31-07-2025

(10.00 am)

Lady Hallett: Dr Mitchell. Closing statement on behalf of Scottish Covid Bereaved by DR

Mitchell KC

Dr Mitchell: I appear as instructed by Aamer Anwar on behalf of the Scottish Covid Bereaved. In their opening submissions for this hearing, the bereaved noted that, for many of their number, this module was of particular importance. Their loved ones who died cannot raise their voices, so the bereaved seek truth and accountability on their behalf.

The bereaved are grateful to the Chair and all at Dorland House for all that they have done to help the bereaved discover the truth. Accountability, however, requires an acceptance and an assumption of responsibility for decisions made and actions taken by the decision makers themselves.

The bereaved consider that it is the professional, moral and ethical duty of those who were in positions of power during the pandemic to take responsibility for their acts and omissions.

The bereaved have listened as witnesses sought to evade accountability for their decisions. While some may consider it acceptable to say they cannot recall key decisions and processes because of the passage of time, the bereaved do not have the luxury of saying it was a long time ago. The passage of time does not dim their memories or diminish the accountability of others.

The bereaved long suspected and now know that protecting the NHS came at the cost of sacrificing care and nursing homes. Untested and infectious patients were cleared from hospital wards into settings where they came into direct contact with those who were amongst the most at risk from the disease.

The bereaved share the reflection of Professor Banerjee of wondering whether the effect of the policies in place was to protect NHS from people in social care, rather than to protect those people in social care from Covid.

The bereaved listened with great care to the evidence of Jeane Freeman. It appeared to the bereaved that over the course of this Inquiry she has emerged as Schrödinger’s health secretary, in Module 2A and in podcasts admitting to an inadequate understanding of how the adult social operated and not responding quickly enough, yet in this module having a good understanding of adult social care and being able to take that into account when making these key decisions.

The bereaved listened as politicians and professionals sought to use statistics to explain away hospital transfers as a mode of infection. While there may be many who are familiar with Mark Twain’s view on the veracity of statistics, much of the evidence called to mind the words of a Scot, Andrew Lang, who noted that some used statistics as a drunk man uses a lamppost: more for support than illumination.

What trust can be placed in these statistics when hospital patients were being transferred into care and nursing homes without being tested, when the sick and dying were not being tested, and when the homes were suffering from clinical abandonment, with GPs not coming out to give even the most basic care and treatment.

It is a matter of great concern to the bereaved that there are many in the Scottish Government and NHS who seem content to conclude that an absence of evidence must mean there’s an evidence of absence.

It is not good enough to claim in the early days of the pandemic that it was enough to leave matters to clinical assessment.

Dr Macaskill gave evidence in Module 2A, when asked if he recalled when in March 2020 Scottish Care had come to the view that there needed to be testing of admissions into care homes. His answer? Very early; indeed, probably late February.

On 11 March he wrote to all care homes advising that serious consideration to restrict access to their care homes should be given.

Further, on 18 March, after a meeting with the Scottish Government, he stated to members:

[As read] “I explained the concerns of providers, that we needed to be reassured that anyone entering the care home was Covid negative.”

In evidence he stated:

“… 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 this to the Cabinet Secretary, and I indicated that what we wanted and needed was testing, to evidence a negative test.”

Why, then, was the policy of 13 March implemented and why did it take until April to changed it?

The politicians and clinicians must have known that the policy of transferring untested patients into care and nursing homes was causing outbreaks and death.

The bereaved considered that should not have taken Alasdair Donaldson, the official responsible for setting up the Vivaldi project, to point out that, as a matter of basic epidemiology and common sense, discharge without quarantine and tests was very dangerous indeed.

There’s much else that the bereaved wish to say about the evidence led during this module and written submissions will follow.

The bereaved have, however, noticed that familiar themes have once again emerged: the need for proper preparation, the need for testing and tracing capacity, the need for equitable access to PPE, the need for effective IPC measures, the need for proper levels of sick pay for staff to allow them to isolate, the need to ensure that staff are not required to work across locations, and the need for proper equality impact assessments to fully consider the impact of decision making on the most vulnerable.

It has also become clear from this module that much more needs to be done to support those who provide care to loved ones at home.

The bereaved are not naive. They know that for the vast majority of residents, care and nursing homes is where they will spent their last days. That does not mean that they and their needs can be disregarded or they are acceptable collateral damage in the mission to protect the NHS. Those who lost their lives were loved, they are remembered, and they deserve justice and accountability.

These are the submissions of the Scottish Covid Bereaved.

Lady Hallett: Thank you very much indeed, Ms Mitchell. Very grateful.

Mr Friedman. Closing statement on behalf of Disabled People’s

Organisations by MR FRIEDMAN KC

Mr Friedman: As my Lady knows, we act for four national Disabled People’s Organisations, or DPO, run by and for disabled people, they are Disability Rights UK, Disability Action Northern Ireland, Disability Wales and Inclusion Scotland.

Disabled people are not a homogeneous group, but their history and social reality gives it many of them cause to be particularly wary of four things: the way they are rendered invisible; what happens to them in institutions; how they can be abandoned in the community; and whether their lives are valued less than others.

In terms of invisibility, the Inquiry no longer needs anyone to tell it that central and local government’s incapacity to collect and deploy data concerning the needs of its people in an emergency is a fundamental problem. There has been underinvestment and neglect of the data infrastructure of social need beyond individual medical care. There is ignorance of what services a person receives from whom and whether those services are provided and, if not, why not.

If disabled people use personal assistants or rely on unpaid carers, there was no voluntary means to formally record those details. For infection control, there was no centralised basis to inform about PPE, testing and vaccines.

The Inquiry will be neither the designer, nor the deliverer, of the integrated data system that health and social care needs, but my Lady can detail the reasons and human cost to disabled people’s visibility that arises from not having it, and you can suggest the combination of ethics, interests, experts and users that would be necessary to make the system effective, national and trusted by the people that it is foremost there to serve. In any methodology of change, Disabled People’s Organisations have to be included and funded to work at the design specification stage.

For disabled people, institutions, particularly various forms of residential homes and confinement, are complicated spaces. Their history is entwined with further invisibility and asymmetries of power. The continuing absence of accessible data for modern care settings does not sit well with the power that providers hold over persons in highly dependent conditions, which is why what should never have been allowed to occur during Covid-19 was the sustained shutting down of on-site, face-to-face, regulator inspections.

They could have been reframed to the pandemic situation, they needed access to PPE and testing. But when even the most committed working cultures can become fearful of criticism and closed off to change, routine inspections should not have been allowed to stop.

What was lost was the opportunity to view the records, see the residents, not just staff, understand the environment and reassure relatives. These things were lost in a fashion that remote calling could never duplicate at a time when the additional critical safeguards were removed: family and other visitors were mostly blanket excluded; death certificates were completed by non-attending physicians; inquests were unlikely; funding for infection prevention control had no auditing. And now, struggling to obtain their own PPE and testing, the regulators, the ones who were supposed to establish the quality of IPC in services, were publicly admitting their lack of capacity and faith to manage the issues themselves.

The principal objective of the inspectorates in all four nations is to protect and promote the health, safety and welfare of people who use care services. They can seek ways to best support the providers to do that but the inspectors are there for the users.

In each of the four nations, the regulators failed in that principal objective: they allowed their independence to be compromised, the nature of their role to be confused and the importance of their oversight function to be undermined.

As the reports of Penelope Dash and Sir Mike Richards show, this regulated crisis of reputation continues. The crisis is worthy of note, given that the UK Government has increased the role of regulators, especially for local authority care.

My Lady, another reason why DPO are ambivalent about institutions is that they believe in independent living in the community. But in enacting the Care Act easements and then failing to monitor how they were really used, DPO say that disabled people’s living independently in their communities was subjected to straightforward abandonment.

The starting position is that easements should not have been introduced. With the threshold for entitlement to social care so high, and the means to challenge its refusal so limited, no government should have legislated to allow local authorities to cease meeting pre-existing eligible needs.

Like the issue of staff movement, there needed to be a national and regional system to expand adult social care through mutual assistance, secondment from other public services and business, and with proper inclusion of DPO, third sector and community participation. We took extraordinary measures on furlough and vaccinations; we should have taken extraordinary measures on this.

However, once enacted, the lasting damage of this emergency legislation has been caused by a legal mythology that barely any authority across the UK needed to use it. The source of the mythology is the way in which the concept of flexibilities has been inflated and distorted. Flexibilities is a word that does not appear in the statute. It appears in the care and support guidance but largely to encourage diverse thinking about how assessed eligible needs are met, not whether needs are met.

Before the pandemic, with evidence about confusion over the law and scarce resources, there was lack of confidence that Care Act obligations were being met. Rather than policing the foreseeable risk that general references to flexibility would generate expanded unlawful interpretation, the government then produced pandemic guidance for easements that made multiple and undisciplined references to flexibilities, including general comments about the power to cancel services.

With foresight, that line between flexibility and easements could be obscured and, in full knowledge that the pre-pandemic system was vulnerable, the government received eight notifications of easements across a country now going through the greatest whole-system crisis since the Second World War. In an organisational act of wishful thinking, for all intents and purposes, no one really batted an eyelid.

At the same time, stakeholder and DPO services received multiple reports that care package services concerning home care were cut, the providers attest to their procured services being reduced, the in-depth studies confirm this to be the case and, even after easements were formally withdrawn, local authorities admitted to reducing activity to life and limb protection.

The idea that it was only eight is frankly ludicrous. If you look at the DPO evidence across the UK, combined with Every Story Matters, disabled people’s worlds were turned upside down. People went without assistance to get meals, were left in bed for days, soiled themselves in wheelchairs, lost home physio or daily contact visits that could forever damage their bodies or neurological development. The authorities that ceased to meet eligible need but failed to declare easements broke the law. But the ultimate damage of that law breaking is that derogation from statutory rights has been refashioned as flexibilities: as we say, a legal mythology and a terrible way of building back not better but worse.

Lastly, the fundamental concern of disabled people is that their lives will not be valued in the same way as others. The issue arises before disabled people are born, it continues throughout life and, during the pandemic, it manifested in DNACPR decisions. Some people at the top of the chains of responsibility still minimise this issue. The approach of the CQC and other reports has not helped the analysis because they focused on whether there was a national blanket policy as opposed to policies applied in a blanket way in local settings or to certain groups, about which the Inquiry has now unearthed ample evidence.

There were blanket approaches to agree to non-resuscitation notices that were flagrantly in violation of existing guidelines. Nothing signed by the clinicians were – so notices signed by clinicians were added to records without consultation. There was literally targeting of people with learning disabilities and in instances where if residents had a DNACPR notice ambulances would not take them to hospital or care homes would not ask.

All of this could only have occurred because of a predisposition about the value of disabled people’s lives and needs that arose in an organisational level in different services across each of the four nations.

My Lady, the Inquiry has been entrusted with strikingly wounded testimonies of what the death and suffering during the pandemic entailed. There are those that tried their utmost to mitigate that reality, and there are fixes that could be made to the system that can mitigate the pandemics of the future. However, the reason why this module is the ground zero of your investigation is because of the terrible inevitability of it all. It was inevitable not just because of the lack of planning but because of the constitutional and economic choices we have made about how we structure our care system. The shameful result is that under the system as it presently exists, disabled people’s lives are absolutely valued less.

The DPO want to thank you and your team because it is only through this Inquiry that the stories and

insights of disabled people about what happened during

Covid-19 have come to matter. As their co-advocates, we

also rely on the contribution of the DPO, because people

like Joanne Sansome are modelling what co-production is

and they are sharing their expertise and theories of

change to disabled people’s lives, which is their human

right to do.

Disabled people can show us what we cannot yet fully

see. From the point of view of ground zero, they’re

telling us what has to be done.

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

Extremely grateful.

Ms Jones – oh no, Mr Straw, so sorry. Closing statement on behalf of John’s Campaign, The Patients

Association, and Care Rights UK by MR STRAW KC

Mr Straw: My Lady, the evidence in this module has revealed

significant failures during the pandemic to understand,

respect, protect, and care for people who rely on adult

social care.

As Caroline Abrahams said, being in a care home

turned out to be almost the worst place you could be

during the pandemic, and people receiving care at home

fared no better. Person-centered care and

individualised provision evaporated while fundamental

legal protections were abandoned.

Caroline Abrahams explained that people in care homes had no rights really at all during the pandemic. Heléna Herklots identified insidious ageism that is embedded in our society. Disabled people felt their lives were less valued. Jane Wier-Wierzbowska explained a care home is not a hospital, it’s a person’s home, but in that moment that was taken away from us.

Some of the key factors that caused untold harm included: one, blanket policies instead of individualised assessments; two, the removal of oversight and inspections; three, the failure to listen to people who rely on care and their representatives; and four, the failure to record equal status and worth to the social care sector and those who used it.

Other important factors will be covered in our written closing submissions.

So, looking at the first of those, blanket separation of people from their essential care supporters had severe impacts on the physical and mental health of people drawing on care, across the wide age groups and diverse needs represented in the sector, and it contributed to many deaths.

Contrary to assumptions by witnesses such as Jeane Freeman, this was not just about social visiting or social impact. Jane Wier-Wierzbowska explained that family carers wanted to continue to provide essential care and advocacy, as they had been doing for years. Yet they were turned away when their loved ones needed them most. She said:

“… I want us to not forget what really matters. The love and care of our families, which no politician or care home manager should be allowed to deny us.”

The harm caused by the restrictions were profound, periods of self-isolation, either for quarantine following an admission from home or hospital or when an outbreak was declared, entailed seclusion in a small room, usually sparsely furnished, often with limited ventilation, and no opportunity for exercise or to let fresh air in.

What a difference access to a care supporter would have made.

As the pandemic continued, such periods accumulated until some people were spending weeks in solitary confinement. Francis, who spent 65 days isolated in her room, said she felt caged like an animal, just fed and watered. She described lockdown as worse than living through the war.

My Lady, we recommend that there should be an obligation for such periods to be recorded and notified for safeguarding purposes, as they must be in mental health or prison systems.

Isolation at the end of life also caused permanent emotional wounds. Jane Wier-Wierzbowska explained the impact of being denied contact with her mother as she was dying. She said:

“… I just felt that I’d let her down so badly and that guilt is with me always.”

Joanna Killian from the Local Government Association recognised the trauma that people suffered when separated from their family members was inhumane and cannot happen again.

Paul Featherstone made clear that the starting point should be safely facilitating access, not denying it.

The measures introduced were particularly harmful for the 70% of people in care homes who had dementia. Professor Banerjee explained that:

“You can’t underestimate the value to a person with dementia … of visits from people they know and love …”

Who provide social stimulation and prompt them to eat, drink, and use the memories that they have.

The loss of that care, he said, will cause a deterioration in those individuals, including through their dementia progressing more quickly.

The disproportionate number of excess deaths of people with dementia underscores how damaging it was when family care was withdrawn: a quarter of all Covid deaths were people with dementia.

As Professor Banerjee explained, this serious adverse impact of Covid restrictions on people with dementia was entirely predictable. Indeed, it was publicly predicted from the beginning of the pandemic, but decision makers didn’t listen.

The evidence of Helen Whately, Professor Holland, Dr Townson, and others was that welcoming access for a care supporter who had appropriate protection, such as PPE and testing, did not significantly increase the risk.

Therefore, as Gillian Baranski and Caroline Abrahams put it, care supporters should be recognised as equal partners in care. Professor Barclay rightly said there’s no question that family carers are a court part of the care team.

My Lady, we call for the right to a care supporter, even during the pandemic, to be protected in law, and implemented via explicit provisions both in individual care plans and in all IPC plans.

This right, which is also known as Gloria’s Law and is set out in the Care Supporters Bill, is backed by over 100 health and social care charities and providers. This right must be enshrined in primary legislation.

As Susan Hopkins begins put it: if you want something done, legislation is where you start, because that requires people to deliver something; everything else is on best endeavours.

And that was demonstrated in practice. Guidance for the English essential caregiver scheme was ineffective and misapplied. The same is true of the fundamental standard on visiting now contained in Regulation 9A. Michelle Dyson accepted that its exceptional circumstances opt-out clause means that it would provide no more protection than the guidance that existed during the pandemic. It is already regularly set aside when local authorities order homes to close in outbreaks.

My Lady, my second topic is oversight and monitoring.

Eddie Lynch described family members as eyes and ears on the ground. In their absence, and the absence of other professionals such as social workers and health practitioners, oversight mechanisms were all the more important.

Despite this, as Ms Ahmed made put it, the CQC in England went AWOL. There was no support for the sector; they were basically shutting down.

Inspections in the other nations were also paused and then fundamentally altered. Remote inspections meant that regulators were speaking largely to care providers and not hearing directly from people receiving care. This created a significant gap, and the withdrawal of effective oversight had serious adverse impact on care standards.

Helen Wildbore gave evidence on the many who were afraid to speak out to challenge poor practice or report it due to fear of retribution, including eviction.

