3. Professor Kevin Fenton

PROFESSOR KEVIN FENTON (affirmed).

Questions From Counsel to the Inquiry

Ms Blackwell: Is your name Professor Kevin Fenton?

Professor Kevin Fenton: Yes, it is.

Counsel Inquiry: Thank you.

Professor Fenton, thank you for coming to give evidence today and thank you for the assistance you’ve already given. You’ve provided a witness statement which is at INQ000148405. If we can go to page 15, please, we can see that you signed it on 13 April of this year. Is it true to the best of your knowledge and belief?

Professor Kevin Fenton: It is true.

Counsel Inquiry: Thank you.

We can take that down.

During your evidence, please speak into the microphone so that the stenographer can hear you for the transcript, and if you need a break at any time just let me know.

Professor, you are president of the United Kingdom faculty of health, you are a senior public health expert and infectious disease epidemiologist, who has worked in a variety of public health executive leadership roles across government and academia in the United Kingdom and internationally, including taking a leading role in London’s response to the Covid-19 pandemic; is that right?

Professor Kevin Fenton: That’s correct.

Counsel Inquiry: You also became the regional director for London in the Office for Health Improvement and Disparities within the Department of Health and Social Care in October of 2021, having previously held the same position within Public Health England from April of 2020?

Professor Kevin Fenton: That’s correct.

Counsel Inquiry: You are the statutory public health adviser to the Mayor of London and the Greater London Authority and the Regional Director for Public Health for NHS England?

Professor Kevin Fenton: That’s correct.

Counsel Inquiry: But it is in your guise as president of the United Kingdom faculty of health that you give evidence to the Inquiry today?

Professor Kevin Fenton: That is correct.

Counsel Inquiry: The faculty is the professional standards body for public health specialists and practitioners with other than have around 4,000 members in the four nations of the United Kingdom and overseas; is that right?

Professor Kevin Fenton: Yes, that’s correct.

Counsel Inquiry: Is membership open to any public health specialist and practitioner?

Professor Kevin Fenton: Those that have completed their postgraduate training in public health are eligible for membership of the faculty and fellowship of the Faculty of Public Health. We do have other accreditations and designations depending on where you are in your postgraduate training and the examinations which you’ve taken on your way to specialisation.

Counsel Inquiry: All right. It’s a registered charity, isn’t it, and a joint faculty of the three royal colleges of physicians in the United Kingdom?

Professor Kevin Fenton: That’s correct, we were established in 1972, so we’re just over 50 years of age.

Counsel Inquiry: What is the aim of the faculty?

Professor Kevin Fenton: Our objects articulate three areas, my Lady, where we have an essential role in the training and accreditation of public health practitioners. First, in setting standards for training, and, as I said, this is a competency-based postgraduate training programme open to doctors and other professionals to become public health specialists. We also look, my Lady, at the standards for public health practitioners across the country. This includes the appointment of specialists and consultants to their senior roles, as well as their continuing professional development, accreditation and revalidation as practitioners. And we have a third critical function which is that of advocacy for the public’s health, looking at the public health system and its functioning and advocating for, on behalf of our members, effective delivery of the public health system and public health, and improving the public health of the population.

Counsel Inquiry: Is addressing health inequalities and the wider determinants of health central to the faculty’s existence and work?

Professor Kevin Fenton: It is. Health inequalities are foundational for us to both improve and protect the health of populations. Health inequalities are essential in understanding individual and community resilience to shocks such as pandemics. As a result, we have a strong focus on health inequalities, my Lady, both in the training and capacity development, in the accreditation of our practitioners, when we assess them for their competence, and we have a strong programme of advocacy on issues and matters related to health inequalities.

Counsel Inquiry: Thank you.

In your witness statement, you say that prior to January of 2020 there was limited communication from the government on the state of the United Kingdom’s preparedness and pandemic planning with the faculty?

Professor Kevin Fenton: That’s correct.

Counsel Inquiry: I see you’re agreeing with that. But in relation to one strategy, the 2011 United Kingdom Influenza Pandemic Preparedness Strategy, about which my Lady has heard quite a lot already, there was a level of communication, wasn’t there? You were invited to provide comments on that strategy.

Was that invitation issued to the faculty before the strategy was published or afterwards?

