2. Ms Caroline Lamb

MS CAROLINE LAMB (affirmed).

Questions From Lead Counsel to the Inquiry

Mr Keith: Could you give the Inquiry your full name, please.

Ms Caroline Lamb: Yes, Caroline Sarah Lamb.

Lead Inquiry: Thank you very much for your assistance in this Inquiry, Ms Lamb.

As you give evidence, could you please remember to keep your voice up so that we may clearly hear you and so that your evidence can be recorded by our hard working stenographer.

You’ve provided two corporate witness statements; is that correct?

Ms Caroline Lamb: That is correct.

Lead Inquiry: Both of which I know you’ve signed and both of which contain a statement of truth.

Ms Lamb, are you currently the Director General for Health and Social Care and also the Chief Executive of NHS Scotland?

Ms Caroline Lamb: I am, and would it be possible for me to just say a few words in that capacity?

Lead Inquiry: Of course.

Ms Caroline Lamb: Thank you. Just before we start, I’d like personally, but also on behalf of NHS Scotland and the Director General for Health and Social Care at the Scottish Government, to express my condolences to everybody who was affected by the Covid-19 pandemic. I’d like to affirm our commitment to learning from this Inquiry, and I’d also like to express my huge thanks to all those who worked across health and social care, and indeed our partners in local government, in the third sector, everybody who contributed towards helping to support the people in Scotland through the pandemic. Thank you.

Lead Inquiry: Are you the most senior official in Scotland in relation to the field of health and social care, that is to say within the Scottish Government?

Ms Caroline Lamb: I am.

Lead Inquiry: I believe that formerly you worked in the NHS in Scotland, you were the chief executive of NHS Education for Scotland, a post that you held from 2015, and then in 2019 you moved closer to the heart of the Scottish Government by leading the Digital Health and Care Directorate from December 2019.

From March 2020 you took on certain roles relating to the ICU surge requirements in the Scottish NHS, in relation to Covid, and you became the delivery director for the extended seasonal flu and Covid vaccination programme, and then you took up your present post, as you’ve said, in January 2021; is that correct?

Ms Caroline Lamb: Yeah.

Lead Inquiry: Now, given that you’re the first senior official in charge of the Scottish public health system to give evidence, I want to just take you through very briefly some of the structures in the organisations which play important roles in the Scottish public health system.

Public health is devolved, is it not, under the Scotland Act 1998?

Ms Caroline Lamb: That’s correct.

Lead Inquiry: Therefore it is something that is run from Scotland and, of course, not from Westminster?

Ms Caroline Lamb: No.

Lead Inquiry: There are in the Scottish Government, are there not, a variety of public health divisions?

Ms Caroline Lamb: Yes.

Lead Inquiry: Health protection, health improvement, drugs policy, Active Scotland and, since the pandemic, two or three further divisions; is that correct?

Ms Caroline Lamb: That’s correct, yes.

Lead Inquiry: All these divisions are based within the directorate of Population Health, and that directorate comes within your general purview of general health and social care?

Ms Caroline Lamb: Yes.

Lead Inquiry: All right.

Could we have, please, up on the screen the organogram INQ000204014, at page 6, which we will recall is the page relating to the structures within Scotland in 2019.

(Pause)

Lead Inquiry: There we are, thank you.

So just to familiarise ourselves, please, Ms Lamb, we can see there in the big yellow box in the middle the “Scottish Government”?

Ms Caroline Lamb: Yeah.

Lead Inquiry: We can see the “Scottish Government Resilience (Ministerial)” and the “(Officials)”, the two entities to which the previous witness referred.

Underneath the yellow box, the “Health and Social Care Directorates”. Is that the directorate with which you’re concerned?

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: We can see in there a number of entities: the Chief Medical Officer, Deputy Chief Medical Officer, Chief Nursing Officer and so on, to whom we’ll return shortly.

Could you just explain where, in the general field of things, that part of the Scottish Government concerned with emergency preparedness, resilience and response comes into it?

Ms Caroline Lamb: Yeah, the health –

Lead Inquiry: Is that a separate division within the Health and Social Care Directorates, or is it another directorate?

Ms Caroline Lamb: It sits within what’s currently known as the directorate of the Chief Operating Officer in NHS Scotland.

Lead Inquiry: Is the directorate of the Chief Operating Officer within the directorate of Health and Social Care?

Ms Caroline Lamb: It is, yes.

Lead Inquiry: So we would put that within the blue box in the middle.

