Transcript of Module 1 Public Hearing on 10 July 2023
(10.30 am)
Lady Hallett: Ms Blackwell.
Ms Blackwell: Good morning, my Lady. May I please call Dr Claas Kirchhelle.
1. Dr Claas Kirchhelle
DR CLAAS KIRCHHELLE (sworn).
Questions From Counsel to the Inquiry
Ms Blackwell: Thank you, Dr Kirchhelle, for the assistance that you’ve so far given to the Inquiry. You have provided an expert report that we have at INQ000205178. Can you confirm, please, that that is your report and that it’s true to the best of your knowledge and belief.
Dr Claas Kirchhelle: Yes, it is.
Counsel Inquiry: Thank you very much. We can take that down.
During the course of your evidence this morning, if you require a break at any time, please just say so. Try and speak clearly and slowly and into the microphone so that the stenographer is able to prepare the transcript.
I’m going to begin by taking you through your qualifications and experience so far as they’re relevant to this Inquiry.
You are currently a tenured assistant professor of the history of medicine at the University College Dublin. Prior to that you were a research associate at the University of Oxford, and you describe yourself as being a historian of bugs and drugs, of laboratory infrastructures and the development, marketing and regulation of antibiotics and vaccines; is that right?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: You are also an honorary fellow of the Oxford Vaccine Group, you have an MA in modern and medieval history from the University of Munich, an MA in social sciences from the University of Chicago, and you are a doctor of philosophy at the University College, University of Oxford.
You have a large number of published journal articles, edited volumes and book chapters, some of which we’ll touch upon during the course of your evidence, and you are the recipient of a number of research and engagement and teaching awards, which are all listed in your CV.
You were instructed by the Inquiry to address the following matters: the history of public health bodies in England, Wales, Scotland and Northern Ireland; a description of the key EPRR functions and structures of those public health bodies, including public health laboratories, which we will feature very much during the course of your evidence; and the impact of the changes of public health structures on issues such as the cohesion of the public health system, information sharing, the workforce, and on pandemic preparedness and resilience.
You make it clear within your report that you were assisted by others in its compilation, but can you confirm, please, Dr Kirchhelle, that the text and opinions stated in the report are yours.
Dr Claas Kirchhelle: Yes, I would, however, like to acknowledge the fact that peers have reviewed this, as of Professor Sally Sheard, Professor Virginia Berridge, Professor John Stewart and I’ve particularly drawn on help by Dr James Lancaster, and I would also really like to acknowledge the fact that I was allowed to draw on unpublished research and insights by Professor Allyson Pollock and Peter Roderick.
Counsel Inquiry: Thank you.
Your report is in three parts, which correspond with the major shifts of public health policy that took place across all four nations. The first part covers 1939 to 2002, and is an overview of the post-war evolution of United Kingdom public health arrangements and infrastructures prior to the major health security oriented regulatory reconfigurations that took place following the 1990s BSE crisis and also the 2001 attacks on the World Trade Center.
Part 2 covers 2002 to 2010, and is subheaded “Centralisation and Fragmentation”, covering the performance of the new integrated health protection bodies at the level of the UK and also the devolved nations, local health services and evolving pandemic preparedness amidst the 2003 and 2009 outbreaks of SARS CoV-1 and swine flu.
Part 3 covers 2010 to 2019 and is subheaded “Austerity and Localism”, with a specific focus on the impacts of new doctrines of localism amidst austerity-related cuts to local public health budgets and the influence of new molecular technologies on laboratory infrastructures; is that right?
You know, Dr Kirchhelle, that Module 1 is focusing on a date range from 2009 to 2020, so why is it necessary, in your opinion, for us to go as far back as 1939?
Dr Claas Kirchhelle: So I think there are two reasons for this. The first reason is that the decisions made between 2009 and 2019 were heavily influenced by doctrines which were put in place prior to this and also by structural path dependencies within public health systems that had evolved over decades.
The second thing is that there’s a huge diversity of different public health systems that have been put in place historically in the UK, so I think you need to have this broad view, this high-level review of these things, in order to make informed decisions about how public health can move forward.
Counsel Inquiry: Is it right, Dr Kirchhelle, that your own experience focuses on the history of public health in England and Wales, and so although your report includes the consideration of Scotland and Northern Ireland, you have drawn on published reports in order to include that information within your report?
Dr Claas Kirchhelle: Yes, that’s true, I’m not an expert on Northern Ireland or Scotland for that matter. The report is a high level report, it summarises peer reviewed published historical evidence, and it also draws, where I can, on primary sources such as those released to me by the Inquiry.
Counsel Inquiry: How much published material is available on the devolved nations compared to that of England or the United Kingdom as a whole?
Dr Claas Kirchhelle: Surprisingly little. If you think about the fact that various devolved arrangements have been in place for quite a while, there’s a remarkable lack of comparative performance data, but there’s also a remarkable lack of really holistic, historical overviews for most of the devolved nations, and then also particularly in relationship to England and Wales.
Counsel Inquiry: Right, but you have done your best with the material that’s been available to you?
Dr Claas Kirchhelle: Absolutely.
Counsel Inquiry: We’re grateful for that.
My Lady has heard already about differing types of laboratories, over various time periods.
I am going to ask you to begin by assisting us in setting out broad definitions of the various laboratories that were available to the various devolved nations over the course of time.
Starting with local laboratories, these are predominantly based in NHS hospitals, carrying out clinical microbiological testing to provide diagnoses for patients cared for as either hospital in-patients or outpatients, and they mostly provide a diagnostic service as well for local practitioners; is that right?
Dr Claas Kirchhelle: It’s a bit more complicated than that. So the laboratories evolved substantially over the course of the 20th century, so whereas nowadays a diagnostic laboratory would definitely perform the functions that you have described, if you go back there’s a broad institutional diversity of laboratories in the UK – with, in Scotland, for example, university laboratories – actually part of carrying out core public health functions, which would still be considered local, in some cases.
Counsel Inquiry: Right. About what public health laboratories?
Dr Claas Kirchhelle: So those get formalised a lot after – actually during the Second World War, when Britain puts in place the Emergency Public Health Laboratory Service in preparation for major outbreaks that are predicted to result from aerial bombing and civilian displacement. So in preparation for the war, the UK designates a series of locations across the country, outside of London, where microbiology can be performed, it will be provided free of charge, to local authorities, and the idea there is to have local microbiological competence that is decentralised and flexible to react to problems as they emerge.
Lady Hallett: Could you just – you are speaking terribly quickly.
Ms Blackwell: I’m so sorry.
Lady Hallett: I do understand how difficult it is, and you’re not the first person, don’t worry, but we have to remember that – maybe if you could pause after the answer, Ms Blackwell.
Ms Blackwell: Yes, of course.
Medical officers of health, I was going to ask you about. When did they come into being and how did they connect with the Emergency Public Health Laboratory Service that you’ve described?
Dr Claas Kirchhelle: The office of medical officers of health emerges in the 19th century and it is one of the first key offices of public health in the UK. The medical officer is in charge of infectious disease investigation and control. It’s also increasingly important – and usually it’s a he – in the form of reporting of diseases. The role evolves quite a bit. For a while they run their own hospitals, at the local level they integrate a variety of services, but after the Second World War they form part of a tripartite function of the new national health service, and this is a similar function across nearly all UK nations, where they function as the central port of call for public health at the local level and can draw on their – what then becomes the public health laboratory service or the various other microbiological services.
Counsel Inquiry: Indeed, did the Emergency Public Health Laboratory Service then become the Public Health Laboratory Service, the PHLS, which we see existing over a long period of time?
Dr Claas Kirchhelle: Yes. The success during the Second World War is so strong that something that is actually just meant as a stopgap emergency solution becomes permanent.
Counsel Inquiry: Did it start off as an integrated network of 19 laboratories across England and Wales but by 1969 had the number of PHLS laboratories grown to 63?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: Many of the new laboratories were located within local hospitals?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: All right.
Now, I’d like to display, please, a figure that comes from your article called Giants on Clay Feet which is at INQ000207449. We can see that here.
If we go to page 17, and zoom in to figure 1, just to familiarise ourselves with these four charts, are the red dots representing local laboratories and the black dots representing regional laboratories?
Dr Claas Kirchhelle: Yes. The distinctions vary over time, but I think between 1946 and 1965 that’s a very accurate description.
Counsel Inquiry: Looking at figure A, we can see that at the north of England and Wales there are mainly local laboratories but in the south they are mainly regional laboratories, and we can see that there is a blue square around the Greater London area, which is blown up and depicted in figure B. So we can see that there were a number – ten in number, I think – of laboratories in the Greater London area.
Would you have described those as local or regional laboratories?
Dr Claas Kirchhelle: The London laboratories were technically not part of the Emergency Public Health Laboratory Service but of the Emergency Medical Service, however they did contribute to the overall microbiological intelligence gathering.