Professor Kevin Fenton: I believe it was done afterwards as part of the general consultation on the 2011 strategy, and this highlights, I think, a key – it’s a challenge, but both opportunity as well. While it is fantastic to be invited to participate in consultations on strategies, it is often better to be at the table at the time when the strategies are being developed, to help shape the content and the paradigms within which the strategies are developed. So on this occasion we provided input at the consultation level.

Counsel Inquiry: Right. You commented on the importance of sharing scientific information between countries, didn’t you?

Professor Kevin Fenton: (Witness nods)

Counsel Inquiry: Why is that so important?

Professor Kevin Fenton: In the management and response to any pandemic, because of the global nature of the infectious disease and infectious disease threat, it is absolutely essential that we work in partnership both with the WHO and we learn from other countries which are also experiencing the infectious disease threat, sharing best and promising practice, sharing data, scientific advances, but also understanding what tools are available for intervention in the pandemic. So that sharing of information is critical.

Counsel Inquiry: Do you know whether or not your comments and concerns in that regard were taken on board and fed into the strategy at any point?

Professor Kevin Fenton: No, not on this occasion, no.

Counsel Inquiry: Right. You will be aware that, as part of the strategy and appended to it is the equality impact assessment which was published at the same time. Did you provide any comments or did you have any consideration of that document at the time that you sent your response to the strategy?

Professor Kevin Fenton: So this would have been done under previous administration for the Faculty of Public Health and my understanding is that there was a reflection on the equality impact assessment, but we recognise with hindsight that the EIA – and given our experience with the Covid pandemic – was not perhaps as thorough or as detailed as it could be, given the nature of pandemics and how they express themselves in terms of inequalities in populations. But we did recognise that the EIA was undertaken.

Counsel Inquiry: Right. Well, we asked Professors Marmot and Bambra to comment on the EIA, as you refer to it, and their view was that the analysis provided the most thorough consideration of equality issues across the strategy, but that it was fairly limited in terms of identifying the multiple issues faced by different social groups, and there was little provided on what actions should be undertaken to mitigate any differential impacts, and that the analysis did not discuss potential inequalities in mortality or morbidity from a pandemic point of view.

Do you agree with those concerns?

Professor Kevin Fenton: Yes, we do. Again, on reflection and on re-review of the equality impact assessment, and again with the knowledge and experience of having gone through the Covid-19 pandemic, it is clear that there are missed opportunities there for us to both understand the impact on groups with protected characteristics but, in a sense, to go further, to understand those wider determinants which are going to have a material impact on increasing risk for those groups but also resulting in adverse outcomes as well.

Counsel Inquiry: Thank you.

You say in your witness statement that throughout the planning and response to the pandemic there was, in your view, a lack of executive awareness across responder organisations around the level of societal risk for pandemic events.

Can you explain what you meant by that, please?

Professor Kevin Fenton: Yes. So one of the challenges of the pandemic influenza plan was that it was exactly that, that there was no space for considering other respiratory infections or a Disease X, another kind of pandemic that would have occurred, and the frame or the mental model in which the pandemic plan was being developed would have suggested that we would build upon the lessons of how we responded to seasonal influenza epidemics, which would largely be related to the health service response, mitigating the impact especially on older people and young adults and children, and ensuring that there is capacity to deliver, for example, antivirals and vaccines.

Now, that –

Lady Hallett: Just pause. Slower, please. We’re doing this a lot, but you speak very quickly.

Professor Kevin Fenton: Okay, thank you, my Lady.

So that provided a frame where the locus and the focus of the response would be largely around the NHS and protecting the NHS, but also looking at other government departments which would be important in that frame.

That does mean that the wider range of executive engagement at different levels of government would be limited because we’re not thinking of the range of pandemic possibilities or the range of interventions which may be beyond the health service which would be required to control or manage those other eventualities.

So if we take an example such as the Covid pandemic, we realised very quickly that we needed to move beyond clinical interventions to look at social interventions, and that then required a wider range of executive leaders at different levels, at national, regional and local, to be engaged in responding, and it was that engagement that we felt was lacking.

Ms Blackwell: Right.

You also say that that difficulty that you perceived in the level of executive awareness was exacerbated by a legislative framework for health protection which you describe in your witness statement as “complex, archaic, and not fit for purpose to address current and future hazards and threats”. Why do you describe the legislative framework in those terms?

Professor Kevin Fenton: For a number of reasons. First, since the Civil Contingencies Act was developed, there have been a number of threats that we had to respond to as a nation, and learning from those responses that needed to be updated and reflected in the legislation.