Is that emergency preparedness, resilience and response division what was formerly called the “Health Resilience Unit”, and does that function, the emergency preparedness, resilience and response function, exist to work with and support the NHS health boards for which you are responsible because you are the chief executive?

Ms Caroline Lamb: That’s correct.

Lead Inquiry: All right. NHS Scotland has a number of parts to it, does it not?

Ms Caroline Lamb: It does, yes.

Lead Inquiry: I think there are a number of territorial health boards; is that correct? 14?

Ms Caroline Lamb: 14, yeah.

Lead Inquiry: Those health boards have responsibility for the population’s health and the delivery of frontline medical services and healthcare within their geographical boundaries; is that correct?

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: All right. Are there four NHS statutory bodies operating at national level in Scotland?

Ms Caroline Lamb: So there are actually eight bodies operating at a national level. You will see on the diagram seven of them are referred to as “Special Health Boards” and one is referred to as “Healthcare Improvement Scotland”. I believe that actually National Services Scotland, formerly the Common Services Agency, is also a corporate body rather than a special health board, so maybe this diagram needs a bit of tweaking.

Lead Inquiry: I think the tweaking is already under way, Ms Lamb.

Ms Caroline Lamb: Okay.

Lead Inquiry: The four major NHS statutory bodies, though – and we need to identify them because we’ll see them on the face of the papers – are: Public Health Scotland, NHS National Services Scotland, which we often see as NHS NSS, NHS Education for Scotland, and Healthcare Improvement Scotland; is that correct?

Ms Caroline Lamb: They are certainly the four bodies most relevant to public health in Scotland, yes.

Lead Inquiry: Yes, and there are four others which are perhaps a little less important for our purposes although no less important in the delivery of healthcare in Scotland: NHS 24, NHS Golden Jubilee and so on. All right.

Towards the bottom of the page you will see, at the bottom left, “Local Authorities” and “Emergency Planning Officers”.

There are 32 local authorities in Scotland. Do they play a pivotal role in the provision of healthcare or social care?

Ms Caroline Lamb: They play a pivotal role in the – having the responsibility for social care. They also play a role in relation to public health, so they have responsibilities in relation to communicable diseases and also environmental health.

Lead Inquiry: Is that because local authorities exist under statutory obligations in relation to communicable diseases?

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: I think under the Scotland Act or the public –

Ms Caroline Lamb: Public Health –

Lead Inquiry: Public Health Act 2008.

Ms Caroline Lamb: Yeah.

Lead Inquiry: Then the CMO, currently Ms Calderwood, is the CMO – at the top left-hand corner – of the Health and Social Care Directorates?

Ms Caroline Lamb: The CMO currently is Sir Gregor Smith.

Lead Inquiry: I apologise. We are due to hear from Ms Calderwood, I think Dr Gregor Smith’s predecessor?

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: The CMO is the most senior medical adviser to the Scottish Government and to NHS Scotland, of which you are the chief executive, and does the CMO therefore report to you, not because you are the chief executive of the NHS but because you are the director general for Health and Social Care?

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: All right. And there is a Deputy Chief Medical Officer as well, we can see, and a Chief Nursing Officer, one or two other bodies to which we’ve seen reference. Is there a body now called Public Health Scotland?

Ms Caroline Lamb: There is, yes.

Lead Inquiry: What was it formerly known as?

Ms Caroline Lamb: Public Health Scotland came into being on 1 April 2020. It brought together parts of organisations, so it was formed out of the health protection Scotland and information services division, which were previously part of National Services Scotland, and NHS Health Scotland, which was a separate organisation.

Lead Inquiry: All right.

On the subject of, while we’re still at the strategic level, if you like, in relation to health services and healthcare in Scotland, is there a body or a framework which exists to promote operational co-operation between the Scottish Government and national public health organisations in the rest of the United Kingdom, to which all the CMOs contribute?

Ms Caroline Lamb: Yeah.

Lead Inquiry: A common framework?

Ms Caroline Lamb: Yes, there is a common framework. There was – I think in the period prior to the pandemic, the Scottish Government had a memorandum of understanding with Public Health England, and that’s now been developed, since Public Health England no longer exists, into a common framework, yes.

Lead Inquiry: All right.

Do you have or have you ever had much by way of dealings with SAGE, the Scientific Advisory Group on Emergencies?

Ms Caroline Lamb: Not personally, however there is – the Scottish Government, Scottish Ministers are able to get advice from SAGE.

Lead Inquiry: Yes, and we can see them at the top of this page, can we not? There is no Scottish SAGE, is there?

Ms Caroline Lamb: That’s correct, there isn’t.

