Transcript of Module 1 Public Hearing on 19 June 2023

(11.00 am)

Lady Hallett: Yes, Mr Keith.

Mr Keith: Good morning, my Lady.

As sometimes happens, I know the next witness, and so he will be examined by Ms Blackwell.

Ms Blackwell: Thank you. May I call David William Donald Cameron, please.

Mr Cameron, will you please take the oath.

1. Mr David Cameron

MR DAVID CAMERON (sworn).

Questions From Counsel to the Inquiry

Ms Blackwell: May I begin, Mr Cameron, by thanking you for the assistance you have so far given to this Inquiry and for coming to give evidence today.

May I also ask you to keep your voice up and speak into the microphone so that the stenographer can hear you for the transcript.

Is your full name David William Donald Cameron?

Mr David Cameron: Yes.

Counsel Inquiry: You were leader of the Conservative Party and the Leader of the Opposition from 2005 until 2010, when you became Prime Minister of the United Kingdom, leading a coalition government with the Liberal Democrats, with Nick Clegg as your Deputy Prime Minister and George Osborne as your Chancellor.

Mr David Cameron: Yes.

Counsel Inquiry: To put that in context, you became Prime Minister in the wake of the 2008 global financial crisis, and you remained Prime Minister in 2015, when the Conservatives won the general election and you formed a Conservative government. In 2016, you stood down following the European Union exit referendum result.

Now, your evidence this morning is going to fall under four topics. First, the architecture in place to deal with large-scale emergencies in 2010 and changes implemented during your time in office; two, the state of pandemic preparedness before and during your tenure; three, your concerns around the World Health Organisation; and, four, the impact of austerity on the health and social care service and underlying health inequalities.

First of all, can we please have on the screen your witness statement, which is at INQ000177808.

Can you confirm, please, Mr Cameron, that this is your witness statement and it’s made true to the best of your knowledge and belief?

Mr David Cameron: Yes, it is. Yes, I can.

Counsel Inquiry: Thank you. For the record, it is in fact signed at page 19, but that signature has been redacted, my Lady, so we don’t need to go to that.

Thank you, we can take that down, please.

So dealing first of all, please, Mr Cameron, with the architecture in place to deal with large scale emergencies in 2010 and changes implemented during your time in office.

When you became Prime Minister in 2010, you tell us in your witness statement that, in your opinion, the existing architecture to deal with large-scale emergencies such as pandemics derived in large part from the Civil Contingencies Act of 2004, and since 2008 had included the national risk assessment and the National Risk Register assessment. So by “architecture”, you mean framework including legislation?

Mr David Cameron: Yes.

Counsel Inquiry: Yes.

But before come being into power, your sense whilst in opposition was that whilst the National Risk Register was a welcome innovation, the overall architecture for dealing with civil contingencies such as pandemics and the national security machine more widely could benefit, in your view, from improvement.

In what ways did you think it should be improved?

Mr David Cameron: Well, I commissioned Pauline Neville-Jones, who had been head of the Joint Intelligence Committee, to write a report on national security and foreign policy in opposition, and one of the recommendations she made was to have a sort of full-on national security council, to have a national security adviser, to have a national security secretariat, and the point was: to, first of all, make sure that the whole government looked at these risks; second, to make sure there was sort of real ministerial oversight, because the National Security Council would be chaired by the Prime Minister; third, to make sure that it was more strategic, thinking right across the board about all the risks, and also making sure it was truly international. So you were looking at risks of terrorism and climate change and space weather and all sorts of things, but also things like pandemics.

Why I particularly thought this was important was, while I think the Civil Contingencies Act and the previous government had done a good job in this regard, I knew that Prime Ministers are always in danger of being pulled into the short term rather than the long-term, and having a National Security Council that you chair and a National Security Advisor, and having as part of that looking at the danger of things like pandemics and – and – it would make sure you did focus on those long-term things as well.

So that was the point of the reform, and I think it worked. I really – I liked the way the National Security Council and the adviser worked and the time the Prime Minister spent on that stuff, because it had a good structure.

Counsel Inquiry: You implemented those recommendations as soon as you came into office?

Mr David Cameron: That’s right. I mean, it was – we were in the middle of the Afghan conflict, and I thought, for instance, we would handle that conflict better if we had a whole government approach and if the National Security Council could address the challenges, and you’d have round the table all the relevant people, whether it was the defence secretary, the aid secretary, the energy secretary, the Home Secretary and the Prime Minister.

Why I think it’s so important is while, of course, Prime Ministers are very powerful, because they’re Prime Ministers, they don’t have a department in the same way that other ministers do, and having the National Security Adviser and the National Security Secretariat working for you and bringing together the whole of government to address these challenges, I thought got politicians involved at the highest level and the right level to make sure this was being looked at properly.

Counsel Inquiry: So a National Security Council, as you’ve described, supported by a National Security Secretariat and a National Security Adviser?

Mr David Cameron: That’s right, and the National Security Adviser had deputies, one of whom was mostly concerned with intelligence and terrorism and security, and the other more with foreign policy, but specifically part of the job of the National Security Adviser, together with the National Risk Register and the National Security Secretariat, was to look at all the potential risks, and, you know, it’s important that we did make a pandemic, a health pandemic, a Tier 1 risk.

So it was about looking across the risks and saying: which ones are the most likely? Which ones do we need to prepare for the most? And, as I say, this pressure always to look at the most pressing risk, the terrorism risk, or the most dangerous risk or the most immediate risk, you need to balance that with making sure you’re looking at all the risks, including ones that might not occur next month or next year but might occur at some stage, and that’s why I think this reform was important.

I’m not saying these things weren’t looked at before, of course they were, but this embedded in the system Prime Ministerial leadership and political oversight and a whole-government approach.

Counsel Inquiry: Thank you.

Now, the risk of a future pandemic was, as you’ve already made reference to, prioritised as a Tier 1 risk and remained as such, did it not, throughout your time in office, one of the highest risks that the United Kingdom faced. Although you tell us at paragraph 12 in your report that it was a pandemic that was prioritised as a Tier 1 risk, in fact it was more discrete than that, it was an influenza pandemic, wasn’t it?

Mr David Cameron: That’s right. I mean, I think – I mean, this is maybe getting ahead of myself, but, you know, when I look at all of this and read all the papers and thought so much about, you know, what subsequently happened, and the horrors of the Covid pandemic and, you know, let me say the massive sympathy I feel for all those who have lost loved ones and for the suffering people have felt and the importance of this Inquiry’s work to get to the bottom of, you know, the decisions that were made, decisions that could have been made, and the preparations for the future, you know, this is the thing I keep coming back to, which is the pandemic was a Tier 1 risk, pandemics were looked at, but there was this – the former Chief Medical Officer Sally Davies has said it was a groupthink – it – much more time was spent on pandemic flu and the dangers of pandemic flu rather than on pandemic – potential pandemics of other more respiratory diseases, like Covid turned out to be.

Counsel Inquiry: Yes.

Mr David Cameron: You know, I think this is – this is so important, because so many consequences follow from that, and I’ve been sort of wrestling with why – you know, I think the architecture was good, National Security Council, National Security Adviser, the risk register and also this new security risk assessment, which was perhaps a bit more dynamic. But that’s what I keep coming back to, is so much time was spent on a pandemic influenza, and that was seen as the greatest danger, and we’ve had flus, we’ve had very bad years for flus, so it is a big danger, but why wasn’t more time – more questions asked about what turned out to be the pandemic that we faced?

And it’s very hard to answer why that’s the case, and I’m sure this Public Inquiry is going to spend a lot of time on that.

Counsel Inquiry: Yes. Because during your time in office, there were several outbreaks of other coronaviruses across the world, weren’t there?

Mr David Cameron: Yes.

Counsel Inquiry: This Inquiry has heard about multiple outbreaks of SARS and MERS, both of which were coronaviruses. I’d like to put on screen, please, the following document: INQ000149116, which is a note of a meeting of experts, including Professor Mark Woolhouse at the University of Edinburgh and also Dame Sally Davies.

