28 July 2025

(10.15 am)

Lady Hallett: Ms Carey.

Ms Carey: Good morning, my Lady. My first witness today is

Ms Joanna Killian.

Ms Joanna Killian

MS JOANNA KILLIAN (sworn).

Questions From Lead Counsel to the Inquiry for Module 6

Lady Hallett: Good morning, thank you for coming along to help us.

Ms Carey: Ms Killian, your full name, please.

Ms Joanna Killian: My full name is Joanna Elizabeth Killian.

Lead 6: You, on 18 March 2024, became the Chief Executive of the Local Government Association, or LGA for short; is that correct?

Ms Joanna Killian: I did.

Lead 6: And prior to that, during the pandemic, I think you were the Chief Executive of Surrey County Council?

Ms Joanna Killian: I was.

Lead 6: Right. And I’m going to ask you, please, about the LGA’s role, but if it would help you to give your evidence to give us some examples of actually what happened on the ground in Surrey, please feel free to do so if you think that would help.

Ms Joanna Killian: Thank you.

Lead 6: I know that you’ve set out in your statement that in preparing the statement, you have spoken to officers who were in the LGA at the time of the pandemic, and may I thank you for your assistance in preparing and collating the survey responses in November 2024 about the pandemic response.

You set out in your statement a description of the Local Government Association, whose membership I think comprises 331 of the 333 principal councils in England, and the 22 Welsh councils.

Ms Joanna Killian: Yes.

Lead 6: Right. Can you just help us at the outset, please, can you give us an overview of the role of the LGA and in particular, the role of the LGA in the pandemic response.

Ms Joanna Killian: Yeah. I mean, before I do that, can I just say, as Chief Executive of Surrey County Council, I was, in that role, co-chair of Surrey’s Local Resilience Forum and chaired a number of the gold command meetings that conducted the pandemic. I also was chair of a homeless charity, so saw the pandemic through a number of different lenses.

In relation to the LGA’s role, we’re a voluntary membership body, but in that role we liaise significantly between local government and central government. We lobby on behalf of our councils to make

sure that policy decisions can land well in places and

make a difference to people that live in our places and

communities. So we interpret guidance, make them fit

for purpose, we lobby for money, but we also do an awful

lot of work to support councils and their partners

improve the quality of services to people living in

their communities.

Lead 6: And help us, does the LGA have a direct line into the

Department of Health and Social Care? How did work during the pandemic?

Ms Joanna Killian: So the LGA has, and had at that time, very strong relationships into a number of departments that were running the pandemic, including the Department of Health.

Lead 6: Presumably also MHCLG as was?

Ms Joanna Killian: Absolutely.

Lead 6: Right.

Ms Killian, can you take it from us that over the last four weeks or so her Ladyship is under no illusions about the underfunding and the fragility of the adult social care sector, but I’d just like to ask, through you, please, to have a look at what the LGA members said in relation to pre-pandemic capacity.

And could we have a look at one extract from the survey, please, INQ000400522_21.

Because I think one of the questions that you posed of the membership was how they would judge the following elements of the adult social care sector in the year leading up to the Covid-19 pandemic.

And if we look down, firstly, at preparedness, a relatively mixed response there with 22% of the English single tier. Can I just ask you to explain what the single tier is, please.

Ms Joanna Killian: Yes, so upper tier councils, or single-tier councils, are responsible for the daily living of care services including adult social care. District councils provide support into that endeavour.

Lead 6: So we can see there 22% of the single-tier and counties thought that preparedness was fairly good, 53% not very good, 20% not good at all. And in Wales, 19% of the authorities thought fairly good, 57% not very good, and 29% not good at all.

I’m going to come back to pre-pandemic planning in a moment but capacity, actually, in England 65% felt fairly good, and similar scores of 67% in Wales. The ability of the care sector to increase capacity – was that increase the workforce numbers?

Ms Joanna Killian: Workforce numbers and potentially capacity within the provider sector itself.

Lead 6: Thank you. Fairly good, 43% in England, 38% in Wales; not very good, 47% and 43% respectively in England and Wales; and then resilience was, in fact, by the respondents – 70% in England thought it was fairly good resilience, 52% in Wales. And that might not necessarily accord with some of the evidence we’ve heard about resilience of the sector.

Can you help at all with your perspective on why some of the respondees might have actually said in England there was fairly good resilience, when we’ve heard perhaps that there wasn’t?

Ms Joanna Killian: So I think one of the extraordinary and, sort of, distinguishing features of the care sector in England is the goodwill, sort of the passion amongst the workforce, amongst providers, and I think that really shone through in the pandemic. So over time, the sector has coped with reducing amounts of money; the sector has just about coped with increasing demand and changing demographics, and that has, required them to be innovative, creative in, sort of, building solutions that could make people’s lives happy.

So there’s something inbuilt about the culture there but, you know, the pandemic definitely tested that resilience, for sure.

Lead 6: And perhaps slightly lower figures, though, in Wales, with only 52% of the authorities there thinking that resilience was fairly good, and indeed 38% saying not very good.

Can you help with why, perhaps, there’s slightly different figures for Wales than there are in England?

Ms Joanna Killian: I mean, I don’t feel, sort of, confident about talking about figures in Wales, but the legislation is different, some of the models of care are very different between the two nations.

Lead 6: Right. Thank you.

Before we look at some of the pre-pandemic planning, just some overarching observations from you, if I may. In your statement you say that the notion of the protective ring was known to be untrue and caused distress for families and for those working in adult social care.

Can you help, Ms Killian, with why that’s the view of the LGA?

Ms Joanna Killian: So it was clear to us from the start of the pandemic that priority was placed in supporting the NHS. I think the Department of Health understood or believed that the NHS delivering sufficient capacity in hospitals, enabling discharge, was necessary to be able to support people that might become unwell.

Our experience from the start of the pandemic was that, sort of, continuing focus on the NHS shifted, I think, esteem away from social care. It led to poor decision making about the allocation of resources, whether that was for PPE to begin with, or vaccinations. It was clear to us that decisions about discharge, actually, put some care homes at threat of harm. So despite great work that our sector did with care home providers, it wasn’t the case universally that care homes were great, safe places for people to be.

I think it was also a terrible misunderstanding of social care in England that so much focus was around care homes. A much higher proportion of people live happily and independently in their own homes who need care and support, and their needs were not addressed early enough in the pandemic.

So we saw holes in provision and, you know, we cannot agree that there was a ring of protection around care homes, or sometimes individuals’ homes either.

Lead 6: Do you think it was that the departments, plural, didn’t understand the adult social care sector, or just got the focus wrong in view of what they thought might be a need to effectively free up as many hospital beds as they did? Do you have a sense of which, if either, or both of those statements might be true?

Ms Joanna Killian: I think it’s both and probably more, actually. I mean, in the early days of the pandemic it was clear that there were insufficient numbers of very senior people within the department who understood what adult social care was, how it was delivered, and the importance, actually, of thinking not just about older people but actually groups of other people that needed care and support in the community. So I think in the early days, insufficient capability or leadership to be able to, sort of, understand; some good policymakers, but again, a gap between how policy might work in theory but actually how it would land.

So I think absolutely a misunderstanding there.

Lead 6: What led to that gap, Ms Killian?

Ms Joanna Killian: I think there had been historically, you know, no senior director general at the point the pandemic started. A small number of people – we accept that the number of officials working on this grew significantly, but this goes to the heart, I think, of how we find ourselves today: that social care was just not, sort of, a priority in the department against the priorities that there were for the NHS. And again, as the LGA, you know, we accepted and understood the evidence that was in play at the time, that recognised that there would be benefit in releasing capacities in hospital, because actually some of the people that might be affected were older people.

So there was a, sort of a logic, as the science developed, but our sense always was that to make capacity available in hospitals, there had to be a safe way of ensuring that people left hospital preferably to go to their own home.

Lead 6: Was there any sense that the gap between the policy and the actual sector on the frontline was as a result of a lack of engagement with the sector?

Ms Joanna Killian: So I will say again, I think there was a lack of sort of experience within the department, and in the early days there weren’t the sort of mechanisms, the robust mechanisms, to liaise with local government associations, providers, service users. And although that improved sort of notably in June 2020 when David Pearson was appointed to lead the social care taskforce, lots of things were done on an ad hoc basis. The LGA was often asked – and we were happy to do so – often asked to comment on guidance, but the guidance often came late, short notice, and sometimes it felt that guidance had just been adapted from an NHS workbook into a social care workbook.

You know, older people living in residential care homes do not live in wards. You know, they live different lives in residential homes, in care homes. And guidance was frequently changing, so, as the LGA, we absolutely offered ourselves and others into a space where we could support the department. And things did improve, but at the beginning it wasn’t the most satisfactory set of arrangements for any party. And nor for the civil servants, who really did want to make a difference.

Lead 6: We may come back to that in a moment. Can I just start, though, with some pre-pandemic planning.

Ms Joanna Killian: Yeah.

Lead 6: I’d like your help perhaps on clarifying different levels of plans that are in place.

Ms Joanna Killian: Yeah.

Lead 6: We have heard from a number of witnesses about the pre-pandemic flu plans.

Ms Joanna Killian: Yeah.

Lead 6: We’ve also heard witnesses talk about business continuity plans and indeed contingency plans. And I wonder if you could help clarify what the plans are meant to be in place and who was responsible for those plans, please.

Could you start with the pre-pandemic flu plans. Was every local authority obliged to have a pre-pandemic flu plan?

Ms Joanna Killian: So, I mean, as you say, it’s important to sort of think about the hierarchies here. Government nationally should, sort of, periodically define the threats to the nation. And as local authorities, we pay attention to those threats. The local resilience forum that are formed under the Civil Contingencies Act are accountable in places for making sure that a county, a group of counties, whatever the footprint of the LRF, are ready to be able to respond to these national emergencies. And absolutely, the flu pandemic was part of that.

As an individual responder council, absolutely it’s for the council to be able to say that they are sort of ready to respond to a national emergency, in that case a flu pandemic. It’s the responsibility of a director of public health within a local authority to make sure that planning for infectious diseases under the 2012 Act are in place.

So there’s a variety of hierarchies but, absolutely, a council must understand their contribution to a flu pandemic.

Operation or Exercise Cygnus that started in 2011 I think exposed some of the frailties of that, and that exercise continued for a number of years. So councils would have had a response to a flu pandemic, but it wasn’t a flu pandemic that caused, you know, such disruption as Covid-19.

Lead 6: Let me pause you there.

What in fact is a business continuity plan and how does it differ from a pre-pandemic flu plan?

Ms Joanna Killian: So imagine I’m in a local authority. One of the national threats, for example, is a cyber attack. It’s really important that councils understand how they’re going to mitigate that threat and they will have a plan in place. If, unfortunately, that threat materialises then councils should also have a business continuity plan, so if the cyber system knocks out all of your IT, there must be a mechanism to be able to meet your needs and that’s what is defined in a business continuity plan, that would be the same in a care sort of scenario, as well. And we make contingencies in that context.

So you would have a national risk plan, a council risk plan, you would have a plan for dealing with a pandemic, you would have a plan to manage the consequence if that pandemic sort of landed in your place. So I hope that’s useful.

Lead 6: Right. Can I ask you this: is a business continuity plan often incorrectly termed a contingency plan, are they used interchangeably?

Ms Joanna Killian: They are – sort of mistakenly.

Lead 6: Right, but they are different?

Ms Joanna Killian: Yeah.

Lead 6: All right. So there’s the business continuity plan and then sitting under it, my word –

Ms Joanna Killian: Yeah.

Lead 6: – a contingency plan for what you do if there is, in fact, a cyber attack?

Ms Joanna Killian: Yes, yes.

Lead 6: All right, understood.

Can I come back to the pre-pandemic flu plans, then?

Ms Joanna Killian: Yes.

Lead 6: And we have heard from Minister Whately that she found it difficult to get hold of the plans. The two that she did see, she did not consider to be adequate. Do you know who was responsible, at that stage, for checking whether the pre-pandemic flu plan was fit for purpose, as far as the adult social care sector is concerned?

Ms Joanna Killian: So, I mean, accountability for ensuring there was a plan would sit with the LRF, it would sit with the Director of Adults, it would rest with the Director of Public Health.

Lead 6: And not only ensuring that there was a plan, but that it was up to scratch, if I may put it colloquially. Was that also with the Director of Public Health and the Director of Adult Social Services?

Ms Joanna Killian: So it would be a sort of responsibility of the local resilience forum. Within a council it would be Director of Adults and Director of Public Health, but sort of a governance framework should underpin it. I think the reality is for many organisations, you know, flu plans were in place, but, I feel I should say again, you know, Covid wasn’t, you know, a flu plan. So I am sorry that the minister felt the plans were unsatisfactory, but many of the plans were built, and existed to deal with a flu pandemic. They didn’t exist to deal with a novel coronavirus with completely different sort of transmission impacts into communities.

Lead 6: Let me ask you, understanding that, that they were effectively a plan for a different virus.

Ms Joanna Killian: Yeah.

Lead 6: Clearly we may not know what the next virus is that is coming. What is in place now so that there is perhaps a flexibility for the plan to either meld itself or adapt itself for a novel virus?

Ms Joanna Killian: So at the moment, the Department of Health, with the Cabinet Office, are sort of working on a new sort of test exercise, Pegasus, and our understanding at this point is that that exercise will test a scenario that would see another respiratory virus be the one that would cause a pandemic, and will test a number of sort of transmission mechanisms.

But as yet, that plan and that sort of risk assessment is not, I think, wholly in the public domain. So I think in local government, Pegasus and all the support framework around that is crucial to enable us to play a part in planning for the future.

Lead 6: That’s what I was going to ask you: is the LGA, as far as you’re aware, involved in Operation Pegasus?

Ms Joanna Killian: We’ve had early engagement and will continue to make sure that we have full engagement on behalf of the sector, partly to come back to this issue about making sure that it’s operationally capable and fit to deliver the response that would be needed.

Lady Hallett: Exercises are all very well, if the recommendations are then implemented. You’ve already referred to one where frailties were exposed, Exercise Cygnus.

Ms Joanna Killian: Yes.

Lady Hallett: And the recommendations were not implemented. So how do we ensure that the Pegasus recommendations are implemented?

Ms Joanna Killian: I think there is a sort of different mindset now within sort of local government. The experience of running and living with a pandemic has made, I think, many senior officers very attuned to the importance of planning, and I think the lessons from Cygnus, but the lessons from Covid is about how do we make sure that there really are robust operational plans in place, and there is a mechanism for us to be held to account for that?

I think one of the things that could be substantially improved is, you know, local resilience fora exist as part of the Civil Contingencies Act. It’s making sure that the right people sit round the table when there is a hint of emergency, so people with really strong operational experience, with the accountabilities, can sort of guide the reaction locally but can also help to plan, I think, through Pegasus now.

Ms Carey: Can I ask you, please, about the lead-up to the discharge policy from hospitals to care homes and the care sector more generally. And you say in your statement that the discharge policy and associated guidance was a key concern for the Local Government Association, and that in the beginning, in mid-February, the LGA considered the risk between not expediting discharges versus the risks in doing so once the patient had been discharged, and you say the LGA at that point did not have a definitive position on the balance of risks.

Did the balance change, though, Ms Killian?

Ms Joanna Killian: So I think my statement is clear that it wasn’t for the LGA to sort of pre-judge any of the sort of medical advice that was emerging, both in this country and from the World Health Organization. It was a fast-moving, new virus.

I think our position was originally based on the fact that there is such good evidence that the longer someone stays in hospital when they don’t need to be, actually the probability of them picking up a disease or losing, sort of, functioning increases. So really strong evidence, which continues to be the case today, that actually enabling people to be moved, if they’re well enough, into their own home to be assessed against their needs is a really, like, important feature of how we deliver social care in England.

So it felt that some of those principles would be absolutely correct in this scenario, but only if mechanisms are in place to ensure that people could be protected, that as the days emerged, that PPE was available. So, you know, our position, on balance, was actually people being in hospital might cause them to get coronavirus. It was our position that people that were vulnerable might need a bed. So it’s on that sort of balance we thought we’d – cautiously and with conditions enabling people to move out of hospital.

But again, best practice is not about moving people into care homes when they do not need to be. It is about making sure that actually people go to their own home. Only about 1% actually should have been admitted into care homes at that point. But there were some very long and hard and sort of difficult debates about that.

Lead 6: I think you say in your statement that the 19 March discharge guidance, when it came out, was sent to the LGA at 4.17 on 16 March asking for comments by 6 pm that evening. And you make the point it wasn’t possible to respond within just over 90 minutes of notice but the LGA did respond by half past midnight that evening.

Did – can you help with – did you understand why there was such late argument within the LGA? And perhaps more importantly, did the engagement improve over time?

Ms Joanna Killian: So, again, you know, we recognised that this was a wholly sort of incredible, difficult, sort of taxing, awful position for the officials to be in, and we recognised that they were working, sort of, furiously to be able to produce guidance, so we were – we understood why things were being passed to us, at one level, so late, but on the other hand, it made it really difficult to get, sort of, considered responses back to test with experts and professionals that we knew we had available.

It was also frustrating for us to know that sometimes guidance was being passed to us to take a view on, but it was under a sort of secrecy seal. That made it harder. But we worked as quickly as we could, you know, recognising that everyone was under pressure at those moments during the pandemic.

Lead 6: I think you say in the statement that the LGA considered that March 19 guidance to be acceptable, noting that it did not override a care home manager’s right to refuse an admission. Does the LGA get any sense of how often a care home manager did in fact refuse to take a patient being discharged from hospital?

Ms Joanna Killian: So we didn’t collect data, and I don’t think authorities did, but anecdotally we know that there weren’t sort of significant numbers of refusals. You know, many care home managers were incredibly sort of flexible and supportive but recognising they had to protect people within their homes as well.

Lead 6: And you go on in the statement to say that:

“It … quickly became apparent that the 19 March guidance was problematic at best, and workable (sic) at worst.”

LGA’s words.

What were the problems from the LGA’s perspective with the 19 March guidance? And if it helps you, I’m at paragraph 334 of your statement.

Ms Joanna Killian: So we were concerned that – for a start it felt it had been sort of lifted from a sort of hospital practice guidance. The reality is that care homes are run in a very different way. I think we were concerned that the model of discharge that we had endorsed or were familiar with made some assumptions about who would assess people to be able to leave. It was based on a model of really experienced assessors being able to make a judgment that people were fit to leave hospital and be assessed, and we were concerned that that sort of professional evaluation may have been missed.

It was also clear that, despite sort of promises, you know, the supply of PPE was not being made available. We were really concerned that, again, testing that had been promised was not available and even where it was, you know, results were not coming in. So there are a number of factors that gave us sort of cause for concern.

But it’s also true that we relayed some of those concerns on that piece of guidance and other guidance, and, you know, occasionally we were listened to, but I think over a very short period of time, I think there were 11 sets of different guidance offered out about the support given to people moving out of hospital. So I think it was really tricky, I think, for councils but, more importantly, care providers to be able to interpret this and know how to do the right thing.

Lead 6: I think you say one of the problems with the guidance was the practical difficulty of isolating people in perhaps some of the smaller care homes.

Ms Joanna Killian: Yeah.

Lead 6: Can you help with any sense of scale of, perhaps not necessarily the number of homes, but how much difficulty there was in England and Wales in isolating people in smaller care homes? We’ve heard, for example, people often had their own bedroom but may have shared bathroom facilities, for example. Can you help with how widespread a problem that is?

Ms Joanna Killian: I can perhaps provide some supplementary information about sort of the numbers of, you know, smaller care homes, but it’s absolutely true that, you know, a significant proportion of care is delivered through small, independent providers. So it may be, you know, a couple of big houses that have been knocked together, so it was just so impractical to think that it was possible to isolate, you know, people (a) into their rooms but into a wing of a very small building. It just was never going to work.

Bigger providers in larger accommodation, there was more potential, but still really difficult to organise like that, particularly for residents who may have had dementia. It just felt like a very sort of severe thing and sort of important practical to deliver.

But I’m happy to provide some sort of supplementary statistics about numbers, if that’s helpful.

Lead 6: Well, we know that on 15 April the adult social care action plan specifically stated that asymptomatic discharges should be isolated for 14 days. Was the LGA consulted in the run-up to the publication of the action plan?

Ms Joanna Killian: So we did have engagement there but again, had concerns about how operationally sort of fit that was. There was an engagement group, there were task and finish groups running at that time, but I think our view was that things only materially improved when Sir David Pearson was brought in to provide that sort of leadership and professional knowledge to the programme.

Lead 6: Right. That action plan, I think, specifically stated that if appropriate isolation or cohorted care was not available to the local care provider, the local authority would be asked to secure alternative accommodation?

And can you help us, Ms Killian, what kind of premises were being considered to – were considered to be appropriate accommodation for someone who was being discharged from hospital?

Ms Joanna Killian: So the view of the LGA, then and now, is that the most appropriate place is for people to be able to return to their own homes, and that, I think, should have been a priority. It’s also the case that the government wanted to explore the sort of – the notion of sort of designated settings with sufficient capacity and designated settings in local authority areas to be able to support people. And progress was made on that, but again, that didn’t feel like the most satisfactory solution.

Lead 6: We know that designated settings were effectively brought in from the late 2020 into 2021.

Ms Joanna Killian: Yeah.

Lead 6: But can I ask you, please, about an example that the Inquiry has seen.

Can I have on screen INQ000545634.

This is in April 2020, from someone working in Telford and Wrekin council. It’s titled:

“Hotel Care Home – anyone giving this a go?”

And can we see there, there was:

“… a quick call out to see if any of you are in the same place as me which is about to commission our local Marston’s pub and lodge to be a post COVID Community recovery setting for older people.

“We are taking a 28 bed hotel and staffing it with our own day care support workers and cleaners …”

And then they go on:

“… and turning it into a [domiciliary] care/extra care/step down hybrid for when the going gets tough.

“We are just sorting the specification [for] this [now] and have a draft project plan underway but could do with a critical friend … in the same boat to talk [about this].”

It may, to some people, sound pretty horrifying, the people that people are going to be discharged to a pub/hotel. Does the LGA have any views about whether that was, in fact, an appropriate setting for discharged patients?

Ms Joanna Killian: So I think sort of councils with other statutory partners were really, sort of, thinking about all the options to keep people safe, triggered by the requirement of the 12 April guidance. And, I mean, I read this and I can understand why people might be concerned about this as a model. But there was, I think, some careful thinking about whether other settings would be appropriate to enable people to leave hospital, and avoid having to go into a care home.

I think the ongoing, sort of, flaw in all the plans was the lack of testing, the lack of understanding of the transmission. But to be fair to my colleagues, it was so pressured, and colleagues really wanted to enable people to be in safe spaces but this is not an ideal way, is it, of managing that.