Lead Inquiry: So when SAGE, which isn’t a standing committee, convenes in London by the Government Chief Scientific Adviser and is chaired by the Government Chief Scientific Adviser or, in health emergencies, co-chaired with the English Chief Medical Officer, will members of the Scottish Government attend that committee if it is an emergency which concerns Scotland?

Ms Caroline Lamb: Yes.

Lead Inquiry: Is it therefore well known that, for the purposes of dealing with health emergencies, the Scottish Government may avail itself of advice both from SAGE, the Scientific Advisory Group for Emergencies, and also from NERVTAG, which is the committee on the top left of the screen?

Ms Caroline Lamb: Yes, that’s correct, yeah.

Lead Inquiry: Are you able to express any views as to whether or not that system works well, in your experience?

Ms Caroline Lamb: I don’t think I can express those views.

Lead Inquiry: All right.

There is also, as we’ve heard a few moments ago, a pandemic flu readiness board, which is towards the top of the page – thank you very much.

Ms Caroline Lamb: Yep.

Lead Inquiry: Very quick off the draw.

“Pandemic Flu Readiness Board and Programme”, and is that the Scottish pandemic flu readiness board and programme – I think it’s the Scottish one – set up following the order of the then Prime Minister and the National Security Council THRC committee in 2017?

Ms Caroline Lamb: I’m not sure which one that is. There were two, so there was the UK and the Scottish one, so I’m not sure what that one is.

Lead Inquiry: I think, because that is absent from pages 7 and 8 – we might just track this down.

Can we have page 7 and then 8.

If it’s missing from 7 and 8 then this will, on page 6, will the Scottish body.

It’s absent, so I think that is the Scottish one, which was put into place in 2017.

Ms Caroline Lamb: Right, okay.

Lead Inquiry: All right.

The 2011 strategy.

Ms Caroline Lamb: Yeah.

Lead Inquiry: The UK Pandemic Influenza Communications Strategy document. In your witness statement, you say this: that there was little requirement for advice being given by the Chief Medical Officer Directorate in Scotland in relation to pandemic flu planning because, primarily, it was considered that once the updated pandemic flu strategy had been agreed in 2011, there were, in reality, few decisions which required input from the CMO Directorate, and you express that view because, as Director General for Health and Social Care, you sit above the CMO; is that right?

Ms Caroline Lamb: Yes, that’s correct.

Lead Inquiry: So is this the position: that following the promulgation and the development of that strategy in 2011, that was the four nations strategy, if you like, that was set for everybody, and unless and until it was further revised or updated or changed, that was the strategy to which all four nations were committed?

Ms Caroline Lamb: Yes, that’s correct.

Lead Inquiry: Can you recall – or, from your enquiries and your research, can you recall that basic tenet, the agreement to the joint UK strategy, being challenged significantly at any time up to 2017 and 2018, when consideration was given to updating it and refreshing it?

Ms Caroline Lamb: No, I don’t recall.

Lead Inquiry: Do you know why there was no update or refresh, to use the jargon, of that strategy before 2018?

Ms Caroline Lamb: No, I don’t.

Lead Inquiry: Could we have a look, please, at that document, INQ000148759. Yes. I think actually this isn’t that document, this is a report on influenza preparedness, but it refers to the strategy. Do you recognise this document?

Ms Caroline Lamb: Yes, I do.

Lead Inquiry: Is it a July 2019 consultation draft prepared by the Scottish Government for your area in particular, but you weren’t in post then, Health and Social Care?

Ms Caroline Lamb: Yes, that’s right.

Lead Inquiry: It superseded an earlier document, but not in fact the 2011 UK strategy, and if we look at page 5 of this document, at the second bullet point, we’ll see – ah. Yes, thank you very much:

“The document highlights that pandemic planning is taking place at a UK level, with the four UK nations working together to update the UK Influenza Pandemic Preparedness Strategy … on which this guidance is based.”

So by July 2019, which is the date of the document on the screen, eight years later, the strategy that was in place, absent rewriting of the earlier document itself, was still based upon that approach from eight years before?

Ms Caroline Lamb: Yes, that’s correct. This document was produced – was the Scottish document that was produced to provide advice and guidance to our health and social care system at the time when the 2011 strategy was being updated but that work had not yet been completed.

Lead Inquiry: And –

Ms Caroline Lamb: At a UK level.

Lead Inquiry: Because the UK rewriting of which – and my Lady has heard plenty in terms of the witnesses who have spoken to it – because that rewriting had not taken place and, as we now know, never did take place because of Operation Yellowhammer, all the subsidiary documentation nationally, including this important document, was still based upon the old strategy, it was still based on the 2011 strategy?

