11 March 2025

(10.00 am)

Lady Hallett: Mr Wald.

Mr Wald: My Lady, I wonder if, before we start, I could

just return to the subject of a particular document

that I mentioned at the end of yesterday, INQ000533868.

I said at the time that it was necessary for us to check

whether there was any requirement or need to apply

a restriction order on that document.

In the event, no such need arises.

Lady Hallett: Thank you very much.

Mr Wald: Our next witness, or our first witness today is Dame Emily Lawson.

Dame Lawson

DAME EMILY LAWSON (sworn).

Lady Hallett: Welcome back.

The Witness: Thank you.

Questions From Lead Counsel to the Inquiry for Module 5

Mr Wald: Please state your full name for the Inquiry .

Dame Lawson: My name is Emily Jane Ruth Lawson.

Lead 5: Dame Emily, we have received two statements from you for this module. I know that you provided a statement, at least one statement, for a previous module.

Dame Lawson: Yes.

Lead 5: In relation to this module we’ve received INQ000572261, and INQ000531295, for which we are very grateful. Both statements are signed. Could you confirm, please, for the Inquiry that both statements are true to the best of your knowledge and belief?

Dame Lawson: Yes.

Lead 5: Thank you very much, Dame Emily.

Could I start, please, with a little bit of your background. I am concerned, when I move on to it, with that period that relates to the pandemic itself, and won’t be asking you questions in relation to more recent professional experience.

Dame Emily, you have a background in academia, I understand.

Dame Lawson: Yes, I have a PhD in molecular genetics.

Lead 5: You worked in the biotechnology industry?

Dame Lawson: Yes.

Lead 5: And you have also worked as a management consultant at McKinsey?

Dame Lawson: Yes.

Lead 5: And following that, you’ve had experience at Morrisons and Kingfisher?

Dame Lawson: That’s right.

Lead 5: I hope to be able to seek your reflections on data, data management and modelling in due course. Can I take it that the experience that you’ve had will enable you to offer reflections based on relevant experience and

expertise?

Dame Lawson: Yes.

Lead 5: Good. Thank you for that.

I move now to your involvement with NHS England.

Between 2017 and 2020 you were employed by NHS England

as National Director for Transformation and Corporate

Operations.

Dame Lawson: Yes, my job title shifted once very slightly when

NHS England and Improvement merged, but it was effectively the same role now effectively spread across two different – well, two organisations that had now come together.

Lead 5: Understood. You also held, from December 2018, a senior leadership role for the joint NHS England and NHS Improvement organisation?

Dame Lawson: Yes, I led the Joint Working Programme to bring the two organisations together.

Lead 5: And between the beginning of April and the middle – beginning of April 2020 and the middle of July 2021, you were the Chief Commercial Officer for NHS England and NHS Improvement?

Dame Lawson: Yes.

Lead 5: Moving on in time, you were seconded to the DHSC from 20 March 2020 to 9 November 2020?

Dame Lawson: Yes.

Lead 5: And in July 2029 (sic) up until July 2021, you held the post of non-executive director of SCCL?

Dame Lawson: From July 2019, yes, until I – yes, that’s right.

Lead 5: How did you come to take on that role at SCCL, about which we’ve heard a certain amount of evidence already in this module?

Dame Lawson: Yes. So the plan that pre-existed me taking that non-executive role in July of 2019 was that the shareholder role in government of SCCL should move from DHSC to NHS England. So in order to prepare for that, but in advance of it actually happening, myself and Miranda Carter took non-executive roles in the summer of 2019 as part of that extended handover period.

Lead 5: I had a go at summarising what SCCL is, or was, in the course of opening this module, the opening submissions given then. Would you, perhaps, explain, as you understand it, what is SCCL?

Dame Lawson: Obviously, you’ve got Paul Webster coming on after me who will probably give a more authoritative answer, but the SCCL was set up partly as a consequence of the Lord Carter review of the potential opportunities for efficiency in the NHS to consolidate the supply chain activities and to try to take advantage of the scale of the NHS in procurement. So with the idea being that if you can buy on behalf of the whole NHS you will get better prices for goods and services than you will if it’s just a single trust doing that.

And by that time in … I mean, SCCL has quite a complicated structure – had, which I can give a couple more sentences on if it’s helpful, but basically the goods and services they were providing services for to the NHS were held in, I think it was 11 towers, and these towers were bid for by consortia of other organisations, so they would then provide the service of buying – for example, one of them was about food and, you know, hotel services, for example; another one was about medical devices, including pacemakers, so relatively straightforward things that the NHS uses a lot of.

And they also contracted originally with DHL but then switching to Unipart, I’m afraid you’ll have to ask Paul for the detail, but I think either in 2018 or 2019 they switched to Unipart who ran the warehouses that then dispatched those goods and services into the NHS.

Lead 5: We’ll come on to that and we certainly will be asking Mr Webster for a little bit of detail on that. But during the pandemic, by way of summary, SCCL fell under the control of DHSC?

Dame Lawson: It did, yes.

Lead 5: We know from a previous module, Module 4, that you also had an important role in relation to vaccines –

Dame Lawson: Yes.

Lead 5: – which we won’t be going back to today.

I want to ask now – just finally, you returned to Number 10 in April 2022 up until September 2023 as Head of the Prime Minister’s Delivery Unit there?

Dame Lawson: Yes.

Lead 5: Moving, then, to how you came to be involved in procurement during the pandemic more specifically. Let’s start in early March of 2020. On 10 March, NHS England’s Chief Executive asked you to investigate complaints from NHS trusts that their orders for PPE were not arriving on time. That’s right, isn’t it?

Dame Lawson: Yes.

Lead 5: And I think we can display our first document in relation to this.

It’s INQ000533074, and page 2 of it, just to get a sense of the kinds of issues that were causing concern. We see there that:

“… WMAS had placed an order for face masks …”

What is WMAS, please?

Dame Lawson: West Midlands Ambulance Service.

Lead 5: Thank you.

“… for face masks and that these have not been forthcoming, and that Anthony Marsh (CEO) is escalating to Simon Stevens.

“London reported concerns around continuing with community swabbing and access to PPE.

“North East and Yorkshire reported that YAS …”

Dame Lawson: Yorkshire Ambulance Service.

Lead 5: “… have moved to RPE because of a lack of appropriate PPE, and that Merseycare were suspending community swabbing due [to] a lack of PPE.”

And finally:

“South West reported that South Devon had suspended due to a lack of equipment and swabs.”

Dame Emily, what was your reaction to learning about these kinds of challenges being faced by NHS trusts?

Dame Lawson: My reaction was to, I mean, connect to the various people who were already looking at this. So this email is from Stephen Groves, who is one of the leads for the emergency response in NHS England, and obviously he was already in communication with – I think the email is to Sarah Parker, who was part of Steve Oldfield, the chief commercial officer – in the department. So what I didn’t want to do was to wade into stuff that was already being handled because yet another person asking questions is often not that helpful. So I was glad that Stephen copied me in.

Lead 5: Let’s look at the email that shows that. It’s INQ000533075, and page 1 of it.

Dame Lawson: Yes.

Lead 5: This shows your discussion with Steve Oldfield, as you’ve summarised for us:

“Got reports today of a hospital going to screwfix to buy goggles.”

Is that Great Ormond Street?

Dame Lawson: It is, yes.

Lead 5: “[Hospital] struggling for PPE as well. Apparently several trusts are down to 2 boxes of masks. As you know, the supply of PPE is critical to staff feeling safe.”

I just wanted to ask you a point about the word “feeling” there. It’s not just a lack or shortage of PPE that causes problems; it’s the prospect of that occurring in the coming days, isn’t it?

Dame Lawson: It is, yes. You know, it was a very worrying time. People could kind of see that the growth was coming and particularly clinical leaders were getting emails and pictures from – and WhatsApps from Italy, which was already in a, you know, really challenging position. So just the emotion and the fear among staff was really high. And so if you can only see two boxes of masks, first of all you don’t feel safe, but secondly it might cause you, for example, to not wear the mask for long enough because you’re like, “Well, I might need it again tomorrow”, and then you potentially have people compromising themselves because they don’t feel safe, not because the supply isn’t actually there. And I think Professor Manners-Bell talked a little bit about that in his report, which I thought he conveyed really well, but that was a very visceral concern.

And obviously in the intervening time between these two emails that you’ve shared I’ve been to the SCCL board meeting in Nottingham, which was on the 11th, so it was exactly five years ago today, where we’d had a normal board meeting and one of the non-execs and I had raised issues. I then had a meeting outside of the board meeting itself with Jin Sahota – I don’t think with Alan Wain but definitely with Jin – to say, “Right, what is the actual response going on?”

So by the time of the email you’re showing me – this is Saturday – I am concerned that we’ve been raising emails, we’ve been writing backwards and forwards, but I’m not seeing that we’re changing what we’re doing in order to deal with this heightening tension and what looks like heightening lack of supplies at the trust.

Lady Hallett: Sorry to interrupt, if you could slow down.

The Witness: Sorry, yes.

Mr Wald: I’ll move on to the latter part of this email in a moment but I pose a question about feeling safe, because evidence has been given to the Inquiry up until now about there being no national shortage, albeit that there were some issues about distribution to individual hospitals. I wanted to have your evidence on the feelings that resulted, even from the prospects of shortages in the coming hours or days.

Dame Lawson: Yes.

Lead 5: And you’ve given your answer to that question.

Dame Lawson: Yes.

Lead 5: Let’s move on, then, to the second half of this email paragraph.

“I thought the release of the PIPP stock would relieve the pressure so not sure if it hasn’t got to people yet or if there are still too strong restrictions on ordering and delivery at SCCL. Would you be ok to write a strongly worded letter to PHE and/or SCCL saying the data says there are stocks and they need to get them out, and [get] back to us instantly with any issues?”

At this point, Dame Emily, the decision had already been made to release the PIPP stockpile, but SCCL had put in place demand restrictions, and so releasing that stockpile had not improved the flow of stock to trusts. Is that the position?

Dame Lawson: Yes. I mean, the whole PIPP stock hadn’t been released, but sort of the ability to start using it had been, but it was not happening in a full flow way; it was happening in a controlled way.

Lead 5: When you say controlled, we’ll move on in a moment to physical problems that were encountered in distribution.

Dame Lawson: Yes.

Lead 5: So that aspect of it I suspect you wouldn’t describe as controlled?

Dame Lawson: Sorry, the physical aspect of distribution from Haydock into the SCCL – (overspeaking) –

Lead 5: Yes, the obstructions, the problems with getting stockpile PPE out of the warehousing.

Dame Lawson: Yes, I mean, I’m happy to – shall we – sorry, shall I wait for the question on that?

Lead 5: Let’s wait for the question.

Dame Lawson: Yeah.

Lead 5: We’ll come on to it in a moment.

Can I first understand from you the reason for PPE not being shipped to trusts in the quantities needed?

Dame Lawson: I think there were several things going on, and I appreciate you’ve probably heard from other people, but if you don’t mind it probably helps if I take a second to lay this out.

Lead 5: Please do.

Dame Lawson: So the PIPP stock, and there is also a second stockpile not mentioned here but was material which was the EU exit stockpile, which was also being released at this point, the PIPP stock is held in what is effectively a deep-freeze scenario in the warehouse in Haydock, run by Movianto, which was subcontracted to PHE. And the – you don’t go into that kind of warehouse to send a couple of pallets to a trust; it has to come out of that warehouse into what’s called the distribution warehouse, which were the ones run by Unipart, and then it can be dispatched to trusts.

Trusts couldn’t order directly from Haydock, and Haydock would not have been able to dispatch. You’ve got the wrong lorries, if you like, that you can’t go in and pick stuff up in the same way you can from a distribution warehouse. So stuff had to be moved twice. And what had happened was SCCL had seen a massive growth in orders not just for PPE but for everything else. And that’s in – both Jonathan Marron’s statement and Paul Webster’s statement give some examples of that. And to give one example, the use of FFP3s had gone up threefold by the end of February in terms of how many were going out per week, and if that is happening to everything that you pick, that makes picking very difficult.

So there was a release of some stock from Haydock, but PHE and SCCL were also concerned to not release that all at once because it might need to last for longer. So that was a controlled release into the SCCL warehouses.

Lead 5: And that is a form of demand management?

Dame Lawson: That is a form of demand management, yes.

You then had demand management at the SCCL warehouses where there were caps on specific items, so from 19 February there was an order limit for FFP3s, from 24 February for 2Rs, two 2R masks which are the fluid resistant masks, and then from 26 February for eye protection, and there were then other controls against orders. So if an order was more than 150% of what they would normally have ordered, it was stopped, that kind of thing.

So there were a bunch of controls going on. And what, of course, the system wasn’t able to see is when was a trust genuinely over-ordering because they were nervous, they wanted to make sure they had the stock, and when did they actually need more because they were treating more patients and because there was a growth in demand? The system wasn’t able to see that. So there were tensions, kind of, all through the supply chain, if you like.

Lead 5: I assume that extremely helpful answer is one that you are able to provide the Inquiry on the basis of what you have gleaned since that time. You were also anxious, quite rightly, to understand what the cause or the causes of the problems were at the time and I want to just bring up on to the screen a document that shows you attempting to do that, and just ask you to the extent that you’ve not already dealt with it in that answer, whether there were any other indications here of what lay behind the problems being encountered.

It’s INQ000533076, and it’s pages 1 and 2.

So this is actually – your email is at the top and then we’ve got, this is from Alan Wain.

Dame Lawson: Alan Wain who was the Chief Operating Officer at SCCL.

Lead 5: Yes, and he is identifying, as he understands it, what the problems being experienced were at the time. And you said that it’s a very helpful email, I assume that you took this to be a sensible explanation of those problems?

Dame Lawson: Is it possible to scan down a little bit?

Lead 5: Yes, I was going to take you all the way through, but starting with “Poor communications”. Did that feed into the problem as you understood it then or as you understand it now?

Dame Lawson: Yes, if I could take a step back, I’m happy to do the detail but just because you asked a broader question a second ago.

Lead 5: Yes.

Dame Lawson: I genuinely thought it was a helpful email, which is what I said at the top. I also thought it didn’t describe the whole situation, I thought it described a very clear view from SCCL of what they were experiencing. It didn’t go all the way to identifying all of the issues and therefore we needed to do more to get underneath the skin of the issues to actually solve the problem, but maybe you’re taking me there.

Lead 5: Okay, well, by all means, if there are aspects of this that are missing, you’ll let us know now.

Dame Lawson: Sure.

Lead 5: I appreciate it’s not your email, but you were sent it, described it as helpful.

Dame Lawson: Yes.

Lead 5: But it may not have been comprehensive as well as helpful?

Dame Lawson: That’s right.

Lead 5: Yeah. So we’ve got “Poor communications”, actually, that appears twice, as items (1) and (2). We’ve then got “Bad behaviour from trusts”.

Dame Lawson: Mm-hm.

Lead 5: Is that something you would agree with? You’ve mentioned that there were problems about understanding what degree of need there was, whether people were seeking more than was immediately needed because of anticipated problems.

Dame Lawson: Yes. I mean, look, I think it signals the level of tension everybody was operating with at the time but it was one of my concerns, because if you – I wouldn’t have described what the trusts were doing as bad behaviour. The trusts were tremendously concerned to be able to treat patients and to be able to keep their staff safe, so I totally see from an SCCL perspective that an increase of 4,500% feels absolutely outrageous, I didn’t feel it necessarily – excuse me, I have probably sped up again – it didn’t fully appreciate the tension that the trusts were also dealing with, so I thought there needed to be a balance here because if we were going to solve the problem we had to solve it for the whole supply chain not just for one part of it.

Lead 5: Yes, the observation is made at (3) that during the course of a single day – “of the day, we took orders for 1 million facemasks.”

Dame Lawson: Yes.

Lead 5: That simply shows how extreme the position was at that time.

Dame Lawson: It does, and I think it’s important to convey just how many – at this point everybody thinks this is a potentially deadly disease. You don’t yet know that it’s only elderly – it’s largely, not only, obviously – elderly people are particularly at risk of getting ill so all staff feel they are putting themselves on the line to come to work, and so you had a massive increase in people putting 2R masks on to try and protect both themselves and colleagues and the patients they were treating. So again, if you’re running a warehouse that seems absolutely outrageous. If you’re running a hospital saying, actually, I want more staff to wear type 2R masks, probably didn’t feel that extreme.

Lady Hallett: I find it rather strange that someone should describe it – I appreciate you have disowned the comment “bad behaviour” from trusts. It seems rather curious to me that one part of the system is accusing another part of the system who, as you say, were doing their best to protect staff and patients, of bad behaviour.

Dame Lawson: I do think this is one of the challenges that we had over this period, and you mentioned that I went on the board on the – in July 2019. One of the three issues that I’d flagged in my work through the autumn as a non-executive, had been the relationships with trusts, and trusts – SCCL at that time felt that trusts were not buying enough through them and that NHS England should mandate it. And I felt that before we mandated it we needed to make sure the service was really working for trusts, and that they thought they were getting what they needed.

So I think this is indicative of the fact that actually, Trusts-SCCL relationships were very mixed and there was a way to go to improve them and now you’ve suddenly put this massive tension on top and that’s brought that out.

Mr Wald: There’s discussion here of limitation and demand management. At this stage, were you asking SCCL to increase their own buying activity?

Dame Lawson: SCCL had been instructed at one of the supply cell meetings right at the beginning of February to increase their buying. So they had both, in fact on 31 January, activated the just-in-time orders that were part of the PIPP stockpile and they had increased their own buying, I think from 7 or 8 February. That’s in the minutes of the supply cell. I obviously wasn’t part of it at the time. So they had already started buying more.

Lead 5: As far as you knew, was SCCL following a policy of not acknowledging control measures, or in other words, not telling NHS trusts about demand control measures in an attempt to prevent panic buying?

Dame Lawson: I’m not aware either way.

Lead 5: Okay. Now let’s see what you’ve – unless there’s anything else you wanted to remark upon with this email?

Dame Lawson: No, that’s fine.

Lead 5: Let’s go to a part of your witness evidence. It’s INQ000531295 and page 9. Paragraph 38. And we can see here you stating:

“I was concerned that SCCL was not anticipating, was not planning for, and had only partial information on future stocks of the amounts of PPE that would be required. My concerns relating to SCCL were confirmed after I had discussions with the CEO and Chair of SCCL on a follow-up call.”

What specifically made you worry that this was the case?

Dame Lawson: Well, it’s partly the email that we’ve just reviewed but it was also multiple conversations with Jin Sahota who was the CEO and Jim Spittle who was the chair over the period – I mean, I send an email on the Saturday night, Alan responds on the Sunday night. We’ve clearly spoken on the Sunday morning. I speak to Jin on Monday the 16th, I check back in with Steve Oldfield and say I’m not sure this is enough, and then we do a joint call together, Jim Spittle, Jin Sahota, and both Steve and I, I think on the 18th. I’m very good on days of the week, less good on dates in my extremely detailed memory of what happened five years ago. And the answers often came back like Alan’s email. Those answers are not wrong but they are also putting the onus of the problem on to trusts as opposed to the fact that, clearly, the distribution system is starting to fail, and at this point, the thing that I found most difficult is SCCL could not tell me how much additional they’d bought. I knew they’d placed additional orders but they couldn’t tell me how much and so – and they also had already flagged to the supply chain cell they didn’t know when these orders would arrive. So we might have increased buying but we didn’t know when it would come.

So I didn’t feel like I was getting sufficient traction from SCCL that gave me confidence that collectively we were going to solve this problem.

Lead 5: These issues came to your attention in March of 2020; is that right?

Dame Lawson: This paragraph relates specifically to those calls between the Alan email on the Sunday night and the conversation Steve Oldfield and I had, I think, on Wednesday the 18th.

Lead 5: Which, I think, takes us to March 2020?

Dame Lawson: This is all in March.

Lead 5: This is all in March 2020?

Dame Lawson: This is March 18.

Lead 5: You were the Chief Commercial Officer at NHS England and a non-executive director at SCCL, weren’t you?

Dame Lawson: I had been appointed Chief Commercial Officer, I formally didn’t take up the role until 1 April 2020.

Lead 5: Is that why we perhaps detect a degree of distance within your statement between yourself and the failings identified? The question is, if you were a non-executive director at SCCL since July of 2019, ie, six months earlier, ought you not to have been aware of this sooner than March of 2020?

Dame Lawson: So my role on the SCCL board from July, obviously there was no pandemic thought of in July of 2019, was focused on the safe transfer of SCCL to NHS England, which was planned for sometime in 2019, probably 1 October, and we, Miranda and I authored a paper to say we didn’t think it was ready, and it was then proposed to transfer on 1 April 2020. Obviously that didn’t happen either.

The concerns I was focused on as a NED obviously first was to understand the company, and second, was to understand why SCCL wasn’t getting the traction with the NHS that everybody thought it should have, and that, you know, Lord Carter had laid out the potential for.

And the three issues that I focused on during the autumn, one was the customer relationships, which I’ve already mentioned; one was the whole tower structure, because it was so complex, the towers were outsourced to a consortium that had put the best bid offer in, and some of those were NHS organisations, some of them weren’t. And the financial model of how the towers both made the margin that they were supposed to make and deliver the best possible prices was not compelling to me in some places. So I did couple of deep dives with tower leads to try to really understand what was working and what wasn’t working. So the commercial model was of concern.

And the third, which, not just me but several other non-executives raised, was that SCCL was about to embark or had just embarked on a major IT transformation and their IT was definitely not where it should be. But at the board meeting where this was raised, the conversation was both, you definitely need to do this, but also, you do actually have the capacity to make this happen, because this is a massive change in a small amount of time?

So that’s what I had focused on in those board meetings.

What happens at the beginning of – well, at the end of January is I am still running the joint working programme, so the two organisations only formally come together on 1 April 2020. I am also running all of the internal functions of NHS England including facilities, estates, IT and HR. So for example, the first way I get involved in the pandemic is doing things like the facilities audit of trusts to make sure that the oxygen supplies are going to be robust. So I have a different role in February. I’m not part of the supply cell.

It’s only part in the beginning of March when Simon first asked me to look at ventilators on 6 March and then at PPE at the beginning of the following week that I start to fully engage in the commercial aspects of the pandemic and connect with Steve Oldfield and the supply cell that he set up.

Lead 5: All right, thank you.

I see the stenographer is heroically coping –

Dame Lawson: Oh, I’m sorry.

Lead 5: – but if we could just reduce the pace slightly, I’m sure that would make life a little easier.

Could we please have on the screen, please, INQ000531295.

Now, in March 2020, also on the 18th, you were told that the layout and set-up of Unipart’s warehouses would not allow any further increases in throughput capacity, weren’t you?

And this is the part here:

“Gareth and I called the CEO of Unipart.”

Dame Lawson: Yes.

Lead 5: “Although Unipart had already upscaled staffing in their logistics centre this was insufficient to meet the throughput required to meet the needs of NHS Trusts. Unipart took on board the concerns raised on the call and went away to carry out research on what would be possible. The next day, 18 March 2020, they informed us that the layout and set up of their warehouses would not allow us any further increases in throughput and capacity. It was becoming very clear that the existing arrangements for procuring and distributing PPE would not be sufficient to satisfy demand.”

What was the problem with the layout of these warehouses?

Dame Lawson: So it’s not a problem in peacetime but all supply chains and warehouses, as again Professor Manners-Bell lays out in his report, have been leaned out over the last 20 years to deal with just-in-time supply. So they don’t hold –

Lady Hallett: Leaned out?

Dame Lawson: So the concept of just in time, so you only have as much as you need for a very short period, which means that the warehouses don’t need to be very big because you can always rely on more stock coming from either a deep-freeze-type warehouse like Haydock or from overseas.

So on average, again, I think it’d be – SCCL would have a more accurate number, but SCCL warehouses would hold about three weeks of stock of items that moved relatively fast, like PPE. And they weren’t designed to hold large stocks and they weren’t designed to scale up, because trusts would order when they needed it, it would arrive within 24 or sometimes 72 hours. So there just fundamentally wasn’t the capacity in those warehouses to stretch. They weren’t sitting there with large amounts of space empty.

Mr Wald: Is it just a feature of the size of the warehouses or was it, as we see in this paragraph, a problem about the layout, a problem about the doors that open and close at a warehouse?

Dame Lawson: I think the doors problem was one of the issues at Haydock that they couldn’t – that it opened onto a particular platform which only certain lorries could come up. I don’t remember a particular issue with the doors at Unipart. But the conversation – Unipart had already doubled their staffing in the week before, and that’s – I remember John saying that to Gareth on this call, and he said, “Look, we’ve already doubled.”

And Gareth said, “Look, it’s going to need to be eight times next week.”

And he said, “Right, okay, let me think about that.”

And then he came back the following day to say, “Look, there is nowhere to go, there isn’t – you can’t fundamentally change the layout of a warehouse and you can’t put eight times as many people in.”

Sorry, I realise I keep speeding up.

Because you just can’t physically fit the people and the, you know, the – sorry, I don’t have the technical language – but the pick-ups, et cetera, they won’t be able to get round the warehouse. So there was nowhere to go in the existing system, we’d maxed it out.

