2. Professor Jim McManus

PROFESSOR JIM McMANUS (sworn).

Questions From Lead Counsel to the Inquiry

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

Professor Jim McManus: My name is Jim McManus.

Lead Inquiry: Mr McManus, you have provided a statement, INQ000183419, to which you have appended your signature and signed the declaration of truth. Is that correct?

Professor Jim McManus: That is correct.

Lead Inquiry: Professor, thank you for your assistance.

You have provided that statement. The Association of Directors of Public Health of which you are the president is a core participant in these proceedings, and you’ve also very helpfully provided for a survey, which was requested in the January of this year, to be sent to Directors of Public Health and the results of that survey have been communicated to the Inquiry, and for that we are very grateful to you.

You’re giving evidence today because, as I say, you are the president of the ADPH. Is that body the representative body for directors of public health in the United Kingdom?

Professor Jim McManus: Yes, that’s correct, we represent the professional voice of directors of public health.

Lead Inquiry: Does every director of public health have the right to be a member of your association?

Professor Jim McManus: Yes.

Lead Inquiry: Does that include deputy directors of public health and consultants or just directors of public health?

Professor Jim McManus: Deputy directors and consultants can become associate members. They don’t have quite the full rights of members but they do have access to training and policy advice and the other services we provide.

Lead Inquiry: Roughly how many members are there in the ADPH?

Professor Jim McManus: We have about just under 200 full members and not quite the same level of associate members. The detail is in our pack, which I can refer to, but that’s about that number.

Lead Inquiry: That’s all right, we only wanted the broad number.

The association doesn’t, and this is the relevancy of my question, represent, for example, local authority officers generally or local resilience forums; you are, as it says on the tin, concerned with directors of public health?

Professor Jim McManus: Yes, absolutely.

Lead Inquiry: All right.

Directors of public health are individual trained, accredited, registered specialists in public health, are they not?

Professor Jim McManus: Indeed.

Lead Inquiry: The first Medical Officer of Health in the United Kingdom, according to your witness statement, was appointed in 1847 in Liverpool?

Professor Jim McManus: That’s right, yes.

Lead Inquiry: So they have a long and glorious history in these islands.

Could you just tell us, please, today what their primary functions are, with reference to their statutory position in a local authority, their responsibility for the health of the community, and also dealing with outbreak management, so with those three pillars in mind.

Professor Jim McManus: So in England directors of public health are placed in upper tier local authorities, that’s county councils and unitary authorities, and they have a set of responsibilities including assessing the health needs of the population, advising the NHS and the local authority on commissioning functions, they have a series of commissioning responsibilities for services like sexual health, drugs and alcohol, and a variety of other things. There’s about 142 individual things that they do. They also have functions in terms of health protection planning and assurance, and they have a duty to be assured and to assure the Secretary of State that the health protection system is working. They also have a duty to improve and protect and promote the health of the population which they serve.

Lead Inquiry: So just to pause for a moment on some features of those functions, they are what is known as the statutory chief officer in a local authority, and you’ve just referred to upper tier local authorities; are directors of public health located in what is known as upper tier local authorities, and they have been, I think, since around about 2013, does that mean county councils, unitary authorities, metropolitan councils and London boroughs?

Professor Jim McManus: Yes, correct, and that’s in England. In Wales and Scotland they’re in the NHS and Northern Ireland they’re in the Northern Ireland public health service.

Lead Inquiry: We’ll come to them in a moment.

Lady Hallett: More slowly, please.

Mr Keith: In relation to England, that is where they operate?

Professor Jim McManus: Yes.

Lead Inquiry: They are not, so that we may be clear, environmental health departments, they are statutory directors of public health, and they’re also not public health consultants within the NHS, the NHS has its own public health structures?

Professor Jim McManus: That’s correct. What you may find, because directors of public health have a duty to advise the NHS, many of us may have honorary contracts with the NHS where we advise the NHS.

Lead Inquiry: Right.

Professor Jim McManus: And apologies for speaking too fast.

Lady Hallett: Don’t worry, lots of us do it.

Mr Keith: You may speak louder, however, if you wish.

Are there around 350 directors of public health in England?

Professor Jim McManus: There’s about 151 in England in terms of local authority chief officers in every local authority. The 350 number is more like to be environmental health officers.

Lead Inquiry: Ah.

Professor Jim McManus: Because you will find environmental health officers are in district councils – chief environmental health officers are in district councils as well. It can be confusing, I appreciate that.