Ms Caroline Lamb: That’s correct. However, we had obviously run our own exercises in Scotland.

Lead Inquiry: Yes.

Ms Caroline Lamb: Therefore we had sought to incorporate the lessons from those exercises into this guidance in order to try to ensure that our system was as prepared as it possibly could be.

Lead Inquiry: If we just look briefly, please, at page 6, paragraph 1.5, we can see there that the strategic objectives set out in that older document, 2011, are to:

“Be prepared to respond to any future influenza pandemic and any new emerging infections.

“Minimise the potential impact of a pandemic on society and the economy …”

And so on.

Page 7, 2.4, you’ve referred a moment ago by implication to the fact that the guidance in Scotland took its own path, even though it was based on the earlier UK strategy. 2.4:

“These strategies promote a culture within services that is person-centred, safe and effective, and which minimises health inequalities across the population.”

In summary and with half an eye on a number of policy documents which were prepared by the Scottish Government, was the issue of health inequalities flagged up in that Scottish guidance in a way that wasn’t in the 2011 strategy?

Ms Caroline Lamb: Yeah, this document draws on a number of other strategies in Scotland which are highlighted at the paragraph above, 2.3, and in amongst that is the recognition of the importance of addressing health inequalities. So in amongst those – in amongst those strategies.

So when I think about the health and social care delivery plan, that’s the document in which we confirmed the intention to establish Public Health Scotland and to have, at the core of that organisation, a mission to tackle health inequalities.

Lead Inquiry: There are actually many, many references to the –

Ms Caroline Lamb: Absolutely.

Lead Inquiry: – Scottish Government’s desire to tackle health inequalities in the rubric of civil contingencies documentation and public health documentation.

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: In a way which, I’m sure you’re aware, isn’t apparent from the English or UK analogues.

Page 10, paragraph 3.6, on the issue of how a pandemic would be responded to, this July 2019 draft guidance says:

“The initial response to the pandemic will be followed by the Treatment phase, as it will not be possible to curtail the spread of the pandemic strain of influenza once it has occurred in Scotland.”

Is that a reflection of the same doctrinal or strategic issue with which I’m sure you’re very familiar, which is that the 2011 strategy presumed that little could be done to prevent spread and, therefore, it focused upon the management of the catastrophic consequences as opposed to preventing their creation, their arrival?

Ms Caroline Lamb: So that’s correct, the 2011 strategy and indeed I think probably all our approaches to strategies to deal with pandemic influenza made the assumption that it would not be possible to contain the spread and, therefore, the focus was on mitigating the impact of the disease.

That is slightly different from an approach to other emerging and communicable diseases where there was an assumption that it might be possible to contain that.

Lead Inquiry: Yes. I think I would press you on the use of the word “slightly different”, obviously the consequences of that divergence were massive.

Ms Caroline Lamb: Yeah.

Lead Inquiry: Page 16, there is a reference to something called “Integration Authorities”.

Ms Caroline Lamb: Yeah.

Lead Inquiry: Could you just assist with what they are? There is a reference to “Health and Social Care Partnerships” in paragraph 5.5, and then further down the page “Integration Authorities”. What are they?

Ms Caroline Lamb: Yeah, so on the – on the sort of organogram that you referred me to earlier, where you – between local authorities and health boards, if I’m remembering this correctly, sit –

Lead Inquiry: If you just pause there, we’ll get INQ000204014 back, if we may, and then you’ll be able to see it clearly in front of you.

Ms Caroline Lamb: Okay, thank you.

(Pause)

Lead Inquiry: It was page 6.

(Pause)

Lead Inquiry: I think our system is slowing down, electronically.

There we are, Ms Lamb.

Ms Caroline Lamb: Okay, so down at the bottom you’ve got, around about the middle, “NHS Scotland … Territorial Boards”, 14 of them, and to the left of that “Integrated Joint Boards” and “Health and Social Care Partnerships”, and to the left of that “Local Authorities”. And that reflects the legislation that brought together integrated joint boards. They are organisations that are responsible for planning and funding services, both community health services and social care services. So social care services that are the responsibility of and were previously delivered by – entirely by local authorities, and some community care services from NHS boards as well. So the principle of that legislation was to enable a sort of more seamless service for people regardless of which organisation was actually – had the statutory responsibility for their care. So that’s where those integrating bodies sit.