The regulator’s role was crucial and the aim of reducing footfall in care homes was not sufficient, particularly as time went on, to outweigh the need for effective ongoing regulatory presence.

In its absence, reports of neglect or abuse of older people in care rose sharply, by 37%. Cathie Williams of ADASS agreed that this risk was obvious to ADASS members “in every conversation … we had”, and it should have been obvious to regulators and government.

It was also an issue for homecare providers.

So while the regulators in future must play their vital role, even during a pandemic, it is also crucial for there to be an effective means of resolving individual complaints and enforcing existing statutory duties. There needs to be a single, clear and confidential mechanism established for people relying on care to safely raise complaints and have them speedily resolved.

There also need to be clear lines of accountability within government. Government witnesses in this module have described having limited levers to intervene in social care, yet local authorities described feeling hamstrung by central government decisions. Care providers in the middle struggled to make sense of the differing approaches from both.

So whilst some of this difficulty arises from the fragmented structure of social care, that does not excuse the lack of transparent accountability.

My third topic is consultation with people who rely on care. There was a clear failure to consult people with lived experience, and the organisations who represent them. Their involvement in key decisions and the formulation of guidance would have helped overcome what Jane Townson called the absence of social care expertise in decision-making bodies.

As Professor Banerjee explained, consultation with people with dementia and their families would have given decision makers a better idea of what the potential challenges are. The information would have been more comprehensive, and also more inclusive for people with dementia. Had they been included, it’s likely that there would have been better and more effective decisions.

Helen Wildbore explained that you cannot understand social care until you understand what it’s like to be a person who’s drawing on care. She said that, from an early stage:

“… the stories were there. The impact was there. “We knew what was happening and they were shouting about what was happening, but still it didn’t lead to any change in policy.”

So even when stakeholders were listened to, as Professor Rayner found, their recommendations didn’t manifest.

Claire Sutton, from the RCN, and others expressed similar frustrations. Helen Wildbore gave an example where suggestions for guidance were rejected within minutes, yet they could not have been properly considered in that time.

This failure to act on the views of people who rely on and provide care and the organisations who represent them was coupled with an alarming lack of data about the care sector. Decisions were made in a state of profound ignorance about the people who would be affected by them. The creation of a central base of – database of comprehensive care sector data is something which many witnesses agreed is needed.

My Lady, my final topic is the prioritisation of the NHS over social care. Within the department, the NHS had weighty resources, together with strong structures of accountability, oversight and expertise. That did not exist in respect of social care.

The serious imbalance in resources was described by Helen Whately as quite extraordinary, and she noted that:

“It was almost as if what matters was hospitals and not the health of the whole population, including those living in social care.”

Unsurprisingly, this meant that the social care sector was neglected. This was unacceptable and a dereliction of legal duties.

Millions of people depend on social care, and yet many don’t think about it until they need it, often at a point of crisis. The failure to give social care the status and prominence it deserves reflects a related failure to accord equal value to people who rely on social care.

One manifestation of this was the failure to provide adequate end-of-life care, an example is Allan(?), a 73-year old man who was refused both hospital admission and also end-of-life healthcare at home. His daughter said she was told he wouldn’t even be given oxygen, “Simply left to die. A dog is treated better.”

His experience, like many others, was a gross violation of his dignity and humanity.

It was disappointing that no one from the NHS came to the Inquiry to address these serious concerns. Helen Whately’s question to GPs “Why aren’t you there?” remains unanswered in this module.

The human rights of many in care were disregarded, yet they provide a vital safety net which is all the more important at times of crisis. They provide the standards below which no one should fall, and a practical tool and framework for the very difficult decisions that people in the care sector had to make every day in the pandemic. We therefore recommend that mandatory human rights training be provided at all levels to effect cultural change.

My Lady, as all the evidence in this module has made clear, people drawing on care suffered a catastrophe during the pandemic. It cannot be allowed to happen again for all our sakes. Thank you.

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

Ms Weston. Closing statement on behalf of Frontline Migrant Healthcare

Workers Group by MS WESTON KC

Ms Weston: My Lady, I speak for the Frontline Migrant Health Workers Group. The group’s members work both in the residential and domiciliary settings, for privately run care homes, in nursing and care assistant roles, for agencies, self-funders and publicly-funded service users. Many are domestic workers but provide social care. My Lady, the group is grateful for this opportunity and for the forensic scrutiny undertaken by this Inquiry.

My Lady, migrant care workers were the backbone of this fragmented sector during this pandemic. Our submissions seek to honour the memories of migrant workers who died during the pandemic, to ensure that the sacrifices and indignities they suffered are remembered and learned from, for those who continue to struggle under the same conditions.

The group’s core point is that discriminatory and exploitative working conditions are a key reason why the risks of transmission disproportionately affected migrant care workers. Endemic problems in the sector of low pay, little recognition and support to care workers generally were compounded for the migrant section of the workforce by punitive immigration policies which prevented them from challenging unsafe work practices or seeking the assistance of public bodies and health providers. In other words, put simply, low wages, poor terms and conditions and the lack of a safety net fatally undermined efforts to control the spread of the virus.

Despite these huge challenges, they performed vital work in protecting the lives and dignity of those in care, a contribution which went unrecognised by the government and the public. In fact, in the thousands of pages of documents disclosed within this module, few references to migrant care workers are found and little thought given to how their conditions should be improved. Thus, the group is grateful for the Inquiry’s recognition of the incredible contribution these individuals made and we ask for this point to be reflected in its conclusions.

In this short closing address we summarise a couple of key points. Firstly, it’s become clear during the course of evidence that the business model at the heart of care provision in the UK was fundamentally ill suited to pandemic resilience. The Nuffield Trust noted in 2019 that the market approach incentivises organisations to provide a bare minimum of services, nothing more. What did a bare minimum mean? It meant no room for planning for pandemics.

Care for profit made a difference to transmission. Some examples are the evidence of Professor Shallcross, that for-profit status was associated with significantly higher odds of infection in residents. Other research has demonstrated that care firms owned by private equity have significantly higher death rates and a significant connection between death rates and high rates of financial leverage. This point was also made powerfully by Paul Featherstone in his witness statement.

Since 2011, 816 care homes have been closed by the CQC, of those 804, ie 99 per cent, were for-profit care homes. Professor Rayner also noted in her witness statement that the not-for-profit sector is structurally more inclined to provide better pay and conditions. The Vivaldi Study made similar findings.

Professor Rayner also explained in oral evidence that not-for-profit organisations providing care also invest surpluses back into their organisations and will be typically governed by local representatives who approached their task with a sense of purpose – of charitable purpose, in the interests of the service users, and are invested in the long-term ongoing provision of that service to meet the needs of that community.

Witness Bella Ruiz agreed when she said:

[As read] “Proper sick pay is possible. I currently work in a charitable care home that pays full sick pay. I am valued, I receive bonuses, I get training for career progression.”

It is possible, my Lady.

Secondly, the second point we would make is the downward pressure on pay and conditions impacted transmission of the virus. Here are the words of some workers who contribute to the group’s evidence:

Victoria told Kanlungan about her feelings during the pandemic and she said:

[As read] “Sometimes you feel like what a miserable life. I can nearly die for £9.10 an hour.”

Camila added, when faced with people clapping:

“What I need is a pay rise. I need an increase in salary. I don’t need claps.”

This was a recurring theme. Undocumented migrant workers were paid especially poorly, and in particular, due to their powerlessness. Gabriella told Kanlungan:

“If an employer sees you don’t have a visa, then they don’t pay you the minimum wage. They will … say ‘… work for me this week, I’ll pay you £600’, not saying how many hours [that will be]. [And then you] work 100 hours.”

As another interviewee put it:

“When you have nothing, you cannot say ‘no’.”

In fact, it was obvious at the outset of the pandemic, we say, that the lack of contractual sick pay for workers in the care sectors would lead to avoidable Covid transmission. The Government’s first draft of the social care strategy in April 2020 recognised this and it suggested paying workers their full wages for up to so many weeks of sickness or isolation during the pandemic. They suggested that they would work with those representing care workers to ensure that there’s a way that staff can flag if they are not receiving the support to which they are entitled.

However, minutes show that this policy was rejected. Why? Because it would be the first time that the government acknowledged that Statutory Sick Pay was not appropriate and clarification would be needed as to why the novel policy would not apply to all key workers.

Whilst Mr Hancock seemed to be unable to recall further details of this discussion when asked in this Inquiry, the reason is clear: the government refused to adapt sick pay to save face and deadly consequences ensued.

David Halpern, chief executive officer of the Behavioural Insights Team, explained that they found in July 2020 that care homes that paid sick leave immediately when someone had to self-isolate had Covid case levels around 13% lower than care homes that did not and that this made the case for paying immediate sick pay for care home staff with possible Covid, and more generally for paying high risk, low income workers to self-isolate.

Having rejected the obvious case for increased Statutory Sick Pay to ensure self-isolation and recovery, the Government’s solution was to distribute funds, not to workers but to local authorities, but this was hopeless without robust monitoring and enforcement and, in the end, far too many workers did not receive the money. In fact, evidence shows that providers were more concerned that the introduction of pay for self-isolation would set a precedent and, cynically, that workers would just take the money and stay home.

Helen Whately MP, when asked, was unable to provide a single example of when a local authority had sought to recoup money that had not been used for the ICF’s intended purposes, citing local authority complaints about too much paperwork. Of course, local authorities were plainly very busy in the fight against the pandemic, as were care providers, and, as Ms Whately explained, she was both seeking cooperation and oversight of the use of the fund, an inherently conflicted role. A simpler and more effective approach would have been to legislate to create a right on the part of care workers to receive full pay upon isolation.

The consequences were devastating for workers. One of the group’s interviewees, Elena, explained that due to a lack of sick pay when she was hospitalised from Covid, she felt she had to rush back to work. She said:

“I felt such anxiety. You don’t know when it’s going to end … I have kids back at home.”

A further key long of this Inquiry is that care workers are individual people. Some have health problems, issues with their families or their accommodation, with domestic violence or abuse. The difficulty for migrant workers is that, when faced with those problems, they are barred from the welfare safety net. Francesca Humi made clear this week migration status was another vulnerability layered on top of all the other risk factors that care workers faced.

When things went wrong, many were blocked from accessing vital services or were too afraid of being reported to the Home Office if they did so. The evidence highlights two fundamental problems with the Government’s approach to the overseas care workers, we say: the structure of the visa system and its implications for public health; and systematic barriers to vaccination for migrant care workers.

It also creates a distrust, the hostile environment creates a distrust, and the group wishes to highlight in particular one important aspect of the system that was routinely overlooked during the pandemic: the sector’s reliance on undocumented care workers, for example, a domestic worker who came to the UK legally but whose visa expired because they were not able to find a new sponsor after leaving an abusive employer.

Whilst Covid-19 was excluded from the NHS charging regulations, researchers demonstrated that undocumented migrants continued to be deterred from seeking medical care, even where conditions were excluded, such as treatment for tuberculosis. This had crucial implications, my Lady, when it came to the vaccination programme.

Gabriela, an interviewee for Kanlungan, put it this way:

“Covid doesn’t care if you have documents or not – it can spread around anyone.”

She questioned how could that flatten the curve if undocumented workers were too scared to engage with public services.

Another point which we would highlight is the sidelining of domiciliary care. My Lady, the Inquiry has heard from a number of groups and submissions on that issue. However, our group’s interviewees do give colour to the devastating consequences that ensued from that sidelining. Elena recounted a particularly harrowing example of this when she was trapped in her employer’s home on half pay on the basis that food and lodging were being provided, or even Jenny, whose elderly employer got Covid-19, and was then told she could not leave the home. She caught Covid-19 herself and then the family delivered food for the elderly service user, but did not provide anything for Jenny. It was Kanlungan that stepped in and provided food so she could survive, my Lady.

My Lady, we have number of very brief recommendations, four in number. First, is we accept that structural change in the sector is difficult, but we do say that the evidence makes a compelling case for the following:

1. To ensure that rates and availability of sick pay in the sector are examined within any forthcoming fair pay review, and that the government promptly adapts sick pay to ensure that key workers are able to self isolate and recover safely, even if the criteria don’t meet the terms of sick pay.

Secondly, a national social care provision adopting a model similar to the NHS is required and the role of profit extraction business models in social care needs to be reduced or eliminated.

Thirdly, action to rebuild trust between Government and migrant worker communities is urgently required before the next pandemic strikes.

Fourthly, remove or reduce fees or in-country visa variation applications to ensure that workers are empowered to make safe decisions to comply with pandemic measures in any future pandemic, my Lady.

Lastly, we would ask the Inquiry to acknowledge and reward the vital work of migrant workers during the pandemic. They were disproportionately affected by the virus and disproportionately affected by the lasting pandemic effects of Long Covid, poverty, insecurity and poor mental health. My Lady, in sum, a properly protected workforce is an essential public health measure if the past is not to be repeated.

My Lady, unless I can assist further, those are our submissions.

Lady Hallett: Thank you very much indeed Ms Weston.

Mr Payter. Closing statement on behalf of National Association of Care

& Support Workers by MR PAYTER

Mr Payter: My Lady, on behalf of the National Association of Care and Support Workers, we focus our submissions on recommendations that your Ladyship may wish to consider.

But before turning to the future, we must first address one significant factual issue: the routes by which the virus entered care homes. This point is particularly significant to care professionals, many of whom have felt unfairly blamed as a result of the overstatement of the scientific evidence in some quarters.

Our primary submission is that the overall effect of the evidence is that it is not possible to determine with any confidence what the dominant route of viral ingress into care homes was, either at any one time, or overall.

Professor Shallcross, who your Ladyship might think was an impressive and lucid witness, was clear about the limitations of the Vivaldi Study. She explained that, in the absence of comprehensive testing in the early stages of the pandemic, it is not possible to identify which of the seven potential transmission routes was dominant. Professor Hall agreed to some extent. Both experts accepted that the picture was complex, nuanced, and likely to have evolved over time.

Through CTI’s careful questioning of Professor Hall, it became clear that the evidential foundation for the conclusion set out in the May 2022 consensus statement is not sufficiently robust to support an equivalent finding by this Inquiry. The absence of meaningful testing data from the early phase of the pandemic significantly undermines any such conclusion. Moreover, the consensus statement was based on a number of assumptions and over-simplifications. Its hierarchy of transmission routes was derived from unspecified expert input, rather than from social contact or mixing data, which does not exist, and it failed to account for key variables such as temporal changes and regional variation. It also inappropriately conflated domestic staff and care professionals, reflecting a lack of precision in its approach.

Later in his evidence, in the different context of quantifying the negative impacts of isolation, Professor Hall said:

“… you only assume things to test them later. So it’s incredibly obvious … to assume that, oh, it’s obvious, it’s common sense.”

That, we submit, applies with equal force to transmission routes.

The Inquiry should also record that hospital discharges constituted a route of ingress into care homes, one that was significant, one where far more could and should have been done to prevent or mitigate the associated risks, and one which reflected the over-focus on the NHS at the expense of adult social care.

We invite your Ladyship to record the position in which care professionals were left, particularly at the outset. Far from being thrown a protective ring, care homes, their residents and staff, were effectively cast adrift and left to navigate the crisis alone. Despite being asked three times by Ms Carey, King’s Counsel, the former Secretary of State for Health and Social Care was unable to identify any specific measures that constituted his so-called protective ring, or even his broken circle, at the point the hospital discharge policy was implemented.

As he ultimately accepted, there was limited PPE and none provided by the Government at that stage, no testing, no designated facilities for isolation, no guidance to isolate residents, no advice against staff movement between settings and wholly inadequate sick pay.

Your Ladyship also heard that the initial business as usual guidance issued to the sector in February 2020 was inaccurate, misleading and persisted for far too long, well into March, despite emerging credible evidence of asymptomatic transmission as early as January and February.

On that point, your Ladyship may wish to recall that a core mistake of the scientific and political response was that assumption that asymptomatic transmission was not possible unless proven otherwise.

As events showed, if that assumption is wrong, it is too late to act by the time it is corrected. In the event of a new pandemic, the assumption should be reversed on a precautionary basis.

My Lady, turning to recommendations for the future, we begin with a general observation, if we may. Your Ladyship is quite properly focused on recommendations that would improve the response to any future pandemic. However, that focus need not and should not preclude recommendations that would also have broader systemic benefits outside of a pandemic context.

We would also respectfully urge your Ladyship not to hesitate in making recommendations that may involve a cost, even a significant one. Your Ladyship will, of course, only wish to make realistic proposals but questions of affordability and implementation are ultimately for those tasked with acting on your Ladyship’s recommendations. In any case, for the recommendations we suggest, early investment is likely to result in long-term savings should a future pandemic occur.

In our written and oral opening submissions, we invited your Ladyship to consider throughout the evidence whether mandatory professional registration of care professionals in England would enhance the response to a future pandemic. We are grateful to your Ladyship and Counsel to the Inquiry for having explored this issue with a wide range of witnesses. There was broad agreement that registration would offer substantial benefits and contribute meaningfully to a number of recurring themes in the evidence that undermined the sector’s response.