Counsel Inquiry: All right.
Dr Claas Kirchhelle: So, again, over historical time periods of almost a century, the distinctions vary and blur a bit.
Counsel Inquiry: Now, if we look at figure C, we can see that by 1946 there were a significantly larger number of both local and regional laboratories. And by 1965, an increase in local laboratories, but around about the same number, if not slightly fewer, of regional laboratories, now configurated in the north west and the sort of southern belt – or the southern Midlands belt of England.
Is it right that there was no formal requirement to send samples or report disease outbreaks to the Public Health Laboratory Service?
Dr Claas Kirchhelle: That’s correct. The idea behind this was very simple: this service was designed to slot into existing public health services without disrupting them, so the idea was you would provide free testing services, free epidemiological expertise, without stepping on anybody’s administrative toes at the local level.
Counsel Inquiry: By 1972 you tell us in your report that the successful integration of local public health and health services was unparalleled in Western Europe or North America?
Dr Claas Kirchhelle: There is no comparable public health laboratory network.
Counsel Inquiry: All right, thank you. We can take that down now.
Moving to a slightly later period, in 1974, was there a major reorganisation of the NHS and local authority services, which led to the abolition of the role of medical officers of health?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: Why were they abolished at that time?
Dr Claas Kirchhelle: There were concerns about the performance of medical officers of health, that the service had become overstretched. I believe there were 550 officers spread over 1,244 local authorities, so that led to concerns both about the overstretched service, and this was also a time when there was significant political desire to reform and make the NHS more efficient. And as a consequence also of the epidemiological shift which we’re seeing, where people are no longer primarily dying of infectious diseases but of non-infectious diseases, there’s also a relative de-emphasis on the infection control duties and – that the MOH, you know, had done previously. So it’s a constellation of different pressures. The effect at the end of the day is that this integrating focal point of public health at the local level disappears and is very difficult to replace.
Counsel Inquiry: In 1988, a report by the then Chief Medical Officer, Donald Acheson, led to further significant changes, didn’t it? Each health authority was then to employ a consultant in communicable disease control, or a CCDC, who was accountable to the newly created office of Director of Public Health, and that’s something that we recognise in the Inquiry because my Lady has heard evidence about that role before this morning.
The regional DPHs, or directors of public health, would co-ordinate health protection across the districts or their regions and report annually on the health of the population in the area that they served; is that right?
Dr Claas Kirchhelle: That’s correct.
Counsel Inquiry: Just pausing and remaining for a moment on the situation of laboratories, though, the 1970s had seen 11 of the Public Health Laboratory Service laboratories close, and by the early 1980s, competition for limited public health resources amidst a growing emphasis, as you’ve said, on non-communicable diseases led to cost-cutting reviews and posed what you describe as a threat to the whole system; is that right?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: From the 1990s onwards, the Public Health Laboratory Service had sole management of the laboratories and charged health authorities and GPs for diagnostic tests; is that right?
Dr Claas Kirchhelle: That’s correct.
Counsel Inquiry: How did that formalised charging arrangement impact the relationship between the Public Health Laboratory Service and the NHS?
Dr Claas Kirchhelle: It significantly complicated the very effective yet quite informal arrangements of the post-war period. You have to imagine public health, especially at the local level, as a bricks and mortar infrastructure, where people knew where to go. It was clear that there was an anchor point within the PHLS. That local anchor point was integrated into a national network, and often there were informal economies of intelligence gathering. So, as a microbiologist, you would speak to your local clinician, you would know what was going on, you would also speak, prior to the abolition, to the MOH. So it was a very dynamic horizontally-integrated system that was still vertically connected upwards, especially after the Acheson reforms, with the ability to surge if there were outbreaks going forward.
The idea of the internal market, that’s introduced in the 1990s, was that you would create efficiency in the system by making the system perform according to market rules. The problem was, however, with the PHLS, that charging for every single service in many ways destroys these informal economies of exchange. It incentivises the NHS and other providers, perhaps, to go with private providers or it incentivises perhaps less testing and less reporting.
So the PHLS was struggling during this time.
Counsel Inquiry: All right.
Moving forward a few years to the mid to late 1990s, the PHLS was divided into ten regional groups with devolved budgets, and that number of groups was reduced to eight by 2002, at which point the Welsh public health arrangements diverged significantly, didn’t they, from those in England?
Dr Claas Kirchhelle: Yes, that’s a result of a major re-ordering, actually more at the English level than at the Welsh level.
Counsel Inquiry: Well, let’s now deal with each of the four nations independently, please, starting with England, and the time period 2002 to 2010.
You tell us in your report that the Blair government made significant reports to health services and the public health infrastructure, and the ones that I want to focus on during this period are the establishment of the Health Protection Agency, the transfer of control of the PHLS local public health laboratories to the NHS hospital trusts, and also the setting up of the primary care trusts.
You describe the establishment of the Health Protection Agency as a painful birth, and that staff described the integration at that time as challenging, which perhaps isn’t surprising, given that it fused into a single entity 80 organisations in 140 locations, and 400 distinct IT applications with 40 to 50 websites.
It was estimated, was it not, that it would take up to five years to fully integrate all HPA services, and did that prove to be the case, Dr Kirchhelle?
Dr Claas Kirchhelle: So the painful birth is a quote from witnesses at the time, actually it’s from the first executive of the HPA who describes it in those words. I’d like to take you back very quickly just into why the HPA was created in the first place.
Counsel Inquiry: Yes, please.
Dr Claas Kirchhelle: This was an attempt to move and fundamentally reform public health reporting to a more upstream function of intelligence gathering and co-ordination. There had been long-standing complaints about parallel hierarchies and competition between the NHS and public health laboratory provision at the local level, and following the 9/11 attacks, but also following a request by the UK’s government, the then UK CMO Liam Donaldson reconceptualised health protection in a very American CDC-led style, where you would integrate and combine responsibilities for infection control, radioactive and chemical hazard control, into one big agency that could, in a kind of command and control system, gather the intelligence and swoop in and help, should there be problems at the local level.
Now, as you’ve already referred to, it’s an organisational behemoth in contrast to the initial infection control infrastructures, and the painful nature of the birth also results from the fact that there are very strong distinct identities within these organisations which are all being integrated.
So what you have witnesses describing is an extreme territoriality of different departments vying for resources within the HPA, and at the same time you have, I think, just a significant organisational challenge. It was set up within a matter of months. There was not years of preparation for this set-up, for things to work. So it was running from 2003; whether the functions were perfect, I think the witnesses agree that there were significant issues.
Counsel Inquiry: Right.
In terms of the transfer of the local public health laboratories, let’s just return, if we can, please, to your Giants on Clay Feet report and look at another set of figures showing, as we can see in the description at the bottom of this page, the extent of laboratory networks under the Public Health Laboratory Service in 1980, and then the HPA in 2010.
Now, what do we see happening in 1980? And take us through how that has transitioned by the time we get to 2010, please.
Dr Claas Kirchhelle: So in 1980 you already see a slightly slimmed down version of the post-war arrangement of public health in England and Wales. We’re not talking about Scotland and Northern Ireland here.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: It’s a very networked infrastructure of public health laboratories, with regional centres that collate information and a very strong national reference system in Colindale in North London, which is now the headquarters also of UKHSA.
In 2010, what you see is the result of this attempt to make health protection upstream and integrated, so a complete handing away of the local infrastructure of public health laboratories to the NHS, the microbiology service which takes over the running of those local labs, and a very significant limitation of dedicated public health laboratory capacity into these regional labs, and London actually has two of these specialist centres.
Counsel Inquiry: Right. So what we see by 2010 is nine, only, what you would describe as regional laboratories? I know that there are only eight dots on the page, but you’ve said that there are two –
Dr Claas Kirchhelle: That’s a feature of the mapping.
Counsel Inquiry: All right.
How did that affect the service that was able to be provided?
Dr Claas Kirchhelle: The ideal of the service was again slimmed down and efficient. So you would have regional teams which would provide local PCTs, so primary care trusts, with advice. They would also be able to commission more detailed public health work from NHS laboratories. But the idea was that the expertise would be condensed in regional centres, which would also provide epidemiologists and epidemic intelligence to counter outbreaks or identify outbreaks.
London again, here, is the centre of most of the specialist laboratories at the time, with Colindale functioning as essentially the heart or the brain of the UK’s system here. But you see here a new vision of public health, which is not unique to the UK, this is something many other countries are doing at the time, but this is this idea of creating a kind of top-heavy, slimmed-down, rapid-response command and control architecture, that is quite different actually from the architecture of emergency that was predominant during the Second World War.
Counsel Inquiry: Is there a difference between a specialist and reference laboratory and a public health laboratory?
Dr Claas Kirchhelle: I mean, both are within the public health service. A specialist laboratory will be able to perform, as the name says, specialist tests and highly also have higher security clearance for specific groups of pathogens.