Lead Inquiry: Could I be permitted to try to simplify it yet further, if you’ll forgive me. The Act I think in 2004 obliged health and social care staff from local authorities to work with NHS health boards to provide a more seamless service?

Ms Caroline Lamb: That’s correct, yeah, it’s 2014.

Lead Inquiry: What is the difference between integrated joint boards, then, and health and social care partnerships? Or are they the same?

Ms Caroline Lamb: So the integrated joint board is the legal structure, the health and social care partnerships are really the operational mechanisms by which they enact those responsibilities and bring staff together into teams.

Lead Inquiry: All right.

That July 2019 document to which you were referring, but we needn’t go back to, refers to two other bodies which are important to be identified, because of the role they play in the field of public health provision in the event of a health emergency.

Firstly, on the far right-hand side of the page the “Scottish Government Resilience Room (SGoRR)”, is that, if you like, the Scottish crisis management –

Ms Caroline Lamb: It is.

Lead Inquiry: – facility?

Then towards the left-hand side of the page, we have “Regional Resilience Partnerships” and, below them, “Local Resilience Partnerships”. Are those the organisations at local level, under the principle of subsidiarity, which bear the burden of both planning and then responding at a local level because all emergencies have local impact?

Ms Caroline Lamb: That’s correct, yeah.

Mr Keith: All right.

My Lady, if that’s a convenient moment?

Lady Hallett: Certainly.

I hope you were warned you may go over lunch.

The Witness: Yes, that’s fine.

Lady Hallett: Thank you very much. I shall return at 1.45.

(12.45 pm)

(The short adjournment)

(1.45 pm)

Lady Hallett: Mr Keith.

Mr Keith: Ms Lamb, before lunch we were looking at INQ000148759, the draft influenza pandemic preparedness document.

Could we have, please, page 29, paragraph 10.2.

Obviously in relation to countermeasures, on account of the strategic nature of the document, which we debated earlier, the only infection control procedures that were identified and debated in the course of this draft document could be those that were related to influenza: hygiene, respiratory and cough hygiene, patient placement, personal protective equipment, safe management of the care environment.

Then if you scroll back out and just scroll slowly down to 10.7: respiratory protective equipment, FFP3 respirators, stockpiles of personal protective equipment.

So obviously it followed, did it not, Ms Lamb, from that strategic approach adopted in the 2011 strategy and then in the draft July 2019 document that the only countermeasures that were really considered were those applicable for flu and, of course, not necessarily for a catastrophic HCID?

Ms Caroline Lamb: That’s correct, this is a plan for a pandemic influenza.

Lead Inquiry: The risk assessment process, is that something which you have an involvement in as the Director General for Health and Social Care?

Ms Caroline Lamb: No, so the risk assessment process obviously we have the Scottish Risk Assessment –

Lead Inquiry: Indeed.

Ms Caroline Lamb: – but that is largely informed by the National Risk Assessment, and what the Scottish Risk Assessment seeks to do is to sort of apply any specific issues that relate to impacts in Scotland.

Lead Inquiry: The same assumptions are made – the same approach, generically, to planning assumptions are made, it basically mirrors with a national bent in terms of the figures, population, casualties and fatalities, the UK approach?

Ms Caroline Lamb: That’s correct.

Lead Inquiry: All right.

Response policy documents. Much of your statement helpfully sets out many of the documents published by the Scottish Government for the purposes of responding to an influenza pandemic: Pandemic Flu Guidance; Preparing For Emergencies; Guidance for Health Boards; the Preparing Scotland document; Scottish guidance on resilience; Preparing Scotland, guidance for Scotland’s regional resilience partnerships; and so on.

I don’t think we need to address any of them in detail, but is it fair to say that both across the civil contingencies field and public health, there have been a significant number of documents published more recently than latterly, so that is to say there were a whole series of documents between 2013 through 2015, 2016, 2017 and then up to that draft that we’ve just been looking at?

Ms Caroline Lamb: Yeah, that’s correct.

Lead Inquiry: All right.

An important separate area on which the Scottish Government reported was inequalities. Did the Auditor General for Scotland produce a seminal report on health inequalities in Scotland in 2012?

Ms Caroline Lamb: That’s correct, yes.

Lead Inquiry: May we have that up, please, INQ000102987. “Health inequalities in Scotland”.

Given that this was dated December 2012, was this regarded as being quite prescient? Were there other comparable documents dealing with health inequalities in the United Kingdom published by any of the devolved administrations?

