8 October 2025

(9.59 am)

Ms Carey: My Lady, good morning. I hope you can see and hear me all right?

Lady Hallett: I can, Ms Carey. Good morning.

Ms Carey: Thank you.

This morning we’re going to deal with two witnesses dealing with the impact of the pandemic on healthcare and the provision for children and young people. And can I ask, please, that Mr Duncan Burton is sworn.

Mr Duncan Burton

MR DUNCAN BURTON (affirmed).

Questions From Counsel to the Inquiry

Ms Carey: Mr Burton, good morning.

Mr Duncan Burton: Good morning.

Counsel Inquiry: Your full name, please.

Mr Duncan Burton: Duncan Alasdair Burton.

Counsel Inquiry: You have, on behalf of NHS England, provided the Inquiry with a very comprehensive, over 250-page statement on behalf of NHS England. And I think you are here this morning in your capacity as the Chief Nursing Officer for NHSE, as I’ll call it for short.

Mr Duncan Burton: That’s correct.

Counsel Inquiry: You set out that you’ve been a nurse since September 1998, held a number of positions since then, and, indeed, are a member of the Royal College of Nursing.

Mr Duncan Burton: That’s correct.

Counsel Inquiry: You, during the pandemic, from September 2019 to April 2021, were the Regional Chief Nurse for the south east of England, and I think since July 2024 you’ve been the Chief Nursing Officer for England, taking over from Dame Ruth May.

Mr Duncan Burton: That’s correct, yes.

Counsel Inquiry: All right. I would just like, briefly, to ask you, please, to explain the role of the Chief Nursing Officer, particularly with emphasis on how it relates to children and young people.

Mr Duncan Burton: Yes, absolutely.

So, the Chief Nursing Officer for England has several different roles, one of which is the most senior adviser on nursing and midwifery matters to government and the Department of Health and Social Care. And also, then, as an executive member of NHS England, have a range of responsibilities across a number of different portfolios. For example, particularly relevant to children and young people is the executive lead for children and young people, the Children and Young People’s Transformation Programme, maternity and neonatal care.

Counsel Inquiry: Can I ask you about that, because you say in your statement that you held the executive responsibility for children and young people, but what does that actually mean in practice, Mr Burton?

Mr Duncan Burton: Yes, so, as executive lead, I’m not responsible for every element of children’s care throughout NHS England. So, for example, mental health care for children and young people would be the responsibility of the executive that’s responsible for mental health, but as – within my role I have a number of different responsibilities for children, so the Children and Young People’s Transformation Programme, which is very much focused on making improvements for care for children, so, for example, around epilepsy or asthma or the rollout of the national early warning scoring system for identifying critically ill children at risk of deterioration.

The other thing, then, I’m responsible for is actually the Children and Young People’s Transformation board, which brings together, across NHS England, all of the kind of elements that people are working on in relation to children and young people, be that through, kind of, the Learning Disabilities Programme or the Mental Health Programme.

We’ve also got representation there from the Department for Education, the Department of Health and Social Care, and partners such as the Royal College of Paediatrics and Child Health.

So, one of my key roles is actually about how do we give voice for children and young people and make sure that the voice of children and young people is really strong in the work that we do. And one of the great things in that transformation board is we have young people who are members of that, supported by a youth forum.

And that continued throughout the pandemic as well.

Counsel Inquiry: That’s what I was going to ask you.

And if I may interrupt you, Mr Burton, obviously you’ve got a very wide remit, a number of which doesn’t cover the impact, necessarily, of the – or not necessarily the direct impact of the pandemic on children, but I would like to focus your answers, please, on pandemic issues, whether they’re pre-pandemic, during, or indeed post-pandemic.

Just help us, then, with the young people on the board during the pandemic. Did they meet often? What kind of input did they have? Can you give us some examples of how they actually positively made a difference to NHSE’s response.

Mr Duncan Burton: Absolutely. So – well, first of all, I’ll just say how grateful I am to the young people that contributed and continued throughout the pandemic to help give their voice to how things were. So one of the reflections from the team, particularly about the work that they did, was feed in actually how it was feeling for them at the time, and we made sure that we tailored the way in which they interacted, so it was online, make sure we had that wraparound support for them to continue to participate in the work that we were doing.

But that also enabled us, and the team, to be able to understand what we might need to be focused on in the pandemic and our response to that.

So they met, the Young People Transformation Programme Board met frequently, I think met on 2 April, so right in the middle of 2020 in the pandemic and looked at a number of the areas around the impacts of the pandemic, in the here and now, and potentially in the future for children and young people.

Counsel Inquiry: Did that include not only the mental health impact but impact on actual medical conditions or was it more focused on the mental health impact on children?

Mr Duncan Burton: It was all of the impacts that were taking place at that time.

Counsel Inquiry: All right. We may touch on the engagement with children and young people as we go through your evidence this morning, Mr Burton, but can I take you back, please, to March 2020, and I’d like to examine with you some of the decisions taken to free up capacity for Covid-19 patients, primarily to free up capacity for adult patients, but look at the impact of that on the provision of healthcare on children and young people. I think, as you told us, you, at the time, were the Regional Chief Nurse for south east England, so not exactly a small region.

And can we go, please, to your paragraph 252, and 16 March 2020, where NHSE published its first iteration of the Clinical guide for the management of paediatric patients during the coronavirus pandemic.

Mr Duncan Burton: Yeah.

Counsel Inquiry: And just to help your Ladyship, the next day, came out the phase I letter which essentially was designed to free up a number – thousands of beds by the cessation of elective care, by increasing private healthcare capacity, and expediting discharges with which I know your Ladyship will be familiar.

But that’s where we are in the timeline.

And we can see there that NHS England advised paediatric services to keep children out of the healthcare system unless essential; use telemedicine – do you mean remote?

Mr Duncan Burton: Yes.

Counsel Inquiry: – remote appointments and the like for non-direct care, and plan for stopping elective procedures and treatments, especially those that may consume critical care and ward resources.

Now, can I ask you about that last subparagraph because people might be wondering why you were potentially stopping elective procedures that might consume critical care because it might suggest that the treatment was urgently needed albeit that it also might have a significant impact on the child or young person. Why was that part of NHS England’s advice to paediatricians?

Mr Duncan Burton: So I think if you go back to the period of time in March 2020 and we were faced with an overwhelmingly significant risk of a huge amount of critical care capacity being needed for dealing with Covid-19, which was unprecedented. Clearly we had to respond to that, and I think what this shows is particularly we were thinking about all parts of the system and actually how it could all contribute to that significant effort of caring for people with Covid-19.

I think, if you look later at the – or the phase I letter on the next day, I mean, clearly, there is – at no point do we stop or suggest we should stop anything that was urgent that wasn’t Covid-19, but we also knew at this point in time that the risk to children, it was emerging that the risk to children of Covid-19 was, in comparison to adults, less on critical care resources, and impact. That is not in any way to lessen the impact that it did have on some children and sadly some children did lose their lives to Covid-19 and I don’t want to lessen that impact at all, but comparatively to adults, it was different.

So we therefore needed, you know, to make sure we were freeing up resource to be able to have sufficient critical care capacity and some of that included the response from our paediatric colleagues in places such as paediatric intensive care.

Counsel Inquiry: Right. I think also the letter set out the possibility of redeployment for students newly qualified and even some junior paediatric staff to adult services. So that brings us on to that phase I letter, and as we know, it was considered vital to free up, I think it’s between – up to 30,000 beds across a number of measures taken during that month, but in particular, by pausing non-urgent services, it was hoped that that could free up 12,000 to 15,000 beds by that measure alone.

Just can I ask you about the letter that was sent out to all the trusts and the various other organisations involved. Do you agree, Mr Burton, that there was no specific reference in that 17 March letter to children and young people explicitly?

Mr Duncan Burton: There wasn’t a specific – it was all-age.

Counsel Inquiry: Right.

Mr Duncan Burton: And obviously we’d issued the guidance the day before, which you’ve just displayed on the screen.

Counsel Inquiry: All right. But I take it that by pausing elective care, or planned care, to call it another phrase, that implicitly included services for children and young people?

Mr Duncan Burton: Absolutely.

Counsel Inquiry: And you say in your statement that in England, patients including children and young people should not normally wait longer than 18 weeks to start elective treatment once they’ve been referred by a consultant; is that right?

Mr Duncan Burton: That’s correct.

Counsel Inquiry: So does it follow that it was obvious that in pausing elective care, it was likely that 18-week target was not going to be met in a large number of cases, whether adult or children and young people?

Mr Duncan Burton: I absolutely think that’s right, yeah.

Counsel Inquiry: Right. As at 17 March, can you help, was there any idea about when elective treatment may be able to resume or was it not possible to say as at the 16th, 17th?

Mr Duncan Burton: I think on the 16th and 17th, if I go back to my time as the Regional Chief Nurse there, we were in the midst of dealing with, at pace, a significant challenge around how do we make sure that there’s sufficient critical care capacity for the wave of Covid that was coming, and therefore, you know, I think whilst we continued to make sure, and be very clear in our communications about the need for the most urgent of elective cases, or emergency cases to continue, we had to focus our energy and effort on that.

So at that point in time I think it’s fair to say we were very much in the midst of focusing on that.

Counsel Inquiry: So there was – for the reasons you’ve set out, no ability to say, “Well, we’re going to be able to start it four, six, eight, 12 weeks”, but was there in fact a plan as at 17 March, or thereabouts, for how resumption would start? Even if you didn’t know when?

Mr Duncan Burton: I’m not sure I’m able to answer. I don’t believe that there was a specific plan although what I would say, as part of any of our EPRR processes, there are – sorry, our emergency response processes – there’s always a look about how do we do recovery. But at that point in time, and my recollection of that point in time, particularly, kind of, if I – I was a member of the gold leadership team in the region of the Regional Chief Nurse, we were very much focused on the here and now, because that’s what all of the energy and time needed to be on.

Counsel Inquiry: All right. There was, however, a plan a few weeks later that was announced in the phase II letter on 29 April of 2020, and it was a plan to really establish how NHS England was going to operate now that patient numbers were beginning to fall, although it was clear that Covid was not going away. Can I ask you, please, about some aspects of the phase II letter.

And could we have on screen INQ000087412.

And there’s the letter on 29 April, and page 5, please.

If we look at the top of the page, the letter from Sir Simon Stevens, as he now is, and indeed Amanda Pritchard, made it clear to the recipients of the letter that:

“Over the next six weeks and beyond we have the opportunity to begin to release and redeploy some of the treatment capacity …

“… [it] means we are now asking all NHS local systems and organisations working with regional colleagues to step up non-Covid urgent services as soon as possible …”

And they also ask that within the regional teams, for those teams “to make judgements on whether you have further capacity for at least some routine non-urgent elective care”.

And attached to the phase II letter was an annex which did in fact make reference to some children and young people’s services and if we look, for example, at page 7 of the annex, we can see there particular reference to maternity care, both antenatal and postnatal care, looking both, obviously, to reassure the women but also to care for the babies that have arrived.

And if we go on, please, to page 8, there is reference there to community services and the bottom bullet point:

“Essential community health services must continue to be provided, with other services phased back wherever local capacity is available. Prioritise home visits where there is a child safeguarding concern.”

Now, may I ask you about that. Clearly, there was, on 17 March, the advice to stop community health services, which would have had an impact on safeguarding concerns, but do you know, Mr Burton, did all home visits, where there was a safeguarding concern, stop or was there able to have some between 17 March and now the end of April?

Mr Duncan Burton: Yeah. So I think just in terms of this letter you – sorry, did you say 17 March?

Counsel Inquiry: Yes.

Mr Duncan Burton: Yes, so I think on 17 March clearly there was the letter that had gone out. On 19 March there was guidance that was – additional guidance that was sent out in relation to community health services, which set out actually, a table which I think is part of the evidence pack.

Counsel Inquiry: Well, if you want me to go to it now to help you, let me slot it in now, and can we have up on screen, please, INQ000049706, which I think might help you, Mr Burton, with the position in relation to community health services.

So let’s just backtrack slightly so it’s clear in the timeline. 17 March, the exhortation to suspend all elective, non-urgent services, including community health services but a few days later, within community health services, there was a letter that was sent out prioritising some community health services, and if we go, please, to page 2, I hope we will have there – there we are – the guidance that accompanied it, about what should be stop – what should be partially stopped, forgive me, and what should continue.

And we can see there in red there was a decision taken to stop National Child Measurement Programme, Audiology, and the Friends and Family Test.

What was the rationale or the basis for deciding what to stop, what to partially stop, and what to continue?

Mr Duncan Burton: Yeah. So I think if we go back to the letter of the 17th, that clearly went to everybody, set a very clear – what the health service needed to do respond to the pandemic immediately. Clearly, this subsequent guidance was around clarifying and making sure it was clear for community health services, and supporting that local decision making, around what areas could be stopped and what areas needed to be kind of managed on a risk basis, and you’ll see as you go through this document, not everything was stopped. Some of this was suggested about what could go on to – online, for example; what needed to continue, particularly if you look at some of the services around those most vulnerable children, looked after children, safeguarding, for example.

So this was really to help and support those community services with understanding what that stop of non-urgent work needed to be.

Counsel Inquiry: All right. So we can see there they stopped some programmes, presumably although preferable for them to continue, it wasn’t sort of clinically necessary to continue the National Child Measurement Programme, Audiology, and the Friends and Family Test. We can see vision screening, a partial stop, say, for newborns, and the six weeks check. And if we just go to page 2 you can see then there are various stops but with the “Exception” column –

Mr Duncan Burton: Yes.

Counsel Inquiry: – the pre-birth, school nursing, community paediatric service was continued, and if we go on, please, to page 5, in the “Continue” section, safeguarding is said to continue.

Do you know whether that was done in person, online, or how it was envisaged that safeguarding community health services would continue for children and young people?

Mr Duncan Burton: Yes, and if I can just go to the safeguarding section of my statement, if that is okay.

Counsel Inquiry: Certainly.

Mr Duncan Burton: I’ll just find that. I think the thing to just reflect on as well is that at this point in time, if you remember, about the 17th, we were also dealing with a new virus, where we were trying to make sure that we were protecting staff as well as patients in some of this decision making.

In terms of safeguarding, NHS England’s responsibility for safeguarding did not change throughout the pandemic, and in fact what our safeguarding teams did was to make sure that we pivoted – or made sure that we kind of reacted to the needs of children and young people in terms of safeguarding. So, for example, one of the things that was coming out very early around this period was that there were a number of looked-after children that were having to relocate around the country. So, you know, we asked for a COPI notice to make sure we were able to share information and data with other parts of the system to make sure we were responding to what we were seeing in terms of safeguarding needs.

But, you know, our responsibilities as professionals didn’t change during this period of time for safeguarding.

Counsel Inquiry: Right. Your responsibilities may not have changed but do you know if actual safeguarding visits took place in person, or did they move to online, or was there a hybrid system? Do you know the position?

Mr Duncan Burton: So, I think in terms of safeguarding, when we say safeguarding visits, there are a number of different professionals that have – well, every professional has a responsibility around safeguarding. Clearly, there were – there are professionals that have responsibility for – well, all are responsible for safeguarding but some have responsibility for identifying needs, et cetera – so, for example, health visitors – during this period. And you’ll see in this document, for example, health visiting, there was suggestions about some of that moving online, some of that stopping, and some of it very much focused on those children most at risk.

So I think it’s fair to say safeguarding activity didn’t stop, but safeguarding activity had to change to keep up with this. So, for example, you know, as testing centres came on, we made sure that the staff in testing centres were trained around safeguarding and what the things they might need to look for and spot in some of these areas. And then we also, as more clinical contacts happened online, we needed to make sure that the kind of guidance around online factored in the safeguarding needs of children.

Counsel Inquiry: Were you, in relation to these decisions that we’ve been looking at, either to stop, continue or somewhere in the middle ground, do you know whether the basis for deciding what to stop and what to continue was taken from a health perspective, a cost perspective, a staff redeployment perspective, all of those things and others? Do you know what the basis was for these decisions?

Mr Duncan Burton: Well, I think I would – I would put cost to one side. I don’t think cost ever at this point in time entered into the – certainly into the conversations I was in or any of the decision making in terms of – that was made at NHS England. I think the decision making that was taking place at that time – actually, could you repeat the question, please.

Counsel Inquiry: Well, really, was it taken on the basis of clinical need or was it taken “We’ll stop that because actually that would free up 100 staff”?

Mr Duncan Burton: Yeah, so it was based on all of those factors. So essentially we had – you know, we had to provide staff to staff critical care services that wave of the pandemic. So we needed to free up staff. We also needed to protect staff, so actually we wanted to make sure that we were – and patients – wanted to make sure that the contacts that needed to be had were the most essential contacts, but also thinking about the needs of most vulnerable children.

Counsel Inquiry: Right. We’re going to look at some of the impacts on children in a moment. But just to deal with the final phase III letter, so there was a plan for some resumption by the end of April 2020, and then, come 31 July 2020, NHS England set out the priorities for the remainder of that year, and specifically stated that the focus was on returning to what they called “near normal” levels for non-Covid health services, and to try to maintain routine elective surgery, and prepare for wave 2 and/or the winter. And we know there were a number of targets set.

There’s just one aspect of the phase III I’d like to ask you about, please.

And could I have on screen INQ000045147.

And it’s reference to, in the letter – page 6, please – to expanding mental health services.

Her Ladyship has heard in other modules about the increase in demand for mental health services as a result of the pandemic, and here we are, at the end of July, with NHS England asking for there to be an expansion and an improvement in mental health services for people with learning disability and/or autism, including, within this, specific reference to children and young people.

If we look just down to the middle bullet point, there’s reference there to asking systems to validate – I think it’s their long-term priorities for mental health services expansion, improving access to – I think it’s psychological therapies:

“- IAPT services should fully resume.

“- the 24/7 crisis helpline …”

Should continue.

And:

“- maintain the growth in the number of children and young people accessing care.

“- proactively [reviewing] … patients …

“- [ensuring] … local access … is … advertised.”

And:

“- [using] £250 million of … new capital to … eliminate mental health dormitory wards.”

Are they anything to do with children and young people, Mr Burton, that last bullet?

Mr Duncan Burton: I would have to come back to you on that one.

Counsel Inquiry: All right. And then clearly work being done, in the next bullet point down, to support people with learning disabilities, autism or both:

“- [continuing] to reduce the number of children, young people and adults within a specialist inpatient setting by providing better alternatives …”

And:

“- [completing] … [the] Learning Disability Mortality Reviews … by December 2020.”

Do you know whether this was designed to cope with people who were already in the system, who had mental health difficulties, and/or to cope with the new people that were coming forward, children and young people in particular, who had mental health difficulties, or a bit of both?

Mr Duncan Burton: A bit of both.

Counsel Inquiry: All right.

Mr Duncan Burton: And I think just, you know, the reason, you know, kind of maintain the growth was because, you know, there was already work happening before the pandemic to scale up services for children and young people’s mental health, and in some ways the pandemic accelerated the need for that.

And I think, you know, to go back to hearing the voice of children and young people, certainly we were hearing directly from children and young people about concerns around mental health, and I know the mental health and learning disabilities team heard the same through their connections and routes and working with organisations.

Counsel Inquiry: Can I ask you about that. I think the Inquiry provided you with extracts from the Children and Young People’s Voices report that the Inquiry commissioned, and clearly in there, there’s reference to the impact on children waiting long times for mental health assessments and the like. Is there anything in that report that surprises you or does it resonate with what children and young people were telling you in the transformation programme?

Mr Duncan Burton: Yeah, I mean, when I read that it certainly resonated with what we were being told, what we heard. And I think it really brings into light the really wide impact of this pandemic on children and young people, not just mental health but physical health and other concerns.

So I think, actually, this is why this Inquiry is really important, particularly for children and young people.

Counsel Inquiry: All right. I’d like to just look at some of the specific impacts with you, and in particular, starting with hospital care. It’s your section E, Mr Burton.

But I think you made the point that there was no change to be – or there was no advice to change the way carers provided for emergency admissions; is that correct?

Mr Duncan Burton: That’s correct, yes.

Counsel Inquiry: But in fact there was a decline in emergency admissions, both, in fact, for adults and indeed children and young people, presumably in part because we were all going out less and so there were fewer accidents and a fewer need to call upon emergency?

Mr Duncan Burton: Yes, I think that’s one of the reasons that – (overspeaking) –

Counsel Inquiry: Yes. Now, we’re going look at other reasons for various declines, but you say at your paragraph 270 that in April 2020, there were 29,500 fewer planned hospital admissions when compared with the year before, so nearly 30,000 fewer planned hospital – and was that a direct result of the phase I letter and the suspension and pausing of elective care?

Mr Duncan Burton: Yes.

Counsel Inquiry: All right. And I think, just to show that in real terms, can we have up on screen, please, page 92 of Mr Burton’s statement.

And a graph here that shows that, for under 18s, elective inpatient admissions dropped off significantly, we can see if we look at the blue shading, from somewhere in and around the region of about 50,000 in 2018, 2019, and then if you look at the steep decline in and around March and April 2020, helpfully highlighted there, a real drop off. And then a slow resumption in elective inpatient admissions, climbing thereafter to almost, by January, 2024, back to roughly where it was pre-pandemic.

Now, you said in your statement that in particular there was – a large proportion of the backlog comprised treatments which were “age-critical in terms of a child’s development”. What did you mean by “age-critical”?

Mr Duncan Burton: Well, I think one of the factors, when we look at care for children and young people, is the needs of children and young people, so for example, a child waiting for surgery, it may be a significant proportion of their life that they’ve been waiting. That has implications for school attendance, it has implications for social interactions with other children and the importance of play, and then that kind of impact, therefore, on their development through their childhood. So, you know, this is why it’s really important, clearly, that the impact of waiting in some ways is different than for, perhaps, an older person waiting. There are different dynamics there.

Counsel Inquiry: So it’s not just the impact on their physical health but on their –

Mr Duncan Burton: Yes.

Counsel Inquiry: – developmental progress. I understand.

Now, one may understand why there was the need to pause elective surgeries in the way you’ve explained but perhaps, more importantly, is how it was recovered thereafter, and can I ask you about that, please, because you say in your statement at paragraph 279 that there was a slower recovery of elective care for children and young people. And in fact, by November 2021, there were over 63,000 children waiting for an inpatient procedure, nearly 6,000 of which were waiting for dental procedures, 6,000 for specialised surgery, 7,300 for trauma and orthopaedic surgery, and 35,000 waiting for general surgical procedures. Would – we think – is that tonsillectomies, would that be in the general surgery camp?

Mr Duncan Burton: Yeah, it could be one of the things.

Counsel Inquiry: All right. So there’s 63,000-odd children waiting for an inpatient procedure by November 2021 and I think, generally speaking, NHS England accepts that recovery of children’s elective surgeries was slower than – slower for children than it was for adults; is that correct?

Mr Duncan Burton: That’s correct, yes.

Counsel Inquiry: Now, can you help why was it the position that the recovery of elective services is slower for children than it was for adults?

Mr Duncan Burton: Yeah. Well, I think there are a number of reasons, and I think also just to be clear that we started to collect data on this, or on the difference between – or disaggregate the elective and non-elective information by age, which meant that from that period of time we could start to see the difference in recovery for children and young people. So I think that was an important step, actually, in terms of being able to identify that there was an issue.

There are a number of different reasons as to why that was. And you will see within my statement, you know, a number of pieces of work that were done to try and support children and young people and the elective recovery of children and young people, but clearly, there was a significant backlog across all ages, including adults, and some of the longest waits were within adult services as well, and so there were a number of different pieces of work that were done to try and bring that together.

Counsel Inquiry: I understand, and your statement sets out the pieces of work but I think the real question I wanted to try and understand was why is it that the recovery for children was slower than it was for adults?

Mr Duncan Burton: Yeah.

Counsel Inquiry: And maybe it’s not that there’s one reason but can you help us with why?

Mr Duncan Burton: Yeah, if you just bear with me one moment.

