lead 3: I think you said they had declared a critical incident. Just tell us what does that mean? What’s that an indicator of?
Professor Fong: So by the time of our visit, and part of the reason that we went in with the team, we took in a team of four that day, they had recently declared a critical incident. Which is to say that they were unable to maintain an acceptable standard of care without resort to extraordinary measures. And in the case of this, the declaration of that incident facilitated what we call a decompression of the unit. They transferred out a large number of patients over a very short space of time. And if I recall correctly, it was 28 transfers in ten days, which is unprecedented in any – outside of Covid it is an unprecedented number of transfers to undertake in that period of time.
Lead 3: When you went to the visit, what were the nurses and doctors telling you about how it had been either in the first wave or now coming up into the start of wave 2 in reality?
Professor Fong: So they were in massive trouble. They had transferred a large number of patients out just to keep their heads above water. We got into PPE. We got onto the shop floor. The doctors and the nurses, and the nurses in particular, were really in trouble and the accounts are very, very distressing. They were telling us that, you know, for them the surge had started, you know, earlier in the autumn and it was beginning to crescendo for them. So – but their accounts were really of just barely hanging on and only just managing with this massive transfer out of patients.
Lead 3: Did they say anything about how the first wave was for them as compared with how they were experiencing the second wave? Better, worse? Were they better equipped to deal with it because they had been through it before?
Professor Fong: So it was mixed. They said they had learnt lessons and were better equipped, but a lot of the adrenaline had gone from the first wave. They said a lot of the support from elsewhere, redeployed staff, had gone, and they felt that actually their public support had started to go by the second wave, they felt that they had been forgotten. And one of the comments I remember is one of them said “The first wave felt like everybody’s war and this feels like nobody’s war.”
Lead 3: Did they say anything about how the trust or the management of the hospital responded? Was there any positive comments?
Professor Fong: So at this particular hospital there was an excellent partnership between the senior leadership at that trust who formed a link between the unit and the regional response teams. It was partly through that leadership that an effective and efficient decompression was achieved, which is what saves the unit in that moment.
Lead 3: I think you spent some time at hospital 2 speaking to the lead ICU matron. I would like to ask you about that, please. It is your paragraph 65.
There is a number of quotes there but just stand back for a moment, Professor, and just tell me what’s your overriding recollection of your conversation with that matron?
Professor Fong: I think that this was the point at which I really realised that it was going to be difficult as we came into this winter. This was, you know, one of the most effective clinical leaders I have ever met and she was very clear that she was trying to look after her staff, she was trying to protect her staff at the same time as delivering care.
It says in my notes that, you know, they didn’t have enough staff to look after the patients coming through the door. They experienced the full range of challenge. They had a unit in which they had to admit at times several of their own members of staff from their own hospital, and some of those people from their own hospital did die, and she told me about how difficult that was. To be a unit, to admit your own staff, to look after your own staff in the middle of all of this, and to watch them die is devastating. They were not alone. They were not alone in that.
Lead 3: I think she told you that they ran out of physical bed spaces and had to resort to putting two patients into one bed space?
Professor Fong: That’s correct.
Lead 3: And she said there that they ran out of normal ventilators and pumps and had to sometimes make decisions about which patients could be taken off a ventilator for a period of time or who could manage a little longer on high flow oxygen without advanced respiratory support. Does that happen sometimes in normal times? I hesitate to use that phrase.
Professor Fong: None of that happens outside of Covid. And this is the thing about intensive care, and we were told this often by different hospitals: intensive care is about the detail. They train you to pay attention to the detail. And for the clinical staff involved, for the whole team, it is about being able to throw the – you know, the kitchen sink at your patient, the cutlery, the crockery, everything at them, and, when that doesn’t work, to be there at the end, to give a good quality of death and to be there for their family afterwards. And for these people, they were unable to do that, and the moral injury that followed from that is very clear, that they are trained – they knew the difference between what they should – could – they should be delivering and what they were delivering, and that was very injurious.
Lead 3: Right. I think you said there that the matron told you it was harrowing for the family but also for the nurse who was unable to provide any comfort to the relative. We perhaps sometimes lose sight of that in the desire to treat the patient but the role that is played at the end of life by ICU staff is obviously important as well.
Help me about what the matron said about the scale of death that they had observed in that unit.
Professor Fong: Yes, and this is one of those things that is really very difficult to capture in figures. The scale of death experienced by the intensive care teams during Covid was unlike anything they had ever seen before. They are no strangers to death. They are the intensive care unit. They look after some of the sickest patients in the hospital. But the scale of death was truly, truly astounding.
I went into this and other hospitals where they said it would be routine to see three to five deaths a day. I worked on a shift where we had six deaths in a single shift. Another hospital told us that they had ten deaths in a shift, two of whom were their own staff.
We had nurses talking about patients raining from the sky, where the nurses said that they – one of the nurses told me that they’d just got tired of putting people in body bags, and at the hospital where they said sometimes they were so overwhelmed that they were lifting – putting patients in body bags, lifting them from the bed, putting them on the floor, putting another patient in their bed straightaway because there wasn’t time.
We went to another unit where things got so bad, they were so short of resources, they ran out of body bags and they were instead issued with 9-foot clear plastic sacks and cable ties, and those nurses talk about being really traumatised by that because they had recurring nightmares about feeling like they were just throwing bodies away.
These people are used to seeing death but not on that scale and not like that. And whatever the figures show you, the experience for them was indescribable. And when we talk about capacity in the healthcare systems, you know, the toll on those teams from that scale – and it really was like nothing else I have ever seen and certainly like nothing else those teams had ever seen in their experience – it was incredibly difficult.
Lead 3: I can see it has taken its toll on you. You are, I daresay, no stranger to death either in your 26 years of experience. Why is even recounting this now so obviously painful for you, Professor?
Professor Fong: I’ve never seen anything like this on any given day. I have served in a clinical role in several major incidents, I was on the scene of the Soho bombing in 1999, I worked in the emergency department during the very serious civilian major incidents in my time with the helicopter emergency medical service, and nothing that I saw during all of those events was as bad as really Covid was every single day for every single one of these hospitals throughout the pandemic surges.
You care – it is painful now because it was very clear what was happening to the patients, it was very clear what was happening to the staff. The staff were very injured by just how overwhelmed they were by the whole thing.
Lead 3: Do you think the patients were getting the care that they needed?
Professor Fong: They were getting the best care that could be delivered. I have said already that intensive care is about the detail. Once you start diluting the detail it kind of stops being intensive care.
It is really hard to describe this, and this is why I think these visits were important, that – whatever
you read in the columns on the Excel spreadsheets and
the data didn’t tell you this. And it didn’t tell you
about the actuality of the thing. And for the smaller
hospitals, the thing that I described of transferring
patients out to try to create capacity, what it meant
for the smaller hospitals was that they were drowning in July suicide bombings, I have attended a number of 7 patients. The bigger hospitals would come in, try to
relieve that pressure by transferring patients out.
When you come in, you transfer patients out, you
transfer out the most stable patients because they are
the people who are most likely to be able to survive on
more limited equipment in a moving vehicle for several
hours if necessary.
But what that meant for the smaller units is that
they were left with a cohort of patients who were most
likely to die. For the smaller units, when we talk
about the scale of death, over the next few weeks those
units would experience some mortality rates in excess of
70% in some cases. 7 out of 10 of every patient that
they had died. And I remember early in the visiting
scheme going into a unit, a small unit, and them saying
at the end of the day, after we had had all these
accounts and accounts of these types, you know, and with
very little to offer them, and they said “Thank you for
coming, we thought we were alone, we thought we were doing …”
Lady Hallett: Try having a drink, Professor. Take your time.
Professor Fong: They said “Thank you for coming, we thought we were alone, we thought we were doing it wrong”. And I just thought how have we left them feeling like this? How has no one told them this is not their fault, it is the surge that has come with Covid that has led this to happen.
But if you are a unit and you are isolated in that way, how can you know that it is not you. You watch seven of every ten patients die. How can you know?
So those experiences basically affirmed for me the need for the visits and the need to try to get this information out.
Ms Carey: Can I ask you about a different visit but still in late December 2020 and what you have described in your statement as hospital 9.
You said there that that was – had a baseline capacity of 17 beds, it had 88 whole-time equivalent nurses, and I think you were there in late December of 2020.
Is this right, they had transferred out 70 critically ill patients in the first wave and 110 in the second wave. Tell us, please, about the visit that you conducted at that hospital.
Professor Fong: So that is correct. So that scale of transfers out tells you the constant pressure that this hospital is at. This is exactly one of the hospitals that I described that is a smaller hospital that is in need of constant decompression to just keep its head above water.
It was a relatively – it was a medium-sized unit. On this occasion I had been tasked to go there by the sector lead to actually have an urgent review of what this hospital needed. It was calling out for help.
I will never forget, I got a phone call – I got asked how long it would take me to get to this hospital and I said “Well, when do you want me to go?” And they said “If you get in your car now and drive, how long will it would be?” So I understood it was urgent.
I got there, I got onto the unit. It was just – it was a scene from hell. The chief exec, the chief operating officer, chief medical officer, nursing officer, they were all on the shop floor, all trying to do it, but this was a hospital in massive, massive trouble.
We went in an intensive care unit first. The intensive care unit was nursing at 1:4 ratio, one specialist ICU nurse to four intubated patients, in the open area. In the side rooms, which have limited capacity, at 1:2. There were so few staff that some of the nurses had chosen to either use the patient commodes in the side rooms and some of the nurses had chosen to wear adult diapers because there was literally no one to give them a toilet break and take over their nursing duties. That was the intensive care unit.
The intensive care unit was full. Their overflow areas were full. Their non-invasive ventilation unit, their respiratory unit was full. This was a hospital bursting at the seams.
I then toured the hospital with the intensive care staff grade, a doctor who then looked after the unit and the rest of the hospital. I will never forget being in the stairwell with him and he’s out of breath on the stairs because he has himself had Covid in the first wave and now is suffering the consequences of Long Covid but he’s still there.
The referrals are coming up from the floor. The referrals are the calls –
Lead 3: Is that for emergencies or …
Professor Fong: From the wards or the emergency department asking for help. That’s what happens in routine intensive care. They say, “This patient is too sick for us, can you take them to intensive care?”
There were six of those referrals from the wards. There is no place to put them in the intensive care unit. We went into the emergency department. I looked through the resuscitation bays through this intensive care staff grade 8. Of the five patients there, there were three patients who also needed incubating, so you have nine more patients who need intensive care urgently. There was no one there to intubate them, there’s no one there to look after them.
When we got to the intensive – when we got to the emergency department, we were told that a patient had died in an ambulance waiting to get into the hospital the night before. The same thing had happened that morning. The oxygen alarms are going off, the chief operating officer is trying to troubleshoot that with the estate’s manager. It is genuinely the closest I have ever seen a hospital to a state of collapse in my entire career.
Lead 3: I think you decided to effect what’s called a rapid decompression of that unit, and did that result in 17 critically ill patients being transferred out that night?
Professor Fong: That is correct. We called it back to the sector lead. I reported it up to the national EPRR team. That’s what we did. We would come up with a plan for immediate support. And the only option here was to effect a rapid decompression.
To put it into perspective, in an ordinary winter outside of Covid, throughout the whole of the country the number of transfers that you might undertake to create capacity through the whole country – in 2019 it was 68. And that night we sent 17 away from that hospital.
And it was all we could do.
Lead 3: How were the staff that you spoke to in that unit?
Professor Fong: They were in total bits. I mean, you know – and they had been doing this throughout the first wave, into the second, for them which had started in late autumn and is now moving into winter. They knew that worse was to come. They were still turning up.
They had had – again, they had had their own staff admitted to their own unit. Again, that they had massive staff sickness. So the other insult was that as Covid surged, so did the levels of sickness among the staff. So there was massive staff sickness.
We didn’t, obviously, have time during that visit to talk to them in a reflective way. We went to them later, you know, and they told us again about the scale of death. It was there that they told me that it was usual to see three deaths a day, more like five. The intensive care consultant told me going on ward rounds and watching patients die in front of you, to the left of you, to the right of you, behind you. You know, that was their experience. And they did everything that they could but everything they could wasn’t enough and that was why it was so hard.
Lead 3: I think you comment in your statement that one of the staff members spoke about holding an iPad up to a family member as the patient was dying and – effectively an end-of-life virtual visit. Clearly horrific for the family on the end of the iPad. What about the impact on the nurse who was trying to help that call?
Professor Fong: So the care never stops in intensive care. There’s always something you can do. And even at the end, when there is nothing more that you can offer therapeutically, you know, your last duty to your patient is to ensure a good quality of death and to support the family through what follows. And that is usually about a relationship being built up with the family over a long period of time, but because of the remoteness of all of this, you hadn’t established that rapport.
And many of the patients’ families understandably wanted to be present virtually at the end when visiting was difficult or wasn’t allowed, and every single unit we went to the nurses talked about the difficulty of that for them. Exactly at a time when you would recuse yourself to give the patient and their family some dignity, you are actually holding a phone or an iPad up, showing them the monitor, showing the family the patient, listening to families imploring the patient not to die and then the howling down the phone, and with nothing else that you can do other than to stay there and to be entrained into that grief. And I think they found that – I know that they found that – there wasn’t a single nurse I spoke to who didn’t talk about how traumatic that was.
Lead 3: I think after that visit you went in very early January to what you describe as hospital 10, and that was a large teaching hospital, is that right, Professor?
Professor Fong: That is correct, yes.
Lead 3: 21 of your statement, a slightly different but allied topic. I think there you spoke to an anaesthetic consultant who told you about what he had experienced on a night shift. Can I ask you about that, please. It is your paragraph 117.
What did that consultant tell you?
Professor Fong: So this was the experience of the large teaching hospitals and they had the other end of it to the small hospitals. They were receiving patients, this constant infall of patients who were transferred from other hospitals in trouble, so they experienced surge in that regard. And they were capable and well staffed and well led, but they were – their units were full. Their overflew – they created another two overflow units within that building. They were ventilating people in their operating theatre departments. They had in the first wave been intubating and ventilating people in their operating theatres. And they too were in massive trouble. No one had it easy.
And as we got into late December, again, the rate of death, the rate of work was massive, and one of the consultants there started a shift, watched six people die, ran an arrest right at the start of the shift and talked – and had resuscitated a young patient and it had been unsuccessful, had spent 40 minutes trying to resuscitate this patient.
And at the end of a resuscitation in which a patient has died, it is quite usual in normal practice to take your team aside, to make sure they’re okay and to try to care for your team, and at that point you go around the team and you work out who you’ve got and you’re all dressed in PPE, and three of the members of the team who had done cardiac compression were medical students who had volunteered to be on the ward and you would ordinarily try to support them, for some of these people it was the first time that they had seen death, and there was no time because more death followed, there were more people arresting.
And so you can’t recover your staff in the moment and you can’t recover them later. And, you know, when we talk of capacity in healthcare, you’re over capacity by the time that you’re at that point.
Lead 3: Yes, I think you say in your statement that after the unsuccessful resuscitation of the young patient, within minutes there was another cardiac arrest, followed by several more, and it was that consultant in the space of a single 12 hour shift where six ICU patients died.
Now, can I will pause you there, Professor, because I would like to ask you about what you did with this information, and could we call up, please, on screen INQ000072310. I would like to ask you about an email that you sent to Patrick Vallance on 3 January. He says:
“Dear Kevin
“Many thanks for sparing the time to speak to me today. Your account was harrowing and disturbing. I have spoken to Chris Whitty about this and he would like to hear more. I think the best plan would be to include Keith Willett [who I think is NHS England] and others in that, but Chris will have a view on how he would like to make sure he hears from a number of people to assess the current situation. As you rightly said, this is a complex situation and the data alone may not tell the story.
“Thanks again for raising it.”
And there is reference to setting up the call.
Now, why did you feel it necessary to speak to Patrick Vallance about what you had witnessed?
Professor Fong: So this is actually an email from Patrick to me with Professor Chris Whitty in copy. I had gone on to a night shift myself at my own hospital around this time. I had gone through a pretty traumatic shift with a lot of death. On the way into that shift I had been speaking to – I had been speaking to Jeremy Farrar, who I knew because I had been a research fellow with the Wellcome Trust, and really just as friend to friends just to rant really about how bad things were and how close to the edge I felt it all was. And he then said to me would I like to speak to Patrick in the morning, who he also knew – Patrick Vallance, who he also knew personally.
So I did my shift and I came off the shift and – and, you know, this was on the back of all the visits and my own personal experience and it wasn’t – I was willing – I – for me, it was all about flow of information. This whole thing was about trying to get the right information to the right people for the best decisions, the best actions, and so it seemed to me that it wasn’t unreasonable to try and share if that information hadn’t been shared.
I must say that I was – I felt really well led and supported by my emergency preparedness resilience response team in NHS England and in particular my line managers, Chris Moran and Keith Willett. They facilitated my ability to do the peer support visits. They understood the need to get this information. And my understanding is that they transmitted that up all the way as far as cabinet and beyond. But – but we somehow couldn’t land that narrative, and so it felt natural to me to have that discussion.
And so that is why I had that discussion and it led to the email that you see there.
Lead 3: And did you then, in fact, I think receive an email from Professor Whitty saying that Patrick Vallance had updated him? He was grateful for it being passed on, and effectively, he said:
“I would find it helpful to get those directly, probably most usefully with a few others to get a rounded picture. The more actual data we have to support the better; anecdotal views on how things are [I think that should be ‘in comparison with’] the first wave are quite varied.
“If you would prefer to talk directly to me that’s also fine.”
He had just come off a ward in UCLH.
Did you speak to Professor Whitty?
Professor Fong: I did, yes. I did the following morning. I spoke to Professor Whitty and relayed the same information really.
And, again, I think both Professor Patrick Vallance and Professor Whitty were very receptive to that. And, indeed, as the email says, resolved to convene a wider group of people to discuss the burgeoning pressures on the wards as it was happening in very early January.
Lead 3: I think, in fact, on the 4th we went into lockdown again, so if that helps ground people with where we are, this is the timescale we’re talking about.
Now, just pausing there. We’re in the troubling times of January 2021. There’s another wave.
Did you continue your visits throughout wave 2 and into and the rest of 2021, Professor?
Professor Fong: Yes. So, in many ways, that was the most important time. The period after the January 4 lockdown I think was the most dangerous period of the whole pandemic for us.
Lead 3: Why do you say that?
Professor Fong: Because even after we’d gone into social restrictions, cases would continue to rise because of the incubation period of the virus. We knew that there was a two- or three-week lag before we would see the peak of our intensive care caseload, and so actually we were very operationally busy during that time, but we recommenced the visits as soon after that as we were able.
Lead 3: Can I ask you about a visit you undertook in June 2021. So it’s your hospital 14, Professor. We are out of wave 2, if ever we were out of it – sorry, wave 1.
Tell us what happened, please, when you visited the hospital in June 2021.
Professor Fong: This was a small, medium-sized district general hospital. So much of what we saw in the pandemic publicly and in the press was of the larger hospitals, the larger teaching hospitals. But this is emblematic really of the experience of the smaller hospitals, but very small baseline capacity, only nine beds, and as soon as you stray much above that, you feel extreme surge. And they had been hit really, really badly all the way through.
And the account there was really telling. The small units have no spare capacity. They’re stretched even on an ordinary day, so any surge for them was particularly difficult to deal with.
And this is an emblematic experience for the smaller hospitals. The ICU consultant there who I spoke to said he got a few hours’ notice before – being told he was going to resident on call, so he would be present in the hospital throughout the on-call shifts.
There’s no provision made for on-call facilities. He talks about having to sleep in the boot of his Ford Galaxy when he was on duty for three months at the start of the pandemic. They talk about running out of PPE. They talk about going to Screwfix to get visors. They talk about running out of theatre scrubs and having to go to the local private hospitals and beg them for their supply and, when they’d run out of that, they talk about having to have one shift where they had no theatre scrubs, and they went around in their underwear and gowns for the shift.
Lead 3: Can I pause you there? Did they give an indication of the pressures with PPE, which wave that was occurring in?
Professor Fong: So that was in the first wave, and the first wave was where most of the equipment shortages occurred.
Lead 3: Did you speak to any nurses whilst you were at hospital 14?
Professor Fong: Yes.
Lead 3: What did they tell you?
Professor Fong: They had had sustained pressure. Even the summer had been bad for them. They had had sustained pressure almost since the pandemic had kicked off in the spring of 2020.
You can see there in paragraph 151, they say:
“… as a team, we’re fractured. We’re not sure how to do things safely. There are so many rules and regulations that have gone out of the window.”
They were a young unit. They had very few experienced staff, and the experienced staff they had left very quickly because of mental health issues.
One of the band 5 nurses, quite a junior nurse, is saying, you know:
“… we were a young unit, most of us with less than a year’s experience. I was newly qualified. I didn’t know what I was doing half the time.”
They had a massive staff sickness rate. Nearly 20%, nearly one in five of their units – one in five of their nurses off sick at any one time.
Lead 3: Were they talking about January 2021?
Professor Fong: This is ‘21, yes.
Lead 3: You’re visiting in June, but they’re telling you how it was in January that year?
Professor Fong: Yes. And January 2021 for them, as a smaller hospital with limited capacity, really, really brought them to their knees.
They talk about how hard the burden was on the intensive care consultants, how many shifts that they had to do. They talk about the consultants having to work ten weekends in a row. This was the same consultants who in the first wave had slept in their cars.
You know, that statement that they made to me in June 2021 when I asked them how they were, you know, coming into the summer, they said “We’re broken. We’re worse than broken”. I don’t know – “We can’t look after nine patients”. That’s their establishment. That’s what they should be able to do. “We can’t surge to any more than that. We can’t surge beyond that.”
And that consultant – and I need to get these words right, but he said “Look, we’ve run out of – we ran out of equipment. We ran out of drugs. We ran out of nurses. We ran out of goodwill.”
You know, that is what this thing did to those people and those units. This is what happens.
I went into another unit of similar size where they talked about how on the television what you saw was these big units who complained about being short of equipment but were usually wearing PPE.
Lead 3: Yes.
Professor Fong: And how they said that they were watching those programmes, and they were standing in their own units wearing cagoules and waterproof trousers that the chief exec had bought from an outdoor shop. And they were angry actually that that is all that people knew, was the sight of well-resourced hospitals, when the truth in the smaller hospitals was just that.
Lead 3: Can I just ask you now: if you stand back and think about the – we’ve looked at a few hospitals there, but if I ask you to stand back and think about the 40 or so visits that you made, what were your takeaways from all of those? What were other things that you were hearing that perhaps you haven’t told us about this morning?
Professor Fong: We had a substantial programme by the end. We had a secretariat of about six people who supported the visits administratively. I had about 40 – maybe 30 or 40 people who staffed up these visits, to whom I am extremely grateful to.
We all had the same conclusions. The first was: we were always surprised at just how supported the staff felt by this. The sense they weren’t alone. The sense they weren’t getting it wrong, that it wasn’t their fault, and that other people elsewhere in the country were experiencing similar or the same. The ability just to talk with people who were going through the same thing was incredibly supportive. Many of them said it was the first time they realised that they weren’t on their own.
It absolutely confirmed my belief that the data, the information, are important, but the insight is gained by going and seeing these people and having a group of people who know what they’re looking at, looking at that system and understanding what it is.
It is easy for us to think that we knew what was going on. And this isn’t just a problem with the NHS. Any large organisation suffers this problem, any multilayered organisation suffers this problem, of what you can measure most easily, that’s seen at the top, between what is actually happening at the front line. And I think that it was easy to convince ourselves that we knew what was happening, but you don’t know.
You don’t know unless you’re the people going into that shop floor. You don’t know if you’re not the people who are putting on PPE before you’ve got vaccinations available, wondering if it’s buttoned up okay. You don’t know unless you’re the people who have run out of body bags and put people in plastic sacks. You don’t know if you’re not the people who held onto iPads while relatives are screaming down the phone. You don’t know if you haven’t sat in transfer vehicles next to a patient who is dying of Covid wondering if your PPE is buttoned up well enough that you might not do the same. It is impossible to know.
And that’s why, although this is not, as you pointed out my Lady, hard numerical data, the information is important. There is more to know than just what you can count. And I think that that was well understood by my EPRR team. I was well supported in that role.
There is a tendency for us in healthcare to, you know, eschew that kind of anecdotal data. It is the lowest form of information. But I don’t think that was true here. I think the information was important. And I think it did change the way that we saw these people. And the most important thing is the need to support their wellbeing.
It is a complex system. It has a social component and it has a technical component. We got good at managing the technical component. The human resource, the people that stop it all from falling apart from day to day, we didn’t really have sufficient mechanisms to measure and monitor that or indeed protect them.