Ms Caroline Lamb: There were other comparable documents published in Scotland, yes. So in, I think it was, 2008, there was a report called Equally Well, which was the ministerial taskforce on health inequalities in Scotland. That was then reviewed I think in 2010, and then again –

Lead Inquiry: 2013 as well?

Ms Caroline Lamb: – 2013, yeah.

Lead Inquiry: So essentially there were – a taskforce or a generic approach applied, adopted by the government in Scotland, Equally Well. The Auditor General for Scotland then sought the views of community planning and health professionals in order to further the issue and the debate revolving around health inequalities in Scotland.

Then – and this will be familiar to you – did NHS Health Scotland then carry out its own health inequalities policy review in 2013?

Ms Caroline Lamb: It did. I believe that that was to inform the review of the ministerial taskforce as well. So, again, it all linked back to the original document, Equally Well.

Lead Inquiry: Then were there four or five even wider reviews of public health in Scotland, all of which made reference to health inequalities: Review of Public Health in Scotland in 2015; Health and social care delivery plan, December 2016; Public health reform programme, 2017; July 2018, Public Health Priorities?

Ms Caroline Lamb: Yeah, so to link those together, the ministerial review of Equally Well, which took place in 2013, I think had some concerns about the extent to which we were making progress in tackling health inequalities, and that was the genesis of the setting up the public health review group, who subsequently reported in 2014.

The question that was set to that group was: how can we be more effective at tackling health inequalities? That review group then reported, and amongst their recommendations was to look at how we bring together the organisations with an approach towards public health and that then was the commission to start to look at setting up what became Public Health Scotland.

Lead Inquiry: In your view, has this proliferation of policy and reviews and documents over now quite a considerable amount of time worked?

Ms Caroline Lamb: I think it’s hard to say that it has worked because we have not seen the reduction that we would want to see in health inequalities in Scotland, and that has been impacted by the pandemic as well as other economic and socio-economic factors.

I think what it has done is, in bringing together NHS Health Scotland, the Health Protection Scotland, previously as part of National Services Scotland, and Information Services Division, who were again part of National Services Scotland, bringing them all together, what that has done is it has established a single national oversight of public health. It is a health board, it’s established as a health board, and accountable to Scottish Ministers, but it’s also jointly sponsored by COSLA, the Convention of Scottish Local Authorities, so it’s got – it’s, if you like, jointly owned by ministers and by local government, and I think that enables us to really have health inequalities at the heart of everything we do, which is also key to other policies across Scottish Government as well.

Lead Inquiry: Is the point that in this particular regard, because this is a joint enterprise between COSLA, the Convention of Scottish Local Authorities, and the Scottish Government, the whole approach to inequalities and the need to address them becomes more embedded into the system?

Ms Caroline Lamb: Yeah.

Lead Inquiry: All right.

Ms Caroline Lamb: Absolutely, and it’s about it being beyond health, so it’s not just about – health and social care systems can only tackle a small proportion of health inequalities. Most health inequalities are driven by economic factors, environmental factors, socio-economic factors, particularly poverty.

Lead Inquiry: I suppose you would say a whole-society approach is required?

Ms Caroline Lamb: Absolutely.

Lead Inquiry: What about in the field of civil contingencies? So with this broad generic whole society approach, is it your view that planners and responders in the field of civil contingencies, and in particular health emergencies, are they equally alert to the need to ensure that plans and responses take into account the needs and the vulnerabilities of those suffering from inequalities?

Ms Caroline Lamb: I would say that I think there’s still work to be done there, so Public Health Scotland was established really after the pandemic struck, so whilst a lot of preparatory work had been done to get us to that stage, probably some of those ideas and ways of thinking were not fully embedded.

I think as well that – you know, I think we would all say that we could have thought more about health inequalities in our planning for emergencies, although, as you’ve already pointed out, the 2019 draft guidance did specifically reference the need to be – to focus on health inequalities in developing those local plans.

Lead Inquiry: But of course it remained in draft form –

Ms Caroline Lamb: It did, yes.

Lead Inquiry: – because of the pandemic.

On the question of funding for pandemic preparedness, is the funding for high-consequence infectious disease planning and response contained within a general consolidated fund or does it come out of the NHS board budgets for which you are in part responsible?

Ms Caroline Lamb: So I guess there’s two aspects to that. So, yes, we provide baseline funding to all NHS boards. Over and above that, since – well, throughout the whole period that this Inquiry has covered, we have provided additional funding for board resilience, including prepared – being prepared for pandemics.

Lead Inquiry: So the budget is controlled by and is run by the NHS boards, which of course receive money from the Scottish Government, and that presumably forms a majority part of the Scottish Government’s expenditure –

Ms Caroline Lamb: It does, yes.