So I think if you go to my statement on page 88, paragraph 302, that sets out number of the kind of key areas why there is potentially a disparity. Clearly the waiting list sizes are different, between –

Counsel Inquiry: But aren’t they smaller for children?

Mr Duncan Burton: They are smaller.

Counsel Inquiry: So shouldn’t it be easier to get through the backlog for children rather than the adult backlog?

Mr Duncan Burton: Well, except children’s services – so, on children’s services, they’re done in more specialist units often, and so that was something that we were seeing happen before the pandemic, we’d seen a shift of some of the elective care into more specialist children’s hospitals, which, I think just to remind people, during this period of time, children’s services were equally impacted and having to provide support to adult services.

So for example, paediatric intensive care staff and paediatric intensive care capacity had been given over to adults. We had staff that were supporting that. We have a smaller workforce in children and young people as well, who, you know, suffered the same things in terms of sickness absence.

So when we’ve got smaller waiting lists, and there is super specialist care on there that has an impact, if we haven’t got the intensive care capacity, the theatre capacity, the anaesthetics. But I think – look, it’s reasonable to say that there was a difference in the recovery period as well, and there was investment that was put in at the time and decisions that were taken around investment which may have benefited, so to help support the elective recovery, that may have benefited adults more than children and that might have been because of some of the high volumes that there were within adults. That’s not to say that there wasn’t investment put in to help support children and young people, for example in 2021 there was an investment into the children’s – some of the specialist children’s hospitals of about £20 million to help support some of the elective recovery of children and young people, but I think it’s reasonable to say there was a multitude of reasons here, and also, because we’ve got data now, I guess to the extent that that was happening before the pandemic, I guess, is a slightly unknown – (overspeaking) –

Counsel Inquiry: Yes. You make that point, I think that at 302 subparagraph (c), there was perhaps a lack of visibility. It wasn’t that there was no data, but can I ask you about subparagraph (d) though, because the disparity may have been due to:

“children’s procedures being seen as less of a priority compared to, for example, adult cancer treatment.”

Are you able to help, Mr Burton, by whom was it seen as less of a majority? NHS England? Government? Department of Health? Society?

Mr Duncan Burton: I think I’d find that very difficult to answer. I would say it’s probably a mixture of the reasons that were taken to prioritise elements of certain elective care were taken at all different levels. So if I think about some of the decisions around the investment in elective recovery, there was funds that were made available to organisations and to trusts to be able to access. Some of those decisions were down to local systems, organisations, around where they needed to put some of the funding to support the elective recovery so I think it’s probably at a number of different levels.

Counsel Inquiry: Did you get any sense, in your role in the southeast region at the time, that children, the recovery of children’s procedures was less of a priority?

Mr Duncan Burton: It’s certainly not something that I explicitly recall. In fact, I think we were very focused on making sure that the elective recovery was done for all ages, but clearly there was, if you look at the scale, and I accept that, you know, there’s a difference in terms of the size of the elective waiting lists, you know, there was a significant focus also on some of the longest waits which tended to be in adult services, you know, we had potentially adults that were waiting for ophthalmology procedures that, you know, their sight would have suffered as well.

So I guess what I’m trying to say is there’s a balance of prioritisation that was going on and also not every system was able to recover at the same pace as others. And you’ll see kind of particularly as we went through wave 2, and the latter wave of Covid, it impacted regions in different ways, and the southeast, for example, we saw, particularly in wave 2, Kent very early on hit hard and then, you know, so I think – there wasn’t one size that kind of fitted all.

Counsel Inquiry: Can we be clear, you have said it wasn’t something that you explicitly recall that children were less of a priority. Was there ever any diktat, document or advice or guidance sent out that explicitly said children were to be less of a priority when it came to recovering elective care services?

Mr Duncan Burton: Absolutely not, and I think, to the contrary, you will see, and in my statement, you know, we’ve provided information about where there were, you know, toolkits, guidance, etc, around elective recovery, and certainly the children and young people’s team, the transformation team, our National Clinical Director, Simon Kenny, for children and young people, were heavily thinking about this early on, particularly in kind of the summer of 2020.

Counsel Inquiry: Yes. All right. Well, we can see on the screen, though, at paragraph 303, that even by August 2022, the data was suggesting the children’s waiting list size was increasing at twice the rate of the adult list, and then you set out below one of the recovery toolkits that NHS England published, setting out what regions the system and providers or what actions they should take to accelerate the recovery of children’s elective services.

But can I ask you in a general sense, do you know, Mr Burton, whether those toolkits and the steps that NHS England took actually did improve the waiting list size for children and young people in England?

Mr Duncan Burton: Well, we still have a difference. I think it’s fair to say we have seen some improvement, but there is still a difference that exists to this day. And I think what we’ve now got, you know, with the toolkits and the support that’s gone in, we now have greater visibility of this, there’s a requirement on systems, trusts to report on this by age and the recovery by age. So there’s a greater visibility of this as well.

Counsel Inquiry: Can we just have a brief look at just some of the data in relation to the backlogs and the waiting lists.

Could I have up on screen, please, page 135 of Mr Burton’s statement.

And I just want to look at where the backlogs were being felt most keenly by children and young people, and indeed, look at the state of the waiting lists as we move through the pandemic and, indeed, up to 2024.

And we can see on screen, if it helps you, and it’s your page 135 as well, Mr Burton, that there was a ranked list of services reporting existence of a backlog, by May, and 82% were reporting a backlog in children and young people’s therapy interventions such as speech and language. And we can see as we go down that table, percentages decreasing through different services that children and young people needed, all the way down to no backlog in the rapid response services.

What are the rapid response services?

Mr Duncan Burton: So that would be, you know, community children’s nursing team that needed to provide, you know, rapid input into care of a child.

Counsel Inquiry: So it’s –

Mr Duncan Burton: Which you would expect by – rapid by nature would mean that you wouldn’t be waiting because it’s an immediate response.

Counsel Inquiry: But significant backlogs as we go back up through that table, in relation to speech and language, community paediatric services, occupational therapy, audiology, and everything in between. So that was the kind of services that had the backlogs, and indeed, there are, there’s data available on waiting lists that is kept by NHS England across all children’s community health services, and I’d just like to look, please, at page 139 and your paragraph 433, Mr Burton.

We can see here that where data was available the total wait list across all community health services for children and young people was 215,000-odd at June 2022. It remained stable until winter 23’ and ‘24, but if we look, it’s actually rising by the time the table ends in April 2024. And so rather than getting better, it’s got worse, if I may put it like that.

Can you help with why it is that as we came out of the pandemic, and are now no longer in the active stages of the pandemic, the waiting list has continued to increase?

Mr Duncan Burton: So I think there’s a number of different factors here, some of which are, you know, recovery from the pandemic, and, you know, the ongoing impact, but there are other things here as well. So there have been an increase in numbers of children coming into autism and ADHD services, there’s a demand on SEND services as well, and there are continuing to be workforce constraints in some of these services as well, for example, you know, within speech and language therapy and places like that.

So demand has not gone down; demand has continued to go up after the pandemic and, you know, community services are continuing to face pressures from a number of different areas.

Counsel Inquiry: Is there any sense that some of the rise might be attributable to people who delayed coming forward in the pandemic and seeking access to community health services, but of course then you get a rise when eventually they do come forward and they’re potentially presenting with worse or certainly not better symptoms?

Mr Duncan Burton: I don’t think I’m able to answer that. I’m happy to look into it but I don’t think I’d be able to give you an answer to that.

Counsel Inquiry: If we keep up on screen, though, please, paragraph 434, below the graph, you say there that of the children currently on community health service waiting lists, the largest proportion have been waiting between 18 weeks and a year, and in April 2024, 88,000-odd children have been waiting between 18 weeks and a year. 32,000-odd have been waiting between a year and two years and over 3,832 children have been waiting over two years.

So on any view, there’s still a large number of children that are waiting from a year upwards for community health services.

Can you identify why waiting list sizes could not be reduced and indeed are continuing to rise, and I think if you look at your paragraph 431, Mr Burton, you might set out there – sorry, paragraph 436, my fault – some of the reasons there why waiting list sizes could not be reduced. And if we go to – that’s it, thank you very much – it’s coming up on screen now:

“Providers consistently reported workforce availability, and an increase in demand and referrals, as the biggest obstacles to reducing waiting lists.”

And we can see there the bottom category in dark blue, workforce availability was a key driver of this, increase in demand, workforce capability and skill mix.

Does that mean you didn’t have the right staff available to deal with these challenges?

I see you nodding.

Mr Duncan Burton: That’s right, yeah.

Counsel Inquiry: What’s the “other” category?

Mr Duncan Burton: I would have to – I would have to look. There may be some very specific local circumstances, for example, within that, I would imagine, but I’m very happy to look into the “others”.

Counsel Inquiry: All right. And “Estates issues”, is that because some of the children’s wards were given over to adult services?

Mr Duncan Burton: But, I mean, this period of time, October 2022, I would think that we would start to have been coming out of that. So there may well be other estates-related issues – you know, availability of clinic space, it may be availability of – or the type of estate, it may be temporary closures, those kind of things – but, again, we can get more detail if you’d like it.

Counsel Inquiry: Just whilst on this, again, “Reported factors preventing reductions in waiting lists”, that top green bracket:

“Not considered a priority.”

And you’ll recall me asking you questions a few moments ago about whether there was a lack of prioritisation. Do you know, does NHS England know why or who is considered not to be a priority?

Mr Duncan Burton: Yeah, well, I think the – I think what I would say is I don’t – I would be very surprised if anybody didn’t think that any of our patients or our children and young people are a priority, but what we have to do is clearly weigh up priorities because there is also – within this, there is community waits. Not only for children, there are communities waits for adults. And I think this is one of the challenges that we all have working in the health services, managing competing priorities and demand for services.

Counsel Inquiry: I just want – we looked at some generalities. I would like just to spend a few minutes with you looking at some of the other services that were affected by the decisions taken during the pandemic, and in particular can I ask you about NHS England’s public health functions.

We know, as you set out in your statement, it’s at paragraph 439 onwards, Mr Burton, that NHS England has some specific public health functions delegated to it by the NHS Act of 2006. I’m not going to ask you about vaccination programmes for Covid, but can I just ask you briefly about vaccinations and immunisation programmes for non-Covid conditions. And I think you say at your paragraph 441 that:

“Vaccines are not mandated for [children and young people] in England … a parent may refuse consent for any or all of the vaccines for [children]. [But] children under the age of 16 may be able to provide consent …”

If they are assessed as being competent. So that’s the, sort of, legal framework.

There are a number of different vaccinations, as you set out at your paragraph 443: for babies under 1, children aged 1, school-age children.

I’m not going to go through all of the vaccines but it includes things like MMR, meningococcal vaccines, diphtheria, polio, all the usual vaccines that we may have had as children.

Can I just ask you about the decision to close schools that was taken. It clearly impacted on the ability for those immunisations that were delivered in school. And do I take it that whilst the school was closed, those immunisation programs were paused until the school reopened; is that correct?

Mr Duncan Burton: That’s correct, yes.

Counsel Inquiry: And can you help now with how those immunisations were able to be picked up once schools opened, and have we recovered back to immunisation levels that we had pre-pandemic or is there a disparity still?

Mr Duncan Burton: Yeah, so there was a catch-up campaign that was done for those children that had missed or had to have their vaccines paused as a result of that.

I think one of the things that I would say is I’m deeply concerned, and in some ways terrified, by the – some of the vaccine rates within children and young people. If you look at measles, for example, the cases of measles in this country, we have too many cases of measles. I’m deeply concerned that we are – we have vaccine hesitancy going on now, so we have other things playing in here now.

Counsel Inquiry: Let me pause you there, because her Ladyship will have heard a lot about that in the vaccines module, which was clearly focused on the Covid-19 vaccines, and clearly you’re talking about a broader range of vaccines.

Mr Duncan Burton: Mm.

Counsel Inquiry: But was NHS England able to recover and ensure that the children that missed out immunisation programmes whilst schools were closed did in fact catch up?

Mr Duncan Burton: Yes.

Counsel Inquiry: Right. Although there are still, obviously, the –

Mr Duncan Burton: But there is still –

Counsel Inquiry: – ongoing concerns by people who perhaps are now vaccine hesitant, not just for Covid-19 vaccines?

Mr Duncan Burton: Yes, yes.

Counsel Inquiry: All right. I won’t ask you any more about that, please, but can I ask you about dental care.

And I think you say in your statement, at paragraph 164, that before the pandemic, rates of tooth decay amongst 5-year-olds had been falling, but by 2020, there was nearly 23.5% of children aged 5 experiencing obvious signs of tooth decay.

And can you help really summarise what the impact of the pandemic was on the rates of tooth decay on children and the impact that actually had on children needing surgery for tooth decay?

Mr Duncan Burton: So I can’t give you the – what was the impact on tooth decay, but in terms of dental services we had to, during the pandemic, stop routine face-to-face dentistry.

Now, we did continue to provide remote advice, analgesia, antimicrobials, et cetera. There was a service set up to help support those in most need through 111, but clearly we had to reduce the services quite significantly. And that did impact children and young people, because actually children and young people are the – you know, tend to be a heavy user of dental services, for the reasons you’ve explained, but also more routine care that is given. For example, some of the preventative aspects had to stop during the pandemic, temporarily, whilst – you know, whilst we responded to the pandemic.

Counsel Inquiry: Yes, in fact there’s a graph that sets out, for example, the population – sorry, proportion of the population that was seen by an NHS dentist during the pandemic.

Can I have up on screen, please, page 57 and that graph, thank you. And in fact this covers children and indeed all the way up to adults. But if we look at the green line, which is representing children aged between the ages of 10 to 14, in September 2018 nearly 70% of children in that age bracket were seeing an NHS dentist, and, look, it falls then, as we enter the pandemic, from nearly 70% down to just below 30%. And there are similar declines across the ages of children, and, for what it’s worth, in adults seeing NHS dentists?

And I think you go on to say that tooth decay was the leading reason for hospital admissions in the 5-9 age groups.

So if we look at the red line on this graph, was it about 67%-ish were seeing NHS dentists of that age group pre-pandemic, and again, that drops to somewhere around 27%, 28%, looking at the graph, during the pandemic, and indeed, drops lowest in March 2021.

Mr Duncan Burton: So, yeah, this is a 12-month roll-in, so you’ll see it impact there.

Counsel Inquiry: Yes, steady decline. And then a rise?

Mr Duncan Burton: Yeah.

Counsel Inquiry: I think you say in your statement that, given that tooth decay is the leading reason for hospital admissions in the 5-9 age group, and indeed there is a link here with children living in deprived circumstances in particular who were affected, they – children living in deprived areas are up to three and half times – have three and a half times higher rates of decay than children living in non-deprived areas.

And indeed, there were – if we look at elective admissions for dental care.

Could we have up on screen, please, page 61 and the graph.

We have there:

“Elective admissions for tooth extractions with a primary diagnosis of dental caries (tooth decay) [in layman’s terms] …”

We can see there, there was, what, just over 2,500 children pre-pandemic aged 10 to 17 being admitted for planned tooth extractions.

And look, if we look at April 2020, it drops to, what – is that below 100 or there or thereabouts? I think 103 children being admitted.

So high admissions pre-pandemic, significant drop off during the pandemic, but clearly a significant impact on children needing tooth extractions for whatever reason.

And it’s fair to say, I think, Mr Burton, it’s not necessarily that they couldn’t see a dentist, there may be other reasons for tooth decay. Does that include children not brushing their teeth?

Mr Duncan Burton: It absolutely does. And also, you know, sugar, sugary foods, sugary drinks, all of those factors impact a child’s dental care.

Counsel Inquiry: Right. We’ve looked at some specific impacts of the pandemic, but can I ask you about two particular conditions – and a change of topic, please – and ask you about paediatric inflammatory multisystem system, PIMS, to use the acronym.

And I’d like, then, to talk separately about Long Covid because they are separate conditions; is that correct?

Mr Duncan Burton: That is correct, yes.

Counsel Inquiry: Right. Can you help us with what PIMS actually is.

Mr Duncan Burton: Yeah, so PIMS-TS was – it’s an inflammatory response that happened – that was found to have happened as a result of Covid for about four to six weeks after, and can cause quite serious illness in children, impact on organ failure, et cetera. So it’s – and resulted in some children in – needing intensive care treatment.

So this was one thing that was identified actually quite rapidly, back in April 2020, early in the pandemic, and actually that was identified very quickly, because of the significant intelligence networks that we have with frontline clinicians feeding in nationally to – to rapidly respond to that.

Counsel Inquiry: Right. And I think you say PIMS is quite a rare condition, it affects about one in every 3,000 children, but where a child does develop PIMS, actually it often requires hospital admission –

Mr Duncan Burton: Yeah.

Counsel Inquiry: – if not to paediatric intensive care units?

Mr Duncan Burton: That’s correct.

Counsel Inquiry: All right. The first case of PIMS was identified in April 2020 and you say that there was a working group set up in May 2020 to try and reach a consensus on the most appropriate diagnosis and, indeed, treatment for PIMS. And I think you say there’s around 2,000 children affected in England by PIMS.

Mr Duncan Burton: Yeah.

Counsel Inquiry: Is that correct?

Mr Duncan Burton: That’s correct.

Counsel Inquiry: All right. And was the work done in relation to PIMS separate to the work done in relation to Long Covid?

Mr Duncan Burton: Yes.

Counsel Inquiry: Right. Okay.

Mr Duncan Burton: And, you know, reflective of the rapid need to respond to this very early in the pandemic.

Counsel Inquiry: So that whilst it is right, generally, that children were less severely clinically affected by Covid, where there was the contraction of either PIMS or indeed as Long Covid, it could actually have very significant and severe and debilitating effects on the children?

Mr Duncan Burton: Absolutely, yes.

Counsel Inquiry: All right. Let me ask you about Long Covid, then, please, and your paragraph 698.

Her Ladyship will recall from Module 3 that in October 2020 NHS England announced a Long Covid plan. Now, your Ladyship may recall that, I think, Professor Powis had a meeting with a number of the groups that were trying to promote the Long Covid effects on children, and it was in October 2020 that the plan was announced by NHS England.

Can you help me with this: the Long Covid plan did not explicitly include provision for children or expressly refer to children and young people in the plan. Do you know why there wasn’t express reference to Long Covid in children in the October 2020 plan?

Mr Duncan Burton: As far as I’m aware, this was – it was an all-age plan so it wasn’t specifically called out. And again, I guess just to say, you know, October 2020, this was also new and emerging, in terms of a condition, and therefore, you know, understanding what needed to happen.

Counsel Inquiry: By June 2021, though, NHS England had committed to establishing 15 hubs for children and young people with Long Covid, and those hubs included paediatric services and extending access to clinical expertise in that field.

You have seen, though, I think, Mr Burton, concern that notwithstanding the work done by NHS England with both the plan and, indeed, the hubs, there was real concern that there was delay in the recognition of Long Covid amongst paediatricians, and can I just ask, through you, to have a look, please, at INQ000587960_2022.

This is an extract from an expert report by Dr Segal and Professor Whittaker that was commissioned by the Inquiry, and at their paragraph 49, they had made reference above to a delay in the collective realisation, as they call it, that Long Covid affected children. There was likely also a minimisation and disbelief by some healthcare professionals, saying invisible disabilities are recognised as challenging for people to understand, hence disabled children and young people may not be believed. Some children’s symptoms were thought to be due to reasons other than Long Covid, such as mental health presentations, symptom exaggeration, school refusal, and some Long Covid diagnoses were dismissed. And indeed some clinicians labelled parents as anxious, hypervigilant and assumed exaggeration of their children’s symptoms, again refuting Long Covid diagnosis and support.

Did you get any sense in your role at the time that there was some paediatricians and clinicians minimising and disbelieving children presenting with Long Covid symptoms?

Mr Duncan Burton: So it’s not something personally I came across in my interactions with clinicians. In fact, from an NHS England perspective, I think our clinicians, certainly our National Clinical Director for Children and Young People was concerned about this, you know, fairly early on, you know, and recognising that this was a new disease process. You know, back in kind of June, July time where, you know, and would say to me – if he was here now – that actually clinicians will recognise that whenever a virus impacts somebody, there might well be some post-viral process that occurs.

And I think, therefore, what you see in the response from NHS England is very much, as we got more understanding of this, services being set up and also, you know, services being deliberately set up for children and young people, but I can also understand from reading, you know, the statement that is online here, this was also a time when there was a very kind of confused picture going on, so I can understand the fact that, you know, we had children impacted by disruption in education and the impacts of the pandemic that would have also, you know, caused other concerns at the time.

Counsel Inquiry: Right. I think you’ve also seen that there were, indeed, children and young people that contributed to the Children and Young People’s Voices report who made similar comments to those by the experts, where they felt they were being dismissed, or they weren’t being taken seriously, and the like. Can you help with, from NHS England’s perspective, did – what did NHS England do to try and either improve the understanding of paediatric Long Covid or to remedy the minimisation of Long Covid symptoms? What steps did NHSE take?

Mr Duncan Burton: Absolutely. So I think, look, we took a number of different steps to support this, so certainly our clinicians worked with organisations or family representatives that were focused on Long Covid, certainly held a number of webinars to provide information, advice, guidance. You’ve got the NICE guidance that was put out in September 2020. You know, there was funding that was put in for, you know, I think £10 million worth of funding that was put in October to set up Covid clinics. There was additional funding then in 2021, I think £2.5 million which was dedicated for children and young people’s Long Covid services.

So I think, you know, this was clearly new and emerging, and as that more information and, you know, evidence base came online, that was being used to communicate.

Counsel Inquiry: Just finally on Long Covid, I think you say in your paragraph 707 onwards in relation to data on children and young people with Long Covid, clearly data was eventually obtained. One understands why it couldn’t be until, indeed, Long Covid was formally recognised as a condition, but in terms of monitoring and reporting data by the children and young people’s Long Covid hubs, you say there was data on the number of referrals collected from March 2021 to June 2022.

Mr Duncan Burton: Mm-hm.

Counsel Inquiry: The results weren’t published, though, because the small numbers could lead to identification and only eight out of 14 of the hubs regularly submitted data, and in fact, there was poor data completion and poor data quality, hence why data wasn’t in fact published.

Can you help with what efforts, if any, have been made to improve data collection from – in relation to children and young people with Long Covid.

Mr Duncan Burton: That is something I’m not able to answer. I’m happy to come back with a response on that.

Counsel Inquiry: All right. Can I turn to some overarching observations, please, with you, Mr Burton. And you say in your lessons learned and recommendations section of your statement that the needs of children and young people can easily be overlooked, and pandemic preparedness needs to account for the physiological differences, but the emotional, developmental, educational differences and the like. What is NHS England doing to prepare now for those, and take account of the different needs and demands that a pandemic may have on a children and young person (sic).

Mr Duncan Burton: If I can just draw this into two spaces.

Counsel Inquiry: Certainly.

Mr Duncan Burton: So I think there is – we have to be prepared for a pandemic that impacts children and young people in a way that perhaps Covid didn’t directly impact. So if a virus happened tomorrow and a pandemic occurred that impacted children and young people, if you think, if I just simply put the kind of – we’ve got, you know, just over 3,000 level 3 critical care beds for adults, we’ve got 312 that are commissioned for children. So the scale of stepping up a response for children is different. The children’s workforce is smaller. You know, even kind of, you know, I’m an adult trained nurse, but drug calculations for children are that much more complex. There’s a whole complexity around the workforce that we would need to consider.

That’s not to say that you couldn’t change some of the adult critical care capacity for children, those older children. But clearly, we need to be prepared for a pandemic that directly impacts.

There are then also, and I think particularly the learning from this pandemic, is the indirect impacts of children and young people. So clearly the kind of, as you’ve said, the education impacts on health and wellbeing and mental health. So in terms of what we are doing, I would like just to draw your attention into the pack around the kind of direct impact. We did almost have an incident within an incident around RSV and the impact on children and young people and I think it’s important to just refer to that, because that gave us the opportunity to think about how do we scale up and respond to an increase in, a significant increase in RSV at the time for children and young people. So surge plans and develop those.