Lead 6: I think, more generally speaking, one of the concerns of the LGA was issues with the lack of PPE and, indeed, the lack of suitable PPE?

Ms Joanna Killian: Yes.

Lead 6: And can I ask you about that – and can take it as read that we’re familiar with the worldwide clamour for PPE, if I may put it like that, but I think in your statement you make reference to the fact that PPE was diverted to the NHS, and indeed the survey found that 42% of respondees said PPE was diverted either very often or fairly often.

We’ve heard a number of pieces of evidence on a similar theme. What did the LGA do when it started to learn that there was certainly a belief by some, if not the reality, that PPE was being diverted or prioritised to the NHS?

Ms Joanna Killian: So, for me, I think it’s going, sort of, back to a principle. In the early days of the pandemic, colleagues in social care were just not prioritised for PPE. It was the case that many care homes, you know, have made use of PPE in their operations pre-pandemic, but they would never have been keeping, sort of, stocks to the level that was required during the pandemic.

So, from lots of intelligence-gathering that the LGA did, it was clear that this was a really, sort of, significant and urgent problem. It was a problem for frontline care workers, it was a problem for, you know, experienced social workers that should have been in homes being able to support people. It was a problem, actually, for CQC not being able to have PPE to be able to go in and make their assessments.

So our experience from the LGA point of view was, despite, you know, very clear stories that PPE was available, it just wasn’t.

And from a very personal point of view, I mean, I remember chairing a gold meeting one Sunday night, relatively early into the pandemic, and it was a gold meeting that covered the needs of hospitals as well as local government and other bodies. You know, there were just no gowns available. There just wasn’t PPE available in any sort of levels to support the functioning of hospitals, let alone care homes. And it was a very difficult moment just to, sort of, work out how do you allocate the very small number of products that we had.

So we absolutely acknowledge that the government sought, through the, sort of, national supply disruption route model – you know, they did deliver drops through LRFs to enable care home provision but some of the drops were wholly inadequate, not fit for purpose, and, you know, LRFs were sometimes hampered because they didn’t have the information about where to drop.

Lead 6: All right. Can I just ask you there, when you say that some of the drops were not fit for purpose, they didn’t contain enough stock, or the stock that they did contain was poor quality or both? Can you help?

Ms Joanna Killian: Stock volume that we had been promised did not arrive. So we might have been told we’d get, you know, 50,000 products, you know, I remember vividly, you know, opening the box – or opening our container and it might be a thousand products. Some of those were out of date, some of those were not fit for sort of medical or care use.

The Clipper service came online, I think in May or June of 2020, and again, that was designed to be, you know, a cool-off arrangement that would allow providers, local government, to go directly into the Clipper system. And things were improving, but even then, again, anecdotal but strong evidence that call handlers, the email processing, again, saying, “Actually, we can’t provide what you need today because we’ve got a supply problem, the NHS has to be prioritised.”

So, you know, things did improve, but not quickly enough to be able to meet the needs of all providers.

Lead 6: Can I come back to the – you mentioned the LRF drops.

Ms Joanna Killian: Yeah.

Lead 6: And we know there were number of emergency drops –

Ms Joanna Killian: Yeah.

Lead 6: – I think from March onwards. One of the things you say in your statement at paragraph 553 is that:

“This emergency planning had set out the expectation that upper tier authorities …”

What are they please, Ms Killian?

Ms Joanna Killian: So upper tier authorities are county councils, city councils, London boroughs.

Lead 6: Thank you.

“… that [those] upper tier authorities would play a role in the distribution to social care staff of face masks from the national stockpile … However, at short notice, the LRF route was introduced …”

And there’s a sense in your statement that that was perhaps – that change in the plan was perhaps not the most helpful. What practical difference did it make to change from having the upper tier authorities distributing to the LRFs doing the distribution?

Ms Joanna Killian: So individual authorities would absolutely know their care providers. They would have had intelligence about what needs they may have had. LRFs cover sort of wider geographies, mostly. So an LRF might cover sort of, say, three or four big single-tier authorities, sometimes. In my case, in Surrey, we had a co-terminus LRF and county council and that made mechanisms easier, actually.

Lead 6: Right. One of the suggestions that we have heard is that local authorities should hold a stockpile of PPE. Is that something that you would recommend? Is it realistic?

Ms Joanna Killian: So a number of authorities would have held PPE prior to this pandemic, but, again, their stocks, had they had them, would have been based on assumptions about a flu pandemic, and therefore had a smaller level of stock.

I think the issue is the importance of the nation having a supply chain that can be drawn down in the event of this crisis. So it may be that, you know, local authorities can hold it and can distribute it, but the fundamental problem was the lack of supply.

Lead 6: Can I change to a different topic, please, and changes to the regulatory inspection regime and, indeed, the impact of that on safeguarding.

And I think you say that the LGA did not raise any objection to the CQC pausing routine inspections, given that there was the Emergency Support Framework in place to act as either intelligence to monitor risk, or, indeed, to support care home providers that needed some assistance, but there was, nonetheless, some concerns, I think, of the LGA about the ceasing of routine inspections, and what were they, please?

Ms Joanna Killian: So I mean, CQC’s function is very much about sort of operational safety care for people in residential settings. It’s a really important tool. And, you know, CQC have – deliver both planned inspections, but are available if there are enough alerts or signals from a place that would cause it to think there was a breakdown in care provision.

So our initial concern was, you know, making sure that where there were safeguarding concerns, that there were mechanisms available. As a local authority, you know, there are statutory duties to make sure that adults are safe and protected, and we were concerned that that initial lack of sort of intelligence gathering maybe had been a deficit.

However, as the pandemic progressed, I think local government, with its partners, its statutory safeguarding partners, put in place some really strong mechanisms to assure itself that, actually, people were being protected and sort of safeguarding threats were recognised and dealt with.

Lead 6: I think – I want to be clear, there’s obviously concerns, once those inspections were suspended, that there may be safeguarding risks –

Ms Joanna Killian: Yes.

Lead 6: – but does the LGA have any detail about what actually materialised and whether there were in fact very real safeguarding cases that were brought to light?

Because concern is one thing, but did it actually happen, I suppose is really what I’m asking you?

Ms Joanna Killian: So there were some concerns, I mean, both in relation to older people, but actually to other vulnerable groups. So reporting levels did increase, for example, for women, for example, you know, who had been in domestic settings at threat of harm from their partners. So for a while, referrals about care home issues dropped, but we did see an increase in sort of vulnerabilities about people being in their own homes without support, as well.

Lead 6: I think in your – in the survey, if I can have up on the screen, please, INQ000400522_83 and then into 84, the survey asked about this and the bottom section there:

“The Authorities were generally supportive” – or sorry, they were asked:

“How supportive were you or not of the Care Quality Commission’s decision to temporarily suspend …”

Generally speaking, you can see there, 26% and 54% were very or fairly supportive in England, higher figures in Wales, where they were very and/or fairly supportive was 91%.

And then if we go, perhaps, to the next page:

“How do you feel the suspension of inspections of care homes” – sorry:

“Do you feel that the suspension of inspections of care homes had a negative [effect] … or not?”

In England, yes, 65%. Sorry, 43%; in Wales, 32%.

Then perhaps slightly different figures for the nos. In England, 36% of authorities felt it had a negative effect. 59% in Wales.

So quite mixed views there about that.

What was the overarching concern, though, from the LGA’s perspective about whether there was a negative impact on safeguarding or not in care homes?

Ms Joanna Killian: I think our view was also based on the fact that we knew, and we know, that, actually, suspension of visitors into care homes was a problem. You know, relatives, friends, visiting, they will often – in the small number of circumstances where there is abuse or harm, they will often spot signs and signals. So for us, yes, we had concern about suspension of inspections, but we were also concerned that actually the mechanisms to understand potential harm was being, sort of, blocked in this dimension as well. The fact that community health visitors at the beginning were not permitted into homes as well.

But, you know, the relationships between councils and providers are strong. I think many councils would have picked up the phone. You know, providers would have rung if they had felt there were concerns. There was a variety of other mechanisms to, sort of, pick up concerns aside from CQC.

The issue about not having inspections was also a concern, I think, from providers that if their ratings had been “required improvement” or, you know, “inadequate”, there was no opportunity for them to, sort of, be seen to have improved their services at this time as well.

Lead 6: I think one of the insight reports that was conducted in 2020 by the LGA – can I have up on screen, please, in fact, Ms Killian’s statement. INQ000587382_200 into 201 – considered why there may have been an increase in safeguarding concerns raised in the second half of 2020. And you set out there that it was attributed to different factors. I’m not going to go through them all, but if you perhaps just scroll down to the bottom bullet point. There was concerns that the rise in safeguarding concerns in second half of 2020 was in part related to “staff not wearing or inappropriate use of PPE”.

From the LGA’s perspective, do you think there was a need for inspections to continue to perhaps ensure that staff were either wearing it or that indeed the PPE was fit for purpose?

Ms Joanna Killian: So CQC’s regime looks at a number of factors, including how safe care is delivered. So they may have well been able to sort of pick up this use of PPE in their inspection. But I just think there are a number of other factors that caused some areas of potential concern.

Lead 6: Just standing back from a moment, does the LGA have a view now on whether the decision to suspend routine inspections was the correct one and should be a model adopted in the event of a future, perhaps, respiratory pandemic?

Ms Joanna Killian: So, you know, inspections take time to prepare for, and if done, sort of, correctly, you know, will look and, sort of, establish great things that are happening as well as, sort of, defects. So if there could be safe provision for inspection, if they could be proportionate to the environment that we would find ourselves in a future pandemic, absolutely, yes, because they’re an important way of gathering information. But it’s also true that people were protected for – you know, through other mechanisms as well.

I think for us, you know, inspection is important but it’s not the only mechanism to ensure people are safe in care homes or their own homes.

Lead 6: Does the LGA have any view on whether a hybrid model, perhaps of some remote inspection, some in-person inspections, might perhaps redress the balance in some way?

Ms Joanna Killian: So, I mean, hybrid activity did take place on the part of CQC, but also other safeguarding partners that are crucial, and there’s some really fantastic examples of that. Hybrid is fine, but at the end of the day I think great inspectors, you know, can understand and, sort of, see and feel how it is to be in a care home doing well, but doing less well. So I think eyes and ears in a place is crucial, actually.

Lead 6: Slightly different topic, in relation to the Infection Control Fund, and certainly there is concern that perhaps the Infection Control Fund was not being used to ensure that staff who isolated received their normal wages, which was one of the main aims of the ICF. Were the LGA aware of problems with the ICF not being used for its intended purpose?

Ms Joanna Killian: We weren’t. We were – we understood why the government, sort of, chose to put in place quite, sort of, onerous grant conditions, including concerns they had about state aid, like, proper use of money, ensuring it was directed. So we could recognise why those grant conditions were in place.

We didn’t feel concerned that money was being diverted to inappropriate areas, and indeed, there was a lot of bureaucracy to complete those grant requests, and we understand that the Department of Health and Social Care has since audited all of that work and are content that it was spent correctly against the grant conditions.

Lead 6: Ms Whately told us that accompanying, say, the publication of the Infection Control Fund package, she included a reference that there should be a care home support plan put in place by the end of May 2020 which should be made public.

From your perspective, perhaps indeed even as the Chief Executive of Surrey, what did you envisage those care plans would include or might include, and do you have any views about whether it was necessary for them to be made public?

Ms Joanna Killian: So there was a requirement to produce a plan. And indeed, sort of, grant release was dependent on having those plans. I think the vast majority of plans were drawn up in good faith and talked about how they would support people in care homes, the expectations they had about people being safe, the really good work that was happening then with the providers, including support to the workforce, including additional payments that were being made.

One of the positive things, actually, about those plans, if you look at them now, they sort of illustrated really, sort of, positive, like, good work to make sure that people were safe.

Lead 6: Can you give us an example, practically.

Ms Joanna Killian: Yeah. So, for example, support being given into a particular, sort of, care home where – I’m just thinking of one that – support being given into a particular care home where, for example, sort of, cash flow was problematic, and there had been really good sort of debate with a provider about, actually, the value of being able to, sort of, forward fund their work, not least to be able to invest in, sort of, workforce reform.

So, I mean, these were expected to be dynamic plans, and I think, in part, you know, they also illustrated the continuing, sort of, financial pressure that those providers were under.

I mean, there was some hesitancy about the plans, because again, the focus was on care homes where many of our members were saying, “Actually, you know, we’ve got to be able to support people living in their own homes, the carer supporting those living in their own homes, as well.”

So it felt slightly unbalanced, but that’s where I think the government continued to think the risk was.

Lead 6: Can I ask about a few discrete topics, please, Ms Killian.

Ms Joanna Killian: Yes.

Lead 6: In your statement, you make reference to the disproportionate impact of Covid-19 on black and minority ethnic individuals and, indeed, migrant workers, and her Ladyship is familiar with the Public Health England’s disparities report that came out in June 2020, but can I ask, what did the LGA do in response to the growing awareness that there was this disproportionate impact on a number of members, particularly of the adult social care workforce?

Ms Joanna Killian: Yeah. One of the roles we have is about support into councils on really, sort of, sensitive issues like this. So part of our role was hearing back from the sector about, sort of, the incidence and the prevalence of this really, sort of, profoundly distressing issue. We encouraged councils to think about in their places, how would they work with health partners to prioritise, say, vaccinations for people from BME communities to make sure that vaccination programmes, you know, prioritised the needs of those people, that where possible, there were, you know, plans in place to deliver those.

I think councils were also concerned more broadly about the impact that – of Covid on BME communities, so there’s some really fantastic examples about councils working in partnerships with faith groups, for example, to encourage vaccination take-up, to encourage testing, which also, I think, had an impact on, sort of, the workforce.

But I mean, the legacy in this area is really bleak. So working together, I think, as we think about the next exercise about how we really do, sort of, protect those groups of people and enable, actually, people to self-isolate, and I think that was a really profound concern, that some of the members of those communities just didn’t feel empowered to be at home or supported.

Lead 6: Perhaps one of the other bleak areas, to use your phrase, was the measures in place to notify DHSC if a care worker had died, and you say that there was a manual process in place but that LGA considered it unsatisfactory. Does the LGA have any suggestions for how notification of adult social care worker deaths could be improved?

Ms Joanna Killian: I think we were concerned that just having a sort of email and directing people to respond to an email and not actually being clear about what would happen, I mean, was our concern. I mean, many people lost their lives, our workers lost their lives, and it was important to have the data to be able to make a difference in the future, but we were just concerned that an email just might drop nowhere and nothing happened. So there has to be a better system, I think, of understanding which groups would be affected in the future and a better way of recording that, sort of, dynamically.

Lead 6: And to be collated by who, the Department of Health and Social Care, MHCLG as was?

Ms Joanna Killian: I think it is important that – you know, this is about, sort of, local intelligence. I mean, some of our councils serve highly diverse communities and they should have that data. It should be collected I think by Public Health England because they can, sort of, think about what the response to that should be. But throughout the whole of this incident, the issue about sort of data collection, data ownership, the value of data, I think, you know, made things more difficult for all parties, I think, whether it’s on this issue or many others.

Lead 6: I’ve asked you a number of questions about care homes. Can I ask you about unpaid carers, though.

Ms Joanna Killian: Yeah.

Lead 6: In your statement you say that one council described the impact on unpaid carers as “intolerable”, where carers were caring without a break in addition to them providing childcare and supporting the person they were looking after.

What role, if any, does the LGA have in trying to support unpaid carers?

Ms Joanna Killian: Yeah. I mean, councils have a duty to assess the needs of carers and that is a really important duty. I mean, we have millions of carers in this country. I mean, through the pandemic I think their contribution just wasn’t recognised sort of nationally, but from an LGA point of view, we were working with councils who were, again, were trying their best to be able to support carers, were, you know, organising colleagues from the voluntary sector to step in to support, you know, organising food parcels, you know, beyond the point when government was funding it, trying to do assessments.

But I think, again, the legacy for unpaid carers is a long-lasting one, and again, it’s something that has to be corrected, understood and corrected for the next pandemic. The levels of isolation, the impact on their mental health, I mean, I think is still to be discovered.

Lead 6: Can I ask you, please, whether the LGA considers that a register of the adult social care workforce would assist in the event of a future pandemic, and if so, in what ways?

Ms Joanna Killian: I mean, there are, again, at the heart of this is the importance of ensuring that care workers are recognised as a really strong, capable profession. You know, if registration enables that, if registration as part of a new employment and career structure is important, then we would absolutely endorse it. On the other hand, I think we have concerns that a sort of onerous bureaucratic registration system would force people out of the market. So we are keen that through the case review, actually we talk to workers about what they want in the context of workforce reforms that the government are putting in place now.

Lead 6: Final question, please, and it just picks up on what you mentioned there about recognition. It’s a word that her Ladyship has heard mentioned a lot, and in fact I think Helen Whately told us that she felt there was certainly an increased focus on adult social care, that there was an increased understanding by people of the need for recognition of the work the adult social care workforce did, that perhaps it might have slipped down the agenda. Do you agree that perhaps there isn’t that focus now on adult social care and we’ve returned to pre-pandemic ways?

Ms Joanna Killian: I think in many ways we are where we were sort of pre-2020. The only change is the work that’s been done on sort of workforce reform but I think as a society, in government, there’s just still a really fundamental lack of understanding about how we support older people, those with learning disabilities, for example, to live happy lives. I just, I think we have not made the progress that I and others would have wished.

Ms Carey: I’m sorry to end on that note, Ms Killian, but that is the final question I have for you. There are some Core Participant questions though, my Lady.

Lady Hallett: Thank you.

Mr Weatherby. Just there.

Questions From Mr Weatherby KC

Mr Weatherby: Thank you very much, my Lady.

Good morning, and I ask questions on behalf of Covid Bereaved Families for Justice UK. And just one point from me and it’s relating to visiting restrictions and it’s something that you’ve touched on already. At paragraph 573 of your statement you say, and I quote:

“The LGA held significant concerns over the impact of visiting restrictions on recipients of care. The restrictions separated clinically vulnerable people from their loved ones, leading to incredible trauma and grief as people died alone or suffered from loneliness or sadness at the absence of a loved one’s touch.”

Does the LGA believe that government restrictions and guidance got the balance right between visiting restrictions as an IPC measure and supporting the wellbeing of residents and their families? And if not, what should we be doing in the future?

Ms Joanna Killian: Yeah. So I should start by offering my condolences to your families and also to, sort of, recognise the pain that people are living with now, still, post-Covid.

I think, sort of, my statement is really clear about how difficult it was. I think from the, sort of, very firsthand experience in my role in Surrey, it was heartbreaking, actually, to, sort of, see the impact on relatives and those living care settings that they couldn’t see their loved ones.

I think, you know, the science wasn’t clear, but, on balance, for a future pandemic, it cannot be that people are separated. I think the trauma that families face now, the trauma of people not being able to see their relatives – and I, sort of, experienced that myself – it was, sort of, inhumane. So I think that really does have to be a different way of protecting the most vulnerable, but ensuring that they can have the most important thing to them, which is, like, love, basically.

Mr Weatherby KC: Yes. How do we do that?

Ms Joanna Killian: So I think we’ve got to really work hard through the, sort of, planning that we’re doing now on a future pandemic. I think we’ve got to think again about how we do deliver, sort of, safe protective care.

We’ve got to think again about, you know, whether it’s right in that scenario to place people in homes. It should have been in their own homes where loved – you know, that sort of relationship can be formed. So I think, you know, we’ve got to work with the science but I think we’ve also got to, sort of, remember what matters to people. And so a whole bunch of objective tests have to be met.

But I think, you know, we’ve got to have a better way of engaging with people who have had the experience, engaging with people that are living in, sort of, residential settings and talking to them and planning, and co-design work. Which I think could have made a difference, actually.

I think people were so shocked and stunned about the, sort of, instant, you know, “We’re going to stop visiting”, I think it was terrible for people.

Mr Weatherby: Thank you very much.

My Lady, my other two points have been dealt with so that’s –

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

Now it’s Ms Jones, who is over that way.

Questions From Ms Jones

Ms Jones: Thank you, my Lady.

Ms Killian, I ask questions on behalf of John’s Campaign, The Patients Association and Care Rights UK.

And I want to ask you about the support that was given to care providers to meet their legal obligations.

Firstly, and related to the question that Mr Weatherby just asked, statutory guidance under the Care Act confirms that the wellbeing principle is a guiding concept and it places individual wellbeing at the heart of the provision of care and support. Can you explain what steps local government officials took to ensure that wellbeing was properly considered during the pandemic?

Ms Joanna Killian: Yeah. So I mean, I’m assuming there’s been a lot of discussion here about, you know, the functioning of the Care Act. But at the heart of the Care Act and other supporting legislation is this sort of driving principle about people being supported to be independent and live well, and for prevention to be in place to ensure that people can live sort of happy healthy lives as long as they can.

So I think genuinely, through the crisis, councils absolutely in thinking about support for not just older people, but a variety of other people, was about protecting their wellbeing. And sometimes that absolutely was about their physical wellbeing, but an awful lot of support went into enabling people to sort of cope and to address, I think, poor mental health that was becoming obvious through stages of the pandemic.

So I think where councils had a very specific duty to an individual, of course it was about protection, but I know, including from my previous role, the importance that councils placed on making sure that, you know, people could cope as well as they could.

So for many councils, as well as sort of delivering on their sort of statutory duties, did a huge amount of work in terms of welfare support, working with the community and voluntary sector, to support people in their places, including people living in their own homes, provided food packaging, you know, delivered sort of online sort of conversations, support. So I think the wellbeing principle was, you know, in the minds of social workers making their assessments as well as it was for councils.

But it was – it was tough to do that, you know, consistently in a circumstance where, for example, you know, people couldn’t see their families.

Ms Jones: Was the conflict that arose between different aspects of wellbeing, so the physical wellbeing that had caused the introduction of things like the visiting restrictions as compared with the more holistic view of wellbeing, as we came to understand the damage that those restrictions were having on people, was that conflict something that you at the LGA were discussing with the people or had ever had to balance before?

Ms Joanna Killian: I mean, I think, sort of, “conflict” is a, sort of, difficult word. I think many colleagues in local government, individual social workers, care home providers, were genuinely trying to, sort of, balance keeping people safe, some of the most vulnerable people safe, based on evidence that was emerging from, you know, Public Health England, from the Chief Medical Officer, in trying to balance that immediate protection against, sort of, the wellbeing principles.

And I think, as the pandemic progressed, I think, you know, more and more people believed the need to get those two in sync was imperative. But I think it was really hard at times to do that, including for people that had to self-isolate. They – these were a very, you know, restrictive bunch of arrangements that people had to live with.