Counsel Inquiry: All right. You describe in your report that the dissolution of local PHLS structures was traumatic. Why do you describe it as such?
Dr Claas Kirchhelle: Again I quote, so this is the words of the contemporaries. A large part of the PHLS workforce was obviously located in these local laboratories; they had existed for decades, and had an extremely strong identity. And suddenly these laboratories were transferred to the NHS, a very different employment system, and the PHLS was against the will, essentially, of the board, fused with a much larger agency, and for members of the PHLS, if you look at the witness seminars of the time, it is described as traumatic and very turbulent, with lots of confusion with – between lots of different systems and also within the HPA.
Counsel Inquiry: What about primary care trusts, their creation and the intention that they would improve or provide a health improvement role? How did they come about and how was that change received?
Dr Claas Kirchhelle: So, I can’t – I think – I think talking through the history of the overall Blairite reforms of the NHS would be perhaps too big now, but the idea of the PCTs is to unify and to make health and public health more efficient at the local level by integrating various functions, including the health improvement function.
Interestingly, however, the proper officer, so, you know, what previously used to be the MOH, and then was the CCDC, that is now moved to the HPA. So the CCDC is employed by the HPA, with these regional teams, rather than being anchored at this local nexus within the PCTs, and – I’m sure we’ll talk about the pandemic responses – it causes all manner of confusion where this function is located within the administrative system.
Counsel Inquiry: So organisational change on a large scale. In terms of government support for the newly formed HPA, you describe in your report that over this period of time that was somewhat erratic because it had received £116 million of funding from the Department of Health in 2013, that was its first year in existence, then that rose to £193 million – I’m so sorry, not 2013; in 2003. Then that rose to £193 million following the 2009 swine flu outbreak, and then went back down to £142 million in the 2012/2013 budgetary year.
That differing rise and fall was also mirrored in staffing levels, wasn’t it? So did that in itself cause a level of confusion?
Dr Claas Kirchhelle: I think this is a classic example of yo-yo funding for public health in and outside crises. So once the immediate perception of a crisis has passed, funding tends to go down. Within the HPA it’s – it’s difficult to comment on whether the funding itself led to confusion. I think it certainly made it difficult to plan for resilience capability building, if there were these huge fluctuations in funding.
Counsel Inquiry: Thank you.
I’d like to move now to the period of time that this Inquiry is concerned with, and it’s really 2009 or 2010 up to the time that Covid hit.
You describe in your report that in 2012, in England, we saw the most complex political restructuring of health and public health services that had happened in decades, or perhaps ever. The primary care trusts were abolished and public health competencies were transferred back to local authorities, as had been the case before their creation, and now we see that the HPA was replaced by what is described as a super-organisation, in the form of Public Health England.
What was the rationale for making these significant and complex changes?
Dr Claas Kirchhelle: So in the case of Public Health England, the rationale is to integrate health protection and health improvement functions. The English reforms actually come after similar reforms in the devolved administrations. So health improvement during this time is becoming very big in international health, and the UK is in line with the trends there.
At the local level, the idea here is, and this is quoting in many ways the reports of the time, is to avoid and overcome what is perceived to be a structurally inefficient structure of the PCTs, and also to empower local authorities to tackle poor health outcomes with their local knowledge. The assumption is local people know best what the local problems are, so if you devolve power to them they will be best able to spend money rationally to take care of this.
Counsel Inquiry: Despite those intentions, was there, at first at least, a blurred statutory overlap between local authority, Secretary of State and the Civil Contingencies Act duties, and I think you describe it in the following terms: what sounded complicated on paper proved complicated in practice?
Dr Claas Kirchhelle: That’s true. I think I spent – on this page I spent probably the most time per page to get my head around who was responsible for what, and I think the Inquiry has shown the famous spaghetti chart.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: I think it’s mirrored in that. So if you want me to explain this, I can. I would prefer to read the report itself so that I don’t get it wrong, it’s so complicated.
Counsel Inquiry: All right, we’ll turn to do that in a short while, but, by way of a very high-level summary, Public Health England combined previously distinct health organisations, health protection and promotion functions, brought all of those together, which involved a merging of 5,000 staff from 120 organisations?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: Right. Although it absorbed many pre-existing structures, it also differed from its predecessors in key ways: firstly, as we’ve just mentioned, the combination of health protection and health promotion. But didn’t it also break with post 1950s English traditions of statutory non-departmental public health bodies, because Public Health England became effectively an executive body, as the Inquiry has already heard, within the Department of Health?
That in itself resulted in what you describe in your report as far greater political control over public health activities by its ministers, and also meant that the employees of Public Health England were effectively civil servants and subject to the Official Secrets Act?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: Was that a cause for concern?
Dr Claas Kirchhelle: That was a significant cause of concern ahead of the dissolution of HPA but also after the creation of PHE. I know that Jenny Harries has also commented on the independence that she still perceives PHE had. What the historical investigation shows is that senior microbiologists, HPA officials, have consistent concerns about what this might do, in terms of Public Health Agency’s ability to speak openly to power. Ahead of the transformation, the BMA surveys its members within the PHE establishment in 2014; they themselves say that it’s more difficult to talk freely. And then, later on, local health authorities polled by Ipsos MORI say that they feel that PHE could do more to lobby for public health protection to the Department of Health.
So there are numerous different points of evidence which I think paint a slightly more complicated than perhaps Duncan Selbie or Jenny Harries have said.
Counsel Inquiry: Just touching upon Duncan Selbie, as you mention him, and the fact that he had, at the time that he took over as chief executive of Public Health England, no scientific or medical background.
He explained in his evidence to my Lady that despite that and the – we’ve talked about the light-hearted way in which that was dealt with in The Lancet article – despite that, he felt that he had sufficient experience in the roles that he had fulfilled prior to taking over the chief executive role so that his lack of medical and scientific knowledge did not create any difficulty.
Do you think that it is a problem, that the chief executive of Public Health England was neither qualified in science or medicine?
Dr Claas Kirchhelle: Let me phrase it this way: it’s remarkable that for 70 years the UK decided to have a medically qualified and scientifically expert executive of the most important Public Health Agency, consistently. And it’s also interesting that the choice for UKHSA seems to have gone in the same direction.
I admire Duncan Selbie’s statement for its frankness and, I think, honesty. I think that it is interesting to see how you would be able to communicate complex scientific information to ministers in meetings as the de facto head of the public health establishment. I have no doubt about the managerial expertise, but I do think that if you look at the statements of previous Public Health Laboratory Service directors and HPA directors, you will see that there was substantial effort that they also had to do to communicate the science effectively.
Counsel Inquiry: The 2012 reforms, about which my Lady has heard, and the creation of Public Health England evoked mixed responses from the English public health community, as we’ve touched upon. When Dame Jenny Harries gave evidence, I took her through five issues which are also dealt with in your report, and I’m going to ask you about now, Dr Kirchhelle.
One, confusion over EPRR responsibilities.
Two, independence from government, which we’ve already touched upon.
Three, funding issues.
Four, capacity issues.
Five, fragmentation of the services.
So in terms of the first of these topics, confusion over EPRR responsibilities, Dame Jenny agreed that there was some confusion over those responsibilities arising out of what she described as a complicated, overlapping or blurred state of statutory responsibilities, and although she agreed that it wasn’t a perfect system before, there was a level of confusion when Public Health England was first created.
However, she said that whenever there’s any level of structural change, there will be a bedding-in period during which there’s confusion. Do you agree with that?
Dr Claas Kirchhelle: Of course. I think the salient question to ask is how long the confusion lasts for. And if we look at the preparedness exercises, if we look at all of the statements that we have from internal reviews of public health and they are cited in the report, you see that this confusion is remarkably persistent. So you would expect that after, let’s say, seven years after the setting up of an agency the confusion would die down, and unfortunately I think in the documents you see that that is not necessarily the case.
Counsel Inquiry: All right.
I’d like to turn to funding, please, and display your report at page 72, paragraph 108. Thank you. We can read through this together:
“Functioning of the new local and national English public health structures was compromised by austerity politics. At the local level, the abolition of [primary care trusts] meant that overall public health performance was strongly dependent on local authority capabilities to commission and deliver effective services. Ministers had promised to ring-fence the public health budget for local authorities. However, an in-year cut of £200 million in 2015 was followed by further reductions over the next 5 years. According to the Local Government Association, this amounted to a real term reduction of the public health grant from over £3.5 billion in 2015-16 to just over £3 billion in 2020-21 …”
That’s a reduction of 14%.