Lead Inquiry: In Scotland, do the directors of public health sit within the Scottish Government, local authorities or NHS boards?

Professor Jim McManus: NHS boards.

Lead Inquiry: How many are there of them in Scotland?

Professor Jim McManus: There’s one for each NHS board, so that would be eight, if I remember the number of NHS boards correctly.

Lead Inquiry: Then, separately, there are a number of environmental health functions which are discharged within the local authorities, but that’s not the matter – the concern of directors of public health?

Professor Jim McManus: Correct.

Lead Inquiry: Then in Wales, where does the director of public health sit?

Professor Jim McManus: Again, they sit in local health boards, so the seven local health boards in Wales, rather than the 22 Welsh unitary authorities.

Lead Inquiry: Northern Ireland, how many directors of public health are there?

Professor Jim McManus: One in the Northern Ireland public health service.

Lead Inquiry: So in Northern Ireland, the sole director of public health is not attached to a local authority but sits within the public health structure generally?

Professor Jim McManus: Yes.

Lead Inquiry: Within the NHS in Northern Ireland or within the Executive Office, do you know?

Professor Jim McManus: The Northern Ireland public health office is part of the – their version of the Department of Health and Social Care, so it’s an executive agency rather than purely NHS provider.

Lead Inquiry: So it’s an arm’s length body, one might call it, attached to the Executive Office, the governance, the governmental system in Northern Ireland?

Professor Jim McManus: Yes.

Lead Inquiry: All right.

You’ve referred rather more prosaically perhaps to some of the matters with which directors of public health are concerned: drugs and alcohol-related issues, obviously mental health-related issues, illicit tobacco, public health aspects of crime and disorder. Are those all areas with which directors of public health become concerned because they all relate, to a greater or lesser extent, to the need, the statutory requirement to improve the public health of the populus?

Professor Jim McManus: Yes. If you take mental health, the duties of commissioning services to provide mental health sit largely with the NHS and with social services and social work departments, whereas the director of public health is more of a public mental health role, which is suicide prevention – suicide reduction, my Lady. So there are complexities and nuances which can sometimes be puzzling.

Lead Inquiry: So –

Lady Hallett: Nothing new there then, I’m afraid.

Mr Keith: We have been looking at, in the last few minutes, the issue of health improvement. Now turning your focus, please, to outbreak management plans, the second pillar of a director of public health’s functions concerns, does it not, the obligation to ensure that there is proper training for outbreaks, proper processes in place to monitor outbreaks, and to deal with all the ancillary obligations which might be engaged, public health campaigns arising out of a health emergency, giving advice to emergency response services, and liaising with the local council and those services as to how best to respond?

Are these functions provided for by statute?

Professor Jim McManus: Some in statute, some in guidance to the directors of public health in different nations, some are derived from good practice sources which are consensus statements between the various organisations, and some, frankly, are custom and practice of good health protection which is put into our training.

So there is a hierarchy, if you like, of responsibilities, my Lady.

Lead Inquiry: Is every local authority obliged to have a specialist director of public health?

Professor Jim McManus: Every local authority in England must have a specialist director of public health as their chief officer, and the statutory guidance was issued in 2013, but revised last week.

Lead Inquiry: It’s important we don’t lose sight of the public health agencies in the four nations.

Perhaps we could have up your statement, which is INQ000183419, please, paragraph 94. I’m sorry to say that it’s not paginated, and I therefore can’t tell you, I’m afraid, which page paragraph 94 appears on.

Professor Jim McManus: I have it open here.

Lead Inquiry: Do you have a copy of your statement with the page numbering on it, Professor?

Professor Jim McManus: I don’t have the page numbers, unfortunately, no.

Lead Inquiry: No, we have the paragraph numbering, we just don’t have the page numbering.

There we are, thank you very much.

So in the United Kingdom, there are, of course, a number of public health agencies. If we could commence at paragraph 95, in England, there are two, of course, the UK Health Security Agency and the Office for Health Improvement and Disparities. You set out there their broad functions: OHID’s function is to improve public health and reduce health inequalities and the UKHSA’s is for health protection.

To what extent would an individual director of public health engage with the national public health agencies, in this case in England?

Professor Jim McManus: On a reasonably regular basis. So engaging with UKHSA would be for outbreaks because UKHSA bear health protection responsibilities, they receive the reports, they will be part of incident management teams, say, for example, if you have a measles outbreak in your area. So there will be regular and ongoing liaison.