Counsel Inquiry: Pause there, Mr Burton, because not everyone will know what RSV is. I know it’s a respiratory virus and I can never pronounce the second –

Mr Duncan Burton: Syncytial.

Counsel Inquiry: Just help us. What is it and why is it such a concern for children and young people?

Mr Duncan Burton: Yes. So it’s a respiratory virus that we’ve tended to get an annual increase in every single year which puts extreme pressure across the health service, including into in paediatric intensive care units, primary care, et cetera. And what we saw happen during the pandemic was because children weren’t mixing in 2020, we were concerned, going into 2021, that we would see a resurgence of that, and we did. We saw it earlier, and we saw, I think it was seven times the normal kind of levels of RSV than previous years.

And I think that’s important because one of the things that has come out of the pandemic is that we will see resurgences of other viruses and conditions that will happen, and so, you know, being prepared for that is really important.

And just to go back to my point earlier about the importance of vaccines, we now have a vaccine for RSV since last year, available for pregnant women, to protect them, to protect babies and young people and this is why actually keeping vaccination rates high is something that’s really important across the board for all conditions going into a pandemic.

Counsel Inquiry: Can I come back to the preparedness point, though, because I think you say in your statement that there was no national pandemic preparedness exercises that NHS England was either involved in or aware of that focused on the specific needs of children and young people.

Mr Duncan Burton: Yes.

Counsel Inquiry: And can I ask you, it may be difficult to answer, but, had there been, what difference do you think it would have made during the pandemic?

Mr Duncan Burton: I think that’s a very difficult question to answer.

Counsel Inquiry: Because wouldn’t we still have had to suspend –

Mr Duncan Burton: Yes.

Counsel Inquiry: – or pause elective care –

Mr Duncan Burton: Yes.

Counsel Inquiry: – given the influx of numbers?

Let me ask you a different way, then. What do you perceive the benefits being of a specific children and young people focused pandemic preparedness exercise?

Mr Duncan Burton: I think the benefits of that are a greater preparedness for areas such as, you know, how do you scale up critical care services for children and young people. What do we need to do around the equipment that’s available? The workforce, the training. All those considerations. And I think also it’s to test out what some of the unintended consequences might be of making those decisions.

So particularly with the smaller children and young people’s workforce, if you have to scale up into more critical care services, with children’s experienced nurses, doctors, et cetera, what does that do to other parts that we might need to continue to make sure happen?

Counsel Inquiry: Do you think that would also include potentially looking at the consequences of redeployment?

Mr Duncan Burton: Yes.

Counsel Inquiry: We have later this afternoon a witness coming from the Institute of Health Visiting, who is concerned about the number of health visitors that were redeployed during the pandemic.

Mr Duncan Burton: Yes.

Counsel Inquiry: And clearly, an impact of redeployment has been that the healthcare system was unable to recover as quickly, as we looked at. So, clearly – do you know if Operation Pegasus has included a focus on the specific needs of children and young people?

Mr Duncan Burton: I think it would be wrong for me to be able to say that at the moment.

Counsel Inquiry: All right.

Mr Duncan Burton: We’ve been – I’ve taken part in the first – the early days of the simulation, and I think we will need to see what the next phase is for me to be able to confirm that either way.

Counsel Inquiry: All right.

Just finally from me, please, one of the other final reflections you have is ensuring that children and young people’s interests are represented in formal response structures.

Clearly, NHS England has the transformation programme and the board that you told us about right at the beginning of your evidence, but can you give us any concrete recommendations or ideas for how there could be better engagement for children and young people?

Mr Duncan Burton: Well, I think just to say I think we really did try to keep the voices of children and young people at the core of everything we did, so I think any response or any future response needs to continue to make sure that we have not only a focus on children through all of the – kind of, all-age services that we provide, but also a kind of coordinating point, which the Children and Young People’s Transformation Board in many ways did during this pandemic, to bring together those different components across NHS England, Department for Education and others.

The other thing – the other one thing I would say which I think is an important recommendation is around data, because I think what we’ve seen – and, you know, you’ve taken me through lots of data this morning – is that the importance of being able to disaggregate data by age is important, and also the work that needs to be done, and there’s a commitment in the 10 Year Health Plan, around a unique identifier for children and young people, which crosses beyond just health into other areas, like education and social care. So I think having these additional things will enhance any response.

Counsel Inquiry: Can I ask you about that, because you’ve set it out at your paragraphs 811 and 812. And I smile because you’re not the last witness, and certainly not the first witness, either, to have mentioned data to her Ladyship.

But can we be realistic, Mr Burton: how realistic do you think it would be to have a single, unique identifier for each child across not just health systems but social care systems as well, and educational services, which would effectively link up health, social care and education? It sounds wonderful in theory, but how realistic is it in practice?

Mr Duncan Burton: Well, look, there’s clearly work to be done to get to that point and in many ways I think, you know, we are certainly looking at whether the NHS number is the unique identifier because everybody has an NHS number. I don’t think it’s a question of realism, I think it’s a question of we need to do this because it’s really important. You know, children, and as you’ve seen kind of from the unintended consequences, children are not an island. This isn’t – you can’t put a child in a health box, in an education box, in a social care – it crosses over, safeguarding crosses over all of those. So I think this is not a question of whether we should do it; we have to do this and find a way to do it.

Ms Carey: Right.

Mr Burton, they are all the questions that I have for you. I know there are some Core Participant questions but I wonder, my Lady, if it might be sensible to take our midmorning break and return to the Core Participants after that?

Lady Hallett: Certainly. I understand you’re content to come back after the break, Mr Burton.

The Witness: Yes, that’s fine.

Lady Hallett: Okay, well, thank you very much indeed, and, as we’ve got through quickly you can have until 11.35 for a break.

Ms Carey: Thank you, my Lady.

(11.16 am)

(A short break)

(11.35 am)

Ms Carey: My Lady, thank you. I hope you can see and hear me okay.

Lady Hallett: I can, thank you.

Ms Carey: And it’s Ms Beattie on behalf of the Disabled People’s Organisations to ask questions next.

Lady Hallett: Thank you.

Ms Beattie.

Questions From Ms Beattie

Ms Beattie: Thank you, my Lady.

Mr Burton, I ask questions on behalf of national Disabled People’s Organisations.

On 3 June 2020 a letter was sent by NHS England and NHS Improvement providing guidance on the restoration of community health services for children and young people. And that letter said, at page 5, that children’s allied health professional services, for example, speech and language therapy or wheelchair services, should be partially restored subject to prioritisation.

And at page 11, it said that, under the Coronavirus Act, reasonable endeavours had to be made to ensure that the provision in a child’s education, health and care plan was delivered.

But despite this, concerns were repeatedly raised well into the pandemic, throughout 2021, that allied health professionals working with children were being inappropriately redeployed.

Do you accept that redeployment of allied health professionals continued for far too long, and that the steps taken to ensure that they were returned to critical work with disabled children were insufficient?

Mr Duncan Burton: So, thank you. I think I would just go back to the scale of the challenge in 2020, and the scale of the challenge that all services were having to respond to in terms of redeploying staff, be that allied health professionals, nurses, medical. We had to respond throughout the period of the pandemic to different waves of Covid, which meant that we had staff sickness, which meant that we had to continue to support the efforts around critical care, elective recovery.

There were steps that were taken, and I think within my evidence pack there is a letter that was sent, I think in December 2020, by the Chief Allied Health Professional around about the restoration of allied health professionals back into community services and the importance of that.

But I think it’s also important to remember it’s very easy to stop things, but actually to scale them back up and restart them is sometimes more difficult, given the scale of the challenges that were happening at the time.

Ms Beattie: I mean, were you aware that some of those concerns involved things like inappropriate redeployment of therapists to cleaning roles?

Mr Duncan Burton: I’m not aware that therapists were redeployed to cleaning roles. It’s certainly never – something that hasn’t come up to me in my time in my role.

Ms Beattie: And that those concerns, particularly from the Royal College of Speech and Language Therapists, persisted throughout 2021, such that they were issuing open letters as late as November 2021 concerned about that redeployment?

Mr Duncan Burton: I haven’t seen those specific letters from the speech and language therapy organisation.

Ms Beattie: The language in the June 2020 guidance letter, that reasonable endeavours were required to secure provision for children with education, health and care plans, was used, and it did not say, for example, that all practical steps should be taken to deliver that provision to children with education, health and care plans. Do you agree that that language did not adequately convey the urgency of what are critical services for disabled children and young people delivered through education, health and care plans?

Mr Duncan Burton: I guess, again, what I would come back to is the scale of the challenge at the time. I think regardless of the framing of the language, and I absolutely appreciate, for disabled children and young people, the pressures that were on them and their needs as well, but in the context of June 2020, where we had still Covid cases, we still had high numbers of staff off sick, we still had to be continuing to respond to the needs of the pandemic and restore services, I think it’s not unreasonable to have expected people to make their best endeavours to restore services.

And also I think that I am mindful about the fact that, and certainly within my roles in the region and my experience of being a trust chief nurse, we would have expected locally for that guidance, that letter, to be interpreted and to tailor the needs for the local community.

Ms Beattie: Thank you, my Lady.

Lady Hallett: You’re up next.

Questions From Ms Douglas

Ms Douglas: Thank you, my Lady.

Mr Burton, I ask questions on behalf of Clinically Vulnerable Families and I have two questions about paragraph 84 of your witness statement on page 31, and that’s where you’ve outlined analysis of the number of deaths in children in England from Covid-19.

This analysis estimated that 88 children and young people died of Covid-19 in England during the first 26 months of the pandemic. You went on to explain that 90% of those children had an underlying chronic condition.

Mr Burton, if they had an underlying chronic condition, can you confirm that those 90% of children who died from Covid-19 would have been classed as clinically vulnerable?

Mr Duncan Burton: I wouldn’t be able to specifically confirm for every single one of those cases. I mean, it’s something we can look at, but I wouldn’t want to give you a definitive answer on that. I would imagine that some of them would be but I wouldn’t want to –

Ms Douglas: Would it be fair into infer that most, if not all, of those children with underlying chronic conditions would tend to be clinically vulnerable?

Mr Duncan Burton: Sorry, could you repeat the question?

Ms Douglas: Would it be fair to infer that those children with underlying chronic conditions are clinically vulnerable?

Mr Duncan Burton: I think you could make that inference but again, you know, in terms of were they on a shielding list or something, I couldn’t confirm that.

Ms Douglas: Thank you.

And the second question, you go on to say that 80% of the children who died had a life-limiting condition, and can I ask, does the category “life-limiting condition” include children with serious but manageable conditions which may affect their life expectancy, for example type 1 diabetes, or is it limited only to conditions where a death is expected regardless of management?

Mr Duncan Burton: Again, sorry, could you repeat the question.

Ms Douglas: That paragraph refers to 80% of the children who died having a life-limiting condition. I’m just trying to explore there whether, when you say life-limiting condition, do you mean children with a serious but manageable condition which may affect their life expectancy or do you mean conditions where death is expected regardless of the management of that condition?

Mr Duncan Burton: Again, I can look into the definitions of this, but I mean, you use diabetes as an example there, that I wouldn’t consider as a life-limiting condition, that it’s a manageable condition.

Ms Douglas: Thank you, Mr Burton.

Lady Hallett: Thank you, Ms Douglas.

Mr Broach should be across the hearing room.

Questions From Mr Broach KC

Mr Broach: Thank you, my Lady.

Mr Burton, I appear for the Children’s Rights Organisations. Can I ask, please, what assessment, if any, did NHS England make of whether both service suspensions during the pandemic and the shift to digital-first models disproportionately impacted children from low income or otherwise disadvantaged families?

Mr Duncan Burton: Thank you. So again, I don’t think I’m able to answer what specific assessment happened in relation to that but certainly there was due consideration given to the change of services to digital online, be that for adults or for children. And that’s why there was never a blanket “everything has to move online”. So if there were families or children and young people that couldn’t access care via digital means, you know, there was an expectation, you know, those needing emergency care, for example, continued to receive that face to face.

Mr Broach KC: Do you accept that there should be formal assessment of whether those kinds of changes are going to have a disproportionate impact on particularly vulnerable groups?

Mr Duncan Burton: I think with anything that we do at NHS England or within the NHS we should consider all types of inequalities, and the impact of inequalities in everything that we should do.

Mr Broach KC: Thank you. And were children and/or families consulted as part of any consideration of the consequences and the proportionality of the impact of these measures?

Mr Duncan Burton: Again, sorry, can you just be – in relation to the change to online –

Mr Broach KC: The suspension of various services and the change to digital first working.

Mr Duncan Burton: So I think, given where we were at the pandemic and the initial response, had to be very much around – there wasn’t wide consultation that was done on some of these changes, because of the nature of the emergency that we were in, and we were having to do guidance in, you know, a matter of hours and days to be able to do this. So a normal type of consultation that we would normally do on significant changes didn’t happen in that respect, but we did try to make sure, where guidance had been issued, as we went through the pandemic, you can see that changes were made to guidance as we got more input from different organisations and people.

Mr Broach: Thank you, Mr Burton.

Thank you, my Lady.

Lady Hallett: Thank you, Mr Broach.

That completes the questions we have for you, Mr Burton. You’ve mentioned a number of times the need for planning and the need for better data. You don’t have to persuade me of that after all the evidence I’ve heard during the course of the Inquiry so far, and I’m sure I’m going to hear more.

So thank you very much indeed for the help you’ve given to the Inquiry and in preparing the witness statement you have. And I don’t know if you have had colleagues help you with preparing the witness statement and with preparing for today, but can you please pass on my thanks to them for their help to the Inquiry.

The Witness: Thank you.

Lady Hallett: Thank you.

Ms Carey: My Lady, there will just be a brief pause before we bring in the next witness, who is Professor Steve Turner.

Yes, I think the witness can be sworn, please.

Professor Steve Turner

PROFESSOR STEVE TURNER (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: Thank you for coming to help us, Professor Turner.

The Witness: You’re very welcome.

Ms Carey: Professor, your full name, please.

Professor Steve Turner: Yes, good morning. I am Stephen William Turner.

Counsel Inquiry: Thank you. You are, I believe, President of the Royal College of Paediatrics and Child Health.

Professor Steve Turner: I am.

Counsel Inquiry: And have been in that position since March 2024.

Professor Steve Turner: Yes.

Counsel Inquiry: I think prior to that, as you set out in your statement, which is INQ000651508, you were the RCPCH – for short – Registrar from spring 2021 to spring 2024, and the Officer for Scotland in the five years preceding that?

Professor Steve Turner: Correct.

Counsel Inquiry: All right, I think you are a consultant paediatrician in general and respiratory paediatrics, currently practising in the Royal Aberdeen Children’s Hospital?

Professor Steve Turner: That is correct.

Counsel Inquiry: All right. Now I think, Professor, you set out in your statement a little bit about RCPCH. You are the membership body for paediatricians and have over 24,000 members across the UK?

Professor Steve Turner: That’s right.

Counsel Inquiry: And I think you may have been present when the Chief Nursing Officer just gave evidence this morning.

Professor Steve Turner: I was.

Counsel Inquiry: Clearly we had an England-focus with that witness, but if at any time you’re able to help us with the position in the devolved nations, please feel free to do so, not least because RCPCH is a UK-wide body.

Professor Steve Turner: With pleasure.

Counsel Inquiry: All right. The Royal College is responsible for education, training, setting professional standards, and informing research and policy, as you set out. And I think during the pandemic you explain that the college engaged with a number of NHS organisations, NHS England, Public Health England as was, now UKHSA, Department of Health and Social Care, Department for Education, and indeed your college offices in the devolved nations having similar engagement with governments and organisations, perhaps less so in Northern Ireland though, in the run-up to the pandemic, given the state of the government as it was in the few years preceding 2020?

Professor Steve Turner: Yes.

Counsel Inquiry: All right. Can I ask you at the outset, you say at your paragraph 7:

“The extent to which these public bodies ensured children and young people were central to decision-making varied throughout the pandemic.”

Can I ask you, please, are you able to give us an example of some good government decision making which focused on children and young people? And then I’m going to ask you perhaps for an example where there wasn’t that focus.

Professor Steve Turner: You start with the harder question. I think that – just to start – going back to March 2020, they were unspeakably difficult times with a lot of uncertainty, and I think that collectively across the UK, the governments made the most sensible decision in doing what they did, and this is a theme that I might come back to a few times in the time that we’ve got together.

The revision, the reassessment of that with the focus on children, would – and I argue should – have been made and changes should have been made.

So, in answer to your question what did government do well, I think governments recognised that what they were doing to children was causing them huge indirect harm. I think there was awareness of that, but the focus of government, which was understandable at the time, was to look after the other end of the age range.

So I think, to be – and I have great sympathy and I spoke to lots of people who were in the thick of things in those days, in the absence of any experience, and in the absence of data, initially those decisions were understandable. So fair enough.

In answer to your question what did they not do so well, and I think this is across all four nations, there was not enough respect given to children. There was not enough consideration given to the innumerable harmful indirect harm that was done to them as a consequence of the provisions made around Covid. And those decisions and the low priority of children in our society, which actually is everybody’s responsibility in this room, continues to frustrate me, annoy me, but enthuse me to carry on championing for children and young people.

Counsel Inquiry: Right. Did you or the Royal College get any sense of why there wasn’t enough consideration given to, in particular, the indirect harms? Is it the fault of one department? One person? Systemic? Can you help?

Professor Steve Turner: Yeah – no – well, I can contribute. I think that when we started, children were on the second tier of priorities for us as a nation. I think if you look at investment, child outcomes, so for example, mortality rates, obesity rates, mental health rates, asthma deaths, these were all going in the wrong direction before the pandemic started. So it’s not a surprise to me that when the pandemic then hit us, that the wellbeing of children was always going to be on a lower trajectory, a poorer trajectory, than that for adults.

So I think if you break down the time course into what happened before the pandemic and then what happened during the pandemic, it’s not a surprise that children were – there was an awareness of children, I’m sure there was, because politicians will have had children and grandchildren, there will have been that awareness but that awareness did not translate to a consideration of: what harm are we doing to our children? There was no reflection on that. And if there was reflection, I didn’t see any evidence of it. And five years down the line, you know, I was in clinic on Monday seeing 5-, 6-year-olds who were still not toilet trained. And they missed out on that opportunity.

So children continue today to suffer for what we did during the pandemic, which is a partial reflection of what was already happening beforehand.

Counsel Inquiry: Understood. We might look at some of the indirect impacts during the course of your evidence, but I think one of the things that perhaps might be emerging is the extent to which there was engagement with children and young people and therefore a focus on them.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: Can you help, from your perspective and the college’s perspective, was there sufficient engagement with children and young people? We’ve heard about from the previous witness a transformation board that was in place by NHS England, but perhaps UK-wide, was there sufficient engagement?

Professor Steve Turner: There’s always room for more engagement.

Counsel Inquiry: Of course.

Professor Steve Turner: You’ll not be surprised to hear me say that. So as a college, we have children in our name, so we – one of our roles is to advocate for children because on a national level there are very few advocates for children. We believe we’re one of them. We have a group called &Us, and we sought the experiences of young people, and we expressed and reflected these views of their experiences across the four nations to governments and to other stakeholders, and I think that, if you cast your mind back, those people who had schoolchildren at that time, there were children everywhere. You could not avoid the fact that there were children sitting at home on tech not doing anything, and so I think the plight of children was – people were aware of it. But what I did not see was a translation of that awareness into something being done about it.

And I’ll just briefly talk about schools., you know, we put out a statement in May 2020 recognising the difficult decision that, you know, it is a risk to reopen schools, but it took an awful long time before that happened, and then it was done with social distancing and masks, and it was just not considering the wellbeing of children.

Counsel Inquiry: Before I look at some of those impacts, I think one of the things you do say in your statement is that the college sought for children and young people to be more central to public communications in the pandemic –

Professor Steve Turner: Mm-hm.

Counsel Inquiry: – which I suspect, ergo, would help them engage with the issues.

Professor Steve Turner: Yeah.

Counsel Inquiry: And I think you say the Royal College wrote to the Prime Minister, amongst others, asking him to host a briefing on children and young people but that suggestion was not taken up.

Professor Steve Turner: Yes.

Counsel Inquiry: And you also wrote to the Secretary of State, Matt Hancock, to meet with children and young people. And I’d just like to look at the letter that was written.

Can we have up on screen, please, INQ000620590.

We are in October 2020, so this is really now with a view to planning for the winter pressures and potentially a wave 2.

Professor Steve Turner: Yes.

Counsel Inquiry: And we can see, as we scroll down, that the college wanted to have the opportunity to work with the Secretary of State to empower more young people and young adults UK wide to understand their role in the next phase of the pandemic, to follow and support others. And you set out how to try to mobilise what is up to 25% of the UK population and a threefold plan.

“Continue to support and promote young people as advocates …

“Develop young people-focused Covid-19 messaging …”

And thirdly:

“Create with you [Secretary] an opportunity for a conversation with us as health youth ambassadors …”

And it was, you said:

“Young people are already working with other UK Government teams and departments and … charities to support [parts] 1 & 2, but we would like to start working with you and your team on scoping … 3, an end of year youth/Secretary of State conversation.”

Professor Steve Turner: Mm-hm.

Counsel Inquiry: And I think you have seen, Professor, a response from not Mr Hancock himself but someone in their correspondence team and if we go to page 3, the DHSC team responded in November, on the 30th, apologising for the delay, making the point that it was a busy time for Mr Hancock who was unable to commit to a meeting at that stage. And then setting out a number of things that the government says it was doing in relation to promoting the needs and welfare of children. It says:

“The Government takes child health very seriously. It knows that getting more children back into school is vital for their education and their wellbeing – particularly for the most vulnerable and disadvantaged …”

I won’t read out the whole letter, but if we go to this next page, please, an acknowledgement that the pandemic has left young people feeling anxious. There’s been advice given.

“NHS services remain open and the government is providing £9.2 million of funding to national and local mental health charities to support adults and children affected by the pandemic.”

A number of issues to pick up there with you, please. Firstly this: generally speaking, was the Royal College satisfied with the response that it got from – in response to its letter?

Professor Steve Turner: We accepted that it was a busy time. I’m sure Mr Hancock was busy, but obviously we were disappointed that we were given soothing words which we could challenge but we weren’t given an opportunity to do that. Yes.

Counsel Inquiry: One part of the plan was to develop young people-focused Covid-19 messaging.

Professor Steve Turner: Mm-hm, yeah.

Counsel Inquiry: Why was it considered by the college important that messaging should be particularly tailored to children and young people?

Professor Steve Turner: Well, it’s always better to do things with people than to them, and I get less young all of the time and I don’t speak – the way I put a message across might not be the same way that a young person would either want to put it across or want to receive it, so we’re very keen to co-produce things with young people.

Counsel Inquiry: We’ve heard and indeed there is evidence from NHS England in particular about decline in attendance at A&E, decline in attendance at GP appointments, late presentation of children with various health difficulties. Do you think that tailored communication to children would have perhaps ameliorated some of that decline?

Professor Steve Turner: Yeah, I – yeah, I think young people would have liked a message to say, “We know it is rubbish out there, we know that when your parents are fed up with you, you’re grounded, and I know the country has grounded you for months. We know. We realise it. And we’re really sorry about it.”

That was just never said.

Counsel Inquiry: Do you think it would have made a difference if there had been an acknowledgement?

Professor Steve Turner: I think just that acknowledgement and that recognition at the top level of what was being done deliberately to children and young people, knowingly and wantonly, recognising all of the harm that it was doing – and there’s a whole list of indirect harms that were done – would it have made a difference? I certainly don’t think it would have made any harm.

Counsel Inquiry: No. Right. I think you do set out in your statement some of the work the college did –

Professor Steve Turner: Yeah.

Counsel Inquiry: – and in particular the RCPCH &Us programme. Can you just briefly summarise what that programme is for us?

Professor Steve Turner: That’s our group of hugely energetic enthusiastic youth workers who go up and down the country to capture the voice of young people, to work with young people, to help young people provide a voice to the college and to other external stakeholders.