“Other estimates by the Institute for Public Policy Research spoke of an even more dramatic reduction of £850 million in net expenditure between 2014/2015 and 2019/2020, with the poorest areas in England experiencing disproportionately high cuts of almost 15 percent. Resulting pressures on local public health were exacerbated by an overall 49 percent real term cut in central government funding for local authorities between 2010/11 and 2016/17 and a resulting practice of ‘top slicing’ whereby authorities reallocated ring-fenced public health budgets to other services broadly impacting health and wellbeing such as trading standards or parks and green spaces. In 2010, Healthy Lives, Healthy People had promised to give ‘local government the freedom, responsibility and funding to innovate and develop their own ways of improving public health in their area’. Freedom and responsibility had been granted – but funding was often lacking.”
Now, Dame Jenny, when she gave evidence, agreed that the ringfenced public health budget reduced over time due to austerity, and she said that she recognised some of the figures that appear in your report, but she went on to say that there are 152 top tier local authorities and a £200 million cut in the year. Well, that’s about 1 million each across the various local authorities. Whilst she agreed that the directors of public health were under significant pressure, she added that the local authorities were actually very efficient in commissioning services and so could generate savings to mitigate the loss.
Do you agree with that interpretation?
Dr Claas Kirchhelle: I would disagree with parts of it. I think Duncan Selbie has put it eloquently, that a £1 million cut for a local authority is a significant cut, and can result in the closure of a crucial health centre or of other crucial services. We see this with the top slicing.
There’s also a difference, in my opinion, between managing cuts efficiently and building resilience and building capacity for public health. So are we managing a decline or are we administering public health in terms of the goals of improving health outcomes?
Counsel Inquiry: In terms of workforce capacity issues – we can take that down, thank you – Dame Jenny Harries told the Inquiry that lots of staff were lost in the move to Public Health England because in part at least there was a change in the hierarchy within the local authority roles; in other words, with some of the directors of public health roles, there was a feeling that they were reduced really in terms of their importance and so that led to a certain amount of loss of workforce capacity. In addition to that, particularly from the smaller local authorities, there was a reduction in staff. Is that something which you recognised during the change taking place?
Dr Claas Kirchhelle: Yes, but just to clarify that PHE would not be the DPH post, right, that would be the local authority now, I believe.
Counsel Inquiry: Right.
Dr Claas Kirchhelle: So I think at both levels there is, as with any big organisational change, quite a significant turmoil. There are early retirements which result, again – and we see this every time a major reform occurs – a loss of expertise, people go into early retirement, knowledge and competence is lost over time, and I believe at some point in the report I quote the figure that 17%, at some point, of local director of public health posts were vacant.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: This is compensated over time, but if you think about this as a process that is less than a decade long before the pandemic hits, that is quite a lot of organisational turmoil at the local level, and also at the national level, to compensate for when you are also tasked with providing resilience.
Counsel Inquiry: You also tell us in your report that by 2021, I appreciate we’re moving forwards now, 69% of the service medical workforce were located in the newly established UKHSA, the Office for Health Improvement and Disparities, the OHID, and the NHS, and of non-clinical specialists, which include the majority of directors of public health and consultants, 90% were in local authorities and largely concerned with health promotion.
So that shift, in your view, inevitably compromised local level infection control capabilities; is that right?
Dr Claas Kirchhelle: It’s an exacerbation of a longer-term trend that starts earlier but I think does gather steam, and this is based on research for the Infected Blood Inquiry that Allyson Pollock and Peter Roderick and James Lancaster did.
Counsel Inquiry: All right. Let’s go back to your report at paragraph 110, please, which is at page 74, drawing these threads together. Thank you.
You say:
“Austerity and workforce pressures also impacted [Public Health England]. Ahead of the formation of the new agency, a 2012 strategy paper had warned of workforce attrition while simultaneously setting out an ambitious vision of maintaining and expanding surveillance capacities as well as of improving oversight and network integration. This vision was difficult to fulfil. Although regular polling of local authorities indicated that PHE’s staff, expertise, data, and services were highly valued and that appreciation increased over time, PHE experienced cuts of core funding. In 2013/2014, PHE had received a non-ring-fenced revenue for operating expenses of £405 million. By 2018/2019, operating activities were priced at £395.8 million, which amounted to an over 9 percent budget fall since 2013/14 in real terms. Although allocation of funds for infectious disease control rose during this period, the number of staff employed for the protection from infectious diseases fell from 2,397 to 2,093 ([a fall of] 12.7 percent) while those employed in environmental hazards protection and emergency preparedness fell from 517 to 476 ([which was a fall of] 7.9 percent).”
Dame Jenny told the Inquiry that almost all public sector organisations had budget decreases around this time, but of course the combined effect of that meant that if the local authority also had insufficient and the NHS had also dropped their numbers of staff, what happened was, in her view, when you met around the local resilience forum table you may not see the person you saw last week because they’d gone to another position. Did you recognise that in her evidence, and did you recognise that as a problem?
Dr Claas Kirchhelle: I agree with the evidence. You also see it in the tabletop exercises and the departmental reviews of PHE, where it’s noted that the pondents(?), so the corresponding people in other administrations, are increasingly difficult to identify. So this is, I think, a systems-wide problem.
You can also refer to the evidence of Dame Sally Davies here, who says that it’s obviously not just limited to public health but also to the numbers of people employed in health services in general.
Lady Hallett: Sorry, just before you go on, if we’ve finished with funding of PHE, do we need to consider paragraph 111 of the report?
Ms Blackwell: Yes, I was going to go on to deal with that. It’s a convenient moment to deal with that now.
Similar to PHA, efficiency drives and external funding played an important role in supplementing core budgets, because in 2013 to 2014 PHE gained an additional operational income of £180.3 million through research grants, commercial services, and contract income. By 2018 to 2019, this amount had risen to £240.4 million. That was a 24.2% increase on the 2013 to 2014 year, including inflation.
Can we just go a little further down, please. Thank you. In fact, let’s pause there.
Is it important to recognise what’s contained within paragraph 111, in looking at the whole picture of funding, both for the HPA and then later PHE.
Dr Claas Kirchhelle: I think it’s a very important story. It starts already with PHLS, with the internal market and the focus of earning money, but under HPA it becomes much more pronounced. So there’s a focus within HPA of winning external grants from funders like, for example, the Wellcome Trust or from the United Kingdom Government, and also in terms of commercialising some of the services, so spinning out intellectual property, or offering contractual services.
Now, in the witness seminars, this is justified by saying it’s a moral imperative to save taxpayer money via income generation from public competency, so to speak. The problem – this is a well known problem in international health – is that if you become too reliant on ringfenced short-term funding for specialist projects, it can come at the expense of core capabilities. So you might end up having a winner, so to speak, in your department which is endlessly generating money, and that winner then becomes favoured in terms of resource allocation by the department, and departments within PHE or HPA might get less support for the ongoing performance of routine health functions.
It also – and this is again from very interesting witness seminars – creates tensions within the public health organisations between departments which are seen to be flush with funding and people who consider themselves as providing core important services but might have less time and resources to devote to winning these external grants.
So there is more money, but it’s often quite limited, it can fall off cliff edges, you can get funding for a special project but then it just drops off, and it might distort management priorities towards incentivising income rather than necessarily guaranteeing core functions.
Lady Hallett: But if one part of the organisation gets a grant and therefore has sufficient funds to do its work, why doesn’t that mean that the money that the organisation would otherwise have had to put into that department not then move to the core capabilities department?
Dr Claas Kirchhelle: I think that’s a very good question. I think you need to see it in the context of an overall decline of funding that is happening. So redistribution might happen, but over time it creates a distortion of priorities within the department to perhaps win funding from certain elements.
There is a telling quote from Sir Mark Walport, the director of public health, talking to I think one of the HPA senior executives where he says, “I’m a bit frustrated with HPA, we would like to fund your infectious diseases department but they never seem to have the capacity to even apply for the grants in the first place”. So I think that would require more detailed economic analysis of HPA and how they redistributed funds. The anecdotal evidence we have from the senior executives and also from the funders themselves suggests that infectious disease did not perform perhaps as well as radiation threats within HPA, and then within PHE that will require further research.
Ms Blackwell: I’d like to ask you about surge capacity, because Dame Jenny Harries told the Inquiry that, in relation to microbiological testing of virus samples that we’re talking about, HCIDs such as SARS, MERS or SARS-CoV-2, microbiological testing of virus samples require what she described as a containment level 4 laboratory. Which is the highest level, isn’t it?
Dr Claas Kirchhelle: (Witness nods)
Counsel Inquiry: And are only situated in two sites for Public Health England: Colindale and Porton Down.
She told the Inquiry that if we have an HCID or a pathogen X that we’re uncertain about, they need to be managed in a way which means that they would almost certainly go to Porton Down, possibly Colindale, and have to be dealt with initially in those high containment facilities; is that right?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: All right. So does that mean that at the time that Covid hit, there were only two laboratories that would have been able to initially handle the pathogen?