Lead 3: In your statement, you speak of the Professional Nurse Advocate programme. We heard a little of that from Dame Ruth, but do you have any views about the utility or otherwise of that programme?
Professor Fong: So the Professional Nurse Advocate programme, which, at least I’m told by Emma Wadey, who was the director of mental health nursing at the time, and Dame Ruth May herself, the data, the information, the insight we gathered through the visits and through the wellbeing surveys informed their decision to support and develop that programme. That programme was there as acknowledgement that there needed to be support and recovery. It for the first time provided nurses with a role whereby they faced their own staff and they cared for their own staff. And, you know, that was such an important thing.
And actually as the visits progressed and the Professional Nurse Advocate programme developed, everyone told us how important that programme was to have one of your own team able to look after you. And so, you know, I was very – Dame Ruth May was very responsive to these data from early on, you know, from the summer of 2020. I think she referred to in her own evidence that it helped convince her that we should try to draw a hard limit of no lower than one intensive care nurse to two ventilated patients in coming waves.
So I was happy to hear that. I was happy to hear there was some consequence from the work.
Lead 3: I think we have probably gleaned your lessons learned, Professor, but what about some recommendations for how not to end up in this position in the event of a future pandemic? Is there anything that you can recommend to her Ladyship to try to ameliorate the stresses on the staff in these ICU units?
Professor Fong: So much of this pandemic was about the concept of capacity and the capacity of the healthcare system. So much hinged upon that. But healthcare – capacity in healthcare systems is a complex feature of a complex system. It requires a complex assessment.
There is, as I have mentioned, in the system a human element and a technical element, and we get good at managing technical elements, but the social element that we depend upon to close the gap between reality and expectation in a system that every single day wants to tear itself apart, and during Covid much more so, we do not pay enough attention to.
So, in terms of the way forward for me, at least through this, I think there are four things.
I think those peer support visits were important. I felt well supported and facilitated to develop them by a team in emergency preparedness and response, who understood the need for them. I’m grateful for that. I was very well led there and very well supported. I think that mechanism is an important mechanism both during the pandemic and outside of that.
Lead 3: The EPRR mechanism?
Professor Fong: Sorry, the peer support mechanism.
Lead 3: Thank you, sorry, I misunderstood.
Professor Fong: Having a mechanism by which you can support colleagues in this way, gather information, to short circuit the flow of information from the front line all the way up to the top. You need to have a mechanism that stops information having to flow through all the filters in between, so that the decisions that are made at the top – there is a way of the people at the front line to signal their experience without it being diluted.
So, firstly, all this in future pandemics, the peer support system was important, this ability to go in and visit hospitals was important I think, and we should preserve and develop it.
It is not just a thing that you magic up. It took effort and nuance to do it. It took time to understand how to get these people to have the trust in you to share the things that …
(Pause)
Professor Fong: To share the things that they shared, for them to know that someone cared really about what was happening to them, to know that they weren’t alone. It takes effort to do that. We will forget that very quickly. You need to preserve those mechanisms and we need to have them. Arguably outside of a pandemic, certainly for one in the future. I think that ability to have that context is important. That’s my first thing.
The second thing is, you know, we talk about learning lessons and preparing for the future. We must – and the knowledge of how to manage a pandemic at operational level – I’m not talking about the strategic lessons, I’m talking about operational level. The pandemic was managed by the teams in the frontline areas day in, day out, not just on intensive care, throughout the hospital, throughout the ambulance service, in the community, general practice, in our social care facilities, in our care homes.
The know-how of how to stop a system from tearing itself apart when faced with a challenge that should have been insurmountable exists still within those people and it must be preserved. I’m not sure we are doing enough to preserve that operational, organisational memory. And organisational memory is short.
So the preparations for next time need to start now and need to be properly resourced, need to be captured.
Lead 3: And your third?
Professor Fong: Is about wellbeing. Again, it is that point about – and I repeat it deliberately because it’s so important but I think so overlooked. We managed the technical aspect of this complex system, we do not look after the social aspect. We go in and we check our machines and our drugs every day to make sure that they are there when we need them in a difficult moment. No one really does that for our staff. We do not have the right mechanisms to measure and monitor, protect and promote the wellbeing of the human workforce upon whom everything depends, whether you are in a pandemic or not.
Wellbeing of the workforce should be a central strategic priority for the NHS, whether it is in the pandemic or not. And it needs better resourcing and it needs better attention than it has had.
The final thing I’d like to say, just a wider scale, is it was very clear when we were going into hospitals about the disparity in the provision for different areas, the smaller hospitals versus the larger teaching hospitals. If you wanted to find an indicator substance to drop into a general population to see where healthcare was most needed, then Covid was it. And it showed us that the care and the resource wasn’t where it needed to be, and we should reflect upon that.
This is the biggest national emergency that this country has faced since World War II. Out of the medical needs that arose out of World War II and the Blitz in part came the recognition of the need to care for – the need for us to be able to care for – the collective need for us to care, as a country. And in part – it was part of the impetus that established the NHS. It was a lesson we learned through that awful experience, that we needed something more going forward.
So we need to learn after Covid those lessons, and perhaps for me the most salient one is that we do not look after the people who deliver the care. If we do not care for the carers, they cannot care for our patients.
Ms Carey: Professor, that’s all the questions I have.
Lady Hallett: There are just a few more questions from Ms Munroe. Can you cope with a few more? And then we will break and it will all be finished.
Questions From Ms Munroe KC
Ms Munroe: Thank you very much, my Lady, and I can say to Professor Fong that during the course of his evidence this morning the vast majority of my questions have either directly or sufficiently been answered and there are literally just a couple, which I hope I can summarise, Professor Fong, and take it relatively quickly.
My name is Allison Munroe, Professor. I represent Covid-19 Bereaved Families for Justice UK and on their behalf just a few questions, please, thank you.
My first question was about data. You have spoken a lot about that and described how the data did not paint the picture of the severity of what you were seeing on the shop floor, as you have described it, in ICU.
Effectively, it is a falsely positive picture was being painted by the data.
So my second question, arising from that, was: was that disconnect between the picture painted by the data and what you yourself were seeing on the shop floor due perhaps in part to a focus on physical bed space rather than considering the question of the adequacy of staffing requirements?
Professor Fong: So I think that it is natural in the face of a fast-moving pandemic that initially you focus on the things that you can count most easily. But as I have said before, not everything that counts can be counted and not everything that you can count counts. It is that old adage.
And so the focus on numbers of beds, it’s not that it was a falsely positive picture but it was an insufficient picture to which you need to add context and insight, which is what these visits did.
So I think that the second thing I would say is that I think there was, at least initially, a misunderstanding of what an intensive care bed is. I think that people thought of it as being some technical piece of furniture into which you plugged a patient. It requires a staff. Not just doctors and nurses, it requires a physiotherapist, dietitians, occupational therapists, radiographers, radiologists, a whole huge team of people. The bed itself is just a shorthand for that. You know, it is no more use to you than an aeroplane is to an airline without its staff.
Ms Munroe KC: Thank you.
Professor Fong, it is very clear from your evidence that you have given us this morning that blanket statements or opinions such as “ICU was not overwhelmed” would be oversimplistic and lack nuance. In concluding your evidence today you mentioned that so much hinged on capacity. Bringing it all together, can we describe what we were seeing during the pandemic then, in terms of capacity being overwhelmed, that it was overwhelmed in different individual locations and at different times throughout the pandemic?
Professor Fong: It is difficult, isn’t it, to know whether – and the language changed in the national assessments between the risk of a unit being overwhelmed and a country being overwhelmed and the risk of it exceeding its “assumed capacity”. From the perspective of intensive care, if you ask yourself what intensive care is, it is the detail, it is the detail and the dedication, the ability to provide everything that can be provided in an effort to provide the best care for a patient who is critically unwell.
If your definition of overwhelmed is your ability to provide that, then at many times and in many places the units were overwhelmed.
You just have to listen to the evidence that was given today to know that these units were beyond their capacity to cope. And the thing is that they did anyway. On paper they shouldn’t have been able to cope with this and they still turned up.
Ms Munroe KC: Thank you. The second point, Professor Fong, is on diluted staffing ratios.
In your witness statement at page 24, paragraph 128, you deal with one of your visits to hospital 11, it is a general district hospital, and you state that initially you met the lead matron and the clinical lead for ICU and asked them how things had been for them, and the clinical lead told you that:
“… they were already at 1:3 and in some places 1:4 nursing ratios …”
You then go on in paragraph 29, in very clear and graphic detail, to describe what the lead matron told you about the effects that was having on many of her staff who she described as terrified.
That visit was January 2021. Professor Fong, from your observations, your discussions, what you saw and what you heard in practice, is it correct that diluting staff ratios continued into and throughout the second wave of the pandemic?
Professor Fong: So my understanding is that there was a clear decision between the first wave of the spring of 2020 and subsequent waves that no unit or units would aim to go no lower than one specialist ICU nurse to two ventilated patients. That was the goal.
And I think that was absolutely important at redefining what capacity really meant for these hospitals. But as the surge came through in autumn for some regions and then in winter 2020 and then into 2021, even that goal was not – you couldn’t sustain it. So, the goal was to hold at 1:2. But even though that goal was set, it speaks to how challenged the units were that they – this unit was not able to maintain that.
And you refer to the paragraph that follows. This unit at this point were in such trouble – they talked about coming into work one day, one of their senior nurses had vomited on the way to work out of nervousness about what she was about to face, how terrified they were. And, you know, this is a team of people that are operating at the edge of their own personal capacity, at great cost to themselves. And so we talk about physical capacity but there is the capacity of a human workforce and that was clearly exceeded here.
Ms Munroe KC: Finally, Professor Fong, in the course of your evidence this morning you have told us from your own real experience of actually visiting, the peer visits that you made, that you saw staffing ratios significantly higher than the recommended 1:1. You spoke of diluting the detail of intensive care.
From your visits, observations, speaking to healthcare workers, Professor Fong, would it be fair to say that, despite the monumental efforts and dedication of the staff that were available, the impact upon the quality of care in ICU can properly be described as devastating in some places?
Professor Fong: Despite the best efforts of everyone really in the system, everyone, the surge in demand for healthcare caused by the upswell of critically ill patients, by Covid-19, meant that it was not possible to deliver the standard of care that would ordinarily be expected in a non-Covid period.
Ms Munroe: Professor Fong, those are my questions, and thank you very much on behalf of those I represent. We are very grateful for the visits that you made and the very powerful evidence you have given us this morning.
My Lady, thank you.
Lady Hallett: Thank you very much. Ms Munroe.
Professor Fong, we are extraordinarily grateful to you for helping us. It is obvious how distressing it was for you and obviously reliving such an ordeal is never easy. It is not easy to describe, as you have had to do this morning. It is not easy for us to listen to. But we had to do it, so thank you so much for all you have done.
Could I also thank you for not only the excellent work you did with the support scheme, for the work you did in the units, but also for your work with the air ambulance service. As you may know from having been the coroner at the 7/7 inquest, I am a huge supporter of the work they do, it’s brilliant. So thank you very much.
I shall return at 11.35 am.
(11.20 am)
(A short break)
(11.35 am)
Ms Carey: My Lady, may I call, please, Professor Sir Christopher Whitty.
Professor Sir Whitty
PROFESSOR SIR CHRISTOPHER WHITTY (sworn).
Lady Hallett: Professor Whitty, thank you for coming along to help again. And, again, I reiterate my apologies for the demands we make upon you and your office, and we’re very grateful for your help.
Professor Sir Whitty: Thank you, my Lady.
Questions From Lead Counsel to the Inquiry for Module3
Ms Carey: Professor, your full name, please.
Professor Sir Whitty: Christopher Whitty.
Lead Module3: We have a statement from you in Module 3, ending 410237, which I think you have in front of you?
Professor Sir Whitty: I do.
Lead Module3: I know you’ve given your background in previous modules, but you became the Chief Medical Officer, I think, on 1 October of 2019; is that correct?
Professor Sir Whitty: It is.
Lead Module3: And you are, by background, a consultant physician in infectious diseases and tropical medicine at UCLH.
Professor Sir Whitty: Yes.
Lead Module3: And you have a number of other qualifications, as set out in your statement. I won’t go through them.
You worked shifts, is this right, throughout the pandemic?
Professor Sir Whitty: I did. I decided at the beginning to stick to my usual rota, and that therefore meant I had – I worked shifts in actually Wuhan – the Alpha wave, and then after the vaccine, in a very different environment, the Delta wave and the Omicron wave, so I did see various phases of this.
Lead Module3: Tell us about wave 1, please. What was it like working – was it on Covid wards that you were working?
Professor Sir Whitty: Yes. In wave 1, I was towards the tail end of wave 1 in the middle of the year, so by this stage a lot of learning had been done already by my colleagues, but I think much of the trauma that was very powerfully laid out by Professor Fong in the last evidence – with it I fully concur, to be clear – was very apparent in many of the colleagues I had. There was a period of recovery. I think what then he described, and I think this is accurate, I was working – I did two weeks over the Christmas/New Year period at the end of 2020, which is in fact very similar to the time he was talking about, and that was an extraordinarily difficult time, even in the relatively privileged environment of a teaching hospital, which is where I work, and fully – I fully agree with his point that actually in less resourced smaller settings, the outcomes were even more difficult.
Lead Module3: When you were working on the Covid wards, what type of mask were you wearing?
Professor Sir Whitty: I wore exactly what was in the guidelines, so that, for most many of the time, was a surgical fluid-resistant mask.
Lead Module3: Thinking towards the end of your – end of the work during wave 2, were there any noticeable differences between wave 1 – sorry, Wuhan and wave 2?
Professor Sir Whitty: I think the scale of the second wave was actually under appreciated in the general public. I think people who had relatives, obviously people who were sick fully understood that this was in fact a larger wave, in terms of total numbers of people who were severely ill and indeed who sadly died. And the first two waves were the ones which had the extraordinary mortality in the very large numbers in ICU.
By the time we get to the delta – most for the delta wave and the Omicron wave, vaccination had completely changed the pattern, so although people were still getting Covid still coming into hospital, it put enormous strain on the system as a whole. The proportion unfortunately who were going to ICU and going on to die was massively lower, and that led to a very different outlook.
Lead Module3: What about the staff in wave 2, though? They’d been through all the various ups and downs from March 2020. Was there any appreciable difference in the way they were feeling and behaving by the end of the relevant period?
Professor Sir Whitty: I think that one thing that in my experience did make quite a big difference was when staff knew that the vaccine was coming, because until that point, there was a very – a sense of: this could go on for literally years with wave after wave.
Once – the second wave in particular was incredibly harrowing, as Professor Fong has laid out, but knowing that there was something which was going to significantly reduce that, I think for many people, it at least meant they felt there was some light at the end of the tunnel, although it was a very long tunnel.
Lead Module3: You set out in your statement the role of the Office of the Chief Medical Officer, and I’m not going to go through it all, but is this right: you are the senior adviser to government. You are independent of government, and you can therefore write reports and make public statements which don’t accord to government policy if that’s how you consider the evidence to fall.
Professor Sir Whitty: That’s correct.
Lead Module3: All right. You have a small private office, I think, including public health speciality registrars. There were three deputy chief medical officers, is that right, during the relevant period?
Professor Sir Whitty: There were, although one of them was mainly working for the NHS.
Lead Module3: And I think you said at its largest, there were 19 members of staff, but typically you only have about 12 members of staff; is that correct?
Professor Sir Whitty: That is correct. And I think the small scale has a big advantage and a significant limitation.
The big advantage is: everybody understands what everyone else is thinking and you can think as a unit. Obviously, the disadvantage is: it’s quite a small resource and, in an emergency of this size, it meant we had to be very careful about which things we prioritised in terms of the things we did and which things we didn’t.
Lead Module3: You do not have, is this correct, a direct role in the organisation or operation of the NHS, and so, therefore, clinical advice to the NHS comes from within NHS England; is that correct?
Professor Sir Whitty: In a purely statutory sense, the 2012 Act significantly changed the way in which the Chief Medical Officer interacted with the NHS and gave the NHS, in a sense, complete independence, and therefore, there’s no role for the CMO in the structure. However, there would be situations where senior members of the NHS, and indeed other members of the NHS, would talk to me for – to really talk through a problem as they appear in the system.
For example, I was in constant contact with Professor Steve Powis, who I think you are going to be hearing from subsequently, and also with Dame Ruth May, who you have already spoken to.
Lead Module3: Yes, right.
I think though you say you may have, from time to time, provided technical advice which might help NHS England make decisions.
Professor Sir Whitty: Yes. And I think this is – there are sort of two kinds of advice I would give on this, but I tried, as far as I could, to say – make clear who was maintaining the final decision-making because, otherwise, things get very confused.
And the first form was – I mean, I am a technical expert, both in the epidemiology and in the treatment of infections; many of my colleagues were not. So sometimes I was actually giving, literally, technical advice from my own personal – professional background, and sometimes it was as a senior member of the collective leadership of the medical profession and healthcare more widely. So those are the two kind of environments.
Lead Module3: I just wanted to be clear about the remit of your role as CMO. It may be at times we trespass into matters that you provided advice from or were in the room when decisions were being made, but please make it clear if you are unable to answer any question or it’s outwith your experience or expertise.
Can I start, though, with this. I think in Module 2 you explained that one of the reasons for the lockdown in March 2020 was to prevent the NHS from being overwhelmed.
Can I ask you this: was “overwhelmed” ever defined by those that were making that decision?
Professor Sir Whitty: Not really. And I think that it’s become, unfortunately, quite a loaded term, where people, depending on what point they’re trying to make, either say things were or were not overwhelmed.
I think the aim of it, though, was to minimise the number of people who died, both directly and indirectly, from Covid in the health service.
And if you would like me to expand slightly on that answer?
Professor Smith yesterday, CMO for Scotland, which incidentally has a slightly different interaction with the NHS – I should have said that on the way – talked about the four harms. I put it slightly differently, but I gave the same four harms. The first harm being the direct harms from Covid, where you’re trying to reduce the number of deaths directly. But the second, and very important for this, is the indirect harms that comes from the system being overwhelmed, or at least unable to cope, and all – in fact, all diseases, not just Covid, having higher mortality rates than they would have had. And I think both of those are relevant to this.
Lady Hallett: Could I ask you to slow down, Professor. Thank you.
Professor Sir Whitty: Apologies, Chair.
Ms Carey: You said in Module 2 that – well, you were asked this:
“What was the understanding as to what would likely happen to the NHS if a lockdown were not imposed?”
And you said:
“Well, I think that the first thing that was going to get to the point where it was no longer able to function in any sense close to normal …”
Taking that answer and the aim to try and minimise the number of direct and indirect, do you think that we achieved that aim?
Professor Sir Whitty: Well, I think that – I’m going to work backwards from what would have happened if we’d gone further.
I think the key thing to remember, and I think people forget this, is that this was an exponentially rising – in the technical sense of the term, an exponentially rising thing, where you have – epidemic, with a doubling rate of three to four days at the point we were talking about. Four doubling times more would have led us to an absolutely catastrophic situation.
Now, I’m not saying that where we were was anywhere short of incredibly difficult, and in many places, individual elements of hospitals, individual hospitals, individual bits of the system were coping nowhere near where they would be if Covid wasn’t there. That’s self-evidently true.
But if we had not had the lockdown, the expectation is that would have got a lot worse. I don’t mean just trivial worse, but really quite substantially worse.
Lead Module3: Do you think that the NHS was able to function?
Professor Sir Whitty: Well, I think that makes it sound quite binary. I mean, the NHS continued to treat sick patients throughout. It continued to treat people who did not have Covid throughout. In fact, in most – I think at all times, actually, there were more people in hospital who did not have Covid than had Covid; I think, certainly for the great majority. I’m sure there were places where that was not true, it wasn’t true in many ICUs, as we heard this morning, but more generally.
So, you know, there was still a functioning health service. It was clearly functioning at well below the capacity that it would have normally.
And I think, you know, just to make a slightly wider context, in a normal winter, the NHS is very, very strained. Lord Darzi has just done a report, I’m not going to go into that in detail, but just making the point: the NHS is under strain in every year, even prior to Covid. This was a major – this was the largest, as you know, medical emergency since the Second World War in a high-income country. And this made the system really not work anywhere near as effectively as it would if Covid had not been there.
But that’s self-evidently true. If that were not the case, it would be extraordinary.
Ms Carey: I ask you because I think you – obviously, you heard from Professor Fong just a moment ago. I think you’ve seen the report from the intensive care experts that the module has prepared. I think you’ve also seen the research that the Inquiry commissioned in relation to escalation of care.
And I just want to ask you about how your answers tally with some of the things that we’ve actually heard over the last nearly three weeks.
Could we have up on screen, please, INQ000499523.
I’m not going to take you through all of the pages, Professor, but could we go to page 3. You will appreciate that this cannot be representative across the entirety of the healthcare workforce, but nonetheless, there were 1,683 healthcare professionals who were spoken to, over half of whom reported that some patients could not be escalated to the next level of care due to lack of resources during either wave 1 or wave 2. A&E doctors and paramedics were more likely to have ever been unable to escalate care due to a lack or resources at either wave.
And so, when you speak at “functioning below capacity”, we understand now what you mean, but what about the people that couldn’t get the care that they would otherwise have got? How does that tally with what you’re telling us?
Professor Sir Whitty: Well, I consider they’re exactly – they’re entirely congruent with one another. And, I mean, what you’ve said in – what was seen in this report in no way surprised me. In fact, that’s the one thing where I probably departed from the evidence of Professor Smith yesterday, almost everything else I agreed with – not everything else, but – was this: that he expressed some surprise. I didn’t express – I didn’t see any surprise in this.
I would caveat this by saying: if you said in the middle of a winter in the NHS pre-Covid – had asked these questions, you would not have got a 100 per cent everyone can be escalated to the next level. And I think it is unrealistic, even in those circumstances, to think this would have been the case.
Pretty unsurprisingly, for the biggest pandemic in 100 years for this country, the system was unable to escalate things in the way it normally would. I don’t think, you know – that doesn’t seem to me a surprising statement, and it is entirely in keeping with what I previously said.
Lead Module3: If it’s not surprising to you or indeed those with whom you work, how do we in future prevent stats like this, evidence like we’ve just heard from occurring again? I know that’s a very broad question. Professor, can I say at the outset, this is not a counsel of perfection. I do take that point. But how do we either surge up or create more capacity so that there isn’t a healthcare worker saying “I couldn’t give that patient a bed”?
Professor Sir Whitty: Well, I think there – I mean, there are kind of broadly only two ways we can do it because we have to assume a future pandemic on this scale will occur. That’s a certainty.
But for the UK, not for the world, but for the UK, this is a one in 100 years event because the last time there was something this big was back in 1919 – 18-19. And for something on this scale, you therefore have to have two things.
You can have more capacity. Taking ICU in particular, the UK has a very low ICU capacity compared to most of our peer nations in high-income countries. Now, that’s a choice. That’s a political choice. It’s system configuration choice, but it is a choice.
But, therefore, you have less reserve when a major emergency happens, even if it’s short of something of the scale of Covid. So that’s the first alternative.
The second alternative is to do things which – and this, in my view, is undoubtedly necessary either way that minimise the scale of the impact of the pandemic, and that of course is what the various attempts at lockdown and other NPIs were really about. But the way out of these is always going to be science in the end, as it was for this one, with vaccines.
Lead Module3: The ability to scale up was something that was done at real speed during February and March 2020, but do you have any thoughts about the timing with which a scale up should happen in the event of a pandemic?
If we take this pandemic as an example, by January, the reports were coming out of the Wuhan. It got progressively worse through January and February into March and the lockdown decision.
Do you have any views as to when during a month or two lead-in to the pandemic hitting that surging and scaling up should take place?
Professor Sir Whitty: Well, I think Professor Fong laid out, absolutely rightly, that the key thing, which is the very limiting thing for scale-up, is people. Trained people. So you can buy beds. You can buy space. You can even put in oxygen and things. And I think we learned some lessons from, for example, trying to set up the Nightingale hospitals, about the difficulties of doing that. But, fundamentally, the limit to that system, as to any system, is trained people, and there is no way you can train someone in six weeks to have the experience of an experienced ICU nurse or an experienced ICU doctor. It is simply not possible.
So if you don’t have it going into the emergency, if it’s an emergency of this speed of onset, you don’t have any illusions you’re going to have it as you hit the peak.
Lead Module3: So does that mean we need more potentially skilled-up ICU nurses, for example?
Professor Sir Whitty: Well, I think – I mean, there are strong arguments for that in between emergencies, and I think the argument – the argument for having them in the hope that we can be better off for a one in 100 year event I think is less strong than some of the other arguments for having more ICU capacity.
Lead Module3: Can I just deal with some other features to your role and the role of the OCMO.