Counsel Inquiry: Right. And at your paragraph 43, you give a number of examples of key projects that the college –

Professor Steve Turner: Yeah.

Counsel Inquiry: – was involved in. There was 360 children and young people engaged by the college sharing their challenges, concerns, hopes and ideas. I understand that. There was also 74,000 children and young people’s voices that were peer reviewed by the college in relation to themes relating to lockdown.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: Now, I understand that, Professor, but are you able to be help with any themes in relation to healthcare, either access of or provision of, rather than the broader harms that lockdown brought to children and young people?

Professor Steve Turner: I’ll try to summarise 72,000 voices. So I think you can break them down into two. There’s children who didn’t have health problems going into the pandemic and children who already had health problems. So if I do those in reverse order, I think that there were anxieties about children who had asthma, epilepsy, diabetes. About, you know, who is there for them? They can’t get in touch with their usual clinicians or, if they do, it’s difficult. So they were one set of anxieties around healthcare.

And then, as you mentioned before, there were children who didn’t have healthcare problems, mental healthcare problems, before Covid, but these emerged. And this – you know, there were – there was, you know, stories of people feeling lonely, anxious, and these were captured. There are many, many themes that were captured. But there were mostly themes of isolation, sadness and need. I don’t think there were any warm, satisfying themes that came out.

Counsel Inquiry: No. You mentioned there particularly mental health care problems, and her Ladyship is very familiar with the rise in demand for CAMHS services, to use the acronym, and other similar mental health services.

And I think in September 2021, is it right that the college made a number of recommendations to the Health and Social Care Select Committee, which included ring-fenced funding for children and adolescent mental health services, and also asked for an overarching child health strategy?

Professor Steve Turner: Mm-hm.

Counsel Inquiry: Can I ask, why was it the college was so keen for there to be an overarching child health strategy?

Professor Steve Turner: I think this goes back to what I was saying before. To increase awareness of children to the wider society, to the wider healthcare system as it was being reorganised, to keep children – and the aim to get children and people in the centre of the vision, because our concern was that children were barely on the periphery of the vision of the government.

Counsel Inquiry: Turning to some of those impacts, we know that staff were redeployed from paediatric settings to help care for adult Covid-19 patients.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: And I think the college agrees and acknowledges that the impact was particularly felt on children from deprived backgrounds who already had worse health outcomes, and her Ladyship has already heard about that. But is it right that the college conducted two projects during the pandemic to look at, perhaps, why there was drops in paediatric attendance in acute and, indeed, in community settings?

Professor Steve Turner: We did two surveys.

Counsel Inquiry: Two surveys, yes?

Professor Steve Turner: We did one early on and then one over the Christmas of 2021, yes.

Counsel Inquiry: Can I ask you about those? And if it helps you, it’s paragraph 18 onwards in your statement. But I think perhaps if we have up on screen, please, a summary of some of the consequences of lockdown before I come to the service.

Can I have up on screen, please, INQ000620599_1.

This just looks at some of the unintended consequences, and then we will look at the findings of the surveys themselves.

Professor Steve Turner: Yeah.

Counsel Inquiry: And if we go to the middle of the page, the paragraph beginning “These benefits”, you say:

“The benefits … are overshadowed by the negative consequences of … lockdown. First and foremost is the direct impact … Emergency departments in the UK experienced unprecedented reductions of [greater than] 50% in attendance … In Scotland, children’s emergency department attendances fell proportionately more than any other age-group. This raises concerns that children with critical illnesses were not accessing health services on time and, therefore, suffering potentially avoidable harm.”

Do you know if the position was the same in Wales and Northern Ireland?

Professor Steve Turner: I imagine it was, but I don’t have any confirmed evidence.

Counsel Inquiry: All right.

And if we just go to the next paragraph:

“At the end of April 2020, [there was] a snapshot survey of more than 4,000 paediatricians across the UK and Ireland …”

And 60% of those who responded had witnessed delayed presentations, particularly in responses revealing – was it delayed presentations in diabetes, children with diabetes?

Professor Steve Turner: Yes, yes.

Counsel Inquiry: And delayed presentations of sepsis and new cancer diagnoses, and indeed:

“There were … nine deaths, resulting mainly from sepsis and malignancy, where delayed presentation was considered by the reporting paediatrician to be a significant contributing factor – higher than the total number of childhood covid-19 deaths reported over the same period in England.”

Professor Steve Turner: Mm-hm.

Counsel Inquiry: It’s not easy to understand why there was the delayed presentation, but I think, at the bottom of that page, there are potential reasons given for it.

Professor Steve Turner: Yeah.

Counsel Inquiry: Including: parents strictly adhering to the ‘Stay at Home’ messaging, parental concerns about getting Covid in hospital –

Professor Steve Turner: Mm-hm.

Counsel Inquiry: – not wanting to disturb doctors during the pandemic as well, and perhaps any combination of those reasons.

Professor Steve Turner: Yes.

Counsel Inquiry: Do you think the ‘Stay at Home’ messaging, for people who urgently needed healthcare provision, got the balance right?

Professor Steve Turner: So, bearing in mind this was in the fairly early days of the pandemic.

Counsel Inquiry: Yeah.

Professor Steve Turner: So this March, April, May time. I have the benefit of being able to look back at whole population data over that period. So I think the short answer to your question is that probably the ‘Stay at Home’ message was not wrong. So when you look at diabetes, which is – many people know, is a problem with insulin, it can be very sick – very life threatening, what we know during the pandemic year of – starting March 2020 through to February 2021, is that there were, for reasons nobody really understands, more new cases of diabetes, and they were more likely to present in a more serious way, so twice as many would need to go to intensive care, but interestingly, and research has looked at time for symptoms, and there was no major increase in delay that might have explained that.

So there’s no doubt that time confirms these initial observations that diabetes outcomes were much worse during that year. But it’s not obviously due to delayed presentations.

Counsel Inquiry: Right. I won’t put it up on screen but I think the paper that we’re looking at there goes on to be concerned about lack of referrals for child protection assessments.

Professor Steve Turner: Yes.

Counsel Inquiry: I think also you are – have seen there were concerns about reductions in cancer referrals, in particular NHSE has data on that.

Professor Steve Turner: Yes.

Counsel Inquiry: And delays in presentations in child protection cases.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: So health impacts, societal impacts, developmental –

Professor Steve Turner: Yeah.

Counsel Inquiry: – and, indeed, child protection impacts.

Now, the reasons for those delays, as we look, may be myriad, but certainly from the perspective of the college, the two surveys that were conducted, one of the concerns was about the impact of redeployment of paediatric healthcare staff.

Professor Steve Turner: Yes.

Counsel Inquiry: And the loss of paediatric inpatient space?

Professor Steve Turner: Yeah.

Counsel Inquiry: And how, indeed, we would recover once there had been the suspension of elective care.

Professor Steve Turner: Yeah.

Counsel Inquiry: And if I look, please, and ask for your paragraph 21 to be called up on screen, we can see there the main findings of the first phase of the project, which ran from April, July 2020.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: There’s about 10% of staff not available to work because they may have been shielding. Understood.

Professor Steve Turner: Yeah.

Counsel Inquiry: Other staff working in different ways, remote working. But up to 40 – sorry, 46% of community trainees were redeployed to acute paediatric care.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: And by the end of the data collection period, 10% were still not working in community settings.

“[It’s] worrying because of the importance of community services for vulnerable children, and the backlog of work such as child protection medicals.”

Redeployment is a tricky issue.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: And can I ask, generally speaking, did the college agree with the initial decision to redeploy paediatric healthcare professionals – or did they not disagree with it, might be a better way of putting it?

Professor Steve Turner: Yes, I wouldn’t like you to think that we had the choice. And I think, going back to what I said at the start, we had to make some very pragmatic decisions as a society back in March 2020. So I think I wouldn’t disagree with it.

I’ll just leave that hanging because I’m sure there’s a question coming from you.

Counsel Inquiry: “Paediatric inpatient space lost to adult services was small but important … with reported issues getting [the] space back.”

Are you able to say or give us an idea of how long there were issues with – obviously it was handed over to adult inpatient, but how long were these issues with getting it back persisting for?

Professor Steve Turner: Months, in some instances. And relatively small, but the loss of community space was much greater and much more prolonged.

Counsel Inquiry: Did the college take any steps to try to raise this as an issue, or lobby?

Professor Steve Turner: We highlighted the survey. You’ll imagine that the atmosphere was very noisy at the time, so – so we did highlight this. And, as I’m sure we’ll come on to, we repeat the survey later on that year.

Counsel Inquiry: Yes. Well, let’s have a look at that, please. If we have on screen paragraph 23, because the survey was conducted, I think, later that year.

Here we are, thank you.

Professor Steve Turner: Yeah.

Counsel Inquiry: The survey started at the very end of November, right the way through to February 2021. And we can see there that the key findings from the survey included 30% of services had redeployed paediatric trainees to adult services at the peak in mid-January 2021, and 13% of services reported that consultants had been redeployed to adult services at the peak in late January 2021, which in fact was – do I take it that was worse than those that had been redeployed during the first wave?

Professor Steve Turner: Yeah, I – yeah. It wasn’t mentioned, so I don’t think there were many consultants redeployed earlier on that year.

Counsel Inquiry: Right.

Professor Steve Turner: Yes, and the implication of that is that it left holes in rotas, it left holes – it left trainees being untrained, and it meant that lots of things that should have happened in a scheduled context didn’t take place.

Counsel Inquiry: The Inquiry is aware that in fact there were more adult inpatients in hospital in wave 2 over the winter of 2021, in particular January – sorry, winter 2020 to 2021 – and in particular January 2021, than there were in wave 1.

Professor Steve Turner: Mm-hm.

Counsel Inquiry: And I just wondered whether you had any observations to make on whether the fact that there was needed to be this redeployment of staff was because there was any failure to plan for winter 2020 or 2021?

Professor Steve Turner: I’m not really in a position to comment knowledgeably beyond that.

Counsel Inquiry: All right. I think you also go on to say that there were paediatric intensive care units that were affected.

Professor Steve Turner: Yes.

Counsel Inquiry: And seven out of 23 paediatric intensive care units were repurposed for adult services, which had a neighbouring impact on their local other paediatric units who had to sort of take up the slack, if I may put it colloquially?

Professor Steve Turner: Absolutely.

Counsel Inquiry: Do you know, Professor, whether there was any impact on the care provided to children who needed intensive care by the fact that some of those services that have now been repurposed to look after adults?

Professor Steve Turner: No, because I think the issue was that it was the paediatric trained staff who were then looking after adults. So I think the people looking after children were appropriately trained and experienced, but if I may also say, this obviously had impact for time-critical surgery, heart operations. So as with all these things, there were many indirect implications.

Counsel Inquiry: And I think generally, the impacts of either the redeployment, the pausing of community health services and elective care and, indeed, some of the changes to the amount of the estate that was given over to adults, all has generally interrupted community care for children and young people meaning waiting lists are climbing; is that correct?

Professor Steve Turner: That is correct. They are –

Counsel Inquiry: All right. Now, I had a look at some of those with the witness that preceded you –

Professor Steve Turner: Yes.

Counsel Inquiry: – but can I ask you, please, about the current position and have on screen, please, INQ000620603.

So we saw with the Chief Nursing Officer that they had begun to rise by the end of 2024, and to bring this more up to date, there is a Royal College news report from May 2025 which shows that new analysis as of March this year, “there were over 314,000 children waiting for essential community health service. Shockingly, this figure represents a rise from February to March, meaning a further 16,000 children are waiting for vital treatment.”

A more sort of – with those sobering statistics in mind, can you help at all as to why the college thinks that recovery of elective care for children was slow and slower than it was for adults, as we heard from Mr Burton?

Professor Steve Turner: I think it probably boils down to priority. I think that children coming into the pandemic were of relatively low priority, relative to adults. During the pandemic, I think that gap widened, and I think they became the lowest of priorities. And I think coming out of the pandemic, the priority for recovery, for restoration of normal services again didn’t focus on children. Children were second or third rate.

I think what’s also important to point out is that the child health workforce, and I’m here talking about paediatricians but I’m talking about the wider workforce that looks after children in the community and in hospitals, it was a really difficult time. People had to work in – there was a lot of friction. They were expected to do things they weren’t trained to do. They were put in situations that really frustrated them and if you look at, you know, the January 2021 census, 15% of the paediatric people responses, they had colleagues who were off with stress.

So I think that the friction, the emotional turmoil of going through all of this impacted on the workforce and, again, I think this is across the whole of the sector. And I think that is also going to be part of why we are in the pickle that we are at the moment.

Counsel Inquiry: Right. And that would echo with evidence her Ladyship has heard in other modules, I have no doubt.

But can I perhaps come back to something we started with and your paragraph 27, please, Professor, and you said this:

“The College recognises that necessity meant that services had to be reconfigured or paused, including the redeployment of child health professionals to adult services and recognises this was the right thing to do initially.”

Professor Steve Turner: Yeah.

Counsel Inquiry: I suspect you might emphasise the word “initially”?

Professor Steve Turner: Yeah, absolutely.

Counsel Inquiry: But you say:

“However, the College was alive to the potential impact …”

What does the college say about whether thereafter, once the eye of the storm, if I may put it like that, had passed, what focus was given to helping health care for children and young people to recover?

Professor Steve Turner: So what might have happened in an alternative parallel universe is that evidence which was collected was used, experience, which was very much collected, was used, and was used as part of an impact assessment that perhaps, come June 2020, people say, “Okay, right, that was a stormy three months. What have we learnt for children? What have we done to children? What harm are we doing to children? And what should we do to redress this?”

And I see very little evidence of that ever happening, and the evidence is that come the second lockdown at Christmas ‘20, the same thing was done. Even though we knew that children, mercifully, were spared from the harm that came from Covid, even my most sick patients, when they and their family got Covid, it was the parents who were unwell. These vulnerable children were remarkably unaffected.

We knew that mental health was going up, we’d seen so many young people coming in with anorexia, we knew we were doing loads of harm and yet we did exactly the same thing when the second wave came.

Counsel Inquiry: I wanted to ask you about the mental health impacts because you say in your statement that although the college doesn’t have strict involvement with CAMHS, it does play an advocacy role in relation to child and adolescent mental health services, and indeed, there was unprecedented demand on CAMHS, and you say:

“In turn, it resulted in an increase in children and young people presenting to emergency departments with complex psychosocial crises.”

And I think it was in December of 2021 that the Royal College, along with the Royal College of Emergency Medicine and the Royal College of Psychiatrists put out a joint statement, and I’d just like to look at that statement.

Can we have up on screen, please, INQ000620625. Thank you very much.

You can see there that the background is setting out the enormous toll that the pandemic has taken on the mental health of children and young people across the country. You make the point there that it’s struggling to keep up with demand. Obviously there was a pre-existing mental health crisis for children, and if we go down, please, in the page, to what your college and your fellow contributors to this statement are doing:

“Proactively engaging with NHS leaders working to improve systems.”

May I just ask you, are you able to give a little bit of detail about what is there quite a bald or bland statement?

Professor Steve Turner: We were doing as best we can providing data to senior decision makers across the four nations. Whether we were heard, I will …

Counsel Inquiry: All right.

Professor Steve Turner: Yeah, the evidence is that we weren’t.

Counsel Inquiry: “Emphasising the importance of expanding paediatric liaison and CAMHS across the UK, to achieve 24/7 access to support for children and young people and improving access to appropriate inpatient provision.”

Can you provide a little detail or colour to that?

Professor Steve Turner: So if you look at adults, adults have inpatient mental health facilities for adults who have acute mental health problems. Children don’t. I live in Aberdeen, the nearest inpatient facility is in the central belt of Glasgow, 100 miles away. So there is no 24/7, there is very limited 24/7 response.

So if a child with autism, for example, decompensates at home and the family are unable to cope with a violent, very agitated young person, they call an ambulance, the child is brought to the emergency department. Well, that’s not right for the child, it’s not right for the other children in the emergency department but we just as a society have no consideration for what might happen out of hours with children’s acute mental health.

Counsel Inquiry: And you call for mental health leadership across departments to be strengthened. The recruitment of staff able to bridge the gap between services and accelerating the rollout of integrated models of care.

Professor Steve Turner: Yeah.

Counsel Inquiry: Again, same question: are you able to give us a little bit more detail about what the Royal College was doing in relation to that bullet point?

Professor Steve Turner: Well, what we were and what we continue to point out is that mental health problems are usually detectable many weeks and months before they happen, and if we can intervene, if we can identify, and get involvement with a child and their family earlier on, many of these admissions can be avoided. We continue to push this message, because the message still needs to be heard.

Counsel Inquiry: You say in your statement that there has been some progress made in relation to supporting the mental health needs of children and young people and you point to some work done by NHS England in 2022 when they published a framework setting out how children and young people with mental health needs in acute paediatric settings could be dealt with. And you say, though, the framework has been implemented differently in different areas.

Professor Steve Turner: Mm.

Counsel Inquiry: Is that necessarily a bad thing or a good thing?

Professor Steve Turner: Well, I guess if it’s done because of local need, I think that’s a very reasonable thing. I think if it’s done differently because of local resources, that’s not a good thing. It’s a question of whether the service has been fitted around the child or whether the child is having to fit around the service.

Counsel Inquiry: I think you welcomed the news in 2023 that there would be a mental health champion in every provider that admits children.

Professor Steve Turner: Yeah.

Counsel Inquiry: Can you help or expand on what the role of the mental health champion is or does?

Professor Steve Turner: Yes, thanks. This worked really well. So we recognised that there was a huge rise in children presenting with mental health conditions, eating disorders, anorexia was the trigger. And we recognised that if we identified a clinician in each hospital who would take a lead for that, because as a paediatrician, I’ve never been trained in mental health but it’s sort of been forced upon me and some of my colleagues have taken extra training. And if we identify people who are able to manage these complicated young people and their families, work with the community, work with the mental health services, perhaps, not surprisingly, things go a lot better. And so there were lots of paediatricians who saw this as a step forward and it worked really well, but inevitably, once it was up and established, there were challenges to it. So funding was questioned, succession planning was questioned, and inevitably, their inbox became a lot bigger with lots of other mental health problems coming through.

So they did work really well, but they could work even better.

Counsel Inquiry: Right. More generally, I think you say the college was vocal, to use your words, on safeguarding issues during lockdown, and there was concern that the needs of vulnerable children were not being met. And I think the college made clear the importance of safeguarding, in particular noting the role that schools play in identifying children who may be vulnerable or subject to neglect or abuse and the like.

Professor Steve Turner: Yeah.

Counsel Inquiry: And does the RCPCH have a view on whether it was right to close the schools?

Professor Steve Turner: Again, initially, I think it made sense. But when you recognise that 30% of children in the UK, wherever you are, were living in poverty, and their school meal is the only good food they’ll get all day, there are obvious problems there.

You’ve talked about safeguarding. You’re going to hear from my colleague from the Institute of Health Visiting later on, you know, there are bad things that happen behind doors within families, and when everybody is staying at home in lockdown and social workers aren’t able to get into people’s homes, those bad things aren’t going to stop happening. And I would argue that if you’ve got everybody locked up in the same house, the things that trigger violence and abuse to children are probably going to be worse.

So there were loads of concerns from the safeguarding perspective about closing schools, and basically locking families away. And that’s notwithstanding all of the educational, societal and all of the other impacts of stopping – of shutting schools.

Counsel Inquiry: May I ask you about a different aspect of vulnerability in children, and, in particular, the college’s involvement in advice on children who were in the shielding programme.

Professor Steve Turner: Yes.

Counsel Inquiry: Can you help, and it’s at paragraph 33 of your statement, Professor, but I think you say there that the college was pleased that the UK Government adopted the college’s advice on shielding for babies, children and young people, recommending that most, but not all, children and young people did not need to shield.

Professor Steve Turner: Yeah.

Counsel Inquiry: Why was that welcome news from the college’s perspective?

Professor Steve Turner: So, again, when we started, we thought this could be really nasty, and there were – there were three categories into which people of all ages were placed in terms of risk, but very, very, very, very quickly, our patients and their parents told us that if – as I mentioned before, children who have gone through heroic of surgery or life-threatening problems, are ventilated at night, when they get Covid, and the rest of the family gets Covid, it’s the parents and the carers who are – so we knew very early on that they, for whatever reason, weren’t affected. Children who have had kidney transplants, whose immune system was suppressed, we were really worried about them, but the virus bounced off them.

So we knew very, very quickly that this virus, for whatever reason, was not doing harm for the vast majority of children in whom we thought it would be, and it was also causing huge anxiety for their parents. You know, “Do I keep my child whose had the kidney transplant in a separate room to all of the rest of the other family? What do I do?”

So we knew that, domestically, this was causing a lot of friction. So when the changes were brought through on behalf of our parents, families, you know, we thought this was great news. And it was really good that the government did listen.

So, going back to your very first question, that was perhaps one good thing that did happen during the pandemic. I got one.

Counsel Inquiry: I think, though, there was still nonetheless a small group of children that were deemed so clinically extremely vulnerable that they did have to continue to shield?

Professor Steve Turner: There was a very small number. And that was done on a case-by-case basis.

Counsel Inquiry: Right. You may be asked some further questions about clinically vulnerable children in a moment.

May I just take a pause and a stand back, please, and just a final few reflections and, indeed, recommendations from you. Really this, if it’s not already obvious, but the college’s overriding message, as set out in your statement, is that pandemic planning cannot simply deal with people who become most unwell with the virus, which in this case was mostly adults.

“As the future generation, babies, children and young people, regardless of the direct impact on this group, must be prioritised.”

You will have heard me asking the Chief Nursing Officer about a number of potential pieces of evidence to suggest that there wasn’t the priority placed on children. The reasons for it may be difficult to ascertain, but can you help, from the college’s perspective, why it was that there was this focus on adults primarily, and particularly not, then, focusing on the indirect harms to children and young people?

Professor Steve Turner: Yeah, I’m in danger of repeating myself. I think at the start it was very reasonable to do what was done. But we very quickly had knowledge, data, experience, that children not being directly affected by the virus but were being hugely, and in some cases irretrievably, damaged by the indirect consequences of what we were doing to them.

I think that the message I would be keen to get across is that there was – before the pandemic, during the pandemic and after the pandemic, there has not been equity. Children are not treated equally in our society. It is a defining characteristic against which we should not prejudice, but children do not get the best in this country. They’re 25% of the population and get 11% of the NHS spend. They rarely ever seem to feature in decision making. I think that senior decision makers acknowledge children, but – but they don’t seem to get it. And the “it” is that, first of all, children don’t undergo an epiphany when they reach adulthood. All of their health and illness issues aren’t – they’re not just taken away. They carry on. And the economic impact is vast.

You know, the Nobel Prize was awarded in 2020 – in 2000 to the guy who demonstrated that if you invest in children, the benefits to society are clear and evident. But that economic, that rights, and that equality argument for looking after children just doesn’t get recognised in any of the four nations in the UK.

So, going back to your question, why were children not prioritised, I think it goes back to that. I think that, for whatever reason, people didn’t think – I’m not going to say that people didn’t think that they were worth it, but people just didn’t realise the harm they were doing, despite organisations, including ours, saying: This is wrong, you cannot carry on doing this.

Counsel Inquiry: In your statement, the college sets out 12 recommendations for how to potentially prepare for a future pandemic. I’m not going to ask you about all 12, Professor, but one of the recommendations you make is that there is a comprehensive paediatric pandemic preparedness assessment –

Professor Steve Turner: Yes.

Counsel Inquiry: – that is undertaken, which will consider staffing, spaces, systems, equipment, ICU provision and the like.

What difference do you think that would make in the event of a future pandemic, assuming it’s one that affects adults still, primarily?

Professor Steve Turner: Yeah, so I think there’s a number of different considerations. So if there was a pandemic – if – had the Covid pandemic affected children equally as it had the adults, thousands of children would likely have died, because we just did not have the resource to provide intensive care on that scale.