Dr Claas Kirchhelle: I’m not sure whether this is the total amount of P4 certified laboratories in the UK. Porton Down and Colindale have certainly historically been the places in the UK where these pathogens were handled, and you see this in the SARS contingency plan from 2003, they actually give you the sample numbers per day that can be handled in these facilities in the 2003 SARS plan, and that is clearly that Colindale would be the lead but Porton Down actually has a greater capacity for processing –
Counsel Inquiry: Right.
Have you discovered through your research any concerns as to the capacity that Porton Down and Colindale provided in terms of the number of samples that they could effectively work through at any one time?
Dr Claas Kirchhelle: I’m uncertain about how you – I can differentiate here now between P4 labs, P3 labs, et cetera. I can only tell you a vague guesstimate in terms of, for example, whole genome sequencing capabilities, which played a key role during the early part of the pandemic, and in 2016 a review of the Colindale’s functions says they can do 600 samples per day in Colindale.
Counsel Inquiry: Right. Can you explain to us, Dr Kirchhelle, how the initial analysis of a pathogen being dealt with at either Porton Down or Colindale would then flow out to the other laboratories?
Dr Claas Kirchhelle: So the sample from Colindale flowing out – so the sample would not flow out, right. It would be typed, it would be processed, but the epidemic intelligence that is gathered would flow out and, technically speaking, inform control attempts at the regional and local level.
Counsel Inquiry: At what stage would PHE’s involvement then pass over to the other local laboratories?
Dr Claas Kirchhelle: So even with the PHLS there was a point when testing would also have been handed over to the NHS.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: This is part of the multi-phased plans which the UK has had since the 1990s, where you divide a pandemic into specific phases by number of cases and community infection, for example, and you would then, at a certain point, perhaps, hand over testing capabilities.
This approach becomes much more pronounced from 2009 onwards, with the rapid deployment of PCR, so molecular-based testing, during the swine flu pandemic. The HPA had been preparing for this. They had in 2006 established a Regional Microbiology Network and they also had good contacts to NHS virology labs which could get this gold standard diagnostic test and then perform this test themselves.
So you need to realise that there’s a big difference in the time periods that we’re talking about. With molecular testing, if you have a PCR machine and you receive the kind of golden recipe, the validated recipe for testing from Colindale, you can technically scale up infinitively, if – with the laboratories, if the laboratories are using this test.
HPA had recognised this capability from the mid-2000s onwards. They did it for swine flu. I think one of the big questions for Module 2 will be how the algorithm for outsourcing or, you know, expanding the testing range was devised for SARS-CoV-2.
Counsel Inquiry: Right. The Inquiry has heard that there may be a criticism laid at the feet of Public Health England that there was little engagement with private testing laboratory facilities in the years running up to Covid-19 hitting. Is that a criticism that you have come across, and do you agree with it?
Dr Claas Kirchhelle: I know where the criticism is coming from, when it’s in comparison to European neighbour states like Germany, which, for example, outsourced or incentivised private testing very early on in the pandemic. However, I think that in the UK case it’s a slightly odd criticism, because the UK has a significant sequencing public capability within the NHS and it also has significant sequencing capabilities within the university sector, of which PHE were naturally aware because they were working with all of these laboratories prior to the pandemic.
So, yes, obviously one could have developed contacts with private industry more, but also I think this is not so much a question of should PHE have automatically gone to the private sector and have mass scale-up with Lighthouse Labs. It’s very interesting to see the NHS capabilities perhaps not being used as strongly as some observers would have wanted them to be used in 2020.
Counsel Inquiry: So, in terms of surge capacity, given what you have said about PCR testing and the position where Public Health England was at the time that Covid struck, do you consider that there were any concerns or any valid concerns in terms of surge capacity within the public laboratory system?
Dr Claas Kirchhelle: Concerns about surge capacity are voiced in multiple preparedness exercises when it comes to the ability to surge beyond the initial hit of one or two HCID cases in the UK.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: That is a perpetual challenge, I believe, for every emerging pathogens, when you move from the core elite capability of processing and public health handling towards a broader health systems response.
Lady Hallett: Are you moving to a different topic, Ms Blackwell?
Ms Blackwell: I am, yes.
Lady Hallett: It’s been suggested that we break slightly earlier.
Ms Blackwell: Certainly, that’s a convenient moment.
Lady Hallett: Very well, I’ll return at quarter to.
Ms Blackwell: Thank you.
(11.31 am)
(A short break)
(11.45 am)
Lady Hallett: Ms Blackwell.
Ms Blackwell: Thank you, my Lady.
Dr Kirchhelle, we’re now going to move to look at the structural changes in Wales, Scotland and then Northern Ireland.
The Welsh public health arrangements, you say, diverged significantly from those in England during the period between 2002 and 2010. The national public health service for Wales was established in 2003, and then Public Health Wales in October of 2009, and Public Health Wales was tasked with managing health protection, epidemiological surveillance and microbiology services, and also health improvement, health promotion and child protection.
Is it right that Public Health Wales employed the seven local health board directors of public health and their staff of public health experts?
Dr Claas Kirchhelle: Yes, I think so.
Counsel Inquiry: There was an integrated network of public health laboratories as well as Communicable Disease Surveillance Centre in Cardiff, and they were maintained when Public Health Wales was created?
Dr Claas Kirchhelle: Yes, so just to confirm that PHLS in England, the reforms abolished the local level laboratories.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: Wales decides to take over that system wholesale in 2002.
Counsel Inquiry: So did they carry out public health as well as clinical diagnosis functions, those laboratories?
Dr Claas Kirchhelle: If they continued to function like the original PHLS, yes, they did. That is, however, for further research, I think.
Counsel Inquiry: All right.
Well, let’s have a look at INQ000107113, which is a report on Civil Emergencies in Wales by the Wales Audit Office. My Lady has already seen this during the evidence of Reg Kilpatrick last week.
Let’s go to page 10 and have a look at paragraphs 17 and 18. Thank you.
“17. Too many emergency planning groups and unclear accountabilities add inefficiency to the already complex resilience framework. The current resilience structure is similar to the structure in England, with local resilience forums based on police force boundaries and with each Category One responder having its own emergency planning capability. We consider that the current structure is leading to inefficiencies at a local level, unnecessary complexity and unclear accountabilities, and is an ineffective framework for resilience in Wales. We also agree with the Simpson Review, that there is an urgent need for a fundamental review of local authority emergency planning services.
“18. Complex reporting arrangements are leading to confusion about the roles and responsibilities of the numerous emergency planning groups and organisations. This complexity risks fragmentation of resilience activity with potential overlaps or gaps in the arrangements for resilience.”
Now, in his evidence to the Inquiry, Dr Andrew Goodall said that he believed that they had addressed some of that complexity by the time of the pandemic hitting, but he agreed that there had been many examples of the duplication of activities happening within the health service and also filtering into the emergency planning groups. Is that something that you recognise?
Dr Claas Kirchhelle: I think this is a challenge across the UK, where you’ve got the Civil Contingencies Act, you’ve got the NHS systems, you’ve got the public health systems, and in an emergency all of these need to work together, also with local responders. So there is an inherent risk of duplication and fragmentation. And it’s evidenced, I mean, in both the tabletop exercises and the reviews of the 2003 SARS response and the 2009 swine flu responses, that this is one of the core problems.
Counsel Inquiry: Right. Can we take that down, please, and replace it with INQ000089575, which is the 2014 communicable outbreak plan for Wales, and have a look at page 2, please, and what’s said here in the preface:
“In recent years, there have been multiple plans in Wales for the investigation and control of communicable disease. All these have contained very similar guidance. Whilst it has been recognised that each individual plan was robust and fit for purpose, the presence of several plans for use in outbreaks has caused confusion as to which plan should be followed. Therefore, at the request of the Welsh Government, a multi-agency working group was convened in 2008 to draw the plans together into one generic template.”
It goes on to say:
“This model plan (‘The Wales Outbreak Plan’) is the result of that work.”
So, just pausing there, a difficulty or a problem had been identified in 2008 of there being a disparate level of plans to follow in relation to the investigation and control of communicable diseases. This was the result that was created in 2014.
Was this essentially a good idea?
Dr Claas Kirchhelle: I think that the identified concern is a correct one. If you have too many plans for too many different diseases, people forget about the plans. We’ve seen that with the difficulty of re-identifying the original 2003 SARS plan from the English government.
The Welsh plan seems to be in line with other model plans developed, for example, for Northern Ireland during this time, where the focus is on generic response capabilities that can then be mixed and matched.
Counsel Inquiry: All right. An improvement, then, in your view?
Dr Claas Kirchhelle: I think bureaucratically yes. I would perhaps like to make a historical point here. I think the Inquiry naturally focuses on legal documents as the guidelines of responses. If you talk to public health experts, they will tell you that an extremely important component of that work is the informal ties connecting them with their corresponding parts in the health systems and also in the national bureaucracies.