Can I ask you about your interaction with NERVTAG, please. I think you say in your statement at 3.45 that you are there as observers to NERVTAG. Have I got that right?
Professor Sir Whitty: Yes. I mean, the architecture is a bit complicated, but fundamentally, NERVTAG actually advises the CMO under ordinary circumstances. Once SAGE was in operation, in practice, NERVTAG advised SAGE. But the CMO has a very close link to NERVTAG. It’s – that’s just the way this particular interaction works.
Lead Module3: So thinking about you, because I think you were a co-chair of SAGE; is that correct?
Professor Sir Whitty: I was co-chair of SAGE. I didn’t sit on NERVTAG, but my colleague Professor Van-Tam sat on as an observer, and indeed, he’d previously been a chair of it before he joined government.
Lead Module3: Does that mean that the OCMO observer does not contribute or feed into the decisions made by NERVTAG?
Professor Sir Whitty: Well, I think people use “observer” in different terms. My view is, an observer is someone who can certainly, in almost all scientific committees, can pose questions and indeed if it’s their area of expertise, make points. An observer is not someone who sits passively. There are some kind of environments where that is exactly what an observer is. But in this environment, I would have expected, and in fact hoped, that Professor Van-Tam, and indeed any other expert adviser, would contribute if they had something useful to add.
But in formal terms, they’re not a formal member, and they’re not a formal voting member, were a vote to occur.
Lead Module3: Understood. All right.
Now, although you weren’t on it, I think the first NERVTAG meeting was 13 January 2020.
And I’d just like to look at INQ000223307, please.
We’re obviously in very early days, but you speak there of – it’s an email from you to a number of DCMOs, other people in DHSC, and you say – you thank him for a note, and you say:
“My view is that any of three triggers would mean we should start taking a close interest and considering risk to the UK.”
So, in short, now the word had come out that there was the virus circulating in China. And you say the three triggers are:
“(1) Healthcare workers dying. This is often the early warning that a new infection is both severe and transmissible, (eg, SARS, MERS, Ebola). This would be most concerning.”
Then spread from person to person, then geographical spread.
Given that one of the triggers was healthcare workers dying, who was it who was responsible for monitoring the number of deaths of healthcare workers?
Professor Sir Whitty: So in a pandemic or major epidemic like this, this is one of the first things people will spot. And of course, the healthcare workers are working in the healthcare system, so people are aware they are there. The deaths occur. They are usually in young and healthy people, in comparison to older populations who are in the general system.
So it’s often, unfortunately – and this is one of the risks of doing medicine, and indeed doing medicine in infectious disease areas, is you are going to be in the first line of people who will be potentially exposed to an infection. And if you look at, for example, SARS, MERS and Ebola, in all of those, healthcare workers weren’t massively disproportionately affected, in terms of the deaths, compared to the general population.
Lead Module3: But given it’s one of the triggers, who is it that’s going to monitor the numbers of healthcare workers dying? Is it DHSC? Is it OCMO? Is it –
Professor Sir Whitty: These data would be coming from China to WHO or by indirect routes. All of them – you know, what I was signalling here is, if you start to see even a small increase in healthcare worker deaths, that is a very concerning sign and one that you would want to – would actually escalate, even if the numbers are small in that situation.
Lead Module3: And then within the UK, who is it that’s responsible for monitoring healthcare workers?
Professor Sir Whitty: Well, I mean, I think in terms of – well, in terms of overseas data, this would come in to PHE, normally speaking; now UKHSA.
In the current – you know, if it was in the UK, of course, it would be the NHS that would first identify this, under normal circumstances.
Lead Module3: So, if I understand you correctly, as at January 2020, you were looking for information coming effectively from China at that stage as to whether there was healthcare workers dying. But do I take it that if we started having healthcare workers dying in the UK, that would be equally an indication of how severe the pandemic could be?
Professor Sir Whitty: That is correct. Remember, this was 5 January. This is very, very early in our understanding.
Lead Module3: Now, given that that is – healthcare workers dying is one of the triggers, certainly from your perspective, do you think steps should have been taken as early as January and February to assess what action could be done to protect UK healthcare workers from either catching the disease –
Professor Sir Whitty: Well, I think there are clearly two lines to that.
I mean, the first and the most important is to try to do what you can to reduce the risk that the disease gets into the UK, if that’s possible, and that it takes off in a major way. And that was covered in the last module. I’m not going to go into that, but, just to be clear, that is the most important thing you can do.
There’s clearly a second area, which is making a decision about where you would start, particularly early on when you don’t understand the infection. And the initial decision was taken that this would be treated, in UK terms, as a high consequence infectious disease. And part of the reason for that – not the only reason, but part of the reason for that is to nurse and provide medical care for people in environments which are relatively highly protected, with highly trained skilled staff who are used to dealing with high levels of PPE, and therefore a much lower probability of coming to harm themselves. There are additional benefits as well to the patient.
Lead Module3: Well, since you mention HCIDs, can I deal with that at this stage.
I don’t think you were involved in the decision to classify and declassify –
Professor Sir Whitty: I wasn’t formally involved in it, but I was aware of it, and I agreed with both the classification and the declassification.
Lead Module3: All right. Well, I was going to come on to the fact that you set that out in your statement.
You – I think you say in your statement – forgive me, I’ve just lost my page – that you made some points about HCIDs, including the significant disadvantages to the disease as being classified. Could you just set those out for us, please, Professor, and it’s at paragraph 3.35 if it helps you.
Professor Sir Whitty: Yes, I can remember what I said on that.
So the advantage to the healthcare workers is the one I’ve just given. It’s very important one. It’s absolutely fundamental. The advantage initially to patients is that they get – they are all cared for in a small number of specialist areas where people can accrue experience of managing a new infection, and that actually is beneficial. They also tend to have access to drugs and approaches which are not available more widely.
However, they come at a significant disadvantage, once you get beyond a quite small number of cases. People have to be moved around the country which can be very tricky. They – and indeed, it can involve exposing staff in transit which is problematic.
They also are in an environment which actually is quite frightening to be in if you don’t need it. I don’t know if anyone has ever seen these on TV or in other areas, but these are not environments which are sort of the easiest ones to operate in. And they are set up principally to protect the staff who are working in them, quite properly, but that can in itself cause some risks actually because the level of barrier between the staff and the patient is quite significant. So there are a number of downsides.
There are also some very clear upsides, particularly with a very dangerous disease or a disease early in its understanding.
Lead Module3: We’ve been told that, as part of the classification of Covid as an HCID, there is effectively a PPE kit that is required to be worn which includes FFP3 masks; is that correct?
Professor Sir Whitty: That is correct, yes.
Lead Module3: Are you able to confirm that the declassification of Covid as an HCID does not have any bearing on what IPC measures are thereafter recommended to people?
Professor Sir Whitty: That is also correct.
Lead Module3: So it could be declassified, and FFP3 could continue to be recommended?
Professor Sir Whitty: Yes.
Lead Module3: A mixture of masks, no masks, depending on the circumstances?
Professor Sir Whitty: Yes, and I think to highlight one point which has come up in various witnesses, not fully being picked up I think, is: you’ve got the kit, but you also have to have the training to use the kit properly.
People who work in HCIDs, and indeed work in infectious disease units, I’m one of them, are trained to use multiple different forms of PPE at quite a high level. You go through training to do that. You practice that training. People take fit testing very seriously, and they are ready for it.
All of these things are not going to be true outside that system, and just having kit but no training often produces little or no benefit. The training is fundamental to making the kit useful.
Lead Module3: By the time Covid was declassified as an HCID, there was UK IPC guidance which effectively said: FFP3s for AGPs, or hot spots where AGPs were going to be conducted, and FRSM in the other areas. I paraphrase. But do you agree with that –
Professor Sir Whitty: That is a good paraphrase.
Lead Module3: Do you think that was perceived by some in the profession as a downgrading of PPE that was required?
Professor Sir Whitty: Well, I’m sure the professions involved being large, I’m very confident you’d find some people who thought that was a downgrading, but I think most people would see that as a quite normal sequence. They may or may not agree with it, but they would see that as – it’s not a downgrading; it’s simply a move from an HCID to an infectious disease for which you have standard precautions for that level of risk.
Lead Module3: Do you think that there was sufficiently good guidance saying notwithstanding that we’ve had FFP3 as an HCID. The reason we’re recommending FRSM in all non-AGP hot spot areas is this. Do you think that that message was sufficiently well communicated to healthcare workers?
Professor Sir Whitty: I think that – well, let me just preamble this. You are inviting me to do so, so I’m going to, by saying that the areas of PPE, it’s a highly specialist area; it’s not one that I get involved in under ordinary circumstances, nor is it my technical expertise.
As you heard discussed yesterday, this has always historically gone through nursing and microbiology/virology groups of experts. That’s where it comes from. So I just want to be careful I don’t sound as if I’m trying to be an expert in this area. I’m not. This is not my area of expertise.
I think that – and I think this is a recommendation I think the Inquiry might – I would invite the Inquiry to consider. I think that the messaging near the beginning of this was quite confused. And I think the reason that it was confused was it was not entirely clear who it was who was ultimately responsible for making decisions in this fast-moving situation.
Can I expand – would you find it helpful for me to expand on it?
Lead Module3: I was going to ask you who was responsible?
Professor Sir Whitty: Well, I think that quite a lot of people thought they were partially responsible, and that’s always an extremely difficult and dangerous situation to find yourself in.
So it wasn’t that people trying to walk away from responsibility, but the sort of quite complex system by which Public Health England, as it then was, the infection control cell, NHS delivery of various things were interacting, and that’s before we get into issues of procurement and distribution, which had a separate set of challenges.
I think works fine if you’re changing every six months or so in a reasonably measured way. Up against the speed of changes that were needed, I think it led to uncertainty. It wasn’t deliberate in any sense, and it wasn’t anybody, as I say, trying to walk away from responsibility, but uncertainty as to who finally was actually trying to both call this and communicate it. And I think that, to me, seems an important thing which the Inquiry might want to consider recommending.
Lead Module3: So to go back to my question: from your perspective, who was ultimately responsible?
Professor Sir Whitty: I think that the ultimate – my view mechanistically was: ultimately, the responsibility for decisions was taken by the IPC cell, which became clearer over time, and technical advice to them came through Public Health England as it then was, UKHSA now, with delivery through the NHS.
But, as I say, I think there was a fair degree of uncertainty. And actually, one of the reasons that some of the DCMOs in my team got pulled in was, in my view, because of that uncertainty. And we took a slightly – if no one else knows – if it was unclear what to do, people would send it to the CMO, tended to be a default for quite a lot of things. But this was not our area of expertise, and that was why I was keen that we didn’t get too heavily involved in it.
Lead Module3: Caveat understood. You said there that you think the messaging was quite confusing. For healthcare workers, is that who you mean?
Professor Sir Whitty: I think for everybody, actually, but obviously the most important people are healthcare workers in the front line who are having to use this.
Lead Module3: Now, speaking of potentially confusing messaging, I think you are familiar, Professor, with the tweet that was put out by the World Health Organization.
Can we have it up on screen, please. I think it is INQ000300579. I’ll just deal with the tweet, and then I’d like to ask you about your involvement with the WHO.
You can see there, this was I think tweeted on 28 March, so we had gone into lockdown just a few days earlier:
“FACT: #COVID19 is NOT airborne.”
At the bottom:
“FACT CHECK: COVID-19 is NOT airborne.”
Did you see this tweet?
Professor Sir Whitty: Yes. I mean, I saw it subsequently. I didn’t see it coming into my inbox, but people drew it to my attention. I was quite surprised by it.
Lead Module3: Well, I was going to say: what did you think?
Professor Sir Whitty: Well, I mean, it was clear that, you know, there was uncertainty in this area. In the UK, we had been discussing – the question whether there was any airborne transmission struck us as: well, of course there is going to be some. But the question was, was it actually trivial and having almost no impact, or was it a major part, or some point between that.
But what we were all certain of – and if you read all the correspondence on this, it’s clear from mid-January onwards we were discussing this – was the degree of it. We all knew that the data were not yet clear enough to make a decision one way or the other. So this seemed surprisingly definitive.
Lead Module3: Now, you set out in your statement that between January and July 2020, you had had 44 meetings of an international nature, 19 of which were WHO meetings. Was this tweet discussed at any of the WHO meetings that you attended?
Professor Sir Whitty: The tweet specifically was not, and I think it would have been slightly odd for people to do it. The general –
Lead Module3: What about the topic?
Professor Sir Whitty: The general topic was discussed, and this was obviously one of the things that – there was a lot of – we were trying internationally to form some form of central view as to what the proportion was. Science is an international issue, and, you know, WHO discussions included this, although many other things as well, in what we were trying to do.
Lead Module3: Did you ever say in any of those meetings, “That is not a helpful tweet to have put out; it may be inaccurate for all sorts of reasons”? Did you ever take them to task, for want of a better phrase?
Professor Sir Whitty: I think if I start taking WHO or anyone else to task for all their tweets, that would be a problem in the system. They were well aware of the fact that this had not landed well.
Lead Module3: All right. Did you ask them to do anything about it? To retract it? To get your WHO colleagues or CMO colleagues on WHO to join forces to re-write?
Professor Sir Whitty: Among the very large number of things I was trying to do at this moment in time, trying to get WHO to retract a past tweet didn’t seem to me one of my roles, no.
Lead Module3: What about – forgetting the tweet itself, but getting WHO to not be as definitive as they were here, given the uncertainty as to the extent to which airborne transmission played a part in the spread of Covid?
Professor Sir Whitty: So I think what WHO was reasonably reflecting was scepticism of the size of the effect. I think what was wrong about this was the degree of definitiveness that was put into this tweet. But, I mean, in defence of WHO, I don’t actually think tweeting is a very good medium for trying to put forward really difficult science, and possibly the question is: would it have been sensible not to tweet at all, rather than the exact wording of this particular tweet, on a subject which is so technically difficult and disputed?
Lead Module3: That’s probably wider than Module 3’s remit, but I take your point, Professor.
Just while we’re dealing with WHO, we heard, is this correct, that guidance from WHO, the UK is not bound to follow it; is that correct?
Professor Sir Whitty: No, absolutely. I mean, it’s multilateral organisation. It’s a membership organisation. There is no obligation on the UK or any other country to follow their advice.
Lead Module3: Generally dealing with your WHO meetings, were routes of transmission discussed in those meetings?
Professor Sir Whitty: They were.
Lead Module3: And help us: what was the general tenor of the discussion about transmission?
Professor Sir Whitty: Well, I think that the debates that you have seen laid out in, for example, SAGE papers where this was debated quite extensively, the EMG group of SAGE, Environmental Modelling Group of SAGE, for example, among them, were reflected in the international literature as well.
So these debates were being had everywhere because they had quite profound implications both for control and for clinical management.
Lead Module3: You said in your statement you had I think 118 international meetings as well between August 2020 and June 2022. Was there anything gleaned from how others were doing it that was, you found, useful to bring back and try and adopt within the UK or England?
Professor Sir Whitty: I think it’s important to recognise that for large parts of certainly the very beginning of Covid, and indeed subsequently at many multiple points, either all of our information came internationally or a lot of it came internationally. The science was international, and in the end, the countermeasures, including vaccines, were an international effort, so this was an international effort at all times.
Different countries have different capacities. UK, for example, is extremely strong in clinical research, was very strong on genomics, but there were others who were giving useful epidemiology information from their experience, so the sharing of information was both normal and was incredibly important in this pandemic.
Lead Module3: And was that coming through you, essentially?
Professor Sir Whitty: No. It came through me, but there were multiple other routes. So people in PHE, for example, would have formal routes. And then UK scientists and clinicians of all sorts have bilateral links with colleagues overseas, and indeed many of the things I got was an email from someone who I – a friend of mine, who I had taught at some point, from another country would email me and say: are you aware of this? And that was extremely helpful as an early warning. But that was happening across the whole system; that wasn’t unique –
Lead Module3: Well, that’s what I wanted to check. If you were the central funnel for this repository and we were to sadly lose you, I didn’t want anyone to think that we would lose with it the channels of communication.
Professor Sir Whitty: That would not make much difference to the UK in that sense.
Lead Module3: Can I just deal with your meetings, to provide some context for some of the other questions I’m going to ask about what was going on in the pandemic.
You had 65 meetings with the Royal Colleges between January and June 2020, 245 meetings with Matt Hancock, not including Cabinet Office or Number 10, 286 meetings between the UK CMOs between January and June 2020.
And so, I wanted to ask you, really, what, for you, was a working day like in January, February, March, April 2020?
Professor Sir Whitty: Well, I mean, it was very long, but then it was very long for huge numbers of people across the system. But what we were trying to do was both absorb information, both internationally and nationally. It was very important to hear what was going on around the country. You have just heard from Professor Fong why it is important to get grounded information from around the country, for example, in one particular area. That was replicated across many areas.
Alongside that there was a large technical effort. Since I was both co-chair of SAGE and a – head of the – chief executive of the National Institute for Health Research, which is the UK’s largest funder of practical applied health research from the government. I had a large bit about trying to get science off the ground, which is an extremely important part of the early – part of the work.
And there was a lot of interactions with political leaders. I mean, you have talked about the Secretary of State for Health and Social Care.
The CMO is the adviser to the UK Government, not to the Department of Health and Social Care, and therefore, obviously, that subsequently involved interacting with the Prime Minister and other cabinet ministers as well as senior officials.
But that came at – a bit later along the track after January and February.
Lead Module3: Can I ask you about that. Taking as you are the adviser to the UK Government, why was there sufficient a significant amount of interaction with Matt Hancock?
Professor Sir Whitty: Well, I mean, he was the Secretary of State for Health and Social Care. In a pandemic he was obviously the lead cabinet minister, but under the leadership of the Prime Minister, and that would be the normal situation.
Lead Module3: All right, so we shouldn’t read anything the amount of communication you had with him or meetings you had with him?
Professor Sir Whitty: Well, I mean, I think if I hadn’t been meeting with him there would have been a serious problem in the system.
Lead Module3: Okay.
Now, you mentioned there research, and I would like to ask you about that, please, Professor Whitty.
I think you set out in your statement the fact that you were the chief scientific adviser and head or CEO of the National Institute for Health Research (NIHR) from January 2016, so pre-dating your CMO role, to August 2021.
You say in your statement that one of the good responses to the pandemic was the way that research pivoted to respond to the pandemic. I would just like to ask you, please, about what you did during the pandemic that built on the NIHR that was already in place?
Professor Sir Whitty: Well, I think we had a unique advantage in the UK of the existence of the NHS as a single provider, essentially, of health services, and a very strong tradition of doing clinical research and a very strong volunteering spirit from the general public.
And I think – I would like to, if I may, just pay enormous tribute to the over a million people who volunteered to do studies as part of the Covid, and the fact that almost every doctor, every general practice that I was aware of was involved in research over this period. It was an enormous effort.
We were able to do this because we have a single system. We had a small number of major funders, ourselves and UKRI, the medical research council, the principal one, and we could therefore make centralised funding decisions. There was a very quick and centralised ethics system that was able to pivot to this, do almost all of this work on this, and we were able to deliver to the NHS extremely rapidly.
If you look at speed of stand-up of research in the UK, it was way ahead of virtually every other country in terms of studies that finally got to see the light of day.
That came at a price, and the price was we were extremely ruthless about the number of studies we supported, because we were very determined that we didn’t start 100 studies, none of which completed. So we pushed it right down. But there was a certain – it was a pretty tough funnel. And we had to switch off large amounts of extremely important research into multiple other diseases to provide the capacity to do this. And it took us quite a long time, I think longer than we expected, to get those back on track. They are now back on track but it took us probably two years to get anywhere near back to where we were pre-pandemic. So I’m not saying this was a cost-free move.
Lead Module3: No. Why was it that it took longer than you had anticipated to get them back on track?
Professor Sir Whitty: I think what we had – when we should have anticipated but – with reality – is people had – staff had left, things – people had moved on. The, sort of, enthusiasm that had got someone halfway through a study had, sort of, begun to run into the sand. They had to restart up again.
So I think it did – I think that the UK’s leadership position on this, which – I think the whole system should feel very proud, it also meant that we then had a dip. But as I say, we’ve now recovered. But I don’t think anybody going into this should be under any illusions. If you swing all of your research capacity in one direction, there will be a kind of hangover period where you will not be able to do things you otherwise would have wanted to do.
Lead Module3: Yes, and a knock-on effect on the research that you were conducting that may have to be paused?
Professor Sir Whitty: Correct.
Lead Module3: Understood.
All right, now I want to ask you about one particular aspect of research, and that is into Long Covid, please.
You deal with this in your statement starting at 497.
But can I just see if you agree with me about this, by February 2023 the ONS estimated a prevalence of over 2 million people in the UK with Long Covid. I daresay it may be higher now in September 2024. You make the point in your statement that long-term consequences of a virus are not new; is that correct?
Professor Sir Whitty: Yes. The scale of this, I think, was not what we had anticipated.
Lead Module3: No. You go on to say that the precise nature and extent of the risks may not be known but it is fairly uncontroversial that there will be a risk of a long-term consequence?
Professor Sir Whitty: Yes. There are – there is one group of risks which are inevitable and one group of risks which are possible, and the inevitable bit is that if people are seriously ill, they will – some people will have long-term disabilities as a result of that. If you go into ICU, there is a reasonable chance you will have a result of going into ICU which is long-term and potentially permanent.
That was unsurprising. So we were not surprised that severely ill people had long-term consequences, although obviously we hoped that that would not be the case.
On the – the bit which was much less predictable in terms of its scale was for people who had milder or – mild or moderate disease also had quite profound long-term effects. Now, this is now unknown with other infections. For example, dengue infection is classic on this, Epstein-Barr virus can do it. So this is unknown, but the great majority of infections this is quite a rare event. And as the numbers you have given – I think we could debate about what the exact numbers are, but as the numbers you have given have demonstrated, this was not a rare event, you know, this was something that happened in a large number of people unfortunately.
Lead Module3: It was obvious, was it not, certainly by March, that there were people falling severely ill with Covid. One only has to think back at images of Italy and our counterpart across Europe. Given that it is inevitable that some people who are severely ill may suffer a long-term consequence, do you think there was strong enough messaging or communication of the long-term risks to the public when we went into lockdown for example?
Professor Sir Whitty: I don’t think that any different messaging would have led to any different behaviours. I think at the point when we started off in Covid, the key – you know, what you don’t want to do is overload large numbers of messages that don’t lead to a particular change. The key thing we were trying to say is: we’ve really got to stop this epidemic in its tracks to the best of our ability.
I don’t think there was any evidence that that message wasn’t heard loud and clear by the general public, and they acted incredibly responsibly and incredibly quickly as a result of that. Whether adding this component to it would have actually been important I think is a pretty open question. I’m not sure I would be convinced by that. Particularly as it was a speculative –
Lead Module3: No, I follow that, but you can’t say that it wouldn’t have had an impact, because we don’t know what impact it would have had if it had – (overspeaking) –
Professor Sir Whitty: No, that’s the speculative.
Lead Module3: I tell you what I wanted to ask you was, do you think in the event of a future pandemic you should be warned: try to keep yourself safe because if you get it you might die. If you don’t get it (sic), you may still suffer a long-term health consequence. That could be as bad as X, we don’t know yet how bad it will be.
But why do you think that messaging might not land with the public in the future?
Professor Sir Whitty: There is a thing we definitely should use to – bear in mind in the future and there’s something which I’m a bit more cautious about. I worried at the beginning, I still worry actually, in retrospect, about did we get the level of concern right? Were we either overpitching it, so that people were incredibly afraid of something when in fact their actuarial risk was low, or were we not pitching it enough and therefore people didn’t realise the risk they were walking into.
I think that balance is really hard and arguably some people would say, if anything, we overdid it rather than underdid it at the beginning. I’m just saying that there – certainly there is a range of opinions on that.
So I’m not certain that loading an additional risk on would in itself be useful. However, I think that the thing which this absolutely blows an absolute hole in, if it need any further, is the arguments for things like the Great Barrington Declaration, that all you need to do is isolate a few people and everywhere else can just carry on with their lives because they are at limited risk. That is obviously not true in this case and those kinds of arguments are not strong ones to advance in any future pandemic unless you can demonstrate it.
And I think we probably should have been swifter off the mark in spotting Long Covid as it emerged, although I think we were relatively quick and it wasn’t obvious we could have done something different as a result because of the way – the main thing we could do at the beginning, before we understood it slightly better, was to reduce the amount of Covid. If you don’t get Covid, you don’t get Long Covid.
Lead Module3: Given the uncertainty as to whether a new virus might have long-term consequences, how bad those long-term consequences might be, do you think there can ever be a pre-pandemic plan put in place to try to mitigate the risk of long-term consequences?