Lead 5: But you’re right that Professor John Manners-Bell deals with just-in-time contracts.

Dame Lawson: Yes.

Lead 5: We’ve heard some evidence about just-in-time contracts, and the problems that they experienced in a global pandemic, last week also. Given that the PIPP stockpile was designed to be used in an emergency, what would need to change in order that that stockpile could be used? What was available for quick use at scale if necessary?

Dame Lawson: You mean in March 2020 or now?

Lead 5: Looking forward.

Dame Lawson: Looking forward.

Lead 5: Extracting lessons.

Dame Lawson: Thank you. So I – the store – sorry, I’m just going to go back a second because I want to be really clear that we’re talking about two different types of warehouses.

The PIPP stock is being held in a warehouse which is not designed to ship directly to customers, and that is entirely sensible. That stock is held for long periods of time. We can come back to stock rotation and how do we make it more robust, but there was not a fault with that warehouse. What we needed was an ability to get stock out of that warehouse into a warehouse where it could be broken down. So, instead of, I don’t know, it would be the wrong number, but a million masks, you can break it down into the hundred thousand that a trust actually needs, along with the gloves the trust needs, the masks, et cetera. Things are picked off of a shelf of masks, picked off of a shelf of gloves, et cetera, which would be in a different part of the warehouse, and you create the right package that the trust has asked for. That can only be done in a distribution warehouse.

So this is not a fault of the PIPP warehouse stock; it was that we’d already scaled up to an extent the supply chain had not been planned for.

The scale problem was with the Unipart warehouses which were not just holding PPE; they were holding everything else. They were holding pacemakers and tubing and, as Alan said to me at the time, custard powder. And all of the – hospitals needed other things. They didn’t just need PPE. So it was apparent to me on the 18th, when I got that call back from Unipart, that the answer could not be in scaling the existing system further. We had to put new dedicated capacity into the distribution chain.

Sorry, so you asked me a forward-looking question and I’ve just answered the past, so just let me come back to it.

For the future, again, this is where I think SCCL has some brilliant plans that it would be helpful to ask them about, but the ability to scale the distribution next time is built into the forward planning of SCCL through a combination of call-off contracts where you can agree that you will now contract with a new warehouse, with a new set of truck drivers, et cetera, to build out the supply chain very quickly. So they’ve planned for that in the way that they are running things now.

Lead 5: All right. Given the problems that were being experienced back in March 2020, you made a request for military aid for civil authorities, didn’t you? A MACA request?

Dame Lawson: I did, yes.

Lead 5: And Brigadier Philip Prosser, who is now a Major General, was assigned to assist.

Dame Lawson: Yes.

Lead 5: We’ll come back to Brigadier Prosser in a few moments and we’ll hear from him directly in week 4 of the hearings in this module. I want to now turn to distribution for social care more specifically.

For social care, rather than being given free supplies like an NHS trust would get, the system was PIPP stock being released to wholesalers who then sold into the social care market. We gather that from your witness statement paragraph 153e.

Is that what was happening?

Dame Lawson: Yes, there had already been one release to the social care providers I think the previous week before I got involved.

I just want to pick up something in your question. Trusts were not getting free PPE at this point; they were ordering PPE which they would have to pay for. The – taking the costs out of the system came later.

Lead 5: So did it come at the same time for NHS trusts and for social care?

Dame Lawson: I don’t think so, no, but I don’t have that detail in my head, I’m afraid. I’m happy to get back to you on that.

Lead 5: Do you think that NHS trusts got it for free before social care did? Or do you not know?

Dame Lawson: I don’t think they got the same quantity of supply but there was a drop of PPE to local resilience for, again, the first week of March – again, it’s before I got involved – that wouldn’t have been charged for. So social care was able to get PPE from a range of places, including the usual wholesalers and through the local resilience fora.

Lead 5: The reason for my question, you say at paragraph 153e, the same paragraph, that:

“This proved insufficient, so social care were later set up to access supplies via the new distribution system.”

Dame Lawson: They were, yes.

Lead 5: From which I inferred, perhaps incorrectly, that there had already been such an arrangement with NHS trusts; is that not the case? Do you want to remind yourself of your 153e?

Dame Lawson: Yeah, I’m just looking at it now.

So a range of approaches were set up very quickly to deliver to social care. So the first which was organised between the department and MHCLG was to use the local resilience fora, and indeed, in my first couple of weeks running this, I remember having conversations with a couple of leaders of local resilience fora to understand what their needs were, what they were getting, what they were not getting.

This was not an established part of the pandemic plan; it was something that was set up on the spot when everybody realised there was a problem.

What we established through April, working with the local resilience fora, is that this was quite insufficient for social care. There’s a lot of very small suppliers in social care, and they were not able to out-compete big suppliers in the wholesale market when the wholesalers had kit and it was very inefficient for them to get it from the LRFs, so we set up the e-portal which we started commissioning at the beginning of April, and it was tested with social care towards the end of the month and then rolled out more broadly over the summer.

Lead 5: Inefficient because, amongst other things, the procurement of that PPE had to be done at the existing market prices in a very volatile market, sometimes, at considerable mark-ups?

Dame Lawson: So social care would have been buying from two different sets of wholesalers, one were the wholesalers who were getting stock from PHE via the PIPP stock, and I believe, but that would be a question for PHE, that that was price controlled. They weren’t allowed to do a massive mark-up. And then the others was in the open market, where yes, the price pressures would have been immense.

Lead 5: Would it be sensible, in the event of a future pandemic that called for emergency procurement, that the social care sector should receive free PPE centrally supplied throughout the period of need?

Dame Lawson: I think having a distribution system that works for all of the different – well, the 58,000 customers that ended up getting PPE through the parallel supply chain retaining the ability to do that would be hugely important. Primary care obviously also desperately needed PPE and were very, very small, and so it was an efficient way, which is why we set up the e-portal.

I think the pricing thing is a slightly different question about what you would do in another pandemic –

Lead 5: Do you have a view?

Dame Lawson: – whether it was free or not.

Lead 5: Can you offer a view about that?

Dame Lawson: I haven’t actually thought this one through in advance, unlike a lot of the other questions. I think it was the right thing to do at the time, because the market prices were horrible at times, although actually came down quickly. And it made no sense for the whole, you know, multiple providers across the UK and the devolved authorities to be bidding against the same manufacturers and the same wholesalers. And if you were going to buy as a government, then recharging people made no sense.

I think, again, I’m probably not the right person to ask the question, but the plan if the PIPP stock had been able to do what it was intended to do, which is to get through the first few weeks of the pandemic, by going via wholesalers rather than distributing for free, then you wouldn’t have needed it. But we needed different PPE and we needed more of it than had been expected so we were in a different situation with regards to pricing.

Lead 5: All right. Well, we’ll hear from other witnesses today who might be able to assist us with that point.

Dame Lawson: Yes.

Lead 5: You mentioned the Parallel Supply Chain. I want to ask you a bit about the establishment of that supply chain. We’ve heard a little bit about it before. Over the weekend of 20 to 22 March, Brigadier Prosser was part of discussions, along with yourself, about whether the SCCL could cope with PPE storage, processing, and distribution. That’s right, isn’t it?

Dame Lawson: Yes.

Lead 5: And you concluded that it could not cope, and was it at this meeting that the recommendation was made that the DHSC should set up the Parallel Supply Chain or PPE Cell?

Dame Lawson: There were actually – sorry, I will get back to the question but just to set the scene.

Lead 5: Do you want to give an answer to the question and then set the scene? Was it at this meeting or at some other meeting?

Dame Lawson: We didn’t call it the Parallel Supply Chain, and we didn’t know, the weekend of 21 March, that we were setting up any kind of organisation. We were trying to solve the problems that we saw in front of us. So there was already something called the PPE Cell which was one of five supply cells that were reporting to Steve Oldfield’s overall supply structure. So we were part of that.

Lead 5: Let’s not get, sort of, distracted by labels.

Dame Lawson: Okay.

Lead 5: What we’re talking about is an in-house government from scratch supply chain, call it what you like. But that’s what I mean. Was it at that meeting or over that weekend that the idea for that came –

Dame Lawson: I think that is the genesis of the Parallel Supply Chain.

Lead 5: Yes.

Dame Lawson: And it’s not just distribution; it’s all aspects of that.

Lead 5: And you wanted to set the scene a bit. Do you still want to do that before I ask a follow-up question?

Dame Lawson: Why don’t you ask the follow-up –

Lead 5: Okay, I’ll do that.

In hindsight, do you believe it would have been possible to resource SCCL to be able to continue to procure and distribute PPE throughout the pandemic rather than creating something afresh, something brand new?

Dame Lawson: No.

Lead 5: No. And why is that?

Dame Lawson: One of the main principles of anybody who focuses on delivery, like me and, indeed, like Phil Prosser, is that you start from what you’ve got, because building something new is always going to be much harder than making what you’ve got work. And I felt, before Phil arrived, and Phil then absolutely took his team through it specifically on distribution – and we can come back to buying – that we had reached the limits and, in fact, gone beyond the limits of the existing system and there were different challenges for the different things that SCCL was doing. So we’d covered in great deal the fact that we had maxed out the warehouse and shipping capability of Unipart that was running the distribution on behalf of SCCL and the NHS.

The buying, there had been a discussion during the week previous with Gareth Rhys Williams. Jin Sahota had written a paper that I think was also co-authored by David Wathey, who was part of the supply cell reporting to Steve Oldfield, to say, “Right, we’re going to need to buy differently, what should that look like?” And the proposal that I became aware of that weekend was that SCCL would continue to buy from their existing suppliers, which made total sense, they were set up on their system, but because they couldn’t easily add new suppliers to their system and because there were real concerns about the contractual basis on which SCCL operated, we needed, if we were going to buy from new suppliers, to set them up separately. So that was what, in Jin Sahota’s paper, he called them wave 2 suppliers.

So that morning of Saturday, 21 March, I set up four teams. The first was downstairs on the second floor of Skipton House, was Phil Prosser, the army, SCCL I think partly on the phone, working through: can you do anything else to the distribution chain or are you going to need to do something different?

In one room on the sixth floor with me you had some of Gareth’s additional commercial – members of the commercial team looking at all of the offers that had come in and saying, “How do we start to catalogue and triage and build a system to track those?”

In another room you had Melinda Johnson from the department, Preeya Bailie from NHS England and a consultant from Baringa looking at our process and trying the current SCCL process and seeing if we could streamline it because it was considered to be very – overly complex, so how could we run something that was robust and smoother?

And in the final room was Hannah Bolton who had come with the commercial team from the Cabinet Office, where I said, “Look, while we’re looking at this whole long list of things and your colleagues are trying to figure out how we catalogue them and how we triage them, can you start looking at some specific deals and figuring out what characterises a deal that might actually be robust? Is it big enough? Is it the right stuff?”

We can come back to this.

Lead 5: I was just coming on to that.

Dame Lawson: So you’re right, therefore, to ask me the question: that was the genesis of the Parallel Supply Chain. I didn’t know it that morning.

Lead 5: And all the while, offers were coming in thick and fast?

Dame Lawson: Yes.

Lead 5: And they needed to be triaged, and you’ve explained how you tasked various teams for that work. You say in your statement that there was an urgent need for some form of prioritisation and tracking of those offers.

Dame Lawson: Yes.

Lead 5: Now, you said that with your experience of modelling, data management, you might be able to offer reflections on how that could be done, or could be optimised. Do you, with the benefit of hindsight, have any reflections on how that task could have been done or perhaps should in the future be done in a more efficient way than occurred during the pandemic?

Dame Lawson: Sorry, are you – could you just do the beginning of the question again, please?

Lead 5: Yes. Offers were coming in thick and fast.

Dame Lawson: Yeah.

Lead 5: You identified an urgent need to prioritise offers?

Dame Lawson: Yes.

Lead 5: We’ve heard quite a lot of evidence now about the High Priority Lane, about alternative models, the rapid response team, the webform, portal. I don’t know whether you’ve followed any of that evidence but whether or not you have, could you offer any reflections on how best to manage offers that were coming in, in order to quickly identify those which were most promising, and necessary, given whichever urgent need was presenting itself at a given moment?

Dame Lawson: Yes. So I think it’s very difficult to answer the question, sorry, because there’s a “What could we have done differently on March 21, 2020”, and there’s a “What would we all do now?”

They’re not the same answer. I can have a go at both, if that’s helpful?

Lead 5: I was asking you the latter.

Dame Lawson: Okay.

Lead 5: Let’s just complete the story. This urgent need gave rise eventually to the VIP or High Priority Lane, did it not?

Dame Lawson: I think there were multiple things happening at the same time. I’m not sure it’s a straight line. I’m happy to explain what I mean by that.

Lead 5: I suppose the question is this: did the urgent need to prioritise that you identify in your statement result directly or indirectly in the creation of the High Priority Lane?

Dame Lawson: So there were two things that we desperately needed to do. The first was to triage offers and find the ones that were actually real, technically qualified and deliverable. The second was to get back to people and to run a professional operation, because that was essential to confidence of ministers, but more importantly, confidence of the public and confidence of staff to show up at work every day. So we needed to do both of those things.

What I asked Hannah to do on the 21st was to do the first one.

Lead 5: Hannah Bolton?

Dame Lawson: Hannah Bolton, yes.

Lead 5: So this is triage procurement focused, rather than expectation management focused?

Dame Lawson: Yes.

Lead 5: Yes.

Dame Lawson: Yeah. What – and there is another exhibit in my EP that I imagine you might come to, which indicates that because both of those needs were true, and Hannah was an individual person and so rather than going to a mailbox you could email Hannah, that very quickly got overwhelmed with people also wanting responses. What I – and I saw some of that because I’m copied on that email from Matt Hancock’s private office. What I didn’t – I wasn’t aware of, didn’t see, was that eventually I think those two things, the “We have to get back to people because it is fundamentally unprofessional not to and we have to get some of these deals done in a safe financially and technically robust way”, I think in retrospect became elided in what eventually became the HPL.

I don’t know whether we could have predicted that on 21 March.

Lead 5: Do you know whose idea the HPL was, its genesis?

Dame Lawson: I don’t. I’m not sure it even would have ever been one person’s idea. We had no playbook. We’d – nobody had ever done this before, nobody had expected this to happen, and so we needed to build something that worked, and then fix it in flight, which we started to do. I commissioned a review of our processes and governance already by 13 April – about 15 April.

So the Cabinet Office team took massive responsibility immediately for sorting out the additional buying, and in fact within a week they also took over the PPE elements from SCCL, because it had got too much for SCCL to continue to run separately. And that was the right decision.

And so I think it was a bunch of pragmatic – again, this is retrospect, because I didn’t see it happening, I was doing about 8 million other things every day and I – the Cabinet Office team was brilliantly owning this, as far as I was concerned. I can see in retrospect that these things got put together in the group that Max Cairnduff is asked to lead sometime around the beginning of April, but I didn’t see that happening and I’m not sure anybody else did.

Lead 5: Let’s return to the question I asked a moment ago. I think we’ve covered enough of the story and your involvement in it.

Dame Lawson: Sure.

Lead 5: As you know, as most people will know now, the HPL proved to be controversial.

Dame Lawson: Yeah.

Lead 5: In some ways counterproductive in the sense that part of the reason, as you explained, for its creation was to manage expectations and maintain public trust thereby. Yes?

Dame Lawson: (No audible answer)

Lead 5: In the event, it, to some degree, resulted in a loss of public distrust, as you know. Yes?

Dame Lawson: Later and for different reasons, but yes.

Lead 5: Later and for different reasons?

Dame Lawson: Yes.

Lead 5: In the initial –

Dame Lawson: But definitely, yes.

Lead 5: – weeks or even months of its operation, it may not even have been known to be operating by the public.

Dame Lawson: Yeah, yeah.

Lead 5: So I return to my question, whether by reference to your experience in data management, modelling or otherwise, can you assist the Inquiry with any reflections on how a system might have been set up or could in the future be set up that might prove more effective at maintaining public trust –

Dame Lawson: So that we didn’t need to – yeah.

Lead 5: – and effective in the efficient procurement of essential medical equipment.

Dame Lawson: Yeah. I have to say, I’m not an expert on customer relationship management, or CRM, systems. I think that’s what we needed but I’m happy to give you my view. When you asked if I had expertise in data and modelling, I thought more of the numbers, but we can come back to that.

What we needed was a proper CRM system that allowed you to put a deal in quickly, which could have been dropped in from a webform, that had contact information, and that then anybody of the, you know, hundred people that might have needed to look at it could drop in at any time, see the last time that was contacted, what was happening with it, where in the production process it was, if it needed support from technical assurance, and we didn’t have that.

What team 2 – I think in my description earlier, so the Cabinet Office team that was looking at all of these offers – did on Saturday, the 21st, was to think about whether an Excel database would be an answer or whether they should go for something more complex. They decided – and I wasn’t in the room when this happened, they told me about it later – to do a – to install the Mendix system, which came from Salesforce, and that then didn’t end up coming to fruition, and we switched later in the spring to Atamis, which was a government approach that already existed. I don’t know why Mendix was the chosen solution. If Mendix had been able to be implemented quickly, that might have been absolutely brilliant, but it wasn’t.

So for those first critical couple of weeks at the end of March and beginning of April, my understanding is everything was being done in Excel databases, which is not designed for that purpose.

So the first answer to your question is I wouldn’t start from here, because if the SCCL database had been extendible, flexible, and usable by other people, we wouldn’t have needed to build the additional supply cell in the first place, the buying bit. But equally, if we had needed to build it, we’d all have been looking at the same – well, not me, I wasn’t doing it – but the buy people would have been looking at the same information.

If we’d been able to rapidly contract for a system that the people involved were skilled to use, again, we wouldn’t have needed another system. And if we’d had five years of further development of artificial intelligence and large language models, you might have been able to quickly write an algorithm that would have been able to do at least some of the screening. Although I also think there are challenges with that technology, we all know it trains quickly and can be biased; so I think we should look at it but I don’t know whether it would have been the answer.

There are all sorts of things that we could do differently now, and in fact I’m pretty sure SCCL is at least partly set up already to do some of those.

Lead 5: And these alternatives that you mention now would be ways of removing what you describe at paragraph 72 of your statement, and others have described in similar terms, as “noise”. You say:

“Because of the seniority of some of the referrers, and because PPE was a ‘hot topic’ already in the media, I was concerned to make sure we minimised ‘noise’ as much as possible.”

Dame Lawson: Yes, I mean, I might rephrase it as “concern”, which is obviously – gives more of a sense of the legitimacy of people’s quite reasonable concerns about what was happening. It was causing enormous – I don’t know what the right word is, but, you know, it was just unbelievably difficult for staff, and therefore for people who were managing things in hospitals, to feel like they were safe every day. So – forgive me.

My major concern was to make sure that we could give a clear message to staff that they would be protected, and trying to manage the media stories was a part of that, was – obviously the most important thing was getting the supply chain working, it wasn’t what the media were saying.

Lead 5: Yes.

Dame Lawson: But it was part of the whole – yeah, we needed to fix all aspects of the system. For some of those we could do – we could build out and improve what we were already doing or what SCCL was already doing. In other places we needed to do something new.

Lead 5: And if a system of the type that you describe, whether Mendix or something beyond Mendix, were operated, it would be desirable, would it not, that those individuals working night and day to procure PPE, say, were insulated from what we described or I suggested – and I think you agreed – was the expectation management aspect of this process. And to the degree that those expectations needed to be managed, that’d be syphoned off to other individuals. That would be desirable, would it not?

Dame Lawson: Yes, and to do that the other individuals need access to the information. So obviously CRM would help but the – there was an element that people were always going to need to pick up the phone and talk to each other, but the extent to which that was taking up huge amounts of time because the information was hard to get – and of course this system would also have to have been extended to, in particular, the British Embassy in Beijing and in a few other places which were absolutely instrumental in the response, and were obviously working in a different timezone.

Lead 5: Either that, or a harder line be adopted with those that had fed offers into the system, into Mendix or whatever else it was, about the processing of offers, that, “We are in the – we are still considering offers, we will come back to you if we need further information from you”?

Dame Lawson: The system did do that. So the webform did give people an immediate response. So that’s not in place the week of the 16th, I’m pretty sure it is in place the week of the 23rd.

Lead 5: The webform did it?

Dame Lawson: Yeah.

Lead 5: The VIP Lane didn’t do it, did it? The VIP Lane received requests for updates from referrers and there was an expectation that those referrers, or at least by those referrers, or even by those who were receiving requests for updates, that the update would be given?

Dame Lawson: Yes, but the update could be quite – sorry, I should probably check which question I’m answering, but the update didn’t need to be terribly extensive. I mean I gave several WhatsApp updates to the Secretary of State who enquired about things, and I would say “This turned out not to be anything” and he would just write back saying, “Okay, fine.” So it didn’t need to be massively onerous, and a CRM system would have helped with that.

I have to say I don’t think it’s reasonable to expect there needing to be no updates to people, particularly the Secretary of State, who was responsible for all of this. But yes, it would have been helpful to have had a really clear data feed so that that wasn’t having to be produced manually.

Lead 5: And you’ve given your thoughts on separating the roles of the provision of the updates from those involved with the primary task of efficient procurement.

Dame Lawson: Yes, to the extent that if all of the information is transparent, then that would have been a helpful – (overspeaking) –

Lead 5: All right.

Dame Emily, I want to move on to another topic, please. I want to ask you about the decision to take greater risks on due diligence.

Dame Lawson: Yes.

Lead 5: During your work on the PPE Buy Cell, it’s right, isn’t it, that you took the decision to embrace or to take on greater risk in buying decisions in order to speed up the process?

Dame Lawson: Yes.

Lead 5: Yes. Could we have on the screen INQ000106355, please. It’s pages 3 and 4. This is an email from Chris Young to the Treasury dated 15 April 2020, so we’ve moved on a little bit in time now.

Dame Lawson: Yes.

Lead 5: It says:

“I discussed with Emily how we rebalance the risk, ie, take slightly more risk on due diligence to help reduce the risk of losing deals and ‘stocking out’ on international procurement …”

And:

“For clarity, we are not preparing to give clinicians any PPE that aren’t going to keep them safe – at no point will this be done, and we continue to be led by the PHE guidance.”

Dame Emily, this approach meant that there would be stock sitting in warehouses that needed to be tested for compliance and full due diligence completed prior to release to the NHS, didn’t it?

Dame Lawson: Yes. That’s right.

Lead 5: And taking the risk of non-compliant PPE and the government bearing the cost of any waste arising therefrom? That follows on from this, this shift, does it not?

Dame Lawson: Yes, although it’s worth qualifying in that we’re not talking about taking stuff that we can see isn’t robust. It’s that the detailed checking of, you know, the way a Chinese company will have on a certificate their qualification, the thickness of the material, et cetera, might be present differently to the way OPSS – sorry, the Office of Product Safety Standards – would do it in the UK. So it was that calibration across different standards that was taking the time. We were not proposing buying things that we could see didn’t have a certificate or anything like that. It was one step down, not a kind of complete removal of the technical standard.

Lead 5: Why was it at this particular stage in the pandemic that you thought that this was necessary or justified?

Dame Lawson: Because the technical assurance part of the eight-step process that you went through with Mr Marron last week was the one we consistently got feedback was the most cumbersome and I remember talking to a couple of the team members from DES, from the MoD buying team who had come on board to do a lot of the technical assurance and they thought they’d done everything they could to speed it up. It was dramatically faster than they ever would have done previously.

But until this discussion, Treasury officially would not sign off a deal which had not been proven to be precisely in the standard, and because of different technical specifications in different parts of the world, that was taking – I mean, maybe 72 hours but even that was sometimes too long in this heated market.

Lead 5: The email refers to offers – or the risk of missing out on certain offers?

Dame Lawson: Yes.

Lead 5: How frequent an experience was that and what sort of offers were being missed, as a result of due diligence checks?

Dame Lawson: Yeah, I mean, I don’t have the data. I can give you what it felt like.

Lead 5: Okay.

Dame Lawson: But I actually don’t think any of us would have the data because we weren’t recording: 16 deals vanished today because of that. But it was really common at the 8.30 meeting for Andy Wood or whoever was reporting to say, “We had eyes on FFP3 masks yesterday but this morning we’ve been told they’ve gone.”

The challenge in answering the question as accurately as I would like to is that sometimes that meant that deal was fake and it hadn’t existed anyway, because it vanished when we started asking for certificates or video evidence of the kit. And sometimes it definitely was that somebody else had bought it. And later on, for example, I found out one of those deals had been because a London hospital had bought the relevant product. So we had a conversation about that.

But the – it was – for anything that was in short supply, which at this point was particularly gowns, but I was increasingly concerned about Type 2R masks, which we weren’t officially short of, because the PIPP stock had loads, had, I think, 156 million, but we were using them so fast so I could see we were about to have a problem with them. And those – what we were wanting to buy was what the race of the world also wanted to buy.

Lead 5: Did this approach to buying contribute to large stocks of excess PPE?