I think if another pandemic was like Covid, and very much affected the elderly, I still think we need to preserve services. I think, learning from what we have done, we need to recognise that the indirect harms of shutting down community services, shutting schools, many years down the line will be leaving ripples of discontent, poor development and harm.

And I think if the next pandemic, because I think it’s a matter of time, hopefully a long time, if that affects children more than adults, then I think we are in a real problem, because we do not have the workforce to look after children now, so if we had an expanded population of ill children with this – with a virus, I think we would be in a very, very difficult place and being having to make some very, very difficult decisions. And I understand that, to continue with the alliteration, it’s Project Pegasus that has been looking at that, that has been looking at that today.

But I think we can plan, but the planning that takes place on a whole-population basis needs to have right at its heart, ‘Don’t forget the children’.

Counsel Inquiry: Right. Which brings me to my final topic for you and it’s your recommendation at paragraph 49.3, and you recommend on behalf of the college:

“That regular children’s rights impact assessments should be carried out and published to accompany all policy decisions or legislation changes which impact them.”

Can you help us, please, what benefits do you think such an approach would have on children’s health in the UK, were there children’s rights impact assessments, as you set out in your statement?

Professor Steve Turner: Yeah, I think it would help people think “child”. I think it would remind people not to forget children. Children do have rights, and these need to be considered in amongst the rights of the rest of the population. So I think that they would very much help people in senior decision-making places to think “child”.

Ms Carey: That may be a good place to stop.

Professor, they are all my questions but there are some questions from Mr Wagner King’s Counsel on behalf of the Clinically Vulnerable Families. He’s just over there, we’ll just pause one moment while we turn to him.

The Witness: All right. Okay.

Lady Hallett: Thank you, Ms Carey.

Mr Wagner.

Questions From Mr Wagner KC

Mr Wagner: Good afternoon.

Professor Steve Turner: Good afternoon.

Mr Wagner KC: As Ms Carey said, I represent the Clinically Vulnerable Families, which is a group, as you can probably guess, that represents the interests of clinically vulnerable, clinically extremely vulnerable and immunocompromised children and families.

I just want to ask you first about the guidance or advice that you published in June 2020 that you were taken to, or you were asked about by Ms Carey, and then was adopted by the Department of Health in July 2020.

The guidance said, one of the things it said, was that the majority of children with asthma, diabetes, epilepsy and kidney disease do not need to continue to shield and could, for example, return to schools as they reopened.

You’re aware of the guidance, and I don’t –

Professor Steve Turner: Yeah.

Mr Wagner KC: – and you don’t need to go to it.

Did you appreciate that children with asthma, diabetes, epilepsy and kidney disease were not actually shielded at that time, had not been told to shield?

Professor Steve Turner: I understood that they had been told to shield, which is why the guidelines said that they did not need to shield.

Mr Wagner KC: Yeah. So – they weren’t told formally to shield in the way that adults were. On reflection would you accept the guidance in that respect was a bit muddled?

Professor Steve Turner: So I do a lot of asthma clinics, and my parents were telling me that they were shielding their children. I think that the message “you should shield if you’ve got asthma” had got out there, and it might well have been a bit muddled, if the initial message was just for adults with asthma to shield, but certainly my experience is that children with asthma were being shielded, with some difficulty, and they were delighted that they were no longer – they were told they no longer needed to shield.

Mr Wagner KC: But you accept that may have been coming from individual decisions taken by parents rather than formal government advice?

Professor Steve Turner: Yes, and I stand corrected. I understood that the original advice that was given to children with asthma, diabetes, epilepsy, was to shield, because at that time we thought that they might be vulnerable, but I was pleased that in the summer of 2020, that it was clarified that they did not need to shield. So I think that did clarify the situation.

Mr Wagner KC: I appreciate, listening to your evidence, that your focus was on – correct me if I’m wrong – it was on encouraging children who didn’t have a higher risk and parents who may have thought their children had a higher risk to return to school because it was better for them to be at school than not to be at school.

Do you accept that there were, nonetheless, children with certain conditions such as chronic kidney disease and diabetes who had higher risks from Covid-19 than the general population?

Professor Steve Turner: I’m sorry, I didn’t catch your question.

Mr Wagner KC: So do you accept that there were certain conditions such as chronic kidney disease and diabetes –

Professor Steve Turner: I see, sorry. Right. I accept that there were some children who might be more vulnerable than others. My personal experience is that there were vanishingly few of them, but no, and that’s why I think the guidance was that there might be some children who do need to shield and that is very much on a case-by-case basis. So I do accept there might have been some and there certainly were some.

Mr Wagner KC: And do you also accept that at that time, in June, July 2020, schools were, in terms of Covid transmission, still risky environments, particularly because of crowded classrooms, poor ventilation, prolonged indoor contact, and the lack of masking?

Professor Steve Turner: I’m – well, so, take that – I think a lot of schools demonstrated some social distancing. I think some schools insisted children wore masks beyond the summer of 2020. But I do accept the premise that if you put people together, infections do spread.

What I don’t accept is that for a healthy child, getting Covid put them at considerable risk, that that meant, from the child’s perspective, that they shouldn’t go to school.

Mr Wagner KC: But for the child who had that additional risk, even if it was just a bit more risk, and that’s – my client’s perspective is from that perspective –

Professor Steve Turner: Sure.

Mr Wagner KC: – do you accept that for some parents, even knowing how important in-person schooling is, and all of the factors you’ve rightly pointed out, it would have still been reasonable for them, making that individual risk analysis, to decide that in-person schooling was not the correct option for their children because they didn’t want to put them to that additional risk?

Professor Steve Turner: I think that for the vast, vast, vast, vast, majority of children with the conditions that we talked about, diabetes, asthma, there was – the individual child was at no increased risk – of no meaningful increased risk for coming to any harm from Covid, and it was very much in their benefit that they got back to school.

Mr Wagner KC: And just finally, do you think, looking back, that the college’s guidance properly reflected that there were some children for whom the risk would have been higher, and the decision making – the factors may have been just a bit different for them?

Professor Steve Turner: I can’t remember the exact words of the college guidance but I think the spirit of the college guidance was exactly right: that the vast majority of children who were initially thought to have some increased risk didn’t actually have that risk, but I also accept that there were some children who were potentially at risk. But that number was tiny.

Mr Wagner: Thank you.

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

That completes the questions that we have for you, Professor Turner. Thank you very much for the help that you’ve given to the Inquiry. I don’t know if any colleagues assisted you, but thank you for what you’ve done, and if they did, thank you to them as well. Thank you for helping us.

Ms Carey: Thank you, my Lady.

The Witness: You’re very welcome.

Lady Hallett: Very well, I shall return for this afternoon’s session at 1.45.

Ms Carey: Thank you very much.

(12.44 pm)

(The Short Adjournment)

(1.44 pm)

Ms Pottle: Good afternoon my Lady. Can you see and hear us?

Lady Hallett: I can, thank you, Ms Pottle. Thank you very much.

Ms Pottle: This afternoon, my Lady, we’re going to hear from three witnesses, the first of which is Claire Dorer. Please can the witness be sworn.

Ms Claire Obe

MS CLAIRE DORER OBE (affirmed).

Questions From Counsel to the Inquiry

Lady Hallett: Thank you for coming to help us, Ms Dorer.

Ms Pottle: Ms Dorer, you’ve provided a helpful witness statement to the Inquiry. It should be in front of you, and the reference is INQ000587851.

Ms Dorer, you have been the chief executive officer of the National Association of Special Schools since March 2025; is that right?

Ms Claire Obe: That’s right.

Counsel Inquiry: Can you tell us briefly what the National Association of Special Schools is.

Ms Claire Obe: We are a membership body currently for special schools which are not maintained by local authorities, and that means, in practice, independent schools, special academies and non-maintained special schools.

We have a sort of two-pronged function: we exist to represent schools with central government and other bodies, and we support schools with advice, guidance and training.

Counsel Inquiry: And you have over 450 member schools across England and Wales; is that right?

Ms Claire Obe: That’s correct.

Counsel Inquiry: And roughly 15,000 placements for children with special educational needs; is that right?

Ms Claire Obe: Yes.

Counsel Inquiry: Okay. In your statement, and you’ve just told us in fact that your members include independent schools, non-maintained special schools, and special academies. And without going into the detail of those statuses and the registration requirements and so on, I think it’s right, isn’t it, that the main difference is that your schools are not run by local authorities; is that right?

Ms Claire Obe: (No audible answer)

Counsel Inquiry: But nevertheless, it is not parents who are usually playing for placements in your schools, those placements are purchased by local authorities; is that right?

Ms Claire Obe: That’s correct.

Counsel Inquiry: Okay. And can you just help us briefly, at a high level, what the differences are, the main differences, between your member schools and special schools that are maintained by local authorities?

Ms Claire Obe: Yes. I mean, in registration terms, it is broadly about level of autonomy. So whilst special academies are public bodies, they are still autonomous from local authorities. Non-maintained special schools are a particular form of charitable independent school, and independent schools are entirely independent of the state.

Counsel Inquiry: Okay.

Ms Claire Obe: Do you want me to say anything about in practical terms?

Counsel Inquiry: Yes, in practical terms, are the schools bigger or smaller? Do they have a wide range of students? How does it work?

Ms Claire Obe: Our member schools tend to be smaller than maintained special schools, so an average size of around 50 to 60 students, whereas quite a high percentage of maintained special schools, which cover a very wide range of special educational needs, our schools tend to be more specialised, often for autistic learners or learners with social, emotional and mental health needs, but also for speech, language and communication needs and sensory impairments.

Counsel Inquiry: I see. And I think in your statement you say that over 62% of your schools support autistic children?

Ms Claire Obe: Yeah.

Counsel Inquiry: And 65% of your schools support those with social, emotional and mental health needs, and that a small percentage support children with speech, language and communication needs, and physical and hearing impairment needs; is that right?

Ms Claire Obe: That’s correct.

Counsel Inquiry: Okay. Before I ask you about the impact of the pandemic on your member schools, I’d like to touch briefly on the situation in your member schools in March 2020, so just before, on the eve of the pandemic.

What trends did your members observe among special schools prior to the pandemic? And you deal with this at paragraph 12 of your statement.

Ms Claire Obe: Yes, we’d seen a trend of rising numbers of children being placed in special schools.

Counsel Inquiry: Can I just ask you to speak up a bit so we can hear you a bit clearer.

Ms Claire Obe: Yes, we’d seen a rising trend of children being placed in independent schools, and specifically in independent special schools. So our schools were seeing larger numbers of children who had joined them with a greater level of complexity of need, and overlapping needs. So children would come with autism and mental health needs as well. It wasn’t single categories.

And a trend of children having been out of education for some time, at the point of placement, or having been through several unsuccessful placements before coming to their independent or non-maintained school.

Counsel Inquiry: Okay. In your statement you also mention children being highly disengaged from learning, and having to learn to trust the adults around them. Could you just elaborate on that?

Ms Claire Obe: We had children who had not been to school for two or three years before being placed, and had had really very little learning during that time, believed that school was somewhere where they went to fail, that there was no point in them being in school, that they couldn’t learn, that they wouldn’t learn, that they would be excluded for bad behaviour.

So there was a huge amount of work that went into establishing relationships that enabled learning to take place when those children arrived in school.

Counsel Inquiry: And am I right in thinking, therefore, that those relationships that the children built with their teachers, or other staff members at the school, were all the more important in helping reengage those children in learning?

Ms Claire Obe: They were absolutely vital.

Counsel Inquiry: Okay. I’m going to move on now to the impact of the pandemic on children and young people who attended your member schools.

Special schools were not required to close during the lockdown; is that right?

Ms Claire Obe: That’s correct.

Counsel Inquiry: Okay. I’d like to ask you now about the attendance of children at your member schools. How many children, roughly, or what proportion of children, were able to continue attending member schools?

Ms Claire Obe: It is really difficult for me to give an exact figure. NASS’s function isn’t to gather data so I’m reliant on what I was told by member schools when we did snapshot surveys. It varied across the pandemic, but once we got through the first element of the first lockdown, we were hearing reports from some schools who said they had a hundred per cent of learners in, and an average of around 75% of learners being in from those who reported to us.

Counsel Inquiry: Okay. I asked you there about the first lockdown. Was it any different in the second period, January 2021 and onwards, was it the same sort of numbers of children attending?

Ms Claire Obe: We saw an increasing number of children attending as we moved through the pandemic as a whole, and certainly for the second lockdown, I think attendance was potentially at a high compared to the third lockdown, where there were more restrictions that I think limited attendance.

Counsel Inquiry: Okay. In your witness statement you mention the use of bubbles as an infection control strategy, that that made it more challenging for high numbers of children to attend; is that right?

Ms Claire Obe: It placed some barriers in the way, or gave schools need to work around them to ensure that children could attend, but it did complicate things with the way that particularly children were transported to school, where the integrity of bubbles was really difficult to maintain.

Counsel Inquiry: Okay. And can you just help us, if children are in a bubble, I suppose the bubble would include a teacher or a staff member. How practically did that make it more difficult to have all the students attend the school? Can you help us with that?

Ms Claire Obe: Can you unpack about the point about having a teacher there, why that would have made it more difficult? I’m not quite clear what you’re asking.

Counsel Inquiry: Pardon me, I didn’t mean to suggest that it would, necessarily, but in your statement you say that the introduction of bubbles made it more challenging for schools to have higher levels of attendance, and I’d just like to explore with you why that is.

Ms Claire Obe: In part, it was about how you get day children into schools. So children would be reliant on local authority transport or taxis. So you might think that a group of children who travel together would naturally be a bubble once they reach school, but they might have been of very different ages and needs so practically they would not then have formed a bubble in the classroom.

You may have had specialist staff who would have to move between bubbles, so particularly any therapists who were working in schools, it would have been very difficult for them to limit to a single bubble, and where children were residential within the school, you had to think about residential bubbles versus school bubbles, whether they would be the same or whether you would have to look about moving across bubbles.

Counsel Inquiry: Okay. And can you help us with what proportion of your schools were residential special schools?

Ms Claire Obe: It’s around 40%.

Counsel Inquiry: Okay. I’d like to contrast the position in your member schools with what the Inquiry has already heard about the attendance of children in maintained special schools, and I’d like to take you now to a figure set out in the Children’s Commissioner Report titled Childhood in the time of Covid – thank you very much. The reference Is INQ000231345. It was published in September 2020 and if we could move, please, to page 8, we see here a helpful graph setting out the percentage of children with an education, health or care plan attending school during lockdown.

So these are maintained schools, and we can see that the figure fluctuates between 10% around 23 March, and goes all the way down to perhaps 2% by 13 April, and overall, the figure up to July is 6% of children with EHCPs attended school from the start of lockdown until the end of May. So this is attendance for pupils with an EHCP attending state-funded education settings, including mainstream settings, as well. So it’s not a direct comparison with your member schools.

But the figure here seems much lower than the figure that you reported to us. Could you give us – well, what you think might be the reasons for higher attendance rates at your member schools?

This can come down. Thank you.

Ms Claire Obe: Yeah, I think that there were a variety of reasons. So the starting point of the most vulnerable children being those who should be offered a school place during the first lockdown would mean that children placed in our settings would have likely been the most vulnerable: those whose complexity of need or social and family circumstances were such that they would have been at greatest risk had they not been in school. And our schools responded to that.

I think a second factor is the autonomy that our schools had, so it was largely down to head teachers, governors, directors, to decide if and how the school could remain open, rather than being a smaller part of a larger local authority or a multi-academy trust.

And then I think a big element was who was employed directly by the school. So you had your teachers and support staff, but, actually, a lot of our schools directly employ therapists, speech and language therapists, OTs – occupational therapists – and mental health staff. And if the school was open and other staff were coming in, then those staff were coming in as well.

So you had that ability to offer a fuller service than if you were a school who were reliant on those health services coming in externally.

Counsel Inquiry: I see. And in your statement you say that it was recognised that because member schools had the facilities and equipment necessary to ensure that those schools remained the safest place for their children, that led to decisions being made for higher attendance. Have I got that right?

Ms Claire Obe: Particularly where children have complex medical needs or health conditions, there’s usually a lot of specialist equipment that goes with that. And particularly where those schools are residential, it was felt that schools were going to be best able to provide that care, and that that couldn’t easily be replicated for all families at home.

Counsel Inquiry: I see. And if we contrast that with the position of maintained schools, do they also employ their own therapists, for example occupational therapists or speech and language therapists?

Ms Claire Obe: At the time of the pandemic, that was much less common, that usually they would be part of a service level agreement with the NHS to buy in a certain amount of resource that would come into school.

Counsel Inquiry: I see. And your schools would purchase those services directly; have I understood that correctly?

Ms Claire Obe: They would directly employ therapists, so the speech and language therapist would be employed by the school and not be commissioned from the NHS.

Counsel Inquiry: Okay. We heard already in the first week of the hearings that children who had an education, health and care plan would have to have a risk assessment carried out before they could attend school, and that there were some difficulties with those risk assessments being carried out. For example, a survey showed that some 75% of parents of children either thought that the risk assessment hadn’t been carried out or that they certainly weren’t aware of one being carried out.

Were risk assessments carried out for children attending your member schools? Was there difficulty with that?

Ms Claire Obe: I’m not able to give you a global position, only as and when it was reported to me. My understanding was that schools carried them out. I don’t know to what level parents were involved in all cases. In terms of physical involvement of parents, it may depend on how far away they lived from school. That might have been a practical consideration.

But in general, yes, risk assessments were carried out and continued to be carried out.

Counsel Inquiry: Can you help us whether there were children who were not offered a place at member schools because of the results of risk assessments? Do you know, or –

Ms Claire Obe: I don’t know, and I think it would be unwise of me to comment when I don’t know.

Counsel Inquiry: Thank you.

Did member schools encounter parents who wished to keep their children away from school due to clinical vulnerability in the household? Are you aware?

Ms Claire Obe: Yes, but my understanding is in relatively small numbers.

Counsel Inquiry: And where that was the case, albeit in small numbers, can you help us with what the approach of your member schools was to those families? Was there a process of engagement to encourage the child to attend or was it felt that the parents’ wishes would be respected? Can you help us with that?

Ms Claire Obe: Again, I think it’s difficult for me to speak authoritatively for all schools. I had heard of cases where staff from the school would go out to try to support the child at home where parents were very concerned. That was obviously limited by how far away from school the family lived, and that could be a long distance.

I also understand that schools were encouraging of children coming back, but respectful of parents’ wishes ultimately. And I think, in many cases, it was concern about the child’s clinical vulnerability that meant that they remained at home rather than about clinical vulnerability within the family.

Counsel Inquiry: Okay. Thank you.

I’d like to ask you now about children and young people’s wellbeing during the pandemic at your school. How did member schools report the impact of the pandemic on learners’ wellbeing?

Ms Claire Obe: It was very mixed, and it changed between groups of children and at times during the pandemic. So we had phases, particularly early on, where there were a reduced number of children in schools, reduced demands for the curriculum, where schools were reporting with some surprise that they were seeing fewer incidences of young people being distressed or exhibiting behaviours which were challenging, that the smaller staff-to-student ratios, even than our starting point, was helpful.

We saw, when more children were back in school, what I would refer to as an initial honeymoon phase where children were relieved to be back, happy to re-establish connections, and again, we saw reduced incidents of distressed behaviours. But that changed once children felt more settled and schools felt that they were seeing children able to reflect their distress at having their routine disrupted.

Counsel Inquiry: You mentioned at the beginning of your evidence the importance of that relationship between staff and pupils at your member schools. And I suppose it perhaps is a mixed picture because a lot of students were able to continue attending their school, but what did your member schools report to you about the disruption to those relationships between staff and pupils?

Ms Claire Obe: Yes, so there were a lot of schools who talked about having to treat children almost as if they were rejoining – well, joining school for the first time when they came back.

Counsel Inquiry: I see.

Ms Claire Obe: So to take them back to the start of re-establishing the relationships, establishing that school was a safe place to be, a place where they could learn. And certainly, when we got to September 2020, schools were reporting that it was almost like having a classroom full of new students, even though they were returning students.

Counsel Inquiry: I see. How did members feel that the pandemic had impacted on children and young people’s learning specifically? I’m going to come on to ask you a bit about the catch-up provision, but if we can just talk about the actual learning done by learners in your member schools and how that was impacted?

Ms Claire Obe: Again, I think the experience varied depending on whether children were in school or out of school. Those who were in school obviously continued to have learning opportunities, but likely on a reduced curriculum and with reduced demands. And then those who were not in school may or may not have engaged with online learning, likely would not have engaged with it.

I think schools found it very difficult to know exactly what the lost learning was, that it was not easy to say, “Well, you have missed X months and therefore if you get those back in some form, you will be caught up.” Because it was so caught up in the learning relationship, the behavioural overlays, it wasn’t always easy to say what was about missed learning and what was about missed educational experience in a broader sense.

Counsel Inquiry: Would I be right in saying that the learning that pupils at your member schools do isn’t tied to a specific curriculum but tailored to them and their abilities and the opportunities to help them thrive? Is that right?

Ms Claire Obe: I think broadly, yes. Schools would deliver national curriculum subjects, but they would differentiate those so that they would be applicable and meaningful for each student. So you would see maths happening, you would see science happening, but what it would look like for groups of children and individual children would be different, dependent on their needs and where they are at their learning stage.

Counsel Inquiry: I see. And so, taking that one step further, if you’re considering the position of children at mainstream schools, teachers would be able to say: well, a 16-year-old at this term should be able to do these things in the math curriculum by this stage, and we know this because previous years have shown us that this is what they should be able to do.

Is it not possible to do that kind of exercise with learners at your member schools because of that tailoring?

Ms Claire Obe: Yes, to a degree. Starting point and a real understanding of need gives you some indication of what you might expect a child to be achieving now and in future terms. A lot of children make non-linear progress and have, I guess, what we would call a spiky profile, so you see peaks and troughs of learning, learning that is generalised and transferred, and learning that isn’t. So it is more difficult, but it’s not impossible.

Counsel Inquiry: Thank you. I’d just like to pick up on something you mentioned about the children who remained at home and whether they would be able to engage with online learning. We’ve heard evidence in the Inquiry already about the difficulty that some students with special educational needs had with home learning and, in particular, difficulties they had with having accessible materials at home. And these are children in maintained schools.

Was a similar difficulty with access to accessible materials, was that encountered by your member schools? Can you tell us?

Ms Claire Obe: It certainly was at the start of the pandemic, because I think no school was well prepared to deliver remote learning, and we didn’t have easy access to remote learning materials which were particularly adapted for learners with special educational needs. For some children, because of physical ability to use a keyboard at home, it was always going to be a challenge to learn remotely.

We heard of schools who had printed hard copy packs and found those easier for some learners, but certainly it was a challenge, particularly early in the pandemic. We had schools that used the Oak Academy resources later in the pandemic, but it did take a while for there to be a number of these for special schools.

Counsel Inquiry: Okay. I’m going to move on now to a different topic, which is the government response to the pandemic, and how that affected children at your member schools, and indeed, the administration.

So, dealing firstly with the announcement of school closures. The association, NASS if I can call it, was in regular contact with the Department for Education from around 9 March; is that right?

Ms Claire Obe: That’s correct.

Counsel Inquiry: Okay. And then on 16 March there were meetings with officials which led you to believe that schools would not be asked to close; is that right?

Ms Claire Obe: Yes.

Counsel Inquiry: And when school closures were announced on 18 March, did you know whether special schools were being asked to close or not?

Ms Claire Obe: We had 45 minutes’ notice of the announcement, at which point it was uncertain what the position would be for special schools.

Counsel Inquiry: Okay. And obviously that uncertainty was resolved. Was that about two days later? Am I right?

Ms Claire Obe: To a degree. I think it was unresolved exactly what was being asked of schools. Because we were approaching the Easter holidays, initially there were suggestions that schools should stay open through Easter, and it took several days before it was clear what was expected of schools.

Counsel Inquiry: Okay. And what was the impact of that uncertainty on your member schools?