Could we go to page 2, please, because under the heading “Clear and present danger” – if we can highlight the third paragraph – we can see it, in fact:

“Coronaviridae, including the severe respiratory infections SARS CoV and MERS Cov. We note that although there are not currently any vaccines available against human coronaviruses there are vaccines for animal coronaviruses …”

Now, this was a note from a meeting in March of 2015, when you were still in office, a meeting chaired by the former Chief Medical Officer, Dame Sally Davies, to whom you’ve just made reference.

Do you remember, Mr Cameron, if this assessment of coronaviruses as posing a clear and present danger was brought to your attention by the Chief Medical Officer in March of 2015?

Mr David Cameron: I’m afraid I don’t recall a specific conversation. But – and it’s difficult, this, because you’re trying to remember, you know, conversations you had or didn’t have seven years ago. And of course before this Inquiry I’ve read all of this documentation, and obviously in the documentation there is, and the government did look at, SARS and MERS, and particularly there is Operation Alice in 2016 –

Counsel Inquiry: Yes, we’ll come to that.

Mr David Cameron: – which I’m sure we’ll come to, but in terms of the specific conversation, I don’t remember that. I would certainly say that my relationship with the Chief Medical Officer was very strong, and we met quite regularly, and because of the experience with Ebola, which I’m sure we’ll also come on to –

Counsel Inquiry: Yes.

Mr David Cameron: – I think this was a government and a Prime Minister that was very concerned about potential pandemics and about dangerous pathogens and about things like antimicrobial resistance and all the rest of it. So we weren’t backward in thinking about it, but it still comes back to this issue, why so much time was spent on a flu pandemic and not so much on these others.

Although having said that, you know, the MERS exercise in 2016, that was looking at a respiratory condition.

Counsel Inquiry: Yes, we’ll come to that in a moment.

Mr David Cameron: Yes, sorry.

Counsel Inquiry: Not at all.

You’ve mentioned Ebola there, Mr Cameron, and indeed you were alive to the dangers that that disease or a similar disease with high transmissibility and high mortality rates posed, and in the –

Mr David Cameron: Sorry to interrupt. I think the point about Ebola, though, it’s less transmissible but it’s highly lethal, and I think that – so we had been looking at pandemic flu, we had a plan for pandemic flu, we obviously wrote about, in the National Risk Registers, SARS and MERS, Ebola comes along, which is not that transmissible but highly deadly, and so you’re – you know, I think the question I keep coming back to is: why weren’t more questions asked about something that was highly transmissible, indeed with massive levels of asymptomatic transmission –

Counsel Inquiry: Yes.

Mr David Cameron: – which was lethal but at a lower level than either MERS or Ebola?

And I don’t have an answer to that question, but that’s clearly where the gap was.

Counsel Inquiry: Well, so concerned were you about the Ebola crisis that you created a new body, didn’t you, a threats body, the NSC(THRC), which is a rather clunky initialism for the National Security Council Threats, Hazards, Resilience and Contingencies committee.

Mr David Cameron: Yes, I thought that pre-dated Ebola, but I may be –

Counsel Inquiry: Well, forgive me, I think in your witness statement you tell us that it was formulated partly as a result of the Ebola crisis, and in addition to which you also formed a horizon scanning committee, both of which were run by Oliver Letwin. And Oliver Letwin was, as you say in your witness statement, in many ways your resilience minister.

Why did you think it was necessary to establish the threats committee and the horizon scanning department?

Mr David Cameron: I thought the Threats, Hazards, Resilience and Contingencies committee, I think it was set up before Ebola, but I have to check that. The reason for that was, as I said a bit earlier, clearly the National Security Council spent a lot of time on terrorism, on security, on Afghanistan, on Libya and Syria, and things like that. And so I thought it was important to make sure that the National Security Secretariat and the politicians in the government spent time on hazards, threats, things like pandemics, and other such things that were less immediate and current, but otherwise you spent all your time on the other things.

So that’s why THRC was set up. Oliver was an extremely capable minister, and had worked in government before and was in the Cabinet Office and sat on National Security Council. So I knew he’d do a great job at chairing that and running that. Then, as you say, after Ebola, he suggested, and I think the letter to me is in the bundle somewhere –

Counsel Inquiry: Yes, we’re going to come to that.

In fact, can we put that on screen now, please, INQ000017451.

Now, this is in fact the contingencies forward look, because the threats committee, as you explain in your statement, had a six-month forward look, didn’t it, which was a much shorter term to – when compared to the National Risk Register, which was five years, and the National Security Risk Assessment, which had a 20-year timeline.

This is one of the updates which, as the man in charge of the threats committee, he would give to you.

Can we look at page 22, please, and paragraph 6.2, and we will come on to the letter in a moment.

At paragraph 6.2, we can see here “An outbreak of a novel strain of an infectious disease causing serious illness (excluding pandemics)” is raised within this forward look. He tells you here that:

“The risk of an emerging infection becoming prominent is always present, particularly at the interface between animals and humans (ie zoonotic infections). Globally, there are currently three main areas of concern: the ongoing cases of MERS-CoV in the Middle East and Eastern Africa; the large number of avian and human cases of influenza … particularly in Egypt; and the epidemic of Ebola Virus Disease (EVD) in West Africa.”

We can take that down, please, and can we go to the letter which you’ve made mention of, Mr Cameron, which is at INQ000146550.

This was a letter sent to you by Oliver Letwin the following year. We can see that it’s dated 22 March of 2016, and we can read through this together. It’s titled “Horizon scanning for international health risks”:

“Diseases like Ebola and Zika can constitute major risks to our national security.

“I have therefore asked the Civil Contingencies Secretariat to develop a new scanning system for international health risks.”

So this is the horizon scanning group.

Mr David Cameron: Yes.

Counsel Inquiry: “The results of this work have now been agreed with all relevant departments and have been endorsed by the Chief Medical Officer.

“I am confident that the new system will enable ministers to:

“- spot major emerging diseases across the world.

“- understand the direct risks to the UK, British Nationals and broader UK interests in the affected countries; and

“- receive expert advice on clear and flexible UK responses and mitigation arrangements:

“A monthly report will be issued to the Health Secretary, the International Development Secretary and me. This will outline: key international health risks, departmental assessments of the impacts, and actions to mitigate the risks. I have asked the Chief Medical Officer to approve each monthly report before it is presented. Attached is an illustrative example of the report for your reference ….

“To avoid this becoming just ‘business as usual’, I suggest that, rather than sending these reports each month to the NSC(THRC), I shall write whenever officials have flagged a health risk of particular concern.”

Then he goes on to talk about the implementation in April.

Were you concerned, Mr Cameron, that rather than – using this as an example – these bodies which you set up extending pandemic preparedness to a whole-government procedure, that what this was doing was encouraging working in a silo, so that fewer people rather than larger departments were going to be involved?

Mr David Cameron: Oh, no. No, not at all. I think this was a really excellent idea of Oliver’s, and I think it came out of Ebola, because – we’ll come on to the World Health Organisation I’m sure – you know, I don’t think there really was very timely information coming out of the WHO about Ebola, and this was Oliver saying, “Let’s have our own horizon scanning to look across the globe for emerging problems”. And the next one that comes along, of course, is the Zika virus, and this – the horizon scanning unit spots that quite early and then there are conversations in government.

So, no, I think this was saying: we can make the national security architecture work even better if we scan the horizons and look for novel pathogens and problems coming down the tracks. And I think that was a thoroughly good thing.

I don’t know what happened to this organisation after I left, whether it continued, but I think this was a really good idea and I think it – I don’t think it was in a silo at all.

Counsel Inquiry: All right. Well, I’d like to ask you some questions about placing Mr Letwin charge. You deal with this in paragraph 21 of your statement, in which you say:

“In terms of oversight of our resilience planning, I found that civil servants were very good at enumerating risks, setting them out and getting them in the right order. However, to get follow on action, I tended to use very strong Ministers in the Cabinet Office.”

And you say that in addition to Oliver Letwin you also had Francis Maude, who were “both very senior and experienced Ministers, driving change and action on those fronts”.

It may be suggested by others to this Inquiry that, rather than having a minister in charge of resilience, there should be an independent assessor, so somebody independent of government responsible for resilience who might be an expert and be able to dedicate himself or herself full-time to the role, and effectively be beyond the civil service.

What’s your view of that, Mr Camera?