But I believe strongly that, you know, staff, both commissioners and providers, really wanted to do the right thing consistently, and sometimes it was just tough to do that.

Ms Jones: Thank you. And then can I ask, what, if any, steps were taken to support care providers in taking individualised approaches to people who need care rather than imposing blanket restrictions?

Ms Joanna Killian: So, I mean, in the early days of, you know, the pandemic – I mean, we’ve talked earlier about sort of multiple sets of guidance that was available, but as things eased – I don’t mean “ease” – as things, sort of, changed, I think a number of providers went above and beyond to absolutely, sort of, tailor and individualise packages in the context of the provisions that were available to them.

And people that run care homes know exactly, I think, about how they should support individual needs, and I know that they worked really hard to meet those needs in the context of the arrangements that were being forced on them, I think.

Ms Jones: Thank you.

Thank you, my Lady. Those are all my questions.

Lady Hallett: Thank you, Ms Jones.

Ms Beattie.

Ms Beattie is over that way.

Questions From Ms Beattie

Ms Beattie: Ms Killian, I ask questions on behalf of Disabled People’s Organisations, and can I ask you, please, about easements, and when they were required and when they could otherwise be avoided under the existing Care Act framework.

At paragraph 669 of your statement you say that:

“… most councils were able to find sufficient flexibilities within the existing Care Act framework to avoid the need to [make use of easements].”

Is it right that flexibilities in this context is about how eligible needs are met, but not whether they’re met?

Ms Joanna Killian: So, I mean, the Care Act duties are clear, and councils knew they had to meet the needs of individuals. Sometimes it was more complex to meet those needs if, you know, day centres, for example, were shut or there weren’t provision in some bits of the sector. But I’m absolutely clear that, you know, local government absolutely knew it had to meet duties towards individuals, and delivered that.

Ms Beattie: So when you use the word “flexibilities” in your statement in that way, you mean that the councils still met the eligible needs but did so in a different way because the usual means were unavailable, for example?

Ms Joanna Killian: Yes.

Ms Beattie: And just to put that into concrete terms, you’ve mentioned day centres, so if, for example, someone had an eligible need of meal support or provision, and they would normally get that at the day centre that they attended and that was in their care plan but the day centre was closed, an alternative could be, obviously, to provide that meal at home or make some other arrangements so that that need was still met; would that be right?

Ms Joanna Killian: Precisely, yes.

Ms Beattie: And an easement, though, would be required, and just to be clear about this, for streamlining of services, instead of providing a genuine alternative it, is that right? Or reducing care to a person that’s provided under their plan?

Ms Joanna Killian: So the matter of easements is a sort of contentious one. Local authorities are, and remain, clear about the importance of delivering for people’s needs. So to even contemplate an easement was a big thing at that time, and it was about I think publicly saying, “Actually, we’re going to have to sort of think about how we deliver needs.” I honestly do not recognise a council saying, “We’re not going to meet the need”, it was about how we would do it differently but still meeting the needs that an individual had.

Ms Beattie: So Ms Killian, just to go back to my question, the streamlining of services as opposed to providing an alternative or actually reducing care would be in easements territory and require an easement; is that right?

Ms Joanna Killian: I’m not sure about the sort of language of streamlining.

Ms Beattie: Okay. I think the LGA and ADASS produced some guides I think, for local authorities for – to explain the easements; is that right? Some joint guides, and that said in terms that streamlining and reducing personal care for a person would be in easements territory; is that right?

Ms Joanna Killian: So I mean, we sort of commented on guidance and I just feel I’m going to repeat myself again. I mean, the importance was about continuing to meet needs. It might have done it differently and in extremis, you know, may have had to acknowledge, you know, I think in your language a sort of streamlining, but I think all councils knew they still had to meet needs effectively.

Ms Beattie: And if that document confirmed that that streamlining or reducing care was in what was called stage 3 or stage 4 of easements, that was definitely easements territory, wasn’t it –

Ms Joanna Killian: Yeah.

Ms Beattie: – stages 3 and 4.?

So again, for example, cancelling home care visits to assist someone with hygiene or toileting needs contained in the care plan and not doing anything in substitute to meet that need would, again, be in easements territory; yes?

Ms Joanna Killian: Yeah, yeah.

Ms Beattie: And is it right that at the time during the pandemic, local authorities were not under a duty to report replacement services or flexibilities, if I can put it that way, to central government, but they were required by the guidance to report easements; is that right?

Ms Joanna Killian: Report incidents? Sorry, I didn’t get the last bit, sorry?

Ms Beattie: Sorry, to report easements. To report their use of easements.

Ms Joanna Killian: Yes, there was a requirement – if an authority took a decision to report an easement, then that had to be put into the public domain, registered with CQC.

Ms Beattie: Not just if they took a decision to report it, but if they were at stage 3 and 4 and using easements, they had to red them, didn’t they?

Ms Joanna Killian: Yes.

Ms Beattie: But at that time, the part 1 of the Care Act duties which include some flexibility were not subject to any reporting or, indeed, regulated inspection by the CQC, were they?

Ms Joanna Killian: Sorry, I’m not sure of the point. Sorry.

Ms Beattie: Well, I think – are you aware that since April 2023, the CQC has had a role of conducting reviews of regulated care –

Ms Joanna Killian: Yes.

Ms Beattie: – and functions by local authorities?

Ms Joanna Killian: Yes.

Ms Beattie: That wasn’t in place during the pandemic time –

Ms Joanna Killian: Yeah.

Ms Beattie: – or during easements’ time. So flexibilities weren’t required to be reported but easements were; is that right?

Ms Joanna Killian: I believe so, but I will absolutely clarify the sort of your language of “flexibilities” versus “easements”.

Ms Beattie: Well, I think it’s – Ms Killian, you had used the word “flexibilities” as saying you said that’s what most councils had done during the pandemic?

Ms Joanna Killian: Yes, it’s recognising – to meet a person’s needs, you know. During the time of the pandemic not all facilities or options were open, so needs were met in – using sort of different tools or different approaches. So that’s my, sort of, language of “flexibility”. I think, you know, invoking a, sort of, easement was something that councils considered very carefully and had reporting requirements attached to it.

Ms Beattie: Do you think that the organisation Think Local Act Personal was right in their report of October 2020 that there were different approaches taken by local authorities across the country, with some using what they called so-called “flexibilities”, and some using easements, such as there was what they described as the very grey area between the two?

Ms Joanna Killian: So only a very small number of councils chose to invoke easements. You know, local authorities deliver care to very different communities in different ways across the country. It’s very different delivering sort of home care in a rural area versus delivering home care, say, in a city. So, inevitably, care packages are built on the basis of what people need, what’s available in their communities. And I think that sort of publication partly, sort of, highlights the difference that have always existed and I think drew a sort of line about how different easements were.

So I’m sort of familiar with that. I think the language of, sort of, a grey area, again, is not helpful in that, you know, councils do have packages built to meet the needs of their communities. They are not, sort of, one-size-fits-all packages, but absolutely, the duty to deliver care is paramount.

Ms Beattie: But is one of the consequences, though, that we are now left without a complete and comprehensive picture of how care plans were subject to replacement services under the Care Act, or actually being eased and reduced and streamlined in stages 3 and 4 territory easements?

Ms Joanna Killian: So I don’t think there is one single record that sort of sets out for every recipient what sort of care package they got, you know, pre-the pandemic, during the pandemic, and for those small number that were affected by easements. We don’t have a single record.

Ms Beattie: And it may be obvious, but do you accept that a system can’t rely on individual disabled people who are care recipients of care plans to make complaints or even commence litigation to establish whether or not the local authority services being provided during the pandemic were being provided flexibly or actually reduced?

Ms Joanna Killian: Sorry, can you just say the question again? Do I? I can’t hear brilliantly.

Ms Beattie: Sorry.

Lady Hallett: Basically, the individual recipient of care or their loved ones can’t complain about the level of care delivered in the care package.

Ms Joanna Killian: So I think, you know, disabled people and other people – I mean, absolutely have a right to be able to express their concerns about the nature of care that they were provided with, and there is a number of routes in to local authorities, to trigger alerts if people are concerned through a sort of section 42 and through to the CQC. So there were mechanisms then; they exist now.

Ms Beattie: Yes. In a pandemic, though, it wouldn’t be right, would it, for a system to rely on individuals isolated in their homes in pandemic circumstances to make those – such complaints in order to find out and again, a systemic – systematic oversight of what was happening in care plans, would it?

Ms Joanna Killian: It wouldn’t be right for individuals to feel like they have to do that, no.

Ms Beattie: And is that all the more so in a situation where the emergency law themselves – itself brought in for Covid, the Coronavirus Act, had altered what were the usual duties to provide and meet needs into a discretionary power? So changing those goalposts, if I can put it that way.

Ms Joanna Killian: So I mean, I think it’s really important to say, I mean, the easement provision was there. It wasn’t used, you know, authorities wanted to continue to deliver the best care packages they could in the circumstances that were there, and present.

Ms Beattie: And is it right that –

Lady Hallett: Sorry, Ms Beattie, I’m afraid we’re going to have to leave it there.

Ms Beattie: Okay, thank you, my Lady.

Lady Hallett: Thank you very much.

Those are the questions we have for you, Ms Killian. Thank you very much indeed. I’m sorry we had to take you back to what was obviously a distressing time for everybody concerned. But thank you very much for your help, and I don’t know how much of this very lengthy statement you produced and how much your colleagues did, but could you thank them for all the help that they’ve given to the Inquiry as well.

I’ve got a feeling we may be asking you for more help in modules to come so I can’t say goodbye, but thank you for the help you have given so far.

The Witness: Thank you. Thanks very much.

Lady Hallett: Thank you. I shall return at 11.50.

(11.37 am)

(A short break)

(11.50 am)

Lady Hallett: Ms Paisley.

Ms Paisley: My Lady, the next witness is Dr Maria Rossi.

Dr Maria Rossi

DR MARIA ROSSI (affirmed).

Questions From Counsel to the Inquiry

Lady Hallett: Good morning.

The Witness: Morning.

Ms Paisley: Dr Rossi, thank you for attending the Inquiry today and for providing your statement to this module, dated 2 April 2025. That statement has been co-signed with Paul Johnston, chief executive officer of Public Health Scotland, and Scott Heald, who is head of Data and Digital Innovation, and the Inquiry understands that they assisted in the production of the statement; is that correct?

Dr Maria Rossi: Yes, thank you.

Counsel Inquiry: Briefly, please, dealing with your background, you hold a masters in health services research and public health epidemiology, and since 2005 you have been registered as a UK specialist in public health medicine.

You joined the pandemic effort at Public Health Scotland in March 2020, where your main areas of work were in response coordination, including adult social care and general liaison with the Scottish territorial health boards, the other UK public health agencies, and the Scottish Government?

Dr Maria Rossi: (Witness nodded)

Counsel Inquiry: And presently you work at Public Health Scotland as head of division for environmental and emergency response in the Clinical and Protecting Health Directorate; is that all correct?

Dr Maria Rossi: Yes, and I also have a medical degree from University of Rome.

Counsel Inquiry: Grateful, thank you.

Public Health Scotland is an NHS Board sponsored by Scottish Government and the Convention of Scottish Local Authorities on behalf of local government. It is Scotland’s national public health body, which leads and others work across Scotland to prevent disease for a long and healthy life and promote health and wellbeing; is that correct?

Dr Maria Rossi: Yes.

Counsel Inquiry: Can you assist, please, how did its joint accountability to both local and national government work in practice throughout the pandemic?

Dr Maria Rossi: So the dual sponsorship to Scottish Government and COSLA is important because public health is actually an area – a discipline of medicine but also an area of other work that has to encompass both health and social care, and we work with government, working on policies, advice, et cetera, particularly during the pandemic phase, therefore it’s important that that sponsorship that was there at the start of our organisation, from 1 April 2020, made an important contribution to ensuring that that happened.

Counsel Inquiry: The Inquiry is familiar with the establishment of Public Health Scotland in April 2020, and the retention of the Antimicrobial Resistance and Healthcare Associated Infection, or ARHAI, within National Services Scotland, but I just have a few questions, please, focusing on the scope of this module.

In your statement you say Public Health Scotland would acknowledge that the coincidence of the start of the pandemic with the establishment of new organisations caused challenges in how it responded to the pandemic.

And if we could have on screen, please, INQ000586047 at page 2. And this is an email dated 23 April 2020 from Dr Ramsay, who was then the Strategic Incident Director for Covid-19, to Angela Leitch, who was the then chief executive. And he said:

“This is an update on developments in relation to the PHS work on the Care Homes situation.

“The number of people in PHS involved in this work has escalated resulting in a lack of clarity in terms of who has overall responsibility and leadership. I have therefore tried to clarify who within PHS is involved in this work associated with the Care Homes issue and to address how this is being coordinated.”

Then scrolling down a bit, it says:

“In view of the increasing complexity of roles in PHS in relation to this topic and the risks for confusion on overlapping work I called a meeting this evening with Scott Heald, and others to discuss the situation and to try to clarify roles and responsibilities.”

Were those the sorts of challenges experienced at the start of the pandemic?

Dr Maria Rossi: Yes, so this relates particularly to the situation within Public Health Scotland, but in the pandemic, of course we had to and wished to work in collaboration with many other agencies. So having a focus within PHS for the likes of care homes was important, and my colleague Dr Ramsay was pointing this out as an issue towards the beginning of April.

Counsel Inquiry: And in the view of Public Health Scotland, did this cause any difficulties prior to 23 April?

Dr Maria Rossi: I should premise that I joined in – towards the end of March, but I’m aware that – well, generally, health protection and public health generally are very used to working across organisational boundaries, team boundaries and topic boundaries, so this wasn’t an unusual situation to have to work in the pandemic with multiple agencies and organisations, so whether – at the start of a pandemic, an unusual event, obviously there is a lot of organisation that goes on in setting up a response, which has to happen in very short time, and Public Health Scotland, or Health Protection Scotland as it was prior to 1 April, had the incident and emergency response plan in place, and when the determinations were made, I believe, in late January that this required that type of response, that process kicked into place.

Counsel Inquiry: And do you think that there was some confusion until the time of this email?

Dr Maria Rossi: I’m not sure I would note it as confusion. There were many people involved in doing a lot of work in very short time frames. So the coordination of that was important and needed to certainly settle at the start, and it took a while for that to settle, mainly because the situation of care home situations had to, by its very nature, involve many agencies. So we didn’t have specifically a care home group in Public Health Scotland before the pandemic –

Counsel Inquiry: We’ll come up on to that, please, in just a moment, but if I can look at the response of Angela Leitch, please, who said:

“Thanks for this update. That sounds much more joined up than had previously been the case.”

So do you think that there was further clarity beyond 23 April, and do you think the organisation perhaps got a grip on that clarity early enough?

Dr Maria Rossi: Yes. By way of example, and Angela Leitch who was our chief executive at the time would have been going to certain meetings, covering certain meetings at the last minute and with, perhaps, colleagues in the health protection area that weren’t with her or, possibly, sometimes, not able to brief her and the impression that she had wasn’t surprising but it must be said that during pandemic this sort of thing did happen recurringly because there were so many entities that had to play a part in it and I think she’s highlighting, particularly in this email from Dr Ramsay – between Dr Ramsay and herself, the issue, for example, of data when there were many sources of data, everyone trying to put something together in order to support the care home situation and that’s being reflected.

Lady Hallett: Can I ask you to slow down. I know it’s difficult.

The Witness: Sorry.

Lady Hallett: Don’t worry, I have a fast speech pattern too, but we have a stenographer struggling to keep up.

The Witness: Of course, apologies.

Ms Paisley: Thank you, my Lady.

And something you just touched upon, you explain in your statement that there were corporate arrangements put in place in Public Health Scotland to drive its response to the pandemic and you say:

“It should be noted that from the outset, none of the corporate groups in these arrangements had a specific [adult social care] focus.”

Was that an oversight or was there a particular reason for that?

Dr Maria Rossi: A pandemic response has to be ready for anything that arises, and care homes, although an important setting, particularly by way of the nature of the virus, the novel virus that was coming on board was particularly vulnerable, there are a number of settings for which we couldn’t, in anticipation, set up processes or pieces of work or individuals dedicated time against for all the time, nor could we always foresee it. So this not something unusual in an emergency response, but an organisation like PHS needs to be prepared to get that coordination into play relatively quickly, and perhaps that’s where PHS being a new organisation had a particular challenge, I guess.

Counsel Inquiry: So in the future, is there a specific corporate group that would be set up to deal with that sector?

Dr Maria Rossi: So we are looking at that and certainly that has already started in the area of data. In the Data and Digital Innovation team that Scott Heald leads, there has already been a review of care home data that has tried – that has looked at multiple sources of information that can inform the care home situation, and that’s even outwith the pandemic but ready for any sort of crisis that could arise.

Counsel Inquiry: Are there any lessons, in particular, to be gained from Public Health Scotland’s initial structure over the first few months of the pandemic that could be taken forwards as learning for a future pandemic?

Dr Maria Rossi: So 1 April had been set as the start for PHS, many months before, I would have thought even a year before. And so in that, in the ensuing time there was much preparation going on for the new organisation. I guess that elements of Health Protection Scotland, as was, got somewhat deviated from the attention of that from December, January of 2020, and therefore that might have taken away from the health protection element of it, but I think that there are many lessons that we have learnt and taken on board from that, and still working to improve on coordination, particularly with external partners, and some work also internally.

Counsel Inquiry: And then one final comment, please, from Ms Leitch on this email. And she says:

“I had asked [an individual] to coordinate to avoid the confusion that was played out at the meeting with DPHs yesterday but I understand from speaking to her that she hadn’t been able to make the connections necessary.”

Is DPHs – is that a reference to the directors of public health?

Dr Maria Rossi: Correct.

Counsel Inquiry: Can you please help, what was the division as between Public Health Scotland and the directors of public health insofar as the pandemic response to the adult social care sector?

Dr Maria Rossi: So the directors of public health are directors in each of the 14 health boards in Scotland. They report through their chief executives directly to Scottish Government and are accountable – that’s the pathway of accountability.

Public Health Scotland is an organisation in itself also directly accountable to Scottish Government and COSLA, and the relationship between the two is that Public Health Scotland is there to advise the public health elements that boards effect at the front line, and it is – and it is very much an advisory role that we have. The directors of public health do not in any way report or are accountable to PHS in their work, which is a different model to what may happen in England.

So the meeting that Ms Leitch would have gone to with the DPHs would have been something at the start that she went to in order to support the directors of public health, an active – a very active group currently and during the pandemic, but it was essentially their role, as directors of public health and the health boards, to protect the – their population based on geographical grounds. Whereas PHS had a national remit in supporting each of them.

Counsel Inquiry: The Scottish Directors of Public Health Care Home Working Group that was attended by Public Health Scotland, one of the main outputs of that group was the ‘Final Joint Framework for Action - Covid-19 Care Home Settings’, which was jointly drafted by Dr Ramsay of Public Health Scotland, and the Inquiry understands that’s date in around April 2020.

Does Public Health Scotland have any views on whether that sort of document was useful in dealing with different lines of accountability during the pandemic, and would something like that help in the future?

Dr Maria Rossi: Oh, definitely. I mean, even in non-pandemic times we work very much with the directors of public health and their teams on the area of health protection, their health protection teams, but that was exactly a nice – a good manifestation of how we work together. What they agreed in that document, with the input from PHS and also directors of public health, was no surprise, but also very helpful to get it down as a schematic that should be followed.

Counsel Inquiry: Just finally dealing with background, please, you explain in your statement that Public Health Scotland was aware of confusion between the role that Public Health Scotland played and the role of local HPTs at the front line. I understand that’s health protection teams. Why do you think that confusion arose and did it have any impact upon the response?

Dr Maria Rossi: So, not infrequently, and it does still happen sometimes, frontline services will say, “Public health said that that’s what we need to do” or “This is a guidance from public health”, and that generic “public health” term could mean, depending on the context, a local health protection team that is directly supporting services in the health boards, or it could be national, ourselves as a national agency, that would be supporting or advising the health protection teams but, by reflection, also advising the local services.

So it would be important – a classic example might be that if a care home had an outbreak and they reflected that public health had advised them to cease visiting or undertake certain interventions, what they sometimes said was Public Health Scotland, and that wasn’t the case, because we did not have a direct relationship with care homes and services of front line; that was always through the health protection teams.

Counsel Inquiry: Thank you.

Can I move, please, to the topic of infection prevention and control. And before we come on to the specifics of who was responsible for the guidance, can I first ask, in the view of Public Health Scotland, is nation-specific IPC guidance required for care home settings in Scotland?

Dr Maria Rossi: So, we take a four nations approach, and always have, and all the more so during pandemic. And on the issue of infection prevention and control, it’s important that any policy or guidance then comes out – that comes out is reflective of how each of our systems work. Health is devolved, therefore our health systems are a little bit – moderately diverse between the four nations.

So an infection prevention and control remit, it’s understandable that we have four teams that work on that, but they do work on a four nations approach.

If anything goes awry in that relationship, certainly that can create a problem, but the evidence base that is gleaned in order to inform guidance, and indeed policy, should be the same, and should use the same criteria to judge it, but there can be nuances and work that goes more or less in depth. So the four nations approach is paramount, but we appreciate and understand how that can be slightly different for the four nations.

Lady Hallett: If I can ask you again to slow down.

The Witness: Sorry.

Ms Paisley: There is space then, perhaps, for nuanced advice in each nation?

Dr Maria Rossi: Yes.

Counsel Inquiry: Are you aware of whether Public Health Scotland or ARHAI provided any training for care homes in respect of IPC during the pandemic?

Dr Maria Rossi: So the training of staff in services is the responsibility of the employer. The – in local health boards, support for training can come either from the local infection prevention and control teams, usually based in healthcare settings, hospitals, or from the health protection teams.

And broadly speaking, although each health board can do it as best fits them, broadly speaking, infection prevention and control teams would support healthcare setting – training, and health protection teams would support advice and guidance for – in community-facing services such as care homes.

However, these are – there are over 1,100, I think, care homes in Scotland, and 14 health protection teams, for example, so the – any training or advice and guidance that was brought from the health protection teams to care homes was very much focused on outbreak management rather than routine training, and I think that that’s a need that needs addressed.

Counsel Inquiry: And would it be the health protection teams that would be best placed to deliver that training, in your view?

Dr Maria Rossi: Interesting question. Something that really needs to be worked through.

The health protection teams would use ARHAI’s National Infection Prevention and Control Manual for that training, so the resource is there produced by ARHAI nationally, but who does the training is actually something for each of the health boards to determine.

Counsel Inquiry: Just a few more brief questions, please, on IPC measures.

Following 1 April, there were three categories of guidance: health protection guidance that was developed and maintained by Public Health Scotland, health and social care IPC guidance developed and maintained by ARHAI, and then joint outbreak management IPC guidance.