In relation to workforce capacity, registration forms a key part of the professionalisation of care work: it provides formal recognition of the value and importance of the role; supports the development of consistent training standards and should, in turn, help drive improvements in working conditions, which will of course encourage recruitment, retention and improve employability.

There is no substantive evidence from the devolved administrations, which have a system already, to support the sole concern raised against a mandatory register in England: that it could affect negatively workforce capacity. The tiered system described by Mr Featherstone to your Ladyship is one way that could ensure that there are no barriers to entry for new recruits from all backgrounds.

As to data, the benefits are multifold. For example, registration would facilitate more accurate workforce planning, enabling the identification of current and projected staffing shortfalls, including on a regional and local basis, and it would allow for better targeting of support in areas under pressure during the pandemic.

As to sector fragmentation, a single register will allow for direct communication with staff, including the rollout of critical training. It could also operate as a constructive and non-coercive channel to promote and perhaps monitor vaccine uptake. It could also be used to contact and encourage former carers back into the sector.

As my Lady knows, NACAS has established a voluntary register for England and this month the Professional Standards Authority confirmed that it met the public interest test for accreditation. The PSA recorded its view that professional registration could help improve care standards and enhance recognition for practitioners from all backgrounds.

My Lady, consideration will need to be given to what information is stored on any register. As a minimum, it should record information on employment locations, training history and contact details. My Lady may also wish to recommend that the existing registration bodies in the devolved administrations review the data held on their registers to ensure that it is capable of supporting an effective pandemic response.

My Lady, NACAS is willing to take responsibility for administering such a register but is not possessive over its work. The critical point is that the register is created.

My Lady, pay and working conditions. Your Ladyship observed in your remarks to multiple witnesses, including Mr Featherstone on Monday, that the overriding message from the sector was a call for recognition. Recognition of their sacrifices, their contributions, their skills, and their equal importance to society alongside the NHS in the event of a pandemic. But recognition must extend beyond words and the clearest and most meaningful form of recognition for the adult social care workforce, as with any workforce in a market economy, is reflected in its pay and the terms and conditions of employment. It is striking, my Lady, that carers in adult social care are not paid at the same rate as healthcare assistants in the NHS, despite performing broadly equivalent roles.

The Employment Bill, currently working its way through Parliament, provides for the establishment of a Fair Pay Agreement sectoral bargaining process in the sector. It was touched upon in the evidence by Michelle Dyson from the department.

Against that background, your Ladyship may wish to consider recommending that existing bodies commissioning adult social care services and the negotiating bodies that will be established should the Bill pass, should take into account the need to strengthen workforce capacity as a core element of pre-pandemic preparedness. That, in turn, requires consideration of improved pay, at a minimum the real living wage but preferably parity with NHS healthcare assistants and the provision of guaranteed occupational sick pay.

Commissioning bodies could embed those baselines in contracts with care providers, as already happens in some areas, and these steps would represent meaningful progress towards achieving parity of esteem with the NHS and incentivising staff not to work in multiple settings in the event of a future pandemic.

My Lady, under the header of pandemic planning and while acknowledging that much will depend on the characteristics of any future pathogen, we invite your Ladyship to consider a number of key starting points that should form the basis of any pandemic plans.

First, equity of access. The Inquiry should recommend that prioritisation for testing, PPE and vaccine provision should be the same for NHS and adult social care, including domiciliary care. It is especially important for domiciliary care. The thrust of the evidence is that home care was marginalised, even with a system already treated as secondary.

Second, adult social care professionals should be recognised immediately as essential workers.

Third, there should be improved national accredited, pandemic focused IPC and palliative and end-of-life training for the sector.

Fourth, pandemic plans must identify designated settings and step-up and step-down facilities. There must be a mechanism for such plans to be reviewed by a body with central oversight of them.

Fifth, scientific and other advisory and working groups focused on adult social care should established at the outset of any future pandemic and should include voices from across the sector, including users, the workforce and providers.

My Lady, finally there are two points that we urge you not to recommend.

First, mandatory vaccination for care workers. We challenge the former Secretary of State on his policy. NACAS members’ views on the policy vary but the point that we sought to make is not that the policy is without merit but is not without consequences. The consequences were a significant net fall in the number of people working in adult social care, as compared to the period immediately before and after the policy was announced and put into effect.

Second, we urge you not to recommend mandatory restrictions on staff movement for care workers, either now or in the event of a future pandemic. During the pandemic, such restrictions were unworkable due to critical workforce shortages and, even if capacity was significantly improved, providers and staff still need a degree of flexibility to manage absences and working patterns. Moreover, with adequate workforce planning and broader pandemic preparedness, such restrictions are unlikely to be necessary at all and that is all before even accounting for the concerns for personal freedom and the discriminatory singling out of this workforce.

Finally, my Lady, may I, on behalf of NACAS, express our sincere thanks to your Ladyship and your entire them for the thoughtful way in which this module has been conducted and for giving a voice to, as Mr Featherstone emphasised on Monday, the amazing adult social care workforce.

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

Professor Rayner, you’re over there. Closing statement on behalf of the National Care Forum by

Professor Rayner

Professor Rayner: Thank you.

My Lady, I speak on behalf of the National Care Forum. My Lady, in our opening statement for Module 6 of this Inquiry, we asserted that social care was overlooked, misunderstood and disadvantaged in a variety of ways, which worsened the impact of the pandemic on recipients of care and support, their communities, care workers, and care and support providers. The evidence we have heard and read over the past month shows that the situation was significantly bleaker than we expressed. My Lady, you and your team have been painstaking in your analysis of the situations facing the sector. You have heard from officials and Government ministers that this was a sector that was underfunded, fragmented and diverse, and the responsibility of 150 plus different authorities. You have heard that care was delivered by a patchwork of local authority, not for profit, small and very large private organisations, that social care is complex, delivering home care, residential care, day services, supported living, extra care housing and more for all ages. You’ve heard from a Secretary of State who felt they had limited levers over the sector and a Care Minister whose evidence indicated her views were overlooked and on occasions overruled, and that there was no real-time data to understand what was happening on the ground.

These things are, of course, part of the picture. However, I hope that you have also heard that, despite these factors, social care is staffed by extraordinary people who during the pandemic worked as hard as they could to keep people safe. You have heard directly from witnesses who gave painful and vivid testimony of the reality of working in a care home during the pandemic, of people working in the community who overcame enormous logistical barriers to access the testing and PPE to continue to deliver.

You have heard about organisations, the majority of which were very small, who turned themselves inside out to cope with unwieldy, often contradictory, interrelated guidance that did not recognise their operating environment, and organisations who completely repurposed their accommodation to enable visitors within extraordinarily restrictive guidelines, and staff and organisations who took on health tasks when community health services stopped coming. They all did this within a backdrop where social care, the people it supports and carers, both paid and unpaid, were not prioritised and this must never happen again.

We heard from some witnesses that all the solutions for social care come under the umbrella of reform and that that task has already been assigned to Baroness Casey. However, whilst we urgently need her focus on social care, what you’ve heard during this module are not the longer-term ambitions of reform. These are the basic necessities of getting social care to be ready for another pandemic. These are not things that can wait; they are urgent. They need gripping and they need action now.

There are two strong themes that I want to emphasise in this closing statement, alongside a reflection on many of the recommendations that the Inquiry has heard. These two areas relate to the status of social care and its role as a public service.

Multiple testimonies during this module has focused on the inappropriate lower status attributed to social care in decision making, resourcing, political focus and prioritisation. Powerful testimony from care providers, local government colleagues, directors of Social Services and others are clear that there were multiple occasions where social care was not recognised for the work that it was doing or for the expertise that was held by those fundamental to its delivery.

Questions asked by the Inquiry have demonstrated starkly the lack of ownership and accountability exhibited by public bodies, both in where they thought responsibility sat and the siloed approach to developing responses to the challenges facing the sector.

Responsibility at the local level swung between NHS England and local authorities and almost always the needs of the acute hospital system trumped those of people living and working in care and support. Even at ministerial level, accountability was unclear and confused, with huge delegation of tasks by the Secretary of State, but seemingly without the associated power, oftentimes leaving the Minister frustrated at the system’s disregard of many of her concerns.

It has been very important that the Inquiry has gathered evidence in relation to the months before the pandemic began in the UK. During these precious missed months of January and February 2020, organisations like the National Care Forum were raising questions and challenging the unworkable nature of advice being put forward by experts without detailed understanding of social care.

While ministers and officials were behind the scenes discussing the presence of asymptomatic transmission, guidance was dispatched that was impossible to implement and created a false sense of assurance about the risks.

During this precious pre-pandemic period, there was no attempt to have a strategic conversation and build a formal partnership with social care, meaning there were multiple missed opportunities to work through the potential implications and the respective mitigations for those receiving care and the care workforce.

The failure to include adult social care meaningfully in pandemic planning must never be repeated. Adult social care and support providers and their representatives must be included as core strategic partners in pandemic planning exercises, expert advisory forums, such as SAGE, decision-making groups, relevant taskforces and policy development. Representatives from adult social care should also be included in governance arrangements at a local, regional and central level, to ensure their perspectives and operational realities are fully considered.

Not recognising the importance of social care resulted in guidance that was nigh on impossible to implement, unsuitable to the settings and the people it applied to with implementation timescales that were far too tight.

This point was made very powerfully when one witness described the impact of the guidance developed in relation to visiting, where the lack of understanding of the needs of those receiving care and support meant that the guidance was so potentially damaging that people needed protection from the measures included in the guidance that had ostensibly been brought in to protect people.

I am of no doubt, my Lady, that you will have understood just what an integral role social care plays in the lives of millions of people. It is clear to us had social care is a vital public service in its own right. However, at the outset of the pandemic, social care was seen as a tool to enable the acute health system to continue functioning. It was noted by the former Care Minister in her oral evidence:

“It was almost as if what matters was hospitals and not the health of the whole population.”

She went on to ask:

“What would it take for … [the NHS leadership] to be thinking about the health of the whole population, including those who receive social care?”

It seemed that the system could see people when they were patients. It understood they needed tests. It understood that those who worked with them needed PPE. It understood they needed access to clinicians to address their wider health needs, yet it seemed to lose sight of those self-same people the minute they stepped out of the hospital door. This is not a new feeling for those receiving care, but it must change.

In reality, the public service that is social care is, in fact, often much more fundamental, and embedded in people’s lives than that of the health sector. It is often providing them with a home, support to access jobs, education, ensuring they have a positive end of life, supporting their connection with family and friends, enabling them to rebuild and reconnect in a million different ways, for a million different people. It is delivered through long-term relationships with an extraordinary workforce who are as diverse in make-up, skills, experience as the needs of people receiving care.

It has been suggested by a witness in this Inquiry that it is unhelpful to pit public services such as health and care against each other. However, I would politely suggest to that witness that the evidence heard during this module would suggest that any amount of pitting that the Inquiry may or may not choose to do, it will find its starting point is fundamental and entrenched dominance by health, the reality of which had devastating consequences for the social care sector and everyone connected with it.

This embedded disregard for social care has sustained beyond the pandemic and it has been alarming to hear from a number of witnesses who spoke of the dismantling of key measures introduced during the pandemic to support adult social care around data and research innovations. It is not good enough for these to have been crisis-based responses and dismantling them hamstrings future efforts for academic research, reform, integration with health services and the ability to respond to early warning signs.

My Lady, during the course of this module there have been a large number of recommendations that we would like to offer our support to. In our written submission we will provide more detailed feedback around the practical implementation of these. However, for the purposes of this statement, these include, but are not limited to: in relation to the workforce, the development of a register of workers and the provision of step-up training to be made available for social care staff in line with new responsibilities and skills acquired during a pandemic.

In relation to IPC, peacetime preparation of key building blocks in IPC, such as fit testing, measures to ensure immediate access to the PPE supply chain and the free supply of PPE in the advent of the pandemic, and the establishment of protocols and understanding of how to prioritise testing and vaccination for all parts of the care sector, to be delivered in situ where possible.

Funding during a pandemic, the ability to get funding directly to providers at pace and without bureaucracy, and the instigation of payment mechanisms such as “pay on plan” that ensure that delivery decisions are not predicated on financial imperatives.

For essential carers, the need to ensure that families and essential caregivers are still able to see their loved ones, and that effective IPC measures are in place to enable this safely.

And finally, around data and digital, to rebuild and sustain the architecture for real-time data to enable early warning signs in relation to the impact of any future pandemic, the development of a social care data observatory, and a commitment to strengthen the digital framework and expertise.

My Lady, in conclusion, it is clear that the people who work in, draw upon, and provide care and support services, were simply not prioritised by decision makers, whose focus was protecting the acute health system rather than citizens in all communities.

Before I close, I want to pay tribute to the amazing work of our not-for-profit members and their care and support workers. They provide an essential public service and enable people of all ages and all circumstances to live good lives alongside the communities and people they love.

The care they provide is the backbone of many communities, families, and local economies, as well as the wider well-being and population health. We forget that at our peril.

My Lady, my final words are to recognise the strength of those witnesses who provided powerful personal testimony to the Inquiry. I have been very impacted by their words, and one phrase spoken epitomised what I have heard throughout: we all deserve better.

Those are our closing submissions, my Lady.

Lady Hallett: Thank you very much indeed, Professor Rayner.

Dr Townson, would you like to take us up to the break? Closing statement on behalf of the Homecare Association by

Dr Townson

Dr Townson: My Lady, I speak on behalf of the Homecare Association, which represents and supports providers of professional home care across the UK. When I delivered my opening statement, I spoke of devastating paradoxes and systemic failures.

I highlighted how professional home care, supporting nearly 1 million people across the UK, more than double those in care homes, was overlooked, misunderstood, and disadvantaged during our greatest peacetime emergency.

Today I stand before you not to rehearse those failures, but to chart a course towards resilience.

The Inquiry has illuminated uncomfortable truths but it has also revealed something profound: the extraordinary capacity for transformation that exists within our care systems when we have the wisdom and resources to harness it.

Through a month of oral evidence, we have heard a consistent narrative: care workers risked their own health and well-being to maintain the dignity and safety for those most at risk at home. Many did so despite being denied the tools they needed: adequate PPE, timely testing, fair wages, and recognition as essential workers.

We have learnt that whilst the government proclaimed ‘Stay Home, Protect the NHS, Save Lives’, the unintended consequence was over 100,000 excess deaths at home by July 2022, most from non-Covid-19-related causes, such as dementia and cancers, a stark displacement that revealed the fatal flaw in hospital-centric emergency planning.

But from around the world we have seen glimpses of other models and different ways of thinking about the role of home-based care and support.

In Italy, Dr Luigi Cavanna’s revolutionary home-based Covid-19 care achieved hospitalisation rates of fewer than 10%. Italy’s national continuity care system delivered hospital-grade diagnostics to patients’ homes, with regions embracing this model seeing death rates six times lower than hospital-focused areas.

South Korea also demonstrated that sophisticated medical intervention can be delivered at home, relieving pressure on hospitals, whilst maintaining healthcare access rather than restricting it.

These countries prove that home can be the safest place during a pandemic, if we design our systems properly.

My Lady, the evidence before this Inquiry demands we fundamentally reimagine emergency preparedness. The traditional model, hospitals as fortresses, homes as afterthoughts, failed catastrophically. We propose a significant shift. Pandemic preparedness must be community-centric, not hospital-centric. This means recognising that in any future health emergency, the battle will be won or lost in people’s homes and communities, not just in hospital corridors.

This paradigm shift requires us to think differently about three fundamental concepts: first, reimagining essential infrastructure. Just as we wouldn’t plan an ordinary emergency without considering water, electricity or transport networks, we cannot plan for a pandemic without seeing home-based care and support as critical infrastructure. At least 9 million people need or receive support and care at home. This is not peripheral. This is the foundation of our care system.

Second, redefining medical intervention. The Italian model and the UK’s more recent Hospital at Home services prove we can deliver sophisticated diagnostics and treatment in people’s homes.

We acknowledge the next pandemic may be entirely different from Covid-19. It may affect children more than older people, or present challenges we cannot yet imagine. But with advances in medical devices, telemedicine, AI and data science, we can use the principles to transform our approach.

Third, reconceptualising workforce deployment.

South Korea showed us that, in emergencies, we can rapidly mobilise volunteers and family members as temporary carers, but this requires preparation, training and systems, not crisis improvisation.

These concepts underpin seven pillars that must form the foundation of future pandemic resilience.

Pillar 1: embedded expertise. Social care expertise, including home care, must be embedded at every level of emergency planning, science advice, and operational command. No longer can decisions affecting millions be made by those who fundamentally misunderstand how care works. A standing expert committee would give decision makers direct access to homecare insights when developing pandemic responses.