Mr David Cameron: I don’t think they’re alternatives, I think they should be complements. As I said, I had the National Security Adviser with his deputies, but the idea of having someone equivalent to that, who is in charge of resilience and threats and hazards at the civil service level, I think is an excellent idea, and I think the government themselves have suggested that. I personally would keep that in the National Security Council architecture. But then you do need a minister to take responsibility. For two reasons: one, otherwise there’s a danger that the ministers round the Cabinet table just think: well, threats and hazards and resilience, that’s taken care of by someone else elsewhere else, so a civil servant. And so they won’t spend time on it.

The second is the reason I give in my statement – which is not in any way to denigrate the incredible work that civil servants do, but I think ministers often come at these problems on a committee asking the question: right, here’s the information, what are we going to do? What are the actions we’re going to take? What is the outcome of this meeting? What are we actually going to do that’s different? And I found that – maybe we’ll come to COBR – chairing COBR as often as I did, that is what I think the Prime Minister and other politicians bring, is: yes, here’s all the information, here is what we need to communicate it to all the right people, to make sure everyone is across it, but what’s the action, what are we going to do?

I think it would be a mistake to park resilience at the official level and not have senior politicians, including the Prime Minister, at the National Security Council discussing it.

Counsel Inquiry: Thank you.

Mr David Cameron: For instance, when we did the National Security Risk Assessment, that assessment came to the National Security Council. I can’t remember the date of the meeting, but I absolutely remember sitting around the table debating with the Secretary of State for home affairs and foreign affairs and defence and all the rest of it, which risks should be where. You know, “Have we got this right?”

That – by its very act, you’re getting people who don’t think every day about pandemic preparedness and the importance of pandemics and other things that can happen to focus on those things as well as the terrorism and the foreign affairs and … yeah.

Counsel Inquiry: You’ve explained why you chose Oliver Letwin and the qualities that he had to be placed in the shoes of, effectively, the resilience minister. And you would of course expect him as resilience minister to deal with the threat which had been already assessed as a Tier 1 threat, that is pandemics.

Mr David Cameron: Yeah.

Counsel Inquiry: So I’d just like to look, please, at Mr Letwin’s witness statement. It’s at INQ000177810.

Can we go, please, to page 2, and highlight the first part of paragraph 6 down to and including the words “much less well prepared”, halfway down. Can we zoom in, please, and highlight that. Thank you.

He says:

“During this period, 2011-2016, I was not directly involved in planning for the government’s response to pandemic influenza in the UK. In retrospect, it may seem surprising that my resilience-reviews did not cover this issue, given the fact that pandemic influenza was ranked high (both in terms of impact and in terms of likelihood in the national risk register). The reason was that I was informed by Cabinet Office officials

(when I initiated the resilience-review process in 2012)

Counsel Inquiry: that an unusually large amount of attention had already been focused on this particular threat because of its position in the national risk register, that (as a result) the UK was particularly well prepared to deal with pandemic influenza, that the Department of Health was preparing to carry out a major exercise to test our national capabilities in the face of pandemic influenza, and that my time would therefore be better spent examining other whole-system risks for which line departments might be much less well prepared.”

Could we go, please, to the next paragraph and highlight paragraph 7, please. Reflecting on that, Mr Let goes on to say:

“I now believe, however, that it might have been helpful if I had delved into the pandemic influenza risk for myself, notwithstanding the amount of attention being focused on this issue by the line department and the consequently high level of preparations for responding to it. This is not because I believe such a review would have been likely to lead to any significant improvements in our preparedness for a pandemic ‘flu itself, but rather because it might have led me to question whether we were adequately prepared to deal with the risks of forms of respiratory disease other than pandemic influenza.”

Are you surprised, Mr Cameron, that Mr Letwin, in the shoes of resilience minister, did not perform any tasks in relation to the Tier 1 risk of pandemic influenza?

Mr David Cameron: Well, I think he explains it, really, which is that this was a risk that he was told that was already well covered because there was already a pandemic preparedness plan. But I must say I thought his statement was incredibly clear and I think he’s being very frank here and saying, you know, the more people who were in there questioning what sort of pandemics we might have, the better. And I think his suggestion about having a sort of “red team” to challenge – whatever architecture you build, it’s only as good as the people within the building and the decisions they make – and his idea of sort of having a “red team” to challenge the thinking I think is an excellent one, because, as Sally Davies has said, there’s always a danger of groupthink, and perhaps that’s what was happening here, is that we were so focused – or the system was so focused on pandemic influenza, because of the well known risks of it, that the system had got itself into a belief that that was the most likely pandemic and that was the one that needed to be prepared for, and so I think Oliver’s statement is very powerful.

Counsel Inquiry: So you don’t think, as resilience minister, ignoring this risk, he let you down?

Mr David Cameron: I don’t think he was ignoring it. I don’t think he was ignoring it. He was doing the work on other risks because this one already had a plan. Some of the other things he was looking at, catastrophic failure of power grids, breakdown of the internet, you know, some even quite … space weather and slightly more wacky things, had had almost no attention, and he thought they needed to have that attention. So, no, I never felt Oliver let me down.

Counsel Inquiry: All right.

I want to move on to the second area of questioning now, the state of preparedness immediately before and during your tenure.

So within a couple of months of you taking up residence in Downing Street, Dame Deirdre Hine produced her report on the government’s response to the 2009 swine flu pandemic, which included 28 recommendations.

Just to remind ourselves about swine flu, it hit the world in 2009, it was an influenza virus, a respiratory disease, causing just under half a million global cases, and 18 and a half thousand deaths worldwide, with a fatality rate of between 0.01 and 0.2%, and causing, sadly, 457 deaths in the United Kingdom.

You were aware of this report, were you not, Mr Cameron?

Mr David Cameron: Yes. I can’t –

Counsel Inquiry: Yes?

Mr David Cameron: I can’t remember the exact circumstances of when I was told about it, but yes, and obviously I’ve read it subsequently.

Counsel Inquiry: Thank you.

Can we put it up, please, on screen, INQ000035085. We can go, please, to page 96, paragraph 5.38. Thank you.

“The National Framework was designed to prepare the UK for a variety of pandemic scenarios up to and including a reasonable worst case in which the clinical attack rate reached 50% and the case fatality rate reached 2.5%. In late April, the limited information coming from Mexico gave cause for considerable concern, but as the pandemic progressed it gradually became clear that a scenario approaching that scale was unlikely. A number of contributors to this Review have noted that it was difficult to switch from the plan we had – predicated on a worse pandemic than that which emerged – to a more proportionate response.”

Can we now go, please, to page 63, and highlight paragraph 3.65, dealing with the worst case. Thank you. Top of the page:

“The worst case in the planning framework is for 750,000 additional deaths. Given pressures on resources, ministers will need to consider whether they wish to make any additional investment required to cope with the full worst-case scenario. I have no recommendation to make on what the correct figure might be for the worst-case scenario, although in Chapter 4 I have recommended that the Government Chief Scientific Adviser convene a working group to review the calculation of planning scenarios. However, I do believe that it would be unsatisfactory if the National Framework implied that government and local responders were prepared to cope with many more thousands of deaths than they were in fact equipped to handle.”

Are you aware, Mr Cameron – we can take that down, please – that these worst-case scenario figures, that a pandemic could affect 50% of the population, it could kill 2.5% of the population, and, assuming a population of around 65 million in 2015, that would equate to infecting 32,500 people and causing around 800 deaths, those figures remained in place and indeed formed the basis of the United Kingdom influenza pandemic preparedness strategy the following year, and remained in place until Covid hit?

Mr David Cameron: I –

Counsel Inquiry: They were never amended.

Mr David Cameron: Yes. I – if you’re asking me was I – I mean, the trouble is I can’t remember exactly what I was told at the time.

Counsel Inquiry: You’ve seen the report now though?

Mr David Cameron: I’ve seen the report now, yes.

Counsel Inquiry: Those figures were never altered during your time in office and, as far as the Inquiry is aware, although there were moves to update the 2011 strategy much closer to the pandemic hitting, in fact those matters were never dealt with. Do you consider that that was a mistake?