Lead Inquiry: – being a devolved issue?

Ms Caroline Lamb: Yeah.

Lead Inquiry: Does the system work well with high-consequence infectious disease budget, in terms of planning and preparedness and response, being managed and operated through NHS Scotland as opposed to centrally from the Scottish Government?

Ms Caroline Lamb: I think it’s hard to say whether that works well or not. Certainly when we – as we went into Covid the funding was managed much more – the funding was increased very substantially in order to put in place the infrastructure that we needed to support things such as contact tracing, testing. That was managed at the point it was felt most appropriate. So some of that was allocated to NHS boards in order to run their local systems, but we also had a national capacity on top of that, and the funding for that was managed by Scottish Government.

Lead Inquiry: All right. But that, of course, was in the particular context of responding to Covid.

Ms Caroline Lamb: Yeah.

Lead Inquiry: But as a system, does the majority of the funding for health emergency planning and response come through the NHS –

Ms Caroline Lamb: It does.

Lead Inquiry: – Scotland structure?

Ms Caroline Lamb: Yeah.

Lead Inquiry: All right.

Exercises, national preparedness and resilience exercises. You will no doubt be familiar, and you may have seen the evidence from the witness who gave evidence prior to you, is it clear that, whilst the majority of the recommendations which flowed from Exercise Cygnus – although Scotland was of course only partially involved in that exercise – Silver Swan and Iris were put into place and implemented, not all of the actions, lessons and recommendations were, for reasons that are now becoming very apparent?

Ms Caroline Lamb: Yes, that’s correct.

Lead Inquiry: To what extent, although you weren’t in post at the time, was your department aware that, notwithstanding the passage of time, and a considerable amount of time, these recommendations were just not being implemented in full?

Ms Caroline Lamb: Given that I wasn’t in post at the time, I’m not sure I can answer that one.

Lead Inquiry: No, but it’s an issue which you address in your witness statement, so you must have given it some thought for the purposes of your attendance today.

Ms Caroline Lamb: So I think we were conscious that – we knew that not all the recommendations had been addressed, so we knew that one of the recommendations outstanding was the 200 –

Lead Inquiry: The refresh of the –

Ms Caroline Lamb: – the refresh of the plan, and we knew that that was in draft, we knew it was ready to go out for consultation. It had taken longer than we had originally expected, and that’s because we had consulted originally with quite a small group, and that had led to some changes to that.

I think the other area that we were concerned about in terms of things not being maybe fully implemented was around the criteria for staff getting access to different types of PPE and the awareness of the PPE stockpile. That was also addressed within that guidance. So that hadn’t been fully signed off either.

Lead Inquiry: Just so that we’re clear about that, one of the recommendations, I think from Iris, was that there needed to be a better understanding of potential use of respiratory protective equipment, the need for a survey of NHS boards and local authorities to understand what their needs might be, and that process of trying to identify what their prospective needs might be was never finally concluded?

Ms Caroline Lamb: We had extended the survey, so we had been carrying out a survey of NHS boards in relation to their respiratory PPE, since I think 2015, and we had updated that survey to include additional questions about the number of staff who were fit tested for FFP3 masks, so we had implemented that, I don’t think we’d yet had time to fully act on all the information that came out of that.

We’d also written to NHS boards in July 2019 to remind them of their responsibility to make sure that staff who would require FFP3 masks were fit tested for those and that they had sufficient of those. That was in response to, I think, an Ebola outbreak.

Lead Inquiry: Could you just explain something about what sorts of masks those are? You say FFP3 masks.

Ms Caroline Lamb: Yeah.

Lead Inquiry: Is that a particular grade of mask which is required in certain HCID scenarios?

Ms Caroline Lamb: Yes, that’s the case. That’s a grade of mask that protects people who are involved in procedures that might create aerosols.

Lead Inquiry: So the position then in relation to PPE and masks is that work was done in relation to raising awareness of the need for the stockpiles of PPE and masks to be up to date, letters were written to the health boards to say “Are you ready”?

Ms Caroline Lamb: Yeah.

Lead Inquiry: But some of the test, particularly fit testing around PPE, wasn’t concluded by the time that the pandemic struck?

Ms Caroline Lamb: Yes, there was variability between the extent to which NHS boards had completed the fit testing.

Lead Inquiry: The other main area where work wasn’t completed was in relation to the production of guidance for those entities, local authorities, dealing with health and social care, but also of course your department, because your department has a greater involvement in –

Ms Caroline Lamb: Yes.