Professor Sir Whitty: I don’t think in the narrow sense of you can reasonably predict what the long-term consequences will be and then have something ready to go for that situation.
What you do need to have is an open mind that this may well happen and then try to work out what are the skills in the health service that are going to need to be shifted towards this.
So, for example, some of the – in my opinion, and I don’t think this is controversial – Long Covid is made up of more than one syndrome.
Lead Module3: Yes.
Professor Sir Whitty: I think probably at least three. And one of them is very specific to Covid for sure, it is not an overlap with other areas. And we weren’t – we didn’t have the skills for that and we had to develop them over a period of time.
Lead Module3: Is that what you set out at your paragraph 4.109?
Professor Sir Whitty: Sorry?
Lead Module3: It is page 63 of your statement, Professor.
Professor Sir Whitty: I’ll get there eventually, but if you read it out to me, then I –
Lead Module3: Yes. You say:
“Separately there is in some patients an overlap with the post-infectious chronic fatigue syndromes, for example that which may occur after Epstein-Barr virus or dengue fever … There is certainly another group of symptoms which occur after [Covid] which seem relatively specific to this infection and have some similarity with … (postural orthostatic tachycardia syndrome) …”
Just help, is that what you were talking about there in your last –
Professor Sir Whitty: Yes, so the three which I’m saying, and I think it is probably more than that, and it’s – actually, maybe I can explain why it is important to do this. It is a post severe disease syndrome, variety of ones, a post chronic – a sort of post-infectious chronic fatigue syndrome, which is a very real and very debilitating situation. I used to do clinics where many of the patients I cared for had this from other infections pre-Covid. So I am well aware of the very profound effects this can have. And then this relatively specific group of symptoms which we hadn’t seen previously after other infections. But there are may be other subdivisions within that and there is probably overlap in there.
Why I think this is important to differentiate these, if I may expand that slightly, is that particularly when it comes to treatment, the treatments may well be very different for those different syndromes, and if you lump them together, you may miss a treatment that’s highly effective in one but not the others or start giving treatments which actually have – tend to have side effects or rather disadvantages to people who are unlikely to benefit.
So, differ – working out what the syndromes are is very important for the subsequent management treatment and, hopefully, recovery of people who have Long Covid.
Lady Hallett: I’m getting messages about slowing you both down.
Ms Carey: Both down, I know. I’m so sorry, it is my fault, Professor.
Let me just go back to where I was, which was actually about research into Long Covid, please, and can you just – I think set out in your statement that over £50 million were spent on Long Covid research projects. Are you able just to give us a brief summary of the value of what you learned from those research projects, please.
Professor Sir Whitty: Yes. So they came in initially in broadly three ways. There is ongoing and there is a large international effort, although the UK has quite a large proportion of the Long Covid research at the moment.
There was initially some – well, even before this I requested a systemic review to look at what we knew about this, and that was important because it helped inform our understanding, inform our clinical management subsequently. I think that was in – from memory that was around about June I asked for that.
Lead Module3: 2020?
Professor Sir Whitty: 2020, yes.
There was an initial large study which was really looking at people who had severe diseases in hospital. So that’s an important subset of people who have Long Covid. And then there were subsequently two waves of additional studies which were looking both at understanding its biology, because that helps to identify what might be treatment, and trying out some of the early potential treatments that might be useful.
We are quite early in our understanding at the moment. I think that we are not yet at the point, in my view, where we can say with confidence: if you have this particular syndrome, here is a treatment that is going to have this particular effect. So – but I think it is absolutely an area we need to continue to do a lot of research in, because there are clearly a lot of people affected, and will continue to be, and it may also have a benefit in understanding the long-term effects of other infections where we have for a long time been, I think – have had really very limited evidence for quite a significant issue.
Lead Module3: Is there research that is ongoing in relation to Long Covid?
Professor Sir Whitty: Yes. There is a very active Long Covid research group led by Professor Kamlesh Khunti, who I think has given evidence – or is going to be giving evidence to this Inquiry for other purposes, but many other people are involved in it. And we have also got, obviously, links internationally, as with all science. I helped to broker some of those with Admiral Levine, who is my counterpart in the US, to make sure, for example, that the US and UK efforts were properly coordinated, as an example, because they put quite a lot of resource into this.
Lead Module3: Can I ask you this in relation to Long Covid as well. You say you were involved in trying to assess whether data coming from studies implied that countermeasures, and in particular vaccines, reduced the incident or severity of Long Covid. What kind of data were you looking at there?
Professor Sir Whitty: So this was really trying to look over successive waves and trying to see whether there was either a high incidence, ie new cases, with people with Long Covid post-vaccination, and then if they had Covid, what proportion of those went on to have chronic symptoms which could be called Long Covid.
I’m going to summarise rather crudely but, unsurprisingly, vaccines that protect people from having Covid protect them from get them getting Long Covid, because if you don’t get Covid you don’t get Long Covid. But importantly, vaccination meant that those people who did get Covid subsequently, it looks as if they get a lower incidence of Long Covid and a less severe manifestation. But it is a bit difficult to tease apart because, of course, different waves have had different viruses and we are now in an Omicron – post-Omicron era, and that is obviously a rather different situation biologically.
Lead Module3: You said in the statement that evidence currently available is vaccines reduce both the incidence and the severity of Long Covid?
Professor Sir Whitty: Yes.
Lead Module3: In relation to the vaccination messaging, clearly her Ladyship has a module dealing with vaccines, but do you think there ought to have been clearer messaging about the potential positive impact that vaccines could have on Long Covid or the long-term consequences of a virus?
Professor Sir Whitty: Yes, I think – the first thing is that until relatively further down the line we had much less strong evidence about this than we had for severe disease, and we were obviously pushing a very, very clear series of communications, based on the very solid data we had that demonstrated that vaccines reduced, very significantly, Covid, severe Covid and death, for which there is absolutely cast-iron and early evidence.
I think arguably we could have added that in, the point about reducing the risks of long-term sequelae. I think whether that would have changed people’s decisions, so those who decided to have a vaccine – or, rather, those who decided not to have a vaccine, fortunately a relatively small minority but still an important one, whether they would have changed their minds had that information been available I think is an unknowable question. But clearly the majority did choose to have a vaccine.
Lead Module3: What about the instance of Long Covid in healthcare workers; can you recall when it was that you first became aware that there were healthcare workers contracting Long Covid?
Professor Sir Whitty: Almost as soon as I was aware – initially with individual cases, of people you just knew, and then increasingly what in medical terms are called case series, just a group of people, and then wider studies. But unsurprisingly, healthcare workers had exactly the same risks of Long Covid as the general population, similar to them in age, gender, ethnicity and so on.
Lead Module3: Are you aware if there was any monitoring of the numbers of healthcare workers that were suffering with Long Covid?
Professor Sir Whitty: Not that I saw. I had quite a lot of data from, for example, ONS, you’ve quoted that, and others looking at Long Covid in the general population. It is possible that NHSE kept those data. I didn’t see them.
Lead Module3: Did you yourself provide any advice or support to those that you knew who were suffering from Long Covid?
Professor Sir Whitty: I think all of us – I suspect everybody listening, not just those who have a particular interest in this Inquiry, actually would be – know people who had Long Covid, and all of us therefore interacted with them as friends, as colleagues, as you would hope.
Lead Module3: I’m asked to ask you this.
Clearly we are aware of the disproportionate impact that Long Covid had on people who are from a black, Asian and minority ethnic background, and I wanted to see if there was any work ongoing to monitor Long Covid within that particular group of people?
Professor Sir Whitty: Yes, ethnicity is one of the things people are looking at in terms of Long Covid in research terms.
Lead Module3: Do you know yet if there is a link between the disproportionate impact of Covid on the BAME community and the rate at which they contract Long Covid?
Professor Sir Whitty: I think what’s not clear, at least in my view, is that – you know, the increased rates of Covid in a pre-vaccine era, which are one of the things which was very important in understanding early on, led to an increased rate of Long Covid, unsurprisingly, irrespective of anything else, in people from black, Asian and other minority ethnic groups. I think whether they biologically responded differently to Long Covid is much less clear, and is a – potentially an important point, because it may lead to differences in the way you deal with treatment.
Lead Module3: You said I think at the beginning in answer to questions about Long Covid it was important to keep an open mind. I paraphrase perhaps. But can I ask you, please – and if we could look at it on the screen at INQ000474233, at 176.
This, Professor, is an extract from the Inquiry’s Every Story Matters record, and there is a chapter in there in relation to Long Covid. In particular, those who were contributing to Every Story Matters have commented that they found it very difficult often when they spoke to their GP or other healthcare services that at times the GP didn’t know how to advise them, didn’t know what they were reporting.
Can you think of – I can see there for example:
“I spoke to my GP and at the same time I was in contact with the community mental health … that’s where we sort of discussed Long Covid because of the fatigue issues. But there wasn’t a lot available at the time.”
I think you have read that section of the record, haven’t you, Professor?
Professor Sir Whitty: Yes.
Lead Module3: Thank you.
Professor Sir Whitty: Sorry, the information may not be available, but do you know what the date is they were talking about?
Lead Module3: No, not necessarily.
Professor Sir Whitty: The reason I say that is I think that up to and including – it’s probably November 2020, there was really very little guidance of any sort for GPs and other doctors to know what to do. NICE then produced some guidance, and after that point I would hope that there was – you know, through a trusted source, based on systemic reviews, on the limited information we had, at least we had a starting point to actually help medical and other healthcare professionals to support people.
I would be very disappointed if people didn’t take it seriously or didn’t believe them. I think that – but I can understand entirely why GPs and other healthcare professionals found “Now what do I do?” a much harder question until we had systems in place.
Lead Module3: If it helps you, although we don’t have precise dates for those whose quotes are recorded here, if we just look at the opening paragraph and the final sentence. Certainly the way this has been summarised is that early in the pandemic contributors living with Long Covid said it was challenging to find any information, advice or treatment, which may chime with the answer that you have just given us.
Professor Sir Whitty: Yes, and I think that is absolutely – clearly true.
Lead Module3: Can you think now of any way we can better advise clinicians in their response to potential long-term impacts?
Professor Sir Whitty: Well, I think that this is – I mean, the first thing that is very important is to hear what people have to say and understand it and believe it, as a starting point.
I think then the question is: are they people who are going to benefit from relatively specific or more generalised specialist support?
For example, Long Covid clinics were set up as part of the response at the point we started to, I think, really fully understand what we should be doing, from about November 2020, and that expertise now exists, and it is multidisciplinary because there are many different aspects to this. Or there might be someone who had a very specific thing, which might be around physical disabilities or others.
And then I think there is also an important – it’s an important point for people to understand that the longer-term outlook for people with Long Covid varies very significantly. Some people make an almost or complete recovery relatively soon, as in a matter of weeks to months, having had, undoubtedly, Long Covid as defined by any area, and others have a much longer course or, indeed, see no improvement. And I think understanding that range is very important. But it needs to be laid out. The strong caveat, as I say, we are in the foothills of our understanding of this important set of syndromes.
Lead Module3: If I can turn to shielding, please, and certainly make a start on that topic before, perhaps, we take our lunchtime break.
That is dealt in your section 9, Professor, of your statement.
You set out there that it was SAGE that recommended shielding of the most at-risk patients in early 2020, and it was the role of your Office to lead the development of the definition of both clinically extremely vulnerable and indeed those who are clinically vulnerable.
Professor Sir Whitty: Yes.
Lead Module3: You have helpfully included a timeline in your statement.
I’m not going to go through every entry, but there will be a couple of dates I would like to ask you about. But can I deal firstly with clinically extremely vulnerable –
Professor Sir Whitty: Yes.
Lead Module3: – and then deal separately with clinically vulnerable, and really the identification of the conditions that gave rise to CEV status.
And perhaps if we call up on screen your actual statement it would be easier to do it that way. Could we have INQ000410237_0086.
There are – there, forgive me – yes.
There are set out there, from bullet point 1 going all the way through, I think, to 6: organ transplants, people with cancers, people with severe respiratory conditions, people with rare diseases, people on immunosuppression therapies, and people who are pregnant with significant heart disease. And those were the people to whom the letters were sent, is that correct, in March 2020?
Professor Sir Whitty: That is correct. Traditionally GPs –
Lead Module3: I was going to come on to that –
Professor Sir Whitty: – identified additional cases, yes.
Lead Module3: There were six categories, if I may call it that, plus the option for GPs to identify those from their own patient list that they may consider to be clinically vulnerable and that made up the shielded patient list, is that correct?
Professor Sir Whitty: That is correct.
Lead Module3: How was it worked out that these were the conditions plus the GP additions would be the ones that were deemed to be clinically extremely vulnerable?
Professor Sir Whitty: So, I mean, there was a kind of – essentially there were two stages of trying to construct a list for the clinically extremely vulnerable, and I think an important preamble to this is that we recognised that being on the clinically extremely vulnerable list and then shielding would be extremely difficult mentally and operationally and for people who had healthcare conditions, which most of these people had, also in terms of healthcare provision actually, so there were significant downsides to it.
So we were – on the one hand, if you start with – essentially you divide it into three concepts – things: the concept of whether shielding was a good idea; whether the lists were sensibly constructed in terms of risk; and the operational elements of was it delivered well.
Just taking the issue of the lists. We didn’t either want to put people on the list who were going to have limited benefit from it, because we thought they would probably come to net harm, nor did we want to have people not on it who we thought would come to net benefit.
Unfortunately at this point we were, of course, constructing a list based on first principles.
So we subsequently – and you may want to come on to this – did a much more evidence-based – in the sense of from Covid evidence-based – list, which was – which led to something called QCovid, which was a risk stratification –
Lead Module3: We will come on to that.
Professor Sir Whitty: But from this period we were having to do it on the basis of: who would you expect would be most likely to die from this infection? And that’s a combination of some early information we had particularly from Chinese and other scientists, remembering we didn’t at this point have a lot of UK data, this is before the wave had passed through. The first wave.
And secondly, just what you would normally expect for an infection, who were the people who were going to find it most difficult to mount an immune response, for example, and therefore be a much higher risk. It was on that basis – it was essentially a consensus statement, which in medical terms is the lowest standard.of evidence, and we accepted that. Well, we thought this was better than no evidence at all. So this is really how this came to be. It was from – people from multiple disciplines came together to do this.
Lead Module3: In your witness statement you set out there were a number of meetings around, I think, 5, 6, 7, 8 March, as the shielding programme was getting up and running, and clearly ended up with the categories that we have just looked at; during any of those meetings was disability as a criteria for shielding discussed?
Professor Sir Whitty: The whole – I mean, I can’t recall absolutely everything that was put as a possibility. Because of the downsides of this, the only groups that we ended up with were people where – were ones where we thought there was an overwhelming probability of substantially increased harm, and from first principles at this stage, disability, however defined, would not have been in that group.
Lead Module3: We know in due course that Down’s syndrome was added to the list. Was there any thought given to that specific addition, of Down’s syndrome, to the CEV list at the start?
Professor Sir Whitty: At the beginning it may have been thought about, but I think we would not have, from first principles, expected to have had the degree of risk that actually transpired.
The reason for doing the work that led to the QCovid system was exactly this, which is the first principles can only give you a very first approximation, and what the QCovid risk score and the research that led up to it did was much more accurately determine what the risk was.
And the reason we put – added people who had Down’s syndrome to this list, in advance of the rest of the QCovid work, was they demonstrated so much higher a risk than you would expect and, importantly, so much higher a risk than the general population, that we thought putting them on early was, clinically, the right thing to do, in advance of other groups.
Lead Module3: We will come on to QCovid but just going back to the GPs adding to those that they considered to be clinically extremely vulnerable, what thought was given to the impact on them of actually having to practically go through their patient lists and work that out, given all the other pressures that were on primary care and GPs in particular as at March/April 2020?
Professor Sir Whitty: Yeah, I mean, can I put on record what a superb job GPs did. I thought they got a lot of flak, entirely unreasonably. They did an incredibly hard job over this period and we added this to their multiple other things they were having to at this point.
Our view was that, again, there were clearly downsides to asking GPs to do it, which is the one you indicate, which is: this is going to produce additional work for people who are already working incredibly hard and in a very stressed system.
But we thought that what we had, which was a list of people with a code, essentially, was too crude, and GPs know their patients far better.
We also said the GPs could remove people from the list as well as add them, so it wasn’t just a one-way door. There could be people where they would make the judgment that actually, for this person’s quality of life, this would be entirely the wrong thing to do. And so GPs had the capacity and the sense to say: of course this is what the central data shows but in fact I know my patients much better and I have made this judgment based on these broad criteria that were laid out.
Lead Module3: Can we look on screen just at a couple of headline figures in relation to the shielding list.
Could you pull up, please, INQ000410237_0080.
Here is the timeline that you have helpfully set out.
Just pausing there. 18 March, the UK CMOs agree the criteria, as we have just looked at. The letters started going out then shortly thereafter. Shielding was announced by the Secretary of State for Housing, Communities and Local Government on 22 March. We went into lockdown the next day. And you can see that by 7 May, if we just scroll down, at that point there were 2.2 million people who were deemed to be CEV.
I won’t go through the various additions between the announcement as to shielding and where we got to on 7 May.
If we go over, please, to 1 August, please. The national shielding programme was paused, although shielding did continue in Leicester and Blackburn with Darwen until 5 October because of persistent high rates of virus in these areas.
Could you help us, please, Professor, why was shielding being paused as at 1 August 2020?
Professor Sir Whitty: As people will probably recall, by this stage the number of people who were being infected by Covid was way down on what it was on the peak and we were very conscious of the major downsides for being – strict shielding for people who were living with it, and our judgment at this point was, outwith these areas which had persisting very high transmission, that the risks of someone being in shielding, with all the mental and other stresses that came with that, by this stage were going to outweigh any possible benefit from an epidemiological point of view. So for that reason it was paused.
Lead Module3: But clearly with the option of keeping it still in areas where there were persistent high rates, as we can see set out there?
Professor Sir Whitty: Yes, because it’s a risk benefit.
Lead Module3: Yes.
Professor Sir Whitty: Quite a difficult balance.
Ms Carey: Yes.
Now I’m going to turn to QCovid, and I wonder, my Lady, if that’s a convenient moment?
Lady Hallett: Certainly.
Obviously we have a very great deal to get through. I shall return at 1.40 pm.
Can I just issue this alert to the core participants to whom I have granted permission to ask questions. I have been looking through them and a lot of them are actually quite lengthy, and given I’m going to be very strict on timings, no generosity today, I’m afraid, they may wish to shorten the questions. I’m not suggesting they don’t ask them, but they may wish to try to shorten some of the preambles and the content.
Ms Carey: Thank you, my Lady.
(12.51 pm)
(The short adjournment)
(1.40 pm)
Lady Hallett: Ms Carey.
Ms Carey: Thank you, my Lady.
Professor, to QCovid, please. Are you able to just summarise briefly what it is, why you commissioned it, and what it told us.
Professor Sir Whitty: Thank you. The point of QCovid was to do a much more accurate assessment of risk for people dying of Covid. The immediate aim was to help to make the shielding list a much more accurate tool, and based on individual risk concluding things like ethnicity and deprivation, so it wasn’t just on individual diseases, which the previous list had been. It subsequently became arguably even more important in that it helped us to identify people who had accelerated vaccination when that happened, so it had two uses in practical terms.
Lead Module3: Pause there. Did it in fact identify a further 1.7 million patients who ended up being added to the shielded patients list?
Professor Sir Whitty: Correct.
Lead Module3: Was it as a result of the work that QCovid had undertaken that you and your fellow CMOs decided that Down’s syndrome should be added to the CEV list?
Professor Sir Whitty: That’s correct.
Lead Module3: I think that was in – I think according to your timeline, Down’s syndrome was added in September 2020.
Professor Sir Whitty: Yes.
Lead Module3: The additional 1.7 million were added in February 2021. And I suppose it begs the question: do you think therefore perhaps that was too late for that rather large cohort of people who should have been shielding?
Professor Sir Whitty: I think – I mean, the first thing is to acknowledge that this was extremely difficult to do because it involved data from multiple sources. The big delay in this was actually principally in being able to pull the data from multiple sources together. And I think, again, if I may make a suggestion for something you might want to consider for a practical solution; the ability rapidly to get data from multiple sources is absolutely critical to these.
So, for example, good ethnicity data would be held in one area, and death data might be held in another area. You’ve got to be able to, in an emergency, be able to pull these together very fast, and only if you can do that can you end up with accurate risk stratification based on individual risk rather than very broad categorisations.
Lead Module3: Do you think that the addition of so many people in 2021 erodes or undermines the credibility of those that were asked to shield back in March 2020?
Professor Sir Whitty: No, I don’t – I certainly don’t think so for the ones who shielded in 2020. Of course, it was very difficult to work out whether the risk – individual risk for people who had shielded because they were in a different category already, and so that is a weakness of the way we did it in two stages, but I don’t think there was an alternative to that.
But I certainly think it was reasonable to have a first pass, and then sensible to have a second, much more individually-based risk subsequently. All of us would have preferred to have been able to do that a bit faster.
Lead Module3: I think you say at your paragraph 9.23:
“Of the 1.7 million ‘QCovid’ cohort, 86% had an ethnicity recorded, of whom 36% were non-white, compared to 17% non-white ethnicity recorded in the adult population.”
Help me with that in lay speak.
Professor Sir Whitty: Yes. In broad terms, what that means – and this is unfortunately unsurprising, given what happened – is that people with – from ethnic minority populations were overrepresented in the population, first point; but, secondly, that we didn’t have complete ethnicity data, so even pulling data from multiple areas together, we didn’t end up in a place where we were able to say with confidence what self-assigned ethnicity was for everybody.
Ethnicity is a complex issue, but obviously the ideal is self-assigned, where people have identified themselves which ethnic group they belong to.
Lady Hallett: Sorry to go back on it. Could I just ask: going back to the suggestion for a possible recommendation, how would you gather the data from all these multiple sources? What are we talking about here? Are we talking about systems that speak to each other? Are we talking about getting permission to share patients’ data? What do we need?
Professor Sir Whitty: In this situation, the – this is not based on individual patient consent because that wouldn’t have been possible to do at the scale we’re talking about, at the speed we’re talking about. But you also have to be very careful, of course, that you only provide exactly the data you need and you’re not overstretching the mark. But some bits of data were held in GPs, some were held in hospitals, some data came from other sources as well, and you need to be able to pull those together.
And there are two elements to that. There is a technical element which is increasingly easy actually. There are lots of ways of getting one database to talk to another. And then there is a legal and societal issue which is: do we want to do this?
Now, I think under ordinary circumstances, the expectation level I think of legal barriers to it is high, and that’s a societal choice, but in an emergency, the ability to, within the law and within parliamentary consent, merge these data sets together, the faster you can do that, the faster you can start to provide accurate information that helps to identify those most at risk.
Lady Hallett: Thank you.
Ms Carey: There are variations across the UK then as to who was added when, when it was paused, stopped. And I’m just going to ask you about 15 September 2021, the shielding programme closed; is that correct?
Professor Sir Whitty: Correct.
Lead Module3: Whose decision was that?
Professor Sir Whitty: Well, because I’m pausing, I can say with confidence, not mine. I can’t remember. I think that was a sort of variety of people came together. By this stage, I think it was reasonably clear, given the much lower mortality and the fact that almost everybody who chose to was double vaccinated by this stage, that the disbenefits of being shielded, which are isolation, mental health issues and others, were likely to outweigh the benefits for virtually everybody.
Lead Module3: Did you have any involvement in putting support in place for those who had been shielding up to then and therefore were no longer shielding?
Professor Sir Whitty: No. I mean, I said there were three elements. There was the conceptual, was this a good idea, which SAGE led. I was co-chair of SAGE, so I can absolutely speak to that. There was the who is in the greatest risk, which we have just spoken about. But the actual delivery of this was done by other departments, actually, not even just – not even other bits of the Department of Health. It was done by local government, the communities department, and by DEFRA, who I think did a great organisational job. But that was a completely separate issue. And then there were issues of financial support for people who otherwise would have been working.
Lead Module3: I’d like to ask you about support, though, because I think you received an email, one of which we’ve got in our bundle.
Can I call up on screen INQ00074822.
In February 2022, you were emailed by someone who had been on – deemed clinically developmentally vulnerable. If we could go on to the second page, once he set out that he was one of millions who were CEV.
He says in that – I say “he”; it may be a she. They say in the document that they “followed the instructions rigorously”. That that meant, for them, sacrificing contact with family, young grandsons, reducing their previously busy and fulfilling life to a miserable and empty nothing.