How was consistency ensured between Public Health Scotland and ARHAI guidance? So, for example, did the guidance interrelate? Did it have links? Can you help us, please.

Dr Maria Rossi: I should also point out that there was a fourth element of guidance, and that was coming from Scottish Government.

Counsel Inquiry: Yes.

Dr Maria Rossi: The links during the pandemic on guidance matters were very easy, so to speak. We had been part of the same organisation up until 1 April, ARHAI and Health Protection Team, as it was, was lodged within NSS, and that relationship continued throughout a good part of the pandemic in a very close way.

So when it came time for guidance to be written, on – in an iterative and infrequent basis, we were working very much in tandem, and in fact, in order to keep up with the changes in policy that then led – had to lead to changes in guidance, we took the tack, in PHS, that we would link directly to ARHAI’s guidance and where it was of additional benefit to provide a little bit more explanation, we did so in our guidance documents, but anything that we put into our guidance that was in relation to a specific point of guidance, if the policy changed, we had to do another version, right, so we tried to keep it through links that that would be the way.

Counsel Inquiry: Now, you refer to two issues, if I can put it that way, in your statement, and you say at 2.3.12:

“The lack of clarity contributed to some of the delay in issuing changes in relation to the guidance, since IPC policy positions came to PHS guidance teams sometimes at third hand …”

Then you also explain that PHS was responsible for supporting local health protection teams in the management of outbreaks, yet the guidance was owned and composed by ARHAI. And you call that an operational challenge.

How were those challenges addressed in the pandemic, and is any further work ongoing?

Dr Maria Rossi: Okay, so those are two separate issues. So briefly, the first one was really more about the pathway of communication from decisions being made or attempting to be made at a four nations basis by an IPC cell, infection prevention control cell that ARHAI participated in with the other three IPCs of the three nations, and the way that that information came ultimately to PHS that were trying to operationalise Scottish policy was sometimes challenging. It could go down a route of directly, ARHAI was directly involved in IPC where decisions were being made and would reflect those back to us, but if there were, understandably, chief medical officers groups involved or Scottish Government policy people involved, the pathway could be more tricky, shall we say.

Counsel Inquiry: Can I just interject at that point. How was that dealt with during the pandemic, practically?

Dr Maria Rossi: It’s a big point of learning, that one, I must say and we’ve taken that on board to work with the – across the four nations much more closely on that and to have a recognised structure pathway for that, including with infection prevention control colleagues. Sometimes changes that we would need to reflect in our guidance came to us very late in the day, sometimes even through press briefings by our political leaders. And we would immediately try to find what was meant by it, what the source was, what was the understanding behind it, in order to put it into our guidance, and that took time.

Counsel Inquiry: So better lines of communication may be one way?

Dr Maria Rossi: Yes.

Counsel Inquiry: And just finally, in Module 3, Dr Phin told the Inquiry:

“I think it’s important to realise that ARHAI’s remit is defined because it’s part of the NHS Assure, which is for healthcare-associated infection. That does leave a gap when it comes to community settings.”

He referred to:

“… the role of Health Protection Scotland in taking the principles that were developed for the healthcare setting, and adapting and trying to use them in those wider settings. This is something that’s being discussed at the moment to make sure that … gap is addressed, and we’re in … discussion with ARHAI, and indeed with Scottish Government about how we address this going forward.”

Was there a gap, then, as regards IPC guidance for the sector during the pandemic, and if so, how is that being addressed?

Dr Maria Rossi: So during the pandemic, as I mentioned earlier, we were working very closely with ARHAI. I think probably the gap there was more along the lines that ARHAI’s remit very much concentrates on healthcare settings, and in pandemic, suddenly we had to do a lot of infection prevention control, interventions, guidance, in relation to the wider community. Things like physical distancing was something that it was – we were aware of it as a concept, a potential public health intervention but, actually, finding the evidence base to back that up required time, and that wasn’t in the outright remit of ARHAI, hence we did have a gap that Public Health Scotland very much wishes to address now.

Counsel Inquiry: Is work going on, then, to address that?

Dr Maria Rossi: So there is work going on in terms of how these gaps that may relate to ARHAI’s work and Public Health Scotland’s work, how do we address them? Are there true gaps, and how can we fill them?

But the other way to think of that is, which is what we’re also proactively taking forward, is working more closely at four nations basis. So UKHSA, on our guidance formulation, and you may be aware of the Mpox outbreaks that arose in recent year, we were very much more embedded in with their guidance teams than during pandemic, and we hope to see more of that going forward.

Counsel Inquiry: Can I change topic, then, please, and can I move to hospital discharge and testing, and moving to March specifically, please. And on 12 March 2020, Public Health Scotland produced guidance for the sector, and the Inquiry heard evidence from Ms Freeman last week that this followed concerns raised on 11 March of reports that some care home providers were restricting new admissions and visitors.

Was Public Health Scotland asked to include any information in the 12 March guidance on accepting patients from hospital or wider hospital discharge issues?

Dr Maria Rossi: So I can’t quote you all the dates of each of our guidance documents, but I do know that there was also a PHS guidance document on that topic, the 13th. So things were happening quite quickly.

In terms of discharges from hospitals, those were – into care homes – that was something that the government were looking at very closely at that stage.

Counsel Inquiry: But just specifically, do you recall if anything was asked to be included about that topic in the 12 March –

Dr Maria Rossi: Not as yet. That was being figured out, so to speak, and worked through with support of UKHSA and the Chief Medical Officer’s team, et cetera.

Counsel Inquiry: And we’ll come on to that in just a moment, but can I please have on screen INQ000189305, which is the 12 March guidance and on page 11 under the heading “Home Visits/Care at Home”, can I take it, then, that this was in part relevant to domiciliary care?

Dr Maria Rossi: Yes.

Counsel Inquiry: And that guidance said:

“People who have been in close contact with a confirmed case of COVID-19 are also being advised by the local Health Protection Team to self-isolate. People who are self-isolating and have no symptoms do not pose a risk to others.”

My question is, given the emerging knowledge of asymptomatic infection and transmission so, for example, in February 2020, SAGE had been unable to rule it out, is there a possibility that that guidance may have provided false assurances?

Dr Maria Rossi: It could have done but it was very much a developing understanding that we had with this novel coronavirus.

Counsel Inquiry: Now, moving to 13 March then, please. You explain that the Scottish Government reminded services to continue to discharge patients into care homes, and the letter that was sent stated:

“In the early stages where the priority is maximising hospital capacity, steps should be taken to ensure that patients are screened clinically to ensure that people at risk are not transferred inappropriately but also that flows out from acute hospital are not hindered and where appropriate are expedited.”

And you explain that it has not been possible to identify advice provided directly by HPS, as it then was, to Scottish Government. However, the letter did include a link to the Health Protection Scotland guidance.

In those circumstances, then, is it the view of Public Health Scotland that it should have been consulted on the contents of that letter?

Dr Maria Rossi: So the letter that you’re referring to is the letter from Scottish Government, not from us –

Counsel Inquiry: Yes.

Dr Maria Rossi: – yeah. Yes, as the Public Health Agency for Scotland, we take very seriously our advisory role to the health boards but also to Scottish Government. That may have to do something with us starting as an organisation, since – we worked closely with Scottish Government even before the institution of PHS. But when the pandemic came along, I think that our specific and structured advisory role to government was not as clear as we would have wished it to be, and we were often involved in such discussions through, perhaps, the Chief Medical Officer’s team, but not directly in advising ministers.

Counsel Inquiry: Are you able to assist with what the view of the – of Public Health Scotland was about discharges at that time? Did it think it was a sensible idea? Was it a requirement? What was the conversation in Public Health Scotland?

Dr Maria Rossi: Yeah, so in the March, it made sense in that we could see this pandemic coming. We could see what was happening in other countries, and the severe challenges that the health systems were undergoing with that, and so it was very logical that we had to make space for the more severely affected individuals who required hospital care. Therefore, creating that space, by ensuring that only people who required to stay in hospital was what was happening, was very much the right policy to undertake.

There are always challenges with healthcare systems nowadays. One very clear one is that of delayed discharges, and that was an issue at the time in March, that it would make sense to find a better place for individuals who did not require to be in hospital for clinical purposes anymore, but should be supported in going either back home or to – or placement for their home.

So we could see how that was a very important issue to consider, and as the knowledge and understanding of how the novel coronavirus was working, we also became very clear that one pathway, the one into care homes, had to be addressed carefully.

Counsel Inquiry: And if I can focus on 13 March, Public Health Scotland had a key role in testing and contact tracing. Did Public Health Scotland have an awareness of the number of tests available at 13 March?

Dr Maria Rossi: Generally speaking, yes, throughout that period of expansion of testing we were kept very much briefed.

Counsel Inquiry: And did Public Health Scotland have access at this time to the numbers of people being discharged from hospitals to care homes?

Dr Maria Rossi: That was more difficult.

Counsel Inquiry: Would that have been helpful information to be provided to Public Health Scotland?

Dr Maria Rossi: Yes, indeed.

Counsel Inquiry: Is that data that is capable of collection, and if so, who should collect it in the future?

Dr Maria Rossi: So that was a big challenge of the – I’m sure we’ll come on to it – the report from Public Health Scotland undertaken by University of Edinburgh and Glasgow colleagues, where they had to look at the discharges from hospital to care homes. And if they didn’t have an actual denominator of individuals to whom this related, then they couldn’t do the work. A lot of time was spent in deciphering what that denominator was, what the numbers of individuals were that were going – that had a pathway from hospital to care homes, using multiple sources of data, because it wasn’t there automatically.

Counsel Inquiry: Is it now available? So, in the event of a future pandemic, is that readily available information?

Dr Maria Rossi: I would have to check if it’s readily available but it’s certainly – the methodology that was used at the time has been progressed, most definitely.

Counsel Inquiry: And was Public Health Scotland ever specifically asked if there would have been enough tests available to test all patients on discharge from 13 March?

Dr Maria Rossi: I think we knew that there wouldn’t be, in terms of the priority for testing at that time was diagnostic. The system needed to make sure that people who had coronavirus, the Novel Coronavirus, and required hospital care, were going into hospital care with that knowledge. So it was understandable that the primary priority for testing at the time was diagnostic.

Counsel Inquiry: And given that you’ve said that Public Health Scotland didn’t have access to the numbers, is it right to say that it was never actually investigated if there would be enough? Was it an assumption that there wouldn’t be enough?

Dr Maria Rossi: We had numbers to the tests – we were kept briefed of the tests on a pretty much daily basis of how many tests were available at UK level in Scotland – but we didn’t have access, ready access, to the numbers of people coming out of care homes. But yes, that would have been useful. Coming out of hospital, sorry.

Counsel Inquiry: Thank you.

Now, the letter sent by Scottish Government also said, based on the emerging picture around Covid-19, that the CMO advice suggests that long-term care facilities should be subject to social distancing. Was Public Health Scotland asked to provide advice on the social distancing in care homes at that time?

Dr Maria Rossi: If by “advice” you mean as I would, that were we asked to seek the evidence base by which that was – that was the thing to do? Not specifically.

Counsel Inquiry: Not specifically. Was it discussed with Health Protection Scotland, as it then was?

Dr Maria Rossi: Yes, and a lot of the information that we had would come from our colleagues down south.

Counsel Inquiry: To combat the risk of potentially asymptomatic patients being discharged into care homes, what is Public Health Scotland’s view on whether all new admissions should have been isolated either before or upon entry to a care home from 13 March?

Dr Maria Rossi: So the isolation of individuals transferring from hospitals, where we knew there was Covid, to care homes where, unless – at that stage, unless people were symptomatic, we assumed that they didn’t have Covid, was very important.

We agreed with that policy as isolation would be one of the hierarchies of control to institute if you’re trying to remove a risk from a population. So that was a very sensible albeit challenging thing to do.

Counsel Inquiry: And do you think it should have come in from 13 March in retrospect or in hindsight?

Dr Maria Rossi: What happened at that stage is that we were very much working on a basis of symptoms being a – evidence of infection, and the advice at that stage was anyone who had symptoms certainly would often not go to – they wouldn’t take that pathway into care homes. But anyone who had been in contact with someone who had symptoms or a diagnosis in Covid in hospital, ie, a contact of exposure, was advised to be isolated as far as was possible at that stage. That’s how –

Lady Hallett: Can I ask something about that? Sorry to interrupt.

Given that Ms Paisley put to you earlier, the basis of someone being infectious even though asymptomatic had not yet been ruled out, and I appreciate that as scientists you act on evidence but, as I’ve heard the expression a number of times, the absence of evidence – I can’t remember which way round it is, but anyway, the fact that you don’t have any evidence doesn’t mean that it’s not going on, surely the wisest course would be to say: look, we think this is only transmitted symptomatically, but just in case, we’re going to recommend that everybody that’s going from a high-risk environment like a hospital is put into isolation. Wouldn’t that have been the sensible course?

Dr Maria Rossi: It could be, but we also have to consider – and here’s the discipline of public health, where it comes in – we have to consider a number of factors when we provide that advice to people who are working at the front line, and if, for example, as we’ve heard, there were issues of PPE supply or training in the care homes, or even the buildings – in the main I think we’re adapted for that, but if those were issues, then issuing such a recommendation on the basis of what we call the precautionary principle might not have been the best at the time.

I think there’s little doubt that symptoms, and at the very start of somebody with symptoms, who might not even realise that they’re coughing inadvertently, is a high-risk time, and therefore, that was taken as the signal to put interventions in a place.

When it became clearer from others’ experience and studies that were being done that solely relying on that might not be sufficient, then the advice changed.

Lady Hallett: But again, going back to principle, surely it should have been – the advice should have been: care homes, unless you have the PPE, unless you have the isolation facilities, do not accept these people from a high-risk environment because it might then spread through a very vulnerable community?

Dr Maria Rossi: But if they were able to keep to the isolation principles, which they should have been able, and most of them did, in a care home where rooms, for the main, are single, then they would have been able to keep the individual isolated for the period of time accorded.

Lady Hallett: I think that was the point of my first question, but anyway I’ll leave it to you, Ms Paisley.

Ms Paisley: Thank you, my Lady.

Can move to 26 March, please, and there was Scottish Government clinical guidance for nursing homes and residential care residents published on that day, and that incorporated Health Protection Scotland advice, and the guidance by that stage was: individuals being discharged from hospital do not routinely need confirmation of a negative test.

My question is: to what extent, in the view of Public Health Scotland, was that decision based on testing capacity?

Dr Maria Rossi: I would assume as a policy decision that was the major factor.

Counsel Inquiry: And Public Health Scotland had also produced an updated version of its guidance on that day. What was the difference in reality between the guidance being produced by the Scottish Government and the guidance being produced by Public Health Scotland at this time?

Dr Maria Rossi: So, generally speaking, and in relation to this, the Scottish Government guidance included more clinical notions that were very useful for care homes to use and abide by. Public Health Scotland does not have a clinical function per se. We’re looking at the public health aspects of interventions and risk assessment, those that relate to a population, in this example a population of a care home, and the risk factors that might make somebody more or less vulnerable to it.

Whereas the Scottish Government guidance, with its clinical advisers, was also able to provide background information and advice on, for example, the condition of dementia that many of the individuals would have had who were in care homes, and other things, such as therapeutics, if that were needed.

But that wasn’t the remit of Public Health Scotland guidance, so they added to that.

Counsel Inquiry: Now the Inquiry has heard evidence from both Ms Freeman and Ms Lamb that mandatory isolation for seven days, either in a hospital or in a care home, was introduced on 26 March, and an annex was added to the Scottish Government guidance on that date.

Can we have on screen the updated Public Health Scotland guidance at page 17, INQ000189302.

And this deals with 14 days’ isolation for an exposed individual. However, it doesn’t mention the seven days’ mandatory isolation.

Do you think there could have been a risk, then, that care homes could have been following the one piece of guidance that didn’t mention the mandatory isolation?

Dr Maria Rossi: So, I’m pretty confident that this guidance that you’ve put here, which I think you noted as 26 March from PHS, would have also noted the seven-day issue. We have to be really clear here and – seven days of isolation was what, at the start of pandemic, was advised for people who were diagnosed with Covid or thought to have Covid because of symptoms. And that reflected the period of their infectiousness as determined from the onset of their symptoms.

Counsel Inquiry: If it helps, this does deal with the seven days isolation for someone who is symptomatic?

Dr Maria Rossi: Yes.

Counsel Inquiry: But the Scottish Government at this point said that all residents should be isolated, and the isolation period could be in hospital or in isolation to ensure that they do not develop new symptoms. And so it’s this, it’s the seven-day isolation for everybody else, that I’ve been unable to locate.

Dr Maria Rossi: So remember that at this point in time, people who had Covid would not normally have been transferred to care homes. So those are the folk who would be isolated for seven days.

The individuals who would be on the pathway from hospital to care homes would have been those that had possibly been exposed to the virus in the hospital, and therefore it was the 14-day period that anybody going into a care home should relate to, because we were waiting for the incubation period of 14 days to complete, so that – and that they should be an isolation during that time, in case the symptoms arose.

Counsel Inquiry: So that’s for people who have been exposed.

Dr Maria Rossi: Exposed.

Counsel Inquiry: But I understand the Scottish Government’s policy was that all residents should be isolated on admission for seven days?

Dr Maria Rossi: It could be that that was in reflection to the early point of pandemic, where the days were changing about what – how long somebody was infectious for, but I think what you’re suggesting there, and I’m not quite sure if that’s correct, I don’t recall seven days being a period of incubation period at any point. It could have been 10 at some stage, it could have been 14. So –

Counsel Inquiry: Can I just ask a general question on guidance, please.

Dr Maria Rossi: Yes.

Counsel Inquiry: Do you think that the multiple sources of guidance in Scotland caused confusion, and going forwards, is there a way that that can be addressed?

Dr Maria Rossi: I am confident it did cause confusion, because we had feedback on that, and I know that Scottish Government had that too. I think we need to work out what to do next time in a crisis, but let’s remember that, generally speaking, it is not for – the Scottish Government rarely puts out guidance in that that is reactive and needs to work in terms of incidents. That is the role of PHS.

The reason Scottish Government were undertaking that was because we were in that emergency footing type of scenario, whereby Scottish Government was leading, it was leading the pandemic even for the roles that PHS would normally have in an outbreak that wasn’t a pandemic.

Counsel Inquiry: In respect of guidance provided to the sector, then, what was the impact of the emergency footing on what Public Health Scotland was able to produce regarding guidance?

Dr Maria Rossi: Our guidance essentially was operationalisation of policy that Scottish Government was developing. In an incident such as Mpox, for example, we would be determining – well, we would be determining PHS policy, not government policy, obviously, but we would be leading on the response in an incident that was non-pandemic, as opposed to in the emergency footing, it was Scottish Government that clearly, legitimately and for good reasons, was leading on the response to the pandemic.

So our role then followed suit to make guidance to inform the local health protection teams on what needed done by operationalising that policy, how to make it happen.

Counsel Inquiry: In January 2025, Public Health Scotland produced health protection guidance methods for guidance development. Do you think that might go part of the way to address the potential for confusion in the various roles?

Dr Maria Rossi: So the methodology piece of work that we’ve done on guidance follows on from 10, 15 years of the Scottish Health Protection Network doing similarly, and this January document revises that, makes it more robust. It is a guidance methodology that is very collaborative, takes in stakeholder views, and allows quite an extensive time period to happen. That methodology, it wasn’t possible to apply it in pandemic because things were happening so quickly.

There is provision with the methodology for a next pandemic or, indeed, an incident that requires quick guidance to take, so to speak, shortcuts, which may very well be along the lines of not being able to consult for as long as needed but certainly that methodology is what we use now, and we look – we are looking forward to seeing how we could apply it better for a next pandemic.

Counsel Inquiry: The Inquiry heard evidence – returning to hospital discharge, please, the Inquiry heard evidence from Ms Lamb that the use of step-down facilities or designated settings was considered by the Scottish Government and effectively discounted due to the potential for staffing issues or risks to people, including additional disruption. Was Public Health Scotland ever asked for advice about the use of step-down facilities?

Dr Maria Rossi: I am not aware, but it might not have come to me at the time.

Counsel Inquiry: In the view of Public Health Scotland, is that something that should be considered for a future pandemic, particularly if it is factored into planning?

Dr Maria Rossi: I think the rationale given for which that path wasn’t undertaken in Scotland is pretty sound. I think what needs to happen differently is that there needs to be greater efforts in training up care homes, should this happen again, in the notions of IPC, in order to make isolation a true intervention for that setting.

The problem this time is that they weren’t trained up. They didn’t have as much equipment or PPE needed as – that would have been able to address that issue. It wasn’t so much that a separate facility was required; the facilities could work if the training and the equipment were in place.

Counsel Inquiry: Do you think that it would be worth having step-down facilities as an option? So should it be included in planning for the future?

Dr Maria Rossi: It should be included as an option, yes, because we don’t know what the next pandemic will be and it could be that the organism lends itself to those types of facilities being needed, definitely.

Counsel Inquiry: But in the view of Public Health Scotland, perhaps if there was greater training in place, that –

Dr Maria Rossi: In infection control, yeah.

Counsel Inquiry: Can we please have on screen INQ000584250, which is an email from Dr Ramsay to a Director of Public Health.

And I believe this email makes reference to the Easter 6 study, and there’s a long quote about that, so I won’t read it all out. But it says:

“… [PHE’s] prediction so far is that they expect based on current trends for 90% of all care homes to have been affected with outbreaks within the next 30 to 34 days unless something is done to alter this predicted spread/trajectory …

“The results were stark: over 50% of the staff were already test positive, so infected, and an even higher [percentage] of the residents were infected …

“The conclusion is that by the time an outbreak is spotted using existing criteria – it is already too late to control it effectively …

“The conclusion of a [public health] meeting on Friday was that the emphasis on testing is misplaced and that the real emphasis must be on preventing infection getting into [care] homes at all.”

And I’m sorry, I chopped and changed through that quote there, but it’s quite a long quote.

These were clearly worrying matters for the sector. Was this escalated by Public Health Scotland to anyone in particular in the Scottish Government that you know of?

Dr Maria Rossi: Yes, this would have been something that, I don’t know exactly to whom, but that government would have been aware of, the work and the dialogue that we had with the directors of public health. I’m not sure if sometimes they would have been copied into such emails or at the meetings. So, yes.

Counsel Inquiry: Now, the Inquiry understands on 21 April Ms Freeman announced it would be mandatory for all hospital patients to have two negative tests on discharge, which I’ll come to in a moment. But as a result of that email and the concerns, do you think that there should have been wider testing announced at that time beyond just the two negative tests on discharge, if there had been capacity?