Pillar 2: equal protection. We must guarantee hospital grade PPE quality, testing access, vaccines, if they exist, sick pay and psychological support across all care settings. The artificial hierarchy that prioritised NHS staff over care workers was not just morally wrong, it was strategically counterproductive. Parity recognises homecare’s critical role in a pandemic response.

Pillar 3: automatic funding. Emergency support must reach all providers immediately and equitably through pre-established systems. The bureaucratic delays that characterised Covid-19 funding distribution cannot be repeated. When crisis strikes, resources must flow automatically, like water through prepared channels.

Pillar 4: valuing the workforce. Sustainable funding must support professional registration, fair pay, training and technology adoption. The pandemic accelerated digital care record uptake from 40 per cent to 80 per cent, proving the sector’s capacity for innovation when supported. This transformation must continue.

Pillar 5: maintaining healthcare access. Face-to-face health and care services, supported by telemedicine, must be protected not suspended. Italian physicians proved that bringing hospital capabilities to people’s homes achieved better outcomes than overwhelming hospital systems. We must plan for enhanced, not reduced, community healthcare during emergencies.

Pillar 6: modern data infrastructure. We must capture everyone giving and receiving home-based care, creating the visibility needed for effective pandemic planning and resource allocation. The data blind spots that hampered the Covid-19 response were inexcusable and must never rec.

Pillar 7: effective governance. Continuing oversight with homecare-specific policy development is essential. Community-based care requires tailored approaches, not hospital focused adaptations, this means dedicated governance structures that understand the unique challenges and opportunities of home care.

My Lady, the Government’s 10-year health plan creates an unprecedented opportunity. Its three shifts, from hospital to community, illness to prevention and analogue to digital, align with the lessons from this Inquiry. We can position homecare as essential infrastructure, working alongside sophisticated medical intervention. Italian analysis showed dramatic cost savings alongside better outcomes offering a compelling case for integrated care models that deliver value in any circumstances. But transformation requires more than policy papers: it demands a fundamental cultural shift in how we perceive home-based care and support, from a poor relation to the health service to an equal partner in improving health outcomes.

We propose a new metric for pandemic preparedness: a community resilience index. This would measure not just hospital bed capacity or ventilator availability, for example, but the robustness of community-based care infrastructure. Besides vital public health data on the severity of infection and transmission rates, this index could assess factors including, but not limited to, the ratio of community care workers to population, workforce sustainability metrics, digital infrastructure penetration in home settings, integration levels between health and social care, community diagnostic and treatment capabilities, data system interoperability. By measuring what matters, our capacity to keep people Safe at Home, we create accountability for community resilience, not just hospital preparedness.

The pandemic revealed that virus variants respect no borders and neither should our learning. We recommend establishing an international homecare emergency response network, sharing best practices, technologies, and rapid response protocols between countries. When the next pandemic emerges, and experts agree it will be when, not if, we must be able to deploy proven interventions immediately, not spend months reinventing solutions that already exist.

Throughout this Inquiry, I have been struck by the testimonies of bereaved families. Their loved ones were not statistics. They were pioneers, contributors, cherished family members, who deserved better from the systems designed to protect them. I have been equally moved by the testimony of care workers, who, despite challenging circumstances, maintained their commitment to those they served. They made impossible choices and sacrifices, they filled the vacuum left by others, sometimes at a cost to their own health or lives.

Importantly too, we have seen proof that homecare workers and managers, when supported, can deliver extraordinary outcomes under extraordinary circumstances. We owe it to those lost and those who served to ensure we learn lessons and implement change in a way that is effective and enduring. Your recommendations will influence whether we emerge from this process with genuine transformation or just good intentions. The difference will be measured not in paper plans but in lives saved and dignity preserved when the next emergency strikes.

The question is not whether we can build better systems, the question is will we choose to do so? History will judge this moment not by what went wrong during the pandemic but by what we chose to do next.

Thank you for the kindness and support of you and your team and for the opportunity to contribute, my Lady.

Lady Hallett: Thank you very much indeed. Extremely helpful.

Very well, we’ll take a break now and I shall return at 11.40.

(11.21 am)

(A short break)

(11.40 am)

Lady Hallett: Ms Peacock. Closing statement on behalf of the Trades Union Congress by

Ms Peacock

Ms Peacock: Good morning, my Lady. These are the submissions on behalf of the Trades Union Congress. I’m instructed by Thompsons Solicitors and led by Mr Sam Jacobs.

What this module has surely made clear is that we cannot afford for the social care sector to be placed in the same position in a future pandemic. It must be better protected.

We return to an account from a care home manager in Northern Ireland who explained:

[As read] “Working during Covid was one of the worst experiences of my career. So horrendous, I left working in care. As an already struggling sector, Covid has magnified every element of underfunding. I am glad not to work in care and will never again.”

The sector lost valuable members of its workforce, both to the virus itself, and to the trauma of the experience. It is to that loss that the TUC directs its lessons learned. In this short oral closing we will touch upon the following topics: infection prevention and control, regulation, vaccine confidence and reform.

In our written closing, we will address a number of related topics, including movement of staff, structural racism, insecurity of work and financial support.

Many of these issues, my Lady, are interdependent. If carers have access to high-quality PPE, which they are trained to use, there will be less pressure on the vaccination programme.

If the social care sector is afforded greater status in society, workforce capacity will improve.

And if care workers are financially supported, they will feel able to self-isolate, and IPC controls will be more effective.

Turning first, my Lady, to infection prevention and control. It will be uncontentious that the lesson in respect of PPE in Module 6, as in previous modules, is that far greater planning and preparation is required. A policy of parity with the NHS is essential. And plans should acknowledge that, in the circumstances of a crisis, central and local government must be ready to step in and support all settings, including the private sector.

Helen Whately raised in her oral evidence an important question regarding the level of PPE which may be appropriate in a future pandemic of an airborne virus. She recalls asking on multiple occasions during the pandemic: is the PPE not working?

Ms Whately reflected on research which shows that in intensive care, where higher levels of PPE were provided, transmission of Covid-19 was lower than in ordinary hospital wards.

This is an issue in common with Module 3, and we endorse the same recommendation as we did in that module: FFP3 should be recommended for all staff likely to come into contact with the virus, where there appears to be more than negligible airborne transmission.

In closing submissions in Module 3 we suggested that healthcare workers should be empowered to implement IPC measures, and that there needs to be significant investment in training because a whole-workforce approach is required.

We consider that position is the same in the social care sector. The recommendations which we will endorse in our written closing, including improved status and professionalisation of the workforce, the introduction of a register of care workers, and improved centralised oversight, will be critical to implementing a robust system of training and monitoring of compliance with IPC.

The workforce deserves, at the very least, the protection associated with adequate IPC training and resource.

Turning next to regulatory intervention in the care sector. As the Inquiry has heard, at the outset of the pandemic, the four nations’ regulatory bodies took a step back, most significantly by pausing routine inspections.

The concerning message sent by Peter Wyman, of the CQC, to Matt Hancock was: we have pulled right back on inspections, data collection will be really light touch.

We agree with the submissions this morning on behalf of the DPO and John’s Campaign, Care Rights UK, and The Patients Association, that this decision led to lost opportunities to understand what was happening in the sector, and to protect its service users.

A number of witnesses to this module have made clear the impact this had upon care settings. Rachel Harvey reflected that Care UK did not get any support from the Care Quality Commission, Care Inspectorate or Care Inspectorate Wales. Regulatory inspections and usual provider meetings ceased and there was only limited communication.

Before routine inspections were cancelled in their entirety, Mary Cridge explains that the CQC:

“… cancelled a number of routine inspections and directed our activities at areas which we considered to have the most risk.”

The CQC chose to focus on high-risk environments, including social and domiciliary care settings, which, she says:

“… presented inherently more risk in terms of opportunities for people to suffer from unseen harm.”

This appears an entirely logical approach but one which was abandoned when routine inspections ceased.

A regulatory vacuum was created in social care. As a result, central government knew very little about what was happening inside the sector.

Minutes from a meeting Helen Whately conducted with the CQC in July 2020 note:

[As read] “… it is likely we will see an increase in a number of services that haven’t been able to cope during the pandemic and therefore a spike of these cases being unveiled in the next few weeks.”

The minutes record Ms Whately’s extreme concern.

The lesson learned is that in a pandemic, where risk is elevated and guidance is novel and evolving, regulators should step forward towards the care sector as opposed to stepping back.

We agree with Ms Cridge that inspections are an integral part of regulation, and in the event of a future pandemic, strenuous efforts should be made to protect the ability to carry out on-site inspections.

Briege Donaghy, of the RQIA, insisted that a single inspector could have taken Covid into a care home, the risk of that as a regulator was unacceptable. That simply belies an unwillingness to take any level of risk, nor to balance that risk against those associated with ceasing routine inspections.

Given what we know about the level of movement of staff and other essential persons in and out of care homes, that explanation does not hold water. We agree with John’s Campaign, Care Rights UK, and The Patients Association that there was an abdication of responsibility.

To ensure that inspections continue, we say that regulatory bodies should be required to hold stocks of PPE, inspectors should be recognised as key workers from the outset of a pandemic, and that they should be prioritised for access to PPE, IPC, training, testing, and vaccines.

Turning now to vaccine confidence, my Lady.

Sir Sajid Javid has stated in evidence that it is importance to build vaccine confidence during non-pandemic times, given the difficulty of doing so during a crisis. This appears an entirely sensible suggestion. However, it is also true that during a pandemic it will be necessary to share information about the specific vaccine workers are being asked to take.

Accounts and survey data collected by this – TUC suggest that many care workers who had general confidence in vaccines, and happily took the flu vaccine each year, did not have confidence in the Covid-19 vaccines. This was due to concerns about the speed at which the vaccines were developed and the adverse reactions suffered by some, and due in part due to the general climate of anxiety and lack of confidence in leadership and government which pervaded the experience of Covid-19 for many care workers.

However, it’s clear from the survey data that mechanisms for sharing information about vaccines and providing support to care workers were not in place or were ineffective. In a survey of over 1,600 care workers, 58% said that they did not feel they were given enough information and support by their employers regarding the Covid-19 vaccines.

On being asked about this data, Sir Sajid Javid confirmed his prior evidence that the fact that the NHS is a centralised state body meant it was easier for vaccine hesitation to be addressed.

He endorsed the need to develop centralised mechanisms for communicating with care workers.

Helen Whately, similarly, considered that registration of care professionals would assist, and noted that greater unionisation of the workforce would provide a channel of communication.

On vaccine as a condition of deployment, we reiterate our position that it ought to be an approach of last resort. Ms Whately has suggested that we need a discussion as a society about when mandating vaccination is appropriate. We agree. But we also say that such discussion requires further research.

Jenny Harries raised a concern that VCOD policies could cause longer-term damage to wider trust and confidence in vaccines. Research is required to confirm whether that risk has transpired. The TUC is concerned that the VCOD policy in the care sector compounded the effects of structural racism, given the higher levels of hesitancy amongst some minority ethnic groups.

More data should be collected on the risks, the benefits and the efficacy of VCOD policies as compared to methods involving information sharing, consultation, engagement via community leaders, and practical support.

Turning finally, my Lady, to workforce capacity, status, coordination and reform.

There is so much overlapping between the severe workforce shortages faced by the sector and the urgent need for improved status for the workforce, centralised coordination across the sector, and long-awaited reform.

The call for reform has been virtually universal amongst those witnesses who have given oral evidence in this module. Everyone from Matt Hancock, to Cathryn Williams, to Sir Sajid Javid has endorsed it. That is evidence which we say this Inquiry cannot overlook.

Despite the unsurprising nature of such a recommendation, it remains critical that the report to this module acknowledges the urgent need for reform. We agree with the National Association of Care and Support Workers that affordability is a matter for those implementing the recommendations, but that improved capacity and resilience will inevitably lead to long-term cost savings.

The interrelated nature of many of these issues demands wholesale change, and a piecemeal approach simply will not place the sector in a better position to face another pandemic. The TUC has long called for a national care service and, following this module, considers it will be a crucial step in improving resilience and the capability to respond to any future civil emergencies affecting the care sector.

Thank you, my Lady. Those are our submissions.

Lady Hallett: Really grateful, Ms Peacock. Thank you very much indeed.

Mr Boyle. There you are. Closing statement on behalf of Royal College of Nursing by

Mr Boyle KC

Mr Boyle: My Lady, the Royal College of Nursing is extremely grateful to you and the entire Inquiry team, for giving it the opportunity to participate in and to contribute to the Inquiry’s work.

Your Ladyship will hopefully have gleaned from the evidence to of Claire Sutton on Tuesday of this week just how keenly felt the desire is that the voices of nurses and all adult social care support workers are heard to assist with learning lessons for the future.

Not everything which the Royal College may wish to see change about the provision of adult social care in England and across the devolved nations can be cured by this Inquiry or subject to a recommendation by your Ladyship. But it has great confidence that there are at least areas where recommendations can be made, or a narrative provided, to ensure adult social care is better fitted for any future pandemic on a similar scale.

I intend to address you briefly on three discrete topics: parity; engagement; visiting. We will address others in greater detail in writing.

First, the evidence has clearly demonstrated the need for parity of esteem between the NHS and the adult social care sector and equity of access to resources. Helen Whately described social care as often being seen as a Cinderella service. Claire Sutton described how social care often feels like a second-class citizen, the poor relation.

However, she added that, if it were to achieve parity of esteem and equity of access to the same resources available to the NHS, that would boost staff morale, go some way to changing those perceptions of inequity, and potentially improve staff retention, which is such a significant issue in this sector.

That evidence echoed Ms Whately’s evidence that one of the things that this Inquiry can do is to raise and remind people about the importance of social care in our system. As Ms Whately observed, that would be a good outcome.

There are practical steps that can be taken to try to achieve that. In particular, the adult social care sector should, looking ahead, have equity of access to pandemic stockpiles or, at the very least, a system by which the care sector can rapidly access sufficient PPE as part of a future pandemic response.

This would avoid the concerns voiced by RCN members in the surveys that were conducted, that your Ladyship heard in the evidence of Ms Sutton and is contained in detail within her statement. It also echoes the evidence of Ms Whately when she said that the fact that care workers were having to go to work and try and care for people without even the level of PPE that the public health team thought they should have was clearly an incredibly bad situation to be in. It was worse than that: it was clearly a life-threatening situation to be in.

Your Ladyship understandably queried with Ms Sutton the extent to which state funding or state resources could or should be used when provision of care may rest with independent private companies or organisations. Ms Sutton’s response was to highlight the prevalence of state funding of those providers through local authorities and NHS commissioning groups. However, even allowing for the fact that there may be private providers involved, from a resident or patient safety perspective, at a workforce safety and retention perspective, the unambiguous ambition should be for equity of access for all those who provide care, through whatever service, whether it be in a large NHS hospital, to a single domiciliary care provider travelling by bus from home to home to help the most vulnerable.

It can perhaps be achieved through the use of central procurement, by way of example. Equity of access to testing for members working in the NHS and in social care should be provided for. Equity of access to training should also be facilitated perhaps in two respects, firstly, recognising that the nature of any future virus is unknown, training by way of generic background, for example, familiarising all staff with where and how to access resources and, indeed, perhaps in relation to human rights, as my learned friend Mr Straw KC advanced to you this morning.

Secondly, there should be the ability to roll out rapid training to all care providers on any new guidance, irrespective of whether they work in an acute NHS setting or in adult social care. Nurses and support workers in social care should not have to best guess how to implement guidance when colleagues in NHS acute settings are having online webinars. Technology should enable new guidance to be packaged with rapid access training for all.

The primary objective of the recommendation the RCN seeks in terms of equality is to try and safeguard the workers and those they care for. The secondary objective, when those patient and workforce safety issues are coupled with equality and protection of full pay, if they need to self-isolate, equality and the recognition of staff in social care retaining the freedom of movement which is enjoyed by their NHS colleagues in their day jobs, will be the elevation of the esteem in which adult social care is held. If one is going to be as safe as one’s colleagues in the NHS and have access to the same equipment at the same time, then the perception of adult social care being of less import should become a thing of the past, which can only be to its benefit in the future.

Ms Sutton summed up this ambition for equity and access and parity of esteem in very simple and stark terms when she told you that to make sure that the 1.6 million people who work in adult social care are on the same footing as the 1.4 million who work in the NHS shortly stated but powerfully communicates the need for a recommendation of this kind.

The second and hopefully obvious recommendation which the RCN invites your Ladyship to consider, is that the UK Government and the certain devolved administrations should ensure that there is professional nursing input from now on in trying to limit the severity of any future pandemic. We should try and avoid the mistakes of the past, such as the publication of unworkable guidance which suggested that carers in care homes could provide care to residents from a distance of 2 metres.

For whatever reason, there was at times a lack of meaningful engagement with the RCN, which is difficult to comprehend, given that it speaks on behalf of over 500,000 nurses and support workers who have an enormous amount of experience and expertise capable of assisting those in positions of authority who may not necessarily have the same healthcare training, background or hands-on experience.