Dame Lawson: No, I don’t believe so. There was a limited amount of waste. I don’t think it can be tracked back to this policy. What we really wanted to do was to put boots on the ground, as Phil said at the time, to inspect in China. And we did do – the British Embassy did do some of that but they didn’t have the capacity to do it for every manufacturer we were dealing with.

So we thought the right answer was to buy and bring it into the country. Because remember, at this point, we had no feeling that we were ever going to have an excess of PPE. We were desperately short of pretty much everything. And so we were buying what we needed in order to make sure staff would remain safe, not just, of course, for this Covid wave but for the wave we knew would come in the autumn.

Lead 5: Dame Emily, when you say there was a limited amount of waste, are you talking broadly the amount of excess PPE that was procured?

Dame Lawson: I’m talking about specifically goods that were not fit for purpose. So there were three categories of things that would have been regard as waste.

So one was goods that were what they said they were, but we couldn’t use them, so the FFP2 ear loop masks are a good example of that, where they were bought to the spec but it turned out they didn’t meet the needs of clinicians in the UK.

The second were goods that weren’t what they said, that – we had bought the right thing, but what arrived was not that, where you could – we could claim back on the contracts and say, “You didn’t supply us with the right thing.”

Sometimes that was a mistake. Sometimes that was because the factory hadn’t produced the right quality.

And the third category of waste is stuff we bought and didn’t need. So there are different criteria for that.

Lead 5: Yes, and my question was, of course, directed at the third of those, because I asked you about large stocks of excess PPE, not defective PPE.

Dame Lawson: Okay.

Lead 5: You’re not suggesting that, ultimately, the amounts of excess PPE were limited in scale, are you?

Dame Lawson: No, you – apologies, you were talking specifically about this policy which allows us to buy things which didn’t exactly meet the specs and needed an inspection, so that’s why – I apologise – I assumed you were talking about things on a different spec.

Lead 5: Okay, not a problem, but it’s in relation to excess PPE that I now want to move on to modelling and demand measures.

My Lady, I don’t know if that’s a convenient moment to break?

Lady Hallett: Certainly, I shall return at 11.30.

(11.12 am)

(A short break)

(11.30 am)

Lady Hallett: Mr Wald.

Mr Wald: My Lady.

Dame Emily, we were just moving on to modelling and demand measurement.

Dame Lawson: Yes.

Lead 5: We can do that now, please. Throughout the pandemic there were real issues in understanding the stock and usage position for PPE across the country, weren’t there?

Dame Lawson: Yes.

Lead 5: Yes. And we know from your statement, paragraph 59(c), that as you say, given NHS England was not the buyer or supplier of PPE, it held no information about usage or stocks of PPE held in trusts at the start of the pandemic?

Dame Lawson: Yes.

Lead 5: And that was, so to speak, a systemic problem. That was a problem that plagued the efficient process of procurement throughout the pandemic, didn’t it?

Dame Lawson: Yes, it got better but it stayed challenging.

Lead 5: It’s the sort of data that ought to be at NHS England’s fingertips for the future.

Dame Lawson: There’s a – that’s going to have a slightly more complicated answer than you might have been intending, if that’s okay. I’ll take a minute. But the answer is, look, I love data, I do everything by trying to get, you know, a really clear view of what’s going on. And I think it’s really important to note that trusts are independent entities, they don’t report formally to NHS England, their staff are employed by the trusts not by NHS England, and particularly in the case of foundation trusts, they have their own boards that are responsible for overseeing their financial performance.

So while it would be enormously helpful, I don’t actually think it’s appropriate for NHS England to be holding inventory data at all times. What I think we need is the ability to turn that on when necessary, for example during a pandemic.

So at the start of the pandemic most trusts had some kind of what’s called an inventory management system, but not all, and some of them were fairly basic and what they couldn’t do was talk to SCCL or to NHS England.

So what we did was, thanks to a colleague called Joanna Peller from Palantir, is we built an inventory tool, which was in place by the end of May, we piloted it at the beginning of May. So we built, frankly, a manual solution to the problem you’re identifying.

The situation we’re in now, we collectively, because SCCL is working extensively on this, is that – I won’t get these numbers precisely right but all trusts have improved inventory management systems, about 130 have a system that can effectively talk to SCCL if needed, and the plan is to continue to roll that out. So partly thanks to what we did during the pandemic, that has move on dramatically.

Lead 5: So summarising that answer, if I can try to: yes, it would be helpful if not essential for NHS to have such data when it needs it but it shouldn’t hold it on an ongoing basis?

Dame Lawson: No, it’s a lot of data that is not up to us. We do use something called the Spend Comparison System to make sure trusts are getting good prices which is related but not the same thing.

Lead 5: You mentioned Palantir but let’s take it in stages.

Dame Lawson: Yes.

Lead 5: In order to address the lack of data you engaged first McKinsey, did you not, to carry out modelling work?

Dame Lawson: Yes.

Lead 5: And that was in an attempt to work out the demand levels.

Dame Lawson: Yes.

Lead 5: McKinsey generated demand models but those models also suffered from a lack of data, didn’t they?

Dame Lawson: So they –

Lead 5: In particular the data relating to existing stock levels in hospitals?

Dame Lawson: Yes. So McKinsey explicitly wrote a model called the Requirement Model, and so the inputs to that model were, first, the infection prevention and control guidance, which obviously changed, but they could update that, and secondly, was actual interviews with staff to say, “This is the guidance, what are you actually using?” And making sure it included a range of staff, not just clinicians but also, you know, cleaners and people bringing food and that kind of thing, to try to get to as close as we could to actual usage rates.

And that uncovered things like, for example, gown usage, was higher in the Nightingales because the loos were far away and so people had to change gowns more often than they did in a hospital, for example. So we did quite a lot of digging to try to get the usage model but as you’ve said, what that didn’t say was how much inventory you had in the trust to start off with. So it was – (overspeaking) –

Lead 5: Which is quite an important starting point in this exercise?

Dame Lawson: I mean, the thing I definitely will carry with me for the rest of my life is that if you can’t see all the parts of a supply chain, you’re in a very challenging position, trying to predict total numbers.

Lead 5: And that challenge was no easier, was it, when Palantir took over from McKinsey?

Dame Lawson: In terms of seeing the whole length of the supply chain, no, because we continued to have a challenge on the far left-hand side, thinking of Professor Manners-Bell’s model, which is we couldn’t see what was coming into the country. We had no data on what would arrive when. That problem wasn’t fixed until July.

Lead 5: Why did Palantir take over from McKinsey?

Dame Lawson: So Palantir were providing support in a range of other areas so Joanna Peller had already built the ventilator allocation tool, which was allowing us to connect case data, hospital information, and ventilator stocks information to make sure we were sending oxygen equipment to the right place.

And McKinsey had done the modelling – by the way, they didn’t just do it for trusts, they did that first, they then extended it to social care, primary care, et cetera, so it became quite comprehensive but that model used as a critical input the reasonable worst-case scenarios that came via NHS England’s modellers, the Imperial model and the Oxford model, and what Palantir is particularly brilliant at is connecting lots of different models and making them work together in an effective way. That’s the particular strength of what they do. So it was appropriate to use that connection to try to add all these data sources together to get to a clearer picture.

Lead 5: They used the reasonable worst-case scenario figures on infection rates and the IPC guidance?

Dame Lawson: Yes, the IPC guidance was – may I just do three categories, because I think it would help? There are three main components of our modelling. The first is the requirements model and I can come back to the different components of that. We’ve talked about some of them. The second is the reasonable worst-case scenario, which also had a whole range of inputs which changed over time. And the third was the risk level of deals not happening – sorry, goods not happening at all, arriving late or arriving wrong.

And in April and May, as I said, we had no sight. So we were trying to track this based on an army – what we call the Tiger Team, literally calling around suppliers to try to figure out the likelihood that something was going to arrive. By June, we were using the data of what actually had arrived to get to more accurate estimates of that.

So there were three components of the modelling. In all of them there was an element of pessimism and I’m happy to expand on that.

Lead 5: I think not, probably, in the interests of time.

Dame Lawson: Okay.

Lead 5: I would like just to move to this: when did you, Dame Emily, first become aware that the UK was on course to have in stock significantly more PPE than it would need for the pandemic response?

Dame Lawson: So there are, again, more than one component to it but I’ll give you –

Lead 5: Let’s start with the date.

Dame Lawson: Well, there are different dates, but what happened in June was we started to have a higher success rate of things actually arriving. And the Uniserve system that would give us the end-to-end view of the whole supply chain, so the stuff in shipping, was put in for the most critical categories quickly. It wasn’t fully operational until the end of July. And so the third component, so the risk level, suddenly dropped, because we could actually see what was coming.

So, starting on 16 June, over the next 12 days we stopped all new buy on all of the PPE items, because we could see that we had what we had committed to the Prime Minister, which was enough for current burn rates, and for create a four-month stockpile. Because what was clear from the reasonable worst-case scenario, and actually got worse from June, was that the autumn wave was potentially worse. So we didn’t only anticipate a growth in cases, but also further supply chain disruption as we went into the winter.

Lead 5: As a matter of fact, most of the PPE that was procured that already been bought by July of 2020?

Dame Lawson: Well, June, when we stopped buying new, yes.

Lead 5: Yes. And the UK ended up with just shy of 7 billion items of excess stock of PPE, didn’t it?

Dame Lawson: Yes.

Lead 5: So that was a considerable excess, eventually?

Dame Lawson: Yes.

Lead 5: Partly due to a series of unknowns that modellers had to cope with?

Dame Lawson: Yes.

Lead 5: They range from infection rates, existing stocks already held locally within NHS trusts, the quantity of PPE NHS trusts were buying for themselves separately?

Dame Lawson: Mm-hm.

Lead 5: When and whether, as you referred to just now, wave 2 and 3 of the virus might hit?

Dame Lawson: Mm-hm.

Lead 5: Whether contracts would actually deliver PPE?

Dame Lawson: Yeah.

Lead 5: Probably, for the transcript, if you say “yes” rather than –

Dame Lawson: Sorry, apologies.

Lead 5: That would be helpful.

Whether the contracts would in fact deliver? There was, of course, a risk that suppliers themselves would simply not be able to provide the PPE that had been promised?

Dame Lawson: Yes.

Lead 5: Whether lockdowns or vaccines would slow or stop the spread of the disease?

Dame Lawson: Yes.

Lead 5: Whether IPC guidance would change and require different levels of PPE in different settings?

Dame Lawson: Yes.

Lead 5: And whether procurement need might increase to embrace the care sector as well as the NHS?

Dame Lawson: Yes.

Lead 5: Anything missing from that list –

Dame Lawson: Yes.

Lead 5: – of unknowns?

Dame Lawson: Yes, a couple of things.

Lead 5: Yes, thanks.

Dame Lawson: So, one, it feeds into the buying bit, but we had really very – until probably – certainly in June, we had little understanding of how good UK Make would turn out to be. So although the first order comes through at the beginning of May, which is aprons, we knew that aprons were very straightforward to change manufacturing to buy and it’s only in August that we get, for example, the Honeywell FFP3 deal. So that’s additional benefit of UK Make.

The second thing, that I don’t think was on your list, were – was item complexity. So to start off with, the model only looked, for example, at all FFP3s as a class. What we came to understand particularly in May, was that, actually, there was a whole range of FFP3 models that we needed to supply in order to meet the needs of staff, and we did a piece of work I won’t dive into to look at that.

Equally, there were preferences. So it turned out ambulance crews liked goggles and not visors and hospital staff liked visors and not goggles, and that wasn’t built into the requirement model to start off with.

So we couldn’t just look at each item as a category, both because of the two things I’ve mentioned, but also because the global manufacturing capacity for those items is very different. So FFP3s are only bought by the UK out of all major economies. We go one level higher than almost every other country. Gloves, for example, are just used so much in the NHS every day that we never really had excess stock of gloves.

So there was the complexity within each category which needed to be brought out in the modelling which was done during May, which was why, in June, we can actually have much more accurate data and therefore feel confident in stopping.

To be clear, this was a conversation early on. I have an email that I sent Jonathan Marron on 8 April to say, “It looks like FFP3s have stabilised, do you think we should tell the team to dial down buying?”

And he quite reasonably said, “We’re not even close to having replaced the PIPP stock. I think we need to keep going.”

And indeed we nearly stocked out of FFP3s at the beginning of – well, in June.

So it was an evolving process. It was very much on our minds to buy – to use taxpayer money effectively, and I absolutely wish that, for whatever reason, we could have got a few weeks earlier in May, and realised the certainty of what was coming, but we didn’t. And I can’t at the moment see a point at which I could have done anything sooner to get to that.

Lady Hallett: When you say “stocked out”, you mean ran out of stock?

Dame Lawson: Very close to running out of stock, yeah. We never had nothing, but we were very close to not being able to send trusts what they needed. So, for example, there’s one day in June – I’m going to forget the exact date although I did know it yesterday – where three – we looked at what trusts received and three out of 73 trusts did not get their ideal pick. So we sent them what they officially needed but not necessarily what they wanted.

Lady Hallett: “Officially needed”? What does that mean?

Dame Lawson: So there are – at the time we were shipping seven different kinds of FFP3 masks, and until the beginning of May it’s really not clear to us, in the centre, the extent to which trusts have preferences for different types of FFP3 masks, based on what they’ve previously used and what works for their staff.

And because we had – were about to run out of some of the PIPP stock masks, the 3M masks, which were the most commonly used in the NHS, we had started to send different masks, and trusts were getting back to us saying that, “But we don’t – we have to now re-fit test all our staff, that’s really inconvenient.”

What then came up was also, actually, some masks didn’t suit certain face types, and we did a different piece of work on that.

So they got a safe number of FFP3s but, for example, they would have had to have re-fit tested some of their staff with a new mask rather than just put it on and go.

Was that okay?

Lady Hallett: I think so. I’m still questioning in my head what you mean by “officially needed” as opposed to what the trust said they needed?

Dame Lawson: So the trust would have told us “We need 1,000 FFP3 masks” –

Lady Hallett: And the system decided they could actually have –

Dame Lawson: No, the system sent them a thousand, and Major Ed Bowman, who was doing the work, then analysed that to say, “That trust usually prefers 3M 9332s and they’ve actually got 700 9332s but also 300 Evusheld masks, so it’s not ideal.”

What we then did was a piece of work to create an ideal pick list for every trust, and – working with them, obviously – and testing their staff to link that to our stock, and then we created the pick list which we then used subsequently.

Mr Wald: Thank you, my Lady.

Dame Emily, just to finish off, quite a long list, then, of unknowns?

Dame Lawson: Yes.

Lead 5: McKinsey passed on their numbers to Efficio whom you mentioned a few moments ago?

Dame Lawson: I don’t think I did but –

Lead 5: Oh, beg your pardon.

Dame Lawson: – yes, they were part of the team, yeah.

Lead 5: They helped to create buying targets within the buy team in the PPE Cell?

Dame Lawson: Yes.

Lead 5: Some of those targets were very high?

Dame Lawson: Yes.

Lead 5: And that is a point that is remarked upon by some of those who have given evidence to this Inquiry, including Sir Gareth Rhys Williams. He makes a particular point about the very high buying targets for body bags, which you may have seen?

Dame Lawson: Yes.

Lead 5: You have. The high buying targets eventually resulted in a report that the Cabinet Office produced.

Could we have displayed INQ000506021.

This is a report called Errors in Modelling.

Dame Lawson: Yes.

Lead 5: With which you may be familiar?

Dame Lawson: I was shown it last night. I was not in the PPE Cell at the time this was produced.

Lead 5: It’s not a document that you’ve produced but could we look at page, first 2, and then 6 and 7.

So at page 2 we have, let’s take the third item in this flowchart:

“Projection guessing at losses from non-performance and late delivery”.

Much of this was guesswork, wasn’t it?

Dame Lawson: Yes, I think it’s not shown on this slide but if you zoom in, it says – sorry, it’s on page 5 –

Lead 5: Yes.

Dame Lawson: – it says figures from 1 June 2020. So yes, at that time we were using the Tiger Team from the military team to call around suppliers and shipping companies to try to understand whether something was en route, and whether it would arrive at its date. We did not have that data.

Lead 5: Can we go back to the first page so we can be clear of the date. 29 January 2021.

Dame Lawson: This paper is produced then, but the slide that they’re showing, it says on page 5, is figures from the 1 June 2020. So –

Lead 5: Let’s go to 5, then.

Dame Lawson: Yeah. So this is the point at which the team did not have the information.

Lead 5: Yeah.

Dame Lawson: A pack produced on 1 January 2021, the Uniserve system would have been in there and they would have known what was coming.

Lead 5: Let’s look at page 6 now. If we can just zoom in on the … there we are.

Dame Lawson: Yes.

Lead 5: Do you see those sort of egg shapes in the penultimate column:

“Revised scenario PPE position (after all additional opportunities).”

And that indicates the degree of surplus.

Dame Lawson: That’s the requirement, not the surplus. Sorry, the revised scenario circled in red, yes. Apologies.

Lead 5: We touched on the figure, the overall figure, just shy of 7 billion items, and we see here – I don’t think those add up to 7 billion but that may be because of the date on which this – the reference date for this document. In any event, there was a very considerable amount of excess PPE procured, wasn’t there?

Dame Lawson: Yes, this chart doesn’t show that, though. I agree with your point that excess PPE was procured. This was used to see were we meeting what the Prime Minister had set as the target which was enough for current usage and the four-month stockpile and what it has in the grey bubbles in the middle, so the pale grey, “Planning signal to current COVID”, et cetera, were estimates.

So it was used to go back to the buying team and say, you know, we still need to buy in this case, for example, gloves, which as I said, were never in surplus, effectively.

Lead 5: Just while we’re on this slide, “The actual Demand signal projected 90 days ahead – while we were buying 150 days ahead.”

Dame Lawson: Yes.

Lead 5: Any reason for that discrepancy in timelines?

Dame Lawson: Yes, because you’ve got two different pressures there. 150 days is the, sort of, commercial good sense, you want to buy – you want to buy manufacturing direct contracts, and in order to get the right deal, you’ll give them some surety of future supply. So that’s quite a common thing to do. That’s – sorry, 150 days is a bit less than six months, isn’t it? So that’s a reasonable thing to do in a– particularly in a challenging market, would have enabled us to get a better price.

I think it would be a good question to put to, you know, much – properly expert modellers, but if we think about the extent to which the Imperial model, the Oxford model were able to even give us accurate numbers 90 days ahead, they would not have wanted to project to 150 days. There’s so many more variables coming in, you’d have had such a wide range it wouldn’t have given us any guidance.

So you’ve got the tension of predictive modelling and you’ve got then the commercial reality of what you have to do to buy things.

Lead 5: But that – I understand your answer in relation to the commercial realities but that 150-day timeline creates a real risk of over-procurement, doesn’t it?

Dame Lawson: I think the real risk of over-procurement is the equation which is laid out on page 2 and which was very similar to the structure that I have in my own thinking, which is you’ve got the requirements model, which has got a bunch of variables that you’re making a really good estimate of but you do not know what is going to happen, for example if the IPC guidance is going to change. That you’ve got in – which is the – your middle column. So the PPE usage. Sorry, yes, PPE usage, the second row.

You’ve got the reasonable worst-case scenario, which is the reasonable worst-case scenario, it’s not saying best guess, it’s saying reasonable worst case. And then you’ve got our abundance of caution based on the fact we lost loads of deals and had some stuff that wasn’t good enough to use, that said says we can’t absolutely assume everything’s coming.

So those – you’ve got three boxes there being multiplied together, all of those have an inbuilt pessimism which we have all accepted is the right answer. Because what we don’t want is for staff to be in a position where they don’t have enough PPE that winter.

So under the ministerial guidance which covers the whole of this page, which was: we absolutely are buying, it may be that we have too much. That is orders of magnitude better than the other scenario, which is that staff are not protected. And so – but all of those bits of pessimism are effectively multiplied together in this model, as this page shows.

Lead 5: Let’s just finish on page 7 of these slides.

And you may have picked up from Professor John Manners-Bell’s evidence, the “whiplash” effect:

“Uncertainties in estimates multiply up [giving] a much bigger error bar for operational activity:

“Duration of confidence of estimate may be much shorter than lead times of activity”.

We’ve touched on that just now.

Dame Lawson: Yes.

Lead 5: “Limited ability to feedback ‘actual’ data and correct forecast …”

All of these things were playing against efficient procurement by which I mean procuring the right amount rather than excess procurement.

Dame Lawson: Yes.

Lead 5: All right. Let’s move, then, finally before I invite any reflections or recommendations, and then move to one last topic.

Could we have displayed up INQ000536417, pages 13 and 14.

It is a statement from Palantir. And it identifies, it’s paragraph 11, if we can make our way to that. Sorry, I think I’ve given an incorrect page number. It would probably be 6 or 7. There we are.

And the next paragraph. Well, I’ll paraphrase: Palantir have told us in their statement that they observed a number of weaknesses. Fragmented data is one.

Dame Lawson: Yes.

Lead 5: You’d agree that that is a weakness?

Dame Lawson: It was, yes.

Lead 5: Or was. Low technology penetration?

Dame Lawson: Yeah.

Lead 5: Due to years of under-investment in technology meant many critical processes were still analogue or manual. You’d agree with that?

Dame Lawson: Yes.

Lead 5: Lack of interoperability between systems, ie, disparate systems belonged to a multitude of different organisations.

Dame Lawson: (No audible answer).

Lead 5: And then fragmented or unauditable information governance. You’d agree with all of that?

Dame Lawson: Just on the last one it would help if I could see it, but I – I think it was –

Lead 5: Yeah, there we are.

Dame Lawson: Sorry.

Lead 5: So we’ve got – it must be page 7, fragmented data is the first.

Dame Lawson: Got it, yeah. Yes, got it. It’s e that you just mentioned.

Lead 5: It’s e.

Dame Lawson: Yes, thank you. I agree with that analysis.

Lead 5: So whilst inviting you to reflect on and offer any reflections/recommendations for how these systems of data management might be improved, are there any that you would add to this list?

Dame Lawson: It doesn’t say – I think there might be an h, but the – yeah, it relates to – so look, I agree with all of those. I think, which might be your next question, we are in a much better place on almost all of that and I’m happy to talk a bit about that. I think there’s another bit which is about expertise, and I think it’s expertise in three places: one is the comfort level of NHS staff in a whole range of roles to actually use the data in data systems so there’s not much point putting in a system people are not going to use.

And that was indeed one of the things that slightly delayed our inventory tool between 4 May and 27 May, because there was a concern about whether it was too much for trusts, for example. So actually making sure people are comfortable to use the data systems is critical.

The second is the expertise that we’re never going to have inside the NHS. It doesn’t make any sort of technical sense to have it, which is people who can do all this extraordinary engineering like Palantir and others.

And then the third is the extraordinary expertise of data analysts and scientists that we had in NHS England and the department, and in trusts, who are absolutely flat out, and so we were using absolutely everybody who did have the expertise across a whole range of pressures and we didn’t have the ability to scale that other than by using consultants.

Lead 5: Why, Dame Emily, do you say we are in a better place? Is it because of changes that have been put in place since –

Dame Lawson: Yes, so – sorry, I cut across you.

Lead 5: No, please.

Dame Lawson: We learnt a lot in the pandemic in a huge range of ways that I won’t start to try to detail, but one of them was this extraordinary power of actually being able to use data to make decisions that we previously hadn’t had. So we do now have, or SCCL can talk about this, they are close to having that end-to-end view of the supply chain on an everyday basis not just in an emergency, but the federated data platform programme which grew out of what we learnt working with Palantir in the pandemic, is completely changing the way that we use NHS data, because in my role as Chief Operating Officer, I can sit down in the morning and immediately see both the whole country performance yesterday on ambulance times and I can dive down to look at what’s happening at an individual trust. And that is because we’ve started to join up these fragmented data systems, building capability as we go.

We’re not there yet, but we are fundamentally in a different position, and it’s acknowledging everybody has systems that do things that they like and that they’re comfortable with, and what we’re not necessarily doing is replacing them; we’re giving connection so that one bit of data isn’t used in isolation and that’s incredibly powerful.

Lead 5: Finally, Dame Emily, as part of your work with DHSC, were issues regarding the need for PPE that properly fitted an ethnically and religiously diverse workforce brought to your attention?

Dame Lawson: Yes.

Lead 5: Did the NHS Confederation contact you in May 2020 raising specific concerns about appropriately-sized masks and gowns available to female and BAME staff in particular?

Dame Lawson: Yes.

Lead 5: And what was your response?

Dame Lawson: So we – that was 26 May, I think you said?

Lead 5: I just said May 2020. It might be the 26th.

Dame Lawson: Sorry, I know I looked at it. I might be confusing other dates.

So at – on 12 May, Major Ed Bowman raised at one of our daily meetings that we were now getting really helpful specific feedback from trusts that said, as I was just explaining to my Lady earlier, the combination of masks we were sending to trusts did not meet their needs. It was not flagged that that was about ethnicity or gender, it’s just that they didn’t fit – well, first of all, that fit testing was a productivity challenge. If you had to keep fit testing people, it used a lot of time. But secondly, that the right combination of masks wasn’t necessarily coming.