Mr David Cameron: Well, I think it was a mistake not to look at – you know, repeating myself slightly, not to look at – not to look more at the range of different types of pandemic. My reaction to reading Hine was, like many of the other reports, it doesn’t mention the potential for asymptomatic transmission, and so, you know, when you think what would be different if more time had been spent on a high infectious asymptomatic pandemic, different recommendations would have been made about what was necessary to prepare for. That’s what I think is … is my focus.

Counsel Inquiry: In terms of focusing on a pandemic other than influenza, it’s right that the strategy in 2011 states as follows:

“Plans for responding to a future pandemic should therefore be flexible and adaptable for a wide range of scenarios.”

Mr David Cameron: Yes.

Counsel Inquiry: So that was acknowledged, but nothing appears to have been done, no further papers were prepared, or exercises undertaken to say how the strategy should be adapted –

Mr David Cameron: Well –

Counsel Inquiry: – no practical solutions?

Mr David Cameron: – there were other exercises undertaken, like Alice, which was –

Counsel Inquiry: We’ll come to that in a moment, yes.

Mr David Cameron: So other – I don’t think it’s right to say the government only looked at pandemic flu, it didn’t look at other things. The risk registers and other documents mention MERS and SARS and other types of pandemic.

Counsel Inquiry: Yes.

Mr David Cameron: So that wasn’t a failing, I think the failing was not to ask more questions about asymptomatic transmission, highly infectious. What turned out to be the pandemic we had. And I think there are occasions where, reading these reports, you can see – was there adequate follow-up –

Counsel Inquiry: Yes.

Mr David Cameron: – to some of the work? I spotted that in one or two places.

Counsel Inquiry: Yes.

Well, I want to come back to Ebola, please. I don’t know if you heard the opening statements to this Inquiry, but Pete Weatherby King’s Counsel, on behalf of the Covid-19 Bereaved Families for Justice UK, began with your words, and I’d like to display, please, INQ000146555, and this is the press release from June of 2015 when you were speaking ahead of the G7 summit in Germany on the wake-up to the threat from disease outbreak.

Can we go, please, to page 2, and we’ll go straight to your words, please, at the bottom of the page, where we can see that in this press release recorded is the following:

“Speaking ahead of the G7, the Prime Minister, David Cameron, said:

“The recent Ebola outbreak was a shocking remainder of the threat we all face from a disease outbreak.

“Despite the high number of deaths and devastation to the region, we got on the right side of it this time thanks to the tireless efforts of local and international health workers.

“But the reality is that we will face an outbreak like Ebola again and that virus could be more aggressive and more difficult to contain. It is time to wake up to that threat and I will be raising this issue at the G7.

“As a world we must be far better prepared with better research, more drug development and a faster and more comprehensive approach to how we fight these things when they hit.”

Indeed, your plan that you set out included a UK vaccines research and development network, with £20 million invested from the outset, and also what you described as a rapid reaction unit, ready to deploy to help countries suffering such devastating epidemics in the future.

Was your warning that Ebola was a wake-up call based on your understanding of the effect that Ebola had had and a concern as to how the global community could improve for next time?

Mr David Cameron: Yes. I mean, I – you know, the reason I chose to raise that at the G7 was I had become really concerned about this whole issue and Ebola was, you know, one example of it, and it was through conversations with Dame Sally Davies and others that I became more and more interested in this. You know, I thought we had taken important steps at home, and this was, you know, genuinely trying to put on the table the UK Vaccine Network and the rapid reaction force that you mentioned, saying that these were going to be our contributions, as well as this horizon scanning unit.

Counsel Inquiry: Yes.

Mr David Cameron: So I thought we were putting in place good steps and it was important to say to other countries: we all need to do this.

Because with Ebola specifically, there was this sense that (a) the WHO was quite slow to announce that it was happening, also quite slow to ask for help, and the help that was given to Sierra Leone, to Guinea and to Liberia was very much ad hoc. I think I put it in my statement. It was in a meeting – it was at a NATO summit, I was next to Obama, and he said, “Look, the world is being too slow on this, we will help with Liberia, can you help with Sierra Leone, can the French help with Guinea?” And it was quite an ad hoc response that led to this, and we spent half a billion pounds sending troops and nurses and all the rest of it. And I think they did a magnificent job, but it was quite ad hoc. So it made me think that we needed to put – again, the international architecture was lacking and we needed to put it in place, and that’s what this press release and that announcement was about.

Counsel Inquiry: Yes, thank you.

I’m going to turn to two exercises, UK exercises, one of which you have made mention of, Exercise Alice, which took place in February of 2016, and the hypothetical scenario of this exercise was an outbreak of the MERS coronavirus in March of 2016, having been reported to the World Health Organisation and caused about 500 deaths, most cases having occurred in the Kingdom of Saudi Arabia.

This was a tabletop exercise, as the Inquiry has already heard, involving the Department of Health, as it then was, the NHS and Public Health England. It was commissioned by the Department of Health in response to concerns raised by Dame Sally Davies about planning and resilience in response to a major outbreak of MERS in England.

The Cabinet Office is described in the report as having observer status. So does that mean that the Cabinet Office was not actively involved but was there in order to observe?

Mr David Cameron: I’m afraid I don’t know the answer to that question. I mean, I think – these exercises are good and it’s important they take place. I think Oliver Letwin’s evidence about they should happen with great regularity and at a senior level I think is absolutely right because –

Counsel Inquiry: Yes.

Mr David Cameron: – as I said earlier, you want in the end to have ministers asking questions about: right, well, what will we actually do? What needs to change? What needs to be put in place? And you want their attention to be focused on this.

Counsel Inquiry: Yes. Well, let’s have a look, please, at the recommendations of Exercise Alice.

They are in document INQ000056239. Thank you.

If we can go to page 16, please.

Here we are, the page of “Summary of lessons/actions identified”. I’m just going to read through a few of these.

At number 1:

“The development of MERS-CoV [special] instructional video on PPE level and use.

Number 4, to:

“Develop a MERS-CoV serology assay procedure [that’s blood tests searching for antibodies] to include a plan to scale up capacity.”

Number 7, to:

“Produce an options plan using extant evidence and cost benefits for quarantine versus self-isolation for a range of contact types including symptomatic, asymptomatic and high risk groups.

Just going back a little further up the page to number 5, to:

“Produce a briefing paper on the South Korea outbreak with details on the cases and response and consider the direct application to the UK including port of entry screening.”

Now, you may be aware that Professor Heymann, the esteemed epidemiologist, gave evidence to the Inquiry last Thursday, and he told the Inquiry that he thought that recommendation 5 was an extremely good idea, to learn from the experiences of South Korea in terms of their response to MERS and to see how those matters could be possibly adapted to the United Kingdom in the event of a similar pandemic.

Do you agree that that was a useful and important recommendation?

Mr David Cameron: Yes, I do. And, I mean, I think it’s – having read through, now, Alice, I – because ministers weren’t involved.

Counsel Inquiry: Yes.

Mr David Cameron: But, you know, there is a sentence in Alice which is “access to sufficient levels of PPE was also considered and pandemic stockpiles were suggested”. That’s a sentence in Alice but it doesn’t make it into the recommendations. So, I mean, if you’re asking were there failures – does it look like there were failure to follow through from this –

Counsel Inquiry: Yes.

Mr David Cameron: – I think the answer to that is yes.

Counsel Inquiry: Thank you.

At the same time – we can take that down, please – there was another exercise being planned, Exercise Cygnus. Now, although this was not delivered by Public Health England until you had left office, in fact it took place over two days between 18 and in 2014 but was postponed due to the Ebola response.

Were you aware at the time that Exercise Cygnus was being planned, Mr Cameron?

Mr David Cameron: I’m afraid I just don’t recall. I haven’t – in the papers, I haven’t –

Counsel Inquiry: Yes.

Mr David Cameron: – seen anything, sort of a note from an official saying, “There’s this exercise going on”. I mean, I’ve seen notes of me saying to Jeremy Hunt, “Let’s do an exercise on Ebola”, and I do remember that, but

I don’t remember – that doesn’t mean I didn’t get a note about it, but I haven’t been able to find one and

I don’t think you have.