Dame Professor Jenny Harries, former Deputy CMO, in her evidence, was taken to a paragraph in her statement in which she said:

“In the early phase of the pandemic few people in DHSC had direct or practical experience of having worked in or [notably] with care homes …”

That is a situation in which input from the RCN and other stakeholders should have been not only welcomed but actively pursued. However, as Ms Sutton described, at times it felt to the organisation that it was pushing at a locked door, and it took some persistence to get through.

We would invite your Ladyship to accept that evidence. Ms Sutton was an entirely credible witness who was very direct and candid and humble enough to accept, on behalf of the Royal College, that when changes were sometimes made, as she put it, it would have been fantastic to think of that as a result of the RCN input, but she did not seek to claim that causal connection. It matters not if one can show cause and effect. The important principle is that those who can speak with authority, like the College and others, are fully engaged by Government.

In that regard, the College invite your Ladyship to recommend that College and other relevant stakeholders should firstly be included in slow-time, pre-pandemic planning for the future; secondly, they should sit on any body or taskforce established to steer the four nations during the course of any future pandemic, the voices of those should be in the room when crucial fast-time decisions are called for; and thirdly and importantly, should be intrinsically involved in the production of national guidance that impacts on nursing and support worker roles, responsibilities and obligations.

Finally, I close on behalf of the Royal College by returning to the very powerful impact of the video played at the opening of this module and the heartbreaking accounts of relatives not being able to be present to comfort those at the end of their lives.

Ms Sutton was asked whether meaningful contact with loved ones for those at the end of life should have been facilitated. “Definitely”, was her response. It was a response not based on pure sentiment, it was backed up by partial and simple rationale. She told your Ladyship that nurses are very good at carrying out risk assessments, that had there been flexibility in the guidance to enable nurses to be able to ascertain whether a visit at that time was safe and could be facilitated, then nurses would be ideally placed to make those decisions with the best interests of those residents, their loved ones and their staff in mind.

Your Ladyship will recall how she explained the different forms that care homes can take, for example: large purpose-built buildings, Victorian houses, and so on.

The RCN’s voice was not alone in that and we commend to your Ladyship the evidence of Joanna Killian of the Local Government Association and some written testimony of Deborah Sturdy.

In any future pandemic, in the event that national decisions or guidance on care home visiting are considered appropriate, the Royal College of Nursing invites your Ladyship to consider a recommendation that includes recognising the human rights of care home residents and their families, recognises the benefits of that partnership of care between staff, family and friends, and recognises the ability of nurses and care home staff to safely facilitate visiting in individual cases at end of life.

My Lady, thank you very much on behalf of all those who have worked in the adult social care sector.

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

Ms Murnaghan. Closing statement on behalf of Department of Health,

Northern Ireland by MS MURNAGHAN KC

Ms Murnaghan: Good morning, my Lady.

As you know, my Lady, I appear for the Department of Health in Northern Ireland, and in these remarks, my Lady, the department would like to emphasise that it made considerable efforts throughout the pandemic to prioritise the care of those in the adult social care sector.

References made by Mr Swann to a “Cinderella service” should not, however, be interpreted as evidence of complacency in the Department but rather as an acknowledgement of the difficulties and indicating an awareness of the need to prioritise tackling those difficulties.

My Lady, the department also agrees that there are valuable lessons which must still be learnt and, to that end, we refute the inferences that, in acknowledging those things that did go well, the Department has perhaps erred by congratulating itself inappropriately.

Prior to the pandemic, my Lady, the adult care sector in Northern Ireland was historically underfunded and entirely regrettably was in a position of structural vulnerability. However, the Department has commenced work on the development of a ten-year adult social care reform strategic plan and, while the scale of the reform that is required cannot be delivered in the short term, a number of shorter-term delivery plans will support that ultimate aim.

To that end, my Lady, the former Minister of Health, Robin Swann, also acknowledged that a stable workforce will be the key to delivering strategic reform and, as long ago as October 2021, he established a Social Care Fair Work Forum with the aim of embedding fair work initiatives and improving terms and conditions of all employees across this sector. In February 2025, his successor announced that the sector would become a real living wage sector and work in Northern Ireland is ongoing to implement that change.

My Lady, I would have some remarks to make about testing in Northern Ireland in care homes. Testing, of course, was a critical additional tool in the protection of the sector and it is uncontroversial to say that, in the early stages of the pandemic, testing capacity was limited.

Although the Department did work at pace to scale capacity, undoubtedly its decisions in relation to both discharge and the testing regimes must be viewed through the lens of the practical reality of there being only a finite number of tests.

In Northern Ireland, all residents and staff in care homes were identified early in the pandemic as being priority groups for symptomatic testing. From 24 April 2020 all residents and staff were tested to risk assess each outbreak. That had changed from mid-May, by which stage an incremental programme of testing for asymptomatic residents and staff was implemented and that was completed by the end of June and was further extended on 3 August. But even then, my Lady, the efforts made by the Department were still constrained by a global shortage of testing.

The position changed considerably when, in late 2020, early 2021, lateral flow tests allowed for the expansion of asymptomatic testing to those working in the supported living sector, as well as those in the domiciliary care sector. When routine asymptomatic testing for staff and residents was introduced, such testing, however, was always in addition to the other full suite of public health measures that were already in place.

My Lady, some remarks in relation to discharge. Unequivocally, the Department reaffirms that throughout the pandemic, the discharge of patients was always a clinical decision based on whether the individual was medically well. Further to that, by April 2020, updated guidance on testing had advised that those who were released to care homes should be tested for Covid within 48 hours of that discharge and, prior to that, from 3 April 2020, the advice was that those residents who may have been exposed should be isolated for 14 days on return to the care home.

In instances, my Lady, when the test results were pending or were positive, the care homes were asked if they had the ability to support isolation. Where they were unable to do so, the responsibility then fell to the trusts to make arrangements for alternative care.

The Department was aware that discharge from hospitals could have an impact and, to that end, it commissioned the Herity report. The Department would emphasise that there has been no shift, subtle or otherwise, in the Department’s assessment of that Herity report.

In his witness statement, the Chief Medical Officer clearly indicated that Covid being likely to enter care homes was from a number of means which included discharge from hospital. The CMO stated, in line with the extant evidence, that this was unlikely, however, to have been the dominant route, and he referenced the CMO Technical Report.

The main point emphasised by the CMO in his statement was the association between care home outbreaks and the level of community transmission. This should not, however, be read as some indication that discharge from hospital wasn’t a possible factor.

My Lady, some remarks in relation to the impact of visiting. The impact of visiting restrictions on both residents and their loved ones was not underestimated by the Department. There was, however, a difficult balance to be struck between protecting residents from infection and preserving their right to connection with their families.

After the initial months of the pandemic, the department consulted with residents and their loved ones and developed the Care Partner scheme.

The Inquiry in this module has heard criticisms that the Department should have consulted more extensively on the scheme prior to its introduction. However, it is, my Lady, we submit, incontrovertible that a balance had to be found between implementing a scheme with such positive benefits for individuals where some care homes could implement this with alacrity, and, on the other hand, waiting to find unanimity across a sector which had a range of different needs and concerns.

We would also emphasise, my Lady, that following the announcement, the Chief Nursing Officer did lead a further six-week engagement with the sector in an attempt to ensure smooth implementation of the scheme, and that consultation included, in October 2020, the provision of additional funding to support that implementation.

My Lady, concerns were also raised in relation to the question of testing that would accompany the Care Partner scheme, and to that end, we would ask the Inquiry to note that the department published a Care Partner leaflet and a frequently asked questions document which did include detail on testing requirements.

My Lady, such has been said of the demands and challenges placed on the workforce in the pandemic, and we agree that the pandemic exacerbated the pre-existing challenges in this sector, and it was in recognising those concerns from care homes that the minister announced that trusts would work in partnership with providers to help manage staff shortages.

Measures that the minister introduced included adjustments to pre-employment vetting to permit employers to recruit staff quickly, the deployment to the sector of suitably skilled individuals from trusts, as well as prioritising deployment from its workforce appeal.

The department also acknowledges the concerns raised regarding the movement of staff between care homes, and that was a risk which the department identified in April 2020 and predated the Vivaldi Study by some three months. It was reflected in guidance to residential and nursing homes, and as early as April 2020, the department provided financial support to help providers respond to the staffing challenges.

Indeed, in the October 2020 funding package, the department enabled care providers to claim for those additional staffing costs, which included block booking agency staff, which was designed to prevent the movement of care home staff between various homes.

My Lady, in relation to data, with the onset of the pandemic, the department recognised the need for specific monitoring information to allow it to quality assure the integrity of information and so ensure that appropriate support was provided.

The department to that end worked closely with the RQIA, the HSCB and the PHA to collect what became a fundamental source of care home data.

It is worth highlighting that the department’s strategic performance and planning group is currently developing a regional real-time monitoring system for care home bed availability, and this initiative will be completed by October this year.

In terms of engagement, my Lady. In terms of engagement, it is not accepted that there was an institutional defensiveness in the department or indeed a need to break down silos. However, we do say that it should still be acknowledged that when an individual wrote to one part of government, this would not automatically equate to communication with the department.

For example, my Lady, there has been criticism of the degree of engagement between the department and the Independent Sector Nurse Managers Network, and the department has confirmed that it has no record of receipt of correspondence referenced in Ms Claire Sutton’s evidence for the RCN. Rather, it appears to be the case that the ISNMN were in fact in contact with the PHA, and the then Health and Social Care Board, which, my Lady understands, is structurally distinct from the department.

Much has also been said in terms of engagement to the extent in which the department engaged with the IHCP. Professor Holland’s evidence on that issue confirmed that the IHCP represents only about 50% of independent care sector providers in Northern Ireland, and is, rather, focused on business interests.

Professor Holland highlighted that the department had well established and constructive relationships with individual care homes. And it was therefore in that context, and in the context of the pandemic, when matters of practice had to be discussed, it was often more efficient to liaise directly with the providers rather than going through the IHCP.

My Lady, as explained by both Professors Holland and McBride, engagement had always to be in the context of the overarching imperative of providing timely guidance.

My Lady, to conclude, the department recognises the very significant impact that the pandemic had on care home residents, their loved ones, and the staff, and the department appreciates the substantial efforts that were made to support those in this sector.

The department remains committed to learning from this module and thanks the Inquiry for the opportunity to contribute.

Lady Hallett: Thank you, Ms Murnaghan.

Mr Macleod, are you over there? You are. Closing statement on behalf of the Care Inspectorate,

Scotland, by MR MACLEOD KC

Mr MacLeod: My Lady, I appear with my learned friend Ms Toner(?) on behalf of the Care Inspectorate, who are very grateful to your Ladyship for the opportunity to have participated in this Inquiry, and in particular in this most important of modules.

At the outset, my Lady, it is necessary in my submission to highlight the context in which decisions were made, and actions taken or not taken.

Key decisions, such as the discharge of patients, the pausing of inspections, and the stopping of visits were all taken at a time when there was no vaccine, a lack of PPE, and significant concern about the effect of the pandemic on how best to deal with it.

In the face of assurances by governments across the United Kingdom that their decisions were made on the basis of the best clinical advice and guidance, “following the science”, as it was put, it was difficult to second-guess that advice in a very fast-moving and uncertain climate. As a result, it may be the case that, in some instances, an overabundance of caution was instinctively preferred to the more careful balancing of risks against rights that was undertaken at a later stage.

Amongst the various areas where the work of the inspectorate has come under consideration, there are two that I propose to touch on today: firstly, the pausing of inspections. On 13 March, the inspectorate took the decision to cease routine in-person inspections of care services, due to the spreading of the virus. This was decided by the inspectorate’s internal goal group, in line with public health advice and in agreement with the government. It is clear that similar precautionary steps were taken by regulators across the country at around the same time.

Against that background, it was perhaps more than a little surprising that Jeane Freeman, the then Cabinet Secretary for Health and Sport, told the Inquiry that she did not agree with that decision.

In any event, the inspectorate redirected its focus to remote oversight, including the following five steps: daily monitoring of notifications from care homes; the use of a red, amber and green staffing alert system from third, a new Covid-19 flexible response team to interpret evolving guidance and to support providers; fourth, at least weekly telephone contact with all services; and fifthly, the weekly intelligence sharing and data dashboards and the sharing of information with the directors of public health and with the Scottish Government.

Despite the suspension of site visits, the inspectorate continued to gather intelligence and to respond to complaints and to offer regulatory support.

Of course, my Lady, as Mr Mitchell frankly acknowledged, that remote model reduced, as he put it, real-time visibility, and therefore had limitations. However, the immediate risk to life from viral transmission took precedence at that early uncertain stage of the pandemic, and the halting of inspections, in the context I touched on at the beginning, was, in my submission, a proportionate response, and the inspectorate stands by that decision.

Secondly, the decision to stop visits. Once decisions to restrict visiting in care homes were taken by the Scottish Government, based on public health

advice, particularly from the Clinical and Professional

Advisory Group, and the Chief Medical Officer, the April to identify which services may be in crisis; 3 inspectorate’s witnesses repeatedly criticised aspects

of the visiting restrictions, especially their

unintended consequences, namely the emotional and

psychological toll on residents.

Your Ladyship heard only yesterday from,

your Ladyship may consider, an impressive witness,

Professor Barclay, that there is no doubt that harm was

caused as a result.

The restrictions created a severe imbalance between

infection control and residents’ human – imbalance,

I should say, between infection control and residents’

human rights, particularly for people with dementia or

sensory impairments.

Mr Mitchell argued that this approach often applied

hospital-like clinical standards to care home

environments, which should instead be treated as

people’s homes.

Ms Marie Paterson from the inspectorate specifically

raised the issue at three meetings with the directors of

public health, and supported by Dr Macaskill of Scottish

Care, at a meeting of the National Contingency Planning

Group, but unfortunately those concerns appear to have

largely fallen on deaf ears.

As the Inquiry has heard, the inspectorate has welcomed the development of Anne’s Law which gives residents the right to remain contact with a nominated loved one during outbreaks. This is, in my submission, a crucial correction to the initial approach, which Mr Mitchell said had at times been overly risk averse.

Turning then to recommendations, my Lady.

Aside from the lessons learnt by the inspectorate and what it could and should have done better, which are all set out in great detail in Mr Mitchell’s statement and in the course of his evidence, potential recommendations are flagged in various statements and other documents submitted to the Inquiry by the inspectorate, and indeed in Mr Mitchell’s oral evidence. They will be augmented in due course in the written submission.

But in my submission just now, there are eight which I invite your Ladyship to consider.

First of all, the rights and wishes of care users. Mr Mitchell stressed the importance of a better balance being struck between the human rights and wishes of social care users and their loved ones on the one hand, and the risks to health that they may face on the other. He said that inspection frameworks should ensure that residents are treated with dignity, respect and compassion, and this was particularly important in relation to visiting restrictions.

Secondly, it’s – secondly, in terms of bolstering compliance, Mr Mitchell suggested a change in the legal framework so that improvement notices could be sustained beyond the point of initial compliance.

Presently if a care home meets the terms of an improvement notice, that notice is discharged even if improvements are not maintained afterwards. That leaves a gap, he said, in ensuring long-term protection.

Thirdly, maintaining risk-based and intelligence-led inspections. Mr Mitchell supported retaining the scrutiny assessment tool developed during the pandemic which had been used to prioritise inspections based on complaints intelligence and staffing data.

This approach was more responsive and targeted than routine cyclical inspections, and allowed for more effective use of regulatory capacity.

Fourth, clarifying roles across agencies.

My Lady, there was clearly a degree of confusion and overlap between the roles and responsibilities of the Care Inspectorate, the health and social care providers, local authorities, directors of public health, Public Health Scotland, and so forth, during the crisis.

There should, in the inspectorate’s submission, be a clearer definition of responsibility, especially during public health emergencies, to prevent duplication and to ensure a coordinated response.

By illustration, your Ladyship heard earlier this week from Dr Maria Rossi from Public Health Scotland, who said she was confident that the multiple sources of guidance had created confusion.

Fifthly, planning for inspectors’ safety. Importantly, my Lady, Mr Mitchell described the difficulties in securing PPE testing and vaccines for inspectors in the early stages. He acknowledged that the organisation should have pushed harder for PPE for its inspectors. As your Ladyship subsequently pointed out to him in the middle of his evidence: it all goes back to being properly prepared, doesn’t it?

He recommended that future pandemic preparedness plans also include designating regulatory staff as frontline workers. Both of these steps, in my submission, will hopefully mean that a suspension of inspections will be unnecessary in the event of any future pandemics.

Sixthly, involving the regulators and policy development. There was, in my submission, a lack of formal consultation with the inspectorate on some matters of pandemic guidance and legislation and, in future, it is hoped that regulators will formally be included in national planning and policy decisions. As an aside, as is clear from the evidence perhaps over the last few weeks, it also appears that the social care sector in general is underrepresented at that high level.