So Ed and a team, including Liam Hawkin, from the east of England, who is a nurse, Amanda Lyons, from the south east, who was a strategy director, worked with a range of trusts to try to get under the skin of this problem and say: which masks were the problem? Was it that the mask itself was a problem or that we weren’t good at fit testing it?

And came back, as I mentioned earlier, with a – basically a spec for what did each of the trusts we were supplying need in terms of FFP3s. We then had some challenges to link that to actual supply I won’t go into.

So by the time NHS Confed is raising with me, which I think is at the end of May, I already knew quite a lot about the problem. The fact that this was also about ethnicity and gender became clear through the work that Ed Bowman led.

So what we did, starting on I think it was 2 June, I spoke to Sue Tranka, who was one of the senior nurses, was to commission a piece of work which did a much broader piece of work. So Sue did a piece of work starting in June that went until October and tested 5,557 staff across a range of ethnicities, and very explicitly looking at gender, to see what was the link between different types of masks and different types of individuals. And that then led to a change in buying to make sure that we had sufficient range and, in June ‘22, to the addition in your electronic staff record of what mask fits you, and therefore should be purchased for you.

Lead 5: When you say “sufficient range”, was the availability of relevant data a problem in this context as well?

Dame Lawson: I mean, I think we’ve made a brilliant use of data in the work – it wasn’t me – that was done to add it to ESR. The data, yes, in that we didn’t know – sorry, let me take a step back. Apologies, because I feel like it’s frustrating when I do this, but –

Lead 5: The question is aimed at this: did you and others have sufficient data on the make-up of the frontline workforce, in terms of gender, ethnicity, to be able to make decisions on PPE that fit properly?

Dame Lawson: No, that was not the issue. So –

Lead 5: Did it have sufficient data then? Was that available?

Dame Lawson: No, that’s not the issue.

Lead 5: Okay.

Dame Lawson: At the start of the pandemic, FFP3s would previously have only been used by a tiny minority of staff. It’s very, very few people used them, they’re very specialist bits of equipment. You suddenly expand that. So our first problem is loads more – you just need loads more FFP3s. We bought everything we could buy in end of March and April of FFP3s, along with everything else. So there is – data would not have made a difference to what we did at the start of the pandemic.

And the issue that is reported to us from trusts is not that it’s ethnicity and gender that is a problem, it’s that fit testing is a pain. And it’s only by investigating that that we find that actually there are some masks that fit some different people more or less well. It’s much more related to individual face shape than it is to everything else.

It isn’t just FFP3s by the way, there was also – really well publicised in April by Christina Criado-Perez (sic) – the fact that women were having to wear gowns that were much too big for them. That was the same issue: we were buying what we could buy. As soon as we had a choice, we started buying much more of a range, and then, as I said, trying to understand what each hospital needed and getting it to them.

Lead 5: So if data wasn’t the issue, how would it be possible to make sure that from the very beginning there was a sufficient range, as you put it, of PPE to fit everyone that needed it?

Dame Lawson: Going forward, first of all we now know which masks fit any staff member who’s been tested. Secondly, we would need to have the right range of PPE in the PIPP stock, which is supposed to, you know, manage those first few weeks of a future pandemic, and each hospital needs to be aware of what the right mix is for their staff. And as you’ve said, the data, the understanding of the ethnicity and gender of the workforce is built into SCCL’s purchasing decisions now.

Lead 5: Mr Kelly, from whom we’ll hear later today, in his statement says that they – discusses a project that gathered evidence from over 5,000 participants to inform PPE improvements.

Dame Lawson: Yes.

Lead 5: How did that project specifically address the needs, if you know, and feedback of ethnic minority healthcare workers, and what impact did this have on subsequent PPE procurement strategies?

Dame Lawson: Yes, so that is the piece of work I mentioned that Sue Tranka led over the summer of 2020, and it reported – I got a draft of the report on 1 October, and that was then built into the buying – the further buying and manufacture of FFP3s going forward, and that resulted in the addition of the information of what you need to your electronic staff record.

Mr Wald: Dame Emily, thank you very much. Those are all the questions that I had for you. I gather that there are additional questions from one of our CPs.

Lady Hallett: Mr Thomas.

Questions From Professor Thomas KC

Professor Thomas: Dame Emily, I am representing the Federation of Ethnic Minority Healthcare workers.

So where we’ve just left off with your questioning, I’m going to continue that theme, if I may.

Oversight of the procurement and distribution of PPE was crucial during this period. We can agree on that?

Dame Lawson: Yes.

Professor Thomas KC: And we’ve heard a lot of evidence about the disproportionate impact of the virus on ethnic minority communities, particularly those who I represent, healthcare workers.

Now, you’ve just said and accepted that you were aware of the problem with, particularly, ethnic minority healthcare workers; that’s correct, isn’t it?

Dame Lawson: I was aware of the challenge of FFP3 masks and that there was some relation to ethnicity in the autumn of 2020. In May 2020, I was aware that a whole range of staff were finding some masks difficult to wear. It was not, at that point, linked to ethnicity.

Professor Thomas KC: Can I just ask you for some clarity on this –

Dame Lawson: Of course.

Professor Thomas KC: – before I put my question to you.

When do you say you became aware that there was a problem with ethnicity and the provision of this particular PPE? When?

Dame Lawson: We became aware through May that hospitals were saying to us that there were particular challenges with particular ethnic groups. We did not have any data on that that showed that until the autumn, and Sue Tranka’s report which looked at a whole range of people.

Professor Thomas KC: So you became aware of a problem in May.

Dame Lawson: Yes.

Professor Thomas KC: And I’m assuming, you correct me if I’ve got this wrong, that you’d have said, “What problems?”

Dame Lawson: Sorry, could you ask me – could you repeat the question?

Professor Thomas KC: Yes. You said you became aware of the problem in May 2020. Yes?

Dame Lawson: That there were masks that didn’t fit –

Professor Thomas KC: Yes.

Dame Lawson: – that staff were finding it challenging to find masks that fit, yes.

Professor Thomas KC: In relation to ethnic minorities, you said just a moment ago, you became aware in May?

Dame Lawson: That was definitely part of the reporting by late May, yes.

Professor Thomas KC: My question to you is: I’m assuming you would have said, “What problems?”

Dame Lawson: The problem of fit? I’m sorry, I don’t understand the question. We were being told that some staff were finding it had to find a mask that fit. That was the problem.

Professor Thomas KC: That was the problem.

Dame Lawson: Yes.

Professor Thomas KC: And those staff were of particular ethnic minorities?

Dame Lawson: No, they were – partly. It was relayed that it was some ethnic minority staff but it was also women and it was also people with beards and it was also people with particularly small faces.

Professor Thomas KC: Forgive me, I’m confused, and it’s probably just me. When you say you became aware of problems with ethnic minorities in May, what were the problems you became aware of? It’s particularly relating to ethnic minorities.

Dame Lawson: Yes, I apologise, I am trying to answer the question. We became aware, first, that certain masks were – well, that trusts were saying: some masks don’t fit some of our staff.

Professor Thomas KC: Yes, but that’s just general. Correct?

Dame Lawson: Yes.

Professor Thomas KC: Right.

Dame Lawson: And we then did a piece of work to work in detail with trusts to see what’s going on, to say what is the problem? So is it the mask –

Professor Thomas KC: When was that?

Dame Lawson: – is it the fit testing?

Professor Thomas KC: When was that?

Dame Lawson: May.

Professor Thomas KC: Right.

Dame Lawson: So that’s the first piece of work which Major Ed Bowman leads, and by the end of May, we now have an understanding for each trust that says the right combination of masks for this trust, which are likely to fit their staff, is the following, and we therefore change our distribution system to make sure trusts are getting as close to that list as possible, and we change our buying to make sure we are continuing to buy a range of FFP3s and not narrowing in on any one particular type.

Professor Thomas KC: Okay. Let me move on to my last question, and it’s this: given your significant involvement in the PPE supply and distribution as outlined in several parts of your statement, particularly where you’ve discussed the initial challenges with PPE orders, help me with this: what feedback mechanisms were in place to capture concerns from ethnic minority healthcare workers regarding PPE, and how were these concerns addressed in real time during the pandemic?

Dame Lawson: So there were – I’m going to say three main ways – well, multiple ways for staff to feed back concerns. The primary one would be within the hospital via their line manager, the health and safety officer, people who were supporting them, and that could potentially be addressed locally because the trust has the responsibility of making sure every staff is protected.

There were, then, one of three routes, depending on the issue. One is it was fixed, great. One was that the product was a problem, so this product was not working as planned, and that would have been reported, depending on the item, but via a hotline that was run by the technical team at SCCL, which we augmented, to make sure that product complaint was reported and then appropriately investigated.

And if there was a – if the product itself was faulty, we obviously would have taken one set of actions. If it was, you know, a sizing issue or whatever, then we would have worked on distribution. And there would also have been – I’ve forgotten the technical term, but there’s a Datix reporting if it actually has – inside the hospital, if that’s generated an unsafe situation for staff, and that would have been fed back through multiple routes including the MHRA Yellow Card system.

So we would have taken action on those, depending on the nature of the problem that was being reported.

Professor Thomas KC: Given the number of – the disproportionate number of deaths of particularly Black, Asian and Minority Ethnic healthcare workers and the complaints made about PPE, do you think you moved timely enough?

Dame Lawson: I think there is – I think there is no operational process in the world that can’t be made better. So I’m never going to say that everything was perfect, because demonstrably, we built at speed, and we then worked to make it better. In this instance, I think we had good processes to collect feedback, particularly if something was unsafe, but also on preference, for example learning that goggles didn’t work well in certain hospitals.

What we didn’t have in March, April and quite a lot of May and June, for some items, particularly FFP3s, was any ability to do anything other than buy what was available in the market and make sure it was safe when it arrived. So we responded by making sure we had the stock, and when we had the stock, we then worked with trusts to make sure they were also getting according to preferences and what would best suit staff.

So I think we did respond absolutely as best we could. As I’ve said, I think it would help – and I believe there are plans to do so – to make sure there is the right range based on actual mapped staff need that we now know, in the PIPP stock going forward, and I would also expect that to be built into a very tailored distribution system that would better connect individual staff needs to the overall supply.

Lady Hallett: Thank you very much, Mr Thomas.

Professor Thomas: Thank you.

Questions From the Chair

Lady Hallett: Can I take you back to the beginning of your evidence, Dame Emily. I got the impression as you went through it with Mr Wald that it was somewhat chaotic. Would that be fair, or is that unfair?

Dame Lawson: It was really full on.

Lady Hallett: It wasn’t just that; it was the structures.

Dame Lawson: Okay, yeah.

Lady Hallett: As you’ll appreciate, as you know, I have already examined the preparedness and resilience of the system.

Dame Lawson: Of course, yeah.

Lady Hallett: And I’ve already made certain comments about the lack of preparedness, in my view.

I’ve also heard about exercises that were conducted –

Dame Lawson: Yes.

Lady Hallett: – to try to enable the system to respond to a pandemic. But I gained the impression from your evidence in the first few answers that you gave that the system couldn’t cope with purchasing and distributing large amounts of PPE required for a pandemic. Now, if all this planning that I’ve been told about had been going on, why was the system in that state?

Dame Lawson: That’s a really good question. So what I have observed by doing my research both at the time but also obviously preparing for this, is that in February in particular, everybody did what they were supposed to do. So NHS England declares a major incident. Keith Willet, the lead of the response in NHS England, asks for a supply cell meeting. On 3 February that happens. NHS England commissioned a reasonable worst-case scenario modelling – sorry, I’m repeating – (overspeaking) –

Lady Hallett: Can I just interrupt you to get to the point I am trying to get to.

Dame Lawson: I apologise.

Lady Hallett: We ran out of time a long time ago.

Dame Lawson: – (overspeaking) –

Lady Hallett: If I could just ask the question again just so you can focus on it.

Basically you told me, just to give one example, the warehouses couldn’t cope with the large-scale distribution that we had.

Dame Lawson: Yeah.

Lady Hallett: Now, why hadn’t that come up in any of the exercises? Why was there that kind of structural problem that meant the system could not cope with buying and distributing at large scale for a pandemic?

Dame Lawson: So I think there was a plan that would have worked for the pandemic that was planned for. What there wasn’t was a plan for when that plan demonstrably wasn’t working. And I think it is putting those different bits of the plan of what’s not working in early March, mid March, is what enabled me to come to the conclusion that said: you can’t keep following this plan, it’s not going to meet the needs of the pandemic we are actually in.

So I think it’s back to the modelling. The modelling tells you some of the answer but it doesn’t give you an answer. You have to then use it to make decisions, and I don’t think there was a plan for if the PIPP stock is not going to keep you going for long enough because it’s got the wrong stuff in it, and if hospitals do not have what they actually need because the IPC guidance says they need something different than what was planned for. And so what we need in the future is both a plan that responds to this, and also a mechanism that says what do you do when the plan is not working? How do you scale? How do you make slightly different decisions?

Lady Hallett: I’m grateful, it sounds as if you agree with my recommendation in the Module 1 report that you need not just a plan for a flu pandemic but something that’s adaptable.

Dame Lawson: Yes.

Lady Hallett: Secondly, you told Mr Wald that there were 7 billion items of PPE that you managed to, as it were, over-stock – I’m not trying to be pejorative.

Dame Lawson: No, I understand.

Lady Hallett: Were those 7 billion items wasted or were they able to go back into the system?

Dame Lawson: I think the 7 billion number is after the things that were used back. So there were things that expired before they could be used rather than what was used. I think Jonathan Marron’s statement says in the end 23-and-something billion out of the 32 were used, and some were used for waste, et cetera. So I think there were heroic efforts both to dial back on contracts and try to buy slightly less to re-use stuff, to donate it to other countries, to sell it in the open market, but regrettably there was a substantial amount of waste at the end.

Lady Hallett: Given the circumstances we faced, do you think there’s anything that could be put in place, apart from the better data management, but by the sound of it that would be better data systems that spoke to each other, but is there any other way one could avoid that amount of – I appreciate you were fulfilling instructions from on high that you had to cater for the second wave, as well – any way we could avoid that level of waste?

Dame Lawson: Yes, and it is having – it’s knowing what you stand up at certain levels of stress, right? So it’s – in particular, we were having to buy everything from a substantial distance which then involved the whole issue of: is it coming at all? It’s a brand new relationship, is this place trustworthy? How long is the boat going to take? Are there holds in Shanghai on what’s being shipped?

There was a massive tension there.

If we had a plan that very explicitly stands up UK Make on certain items, if the PIPP stock has been adjusted for the kind of things we have just discussed, and if we are not overly reliant on wholesalers to buy stuff – because wholesalers had the same risks we did, there was a whole layer of risk built into this market – actually having a direct understanding, if not relationships, with the people who are making the stuff, so you cut out that level of uncertainty, that would have helped.

I would also say, again, I would love to have not had that waste. I’m really glad that we had enough PPE in the second wave, and I think it would have – I think in any future pandemic there will always be a mismatch. I’d rather it was that way round. I would love it not to be the same scale.

Lady Hallett: I understand.

Thank you very much indeed for your help, and I do understand that maybe it’s a difficult week for you.

The Witness: Thank you.

Lady Hallett: So, thank you for coming along and for your written statement and for the evidence you’ve given today.

Dame Lawson: Thank you.

Lady Hallett: Ms Shehadeh.

Ms Shehadeh: My Lady, our next witness is Paul Webster, so can I ask that he be sworn or affirmed now.

Mr Paul Webster

MR PAUL WEBSTER (sworn).

Lady Hallett: Sorry to keep you waiting, Mr Webster.

The Witness: No problem at all.

Questions From Counsel to the Inquiry

Ms Shehadeh: Can I ask you first of all to state your full name.

Mr Paul Webster: Yeah, Paul Webster.

Counsel Inquiry: Thank you.

Now, you have provided the Inquiry with a number of witness statements. I’m just going to read out the Inquiry document reference numbers and then ask you to confirm that they are indeed your evidence.

So you have provided us with a statement dated 27 June 2024. It runs to 59 pages. That is INQ000492085.

You’ve provided us with a statement dated 6 January that runs to 4 pages. That is INQ000533280.

You have provided a further statement of the same date that runs to 3 pages. That is INQ000533279.

And, finally, another statement, January 2025, that runs to 8 pages. INQ000533278.

Can I ask you this: are the contents of all of those statements true to the best of your knowledge and belief?

Mr Paul Webster: Yes, they are.

Counsel Inquiry: Thank you. And we’ll be largely dealing with the contents of the 59-page statement, INQ000492085, if that assists you.

Can we turn briefly to your own professional background before we start to discuss the events of the pandemic.

You are the executive director of governance, and legal and company secretary of SCCL; is that correct?

Mr Paul Webster: Yes, it is, yes.

Counsel Inquiry: And SCCL is Supply Chain Coordination Limited; is that right?

Mr Paul Webster: Yes.

Counsel Inquiry: We’ll continue to use SCCL, if that’s all right?

Mr Paul Webster: Seems sensible, yes.

Counsel Inquiry: Now you’ve been directly employed at SCCL since 2022, but actually your involvement with the organisation began some years prior to that, didn’t it?

Mr Paul Webster: Yes, in about 2016 I was part of the Department of Health team that was helping develop and then implement the new model, and then – but at that stage I was seconded to the department from the Cabinet Office. All rather complicated, but actually essentially the same job in the same organisation.

Counsel Inquiry: Yes. And by the period in the pandemic that we are discussing, so roughly from January 2020 onwards, you were working at SCCL –

Mr Paul Webster: Yes.

Counsel Inquiry: – under some form of arrangement?

Mr Paul Webster: Yeah, and had been since the company was set up in 2018.

Counsel Inquiry: Now, SCCL is a company limited by shares and it was created on 25 July 2017 by the Department of Health and Social Care.

We’ll come on to the structure. Can you give us a very brief overview of the purpose of SCCL?

Mr Paul Webster: Yes. So the new model that was implemented in 2018 had constituent parts of the NHS Supply Chain in terms of procurement, delivery and IT, and the intention was that there would be a body that sat across the top of that, the management function, which would manage the individual contracts within that model. So it is referred to as the management function of the NHS Supply Chain, but its role at that stage was effectively as kind of contract management direction setting.

Counsel Inquiry: Is it right that SCCL was initially wholly owned by the Secretary of State for Health and Social Care?

Mr Paul Webster: Yes.

Counsel Inquiry: And that ownership was transferred to NHS England on 1 October 2021; is that correct?

Mr Paul Webster: It is, yes.

Counsel Inquiry: Right. And so in fact, ownership was transferred while the pandemic was ongoing?

Mr Paul Webster: Yes, the original intention had been for that transfer to happen earlier, but it was delayed because of the first wave of the pandemic and people having other things to focus on.

Counsel Inquiry: You’ve told us a few moments ago that the idea behind SCCL was that it would perform contract management services, effectively. It was organised using something called the Future Operating Model, and it oversaw something that’s widely referred to and is in fact the NHS Supply Chain.

The NHS Supply Chain, regardless of what it says on the tin, is not the entire supply chain for the NHS in England, is it?

Mr Paul Webster: No, that’s right. And I think there is some confusion at times that it is a part of the supply chain into the NHS. It’s the bit that has a kind of trading name of NHS Supply Chain, but there are other ways in which the NHS will receive products of the same sort that we provide.

Counsel Inquiry: So NHS trusts or NHS customers, from your perspective, are able to place orders with the NHS Supply Chain, or SCCL, but they’re also free to purchase items they need from the open market – (overspeaking) –

Mr Paul Webster: Yes, and they do that, yeah, on a regular basis. I think our market share is somewhere in the region of about 65%, slightly higher, probably, than that. So that, yeah, there is – there is a significant proportion of those products are purchased through other routes.

Counsel Inquiry: I’ve used the phrase the “Future Operating Model” a few times. We perhaps ought to explain it. Can you give a very brief overview of the idea behind the Future Operating Model?

Mr Paul Webster: Yes. So from 2006 through to 2018 there was a contract that was held by the NHS Business Services Authority with DHL which provided the NHS Supply Chain service at that point. So one contract for procurement, storage, distribution of products, plus all of the sort of the back office and IT functions.

That had a market share of penetration of about 35%, and the view from the Lord Carter review was that by placing a greater focus on leveraging the NHS spend, you could drive up that market share and thereby reduce the costs of products, and you would remove some of the duplication from the system with competing organisations by essentially buying the same product and selling into the NHS.

So the idea was that we would break down that model into its constituent parts, which essentially are three: the buying element, the logistics element, and then the IT element, with – and as I’ve said, with SCCL over the top as a sort of overarching contract management.

Counsel Inquiry: And you’ve told us in your witness statement INQ00492085, at paragraph 3.2, that the idea was to increase the market share of the NHS Supply Chain, and it was at about 36% under DHL and was the target to increase it to 80%?

Mr Paul Webster: Yes. That was the target, yeah.

Counsel Inquiry: And you tell us in your statement that it’s now risen to 60%; is that still roughly accurate?

Mr Paul Webster: I think it’s probably higher than that now but it’s somewhere between 60 and 70%. And it varies by product line. So we sell more of high-end capital equipment than we do some other products, for example.

Counsel Inquiry: And are you able to tell us roughly the market share of clinical consumables that SCCL was supplying at the time of the pandemic or not?

Mr Paul Webster: I’m not sure I could. I can probably – well, it’s – the difficulty is that our customer base is fluid. So some trusts will buy products from us one day but then not the next. So we don’t have a consistent flow of products or consistent requirement for products.

So we would have – and at the start of the pandemic we had customers who didn’t buy product X from us asking for that. So it’s difficult to give you an accurate figure. It’s also quite difficult to know what the overall market is that we are taking a percentage of, if that makes sense.

Counsel Inquiry: It does. The NHS Supply Chain is not designed to make a profit, is it?

Mr Paul Webster: That’s correct. It’s not.

Counsel Inquiry: And I think you use in your statement the phrase “buy price equals sell price”, so does that mean that SCCL allows NHS trusts to buy items at the same price that it purchased them itself?

Mr Paul Webster: Yes, so the previous model, if we bought a pen for £1, we would sell it to the NHS at £1.05, and that five pence went towards the overall cost of managing the model. The new model was predicated on the basis that, exactly as you say, if we bought it for a pound, we would sell it to the trust for a pound, and we were funded by NHS England for those costs that would otherwise have come out of what was the margin of the previous model.

Counsel Inquiry: Can we have on the screen, please, INQ000347820.

This will be very familiar to you, I’m sure. This is a representation of the tower system.

Mr Paul Webster: Yes.

Counsel Inquiry: Or the – that makes up the NHS Supply Chain.

Is each of these towers run by a separate contractor put in place by SCCL?

Mr Paul Webster: Yes. That’s essentially it. All of the products that we sell were split into one of the 11 categories that you see at the top of – the 11 boxes there. So only one organisation would buy one particular product. So there were 11 what we called “towers” but effectively were category managers. We went out for – well, the department rather than SCCL went out for a procurement for each of those towers. Now, some of the providers have more than one or had more than one tower, so we don’t have 11 separate providers, but they operated as separate buying entities.

Counsel Inquiry: They were buying entities. So were these contractors in turn letting contracts for the supply of individual items?

Mr Paul Webster: Yes. But –

Counsel Inquiry: Or – (overspeaking) –

Mr Paul Webster: – but as agent for SCCL. So as far as the customers were – and indeed the suppliers – they thought or they believed that they are contracting, as they are, with SCCL.

Counsel Inquiry: All right. In terms of PPE, am I right in saying PPE did not neatly fit into just one of these towers?

Mr Paul Webster: Yes. So it was bought by, I think, towers 2, 8 and 11, I think. But PPE prior to the pandemic was a tiny fraction of the products that we purchased. I think our spend – and I’ll get the figures wrong, but was roughly in the region of £100 million spent on PPE out of a spend of about 3.5 billion. So there wasn’t a category of PPE; there were items, such as gloves, that were purchased routinely, but there wasn’t a category of PPE. So it doesn’t sit neatly into one of those 11 towers.

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

In terms of the contract management function of SCCL, just very briefly, how did that work in practice? For example, if one of the CTSPs, one of the contractors running a tower, the company with whom they had contracted in turn failed to deliver something and it caused problems in supplying an NHS trust, what would happen, what would SCCL’s role be?

Mr Paul Webster: Well, as it relates to the customer, they would take that up with us as the provider of the service. We would then contract manage that tower to make sure that we understood where the responsibility lay. But in terms of how the system, the NHS system, would see that, they would see it as a failure of the NHS Supply Chain and therefore of SCCL. We had, then, contract management steps in place to be able to manage our relationship with the individual towers to pick up any issues that were arising.

Counsel Inquiry: All right. I’m going to move on to ask you about the contractual arrangements around the PIPP stockpile, the pandemic stockpile.

Mr Paul Webster: Sure.

Counsel Inquiry: That was set up in 2009. So it predated the creation of SCCL.