With OHID, the regional directors would be people who would have direct lines to directors of public health and back, so most directors of public health come together in regional groups in England, and UKHSA and OHID are usually part of those regional groups. So the liaison is quite frequent.

Lead Inquiry: That’s very clear, thank you.

Paragraph 96, Northern Ireland, there is a Public Health Agency established in 2009. Are you able to say whether or not the links are analogous to those that you’ve described in relation to England?

Professor Jim McManus: The Northern Ireland links will be slightly different and various, so there will be links to the various local authorities, my Lady, for different functions like environmental health and other functions, care homes. There will also be links to the health and social services boards and general public campaigns. This is a pattern you will see repeated across the United Kingdom. Everyone does it slightly differently.

Lead Inquiry: Scotland, there is the Public Health Scotland agency, with comparable functions to those of its brother and sister agencies.

Professor Jim McManus: Indeed, and they meet regularly, the directors of public health in Scotland, with Public Health Scotland on a reasonably regular basis.

Lead Inquiry: Then Wales, finally, there is a Public Health Wales body established in 2009, and therefore we presume there are links between that public health agency and the NHS health boards which, in Wales, employ the directors of public health and their teams?

Professor Jim McManus: Indeed, and they meet regularly too.

Lead Inquiry: All right.

Remaining focused on some of the structural links, please, in your witness statement at paragraph 201 – you don’t need to turn to it – you say that directors of public health do not routinely sit on local resilience forums. Local resilience forums are those important bodies at local level primarily engaged to deal with planning and preparedness and also, through strategic co-ordinating groups, responses.

They obviously have a major role in emergency preparedness. To what extent can LRFs draw upon the expertise of directors of public health when planning and responding to public health emergencies?

Professor Jim McManus: So when LRFs are planning for emergencies, the director of public health is at their disposal. So I, for example, am often asked by our local resilience forum to input into the risk register and to plans.

I think the important thing perhaps to assist my Lady is that health protection and civil resilience have significant overlaps but there are also significant distinctions. So, for example, if you were taking a flood, there are obviously significant health issues that arise because of a flood, not least from contaminated water, and the advice and the guidance of the director of public health will be important then. But, similarly, having a health protection plan or at least a list of things that need to be done during those issues will be important. The resources of the LRF such as the mobilisation of equipment and assets will be crucial. They’re not under the direct control of the director of public health, but a director of public health will need them to achieve health protection outcomes in a flood, for example.

Lead Inquiry: So, Professor, very practically, imagine that there is a health emergency in a local area, perhaps a modest pathogenic outbreak or, I don’t know, a particularly serious incidence of food poisoning. Who leads the emergency response? Is it the local resilience forum comprising Category 1 and Category 2 responders? Is it a strategic co-ordinating group comprising Category 1 and 2 responders and led by the police or the emergency services? Or would it be a director of public health leading an outbreak control committee or some such body? Who is in charge?

Professor Jim McManus: It will depend entirely on the nature of the incident. So if you have a measles outbreak, it will be an incident management team with the director of public health, the relevant national agency, in the case of England UKHSA, local environment, mental health, and anybody else we need, for example, such as school headteachers. If it were a flood, then it would be more likely to be led by the LRF. If you had a significant blood-borne virus outbreak, it wouldn’t be led by the SCG or the LRF, for example, because you’re not going to be deploying cordons and fire engines and other pieces of equipment.

So it depends entirely on the nature of the incident. Health protection incidents will be led by the director of public health and local environmental health in partnership with UKHSA.

Lead Inquiry: Who calls who to say, “In the context of this particular health emergency, it must be the director of public health that takes the lead”, or who calls the director of public health to say, “In this emergency we would like you, please, to attend the local resilience forum or the strategic co-ordinating group and take charge”? Who has that power?

Professor Jim McManus: Essentially any Category 1 responder has the power to kind of call an incident, but if it’s a health protection issue, in practice if I know about it first, I will call UKHSA and the environmental health department and convene a team. If they know about it first, they will convene a health protection team, and we will meet together. So an incident management team will occur. So if you have an outbreak of measles in a school, for example, then usually the call will come through the UKHSA and the meeting will convene with the director of public health.

Lead Inquiry: Does it work well in practice, Professor? There is obviously a world of difference between flexibility and confusion. Is there an argument for having the director of public health in a local authority area an ex officio member of the local resilience forum, so that he or she may never be left out of account?