If we go a little bit further down the page to the paragraph that starts “and still nothing”. He says:
“And still nothing. No information. No perspective. No parameters. Instead, it’s simply been announced that ‘all restrictions will be ended within the month’. We’ve not heard from or seen either yourself or Mr Vallance for months. You seem to have disappeared entirely, and your advice and knowledge either ignored or suppressed. I for one am angry, resentful and fearful. Am I and the millions like me to presume that the government and health authorities have simply decided that we are not worth keeping informed? How do I go about making a practical assessment of the risks to myself of the ending of restrictions? I feel entirely disregarded.”
I assume that wasn’t the only correspondence –
Professor Sir Whitty: No. I mean, I try making myself relatively available, so people email me on multiple different routes, and this was typical of quite a lot of people who had been shielding.
I think it demonstrates at least two things, probably more. I mean, the first of which is the – although shielding had some very important at least conceptual advantages – we might come back to the evidence base for that subsequently – but the reasons for it were sensible in concept, and I thought it was executed reasonably well when it was set up. As an outsider, I thought it was an extraordinary logistical exercise. It had some real disadvantages of people’s loneliness and mental health which this person I think lays out really clearly and I think entirely compellingly.
And then, secondly, I think this was a period when there was much less information in the general public. I mean, Sir Patrick Vallance and I only appeared only on TV if we were asked to by the government. It wasn’t a choice; they choose to or they don’t. And this was mainly I think an issue of: you cannot overcommunicate in a situation like this, where someone has been essentially taken out of society, and information is very important.
I mean, I tried to get and then signpost to people some information myself, but that’s clearly inadequate and a hopeless way of trying to achieve this aim.
Lead Module3: Can I ask you about one aspect of this email: the reference to making practical assessments of risks, or risk assessment to put it another way.
How were people who had been shielding and then were told not to, to practical work out whether they were at risk now, or lower risk, or higher risk? It just seems very difficult. What thought was given to helping people who were advised to risk-assess how practically to do it?
Professor Sir Whitty: I think – I mean, there was a lot of debate about what the best thing to do was, and what was useful centrally, which tends to lead to very crude risk classifications, and what was done best locally, ie via GPs or others who actually have a better understanding both of local situations and the individuals’ risk, those two are potentially synergistic, but they have to operate together.
The problem for people was, you know, lots of people who, when shielding ended, continued for practical purposes to shield for quite a long period afterwards, even when we actually made increasingly strong statements saying: we don’t think that this is now necessary, I think people felt that they were at significant risk if they went out, if they met people, if they had other social interactions with inevitable negative consequences.
Lead Module3: Quite, because it occurs to me that there may have been pockets of infection in various parts of the country. So how were they, in an area where Covid was rife, to work out what they should or shouldn’t do? It was a difficult ask.
Professor Sir Whitty: It was a very difficult ask. I mean, I think at the – there was a period when the government had a system called tiers, which was discussed in the last module. During that period – and you referred to it before the break – there were areas, for example, that were in shielding. Either they didn’t leave it at the time others did, like Leicester and Blackwood and Darwen, or they went back into it for practical purposes, as for example London did, earlier than others.
So at a very macro level, there were points when there was local difference, but it’s not just the local difference; it’s also the individual circumstances. How much potential benefit is this person getting, and also how much risk are they – and damage are they accruing, and that’s going to vary very significantly from person to person. That really can’t be captured by government advice. That has to be more tailored.
Lead Module3: I think you set out in your statement attempts to consider the effectiveness or otherwise of the shielding programming. Can I ask you about that. You say:
“The Office of Chief Medical Officer did not directly undertake evaluation of the effectiveness of shielding advice. It is not possible to assess the effectiveness by reference to the numbers of people hospitalised because of various confounding factors.”
But just – I’m going to ask you about the effectiveness or otherwise of a shielding programme. Do you think it was effective at protecting the most vulnerable members of our society, health-wise?
Professor Sir Whitty: I think it – I think it was beneficial in one way, and harming in another way, and uncertain in a third.
The first one is, for people who would normally have said: I’m at great risk, and I wish to isolate myself, which is a very natural and proper response and would have well preceded Covid – and that’s something which has happened in multiple infections; people who are at greatest risk choose to reduce their social contacts – it did provide a practical level of support from the government, which otherwise would not have been present. So both financial and providing food, providing medicines, providing some levels of support. That bit I think was a good thing. I don’t – I think – I’m reasonably confident that was a sensible thing to provide.
I think my view is that it is likely that – the second bit, which is clear, is that there were significant harms to shielding, which your last email that you showed up I think is a very good testament to.
And then the third element which is, did it actually lead to a reduction in infection and therefore a reduction in mortality is extraordinarily difficult actually to test because the group of people who were shielded were, by definition, at massively greater risk or substantially greater risk than the general population. So if they got Covid, they were much more likely to die – that was the reason they were shielding – and they were often people who, because of their care needs, were likely to have multiple contacts that others wouldn’t, making the incidence, how many cases they were, also difficult to tell.
If it would be helpful, I can give a slightly more technical answer, but that depends whether that’s helpful.
Lead Module3: Well, can I ask you about Professor Snooks’s conclusions, and then we’ll consider whether we need to descend to the technicalities.
Could I have up on screen, please, INQ000474285_52. And I think you are aware, Professor Whitty, that Professor Snooks has considered some of the evidence and evaluated some of the evidence on the efficacy of the shielding programme. And she concludes at her paragraph 147 and 148:
“There is no evidence of overall reductions in Covid-19 infection associated with shielding, except in the subgroup of rheumatoid arthritis. There is evidence that hospital acquired infection was higher in the shielded group. As the mechanism for protecting CEV people from serious harm or death during the pandemic is to avoid infection, these results cast doubt on the effectiveness of the shielding policy.”
She makes the point:
“There is little high-quality evidence on the impact of shielding on mortality, but those researchers that have investigated this have not found consistent or sustained effects - in the majority of studies, mortality has been found to be higher.”
And she goes on to make the point, of course, that you can’t know what would have happened if we didn’t shield.
Can I ask you, please, do you agree with those conclusions set out there, or not?
Professor Sir Whitty: Well, firstly, I heard Professor Snooks has just had a medical event, and I’m very sorry. I hope she makes a rapid and full recovery.
I mean, she contributed very importantly to the literature of people trying to study this, and her own papers are extremely caveated and make clear the methodological difficulties, and I thought actually her expert witness summary of the various evidence was a sensible summary of a complex and rather confusing field.
I was quite surprised that she came out with such a strong statement, having come up with such a nuanced set of reviews of the various areas, and I think what – I am going to make my technical point, actually, because I think it’s important for actually understanding this.
In these kind of epidemiological studies, observational studies, what you’re trying to work out is the difference – whether a particular exposure leads to a particular outcome. That’s simply what it is; exposure and outcome.
But there are a bunch of what are sometimes called confounding factors. Those are things you can measure and you can deal with in analysis. But there are other things which are called biases which you simply cannot deal with by analytical means. If you have got a bias in a study, it is essentially going to be very difficult to interpret through to worthless. That’s the reality.
The difficulty of studies is never finding the exposed group; it’s finding the control group, and if the control group is systematically dissimilar in every way from the exposed group you are interested in, then it’s incredibly – it’s basically impossible to actually draw a conclusion.
My view is, this is – to use something you discussed with Professor Smith yesterday – absence of evidence one way or the other really, rather than evidence that this did not work. I’m not excluding the possibility that it didn’t do what we were intending. I’m not saying that it was highly effective. I’m certainly not saying that. But I just think – I wouldn’t go as far as Professor Snooks has in the way she’s interpreted in this summary. As I say, the rest of her analysis and her own studies I consider are very nuanced and appropriately caveated.
I’m sorry that was a bit technical, but I thought it was sensible to do –
Lead Module3: No, so I suppose it comes to this: in the event of a new pandemic, would you devise a shielding programme again?
Professor Sir Whitty: I think there are two things I would definitely do. I think shielding I’m unsure about. It would depend on the situation.
I definitely think that the risk stratification is really important because there are many other things that flow from them, and indeed you don’t know what will flow from them always when you do it. So we didn’t actually know that QCovid would end up being extremely important to help us with vaccination prioritisation.
Secondly, I do think it’s important to put in place a mechanism to support people who rationally have chosen to take themselves out of society to the best of their ability to protect themselves.
Whether the particular approach to shielding we took is an appropriate one to use again in a respiratory infection, I honestly don’t know. I think it’s going to depend on the situation. There are many kinds of pandemic, of course, where it would be completely irrelevant. It wouldn’t have helped in HIV, for example, or many other important pandemics.
I think it does – and my final point, and I’m going to give it a third kicking, and then hopefully I’ve done my kicking for it – it demonstrates yet again why the Great Barrington Declaration approach, where you say – you can shield the vulnerable and leave everyone else makes no medical sense because shielding someone from a respiratory infection is extraordinarily difficult to do. People tried really, really hard here, as you can read from that email and many others that you will have seen in your testimony, and it is important to note that even there, with a highly transmissible respiratory infection, very, very hard.
Lead Module3: I suppose one of the points she’s making there is that you don’t get nosocomial infection under control when you have clinically vulnerable people who need to go to hospital to manage their underlying infections. It’s a pretty dire situation for them.
Professor Sir Whitty: Well, I think I would go further than that, actually. That was – part of the logic of shielding was we knew that, inevitably, there would be infections at a higher rate in hospital than out of it, and part of the point was to ensure that people who were at the greatest risk didn’t go into hospital at the point of the peak epidemic.
Lady Hallett: In relation to the Great Barrington Declaration, for those who haven’t followed, was that October 2020?
Professor Sir Whitty: I can’t remember the exact date, my Lady.
Lady Hallett: It was the autumn of 2020.
Professor Sir Whitty: Yes, but its basic concept was you could shield some people and then let the – the infection die out of its own accord through others. I’ve given quite a long critique of it to the Inquiry previously, but I’m sort of, in a sense, evidencing the points I made previously.
Ms Carey: Finally this on the CEV: do you think that there should be more advance planning to help identify others that might be at risk – I suppose that depends on the type of virus that you’re dealing with – or is there anything you can think of that we could do to help plan a shielding programme in the event that it were needed?
Professor Sir Whitty: I was actually, in this situation, pleasantly surprised by how quickly NHS England, through its digital systems, was able to identify the people we had highlighted as high risk. So I actually thought they did a great job, and that was obviously pre-done; that wasn’t done during the pandemic.
For the specific risk, though, the QCovid model, absolutely, you could not do that until you know what the specific risks are, so that has to happen, unfortunately, once you’ve already got some real data.
Lead Module3: Clinically vulnerable people, please, Professor.
Can I show on screen the guidance, INQ000348029.
This was the guidance that was disseminated on 16 March 2020, and I think the list of those that are required is set out on page 2 or 3 of that document. Page 3, please.
Now, this is in a different category and a wider category; is that correct? I think you say in your statement the clinically vulnerable group encompassed approximately 17 million people who were eligible for the vaccine and therefore potentially asked to socially distance.
Professor Sir Whitty: Yes. So, specifically this was, for practical purposes, the same list as for a flu vaccination, for those who are not – haven’t reached the age threshold. That was for practical reasons, but we thought that the risks were likely to be very similar, and they knew that they were eligible for a flu vaccine, so, in a sense, it was a group that was pre-identified, and you could simply translate that across.
Lead Module3: Right, okay. So it was 70 or over, under 70 if you had various health conditions, or those who are pregnant.
Professor Sir Whitty: Yes.
Lead Module3: All right. And they were asked to socially distance, and indeed if you go down to page 4, please, the guidance sets out there the various things that were asked of the clinically vulnerable.
Can I ask you about pregnant women.
There were a number of pregnant healthcare workers who clearly will have read this and, in accordance with the guidance, were now being told to work from home where possible. Was there any consultation with the Royal Colleges, either obstetrics and gynae, or Royal College of Midwives, prior to the clinically vulnerable guidance being published?
Professor Sir Whitty: Yes, there was quite a debate. I mean, I wasn’t leading this; Professor Jenny Harries was.
And can I just do a quick side point? Professor Harries, whenever there was a really difficult problem, she walked towards it, which is one of the reasons she appears in front of you a lot, but she has dealt with many of the most difficult issues. That was her choice. I think we all owe her a debt of gratitude for doing that. This is one of the issues where she was leading.
And the Royal College of Obstetricians and Gynaecology, who are obviously the experts in this area, the Royal College of Midwives, came up, with others indeed, with a joint statement about their view about where the risk was, based on the limited data but the important data they had initially. And we signposted where we could their advice because they were the experts in this field. But the decision was that it was too complicated to try to put so many caveats into the social distancing information.
And we did have a residual concern that the royal colleges had quite a clear view based on data, which I think was the right place to start, that the risk was principally in the last trimester of pregnancy, the third trimester of pregnancy. This obviously extends, and this is where the difference is, and it’s a subtle but important difference potentially into the first and second trimesters as well.
I think what subsequent data has shown is that there is an increased risk probably across pregnancy, but that risk is clearly much greater at the tail end of pregnancy. So, in a sense, both positions were a reasonable position to take, given the limited data that was here. We tried to make sure that there was no conflict, but there remained some ambiguity.
Lead Module3: I think you have seen an email from the Royal College of Medicine of being critical of you for not –
Professor Sir Whitty: Royal College of Midwives.
Lead Module3: Sorry. Royal College of Midwives – forgive me; you’re quite right, Professor – saying – critical of you for not providing guidance for employers, saying fairly and squarely this is the job of the four CMOs. Was it your job?
Professor Sir Whitty: No, is the short answer. I mean, I think that, perfectly understandably, the Royal College of Midwives, and remembering that whereas the obstetrics and gynaecology college is essentially my professional groups, where the doctors and midwives tend to be a different group, but quite understandably people seemed to think early on in the pandemic that anything that was important had to be signed off by the CMOs. Given how few of us there were trying to do a lot of different areas, I didn’t think it was sensible for us to be trying to sign-off every bit of guidance. I thought that really would lead to extraordinarily poor decision-making by us and/or a block on the system. So it wasn’t our job to do the guidance and we didn’t.
But we did appreciate the point they were making which was that there was a potential difficulty between if you passed this document and their document, their joint document, you could say, “Well, what am I supposed to do?” And we tried to signpost people to the expert document, ie the one that was jointly put out by the obstetricians and the midwives.
Lead Module3: New topic, please: routes of transmission. Professor, bear in mind that her Ladyship’s heard a lot of evidence about this already in the preceding weeks.
But I want to ask you about the terminology because, forget the extent to which airborne or aerosol transmission played a part, it was acknowledged, I think, fairly early on there was likely to be airborne transmission. Would you agree with that?
Professor Sir Whitty: I agree with that.
Lead Module3: Airborne, aerosol, any other variation seemed to be used either interchangeably and the droplet definition size causes a degree of confusion potentially. Do you have any views or observations to make about the terminology we should use going forward when dealing with a respiratory virus?
Professor Sir Whitty: Well, some of your expert witnesses, rightly in my view, said that part of the problem comes – that different people from different disciplines work in this area and use terms in slightly different ways, and I think that isn’t helpful. I come from a medical background, so I tend to use “aerosol” and “droplet”.
But I think actually in practical terms the question is, is it a near field risk or far field risk? And I think in a sense that makes it less of a – almost pseudo technical argument and into a practical one which is that if you are more than 2 metres away from someone, how much have you reduced your risk? The answer is if it’s a droplet-based thing, in terms of ballistic droplets in medical speak, you’ve reduced it to, for practical purposes, close to 0. If there is still aerosol transmission, that is going to be much further.
And, secondly, it has an importance in terms of time. So droplet risk is only important for the immediate period after someone has actually been in the place. Aerosol – again, using the medical terminology rather than the engineering one – is important for a period after that and can be downwind of that.
I think it is often easier just to use the “okay, what is the practical implications starting point?” rather than the theoretical basis for it.
Lead Module3: Do you think, therefore, there is a need for the IPC guidance to be effectively redrawn to draw up that near field/far field distinction?
Professor Sir Whitty: I think it is a lot easier for people to understand and avoid these – you read, sort of, droplet sizes and try to work out what you’re supposed to do.
Lead Module3: Can you help me with whether, at any point during our relevant period, you became of the view that aerosol was the dominant route of transmission of Covid?
Professor Sir Whitty: I am still unsure whether it reaches that level of importance but it is certainly substantially more important than we – the collective view was right at the beginning. I don’t think any of the evidence you’ve heard would dispute that that – that the mid-point of medical and scientific opinion undoubtedly shifted over the first year of the pandemic. There were people who were outliers on both ends of the argument – and indeed still are – but in terms of the mid-point, that shifted during that period.
Lead Module3: Given that it was acknowledged that it was possible, the extent of airborne transmission was not known, do you think at the start of the pandemic in March 2020 there ought to have been FFP3 recommended for those working within the healthcare system?
Professor Sir Whitty: Well, I think that hinges on a number of things but I think that includes how frequently a situation where an FFP3 will make a difference compared to a surgical mask, if there is a difference, and second question is, is there a difference at all? You saw the evidence both of Professor Hopkins, who I would consider one of the leading health protection people in Europe, and your own expert witnesses, who agreed with her the next day, that actually the evidence that there is a difference between these forms is in fact extremely weak. That may develop over time. That’s not to say it doesn’t exist. It is simply that at this point.
Then the question is, are there any downsides to wearing an FFP3 compared to wearing a splash-proof surgical mask? And the answer is pretty clearly “yes” and they form two groups. There’s one group which you’ve dealt with quite comprehensively, which is the disadvantages to the individual. I thought it was interesting that what your expert witness said that when they introduced them in their hospital, people who had be complaining they wanted them now complained they didn’t want them because they were so uncomfortable. I would encourage anyone who doesn’t believe me to try and wear an FFP3 all working days, day in, day out. It is not easy. It is very uncomfortable.
But it is also an additional barrier between clinicians and patients, and patients, I think, sometimes get a bit lost in this. Every layer of PPE can potentially protect healthcare workers. That’s the principal goal. But it can also protect patients under certain circumstances. That’s also a co-principal goal. But it also provides a barrier between the clinician and the patient. A mask at all does that. It is much less easy to communicate. FFP3 is harder to hear through. It’s harder to express emotions through. Again, there is weak but reasonable research evidence but it is observationally true.
I worry, I have to say – and I wasn’t involved in these. I’m trying to just expand because I think some bits of the debate were well covered previously and some bits were not.
If you are hard of hearing, if you’ve got early dementia, if your first language is not English, actually having people unable to speak clearly and unable to express emotions does have downsides for the provision of care. I’m not saying that overweighs it, but I think people have talked loosely of the “precautionary principle”. As previously, I consider that is only a useful principle where there are no downsides, otherwise you’re talking about balance of risk and balance of risk is a different concept.
Lead Module3: Quite a lot to take in with that answer, professor, But let me just ask you about that.
We’ve heard about the discomfort and, in fact, more than discomfort, the actual physical marks it leaves on people’s faces, the dehydration and the like. But one of the things you say in the technical report is that IPC there helps workforce morale, it supports and reassures clinicians. So forget the science for a moment. If the workforce felt more reassured by wearing FFP3, is there not an argument for enabling that to happen, supplies allowing?
Professor Sir Whitty: Yes. So I think – so, firstly, I completely agree with the point which, as I wrote it, is probably –
Lead Module3: It was surprising?
Professor Sir Whitty: – and I think that one of the things we got wrong early on in the pandemic is the communications – and I think it goes back to my previous point about confusion – communications within the medical professionals who were giving IPC advice and those who were having to work on the front line meant that I think there was – through a combination of shortages of supplies which were certainly felt locally (even if they weren’t true at a national level, they were certainly true at a local level), plus a concern that the reason that people were giving advice was essentially because of shortages, plus a concern about were they being given adequate protection given the very big risks they were facing. You heard what Professor Fong was saying. You know, you can see entirely why people get to that.
I think that was not as well handled as it should have been and we should have predicted that and done that better. I mean, there was no doubt about that. We talk about “we” collectively, rather than we, the –
Lead Module3: Can I pause you there in your mid-flow.
Professor Sir Whitty: I’m getting to your answer but I’m trying to explain the reasons for it.
So, therefore, I think that what Professor Smith put in place with his colleagues in Scotland, and what I was advised by Professor Hopkins in her evidence to you, is correct, which is it is sensible to say to people, “Our advice is professionally we don’t think this will make a difference, but if you feel this is important for your particular situation, this is available for you.”
And that might have been particularly right at the beginning because of what was available in the country at that point but I think, in principle, that seems to me to be a reasonable position to be.
The counter-argument to that – and I’m giving a long answer because you’ve covered this ground a lot of times and therefore I want to give you a complete answer – is that some people want to have some freedom to be able to go up above where they wanted to be. The counter-argument, if you have got stocks available everywhere – so leaving aside the zero sum nature of this, the shortage of stocks – is that quite a lot of people actually want to be told, “Can you just tell me what it is I need to do and I will do it”. So some people prefer the one and some people prefer the other.
That’s the reality. But I personally would give people choice within reason.
Lead Module3: Do you consider that FFP3 offers a higher degree of protection from inhalation of aerosols and FRSM?
Professor Sir Whitty: In the sense of would I use FFP3 if I was going into a room with someone with multidrug-resistant TB, yes, I do. If I was doing an aerosol-generating procedure in a very dangerous disease, yes I would. Did I use FFP3 when I was on the wards with people with Covid? No, I didn’t. I followed the guidance. Had the guidance been FFP3 I’d have followed that.
I mean, my view about this is the guidance is usually there for a perfectly logical set of reasons and when there’s a 49%/51% call, I’m going to go in the hands of the people whose professional job this is, which isn’t me, and I will follow the guidance. So the answer is I did what was recommended, not out of a point of principle, but just because I think, “Fine, that’s what the experts have recommended, I’m comfortable with that”. People clearly weren’t comfortable with that and that was our failure, was the fact people did not feel, for understandable reasons, comfortable.
Lead Module3: Well, that brings me back to something you said a moment ago. You said the comms should have been better. How? What would we do differently next time?
Professor Sir Whitty: Well, I think that there were ultimately, as I say, three things which coincided the first of which was we were of course managing a situation where the level of knowledge was extremely weak. So it was very difficult for anyone hand on heart to say, “Well, I’m an expert in this area, I know what the risk is and this is the risk”, because actually there was a lot we didn’t know. So there was genuine uncertainty. The second problem – and that’s going to be the same the next time round.
The second problem was what I referred to earlier which was I considered there was a confusion about who was leading, at least in England, this area. I was confident it wasn’t our team. But I was not clear exactly who it was and I don’t think the people involved were exactly clear, although they were all trying to do their bit – this was not an abrogation of responsibility – and that really, I think, made it much harder to come to a clear communications area.
And thirdly, there was a real mismatch for many people in frontline and other services between being told there are no problems with stock-outs and actually either their immediate experience or – I think, in practice more commonly but nevertheless importantly – second-hand experience where they would see on Twitter, they would see among their friends stories of and they would say, “Well, that can’t be true” and that leads to an erosion, a perfectly understandable erosion of trust.
I think these things came together and I think – you know, I can’t emphasise too strongly that this was the area where I think that the break down of the otherwise incredibly unified view on Covid was most obvious within the medical and nursing professions, and I think this is clearly something we have to do better next time.
Lead Module3: I did ask you how.
Professor Sir Whitty: Well, I think that the first thing is we’ve got to have either stocks or the ability to create stocks of all reasonable PPE. Now, on this one, FFP3 is UK standard stock but obviously for many, many smaller numbers of cases surgical masks are obviously widely available. We weren’t using gowns routinely, so that was a new departure and, of course, we practically had a situation where every country in the world simultaneously wanted a massive increase in this and some of the countries that were producing it were themselves under strain, China in fact being one of them. So the result was big increase in demand and no increase initially in supply and that caused problems. I mean, I obviously wasn’t involved in this but I’m just making an obvious point.
So having confidence that you either have the stock or can create the stock, having internal capacity – for example, Germany had much greater capacity to make than we had. Coming back to “make”, that’s not a – that’s just a fact – is the first one.
Secondly, I think you’ve got to have a system that is capable of making decisions on this where the senior person who is the final arbiter, if there is an issue of debate, is clear from the beginning rather than trying to work it out in flight, which is in my view where we ended up.
Lead Module3: Pause there, because I do want to come back to the UK IPC call, but can I just try to finish my thread of thought.
Would you advocate for further studies to be done to determine the protective nature of FFP3 over FRSM?
Professor Sir Whitty: I think it is sensible to do that but to acknowledge that it would only be relevant infection by infection.
Lead Module3: Yes.
Professor Sir Whitty: So you can’t translate something that is in one infection to another. And you need to have quite large numbers.
This goes to a slightly wider point, which is the majority of the transmission that went to healthcare workers in the hospitals certainly, primary care may have been different, was from other healthcare workers, not from patients. And vice versa. The large nosocomial spread in hospitals was between patients appeared to be principally between patients not via healthcare workers.