Counsel Inquiry: Just to remind ourselves, that was the Civil Contingencies Act that was brought into force in 2004; yes?

Professor Kevin Fenton: That’s correct. Second, we had had a significant number of reorganisations of the health and care system with new organisations, new players, with new responsibilities for health protection and pandemic response, and there had to be clarification of the roles, responsibilities, the governance for responding to pandemics in that – in the new environment that we were operating in.

So the legislation also had to be updated to reflect that.

Thirdly, armed with the knowledge that we now have, and that we had at that time in terms of the range of interventions that would be required to manage potential infectious disease threats, we needed to ensure that we were – the legislation would have allowed for the use of a wider range of tools for intervention, and again we saw, my Lady, the importance of this with the Covid-19 pandemic, where we had to move beyond the sort of interventions which were planned for pandemic flu to include a wider range of strategies to control the infection.

Counsel Inquiry: All right.

The Inquiry has heard evidence about the huge changes brought about when the Health and Social Care Act of 2012 became brought into force.

What do you say were the concerns from your organisation in terms of the assurance role that was taken forwards without specific funding being ringfenced and whether or not the changes that the Health and Social Care Act implemented led to a lack of clarity in terms of an understanding of roles from one public health worker to another.

Professor Kevin Fenton: So the 2012 Act has been described as one of the most significant changes and reorganisations of the health service since its creation 75 years ago. For public health practitioners, it meant that we had public health practitioners now operating in many different organisations, in Public Health England, in local government, in the NHS, and elsewhere. So the need post reorganisation to bring that public health family together, to clarify roles, responsibilities, the governance, ways of working, for example, for pandemic response, was critical, and Public Health England played a very important role, in its inception, in helping to knit the system together and ensure that there was an understanding of how different parts of the system work.

Now, the challenge there is that the assurance functions and the capacity to do assurance also changed as a result of the reorganisation. So because we had staff moving to different – in different directions to different organisations, we know that health protection capacity, for example in local government, was perhaps not as well invested in as it needed to be to do some of the assurance functions, although it existed.

Similarly, infection prevention and control responsibilities and assurance, that was a core function and competence that we knew that we had challenges with capacity across the system, in part because of the reorganisation and different functions.

Counsel Inquiry: One of the problems that you identify in your report is the professional exposure of NHS staff to community settings and the reduction of that once the Health and Social Care Act had really taken force. Why was that a problem, and does it still persist?

Professor Kevin Fenton: So prior to the 2012 change, public health staff were embedded within the PCTs within the NHS. That provided both NHS staff to be exposed in a much more hands-on and much more comprehensive way to their public health roles and responsibilities.

Post 2012, as staff moved to different organisations, the NHS lost to some extent that close relationship with public health expertise and public health functions, and that over time had to be rebuilt. In fact we often speak about public health coming back to the NHS, over the subsequent years, by virtue of regional public health directors holding joint appointments with the NHS, the regional teams of Public Health England and UKHSA now working more closely with the NHS, but that had to be rebuilt.

So the reorganisation and the shifting of public health capacity to different organisations meant that that exposure, that ongoing learning, but also some of the partnerships which were key prior to 2012 were ruptured initially and then had to be rebuilt.

Counsel Inquiry: Right.

You describe that the public health specialist generalist workforce had reduced exposure to health protection duties. Now, can you help us, please, Professor Fenton, with that phrase, “specialist generalist”? The Inquiry has already heard of it, I think when we quoted a passage from your witness statement to another witness, but we were not able to find a clear definition of it. So can you help us with that first of all, please?

Professor Kevin Fenton: Absolutely. So, my Lady, if I may use myself as an example, I’m a public health specialist because I have completed my five years of postgraduate training in public health, and I operate at the level of a consultant for public health medicine. I’m a generalist because I have been trained and demonstrated my competences in all of the key pillars of public health practice, which include health protection, health improvement, healthcare public health, with a strong focus on data knowledge and intelligence. So I’m a generalist because I have competencies in all of those areas and I’m a specialist because I have been accredited.

Counsel Inquiry: Right. When you say that public health specialist generalist workforce had a reduced exposure to health protection duties, is that what you’ve just explained to the Inquiry?

Professor Kevin Fenton: Yes, and a really good example of this is if you have a specialist organisation which is focused, for example, on health protection and you have other public health practitioners in other organisations which do not have that as their core function, then the ability of those practitioners to get exposure to and experience in health protection diminishes.