Professor Jim McManus: I would say yes. I think many of our members would say yes, my Lady. In some places directors of public health have exceptionally good relationships with their LRF. We are dependent on culture relationships and partnership, and in my personal experience those work, but it does no harm for that to be underpinned by exceptionally clear guidance and rules.

One of the difficulties, I think, is that the Civil Contingencies Act 2004 and the Public Health Act 1984 perhaps do not always align in their expectations of systems, and people do not always understand the complexities and the interrelationships when they create national guidance.

Lead Inquiry: Just to add yet further complexity, Professor, and you know what’s coming, there is something also called a local health resilience partnership, which we believe comprises local health organisations, regional representatives of public health agencies – you have referred to the regional representatives of the PHE a few moments ago, or UKHSA as it now is, and others.

Do directors of public health sit on that body, the local health resilience partnership?

Professor Jim McManus: Yes, and by law they are expected to co-chair the local health resilience partnership. The complexity comes in because some LHRPs, my Lady, span multiple areas, such as in London. In other areas the LHRP is coterminous with the geographical area of the director of public health. So you may find a single LHRP covering the area of four, five or more directors of public health in England or one director of public health.

I would put that down to a need to better understand local variation when planning national guidance.

Lead Inquiry: Are local health resilience partnerships only ever regional, so do they sit above geographically local resilience forums, or do they both occupy broadly the same space?

Professor Jim McManus: They are not always coterminous, so if you may take, for example, a local resilience forum that covers the entire area for one police force, you may find more than one police force. You may find there is more than one local health resilience partnership in that, because currently the local health resilience partnership may follow the geographical boundaries of the integrated care system.

So some of us have a local resilience forum and a local resilience partnership that is the same, and others find we have more than one local resilience forum or one local resilience forum and more than one local health resilience partnership. It is something which could be tidied up.

Lead Inquiry: It’s a recipe for confusion and duplication, is it not?

Professor Jim McManus: I think it can be if you don’t have the good relationships and good understanding, I would agree.

Lead Inquiry: All right.

Turning to another part of the structure, a health emergency may well have an impact not just on the healthcare services in a locality but on the adult social care sector. To what extent do directors of public health work with local authorities in their provision of social care and with the private, largely private, care providers?

Professor Jim McManus: There are several ways. The first way of interest to this Inquiry, my Lady, might be infection control guidance and infection control in care homes, which is often shared between directors of public health and the local NHS.

The second route may be in terms of providing training and advice.

The third route is that directors of public health have a legal responsibility to provide advice and guidance to NHS commissioners, and many of us also take that duty seriously with social care in terms of providing evidence for effective care, prevention services in care homes and so on, and a number of us provided, during the pandemic, trauma training for care workers. In fact I went into care homes personally and did some – delivered some of that training. So there are links.

I think it would be fair to say that those responsibilities could be clarified better, particularly in relation to infection control, because some of those responsibilities overlap somewhat.

Lead Inquiry: All right.

Lady Hallett: Pause there? 11.15.

Mr Keith: Ah, thank you. Saved by the bell. Thank you.

Lady Hallett: We take a break for everybody’s sake but particularly our wonderful stenographer. Back at 11.30.

(11.15 am)

(A short break)

(11.30 am)

Mr Keith: Professor, it is obvious from your witness statement that the Health and Social Care Act 2012 was a seminal moment in the life of public health functions, because it transferred most public health functions to local government from the NHS in England.

Could you just outline for us, please, the major challenges which that transfer gave rise to in terms of the cultural organisational differences, the lack of understanding as to what was expected of directors of public health, and the problems with data flows?

Professor Jim McManus: Certainly. I think there were multiple, so I’ll necessarily summarise.

There was the difference in local authority and NHS structures and cultures. There was the fact that directors of public health retained some functions in relation to the NHS after transfer, my Lady, so the LHRP we’ve heard, but there was also a duty to advise and assist the NHS commissioners. There were even issues of pay structure –

Lead Inquiry: Would you go a bit slower, please, Professor.

Professor Jim McManus: Sorry, I do apologise.

Lead Inquiry: It’s quite all right.

Professor Jim McManus: There were also issues of pay structures. There were issues of budgets and financial transfers and responsibilities and even down to discussions of who paid for what. So, for example, if you look at sexual health, paying for HIV testing is the responsibility of directors of public health, paying for HIV treatment is a responsibility of the NHS. But NHS clinicians delivering HIV services outside London often work in premises paid for by the director of public health to deliver sexual health services. So the complexity is a fact of our life, and those complexities came.