Dr Maria Rossi: So the thrust of the email that was just on screen there was outlining that the evidence that had been gleaned from the Easter 6 studies undertaken by UKHSA, or through UKHSA, was showing that by the time the care home itself had appreciated that they had ingress of the virus into the home, it was highly likely that many more folk than they expected were already infected, and, therefore, doing testing would illustrate that, fine, but would it have impact?

Because at the point when a care home is diagnosed, so to speak, with an outbreak, you must get the interventions into place. It has to switch to the interventions.

So testing everybody at that stage would have been redundant, so to speak, once – once there was almost – well, one case, we came to learn, by the time you have one case. The importance was getting the interventions into place.

And the point that’s being made in the email is that we need to shift our emphasis to prevention of it getting into care homes at all, because by the time it’s in, it was so transmissible that it spread rapidly.

Counsel Inquiry: And in respect of the decision to require two negative tests on discharge, on 20 April, Public Health Scotland, the CMO directorate and the CNO directorate, had advised for 14 days’ of isolation, and again, the position was: no test required prior to admission.

What were the reasons, or were they similar to what you’ve just been discussing for advising that no test was required prior to discharge?

Dr Maria Rossi: So if you are instituting isolation for anybody coming from hospital into a care home, anyone, then the test itself doesn’t add much if you have somebody who has no symptoms, because you are undertaking the intervention that you would put into place, whether their test was positive or negative.

So the emphasis on testing, as is outlined in the email, was overly egged, shall I say – shall I suggest.

The important thing was the interventions were effective and impactful once they were undertaken. And the testing in this instance, the initiative, did create problems, as you had an individual who was, for all intents and purposes, ready to go back to a home, or indeed their home, the care home, but was being prevented from doing so because a test had not come back as negative.

And there are many reasons why a PCR test for Covid came back as positive and yet it did not necessarily present a risk to the care home. One of them is if you had the interventions in place at the care home, you could isolate the individual from others, but another one is also that we were learning all the time about these – the PCR tests for – and this novel virus, and the PCR test is able to assess how much generic material – or assess the presence of generic material, but not necessarily whether the virus is viable.

Counsel Inquiry: I wonder if I can just – perhaps in summary then, it’s that – not that the tests weren’t important but the view of Public Health Scotland was that there were other measures which were perhaps more appropriate in care homes at this point than just testing itself?

Dr Maria Rossi: Yes. And testing had its own potential disbenefits or harms.

Counsel Inquiry: Can I ask a question, please, on the PAC process that was put in place by the Scottish Government.

Now, the Inquiry has seen evidence submitted by Public Health Scotland that this process led to delays in guidance that was produced. And at paragraph 8.5.11 you say:

“… in one instance, [Public Health Scotland] advised Scottish Government of delays in 11 sets of guidance as [Public Health Scotland] waited for a response from the Scottish Government: six of the 11 guidance documents had been with Scottish Government for nine days …”

And the Inquiry has seen that a number of those specific pieces of guidance were relevant to the care sector, including both care homes and domiciliary care.

Did Public Health Scotland agree with the need for the PAC process, and did it cause any particular delays as regards to the adult social care sector?

Dr Maria Rossi: So PAC stands for policy alignment check?

Counsel Inquiry: Yes.

Dr Maria Rossi: Which meant exactly that: that there were concerns on the part of the Scottish Government that Public Health Scotland’s guidance sometimes they thought seemed to come out in misalignment with the government’s policy. Maybe that was the case in some instances, I can’t put my finger on any, but what it did do was, in its operationalisation, it may have allowed for a less black and white way of a policy being rolled out at the front line.

So if I can give an example of the discharge testing, for example. Yes, the policy was: anyone going into a care home from that certain date from a hospital required two negative tests. But there were instances where that wasn’t in the best interests of the individual and wasn’t actually needed even to safeguard the care home. But with a policy that was as black and white as that, that would – we were getting reports from – via our health protection teams from care homes that that was preventing people going back to their home when in fact they were fit enough to do so.

So if we didn’t put that nuance, that explanation, into the operationalisation of the policy, then that would clog up the system, so to speak.

So those types of reflections in our guidance sometimes were felt to be misaligned with the policy when, in fact, there was good justification for that. A test always has to be consented –

Counsel Inquiry: Just to clarify that, in the view of Public Health Scotland, was it necessary and did it lead to delay?

Dr Maria Rossi: I would like to see in a future pandemic that we didn’t require a PAC process.

Counsel Inquiry: Grateful.

I have two final topics and I just wonder if I could ask, if you could keep your answers just a little bit shorter, if that’s possible, please.

Dr Maria Rossi: Sorry.

Counsel Inquiry: On data, the Inquiry understands Public Health Scotland acknowledges that there were gaps in respect of the data it held regarding care homes. Can you please give a brief overview of the difficulties in respect of data and whether any steps have been taken since to resolve them?

Dr Maria Rossi: A key one I’ve already highlighted is that for individuals who are being discharged from hospitals to care homes, and although the information could be gleaned from multiple data sources, that was something that we’re working on just now. We have a very good pathway of data for notifiable diseases and organisms, an electronic pathway from the health boards’ laboratories to Public Health Scotland. So that worked well.

There were – there was information, for example, on even care home outbreaks that we didn’t have a system in place for, but if we had had, would have made things much easier, but also, for outbreaks of all sorts of settings, not solely and we’re working that up with the systems that we have in place to make that a much more routine element of data.

Counsel Inquiry: And briefly, then, dealing with visiting guidance. In your statement you say in retrospect, a more nuanced and locally sensitive approach might have been implemented for care home settings in the summer of 2020, and a less restrictive visiting regime for some of this period would likely have led to some preventable illness and/or deaths arising. Where does Public Health Scotland see the balance lying in respect of visiting restrictions in the event of a future pandemic?

Dr Maria Rossi: So visiting restrictions for a care home were addressing the risk of the virus coming into the home when it wasn’t already there.

A key mitigation for that was vaccination once it was ready. So that came in December 2020. After that period, and a bedding-in period of rolling out of the vaccination and individuals reacting to that through their immune systems, that would have been the time to start to reduce on the restrictions, the quite heavy restrictions that were in place, both for visiting and other elements, and the impression is that the restrictions went on for too long. This was in the hands of Scottish Government, who were leading on the response, and we would have wished to have been able to influence that more and shorten the time period whereby visiting restrictions were in place, and other interventions.

So vaccination would be a key point after which it would have been important to review more regularly and ease up on the restrictions.

Counsel Inquiry: And just one final point before I ask for your final reflections. I understand Public Health Scotland wish to clarify whether it had any role in the regulatory inspections during the course of the pandemic, and I just wonder if you could assist with that.

Dr Maria Rossi: Yes, we had no role in that – we had an advisory role to Care Inspectorate as we did when requested.

Counsel Inquiry: Now, beyond anything we’ve already covered in your evidence; are there any further recommendations you would urge the Inquiry to consider, please?

Dr Maria Rossi: So I think we’ve touched on the role of Public Health Scotland in advising government. We would like to see that more structured as we move forward, particularly for a next pandemic. We haven’t touched very much on the human rights-based approach that we’ve already done much work with Scottish Government in the sphere of care homes, but we would like to see that progress, and it will do through a code of practice on Anne’s Law, but bearing in mind that there still needs to be safeguarding from what our health protections do in supporting care homes that have outbreaks.

The testing we’ve also touched on, and it would be really very useful to have some sort of evaluation of testing during a pandemic at population level. The very expansive – it’s not specifically related to care homes, but that was part of it.

And I guess, finally, strengthening IPC. And we’ve touched on the collaboration both at four nations basis and with other organisations, including ARHAI.

Ms Paisley: Thank you very much.

My Lady, those are my questions.

Lady Hallett: Thank you very much, Ms Paisley.

Ms Mitchell, who sits up there.

Questions From Dr Mitchell KC

Dr Mitchell: I appear on behalf of Aamer Anwar on behalf of the Scottish Covid Bereaved.

Donald Macaskill, the CEO of Care Scotland, that’s the membership body for organisations that provide care in care homes, home care and housing support across Scotland, has given evidence to this Inquiry, and part of that evidence related to the relationship between Public Health Scotland (or, as it was then, HPS) and itself. And he said that they were disappointed with the process of the development of the guidance of 13 March.

He said:

[As read] “We found that there was a minimum level of engagement with Public Health Scotland in the time of the guidance, as was seen both here in the necessity to both repeat that guidance …”

And that meant to change the guidance from the early days of 13 March to the later guidance:

[As read] “Mainly as a result of our remonstrations later in the month, we found both here but also through the main, professional respect from Public Health Scotland and its understanding of the social care sector and its unique situation, particularly in relation to infection prevention and control in care homes, to be wholly regrettable.”

Were you aware of the views of Care Scotland at that time, ie March 2020?

Dr Maria Rossi: I was aware of it. I wasn’t involved directly in that aspect.

Dr Mitchell KC: Were there any steps taken by Public Health Scotland to resolve the issue?

Dr Maria Rossi: So there were a number of groups that Scottish Care as well as PHS partook of in the sphere of care home work throughout the pandemic. So that would be a key way of undertaking that.

The other way was through the advice that was being given to government, and the feedback that Scottish Care were offering government, and trying to play into that and provide our advisory role a little bit better. But that – as I’ve mentioned before, that was already quite challenging.

Dr Mitchell KC: Well, I’d like to ask about the feedback that Care Scotland gave. Care Scotland indicated that they had limited engagement in respect of the guidance on 13 March, and Mr Macaskill was asked whether or not he was given time to consult, and he was asked:

[As read] “Is it correct, I think you were only consulted, is it, on 12 March about the draft guidance?”

And he said:

[As read] “Yes. And given the quite tight timeframe, a matter of hours to make comments. And it’s not just in terms of admission; we made comments about the reality of how difficult it was to transfer a system of essentially infection prevention and control methodology developed for an acute sector such as hospital into an environment such as a care home, particularly as a residential, but including a nursing home, which was first and foremost somebody’s home.”

Were you aware of the fact that Care Scotland considered it had been given insufficient time to have input into this process of the guidance of the 13 March?

Dr Maria Rossi: Yes, and time and pace were a big limitation of everyone in the pandemic effort. I can’t remember when – what the date of the previous guidance to the 12 March was, but we did produce the 12 March and then we produced the 13 March. So you can imagine that the time to consult with various partners would have been very challenging and limited, and that’s not to say that we shouldn’t find a better way of doing that, obviously, but there were time imperatives based on something that, actually, we were trying to operationalise what was coming from government, so even getting that took time.

Dr Mitchell KC: Indeed, I wholly understand the imperative of time. It just seems a very short period of time for that whole sector to respond in that way, given we know what the limitations of the guidance were available for the care sector. Do you think it was too short?

Dr Maria Rossi: Yes, all of our time was too short to undertake the challenges that we were dealing with, definitely.

Dr Mitchell KC: Moving on, then, in relation to testing, what Mr Macaskill said was this:

[As read] “Against that backdrop we then had the new coronavirus being introduced, and we were very clear as an organisation, listening to our clinical colleagues out in the field that they needed additional reassurance and simply saying ‘We leave this to the professionalism of clinical assessment’, I’m sorry, it didn’t wash at the time. I communicated that to the Cabinet Secretary and I indicated what we wanted and needed was testing to evidence a negative test, which, with nothing else, could mean – and we appreciate this testing was for the moment”, and I think you’ve highlighted that caveat in your evidence already” – and we appreciate that the testing was for the moment but it would mean a reduction in the potential period of isolation for an individual in a care home.”

Were you aware of the views of Care Scotland about the need for testing before discharge?

Dr Maria Rossi: Yes, I can’t say precisely when, but yes.

Dr Mitchell KC: Do you think that would have been before the policy was put in place to allow without discharge?

Dr Maria Rossi: I can’t say.

Dr Mitchell KC: Given the views of Care Scotland’s undeniable expertise in this area, why were those views and their concerns not followed?

Dr Maria Rossi: So you’ve noted the understanding of Care Scotland in relation to the tests to be applied to individuals coming from hospital to care homes, and the seeming understanding that, if two negative tests derived from an individual who was still in hospital, but making their way to a care home, meant that their isolation in the care home would reduce in days, that’s not the case. I think it’s – I think that was part of the problem of the overreliance on testing, that there were – it was very difficult and challenging. We were all learning, but it provided false assurance in many instances. For someone, an individual going from an area of risk, hospitals, to an area of, let’s assume no risk, a care home that didn’t have the virus as yet, if they were negative upon departure from the hospital but had not been in so-called isolation at that point, they carried that risk for another 14 days into the care home, therefore the negative tests would have been not very much help at all.

Dr Mitchell KC: I see what you say in relation to false confidence and I think, my Lady, picked up on this in her question to you. It was at a time when the very most vulnerable people were at greatest risk, and there were no other procedural safeguards in place, so surely even though limited as it was, it was better than nothing?

Dr Maria Rossi: Well, there were other possibilities. You could keep the individual in hospital, but at that point you had to balance the risk of staying in hospital, for someone who otherwise didn’t require to, from the benefits of not.

You could, as we advised, have them in isolation in the care home, and if a care home struggled with that, they had the Health Protection Team to advise them on it 24/7, and we worked seven days a week at that stage, but there was also an on-call service that the care home could call upon if they couldn’t figure it out, if they had difficulties with equipment – I’m talking about the isolation once the person had transferred.

And we’ve heard also about facilities could have been used, as step-downs, but that also was considered.

So there were choices, and choices have to be made on the basis of the balance of harms and risks – and benefit. Sorry.

Dr Mitchell KC: There came a stage when the – when a report was brought out in relation to where Covid may have come from when entering care homes, and it included staff movement, but also included the possibility of a relationship between positivity and outbreak in care homes and then, I think, as you’ll understand or, perhaps, you can confirm you do know, that at a later stage the report was slightly changed as a result of the Office for National Statistics getting in contact?

Dr Maria Rossi: Yes.

Dr Mitchell KC: Are you aware of that?

Dr Maria Rossi: Yes, yes.

Dr Mitchell KC: And are you aware of the reasons why it was changed?

Dr Maria Rossi: Yes, I’ve seen the letter from Mr Humpherson who made reflections on the October version report which PHS then revised, according to his advice, into the April version, and he did not object to the methodology used or the results or the conclusions, but strongly suggested that they could have been outlined more clearly and that is the extent of – not the extent, but the nature of the changes undertaken for the April report, in addition to including some further information that had come to light.

Dr Mitchell KC: Indeed, further information including some wrong instances that people were included in care home discharges when they weren’t?

Dr Maria Rossi: So I think there was an instance of six discharges that were re-categorised as not being from hospital to care home, and that was a reflection of the challenges around the data. And in the interim, after the publication in October, the team had noted that there were six discharges relating to three people who had not actually gone from hospital to care home, and therefore, in the April report, they were excluded.

Dr Mitchell KC: But there was also a different emphasis placed, was it not, on the understanding of a causal relationship between positivity and outbreak in care homes?

Dr Maria Rossi: So what was being assessed was the discharge from hospital and some further information was done on whether a person was tested and tested negative, tested positive, or untested in further analysis, but that didn’t change the conclusions, and did not increase the causality of the study, because the study was not of a – using the method that could outline cause and effect, it could only give an observation as to what may be acting here in terms of risk factors, and the dominant risk factor was the size of the care home.

Dr Mitchell KC: Indeed, and part of the difficulty with the whole report was that the data – you’ve referred to data earlier – was very limited in relation to the period of time when the first discharge was made; is that correct?

Dr Maria Rossi: Limited in what way?

Dr Mitchell KC: The data was limited in respect of there being little information in relation to testing because there was so little testing being done?

Dr Maria Rossi: The team that undertook the report took all tests and all people discharged as they could identify. The challenges were around how they gleaned that. So yes, there was always potential for certain individuals or discharges to have been missed.

Dr Mitchell KC: Indeed. Moving on, then.

You touched upon visiting restrictions and I’d like to take you back to that. One of the most distressing post-pandemic issues for people that lost loved ones, as I’m sure you may appreciate, was that there was no consistent visiting guidance given by any public body to any care home, and as a result, people now consider whether or not they should have done things differently or they blame themselves, they should have tried harder, and of course, that’s clearly not their fault, and that should be made clear.

Ought, in retrospect, do you think Public Health Scotland should have provided some guidance, even at a high level to allow people to know when it was appropriate to ask for a visit and when not?

Dr Maria Rossi: We did do that in our guidance. We outlined that for a large part of the pandemic, that when there were the severest of visiting restrictions in place, that there should be, based on individual risk assessment, the possibility to attend to visit a loved one in a care home in that end-of-life phase, or to relieve distress. So we did give those high-level pointers.

I think the point that you’re understandably making is that could be left to interpretation, but I’m afraid that’s the way that risk assessment in the public health sphere works. There has to be a review at that individual level, and it doesn’t have to take long at all, of what the harms and the risks – the harms and the benefits are of undertaking a certain action.

And if a care home manager was thinking: gosh, this guidance, I’m not sure what they mean by distress, they could have picked up the phone to the Health Protection Team and the onus should not be on the relatives and friends that found themselves in the midst of that. That is true. That will have been very difficult for them, but there were – there were resources in place to try to support that process, and allow for exceptions, two of which were outlined in our guidance.

Dr Mitchell KC: If there were such guidance and were such resources available, but the experience of the Scottish Covid Bereaved was that they were at a loss, going forward, would it be better, then, if such guidance was made perhaps more strongly or more obvious to those that would need it?

Dr Maria Rossi: So the initiative around that’s led to Anne’s Law has tried to address that, and has, to all intents and purposes, addressed that, but many of the principles that are outlined now in statute through Anne’s Law, over the course of the pandemic came into being even through our guidance. So at one stage – and I can’t recall when, perhaps even a year into the pandemic – we tiered the type of visiting that might take place in a care home: from routine, when there was no outbreak, to named persons, where every individual could lodge with the care home management the names of three people that, if there were an outbreak and residents were limited to one visitor per day, it could be any of those three.

But even there, if none of those three were available, it was perfectly fine for an exception – a fourth person to come on board. And that’s where that risk assessment tries to help the process.

And the third tier was, if for some reason it was completely clear that there should be no visits into the care home, then only in those instances would a named person, one per resident, not be allowed in, but only for end-of-life or distress situations.

Dr Mitchell: Thank you.

My Lady, those are my questions.

Lady Hallett: Thank you very much, Ms Mitchell.

Thank you very much indeed, that completes the questions we have for you. Thank you to you, obviously, Dr Rossi, for your help but also to your colleagues who helped contribute to the witness statement provided. And don’t worry, if there’s stuff included in the witness statement, I promise you, that’s always considered as well as the oral evidence you’ve given.

The Witness: Thanks.

Lady Hallett: So thank you very much indeed. I shall return – I’m sorry, we have a lot to get through today and I have to rise early, so 1.50 pm.

(1.06 pm)

(The Short Adjournment)

(1.50 pm)

Lady Hallett: Ms Hands.

Ms Hands: Good afternoon, my Lady. May I please call Mr Paul Featherstone.

Mr Paul Featherstone

MR PAUL FEATHERSTONE (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: Thank you for coming to help us, Mr Featherstone.

Ms Hands: Mr Featherstone, you’re attending today as the Chair and Founder of the National Association of Care and Support Workers, or NACAS; is that right?

Mr Paul Featherstone: That’s correct.

Counsel Inquiry: And in addition to the roles that you hold within NACAS, is it also right that you have worked as a support worker in domiciliary care, and provided care to your mother, who had dementia?

Mr Paul Featherstone: That’s also correct.

Counsel Inquiry: And you have provided a statement to the Inquiry which can be found at INQ000569768, and within that, you have explained how it is informed by your own knowledge, the experience and evidence from NACAS members, including through two surveys that were undertaken; is that right?

Mr Paul Featherstone: That is right.

Counsel Inquiry: Now, you have explained how NACAS represents and provides education, resources and training for care workers both in domiciliary and residential care?

Mr Paul Featherstone: Yes.

Counsel Inquiry: And that includes nurses who are employed, self-employed, or agency staff?

Mr Paul Featherstone: Correct.

Counsel Inquiry: So is it right to say that you do not represent care home providers?

Mr Paul Featherstone: That’s also correct.

Counsel Inquiry: Now, NACAS has seen its membership grow substantially from around 4,000 in March 2020 to around 15,000 today. What do you think has led to such fast and significant rise in membership?

Mr Paul Featherstone: Well, I think it’s because of our mission statement. Our mission statement was to provide support, career support, to the care workforce.

The overriding catalyst for me to set up NACAS was to shine a light on the care workforce, and I think that the members see that they belong to something that is exclusively for them, and they get a lot of support and encouragement from it.

So I’m – if I’m allowed to say this, I’m quite proud of the fact that we’ve gone – you know, our membership has tripled in, what, three or four years, and some feedback that we’ve had from members actually mentioned the fact that they are so pleased that they found NACAS and that they are happy to be – you know, proud to be members.

So, yes, I’m very pleased of where we are now, and in the short space of time that we’ve been in existence.

Counsel Inquiry: Yes. And I think you said NACAS is UK wide but is it right that the majority of your members are based in England?

Mr Paul Featherstone: That would be correct.

Counsel Inquiry: Do you know what percentage of members are based in the devolved nations?

Mr Paul Featherstone: This would be a loose estimate but I would imagine 60% of our members are from England, with the other 40% being split across the – Scotland, Northern Ireland and Wales.

Counsel Inquiry: And you have explained in your statement that two of the key reasons why NACAS believes that there was a lack of resilience in the adult social care sector at the time of entering the pandemic, are significant staffing shortages, and public perception of the adult social care sector, along with a few others in your statement.

So if I may deal with the first, what were NACAS’s members’ experience of the shortages in the workforce as we entered the pandemic?

Mr Paul Featherstone: Well, I think they were genuinely worried that – I think there was a general concern that: could they cope? Pre-pandemic – I mean, it’s well known that there are significant staff shortages even today, but at the start of the pandemic it was an unknown, and I think there was a lot of uncertainty from the membership.

But I think that uncertainty has been somewhat waylaid by the resilience of the workforce. They’ve found a way, they’ve coped, and they’ve managed through what was a very, very difficult period of time.

Counsel Inquiry: And what do you mean when you say public perception of adult social care, and what was the impact of that during the pandemic?

Mr Paul Featherstone: Well, if I may say, I always described the social care workforce as the invisible visible workforce, because much of what we do is behind closed doors, whether it’s in a nursing home or it’s in a person’s own home, whereas our National Health Service, the wonderful doctors and nurses, people can see what’s going on day to day, but in social care it’s not. So that’s the perception, I think. People don’t think about social care until they actually need it.

So it’s something we need to get changed. The narrative needs to change around what care working is. It needs to be seen as a distinct profession in its own right, along with our colleagues in the health care.