Ms Claire Obe: I think in practice for children, I would hope relatively little, but for the school leaders who were trying to plan for that, huge stress about what they were being asked to do, how they were being asked to do it, what resources would be available to them, and whether they would have the staff to be able to deliver it. I think that was the key concern, because by this point we were seeing schools staff who had Covid, who were not going to be able to attend, and I think initially there was the belief that it just might not be possible to safely offer a service to enough children.

Counsel Inquiry: Okay. And on 19 March, your schools were given confirmation that they would be funded to remain open; is that right?

Ms Claire Obe: Yes.

Counsel Inquiry: That was a concern, was it, for member schools?

Ms Claire Obe: There were significant concerns for our independent school members, who had been contacted in some cases by placing local authorities to say that “If the go-ahead is given for all schools to close, we will cease payment.”

Counsel Inquiry: I see. So it was resolved on the 19th, so the day after school closures was announced, that actually there would be funding to remain open?

Ms Claire Obe: Yeah.

Counsel Inquiry: Okay. And then on 20 March, so two days later, it was confirmed that staff and special schools would be treated as key workers. I suppose that’s also important if schools are to remain able to accept pupils?

Ms Claire Obe: Okay.

Counsel Inquiry: What impression did you form about the Department for Education’s preparedness for school closures?

Ms Claire Obe: I feel they were very underprepared. I think I’ve mentioned a number of times willingness of individual officials, but a real sense that the Department for Education was a secondary consideration within government as a whole, and felt that they were playing catch-up, which in turn meant that schools were playing catch-up, and we always felt that special schools were catching up several days, if at all, after guidance had been issued to mainstream schools.

It felt that there had not been a solid plan in advance, and it felt as if that plan was being formed and reformed on the spot, really.

Counsel Inquiry: We heard this morning in evidence that children were the second tier of priorities for us as a nation. Would you agree with that sentiment?

Ms Claire Obe: Absolutely. We were given lots of information that the virus wouldn’t affect children in the same way, that children wouldn’t get Long Covid, that children would bounce back without serious problems. I didn’t ever see a persuasive evidence base for that being the case, and I think experience has told us since that it wasn’t the case.

Counsel Inquiry: Okay. Just before I conclude by asking you about your recommendations, I’d like to ask you about a statement in your witness statement, you say that many schools were taking a “trauma informed” approach to mental health provision for children because many children’s experience of the pandemic will have been traumatic.

Do you think that this applies particularly to clinically vulnerable children and children who live in families with a clinically vulnerable member? Or does it apply equally to all children who experience bereavements and reduced connections during the pandemic?

Ms Claire Obe: I would say for all children. I think if you look at the numbers of life traumas children experience, children with special educational needs often have experienced a larger number of adverse childhood experiences but I believe this is relevant for all children.

Counsel Inquiry: Okay. And do you think that targeted mental health support is particularly needed for clinically vulnerable children and those in clinically vulnerable families, or following on from what you’ve just said, is your position that that would be important for all children in families?

Ms Claire Obe: I would make a particular case for children with special educational needs because they are at a higher risk of developing a mental health problem, and yet they are often excluded from mainstream mental health services. So children with learning disabilities may not be offered talking therapies. A lot of psychological therapies are not aimed at children with special educational needs and/or autism, and I think they are a largely neglected group.

Counsel Inquiry: Okay. And my final question for you is, taking a step back and overall examining the government’s response to the pandemic and how children at member schools were affected, what recommendations would you have for any future pandemic?

Ms Claire Obe: I think it is essential to recognise the impact on children and to factor that in from planning at the earliest stage. I think the Department for Education needed to be a far more central department within government within the pandemic planning. And I would like more awareness of what the real losses are to children during a pandemic. And of course, for schools, lost learning is really important, but the loss of relationship in learning, the loss of the wider experience of education, and the impact that had on mental health and wellbeing I think is causing more problems now than whether or not certain elements of the curriculum were not covered.

Ms Pottle: Thank you very much, Ms Dorer. I don’t have any further questions for you.

My Lady, there are no questions from Core Participants for Ms Dorer. Do you have any questions for the witness?

Lady Hallett: No, I don’t. Thank you very much indeed, Ms Pottle.

Ms Dorer, thank you very much for the help you’ve given to the Inquiry and for coming along today to assist us again. I’m really grateful.

The Witness: You’re welcome.

Ms Pottle: Yes.

My Lady, next this afternoon, before the break, we have another witness, and that’s Ms Alison Morton. She’s just being brought into the witness box now.

Ms Alison Morton

MS ALISON MORTON (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: Ms Morton, I hope we haven’t kept you waiting too long.

The Witness: No, not at all. Thank you.

Ms Pottle: Ms Morton, can you please give us your full name.

Ms Alison Morton: Alison Jane Morton.

Counsel Inquiry: Thank you for attending and for providing a helpful witness statement to this Inquiry. It is – it should be in front of you and the reference is INQ000587870?

Ms Alison Morton: That’s correct.

Counsel Inquiry: Ms Morton, you are the CEO of the Institute of Health Visiting; is that right?

Ms Alison Morton: That’s correct.

Counsel Inquiry: What is the mission and purpose of the Institute of Health Visiting?

Ms Alison Morton: So, we are a fairly new professional body, we were established in 2012 to really lead excellence in health visiting – in England primarily, at the start; we’re now UK wide. We have four areas of our work –

Counsel Inquiry: Sorry, if we could just pause you there. We just need to go a bit more slowly. The stenographer is making a note, a transcript of your evidence.

Ms Alison Morton: Okay, fair enough.

Counsel Inquiry: So you said primarily established in England, in –

Ms Alison Morton: In 2012, that’s correct.

Counsel Inquiry: In 2012.

Ms Alison Morton: And there are four areas of our work: learning and development, so that’s about health visitor training; innovation and reach; we do some work to influence policy; and then we support a membership.

Counsel Inquiry: Okay. And the Institute of Health Visiting is registered as a charity in England and Wales; is that right?

Ms Alison Morton: That’s correct.

Counsel Inquiry: But I think you told us it has growing membership in Scotland and Northern Ireland –

Ms Alison Morton: That’s correct.

Counsel Inquiry: – is that right? Okay.

Can I begin by asking you, what is the significance of the first years of a child’s life from a health visiting perspective, and how do health visiting services contribute to the best start in life for children?

Ms Alison Morton: Okay, so there’s global evidence that tell us that the first 1001 days is the most critical period of human development. It’s a time when babies’ brains can be shaped by the environment in which they live, either positively or negatively. So if you’re in a nurturing environment, children do well. If you’re in an environment where you’re exposed to increased stress, it can impact brain development and actually cause epigenetic changes in the brains of babies. So it’s really crucial.

In terms of health visitors, so we are specialist community public health nurses, so a background in nursing or midwifery. We then work with all families. So what’s unique about health visitors, we’ve had specialist training to work with families across physical health and mental health – and that’s for children and their parents – child development, social needs and safeguarding.

And probably to summarise, the unique contributions of health visiting, as part of the health workforce, is our reach, our range of skills and our response.

So we are only the service that proactively and systematically reaches all families with babies and young children from pregnancy to the age of 5, and that has unique contribution across the health education and social care system.

And in terms of our range of skills, so we’re able to work with an undifferentiated population. So we’re going into families’ homes and can give parents health promotion advice to give their child the very best start but we’re also looking for deviations from the norm, you could put it, for children who aren’t thriving and for parents who need a little bit of extra support because we know that small problems can grow into big problems if we leave them, and that’s across the whole remit of skills that I mentioned earlier.

And then in terms of our response, health visitors offer three levels of support: so the universal offer that I’ve mentioned. We also offer targeted and specialist support to families with increased need, and either deliver that directly or we connect families to the wider support system, so that might be specialist services or voluntary sector groups that might benefit families in those early years which are – can be highly stressful for any family, having a new baby.

Counsel Inquiry: Of course. You talked about the sort of universal offer, and – so that’s the five mandated contacts; is that right?

Ms Alison Morton: That’s correct.

Counsel Inquiry: And those are contacts that are made with every family, so there’s the antenatal contact and then the contact shortly after the child is born; is that right?

Ms Alison Morton: That’s right.

Counsel Inquiry: And then following on from that, when is the next contact?

Ms Alison Morton: So the first three contacts – so the first two you’ve just described, and then the third one is the six week contact, and all of those three really form the first assessment, because it’s such a dynamic period of change. How you are in pregnancy can change after birth and by the time you get to six weeks you can have a reasonably good idea about how a family are doing. So those three clustered together. And then there are two further checks: one at 1 year and the other one between 2 to 2½.

Counsel Inquiry: I see. And you said that health visitors can also offer additional support if that’s required, and so please correct me if I’m wrong, a health visitor would see a family during those required visits and if they picked up on, let’s say, a poor perinatal mental health, then they could offer additional contacts or referral to other services; is that right?

Ms Alison Morton: That’s correct. So the example that you’ve just used, for perinatal mental health, that can range from a mother who might be struggling with depression, which could be managed by a health visitor in the community or it might be a mother who’s on the verge of suicide and we’d be looking for red flags for suicide, or a parent who had very serious mental illness that would need to be supported by specialist services.

So the health visitor has a crucial role connecting those families to the best support available.

For other families it might be loneliness and they need to go to parent and toddler group, for example, or one of the wonderful services offered by many charities.

Counsel Inquiry: Okay, and just before we move on from that, I’d like to ask you in particular about safeguarding. That is a topic of particular interest in this module. What role do health visitors play in safeguarding children?

Ms Alison Morton: So, fundamentally, need is often hidden in family homes, and so this is why the reach is so important, to get out into family’s home and to see the baby in the context of the family in which it’s living in.

And our radar is up, our primary role is as a specialist nurse to improve public health, but safeguarding is a thread that runs through everything. Safeguarding incidents don’t just happen out of the blue. Normally, families will gradually deteriorate and life will become more difficult for them, and the idea is we spot families early, before it reaches crisis point, and support them to get early intervention that can make a difference.

But equally, we’ll be out there looking for the signs of abuse, child abuse, which could be physical abuse, sexual abuse, emotional abuse, neglect, and we’ll be looking for those signs when we’re working with families. We’re fundamentally trying to build that relationship with families so that we elicit need. And this is really important because often need is hidden. But if we have a relationship with the families, then often they will start to tell us about the things that are really bothering them, and that might be domestic abuse, serious mental illness, intrusive thoughts, lots of things which can impact on parenting.

Counsel Inquiry: And is seeing the family – I think you touched on this briefly – in the home environment, why is it particularly important or significant that health visitors see babies and families in their own environment?

Ms Alison Morton: Yes, really significant. So you are seeing the child in the context in which they live. As soon as you walk into that home, you’re, without even consciously thinking about it – when you ask health visitors what they’re doing, you’re scanning the environment and you’re looking for signs of anything that’s not quite right in that home, I guess. Substance misuse, the smell of neglect and poverty. There is a smell, when you walk into a family’s home, which you can spot. The interaction between the child and its parents can tell you an awful lot about child maltreatment, how the child is dressed – you know, we’re not looking to see whether the houses are tidy. You know, it’s something very different that we’re looking for. Looking for signs of neglect.

And I can tell you hundreds of times where I’ve walked into a family’s home where you might see them on the high street or they come to the clinic and everything looks fine and then when you go in the home – yeah, I remember a mother that I went to see where literally it was knee-high nappies around her living room. She was shut behind curtains, kind of rocking on her bed, because she couldn’t cope with her baby and she didn’t know what to do. And because I was the health visitor, I could get in there and say – and the interesting thing was, I knew this mother when she was pregnant, and she’d been brought up in care, and she told me that she wanted to be a great parent, and I believed her.

And so when I went into the home and I saw the nappies and every dirty plate you could imagine, I said to her, “How can we get you back to where you were, what you wanted to be?” And that’s the role. It makes me emotional talking about it.

Counsel Inquiry: Of course.

Ms Alison Morton: And that’s the role of the health visitor, to get alongside families.

Counsel Inquiry: Okay. I want to move on to ask you a bit about the pandemic response to health visiting in England, but just before I do that, can I just cover with you, very briefly, health visitors, the workforce. In March 2020, how did the workforce numbers compare in March 2020 with previous years?

Ms Alison Morton: Okay. So health visitors has been on a rollercoaster over generations. It feels like society remembers and then forgets how useful we are. And so prior to David Cameron’s government they had come to an all-time low, and so he put in what was called the Health Visitor Implementation Plan, and increased the number of health visitors to just above 11,000 in England. It was a big piece of work that spanned four years.

And since 2015, when that peaked, we’ve seen a – well, now, where we are today, a 42% reduction in the number of health visitors. But at the start of the pandemic it was 30% under the 2015 high. And so it slid down, and it’s carried on sliding. There are no brakes on this.

Counsel Inquiry: Okay. And I suppose it follows on from that that the caseloads for each health visitor, because the number of children isn’t decreasing by 30%, so the caseloads for health visitors were higher than –

Ms Alison Morton: Yes.

Counsel Inquiry: – in March 2020 than they had been back in 2015; is that right?

Ms Alison Morton: That’s correct, yes.

Counsel Inquiry: Okay.

Ms Alison Morton: So Gabriella Conti did some research in February 2020, and she reported that the health visitor caseload sizes, 80% of health visitors had caseloads of more than 250, which was the recommendation modelled by David Cameron’s government.

Counsel Inquiry: Okay, so 80% had caseloads in excess of 250, which was the recommended number?

Ms Alison Morton: Yes.

Counsel Inquiry: Okay. Now I’m going to move on to the pandemic response and how that impacted on health visiting.

First, I’d like to ask you about redeployment and the partial stop to the service, and my Lady has heard a lot already about the phase I letter, so I’ll try to take this briefly.

On 17 March of 2020 the NHS chief executive wrote to all NHS trusts and providers of community health services outlining actions that he was asking every part of the NHS to put in place to protect the NHS, and the letter included a direction to redeploy health visitors to direct clinical practice.

And if I could just pull that letter up now, it’s INQ000087317.

And here this is page 1, and we can see the reasons: to free up the maximum possible inpatient and critical care capacity.

And then if we can go on to page 5, please, paragraph 3(g). So the directive was:

“All appropriate registered Nurses, Midwives and AHPs …”

That’s allied health professionals, that would include health visitors; is that right?

Ms Alison Morton: That’s correct.

Counsel Inquiry: Yes.

“… currently in non-patient facing roles will be asked to support direct clinical practice in the NHS in the next few weeks …”

We can take that down.

So am I right in thinking that this was the basis for the redeployment of health visitors? Not every health visitor but many health visitors; is that right?

Ms Alison Morton: Yes, that’s correct.

Counsel Inquiry: And in your view, was it appropriate to classify health visitors as being in non-patient-facing roles?

Ms Alison Morton: Not health visitors in general. So the term was interpreted in very different ways. So the range of redeployment ranged from zero to 63%, so in about a third of provider trusts no health visitors were redeployed but in the rest they were and it was down to local modelling and that interpretation of that term, and so in principle, what they were asked to do was make sure there was enough capacity to deliver the core service that – most of the service had been stopped, but also to respond to need.

And so our view is it was inappropriate to redeploy health visitors because they were needed most on their own front line. We strongly predicted that need would go up, and it was totally inappropriate.

Counsel Inquiry: Okay. And you say 63% of health visitors you think were redeployed. In your witness statement you say that there’s not a dataset that captures this information, so how was that figure arrived at?

Ms Alison Morton: So this was a really comprehensive piece of research led by Professor Gabriella Conti which I thank her for doing it, based on Freedom of Information, and she asked all local authority providers to send information on the level of redeployment.

And just to confirm that it was up to 63% within provider trusts, so that was the peak, so there was a large range.

Counsel Inquiry: Yes.

Ms Alison Morton: So it wasn’t 63% of health visitors, but it raises an issue that we still don’t know how many were redeployed. Because there was no national dataset to collect that information. What we do know is in the areas where they were redeployed it has a massive impact on the health visitors who were remaining.

Counsel Inquiry: Yes, well, in fact, I’d like to now take you to Professor Conti’s report, which is – ah, thank you very much. This is a publication about the impact of Covid-19 on health visiting in England, authored by Professor Conti and Abigail Dow.

Can we move to page 4, please.

So in this article, Professor Conti draws out the impact of redeployment on health visiting caseloads. So if we look at the text there:

“Health visitors who were not redeployed were faced with increased caseloads during a time of great uncertainty … 38% of respondents reported an increase in the caseload size – the number of children they were responsible for … three-quarters … were already caseload holders,” and one in five acquired a caseload after 19 March.

And then the distribution of increases in caseload size are displayed in the figure which we’ll turn to in a moment, but it is summarised here: a number of respondents had their caseload increased by up to 200 children.

Just pausing there, you had said, I think, in your evidence that the recommended number overall is 250 children; is that right?

Ms Alison Morton: Yes, so that’s 200 more than the original caseload that they have. We don’t have a benchmark of what it was in that research, but yes, 200 extra children. And to put that into context so –

Counsel Inquiry: Just before we do that, can we look at the figure now, please – yes, table 2, pardon me.

So we can see here the increase in caseload size. So among the respondents, the highest percentage had a relatively modest increase of one to ten children, but some 20% of respondents, at the bottom of the table here, we can see had either between 51 and 100 more children, or between 101 and 200 more children on to their original caseload.

Okay, we can take that down.

Ms Alison Morton: Thank you.

Counsel Inquiry: Sorry, you were saying, just to put that figure into context?

Ms Alison Morton: What I was going to say is that a midwife has a caseload of about 35 families and a social worker about 25. And the worst we heard when we were surveying this is that some health visitors had caseloads of 750 children, which is literally impossible. Nobody can manage that many children. It’s just a paper exercise and we let families down. It means less time for families.

Counsel Inquiry: Okay. Well, I’d like to take you now to a document. INQ000587957, please.

This is an excerpt from the expert report which, my Lady, we’ve covered briefly – pardon me, we’ve covered already, Professor Catherine Davies, the child development expert. In her report she notes that:

“Health visitors, particularly in England, reported feeling overwhelmed and underprepared to meet the growing needs of families. In 2021, only 9% of health visitors in England reported working within the recommended caseload of 250 children, per full-time equivalent … compared to around two-thirds in Scotland and Wales. In England, 49% reporting caseloads of 500-699 children; in Scotland the corresponding figure was just 3%.

“More than one in four health visitors in England were responsible for over 750 children, whereas no health visitors in Scotland or Wales reported such high caseloads.”

And so I take it, Ms Morton, from your evidence – that can come down now – from your evidence comparing health visitors to midwives, who have a caseload of 35, that those caseloads, those very high caseloads, you think, and correct me if I’m wrong, that that would have interfered with the ability of a health visitor to deliver the service required; is that right?

Ms Alison Morton: A hundred per cent, yes. So what happened is they had to prioritise, and prioritisation has a human cost so that means some people had to be told, “Sorry, I can’t help you.” And health visitors had to deliver that message. They were the front line, I guess taking the flak for having insufficient capacity to meet families’ needs in the way they wanted to. Health visitors want to come to work to support families and deliver high-quality care.

Counsel Inquiry: Okay. I’m now going to move on to another topic which is the partial stop of the service.

On 20 March, NHS England and NHS Improvement published the first iteration of the Covid-19 Prioritisation Within Community Health Services Plan, and if we can take that up now. We’ve actually seen it this morning very briefly.

The reference is INQ000059706.

So this is the letter – just sticking with page 1 for a moment, it sets out, at point 2, that:

“By default, practitioners are to use digital technology to provide advice and to support patients wherever possible.”

And then if we scroll down, please, through to page 3, so this was the letter about community healthcare and how it would be impacted. And yes, we saw this, this morning.

So there is a schedule, if you like, for children and young people’s services, some would stop fully, and then the partial stopped services included vision screening, and if we continue on, yes, here we are. Number 5. This is a service that was to be partially stop, so pre-birth and 0-5 service, which is health visiting. And the direction was to:

“Stop except:

“Stratify visits and support for vulnerable families

“Safeguarding work

“All new-birth visits

“Follow-up of high risk mothers, babies and families

“Antenatal visits and support (but consider virtual)

“Phone and text advice – digital signposting.”

And blood spot screening was to continue.

We can take that down.

Am I right in thinking that, as a result of this directive, that families then would not be offered the five mandated universal health contacts, but that instead they would have – and this for all families, I appreciate the position is somewhat different for vulnerable families, but for all families, they would just have the antenatal contact and the new baby visit; is that right?

Ms Alison Morton: That’s correct.

Counsel Inquiry: Okay. And in respect of vulnerable families, was there additional guidance to help health visitors determine which cases to prioritise and who should be classed as vulnerable?

Ms Alison Morton: So, no, there wasn’t any national guidance at the time, in terms of what constituted vulnerability. There were three high levels of vulnerability that were set out: children who were clinically vulnerable; children who were under the care of children’s social care, looked-after children in child protection, child in need families; and then there was this generic level of children with additional vulnerabilities for environmental factors and other factors.

But there was no national definition for that at the start of the pandemic. That didn’t come until about September 2020. So that had massive implications in terms of – well, first of all, clinically, knowing who to triage and to prioritise, and, secondly, for service level planning, in terms of making sure you had sufficient capacity to meet those needs.

Counsel Inquiry: Okay.

Something else I want to ask you about is you spoke at the beginning of your evidence about health visitors going into the home and spotting need. With this partial stop, is it the case that some children who might not have been identified as being vulnerable, or families who weren’t identified as being vulnerable, would not have been seen and would not have been spotted? Is that right?

Ms Alison Morton: That was our biggest worry, because we felt that the logic was flawed to focus on known vulnerable, because the whole point of the health visiting service is to spot the children who are vulnerable. And this period between pregnancy and the age of 1 is a very high risk period for babies – and for women, actually. So you have the highest rate of homicide, the highest rate of serious incidents. The highest rate of women taking their life through suicide is in the period, interestingly, from 6 weeks up to 12 months, and that is long after the midwifery services have gone.

And so, in essence, we were stripping away this key health service to reach into families’ homes in a very vulnerable time.

And what we know is some families will ask for help, but some can’t, and some won’t. Can’t because they haven’t got capacity or they feel overwhelmed, maybe they feel stigma. And won’t, because there are some families, small numbers, who want to cause harm to their children. And so that made children vulnerable.

And the other thing to say, this is a dynamic period of change. So you might be perfectly fine at the new birth visit and things will come crashing down a few weeks later. And the whole purpose of that six-week contact is to find particularly perinatal mental health problems, which go up, often not manifested at the new birth visit. So cutting that six-week contact was a crucial one to cut for us.

But also losing the eyes on those infants who are citizens in their own right and don’t have a voice. Who was going to spot babies in distress in their home? And that was a key role for the health visitor which was stripped out and wasn’t really appreciated, I don’t think, or the significance – the protection wasn’t afforded to them.

And one of the things I always mention is that school-age children get seen 38 weeks of the year, five days a week, by an adult outside of the home. If you look at the rates of referrals to children’s social care, and I included it in one of my evidence submissions, exhibits, you’ll see that they fall during the school holidays, and increase when children go back to school.

So that tells us something very significant about the role of adults outside the family home in spotting vulnerability, and babies aren’t afforded that protection. The only service they have is health visitors that reaches all families, and that was stripped out. And that had a huge cost, and some children paid the highest price.

Counsel Inquiry: Before we move on to discuss the impact on children and the families themselves, I’d just like to ask you a bit more about the use of digital technology.

So we saw in that prioritisation plan a requirement that digital technology be used wherever possible, and I think you’ve already told us in your evidence about the importance of the home visit, of the visits taking place in a child’s home.

In your view, was digital technology able to provide a reasonable level of service for home visiting? Was it a service that could safely be delivered remotely?

Ms Alison Morton: So I think digital had some benefits, health visitors had some experience of using digital prior to the pandemic. They were, in terms of nursing, on the front foot. So we had things like ChatHealth, a text messaging service that parents could text us and get real-time advice. We used the website quite a lot.