There were also, I think, other – there were huge opportunities. The ability to work with communities in ways we didn’t. And forgive me, I may not have answered the last two parts of your question.

Lead Inquiry: The cultural differences, the lack of understanding on the part of local authorities as to what directors of public health do, and, secondly, accessibility to data flow, because of course directors of public health were receiving data and transmitting data from a different environment, from within local authorities as opposed to the NHS.

Professor Jim McManus: Yes. So data has always been very challenging and data flows have been challenging, even with data agreements, and data agreements eventually have become more sophisticated, but certainly in the early days some of us got access to data by things like honorary contracts with the NHS, or data sharing agreements, which were very complex, and I think are a subset of the entire data sharing challenge that we have as a public sector in terms of sharing data.

Culturally, local authorities and the NHS are exceptionally different. In local authorities, elected members are essential if you want to be successful in public health. So there was a significant change exercise required in most areas. Some authorities did it exceptionally well, as the King’s Fund report, the second King’s Fund report, in the bundle, concludes, others found some challenges.

My view, looking back on it, is it has brought many more assets than challenges and is the right place for us to be, but there are things that could be clearer.

The particular point, I think, Mr Keith, is the guidance. The guidance in 2013 was perhaps somewhat hastily written, and there were a number of areas which were unclear – that had been unclear before 2013, my Lady. So perhaps the crystallisation of the functions of directors of public health in England has happened in some ways, I would say, since transfer rather than before.

Lead Inquiry: All right, thank you.

Budget. The public health grant is paid to local authorities by the DHSC, is it not?

Professor Jim McManus: Indeed.

Lead Inquiry: That grant of public money is then used by local authorities to discharge its public health functions through, primarily, the role of directors of public health. Has DHSC spend on NHS England increased or decreased in real terms since that transfer?

Professor Jim McManus: On NHS England it has increased.

Lead Inquiry: What about in relation to the block payment, the grant to local authorities?

Professor Jim McManus: It has decreased. There were a series of cuts starting in the financial year 2015 to 2016 which has cut between, depending on which estimate you read, 26% and 33% in real terms out of the public health budget.

The Health Foundation estimates that £1 billion is missing from the public health grant from where it should be.

Lead Inquiry: We are not here to debate the merits of public sector cuts, funding cuts, but has the impact of those reductions in funding fallen equally across the four nations and the constituent parts of the four nations, or have some areas in fact, as it has transpired, been the subject of greater cuts?

Professor Jim McManus: So the public health grant is an England-only grant, and some areas – there is analysis which shows that some areas have fared worse per head of population. So northern areas and areas of greater deprivation have seen a greater per capita reduction in spending power on the public health grant than some areas in the south.

Lead Inquiry: All right.

Now I’d like to turn you, please, to the specific issue of emergency preparation and preparedness. In your witness statement at paragraph 100 – that’s INQ000183419 again, please, thank you very much – you’ve set out a number of categories or headings: preparation, prevention, prioritisation, collaboration and advice.

In the context of dealing with outbreaks, so outbreak management, do and did, in the context of the Covid-19 pandemic, directors of public health work in relation to taking a proactive approach to sourcing personal protective equipment, recalibrating their services, so that’s to say services in relation to sexual health, drug treatment services and the like, co-ordinating and dealing with the local systems for testing and tracing, and, consistent with what you’ve said already, providing a primary source of knowledge and advice and information for all the numerous people who take part in the emergency response system at local level?

Professor Jim McManus: Indeed, and I think – it, I think, could have been better had the cuts and the impact of austerity not happened, and I think could have been better had we had some better working with aspects of national government.

Lead Inquiry: I’ll come on to that issue in a moment, but is that a broad summary of the areas that directors assisted with? I should add to those, while you think of the answer to that question, that your statement deals: at paragraph 117, with the help that was given in relation to the provision of food banks and parcels and the delivery of prescription medicine; paragraph 119, the assistance that you gave to schools and the advice that you gave in relation to the closure of schools and the impact of the closure of schools; and at paragraph 120, elsewhere in your statement, the assistance that the directors of public health gave to directors of adult social care services who were concerned, of course, with the public health elements of decisions to shut, open or restrict access to care homes?

Professor Jim McManus: I think that is a very fair summary, yes.

Lead Inquiry: All right.