Point 7, my Lady: requiring effective design of buildings. Ms Campbell, King’s Counsel, was right to say that we’ve heard very little oral evidence about this issue but Mr Mitchell talked about it and it is something that the inspectorate has put significant effort into promoting. To quote from Mr Mitchell’s evidence:

“… what we learned from the pandemic about [IPC], about ventilation, fresh air, [is that] it is possible to design care homes better to take account of those. So for example, in a large care home, small group living is better [he said]. So creating spaces … that can be used to cohort both staff and residents, if there’s an outbreak, is helpful. But if the building is designed to accommodate that, it’s even more helpful.”

That is only one part of it, my Lady. Yesterday, Rhona Arthur spoke very movingly about her late father’s time in a care home, rejuvenating the greenhouse, showing nursery schoolchildren how to grow tomatoes, I think, and playing the piano, and so forth. That chimes with what is said in the inspectorate’s design guide and I urge your Ladyship to consider it.

It’s at INQ000510071. At page 11, it is said within that document:

[As read] “A care home must not only be seen as a physical building but as a culture and a society in which a person lives, experience of support, opportunity and citizenship.”

It is vital, my Lady, in my submission, that care home design facilitates that aspect as well as the health and safety of the people who live there.

A final point, point 8, is about instituting exercises between stakeholders, again, I think a point that no one else may have made.

Drawing from his prior experience as a senior police officer, Mr Mitchell recommended the use of inter-agency exercises between the various stakeholders. This results not only in a better ability to react when the time comes but also to establish relationships between the relevant individuals.

In conclusion, my Lady, the evidence produced by the inspectorate provides a detailed account of its operational decisions and practical and forward-looking recommendations to strengthen care regulation and coordination in future emergencies. At its heart, that evidence underscores the importance of clarity, proportionality, collaboration and rights-based care across all aspects of the care system.

My Lady, unless there is anything else in which I can assist at this time, that concludes the submission on behalf of the inspectorate.

Lady Hallett: Very grateful, Mr Macleod, thank you very much.

I think we’re now going to Mr Rafferty, who is remote. Closing statement on behalf of Regulation and Quality

Improvement Authority by MR RAFFERTY

Mr Rafferty: Yes, good afternoon, my Lady.

Lady Hallett: I can’t see you yet, Mr Rafferty, but, by all means, start speaking, if you don’t mind the fact that I can’t see you.

Mr Rafferty: No, my Lady, I’m more concerned that you can hear me correctly.

Lady Hallett: I can hear you perfectly well, thank you.

Mr Rafferty: Thank you.

My Lady, the Regulation and Quality Improvement Authority, the RQIA, is thankful to you for the opportunity to make brief oral submissions this afternoon at the conclusion of Module 6 of this Inquiry and to you also for permitting it and for me to do so remotely.

Lady Hallett: I can now see you.

Mr Rafferty: Very good.

In preparing to provide the Inquiry with the witness statement of Ms Briege Donaghy, RQIA’s chief executive and her oral evidence – and, in the time since, the RQIA is grateful to the Inquiry for the disclosure and the assistance that it has received – the RQIA has listened with great care to all of the issues which have been raised in this module. In making these closing submissions, the RQIA wishes to make plain that it seeks to acknowledge the experience, the endurance and resilience of service users and of their families, its own staff and of service providers during the Covid-19 pandemic. The RQIA recognises the manifold impacts of the pandemic upon families, particularly the lost of loved ones, and recognises and appreciates their determined pursuit for the truth. The RQIA also seeks to acknowledge that relationships of trust and support between it and its staff, with patients, service users and families, and service providers, are of paramount importance when it seeks to heal and learn from the lessons which arise from this investigation.

In the time available it is not, of course, my Lady, possible to traverse all of the substantive points of evidence which may be relevant to the RQIA. However, from its own evidence and its continued observation of the evidence received by the Inquiry from others, it is perhaps appropriate to reflect on four particular issues.

The first is in relation to inspections, my Lady. Having listened to the evidence in this Inquiry, no person could now be, if they ever were, in any doubt as to the importance of inspections of care homes and domiciliary care providers by the RQIA. As the challenge and difficulty of having safe inspections may arise during a pandemic, so does the need to protect the ability of the RQIA to perform inspections and its regulatory functions and it is right that, in circumstances where there was any material impact at all on the RQIA’s inspection of adult social care, the Inquiry investigates the reasons for this and their impact. My Lady, I know that the Inquiry has heard much evidence on these issues from the RQIA and others.

The RQIA’s position moving forward is that its regulatory role must be, and it must be permitted to be, one which is adaptive to the modern demands of adult social care, for example in circumstances where people now live longer and seek independence for longer, and which adopts modern approaches, including the assessment of intelligence and technologies to discharging those regulatory functions.

The Inquiry has heard, my Lady, that the RQIA is required by current regulations made in 2005 and 2007 to inspect care homes twice per year and domiciliary care agencies once per year. This model of inspection is of its time and, my Lady, the RQIA is firmly of the view that this time is passed.

The RQIA, as the Inquiry has heard, is a small organisation of professionals and its assessment, supported by the evidence that the Inquiry has received from others during this module, is that inspections should not be performed simply by reference to frequency. This is not the most effective way to regulate adult social care to secure the safety and quality of services.

Rather, the RQIA’s regulation of the adult social care system should have, as a core element, which are reflective of informed judgements about the likely levels of risk. One factor, my Lady, well of course be timeliness. Services must be inspected regularly, but this must not be at the cost of thoroughness or a substitute for professional and informed judgement.

In order to achieve this change in approach, RQIA’s role as an independent healthcare regulator (remote link disruption) and relevant policy, policy and legislative change is required.

The RQIA restates the need for modernisation of the current regulatory frameworks, for health and social care services in Northern Ireland, with a move to using information and data, including information from service users and families to identify equality of service provision and enable it to take appropriate action.

The second point, my Lady, is related to the first and is of no less importance. Whilst the RQIA submits that inspection activities play a key role in its ability to carry out its functions, that is of course one very important part but it is not the only important part. The RQIA wishes to make clear that the strength of its relationships with service users and families and their advocates with service providers, other regulators and agencies, and with the Department of Health, is central to its ability to carry out its functions.

This is best exemplified in relation to inspections. Using a risk-based model, my Lady, requires first a sound assessment of the risks. This depends upon access to information. Collecting, analysing, evaluating and interpreting this information makes it meaningful and actionable, for decision making. Information can come from families, service users, advocates and from care homes and domiciliary care agencies directly, including through their staff and from other regulators and agencies.

There can be little doubt that the RQIA’s role will be enhanced and it will be best able to implement an effective intelligence-led and risk-based regulatory system when all partners, including those service users and their families, trust RQIA and communicate freely with it. For this to happen, there must be transparency and a clear flow from information to action.

Service users and their families should be in no doubt, my Lady, that the RQIA values and respects their experience and their information, and that RQIA’s actions are governed by the public interest and guided in line with the values of integrity, honesty, objectivity and impartiality.

The RQIA has heard in this Inquiry how it needs to take key steps in order to build its relationships with service users and families and with service providers, and these are to communicate – and to communicate effectively. It intends, my Lady, to redouble its efforts to achieve these steps.

The third point is in relation to DNACPRs. The Inquiry will observe, my Lady, that the issue of DNACPRs was addressed in simple and short terms in the statement of Ms Donaghy. As a result of investigations carried out prior to giving evidence in the Inquiry, the RQIA was in a position to confirm that DNACPRs were not a matter raised with it in any or any significant way during the pandemic itself.

What has arisen in this module however, and of which the RQIA is now acutely aware, is that DNACPRs is an issue with which it could have a role. The RQIA will assess whether it could have a role in, for example, the checking and testing of advanced care planning arrangements in Northern Ireland. It will consider the evidence and the views of its staff, of the report which has been prepared by its regulatory colleague, the CQC, and it will seek and consider the views of other relevant stakeholders in Northern Ireland.

The fourth issue, my Lady, is in relation to isolation and the ability of care homes and domiciliary care agencies to have and to implement effective and safe policies and procedures for isolating. The importance of this, in the context of steps taken during the pandemic, which saw the restriction of visiting and access of family members to their loved ones, is appreciated.

The need to ensure that the RQIA maintains an up-to-date picture of the readiness of adult social care to move to react to emergency situations is again patently clear. The RQIA is developing its view, which is strengthened by the evidence that it has heard in this module, of the areas of practice and the data which require ongoing attention and where refinement is needed.

This will help RQIA to identify and understand where change is needed and how change can be embedded for the future. RQIA is committed to taking the practical actions required, both in relation to matters around available information and, more generally, to improve its ongoing responses at and to fortify it and the adult social care against challenging times.

In conclusion, my Lady, the RQIA is committed to assisting the Inquiry. It looks forward to the findings and recommendations which will enhance its ability to carry out its core purpose of securing and improving the quality and availability of health and social care services in Northern Ireland more effectively.

In this spirit, it has sought to engage with the Inquiry with candour, openness and transparency. This is reflected in the evidence of the RQIA where it has acknowledged its shortcomings during the pandemic, and sought to indicate where it can improve now and in the future. It is committed to listening and reflecting and putting into action the learning from this Inquiry. It recognises that more work and change is necessary in order to protect its regulatory function and it is ready to take these steps.

Thank you, my Lady. Those are the submissions we have for RQIA.

Lady Hallett: Thank you very much indeed, Mr Rafferty. I’m very grateful.

Right, we shall break now and, I’m afraid, a shortened lunch, I shall return at 1.30.

(12.39 pm)

(The Short Adjournment)

(1.30 pm)

Lady Hallett: Ms Wilkinson. Closing statement on behalf of the Care Quality Commission

by MS WILKINSON KC

Ms Wilkinson: My Lady, the Care Quality Commission wish to thank you and your team for the obvious care and attention paid to the important evidence heard in this module and wish to assure the Inquiry that they too have followed the evidence attentively.

CQC acknowledges the observations of many witnesses about the impact of decisions made during the pandemic and their varied experiences of CQC over that period.

It has become clear that a number of themes have emerged from the evidence, and I will wish to address you briefly on three of them, with expansion in written submissions to follow.

Those three matters are: the pausing of routine inspections, discharge guidance from hospitals, and contingency planning.

First, pausing routine inspections and what should happen in the future. It’s important to note the qualitative difference between routine inspections and inspections prompted by intelligence regarding a risk of harm.

To quote from Helen Whately’s summary, she said:

“… a care home or care provider was only going to be inspected every so often, anyway, to do their rating as to whether they are good or requires improvement … and it might make sense in the future, as it did in this, to deprioritise doing those because those aren’t triggered by a particular concern about the care home and everything is going to be different probably in the care setting during a pandemic anyway, so are you even going to get a fair sense of how you should be rating a care provider in that circumstance?”

However, risk-based inspections of the kind referred to earlier by the TUC differ, and are critical in ensuring safe care, and these are never paused.

CQC would invite the Inquiry to conclude that at the time, in March 2020, as regards routine inspections, the competing interests, with a need to ensure that the public received safe care whilst not exposing the vulnerable in those care homes to the virus being introduced by an inspector crossing the threshold without adequate PPE, testing or vaccination, the clear mandate at that time to those not designated as frontline workers, as CQC inspectors were not, was to stay at home, because the risk of death to the vulnerable was too great and it was not known how long that threat would persist.

Amongst the many witnesses from whom this module has heard, there was Ms Gillian Baranski from Care Inspectorate Wales, whose evidence on this same point, as the Welsh regulator, was, it is suggested, powerful.

She said:

“… the thought of our inspectors taking Covid into a care home, of which we were the regulators, and we know how vulnerable many of the people who live in our care homes are. That just seemed unacceptable.”

One might test the merit of that decision to pause by imagining the very criticisms that might now be faced by regulators in this Inquiry if they had continued their routine inspections without adequate PPE and could be traced, just as care worker movement has been, as one of the key sources that introduced Covid-19 into care homes.

This balance, in favour of a pause, was canvassed with and understood by relevant stakeholders and ultimately endorsed by government. Indeed, the Inquiry will recall the very clear evidence from the then Secretary of State Mr Hancock, which was for the CQC to pull back more than they were currently planning on inspections and data collection, to reduce the administrative burden on providers of social care.

He told the Inquiry that he considered the consequences of pausing inspections to be:

“… a balance, and that’s the challenge … often in policy, especially in these terrible times, we were taking actions in order to preserve life.”

CQC understands and accepts that, to some providers and users of services, it would have felt different, as many things did during the pandemic, but CQC does not accept that it is a fair characterisation to say it abandoned the adult social care sector, went AWOL, or withdrew its oversight.

From mid-March 2020 onwards, CQC gathered information to carry out its duties in the following ways: inspectors made proactive telephone calls to providers in their portfolios, which triggered further action from CQC where a provider was not coping. And that did include the virtual meetings and online meetings that were called, in those times, “management review meetings”, and it did include in-person inspections.

Between 4 May and 29 October 2020, there were 11,935 ESF calls with care home providers within the sector, and an additional 6,281 to domiciliary care providers.

Intelligence was also gathered from provider collaboration reviews from July 2020, and the “Give feedback on care” form on the CQC website, which received 138,000 comments between March 2020 and June 2022. Emails and telephone calls raising concerns, Including whistleblowing, were another source.

All this information was logged on the customer relationship management system and reviewed by the National Customer Service Centre.

It marked a 50% increase in contacts from the public and 55% increase from people working in the services.

In addition, large sample groups of providers received targeted IPC inspections. So whilst there may not have been the same sights, sounds and smells available, there was a sound body of intelligence to understand, prioritise, and target risk, and in this way CQC maintained oversight during the pandemic.

For the future, however, my Lady, lessons have been learned. And as this Inquiry is aware, there is ongoing transformation within the CQC.

Whilst it will always be for government to determine how best to protect public health, depending on a future pandemic’s transmission route, CQC recognises that there would need to be the widest toolkit available to enable regulation to continue. This could include, and should include, a robust registration system, broad intelligence-gathering methods, but also, CQC has said and maintains it is committed to the recommendation it made in its written evidence: to recognise the importance of on-site inspections, and to ensure the ability to continue to conduct them in a future pandemic.

Secondly, discharge from hospitals to care homes and future guidance drafting. CQC did not draft the Covid-19 hospital discharge service requirements that the Department of Health and Social Care issued on 19 March 2020. When the Department’s sought CQC’s agreement to suspend entirely the requirement for trusted assessment before a patient was discharged from hospital, CQC refused to agree.

Mary Cridge explained that this was because CQC will always put safety first, and the trusted assessors must take account of the legal responsibilities of the social care providers, who must ask themselves: can they care for this person safely?

CQC’s only engagement in the full document was to ensure that the content of annex C, the trusted assessor guidance, remained as unaltered as possible, changing only to require that the NHS employ and use more trusted assessors.

Going forward, CQC’s position on drafting this sort of guidance is, as stated by Mary Cridge:

[As read] “Our position on current powers, on guidance, are confined to guidance about compliance and how to meet the fundamental standards. It doesn’t go wider than that. We think government after the best placed to provide guidance in a pandemic.

“What we need is guidance that is relevant to social care and is not health sector guidance adjusted for social care. It’s a very diverse sector, with lots of different-sized providers. The best way to really good guidance is to have that genuinely co-produced with those who provide services, those who receive services, and the various experts.

“CQC has a role in that, perhaps even as a lead facilitator, but I think,” she said, “CQC providing guidance about guidance, that’s not a healthy state. It’s the road to confusion for providers.”

And finally, my Lady, contingency planning and the CQC’s role in future preparedness.

At present, the regulations by which CQC must exercise their oversight do not presently require any provider or local authority to hold a pandemic plan. What was required, both in 2020 and remains the position today, is that when a care home registers with CQC, they are told they may be asked to supply some additional documents, which, depending on the type of service they plan to provide, may include a business continuity plan and an emergency plan.

To date, there has not been a definition that emergency plans must include pandemic plans.

As was clarified during Joanna Killian’s evidence, the aim of a pandemic plan differs from that of a business continuity and business contingency plan. She said that it falls to national government to define the threats to the nation, which range from flu pandemics to cyber attacks.

It then falls to the local resilience forum to make sure that the local authorities within their footprint are ready to respond to a national emergency. A business continuity plan is a mechanism to make sure that business can continue in the event of a cyber attack or similar threat such as a flood.

It is with this evidence in mind that the recollection of Helen Whately should be viewed when she was referred to a WhatsApp message dated 3 March 2020 stating, in relation to an Essex local authority contingency plan, that providers are required by CQC to have plans in place to provide safe care in the event of a pandemic. She suggested that she would expect CQC to be the natural organisation to oversee plans held by providers or local authorities, given the new powers to inspect.