So what I’m trying to say is that it’s good to see these plans evolving. I think that the people, the experts within the public health establishment were much better at abstracting from this than just following by rote a planned system down than perhaps these documents lead us to believe. I’m sure we’ll talk about the influenza framework in a bit, but I think this is a consistent observation in the history of medicine, is that the informal ties, the informal networks, regular phone calls between heads of agencies, can do much to compensate for, at first glance, administrative fragmentation or narrow thinking on paper.
Counsel Inquiry: All right, thank you.
In terms of funding, the Inquiry has heard from Dr Quentin Sandifer, who was the executive director of public health services and Public Health Wales between 2012 and 2020.
He told the Inquiry that in his view Public Health Wales was in no way held back by the funding made available to it by the Welsh Government.
He set out a series of figures, and his evidence was also complemented by the witness statement of Dr Tracey Cooper, who was Public Health Wales’ chief executive from June of 2014.
She in her witness statement said that the service, Public Health Wales, had been strengthening and transforming its workforce model and capacity over the course of time, embracing and developing an approach to what she described in her statement as multidisciplinary practice, and again that there were little problems caused by any level or decreasing level of funding.
But she did highlight what she described as a fragile microbiology service that indeed needed an input of finance, and she described how that took place over the course of time that she has been chief executive of Public Health Wales.
Do you recognise that there was a fragility in terms of the microbiology laboratory capability, and that that has or was improved?
Dr Claas Kirchhelle: That’s very difficult to say, because there are so few comparative reviews of the UK health systems. I think the evidence that’s been submitted shows an interesting discrepancy between funding levels and perceived robustness. Again, I think this is subject to more research.
Counsel Inquiry: All right.
Dr Sandifer told the Inquiry that there was a shortage of microbiologists caused by a number of factors, including the retirement of senior microbiologists and difficulties encountered in Public Health Wales of recruiting more people into post.
Was that a particular problem identified and experienced in Wales, and is that something that was shared across the United Kingdom, and is that something which you recognise from your research?
Dr Claas Kirchhelle: I come back to the points I made earlier about the overall decline of intention for infectious disease threats from the ’70s. In my report I cite a warning from 1980 that is nearly identical to the warnings we have in the 2010s about lack of competence for infectious disease control and microbiological capabilities. So this recruitment problem that is experienced by seemingly many health services across the UK is not unique to the UK, it’s certainly also prevalent in northern American services, so I think this is part of a broader structural issue in terms of how educational programmes perhaps incentivise people to specialise in these areas or not.
Counsel Inquiry: All right.
As far as you are aware from your research, did the lack of ability to recruit into these roles have any correlation between a lack of funding or was that not the problem?
Dr Claas Kirchhelle: I think that’s very difficult to say in hindsight. If you don’t have enough people, and the funding is challenging, it’s difficult to untangle these different factors.
Counsel Inquiry: Did Wales have a problem with their laboratories not being fit for purpose?
Dr Claas Kirchhelle: Again, since this is a high-level review, I haven’t looked explicitly at the grading of the Welsh microbiology laboratories. They did have a robust spatially distributed infrastructure at the handover point of the PHLS. How much investment was made in upgrading facilities, especially with regards to these massive technological transitions that happened between 2000 and 2020, again I think that is something that needs to be looked at in more depth.
Counsel Inquiry: Well, one of the documents which you have been invited to look at is an application that Public Health Wales submitted for additional funding to the Welsh Government to strengthen its own specialist health protection services, particularly in microbiology.
Let’s have a look, please, at some of the issues that arise and that are set out during the course of this paper. Thank you.
This is:
“1. A paper on the proposed model to strengthen the National Health Protection Service [and it] was presented on 27 November 2018. It was noted that investments already made were positive first steps but the model developed required significant additional investment and the whole system approach to strengthen the National Health Protection Service required agreement with the health boards and other trusts. It was agreed that wider engagement with health boards and trusts should take place before proposals to the Minister were finalised.”
“2. The Chief Medical Officer and the Chief Nursing Officer hosted a workshop on 17th May 2019 with key representatives from each health board and trust to discuss the proposed model. At the workshop there was general recognition of the challenges described and general endorsement of the proposals including staffing models presented. Although the financing of the known gaps in funding for the proposed model was not specifically addressed many delegates commented that they had been to like events in recent years without any progress being made.”
So:
“3. A decision is now required whether to recommend to the Minister for Health that the strengthening of the National Health Protection Service is a Welsh Government priority and such this service should be prioritised for investment each year up to 2022/23.”
Now, if we move down to the summary of the challenges and just look at the next two paragraphs:
“4. The current microbiology infection services in Wales are fragile and are struggling to deliver on a day to day basis the prevention, early diagnosis and frontline support that professionals and the public require. As a result, avoidable admissions are adding to the pressure on hospitals and clinicians in many cases do not have access to the early diagnostics they require to guide early and effective treatment which in turn impacts on in-patient bed days.
“5. The current microbiology laboratory estate cannot exploit the opportunity that new testing technologies and robotics can provide. In addition to the lack of access to rapid testing, there are some specific workforce/skill capacity challenges, the current workforce needs to be reskilled and redeployed and the service is unable to recruit to key professional leadership roles.”
Then if we just move to paragraph 10, please:
“Health security has become a greater public health threat, professionals are not confident that they could at all times provide an effective response to high consequence infections as there are points on the patient care pathway that are single person dependent.”
So it appears that at the time that this application was made, there were serious concerns about workforce capacity, about the state of the laboratories, and that there was a plea being made to the Welsh Government for further investment in these regards.
Do you recognise that that was a problem that had been caused by the way in which Public Health Wales was set up and the funding situation?
Dr Claas Kirchhelle: I think it’s difficult to interpret this document, because there’s clearly an overlap here between NHS diagnostic services and public health laboratory services, which can be distinct, do not have to be distinct.
Counsel Inquiry: Should they be distinct?
Dr Claas Kirchhelle: That is a political decision at the end of the day, and solutions vary according to countries. They can be effective if they are well resourced, well financed and well staffed.
What I would like to say again, and this is – it’s important to understand the depth of the technological change that has taken place here. It’s one thing to provide a classic microbiological service with perhaps limited PCR capabilities; whole genome sequencing requires a raft of expertise such as bioinformatic technologies, input from academia that may have been easier to draw on in other parts of the UK, I’m thinking of the Cambridge/Oxford/London triangle, when it comes to Colindale developing capabilities with Sanger, as opposed to the devolved administrations in other parts of the UK.
So I think the historical point here is to recognise that microbiology requires resourcing, it requires staff, but that we are now in a different age of microbiology which might require different forms of expertise that aren’t equally distributed across the UK.
Counsel Inquiry: Are you able to comment on the capacity of Public Health Wales to look to the English laboratories, the United Kingdom-wide laboratories, as and when there might have been need to do so?
Dr Claas Kirchhelle: I think it’s an inherent dilemma within the UK system that Colindale is “so good” with the reference services. I think for a long time laboratories in all devolved administrations have looked on Colindale to provide expert reference services, and I think that that can sometimes create capacity issues when perhaps more specialist microbiological analysis may be required within the devolved administrations themselves.
I know that the Inquiry has looked at HCID treatment capabilities in these different countries – in the different nations, and I think it’s quite remarkable, and it speaks to the theme of the Giants on Clay Feet article, how strong the central capacity in the south of England has been built, but perhaps how little consideration has been given to building sustained capacity in other parts of the UK.
Counsel Inquiry: What we see in this application for funding and the issues that it raises in terms of capacity, does that give you concern or should that give the Inquiry concern that, as of January 2020 when Covid hit, Public Health Wales and the Welsh system may not have had sufficient workforce capacity or laboratory capacity to deal with an HCID outbreak?
Dr Claas Kirchhelle: I think this document speaks to a consensus amongst experts who knew their field, and this was a very serious concern that was raised, so absolutely, the Inquiry should take this seriously.
Counsel Inquiry: All right. Thank you, we can take that down, please.
Moving up to Scotland, by 1945 Scotland already had a long-standing tradition of independent public health legislation and independent health systems, did it not?
Dr Claas Kirchhelle: (Witness nods)
Counsel Inquiry: Scotland decided not to join the Emergency Public Health Laboratory Service which was set up in 1939 in England, which Wales was also part of. I’d like to ask you to what extent did the Scottish Government or public health bodies in Scotland have control over testing carried out at the University Hospitals where their laboratories were based?
Dr Claas Kirchhelle: I think we should not make the mistake of correlating current efficient management systems with the 1940s. These were high-powered university professors who part-time did a bit of microbiology and then also worked in teaching. So the degree of central control was perhaps more minimal than now.
The one key point I think always to make about the devolved administrations is that the population density is far lower and, as a consequence, if you have eight people who know each other and talk to each other regularly, it’s far easier to have efficient co-ordination and you need less formalised management control structures in these situations, and Scotland has – this is the historical consensus – a long-standing tradition of this communitarian-based, consensus-based decision-making in these areas.