Counsel Inquiry: All right. Well, we haven’t, no. But this was an exercise designed to assess the UK’s preparation and response to an influenza pandemic. The Inquiry has heard about it already and no doubt will continue so to do throughout the course of these public hearings. But it involved 950 representatives from the devolved administrations, the Department of Health, 12 other government departments, NHS Wales, NHS England, Public Health England, and eight local resilience forums, and six prisons took part in the exercise. Huge, then, in terms of organisation. October of 2016, planning for this exercise began I’d like to look briefly, please, at some of the recommendations from this exercise, whilst acknowledging again that you had left office by the time this report was produced.

Mr David Cameron: Yes.

Counsel Inquiry: Could we go, please, to page 30. Now, we can see that here we have the “Table of Lessons Identified”. I’m going to move through these quite swiftly, because the common theme of the recommendations that I’m going to highlight is capability and capacity in health and social care.

So we can see at KL 4:

“An effective response to pandemic influenza requires the capability and capacity to surge resources into key areas, which in some areas is currently lacking.”

LI 5, please, further down the page:

“Further work is required to inform consideration of the issues related to the possible use of population based triage during a reasonable worst case influenza pandemic.”

LI 16, please. Thank you.

“Expectations of the MoD’s capacity to assist during a worst case scenario influenza pandemic should be considered as part of a cross government review of pandemic planning.”

LI 17, please:

“The process and timelines for providing and best presenting data on which responders will make strategic decisions during an influenza pandemic should be clarified.”

If we can have LI 18, please:

“A methodology for assessing social care capacity and surge capacity during a pandemic should be developed. This work should be conducted with Directors of Adult Social Services and with colleagues in the Devolved Administrations.”

And finally LI 20:

“[Department of Health], NHS England, CCS and the Voluntary Sector and relevant authorities in the Devolved Administrations should work together to propose a method for mapping the capacity of and providing strategic national direction to voluntary resources during a pandemic. Given the experience of Exercise Cygnus, it is recommended that this work draw on expertise of non-health departments and organisations at national and local level.”

Standing back for a moment, Mr Cameron, and considering that these recommendations were made in October of 2016, would you have expected the government to have implemented the lessons learned from Exercise Cygnus by January of 2020?

Mr David Cameron: Well, you would … I don’t really want to comment on my successors, but, I mean, you would hope so. I mean, I’ve thought a lot about this, because, you know, having been back through all the paperwork and everything, I haven’t found any moment when I was asked or the Treasury was asked to approve sort of surge capacity for PPE supplies or anything like that. I think that’s because there wasn’t enough attention on the sort of pandemic that we ultimately experienced. But I hadn’t – I hadn’t – I don’t recall any recommendations like that. But these, as you say, are quite clear, and I think that the Treasury, while – I’m sure we’re going to come on to – money was tight and we made difficult decisions about public spending, when we did need to spend money on important priorities, when we had to spend money on Ebola, we did and we would.

Counsel Inquiry: All right. Well, before we come to deal with austerity and the effects of that on health and public health, I’d just like to draw together the lessons that we have just seen identified in these exercises.

So in Exercise Alice, we saw recommendations of a need to plan for scaling up testing capacity, for isolation and self-isolation options, for asymptomatic transmission and issues with the provision of PPE.

Do you know whether those matters were addressed during your time in office?

Mr David Cameron: What I know is that there were – there was capacity for isolation when we had the Ebola outbreak in Africa, and obviously there were some cases in the UK, but, you know, I would say that the problem with Alice was that it was a MERS outbreak with a very high degree of mortality, 35% mortality, but a very low case load. And so, again, that wasn’t anywhere close to the sort of pandemic we then actually experienced.

Counsel Inquiry: By the time you left office, do you accept, Mr Cameron, that there had not been any planning specifically of the effects of a pandemic? By that I mean this: there had been no planning, for instance, by the Department of Education, about the impact of school closures, had there?

Mr David Cameron: Well, the – I don’t know the answer to that. Somewhere in the bundle there’s mention of school closures, I think – is it with respect to Cygnet? But –

Counsel Inquiry: Certainly that it should be looked at, yes. It was raised as a recommendation.

Mr David Cameron: The point is, during my time in office, there were investigations into SARS and MERS and other types of pandemic, including Ebola.

Counsel Inquiry: Yes.

Mr David Cameron: But there wasn’t one into a highly transmissible coronavirus-style pandemic like we had, and so these questions weren’t asked.

Counsel Inquiry: But even in relation to an influenza pandemic, which had, as we have already established, been a Tier 1 risk during your whole time in office, here we have Exercise Cygnus, reporting just after you’ve left office, saying that there should be plans and research into the effect of school closures in the event of a pandemic. That hadn’t been done. It was being raised as a recommendation in Cygnus on your departure from office because that planning hadn’t been done, had it?

Mr David Cameron: Well, it had been – it was raised – as far as I can see, that’s the first time it was raised.

Counsel Inquiry: Yes.

Mr David Cameron: After I’d left office.

Counsel Inquiry: Yes, which means that that type of planning was absent during your time in office.

Mr David Cameron: But I don’t – I haven’t seen a report while I was in office saying that sort of planning should be done, because the pandemic preparedness plan, which had been worked up by the previous government and then amended and improved and enhanced during my time in office, there were lots of recommendations made and all sorts of things about stockpiles of Tamiflu and all the rest of it, but it didn’t go into things like school closures.

Counsel Inquiry: No. Had there been any planning of the economic, political and social consequences of the imposition of restrictions in the event of a pandemic?

Mr David Cameron: Well, the answer to that is, first of all, our whole economic strategy was about safeguarding and strengthening the economy and the nation’s finances so that we could cope with whatever crisis hit us next. And I think that’s incredibly important because there is no resilience without economic resilience, without financial resilience, without fiscal resilience. And so that was absolutely line one of our plan of dealing with any unexpected crises.

Also I think I’m right in saying that in the National Risk Registers in 2014 and subsequently, there was quite a lot of examination of how to respond to different catastrophic economic problems that these sorts of pandemics would bring about. There was national business resilience planning going through area by area looking at what you might have to do.

But I think all of those – I mean, a plan, you know, is only as good as the financial and economic capacity of a country to deliver it, and that was the most important thing of all.

Counsel Inquiry: You’ve told the Inquiry that as soon as you came into office in 2010 and you made significant improvements to the architecture of planning and resilience, that one of your major intentions was that that would lead to a whole-system –

Mr David Cameron: Yeah.

Counsel Inquiry: – level of preparedness. Do you accept that you failed in that desire? By the time you left government in 2016 there wasn’t wholesale preparation and resilience, was there?

Mr David Cameron: I don’t accept that, because we set up a much superior architecture for looking at risks, for judging risks, and planning for risks, and that’s what the National Risk Register, the National Security Secretariat, the National Security Council did, and I think there was more attention, including more attention of senior politicians, onto those sorts of risks than there had been previously. But, as I’ve said, the problem was that when pandemics were looked at, there was too much emphasis on pandemic flu, and when other pandemics were looked at, including Ebola, including MERS, they tended to be high fatality but low infection, and, you know, the regret – and you see it in Oliver Letwin’s evidence, you see it in George Osborne’s evidence – is more questions weren’t asked about the sort of pandemic that we faced. But I think many other countries were in the same boat, of not knowing what was coming. But I would argue we did more than many to try and scan the horizon, to try and plan. We did act on Ebola, we did carry out these exercises, we did try to change some of the international dynamic about these things, and we planned and prepared in accordance with that.

Counsel Inquiry: The evidence of Mr Mann and Professor Alexander that was received by the Inquiry last Thursday included them posing this question: who is in charge of keeping the country safe?

What is your answer to that question?

Mr David Cameron: Well, the Prime Minister is always in charge of keeping the country safe, and under my reforms the Prime Minister was much more actively involved because he was chairing the National Security Council, the National Security Adviser was appointed by him, reported to him, and in my case I’d set up a specific subcommittee on threats, hazards and resilience that looked exactly at this area with a highly capable minister in. I’m sure there are further improvements we can make, and the government has announced some which seem to me sensible, with the proviso that I made.