Mr Paul Webster: Correct.

Counsel Inquiry: And is it right that SCCL effectively inherited responsibility for managing the stockpile?

Mr Paul Webster: Yes. So we managed it under a contract with PHE as they then were. So we are very much a transactional organisation rather than a – rather than the body that makes the decisions in respect of the stockpile.

Counsel Inquiry: So is it right that Public Health England owned the physical stock in the stockpile?

Mr Paul Webster: Yes.

Counsel Inquiry: But SCCL ultimately was responsible for managing the contract, for the contractor who was –

Mr Paul Webster: Movianto.

Counsel Inquiry: – monitoring the stockpile, administering the stockpile?

Mr Paul Webster: Yes, and we were responsible for some of the – for the purchasing of the products that went into the stockpile, albeit that we weren’t responsible for deciding what those products should be.

Counsel Inquiry: You have, in your witness statement, described a process of stock rotation, one of swapping out, one of product cycling, as well. You’ve explained that the procurement cycle for items in the stockpile was 12 months. What does that mean? Why did it take 12 months to run a procurement cycle?

Mr Paul Webster: I think that reflects just the time it takes to run an EU, as it then was, compliant procurement, most of which was done through frameworks, us putting in place frameworks. That takes time. And then once you’ve placed orders, ensuring that you actually have those – those orders have arrived, there’s a significant lead time on the majority of those products, so 12 months is a relatively safe assumption as to the time, if you start from scratch, you can have products in a warehouse.

Counsel Inquiry: You’ve told us in your statement that most products have a 60-month shelf life from the point of manufacture?

Mr Paul Webster: Yes.

Counsel Inquiry: It is also possible to extend the shelf life of products for up to 10 years; is that right?

Mr Paul Webster: Yes. Although I’m straying into territory, and I have to rely on my colleagues rather than my own knowledge.

Counsel Inquiry: That 60-month shelf life, was that something that was taken into account when considering whether to start a fresh procurement cycle, that 12 months that you’ve just described?

Mr Paul Webster: Yes, and as were some of the other ideas that – you just mentioned in terms of, sort of, cycling through. And so, for example, gloves, which is something used all day every day, we would take, as they reached the end of their shelf life, we would take them out to the stockpile and put them into the general NHS Supply Chain and then replace. So the idea being that where you could increase the life of products in the stockpile, you would.

Lady Hallett: To what extent is taking stuff out of the stockpile, when otherwise it would become useless, used generally?

Mr Paul Webster: It depends on the volumes of products that you’re using. So gloves is the most obvious example, because that is one that you know you’re always going to use. Some of the other products that are in the stockpile just weren’t used regularly. I was listening to Dame Emily Lawson’s evidence earlier on about the number of FFP3 masks, for example, that was being used. You wouldn’t cycle that through because the volume of demand was so much less. So I think gloves was the one that was the main product that was cycled through, just because there was that demand.

Lady Hallett: I would have thought a lot of items of PPE were likely to be in use most of the time in NHS trusts?

Mr Paul Webster: I think the reality – and again, I’m straying into territory that I’m not an expert on – is, as I said, that we only spent about £100 million on PPE out of the overall spend of 3.5 billion. It’s a very small amount of the everyday products that an NHS hospital uses in order to be able to function .

Lady Hallett: So who should we ask about how you make sure the stockpile doesn’t end up wasting product?

Mr Paul Webster: In terms of what is in the stockpile, and decisions as to when products should be cycled through, those were decisions made by PHE, UKHSA as they now are.

Lady Hallett: Sorry to interrupt.

Ms Shehadeh: I think you mentioned the name of the contractor, Movianto –

Mr Paul Webster: Yes.

Counsel Inquiry: – that was tasked with administering the stockpile, warehousing it, and so on. Were they responsible for that product cycling and notifying SCCL if they needed to be in –

Mr Paul Webster: They were aware of the products that were there, and then – and obviously the shelf life of those products. So they would report on a regular basis into SCCL, and we would then, in turn, discuss with PHE what the right way of either replacing or renewing or recycling the products would be, depending on the product.

Counsel Inquiry: So to be clear, Movianto would report to SCCL, SCCL would then liaise with Public Health England for instructions; is that right?

Mr Paul Webster: Yes.

Counsel Inquiry: And so would you say that in January 2020, SCCL had good visibility of the status of the items in the stockpile?

Mr Paul Webster: In the PIPP stockpile, yes.

Counsel Inquiry: In the PIPP stockpile. Do you make a distinction there with other stockpiles?

Mr Paul Webster: No, just trying to be – well, there was also the EU exit stockpile, but the PIPP stockpile was one that obviously we managed so we had the greatest visibility of.

Counsel Inquiry: Yes.

My Lady, I am conscious of the time. There are other topics I wish to cover, so I am in your hands as to –

Lady Hallett: Certainly, we could break – I think you were warned – well, I don’t know if you would have been warned because I think we went on rather longer with Dame Emily than we intended, but we’ll break now and come back at 1.45.

(12.45 pm)

(The Short Adjournment)

(1.45 pm)

Lady Hallett: Ms Shehadeh.

Ms Shehadeh: Before the break I was asking you about the PIPP stockpile and the contractual arrangements around the management of that. So we’ll carry on from there.

Did SCCL have visibility of the state of the stockpile in England, the PIPP stockpile in England?

Mr Paul Webster: Yes, yeah, we had no responsibility for any of the other devolved nations.

Counsel Inquiry: No.

Can we have up on screen, please, INQ000330795.

This document shows us the status of the PIPP stockpile in England, we see there England figures only, at row 5, and it’s updated on 27 January 2020.

There’s information in this table around stock levels but also the expiry dates and the status of certain items in the PIPP stockpile.

In respect of surgical facemasks, there’s a note that says:

“No significant volume expires until 2021.”

But we also see that of the 156 million, 84 million of these have no labelled expiry date and are currently undergoing QA testing – is that quality assurance testing?

Mr Paul Webster: Yes, sorry.

Counsel Inquiry: Yes – to demonstrate the product remains fit for use.

So the reality is, in relation to surgical facemasks, there is a significant proportion in respect of which the expiry date wasn’t known in January 2020; is that right?

Mr Paul Webster: I don’t know enough to be able to tell you confidently, I’m afraid. I’ve seen this last week but I’m not sure where – from where it comes.

Counsel Inquiry: Right. So this level of detail contained is this table, when we talk about visibility of the stockpile, would SCCL have been aware of this level of detail about the status of the items in the stockpile?

Mr Paul Webster: My honest answer is I don’t know. My assumption is yes. But I’m afraid I couldn’t tell you with any certainty, I’m afraid.

Counsel Inquiry: It’s all right, it was a long time ago. The table also tells us in relation to FFP3 valved respirators, that stocks were stressed and it was expected that by 1 April 2020 there would be around 1.3 million in date. I’m sorry, by 1 April 2020, we expect circa 1.3 million to be in date and 120K by August 2020. But there was also work going on in respect of shelf life extension there, and the activation of JIT, is that just-in-time –

Mr Paul Webster: Yes.

Counsel Inquiry: – arrangements, the delivery in between five to 11 weeks.

Looking at that, there were a number of key items that were required for the pandemic response within the stockpile in respect of which work was ongoing simply to ascertain whether they were still safe for use. Does this reflect, in your view, a properly managed PIPP stockpile?

Mr Paul Webster: Well, I think you have to remember that it’s for a stockpile for a different pandemic to the one that then transpires. But it seems to me that the system of understanding when products will expire and which of those are capable of being given additional shelf life by further testing is sensible and being on top of how many of those there are would appear to be a sensible approach.

Counsel Inquiry: Certainly having the information at your fingertips is important. In relation to having the stockpile ready to deploy, when faced with a pandemic, this is not the optimum status of a stockpile that’s ready for use, is it?

Mr Paul Webster: I’m not sure why not.

Counsel Inquiry: If there’s a stockpile in respect of which there are significant numbers of key items that have to undergo testing in order to determine whether they are safe to be deployed, would you agree that –

Mr Paul Webster: But that’s about extending their shelf life beyond the current shelf life, which is largely done by the manufacturers to provide their own confirmation that that product remains fit for purpose for an additional period. So what it does is it avoids a need to take stuff out of the stockpile and then buy new in. So it’s a case of active stock management as opposed to, you know, at any point in time products that have come in will be nearing the end of a shelf life.

Counsel Inquiry: All right, well, just staying with the example of the FFP3 valved respirators that we have in the table, the first line there is respirator volumes are currently stressed. So there were pressures around the stocks of those items; do we agree?

Mr Paul Webster: That’s my assumption based on that, yes.

Counsel Inquiry: All right, then the next sentence is:

“By 1 April 2020 we expect circa 1.3 million to be in date.”

So as at January 2020, which is the date at which this table was put together, there was uncertainty, there was an expectation that 1.3 million would be in date but that wasn’t a given, was it, and that they would be in date at a future date, so not until April 2020.

Mr Paul Webster: But then the next line does say that, however, there’s going to be 4.6 million that we think will be shelf life extended. So I guess it is a snapshot in time, and I can’t give you very much more information than that, I’m afraid.

Counsel Inquiry: All right. One final question on this table, then we can take it down. Would you agree that more of the stockpile should have been ready to go without the need to extend its shelf life or carry out QA testing when it is needed to be deployed? A greater proportion should be ready to go at any given moment?

Mr Paul Webster: I’ve never been responsible for managing a stockpile so I’m talking from a position of ignorance, but what I see here is that there is what would have been considered a sufficient number of products available in the stockpile, and there would then have been a – this table, I imagine, would have been discussed between SCCL and PHE and decisions made as to whether additional products are required to be purchased, whether products should go back in for retesting or additional shelf life. So the decisions would be being made on a regular basis based on the information that is included here, to ensure that at all times the stockpile had what was expected to be needed.

Counsel Inquiry: Thank you. We can take the table off the screen now. Thank you.

Professor Sanchez-Graells, who provided evidence to this Inquiry, has said that the control and management of the PIPP stockpile had been under a complex chain of contracts, and that this contractual complexity, as he put it, created operational difficulties, and that it also affected the procurement of goods to replenish the stockpile, for example in the case of items running out of date. Would you agree with that characterisation?

Mr Paul Webster: Well, I think he makes that statement more widely about the whole model, and I’m not sure I would agree. I don’t think it has the level of complexity that he is suggesting it does. As we talked about before lunch, each of the 11 towers were responsible for a number of items, and therefore they were solely responsible for buying those items, so there wasn’t that level of complexity about who would be buying the items. And as I said before, we were the sort of overarching customer point, or customer-facing element.

So I know he talks a lot about complexity, I think it is probably not as complex as he suggests it is.

Lady Hallett: Dame Emily Lawson said the tower structure was complicated.

Mr Paul Webster: She did. I – yeah, I don’t think, in practice, it was as complicated as it might – I appreciate that looking at it onscreen it looks complicated, but the idea that each of the products was in only one category meant that you are effectively asking people to have speciality and knowledge of only a smaller proportion of products as opposed to the whole. We have 600,000 products in the catalogue at the moment, so, rather than having to have knowledge of all 600,000, you’re looking at the however many thousand that will make up your particular areas of expertise. I think, in practice, it’s probably more simple than it looks, but I do understand that to the outside world it looks incredibly complicated.

Ms Shehadeh: Just to wrap up questions around the PIPP stockpile, then, as far as you can recall, was SCCL satisfied with how it was being administered by its contractor?

Mr Paul Webster: Yes. There were no contractual issues.

Counsel Inquiry: Moving on then to the events early in the pandemic, so from early 2020. You’ve described in your statement that trusts started significantly increasing their orders, and we know from other witnesses that of course at the same time, supply chains around the world were disrupted. And obviously that affected the work of SCCL as well. Lockdowns brought a halt to the production of some items; is that right?

Mr Paul Webster: Yes. I mean, I don’t think there’s any secret that there was problems, you know, for worldwide supply chains.

Counsel Inquiry: And there were also shipping delays and export bans?

Mr Paul Webster: Yes.

Counsel Inquiry: All right. In terms of how that impacted the work of SCCL, some witnesses have referred to SCCL’s contractual arrangements collapsing when faced with this global market disruption. How would you characterise the effect of global market disruption on, let’s speak first about the business-as-usual contracts that were in place.

Mr Paul Webster: So, as I said earlier on, business as usual included very, very small elements of PPE, 100 million out of 3.5 billion, and those other products are those that allow a hospital to operate on a daily basis. It’s all of the products that are used in everyday procedures, in operations and including food, as well. So without those products, a hospital doesn’t function, and if our supply chain breaks then hospitals are very quickly unable to operate as they are intended to do.

That element of the business was what we focused on, on keeping going, and we continued to deliver right the way through the pandemic and beyond with very high levels of delivery. There were obviously some products that were harder to source and also subject, as you said, to delays in shipping and the like, but by and large the ‘business-as-usual’ element, which is the vast, vast majority of the business, kept going, kept delivering, and a significant number of people involved in the supply chain were working ferociously hard to ensure that was the case.

The problem comes when you then add PPE on top of – or the demand for PPE on top of what is already a finite resourced supply chain, and ask it to deliver products that have grown exponentially in terms of demand. We have a finite number of warehouses and a finite number of warehouse lorries to do deliveries and we were only ever set up to deliver products to 240 NHS trusts. Being asked then to deliver PPE in volumes that were so significant, and then ultimately to 58,000 locations, means that, you know, that’s just not sustainable.

Counsel Inquiry: The 58,000 locations you mentioned, that’s a reference to when – does that include care settings – (overspeaking) –

Mr Paul Webster: Yes, so that was where the PPE was then ultimately being delivered to. So when we – we talked before about our market share. So we were a business set up to manage roughly 50, 60% of the hospitals – or NHS trusts’ hospitals’ daily requirements, and did that, and our capacity allows us to meet those levels. It just wouldn’t have existed or survived had we been able to or been required to add the levels of PPE, such that, you know, even the 800 people you heard about last week in terms of doing the buying to Parallel Supply Chains through Clipper.

Counsel Inquiry: The long and short of it is, however, that had the Parallel Supply Chain not been set up, had the procurement of PPE not been effectively taken out of the hands of SCCL, SCCL would have been unable to provide what the NHS needed, is –

Mr Paul Webster: Absolutely, but we would have had to make a choice: do you either by PPE and then not provide any of the products that NHS actually needs to be able to deliver or do you split it up? The decision – it seems like the decision was eminently sensible.

Counsel Inquiry: You’ve described in your statement the amount by which demand for all items, not only PPE, but of course including PPE, surged, and NHS trusts were placing much larger orders than they had been historically, and NHS trusts that hadn’t placed orders with SCCL began to do so –

Mr Paul Webster: Yes.

Counsel Inquiry: – is that right? Now, one of the ways that SCCL responded to that, and we know that SCCL was liaising with DHSC, and we’ve heard from Dame Emily Lawson about her involvement, one of the ways SCCL responded to that was through instituting demand management. In simple terms, does that mean cancelling down orders placed by NHS trusts?

Mr Paul Webster: In some cases but most – certainly initially, in looking at those anomalies in demand – sorry, in ordering patterns, I think, Dame Emily referred to 150% as – so if somebody had normally ordered 100 and was suddenly asking for 150, someone would question whether that was needed because it was just simply a question of trying to make sure that as many customers got as many products as we could give them with, as you said, an increasing customer base, customers who’d never bought certain items from us coming to us because their existing routes no longer existed.

Counsel Inquiry: And is it right that there was no centralised information on inventories, so for example SCCL couldn’t know how much stock was held, whether as a buffer for immediate use, by any given NHS trust?

Mr Paul Webster: That’s absolutely correct and that’s one of the biggest problems we faced, is knowing if somebody was ordering 1,000, did they already have 1,000 in stock, or was it because they had absolutely none? So knowing where stock was and how much stock existed was impossible, and to a large extent, still remains the case now.

Counsel Inquiry: You’ve said in your statement at paragraph 7.32, your statement INQ000492085, that:

“Demand control (rationing) was not routinely communicated widely at the start of the pandemic as this often serves to encourage customers to place multiple orders to get around any rationing which defeats the objective of ensuring that all orders are fulfilled at least in part, ie a fair share goes to all customers.”

You’ve given a reason there for not routinely communicating widely rational control. Firstly, what do you mean by not communicating widely? How was rationing communicated to NHS customers?

Mr Paul Webster: My understanding or recollection is that trusts were informed, both by the department and others, not to stockpile, and I think in one of the earlier paragraphs at the top of that page, there is the information that we sent out to trusts explaining that we were trying to meet as many people’s demand as possible.

But what we didn’t do is say, “We are now only going to allow X number of products or X per cent of your orders to be fulfilled”, because that did breed the sort of stockpiling behaviour in some cases that not dissimilar to – we saw in supermarkets and whatever, people buying as much as they could, not necessarily as much as they needed.

Lady Hallett: Can I just take you back – I’m sorry to interrupt, Ms Shehadeh. Can I just take you back to one of your answers a minute ago. You said that one of the problems, as was put to you, was that the difficulties of knowing how much stock trusts held, and you said that that’s still the case.

Dame Emily said that there is now in place a system whereby in an emergency, SCCL could find out, and the systems – (overspeaking) –

Mr Paul Webster: Well, I think – and again, my recollection may not be quite right – I think she talked about a number of trusts that have inventory management systems in place, and that certainly isn’t all – my understanding is there are about 60 or 70 trusts that have an inventory management system that is capable of talking to us or providing reports. But it’s certainly not the full extent of the NHS, and we are working on a project with NHS England to introduce inventory management systems into 20 new trusts to give us realtime data that will say – so it wouldn’t just – so I know Dame Emily was talking about it being used in an emergency, but for actually a supply chain business like ours, we want to have that information all day, every day. We want to know how many bandages you’ve got, how many sutures you’ve got, so that we can help manage that. And some of the – particularly some of those products that are used in operating theatres, for example, as they’re being used, we know that that’s one less unit, and that’s a point we’ll place a reorder without the trust having to do anything.

So it’s that kind of data that we just didn’t have going into the pandemic, and largely we don’t have as a system even now.

Lady Hallett: So it’s 60 already got this new management system.

Mr Paul Webster: That’s my understanding.

Lady Hallett: 20 you’re rolling it out to?

Mr Paul Webster: Yes.

Lady Hallett: Remind me how many trusts there are.

Mr Paul Webster: About 240.

Lady Hallett: So you’ve got a long way to go?

Mr Paul Webster: Yes. And it’s not cheap and that’s the trouble. There’s a benefit to it, but I think our number one recommendation, certainly from our perspective, is that if the money can be found, inventory management systems throughout the NHS would be a benefit.

Lady Hallett: Thank you.

Sorry to interrupt.

Ms Shehadeh: Finally on this point, did SCCL consider that NHS trusts might have been concerned that they weren’t able to source PPE from SCCL, and this in itself might have caused panic buying if they weren’t being communicated with?

Mr Paul Webster: I think it’s less about the communication but more about the concern. I think the concern that you outline is very real. You need – you suddenly need a quantity of products that you’ve never bought in that volume before, the place that you may have typically bought from doesn’t have access to it, and then what you think is the, sort of, NHS’s own supply chain also doesn’t have it, certainly in the volume. So that kind of concern and fear element, I think, is only – it’s only natural.

Counsel Inquiry: Is it right to say that SCCL did not have plans in place that anticipated a pandemic?

Mr Paul Webster: SCCL as a – well, we had – we managed the PIPP stockpile, so that was our understanding of what the pandemic plan would have been. So we would have, and the contract that we had with PAG and Mo – with Movianto made clear all the steps that would happen and how that stockpile would be deployed. So to that extent, there was a plan.

Counsel Inquiry: In terms of supply chain disruption in terms of what would happen once the stockpile had been used up, SCCL didn’t have a plan as to what came next, did it?

Mr Paul Webster: No, but I’m not sure that in that circumstance we would have been expected to because, again, we take instructions from PHE about the volume and the nature of the products to be put in the stockpile and the – so – and, again, my understanding is the expectation was that PIPP stockpile would have been sufficient – I can’t remember, I’ve got the number in my statement – the first X weeks of a flu-type pandemic. So there would have been an expectation then that that would have been replenished. So I think there was a plan, but in terms of did we have a separate plan, no, we didn’t, but I’m not sure that there was an expectation that we should have done, because we would have been operating under the instruction of PHE, who would be making all the calls about whether there was a pandemic, when to deploy that stockpile, and in what form.

Counsel Inquiry: You now have in place something you refer to as a pandemic “playbook”. Does that address –

Mr Paul Webster: Well –

Counsel Inquiry: – that –

Mr Paul Webster: – some of that is an internal facing in terms of – so one of the – in terms of how we deploy our own resources, we had lots of people working incredibly hard, but then we’ve still got, on PPE, ignoring the difficulty of maintaining the BAU ways of working. So we have a greater level of planning as to how we would manage, because again, like the rest of the country, we were dealing with people not being able to get into the office. Skipton House, where Dame Emily Lawson was based, was where we were largely based; that became – that was shut down. And it’s all that kind of “How do you work in a pandemic?” So that’s in our plan.

We have the ability to scale up, should we need to reopen, effectively, the Parallel Supply Chain, that kind of thing. So all of that is in there.

But again, a large amount of that we will be acting under the instruction of whether it’s UKHSA, the Department of Health or NHS England, depending on who is calling the shots at that point.

Counsel Inquiry: All right, thank you. Thank you. And you go into more detail about that in your written evidence for which we’re grateful.

I’m just going to move very swiftly on to the physical warehouses. We’ve heard a bit about that this morning.

Mr Paul Webster: Yes.

Counsel Inquiry: There’s a distinction between a distribution warehouse and a storage warehouse, if I can put it in those terms. You say in your statement that the Haydock warehouse was accessible 24 hours a day, seven days a week. Am I right in saying that in respect of distribution of the stockpile, your analysis is that the issue wasn’t with logistical or physical issues but rather it was around measuring and monitoring demand signals?

Mr Paul Webster: Yes, that’s – yeah, that’s right.

Counsel Inquiry: Can I put up on screen, please, INQ000569777.

This is an extract from an account by Matt Hancock in his book entitled Pandemic Diaries. If we go to pages 6 and 7 of that document – that’s printed pages 95 and 96. Thank you very much.

I just want to ask you about the way he describes the difficulties with the warehouse:

“Continuing to work through the practicalities, Steve Oldfield updated me on the huge stocks of PPE in a warehouse in the north-west: a billion items. Just one problem – we can’t get it out. It turns out that when they laid down the PIPP stockpile in the 2000s, no one thought about the circumstances under which we might need it, ie, an emergency, in which time is of the essence. It’s a huge storage unit which only has one door.”

Just pausing there, on a factual level, is it accurate that the Haydock site only had one door?

Mr Paul Webster: I don’t believe that is the case.

Counsel Inquiry: All right, and in terms of difficulties, with moving something out of deep storage into a distribution warehouse, would you accept that that process in and of itself takes up valuable time that isn’t available in an emergency?

Mr Paul Webster: No, because we can demonstrate that at one point they moved 1,000 pallets in a 24-hour period. I don’t know where the information came that goes into this extract, but I wanted to check before I came here, and one of my colleagues has shown me that if you put the Haydock site into Google Maps you’ll see that there are a dozen lorries all loading up at the same time. So I think there is some misinformation in terms of how this story has been relayed.

Undeniably, it is quicker to move product from a distribution warehouse because that’s what it – because the stuff is coming in and going out on a daily basis. Deep storage is there for a particular period, but it’s a modern facility with modern technology, and as I said, capable of moving 1,000 pallets in 24 hours.

So it – the stock can be moved.

Now, Dame Emily Lawson gave an incredibly articulate explanation of what happens next in terms of then being transported to and being broken down into the right size of packaging or parcels, depending on the nature of the organisation then receiving the products, because obviously it’s different if you’re going to an NHS Trust than if you’re going to a care setting. But I’m not aware that the problems that this suggests, in terms of ability to access stock, and then move it around the country, are anything like as they are portrayed here.

Counsel Inquiry: All right, and then finally, you tell us in your statement that SCCL has now brought the procurement of PPE in-house.

Mr Paul Webster: Yes.

Counsel Inquiry: What does that mean, and how will that affect preparedness in a future pandemic?

Mr Paul Webster: So that chart that you showed at the start of the session has now been largely rubbed out. The procurement of medical products, so eight of those 11 towers, has come in-house, in part as a recognition that if there was an emergency situation, being able to deploy those procurement people to buy particular products rather than the range. So, previously, they only bought whatever capital equipment. Now we can say, actually, you are now buying PPE or you’re now buying whatever it is. So there’s an element of building some greater level of control over our staff and our procurement patterns.

It will help us a bit with resilience, as well, and it means that the decisions that we will – we will be able to respond quicker to direction from NHS England or the department without having to go to a third party, which is what the case was with the towers.

Ms Shehadeh: Thank you.

My Lady, I am conscious there are questions from others. Those are all – (overspeaking) –

Lady Hallett: Thank you very much.

Mr Weatherby.