Counsel Inquiry: Right.

Professor Kevin Fenton: That can only been overcome by creating strong links in place at local levels where you share and you continue to build and train together in your public health practice.

Lady Hallett: Professor Fenton, I’m afraid I’m still not getting this generalist specialist, specialist generalist.

What is wrong with just being a specialist in public health?

Professor Kevin Fenton: Because you can be a specialist, the term can be used as a specialist, if you do not have your competencies in all of the domains. So, for example, there are colleagues who may have done many years of training in health improvement or health protection and have become specialists in those areas, but they’re not generalist specialists because they don’t have the competencies in other areas of practice. We therefore call them defined specialists because that shows that they have –

Lady Hallett: I shouldn’t have asked.

Ms Blackwell: I was going to say.

Professor Kevin Fenton: Well, defined specialists have expertise in one domain or one area of public health practice, and they’re specialists in that domain only.

Counsel Inquiry: So can I attempt to use a slightly different way of describing it: so a specialist only has a specialism in one area of public health, a specialist generalist or a generalist specialist has that specialism but also a much wider experience of other aspects of general health?

Professor Kevin Fenton: If I may quickly add to that.

Counsel Inquiry: I’m sorry, I think I made it even worse. I’m sorry.

Professor Kevin Fenton: You’re a specialist by virtue of having trained and developed a certain level of competency in a domain in public health. Okay? And the specialist would be the equivalent of a consultant practising in cardiology or nephrology. So that’s a specialist.

Now, you can be a generalist specialist if, like me, you’ve trained in all of the domains in public health practice and you have been accredited to practice in those domains. That’s a generalist specialist.

You can be a defined specialist if you have only worked in and trained in one area, and that means that you’re not generalist, you’re just defined, so you’re a defined health protection specialist. You may be a defined specialist in health improvement where you’re doing work on health promotion and tackling inequalities.

Counsel Inquiry: All right. My Lady, I hope that’s clearer?

Lady Hallett: I think we’ll leave it there.

Ms Blackwell: Good.

What was the effect on public health of the abolition of the government offices of the regions in 2010?

Professor Kevin Fenton: So the regional tier in any health system, especially one as complex as what we have in England, is really important, because it provides the connection between place, which is where you do a lot of the delivery of your prevention programmes, your clinical services and services to the population.

Counsel Inquiry: The locality?

Professor Kevin Fenton: The locality.

Counsel Inquiry: Yes.

Professor Kevin Fenton: And, of course, national government, where policies develop, where programmes are funded and where you may have that drive for particular programmes. So the regional tier is important to connect, it’s important to assure, it’s important to train and it’s important to share best and promising practices.

So the government regional offices had that really important function before they were abolished.

With their abolition and with the creation of Public Health England, then the regional tier of Public Health England took on and had some of those responsibilities to ensure that for public health practice there was that connectivity between national to local.

Counsel Inquiry: Right, and was there any problem with Public Health England taking over that regional level of responsibility and assistance?

Professor Kevin Fenton: Not necessarily problems, but because of the nature and scale of change that occurred in 2012/13 there was a lot of forming and developing new relationships, ensuring that the capacity to do that co-ordination was in place, and ensuring that we had the mandate as well as the authority to do some of the pulling together in different areas of public health practice, bearing in mind that at local level, at regional level and at national level, there are defined authorities in the legislation and in what organisations had to do. So it was important for Public Health England to create that space where it was able to operate effectively at the regional tier.

Counsel Inquiry: Has that been done successfully, in your view?

Professor Kevin Fenton: Well, as you know, Public Health England doesn’t exist anymore, but I believe that over time that regional role demonstrated itself to be a very effective tier in supporting the work and leadership of local government, and we’ve seen it replicated with both OHID, in the Department of Health and Social Care, as well as UKHSA having regional tiers as well.

Counsel Inquiry: All right, so that regional level that you describe hasn’t been completely lost, it’s just been subsumed or taken over by other organisations?

Professor Kevin Fenton: Yes.

Counsel Inquiry: Yes. All right.

Inequalities and community resilience. You say in your witness statement that in terms of the role of inequalities in pandemic planning:

“… interventions were largely universal and there is a lack of evidence that health inequalities in impact and outcome were key considerations.”

What is problem with an intervention being universal?