But at the pinnacle of it must be the Prime Minister, because, from all my experience of chairing COBRs, whether it was during terrorist problems or Fukushima nuclear disasters or Ebola or anything else, the system works extremely well, but the system works better when the Prime Minister is in the chair asking questions, driving changes and making sure decisions are made.

So my answer is: it’s the Prime Minister.

Counsel Inquiry: Thank you.

We’ve dealt with your concerns around the World Health Organisation and how you sought to deal with those, so I’m now going to move on to the final area of questioning, the impact of austerity on the health and social care service and underlying health inequalities.

I’d like to display, please, paragraph 26 of George Osborne’s witness statement, which we have at INQ000187308. Paragraph 26, please.

“Reducing the deficit and placing debt as a percentage of GDP on a downward path was also essential to rebuild fiscal space to provide scope to respond to future economic shocks. A responsible approach to repairing the UK’s public finances following the financial crisis was essential. I have no doubt that taking those steps to repair the UK’s public finances in the years following the financial crisis of 2008/09 had a material and positive effect on the UK’s ability to respond to the Covid-19 pandemic. The most urgent task facing the UK economy, as stated in Budget 2010 … was therefore to implement an accelerated plan to reduce the deficit. Indeed, there was cross-party consensus on the need to reduce the deficit following the financial crisis.”

You have also made reference, Mr Cameron, to the need for this to happen and, in your view, for the positive effect that that had on the state of the country’s finances going into the Covid-19 pandemic.

I make it clear – we can take that down, please – that the purpose of the following questions that I have for you is not to explore whether that policy was right or wrong. That is no part of this Inquiry, to descend into those political areas. But what we are interested in are the impacts and consequences of that policy in three areas, please: health, inequality and societal resistance.

The Health and Social Care Act of 2012 changed the landscape of public health, did it not, because it transferred to local authorities public health features, and the involvement of directors of public health?

So from that time, from 2012, those areas of public health were no longer funded through the Department of Health, in the way that they had been before.

Mr Osborne says, at paragraph 71 of his witness statement – we don’t need to put this up – that the Department of Health’s budget from 2011 to 2012 until 2014 to 2015 was to increase in real terms in each financial year, and that that growth occurred in circumstances where all other departmental budgets, other than overseas aid, were cut by an average of 19% over the same period.

He also goes on to say that in 2010 the budget for public health was ringfenced, but of course, as we’ve just discussed, that was only relevant up to 2012, at which point in time public health was no longer funded through the Department of Health.

Do you accept, Mr Cameron, that the health budgets over the time of your government were inadequate and led to a depletion in its ability to provide an adequate service?

Mr David Cameron: I don’t accept that, neither on a sort of big picture level or on a small picture level. I mean, the big picture level, I don’t think you can separate the decision and the necessity of getting the budget deficit down and having a reasonable debt to GDP ratio, so you can cope with future crises, I don’t think you can separate that from the funding of the health service or indeed anything else.

I mean, if you lose control of your debt and you lose control of your deficit and you lose control of your economy, you end up cutting the health service. That’s what happened in Greece, that’s what happened in countries that did lose control of their finances. So I don’t think you can separate the two.

So we made the important decision to say that the health service was different, its budget would be protected, and so there were real terms increases every year and so, for instance, there were 10,000 more doctors working in the NHS at the end of the time I was Prime Minister than there were at the beginning.

Would everyone like to spend even more on the health service? Yes. I mean – you know, making these difficult choices about spending was – it wasn’t a sort of option that was picked out of thin air. I believed, and I still believe, it was absolutely essential to get the British economy and British public finances back to health, so you can cope with a future crisis.

Counsel Inquiry: The Inquiry has received witness statements from Jeremy Hunt, who was the Secretary of State for Health, and then Health and Social Care, from 2012 to 2018. Were you aware that during the time that you were in power, Mr Hunt laboured considerable concerns about the structural problems within NHS capacity and the workforce and funding, as he has set out in his witness statement?

Mr David Cameron: I’ve read his witness statement. I – he was a very capable health secretary. I worked with him extremely closely. Of course he was always batting for the NHS and for all the extra resources he could get. These decisions were arrived at collectively. I agree with a lot of what’s in his witness statement, you know, where he says there’s more that could be done, for instance, for future workforce planning. But I will absolutely defend the record of the government in both getting control of the finances and increasing funding for the health service at the same time.

Counsel Inquiry: Aren’t these concerns, Mr Cameron, that Jeremy Hunt sets out, structural problems with the NHS and workforce and capacity, the real issues which preparedness for a public health emergency needs to address, not papers and guidelines and protocols, but action to remedy fundamental problems?

Mr David Cameron: Well, I think what’s needed to prepare for a pandemic is, first of all, you’ve got to have that overall economic capacity. As George Osborne puts in his statement, without our action you could have had almost a trillion of extra debt, and you would have – as well as a coronavirus crisis and a public health crisis, you’d have a financial and economic and fiscal crisis at the same time.

But I think the answer to your question is that the best way to prepare is to have a strong economy and the next thing you need to do is prepare for all of the relevant pandemics that you might face, and we’ve already discussed where, you know, the system I think didn’t spend enough time on the sorts of pandemic that we did end up facing.

Counsel Inquiry: Do you accept, Mr Cameron, that the government was repeatedly warned about growing pressures on the NHS? Firstly, from the Nuffield Trust annual statement in 2015, which detailed growing concerns that demand was outstripping capacity and “the warning lights on care quality now glow even more brightly”, and finally, in 2016, in the Nuffield Trust annual statement, before you left office, which stated:

“Slowing improvement in some areas of quality, combined with longer waiting times and ongoing austerity suggests the NHS is heading for serious problems. It seems likely that a system under such immense pressure will be unable, at some point, in some services, to provide care to the standards that patients and staff alike expect.”

Mr David Cameron: Well, of course there were pressures on the NHS, as there were pressures on many public services, but at the end of my time in office I think public satisfaction with the National Health Service was still extremely high. I think the King’s Fund, it might have been, was ranking it as one of the most successful health systems in the world. We’d virtually abolished mixed sex wards, we’d got hospital infections down, we were carrying out 40% more diagnostic tests every week. There were successes in the NHS as well as pressures. But there are – you know, there are always pressures on these services, and our job was to try and sort out the economy, which we did, so we could then have bigger increases in health spending, which then followed.

Counsel Inquiry: In preparation for your evidence today, you were invited to consider the witness statement of Professor Kevin Fenton, who was the president of the United Kingdom Faculty of Public Health, which is a professional standards body for public health specialists and practitioners, with over 4,000 members.

You will know, then, that according to Professor Fenton, health protection teams saw successive reductions in funding and capacity over the pre-pandemic years and a lack of investment in regional emergency preparedness, response and resilience teams. The summary of his evidence as provided to the Inquiry, so far in written form, is that there was no ringfencing of funding to local government for health protection, that health protection teams had their funding reduced and their capacity reduced, and that ultimately this resulted in a lack of capacity for pandemic preparedness.

What’s your response to that, please?

Mr David Cameron: Well, I read the Fenton report, as the other reports. I thought … I mean, I don’t want to be too critical, but throughout all of them I thought there was very little acceptance that it is possible to reform public sector organisations, sometimes to merge them and get rid of duplicating bureaucracies and overheads and get more output for the same amount of money.

I thought in Kirchelle, in Marmot, in Fenton, there was just this assumption that you only ever measure inputs rather than measuring outputs. So, for instance, I would say that the creation of Public Health England, where it was merging together a lot of other bodies, increased the focus on public health, meant money was spent more wisely, and I would argue also that the Health and Social Care Act, by putting public health into local authorities, that was the right place for it. Local authorities are responsible for housing and for education and for licensing, and so making them responsible for public health is very logical, and even – I think most of the experts coming to your Inquiry, I don’t think people are arguing to turn the clock back and put it into the health service.

So I think these were good reforms, and yes, we faced very difficult financial circumstances, but where we could we tried to encourage the spending of money more wisely and sometimes the merging of public bodies was a sensible thing, but they don’t seem to give that much credence.

Counsel Inquiry: Well, you’ve mentioned the evidence of Professor Sir Michael Marmot and Professor Clare Bambra, you’ve clearly read their report, and you will know that they gave evidence to this Inquiry on Friday. Do you accept their evidence, Mr Cameron, that health inequalities increased during your time in office?