Counsel Inquiry: And what impact do you think that perception had at the start of the pandemic?

Mr Paul Featherstone: I think – I mean, it’s difficult to quantify impact, but I just think that social care – because it seems the Cinderella service to the NHS, I just think that there was a misunderstanding of what social care stands for and what it is. I mean, I think that’s probably the best way I can put it.

Counsel Inquiry: And you have described how the lack of resilience in the workforce at the start of the pandemic led to an increased workload and responsibility for those that were working in adult social care, and the impact that had on their mental health, wellbeing and the long-term retention and recruitment within the sector.

Firstly, do you know if there was sufficient training and support for care workers to deliver the additional tasks?

Mr Paul Featherstone: As far as I’m aware, the training for social care, in my own experience, is hit or miss. One of the things that we provide as an association is access to better quality training – or we like to think it’s better quality training.

I think that the workforce are reasonably well trained – well, better than reasonably well trained. I think they’re well equipped to do the jobs that they are doing.

In terms of the training throughout the pandemic, I don’t have a particular comment about that, but just to say that the workforce do receive what I would consider to be adequate training, more than adequate training.

Counsel Inquiry: What about access to mental health support and wellbeing for staff during the pandemic?

Mr Paul Featherstone: Well, I mean, again, that’s one of the things that we were able to offer as an association is access to – sorry, excuse me, health and wellbeing support to the membership. You know, we could give them access to counselling sessions and things like that. Because without doubt, our members, again, said that they felt as though their mental health was deeply affected by working through that pandemic.

So we tried to, as best we can, or could, offer some kind of mental health support to the membership, because it was needed.

Counsel Inquiry: When was that support available from?

Mr Paul Featherstone: Where?

Counsel Inquiry: When, sorry.

Mr Paul Featherstone: It’s always been a benefit of the association to get access to mental health, so it’s been there from 2019.

Counsel Inquiry: And was there a lot of uptake for that support during the pandemic?

Mr Paul Featherstone: I can’t give you specific numbers but I do know from feedback from members they were very grateful they had access to that, and those that did use it found it very, very, very useful.

Counsel Inquiry: Were you able to provide it to everybody that required it, or came to your service for that support?

Mr Paul Featherstone: Yes.

Counsel Inquiry: Another consequence of the staffing shortages that you’ve described showed through the respondents to one of your surveys, where they reported that there’d been changes to care ratios, and in your statement you quote a NACAS member who said that:

“… terrible staff shortages meant that there were two carers and one nurse on night shifts for 48 residents. For more than a year, me and many others worked on this ‘ratio’.”

Were those kinds of practices and experiences widespread, from your experience?

Mr Paul Featherstone: I can only refer back to what the members have said through our surveys and I would concur that that was fairly widespread during the pandemic, yes.

Counsel Inquiry: You also say in your statement that there are a number of systemic and structural issues that impacted the ability of the sector to respond to the pandemic, and you’ve listed three that you have deemed most noticeable, and I’d like to go through those with you today.

So the first is that there was a lack of care sector visibility and representation within government. Where, in particular, do you believe that there was a lack of visibility? So was that central government, local government, or public health?

Mr Paul Featherstone: Central government. I personally believe that because social care was misunderstood, is misunderstood, and to some degree I think it still is, there was that complete lack of visibility. There was – it was all – at the start, it was all NHS, NHS, NHS, and nobody was talking about social care, which was odd, to say the least. I mean, they go hand in hand, social care and the NHS. But you would never have thought, in my humble opinion, that there was a social care sector at the start of the pandemic, because it was never spoken about.

Counsel Inquiry: Mm.

Mr Paul Featherstone: And it was quite frustrating to see that lack of visibility and lack of acknowledgement.

Counsel Inquiry: And I think you have included in your statement some of your members’ responses to survey questions around this topic. So I’m at your paragraph 36 and 37 if that assists. One of the questions in that survey was: did the government make the right decisions during the pandemic? To which 78 responded, “No”, and several members reported that there appeared to be no long-term planning or strategy in government decision making?

And at paragraph 38 you have provided some examples from your members. Could you perhaps summarise some of those for us?

Mr Paul Featherstone: Well, I just think what you’re hearing there are the voices from the front line that there is – there was no cohesive – what’s the word I’m looking for? There was no cohesive communication, if you like.

So I can only go on what the members are saying through their survey. They lived it. They were there. They were experiencing what the government was or was not doing. So I am going to defer to our members, because, I mean, unfortunately I wasn’t active. I wasn’t an active care worker during the time of the pandemic. So if that’s what our membership are saying to us, “This is what happened”, I think we need to listen to them and learn from that, if that makes any kind of sense.

Counsel Inquiry: Yes, thank you, Mr Featherstone.

One of the policy decisions that you have referred to in your statement is around the hospital discharge policy. So what was NACAS’s view on the policy and perhaps your experience around its implementation?

Mr Paul Featherstone: Okay, I think the discharge policy into care homes was ill advised at best. It was not a good decision to discharge Covid-positive patients into a care home.

We were able to play a minor part in bringing that into the public eye. As an association, we were contacted by Sky News, to find out whether or not we had any members who had had experience of discharged patients coming into care homes, and we were able, through our network of members, to put the Sky reporter in contact with a care home provider in the south west. And that – through that engagement with that reporter and that care home owner, we were able to play a small part in bringing that much more into the public eye. I’m not going to say here we were the cause of it or the reason for it, but we certainly played a small part.

Counsel Inquiry: Could you perhaps, if you know, tell us a little bit more about the experience that you were hearing from those care homes or from your workers directly?

Mr Paul Featherstone: It’s just that they were just having to think on their feet as to how best to protect the staff within those care homes, whether it’s creating Covid rooms and things of that nature, but they were absolutely having to think outside the box, if you like, to keep everybody as safe as possible. That was coming through to us from some of our members.

Counsel Inquiry: Did you hear about any issues that they were having with implementing some of those measures, for example, like you’ve just said, around cohorting or isolating patients, residents that were coming in?

Mr Paul Featherstone: I don’t have any specific examples to give you. Again, I can only refer back to what was in my statement from our members, through – you know, through the survey questions, but I don’t have any other experience – you know, knowledge or experience to share with you today.

Counsel Inquiry: Okay. And what about any concerns that you may have heard around testing before discharge?

Mr Paul Featherstone: Again, I think the members again were very concerned that there was no testing or very limited testing prior to discharging people into care homes. Which, looking back at that, was nonsensical. There should have been a layer of protection provided before someone, bless them, who is living with Covid or suffering from Covid is discharged into a care home.

Counsel Inquiry: Turning then to another topic and that’s visiting of loved ones in care homes. You have told us in your statement how some of your members have observed that the restrictions on visiting were different between care settings. Are you able to help us as to why you think that might have been?

Mr Paul Featherstone: Well, I think restricting visiting into a care setting is in and of itself a draconian measure. If you’re caring for somebody with, for example, advanced dementia they’re already in a confused state. And not to see their loved ones, which may have been, you know, a source of extreme comfort for them during that pandemic, I imagine it would have caused even more confusion. Why am I not seeing my wife or my husband?

And I think if the care homes were allowed to think – not for themselves, but been able to think: what can we do to the best of our ability to make people safe – that’s the staff and the residents – and allow them access to their loved ones?

I mean, it’s fundamental that you’d want to be close to a loved one, especially, you know, at end-of-life care, for example.

So I think to restrict access to loved ones into a care home, I think was extreme. I think there should have been more thought given to how it could have been done to allow people access to their loved ones. I mean – yeah, I mean, it’s quite an emotive topic, but people should have had access to their loved ones. It’s – to me, it’s fundamental and it’s – they should have had the right.

And I think if the care homes were given that flexibility to be able to say, “Well, if we did this measure, if we implemented that measure”, we could let one or two family members in to see their loved one.

Counsel Inquiry: And you have touched there on the impact of the restrictions on the residents of care homes, but in your statement you’ve also included some examples of the impact on staff.

Mr Paul Featherstone: Mm-hm.

Counsel Inquiry: So if we may have on screen, please, INQ000569768, page 18, paragraph 60. Thank you.

Paragraph (a), one respondent to the NACAS survey said that:

“more emotional and physical support was needed from staff as the clients didn’t have visitors to speak to or to do small things for them which would normally be carried out day-to-day by family members, neighbours, et cetera. Clients were in a depressed state, which in turn affected their general wellbeing and health.”

Then at subparagraph (b), another member said:

“Literally their whole family support was taken away and strained carers were left to plug that hole.”

Were those kinds of views and experiences widespread amongst your members?

Mr Paul Featherstone: I’d have to say yes, it was widespread. I mean, if you can try and imagine trying to fill the gap of a family member, when that family member – I mean, I’m talking, by family member, I mean the person actually in the care setting is no longer allowed to see that family member but a care professional is now expected to fill that gap, that is going to have a – take a toll on their mental health, and understandably, because they are not family. I mean, they are family in the sense that they are there to provide the care and support to them but they’re not that person’s flesh and blood, and to have those care professionals step up like that and be able to do that function, I think speaks volumes for our care workforce. I think they were – they went above and beyond.

Counsel Inquiry: And picking up on that first experience there of emotional but also physical support, as well, so is it right that family members or carers that were coming in would quite often provide additional physical support with tasks, that that burden then fell upon the care professionals?

Mr Paul Featherstone: Yes, I think that’s a fair statement.

Counsel Inquiry: You – a slightly different topic, please. And that’s access to sick pay and isolation policies.

In your statement you say that NACAS considers that the insecure nature of much care work and the absence of limited availability of occupational sick pay significantly impacted care professionals’ ability to self-isolate and shield during the pandemic.

Can you tell us a little bit more about the experiences of your members around their ability to self-isolate and shield and whether access to sick pay informed or affected those decisions?

Mr Paul Featherstone: I do believe that the access or non-access to sick pay did – it did influence their decisions. I firmly believe that a lot of care professionals thought to themselves: I can’t afford to get sick, because if I can’t work because I’m sick I don’t get paid.

So I think there would have been occasions where a care worker was not feeling a hundred per cent, feeling a little bit under the weather, would have gone to work because they needed to earn money and because, in some instances, you know, there was no – anything else other that Statutory Sick Pay. They just made that decision, that: I need to go to work. I need to go to work to earn a living. And I need to go to work because if I don’t go to work because I’m sick, I’m not going to earn anything.

So that’s – it’s a heck of a decision to have to make, isn’t it? Especially in a pandemic. It’s maybe an area that needs to be looked at in terms – in terms of sick pay, but they need – they need to be able to make that right decision about not going into work if they’re feeling under the weather.

But I just think in that pandemic – in that situation right then, they made those conscious decisions to go to work because they don’t want to let their clients down. They go to work because they care.

Pardon. No pun intended.

Counsel Inquiry: Turning to the second systemic and structural issue that you’ve identified in your statement, and that is unclear accountability. Can you explain what you meant by that?

Mr Paul Featherstone: Well, I mean, I think it’s just a general statement. There just didn’t seem to be anyone or any one organisation taking accountability for things. Everything was done – and I hope I’m answering the question – this is my – I think everything was done in a rush. It was done almost reactively. There was no cohesion around the decision-making processes. That’s the way I saw it. Others may see it slightly different. But that’s my understanding of it. There was no clear person, organisations, you know, taking a specific accountability for things.

Counsel Inquiry: And you describe a lack of integration and coordination between health and social care services and a fragmented structure in your statement. How do you think that impacted the response of the adult social care sector during the pandemic, and how do you think it could be improved in future?

Mr Paul Featherstone: Well, I think this is – this goes to the heart, the nub of the matter. There’s no parity of esteem between health professions and social care, and that needs to be brought up fairly rapidly, in my opinion. There needs to be absolute parity to between health and social care and adult social care. So that the communication lines between those two facets are much better aligned.

And if I may say so, it goes back to the visibility question that you asked me earlier. It would certainly raise the public’s perception of what social care is, and what it means, and what it means to work in it.

Counsel Inquiry: And the third and final systemic and structural issue you identify is inadequate regulation.

Mr Paul Featherstone: Mm-hm.

Counsel Inquiry: Again, what did you mean by that in the context of the pandemic?

Mr Paul Featherstone: England is the only nation in the United Kingdom that doesn’t have any form of mandatory registration. And I think that there been a register in place, any data held on that register I think could have been a massive fillip during that pandemic. That’s – that’s where I was coming to there, in terms of – excuse me, that’s where I was referring to in terms of lack of regulation.

Counsel Inquiry: I’d like to ask you some more questions about the register. Before I do so, you said there that data could have been a massive flip during that pandemic.

Mr Paul Featherstone: No, it’s –

Counsel Inquiry: Can you just explain –

Mr Paul Featherstone: I beg your pardon, I didn’t say “blip”, I said “fillip”.

Counsel Inquiry: Fillip.

Mr Paul Featherstone: You know, it could have been a huge asset is what I meant to say. Sorry, if I said “blip”, I didn’t mean to say “blip” at all.

Counsel Inquiry: No, no, that’s okay, I think that might have been my mistake.

But if I may just ask how it could have been a massive asset during the pandemic?

Mr Paul Featherstone: Okay. Is it okay if I refer to my notes here –

Counsel Inquiry: Yes.

Mr Paul Featherstone: – so I get everything right?

If there was a register, a form of register, in England, then that data could have been made available to all the emergency services, all the relevant organisations within healthcare. I mean, there’s rapid deployment of information, if you have got a register with 1.5 million people on it, I mean, that’s if everybody was on the register, you could just disseminate information real-time instantly. It would enable people to – it would mean rapid deployment, so people with certain skills, certain attributes could be deployed in the right areas through the data on the register.

It could be a skills-based, role making. There’s direct communication, which I just referred to. I mean, say, one of the massive areas of support that the register could provide its registrants is that dissemination of information. So as the information is being made public, then instantly, there’s a scope there for us to disseminate that information to everybody on that register. So everybody gets the same information at the same time. I think that would be – that alone would have been invaluable.

And it also – it would also provide an opportunity for people who maybe leave social care that were on the register. We’d still have that data so we’d still be able to communicate with those people to say, “Would you be prepared to volunteer your services as a former care professional and help out in this pandemic?” I mean, God forbid there’d be another pandemic, but that’s something that register could help to do. It would enable us to give – provide access to these people who may want to say, “Do you know what? Yes, I’m quite happy to lend my services during the pandemic”, and that data held on the register could be a fundamental point of that.

I think there’s – it’s capable of doing so many things. It’s not just a register of people or care professionals; it enables us to be able to be much more proactive in getting information out there and deploying the workforce where it’s needed.

Counsel Inquiry: And who do you envision being eligible to join such a register? So for example, would it include unpaid carers?

Mr Paul Featherstone: Well, at the moment, we are – we are actually concentrating on the paid professional workforce. That’s not to say that in future, our work could look at extending that to the unpaid care professionals, but at the moment, we are just focusing our attention on the paid workforce.

Counsel Inquiry: And Mr Featherstone, when you say “at the moment”, do I assume from that that you’re referring to the care professional register that your organisation has helped to set up, the voluntary register?

Mr Paul Featherstone: Yes, maybe I should have said that at the outset.

Counsel Inquiry: Not at all.

Mr Paul Featherstone: So yes, we operate the care professional register. It’s in a prototype framework at the moment. I’m pleased to say that through some hard work, we have been able to pass the Professional Standards Authority’s public interest assessment so that we now know that the CPR, to give it an acronym, is fit – sorry, not fit, it does meet the public interest. So at the moment, yes, we are – we do maintain that register.

Counsel Inquiry: And that will be a voluntary register for professional social care workers that are paid –

Mr Paul Featherstone: Correct.

Counsel Inquiry: – in England?

Mr Paul Featherstone: Yes.

Counsel Inquiry: And what will the care professionals that join the register benefit – what will they get from joining?

Mr Paul Featherstone: Well, we see it as a statement of their professionalism, that they take accountability for their actions. They demonstrate that they are properly trained and qualified to carry out – can I call it the care profession? – because that’s what I fundamentally and firmly believe it is. That it raises the profile of care working as a profession, alongside the individual care worker. It gives a certain prestige, a gravitas, to the work that we do. And that’s the Royal “we”, because I still consider myself a care professional.

There’s – it’s a public declaration that I care about what I do. I am a professional and I’m happy to have an entry on that register to demonstrate that.

I mean, it improves employability. There’s so much that being on that register does. It’s not about control. Again, registration is about protecting the public interest and that public interest is better demonstrated through a person who takes accountability for their –

Counsel Inquiry: And just if I may, what information will be recorded on that register? So I think you alluded to, perhaps, qualifications?

Mr Paul Featherstone: Yes.

Counsel Inquiry: Personal information, ethnicity, those – that kind of data, as well?

Mr Paul Featherstone: We do capture that data but that data is not shared if the register is searched, if you understand what I’m saying.

Counsel Inquiry: So it will be available publicly to be searched?

Mr Paul Featherstone: The register in its present form can be searched. Because, for example, if you went onto the register website and put my name in there, it would show up my name, whether I’m active in the profession, and what training I’ve done. It doesn’t – and my PIN number. It doesn’t display anybody’s personal information or their ethnicity, because that would be wrong. But the only information that somebody needs, we feel we need to see, is what’s their name, are they qualified, what training have they done, and are they still active on the register? And then they can make an informed decision then.

Lady Hallett: Forgive my interrupting, this a voluntary register and you’ve set out very clearly the possible benefits to your members. I have heard an argument to suggest that if you had a mandatory register, that that might discourage some workers from entering the profession?

Mr Paul Featherstone: I do think that’s a valid point. It has – it does have some credence. But to me, speaking personally as a care worker, I think it’s right that there should be some kind of mandatory element to it, especially if you’re declaring yourself to be who you are: a professional.

I think the – I’ve heard those comments around the possibility of the workforce being depleted because people don’t want to go on a register, but I think that’s one of the challenges. We need to form the register in such a way, my Lady, that it doesn’t create barriers.

So it could be that we have a tiered type of register, sort of: people are brand new into the sector; people who are more experienced, maybe have completed all their mandatory registration; and then maybe a higher tier for those who have got significant experience, training, and/or an educational qualification.

So that’s why – that’s our thinking on how we could reduce the barriers.

And the other thing that hasn’t been mentioned, but I think I should mention, is the cost. We wouldn’t want the cost either of registration to be a barrier, but, at the same time, any register would have to be sustainable. So we are mindful of that. And when we are setting – thinking about settings costs, they would be at a level that would be, we think, manageable to be able to, you know – not to distract – detract from people wanting, my Lady, to join the register.

But I do take the point.

Ms Hands: Thank you.

Moving on to a different topic, Mr Featherstone, and that’s IPC measures and PPE. So one of the IPC measures the Inquiry has received a lot of evidence about is the restriction of staff movement, which you’ve addressed in your statement.

So, starting, if I may, with what NACAS’s views and its members’ views were on the guidance and timing of that guidance around May 2020.

Mr Paul Featherstone: I do apologise. Could you just repeat the question for me?

Counsel Inquiry: Yes, of course. The topic is around restriction of staff movement.

Mr Paul Featherstone: Yes.

Counsel Inquiry: And guidance was issued around May 2020. And I was asking what your members’ views were on the guidance and the timing of the guidance.

Mr Paul Featherstone: I think the members’ views of the guidance was mixed. I think it was a bit – there was either very limited, or it was – it’s either limited or it was changing too frequently.

I mean, from my experience receiving feedback from the members, they – it was that they couldn’t get access – sorry, they couldn’t get access to stuff like the PPE that would improve their – you know, their … I can’t think of the right word – improve their protection against contamination.

But I think generally, they were – they felt as though the guidance was either out of date or it was – not not relevant, but it was too ad hoc.

Counsel Inquiry: Are you talking about the PPE guidance there, around IPC and PPE?

Mr Paul Featherstone: I mean, I think that’s included in it. Because, you know, as part of the infection prevention and control measures, one would expect to have access to the appropriate equipment, protective equipment. So that’s where I was coming from there.

If I’ve misread – misunderstood the question, I apologise.

Counsel Inquiry: That’s okay. I think in your statement you spoke about your members reporting mixed views on restrictions of staff movements, so we have that there. Did NACAS play any role in advocating for any changes to the policy or guidance around staff movement?

Mr Paul Featherstone: I beg your pardon, in terms of restricting movement, through social care, one has to recognise intrinsic nature of domiciliary care work. So it would be difficult to restrict movement in that setting. But I think, in terms of restricting movement in care homes, that would need to be carefully thought through as to how that would work, in terms of staff flexibility, providers wanting flexibility, and things of that nature. So I think a blanket ban would be inappropriate in terms of staff movement.

There needs to be a – just to say: right, stop, I think that’s a complete – no, I don’t think that would be appropriate.

Counsel Inquiry: Okay. You mentioned there around access to PPE, and you’ve told us in your statement that NACAS bought and distributed 2,000 disposable face screens.

Mr Paul Featherstone: Yes.

Counsel Inquiry: Just to clarify, were they face masks or perspex screens?

Mr Paul Featherstone: They were perspex single-use screens. The reason we did that was I was getting regular calls from members to say, “I can’t get hold of PPE”, so I just took it upon myself to try to do something about it. I felt almost like an obligation to our members to try to do something. So we purchased a quantity of those masks and shared them out on a first come, first served basis. I mean, it was – that didn’t even scratch the – scratch on the surface, but it – I just felt that we needed to try to do something to help them.

Counsel Inquiry: Did that distribution include to people that were working in care homes and domiciliary care?

Mr Paul Featherstone: Yes, yes.

Counsel Inquiry: Okay. I wanted to ask you about some of the feedback you received from a NACAS survey around training about – for Covid-19 and the risks that workers faced. We don’t need it on screen. Thank you. But in a questionnaire that NACAS put out, approximately 47% responded that they hadn’t had any training, and 87% that did receive training said that it did not include information about a potential enhanced risk to ethnic minorities.

From your members’ experiences, was there widespread training around the risks for Covid-19 in the adult social care sector?

Mr Paul Featherstone: Not that I was aware of. I can say, my Lady, to this Inquiry that one of our corporate members did put together a Covid training package which they made available to our members should they want to access that. That is the only example I can give you where there was specific training for Covid, but that was something that was done in-house, through our corporate partner.

Counsel Inquiry: Do you know when that was made available?

Mr Paul Featherstone: I would say around about 2021. I can’t – I’d have to give you – come back to you with an exact date. It should be fairly easy to find –

Counsel Inquiry: Thank you.

Mr Paul Featherstone: – because it’s still on our training platform.

Counsel Inquiry: And perhaps it’s an obvious question but do you think that it would have helped if there had been more training and support available to members?

Mr Paul Featherstone: Oh, definitely.