Professor Kevin Fenton: So while universal interventions are able to give you the reach and coverage that you seek in order to have an effective public health approach, it often does so at the expense of those who are hard to reach, hard to engage, or those who may not trust health services and therefore will not take up the universal offer.

So in general in public health practice, my Lady, we try to ensure that we have a combination of universal approaches to delivery and what we call targeted approaches, where we’re able to both fund and invest in specific programmes that are able to engage those who are hard to reach, hard to engage or furthest from clinical services, preventative services.

Counsel Inquiry: Is that an important aspect of pandemic planning, or should it be?

Professor Kevin Fenton: It’s an important part of all public health practice which also includes pandemic planning and preparedness and response.

Counsel Inquiry: Right.

The Inquiry has heard evidence from Sir Chris Wormald, who is the permanent secretary of the Department of Health and Social Care, and when asked about whether pandemic planning should include consideration of inequalities and vulnerabilities, he expressed a view that such planning would only take matters so far until the precise nature of the emergency became known, and that that level of uncertainty, of what might be coming down the line as the next pandemic, necessarily carries a degree of imprecision.

That evidence was echoed by Roger Hargreaves, currently the director of the COBR unit, and indeed yesterday by the First Minister of Wales.

Do you agree that there is only so much that can be anticipated in terms of pandemic planning of those who are likely to be affected in a certain way by dint of their inequalities or vulnerabilities?

Professor Kevin Fenton: You won’t be able to do everything in planning to mitigate the impact of inequalities, but there is still a lot that can be done.

Counsel Inquiry: Tell us what that might be, please.

Professor Kevin Fenton: For example, co-production with – in the plans, and ensuring that in the development of the plans you have due regard to tackling inequalities, which go beyond the equality impact assessment, but co-producing, for example, with local partners who are in contact with local communities or vulnerable communities to ensure those perspectives are included in your plans and your plans are tested against those perspectives.

Second, you can ensure that you have the mechanisms in place to engage with and to access those communities which are at greatest risk, either through – understanding your communication channels, for example. How do you reach out to and engage with vulnerable communities? How are you working with the voluntary and community sector, and what mechanisms are in place either in local government to assure ourselves that we have the routes of communication and outreach to engage with vulnerable communities? Then, finally, ensuring that data and the infrastructure for data and data sharing are available and are designed before the pandemic or before the shock, so that you’re able to capture the information that you need to characterise and to understand the impact on vulnerable populations.

So those are things that can be done prior to an event which then set a stronger foundation for your response for equity in the event.

Counsel Inquiry: All right.

The Inquiry has received a witness statement from Ade Adeyemi, who is from the Federation of Ethnic Minority Healthcare Organisations, and he has told the Inquiry that addressing health inequality has thus far suffered from an unsustainably hodgepodge approach. A pattern of infrequent and short-term funding for healthcare strategies targeted at supporting those from ethnic minority backgrounds may have harmed emergency planning for the pandemic.

Do you agree with his concern?

Professor Kevin Fenton: I do.

Counsel Inquiry: How do you think that the rather scattergun approach that’s been adopted thus far can be more streamlined and focused in order to achieve what you’ve just set out as being necessary for the planning of pandemics and taking into account inequalities and vulnerabilities?

Professor Kevin Fenton: Well, I must, first of all, my Lady, reflect that things have significantly improved as we have exited the pandemic, given our experience with seeing these inequalities emerge and the detrimental impact that the inequalities have had on communities across the country. But there are a few things which must be in place if we’re going to do this better.

First, there has to be leadership commitment from highest levels of government and at all levels of government to address these inequalities, recognising the detrimental impact it has on overall population health.

Second, we need to ensure that we’re investing in programmes which are culturally competent, co-produced with our communities, and ensuring that we’re using the assets that we have to deliver those programmes effectively.

Third, I’ve already mentioned the importance of having good data that enables us to both understand where inequalities occur and to be able to evaluate the impact of our interventions. Right? So the data’s really important to understand are we making the right difference.

Fourth, ensuring that we have ways in which we are communicating and engaging with communities. What are those channels and how do we access them and leverage them so that we’re both bringing communities in, co-producing and developing with our communities.

Then, finally, we know that for a number of the inequalities that we observed, the experience of our communities on poor trust, stigma, discrimination, including structural racism, has repeatedly come up as a huge issue that our communities need us to confront and address, and I think that, and I believe that organisations working in health and care have a responsibility to visibly state and to visibly act on these inequalities in a much more comprehensive way.