Counsel Inquiry: All right.
Following devolution, did the years between 1999 and 2004 see the Scottish Government re-emphasise a collaborative approach to health service provision by abolishing the internal market and that collaborative approach, and the need to tackle health inequalities was emphasised in official planning documents such as the 1999 White Paper Towards a Healthier Scotland?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: All right. Did initial reforms see the merging of Scotland’s 47 NHS trusts into 28 local healthcare co-operatives?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: In 2005, was Health Protection Scotland formed to act as a centre of epidemic intelligence capable of rapidly reacting to major incidents whilst liaising with other United Kingdom and European public health hubs?
Dr Claas Kirchhelle: Yes. I think even the names for UK organisations are a clear clue that – you know, how should I say? – philosophical development of health protection is evolving along similar lines. So you’ve got HPA, HPS and then now you’ve got PHS, PHE, PHW. So there is a clear – and, again, it speaks to the wider academic culture in which these agencies are based, that there’s a clear line of thought that is leading to this evolution.
Counsel Inquiry: Did Health Protection Scotland integrate microbiology and surveillance capabilities that had formerly been provided by the Scottish Centre for Infection and Environmental Health? I think you describe in your report as, rather than creating a parallel public health system and employing its own health protection teams, Health Protection Scotland worked as a division within the NHS National Services Scotland organisation.
How did that differ, then, from the way in which matters were organised in England and Wales?
Dr Claas Kirchhelle: So, in Wales, NPHS creates a completely – almost completely integrated organisation that uses, within also the NHS structure – at first NPHS and then later, via PHW, employs people from the local level to the national level.
Counsel Inquiry: All in one organisation?
Dr Claas Kirchhelle: In one, exactly.
Counsel Inquiry: Right.
Dr Claas Kirchhelle: At least that’s my understanding.
In the Scottish case it builds on these pre-existing traditions of having rather loose co-ordination via CD(S)U, and that tradition is perpetuated with HPS, which again co-ordinates. We aren’t speaking about a huge population, we’re speaking about a manageable smaller number of health boards, so the system you might choose for that might be different strategically, and in the Scottish case, again, because it is smaller, people know each other, so looser epidemic intelligence might do the job just as well. To give the historical context of this, the reason Scotland has this arrangement at all is because in the 1960s they had outbreaks that they didn’t realise they had because they had no integrated epidemiological function, so London told the Scottish authorities that they had typhoid and paratyphoid outbreaks. So this is why this focus on epidemiological integration is made but perhaps no streamlining of a coherent – well, I shouldn’t say “coherent”, but fully integrated microbiological system.
Counsel Inquiry: So it worked for Scotland because of the history which you’ve just set out but also the size of the population?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: And the relationships that existed between those who were running the services?
Dr Claas Kirchhelle: Yes, and that is something that is specifically fostered by repeated Scottish administrations. Scotland is remarkable for health liaison committees from the ’60s and ’70s onwards that are designed to foster this collaborative spirit.
Counsel Inquiry: Is it right that Public Health Scotland became a legal entity in December of 2019 and came into operation in April of 2020?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: The Inquiry has heard about those timings, and the fact that it effectively brought together three legacy bodies: the Health Protection Scotland, the Information Services Division, and the NHS Health Scotland agency.
In her evidence to the Inquiry, Dr Catherine Calderwood has spoken about funding of Public Health Scotland, and has said that there was a specific budget within the overall healthcare budget to fund pandemic and emergency preparedness within NHS Scotland and specifically public health.
But she said that a small proportion of the overall healthcare budget is used to fund public health, only a small proportion of that, and that there has long been criticism from those working in public health in Scotland that – in prevention services, in resilience groups, towards the government funding bodies, and that their view is that public health has not received the funding required for optimal functioning and outcomes, and that that in itself has had a knock-on effect on the ability of those organisations to properly engage in pandemic planning.
Is that something that you recognise from your research?
Dr Claas Kirchhelle: I think it speaks to the overall problems within the UK system. So even within the NHS system you can have public health budgets being raided. This is something that, for example, in the case of the UK during the PCT era of the New Labour government is repeatedly criticised by the Chief Medical Officer, Liam Donaldson, actually – I’m quoting here – saying public health budgets are being raided within the NHS to provide other more short-term priority services.
So I think the wider point here is to say that, regardless which organisational structure you choose to embed your public health system in, you need to protect the core budgets because clinical colleagues can take resources from public health and, in the case of the local authorities, if you don’t fund sufficient public health services they will also, regardless of efficiency, be unable to deliver core functions.
Counsel Inquiry: Over this course of time between 2002 up until the onset of Covid, does your research tell you that there were, as we’ve just discussed in terms of Wales, any workforce or laboratory difficulties or problems within Scotland?
Dr Claas Kirchhelle: Not that I know of, but that is a factor of, I think, the six weeks that I had to research the report. So if I had more time, perhaps I would be able to find something.
Counsel Inquiry: All right.
I want to move now to look at Northern Ireland, and the evolution of health services in Northern Ireland, which in broad terms are parallelled by what was happening elsewhere in the United Kingdom.
In 1953 there was the creation of Northern Ireland Central Public Health Laboratory, and that network expanded, and then, following the passage of the 1999 Northern Ireland Act, did Northern Ireland regain its competencies for structuring its health and public health services on its own?
Dr Claas Kirchhelle: I believe so, yes.
Counsel Inquiry: All right. Is there a significant divergence from Wales and Scotland in Northern Ireland in terms of how the surveillance functions of the laboratories were set up?
Dr Claas Kirchhelle: Northern Ireland is very interesting, because in 1999 the decision is made to outsource or to contract the PHLS and then later the HPA to provide the epidemiological functions of Northern Ireland. So rather than directly creating its own completely homogeneous public health system, the key epidemic intelligence point is actually provided by the PHLS, and the PHLS representative is accountable both to the Northern Irish government and the CMO, but also to the PHLS. So this is a very unique contractual engagement, maybe the result of the smaller population size of Northern Ireland during this time. I haven’t found any detailed justification of why this decision was made to outsource rather than build the capacity within Northern Ireland.
Counsel Inquiry: There were a number of health and social services boards created, and also local health and social trusts which were in charge of the laboratories; is that right?
Dr Claas Kirchhelle: Yes. These trusts, however, and these arrangements pre-dated the Good Friday Agreement.
Counsel Inquiry: Yes. Did they carry on post the Good Friday Agreement?
Dr Claas Kirchhelle: Yes. Yes.
Counsel Inquiry: Is that still the position in terms of the local trusts running the microbiological services?
Dr Claas Kirchhelle: No, so in 2009 Northern Ireland undergoes significant reforms, both for the public health system but also for its wider health and social care system. So you’ve now got a completely integrated – and I hope I’m getting my terminology right – Health and Social Care Board, which commissions services from health and social care trusts –
Counsel Inquiry: Right.
Dr Claas Kirchhelle: The report contains the correct terminology here. But essentially what you have is a completely now integrated system of commissioning from trusts and also from local health authorities of microbiology services, but the trusts run most of the major microbiology labs, including the central one in Belfast which is run – I think by the East Belfast trust, but the correct detail is in the report.
Counsel Inquiry: All right.
You tell us in the report that there was a review of Northern Ireland’s public health functions in 2004 and that that review expressed concern about an over-reliance on English services and suggested replacing the HPA’s CDSC Northern Ireland with a new regional Northern Irish health protection body, and is that what happened?
Dr Claas Kirchhelle: That is what eventually happened. In the case of Northern Ireland obviously the overarching political context is very important to understand. There were repeated breakdowns of power sharing, and so multiple reviews expressed slightly varying concerns and the actual time windows for political action were around 2009 for many of these reforms that then eventually took place.
Counsel Inquiry: I want to bring us forwards now to 2015, when the then Minister for Health, Simon Hamilton, announced that in response to recommendation 1 of The Right Time, The Right Place report by Sir Liam Donaldson, that he would appoint an expert clinically-led panel to consider and lead an informed debate on the best configuration of health and social care services in Northern Ireland.
That board was led by Professor Rafael Bengoa, a name that was mentioned during the evidence of Robin Swann to my Lady on Friday.
Now, the resultant Bengoa report covered the issues of inequalities, the ageing population, primary care and hospital services, and workforce as well, and the main recommendation of the report was that there should be a triple aim within health and social care in Northern Ireland to improve patient experience, to improve the health of the population, and to provide a better value in terms of funding and output.
That report in 2015 was then taken forwards, because in 2016 there was a further review that drew upon the Bengoa report of the Northern Ireland health system called Systems, Not Structures: Changing Health and Social Care. In your report, you say that in 2017, acting on the recommendations which followed on from the committee and then the report which was provided in 2016/2017, that Stormont then introduced a new ten-year health and wellbeing plan; is that right?