Mr Weatherby: Yes, my Lady I’m asked to shorten our –

Lady Hallett: Well, I’m sorry, it’s because we’ve run over, but if you can’t without affecting the substance then –

Mr Weatherby: Well, I was about to say, you covered parts of them anyway.

Lady Hallett: All right.

Mr Weatherby: Can I just have a quick go.

Lady Hallett: Yes, of course.

Questions From Mr Weatherby KC

Mr Weatherby: Mr Webster, I ask questions on behalf of members of the Covid Bereaved Families for Justice UK, and my Lady was asking you questions about the inventory system or the lack of inventory systems in trusts. And you gave us your answer about that.

In your witness statement you described it as a major difficulty with the system that SCCL had an idea of what was being ordered by trusts but it had no way of tracking what individual trusts actually already had, and that gave rise to serious issues, your words, during the pandemic because it was impossible to know how much stock of a particular product a specific trust or the wider system held. Okay?

Mr Paul Webster: Yes.

Mr Weatherby KC: So you’ve been involved since 2016, I think you said?

Mr Paul Webster: Yes.

Mr Weatherby KC: Did you or any of your colleagues not consider this ahead of the pandemic: that SCCL might have the need to monitor the inventory of PPE across the system, PPE and other critical supplies, as well as usage? Was that never considered?

Mr Paul Webster: Well, yes, in the sense that would it be helpful to know what is stocked and where? Being able to do something about that is the issue, and as I explained a moment ago, putting in inventory management systems is an incredibly expensive undertaking –

Mr Weatherby KC: Yes.

Mr Paul Webster: – and not one that we would be able to do. So it relies on each NHS trust making that information available centrally.

Mr Weatherby KC: Yes.

Mr Paul Webster: So would it be a good idea? Incredibly so. Was it something that we were able to influence? Unfortunately no.

Mr Weatherby KC: Right. My question was, was it given thought ahead of time –

Mr Paul Webster: Not in the sense of a pandemic, but in the sense of actually running an efficient supply chain knowing what stock exists throughout that end-to-end supply chain, both downstream and upstream into our customers.

Mr Weatherby KC: Yes.

Mr Paul Webster: Yes, we would regularly feel that the lack of that information was a – (overspeaking) –

Mr Weatherby KC: Yes, and did you escalate that? Did you feed it up the line to government?

Mr Paul Webster: It would have been part of the ongoing discussions.

Mr Weatherby KC: Yes, okay. And finally this, then: the real problem now, five years on from the onset of the pandemic, the real problem now, is that the progress that’s been made is not sufficient, and that’s because of limited funding. Is that a fair way of putting it?

Mr Paul Webster: I think so, yes.

Mr Weatherby: Yes, thank you very much.

Lady Hallett: Very grateful, Mr Weatherby. Thank you.

Mr Stanton, right the way over there.

Questions From Mr Stanton

Mr Stanton: Thank you, my Lady. My Lady, I’ll do my best to shorten my questions also.

Good afternoon, Mr Webster.

Mr Paul Webster: Good afternoon.

Mr Stanton: I ask questions on behalf of the British Medical Association. My first question relates to the question of communication with healthcare workers. I’d like to ask you the question: given that healthcare workers were risking their lives to care for patients, do you believe that there should have been more honesty and candour with frontline healthcare workers about the reality of PPE shortages? For example, healthcare workers were assured that PPE was stockpiled and available to flow into the system while in fact rationing and demand management was taking place in a number of different forms.

Mr Paul Webster: Well, that communication largely, in terms of reassurance, came from elsewhere within the system. Should we be as honest as possible with healthcare workers in an ideal situation? Absolutely, we should. I think in part, it came from – as I said, PPE was such small fraction of what the NHS uses on any daily basis that there wasn’t an expectation that that type of PPE would be needed in the volumes that turned out to be. The PIPP stockpile is there for a flu-type pandemic, not the kind of virus that Covid is.

But to your question, should there be as much candour as possible, yes, yes, absolutely.

Mr Stanton: Did you think, then, that that occurred? That there was in fact candour and honesty? We heard earlier from Dame Emily Lawson that they were desperate – well, she described the situation as being desperately short of pretty much everything. Do you think healthcare workers on the front line who were taking on very serious risks were aware that the situation was quite as bad as it was?

Mr Paul Webster: I can’t speak to what they would have known. We wouldn’t routinely have a discussion with clinical – between us and clinicians. Our discussion would be with procurement managers within a trust and it’s there that we are having the discussions about volumes. We wouldn’t expect to then push out further information into healthcare providers.

Mr Stanton: Thank you, Mr Webster. I’ll move on to another question area. This area relates to the extent to which you received input, clinical input, into procurement decisions. I’d like to refer you, please, to a document.

INQ000339268. It’s page 40 of that document.

If you could let me know when you have it, please.

Mr Paul Webster: I do, yeah.

Mr Stanton: Thank you. If you see the second paragraph of that document, it begins:

“DW …”

And that’s the person David Wathey, who is elsewhere named in full in this document.

“… advised an area that had arisen … is the supply of FFP3 masks, seeing a three times surge in demand over the last few weeks in orders coming through NHS SC, the reason for this will be trusts preparing, such as fit testing activity which will have increased demand. DW advised if we model that level of demand we’ve identified for certain product lines in the FFP3 we will be in a position where we would not be able to support BAU [business-as-usual] demand, as a result of this, we have taken a decision today that we are going to place a restriction on orders that are placed on the NHS SC system to limit these to BAU demand levels, this will be based on the customers last 12 months BAU demand. The system will place a ration on this, daily ordering will be monitored to ensure there is no abnormal ordering.”

My question is, would you accept that this is a blunt and bureaucratic response that lacked insight into the clinical and ethical importance of the equipment being restricted?

Mr Paul Webster: Well, it’s a decision made by the department and not by NHS Supply Chain.

Mr Stanton: Yes.

Mr Paul Webster: So I – it would be wrong for me to put, kind of – put into words what they were trying to do here. But in terms of trying to ensure that people have access to as much product as possible, there has to be some limit. If you only have a finite capacity at any given time, you can only give out that many. But as to whether – how they came to that decision, that would be something the department or David Wathey would have to –

Lady Hallett: It’s rather a strange criterion, isn’t it? Business as usual doesn’t usually involve too much use of FFP3 –

Mr Paul Webster: Yes, as we heard this morning, yes.

Lady Hallett: Whereas when you’re fighting a virus of this nature then it’s more likely to be. So business as usual wouldn’t help anybody, would it?

Mr Paul Webster: As I say, it’s probably something –

Lady Hallett: Wasn’t your decision?

Mr Paul Webster: Yeah. Yes.

Lady Hallett: Right.

Sorry for interrupting, Mr Stanton.

Mr Stanton: No problem at all, my Lady.

Mr Webster, I’ll move on to one further document, if I may.

If I could have up on screen, please, INQ000553817.

Again, if you could indicate when you can see that document, that would be helpful.

Mr Paul Webster: Yes.

Mr Stanton: Thank you. This a witness statement from Rosemary Gallagher on behalf of the Royal College of Nursing, and at paragraph 23a you should have feedback provided by RCN members on procurement stock that had been procured. And we have one example, at 23a, which reads:

“So far we have had 4 different types [of mask] from two different manufacturers, none have been clinically acceptable, they simply do not fit. I am aware that contracts have already been signed to purchase. When I have fed back to cabinet office that they don’t fit, I was told any mask was better than nothing.”

Then over the page, page 8, 23b. You’ll see some further feedback:

“The clinical engagement is being done AFTER the purchasing decisions have already been made. It is paying lip service to it and it is too late once decisions have already been made based on tech specs, NOT clinical specification and evaluation.”

So my question, Mr Webster, is: in your experience, was this type of end user experience missing from the procurement process during the pandemic, and would you have benefited from this type of input?

Mr Paul Webster: Well, I think this extract refers to a period when the Cabinet Office was buying the products. So it was FFP3 masks, as Dame Emily mentioned this morning, were used in a far smaller number, and at that stage my understanding is that the testing didn’t – and the specification didn’t involve the sizing element that was clearly, with hindsight, something that would have been beneficial. But at the time, it wasn’t.

And I think it’s – this – I imagine – and again, I don’t have the expertise to speak to this, but I imagine this is one of those things that you learn as time goes on. It would have been helpful to know that in advance, absolutely it would. But I think at the time, there wasn’t that recognition that the size was going to be the issue that it clearly became later on.

Mr Stanton: Just thinking in more general terms and looking to the future, do you think the process that was in place at the start of the pandemic was missing this end-user feedback, and is this something that you’d recommend for the future?

Mr Paul Webster: I think end-user input into specification of any product makes sense. Absolutely, yes.

Mr Stanton: Thank you.

Mr Webster, my final question, which I’ll shorten, is a question that was put to Dame Emily Lawson earlier, and I think you indicated you heard her evidence. The question was, why did it take a pandemic for the issues around FFP3 types – that would fit a variety of different face types – take – to be recognised during the pandemic, why wasn’t it recognised earlier?

You obviously heard, I think, Dame Emily Lawson’s answer. Do you agree with the answer she gave?

Mr Paul Webster: I’m not sure I necessarily recall what – what her answer was.

Mr Stanton: Her answer was along the lines: FFP3 was quite a specialised piece of equipment, it needed to be used during the pandemic across a much wider range of healthcare worker, and they simply didn’t know at that time the number of different types that would be needed.

As somebody who has worked in this area for quite some time, would that be your assessment?

Mr Paul Webster: That’s certainly my understanding, yes.

Mr Stanton: And would that be the case even though a particular group that had issues with fit testing were women, and women make up 77% of the healthcare workforce?

Mr Paul Webster: If you’re asking now would that still happen, or at the time? So at the time there wasn’t that expectation or recognition that size and shape was going to be so important, which is why the specification for FFP3s in the PIPP stockpile were as they were. If you’re saying, as we look forward, would we expect the specification for products going into any new stockpile to reflect the experiences of clinicians of whatever gender or whatever race, then absolutely you would expect that to be a lesson taken away and incorporated into the specifications for the future.

Mr Stanton: Thank you, Mr Webster.

Thank you, my Lady.

Lady Hallett: Thank you, Mr Stanton.

Those are all the questions we have for you, Mr Webster. Thank you for the help you’ve given to the Inquiry and for coming along to give evidence today.

The Witness: Thank you.

Ms Shehadeh: My Lady, our next witness is Julian Kelly.

Lady Hallett: Thank you, Ms Shehadeh.

Mr Julian Kelly

MR JULIAN KELLY (sworn).

Lady Hallett: Sorry to keep you waiting, Mr Kelly.

The Witness: That’s okay.

Questions From Counsel to the Inquiry

Ms Shehadeh: Can you state your full name for the record, please.

Mr Julian Kelly: Julian Kelly.

Counsel Inquiry: Thank you very much. You have provided a witness statement to this Inquiry. It is INQ000528585, and it runs to 143 pages and is dated 23 December 2024. Can I just ask you, are the contents of that statement true to the best of your knowledge and belief?

Mr Julian Kelly: Yes.

Counsel Inquiry: Thank you. You have been the Chief Commercial Officer for NHS England and you’ve held that post from April 2019 and you’ve also acted as its deputy Chief Executive; is that correct?

Mr Julian Kelly: No, I’ve been the Chief Financial Officer not the Chief Commercial Officer, I think is what you said, since 2019. But I have been the deputy Chief Executive since July 2021.

Counsel Inquiry: Thank you. I’m so sorry. Chief Financial Officer?

Mr Julian Kelly: Yes.

Counsel Inquiry: You, in terms of the rest of your professional experience, you tell us at paragraph 9 of your statement that prior to joining NHS England you were the Director General Nuclear, and you were also the Director General of Public Spending and Finance at HM Treasury; is that correct?

Mr Julian Kelly: That is correct.

Counsel Inquiry: And you’ve held a number of other senior roles including with the UK Border Agency and also in the private sector; is that correct?

Mr Julian Kelly: Yes.

Counsel Inquiry: And what were your responsibilities within NHS England during the pandemic?

Mr Julian Kelly: So largely I was responsible for agreeing the aggregate funding arrangements with government which were used for funding the NHS, for agreeing and setting some of the rules for commissioners and providers by which they spend that money. And then, as needs required, there were specific programmes and projects that I got involved in.

Counsel Inquiry: Thank you.

In terms of a brief overview of what NHS England did at the time and its responsibilities in relation to procurement generally, NHS England is an executive, non-departmental public body sponsored by DHSC. What does that mean in simple terms?

Mr Julian Kelly: We are an arm’s-length body, ie a separate organisation with a separate legal identity, where the objectives we are required to meet are set by the department, the funding provided by the department, and we are accountable to the department for seeking to meet those objectives with the money that they give us.

Counsel Inquiry: And is it right that NHS England doesn’t itself provide services to patients, but it makes sure that they are provided by commissioning services?

Mr Julian Kelly: Yes.

Counsel Inquiry: And this module, as you know, is focused not on services but on key medical equipment and supplies.

In normal times NHS England has a very limited role in relation to physical items that are used in the NHS; is that right?

Mr Julian Kelly: Yes, we were not and are not responsible for directly buying the goods and services that, for example, hospital trusts use every day.

Counsel Inquiry: That said, during the pandemic, NHS England did carry out some very limited procurement of medical devices and some cover-alls and gowns; is that correct?

Mr Julian Kelly: Yes, and we bought some pulse oximeters which were distributed to GPs, for example, but, as you say, in pretty limited circumstances.

Counsel Inquiry: In respect of procurement of PPE and other key equipment and supplies, NHS England did of course have a role, principally assisting DHSC, in setting up and running the Parallel Supply Chain and in liaising with the NHS. Is that a fair summary?

Mr Julian Kelly: Well, I would summarise it as we provided people and resource to support the department in setting up the PPE Cell, and then of liaising with them to communicate to the NHS what was going on and what was expected of the NHS.

Counsel Inquiry: In terms of communications with the NHS, I’d like to ask you now about how NHS England sought to engage with the NHS in preparation for the pandemic in January and February 2020, if I may.

Can we have up on screen, please, INQ000409919.

So this is a presentation from NHS England and NHS Improvement dated 1 February 2020. It summarises what actions NHS England was taking in January and February 2020.

Could we go to page 1, please, or page 2. This is effectively a snapshot in time of what was known at this stage. So:

“On 9 January, Public Health England [a different organisation] declared an Enhanced national incident due to an outbreak of novel coronavirus in … China.”

In terms of your organisation’s actions, NHS England and NHS Improvement opened an incident coordination centre on 22 January, and on 30 January NHS England and NHS Improvement declared a level 4 national incident. Briefly, what is the significance of declaring a level 4 national incident?

Mr Julian Kelly: In simple terms, it means NHS England takes the authority to give stronger direction to NHS providers as to what they should do during that incident. Normally, for example, hospitals are autonomous organisations making their own decisions, but in a level 4 incident, we will take responsibility for giving stronger direction on certain issues.

Counsel Inquiry: So does it limit the discretion of NHS trusts in their decision making, effectively?

Mr Julian Kelly: Yes, for certain things. I mean, clearly, on a day-to-day basis you’re running an emergency department, you’re still responsible for running an emergency department. We’re not going to tell you exactly how to do that. But where, for example, we think new capacity needs to be put in place, or, you know, there’s a particular response – you know, things we want to do to enhance staffing, we will give a stronger instruction.

Counsel Inquiry: Can we go to page 6 of this document, please. And also page 5. Thank you. So those two slides are about the assurance work that was being done. Effectively, NHS England was liaising with NHS trusts to ensure that they were ready in the event that they had to deal with the pandemic.

We can see there that CCGs were asked to complete assurance assessments of general practices, and over the page, we see that there was assurance work being done by multiple NHS organisations to ensure that they were ready.

Were the sorts of questions that were being asked by NHS England at this point, did they extend to stock levels of PPE and the ability to comply with any emergency IPC guidance that might be issued?

Mr Julian Kelly: So as you see from the third bullet, we were asking people what the supplies of their PPE were at that point in time, and we were clearly – I think I’m right, if you’re able to show one of the other slides, asking people “Have you exercised your staff ready for” – what at the time we were preparing for was a high consequence infectious disease, which has certain protocols that have to be followed. So it was, you know, are people prepared? Have you exercised? Have you briefed your staff? And, as I said, we were at least asking people “Do you have adequate supplies?” at that point in time.

Counsel Inquiry: And the answer was generally adequate supplies of PPE reported, and that was the answer coming from NHS organisations, was it?

Mr Julian Kelly: Yes. I mean, clearly if you were to look at the slides that go further on, there are varied responses between hospitals and, for example, what we thought was going on in GPs.

Counsel Inquiry: Yes.

And thank you, we can take that document down.

In relation to messaging, going to NHS trusts regarding the PPE supply from others, can we have up, please, INQ000049357.

This clearly carries the Department of Health and Social Care header. It’s not an NHS England letter. But this letter is addressed to suppliers to the NHS. And this letter asks suppliers to conduct a full risk assessment of the impact of the pandemic on their supply chains and to consider demand management plans in the event of excessive or unusual ordering patterns.

Did NHS England have input into this communication?

Mr Julian Kelly: I don’t know, is the simple answer to the question. You would have to ask the department. I mean, I suspect, who would have seen it, aware that it was going out, but I don’t know what specific input we had.

Counsel Inquiry: All right. Was NHS England aware that this letter was going out to suppliers to the NHS?

Mr Julian Kelly: As I said, I think we did – we would have seen it. There was a supply chain cell which had been set up between ourselves, the department, PHE, and various others at the beginning of January, February. It would not surprise me if this letter was shared before it was sent out.

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

So in January and February 2020, NHS England was asking NHS trusts, very sensibly of course, to carry out assurance, checking to ensure that they had adequate supplies of PPE. In February, the DHSC was encouraging suppliers to monitor ordering patterns, to consider demand management. And we’ve heard from Mr Webster, speaking on behalf of SCCL, that SCCL was experiencing a surge in orders.

All of those threads taken together, did that put NHS trusts in a position, do you think, where they were being asked to demonstrate that they were prepared but were struggling to access PPE from the normal sources?

Mr Julian Kelly: I think right at the start, in February and March, you clearly see, as you have just described, trusts concerned about what might be coming down the road, and starting to try to increase the level of their local stocks.

I mean, at this point, the number of patients actually in hospital – I mean, I forget – I don’t know the precise numbers, but they were very, very small. So you can see them preparing.

The steps that the department, PHE and SCCL agreed to take in the middle of February, which is to begin to put some limits on what orders are fulfilled, is clearly people thinking: how do we just sensibly manage the stock? And the communication that because from NHS England on 2 March is saying to people: yes, okay, make sure you have enough stock. And certainly for what you can forecast is going to happen over the short term, so I would say two to three weeks, given – because it also says “anticipate that normal supplies can continue”, and there was a sort of two to three-week timetable for those flows, ie, don’t start to create very large stocks.

So I think that is the communication that is going on, even while the department and PHE are at this point, I think I’m right in saying, agreeing to start to put the PIPP stockpile at the disposal of the NHS.

Counsel Inquiry: I think the letter you’re referring to is 2 March 2020. We do have that.

So could we have on screen, please, INQ00087445.

Is this the letter you had in mind?

Mr Julian Kelly: That’s the letter I had in mind.

Counsel Inquiry: Can we go to page 3 of that document, please. These are the bullet points that are giving direction or guidance to NHS and trusts that you’ve just taken us to; is that right?

Mr Julian Kelly: That’s right.

Counsel Inquiry: So:

“Ensure local stock levels are maintained at levels proportionate to anticipated short term demand, underpinned by regular replenishment from normal supply routes and NHS Supply Chain.”

So this letter is effectively asking trusts not to create local stockpiles. Did that need saying because you observed that local stockpiles were being created?

Mr Julian Kelly: Well, I – I am – and I wasn’t party to this letter at the time, but from having spoken to Keith Willett, who is our national clinical incident director, this is them, in coordination with seeing what was going on with the department and PHE, just trying to control the immediate demand so they could manage the flow of stock equitably and maintain sufficient reserves as they looked ahead.

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

We know that eight days later, NHS England’s CEO asked the CCO to investigate issues arising from trusts being unable to secure the PPE that they needed. So it’s a fast-moving picture.

We’ve heard Dame Emily Lawson’s evidence of what happened next after NHS England gained a fuller picture of how NHS trusts were struggling to access PPE. So I won’t ask you about that.

Prior to that, NHS England was also engaging with the status of the stock in the PIPP stockpile; is that right? I’m jumping around in timeline a little.

Mr Julian Kelly: Yeah –

Counsel Inquiry: There were concerns – NHS England had concerns about the stockpile as early as January 2020; is that right?

Mr Julian Kelly: Well, I think at the end of January it wasn’t necessarily that we were concerned, ie, that we were – that we were – and indeed, Professor Willett was immediately concerned there wasn’t enough in the stockpile. His question was: can I reassure myself that these – you know, that this stockpile is in reasonable shape?

So at that point, and I think it’s in one of the documents you had in my EP, you know, we asked for information about what was in the state of the stockpile – sorry, what was in the stockpile at that point in time.

He was also asking the question of the department, whether they were going to reverse a decision that had been made to start to decommission the EU stockpile or the stockpile that had been prepared for the potential Brexit disruption, because he was clearly thinking: entirely uncertain what is going to come, at this point in time we should preserve, you know, as many of the stocks and supplies that there are.

Counsel Inquiry: All right.

It’s at paragraph 199 of your witness statement that you say that:

“On 27 January 2020, in expectation of a pandemic requiring PPE measures, NHS England’s National Director for Emergency Planning and Incident Response approached DHSC to discuss concerns regarding the PPE stockpile.”

Are you saying now that “concerns” possibly isn’t the right word at this stage? NHS England wasn’t “concerned” or “worried” about the stockpile as such?

Mr Julian Kelly: Well, I mean, whether – having spoken to Keith, I don’t think he was immediately thinking there definitely isn’t enough. He is concerned to make sure that he does understand what there is there, and that appropriate steps are being taken.

Counsel Inquiry: All right. Thank you.

I’d like to move on to a different topic now, still focusing on work that NHS England did with NHS trusts but this time I’d like to turn to the Trust Supplier Sourcing team, the TSS, as you refer to it in your statement. Can you tell us briefly what the TSS was.

Mr Julian Kelly: Yes. And could you just remind me where the paragraph in my statement is where I raised that?

Counsel Inquiry: You might want to turn to paragraph 222, page 48 of your witness statement.

Mr Julian Kelly: So at the time, there were a lot of leads, offers as to where PPE supplies could be bought. A lot were coming into individual hospital trusts because they were also seeking leads. This was also a point in time where the department was trying to give much stronger coordination of buying, as they tried to make sure that people were not – you know, that NHS trusts and the department were not competing with each other, and the department and NHS England wanted to make sure individual hospital trusts were properly engaged in that process.

So what the decision was to identify a trust and a commercial lead who would take responsibility for coordinating the leads that were coming into trusts across the country for individual commodities, and then to pass those leads on to the national buying team, who at the time – well, throughout the period, I was trying to work out which might actually lead to actual stock that can really be bought at scale.

Counsel Inquiry: And for the TSS or the lead trust, were they then effectively triaging and investigating offers of PPE supply?

Mr Julian Kelly: I think they were largely coordinating all the offers and passing them on to the departmental team. I will admit I don’t know how much triage they were actually doing. If you’d like to know, I’m sure we can follow that up.

Counsel Inquiry: I’m sure we can deal with that level of detail with others. And when you say the departmental team, you mean the DHSC, the parallel supply team?

Mr Julian Kelly: Yes, the PPE Cell.

Counsel Inquiry: And we read in your statement also that trusts were collaborating, were sharing excess stocks of their own PPE with others, for example.

You’ve also described at paragraph 258 of your statement that some trusts had hired their own warehouses for PPE, and put together local distribution systems, and some used storage systems made available by Local Resilience Forums.

Were NHS trusts, outside of the work of the TSS, which involves passing on promising leads, were NHS trusts basically creating their own versions of Parallel Supply Chain, mini Parallel Supply Chains?

Mr Julian Kelly: I wouldn’t describe it like that. I would say that in this case trusts were deciding whether they needed better local storage arrangements from which they could then work out how they distributed the goods that they were then receiving out to their individual sites.

So, for example, I know that Manchester trust, which is a very big trust with lots of sites, did procure a warehouse facility and I am assuming that was because they thought it was better that they had a bigger, single central location from which they could manage, I want to say the last leg of the distribution to their local sites.

Counsel Inquiry: Thank you. I’m going to turn briefly to ventilators.

Now, I’m conscious NHS England was not responsible for sourcing or procuring ventilators, but it is right that NHS England was responsible for the allocation of ventilators – within England, that is?

Mr Julian Kelly: Yes.

Counsel Inquiry: And NHS England also assisted with the modelling for ventilator need; is that right?

Mr Julian Kelly: Yes.

Counsel Inquiry: You’ve set out in your statement that the allocation process was based on three principles so that they should be held centrally by NHS England, that they would be distributed as required between hospitals and between regions; is that right?

Mr Julian Kelly: Yes, I mean, so it’s hospitals within regions, yeah.