You’ve just mentioned the difficulty that directors encountered in dealing with central government. Obviously directors have to work with a range of government bodies, and particularly in central government, so not just the UKHSA and the local – the national public health bodies and the OHID, but with civil servants in central government, with the CMOs, of course with other devolved administrations, as well as the NHS and the local authorities.

What were the problems that were generally encountered in dealing with, communicating strategically with, central government?

Professor Jim McManus: I think there were several. The first was that there was very much a top-down approach taken, which …

The second was that it was often apparent that the departments we were dealing with had not read their own guidance about the role of the department, the director of public health, and were quite – not clear about what we could and should do.

The third was setting up parallel systems when we could have used local capabilities to set up local capabilities for test and trace, for example.

I think the fourth challenge was sometimes we had no response or communication, and we found out at the same time as the rest of the population, on the 5 pm bulletin, about the new guidance.

If there was another challenge, I think it would be perhaps lack of understanding of the fact that directors of public health have to rely very heavily on their local communities and the voluntary sector, who have been amazing and without whom we would not have been able to do our role, and the same with environmental health officers.

And I think generally communication and lack of understanding of what our role is, and sometimes, actually, a lack of understanding of local authority capabilities, significantly.

Lead Inquiry: Now, that latter issue particularly, why does that matter? I mean, it is in the way of central government to want to impose things by way of diktat, top-down communication, as you’ve described it, and it may well be that even in the best ordered systems relevant parts are left out of key communications or guidance. But insofar as directors of public health are, in their essence, local directors of public health, why does and why did it, in the course of the pandemic – why did leaving them to some extent out of the loop matter when it came to the provision of public health countermeasures locally?

Professor Jim McManus: Firstly, because we are trained and expert in some of these, such as contact tracing. Secondly, we have a range of services, such as sexual health, which are equally expert in contact tracing. Third, we know our local areas and our local communities. So if I may give an example, my Lady, putting a vaccine centre in a golf club in a deprived area a mile and a half from the deprived area with no public transport is something we could help areas avoid.

I think the fourth reason I would give is that we have capabilities that we could mould and shape rapidly, such as test and trace, and it was pretty obvious when local directors of public health and local authorities took on test and trace additional work, that the improvement in test and trace was marked nationally in multiple reports.

Lead Inquiry: Was that the position throughout the pandemic, or with the passage of time did the communications between central government and local directors improve, and was there a greater understanding latterly of the huge significance of local public health advice and reliance upon local facilities for the purposes of test and trace, contact tracing and so on?

Professor Jim McManus: In part. I think it grew. It certainly became much better. The support of the Chief Medical Officer in working very closely with directors of public health from January onwards was helpful. What I think was still a problem was some departments still didn’t understand what we did. In around May to June 2020, we produced, as a group of agencies with ADPH, the first guidance on local outbreak plans, and I was one of the people who wrote that guidance, and we identified the role of local directors of public health.

So it grew and it became clearer and communication improved and mechanisms improved dramatically, but for the first few months of the pandemic there were parts of central government that did not have a mailing list to reach out to directors of public health, they physically couldn’t contact us.

Lead Inquiry: There was nevertheless good contact arranged in part through the ADPH with Professor Sir Chris Whitty, of course the CMO, and were there regular discussions between the Office of the CMO in England and counterparts in the four nations and directors of public health through the ADPH?

Professor Jim McManus: Indeed, and I think the communication from Sir Chris to us was exemplary, at times we were meeting weekly, and similarly our liaison with the other CMOs was extremely helpful, my Lady.

Lead Inquiry: So we’ve been discussing, Professor, the structural system and whatever inadequacies there were, as my Lady find them to be, that pre-existed the pandemic.

When it came to the impact of the pandemic itself, was the public health and the local public health system ready for or capable of dealing with the sheer scale and severity of the pandemic that in fact ensued?

Professor Jim McManus: I have to say partly yes and partly no, and the reason for partly no was partly because of funding. I think the national plan was unclear. We seemed to prepare for flu when a coronavirus, I would have thought, would have been a perfectly plausible scenario. A range of scenarios nationally were not explained. Some of the communication from national government was lacking. Participation in national exercises was unclear. And I don’t believe we learned the lessons from the 2009 pandemic. I think the lack of resourcing was unhelpful.

I think there was also a view that government would create parallel systems rather than working with the capabilities we already had.

If I might make one final issue, this was seen as an NHS challenge, which meant – which in some ways put a burden on the NHS, my Lady, to be in charge of something that was a public health challenge, not an NHS capacity challenge. So the roles about – from the beginning, were about the NHS.