Counsel Inquiry: The final IPC measure I wanted to ask you about was in regard to testing and whether your members reported any issues around access to testing or issues with following the testing regimes that were introduced.

Mr Paul Featherstone: We certainly had instances of members not being able to get access to testing kits. Again, this was something I tried to do something about. I tried to get on to the government portal that was distributing the testing kits at that time, but because NACAS was not providing care, I couldn’t get access to that. The idea was that if we were able to get access to those kits, then we could get, you know, we would get quantities of them and ship them out to members who were having trouble getting the kits. But yes, there was – there are, I think, several instances where members were having trouble getting access to the testing kits, certainly at the start of the pandemic. It got better.

Counsel Inquiry: Finally, in regards to lessons learned and recommendations, you have identified in your statement some areas that went well, and I just wanted to ask you if you could perhaps provide us with a few examples of those?

Mr Paul Featherstone: I’m sitting here and I’m struggling to think of an answer, but I mean, it certainly wasn’t all bad. I think the – I mean, the vaccine rollout was, I think, is a good example of things that did go well. That was done very, very quickly, even though there was a, you know, there was some reluctance on some people not to get vaccinated but I think the government should be commended on the speed in which the vaccine rollout was implemented. I think that’s probably the biggest spotlight I could shine on something that did go well.

Counsel Inquiry: And then, in terms of looking to the future, you’ve identified some key objectives that you think are important. Perhaps you could explain what they are.

Mr Paul Featherstone: I mean, moving forward, I think – and probably I’m repeating what a lot of other people have said sat in this chair, but we need to give proper recognition to our workforce, and that would be my biggest recommendation, is let’s get our amazing workforce properly recognised. And dare I say it, properly paid and remunerated. We need to do more around the narrative of how brilliant being a care professional is, rather than concentrate on the negative side of care working. That, for me, moving forward, would be job done. If we can get our amazing workforce – I keep calling them amazing because they are. I mean, they’re the ambassadors for their providers, they’re out there doing the job, you know, seven days a week, 365 days a year. We need to give them that respect, can I say that? They need to be respected and recognised as the amazing people that they are.

And I can’t – I mean, it might seem silly and a little bit simple to say those things but that’s what I would love to see, moving forward, is that focus given to our workforce, and being brought up to the same level as our colleagues in the National Health Service. We need it. It’s far too long overdue.

Ms Hands: Thank you, Mr Featherstone.

My Lady, those are my questions.

Lady Hallett: Thank you, Ms Hands.

Ms Peacock. Ms Peacock is over there. Just a few more questions.

Questions From Ms Peacock

Ms Peacock: Thank you, my Lady.

Good afternoon. I ask questions on behalf of the Trades Union Congress. My questions are on the topic of regulation in the care sector during the pandemic.

You refer in your statement at page 41 to the decision of regulators to pause routine inspections in care settings in March 2020 and you explain that:

“… the CQC continued to inspect in response to immediate risks and concerns about safety as identified by staff or members of the public, but this totalled just 50 inspections between 16 March 2020 to July 2020.”

My question is, what do you consider was the impact of this reduction in inspection activity upon the safety of care settings?

Mr Paul Featherstone: I mean, I think to reduce inspections during the pandemic was the – is reverse psychology. I think during a pandemic there should have been more inspections. I mean – and I suppose even if those inspections, when we – were not, you know, full inspections, but there was some level of inspection throughout the course of the pandemic, that would have been very, very useful.

And also, they needed – it needed – the CQC needed to be more supportive during the pandemic, because we have members who have – you know, it’s in my statement, I think, we have members saying that the support from CQC was not as it should have been.

So that – so the impact would have been – well, severely felt. I mean, if they are going to cut back on inspections, that, to me, is a detrimental step. There should have been more, not less.

Ms Peacock: When you say there should have been more, are you able to elucidate why that would have been – why during a pandemic inspections are particularly important?

Mr Paul Featherstone: I think it would have been – it would have been a vehicle to raise issues and concerns about whether an establishment was failing to meet a certain standard, for example.

This is just my view, being asked – as I’ve been asked the question today, but I just think that, rather than minimise the amount of inspections, there should have been more, even if they were slightly redacted inspections. Because I think that would have had a bit of a more of a positive impact on the provider. You know, it would have been – I just think in general it would have been – it would have been better if more – more was done in terms of the inspections.

I hope I’m answering your question for you.

Ms Peacock: Thank you.

And in addressing why routine inspections were paused during the pandemic, Mary Cridge of the CQC set out in her supplementary witness statement that:

“… [the] CQC did not want to put our employees, or anyone that we came into contact with, at any greater risk than they already were.”

However, you mention in your statement that the significant reduction in on-site inspections inevitably placed care home residents at greater risk of harm at a time when they were particularly vulnerable; and you’ve just explained some of that risk.

Was there a failure of the CQC and other regulators to recognise and to balance the risks involved in significantly reducing on-site inspections as against the risk of transmission potentially associated with on-site inspections taking place? In essence, should more emphasis have been placed on mitigating the risk of transmission so the inspections could take place?

Mr Paul Featherstone: I think so, yes, but then that’s a difficult balance to try to get to, but there should have – but there should have been a …

I’m trying to say the balance between the risk of infection and non-risk of infection needed to be looked at. I think – I can understand Mary Cridge’s statement, saying she wants to protect the staff, but the people in the care homes themselves wanted to protect their staff. So surely, between them, there could have been some middle ground that could have been reached that: yes, there might still well have been transmission, but could it have been reduced? Possibly.

So that’s why I think – that’s my initial thought there is: more should have been done, more engagement, and maybe – I don’t want to use the word “failure”, but maybe there should have been that collaboration between the CQC and the providers as to what can we do together to make sure that you’re still getting inspected and mitigate the risk of transmission? I don’t think that was done.

Ms Peacock: Thank you. And turning to look at future pandemics, Mary Cridge has stated in her evidence that:

“… in the event of a future pandemic, strenuous efforts should be made to protect the ability to carry out on-site inspections as much as is practically possible.”

So my question is: do you agree that strenuous efforts should be made to maintain in-person inspection activity in a future pandemic? And do you have any reflections on how that may be achieved? Is it an issue of planning and preparation, for example?

Mr Paul Featherstone: I think that’s exactly it. I think it’s preparation and planning. There needs to be – I’m going to refer back to my previous answer – that there has to be that aligned thinking around protecting the staff of the, you know, the CQC staff, but also the residents and staff within the care setting itself, and maybe that was lacking during the pandemic, and that needs to be looked at moving forward, so that care providers are not left wondering about when the next inspection might because it’s a pandemic, but also, may I say, that when care providers are asking for guidance and support from the inspectorate, they don’t get told, “We’re not here to give advice”, or things of that nature.

That simply doesn’t help the situation at all, you know, and places everybody on a – yeah, it’s just not an acceptable situation for that to happen.

Ms Peacock: And just by way of a short follow-up, Mary Cridge, I think has suggested that inspectors should be treated as key workers from the outset of a future pandemic and that they should be given priority access to testing, PPE, vaccinations and IPC training. Is that a recommendation you and your members would support?

Mr Paul Featherstone: I think that’s a good point. I think they should, if they’re going to be out there doing the job in the pandemic then absolutely they should be able to get access to that equipment.

Ms Peacock: Thank you.

I’m grateful, my Lady, those are my questions.

Questions From the Chair

Lady Hallett: Thank you, Ms Peacock.

Can I ask you a question? It sounds as if you might have – your experience in social care was in Wales, was it?

Mr Paul Featherstone: Correct, my Lady.

Lady Hallett: Bit of a clue in the accent.

You have said your membership is 60% English and the other 40% around the devolved nations.

Mr Paul Featherstone: Yes.

Lady Hallett: You haven’t actually specified any differences around the four nations of the United Kingdom. Did you detect any particular problems that were more prevalent in England or more prevalent in Scotland or …?

Mr Paul Featherstone: I didn’t detect anything along those lines during the pandemic, my Lady, no.

The members who contacted us throughout the pandemic would have been across the whole of the UK. But I can’t sit here and tell you I can say “Well, this happened in Wales, this happened in Scotland.”

Each of the devolved governments reacted slightly differently to the pandemic. I think – from a personal level, I think the Welsh Government did a reasonably good job, but I can’t give you a specific example of differences in the regions as a whole, sorry.

Lady Hallett: No, I’m very grateful. That’s what I detected: that actually the concerns you were hearing seemed to be replicated around the United Kingdom.

Mr Paul Featherstone: Yes.

Lady Hallett: Is really the impression I got from your evidence.

Mr Paul Featherstone: Yes, they were. I think that’s a fair comment, yes.

Lady Hallett: Well, thank you very much indeed.

That completes all the questions we have for you. I’ve received a number of messages during the course of this module, and I can promise you that the message I received particularly loud and clear is the message you wanted to get across, which is the importance of recognising the social care workforce.

And if I might say so, you asked if you could be proud of setting up the association, you should be rightly proud. It was obviously a gap that you foresaw long before many others had. So thank you very much for all you’ve done to try and get the care profession recognised, and it is certainly a message I have received.

The Witness: That’s very kind of you, my Lady.

And might I just finish by saying, can I thank, my Lady’s Inquiry for giving me the opportunity to give a voice to our workforce. Very grateful.

Lady Hallett: Thank you very much indeed, Mr Featherstone.

Ms Cecil: My Lady, may I call Professor Hatton. He’s just on his way in.

Professor Chris Hatton

PROFESSOR CHRIS HATTON (affirmed).

Questions From Counsel to the Inquiry

Lady Hallett: I hope we haven’t kept you waiting, Professor.

The Witness: Not at all, my Lady.

Ms Cecil: Thank you, Professor Hatton.

You are here today to assist the Inquiry with regard to the specific position of people, adults, with learning disabilities in the social care sector.

To that end, you have produced, along with Professor Richard Hastings, an easy-to-read report and a full report for the Inquiry.

Professor Chris Hatton: Yes, that’s correct.

Counsel Inquiry: Just for those, the assistance of those following, the Easy Read report is at INQ000616456, and the full report is at INQ000587296.

In terms of your professional background, you are a professor of social care at Manchester Metropolitan University.

Professor Chris Hatton: Yes.

Counsel Inquiry: You set out within the report a very impressive and extensive list of both your experience and qualifications. Perhaps if I can just draw these two out: from 2013 to 2019 you were the co-director of the Public Health England Learning Disabilities Observatory?

Professor Chris Hatton: Yes.

Counsel Inquiry: And you are also a senior investigator at the National Institute for Health and Care Research?

Professor Chris Hatton: Yes.

Counsel Inquiry: Your co-author, Professor Richard Hastings, is also in attendance today.

Professor Chris Hatton: He is.

Counsel Inquiry: He is a professor of psychology, health and social care. He holds the 125th Anniversary Chair in the School of Social Policy and Society, alongside being the director of the Intellectual Disabilities Research Institute, IDRIS, at the University of Birmingham.

Professor Chris Hatton: He does.

Counsel Inquiry: Thank you.

If I can turn then, please, to the report. Just dealing with methodology for a moment, much of the report draws on the Coronavirus and People with Learning Disabilities Study, a study that you and Professor Hastings undertook?

Professor Chris Hatton: That’s correct.

Counsel Inquiry: Thank you. And that tracked the lives of adults with learning disabilities across the UK at four points during the Covid-19 pandemic, the first of those in December of 2020?

Professor Chris Hatton: Yes, correct, through to late 2022.

Counsel Inquiry: Indeed, thank you.

If I can ask you first of all, please, what is a learning disability? How is it defined?

Professor Chris Hatton: A learning disability – “learning disability” is the term that’s used in the UK. Internationally the term “intellectual disabilities” is quite often used.

I think a really important thing to point out is that a learning disability is not a health condition. It is – as it says on the tin, it’s an issue with learning new things.

There are three elements to common ways in which learning disability is classified or identified. One is about an issue with cognitive ability, quite often measured through IQ testing.

The second is an issue with managing the kind of functional tasks of daily life. So that might be from things like, kind of, reading and reading, getting around, being able to care for yourself and social skills.

And the third element is that it is a condition, a diagnosis, an identification that happens during childhood, to distinguish it from cognitive impairment due to dementia or traumatic brain injury.

Counsel Inquiry: Indeed. And to put it in another way: it’s a lifelong developmental condition?

Professor Chris Hatton: Yes.

Counsel Inquiry: Thank you.

In terms of health needs, we’ve heard already from Professor Banerjee in relation to individuals with dementia that you should not treat, effectively, that group as one homogenous group, there are obviously quite differences within it. To that extent, what do the needs and extent of the disability vary?

Professor Chris Hatton: Yes, we’re talking probably about over a million adults with learning disabilities across the UK, so any group of a million adults is going to be incredibly diverse. The way that people’s needs have been characterised, some of the terminologies that people might find offensive, is in terms of how severe a person’s learning disability is; typically from sort of mild to moderate learning disabilities, so most people with learning disabilities have this designation of mild to moderate. People will usually be living fairly independently, maybe with some support, and that’s distinguished from a smaller number of people with moderate to severe, severe to profound learning disabilities.

And that characterisation, people normally need a lot more support with kind of daily living and they are people who are much more likely to be getting adult social care services in the UK.

Counsel Inquiry: Indeed. And within your report you point to one of the issues being identification of those with learning disabilities, and that it follows from, effectively, the level of need that a higher level of those individuals with more severe learning disabilities will be known to services.

Professor Chris Hatton: That is correct. So overall, probably only about a quarter of likely adults with learning disabilities are known to health and social care services. So there are large numbers of adults with learning disabilities who don’t get adult social care support most of the time, but under conditions of emergencies, like a pandemic, some support might be needed. But those people will not usually be known to any health or social care agency.

Counsel Inquiry: I am going to move on to that in just a moment but continuing, if I may, just on need for one moment. There are also those with profound and multiple learning disabilities within that group; is that right?

Professor Chris Hatton: Yes, and people with profound and multiple learning disabilities need pretty much round the clock support. Many people are still living with families at home, but with extensive support coming in, rather than necessarily living in, kind of, care homes, which I know have been discussed a lot in this Inquiry, but there’s a real importance for that group of ongoing therapy and support, because in the absence of that, there might be permanent damage that’s caused without that kind of therapy being available.

Lady Hallett: Forgive my interrupting. You said there were three criteria all coming within the category of having a learning disability, one of which was a diagnosis during childhood.

Professor Chris Hatton: Yes.

Lady Hallett: But you’ve also said there are one million adults across the UK with learning disabilities. Does that mean it’s one million diagnosed? Or is that your best estimate if they all came within your purview?

Professor Chris Hatton: Yes. It’s – one million is the best estimate. There are much higher numbers of children identified with learning disabilities in education than there are in adulthood. So there’s something called a transition cliff, where many children identified in education systems don’t then go on to be identified in adult services, but the one million is our best estimate, yes.

Lady Hallett: The reason I ask is because you said one million across the United Kingdom but only a quarter known to the health and social care authorities.

Professor Chris Hatton: Yes.

Lady Hallett: It just seemed to me that if there is a diagnosis, why are they not known?

Professor Chris Hatton: Yes, that’s based on research, based on prevalence estimates, going out and assessing people directly.

Lady Hallett: Thank you. Sorry to interrupt.

Ms Cecil: No, not at all.

I wish to turn now, please, to focus on the interrelationship with adult social care within the United Kingdom.

In that respect, can I please call up the Easy Read report, we’re aware that a number of individuals with learning disabilities are indeed following today’s proceedings.

If we can go to page 4 of that, this sets out, essentially, a profile of what is known about those adults with learning disabilities and the types of care they do or do not receive.

So the first aspect is that most adults with learning disabilities do not get support from their local council, otherwise known as social care; is that right?

Professor Chris Hatton: Yes, that’s as we’ve discussed.

Counsel Inquiry: Indeed. Turning to those people that do get social care and support, the majority of those are aged under 65?

Professor Chris Hatton: Yes, the vast majority. So it’s usually over 80% of adults with learning disabilities getting social care are under 65.

Counsel Inquiry: And just to place that in some level of context in relation to adult social care generally, it’s about 18% of all adults receiving adult social care have learning disabilities?

Professor Chris Hatton: Yes.

Counsel Inquiry: Typically, again, looking at the demographic profile, the age profile, they were typically younger –

Professor Chris Hatton: Yes.

Counsel Inquiry: – those individuals with learning disabilities, with 88% of those adults being under 65?

Professor Chris Hatton: Yes.

Counsel Inquiry: In terms of where individuals live, as we see here, the majority of people, of adults with learning disabilities, depend on family for some form of their care, often living with their family or receiving support from their family?

Professor Chris Hatton: It is the most common living situation for adults with learning disabilities who are getting social care, living with family, parents or siblings.

Counsel Inquiry: The next most common is living in flats or shared housing or supported living?

Professor Chris Hatton: Yes, that’s correct, and that is an expanding number of people.

Counsel Inquiry: Indeed. And then expanding again, we have those individuals that use day services or take part in community groups.

Professor Chris Hatton: Yes, so those services are often available to people in a wide range of living situations. So yes, but they’re a really important part of adult social care for this group.

Counsel Inquiry: And what’s not included in the easy to read report are those numbers that live in residential, the people that live in residential care, and just dealing with that, it’s quite a small part of that population?

Professor Chris Hatton: Yes.

Counsel Inquiry: It’s around 16% –

Professor Chris Hatton: Yes.

Counsel Inquiry: – of those aged under 65?

Professor Chris Hatton: Yes, it’s relatively small and it’s decreasing over time.

Counsel Inquiry: Indeed. And that compares to those over 65 who live most commonly in care homes, those adults with learning disabilities, and those numbers are increasing over time.

Professor Chris Hatton: Yes, and there may be some adults with learning disabilities, some older adults with learning disabilities in general care homes who aren’t identified as a person with learning disabilities or having those needs.

Counsel Inquiry: With regard to the social care services that are provided across the United Kingdom, there is – it varies, depending on geography and areas of social deprivation. Does that sum it up?

Professor Chris Hatton: Yes, I mean, there’s not good evidence in terms of comparing across the different parts of the UK, but there is consistent evidence of variation within countries, so different local authorities have different levels and profiles of the kinds of services that they offer to adults with learning disabilities.

Counsel Inquiry: Indeed. Moving to data, more generally, in terms of data, how good is the data with regard to adults with learning disabilities and social care? I appreciate it’s a broad question. Just a snapshot.

Professor Chris Hatton: In the context of the pandemic, I think there are, kind of, two answers to this. One is the data are not good at all, it’s really hard, there aren’t consistent tracks of data over time, there’s not consistency across countries. There’s real issues with the reliability of what’s recorded when there are data systems. So I think that’s one set of things. But having said that, I think in the context of the pandemic, there was clearly enough evidence and enough data there to make informed policy decisions in terms of pandemic planning before the pandemic.

Counsel Inquiry: And just picking up, if I may, on each nation and the way in which data is collated, it’s not consistent across the four nations, is it? So that poses its own challenges.

Professor Chris Hatton: No. For some people it’s people known to services. For some, it’s people getting, kind of, long-term care. There’s differences in the minimum age, there’s differences in, kind of, how that information is collected, and how often, so they vary hugely, and in some places, there’s currently not been any data collected at all, for example in Scotland.

Counsel Inquiry: Indeed. So in Scotland there’s been no data on social care services received by those individuals with learning disabilities since 2019?

Professor Chris Hatton: That’s correct, and I think again, this is thinking forwards, that I know there’s been a lot of discussion of data in this module, but recommending the new data system will take years. So I think there needs to be something around data that is more immediate and short-term and pragmatic than that as well.

Counsel Inquiry: Indeed. And you do set out some of those recommendations towards the end of your report, and we may touch upon those later.

But if I can just pick up, also, on Northern Ireland because Northern Ireland in particular has significant data limitations.

If I may call up the statement of Joanne Sansome, please, paragraph 97. What we see here is that she records, on behalf of Disability Action Northern Ireland, that:

“The sheer absence of data within the Care Sector is shockingly demonstrated by the fact that during the pandemic there were not even accurate figures of the number of adults with learning disabilities receiving health and social care in Northern Ireland”, instead relying on estimates all the way back to 2015.

And we’ve also heard evidence in the course of this module from the Chief Medical Officer of Northern Ireland, Professor McBride who explained it’s not possible to disaggregate data, including by adult social care.

What challenges did those pose in monitoring – well, first of all, identifying those adults with learning disabilities, and secondly, in monitoring the impacts of the pandemic?

Professor Chris Hatton: Well, it makes it impossible to identify people and that makes it then very difficult to track any impacts of the pandemic. So the only sort of continuous data series over a length of time, kind of before and through the pandemic, is probably England, and in England we found that the number of adults with learning disabilities getting social care dropped during the pandemic, but there’s not sufficient continuity of data across other parts of the UK to be able to draw any firm conclusion. And that’s a real – a real problem when you’re trying to understand the impacts of policy or practice in different parts of the UK.

Counsel Inquiry: Indeed. And a further example you give within the report is that there’s no public data on mortality, so deaths among adults with learning disabilities in Northern Ireland also; is that correct?

Professor Chris Hatton: Yes, there wasn’t anything produced that we know of during Covid about Covid morality or all-cause mortality in Northern Ireland.

I mean, Northern Ireland is smaller in terms of population, which might present some challenges in terms of the sophistication of the analyses you can do, but it’s clearly sufficient for people to be able to draw the conclusions you need to make policy choices.

Counsel Inquiry: And in terms of collation of data, what might that look like in terms of good quality data? What does it mean? You’ve said it, and we’ve heard many times, we need more data, or data is insufficient, but what does “good” look like in this context and what is needed in this particular context?

Professor Chris Hatton: I think in this context the first thing is to work out the purposes for which you want data. I think a blanket “We need more or better data” doesn’t really help anybody. So I think having a clear set of purposes of what you need the data for is step one.

I think then there’s something then at looking at what the data are that are available, whether you can link them, whether you can actually disaggregate them, what that gives you that enables you to answer some of those policy questions or planning questions you have. And then it will be a question of working out how to fill in the gaps. I think there are basic things like consistency, reliably – you know, reliability of coding.

So, for example, in GP systems, they don’t reliably record the ethnicity of adults with learning disabilities. That’s quite a basic thing. So I think some of it is we can really improve and fix what we have and make better use of it, and that, I think, is a more – you might have some more immediate protocols for use in terms of pandemic planning and then pandemic action than you would by staking everything on building the perfect data set at some point down the road.

Ms Cecil: Thank you very much.

My Lady, this may be a convenient moment.

Lady Hallett: Yes, of course.

I hope you were warned that we take a regular break. I shall return at 3.15.

(3.02 pm)

(A short break)

(3.15 pm)

Lady Hallett: Ms Cecil.

Ms Cecil: Indeed.