Mr David Cameron: Well, I accept – I mean, I’ve read their reports.

Counsel Inquiry: Yes.

Mr David Cameron: I accept that after 2011 in lots of countries in the world life expectancy continued to improve but didn’t continue to improve so quickly. Now, their conclusion is to look a lot at austerity and what have you. I’m not sure the figures back that out. We had some very difficult winters with very bad flu pandemics, I think that had an effect. We had the effect that the improvements in cardiovascular disease, the big benefits had already come through before that period and that was tailing off. Then you’ve got the evidence from other countries. I mean, Greece and Spain had far more austerity, brutal cuts, and yet their life expectancy went up. So I don’t think it follows, and I found – you know, I mean, there is one sentence in Bambra and Marmot that just baldly says, you know, child poverty increased. Well, actually, the number of children living in absolute poverty went down, the number of people living in absolute poverty went down, the number of pensioners living in absolute poverty went down very considerably. So I –

Counsel Inquiry: So you don’t agree with it?

Mr David Cameron: Well, I mean, they’ve got lots of important evidence and I’ve looked at it very carefully and will think about it very carefully, but I did find their – I found that they had leapt to a certain set of conclusions quite quickly, not all of which was backed up by the evidence. And they don’t mention the evidence that I’ve just mentioned, which I think is quite important.

I mean, added to the fact that I agree with Professor Bambra that social and economic conditions have a big bearing on health inequalities, and so therefore the fact that there were 2.6 million more people in work, there were over half a million fewer children in households where no one worked, these are – there were – obviously a big dent in pensioner poverty because of the triple lock and the increase in the pension. These are positives as well, which – they don’t seem to get mentioned in the same way.

So I had my problems with them, but I’m sure that the Inquiry can look at all the evidence and come to its conclusions.

Counsel Inquiry: Do you accept that cuts to public health budgets tended to be largest in the most deprived areas and that, as a result, local authorities working with the most vulnerable populations faced the biggest challenges in carrying out their public health functions?

Mr David Cameron: No, I don’t necessarily accept that. The way the local authority spending decisions were made was to try to make sure that the reductions in spending power in each local authority were broadly equivalent, and obviously when you’re looking at spending power you’ve got to look at the grants from central government to local government, the business rate revenue and the council tax revenue. So, for instance, I mean, I checked this last night, the 2015 settlement was for a – no council should lose more than 6% of its spending power. So that does affect different councils in different ways in terms of their grant, but it affects them in a more similar way when it comes to spending power, and it’s obviously the spending power that –

Counsel Inquiry: Yes.

Mr David Cameron: – (inaudible) that matters, and I think that’s a better way of measuring it.

Counsel Inquiry: All right.

Were you aware whilst in government of evidence that people from lower social economic groups and minority ethnic groups would be more likely to be affected by whole-system catastrophic shocks?

Mr David Cameron: I think it was well known, and I knew, that when you have health pandemics of any sort you get differential effects on different parts of the population.

Counsel Inquiry: Yes.

Mr David Cameron: I think as coronavirus turned out, the biggest category – that’s the wrong word, the biggest impact was obviously on older people, but many of our policies were directed towards lifting people out of poverty, the – more jobs, the first national living wage, the big increase in the minimum wage, taking 4 million people out of paying income tax. All of these things, the reform of universal credit and the reform of welfare and the whole effort of getting people out of without of welfare and into work, all of these things have an economic and social benefit, but also have a health benefit too.

Counsel Inquiry: The Inquiry saw last Friday that pre-existing health inequalities only featured minimally in the UK pandemic planning, in fact they were barely mentioned at all. Do you accept that this was a significant omission?

Mr David Cameron: I think all plans can be improved and updated, and I’ve read the evidence about that, and I’m sure that future plans will. But if you’re asking was it – you know, did you understand, did your government understand the importance of trying to left people out of poverty and into work and into prosperity, yes, absolutely, that’s what the whole plan was about.

And going back to this economic thing, because it is important, you know, over the period of my government, in the G7, after America we had the fastest growth of GDP and fastest growth of GDP per head. So this is important, because ultimately, your health system is only as strong as your economy, because one pays for the other.

Counsel Inquiry: Do you agree that different political decisions will have to be made in the future if a strong public health system is to be nurtured to withstand another pandemic?

Mr David Cameron: I think different decisions – well, I think we need to improve the way we look at pandemics and the way we plan our resilience, because while, as I’ve said, you know, the architecture was there, the structure was better, the involvement of ministers was better, the dialogue between ministers and civil servants was good, there is this gap that I keep coming back to, which is: how do we make sure that you’re not subject to groupthink, that you don’t plan for one type of pandemic, because it’s very current, it’s very risky, it’s very dangerous? You need to have teams going in to question the assumptions. And, I mean, the biggest one was this issue about asymptomatic transmission.

I kept looking through all these documents, looking for, “What about a pandemic with wide-scale asymptomatic transmission?” And if that question had been asked, then a lot of things would follow from that.

You know, in Jeremy Hunt’s evidence, the hospitals in Hong Kong had to have three months of PPE supplies. I was never asked: can we have funding for three months’ PPE supplies for every hospital? But had I been asked, we would have granted it. That’s not expensive. That’s not a huge commitment. But that comes out of planning for the right sort of pandemic.

So, you know, all these questions about economic policy, we can have an argument about was it the right economics or the wrong, I think it was the right economic policy, but the real problem was time spent quizzing the experts on what potential pandemics were coming, and preparing for those in the right way, and the questions that would follow from that.

Ms Blackwell: Thank you.

My Lady, that concludes my questions of Mr Cameron. I know that prior to today permission has been given to Ms Mitchell King’s Counsel on behalf of Scottish Covid Bereaved Families for Justice to ask a short series of questions. May she be allowed to do that?

Lady Hallett: Certainly. I would normally break now, but if the stenographer can carry on for Ms Mitchell’s questions?

Thank you very much.

Ms Mitchell.

Questions From Ms Mitchell KC

Ms Mitchell: I’m obliged.

Mr Cameron, I’m senior counsel instructed by Aamer Anwar & Co for the Scottish Covid Bereaved.

You have made it clear both in your written evidence and your evidence here today that you understood that pandemics were a very real threat, and you might not have understood or remembered the phrase “clear and present danger”, but you would agree with me that, as a Tier 1 risk, is certainly was something that was immediate, important and potentially grave in terms of risk?

Mr David Cameron: Yes.

Ms Mitchell KC: We’ve also heard that, given pandemics have happened throughout history, it was a matter of when and not if a pandemic would occur?

Mr David Cameron: Yes.

Ms Mitchell KC: Your language, indeed, “We will face an outbreak like Ebola”, made it clear that you understood effectively that a pandemic was inevitable?

Mr David Cameron: Yes.

Ms Mitchell KC: You also referred to it I think here and also in your statement about taking a longer-term strategic view and trying to fix the roof while the sun is shining. Presumably because whilst things are good you put plans in place so that when the pandemic arrives, it will allow those to deal with it, to weather the storm safely?

Mr David Cameron: Yes.

Ms Mitchell KC: Because presumably you appreciated that failure to properly plan would be likely to have a catastrophic effect for the United Kingdom?

Mr David Cameron: Yes.

Ms Mitchell KC: Can I ask you to look at the following document. It’s document INQ000087193, and we’re looking at page 7 of that document.

While we’re waiting for that document to come up on screen, this is a document from the Public Accounts Committee of the House of Commons entitled “The whole of government response to Covid-19”.

Now, I’d like to draw your attention, please – I’ll wait until it arrives on screen – to the heading “Conclusions and recommendations”.

Mr Keith: My Lady, I’m extremely sorry to have to get to my feet. My learned friend knows very well that we’re constrained by the rules of Parliamentary privilege, not to be able to put Parliamentary material which includes NAO reports in a way which calls into debate the merits of whatever conclusions have been drawn by the particular Parliamentary body or anything in fact said in the chamber of the House of Commons.

So I’m just a bit concerned that we may be breaching Parliamentary privilege by going down this line of examination.

Ms Mitchell: Well, there’s certainly a way, my Lady, that I can ask the questions without having to refer to those documents, so I’ll be able to do that in that way.