If I may give one example, we were informed by some bits of NHS England that they were going to take workforces that we commissioned and redeploy them on to wards, and by that I mean health visitors particularly, among others. Health visitors do vitally important work to protect very vulnerable children. If you had removed every health visitor in England and deployed them in a Covid ward, there would be significant safeguarding risks and children could be harmed.

So the culture of partnership ought to have been better where each part of the system values the other.

Lead Inquiry: My question was in fact directed more towards the impact of the sheer scale and size of the pandemic, but you’ve addressed many of the areas where, in your professional opinion, the system was not adequate and the reasons for that. I’d just like to pick up some of the points from that answer.

Firstly, your witness statement makes plain that national guidance and planning for emergencies needed to have done more to address health inequalities. Why, in the discharge of functions by directors of public health, is a better understanding of health inequalities necessary?

Professor Jim McManus: I think there are several reasons. Firstly, because people who are least – have least access to health services and are least well are least able to withstand the multiple impacts of a pandemic on physical and mental health and economic impacts. They come off worse, as, for example, many reports have shown.

I think the second issue is that they are often most vulnerable for protective measures. So black men working in manual roles where they had to have contact with the public were at far more risk than people in professional roles who could work from home.

From time immemorial, every pandemic has hit those worst who have been least able to bear the burden. So health inequalities have to be at the centre, and I don’t think – and forgive me for perhaps not answering your question earlier – that we did not anticipate the severity of this virus in the early stage, to which we were largely naive, and therefore I don’t think our plans were sufficient nationally at any level of the system.

Lead Inquiry: All right. Exercises. You say that the survey, to which you have made reference, reported that many directors of public health stated that they had never been involved in nationwide exercises. Is there an overwhelming case for bringing directors of public health more formally into nationwide exercises for emergency planning?

Professor Jim McManus: Undoubtedly, so that you understand local capabilities and can use them effectively before the pandemic happens and can deploy them.

Lead Inquiry: The survey also reported that many directors of public health felt that there was insufficient data sharing arrangements between local NHS facilities and the local authorities, so in essence two vital parts of healthcare and social care response at a local level were not always aware of what each other was doing.

Is there now an equally strong case for examining the data sharing arrangements between the NHS and local authorities when it comes to emergency responses?

Professor Jim McManus: Undoubtedly. You will be aware, my Lady, that the Civil Contingencies Act has a power for information sharing, but there is a view among some agencies that that is overridden by data privacy and data security. We do not have information and data governance right for an emergency in any part of the United Kingdom in the way it needs to be to save lives.

Lead Inquiry: Next, the King’s Fund report, to which you again referred earlier, stated that not enough public health consultants had the necessary training, skill sets and experience. Is there now also a case for a more regularised and formalised structure of training of public health consultants along with directors of public health?

Professor Jim McManus: I would agree, very much so. There is health protection training and experience included in the requirements for training to become a consultant in public health or a registered specialist, but training beyond the minimum is vital in these roles, and should be continuous and indeed should be continuously assessed.

Lead Inquiry: In your statement, finally, at paragraph 253, you set out a number of reflections on the UK’s preparedness and resilience nationally and locally. We’ve picked up many of these already in the course of your evidence, but just to focus on those few that remain.

So paragraph 253, it is the pre-penultimate page in the document, if that assists, electronically. Thank you very much.

Is this what you suggest and recommend, Professor? At paragraph 253, in terms of the planning, the risk assessment process, the planning assumptions which underpinned the national response, there needs to be greater flexibility to respond to the different types of viruses and the ranges of scenarios which might eventuate. I’m not really asking you to address that in detail because my Lady has heard a great deal of evidence about that, but you would concur in the proposition that there needs to be more imagination and more flexibility when it comes to planning for future hazards?

Professor Jim McManus: Indeed. Indeed.

Lead Inquiry: 255 and 256, you believe that the role of the directors of public health should be clarified and strengthened, and we’ve debated this in relation to the links at a local level to local resilience forums and resilience partnerships, and that the links between the local resilience forums and the local health resilience partnerships structures need to be reviewed and clarified for the reasons that you’ve given already.

258, there needs to be more thought given to a better standing and reserve capacity in terms of the health protection functions or abilities of directors of public health, and that necessarily brings in the question of resources and budgets, to which you’ve already made reference.

260, there needs to be a better cross-government approach to responding to pandemics, with a recognition, you would say, more formally of the directors of public health as a local system leader; that is the issue we debated at the start concerning who is in charge when it comes to a local health emergency.