But in terms of replacing – there’s two issues. Replacing a quick contact to give advice, perfectly fine. Replacing a mandated universal holistic assessment, impossible. You can’t deliver what you’re supposed to deliver over the telephone. You can’t assess a baby if you can’t see it. And when you look at the schedule of interventions for the Healthy Child Programme, it sets out a whole raft of tasks that the health visitor is supposed to complete:

Assessing child growth. Well, you can’t weigh them over the phone, adjusted simplistic.

Looking at parent-infant interaction. You can’t see that over the phone.

Looking at the wider context of the family home, the safeguarding elements that I’ve mentioned. You can’t do that over the phone.

So there were loads of things that were missing. Infant mental health is a new area that we’re working in in health visiting, so looking at the way the baby interacts with the parent. And you can’t see that over the telephone.

Counsel Inquiry: And were training and equipment made available to health visitors to carry out their roles virtually, do you know?

Ms Alison Morton: So, at the start of the pandemic, this was the brave new world, so we hadn’t done video contacts at all, and so what we did at the Institute of Health Visiting is we looked across the country – I’d actually worked previously with a professor, Carl May, who did research into telemedicine, so knew where to look for how do we implement this as best as we can. It was never meant to replace those contacts. It was suboptimal, it was a ‘better than nothing’ alternative, but it wasn’t a health review.

So we wrote some advice, practical advice, for health visitors how to implement, but they lacked the – many areas lack – lacked the IT equipment to do that quickly. So it was a huge learning curve for services to quickly find the kit that they needed.

Counsel Inquiry: Okay.

Ms Alison Morton: But quickly they did, yeah.

Counsel Inquiry: Okay. So at the very beginning there wasn’t necessarily – there wasn’t the equipment or advice in place, but as things progressed, advice was put in place –

Ms Alison Morton: Yes.

Counsel Inquiry: – and the equipment was found. I just want to pick up on one aspect of your response, and you said it was never meant to be more than a temporary thing. I take it from that that some remote health visiting service continues; is that right?

Ms Alison Morton: Yes, absolutely. Yes, yes. So – and our view is it’s perfectly fine for follow-on contacts, but not for the universal assessment. And that really is a sharp line for us. We don’t think you can replace it.

And what the problem was, was those virtual contacts got counted in the national dataset, which massively skews the England data. So it looks like children are being – having this holistic assessment, when in actual fact some might have had a one-hour home visit, with PPE, and the others – I mean, I heard stories of 45-second phone calls to families.

So you have to put this into context. And I’m not wanting to judge the health visitors out there, I’m on their side. They did their very best. But if you have huge numbers of children that you’re just tying to get a sense of who’s vulnerable, often they’re – you know, administrators were ringing families up and saying, you know, “We’re just working out who needs a contact. Are you okay?”

“Yes, I’m fine.”

And then ticking that as you’ve had the contact. And it can’t possibly be the same.

Counsel Inquiry: Okay. And so I take it from your answer that when it comes to data recording whether universal contacts have taken place, there isn’t a distinction in the data between virtual contacts and those that are in person; is that right?

Ms Alison Morton: No. Not with the main data collection method. There is a voluntary dataset which has been brought in, which is starting to collect that, but not routinely for all provider trusts, no.

Counsel Inquiry: Okay. Can you help us with when the redeployment came to an end? So I think in your witness statement you deal with this at paragraphs 39 to 40.1.

Ms Alison Morton: So that was an interesting one. So it went on for quite a long time. We know that the average duration of redeployment was about 2.2 months but there was a huge range. So some areas brought their health visitors back very quickly, and others – at the summer of 2020 we had regular contacts with the government saying we were concerned that health visitors were still being redeployed, and it took until 2 October, when a letter was finally pushed through, led by Ruth May, the Chief Nursing Officer for England – and I thank her for her intervention for that – sending a letter out to trusts to say health visiting redeployment must end.

And that was – I guess that was the final point where we really started to see it shift and health visitors were brought back. So a lengthy process of redeployment. But again, as we approached December, and there was talk of this – kind of, the winter surge coming, and then the vaccinations were coming on board, there were also suggestions that health visitors should be redeployed again in December, and we really had to make a strong intervention for that not to be the case. And it was stopped, thank goodness.

Counsel Inquiry: Yes, so there wasn’t a second redeployment of health visitors?

Ms Alison Morton: No, no.

Counsel Inquiry: That’s right. Okay.

Ms Alison Morton: But I think a lot of people wanted them to be redeployed because they were incredibly helpful in their redeployed roles.

Lady Hallett: What were those roles? Sorry to interrupt. What were those roles, Ms Morton, roughly? I mean, I appreciate it’s hard to generalise but …

Ms Alison Morton: Yes. I think the intention was that they were qualified nurses so they would go and work in NHS hospitals to support acute health care and that’s what the minister Jo Churchill said, health visitors were most needed to care for acutely ill patients. We would disagree with that. We think they were most needed to care for families.

So some went off to hospitals to do nursing, but the worst thing was some were sent off to do administration, to answer telephones, to deliver parcels of prescriptions, and that, you know, really saddened health visitors to know that their families were left behind in huge need, because needs soared through the roof, and health visitors were out there doing jobs that could have been managed by somebody else. It didn’t need to have this tiny 6,000 health visitor workforce redeployed when they were needed most with families.

Lady Hallett: Thank you.

Ms Pottle: I’m going to ask you now about an evaluation of the impact of the changes to health visiting on children and their families. I think you’ve given evidence about the role that health visitors play in safeguarding. In your statement, you report a figure that 82% of health visitors who were surveyed reported an increase in domestic abuse in 2020. Is that right?

Ms Alison Morton: That’s correct, yes.

Counsel Inquiry: And that – you also deal with the thematic analysis commissioned by the Child Safeguarding Review Practice Panel which was published in 2021, which identified a key factor which increased the risk to children, was the impact of adaptations for Covid safe practice.

So if I can – I’ll just pull it up now, Ms Morton. It’s INQ000103841, and this is the graph from the Child Safeguarding Review Practice Panel and it says:

“The relative impact of Covid-19 factors in a sample of cases audited by the panel”, and the adaptations for Covid-safe delivery – it should be just on the screen in front of you.

Ms Alison Morton: Yes.

Counsel Inquiry: Yes. We can see there a significant impact in 16 cases, and some impact in two. And I suppose adaptations for safe delivery would include virtual visits from home visitors; is that right?

Ms Alison Morton: Yes, that’s right.

Counsel Inquiry: Okay. And so I think in your evidence earlier this afternoon you said that you thought that because of a lack of home visits by health visitors, some children paid a high price. Would you agree that the results of the Child Safeguarding Review Practice Panel bear out the impact of virtual working by home visitors on some of the cases that they had looked at?

Ms Alison Morton: Yes. For me, this was a serious wake-up call, because this was hard, concrete evidence that children were being harmed by these practices. So there were two categories of impact. So one was that the adaptations for Covid-safe and the other was the increase in family and parental stresses and both are significant in the deaths, or in serious incidences for these children, which had catastrophic life-ending and life-changing consequences for these children.

And they were the canary in the coalmine and we needed to listen to them and make their voices count, even in their deaths. Children like Star Hobson and Arthur Labinjo-Hughes hit the headlines, and there were many others. And I guess, for me, this is the most sad part of the pandemic, how we let these children down.

Counsel Inquiry: Okay. We can take that down now. Thank you.

In terms of perinatal mental health, how did the pandemic impact on perinatal mental illness, and you deal with this in your witness statements at paragraphs 118 and 119.

Ms Alison Morton: Okay. So the pandemic exacerbated family stresses. I mean, that was plain to see, and had a significant impact on perinatal mental illness. In one study very early in the pandemic, 50% of mothers surveyed in London reached the category – the threshold for post-natal depression and health visitors were concerned for two reasons. So one was this increase in risk factors, and things like social isolation, lack of support, just imagine what it feels like to leave hospital with your new baby, and you can’t see your family, you don’t have any help from the health visitor, and you have not done this before, you know. So it was entirely predicted that this was going to happen.

But then the second concern was the lack of capacity to find these women and to get alongside them and to offer help, because we know that early intervention makes a huge difference to outcomes.

Counsel Inquiry: Okay, and sticking with perinatal mental health, why is it important that issues with perinatal mental illness are picked up for babies in particular?

Ms Alison Morton: Okay. So for babies, whilst not inevitable, having a mental illness can impact parenting capacity. There are many parents out there with mental illness who do a great job, but the risk of not doing well is higher if you have a mental illness. It’s harder to tune into your baby. You neglect yourself, you neglect your baby, and at the psychotic end, you know, it can have catastrophic harms, both for women and for the infants themselves.

Counsel Inquiry: Okay. I’m going to ask you now, just briefly, about the devolved administrations. So we know that the Institute of Health Visiting is registered in England and Wales, but I’d like to ask you just briefly if you can help us with whether redeployment took place in Scotland, Wales and Northern Ireland.

Ms Alison Morton: Okay. So as I said, we weren’t working across those nations, but I have looked at the witness statements that you’ve provided me with, and my impression is that – well, firstly, they had more comprehensive services before they went into the pandemic. So they were better staffed at the start. So we were on the back foot in England, but in the other nations, they were better equipped.

Redeployment, as far as I know, was much more measured. Less were sent and they were returned quicker. Face-to-face and non-face-to-face, they had the same issues that we had in England, but the sense that I’ve heard is that they had quicker access to PPE, and that was the rate-limiting factor for doing home visits, not having PPE, and then fundamentally, their services were reinstated faster, and the good news is that the governments in the devolved nations have all committed to further investing in health visiting.

Counsel Inquiry: Okay. I’m going to move on now to your reflections and recommendations for the future. And just taking a step back from the detail of the evidence that you’ve given us, can I ask you, overall, in view of the Institute of Health Visiting, was redeployment and a partial stop to the service a proportionate measure to protect the NHS during the first wave of the pandemic?

Ms Alison Morton: I don’t think it was appropriate. I think, knowing, with the global evidence that we had, so the harms of doing that were entirely foreseeable and predictable and we knew that because of the global evidence of the importance of the first 1001 days and the impact of adverse childhood experiences on children. We didn’t take enough notice of the early warnings from the other nations who were ahead of us in the pandemic, China, Brazil, and so on. And we didn’t take enough notice of the frontline practitioner intelligence. Very early in the pandemic, we were writing to the government. We did surveys, health visitors were telling us – they were the eyes and ears on families, they knew the struggles families were having, and that wasn’t taken seriously enough.

It was labelled as anecdotal at the time, so it was a huge mistake. Health visitors were most needed working with families. Need went through the roof and we needed to be out there supporting them in this very stressful time.

Counsel Inquiry: I’d like to take you now, just to finish, if I could, to your witness statement, which is INQ000587870, to paragraph 189, this section here, which I think encapsulates your evidence on this point.

And I’ll just read it out, about the role of health visitors:

“… they are the only service that proactively and systematically reaches all families with babies and young children who are not afforded the same protections that school-age children have from schools. The most disadvantaged and vulnerable babies and young children are often invisible to other services without an effective health visiting service to identify needs and risks that may change over time. In our view, whilst policymakers did recognise that pandemic countermeasures such as lockdown would likely expose children to increased risk … they failed to recognise that health visiting would therefore need to play a greater role to mitigate the impact of lockdown on the wellbeing and safety of babies and young children. At that time, health visiting was still categorised as a partial ‘Stop’ service. In our view, this decision was fundamentally flawed and highlights an essential opportunity for learning – both in preparing for future pandemics, and in ensuring safe and effective support for families with babies and young children, as part of standard practice.”

Is there anything you’d like to add to that?

Ms Alison Morton: It captures it really well. I mean, as far as I’m concerned there were three main failings: one was the decision to stop the service and to redeploy health visitors. The second was this failing of virtual by default, which I think lessons needed to be learned faster. And the third was when need increased, and we knew it had increased significantly, there wasn’t any measures put in place to strengthen health visiting at that time, and there haven’t been since, and we’ve continued to see our workforce depleted.

Ms Pottle: Thank you very much, Ms Morton. That’s the end of my questions for you. There are no questions from Core Participants.

Does my Lady have any questions for this witness?

Lady Hallett: No, I have no questions.

Ms Morton, I appreciate that health visitors may feel they’re underappreciated, but I’m sure you know, those of us who still can remember, 45 years on, the comfort of a health visitor when you’ve got a new baby, and of course the benefit for the baby of having a much more confident and happy mother. So on behalf of all the mothers that you help and the babies that you therefore help, thank you very much, and thank you to all your colleagues who carried on trying to help people during very difficult circumstances.

The Witness: Thank you, yes.

Lady Hallett: Thank you.

Very well, we’ll take the break now, Ms Pottle, I think.

Ms Pottle: Yes, that’s right, my Lady.

Lady Hallett: And I shall return at 3.20.

(3.06 pm)

(A short break)

(3.20 pm)

Ms Cayoun: My Lady, can you see and hear me?

Lady Hallett: I can, thank you, Ms Cayoun.

Ms Cayoun: Thank you. May I then call the next witness, Mr John Barneby.

Mr John Barneby

MR JOHN BARNEBY (sworn).

Questions From Counsel to the Inquiry

Lady Hallett: Mr Barneby, I hope you were warned that you would be the last witness of the day, so I hope the wait hasn’t been too long.

The Witness: No, it’s been fine, my Lady. I’ve been very well looked after, thank you.

Ms Cayoun: Thank you, Mr Barneby.

You have produced a witness statement for this Inquiry, I think it is in front of you, and the reference that we have for it is INQ000648389.

I think you signed that statement on 1 July 2025. Are its contents true to the best of your knowledge and belief?

Mr John Barneby: They are.

Counsel Inquiry: Thank you.

Mr Barneby, you are the chief executive of Oasis Learning, and I understand you have been with Oasis since 2008, and that from 2014 and throughout the pandemic you held the role of Chief Operating Officer; is that right?

Mr John Barneby: That’s correct.

Counsel Inquiry: Thank you. You have told us in your statement that in January 2020 Oasis had 52 academy schools under its membership and that these were spread across the North West and Humber, the West Midlands, London, the South West and the South East, and that there were 30,167 children attending in total; is that right?

Mr John Barneby: That’s correct, yes.

Counsel Inquiry: Thank you.

And in terms of some of the characteristics of that pupil population, I understand that in January 2020, 33% of your students were eligible for free school meals, which is almost twice the national average at the time of 17.3%; is that right?

Mr John Barneby: That is correct, yes.

Counsel Inquiry: Thank you. And 15% of your students had special educational needs and disabilities, so roughly comparable to the national average at the time, and 32% of your children had English as an additional language, significantly more than the then national average of 19.5; is that all right?

Mr John Barneby: That’s correct.

Counsel Inquiry: Thank you.

You also tell us in your statement that Oasis chooses to work in some of the most disadvantaged communities in the country; is that right?

Mr John Barneby: That is right.

Counsel Inquiry: Thank you. Mr Barneby, you may know that we have heard earlier this week from Sir Jon Coles of United Learning, and Sir Hamid Patel of Star Academies, both of whom described the ways in which they were able to get ahead, so to speak, of planning for school closures even before government guidance to that effect had arrived.

In your case, you tell us in your statement that you had established your national Covid-19 Taskforce as early as January 2020. And that you first briefed your academies about Covid on 5 February 2020. And we understand from your statement that from that time on you had a central team able to distill and distribute guidance. And you tell us, for example, about meeting regularly on a Sunday night with that team to listen to government briefings and then decide how you would communicate key points to head teachers the next day.

Can you give us a sense, please, Mr Barneby, of why that centralised distilling of information was important for your schools and communities, and perhaps what benefit it brought that individual schools might not have had.

Mr John Barneby: Yeah, so I think, as you say, we realised fairly early on, in late January, that, particularly when the virus came to Italy, that it was not under control or controllable. And that, we have a fairly mature set of risk management systems in place, we run disaster recovery days and continuity planning days. So we had the mechanisms in place to manage a major event, and so some of those processes started to kick in and that’s why we formed a Covid taskforce towards the end of January and then later on turned it into the leadership team who were actually leading the organisation through this period. Yeah.

Counsel Inquiry: Thank you.

Another aspect of your organisation that may have been somewhat unusual in the sector was your seemingly very large and centralised IT team. You tell us that prior to the pandemic you had an IT team of 110 staff, and throughout your statement you describe the ways in which you leveraged this to manage all aspects of the shift to online learning and working, and particularly to provide IT support directly to families.

Would it be fair to say, Mr Barneby, that that central capacity, was key to your pandemic response?

Mr John Barneby: Yes. So the taskforce that we established, as you said, met on, typically often on Sundays because that’s when the announcements were made. There was typically a gap between the DfE guidance coming out, so we had to ensure that we had really thought out what the announcements meant, and then, as the questions started to come in from schools, from parents, we were able to respond to them. So that national infrastructure that we had made a massive difference. In terms of IT, you know, we know that online learning was the only way to really continue making sure that education was happening.

So at the beginning our taskforce, we set out three priorities: number 1, how do we keep our children and staff safe? Number 2, we want to go beyond, Oasis as an organisation, as you say, working in some of the most challenging areas in the country, and our community model was key to that, so how do we go beyond the school to support families and communities?

And then number 3: education is not optional. And that number 3 is where the IT team came in, and where we were able to take all of our shared laptops or the student laptops from within schools, around 4,000 devices, to audit all of our family homes for connectivity and also for equipment availability, and then to redistribute all of those devices across the country based on the needs of our students from the audits.

Now, it’s one thing to move to online learning, this is where the gap between policy being created and then practice on the ground exists. So a lockdown of schools, a move to online learning as a policy is one thing. The practice of deploying that equipment, of telling families, “You can access these online materials using any devices you’ve got at home”, means that there’s a significant overload of technical support needed. And so we shifted all of our IT teams, we created a call centre, and families were able to phone up for support and this was a critical part of the beginning of getting children learning through the myriad devices that we had at the beginning of this.

Counsel Inquiry: Thank you very much indeed, Mr Barneby, for that summary.

I want to ask you largely about something that may fall between items 1 and 2 of what you just identified as your core mission and that is about the approach that Oasis took towards safeguarding throughout the pandemic.

Just before we do that, can I ask, is it right that in ordinary times, so outside of a pandemic, schools do play a role in safeguarding but that’s largely about identifying and reporting concerns to children’s services who have the primary statutory responsibility for safeguarding?

Mr John Barneby: That is not right. So children – schools play a major role in safeguarding children every day. So we would say safeguarding is everyone’s business. It is our number 1 priority to make sure that children are safe. It is where the trust exists in the education system.

As part of that, referrals are made. So particularly critically vulnerable children, children missing in education, where we get the signs of domestic abuse or violence, we’re making referrals in to children’s services. But schools play a critical role in safeguarding all the time.

Counsel Inquiry: Thank you, Mr Barneby. You said a moment ago “it is where the trust exists”. What do you mean by that?

Mr John Barneby: We’re trusted, in this case, with 32,000 young people every day. We’re working with some of the most disadvantaged communities. Often the relationships, the trusted relationships that form between adults and children in school, is incredibly important to us understanding what those children’s needs are. You know, in a holistic sense, not just education, but socially, emotionally, physically, spiritually. And then caring for that whole person.

So there is an underlying sense of trust and relationship that exists that allows that practice to be – to be effective.

Counsel Inquiry: Understood. Thank you.

With that in mind, then, can we please look at the guidance that was produced when schools first closed in March 2020. Thank you very much.

For the record, that is INQ000520192.

This was the guidance published on 22 March entitled Coronavirus (COVID-19): Guidance on vulnerable children and young people. And we see here the introduction the definition that the government had identified for which children ought to be able to access school placements.

I won’t linger here, Mr Barneby, because I think we’re all now familiar with that definition.

If we can look over the page, please, we see also the additional category:

“We know that schools and other education providers may also want to support other children who are vulnerable where they are able to do so.”

And that is the provision that enabled schools to have a discretion to identify other children who didn’t fall within the categories we saw a moment ago.

And I want to ask you in a moment about how Oasis went about operating those – or identifying children within those categories. But first of all, if we can please look at page 6 to just consider another part of the guidance. Thank you.

Under the heading “Do vulnerable children have to continue to go to school?”, the Department for Education set out the expectation that vulnerable children with a social worker would attend, and said:

“In circumstances where a parent does not want to bring their child to school, and their child is considered vulnerable, the social worker and the school should explore the reasons for this, directly with the parent, and help to resolve any concerns or difficulties …”

Mr Barneby, would it be right that this guidance essentially gave rise to a new sort of pandemic-specific facet of safeguarding work created by the very fact of school closures, so the job of identifying vulnerable children and encouraging families to send their children to school?

Mr John Barneby: So, for schools, vulnerable children have always been a particular focus area for safeguarding by the very definition that they are vulnerable.

I think we saw an increase in vulnerability, but also in new categories of vulnerability. So we – food poverty became a major issue. Ability to pay utility bills became a major issue for us. We saw a massive increase – 50% increases in domestic abuse and violence over that period of time.

So the practice changed, that some of the problems were – have always been there in society –

Counsel Inquiry: Thank you.

Mr John Barneby: – but some of the practices changed.

Can I just expand a bit on that? Because we obviously received this practice, and getting children back into school, you know, we support the policy of vulnerable children being in school. That is easy to say.

Counsel Inquiry: Yes, we’re going to come, Mr Barneby, in some detail to look at exactly how you did that because we want to get exactly under the skin of why it’s easier to say than it is to do. Just before we get there, the guidance here envisaged that this was a job for social workers and schools together.

In practice, did you find that it was a joint endeavour, and that social workers were working together with schools on this?

Mr John Barneby: So, we – our referrals to social workers increased significantly over that period. I don’t believe there was capacity in the system to respond to all those referrals. There was –

Counsel Inquiry: I’m so sorry, it may not have been clear from my question. Let me ask it again. This particular job of reaching out to families to try to encourage children who had been identified as children who ought to go to school, so that narrow task, was that something schools were being assisted by, by social workers, or should I interpret your answer to mean that because the system was under stress, there wasn’t that capacity?

Mr John Barneby: I think that’s where I was getting to. In reality, certainly in Oasis, we were making the calls home. We were doing the work to get the children in. There was not the capacity in the system for social workers to fulfil that role, and that’s no disrespect to social workers; they were very busy.

Counsel Inquiry: Yes, thank you very much.

Let’s start to look, then, at exactly how Oasis did it. Can we go back to your statement, please, and look at paragraph 37 of that, which is at page 12. Thank you.

So under the heading “Vulnerability Assessment” we learn, first of all, about how Oasis identified which children, in accordance with that guidance, might be offered a place at the school. You say:

“… we had significant concerns about the safety and welfare of our pupils during the lockdown period. During the Covid-19 period an additional section was identified within our approach to safeguarding …”

And carrying on, you say:

“Each of the academy Designated Safeguarding Leads … were instructed to undertake dynamic risk assessments on all pupil lists against four categories of vulnerability …”

And we see there the four categories.

I have a number of questions about this. First of all, we saw from the guidance a moment ago, and we know that there was provision for children with education, health and care plans to attend. You have included here also those who were in the progress of getting an education, health and care plan. Why is that?

Mr John Barneby: So there was often delays to children actually receiving these plans, when we understand that the needs are there. Given the situation that we were in, we thought it was best, and again, going back to those principles of the Covid taskforce, how do we keep children and families safe? Our number 1 principle. And then that principle of education is not optional. And so that combination meant that we applied more generous approaches to making sort of categorisation of vulnerable children to make sure that we had as many children as possible in the school.

Counsel Inquiry: Thank you. The next bullet point says:

“Those children classed as ‘vulnerable’ under an Oasis definition of vulnerability including, but not limited to, other safeguarding issues, young carers, victims of domestic abuse, food poverty issues, et cetera.”

I think that this is your interpretation of that otherwise vulnerable category that we looked at in the guidance. How did you go about expanding on this? Was it based on what you already knew about your pupil population?

Mr John Barneby: Yes, so all our Designated Safeguarding Leads, our DSLs, worked throughout Covid, often in school, and we applied this dynamic risk assessment approach, so we would take everything we knew, the categorisation of children formally, and then everything we knew about the families and then we would effectively RAG rate children based on that. So if you were red you were considered critical support needed, and we would ensure that you would have a call every day. At home, we would have you in school –

Counsel Inquiry: It might just help, Mr Barneby, if we can have, please, paragraph 38 of your statement on the screen as we go through this because I think you have set out some of it there.