So actually the evidence that the big problem for both healthcare workers and patients was the lack of PPE, that was a barrier between them, isn’t held up by actually what was seen, which was transmission between healthcare workers.
Now, if you make someone wear a FFP3, my own prior would be when they go into the staff room, whatever it is, they are even more likely to take it off than if they are wearing a surgical mask, which in fact you can wear perfectly easily and comfortably for quite a long period.
So it’s not – and this is the point Professor Hopkins made, which I completely concur with. The question is not what happens in a lab. The question is what happens when people are using it day in day out in operational circumstances. And if it doesn’t hold out in that situation, it’s not doing a heck of a lot of good.
Lead Module3: I follow that. But in the technical report, I think you commend that lab trials are of evidential value. We’ve heard of observational studies, as well, tending to suggest that FFP3 is more protective than FRSM, and certainly more protective than no mask at all. And I think Sir Gregor yesterday said that observational studies were useful.
We appreciate the ability to do a randomised control trial may be difficult to determine whether FFP3 is more protective, but having set this hare running, having had 20 years-plus of a division between FFP3 and FRSM masks, it now appears during the Inquiry we’re saying their protective effect may not be quite as we – I can’t help but wonder if we’re making it worse for the healthcare workers now, to tell them it didn’t matter, when it clearly did matter so much during the relevant period.
Professor Sir Whitty: Yes. So I think, in a sense, your hierarchy is exactly right. We need to do the lab studies first because if there’s no lab difference, there won’t be any difference in reality certainly.
We then need to do the observational studies. Trials are essentially a kind of – the gold standard of evidence for clinical medicine and health protection. Trials in this area will be very difficult. They would have to be large. They have to be what’s called cluster randomised. You couldn’t do them on an individual basis. There’s a variety of things that would be tricky on this, potentially.
And so, you know, I agree that we need to get a much stronger evidence base, or say: we’re not really clear, and we think you’re fine with the surgical masks, but here are FFP3s if you wish – if you are at particularly high risk or you have particularly high concerns.
I think – I mean, you know, that’s a pragmatic answer; it’s not a good scientific answer.
Lead Module3: Asymptomatic transmission and asymptomatic infection. We have the difference well in mind, Professor, but in the event of a new respiratory virus, should the UK assume asymptomatic transmission until it’s shown that the virus does not transmit asymptomatically?
Professor Sir Whitty: I think we should definitely assume that some degree of asymptomatic transmission could occur. It would be foolish to not assume that. But it is quite practically important to at least have a first pass view as to whether it’s likely to be a major part of transmission.
So, for example, quite a lot of our initial public health guidance was for symptomatic people, and the reason for that was to allow people who were not symptomatic to go about their daily businesses. Had we said everybody is at equal risk of passing something on to you from day one, we would essentially have been saying: symptoms are irrelevant; we’ve got no test for you; sorry. So what do you do then? You practically have got some very, very serious societal answers, and the same is true in the health system.
So I’m not saying that it’s not reasonable under certain circumstances – under all circumstances to assume it may well occur, and at some circumstances, it may well be – the prior view should be: this is likely to be a major part of it.
If we have another Covid-like infection, I think we would now start from the principle that asymptomatic transmission is a significant part, as opposed to starting from the MERS and SARS environment where we started with: actually, this is unlikely to be the case. So I think we’ve now moved our starting point. But we shouldn’t assume that that is a cost-free decision. It is not. It comes with quite significant societal and other costs.
Lead Module3: UK IPC cell guidance. I just want to touch on it very briefly. We probably covered it in part.
But you’re not the sign-off, if I understand your evidence correctly, for the UK IPC cell guidance.
Professor Sir Whitty: Correct.
Lead Module3: All right. Now, we heard a little bit of evidence about the senior clinicians group, and I’d just like to hear from you, please, what role, if any, did they have in amending, looking over, approving, being cited on, whichever terminology you want to use of the cell’s IPC guidance?
Professor Sir Whitty: The UK senior clinicians group – can I say a little bit about that because it makes more sense for my answer?
Lead Module3: Yes.
Professor Sir Whitty: It was something which I and colleagues set up, I chaired, between the senior clinicians in government across the four nations, and it was explicitly not a decision-making body. That was in its terms of reference. It was not a decision-making body.
And it really had three functions, one of which was information exchange; the second of which was essentially mutual support which, I mean, leads to, for many people, lonely and difficult jobs.
But the third one was to allow people to discuss difficult, technical issues with their peers. That doesn’t mean the group takes the decision, but it means that you can then have a robust discussion amongst people who are all experienced and all decision-makers in some field, and then the person who is the decision-maker takes it back to make the decision in the place they should.
So it’s a form of peer review. And on at least two occasions that I can remember, IPCC discussions were escalated to this group for a discussion, and there was quite a strong discussion. Almost invariably, that happens when it’s a 49% /51% call. So if it’s obvious what to do, you don’t escalate it; you just decide. But these were ones where people were unsure, and they wanted to get – to check in with other people and see what their view was.
Lead Module3: Was one of those the acute shortages IPC guidance –
Professor Sir Whitty: So the acute shortages protocol, yes. And the question really is: is it better to take the risk of running out of PPE completely and keep people as they are, or to try and re-use things with the risks that go with that, but the result of which is you have a high probability – you have a much lower probability you’ll run out. And that’s a debatable question, and that was debated as one of those things.
Lead Module3: In relation to the senior clinicians group, you say that it brought together initially OCMO, Public Health England and the NHS and was expanded to include further clinicians, including the other UK CMOs, and you generally chaired the group.
Why were the other CMOs not involved from the outset?
Professor Sir Whitty: Well, it just – its initial point was on an England-wide basis. We started off with the medical director of the NHS, the chief medical adviser to Public Health England, as then was, and me, as the senior clinicians in each of – the areas of government. It soon became obvious to us that this was a useful forum, and since quite a lot of the decisions had to be taken on a four-nations basis, and also importantly other CMOs, other chief nursing officers had other skills – you’ve heard this from some of my colleagues – it both broadened the geography but it also broadened the skill base. And they, of course, also were in lonely positions, and it was useful for them to have the support, so I thought there were several reasons that was helpful.
Lead Module3: Final question in relation to the IPC guidance. We saw a CAS alert that you issued, I think it was sending out the acute shortages guidance actually, at 4.43 on a Friday afternoon, and you may have heard other people speak about the late dissemination of guidance. It came through your office, obviously not from your office in terms of the guidance itself.
Can you help from your perspective, particularly being on the ground doing the shifts as you were, as to is there ever a good time to publish the guidance?
Professor Sir Whitty: Well, I mean, firstly, just on a technical point. CAS alerts go through my office. Some of them I sign, and some of them, I don’t. If I sign them, I’ve agreed them. If I don’t sign them, it doesn’t mean I don’t agree them; it just means it’s not for me, just – it’s a technical point.
There is an absolute damned if you do and damned if you don’t on this one where, on the one hand, if you do it on a Friday afternoon, you are guaranteeing chaos, and if you do it on the Monday and people have run out of PPE as a result of that, they will legitimately say: well, you made the decision last week and you didn’t tell us until Monday. So it’s kind of – you can see where the difficulties come.
However, I think, in this case, I think our view was, having looked at it, we could have issued it earlier at a bit more risk, and I think that would have been the right thing to do, or to probably to have held this one over.
So I’m just making the general point. But I think you should avoid – I think the implication of what you’re saying is completely right. You should absolutely avoid issuing guidance just before a weekend. Subsequent modules will come across situations where we took the reverse decision and have also been criticised for that, so, just to be clear, these will never be straightforward.
Lady Hallett: But, I mean, during a pandemic, so many people were working a seven-day week. Was there such a thing as a weekend for most people when this alert was going?
Professor Sir Whitty: Not in terms of the clinicians who were working on the ground. Absolutely not. People work all the way through. And a lot of people were working a seven-day week. Nevertheless, the system tends to be better, everybody tends to be in their place Monday to Friday. Large numbers don’t. But if you’ve got – six people need to sign off on something and one of them’s not there, then you can slow things down. So I think the challenge to us, did we do the right thing on this, was a fair one. But you are also right, a huge proportion of the system was working all the time.
Ms Carey: I would like to ask about risk factors, please.
Can I have up on screen INQ000410237_44.
There were, as the pandemic demonstrated, a number of people at higher risk than others of being infected and/or dying.
I’m not going to ask you about each and every one of them, but if we just look at the infection fatality rate, and once you start to look at the figures for the 60-plus, 70-plus and 80-plus brackets, a significant jump there.
If we go, please, to page 45. The proportion of people infected that were hospitalised. Again, look at the 60-plus range. Significantly higher numbers there. And, again, I’m afraid for the fatality rate for hospitalised people, again, significantly grim numbers as you get older.
Do you think the risk to elderly people was significantly well publicised at the start of the pandemic?
Professor Sir Whitty: Yeah, I think of the risks that became apparent over the pandemic, this was the biggest, by some distance actually. This trumped all other risks pretty well.
It was also the first to be identified, and I would like to pay tribute to Chinese scientists and clinicians who did so, and then the same was true in Italy. So by the time it hit the UK, we were already aware of this risk. You can see the date of this. This was before our wave was fully underway. And so this was identified, and I do think this was identified in the public.
The bit we were a bit more cautious about saying but did fortunately did prove to be the case was the other end of the age scale, where initial data suggested that children were relatively unaffected, in contrast to something like pandemic influenza, which would definitely hit children as well, particularly the youngest children, and that did fortunately prove to be the case. That doesn’t mean there weren’t children who didn’t become very sick – acutely, chronically, and some tragically died – but it was a much lower risk in that group. But the older age, I think, was both certain and publicised quite early on.
Lead Module3: The risk to ethnic minorities we have touched on, but can I ask you please about the data. And while we call that up on screen – it’s INQ000176354, page 14, please – this is a report that I think was commissioned by you; is that correct, Professor?
Just in a sentence or two, why did you commission this report?
Professor Sir Whitty: Well, I was very concerned, as many others were, that there were some groups who were either likely to be at greater risk and we needed to test that question, or where there was strong evidence from early observations that they were at greater risk, some of which were predictable, linked to poverty – I’m afraid poverty is a risk factor for infections everywhere – some which we had not predicted – obesity would be an example – and some, like ethnicity, where we thought there was a reasonable chance, but it was a more complicated area.
And then – so there was a quantitative element to this, where we tried to identify what the level of risk was for different ethnic groups to a reasonable degree of granularity, so not, for example, just South Asian but also people who are British Bangladeshi, British Pakistani and so on. But then this was also aiming to put that – those data in context and ask: why is that? What’s the driver of that? Because that’s quite important for what you then can do about it.
Lead Module3: Can I ask you, please, if you are able to, to answer – it sets out the review questions that the report was aiming to answer, and if you can, Professor, can you help:
“Are individuals in BAME groups more likely to be tested for and/or subsequently diagnosed with Covid-19?”
What was the outcome of the report?
Professor Sir Whitty: The answer for each of those two, and I’m also incorporating more recent data; it was in line with what was here. They were not more likely to be tested or less likely to be tested, the exception being people of Chinese British ethnicity, just for a detail of precision, but they definitely were at higher risk of being diagnosed with Covid-19 infection. This difference, though, was different between the two first waves. So in the first wave, people of black ethnicity were particularly high risk of being diagnosed, people of South Asian were at increased risk, and in the second wave, that reversed. So the risk was greater in people of South Asian heritage.
That was largely to do with where the waves were at their worst. So in the first wave, London, which has a large proportion of the British black population, and the second wave, the Midlands, where a higher proportion of the British Asian population live.
Lead Module3: I think – did you say there then that question 2, are the individuals more likely to develop severe clinical presentations?
Professor Sir Whitty: Yes, and the answer here, unfortunately, was also yes.
This is quite different biologically, so this is someone who has already got an infection. Are you now likely to get a bad disease? And there were higher rates in people of ethnic minority groups, some of which were, for predictable reasons, like higher levels of diabetes, but many of which were not.
Lead Module3: Is infection with Covid more likely to lead to mortality within BAME groups?
Professor Sir Whitty: Yes, that was clear from wave 1. In wave 2, as I say, I made the point about slight differences between the different ethnic groups and the different waves, but the short answer is yes.
I can give number to each of these, but the –
Lead Module3: It’s in the report, and I’m afraid time precludes us from going into that.
Question 4:
“What are the social and structural determinants of health that may impact disparities in COVID-19 incidence, treatment, morbidity and mortality in BAME groups?”
I suspect there are many, but can you give us an answer to that?
Professor Sir Whitty: Yes, so this, in a sense, was the key question which this report was answering which the previous reports had not, is the “why” questions.
A lot of this could be explained by things like occupation, like poverty, like crowding, like living in urban settings. You know, there was lower levels of Covid in the first two waves in rural settings than urban ones. But that could not provide the full explanation. So there was clearly an additional element, and this was trying to tease this apart.
I can give a long answer to it, but the short version is that there are some bits of this we could clearly do something about, and there were other bits that were much harder to do with structural issues in society and indeed, arguably, structural racism in some bits of the system. That is what this report suggested.
In terms of treatment, this can broadly be divided into treatment seeking. Do people – are people being properly informed so that they seek care at the right moment? Are the treatments being accelerated fast enough through the system, or is there a failure to recognise early on? And should the treatments actually be different because there is biological basis for that being from different ethnic groups. And it was able to answer those questions less well, I would say, than the first set of questions. Then mortality and morbidity are beyond that. I can go into them if you want.
Lead Module3: No, but can I ask you this. This is a report that came out in June 2020, I think –
Professor Sir Whitty: Yes.
Lead Module3: – and as a result of this, are you able to help with any interventions that you brought to bear to try and mitigate or in some way address these risks?
Professor Sir Whitty: Well, I think exposing them was in itself very important because I think it highlighted to people in the healthcare system the particular vulnerabilities that people from ethnic minority and indeed some other protected groups were in.
The second thing was Kevin Fenton, Professor Kevin Fenton, who was the person who led this study, then did a lot of work making sure that it was in front of, for example, mayors, so they could look at local issues, but also, for example, occupational health groups so that people were aware that these were issues that were particularly high risk for particular ethnic groups or particular other high-risk groups. So I think Professor Fenton did a really good job on that.
We also launched a number of research studies under the NIHR system better to understand this, both from a biological point of view and from social point of view because, in a sense, unless you can understand the drivers, it’s very difficult to tackle the underlying problems.
Lead Module3: Can I just ask you about that, Professor, because it may be suggested that in fact the disparities or the disproportionate impact on BAME communities in particular is nothing new and that having more research, having another report, saying things like “we need better comms”, it all sounds very good, but it doesn’t actually practically help the person who is BAME who might be living in a socially deprived area.
I’m trying to sort of understand what practically can be done next time to help reduce what is probably going to be an obvious disparity.
Professor Sir Whitty: I think you are obviously precisely right, that some bits of this are (a) predictable and (b) unremediable, in the immediate crisis of a pandemic. So if you want to do something about it, you should have done it over many years previously, and that’s just a practical reality.
But the point about doing the research, the point about trying to pull these issues apart is, it can also identify some issues which you actually can do something about. That’s the point about it really.
So, for example, we identified that people who were front of house staff, people who were public transport, taxi drivers were overrepresented in these groups, and we therefore looked at those environments and thought: what can we do that would reduce the risk of these environments because we’ve clearly got a problem on our hands which – for which solutions are potentially possible.
Lead Module3: Understood. What about the BAME healthcare worker?
Professor Sir Whitty: Well, I mean, that was – that is one of the reasons that we want to talk to the occupational health groups. But the main risk to BAME healthcare workers was much less easy to deal with by these relatively mechanistic things.
Some of the risk came from living in communities where there was higher incidence, particularly in the first wave, and that’s just an inevitability.
There was a legitimate and perfectly reasonable discussion about: should we be doing particular sets of, for example, PPE for people of different ethnic groups, taking people from different ethnic groups even out of the workforce altogether. These raised really quite difficult questions including, in fact, in the second case, was this going to disadvantage people from ethnic groups because they would be excluded from work, excluded from a variety of other issues.
But it did at least mean people were asked the questions and were trying to work out were there equitable and helpful solutions to them.
Lead Module3: There is further detail about this, the limitations. There’s an issue you raise in the report about data capture in relation to ethnicity that’s set out in the report. I’m not going to ask you about that, but I just want to ask you this.
You, in your technical report, make reference to having tailored communications, and it made me think, was there any example you can give of a good tailored message in relation to the disproportionate impact on the BAME community?
Professor Sir Whitty: Yeah, well, I mean, it’s obviously – you have to start off with the bad and move to the good. I mean, initially, we started off with an almost exclusively white group of people in front of podiums through the BBC speaking in English. I was one of them. Not criticising that in itself. The people giving the message were as important as the message itself.
There was also – we were slow off the mark, and I’ve said that in my report, in terms of translating into many of the languages which are commonly spoken in the UK. We were slow off the mark in identifying that sources information people were getting, for example, from radio or TV channels from overseas, so they were actually not getting any of the messages we were giving through our channels of communication.
I think we did get a lot better at it over time. The biggest – I mean, the easier ones to fix, in a sense, were the ones I just highlighted because you can do those centrally. I think by far the most important was actually in people who were having – and Kevin was an example – discussions with community leaders, with people who were voices people would listen to and actually would feel much more affinity to than what they would see as potentially alien or even, you know, automatically distrusted authority figures who were really not the right people to be giving messages. So the messenger was as important as the message.
Lead Module3: I have three discrete topics that I need to cover with you by 3 pm, and it’s not to do them any disservice, but can I just ask you briefly about AGPs, please.
In your technical report, you say that the question of what procedures were deemed to be an AGP or not was probably the biggest source of tension amongst the health profession. And it leads us to the question, does it not, Professor: how is that to be resolved before the next pandemic?
Professor Sir Whitty: I mean, I think it – we need to look at this, because this was not specific to Covid; this was actually a much more general point, and I’ll use two examples, one of which I – in both of them, I made some intervention.
I mean, the first one was – you have got it in the bundle; I’m not going to refer to it – where the British Society of Gastroenterology and various others said: look, we don’t agree with judgments that have been made about whether endoscopy was an aerosol-generating procedure.
My view on that was that the initial technical advice was reasonably done, but the challenge was also a reasonable challenge from a respectable body and should be taken seriously.
So we did – we then set up a mechanism, so we didn’t end up with a “Computer says no” approach, for people to be able to challenge these. So I thought that was a helpful intervention, and gastroenterology, in my view, was – a priori top end endoscopy was likely to be more risky than bottom end endoscopy, but I won’t go into the graphic details of that.
Lead Module3: No.
Professor Sir Whitty: The second one, which I think is a more fundamental one, and we really have got to come to a conclusion about, was around CPR.
The reason for that is you do – absolutely do not want to put someone doing emergency resuscitation at risk but a delay of even a large number of seconds, certainly minutes, in that situation also puts the patient who has collapsed at significant risk and that may be a risk of death or it may be a risk of brain injury. Therefore, you don’t, on the one hand, want to not have protection if that is needed, but you do not want to have something which is going to delay things if it is not needed.
So settling this question seems to me a fundamental issue. And if you look at expert bodies around the world they have not come to a settled view. So the debate in the UK reflects the international experience as well.
Lead Module3: That begs the question, why hasn’t it been settled by now? This has been going on since the beginning of the pandemic. It caused the tension you speak about in the technical report. It caused a great deal of upset in the correspondence, many of which you were copied in on. And I throw into the mix Professor Beggs’ conclusions that some of the AGPs that were deemed to be aerosol-generating in fact may not have produced as many aerosols as initially thought.
Why isn’t there a degree of certainty now, four years on, as to what amounts to an AGP or not?
Professor Sir Whitty: I think – I mean, to me, this seems something which internationally we have got to sort out. I mean, I’m not the person going – to do this. This is not my area of professional trade obviously.
I think it is important that the people who are co-designing the research on this are people, like paramedics, who are actually having to do it, because they have to feel confident that the methodologies are strong enough that if it comes up with an answer they are not expecting, they are satisfied it is strong enough, and vice versa. So I think we need to do this in a way which everybody gets together and decides this is the way we are going to do it, and do it reasonable effectively.
Lead Module3: Another controversial area, if I may. We are going to be hearing next week from Professor Summers and Dr Suntharalingam, and the doctor was part of a panel of three experts, they were asked to develop a clinical prioritisation tool in the event that critical care became saturated. And I think you were at one stage going to be the recipient of any guidance and report that was prepared by that panel.
In opening I said it was pretty unpalatable to think that we had to think about this, but I would like your observation, please, on, firstly, why did you want there to be guidance. We know the guidance didn’t come to fruition because it was considered that critical care capacity wasn’t going to be saturated. Do you think we should have such guidance in the event of a future pandemic?
Professor Sir Whitty: So I think there are many things I would do differently, but this is not one of them. I think it was important that the process of the guidance was considered, because had we gone up two or three doubling times – and remembering this is exponential, so the difference between three doubling times and where we got to is profound – we might well have been in a situation where very junior staff were having to make incredibly difficult decisions, for which they were not experienced enough, and that would have been – they would have needed the support of something to do that.
But, absent that – and we didn’t, fortunately, get to that, we got to an incredibly difficult place, as Professor Fong laid out, I’m not in any sense minimising it – our view was, having a – what is essentially relatively mechanistic system that deviates from normal practice was not appropriate, and indeed it wasn’t appropriate in the views of people who wrote it.
And the guidance is – I mean, it’s perfectly open. It was discussed by lots of different groups and it is now published in a journal. You can find it very easily on the web. Endorsed by the critical care society, which is the official – one of the relevant bodies.
So it’s not – there is nothing – this is entirely open, as it should be. We didn’t need it this time. Hopefully we will never need it. But to have a process where people can debate this and actually say, under a circumstance where we had a situation even worse than Covid today – and that is not an impossible situation, appalling bad though Covid was – to actually pre-agree that – you may have to tweak it based on individual things – seems to me a sensible thing to do.
So I was very grateful to the people who took on this difficult task. I thought they were excellent and I thought that what they did was a useful and sensible thing.
It didn’t receive universal endorsement from all the groups you would want it to, and that’s one of the reasons you wouldn’t want to do it in the heat of the moment. You need to make sure that, for example, the disability groups, who had concerns that – mental health charities which had concerns actually can talk those through.
So I think trying to do it against the clock, which of course we had to do here, is not the right approach to it. So I would much rather we are open about it, have a proper discussion, and work out, in the very, very strong hope and expectation you will never use it. This is very much an absolute end-of-the-road thing.
Lead Module3: So if I understand your evidence correctly, the reason why the guidance wasn’t proceeded with was because, thankfully, we didn’t get to the point where critical care was saturated; is that correct?
Professor Sir Whitty: The technical answer is that the guidance was explicitly – and you can read this in the guidance, this is – as I say, it is published – designed for what’s called CRITCON 4.
Lead Module3: Yes.
Professor Sir Whitty: And CRITCON 4 means essentially the whole system can’t offload or anything – there is a principle of the CRITCON system which I am sure you have either heard from or will hear from, that if you get to 4, nowhere is full until everywhere is full – nowhere is overwhelmed, rather, until everywhere is overwhelmed.
And we didn’t reach that, we reached the situation – many places individually were overwhelmed at different points, in my judgment, but that wasn’t what this guidance was designed for. And I think it would have been appropriate to take a much more, in a sense, mechanistic – although well thought through – approach rather than proper normal practice, which is to judge an individual’s circumstances and preferably discuss with them and their family. That is how this should be done in ordinary circumstances.
Lead Module3: I take it from what you have said then that the guidance was not pulled because it was optically too difficult to say to people “We may have to consider this”?
Professor Sir Whitty: It had been circulated amongst – perfectly openly, amongst a large number of charities and pressure groups, who were very good, who were very expert, and it has been published online. So, I mean, I think that itself answers it.
Lead Module3: Stay-at-home messaging. As one of those behind the podium on occasions, do you think that we get the balance right between telling people the NHS was open but equally protect the NHS, save lives, stay at home? What do you think about that balance, Professor?
Professor Sir Whitty: I don’t think there was ever going to be a perfect balance on this one. I am confident what we didn’t do was to identify – over and over again, you couldn’t say it too often, I said it, Professor Powis said it, many others said it from the podium, that the NHS was open and in particular if it was urgent, an emergency, life-threatening situation, you must go to hospital as you usually would. And there is reasonable evidence in my view, for example, that the number of people who came into hospital with heart attacks was lower than you’d predict. I don’t anticipate there’s any reason there’d have been fewer, so some of these people were staying at home who otherwise would not have done, and they would have had remediable conditions.
So the bigger bit, which was did we get the message across that people should still go to hospital, I think we didn’t get it across well enough. We tried. You know, we tweeted, we talked to it the podium and so on.