Then 262, finally, but no less importantly, the need to tackle inequalities in order to provide a better foundation for future public health response.

Professor Jim McManus: I would agree strongly with all of those points, yes.

Mr Keith: I am very pleased to hear that, since they are your recommendations.

My Lady, has granted permission to my learned friend Ms Munroe King’s Counsel to ask questions.

Lady Hallett: Ms Munroe.

Questions From Ms Munroe KC

Ms Munroe: Thank you, my Lady.

Good morning, just still, Professor McManus. My name is Allison Munroe and I ask questions on behalf of Covid-19 Bereaved Families for Justice UK.

In your statement, Professor McManus, at paragraph 46, you talk about the need for discussions and consultation between relevant bodies, sectors and professionals early and regularly as being key and one of the key things to learn from the pandemic. Also, about 10, 15 minutes ago you talked about the very good communications between yourselves and Professor Sir Chris Whitty and other CMOs.

My question to you, Professor McManus, bearing that all in mind, is: could you assist us, please, in terms of describing, in your view, the adequacy or not, as the case may be, of the communications between public health directors across the four nations?

Professor Jim McManus: Forgive me, do you mean how directors of public health communicated with one another?

Ms Munroe KC: Yes.

Professor Jim McManus: I think it is fairly complex. So the Association of Directors of Public Health brought directors of public health regularly together, usually with government, for pan-UK webinars or seminars. Some of those would be England only. We have an ADPH council which includes representatives of all four nations and the members of that council then feed back to the directors of public health in their constituent nations and they advise us on policy.

So, for example, we found ourselves comparing how test and trace was run in the different nations and looking to learn from one another, from examples – I’ll take Sandwell, in the West Midlands, I know that some of our Welsh and Scottish directors of public health looked to compare lessons from Sandwell. It’s a challenge because the different four nations each have a different public health system, but the level of principles, the level of good practice, the level of the science, the level of common challenges, those often can be shared across the four nations.

Am I answering your question?

Ms Munroe KC: Yes. Yes, you are. You’ve mentioned the different structures that exist between the four nations and the public health offices. Did that pose any particular difficulties or problems or was that something that you felt was adequately addressed in terms of the communications?

Professor Jim McManus: I think one can always do better. The level of complexity in this system relies on exceptionally good communication across every player. I think it is a regret on the part of directors of public health, my Lady, that communication between national governments and local directors of public health, certainly in England, was sometimes less than optimal, and could have been improved. Which made us look to share communications amongst ourselves by setting up fora where we could share information. So, for example, there was a mental health impact collaborative group set up by ADPH for directors of public health in four nations specifically to enable us to share information when it wasn’t flowing from national to local.

Does that help you?

Ms Munroe KC: It does. Finally, Professor McManus, again, in your statement – we don’t need to go to it, but it’s paragraphs 41, 42 and 43 – you make reference or you note that there were no records of any ADPH reps attending meetings with the United Kingdom Government or with the devolved nations specifically to discuss Covid-19 prior to 21 January 2020.

Professor Jim McManus: That’s correct.

Ms Munroe KC: Is that correct?

Professor Jim McManus: Yes.

Ms Munroe KC: Do you know why that was, there were no meetings? Or no records, rather, I should say, of meetings.

Professor Jim McManus: I think the top-down culture of communicating. If you cast your mind back to the somewhat bewilderingly complex diagram that Mr Keith showed at the start of the Inquiry for each nation, what becomes very apparent is that there were missing lines in communication, and if – I remember distinctly the England one: the lines of communication to directors of public health and to some local fora were very dependent on one or two lines only, my Lady, and if they didn’t work, we didn’t know what was going on, we found out by looking at the television or reading the papers.

I think it’s partly that I would say that the three nations other than England have a greater – had a greater awareness of the role of directors of public health, and a greater understanding and a greater willingness to work with them, than was apparent in England prior to the first wave of Covid on pandemic preparedness. It felt top-down, and that should be one of our chief lessons.

Ms Munroe: Thank you very much, Professor McManus.

Thank you, my Lady.

Lady Hallett: Thank you, Ms Munroe.

Thank you very much indeed, Professor McManus. Thank you very much for your help.

The Witness: Thank you, my Lady.

(The witness withdrew)

Mr Keith: Ms Blackwell will be calling the next witness.

(Pause)

Ms Blackwell: My Lady, please may I call Professor Kevin Fenton.