Lead Inquiry: – adult social care than its analogous department in London?

Ms Caroline Lamb: Yes, that’s correct, although since 2000 – in 2016 we issued standards for organisational resilience for NHS boards, and in amongst those standards was a requirement for plans to be developed in partnership with regional resilience partnerships and health and social care partnerships. So although that 2019 formal guidance hadn’t actually formally been issued, there was already an assumption within those standards for NHS boards that they would be working together with partners to develop multi-agency plans.

Lead Inquiry: But the guidance –

Ms Caroline Lamb: But the guidance hadn’t formally issued.

Lead Inquiry: The process of drawing up the guidance hadn’t been finished and so you weren’t able to conclude that process by which those persons or entities responsible for adult social care knew where they stood definitively in relation to the provision of care in the event of a pandemic?

Ms Caroline Lamb: We had, by producing the NHS board standards for organisational resilience in 2016. And then I think updating them in 2018, what we had done was to set out the standards that we expected boards to self-assess themselves against, and that did include working with their partners who were responsible for the provision of social care in producing those joint multi-agency plans. But you’re correct that we hadn’t formally issued the guidance as to how to do that.

Lead Inquiry: Finally, following the pandemic, there was, in Scotland, a report from the Auditor General drawn up and published entitled NHS in Scotland 2020; is that correct?

Ms Caroline Lamb: That’s correct, yeah.

Lead Inquiry: Thank you very much. Did that state on page 4 that:

“The Scottish Government could have been better prepared to respond to the … pandemic. It based its initial response on the 2011 UK Influenza Pandemic Preparedness Strategy [is that the strategy that we’ve been debating?] but did not fully implement improvements identified during subsequent pandemic preparedness exercises.”

Are those the failures, such as they were, that we’ve also been debating?

“It also did not include an influenza pandemic as a standalone risk in its corporate or health and social care directorate [your directorate] risk registers, despite assessing it as high risk.”

Did the absence of, some might say, a formulaic reference to influenza pandemic in the department’s high level risk register matter ultimately?

Ms Caroline Lamb: I think it’s clear that we were already involved in a lot of work to improve our preparedness. I think the issue here is that maybe our risk management processes didn’t adequately reflect the activity that we had under way, and it really should be the other way round, that our risk management assessment should influence our activity.

Lead Inquiry: The Auditor General’s report made reference to a number of ways in which the recommendations from Silver Swan, Iris and Cygnus hadn’t been fully implemented and suggested that the Scottish Government should update and publish national pandemic guidance for health and social care.

Ms Caroline Lamb: Yeah.

Lead Inquiry: Has that been done?

Ms Caroline Lamb: No, that’s not been done yet. We are reviewing – that 2019 guidance is being reviewed in the light of experiences from Covid, from the initial wave, but also subsequent waves of Covid that we’ve been through.

Lead Inquiry: That report from the Auditor General was dated February 2021.

Ms Caroline Lamb: Yeah.

Lead Inquiry: We now are, I’m told, in June 2023. That’s a considerable elapse of time. Why has that guidance not been brought together?

Ms Caroline Lamb: I think that’s a reflection of the fact that the system has been through successive waves of Covid and also intense pressures.

Lead Inquiry: Has the Scottish Government nevertheless established a Standing Committee on Pandemic Preparedness?

Ms Caroline Lamb: That’s correct, yes.

Lead Inquiry: As it suggests, it’s a standing committee. Is that now a committee that is continuing to meet to address all aspects of pandemic preparedness?

Ms Caroline Lamb: Yes, that’s the intention of that committee.

Lead Inquiry: Not just influenza but other catastrophic HCIDs?

Ms Caroline Lamb: That’s correct.

Lead Inquiry: Is that a committee that reports to part of the Scottish Government or is it an external committee?

Ms Caroline Lamb: It’s – it has an external chair but it reports to ministers.

Lead Inquiry: Are there scientists and technical experts who contribute to the committee along with the Chief Medical Officer?

Ms Caroline Lamb: Yes.

Mr Keith: Thank you very much.

My Lady, those are all the questions that I have for Ms Lamb. There are no areas which I don’t – appear to have not covered.

Lady Hallett: Thank you, Mr Keith.

Thank you very much indeed, Ms Lamb, I’m very grateful for your help.

The Witness: Thank you very much.

(The witness withdrew)

Ms Blackwell: My Lady, the next witness, Jeane Tennent Freeman OBE is appearing over the link.

Lady Hallett: Thank you.