I’m obliged to my learned friend for highlighting that before that route was gone down.

Lady Hallett: Thank you.

Ms Mitchell: While you were in government and when you were Prime Minister, did you make any plans for the effect economically on individuals in the United Kingdom?

Mr David Cameron: Well, I think, as I answered earlier, there are two answers to that. One is, the biggest thing was to get the British economy and the public finances in a state where they were capable of responding to the next crisis, because, just as I answered earlier, you know, we will have another pandemic, we will have another economic crisis of some sort, whether it’s a recession or a banking crisis or an insurance … who knows what it will be. The question is: do you have the capacity, do you have the spare capacity to suddenly borrow another 10, 15, 20% of your GDP to help the country and help people through it? That’s the key question. And that was very much in my mind when we drew up the plan to reduce the budget deficit and get the debt/GDP ratio under control, because that’s the responsible thing to do.

The second answer is that, as I think I said, in the national risk assessments there’s quite a lot of people about national business resilience planning, working out, if you had a pandemic flu, and even with the pandemic flu we were looking at, which would have had, you know, hundreds of thousands of deaths and a huge effect on the economy, what do you do to help the various sectors of the economy to recover?

So to that extent, yes, there was a plan.

Ms Mitchell KC: Well, your plan was about the country. What I was asking you about, and if I’d ask you to focus on the question: was there a plan made for the economic impact on individuals during a pandemic?

Mr David Cameron: Well, until you know exactly what pandemic you face and whether you’re going to need to have people at home, so you have a furlough plan, or you’re going to have to act in a different way, and you might need to cut VAT or change tax rates or … you know, you need to have – those decisions could be made very quickly, as they were, to the credit of the Chancellor, when the pandemic hit, but you need to have the capacity in the economy to do it.

Ms Mitchell KC: You clearly understood that the effect of a pandemic might mean that people were sick and weren’t able to attend work and businesses might have problems?

Mr David Cameron: Yes.

Ms Mitchell KC: Did you, while you were in government, put any plan – make any plans, have any conversations about what a furlough might look like, about what an economic plan might look like? Were those discussions had?

Mr David Cameron: Well, I can’t remember every discussion I had, but I have seen that in the national risk assessments those sorts of things are looked at. And obviously in government, when we were looking at the threat of pandemics or the threat of terrorist attacks, or the threat of something worse, you know, a major terrorist attack that could take out a whole city, what would you do in order to keep the economy going and help people, yes, we did have those conversations.

Ms Mitchell KC: What I’m actually specifically asking about, though, is not at the level that you’re talking about; I’m talking about the individuals who would not be able to go to work. I’m talking about the businesses that needed to keep going. There were no concrete plans made for that; correct?

Mr David Cameron: Well, I mean, you keep asking me this. I mean, I think – I will have to go back over the national risk assessments – I think there were plans looking at individual sectors and businesses and what would have to be done. So – but maybe I can look that again and give you a written answer, because I … I don’t want to say there’s something in them that there isn’t. But I think they do address some of these questions.

Ms Mitchell KC: I’m sure the Inquiry would be greatly assisted if you can find anything in relation to the economic planning, but as of today’s date you can’t think of anything?

Mr David Cameron: Well, I can, which is, if you have a strong economy and good public finances, you can flex your tax, your benefit system, your spending. You have the enormous financial capacity of the British state to act and help people.

Ms Mitchell KC: We now know that over 227,000 people died from Covid, and we’ve heard evidence that the UK was not prepared for a pandemic. We’ve heard evidence that, after years of underfunding, cuts, inequalities, that this impacted upon the devastating scale of the death.

In retrospect, do you agree that, as Prime Minister, it would have been wise for you to plan for economic impacts of the pandemic? And I mean by that the furloughs and the business schemes. So you had a plan readymade, off-the-peg, available to implement, so that the government was not left scrabbling around and making ad hoc decisions in very fast time right at the very moment when they could have better been focusing on other matters like the pandemic?

Mr David Cameron: Well, I just – I’m afraid, with great respect, I’m not sure I agree with the premise of the question. I mean, the furlough scheme came in very quickly, very boldly, and made an enormous difference, and that was possible because we had the financial capacity to do it. But it proves the point that, you know, for all the plans you can have in the world, until you actually see the nature of the pandemic and how it’s developing, planning in advance exactly what your economic responses are going to be is only of, I would argue, limited use.

Ms Mitchell KC: It would certainly be useful, though, to have an economic response which took into account something you knew which would happen, which is people would be sick and off work.

Mr David Cameron: Yes, but what you don’t know is: are you going to have a pandemic where people who are symptomatic stay at home, or are you going to have a pandemic where, effectively – I mean, the committee I’m sure will decide whether right or wrong – you have a lockdown and everybody stays at home? So these are two, you know, different types of pandemic requiring two different types of economic response.

Ms Mitchell KC: Despite what you say about planning, do you accept that when the pandemic arrived, the UK still found itself in a situation where essential medical items, such as the ventilators, stockpiles of PPE, hygiene control were not still readily available?

Mr David Cameron: Well, clearly there were problems when the pandemic hit, and I think this does go back to identifying the different sorts of pandemic that could hit you and planning for each one. And I come back again and again to this issue about, you know, asymptomatic transmission of an easily transmitted virus, which is, yes, lethal, but much lower than MERS or lower than Ebola, and that’s what we had, and, you know, more – if more time – if more questions had been asked inside the system or challenging the system about that, then lots of consequences about PPE and about surge capacity and Nightingale hospitals and all the rest of it, a lot of consequences might have followed.

Ms Mitchell KC: So we were not only preparing for the wrong pandemic but the wrong questions were being asked? Can I ask –

Mr David Cameron: So I think it was more we were – I think it’s wrong to say we were preparing for the wrong pandemic. I mean, there could easily have been – there could still be a pandemic flu and it’s good that we have been prepared for that, but as Oliver Letwin says in his evidence and George Osborne says in his, and they put it perhaps better than I have, a lot of time was spent preparing for a pandemic that didn’t happen rather than the one that did happen.

Ms Mitchell KC: In retrospect, Mr Cameron, do you think that, as Prime Minister, your government’s failure to plan for the economic impacts on individuals and businesses played any role in the catastrophic loss of lives when the storm of Covid-19 arrived in the UK some four years after your departure?

Mr David Cameron: Well, I’m desperately sorry about the loss of life. So many people have lost people who are close to them, and there has been a lot of heartache, and obviously that continues, and people also suffered in all sorts of ways through the pandemic. That’s why this Inquiry is so important. I’ve tried to be as frank as I can and as open as I can about the things my government did that helped put in place the right architecture for looking at these threats: the horizon scanning, the units we put in place, the exercises that were undertaken. But I’ve also tried to be frank about, you know, the things that were missed, and the thing I struggle with is why they were missed, because – you know, it was not asking questions about asymptomatic transmission of an easily infectious disease with a certain level of lethality that we hadn’t seen before but nonetheless might appear. You know, that is, I think, where some of the difficulties flow from.

I mean, there’s then a whole question of how the response is actually managed in practice, which I know the committee will come on to.

Ms Mitchell: My Lady, I have no further questions.

Lady Hallett: Thank you very much, Ms Mitchell.

Ms Blackwell: That concludes Mr Cameron’s evidence.

Lady Hallett: Thank you very much for your help, Mr Cameron.

(The witness withdrew)

Lady Hallett: I’m also being encouraged to break now so that the stenographer can rest her work fingers. I’m also being encouraged to resume at 12.45 and then sit until 1.30, and then have lunch. Is that going to cause people serious problems? If it doesn’t, then I will return at 12.45.

Ms Blackwell: Thank you, my Lady.

(12.30 pm)

(A short break)

(12.45 pm)

Ms Blackwell: My Lady, just before we return to the evidence, may I invite you to provide permission for Mr Cameron’s witness statement to be published.

Lady Hallett: I do.

Ms Blackwell: It was put up on screen at the beginning of his evidence. Thank you.

Lady Hallett: Thank you very much.

Mr Keith: My Lady, Sir Christopher Wormald, please.

Lady Hallett: Sorry to keep you waiting, Sir Christopher.

The Witness: No problem.