Counsel Inquiry: How do those who are charged with the responsibility of creating guidance and documentation that is designed to assist going forwards in terms of pandemic planning harness that sort of information which you’ve just set out, Professor Fenton?

Professor Kevin Fenton: So this is really an opportunity for us, as we emerge from the pandemic, not just to learn lessons but to create enduring legacies that enable us to act differently to achieve different outcomes.

I’ve already mentioned the importance of ensuring that at the planning stage that we’re doing our planning of all of our responses through an equity lens.

Counsel Inquiry: What does that mean?

Professor Kevin Fenton: Asking the question: who are the ones who are most likely to be negatively impacted by this incident or pandemic or event, and what are the ways in which we both need to engage and help to mitigate those impacts from upfront? So start with that planning for equality.

We often say in public health, my Lady, if you plan for those that are furthest and hardest to engage, then automatically you have been able to design a system or programme that will engage everybody.

So the first is ensuring that we have that strong focus on equity and redesigning through an equity lens.

Second, there needs to be training and capacity building around this issue, because we have to leverage the experience of the pandemic to ensure that our leaders as well as those delivering programmes have the tools and the training they need to do this.

Then third, recognising the importance of the communities’ voice in this space is critical, and using ways in which we’re bringing communities to help to design, or research programmes, or prevention programmes, or policies, by co-production and engagement we will end up with much richer programmes and richer strategies. So those are three ways in which we could do things differently.

Counsel Inquiry: Having a clear line of contact and communication between those who are involved in making the decisions about the creation of these strategy and guidance documents, with your organisation and with voluntary organisations who exist to promote the better understanding of those who suffer from health inequalities, other inequalities and vulnerabilities is vital, in your view, in taking this forwards?

Professor Kevin Fenton: That’s correct. One of the learnings of our experience must be that there needs to be a widening of the tent, a diversity of thought, experience, and perspectives that is brought to bear in designing plans and policies which are geared towards pandemic planning and pandemic response, but to use that discipline of engagement and partnership in everything that we’re doing in our public health programmes.

Now, I should say that this is part of the modus operandi for local government. Right? So the closer you are to the community is the more this is being done. The challenge is for national government partners to say: can we go further and can we do more in this space?

Counsel Inquiry: Finally, Professor Fenton, I just want to ask you about the strength of the public health workforce and that being a necessity for an ability to react to the next pandemic as it may be coming down the line.

How do we ensure that the public health workforce is strong enough and has sufficient capacity in order to be able to react in an appropriately resilient way?

Professor Kevin Fenton: Well, I think first it’s recognising the – and valuing the importance of the public health workforce and the public health system as a key part of our national infrastructure for resilience. We would not have been able to get through the pandemic had it not been for the phenomenal work of public health practitioners working at national, regional and local level, in academia, in lots of other sectors. So recognising that asset and valuing that asset and investing in that asset now and for the future will be critical.

Second, ensuring that you have the voice of practitioners, generalist specialists, engaged in planning and policy development at every level of government; and that ensures that the key skills which are required for effective pandemic planning and response are integrating that experience of public health practitioners.

Then thirdly, in addition to investing in a strong workforce and ensuring that we continue to invest in the numbers required to deliver, to think about opportunities for continued partnership both with public health practitioners and those developing policies, again at every level of government.

So there are things that we have to do, but it really does begin with understanding the public health system, valuing the assets that we have in our public health workforce, and ensuring that it’s fully integrated into our planning and response at every level.

Ms Blackwell: Thank you.

My Lady, you have provisionally provided permission for five minutes of questions to Covid-19 Bereaved Families for Justice UK, so I will hand over, if my Lady agrees, to Ms Munroe.

Lady Hallett: I think you may have deprived Ms Munroe of five minutes too, I think it was ten.

Ms Blackwell: Oh, was it? I’m so sorry.

Ms Munroe: I was about to say, my Lady. Thank you.

Questions From Ms Munroe KC

Ms Munroe: Good afternoon, Professor Fenton. My name is Allison Munroe, and I ask questions on behalf of Covid-19 Bereaved Families for Justice UK.

The first question, you have already touched upon this in answer to questions from Ms Blackwell King’s Counsel, it’s about data gathering. I preface it by, if I may, reading just a short passage from a statement from Ade Adeyemi – you’re nodding at somebody that you’ve heard of, obviously – he is a healthcare professional from FEMHO, which is the Federation of Ethnic Minority Healthcare Organisations, a coalition of over, I think, 50,000 healthcare professionals.