Whether we pushed too strongly on the messages of the risks of Covid, I think that’s a much harder one actually, because it was really important that people understood why – if they were going to do this terrible thing for their society, for the economy, for their families, they understood why it was. The scale of the problem.
I think actually my experience was the overwhelming majority of people thought they were doing it for the most vulnerable in society. It was entirely altruistic. So – and that was certainly my judgment, particularly amongst younger adults, who made a decision that they were going to put their lives on hold to protect others, which I think is extraordinary.
Lead Module3: Do you think if those that were deterred from coming to hospital had come to hospital, the hospitals would have coped?
Professor Sir Whitty: I think the hospitals – I mean, the hospitals would have been able to improve their situation. So they might not have been able to do absolutely everything they would have been able to do pre-Covid, particularly at the points of the year outside the winter pressures, but I’m confident they would have been able to do things, for example, for someone who’s had a heart attack, which are not possible to do at home.
Lead Module3: Finally this, please, Professor. Your technical report, albeit that we are not the intended audience for it, sets out a number of recommendations, and you have spoken already today about things you would like her Ladyship to consider, but are you able to now to give us one or two concrete recommendations, in addition to those that you have already mentioned, that you think that her Ladyship should bear in mind in the event of a future pandemic?
Professor Sir Whitty: Yes, so if I bank the ones I’ve said as I went along –
Lead Module3: Please do.
Professor Sir Whitty: – I would say that the biggest one that I think deserves slightly more emphasis even than I have given it is having the mechanism to be able to do research very, very fast.
Ultimately, what reduced mortality rates overall from the first wave to the second wave was research and individual clinicians learning, and the second – but then the second thing was the prevention, the vaccine in particular. Without that – if that had been six months later, if the things like the dexamethasone treatment had been three, five months later, the mortality rate, terrible as it was, would have been even worse than that.
So I think people always, at the beginning of pandemics, underestimate that it is actually the science that is going to get them out of the hole, not all the other things they are doing. The other things are holding the line until the science does the work. And putting that absolutely central I think is important.
Then I think the second one really flows from your points about ethnicity. If we are not serious about trying to tackle health inequalities between pandemics, there is no way you are going to be able to do it when the pandemics occur. So that is – you know, part of our preparation is to reduce the vulnerability of the people we know are already vulnerable. And this will have immediate effects straightaway, on a whole – beneficial effects on health, but then when the next problem hits we will be in a much stronger position.
And I agree with Lord Darzi’s conclusion of his recent review that we went into the pandemic in a less strong health overall state, and I think that contributed – it was definitely not the cause to, but it’s definitely contributed to particularly some of the disparities we saw.
Ms Carey: My Lady, that concludes my questions. May that be a convenient moment for the afternoon break?
Lady Hallett: Certainly.
One more session after this next break, Professor Whitty, and I promise you we will be finished by 4.30. So done for this session.
I shall return at 3.10.
Ms Carey: Thank you, my Lady.
(3.00 pm)
(A short break)
(3.10 pm)
Lady Hallett: Right. It is Mr Jacobs.
Where has he moved to?
Questions From Mr Jacobs
Mr Jacobs: Over here, my Lady, thank you.
Professor Chris Whitty, a few questions on behalf of the Trade Union Congress. The questions are on the disparate impacts on different groups of healthcare workers.
You suggest in your witness statements that the key to improving the safety of higher-risk individuals was principally to optimise safety for all rather than trying to differentiate by every risk group in the workplace.
Professor, there is no disagreement from my client on that as a general principle, but would you also agree that the assessment of individual risk do play a role in seeking to address some of those disproportionate impacts?
Professor Sir Whitty: I do agree with that, and I think the question is where you draw the line. So, for example, the existence of the clinically extremely vulnerable group is an example where we drew a line which said: actually your risk here is so high that you do need to be treated in a different way. But what I think we were trying to avoid is a situation where every single person was assessed on completely different risks and we ended up in an extremely difficult situation to actually provide realistic and achievable guidance, when it would be much better for all to optimise the outlooks for everybody.
So I think we are in agreement, I’m just amplifying my point.
Mr Jacobs: And perhaps taking that forward, a known comorbidity is something that can be identified in a risk assessment. Some determinants such as quality of housing are more difficult to address in a risk assessment, is that right?
Professor Sir Whitty: Correct.
Mr Jacobs: If we consider the position of porters and cleaners within healthcare, part of the workforce on lower income, higher outsourced work, higher incidence of those exacerbating social and structural determinants. Beyond the pursuit of a safe working environment for all, what are the steps that can be taken within healthcare to try to provide some additional layers of protection?
Professor Sir Whitty: I think – I mean, acknowledging that this is quite a long way from my area of practice, so I can make some general points but I wouldn’t want to claim that this is something where I’m the right person to give a definitive answer, but I think there are two things which we can do which we currently don’t do.
I think the level of training for people who are not patient facing in one sense but actually are in reality is often much lower than would be optimal. And I think ensuring that there is a minimum level of training – you know, being a porter is a difficult job physically. You are also close to patients a lot. For example, people who are providing meals are close to patients a lot. And I think they are not trained in PPE to the same level. And I think, of course, they see a lot of people in quite close succession. So there’s a training element.
I think the second element is I can – I worried throughout the pandemic as to whether we were dealing with the financial situation of people who were not on an employed basis. Permanently employed basis was optimal.
We know from the care sector, for example, where the data is clearer, that people who were not paid sick pay fully were more likely to come into work when they had symptoms, and therefore spread disease around.
So I think there are a set of issues around this that we need to look at quite carefully in advance of the next emergency, it doesn’t have to be a pandemic.
Mr Jacobs: So training and financial position, two practical steps that could potentially be looked at to try to address this disproportionate impact.
Finally, you have given evidence in response to Ms Carey’s questions about some of the structural determinants and health inequalities which are relevant to disparate impact. You have described how it is for society – I hope I don’t paraphrase too unfairly – to decide whether and how to answer those in advance of a pandemic.
A healthcare worker who perhaps perceives inequalities not just within society but within the healthcare service may feel that those broader matters could serve as a distraction or even excuse from taking a hard look at matters that actually exist within the healthcare service. From your perspective, taking your point that you are not directly responsible for these matters, do you think that there has been any sort of real or sufficient focus on structural issues not just within broader society but within the health service that the health service can do something about?
Professor Sir Whitty: Well, I will take those in two parts. The first part I would completely reject the idea that there is a tension between trying to sort out disparities in society and trying to sort out disparities in the health service. I consider those are, in fact, synergistic, and doing one will help to reduce the other, for those who are working in the system. So I just wanted to be really clear about that.
But on your second, I mean, the point that was made, I think rightly, in the – getting behind the data, which the Inquiry – the chief counsel laid out, was this is a real – this should be a wake up call, as if one were needed, that these problems exist within the health service as well. And that point was made and I think most people would agree with that point.
And the time to try to fix them is not in the middle of the crisis. The crisis demonstrates this is a problem. Sometimes it gives a sense of urgency but also unfortunately it gives multiple other things that need to be done simultaneously. I think that, you know, we do, between crises, need to look at these issues very systematically and seriously.
Mr Jacobs: I will leave it there.
Thank you, my Lady.
Lady Hallett: Thank you very much Mr Jacobs, very grateful.
Who is next? Mr Stanton?
You’ve gone over there as well?
Mr Stanton: Yes, my Lady.
Lady Hallett: It’s so that you don’t have to turn – have your back turned round to them.
Questions From Mr Stanton
Mr Stanton: Good afternoon, Professor. I appear on behalf of the British Medical Association and I have a question for you about the harms experienced by healthcare workers.
In your view, how do we ensure that the response to a future pandemic or health emergency avoids the severe and ongoing physical and mental health impacts experienced by healthcare workers in the Covid-19 pandemic, as described so powerfully earlier today by your colleague Professor Fong. And Professor, when answering could I ask you to consider the extent to which low staffing levels have contributed to these harms?
Professor Sir Whitty: Well, unfortunately, the answer to the first one would take a long time, and I will give a couple of comments but this is something which to give a proper answer would take more time than her Ladyship will definitely want us to take.
Staffing levels definitely make a difference, because if you have some degree of capacity to surge, which a greater staffing level gives you, you can deal with a higher degree of emergency without stressing the system more than you otherwise would do.
The difficulty, of course, in the health service is you are – at any given time, there are multiple competing demands that those who are leading it – and I’m not leading the NHS bit of it, so I’m not saying this on my own behalf but making an obvious point – have to compare to one another, and if you have high staff levels sufficient to deal with an emergency, that means some other part of the system, given the same degree of envelope, is going to be relatively squeezed to make room for that.
And that’s the difficult choice that political leaders and leaders of the system have to take, and I’m just being fairly clear about that.
But the idea that actually if we had had more capacity, particularly in intensive care but more widely, that would have given more headroom and therefore reduced the number of places which came to the kind of state that Professor Fong was talking about, clearly that is true, with the caveat I made previously.
Mr Stanton: Yes. Thank you, Professor.
Next and final question relates to the recording of healthcare worker infections and, sadly, deaths whilst at work.
Do you agree that it is unacceptable that we do not have reliable published data about how many healthcare workers were infected while in service, particularly those who then tragically died, and that in future there needs to be a better system for recording these impacts?
Professor Sir Whitty: A lot of the problem that came – so, firstly, data existed. I mean, every day I had data which told me how many healthcare workers had at that point died and who had died in the last week. So data were flowing.
I think one of the things that were very difficult were defining what is a healthcare worker. If you are a doctor working in a hospital then it is a pretty clear yes, but there are many people who were – actually could be counted either way, and then that’s before we get on to the question about where was the infection from, their workplace, and where was their infection – what would have happened even had they not gone to work. And that’s a much harder question to answer very often.
But the principle that there should be data available is absolutely right, for lots of reason, but one goes back to something which my Lady talked about earlier on, which is if your – if one of your earliest indicators that something is wrong is healthcare workers are dying, therefore knowing that healthcare workers have died is a really important thing to do, because that can tell you at an early point that you are in a new situation that you need to do something about.
So I think it is more than a kind of workforce welfare point, which it absolutely is and should be, rightly, it also is a very important point of how you actually spot trouble early on, where you have a realistic chance of heading it off.
Mr Stanton: Yes, Professor, the reason I asked the question was, the RIDDOR system, with which you may be familiar was clearly not fulfilling this purpose.
Whilst there was a flow of data within the NHS, it appears that that flow was not accurate. There was a report in 2023 that you may have seen in the British Medical Journal along the lines of a tribute to healthcare workers, and they expressed the view that their account may not be complete, and invited families who may have suffered a bereavement to come forward.
Now, the British Medical Journal in 2023 doesn’t know how many doctors sadly died. That tends to suggest there’s something wrong with the system?
Professor Sir Whitty: So, firstly, I recognise the point you are making, I agree with it and I think it is important, for the reasons you have given. It is also important to acknowledge every healthcare worker who has died. So – I very strongly believe that.
If I may make a hard-edged comment about my own union, which you kindly represent, they have not been at the forefront of trying to allow data to be merged from different sources, which would allow for better data outcomes in future crises, and if you could take back to your distinguished clients that recommendation, that they think about that seriously, I am sure that that would be a very useful outcome.
Mr Stanton: Thank you, Professor.
Lady Hallett: I’m not sure you expected that, Mr Stanton.
Mr Stanton: Thank you.
Lady Hallett: Right, Ms Hannett.
Questions From Ms Hannett KC
Ms Hannett: Professor Whitty, I appear on behalf of the Long Covid groups.
My Lady, Counsel to the Inquiry has very helpfully put many of the questions or topics that we wanted to put to Professor Whitty this morning, so I have been able to reduce the number of questions considerably.
First topic, Professor Whitty, if I may, deals with recognition of Long Covid. In your oral evidence in Module 2 you accepted that the evidence of Long Covid was not in any way uncertain by October 2020.
You were asked questions this morning about those with Long Covid having their symptoms disbelieved by the medical profession. Do you agree that the prompt public recognition of Long Covid in 2020 by you would have prevented or ameliorated the delayed diagnosis and disbelief of Long Covid sufferers and helped individuals protect themselves and their families from some avoidable harm?
Professor Sir Whitty: Well, I hope that the fact that I set in train in I think June of that year the first systematic review of it and tried to accelerate research so that we had an ability to have an evidence base is evidence that I, in a sense, fundamentally agree that it is important that it is identified and acknowledged. But I am slightly puzzled if you are implying that I was not aware of it and making it aware to others, because my hope is that I was doing so as fast as I was getting information myself.
Ms Hannett KC: Professor Whitty, the question was whether public recognition, perhaps in a press conference or otherwise by you, in summer or autumn 2020, would have assisted those Long Covid sufferers who were disbelieved by medical professions – if you, as the Chief Medical Officer, had identified the existence of Long Covid at that stage?
Professor Sir Whitty: I can’t – this is – I genuinely can’t recall when I, in a press conference, first talked about it. But the reason for dealing – within a professional group, and you are asking about professionals, I was certainly trying to ensure that, at a professional level, this was which was addressed at a relatively early stage after this was first identified.
Ms Hannett KC: Professor Whitty, if I can move on to research into Long Covid.
Professor Brightling and Dr Evans state in their expert report on Long Covid there is an urgent need for further clinical trials testing both pharmacology and non-pharmacological therapies for adults, children and young people living with Long Covid. Do you agree?
Professor Sir Whitty: I do.
Ms Hannett KC: And as we have heard this morning, the NIHR has put out two funding calls into Long Covid, the first in 2020, the second into 2021. There hasn’t been any new NIHR funding into Long Covid research since 2021. Professor Brightling and Dr Evans say that the research, which they identify as urgent, should be supported by dedicated national research funding. Do you agree with that?
Professor Sir Whitty: Well, I think there is a difference between new research calls and continuing research funding which is continuing in the UK and elsewhere.
Ms Hannett KC: Professor, there is only one national funded research project into pharmacological interventions, for example. Do you accept that further research of that nature, for example, should be funded by national funding?
Professor Sir Whitty: One of the problems for research into Long Covid, and I’m going to give it a technical answer, apologies for that, is that simply randomly firing possible treatments into the system is never a sensible idea. So you’ve got to have a strong evidential basis for why you are doing either repurposed old drugs or, in due course, when we understand the biological foundations of the different syndromes of Long Covid, actually designed for Long Covid specifically.
If you don’t do that, the risk is that you actually do more harm than good, because all drugs come at a side effect cost to the individual.
So I think the question about when is it the right time to do therapeutic trials, in terms of your underlying understanding of the epidemiology and biology of diseases, varies very significantly, and it does with Long Covid itself. Also the UK is not the only country doing research, it is an international effort, and I have talked about some of the discussions we have had with others.
That’s not to say we should not continue to do therapeutic trials when there is a good reason to do so, but when you do a therapeutic trial which has no biological basis in the view of disinterested observers, the risk is you either cause actual harm, because you are using treatments which have limited chance of success but a reasonable chance of side effects, or you make the field more difficult for subsequent studies and more appropriate treatments.
I realise that is a technical answer but it is an important technical answer.
Ms Hannett KC: Final topic then, Professor Whitty, given the time that I have left, planning and monitoring of long-term sequelae.
In your witness statement and evidence this morning you accept that the initial planning for Covid-19 didn’t take any account of the long-term consequences, ie Long Covid. You also accepted that the possibility of some long-term sequelae was accepted but the nature and scale of those was not foreseeable.
Given that the possibility of chronic sequelae was accepted, do you agree there should have been surveillance of that from the outset of the pandemic just as there was of the acute effects of Covid-19?
Professor Sir Whitty: I think it is difficult to know how you would have picked it up in a different way to how it was picked up as it was picked up.
I mean, people who had had severe infections and ended up in hospital generally are followed up when they leave hospital. That is a normal clinical practice. And to that extent they would have been picked up at a relatively early stage. I think that the bit which was the more surprising was the degree of disability that Long Covid caused people who had had a mild or moderate initial infection.
The problem there is it is not really clear how you could have put it in place, not knowing what the symptoms were or who would be affected, an appropriate sampling mechanism, particularly in the first wave, where the great majority, I would suspect, of people who had Covid of a mild sort were in fact not diagnosed, because getting diagnostics at that stage was much harder than it was later on. So actually knowing who had Covid was really tricky at that point.
This is not saying I disagree that we couldn’t probably have done something better than we did but I think it is not one of those ones where you look at it and think: well, it’s obvious that’s the thing we should do. I think it would have been quite hard to do for the non-hospitalised patients. For the hospitalised ones, as I say, I think a mechanism is relatively straightforward.
Ms Hannett: Thank you, my Lady, I leave it there.
Lady Hallett: Thank you very much Ms Hannett.
Mr Pezzani.
Questions From Mr Pezzani
Mr Pezzani: Good afternoon, Professor, I ask questions on behalf of Mind, the mental health charity.
The main contextual document I wish to refer to is the expert report for this module of the Inquiry by Drs Guy Northover and Sacha Evans about child and adolescent mental health services. I hope you’ve had an opportunity to look at that report. It was produced after your statement, but I hope you’ve seen it?
Professor Sir Whitty: I’ve read it, with the important caveat that I’m neither a child health doctor nor a psychiatrist, so therefore I was reading it as an interested doctor and an interested public health person. But with that caveat in mind, yes, I read it.
Mr Pezzani: Thank you.
My first question relates to planning, specifically before the pandemic, in relation to the potential impact on the mental health of children and young people.
You may recall that Drs Northover and Evans record at paragraphs 10 and 162 of their report that there were no specific plans in place for mental health inpatient services in the UK’s pandemic preparedness, despite the likely serious toll on everyone’s mental health due to social isolation, anxiety, financial stress, and grief –
Lady Hallett: I’m missing a lot of what you are saying. The stenographer is too.
Mr Pezzani: I’m sorry. I will go through it more slowly.
There were no specific plans in place for mental health inpatient services in the UK’s pandemic preparedness, despite the likely serious toll on everyone’s mental health due to social isolation, anxiety, financial stress, and grief, and no consideration was given to the impact on children and teenagers who would face disrupted schooling and social isolation.
Paragraph 162, Professor, is broadly to the same effect.
Are Drs Northover and Evans correct that prior to the Covid-19 pandemic, there were no specific plans in place for mental health inpatient services or other aspects of mental healthcare in the UK’s pandemic preparedness strategy?
Professor Sir Whitty: In broad terms my view is yes.
Mr Pezzani: Are you able to assist on the reason that there were no such specific plans for the mental health impact of the pandemic?
Professor Sir Whitty: I mean, I think that – as I think was laid out very clearly in her Ladyship’s first report, the pandemic planning had many areas where we had gaps in our capacity.
I want to be clear that I think there is a big difference between a plan and a capability. Actually, I think a plan is less useful because there was no way we could have told in advance exactly the mechanisms and routes and outcomes that would have happened with Covid, and many of the – some of the effects were direct from the disease but many of them were indirect, via the lockdowns, which were again, in themselves, unpredictable, because they weren’t part of the plan. So I think that would have been tricky.
But your general principle that we should take account of particularly inpatient services I completely agree with, and that’s for many reasons but an obvious one is that many people living with mental health conditions find it particularly difficult to adhere to some of the very difficult things during Covid, and these are closed environments where close contact is often needed. So for many reasons I think that is an area where we could reasonably do a lot better in any future areas. So I – basically I am agreeing with you in a rather long-winded way.
Mr Pezzani: I’m grateful.
Can I just quickly follow up on your distinction between planning and capability and ask you just to expand on what you mean about the importance of capability in this context.
Professor Sir Whitty: So the big difference here is that a plan is basically to say: if a pandemic hits, we are going to do the following, A, B, C, D and E.
Well, we don’t know what kind of pandemic – remembering the last pandemic the UK suffered from with any seriousness was HIV, completely different. It had effects in mental health areas but completely different to the current one. So I’m very unconvinced that a plan will necessarily help us, but having capabilities, having people who are trained, duly, in infectious diseases as well in mental health, maintaining that, maintaining stocks of PPE that are available and appropriate in these environments, those all strike me as things we should be doing. They are capabilities, not plans.
Mr Pezzani: I’m grateful.
Would those capabilities include sufficient resources to meet potential needs arising during a pandemic, for example, from increases in children and young people with eating disorders and the continuation of those surges post pandemic, which you will have seen Drs Northover and Evans have reported upon?
Professor Sir Whitty: Well, I think that is two very different things. I’m a little cautious about having as a reason for a particular area of skill in the UK – or capacity in the UK – something essentially held in readiness for the next emergency. I think the chances that would be maintained over time are incredibly low. So I think, even if it’s desirable, it doesn’t strike me as practical. I’m not sure it is desirable actually.
On the other hand, the surge in child and adolescent mental health demand that we have seen post-pandemic, which is on the background of an increasing wave before that, so it is not just caused by that but I think it has been accelerated by that, and specifically the impact on eating disorders of various sorts, I think is a very serious issue and I think we need to have a clear view on this. Is this something which is going to revert back to the trend line that was there before or is this something which has actually been a step change and which is now with us for a long period of time. And that has quite different implications for how we configure services in my view over the next 10 to 15 years.
Mr Pezzani: I’m very grateful.
Finally, in relation to children and young people living in deprivation and the mental health impact on Covid countermeasures on them in particular, I noticed in paragraph 4.58 to 4.60 really of your fifth witness statement that you identified people living in deprivation being harmed by and I’m quoting, “the countermeasures to COVID-19” in a way that is greater – I have stopped quoting – in a way that is greater when compared to more affluent areas.
You said:
“It was in my view predictable that there would be significant structural inequalities in the health outcomes for COVID-19.”
But:
“It was not in [your] view entirely predictable which groups would be most affected other than that broadly people living in deprivation tend to have less good outcomes from most infections and indeed most public health problems.”
Would a mental health impact on children and young people from disadvantaged areas fall into your broad category of a predictable effect, Professor?
Professor Sir Whitty: I think it was unpredictable before, but is entirely predictable once we knew what we were going to do.
So I will take the example of home schooling. Home schooling is a much harder thing to do for families which are dependent on physically going out to work, people who are living in much more restricted environments than it is in more affluent areas. It is difficult for everyone but it was even more difficult in those areas.
So, insofar as schooling is one of the ways you can reduce anxiety and mental health issues in the medium to long-term, which there is reasonably good evidence for. Therefore, as soon as it was clear we were going to have to do that, you would anticipate that this would have been an even greater effect in areas of deprivation. Before you saw any data you could be, unfortunately, confident that was likely to be the case. And indeed in my view it was the case.
Mr Pezzani: I’m grateful, thank you very much Professor.
Lady Hallett: Thank you very much.
Ms Weereratne, please.
Questions From Ms Weereratne KC
Ms Weereratine: Thank you, my Lady.
Professor Whitty, I’m over here.
I ask questions on behalf of the Covid-19 Bereaved Families for Justice Wales group. My questions are about DNACPR notices and the use of frailty scores and the escalation of care, which you do not cover in your current witness statement, so I have to set a bit of context as follows, so bear with me.
At the outset of the pandemic there was widespread reporting of unacceptable practices around DNACPR and the use of clinical frailty scores in the escalation of care and ceilings of treatment. It was made clear to healthcare professionals through various guidance and statements that it was unacceptable for advance care plans or DNACPRs to be applied to groups of people or on a blanket basis and that decisions must continue to be made on an individual basis according to need.
So my question is, are you aware that nevertheless the inappropriate use of DNACPRs notices continued throughout the pandemic?
Professor Sir Whitty: So, firstly, to give an extremely clear statement that I completely agree that it is unacceptable to have blanket approaches to this for multiple reasons which I didn’t need really to spell out. It is not normal practice medically. It is not good practice.
I am in favour of advance care planning to be clear. Having the opportunity in advance of an emergency to discuss with someone rationally, with their families, what would you wish to do is entirely good medicine, as all of us should be doing. I want to be clear those are two separate things. Blanket things absolutely not, advance care planning is a very useful thing to do.
I have not been involved in any of the areas which were testing whether there was any evidence of this, but certainly anything I have ever said would under no circumstances have done anything other than saying I’m totally against blanket approaches to DNACPR. So I want to be clear about that.
Ms Weereratne KC: Thank you. Just so you know, the basis of that question came from the Parliamentary and Health Service Ombudsman witness statement to this Inquiry in terms of the findings he has made on inappropriate DNACPR practice.
But the question I wanted to ask you is, given there was an early flagging of this issue, what was done to monitor compliance with the guidance and to prevent inappropriate practices from occurring?
Professor Sir Whitty: Well, I mean, I think other than the fact that I don’t think any responsible body did anything other than say this is the wrong thing to do, it’s making it clear that this was not an area I was immediately responsible for and therefore this wasn’t an area I was leading. And that’s not – you know, if I had been asked I would have made a clear statement, as I just made, as I am sure every senior clinician would. And Sir Gregor made the same yesterday in regards to Scotland, for example.