Professor, may I now turn to the impact of Covid-19 and again call up, please, the Easy Read report, page 5, INQ0006 – thank you very much.

And these are the headlines, ultimately, aren’t they, in relation to people with learning disabilities. And so, as we can see here, that during the pandemic, people with learning disabilities were, firstly, more likely to get Covid-19 than people without learning disabilities.

What did your research demonstrate there?

Professor Chris Hatton: That’s correct, the evidence that we’ve found, there’s actually quite good evidence in the UK about the deaths of people with learning disabilities during Covid internationally.

They found that during the earlier phases of the pandemic, before the vaccine was widely available, people with learning disabilities – well, adults with learning disabilities were between – seven times more likely to die from Covid-related issues compared to people without learning disabilities.

Even with the advent of the vaccine, absolute death rates for people with learning disabilities from Covid dropped, but there was still that disproportionate gap in the risk of Covid death between people with learning disabilities and people without learning disabilities.

So this was a very stark difference that remained throughout the pandemic.

Counsel Inquiry: Indeed. And we see that, don’t we, at the very end of this page, where it says that individuals with learning disabilities were much more likely to die from Covid in that regard.

And you’ve given some of the statistics. In the first wave, I think it was – overall it was 8.69 times more likely to die. The second wave, approaching seven times, as you said, more likely to die.

And you explain that later in the pandemic that risk decreased, but it was still between four to ten times more likely than those without learning disabilities.

What does that mean? Why do we have that range there, four to ten times?

Professor Chris Hatton: The range is usually about methods. Because of all the issues that we’ve talked about, with data, about identifying people with learning disabilities, about how people use different – and whether the people are dying in particular kinds of services, there are different ways to do that so you get that range. I guess what you get is a very consistent pattern of increased risk of death. And that is particularly high, from the evidence that we have, among people with Down syndrome within the group of people with learning disabilities.

Counsel Inquiry: Indeed. And that’s one of the further disproportionate impacts, isn’t it? There are other aspects or risk factors that come into play, one of them being, as you say, Down syndrome. Others mirror what is known more generally about Covid and disproportionate impacts, for example, on men, age being a risk factor –

Professor Chris Hatton: Yes.

Counsel Inquiry: – minority ethnic individuals also facing greater risks, and then multiple health conditions, and in particular those with profound and learning disabilities that we were talking about earlier?

Professor Chris Hatton: Yes. I guess one thing I’d say on the age front is that the peak age of death from Covid for people with learning disabilities was younger than for the general population, so the peak age was some time between 50 and 64 years old.

Counsel Inquiry: Thank you.

And with regard to other aspects that feed into that, as we’ve seen from that – the Easy Read report, those individuals with learning disabilities were more likely, firstly, to get Covid, as in to be infected?

Professor Chris Hatton: Yes, sorry, I realised I did answer a different question to the one you asked a little bit earlier.

Counsel Inquiry: Not at all. It’s the headline point from the report, ultimately.

Professor Chris Hatton: So people were almost twice as likely to be infected with Covid. People also more likely to be hospitalised with Covid, but once in hospital, with Covid, there’s one study suggesting that people were less likely to get active Covid treatments in hospital compared to other – people with learning disabilities were less likely to get active treatments in hospital compared to people with Covid.

Counsel Inquiry: Indeed, and you’ve set out the various statistics within your report, I won’t go into details with those now, but they were less likely, for example, to receive non-invasive respiratory support, intubation, less likely to be admitted to intensive care units, and overall, there’s a 56% increased risk of dying after they were hospitalised compared to those individuals without learning disabilities in hospital.

Professor Chris Hatton: That’s correct, yes.

Counsel Inquiry: Thank you.

In terms of the risks of death – we’ve obviously just gone through some of those aspects, but if I can just pick up one further aspect there, and it relates to one specific risk factor, and that is in relation to care homes. You explain within the report that UK evidence is relatively limited not least because there are relatively few adults with learning disabilities that reside in such settings.

Professor Chris Hatton: Correct.

Counsel Inquiry: But what does the evidence that you do have show or demonstrate?

Professor Chris Hatton: The evidence showed that living in what’s described as a congregate care setting or residential nursing care home was associated with increased risk of death for adults with learning disabilities compared to adults living in other situations.

Counsel Inquiry: Did that remain the case throughout the pandemic or was it limited in time to any of the waves?

Professor Chris Hatton: No, it was a consistent finding throughout the pandemic.

Counsel Inquiry: Now if I may look at it through the other end of the telescope and in a broader sense and just place that, please, within the context of deaths in care homes more widely, obviously increased risk for those adults that were in care homes that had learning disabilities, but compared to the broader care home population, they were at less risk than others, than those in older people’s homes; is that right?

Professor Chris Hatton: That’s correct, and again, I think one of the big differences in care homes that tend to be registered for adults with learning disabilities versus care homes for older people is that they’re much smaller in terms of the number of people who are living in those care homes. So the average is something like nine or ten adults in a care home as compared to, you know, perhaps 40 or more in care homes for older people.

Counsel Inquiry: Indeed, and you set that out within a table within your report, it’s at page 14 of your report. And we see that the picture is similar, this relates to the position in England, and so we see here the care homes without nursing registered for older people, as you say, with learning disabilities compared to those registered for older people. If we go down, average number of places per home, 9.8 for those with learning disabilities; 30.2 for those for older people, and although the numbers increase, there is still a differential when it comes to care homes with nursing. If we go across, for those individuals with learning disabilities, it’s around 38.2 places per home compared to 54.2 places for those that are older without learning disabilities.

Professor Chris Hatton: That’s correct.

Counsel Inquiry: Thank you.

And in terms of your research, are there any features of smaller homes that you can point to that you consider decrease that risk? Is that something you can comment on?

Professor Chris Hatton: Well, I think it’s a general feature that smaller care homes reduce risk of Covid transmission in a wide variety of ways. So, obviously, it reduces the number of people who you are, kind of, with every day. It reduces the number of staff who were coming into the home. So I think all those things help, and it’s easier to negotiate, I guess, a kind of restricted life if you have smaller numbers of people together.

Counsel Inquiry: Thank you. And then just dealing with a connected matter, which is all-cause mortality, what was the position immediately prior to the pandemic in that regard?

Professor Chris Hatton: So before the pandemic, consistently people with learning disabilities were more likely to die from all-cause mortality than other groups of people. So that was an inequity that was, kind of, well established and not really shifting beforehand. During the pandemic, all-cause mortality actually disproportionately increased for people with learning disabilities compared to other groups, so that existing inequality got worse.

Counsel Inquiry: Indeed, by May of 2020 it had doubled, effectively, that of in 2019?

Professor Chris Hatton: Yes.

Counsel Inquiry: If I may now just touch upon, please, the position of vaccinations for those adults with learning disabilities, the Inquiry has heard fairly substantial evidence in relation to this, both in Module 4 but also in relation to the healthcare module, Module 3. And for these purposes, by December of 2020, the vaccination programme for rollout had been updated –

Professor Chris Hatton: Yes.

Counsel Inquiry: – in terms of prioritisation to include those clinically extremely vulnerable people individuals in a banding along with those individuals who are aged 70 and older?

Professor Chris Hatton: Yes.

Counsel Inquiry: That also included Down’s syndrome?

Professor Chris Hatton: Yes.

Counsel Inquiry: And those with severe and profound learning disabilities; is that right?

Professor Chris Hatton: People with severe and profound learning disabilities I think were put into band 4. The issue, there again, as we’ve talked about before with the data, is that would have to be based on GP records, and GP records do not consistently or reliably record that at all. So making that a requirement in terms of having to specify that group would have led to a huge amount of bureaucratic gatekeeping, which would be completely counterproductive in a pandemic, when the evidence was quite strong that it’s people with learning disabilities as an entire group who are at increased risk.

So the position they eventually came to, which I think makes sense, was everybody registered with a GP as a person with learning disabilities would be placed in that priority band 4 – priority band 6, sorry.

Counsel Inquiry: Not at all. So there were practical difficulties in the initial instance but certainly within the report, as the pandemic went on, you point to that as being one of the success stories and points of learning in terms of the actual rollout to individuals with learning disabilities; is that right?

Professor Chris Hatton: Yes. So in the end we have data for England showing that rates of vaccination for adults with learning disabilities was actually slightly higher, if anything, than for other groups of people. And we did see a very proactive mobilisation of vaccination efforts that, again – that were reasonably adjusted to people with learning disabilities, as is required in the Equality Act. But there was a fantastic mobilisation of vaccination efforts which really stood out as being different, I think.

Counsel Inquiry: And some of those different mobilisation efforts included proactively going to those individuals’ homes to – for vaccination purposes?

Professor Chris Hatton: Absolutely, yes. And that will kind of – wouldn’t normally happen, but yes, there was, you know, visiting – visiting homes where there would be groups of people and vaccinating everybody at the same time where you could.

There’s a small minority of adults with learning disabilities, often people with quite complex needs, people with profound and multiple learning disabilities, for whom a vaccination is not possible, for various reasons. This might be on health grounds or it might be a very severe needle phobia. And I think there’s a real issue about what happened in the pandemic to that group of people.

Counsel Inquiry: Indeed. And certainly some of those issues have been explored previously at length.

If I can now turn, please, to the – turn back to the Easy Read report to page 8. Pre-pandemic, there were known issues with do not attempt cardiopulmonary resuscitation notices in relation to adults with learning disabilities; is that right?

Professor Chris Hatton: Yes, there was quite consistent evidence from the Learning from Deaths Review and from other sources that quite high proportions of adults with learning disabilities who had died had a DNACPR. These were reviewed by local health service staff, and a proportion of them were found to have been completed without due consultation. And this fitted with consistent stories about were coming up about, kind of, people discovering a DNACPR on their relatives’ notes when they were in hospital without them knowing how that had got there.

Counsel Inquiry: If I can just interrupt you, you say this fitted with the stories that you were hearing?

Professor Chris Hatton: Yes.

Counsel Inquiry: Do you mean during the pandemic?

Professor Chris Hatton: Some of that was before but it was – potentially there was some evidence that during, that increased.

Counsel Inquiry: So that’s – that was going to be my next question, is what was the impact during the pandemic, and what we see here is that in the pandemic, some people had – with learning disabilities had DNACPR in their notes, but they or their family had not agreed to this.

Professor Chris Hatton: Yes, that is the case.

Counsel Inquiry: Setting aside the aspect of agreement, in relation to the communication, was that something – were there problems with the communication processes that were gone through in terms of consulting families or those individuals themselves?

Professor Chris Hatton: Yes, people reported quite widespread problems with how DNACPR decisions would be communicated to them. Again, there was some of that before the pandemic, but there was certainly more of that, potentially, during the pandemic.

Counsel Inquiry: Indeed. And within your report you set out the findings of various reviews, including the CQC, Care Quality Commission. Again, we’ve heard some evidence in relation to that so I’m not going to take you there, but just to go to the next aspect, please, it says:

[As read] “Some groups of people were all given DNACPRs at the same time. This is not okay.”

I just want to pick up on one aspect of that, if I may, that in terms of the NHS, they resorted to sending out letters to doctors and healthcare workers to explain that, for example, the terms “learning disability” and “Down’s syndrome” should never be a reason for issuing a DNACPR order or to be used to describe the underlying or only cause of death.

Professor Chris Hatton: Yes. And you wonder why they felt the need to issue those letters, what the practice was that led them to issue those letters. And certainly there didn’t seem to be much that we could find that was written down but people quite consistently reported GP practices, for example, sending round those kinds of letters.

Sometimes they were rescinded under challenge but that was definitely an issue. And again, the sort of – the high-level issuing of a letter doesn’t necessarily mean widespread implementation of that in practice, hence all the reviews from PHSO and CQC and others in other parts of the UK.

Counsel Inquiry: Thank you.

So, and in terms of the people that you were speaking to and the research that you conducted, were concerns expressed that people with learning disabilities were having those notices recorded solely on the basis that they had a learning disability?

Professor Chris Hatton: Yes.

Counsel Inquiry: More broadly, is it right to say that a large number of people were very scared about the prospect of having those notices put in place?

Professor Chris Hatton: Yes, they were. I think people had not had the conversation about what that meant. I think people had not had the conversation to then be able to make an informed choice about that. And I think people were concerned that a DNACPR notice accompanied other things that might or might not happen to them in hospital in terms of health treatments.

So people were concerned that that might be a marker of other issues in terms of lack of health treatments that they may get during Covid.

Counsel Inquiry: Indeed, within your report then you go on to explain that people and their families did not get easy-to-understand information about those notices or the process or end-of-life conversations –

Professor Chris Hatton: Yes, and this is –

Counsel Inquiry: – and planning?

Professor Chris Hatton: Yes, this a consistent feature of people’s experience in the pandemic in all sorts of ways.

Counsel Inquiry: I want to move on now, please, to other impacts that individuals faced, and the first one being the imposition of PPE and face masks. And certainly, in relation to some individuals with learning disabilities they were exempt from wearing face masks but for some it was quite difficult, is that right, for them to understand why they might need to or, indeed, experiencing others caring for them with face masks around them?

Professor Chris Hatton: Yes. So again, we’re talking about a very diverse group of people. So I think many people with learning disabilities understood why they were needed, even if it was uncomfortable or really strange in terms of trying to sort of interact and communicate with people who knew you well. Many people who had an exemption still wore face masks anyway when they were out because of their sense of public duty and protecting others as well as themselves, but yes, for some people it was incredibly difficult in terms of communication and in terms of heightening how scary the whole Covid pandemic was.

Counsel Inquiry: And you’ll be aware that a number of people were subject to visiting restrictions if they lived in either forms of supported housing or, indeed, in care homes or alternatively, were subject to restrictions in their own homes –

Professor Chris Hatton: Yes.

Counsel Inquiry: – during the pandemic as a consequence of the various non-pharmaceutical interventions put in place.

If I could just call up, please, the Every Story Matters record for this module. It’s INQ000587564 at page 50.

This records the account of an individual whose son was in a residential care home with severe autism and learning disabilities. She explains that she was unable to visit him, they could not visit through a window, or Facetime, because he would not understand and so become upset:

“… it was a choice between keeping him calm or upsetting us all by seeing him through a window.”

Do those experiences also resonate with some of what you found during your research?

Professor Chris Hatton: Yes, the research that we did, this is not an extreme or particularly unusual heartbreaking story, and there are stories that people have very much like this in a whole range of situations, and that have, I think, quite a lasting impact on people, that those experiences and those memories are still quite raw for people, if you ask people about them now, so there is a real sort of long-lasting impact of those restrictions and how they were handled and how they weren’t particularly adjusted for the circumstances that people with learning disabilities found themselves in.

Counsel Inquiry: Thank you. And on the converse side of that, you also had difficulties – or we’ve heard evidence of people who were living at home and are very frustrated because they’re not being allowed to go out and the problems that that caused within their own home and those individuals that were caring for them and the relationship breakdowns that took place.

Professor Chris Hatton: Yes.

Counsel Inquiry: Is that also a feature?

Professor Chris Hatton: Yes, absolutely. So people’s worlds became incredibly small, often – well, we’ll come to this, but social care support was withdrawn or severely reduced. And, you know, many people did not really understand why they couldn’t go out. I should say in terms of some of the early advice on being able to leave the house, again, early advice and guidance was only once a day for everybody. That was subject to legal challenge and that was changed for people in some groups including people with learning disabilities.

So again, I think that’s an example of how the lack of consideration of adults with learning disabilities led to a period of distress that was completely unnecessary because if that guidance had been written that way in the first place it wouldn’t have been an issue.

Counsel Inquiry: And that’s one of your overarching recommendations, isn’t it, that there needs to be accessible guidance for individuals with learning disabilities and their families and friends who are caring for them?

Professor Chris Hatton: Yes. So NHS England has had an Accessible Information Standard since 2016 that applies to health and social care services. They refreshed it in June 2025 partly because it hasn’t been implemented. So some of the building blocks are there; they are just not being used.

Counsel Inquiry: Indeed. More broadly within your report, you set out in quite some detail the impact of the withdrawal of services, care, support, and more broadly, social care provision during the pandemic.

Professor Chris Hatton: Yeah.

Counsel Inquiry: And you also set out the impact of that disruption to routines, but also physical impacts, cognitive impacts, and, indeed, behavioural and emotional impacts. And we, more broadly, have heard evidence in relation to the impact upon individuals’ health and wellbeing.

Professor Chris Hatton: Yes.

Counsel Inquiry: And similarly in relation to family carers, we’ve heard evidence of the very substantial impacts on those, concerns of physical and mental health, and your report mirrors that, doesn’t it, in terms of identifying burnout, anxiety, isolation, fear, and a sense of abandonment?

Professor Chris Hatton: Absolutely.

Counsel Inquiry: Can you just expand on the sense of abandonment, because I know that’s another area in which you feel strongly that there needs to be some form of future planning and rebuilding?

Professor Chris Hatton: Yes. So people with learning disabilities and family members quite often will talk about today, that the importance of that sense of being abandoned, just being left on your own to get on with it with no warning, sometimes it felt like it was overnight. There was no sense of transparency or fairness and no sense of when things might ever come back. And again, they haven’t yet come back, as far as we know, to pre-pandemic levels, which is at the end of a decade of austerity anyway. And I think that abandonment is really important for this Inquiry, that the loss of trust that people have in services and in governments to help them when the chips are really down, and I’m not sure that governments and social care services have really appreciated the job they have to rebuild that sense of trust, that in the absence of that, that’s going to make a lot of other things that governments and services are trying to do a lot more difficult.

Counsel Inquiry: Indeed.

And then finally, if I may, within the easy to read report, you set out, very clearly, lessons learned, things that you have learned, and then in terms of recommendations, things to do in a future pandemic, and then separately to that, things that can be done now.

If there was one overarching recommendation or message to take away from your evidence today, what would that be? The most important one.

Professor Chris Hatton: Yes. I think what we’ve been discussing is how many of the building blocks are there and they weren’t perfect, but in terms of information, in terms of aspects of systems, in terms of guidance, that was – some of that – enough of that was there for policymakers to really plan properly for a pandemic.

So there is no excuse for a government to not – to say that they don’t know who, where adults with learning disabilities are, in terms of social care services. It’s no excuse for them to say they have no information. We know that people with learning disabilities are at vast increased risk of health inequalities, for example, that will make a massive difference.

So the real issue is that there was nobody who was picking up those threads and turning it into pandemic planning that was national and that could be then thought of in a local way. So I think our main recommendation is to find a mechanism and find a way that people with learning disabilities’ family members to be closely involved in some kind of way to do coherent pandemic planning, that has some kind of clout institutionally, that has some kind of independence, that has some kind of transparency so that people can trust in it.

And I think that would find a lot of things that can be done in the short term, we’ve talked – we’ve got a lot more sort of specific recommendations in there but without that kind of drawing together and that sense of urgency, I think all those threads would be lost.

Ms Cecil: Thank you very much.

My Lady, those are my questions but there will be some more questions for you.

Questions From the Chair

Lady Hallett: There are. Just before Ms Beattie asks her questions, can I ask you the same question I asked the previous witness. Your report does cover England, Wales, Scotland and Northern Ireland. Were there any particular discrepancies, or better practice, worse practice, in any of the nations that you or your colleague Professor Hastings wish to emphasise?

Professor Chris Hatton: In terms of the experiences of people through the pandemic? In a way, to our surprise, there weren’t, really, big differences across different parts of the UK, because they have quite different systems when it comes to adult social care, but we didn’t find particularly big differences. I think there are some differences in how responsive national governments were, so for example, in terms of vaccination, the first country to decide that everybody with a learning disability on the register would be prioritised was Scotland. So devolution helped, I think, in terms of Scotland having the leeway to do that, but there were not big differences in people’s experiences of services, which was something that we were exploring.

Lady Hallett: Thank you very much.

Ms Beattie.

Questions From Ms Beattie

Ms Beattie: Thank you, my Lady.

Professor, I ask questions on behalf of Disabled People’s Organisations, and the questions concern Care Act easements and reductions in services.

In your report you touch on Care Act easements as an example of legislation during the pandemic with particular relevance to adult social care for adults

with learning disabilities, and you’ve explained earlier

in your evidence how adults with learning disabilities

use social care.

You say in your report that the local authority

adult social care responses to the pandemic did not seem

to map onto whether local authorities had used easements

or not. So my question is, did that reflect that only

a few local authorities were actually formally using

easements, while others seemed to reduce services

without formally using them?

Professor Chris Hatton: Correct, yes. So, in terms of geography and in terms of

time, many more people will experience those reductions

in adult social care services whether they were in an

easements area or not.

Ms Beattie: And did that – the fact that – it didn’t seem to map

onto what local authorities were doing, and there seemed

to be a disconnect there, did that reveal a lack of

oversight and transparency around those reductions in

services?

Professor Chris Hatton: I think that’s – we don’t really have much evidence to

speak to that, but I think I can say the experience of

adults with learning disabilities and family members,

they experienced it as lacking in transparency and

lacking in fairness and lacking in due process.

Ms Beattie: And I think you said earlier that people, for example, with profound and multiple learning disabilities who may live at home with extensive support coming in might suffer permanent damage if that support was reduced. Is that the kind of impact that was experienced?

Professor Chris Hatton: Absolutely. So people with profound and multiple learning disabilities are quite a small group in terms of number, but in terms of support people need, they need quite extensive support. And that’s exactly the kind of thing where there’s permanent impact.

So, for example, postural care. If you’re a person with scoliosis and you miss out on three years of postural care, that might be damage to your spine which no amount of future postural care will completely correct.

Ms Beattie: And would it be of benefit to have greater transparency on – in a future pandemic, or in any event, on reductions to services of that nature?

Professor Chris Hatton: Absolutely. Yes. I’m always in favour of transparency. And I think one of the things we can do around that, around data, is set protocols for publication of data of evidence in advance. So that we know exactly when things are going to be published. Because otherwise, you can get delays in publication and people start to question why those delays are happening. I think protocols on transparency, what data is going to be

released when, in advance, I think that will really help

in terms of transparency.

Ms Beattie: Thank you, my Lady.

Lady Hallett: Thank you very much, Ms Beattie. Very

grateful.

Professor, that completes all the questions we have

for you, thank you very much indeed. And I think

Professor Hatton – Hastings is also sitting here – for

somebody whose name begins with “Ha” as well, I should

have got that right, shouldn’t I?

Thank you both very much indeed for all the help

you’ve given to the Inquiry in preparing the report, and

the easy reading report, which is obviously a great help

particularly for this particular aspect of our Inquiry,

so I’m really grateful to you both for your help and for

coming today.

The Witness: Thank you, my Lady.

Lady Hallett: Very well, that completes today’s hearing.

I shall sit again at 10.00 tomorrow morning.

(3.46 pm)

(The hearing adjourned until 10.00 am the following day)