We don’t need to bring up his statement, but, my Lady, for reference, it’s INQ000174832.

Mr Adeyemi in his statement on behalf of FEMHO has expressed their deep concern as to how socio-economic factors exposed essentially the existing fault lines that were there in terms of disparities for poorer communities in the country generally but particularly for those ethnic minority communities from the Indian, Pakistani, Bangladeshi, black African and black Caribbean diaspora.

He says in paragraph 15 of his statement:

“FEMHO believes that that planning, forecasting and preparatory work for a high-consequence infectious disease such as Covid-19 did not properly consider the context of a multicultural UK and a global diverse health and care workforce. UK laboratory, field modelling and case studies prior to Covid-19 did not include references to race and/or ethnicity. The absence of a national system of data capture regarding race and ethnicity may well be one of the biggest system failures in emergency planning from the Covid-19 pandemic.”

Now, Professor Fenton, do you share Mr Adeyemi’s view that that absence of a national system of data capture was a huge system failure?

Professor Kevin Fenton: Well, I do agree, and as I mentioned earlier that one of the lessons and, I hope, legacies which emerges from our experience of the pandemic will be to understand and to utilise data better, especially data that can allow us to understand these differences across groups, population sub-groups, and that allow us to evaluate the impact of the interventions that we’re putting in place. So that has to be a core lesson from this.

In many parts of health and understanding health disparities in the UK, we have been calling for greater disaggregation, separation of the data, to help us to understand these racial and ethnic disparities, but also disparities by other protected characteristics. So it is vitally important that as we emerge from the Covid pandemic we do learn the lessons and invest in systems, data systems, that allow us to understand these effects much better.

Ms Munroe KC: Thank you, Professor Fenton. You have in large part answered my next question, but if I may just ask sort of supplementary to that: presumably different parts of the NHS and other health authorities and government and local authorities have different systems, some are more effective and some are more efficient than others in terms of data capturing. How does one sort of bring that all together so that in fact you’ve got a consistent system of data capturing? Because it’s no good if some people are doing it well and others are not doing it well. It’s going to lead to inaccuracies.

Professor Kevin Fenton: That’s right. You know, and with the most recent organisation of the health and care systems, where we now have the creation of integrated care systems, ICBs, and stronger working between local government and the NHS, I believe we have an amazing opportunity to look at data differently, how we share data, to understand and improve population health, and how we use those data to tackle inequalities.

So I believe the building blocks are there for us to do things better, but it does require additional resources, capacity, training and those data sharing agreements that allow organisations to share their information more effectively.

Now, at the national level, organisations such as the UKHSA and OHID, in the Department of Health, also have a role to play to ensure that the data that they’re routinely collecting from health and care systems are not only reported showing overall trends but that the discipline in ensuring that we’re unpacking those data and describing the characteristics of epidemics or health challenges by a range of characteristics, that also has to be part and parcel of what’s done at the national level as well.

So wherever you are in the system, the discipline of using data differently and better must be a lesson from the pandemic.

Ms Munroe KC: Presumably, Professor Fenton, part of that training that you’ve described is a realisation, perhaps, that data capture is important, and culturally to understand why it’s important?

Professor Kevin Fenton: Well, you know, as a public health practitioner I would definitely agree with you, and my Lady, this is the core currency of what we have to do to improve the health of populations. Because if you don’t have data and if you’re not able to describe the health needs of your population, then you will forever be limited in meeting the needs of those populations or in being able to evaluate the impact of your efforts on whether or not you’re making a difference in the lives of those communities. So data are important.

Ms Munroe KC: Thank you, Professor Fenton.

The next question doesn’t arise explicitly from your statement but more perhaps from a Public Health England report entitled Beyond the data: Understanding the impact of COVID-19 on BAME groups, of which you’re the first name in the foreword of that report.

Again for reference, my Lady, it’s INQ000120838.

Professor Fenton, do you think that the lack of data has been an impediment or a block, perhaps, to challenging and combating structural and/or institutional racism and, if so, how?

Professor Kevin Fenton: So in the report – and I’d like to just acknowledge, we engaged 4,000 people over a six to seven-week period to develop this report in the first wave of the pandemic, and I want to acknowledge both my colleagues in Public Health England and of course the CMO and the then Secretary of State for Health for commissioning this report, because we needed to understand the patterns of disease and its impacts that we were observing.