But, you know, this wasn’t an area I was involved in and therefore I’m not able to give you any more advice than you can get from reading the ombudsman’s report and wider reportage on this.
Ms Weereratne KC: I’m grateful, thank you very much.
My next question is about the use of various scoring systems as a risk assessment tool, such as the clinical frailty score, ISARIC 4C, and you mentioned QCovid in your evidence.
The bereaved families group that I represent are concerned that there was some conflation between those sorts of risk assessments and a lowering of the threshold for the use of DNACPR notices, that’s one thing, and possibly related to that but the converse issue is raised by Professor Lockey of the Resuscitation Council UK who addresses misunderstandings amongst clinicians conflating DNACPR notices with the use and escalation – use of DNACPR notices and the escalation of care.
Professor Lockey also refers then to the ReSPECT process in England, which he says has been introduced to mitigate such concerns, personalising care and also ensuring alignment of treatment and personal values of patients.
The question is, related to the fact that there is no such roll-out of ReSPECT in Wales whilst it does exist in other nations. Would you agree with Professor Lockey that the absence of a nationally standardised process creates patient risk?
Professor Sir Whitty: I’m not going to comment on Wales because Sir Frank Atherton I think is coming to this Inquiry on Monday, so I think that would be more appropriate if he addresses how Wales is addressing this.
The general principle that there is – the decision to have – for a patient to decide, usually themselves with their families, in an ideal situation, that they do not wish to have resuscitation is unrelated to do you want to go on to do major – other forms of care. They are – they should – you are completely correct, I want to reinforce this, is seen as completely different decision pathways. That – just to agree, sort of, in a sense, agree with you on that one.
On the second one, I think there may be a misunderstanding about what QCovid is if people think that this could in any way have any implication for –
Ms Weereratne KC: I’m going to stop you, Professor, simply because my question was about ReSPECT and not about QCovid and whether you think that the absence of a nationally standardised process would affect patient safety?
Professor Sir Whitty: Well, you did mention QCovid and I wanted to correct a misapprehension. I wanted to be clear that QCovid is a system for trying to ensure that people at the highest risk are aware of that risk. It is in no sense something that would be used for any kind of care decisions of the form you are talking about. I just didn’t want that to lie on the record uncorrected.
Are there advantages to having national systems? There are advantages to having systems which are widely accepted within medical nursing and other areas. You want to have a systemic framework and then you need to make sure that individual patients have an individual conversation with individual clinicians, or if they can’t themselves ideally with families or people who represent them. So a national system is – and you know this, but I’m just reinforcing this, is very different from a national approach to who would get resuscitation and who would not. That should be an individual decision.
Ms Weereratne KC: So I’m going to take it that that was an answer – the answer is yes to a nationally standardised process such as ReSPECT?
Professor Sir Whitty: That is one approach to it. I’m not saying that’s what any particular nation should do. But certainly there should be a systemised framework in my view. It could be ReSPECT, it could be other forms.
Ms Weereratine: I’m grateful.
Thank you, my Lady.
Lady Hallett: Thank you very much.
Mr Wagner.
That way.
Questions From Mr Wagner
Mr Wagner: Professor Whitty, my name is Adam Wagner and I ask questions for the Clinically Vulnerable Families. I want to ask you about two topics, please. The first is shielding.
Professor Whitty, shielding was paused on August 2020 and children returned to school about a month later. Did you or your office assess the risk to clinically extremely vulnerable children and clinically extremely vulnerable adults living with children, of that double whammy in the timing of shielding ending and the school restarting?
Professor Sir Whitty: Well, I mean, firstly, there was – around that time, and I can check on the dates but if you will allow me just to say around that time, there was a decision to remove the great majority of children from the clinically extremely vulnerable list, and that was done on the basis that the risk to the children was now, we felt, solid enough that the risk was so much lower that the benefits to them of shielding, with all the disadvantages in terms of childhood development, and I think we have heard from Mind, for example, some of these that accrue if you don’t have access to education, would be denied them, with limited benefit given the increased physical risk.
So the four CMOs wrote to parents about school starting again in relatively unambiguous terms at that time. And I would refer you to that letter if you want to see our views at the time. They were laid out to parents, laid out over about four pages. We wanted to lay out the arguments.
But, in a sense, those two decisions were both aimed at trying to support children and their development, accepting that the children were coming to very significant harms from some of the social interventions that were necessary during Covid to reduce the risks of the kinds that I thought Professor Fong so powerfully laid out. So that’s the children’s side.
In terms of the adults, yes, consideration was given to this, and there was a lot of concern about what to do to maintain, firstly, the reduced risk among adults who were clinically extremely vulnerable, but also trying to reduce the impact on the lives of those living with them and trying to make sure that those two aims, which are in some sense in tension, to the best of our ability were balanced against one another. So that – I mean, I hope – I realise that doesn’t give you exactly the answer you wanted but it’s, I think, an accurate reflection of our thinking at the time.
Mr Wagner: Thank you.
Was any thought given to a more gradual transition out of shielding, as they had in Scotland, rather than the sort of cliff edge of just ending it at that point, or pausing it completely at that point?
Professor Sir Whitty: Well, I mean, shielding, both to go into it and to come out of it, was a voluntary issue. So, as some of the data which has been shown, I think, from the ONS to this Inquiry demonstrates, many people who were clinically vulnerable chose, perfectly reasonably, to continue to do what they had previously done. They did that on a more informal basis. So the cliff edge, as you put it, was, in a sense, a choice cliff edge for many people.
Where it was more problematic was around delivery of some of the services. But this was, as you will recall, a period when the incidence of Covid was much lower than it had been at the point that shielding was introduced and, as we have heard from some of the previous evidence, the downsides of people being in shielding were very substantial. So that was the basis on which this judgment was made.
Mr Wagner: Just related to that question about children living with clinically extremely vulnerable family members, and a lot of people who shielded obviously lived with other people in their homes who were not being shielded and would go out into the community more and potentially contract Covid, did you consider a design of the shielding programme, or might you consider if you were doing it again now, that focused more on the household than the individual? So gave advice and support to all members of that household how to support that ultimately and protect that clinically extremely vulnerable individual?
Professor Sir Whitty: There was quite a lot of advice to households actually as part of the clinically extremely vulnerable shielded programme. So it wasn’t that they were – there was no advice. I think that would not be an accurate reflection.
The difficulty here is the one that I have indicated. What we were trying to do was minimise the disadvantages of shielding for those who didn’t need it whilst maximising the protection for those who were considered to need it as part of the – initially a judgment by the senior clinicians and subsequently, more accurately in my view, the QCovid system.
And those – you know, as I’ve said in my previous answer, there was some tension between those aims. There is no doubt about that. But that was true for many of the decisions taken during Covid, of course, there was tension between aims.
Mr Wagner: Just going back to the pause in shielding and in fact the end of shielding, might it have been desirable or possible to include some additional mitigating measures once shielding was ended? Thinking, for example, about – at the time shielding ended, the airborne route of Covid was very clear: requirements for better ventilation in public buildings, air filtration, that sort of thing. Might that have been twinned together?
Professor Sir Whitty: I think we didn’t deal with ventilation earlier in the talks, so I’m going to give a slightly longer answer to that because I think it is a really important point.
I do think that one of the things that has come out of Covid is we should take ventilation in public buildings in particular much more seriously. Sorry, that is a very important point you have raised. Non-specifically. So that is for Covid, but also for flu, also for RSV, also for many other infections. It also incidentally has an additional benefit for indoor air pollution; something I have written on in a previous annual report.
So I think we should be taking indoor ventilation of public buildings a lot more seriously and probably more vigorously than we previously had.
There is a slight rider to that which I’m going to put on the record, which is there is a risk that that can lead – if we are not careful – to reduced thermal safety. So elderly people are also at risk if they get cold. So what you don’t want to do is have something which actually leads to good ventilation but leads to very significant cold-related risk in the winter months. But that is a solvable problem in engineering terms for most public buildings, although not all.
Mr Wagner: My second topic is masks. You have said you are not an IPC expert, as in that’s not your background, is that fair?
Professor Sir Whitty: That is correct.
Mr Wagner: I just want to put to you a couple of points that the experts that this Inquiry’s instructed relating to IPC have made. Professor Beggs, on the physical science has said:
“From the evidence presented above, a consistent emerges that face masks are likely to inhibit the transmission of SARS-Cov-2 in healthcare settings and that respirator masks appear to afford superior protection to healthcare workers as opposed to surgical masks.”
He also says more research is necessary, which I know you have also agreed with. Do you disagree fundamentally with any of those points?
Professor Sir Whitty: I would put much more emphasis on the more research is needed than Professor Beggs would.
Mr Wagner: The IPC experts that the Inquiry instructed, particularly Dr Shin and Dr Warne, agreed that the IPC guidelines should be updated to recommend routine use of FFP3. As a non IPC expert would you defer to that conclusion?
Professor Sir Whitty: Firstly, my reading of their expert review was they also felt that the evidence was weak. I’m happy to be corrected on that, but that was my reading of it. Therefore, I do not think they were saying definitively that that is what the evidence showed. This is an area where we will have it get some greater consensus. I think some of the questions I was asked earlier I thought were very fair and to the point on this. I don’t think from where I sit – and I am not an expert in this area – those who are experts in the area have yet to reach a point of sufficient unanimity that making a move to something which is much harder to use is an appropriate one, until I’m instructed otherwise by people whose expertise this is.
I would want to add an additional point, I would be very cautious about using FFP3 masks in the general population without fit testing. I think the benefits of that strike me as way, way further down even than the previous ones, in terms of probability, and the down sides of them I think are quite significant. It doesn’t mean people shouldn’t if they wish to, but I would not want to be implying we are recommending that.
Mr Wagner: But it is possible for the members of the public to be fit tested?
Professor Sir Whitty: It is possible and if they wish to there is nothing to stop them doing that. But I think for us to recommend that based on the evidence we have currently got, that could well lead to people who are disbenefitted by FFP3s for a variety of reasons, including communication, doing so. So I think it is sensible to leave it as it is at the moment until the evidence base is stronger.
Mr Wagner: Would you say the same about FFP2 masks?
Professor Sir Whitty: In the UK we have used FFP3 largely because that has been HSE guidance rather than for any other reason.
Mr Wagner: On that topic – you said you would not recommend for the general public, but you said earlier that one of the things you would change going back would be to give healthcare workers the choice to wear FFP3 masks if, for whatever reason, they decided to. Would you extend that to patients and visitors to hospitals? I’m thinking about clinically extremely vulnerable patients and visitors who decided they wanted to wear an FFP3 mask and it wasn’t clinically contraindicated?
Professor Sir Whitty: Firstly, people are free to do what they want in terms of their protection, I think it is an interesting and difficult question for someone on the front door to make sure that everyone is wearing a new face mask when faced with that situation. I saw one of your questions you previously asked, my view is I could see arguments on both sides of that particular argument, but certainly the principle that people should be able to use FFP3s if they wish to and if it is not contraindicated by other considerations, is just a matter of freedom of choice as much as anything else.
But I would go back to a previous comment that an FFP3 absent fitness testing – and it is much easier to access FFP3 than it is to access proper fit testing – it is not obvious that it necessarily produces benefit over any other mask.
Mr Wagner: My final question, linking the two topics of masks and shielding, do you think now that public advice on higher quality masks, combined with a swifter acknowledgement of the risks of airborne transmission, would have helped reduce the impact on the clinically extremely vulnerable of the very stringent shielding measures?
Professor Sir Whitty: I certainly think that if we were running the way we did things again, we would have emphasised masking in general at an earlier phase of the pandemic than we did. I think that is very clear.
I think we would have introduced surgical masks for everybody at an earlier stage within healthcare settings. What I do not think that I would go as far as to say is the evidence is there for – when you say higher quality I presume you mean an FFP3 and for the reasons I have previously said I don’t think I go that far. I don’t think the evidence base is there to make that statement.
Mr Wagner: But what about –
Lady Hallett: I think you have asked enough your questions, thank you, Mr Wagner.
Mr Wagner: Thank you.
Lady Hallett: Right, Who is next? I have lost my list. Ms Sen Gupta.
Questions From Ms Sen Gupta KC
Ms Sen Gupta: Thank you, my Lady.
Professor Whitty, I represent the Frontline Migrant Healthcare Workers Group. To provide some context, our clients’ members include two particular categories of healthcare worker. First, outsourced non-clinical workers, not directly employed by the NHS, such as hospital cleaners, porters, security guards, medical couriers and taxi drivers who were in precarious employment, including zero hours contracts, on low wages and includes 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 just going to ask you about risk assessment. At paragraph 5.58 of your second witness statement you referred to one of the roles of the Office of Chief Medical Officer as being to assess which groups were most vulnerable to Covid-19. For the transcript, that is statement was produced in Module 2 and is Inquiry reference 184638 but it need not be displayed thank you.
Professor, were any of the following categories of healthcare worker assessed by the Office of Chief Medical Officer as being particularly vulnerable to Covid-19? First, low income health workers?
Professor Sir Whitty: I’m going to stop you at this point because, firstly, it would have been very useful to have had a bit of context for this, to have been able to read the context in which I said that. I think it probably sits slightly outside what I actually think and therefore I suspect it had a context around it. So can I just park that.
Secondly, our job, insofar as we were trying to identify particular risks, I think I discussed earlier on that, for example, the QCovid system was the mechanism by which we did that and that looked at multiple issues and one of the reasons, for example, it was highly praised by the Runnymede Trust and others was because it did bring in things like deprivation and ethnicity in a way that other risk scores didn’t, and that was very much something we wanted to do.
But it was definitely not my job or that of my very small team to take every single risk group in the UK and say which individual bits of that risk were relevant. This is not in any sense to belittle the importance of the question you are asking. I fully agree the question you are asking is an important question, but absolutely it is not the role of the Chief Medical Officer to do that and it would be silly for me to start randomly firing out answers on something which it is very obviously not in my area of professional responsibility.
Ms Sen KC: Professor Whitty, the reason I ask that question is because you refer specifically to the OCMO as being involved in conducting such assessment during the initial waves of Covid-19. But can I take it from your answer that you agree that it would have been helpful for those categories of worker that I mention, low income health workers, precariously employed health workers, outsourced health workers and migrant health workers to have been assessed as being particularly vulnerable to Covid-19?
Professor Sir Whitty: I think actually what I would have preferred to have happened, and normally I don’t stray into areas outside health, but because I made this point multiple times in government and publicly, I think what would have been actually more helpful is to make the employment of people less precarious during Covid.
I think that solves the problem in a much more sensible and fundamental way than trying to identify someone who is at high risk and then saying you are at high risk. How that is done is very much not for me. That is an economic question. But I think reducing economic precariousness is one of my strong recommendations to my successors, including in the technical report I think that we wrote. I’m pretty sure we made that as a recommendation and I have certainly said that publicly many times.
Ms Sen Gupta: Thank you very much.
Thank you, my Lady.
Lady Hallett: That’s very kind. Thank you very much, Ms Sen Gupta.
I think, Ms Munroe, is it you?
Questions From Ms Munroe KC
Ms Munroe: My Lady, thank you. Many of the questions I had intended to ask Professor Whitty have been dealt with, and I’m grateful to Ms Carey KC, during her examination. So I just have a few further matters and some points of clarification, if I may.
Good afternoon, Professor Whitty. My name is Allison Munroe and I represent the Covid-19 Bereaved Families for Justice UK. As I said, Professor Whitty, just a few matters arising from your evidence and questions of clarification.
Firstly, in relation to the issue of technical advice and NHS 111; in an early CAS alert on 3 February 2020, the members of the public were advised, if they had been exposed to Covid-19, that they should phone NHS 111 and not be referred to emergency departments unless seriously ill. This alert also highlighted public health advice and guidance including advice for travelers and those who had been to mainland China, etc.
The question is this, in terms of your office, what involvement did the Office of Chief Medical Officer have in the development of that advice?
Professor Sir Whitty: At a high level we had one important contribution to it, but in terms of the actual algorithms behind NHS 111, we haven’t had any involvement that I’m aware of, certainly I have had no involvement in it. It is a technical, and an important one, not one for us.
The reason for that advice, I hope self-evidently, was to make that sure individuals could access care, very important the patients could access care, but also in a way that minimised the risk to other patients if this person was particularly at high risk of Covid particularly early on, and also healthcare workers.
The important thing was to allow people to access care in an appropriate way and then they could go – if they were at low risk of Covid and it was assessed by that to an ordinary place where they could be assessed, that would be convenient for them, meaning their other non-Covid problems be dealt with, recalling that at this point the great majority of people who might have had Covid actually didn’t – that changed over time – but if they did have Covid, that they could be dealt with in an area which would minimise the risk to other patients, to families, to relatives and to staff. So the logic behind it I hope is reasonably clear, but I think it is worth laying out.
Ms Munroe KC: Thank you very much Professor Whitty. You have answered my second part of that question in terms of, in your capacity as Chief Medical Officer what involvement you had in that advice.
Second topic. Preparation for autumn/winter 2020. It would seem, Professor Whitty, that as a result of reports such as the Academy of Medical Sciences Report, entitled “Preparing for a Challenging Winter 2020/2021”, which was published on 14th July 2020, and which was endorsed, subject to a minor amendment, by SAGE on 9th July 2020, that it was known by the summer of that year that the likelihood of a significant wave in terms of infection in the autumn and winter of 2020.
Now, Professor, we have heard, in some often very often visceral terms, evidence from bereaved families, and only this morning the evidence from Professor Fong about the devastating impact of the second wave.
My question is this, were you satisfied that sufficient steps had been taken in the spring and summer of 2020 by the Office of the Chief Medical Officer and indeed you in your capacity as CMO, to prepare the NHS for that second wave, in particular to maximise infection control in healthcare settings and minimise healthcare acquired infection, which was known to have been a significant factor in the first wave?
Professor Sir Whitty: Thank you. Firstly, it was in my view highly probable – and I said this from quite early on in the pandemic – that there was going to be at least another wave in winter and that was covered in evidence to the last module and it was Patrick Vallance who commissioned the Academy and Medical Sciences report – I co-commissioned it to some extent, but it was really Professor – now Lord Vallance – who commissioned it – and we were very aware of the risks to it. The risk was fully acknowledged.
Secondly, the main thing that was being done by Sir Patrick and me was around trying to minimise the risk of a very large pandemic in terms of government actions. That was the principal foundation of our work, recalling that there were only three senior clinicians in the Office of Chief Medical Officer and a lot in NHS England.
NHS England, remember, I also have no statutory responsibility for. So in terms of what I could do within the NHS, the answer is I can advise but it is at quite – one remove.
We were, however, well aware of and very cautious of the risks of nosocomial infection within the NHS. Fundamentally the best way to deal with this was to reduce the amount of infection in society. That is by a very long way the biggest way to get around that and all the other elements are secondary to that. So that’s where we put the majority in terms of my team of our effort.
Was the NHS prepared for it? Well, the NHS, now speaking as a doctor, I worked through the – in fact I worked near the peak of the second wave. I was very heavily involved on the wards at that stage. We were a long way away from being in a good place and Professor Fong’s evidence this morning I thought very powerfully illustrated that and incidentally illustrated why some of those who minimised Covid are so wrong. We had learnt a lot and actually some of the other evidence that has been or will be in front of this module demonstrates that the NHS, which is a learning organisation – I don’t mean that in a pap corporate sense, but individuals within it learn very rapidly – I think handled the second wave, despite the fact it had a huge number of cases, a lot better and that’s because individuals in wards, in primary care, in other areas, mental health and many other areas, had learnt and did it better.
But there was still a lot of nosocomial transmission, there was still many, many deaths and the system was in many cases under extraordinary strain, as was described earlier. So I wouldn’t, in any sense, want to be painting a falsely rosy picture and indeed that was not my personal experience working in that environment.
Ms Munroe KC: Thank you very much.
Asymptomatic testing. Just one question in relation to this.
Professor, in your Module 3 statement – and my Lady, for reference it is INQ000410237, at page 76, paragraph 8.3 – you recall that to you wrote to Jeremy Hunt on 18 August 2020 about asymptomatic testing of healthcare workers, expressing the view that this was best implemented as part of a study given the low incident at that stage.
Then, some 13 days later, on 1 September 2020, you recognised in an email to Professor Powis and Professor Sue Hill that during an autumn/winter surge regular testing of all patient facing staff would be needed. Now, asymptomatic testing of all patient facing NHS staff begins in the week of 9 November 2020.
My question is this, Professor, given the known likelihood of the significant asymptomatic infection, the risk of asymptomatic transmission and the likelihood of a significant imminent second wave, do you feel that sufficient steps were taken to ensure that asymptomatic testing of healthcare staff was initiated quickly enough?
Professor Sir Whitty: It was pretty obvious that the advantages of asymptomatic testing in principle of staff. But there were two very major limitations and one additional reason we didn’t want to do it across the board at an early stage.
The first limitation was we did not know how frequently we would need to test to actually achieve the aim, which is to reduce transmission amongst patients and staff. That could have been once a week, it could have been once a fortnight, it could have been every other day, it wasn’t clear. And having better information on that meant we would have a better targeted approach.
Additionally, the PCR testing that was available to us up to around about the end of October had two very major disadvantages. It didn’t give an instant result and secondly some people could remain positive for many weeks after in fact they had probably become non-infectious; six weeks or more was possible, which in a highly stressed system, having significant numbers of healthcare workers or care workers removed from the system despite actually not being infectious but because of this problem would have been a limitation. That was an important research question.
The third thing, however, was we did not have enough tests. This was the biggest issue by some distance. I can read through, if you wish, but I am sure you don’t wish and I am sure her Ladyship even more doesn’t wish me to, exactly how many tests we had at various stages. But really going up until early October to do asymptomatic testing of all patient facing staff, let alone wider NHS staff, would have been well beyond the testing capacity we had even though – although we had expanded it out. It simply wasn’t a practical reality.
What turned this into a possibility and really transformed our whole management in a way which was only second to, but a long way second to vaccination, was the ability to do lateral flow testing which was point of care. That allowed people to have an immediate result. It allowed them to do it in multiple areas and even though the lateral flow tests were less effective in the sense of less sensitive than PCR, they actually correlated pretty well with infectiousness. Therefore, people could test themselves quite regularly and quickly, not just in terms of healthcare workers but in a number of other environments and that made possible a whole range of things that previously hadn’t been.
I did, however, before we had the lateral flow, I was nervous and the email you laid out is an important demonstration of this, that we would get ourselves to winter wishing to be able to test people and without capacity and I wanted to make sure that was not a limitation. So I was saying: look, okay, we don’t have the data yet and the rates are low now, that won’t be case in two or three months, are we ready for that? Please can we ensure we are ready for that.
That was the logic about why those emails were being exchanged.
Ms Munroe KC: Thank you. That is a very thorough and full answer.
My last topic is about shielding. You have been asked a lot about that and most of my questions have been dealt with and it is clear from your evidence we have an idea of your views on shielding, its logic, its effectiveness and indeed its appropriateness or not in a future pandemic.
If I may come back to one point in relation to that. Would you agree that the provision – that there should have been a provision made from the outset as part of the shielding scheme for enhance protective measures for CEV people accessing routine or indeed emergency healthcare, and that the absence of such measures was in fact a fundamental flaw in the shielding scheme?
Professor Sir Whitty: I mean, noting the bit I said I wasn’t so strong on and be able to answer questions on was the operational side. I was responsible for the concept, not personally, but I had a responsibility for the concept and the choice of who was most at risk by two different mechanisms.
My understanding of this was that there actually was an attempt to make sure that there was easier access to a variety of forms of information for people who were clinically extremely vulnerable, in addition to help with things like medicines and other things, which was a fundamental part of the package.
Without being able to quote chapter and verse, because this isn’t my area of real knowledge, it was in fact done in a different department to the one I’m housed in. So I was much less involved even in sort of corridor conversations on it. My understanding is that there was actually some degree of support but it may not have been insufficient; I don’t know. That is not me saying it wasn’t sufficient, it is just me saying I don’t know.
Ms Munroe: I understand and appreciate it. Thank you very much Professor Whitty.
Thank you, my Lady.
Lady Hallett: Thank you, Ms Munroe.
That completes the questions for today. Professor Whitty. Yet again I’m extremely grateful to you for all the help which you have given the Inquiry and for the thoughtfulness of the responses that you have given; they have been extremely helpful.
I’m sorry I can’t promise you we won’t meet again. I will give instructions for the teams to limit the demands we make upon you and your office as best we can, but I think, as you probably guess, it is inevitable I think we are going to have to ask you to come again. But thank you for everything you have done today.
Very well, 10.30 am, Monday, 30 September.
(4.17 pm)
(The hearing adjourned until 10.30 am on Monday, 30 September 2024)