Mr John Barneby: Yes, thank you.

So where children were deemed thorough this risk assessment process, to have a critical vulnerability, including our own categories of vulnerability, then we would ensure we had contact every day. Our preference was to have children in school who were red category, but equally, some of those children are the hardest to access, as well.

Then children who were amber, calls were required every two to three days, and those that were green, every four to five days.

In total we made 118,000 calls between lockdown 1 and 2, and indeed, when we look at our attendance, you know, we were at 33% of vulnerable children attending schools regularly compared to a national of 9%.

Counsel Inquiry: We’re going to come in a moment to look at that –

Mr John Barneby: One of the things that we did that made this successful –

Counsel Inquiry: Mr Barneby, I am so sorry. I don’t want to interrupt you, I just want to go through it in stages so that we have everything we need about exactly how you did that.

I just want to ask you for a moment about that dynamic risk assessment because one of the things we read from your statement is that that was undertaken on your entire pupil roll, so 30,000 pupils. So does that mean that your safeguarding leads were not just looking at the children they already thought might be vulnerable, they in fact took a fresh look at all children and thought about whether they might now be vulnerable?

Mr John Barneby: Yes, so it’s a combination of our safeguarding leads, pastoral staff, teachers. What did we know about those families? And again, this principle of how do we keep our children safe through this? And as we say, we did that work to review against statutory categories and then our broader understanding as well.

Counsel Inquiry: One of the concerns that we know that the Children’s Commissioner raised at this time, because we heard evidence from her last week, was that it might all – it might not always be known in schools exactly what a child’s circumstances were, sometimes local authorities had information about children that weren’t making their way into schools. How were you satisfied that your designated safeguarding leads had everything they needed to be able to undertake that dynamic risk assessment?

Mr John Barneby: Well, you’d go off the information that you’ve got available to you. I think schools have a uniquely trusted relationship with families. It is, when you think about society, it’s the only bit of social infrastructure that exists in almost every community. It’s the only bit of social infrastructure that families and children proactively visit on a daily basis. So our understanding, through those relationships, of children and families and things going on in children’s lives is significant. And so it was that understanding and knowledge that we applied into that risk assessment process.

Of course, when we are speaking to other agencies and making referrals we are using some of that knowledge as well.

Counsel Inquiry: Thank you.

You went on then, and I’m sorry to have cut you off, to tell us about the keeping in touch calls and the home visits, and we learn from this paragraph that if a child was not – and I’m sorry, it may be the rest of the paragraph, which is over the page – that if a child was not attending remote learning or if their family wasn’t picking up the phone for those keeping in touch calls, that’s when you would conduct a home visit; is that right?

Mr John Barneby: Yes. So, as I say, we made just over 118,000 calls home. One of the reasons – and I was just chatting about the percentage of children attending – vulnerable children attending our schools, at 33% attending regularly versus the national 9%, one of the things we attributed to that is some of the technological changes that we made.

Counsel Inquiry: Mm-hm.

Mr John Barneby: And we shifted our phone system from the school into teachers’ homes, so that they could use the school number to make the calls home.

When we did that, the percentage of parents answering the call from this trusted number, versus an unknown mobile, increased significantly, and that allowed our contact with families to be more effective.

And then through – as I say, if we couldn’t get hold of a family, we would complete a home visit. We had a clear protocol for keeping our staff safe during those home visits, and equally to help parents understand what those visits were about. You know, there was a stigma attached to being considered a vulnerable family that – that people started to know about and we were acutely aware of positioning our home visits to not make that a thing.

The other thing, we were very careful about keeping our staff safe as well, and so those protocols would control how staff entered a house, if they needed to, but also how they decontaminated when they came back as well, to make sure that the virus wasn’t taken into a home environment or back into the school.

Counsel Inquiry: Thank you, Mr Barneby. You’ve spoken with great precision about some of those statistics on, for example, the number of calls, and we know from your statement that you were able to do so because you kept very careful data, and collected it nationally, to understand what was going on. And you have exhibited to your statement, a report from July 2020, all of that data.

If we can look at that, please, it’s at INQ000643927. Thank you very much.

Before we look at some of it, we see from the first paragraph, last sentence there, that you say:

“Throughout this report there is a distinction made between ‘vulnerable children’, as defined in both [Her Majesty’s] Government advice and the OCL categories and those who are ‘clinically vulnerable’ to coronavirus due to underlying medical conditions and/or shielding because of family members.”

Can you explain that, please. Was there a difference in how you monitored and supported those with clinical vulnerabilities, as opposed to how you monitored and supported those with safeguarding vulnerabilities?

Mr John Barneby: Yes, so we were obviously very keen to get safeguarding vulnerable children into school wherever possible. Clinically vulnerable children, we needed to take a very approach, by the very nature of the impact of them catching Covid could have been significantly more serious. And so our support around them was ensuring that they had the resources and capacity at home to take part in home learning, to make sure that food wasn’t a significant issue in their families, to think about how we were supporting the wider families as well.

Counsel Inquiry: Thank you.

If we now come, then, to look at the graph that’s on this page, it’s headed “Number of vulnerable children across OCL”.

And I think that the different coloured bars show us the numbers as they were across time, so the light blue is 6 April and the green is 13 July.

And what we can see here is that, by some considerable margin, there are more children in the category of “Other Vulnerabilities”, and thinking back again to the guidance and then to your statement, I think this is the Oasis group of identified characteristics about vulnerability rather than any of the government guidance groups.

Just reflecting on that, does that suggest to you that the government’s definition of which children were vulnerable was lacking at all? Or perhaps, on the other hand, does it suggest to you that the flexibility afforded by that final category was particularly important?

Mr John Barneby: I think that the latter option: the – the flexibility of that category allowed us to give agency to local leaders on the ground to assess which children they felt needed additional support and then, through that risk assessment process, to then allocate that support accordingly.

It feeds back into what Oasis is about. It’s a fundamentally – we are about communities, about going that extra mile for our communities. Education is one key part of that. And I think that was borne out in the way that we managed this.

Counsel Inquiry: Thank you.

If we can look at now I think it’s page 3 of this document. Apologies, I’m taking it slightly out of order, thank you.

These are some of the statistics that you referred to earlier – I’m so sorry, it’s page 2 in fact. Thank you very much. If we can slightly zoom out so we can see the heading. Thank you very much indeed.

These are some of the aspects of what you were learning, I think, about your children’s circumstances that you talked about earlier. So we can see, under the first heading “Domestic abuse/violence”, you say that:

“Since [the week commencing] 6 April, this group has seen the largest increase of any … a 50% increase.”

If we can look next at “Food poverty”, the second bullet point there. Again:

“Since [the week commencing] 6 April, children considered vulnerable due to food poverty has increased by almost 200 …”

Again, if we can look under the next heading “Other Vulnerability”:

“The largest vulnerability group in all the lockdown weeks has been children classified as ‘Other Vulnerability’. This week the ‘Other Vulnerability’ group has increased by 58.”

And we learn that:

“The increases are largely driven by mental health issues of both parents and children.”

Was this information, Mr Barneby, being gleaned from those keeping touch with phone calls and home visits?

Mr John Barneby: Yes.

Counsel Inquiry: And what does it tell you – if this isn’t too obvious a question, what does it tell you as a school or as a group of schools about what your children were experiencing in those weeks of lockdown?

Mr John Barneby: I think it was incredibly challenging for children, for families. The social infrastructure that was available for children was no longer available in quite the same way. We have a number of families that are seasonal workers that didn’t have furlough, so income streams stopped. Living conditions weren’t adequate in some households – normally, let alone in lockdown. And then access to technology was extremely limited for some families as well.

In fact I was in one of our schools just after lockdown 2 ended – actually working on reception, I was working at some of our schools to make sure I understand what’s going on – and I met a mum there, who came in and had just had her mobile phone – would have just had her mobile phone, and she came in and said thank you. And we had issued six laptops – six iPads to her, one for every child, and as a result, she’d been able to access online learning and had been able to get through this. And she was saying, “I just don’t know how we would have done it. I don’t know how our children would have been able to access learning, would have been able to speak to their friends, would have been able to continue with a degree of normality.”

Counsel Inquiry: Thank you. Can we look then at page 3, where we were earlier. This is a table that shows us, as at July 2020, the proportion of vulnerable children that were attending at your schools. And we see highlighted in green there, and that’s the green from the original document, that 18 of your schools, I think, had over 50% of their vulnerable children attending. And indeed, at the top, some very high numbers: 100, 94, 93 per cent.

There is a decrease, and we won’t go there, but on the next page there’s a figure that’s as low as 7%. So there was clearly quite a range. As you say, the average, I think, was 33%, so considerably higher than the national average at the time.

So the first question then, Mr Barneby, is how – what was happening in those schools that were managing to reach 100 or 94 or 93%? What were they doing that was so effective to get vulnerable children into school?

Mr John Barneby: So I hope you can see, firstly, from this report – this was a report that we used to regularly get in from our safeguarding teams. We took this very seriously. And as a result of that, we were monitoring, we were receiving regular reports and monitoring and then following up and supporting schools where they weren’t successfully getting children in.

There are so – it’s a very complex answer to your question because there’s so many variables around what was allowing vulnerable children to come in or not come in. What we know is that the regular calls home, the home visits, the infrastructure that we had, the advice, that we were providing as a national team to DSLs, the things that they were telling us that was working and we were sharing across the organisation, meant that we were able to gradually increase the number of vulnerable children coming in.

Counsel Inquiry: And do you know – this might be too much of a detailed level – but do you know what those schools were doing so well? Was it something in the conversations? Was it the relationships? Clearly there’s a range, and yet the central management and the messaging appears to have been the same because it was the same central management team? So what was the difference, Mr Barneby, between those who were doing it very well, and those who were struggling?

Mr John Barneby: So I think all of our schools did a fantastic job in this area, that’s the first thing, I think our Designated Safeguarding Leads are – deserve a huge amount of gratitude for the work that went on.

There are two sides to this. There is the work that the school is undertaking and then there are decisions that families are making as well. And I think your presentation of this data to say that a difference in terms of what was going on in the schools leading to the result of this, I think the circumstances that families were in, was perhaps the biggest influencing factor as to whether vulnerable children were coming in or not.

Counsel Inquiry: That sounds entirely fair, Mr Barneby. Let me explain. The reason that I ask is because you will be aware that part of this Inquiry’s role is to make recommendations about preparing for a future pandemic or a civil emergency. And in a future emergency, it’s conceivable that there would be a need again to identify vulnerable children, and to create a process for ensuring that those children had access to a place of safety.

And so I’m wondering whether, based on your experience, there is anything that we can extrapolate for the bigger picture?

Mr John Barneby: I think it is a rigorous daily approach, you know, a belief that we can get these children, that we won’t give up, we won’t stop, even when they don’t answer the calls, when they don’t respond, you know, when – we will go there and we will try and establish if families are in the homes or not. And I think it is that constant, relentless focus on safety and safeguarding that allowed us to be significantly above the national position.

Counsel Inquiry: Thank you, Mr Barneby.

I’ve been passed a note to say that you and I both need to slow down a little bit so I apologise and if you could also please speak a bit more slowly.

Just one more graph amongst this data, please, if we can look at page 6. Here at the top we have a graph that shows the number of home visits that were being undertaken, and just to remind us, I think we said earlier that home visits were undertaken if a child had a high, to put it bluntly, RAG rating and if they weren’t presenting for remote learning and if keeping in touch calls were not answered.

We can see here some quite clear trends. So in June of 2020 there seems to have been quite a significant spike in the number of home visits that were necessary and also – did I say June? I meant May. Clearly we have a spike in May and June.

Are you able to help us understand the reason for those spikes, please?

Mr John Barneby: Yes, I think initially – I think as Covid, as the lockdowns went on, the challenges of being at home became greater and greater and we saw more disengagement and as a result of that, the home visits increased.

Counsel Inquiry: Thank you.

I want to move on now to the related topic, please, of children missing out on education. Can we look, please, at paragraph 45 of your statement. You say here:

“A distinction was made during lockdown between” –

I’m sorry, let me give the reference. It’s INQ000648389, and it’s page 14. Thank you, paragraph 45.

You explain that:

“A distinction was made during lockdown between children who were missing out on their education … because of a refusal to engage in home learning and those children deemed missing from education under the statutory guidance.”

Can you explain that to us, please?

Mr John Barneby: Yes, so children missing from education relates to children who we have not seen, we’ve not been able to contact for a certain period of time, typically ten days, and we complete a series of relevant checks to try and track those children down, and then after that ten-day period we typically report that as a child missing in education to the local authority, and in normal circumstances after a certain additional period of time, typically another ten days, they would come off roll, so that’s children missing on education.

Children missing out on education, which was one of the biggest challenges is where children were either engaging at the beginning and then stopped engaging, or didn’t engage at all. So they were missing out on the learning, rather than actually – we knew where they were, we knew they were safe, but they weren’t necessarily engaging in learning.

Counsel Inquiry: One group of children who may have missed more education than others, perhaps both in terms of remote learning during school closures and in-person learning when schools opened, is those who contracted Long Covid. Were you, Mr Barneby, or are you aware, of Long Covid having been an issue affecting attendance in your schools?

Mr John Barneby: I don’t think we knew that much about Long Covid at that time. So I think we were looking at clinically vulnerable children as a category. I don’t think we were really – I don’t think we had that understanding of the impact of Long Covid at that stage.

Counsel Inquiry: And do you recall – perhaps I should take from your answer that the answer to this is going to be “no”, but do you recall receiving at any stage guidance or information about Long Covid in relation to how to identify it, how to support pupils with it, in managing their symptoms or extra educational needs?

Mr John Barneby: No.

Counsel Inquiry: And are you now able to say whether Long Covid is having an impact on children’s educational needs or equally, is that not something that is being monitored?

Mr John Barneby: It certainly is – has had an impact on children’s educational needs. The mental health and wellbeing fragility of children that do have Long Covid clearly has an impact on them coming into school. We see increased, you know, emotional school avoidance, and yeah, every day that they miss is a challenge.

Counsel Inquiry: Thank you. Another group of children whose attendance may have been impacted differently to others are those children who have or had a clinical vulnerability to Covid-19, or who lived with a family member with a clinical vulnerability and who were, therefore, understandably worried about contracting the virus.

Since 2020 – I beg your pardon, since September 2020, it’s been the policy of the Department for Education to mandate attendance unless a child is designated as being unable to attend by their doctor.

Some families have taken the view that they don’t feel able to send their children to school if they consider it unsafe to do so, perhaps even without that medical certification, because they’re worried about vulnerability to Covid-19, either of their child or someone in the household. Have you been aware yourself of that as a particular concern affecting attendance?

Mr John Barneby: No.

Counsel Inquiry: Thank you.

Turning then to the broader issue of attendance, can we look, please, at page 58 of your statement. Thank you very much.

We see here some tables explaining changes in the rate of attendance between the year before the pandemic, and between the last complete academic year. And I want to ask you particularly about table 20, please. That is about rates of persistent absence.

What is persistent absence, please?

Mr John Barneby: Persistence absence is children who are attending school less than 90%.

Counsel Inquiry: Less than 90%. Thank you. And why is that a metric that matters?

Mr John Barneby: Below 90% has a significant impact in children’s outcomes.

Counsel Inquiry: Thank you.

And we see that the difference is quite significant in the year before the pandemic as compared to last year. So we see Oasis Community Learning, 2018-19, at just under 10%, and now just over 20%. So that is a doubling at primary level.

And if we can look over the page, please, at table 22, that is the same statistic for secondary school, and we see, again, a very significant increase in persistent absence in the year ending 2019, to the last academic year.

Just looking at this table, would we be right to understand from that that one in three secondary students are missing 10% of the school year?

Mr John Barneby: Basically stated, that’s correct, yeah.

Counsel Inquiry: And what do you understand are the key drivers of that trend?

Mr John Barneby: There’s a range of issues, and fundamentally, the relationship between schools and families has changed, and we’ve spent a lot of time working with families to help them understand the importance of being back in school.

There are a number of – we talk about Long Covid. There’s Long Covid clinically as a disease and then there’s Long Covid, the impact on people. And as I said earlier, the impact of being at home, particularly for disadvantaged families, was significant. You know, mental health, we saw a huge increase, to the extent that we have invested now in a mental health team as a result of trying to help get children back into school and to support children to regularly attend again.

Anxiety, emotional school-based avoidance, are really key long-term issues that we are continuing to try to solve.

Counsel Inquiry: As well as telling us about your National Mental Health Team in your statement, you describe the Oasis Encounter scheme, which delivers therapeutic work not just for children but for families. And it seems, if I’ve understood it correctly, sometimes for parents in particular. Is that a post-pandemic phenomenon? And if so, what should we understand from that?

Mr John Barneby: Yes, so Oasis Encounter is a programme that supports parents primarily, but also children as well, in helping them re-engage with education again. And we’ve had quite significant success through this. It worked by helping parents understand some of the reasons. So, for parents, the presentation in a child of not attending school might be “I don’t want to go to school, I don’t like it” –

Counsel Inquiry: I’m so sorry, Mr Barneby, I’m going to ask you again just to slow down a little.

Mr John Barneby: Sorry.

Counsel Inquiry: Thank you very much.

Mr John Barneby: The issues presenting themselves to parents around children not attending school might well be their child saying, “I don’t want to go to school, I don’t like school, I don’t want to attend, I don’t need to go”, and trying to help parents understand the thing that is behind that. So what is the anxiety or thing that is actually preventing that child from wanting to go into school?

So Oasis Encounter brings together parents in small groups, allows them to share the stories and challenges that have been going on, and then we provide a series of inputs that help parents navigate these issues, and equips them to work with us to bring children back into mainstream education again.

Counsel Inquiry: And I think you said you’ve had some success with that. Did you mean that that is improving attendance statistics?

Mr John Barneby: Yes, significantly. I forget the exact stat but it’s a significant increase in children that have been through, and parents being through Oasis Encounter are now reengaged back into school.

Counsel Inquiry: Thank you. On a different topic you have also explained in some detail in your statement the challenges that your schools faced, for example, with obtaining PPE, implementing social distancing, implementing testing, and being able consistently to implement cleaning regimes. I think you even tell us it was difficult at times to find enough cleaners to be able to carry out what you needed to.

I want to ask you about your experiences of managing ventilation in buildings. You tell us something about the challenges of doing that, both in old buildings and in new buildings. The main question is, what lessons can we draw from your experiences in order to improve, if possible, ventilation in school buildings for the future?

Mr John Barneby: Yeah, so we faced, I think like many schools, we had the CO² monitors in place. We followed the protocols that are available to us. Typically in the older buildings it meant opening windows, and that created all the challenges around running the heating, keeping children warm. We had people sitting in coats in rooms tying to get the ventilation to be satisfactory. That is not a great learning environment. So that’s the old buildings.

The new buildings, many of them are built with passive ventilation systems. They don’t necessarily move air around at the right pace. Some of our new buildings don’t have windows that open, so you are relying on this passive ventilation system to move air around the building, which has varying degrees of effectiveness.

The thing I think we need to learn is that the environment of classrooms is critical to children learning. And so ventilation during Covid is one issue of managing that, but there is a bigger picture issue around having effective school buildings, having classrooms where the temperature is right, and suitable for learning, and I think we could probably, if we went and looked back at the data, start to track correlational between outcomes and attendance based on the quality of school buildings and the environments.

Counsel Inquiry: Thank you, Mr Barneby, I’d like to turn now to your conclusions and what you say are some of your lessons learned for the future. You make a number of points in your statement and I won’t go through them all, but one that I want to ask you about, because I don’t think anybody else has raised this, is something that you call the Benefits of PedTech. Can you explain, please, what that is and why you think it might be important in the future?

Mr John Barneby: So just to set the scene, so by the end of Covid, we had deployed 32,000 iPads. We had a universal offer of education, and then when you have a single platform in every home, you can target, you can create a coherent, online education system. So the thing about doing that is that there is a change in pedagogy that’s required. So teaching to a class where you can see people is one approach; teaching online changes the way that assessment works, the way that tasks are being set, and the way that you manage conversations. Indeed, some of the curriculum that is suitable to be taught online, the way that breaks need to happen. And so PedTech is this concept of really thinking about the deployment of technology for the purpose of learning rather than the deployment of technology.

So how do you actually line up an approach to teaching that fits with the technology that’s deployed? And that’s something that we spent a lot of time as we were deploying the technology across Oasis, of training our teachers, of making sure that they were equipped to maximise what was a very considerable investment that we made.

Part of our thinking behind that and the reason that we were able to mobilise such a large-scale deployment was that we were already thinking about this. We already had a view that at some point the – children will need a device to maximise their education, just close down that digital divide, and if we look in society, if anyone has studied economics, you will know that whenever there is an industrial revolution in this country, two things need to happen: number 1, the education system has to change itself, has to develop the skills that people need; and number 2, the gap between those that have and those that have not, gets wider. Every time.

And I think part of our approach in Oasis for the communities that we serve was to make sure as we go into this next industrial revolution, which is AI and robotics, that our children don’t get left behind.

And because we’ve had this strategy thinking going on, we’ve already had a plan to deploy one-to-one devices. And so as Covid hit, we were able to pick up that plan and start deploying the devices out. It’s what allowed us to bring online learning, you know, on much quicker than many others.

Counsel Inquiry: Thank you very much, Mr Barneby. Was there, I think, anything else that you wanted to say by way of lessons learned or overall reflections?

Mr John Barneby: I think overall we talk about school closures; our schools didn’t close. Schools were not closed. You know, you’ve seen 33% of vulnerable children in school. You know, head teachers I spoke to, they worked harder than they’d ever worked. DSLs worked harder than they’d ever worked. Teachers that weren’t in school were working. So this idea of the school building or the school being closed wasn’t the reality on the ground. And I think I would end just by saying, you know, a huge thank you to Oasis staff, but actually to the wider education profession for – for keeping our children safe, for trying to minimise the impact on learning of children, and their future careers and opportunities.

Ms Cayoun: Thank you very much, Mr Barneby. Those are all my questions, and there are no questions from any Core Participant.

My Lady, do you have any questions?

Lady Hallett: Thank you very much indeed, Mr Barneby. You’re an evangelist of the best kind.

The Witness: Thank you, my Lady.

Lady Hallett: You obviously believe wholeheartedly in what you’re doing, and obviously we all echo the efforts made by people like your staff to keep children safe and to keep them learning.

Can I ask, what is the funding model for Oasis? Is it government funding? Central funding?

Mr John Barneby: Yes, so – so, Oasis is a group of charities, and one of those charities is Oasis Community Learning, which is what we’ve been talking about today, and Oasis Community Learning runs, now, 56 schools across the country. And there are other charities – so the vision for Oasis is a vision for community, and education is one part of that.

And alongside that we run Stop the Traffik that’s trying to prevent people trafficking.

We run Oasis Restore. That’s the new secure school that’s trying to change the question around young people’s social justice, to say – rather than saying “What did you do?”, saying “What happened to you?”

How is this 11-, 12-, 13-year-old locked up? What’s happened to that child?

We run food banks, food pantries. We do debt advice work, family support work. And it is this integration, the holistic offer brought together around a hub, including the school, that provides what we think is this, sort of, piece of social infrastructure, this village, if you like, that allows children and families to thrive, that gives some of the most disadvantaged communities that – that advantage, that social justice, to help them have the same opportunities that many of us in this room have had.

Lady Hallett: Very worthwhile cause.

Thank you very much indeed, Mr Barneby, for all that you’re doing at Oasis, and thank you for all the help you’ve given to this Inquiry. It’s been a very interesting afternoon. Thank you.

The Witness: Thank you, my Lady.

Ms Cayoun: My Lady, that concludes the evidence today.

Lady Hallett: Thank you, Ms Cayoun. I shall return tomorrow for a 10.00 start.

(4.10 pm)

(The hearing adjourned until 10.00 am the following day)