Counsel Inquiry: All right. They were also allocated to devolved nations based on an objective number of ventilators per million population; is that right?

Mr Julian Kelly: Yes, that would have been decided by the department who was responsible for the coordination across the four nations. That would not have been the job of NHS England.

Counsel Inquiry: And the prioritisation of where ventilators would be sent at any time, that was based on actual data and patient numbers; is that correct?

Mr Julian Kelly: Yes.

Counsel Inquiry: And the way it worked in practice was that on arrival into the country, if they were new ventilators, that is, that had been bought, they’d be transported to a warehouse in the Midlands and then the military would assist with transport onwards; is that your understanding?

Mr Julian Kelly: That is my understanding.

Counsel Inquiry: Was all of this work called the National Ventilation Allocation Programme?

Mr Julian Kelly: That’s my understanding.

Counsel Inquiry: NHS England also carried out work in relation to the supply of oxygen. Summarising it, in your witness statement, you don’t pretend there were no issues around oxygen but the analysis in your witness statement is that issues around oxygen supply did not relate to the procurement or physical distribution around the country of oxygen; they were to do with the state of the NHS estate and its buildings; is that right?

Mr Julian Kelly: Yes.

Ms Shehadeh: I have one other topic that I’d like to ask Mr Kelly about, but is this is an appropriate time for a break?

Lady Hallett: If you’d rather just complete your questions, that’s fine. It’s up to you.

Ms Shehadeh: Perhaps if we can turn to changes and lessons learned then, at this point. I’ll try not to keep you too long, Mr Kelly.

One of the suggestions within the witness statement that you provide is that there should be the ability to centrally procure when a level 4 emergency is declared. We’ve talked about the significance of declaring a level 4 emergency, that some discretion is taken away from NHS trusts and NHS England has the ability to provide more direction.

Is it envisaged that NHS England would carry out that procurement centrally, or that some other body would do that?

Mr Julian Kelly: Well, what I think we learnt from the pandemic we have just been through was you needed the capability to surge capacity. I think in an ideal world, we would plan for that capacity to be within one place, building on an existing infrastructure and system. I think the best place for that actually is SCCL, if properly constituted and set up and with a clear requirement upon them to plan for that eventuality, because it is best if you can surge capacity of an existing system and you’re not having to create something from scratch which was, of course, our experience in the last pandemic, was that we did need to create parallel capacity from scratch.

Counsel Inquiry: Part of creating that parallel capacity in the Parallel Supply Chain of course was the seconding of staff from various government departments and other bodies to create that new team. In terms of lessons learned, has NHS England made any changes as relate to the surging of staffing, different skill sets around distribution, logistics, modelling? Has NHS England done any work in relation to how NHS England, the NHS, SCCL, might be better prepared to deal with emergency procurement if the needs arose again?

Mr Julian Kelly: So the responsibility both for the stockpile and for thinking about how you prepare for the pandemic actually still remains with the department. SCCL, I think, have done actually quite a lot of work to think about how they could prepare for the future. I think Paul Webster just spoke about some of it, but it includes, and actually the decision by the department to hold on to the extra capacity warehouse and logistical capacity that was created through the Parallel Supply Chain, now properly integrated as part of SCCL, the work SCCL have done, which again Paul described just now, which is effectively to, I’m going to say in-source the buying capability that used to be in the towers, and is now provided by, for certainly medical consumables, a single team within SCCL who have standard operating procedures, clear training programmes.

So I think if you were to ask Andrew New, the chief executive, he is more confident that that actually creates the platform from which, if you needed to surge buying capacity, again, you could. Even if you are taking staff and resources from other bits of government or from elsewhere, they have thought about how the IT system is set up so you could actually put new customers on it faster than was possible.

We, you know, they have held on to some of the IT systems you would need to put in place if you actually want to track what is coming out of the factory door in China all the way to the port in the UK, have a new logistics supplier contract which aims to embed that more fundamentally in the way they work. And I think as Paul also was describing, we, with them, have been investing in some of the inventory management systems you would want in individual hospital trusts. And now we’re doing that because actually we think there’s an economic case to do it today, but it would have the added advantage that you would then have kind of more realtime visibility of what is going on in individual hospitals, and we, in NHS England, have invested in a data platform which, again, I think it was – Emily was describing this morning, makes it much easier to connect a wide variety of systems across the NHS so you can pull all of that information very easily and rapidly together in one place.

Counsel Inquiry: And is there anything beyond what you have just outlined that, reflecting on your experience in NHS England during the pandemic, you would recommend so that NHS England and SCCL are better prepared for a future pandemic?

Mr Julian Kelly: I mean, actually, the decision has already been made to have a bigger stockpile, and the work I think that is underway to think about what are the different things you might need with different sorts of pandemics. I mean, I am not the expert in that field, but just to test the thinking of, you know, what are the sorts of things one might need? And where might it be appropriate to hold things in stock versus you need to have a plan to surge the ability to access other goods? You know, that clearly is a bit of work that needs to continue to be done.

I would say we should make SCCL or whoever – if they are going to be our – I’m going to call it the provider of last resort, like the platform upon which you would surge capacity, I think there that be a formal part of pandemic exercises in the future, because you really want to exercise your actual physical ability to change, you know, your practice from business as usual into emergency or crisis situations.

Ms Shehadeh: Thank you, those are all my questions.

Lady Hallett: We’ve got about 10 to 15 minutes more questions, Mr Kelly, and we usually take a break for everyone’s benefit, but particularly the stenographer. Are you okay if we take the break now or would you rather get the questions done so you can get on?

The Witness: I really don’t mind. Whichever is easiest for –

Lady Hallett: Are you sure?

The Witness: Yes.

Lady Hallett: In which case I think we’ll take the break now and I shall return at 3.20.

(3.06 pm)

(A short break)

(3.20 pm)

Lady Hallett: Mr Weatherby.

Questions From Mr Weatherby KC

Mr Weatherby: Mr Kelly, I ask questions on behalf of the Covid Bereaved Families for Justice UK group. Can I start with the adequacy of PPE stocks. So you’ve already been taken to the report of 1 February which included the assessment of generally adequate supplies of PPE, and you’ve told us that was based on asking trusts to undertake an assurance process and that – rather than any kind of detailed look at actual supplies or forecasted demand. Yes?

Mr Julian Kelly: I don’t believe it was based on a forecasted demand for, let’s say, the kind of reasonable worst-case scenarios that subsequently emerged.

Mr Weatherby KC: Yes. So you refer certainly in your statement to just undertaking an assurance process.

On the next day, 2 February, in your witness statement at paragraph 201 you refer to an email that was received and dealt with by Mr Willett, Keith Willett, that you’ve referred to, and I wonder if we could have that up. It’s INQ000409918.

This from a clinical director in Alder Hey, Simon Kenny, to Mr Keith Willett that you’ve referred to, and I am just going to start at the bottom and work up. It’s:

“Hi Keith, I know you are really busy – but [redacted] is [an] intensivist in [the north west] and it sounds as though stock levels of PPE are very low and resistance to buying more on grounds of costs.

“Not sure if there has been messaging to trusts from NHSE on this …”

And so it goes on.

And Mr Willett replies above that:

“Simon, stock levels are not low in the NHS supply chain – I literally have millions of sets – I have the EU Exit stockpile too!”

And then it refers to costs.

And Mr Kenny replies “Very helpful”.

So you refer to that in your witness statement and you say in your witness statement that in fact, despite that reassurance that’s given it was then escalated up to DHSC.

Given that NHS England didn’t have detailed knowledge of the stockpiles, and it had raised these concerns with DHSC, and they didn’t have any model for the demand to come, or inventory data, and was aware of these reports, okay, anecdotal reports, but reports nevertheless, which it took seriously, do you think that, would it be right that there wasn’t really a robust evidential basis for the reassurance that was given by Mr Willett in that email, or indeed in the 1 February report?

Mr Julian Kelly: So at this point in time I don’t think Keith’s reassurance to Simon is wrong. Simon’s email, I think it’s dealing with actually, when you look at it, a very specific issue which is really straightforwardly a trust coming to the end of the financial year trying to make sure it’s balancing its books.

Mr Weatherby KC: Yes.

Mr Julian Kelly: And at this point in time – so, you know, before I think people have necessarily really appreciated everything that will come, it sounds like there’s a bit of an instruction to kind of control the budget on very local grounds. But Keith, I think, has at least an awareness. I can’t quite remember when he is shown the sort of update on the PIPP stockpile and the stocks, which is also in my bundles.

Mr Weatherby KC: Yes, sure.

Mr Julian Kelly: So he knows there are, as he says, literally millions of sets –

Mr Weatherby KC: Yes, okay –

Mr Julian Kelly: So at this point I think it is not a supply issue; I think it is a specific local issue.

Mr Weatherby KC: Okay, point taken about the email, but I’ll put it in the context of the 1 February general reassurance. Do you not think that NHS England should have been more transparent about the position it was in at that point, particularly now with the benefit of hindsight what we know happened, that –

Mr Julian Kelly: I think –

Mr Weatherby KC: Just let me finish the question.

Mr Julian Kelly: My apologies.

Mr Weatherby KC: It simply didn’t have sufficient data to determine whether there was adequate supplies for the purpose that on 1 February it was reporting, ie, where we were in terms of the onset of the pandemic.

Mr Julian Kelly: So if I can separate two things, which is the exercise that Keith had instigated to ask NHS providers and commissioners whether they were prepared and preparing for an incident, which includes a whole series of questions, one of which is, can you check that your stocks of PPE are adequate at that point in time? And then two, the question is looking ahead, what might be about to happen, and his question to the Department who are responsible for the PIPP stockpile, which is “Can you provide me with some” – you know, Keith asking them, “Can you just provide reassurance about the state of the PIPP stockpile?”

So I think it is fair that Keith and his team get back a set of reassurances they do from the, if I call it the awareness raising and preparing, sort of operation exercise they instigated, but that is different from Keith looking ahead and asking, “Okay, can you tell me what the state of the PIPP stockpile is?” And the work that’s commissioned at the same time, which NHSE with PHE agreed to do, which is start to kind of do some reasonable worst-case scenario modelling, and the actions that are being taken by the Department in parallel, which include, around the end of that first week in February, asking SCCL to increase their buying.

Mr Weatherby KC: Yes, okay. Sorry, I’m not trying to talk across you or cut you short, but time is very short.

It may well be that at 1 February, for the 1 February’s purposes, there were generally adequate supplies. But going forward, and the purpose of the 1 February report, it should have had made clear that whereas we may have adequate supplies as of 1 February, we’re certainly not going to have adequate supplies on 1 March or 1 April. That’s the message that should have been given, isn’t it?

Mr Julian Kelly: No, because I just want to again separate the two exercises. There was an exercise which is reporting what have we just had fed back from NHS providers and commissioners at the end of January? And there’s a separate exercise which is looking ahead, and as I said, includes NHSE and PHE agreeing to do some sort of reasonable worst-case scenario modelling to say, “Okay, but if we look ahead over a course of three, four, five months, what might the demand be and what do we think is the state of the stockpile relative to that demand?”

And I would just say the slides which say “general reassurance” are just reporting back a specific exercise, and that is separate from the work that gets commissioned out of the supply chain cell to say, “Okay, what do the stocks look like and what do we think about the future?”

Mr Weatherby KC: Okay, well, I’m going to move on from that but finally on the same point, that when NHS England did create national and regional projections of demand in February and March, and I’m referring to your paragraph 219, those projections only considered direct Covid care in the acute care sector, and they then failed to capture the level of demand across primary care, ambulances and other healthcare settings. Why was that?

Mr Julian Kelly: So at that point in time, we are probably focused on the demand that is going to be experienced in hospitals. We were still preparing, I think at that point in time, for dealing with a high consequential infectious disease, that has quite a specific protocol within GP settings. Again, I’m not the expert, but you would have seen probably much lower levels of kind of PPE demand. So the focus is on where we are expecting to see the vast bulk of the demand within the NHS.

Mr Weatherby KC: Let me move on. Oxygen. You’ve told us, and told us through your statement, that NHS England weren’t aware of any procurement issues that arose in relation to the supply of oxygen, as opposed to the infrastructure, which I’ll come on to in a moment.

In Module 3 the Inquiry heard from Dr Crisp from NICE who gave evidence about NHS England guidance on 9 April, referring to the reduction of required levels of oxygen saturation. So the most acutely ill patients, 94-98% saturation, and the new guidance, said that it was reasonable to go down to 90-94%, because of supply problems with oxygen.

Were you aware of that?

Mr Julian Kelly: So as I explain in my witness statement, the issue was not per se the supply of liquid oxygen to hospitals; it was the confidence and ability to flow that in sufficient volume to enough beds if we saw, or when indeed we saw, very high levels of demand for oxygen therapy.

Mr Weatherby KC: Right. So infrastructure?

Mr Julian Kelly: And that was to do with the state of the infrastructure, the pipes, the – and I apologise, I’m about to use words that I even barely understand, but the evaporators and various others of the mechanisms.

Mr Weatherby KC: Okay. The actual legend by the guidance from Dr Crisp as put into evidence suggests the guidance was lowering O2 saturation in response to limited supply, not infrastructure, but limited supply.

Mr Julian Kelly: But it’s the supply to the bed. So it isn’t that there isn’t, like, a tank, a sufficient tank with enough liquid oxygen on the hospital site, it’s the ability to flow it to the number of beds. So it’s literally the – taking it from the tank through the pipes to the bed and it’s the ability to flow enough of it to enough patients. So it’s the supply issue to the bed rather than the kind of aggregate volume of liquid oxygen that is available to the hospital.

Mr Weatherby KC: Yes. In terms – final point. In terms of infrastructure, you have described in your statement what you’ve just touched upon at paragraphs 321 to 325, and you state that NHS England has mandatory guidance in place to ensure the infrastructure is adequate. But that is monitored by, although it’s mandatory, it’s monitored by self-reporting.

Do you agree that the pandemic revealed that the self-certification process or requirement was inadequate as many hospitals didn’t meet the mandatory guidance?

Mr Julian Kelly: Well, it certainly revealed that where trusts had maintained good governance and maintained some of the expertise, they were the trusts that tended not to have problems. And those who had not maintained some of that governance is where we saw some of the problems emerge. It is always a question as to how many things you are trying to sort of monitor nationally, and what is the responsibility of individual boards within hospitals who are responsible for the safe operation of those hospitals.

Mr Weatherby KC: Okay. Can I take it that that’s a “Yes”?

Mr Julian Kelly: Well, there were certainly issues.

Mr Weatherby KC: And do you agree that plans for preparedness in the future must ensure that that self-certification process is changed so that it doesn’t lead to the same problem in the future?

Mr Julian Kelly: I would say it is a question the boards need to ask themselves, which is: are they maintaining the, sort of, right standards within the estate, and I also flagged, as part of the lessons learnt in my report, one of the issues is going to be are we able to invest enough into the critical infrastructure risk within the estate to maintain the quality –

Mr Weatherby KC: Okay, so can we take that as a yes, as well?

Mr Julian Kelly: Certainly yes on we need to maintain the quality of the estate.

Mr Weatherby: Okay.

Lady Hallett: Thank you, Mr Weatherby.

Mr Thomas is over there.

Questions From Professor Thomas KC

Professor Thomas: Mr Kelly, I’m representing FEMHO, the Federation of Ethnic Minority Healthcare Organisations.

Mr Kelly, at paragraph 242 of your witness statement you note concerns with the FFP3 masks not fitting black, Asian or minority ethnic staff adequately, due to – often due to facial hair or for religions reasons.

My question is this: what steps were taken to address these fit issues, and was there consideration or procurement of alternative types of respiratory protective equipment to better meet the needs of these particular groups?

Mr Julian Kelly: I don’t have a lot to add to what Dame Emily Lawson said this morning, which was actually at the beginning of the pandemic, as I understand it – I was not involved, it was not NHS England’s decision, there was a decision by PHE to procure, I think, a few thousand powered hoods to provide some alternative to the use of FFP3 masks, and as these issues began to be raised in May, there was clearly consideration to, did a broader range – you know, was there a broader range of masks that were available on the market? I think that did become part of, as things became available, part of the approach of the PPE Cell, as well as the work that was done by the Deputy Chief Nursing Officer to understand what was really driving this, how could we improve the training and resources available to individual trusts in how to do fit testing to make sure those things were being done properly, as well as a reminder to boards and the leadership of NHS trusts of their responsibilities to make sure that staff had been appropriately fit tested.

Professor Thomas KC: Sorry, Mr Kelly, can I just cut through this. The reality is this was not thought of as an issue, despite it being absolutely clear that one size would not fit all? That’s the reality, isn’t it?

Mr Julian Kelly: I don’t think that’s the case. I think, in advance of the pandemic and when the requirement was set for the PIPP stockpile, people had thought that you would need a variety. I think issues emerged in May and the teams responsible took action to try to address the issues that emerged in May, as you were discussing with Dame Emily this morning.

Professor Thomas KC: Sorry, I don’t understand, and perhaps it’s just me.

If this was an issue that you and your team were aware of beforehand, why is it that such a disproportionate number, particularly of the groups that I represent, had problems with fitting of this equipment? Because it’s not making sense to me. Perhaps you can help.

Mr Julian Kelly: So it was not my team that was responsible for what was in the stockpile before the pandemic, though I understand consideration was given to what was the kind of variety of masks that you would need for different groups of people.

It is why there was such an effort, as described this morning, and by others, to seek to, you know, buy stock through the pandemic. And issues emerged in May – or where there were problems, it is why the teams took action to respond to what was going on, on the ground. And clearly it’s why, you know, lessons being learnt now, which is a– the work to enable the employment – the electronic staff records to record what the preference is for individual members of staff, to look at how you can keep a rolling programme of testing staff, as well as the research that is going on or planned to look at, like, what alternatives there are.

Professor Thomas KC: Let’s look to the future. It’s crucial that NHS England learns from the experiences of the pandemic to improve its procurement processes. I’m sure you’ll agree with that. Yes?

Mr Julian Kelly: Well, it’s – I mean, yes, NHS England, yes, what we have learned that I discussed earlier with the supply chain, and yes for the responsibilities that the department and others still hold.

Professor Thomas KC: Right. So the development and implementation of a fit testing algorithm indicates a move towards addressing some of the challenges faced during the pandemic. However, ensuring that these improvements are sustained, and that inclusivity remains a core consideration in the procurement strategies, you would agree that that’s essential for future preparedness.

So, at paragraphs 248 and 249 of your witness statement, the publication of a fit testing algorithm and processes by NHS England, looking forward, help us with this: what long-term reforms are planned to ensure that inclusivity is fundamentally integrated into the procurement processes, particularly concerned concerning the needs of ethnic minority healthcare workers?

Mr Julian Kelly: So the things I just said, which is the lessons from the pandemic to make sure that the stockpile that we now have or is planned for the future has as broad a range of relevant masks as are necessary, the work that’s already been done to automate the electronic staff records so it is possible to actually log individual staff preferences, the work I just spoke about, which is how do you have a sort of rolling programme of fit testing and training the trainers. And the research, that I cannot remember if it is planned or already under way, to look at what alternatives are there for individuals where an FFP3 mask might never work, for example the use of powered hoods and other bits of equipment.

Professor Thomas: Thank you, Mr Kelly.

Lady Hallett: Thank you, Mr Thomas.

Those are all the questions that we have for you, Mr Kelly.

As I said to Dame Emily, I do understand that this is a difficult week for you, so thank you very much for taking the time to come to help us and for your written statement.

The Witness: I appreciate it, thank you.

Lady Hallett: Thank you.

Could you pause, please. Sorry.

Mr Alan Brace

MR ALAN BRACE (sworn).

Lady Hallett: Sorry you’ve been kept waiting for so long, Mr Brace.

The Witness: Not a problem.

Lady Hallett: You’re the last witness but certainly not the least, today.

Questions From Counsel to the Inquiry

Ms Shehadeh: Could you state your full name, please.

Mr Alan Brace: Yeah, Alan Brace.

Counsel Inquiry: Thank you, you have provided the Inquiry with a witness statement dated 9 December 2024. And it is INQ000527571.

Can I ask you, are the contents of that witness statement true to the best of your knowledge and belief?

Mr Alan Brace: Yes, they are.

Counsel Inquiry: Thank you.

You were the Director of Finance of the Health and Social Services Group in Welsh Government during the pandemic; is that right?

Mr Alan Brace: Yes, that’s correct.

Counsel Inquiry: And prior to that, you have held a number of senior leadership roles within the NHS in Wales –

Mr Alan Brace: Yes.

Counsel Inquiry: – and also within Welsh Government. So I’d like to really focus on the work that you did during the pandemic, and you were in fact asked to chair the PPE Sourcing and Distribution Group between June and September 2020, were you not?

Mr Alan Brace: Yeah, I was approached around about 23 March by Dr Andrew Goodall, who was director general. Basically there were growing concerns around PPE at the Welsh Government NHS social care ministerial level. So Andrew asked me to take a leadership role on behalf of the – on behalf of himself, really, and to focus on the sourcing of PPE, any storage issues, but also distribution at that time.

There were two main challenges: buying replacement product and distributing the product that we had.

Counsel Inquiry: And were you doing this as well as shouldering your responsibilities for finance for the NHS in Wales?

Mr Alan Brace: Yeah, I kept on with all of my responsibilities as Director of Finance and got involved in things like the field hospitals taking over private hospitals. So there was a fairly significant component to the other part of my job.

Counsel Inquiry: And you reported to the Director General of the Health and Social Services Group, or chief executive of NHS in Wales, so that would have been Dr Andrew Goodall at the time; is that right?

Mr Alan Brace: That’s correct.

Counsel Inquiry: You’ve described your role during in the pandemic as providing a bridge between Welsh Government and the NHS in Wales to ensure coordination and communication across Welsh Government. On a day-to-day basis, what did that look like?

Mr Alan Brace: There was probably two phases for me for the time I was involved in the – in PPE particularly. The first phase was probably March, April and May, which was really all about stabilising the position we found ourselves in both on the distribution front to health and social care, but also on the replenishment front around how we would replenish the stock that was quickly depleting, and I didn’t really have any time, or inclination really, to set up any new groups then. I was outside the planning and response structure. There was a countermeasures group who was involved in the release of the PIPP stockpile.

So my focus in that period was just to stabilise both the distribution and the replenishment. As that became more stable, I then established two main groups: the sourcing and distribution group, which was to not just keep things stable, to start to build resilience and to think about planning ahead, particularly for the winter.

I also set up a policy and modelling group, to start to have a look ahead around any changes to guidance and what that could look like in relation to volumes.

I was also running, for a lot of that period, a weekly meeting with the PPE leads from every health board in Wales, and sitting alongside that I also had a weekly meeting with the directors of finance for the NHS in Wales, who in Wales are also directors of procurement. So there was a crossover on some issues, I think, where I needed perhaps more sort of involvement with a procurement hat on. I use that sort of structure as well.

Counsel Inquiry: Thank you.

I’d like to turn to the relationship between the NHS in Wales, the Health and Social Services Group, and NWSSP. NWSSP is the NHS Wales Shared Services Partnership; is that right?

Mr Alan Brace: That’s correct.

Counsel Inquiry: And it is the organisation that procures goods and services for use across the NHS in Wales?

Mr Alan Brace: Yeah, and it also is responsible for storage and distribution of goods, as well. So it’s the sourcing, storage and distribution organisation for the NHS in Wales.

Counsel Inquiry: And is it correct that the NWSSP provided almost all of the medical consumables needed within the NHS in Wales on a day-to-day basis?

Mr Alan Brace: Yes, that was the basis of the shared service.

Counsel Inquiry: Health boards and trusts occasionally bought from other sources. They were free to do so. Is that right?

Mr Alan Brace: It was probably very limited. Each of the local health boards would also have a small procurement team that was also employed by the shared service. So they were literally outposted in LHBs and trusts, and if they felt that there was probably more of a need for a local procurement they would handle that on behalf of Shared Services but within the NHS bodies.

Counsel Inquiry: And broadly speaking, prior to the pandemic, NWSSP’s remit did not include provision to social care or to GPs, dentists, pharmacies, community healthcare providers; is that correct?

Mr Alan Brace: That’s correct.

Counsel Inquiry: Yes. And how would you describe the relationship between NWSSP and the Health and Social Services Group or Welsh Government, organisationally?

Mr Alan Brace: Organisationally, very close. There were certainly elements that Welsh Government also had a relationship with Shared Services on, particularly expert advice on capital, building programmes and development, and also there was an SLA in place for the PIPP stock that Welsh Government was responsible for.

Counsel Inquiry: Sorry, to stop you there. SLA, service level agreement; is that right?

Mr Alan Brace: Yes, service level agreement. Sorry.

Counsel Inquiry: Sorry, do carry on.

Mr Alan Brace: Generally most of the relationship was between Shared Service and the local health boards and the NHS trusts. There was a committee. Welsh Government were represented on that committee. My deputy sat on that committee, which really just picked up any issues that were relevant for the Health and Social Services Group, and a coordination, and information exchange function.