Having data by race ethnicity is critical both to understand how the disease is manifesting itself across different groups but it is important to recognise that data by race ethnicity only tell you a part of the story. Many of the differences that we observe when we describe these racial disparities are a function of other things, for example the social and economic background and status of the individuals and the communities. It may also reflect, as we now know, those communities’ experience of structural racism.

So it’s important that not only we have comprehensive data that enables us to describe the differences but we need to look beyond the data, which is why in this report we also engaged and heard the stories, my Lady, of communities across the country, of networks of professionals, so that we’re able to, in addition to the quantitative data, ensure that we have the stories and the qualitative data of the impacts that were being seen at that time.

Ms Munroe KC: Thank you.

Professor Fenton, is a lack of any such sort of national or a really structured organisational way of gathering data in a data gathering system itself indicative or evidence of structural and institutional racism?

Professor Kevin Fenton: I can’t comment to that, I know that it is very difficult in general to move beyond the sort of routine elements in data collection for a variety of reasons, and yes, as an epidemiologist, I’d love to have not only data on race ethnicity but certainly sexual orientation, disability status, I’d love to know the neighbourhood that you’re living in, to understand the sort of social and economic challenges that you may experience. But in health data you may be extremely limited to be able to collect that on a routine basis.

So what national organisations can do is to provide the frameworks that allow for data sharing, so that you can combine different datasets to get a better understanding of the patterns that you’re observing and that we can – national organisations can facilitate that data sharing and that collaboration which is necessary for a richer understanding of the patterns of the disease that we observe.

So it’s really important that – this is a very difficult area of practice to get the sort of data that we need, but there are ways in which you can partner differently, work differently, to tell that story as well.

Ms Munroe KC: You’ve mentioned other protected characteristics and other groups such as disabled people, LGBTQ+ community; the issues that we’re talking about in relation to ethnic minority communities equally apply?

Professor Kevin Fenton: They do, and that’s why we say if you’re able to set the systems up that allow you to collect that sort of information, then you’re able to have a richer dataset to allow you to understand inequalities in different domains as well.

Ms Munroe KC: Thank you.

Finally, Professor Fenton, again returning where we began with Mr Adeyemi’s statement, paragraph 17 of his statement, at page 5, he makes reference to one of his members, a Dr Ananta Dave, who is a chief medical officer for NHS Black Country Integrated Care Board and president of the British Indian Psychiatric Association, and she states:

“There was a lack of planning around risks to vulnerable groups such as BAME and older adults in care homes. It was a combination of ignorance and apathy. The government should have been gathering this data because the awareness would have been there about the impact on the vulnerable and the planning about the early stages.”

Do you share that view, Professor Fenton?

Professor Kevin Fenton: So earlier I spoke about the mental model or the paradigm within which the pandemic – pandemic influenza planning was taking place, and I think that mental model, given our experience with seasonal influenza, meant that there may have been less of a concern with inequalities because of the patterns that we see on a seasonal basis, and our prior experience with the H1N1 pandemic.

So there’s a – we can understand why this occurred, but I do think that actually moving forward, especially armed with our experience with Covid-19, we now have both the rationale and the opportunity to do things differently, to ensure we understand those populations which are going to be at greater risk, that we have data systems, my Lady, that enable us to characterise and understand where those communities are, and we have the ability to both deliver programmes and evaluate the impact of those programmes on those communities. So that has to be a legacy moving forward from our experience.

Ms Munroe: Thank you very much, Professor Fenton, you have answered again in anticipation the next part of the question. So thank you very much.

Thank you, my Lady.

Lady Hallett: Thank you, Ms Munroe.

Ms Blackwell: That concludes Professor Fenton’s evidence.

Lady Hallett: Professor Fenton, thank you very much.

The Witness: Thank you, my Lady.

Lady Hallett: Thank you very much for your help, it’s been extremely interesting.

The Witness: Thank you very much.

(The witness withdrew)

Ms Blackwell: Is that a convenient moment for the break?

Lady Hallett: It is. 1.55.

Ms Blackwell: Thank you very much.

(12.55 pm)

(The short adjournment)

(1.55 pm)

(Proceedings delayed)

(2.00 pm)

Mr Keith: My Lady, this afternoon’s witness is Professor Mark Woolhouse, please.