But CQC is not qualified to risk assess what amounts to an adequate pandemic plan for a care provider. Indeed, its work in oversight of local authorities is limited to their duties under Part I of the Care Act. It is, however, expected that setting the criteria for adequate pandemic plans will be part of the government’s current work referenced by Michelle Dyson as the pandemic preparedness strategy to tackle the five different potential transmission routes, and CQC can

confirm that it is one of the organisations which has

been invited to be “around the table” in this planning

work, and CQC stands ready to play whatever part is

deemed necessary as a result of that process and this

Inquiry’s recommendations for the future.

My Lady, those are those three matters highlighted

by CQC at this stage.

Lady Hallett: Thank you very much, Ms Wilkinson.

Mr Rawat. Closing statement on behalf of the UK Health Security Agency

by MR RAWAT KC

Mr Rawat: Good afternoon, my Lady, I am here on behalf of the United Kingdom Health Security Agency, or UKHSA as I will refer to it going forward.

My Lady, at the start of these hearings, you rightly described the impact of the pandemic on the adult social care sector as devastating. The complexity of the sector presents its challenges, but what must be remembered is that those it is intended to support are often the most vulnerable among us. It is vital, therefore, that we all continue to learn and implement lessons for the future.

As your Ladyship has heard, UKHSA, like Public Health England before it, has a discrete role to play in supporting the sector. That operational role encompasses surveillance of pathogens and infectious outbreaks, contributing public health advice to national guidance published by Government departments and producing IPC guidance and, at local level, UKHSA’s health protection teams offer specialised support. UKHSA does not have policy oversight for the sector nor is it a regulator of it.

Our corporate witness statement and our opening statement set out UKHSA’s reflections as to what, having regard to the agency’s role, could be better done to support the sector for a future pandemic. I want therefore today to address two matters: the first has been a central issue in this module, and that is the impact of hospital discharge decision of March 2020 on infection rates in care homes; and the second is the production of guidance.

To turn to the first, discharging an individual who no longer needs to be in hospital has long been een as best practice and continues to be so. There are good clinical reasons for this. But it meant, for example, that even prior to the pandemic, guidance existed for the discharge to a care home of a patient who had flu symptoms or had been diagnosed with a flu infection. It’s not in dispute that Public Health England was not consulted on the policy decision to free up NHS bed capacity and only became aware of it when it was announced on 17 March 2020.

You’ve heard evidence for the rationale for that policy decision, including from the former Secretary of State for Health and Social Care. He spoke of concerns that hospitals were “likely to be overwhelmed” and, as Mr Hancock explained, the policy decision was made at a time when it was recognised that there was limited testing capacity.

The consequence was that Public Health England and others worked at pace to produce what has been called in this module the April Admissions Guidance published on 2 April 2020. This was consensus guidance coordinated by DHSC and to which the NHS, CQC and Public Health England contributed.

It preceded the announcement on 15 April 2020 that all symptomatic care home residents and staff would be offered a PCR test. It has been argued that hospital discharge was the predominant route by which Covid-19 reached care homes, particularly in those early months of the pandemic.

The Inquiry is very familiar with the technical report published by the Chief Medical Officer and Professor Laura Shallcross – who undertook the Vivaldi 1 Study at the invitation of Professor Susan Hopkins, then incident director for Public Health England – drew your attention to the schematic in the technical report which set out seven potential routes of ingress for Covid-19 into care homes. You will have noted that the authors of that part of the technical report came from UKHSA. The technical report, citing various research studies, paints a more nuanced picture of ingress. It was why Professor Shallcross could make the point that there was a dynamic component to the contribution of different routes, depending on, for example, the time point of the pandemic.

The list of relevant studies begins with Easter 6 in April 2020 and continues with other studies conducted in 2021 and 2022. We intend to address the findings of those studies in our written closing statement but your Ladyship may find that they offer the best evidence as to the contribution of different routes, including hospital discharge, to infection rates in care homes.

When considering those studies, it is useful to keep in mind the following: first, the need to have regard to the intended purpose of a particular study; second, the extent to which a study identified its own limitations, including as to what data was then available; and, third, the need to take care when comparing different studies done at different points in time.

Stepping back, however, what the studies do show is that hospital discharge does not appear to have been the dominant route of ingress, that there was a correlation between care home outbreaks and rates of community transmission, and that staff living in the community and moving between care homes unintentionally was an important route of ingress.

Looking to the future, consideration of what is a complex issue cannot be seen as a simple binary choice between hospital discharge, on one hand, and movement of staff, on the other. The 2025 National Risk Register identifies a respiratory pathogen as the most likely cause of a future pandemic affecting the UK. It would undermine effective pandemic planning if a particular fruit of ingress into care homes were not given proper examination.

So, of course, the impact that hospital discharge could have in a future pandemic needs to be prepared for. However, as your Ladyship has heard, that staff will work in more than one care setting is a long-established feature of the sector and to ignore, therefore, the possibility that staff movement could make a contribution to infection spread in a future pandemic is to undermine the need to look at practical measures that may mitigate that risk.

As with support payments for those isolating, such measures are not within UKHSA’s gift but they do need to be given thought. Could that mitigation involve, for example, supplementing incomes in a time of emergency so that staff do not need to move and, if that measure is adopted, then how do you plan for sufficient staff members across all settings?

My Lady, wider points have also been made about the role of DHSC and Public Health England in relation to data. It’s been suggested by reference to the Vivaldi Study that there was a cultural reluctance to share data, that there were occasions when the utility of Vivaldi was ignored by some, whilst its data was also being presented by others as their own.

Professor Hopkins told you of the importance that Public Health England and UKHSA place on being able to conduct and publish research independent of government, and of the ethical standards expected of their scientists and which those scientists expect of themselves. That’s not to ignore, as Professor Hopkins acknowledged, that some things could have been progressed faster but the Inquiry is aware, across all modules, of the numerous studies that Public Health England produced and shared during the pandemic.

The difficulties in getting PHE data into the NHS Foundry, managed by NHS Digital, was the example canvassed with witnesses and it will be for you to decide if those difficulties were reflective of a culture or flowed from the practical need to ensure that there was appropriate measures in place to allow for lawful data sharing as well as the infrastructure to transfer data safely.

UKHSA’s corporate statement addresses how Public Health England and then UKHSA collated and used data. The agency has never suggested that the infrastructure in place before the pandemic was as effective as it could have been. The evidence is that data sharing improved rapidly during the pandemic. However, as your Ladyship is aware, UKHSA has in more than one module argued that building better data systems and addressing associated governance issues is key to pandemic preparedness.

Professor Hopkins pointed out that much has returned to pre-pandemic baselines and yet not every change requires significant financial resource or the creation of a bespoke system. As Professor Hopkins explained to you, it remains the case that the fact that someone is living in a care home is not automatically recorded in GP records. The workaround adopted during the pandemic was to use postcodes. Moving to a situation where this simple detail is recorded, something which might, we acknowledge, need regulation, would prove valuable. As to the use of Vivaldi data, Professor Shallcross’ evidence was that:

“Absolutely everybody was very receptive to the information we were putting out.”

As Michelle Dyson pointed out: Vivaldi was an important study which provided robust and independent validation of steps, including in relation to staff movement, that DHSC was already taking.

My Lady, to turn briefly to the question of guidance. The expectation is that in a future pandemic, UKHSA would continue to fulfil the role it has in the production of national guidance. The guidance produced for the adult social care sector during the pandemic drew upon that which existed before the pandemic.

It reflected the need to have guidance which could be adapted to different care settings. It is ultimately those providing care who have the best understanding of a particular setting and of the needs of those that they look after. They are best placed to undertake the risk assessment which is a necessary step to implementing national guidance, and should be seen as such and, in doing that, the oversight shown by DHSC, as well as the operational work undertaken by CQC and the Health and Safety Executive, and directors of public health, in peacetime, will be critical to assisting different care settings.

UKHSA’s corporate witness statement has set out how the agency now interacts with the sector, including with care providers and particularly through the work of its dedicated ASC team. Learning from the pandemic has been embedded and is being embedded. However, UKHSA recognises that more work can be done to ensure that guidance continues to be directed towards specific components of the adult social care sector, reflecting the different ways that care can be provided.

Further, guidance is always better for a stronger evidence base. Whilst research funders such as UK Research and Innovation and the National Institute for Health and Care Research, cannot fund all areas where research is needed. UKHSA can contribute by highlighting key evidence gaps to those funders to consider when determining funding priorities.

Finally, an important lesson from the pandemic is the need to find ways to listen to the direct experiences of those who use the care sector as well as family and friends, and then to use those experiences to inform the production of guidance.

My Lady, those are the submissions for UKHSA. Thank you very much.

Lady Hallett: Thank you very much, Mr Rawat.

Ms Khalique. I think you’re – oh, you are – Closing statement on behalf of the Welsh Government by MS

Khalique KC

Ms Khalique: Here, yes. Good afternoon, prynhawn da, my Lady.

My Lady, the Welsh Government has listened very carefully to the evidence and reflected on the concerns of the Core Participants and the bereaved families. Full written submissions will, of course, be provided later but I make the following brief submissions to address a number of key areas.

First, it is important to be clear about the Welsh Government’s role in the social care sector. The Welsh Government, as you’ve heard before, sets national policy and legislation, whereas day-to-day responsibility for managing and delivering adult social care in care homes and domiciliary care falls to the 22 local authorities who also commission services, and also to the care providers. The Welsh Government does not have operational control in this area, and that is an important distinction.

Second, on hospital discharge, Vaughan Gething, in his evidence, explained that the discharge framework dated 13 March 2020 was underpinned by the need to manage the risk that Wales, as a whole, was facing, at that time, of the potential catastrophic collapse of the health and social care system, if action was not taken to try to ease the pressure of hospital capacity at that time.

In this, and in all other decisions during the pandemic, as noted by Mr Gething, the Welsh Government considered the balance of harms inherent in one decision as against the alternative. Decisions had to be taken at pace and were based on, to quote Mr Gething’s words, “The best understanding of the scientific and medical evidence available at the time”.

You also heard from Albert Heaney. He accepted that, with the benefit of hindsight, it would have been better to test upon discharge from the beginning of the discharge framework being in place, but that approach was not in the scientific or medical advice at the time, and you will recall that the Welsh Government accepted in opening that, between 15 and 29 April 2020, there was a delay between the decision to require negative tests before admission to a care home being made and the communication of this decision to health boards and the publication of the updated guidance. This was acknowledged by Mr Gething and Mr Heaney in their oral evidence.

Third, on asymptomatic testing. Mr Gething confirmed in his evidence that decisions on asymptomatic testing were similarly based on the scientific advice available at the time and not based on testing capacity. However, you heard from Mr Gething that, had the advice to engage in asymptomatic testing come earlier, the reality is that the Government would have faced the very practical challenge of delivery and how to prioritise the tests available.

In May 2020, targeted asymptomatic testing was introduced in care homes. General asymptomatic testing in care homes was not introduced before 16 May because the advice received up to that point by the Welsh Government was that the scientific evidence did not support it. You also heard in evidence that the advice relating to asymptomatic testing of all care home residents that was referred to by Matt Hancock in a Health Minister’s meeting on 5 May 2020 was never shared with the Welsh Government at any level nor were its contents reflected in SAGE advice at that time.

Fourth, on visiting restrictions. My Lady, the Welsh Government always sought to strike a careful balance between preventing the spread of Covid-19 and the significant risks to vulnerable care home residents and staff, and the need to promote the wellbeing of those residents.

Mr Gething reflected in evidence that, in hindsight, the Welsh Government could have progressed permitting low-risk visiting sooner but, at the time, again, the scientific evidence and knowledge was not there to support this. The Inquiry has also heard there were many iterations of the care home visiting guidance in which restrictions were adjusted to reflect a developing and evolving understanding of the virus.

You heard from Gillian Baranski. She told the Inquiry that the guidance sought to achieve this difficult balance and Care Inspectorate Wales delivered seminars to aid the understanding of guidance and risk assessment. The Welsh Government and the Inspectorate sought to ensure stakeholder groups and the needs of people with specific vulnerabilities, including those with learning disabilities, were recognised in that guidance. Mr Heaney confirmed that the Welsh Government did not endorse a blanket ban approach to visiting, and took prompt and appropriate action when it became apparent that some local authorities or care providers had introduced blanket bans at a local level.

In recognition of the benefits of social contact and wider wellbeing, the Welsh Government sought to approach the issue innovatively and successfully rolled out the visiting pod scheme, enabling safe visits to take place outdoors, and promoted the use of video technology by a device loan scheme.

Fifth, on inspections in care homes. The decision to pause routine inspections was taken in March 2020 amidst a rapidly emerging picture of Covid-19 and was made due to the very real risk of inspectors bringing the virus into care homes to a vulnerable cohort of residents. As Ms Baranski recognised in her evidence, inspections are a powerful tool in the regulatory framework but they are only one of a number of ways in which assurance is and was provided within the social care system. You heard from Ms Baranski that, despite the temporary pause, inspectors continued to monitor and follow up on notifications, concerns and safeguarding incidents, and services that were already on the enforcement pathway to ensure quality and safety of care.

Although inspections were paused, my Lady, Care Inspectorate Wales intensified its scrutiny and monitoring of services, a series of check-in calls with providers were introduced from 30 March 2020, which performed a supportive function to providers, and was a further source of information for the Inspectorate.

Finally, on PPE. The Inquiry has heard evidence that PPE supplies did not run out at a national level in Wales, but challenges were experienced in the very early months of the pandemic due to distribution difficulties at a local level. As Mr Gething explained, about two-thirds of the care sector PPE needs were met by NHS Wales Shared Services Partnership by 7 May 2020 with the remainder being met by other sources. In terms of learning in this area, Mr Gething reflected that, in the event of a future pandemic, the Welsh Government should immediately progress to an NHS Wales Shared Services Partnership-led procurement of PPE for the care sector, as this model worked very well once established.

Overall, and to conclude, throughout the pandemic, the Welsh Government was committed to protecting the people living and working in the care sector, and balancing the protection of the health and well-being of recipients of care and the need to save lives.

My Lady, the Welsh Government is very grateful for the opportunity to assist the Inquiry. Thank you.

Lady Hallett: Thank you very much indeed, Ms Khalique.

Now, Mr Mitchell. Closing statement on behalf of Scottish Ministers by MR

Mitchell KC

Mr Mitchell: Thank you, my Lady. This is the closing statement on behalf of the Scottish Government. I appear today along with junior counsel Julie McKinlay, and we’re instructed by Caroline Beattie and Heather Auld of the Scottish Government Legal Directorate.

To begin where this module began, and indeed where it ended, that is with the impact evidence, the poignant testimonies could not fail to move. This form of participation in the Inquiry process shows a bravery that an onlooker may not fully understand, and that we who regularly appear in courtrooms perhaps come to take for granted.

The Scottish Government pays tribute to those who participated in the film and who gave evidence. It passes its sympathies and its condolences to the bereaved across the UK. It acknowledges the Herculean efforts of the workforce, including the unpaid carers, who looked after our most vulnerable. As Ms Freeman said, their response was absolutely exemplary.

Today we examine some of the issues that arose in evidence to which we can offer some context and clarity.

In Scotland, adult social care was prioritised in the pandemic response alongside the NHS. The Scottish Government did have a good understanding of the sector. There existed a wealth and breadth of specialist knowledge. Policy officials, professional advisers and advisory groups all contributed to keeping ministers fully informed.

Prior to the pandemic, there was extensive, meaningful engagement and consultation with the sector. During the pandemic it intensified.

The evidence would suggest that stakeholders accept this to be so.

As Ms Freeman observed, Scottish Care was a key and critical voice. Ms Lamb noted that a broad cross-section of stakeholder voices was listened to, albeit those voices were not always in agreement.

Turning to the decision to discharge patients into care homes. Ms Freeman pointed out that decisions made by the Scottish Government were not binary, but were decisions between levels of risk. In March 2020, delayed discharge had to be effectively tackled. We stress the following points: first, the discharge of a patient from hospital is a clinical decision over which the Scottish Government has no control.

Second, the Scottish Government cannot and did not compel care providers to accept admissions from hospitals. It did ask local authorities to put additional effort into reducing delays in discharging those assessed as clinically fit.

Third, from the outset, great efforts were made to ensure that the process of discharge was conducted safely, through guidance directed at social distancing, clinical screening and periods of isolation.

Testing prior to admission was introduced just as soon as capacity existed.

Fourth, not all patients were discharged into care homes.

Fifth, hospital discharges were not the dominant route by which the virus entered care homes. Analysis has revealed ingress of infections to be primarily attributable to staff footfall and directly related to care home size.

The Scottish Government submits that the decision to discharge reflected a considered approach to a long-standing issue. It required to be taken amidst an urgent, rapidly developing situation. While protective measures at this time were, as Ms Freeman acknowledged, perhaps not fully adequate, they were the only measures available to us at that point. The alternative was to leave someone ready for discharge in hospital, which was a high risk environment.