Counsel Inquiry: Thank you. I’m going to turn to the Welsh share of the PIPP stockpile, if I may. You tell us in your statement that the Wales share of the UK health countermeasures stockpile was 4.78% based on the Barnett formula, and the administration of the stockpile was delegated to NWSSP, as you’ve just told us, through an SLA. Was NWSSP ultimately responsible for the storage and then onwards distribution of the stock in the PIPP stockpile?

Mr Alan Brace: Yes, I think the plans that were in place, there was a countermeasures group put in place to oversee the release of the PIPP stockpile to the NHS.

Counsel Inquiry: And did the Health and Social Services Group, or Welsh Government more broadly, monitor the stockpile prior to the arrival of the pandemic to ensure that it was fit for purpose?

Mr Alan Brace: That would have been the responsibility of NWSSP unless there were any issues that they needed a different decision made by Welsh Government, basically.

Counsel Inquiry: Can we please display INQ000298983.

This is the ministerial advice provided to Vaughan Gething who was in post as Minister for Health and Social Services at this point. And this ministerial advice asks him to agree to the release of the Welsh share of the PIPP stockpile.

Could we turn to page 3 of that document, please.

There’s a summary of what actions are taken by other nations and then we come to Wales in the middle of the page:

“… has a COVID-19 Health Countermeasures Group in place, chaired by the Health Emergency Planning Adviser”, as you’ve just outlined to us, and “includes key officials from Shared Services Procurement …”

Is that NWSSP? Shared Services Procurement?

Mr Alan Brace: Yes.

Counsel Inquiry: Effectively, through this structure, NWSSP is in the process of making up distribution boxes of PPE for GP sites across Wales.

And we have there a breakdown of what is going to be distributed to GP surgeries in Wales.

So this is principally at this point in March, 6 March 2020, a request that NWSSP be permitted to push out supplies of PPE to GP surgeries; is that right?

Mr Alan Brace: Yes, that’s correct.

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

Vaughan Gething has been frank with the Inquiry in his witness statement regarding the stockpile itself. Can we have up INQ000536418, thank you.

Paragraph 104 of his witness statement. He tells us he encountered issues regarding distribution from the stockpile:

“The pandemic influenza stockpile of PPE was crucial during the first four months of the Covid-19 response but the key issues for us were how quickly the PPE pandemic stockpile would be used up, how rapidly supply chains would fail and frankly that a small amount of our stockpile was not fit for purpose. However, having the stockpile in place did buy time for the NHS Wales Shared Services Partnership to successfully secure ongoing PPE supplies from other sources.”

Thank you.

Were you aware that there was, as he puts it, a small amount of the stockpile that was not fit for purpose?

Mr Alan Brace: Not at the time I got involved in PPE, but in one of the meetings, I believe it was probably one of the trade union discussions, an issue was raised around respirator masks, what they call the FFP3, where a question was raised about out-of-date stock, and Mr Mark Roscoe from Shared Services responded to say that there was out-of-date stock that had been re-tested, some of it re-dated, but given the pressure on the stockpile, some of it was sent out having been tested but with – the dates were out of date. And that was the only real issue that I personally got, you know, picked up around the issues with the stock.

The bigger issues for me was the speed that they went out, and the basis that they were going out with. As I described earlier, Shared Services not only procured for the NHS but they stored and distributed, and that was very much a pull system where the NHS would ask for stock and it would go to the delivery point, who had requested the stock. The countermeasures was very much about a push system, and that created quite a bit of confusion, I think, initially in the NHS and obviously subsequently in social care.

Counsel Inquiry: All right, we’ll come to that shortly, but just returning to the issue of the FFP3 respirators, were you aware that in fact the Welsh share of FFP3 masks within the stockpile had expired? Of that product, FFP3.

Mr Alan Brace: What I understood at the time was that stock had expired, had been re-tested for suitability, redated, but not all of the stock had been redated, and that was the only sort of dealings that I had with – about that issue with the PIPP stockpile.

Counsel Inquiry: All right. The NWSSP’s remit was widened. It was expanded to encompass the social care sector, and that decision was made on 19 March 2020. Is that right?

Mr Alan Brace: That’s correct, yeah.

Counsel Inquiry: So that dramatically increased the NWSSP customer base, effectively, and distribution targets, didn’t it?

Mr Alan Brace: Yeah, it sort of bought two challenges, really. One was greater pressure to replenish the stock, and the second challenge was not an established distribution network, that had to be sort of agreed quite quickly with the local authorities in Wales.

Counsel Inquiry: By 7 May 2020, around two-thirds of the social care sector’s needs were being met by NWSSP. Is that right?

Mr Alan Brace: That’s correct, yes.

Counsel Inquiry: In other words, the care sector was still making its own arrangements to secure one-third of the PPE that it was using day to day?

Mr Alan Brace: Yes, I understand that even after that date, there were still ongoing procurement buy-in by parts of the social care system in Wales.

Counsel Inquiry: And so local authorities, largely, were having to carry out procurement of PPE in relation to that PPE, to that one-third that was not supplied by NWSSP; is that right?

Mr Alan Brace: Yes.

Counsel Inquiry: And during that period, would you accept there was an element of competition over the same types of items? NWSSP was trying to source PPE, local authorities and the care sector were trying to source PPE; they were both after the same things, essentially?

Mr Alan Brace: Probably not to any great extent. I don’t think the local authorities – as I understand it, it was some of the elements of the social care system that was within the private sector had made their own arrangements, but I don’t believe it was – the local authorities didn’t collectively purchase PPE. They had spread their procurement expertise quite thinly amongst the 22 local authorities, so there was no central capacity or capability to do very much in relation to PPE. So that’s why the shared service actually took over social care.

Counsel Inquiry: And it wasn’t until October 2020 that NWSSP formally confirmed it was going to be able to supply most of the PPE needs of the social care sector; is that right?

Mr Alan Brace: It was a lot sooner than that, I think. The formal SLA was probably signed later in the year, but I think from 19 March, when social care came under the shared service, the objective was to supply all of social care needs from the one source.

I think there was a slight delay around the formal service level agreement but that was just more of an administrative issue rather than anything to do with any delay in shared service trying to cover all of social care.

Counsel Inquiry: So the service level agreement was in place by October 2020. When do you say in fact NWSSP was supplying most of the needs, the PPE needs, of their social care sector?

Mr Alan Brace: From memory I think we felt a lot more confident and assured around the NHS by the end of April/beginning of May. I think we probably felt a little bit more confident and assured for social care through sort of June and July. I think it was probably during that period we started to feel that, with the volumes that we were sourcing, with building resilience into our stock, that we felt that we – felt a little bit more confident and assured.

There were individual items which remained a constant challenge but I think generally through that summer we felt more confident and we started to turn our attention to the winter plan then to make sure we had enough stock to get us through what felt like it was going to be a difficult winter.

Counsel Inquiry: All right. When you say you felt more confident and assured, at what stage would you say the social care sector was having the majority of its PPE in fact supplied by NWSSP?

Mr Alan Brace: I certainly believed by – through the summer, we had put that on a – for those who needed it supplied by Shared Services, I think we were then supplying. I believe. From my understanding.

Counsel Inquiry: And why was there such a delay between the announcement on 19 March and the signing of the SLA in October?

Mr Alan Brace: I think at the time I was pretty much sort of working on my own at a Welsh Government level with colleagues around me. Shared Services was a smallish team, actually, focused on, you know, sourcing material, distributing material. There was no issue between local authorities and Shared Services or Welsh Government on the need to put it on a formal footing.

The thing that really sort of probably held it up was more in the modelling and the data. I think local authorities took quite a while to have an agreed methodology across 22 local authorities that could feed into a service level agreement that would form a more formal basis of the type of volumes that were both needed and also required to be sourced. So it was more in the modelling and the data side rather than in any intent or any disagreement on Shared Services continuing in the role. I think the decision was made in 19 March. All of us just really focused on dealing with health and social care as one and the same thing.

Counsel Inquiry: You talked about modelling and data, perhaps we’ll turn to that now. You’ve addressed the social care sector. Is it right that there were also real difficulties in getting a clear picture of existing stocks within the NHS state in Wales, stocks held by individual health boards or indeed hospitals, and indeed their usage rates? That was a challenge that you faced at the outset of the pandemic; is that right?

Mr Alan Brace: I think that certainly was the situation in the last part of March and up until the beginning of April when we had asked the military to go in and assess what the issues were, and they produced a report on 2 April which was exceptionally helpful in highlighting the things we needed to quickly put right.

So I think from the NHS side of things we certainly had sort of got into a better position early April, and because Shared Services had traditionally distributed and stored items, you know, the systems weren’t ideal but we had a lot more data and a lot more intelligence and insight into the NHS. We, I guess collectively, had to sort of try and create that as quickly as we could within social care.

Counsel Inquiry: I think we have the report you’re referring to dated 2 April 2020.

Can we have up on screen, please, INQ000299126.

I’m very grateful indeed.

This is a report produced by the military, having conducted review into the distribution and logistics arrangements in place for PPE. Was this done at your request?

Mr Alan Brace: Yes. When I took up the role in PPE, as I said, there were sort of two main challenges. Could the UK Government replenish stock? But the other one was what I probably would say is a disconnect between Shared Services believing that they had pushed out enough stock to the NHS and before, I guess, I got involved, a lot of issues being raised by the NHS, particularly with Dr Andrew Goodall, I guess, saying that there was real concerns around the availability.

So there was a slight disagreement, I guess, or a disconnect between what Shared Service believed was out in the NHS and what the NHS believed they had, and we didn’t really have any significant capacity or capability to spend a lot of time on this. So the military seemed to be an obvious choice to quickly try and understand what the issues were.

And I guess they confirmed that there was enough stock out there. They didn’t encounter any of the hospitals without stock, but because, I guess, they were pushing the product out, there clearly was coordination issues at the hospital end about what stock was held where, and how to sort of distribute that as quickly as possible across the various sites and hospitals within the hospital.

Counsel Inquiry: Can we go to pages 3 and 4 of that document, please. Go to page 3 first. At paragraph 11:

“The assessment is that the NHS Wales PPE distribution system has sufficient capacity to meet current demand.”

So there was capacity, as you say, and resilience to meet the likely increased demand, but there are certain pinch points.

Examples are given.

“However, at current usage rates, NHS Wales SSP only have four weeks of supply of PPE in storage, with no clear idea of where and how the supply will be replenished.”

So there may have been PPE within actual hospital buildings or care settings but the reality is, at this point, there was the prospect of only having four weeks’ supply in storage; is that right?

Mr Alan Brace: Yeah, that was when I got involved, my – I was concerned about distribution but by far my biggest concern was getting clarity and assurance from the UK Government that they could fulfil their obligations under the emergency plan, and that proved exceptionally difficult. So I think at the 2 April, I was really spending quite a lot of time there trying to get clarity and assurance from Department of Health in England around can they meet the needs because the stock was diminishing more rapidly than we had anticipated, and we really wanted to know, were they able to fulfil their obligations or not?

So yeah, that statement was true, I think. There was no assurance that stock, there was no guaranteed dates or no guaranteed volumes about when we could expect stock to arrive, and procurement was the response, the plan for the PIPP stock was the responsibility of the UK Government.

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

Can we just turn quickly, then, to your – you had a role in liaising with UK Government regarding PPE; is that right?

Mr Alan Brace: Sorry, I think I missed that last bit.

Counsel Inquiry: I’ll speak up. You did personally carry out some work liaising with UK Government regarding PPE.

Wales also took part in mutual aid arrangements between the four nations of the UK, is that right?

Mr Alan Brace: Yes, that’s right.

Counsel Inquiry: Can you describe in brief terms what you think are the most important lessons learned from that work that you did liaising with UK central government regarding PPE, both the stockpile and then PPE that was procured, and mutual aid arrangements and the sharing of PPE between nations.

Mr Alan Brace: Yeah, on the first point it was fairly obvious, you know, and we probably were a very small coordinated type team with a very centralised approach in Wales. I think Scotland and Northern Ireland were probably the same. England was quite fragmented and disjointed. You had trusts procuring supply chain, you had NHS England, you had the Department of Health. So it was really difficult to be able to sort of talk to anybody and get that sort of confidence, clarity and assurance about what was going to get procured and when could we expect it.

And that never really – in that first phase, we never got to a stage where we could get any confidence or assurance so we quickly made the decision that we would have to start sourcing ourselves. There was no other option, the stock was going too quickly, and we needed to sort of make sure the front line was protected in health and social care.

Counsel Inquiry: Is that why NWSSP was then tasked to take that on?

Mr Alan Brace: Yes, absolutely. The mutual aid question, I guess, is slightly different.

There was very good, I guess, understanding, cooperation around the need for mutual aid. The First Minister and the Minister for Health, Vaughan Gething, was hugely supportive of helping any other country that we could. And we did put formal arrangements to start sharing data, intelligence and where we could help, and we probably had stronger relationships through procurement networks with Northern Ireland and Scotland, but the approach to mutual aid, once we got it on a better footing, was actually very positive and helpful. And we had some help from other countries and we were – we were – actually were a net helper. We managed to particularly give England quite substantial amounts as a result of our sort of sourcing activities.

Counsel Inquiry: You say you were a net helper. Wales provided more items of PPE by way of mutual aid than it received from others, didn’t it?

Mr Alan Brace: Yes.

Counsel Inquiry: Reflecting on your experiences during the pandemic, what would your lessons learned be, if you were to give advice as to how Wales could be better prepared, not only for the procurement of PPE but you’ve alluded to real issues around distribution, how Wales could be better prepared for both of those challenges in the future?

Mr Alan Brace: Yeah. I think the Wales Audit Office report I’d fully agree with their insight and their recommendations, their very helpful recommendations for the future, so I won’t sort of repeat those. And there are certainly – certainly improvements need to be made in planning. But I’ve always believed that plans are great but it’s people that makes plans work, and we were really fortunate in Wales to have some very experienced procurement professionals sitting within an organisation that had central responsibility for buying, storing, distributing, and fairly sort of joined-up established relationships, and I think they were critical, particularly in that early phase of the pandemic.

The other thing which I think is really important, and particularly for Wales, is something that I call small country governance. One of the things that really helped was, rather than adding to groups that were probably too many and often conflicting, the ability to get key people together really quickly, get a really good handle on a problem, and then put in place actions really quickly, and for that to sort of go quickly through structures even up to the Minister to get approval for something was actually quite fundamental and important, I think, in our ability. And it’s hard to capture that, I think, in the usual formal approach to emergency planning, because most people would say, “Well, what does that look like as a plan?”

And I think probably for Wales, we could probably put a lot more attention on sort of trying to capture that in a slightly different way.

Then my last point, which I think remained a worry or me, is the collapse of global – we had understood the just-in-time global supply chains probably for cost reasons was the way to do things, and when they collapsed, we had no resilience in our supply chain.

And I still worry for future pandemics how we build resilience, because resilience comes at a cost, and ideally, the most resilient approach is UK manufacturing that we could probably rely on, but we’re probably not big enough to manufacture all our PPE needs, and there would, I guess, need to be an understanding that at times, public money would have to be used to write stock off and to replenish stock that was out of date, and that’s always a challenge, I think, when there’s competing demands for public money.

The more you spend on pandemic responses, the more resilient you probably are, particularly the supply chain, and how you deal with sort of sourcing. But it’s a difficult juggling act.

So I think a debate around what does resilience really look like, then, given the lessons that we learned from this and given the lessons of PPE, I think would be critical.

Counsel Inquiry: There was an attempt in Wales to stimulate domestic manufacture of PPE. I wonder whether you’re able to tell us how much of that capacity has been retained post-pandemic?

Mr Alan Brace: I wouldn’t know. I mean, I retired in June 2021 so I wasn’t around for how much was sort of kept on. I mean, I know for certain, you know, the Royal Mint made visors. I think that stopped. That was just something to support the pandemic. And whereas that was critical, it was never a huge part of meeting the demands and the needs that was generated by the thing.

But I think – I understand some aspects of it continued, but I think some was definitely more of a call to arms for companies to help produce, but with a clear idea that they would stop at the end.

Counsel Inquiry: And then in terms of recommendations going forward, would you agree that the care sector in Wales should be part of distribution plans for PPE from the outset?

Mr Alan Brace: Oh, yes, absolutely, I think one of the issues with local authorities, is that there are 22 local authorities in Wales which means procurement expertise is often spread very thin. I think when the pandemic hit, they started to create groups outside the main planning thing, which I don’t think helped, and their more natural route was through to the Welsh Government procurement team which weren’t really doing anything on procurement at all.

But equally, they had no central storage or distribution capability, and I just think it would make entire sense that for business as usual, social care is dealt with by the Shared Service. I think for emergency planning and pandemic response, that just – it’s a scaling up of business as usual, rather than trying to create things from new, which I think the lessons from the pandemic are never do that, trying to create organisational-type models, groups, can often add to the problem – not help.

Ms Shehadeh: Thank you, my Lady. Those are all my questions.

Lady Hallett: Thank you very much indeed.

Mr Weatherby has a couple of questions for you.

Questions From Mr Weatherby KC

Mr Weatherby: Very briefly indeed, Mr Brace.

I ask questions on behalf of Covid Bereaved Families for Justice UK. Firstly, you note at paragraph 47 of your statement that:

“The first meeting of the Covid-19 Planning and Resource Group was held on 20 February 2020.”

Given that it was a strategic group, and looking at the state of preparedness, are you able to help us as to why it wasn’t in fact stood up before 20 February?

Mr Alan Brace: The planning and response structure that was put in place in February was much more of a government service joined-up structure. So there was – the NHS were represented on –

Mr Weatherby KC: Yes.

Mr Alan Brace: – there was a subgroup of Welsh Local Government Association, directors of Social Services, and Welsh Government officials, so it was very much to quickly connect up what was happening at a government level with what was happening operationally. So I think it was much more than a strategic –

Mr Weatherby KC: Yes.

Mr Alan Brace: – it was more of a practical “what are the problems, how do we deal with them” structure.

Mr Weatherby KC: Yes.

Mr Alan Brace: And I’m not sure – I wasn’t – I never sat in that structure, actually, in my roles –

Mr Weatherby KC: Right, would you agree that it might have been preferable had it been set up earlier, given its role?

Mr Alan Brace: Certainly for all aspects of the pandemic, speed was important.

Mr Weatherby KC: Sure. Now, my other point, I was going to pick up the point you’d made already, that the NHS Wales Shared Services Partnership was expanded to procure and supply PPE for social care settings only on 19 March, and I was going to ask you whether you agree that it should have been set up earlier but I think you’ve probably answered that by saying that you think it should do so as business as usual?

Mr Alan Brace: Yeah, I think the only additional point would make is that when you look at the countermeasures group and the social care subgroup, PPE was getting flagged earlier than that. And I think around 9 March the countermeasures group actually advised the minister that, where possible, the local health boards should help out social care because they seemed to be having emerging difficulties.

Mr Weatherby KC: Right. But going forward, your recommendation is it should simply be dealt with as, throughout, business as usual, never mind in an emergency?

Mr Alan Brace: Yes, and you’ve got a much stronger foundation then to deal with both health and social care collectively.

Mr Weatherby: Thank you very much.

Lady Hallett: Thank you very much, Mr Weatherby.

Ms Parsons, who is over that way.

Ms Parsons: [microphone not on]

The Witness: That’s a little bit quiet but that may be probably because I’m probably slightly deaf.

Lady Hallett: No, it’s quiet for me too. Try again.

Ms Parsons: Is that better?

The Witness: Yes, that’s much better.

Questions From Ms Parsons

Ms Parsons: Good afternoon, Mr Brace. I ask questions on behalf of Covid-19 Bereaved Families for Justice Cymru.

Just one, possibly two, topics. Firstly, please, modelling and distribution of PPE.

You say in your statement that with the help of modelling, by late April 2020, you achieved, and I quote, “a clear burn rate picture across all key categories of PPE”.

That’s paragraph 75, Mr Brace.

Then you explain, just a few paragraphs later, that burn rate means days remaining of PPE. Do you recall that part of your statement?

Mr Alan Brace: Yes, I think the burn rate probably means two things. It was the rate that stock was getting used up, as well as sort of what stock we had left, you know. One of the two key pieces of data, that certainly I was interested in, was how quickly we were using the thing, particularly as guidance was changing, but what that meant in terms of stock held and then how quickly we had to replenish and how much more we had to do to replenish.

Ms Parsons: I understand that. And as far as you were aware, Mr Brace, did Wales ever run out of PPE at a national level?

Mr Alan Brace: Not at any time from my involvement was I aware that we had run out. The military on 2 April said that we hadn’t, but there were issues on distribution, and the only other time, actually, probably late April, a call came through to the ministerial team that one of the care homes in one of the local authorities in Wales had run out of PPE, and there was none available. I contacted Mark Roscoe in Shared Services who said that’s very unusual because the joint equipment store has been replenished.

He sent a van there and actually the joint equipment store was complete with stock, but there were clearly communication or distribution issues just between that care home, the local authority, and the joint equipment store.

So that was the only other occasion that, in my dealings, it was raised with me that we were out of stock.

Ms Parsons: Thank you. And so to summarise that, what you’re saying is the only instance that you’re aware of was in fact a false alarm, because there was stock, it’s just that it hadn’t been communicated?

Mr Alan Brace: Yes, absolutely.

Ms Parsons: Right. Members of the group who I represent, Mr Brace, witnessed real shortages of PPE and inadequate PPE. They I did so, Mr Brace, in every healthcare setting, hospitals, hospices, care homes, and for them, I’m afraid, they would have felt neither confident nor assured that those who were caring for their loved ones had what they needed.

Now, my question is this: from your position as chair of the PPE Sourcing and Distribution Group, can you explain, please, or help us understand why, if Wales never ran out of PPE at a national level, problems were so evident at a local level?

Mr Alan Brace: Yeah. And look, could I, not for any sort of effect at all, but my dad died in a care home in April 2020 in Wales so this one, I’ve grappled with ever since I was involved with PPE. And I think there were sort of two issues. I think guidance and the change in guidance, I think, caused a lot of tension at the direct service end around what PPE was required and did we have the right mix of PPE. So that was definitely an issue.

And I certainly understood, before taking up PPE, that there were concerns raised with Dr Andrew Goodall and others around there not being PPE.

The only assurance that I could take was the military had said, “Look, we’ve checked this, and it is”, but there are all of those tensions that I just described.

I think social care, given sort of the need to really sort of knit together something a lot more central, and to build some central insight and intelligence, I would not sort of really want to comment about sort of every instance of where that was felt in social care.

Ms Parsons: Just this, before I end, Mr Brace: I think you referred to coordination issues at the hospital end about what stock was held and where across sites and within hospitals. So moving away from the care sector to the hospital sector.

Mr Brace, this conjures up images of stocks of aprons, FFP3 masks, gloves being stashed in a cupboard somewhere and overlooked by hospital staff. Is that what you intended to convey, or was it something else when you talked about that disconnect?

Mr Alan Brace: No, absolutely not, and very early on I met with all of the PPE leads weekly, but we were in conversation daily, and they always were able to assure me that there was enough stock in all of their locations, apart, as I said, from – I took over about 23 March, so I certainly understood that there were concerns before I took over.

After I took over, those concerns never came to sort of any of the groups that I was on or to my personal attention, that there were still issues where – it certainly wasn’t stock stuffed in cupboards. I think every hospital has got a central receipt and distribution point that then distributes stuff to wards. So there would have been stock in receipt and distribution points and I guess the challenge was how was that – how quickly. And a feeling, I think, among staff, as the guidance was changing, was it the right PPE? So they may have felt they were out of PPE but they were out of a certain type of PPE.

Ms Parsons: Lastly this, if I may, just to end, the Inquiry heard yesterday, Mr Brace, evidence from a supply chain expert called Professor Manners-Bell, and he said this:

“… not getting [goods or] PPE to the right place means a critical supply chain failure. You [might as well not] have bothered to have had those goods in the first place if you’re not able to get them to where they’re needed at the right time, to the right people.”

And in respect of that, Mr Brace, do you agree, and was it a failure in supply chain that members of the group witnessed during the pandemic in Wales?

Mr Alan Brace: The big issue that I guess confronted me straight away was the emergency planning was based on a push system, so you just pushed out standard packs to the NHS as an example, and therefore, the NHS had to adapt between where that stock was and then distribute, which wasn’t how they would normally operate with the Shared Service.

So I think that was absolutely one of the early problems, and one of the lessons for the future is, you know, going against a normal way of working was far from helpful.

Lady Hallett: Thank you very much.

Ms Parsons: Mr Brace, thank you.

Lady Hallett: Thank you very much indeed, Mr Brace. It must have been really difficult for you to lose your father when you were trying to cope with so many different tasks. I lost count of how many hats you were wearing, but I’m really sorry to hear that he died in a care home.

So thank you very much indeed for all that you tried to do during the pandemic and for all the help you have given to the Inquiry. And a safe journey back to Wales.

The Witness: Thank you, my Lady.

Lady Hallett: Very well, I shall return at 10.00 tomorrow.

(4.33 pm)

(The hearing adjourned until 10.00 am the following day)