Looking now at infection prevention and control, the principles of sound IPC practice have long been recognised in Scotland. Since 2012, Scotland has published a National Infection Prevention and Control Manual. It contains standard precautions. It was, and continues to be, applicable to all care staff, in all care settings, at all times, in respect of all patients and service users, whether infection is known to be present or not. It ought to have been well known to the care sector, although, as Ms Freeman recognised, training and delivery were not consistent.

On 12 March 2020, HPS issued guidance specific to the social care sector. On 13 March that guidance was supplemented with standalone clinical guidance for care homes issued by Scotland’s Chief Medical Officer and that was updated on 26 March and 15 May.

Earlier in the pandemic, understanding of the virus and its effects developed rapidly. Guidance existed for the well-being and safety of individuals. There was a clear need for updates as new data and evidence emerged. Whilst recognising that it was challenging for care homes to respond to changing guidance, it was essential that it be updated and at speed.

A few brief words on PPE. Concerns were raised in evidence as to its availability, yet it is important to remember pre-pandemic arrangements for its supply and the speed with which the Scottish Government and partners responded to increased demand.

As the Inquiry heard in Module 5, when in March 2020 concerns were raised, swift action was taken to support the sector. The Module 5 evidence suggested that by the latter half of April, concerns about PPE supply in care homes had subsided.

Considering funding and sick pay, the Inquiry heard evidence about what is said to be the negative effect of fiscal austerity in the sector. However, in contrast to some other parts of the United Kingdom, since 2009-2010, expenditure on ASC in Scotland increased in real terms by 7% in total and by 5% per capita.

In 2020-21, Scottish integration authorities received funding of £561 million for Covid-19, and £712 million the following year. This was in addition to wider social care support, such as reducing delayed discharges, loss of income, and staff costs.

On 12 May 2020, an initial £50 million in sustainability payments was announced, with a further £50 million on 3 November 2020.

In relation to sick pay, some social care staff were reluctant to be tested for fear that a positive test would lead to self-isolation, a reliance on SSP and a reduction in income.

In June of 2020 the Scottish Government put in place its Social Care Staff Support Fund to ensure that social care workers absent from work due to coronavirus or self-isolation received an amount similar to their usual salary.

Further, in July 2020, it introduced a death in service scheme. A one-off payment of £60,000 was available to a named survivor of any social care worker who died without death in service cover as part of their contracted pension arrangements.

Both measures had retrospective effect.

Thinking now about visiting. The Inquiry heard powerful evidence of the effect that visiting restrictions had on care home residents and their families. Yet, as Ms Freeman noted, decisions in this area highlighted that the entire experience of the pandemic concerned the balance of harms. There was no situation at any point where a decision could be made that carried no harm.

The Care Reform (Scotland) Bill promoted by the Scottish Government received Royal assent on the 22nd of this month. Amongst other provisions, the Act imposes a duty on Scottish Ministers to require providers of care home services for adults to facilitate certain visits. Those provisions are known as Anne’s Law, in memory of Anne Duke, whose family were unable to see her for extended periods during the pandemic.

The Act strengthens residents’ rights, allowing them to identify at least one essential care supporter. This will help ensure that supporters can continue their role, even in infectious outbreak situations when visiting is barred(?) for others.

That the Scottish Government introduced Anne’s Law is recognition that families and friends play an essential part in the health and well-being of residents, and that the care home is their home.

Turning to information and advice for unpaid carers.

Access to information was a key issue for them and for local carer support services. Carers needed advice on how to protect the person they were caring for. That person was often at higher risk. Carers also felt an added responsibility to protect themselves from infection, both to reduce risk of transmission to the person in their care, and so that they might continue to provide that care.

In March of 2020, the Scottish Government created pages on its website to help people and carer organisations find the most up-to-date information. It created similar pages for young carers on the Young Scot Young Carers platform, covering a range of practical issues, including infection control and PPE.

Finally, turning to regulation. The Scottish Government was aware of concerns raised by the public regarding both pausing and resumption of care home inspections. From 13 March 2020 the Care Inspectorate paused physical inspections due to potential risks posed to care home residents and staff, and to Care Inspectorate staff.

On 17 April, following a deep dive meeting on care homes and a resolution that the Care Inspectorate should reinstate inspection visits, the Scottish Government requested that directors of public health take immediate action to ensure an enhanced system of assurance; that is, by working with the Care Inspectorate, local IPC teams, primary care teams and others to oversee the provision of local support and assurance to care homes.

As Ms Freeman made plain in evidence, the Scottish Government wished to see inspections resume, albeit in a manner that balanced potential risks.

Decisions to perform in-person inspections were informed by individual risk assessments of each home, under the clinical direction of directors of public health. This allowed consideration such as quality of care in each home to be taken into account.

My Lady, we conclude by, on behalf of the Scottish Government, once again passing sincere condolences and sympathies to those who have lost loved ones and to

those who continue to suffer, and by once again

acknowledging the efforts and sacrifices of our

workforce in the pandemic.

Before I sit down, I would like, on behalf of the

Scottish Government, to extend our thanks to the Inquiry

for the work that has gone into this module. Those

thanks of course go to everyone involved: the legal

teams, the ushers, witness support, and RTS, and of

course to you, my Lady, for your continued chairing of

this Inquiry. Thank you.

Lady Hallett: Thank you, Mr Mitchell.

Mr Allen.

Closing statement on behalf of the Local Government Association and the Welsh Local Government Association by MR

Allen KC

Mr Allen: Ah, yes. My Lady, good afternoon and, as you

know, I represent both the Local Government Association

and the Welsh Local Government Association. Before

I start, may I just echo what Mr Mitchell has just said

about our thanks generally to the Inquiry teams. He put

it very eloquently and I can’t find better words than he

used, so thank you on behalf of my two associations.

Both are very grateful to the Inquiry for the

opportunity for their chief executives to give oral

evidence in this module and both will have more to say in due course in their written closing statements.

Today I shall only summarise shortly some key points that they wish to make orally and at the conclusion of the hearing part of the module.

There are some common general points. My Lady, you know, for their part, both those associations aim and have the aim to ensure that the delivery of the best possible adult social care is done by their member authorities. You know how both are concerned to help local government to help people from all walks of life to live their lives to the best and that they will undertake that work in another emergency to the best of their ability, building on the experience of the last, and the wisdom that will emerge from your report on this module.

They are both fully aware, as you now will be, of the mental, physical, financial, logistical constraints of this pandemic for the provision of ASC. While every aspect of care at such times is more cumbersome and dangerous, both associations and their members know the essential importance of effective, humane and thoughtful engagement.

You’ve heard how, despite the many problems of lack of PPE, of difficulties over testing and vaccination and in the face of sometimes confusing and contradictory advice, those connected with the adult social care sector, whether in England or Wales, worked tirelessly and diligently, and you’ve heard also how this sector is not well understood, and how too often, particularly in the early phases of the pandemic, local government stepped up, even though government in London and Cardiff did not act as fast or as well, perhaps as it should have.

You have heard also of the many awful situations in which the pandemic took the lives of those receiving or giving adult social care, despite the sector’s best efforts. Their bereaved families carry the weight of this trauma and both associations repeat their fullest sympathies to all those thus affected.

Now, my Lady, focusing particularly on points relating to the LGA, the Association fears that the country is still not addressing the fissures in adult social care provision that have so been exposed during the pandemic and by the hearing in this module. We are simply no closer, even in these peacetimes, to a sustainable and thriving sector or a national understanding of social care’s inherent value or ensuring care recipients can always live as they wish. There is now a fear in the sector that the focus on improving adult social care is on the back burner, while yet another NHS organisation is underway. That is why this module is so important.

There are four points for immediate urgent action which sit alongside the recommendations in Joanna Killian’s witness statement, which need to be made orally and now.

First, we need sustainable funding and meaningful reform that is co-designed with all involved. You’ve heard the Casey Commission is on the horizon, but that multi-year process is no substitute for action now. Addressing deficits in resources and capacity that this module has exposed, system changes for both emergency and normal times are absolutely necessary now.

Second, government, Whitehall and the NHS must work closely and regularly with the adult social care sector to ensure that policy translates to feasible and desirable practice. Local government must be an equal and trusted partner in planning for, and responding to, emergencies, and that means better involvement for local government in this autumn’s pandemic preparedness test, Exercise Pegasus. It means engagement with all pandemic planning with senior LGA representation at relevant COBR meetings, and it means co-design and co-production of all relevant guidance, both in respect of pre-pandemic planning and any new guidance that might be required during the next pandemic, as and when it occurs.

Third, more work needs to be done to work out the very best way to balance steps to keep people safe whilst enabling them to see their loved ones and their loved ones to connect with them, and allowing them to be assured of the care recipient’s well-being.

This is not an easy issue. It involves looking again at issues such as the content of Care Act easements, of visiting restrictions, and also decisions to suspend CQC’s routine inspections. Central advice and guidance must be fully aware of the multiplicity of different physical care settings, and must enable local flexibility.

Lastly for the LGA, it wishes to reiterate, with emphasis, that adult social care must have parity of esteem with the NHS, both ordinarily and, even more importantly, in a future health emergency. As a minimum, this requires a mandatory cross-Whitehall and NHS programme of induction for new and existing senior civil servants and officials, whose departments have an interface with the adult care and support sector, to increase understanding of adult social care’s operational and policy imperatives.

Now, my Lady, changing my focus to the Welsh Local Government Association, it notes and agrees with these points, insofar as they are relevant to Wales, but it wishes me to present orally three points of critical importance to Wales, which sit alongside the longer and detailed recommendations in the witness statement of its chief executive, Chris Llewellyn.

Well, first, the Welsh Local Government Association also emphasises the LGA’s last point about parity of esteem with the NHS. In a pandemic, the health and social care sectors are equally important and they are truly interdependent. They must be treated as such in all matters of policy and operation, whether testing, PPE, financial support or public health control and easements, and this must not be seen as some mere chimerical aspiration.

The evidence from the Care Inspectorate Wales, from Care Forum Wales and ADSS Cymru was equally to the same effect. The mantra in future must be: protect health and care equally. Government policy and action must follow through on this aim. It is essential this happens.

Second, despite the evidence to the contrary from the former Minister for Health and Social Services, Vaughan Gething, any assumption that social care settings are safer than hospitals must be rejected as a fallacious generalisation. No future policy should be built on this assumption. Policy must be built on the recognition of the many and varied constraints on delivering residential care, the dangers of homecare, and the dangers arising from a peripatetic and part-time workforce. Obviously, this requires a deeper look at discharge policies.

Third, again echoing points made by the LGA, the WLGA emphasises the importance of investing in the workforce. It is not enough for the Chief Social Care Officer for Wales, Albert Heaney, to have noted how the system is very fragile, with problems of high turnover of staff, and a very low-paid workforce. It is obvious that such fragility, if continued, will cost lives in a future pandemic. So the WLGA emphasise, this is the time for urgent meaningful action to improve the resilience and quality of the social care sector and to rebuild public confidence.

My Lady, the associations thank you yet again for your attention, and they will flesh out their submissions in writing and submit them in due course.

Lady Hallett: Thank you for your help, Mr Allen.

Lastly, Ms Stober. Closing statement on behalf of Association of Directors of

Adult Social Services by MS STOBER

Ms Stober: Thank you, my Lady. Can you hear me?

Lady Hallett: Yes.

Ms Stober: I represent the Association of Adult Social Care Services. My Lady, may I apologise for my phone going off earlier on today, even though it was completely switched off.

ADASS welcomed the opportunity to contribute as Core Participants in this Module 6. They were anxious to acknowledge the sorrow to the bereaved and those needing and working in social care who were traumatised by the experience, or who still suffer Long Covid, to pay tribute to unpaid carers, to the committed care staff and to mark the very significant efforts everyone who worked excessively long hours, days and nights, over months, without break.

My Lady, you’ve heard with remarkable consistency from witnesses that what happened to people needing and working in social care was both tragic, in terms of the lives lost or compromised, but you’ve also heard evidence of remarkable demonstration of commitment, courage, and the best of human nature.

In relation to better and timely planning for a future pandemic, ADASS has the following five recommendations which they would like the Inquiry to consider reflecting in the recommendations of the final reports of this module.

First, a thorough review of the infrastructure needed at every level, national, regional and local, such that social care and our social and psychological needs are addressed in a pandemic, alongside the clinical and hospital focus. That means ensuring that there is regular social care advice to scientists and government at the highest level, alongside the NHS, from the people with operational as well as policy experience. It means a review of the local resilience forum, and the NHS arrangement and accountabilities and what the best mechanisms are for planning and responding in the case of a national care and health emergency.

2. The creation of a national mechanism that could take the form of reserved taskforce to be stood up annually, so as to continually review and assess readiness and fit test plans. It should cover the work of the same advisory groups as that of the taskforce that Sir David Pearson chaired in 2020. It should review the recommendations made by each of those advisory groups, be informed by and draw on regional perspectives, for example the ADASS regional chairs, be ready to stand up at the earliest indication of a future pandemic.

Central government should be required to act on the recommendations of such a taskforce with relevant partners to ensure that social care leadership and workforce are trained and equipped to deal with a pandemic. This would include the identification of those needing and working in care and effective mechanisms for shielding, vaccination, testing, PPE provision, data, professionalisation, pay and sick pay, access to healthcare, mental health support, access to care, support and safeguards, such that we’re all better protected, connected and valued.

3. Serious consideration should be given to increasing awareness, recognition and valuing of social care through embedding very operational experience and social care personnel in government with cross-government recognition and mandatory induction delivered by leaders in social care field for DHSC’s civil servants, and politicians with briefs in social care and the NHS, and also for people working in senior roles in the NHS.

4. A thorough revision of the discharge to access practice, to include greater focus on integrated intermediate care, namely the care, treatment and support offered to people, so as to avoid the need for hospital admission and to enable people discharged from hospital support to recover, rehabilitate and, if long-term care is needed, to weigh up the benefits, risks and cost of the option.

5. ADASS would recommend a quality safety and safeguarding are integral to planning for, and responding to, a pandemic, given that people needing and working in care and support may once again be behind closed doors, at home, or in closed institutions.

Finally, my Lady, there is a collective hope that the Inquiry will make a mark in recognising just how essential social care is for all our lives, and to start to build a new social contract about how we live, work and care for each other.

Thank you, my Lady.

Lady Hallett: Thank you very much indeed, Ms Stober.

Ms Carey.

Closing Remarks by Lead Counsel to the Inquiry for Module 6

Ms Carey: My Lady, may I just conclude these hearings by inviting you to publish an additional 70 statements later. I won’t read all of them, but up on screen now are going to be the names, indeed the reference numbers, and a description of the people and indeed the organisations that provide the statements to us. They include from local government, interest groups, the Northern Irish health and social care trusts, politicians, the COSLA survey, and indeed some remaining impact witnesses.

May I finally just say this: a few word of thanks from me. Many of the Core Participants have been kind enough to commend the Inquiry for the smooth running of this module. As I think your Ladyship knows, but others may not, those words of thanks go not just to counsel and the solicitors but to the paralegals, the secretariat, the operations team, and to all the other staff, security here at Dorland House, who have looked after us so very well.

I truly am grateful.

Closing Remarks by the Chair

Lady Hallett: Thank you very much indeed, Ms Carey. And can I add to that list, I entirely echo what you say, can I add our very patient stenographer –

Ms Carey: Indeed.

Lady Hallett: – who has had to cope with a lot of very difficult evidence.

Ms Carey: Indeed.

Lady Hallett: Thank you very much. That completes the hearings into Module 6, the care sector. It has been an intense and, at times, difficult five weeks. I’ve heard some powerful evidence, and some powerful advocacy, and from the very first moment I met the bereaved during my consultation on the terms of reference, and I went around the United Kingdom, I learned just how important this module would be to so many.

I hope that those who have suffered so much agree that we have conducted a thorough inquiry and investigation into the most important issues. I certainly believe that we have.

And as Ms Carey has said, we’ve done it with the assistance of so many people: obviously the Inquiry team, the witnesses, the material providers, the Core Participants, everybody involved in putting on hearings here, and Core Participants’ representatives, many of whom have provided substantial insight. And I’m extremely grateful to everybody.

If I could be forgiven the repetition, I will now be considering all the material, the oral evidence, the written material, and of course any written closing submissions that the Core Participants may submit. I’m afraid we’ve had to restrict their time for oral submissions, but there will be no restrictions on the length of their written submissions.

I understand the need for urgency in publishing my findings and recommendations, and we will do the best that we can, but everyone, I’m afraid, must remember that the report writing for this module in itself would take some time if we are to get things right and, in any event, the Inquiry team as a whole are already working

on several reports, but I do undertake that we will

publish the report as soon as we possibly can. And

I very much have taken on board the point that, as

worthwhile as Baroness Casey’s review will be, it’s

going to come sometime in the future, or the results of

it will come sometime in the future.

So, thanking everybody for all their assistance,

I will now declare these hearings at an end. The next

evidential hearings for Module 8, Children and Young

People, will begin on 29 September.

Thank you all very much indeed.

(2.33 pm)

(The hearing concluded)