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: Was that plan implemented?
Dr Claas Kirchhelle: That’s difficult to say because obviously it’s a ten-year plan –
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: – and there were problems with power sharing after this, and my report ends in 2019, so I’d leave that to the experts of Module 2.
Counsel Inquiry: Well, that’s what I was getting at. Although the report had been presented in 2016/2017, we know that there was then a breakdown of the power-sharing agreement between 2017 and 2020, so are you able to in any way accurately predict which parts of the report were brought into force and whether the aims were in fact ever achieved?
Dr Claas Kirchhelle: Again, that’s very difficult to say because, even with the best will of an administration, given the breakdown of power sharing, given the uncertainties of planning – and I think you’ve also got another expert report on this – that it’s – any ambitious reform could not have been completely implemented, given these circumstances. But again I guess I waive my right here as a historian to say that I focus more on the past and not on the current implementation.
Counsel Inquiry: All right.
Having looked at the structure of public services and their history in all four nations, I want to turn now to talk about what you as a historian are able to comment upon in terms of the pandemic preparedness of the United Kingdom, and focus first of all on what you describe in your report as being the first major test of the preparedness frameworks which occurred in 2003 when the global alert was issued for SARS in March of that year.
You say fortunately the UK experienced a small number of probable cases and no fatalities before the World Health Organisation announced that human-to-human transmission had been broken in late July of 2003.
But you do record that between March and July of that year, the Public Health Agency dealt with 368 reports of suspected cases, of which nine were classified as probable, and one eventually tested positive, following PCR confirmation.
You go on to say that the outbreak nonetheless revealed the significant strains that even a comparatively small outbreak could place on the UK’s public health systems.
Can you expand upon that, please, and why you say that despite there being a relatively minor outbreak and only one confirmed case, that that led to obvious strains?
Dr Claas Kirchhelle: So the volume of testing that was suddenly required stressed the new arrangements. So we have to remember that, in the case of SARS, HPA was just in the process of being set up.
Counsel Inquiry: Yes, in its infancy?
Dr Claas Kirchhelle: Yes, actually it’s created right in the middle of the pandemic wave, so that might explain some of this. However, later assessments do reveal that the new PCTs may have had too little PPE, so personal protective equipment, stored to deal with prolonged surges, and later reviews also – and this is an important thing – revealed that there was a problem with regards to local access to epidemic intelligence that was relevant to the local level.
Counsel Inquiry: What were those problems?
Dr Claas Kirchhelle: The problems were that the local level was reporting suspected clinical diagnosis of SARS up to HPA, but there was a problem of communicating this down effectively via the regional health protection teams to the relevant clinical authorities within the NHS.
We have to remember that SARS at this time was primarily a big challenge in nosocomial, so in hospital settings, and that PCTs and authorities within the NHS and also at the local authority level had a big problem with the fact that they did not have all of the information at their hands that they might have had earlier.
The second thing is obviously to remember that people barely knew the new structures of HPA at this time, so in testimonies of the time the microbiologists recall that they spent a lot of time just phoning laboratories that had previously been PHLS to send samples and report samples up to the HPA, for example.
Counsel Inquiry: So was there a lack of clarity in terms of which laboratories were performing which assessments and which roles?
Dr Claas Kirchhelle: Yes. That is one of the problems. That can, however, obviously be explained by the structural flux within –
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: – which the system was. The more salient point I think was lack of access to relevant information. Another point that was identified was lack also of local epidemiological competence to act on this information now that HPA was more regional based, and obviously, for the Covid 2 outbreak, the lack of PPE stored within primary care trusts.
The final point that one later review revealed was a fear that, given the small number of staff working at HPA, there was a danger of burn-out of key personnel during prolonged surges.
Counsel Inquiry: I just want to take a look at paragraph 83 of your report, which is at page 58, because you produce a quote from the PHLS’s former head of virology, Philip Mortimer, and you can see that towards the bottom of the paragraph. Let’s just pick it up, please, three lines up from the bottom, and if we can – thank you – read through what you say here about Philip Mortimer’s warning:
“Writing in 2003, the PHLS’ former head of virology, Philip Mortimer, warned that over-reliance on centralised epidemic intelligence in the absence of sufficient local capacity for testing, contact tracing, and isolation beds could prove costly during future pandemics. What was needed was sustained investment …”
Let’s look at the quote itself, please. He says:
“… it should not be assumed that a resurgence of SARS is unlikely, or that a further outbreak would be controllable … if there are weaknesses or deficiencies it should not be thought that they can or should be repaired by quick fixes each time an acute threat materialises. Such expenditures fail to build the infrastructure needed to maintain a comprehensive capacity for rapid and technologically appropriate response to new pathogens, and over time they distort facilities and so hinder the effective management of the laboratory.”
In your article Giants on Clay Feet you describe what Philip Mortimer is expressing here as being prescient because of what we now know went on to happen with Covid-19.
What notice was taken of these sorts of issues, not necessarily from Mr Mortimer himself, but from what you have seen, the concerns that you have said were expressed coming out of the SARS outbreak? Did it lead to any action within any of the areas about which concern is being expressed?
Dr Claas Kirchhelle: So the UK does develop a SARS plan that is published in – well, not officially published, not publicly published – late 2003 following the experience of the SARS pandemic, and that plan warns that there may be community transmission of a recurrence of SARS CoV-1, which is a distinct virus from SARS-CoV-2.
The plan has numerous recommendations for how authorities should deal with it. To my knowledge I have not seen any other plan that is building capacity to address the gaps –
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: – identified in this plan.
I should say that Mortimer’s warnings here are not isolated. These are warnings that surface from other people in the health system too, and –
Counsel Inquiry: Can I just ask –
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: – the health system within the United Kingdom or worldwide?
Dr Claas Kirchhelle: In the United Kingdom primarily. There are, however, also concerns in other western health systems raised about the ability to provide sufficient surge capacity should an outbreak like SARS prove more sustained.
There’s also initially a recognition that if you want to control SARS you need to act very fast and hit it very hard when it comes to, for example, improving infection control procedures within hospitals and resorting to things such as school closures. The 2003 plan actually mentions hospitality sector closures in response to it.
So these are significant learnings in many ways that are taken here. We will come to 2009 with the swine flu pandemic –
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: – which is a different, obviously theoretical – well, no, a real risk.
Counsel Inquiry: All right. Certainly as of 2003, concerns expressed in the way in which we see here not only by Philip Mortimer but also by others within the United Kingdom and worldwide?
Dr Claas Kirchhelle: I believe the person who signs off on the 2003 SARS report is Peter Horby, so –
Counsel Inquiry: Right.
Dr Claas Kirchhelle: – that is somebody obviously who is quite senior within the UK public health –
Counsel Inquiry: Yes, and has assisted the Inquiry.
Dr Claas Kirchhelle: Yes.
Counsel Inquiry: Before we move to look at what we learnt from the 2009 swine flu outbreak, I just want to remind ourselves that, in terms of the chronology, in 2007 between SARS and swine flu there was Exercise Winter Willow, which was a large-scale pandemic tabletop exercise of 5,000 participants, and it highlighted potential – what’s described as response misalignment resulting from devolution, as well as the need to strengthen linkages between established local and regional resilience structures and their equivalents within the NHS.
So an indication, then, that there needed to be links strengthened within the various four nations.
Then to the 2009 swine flu pandemic. You say in your report that the official reviews painted an overall positive picture of the United Kingdom response, and that praises were centred around advanced procurement orders, the rapid development of the PCR diagnostic test by Colindale and various responses on the ground.
This Inquiry has heard much about the subsequent review that was commissioned and in relation to which Dame Deirdre Hine produced her report the following year.
Now, in the main the report appears to be positive, but in your report, Dr Kirchhelle, you point to what you describe as difficulties, issues that were raised by independent observers, by historians, and by public workers in the field.
Do you suggest that the sentiments and decisions expressed by Dame Deirdre Hine being at odds with the expressions of concern that you have found, could be explained by the people and the positions of those people who were asked to provide information for the report?
Dr Claas Kirchhelle: I think there is a clear misalignment, despite this being a very good report overall of the swine flu pandemic, of what people at the national level say about the UK response as opposed to independent research which was conducted at the coalfront of the pandemic during the pandemic.
Counsel Inquiry: What are those differences?
Dr Claas Kirchhelle: Key differences in the response are – that emerge as a result of detailed interviews of frontline workers in 2009 are that there was much more pronounced misalignment and confusion about responsibilities at the local level than appears in the report. The report also says that there were confusions and that in future, again, integration needs to be strengthened. But what especially Professor Virginia Berridge, of the London School of Hygiene and Tropical Medicine, conducted during this time shows that there were significant – also – tensions about responsibilities between NHS, HPA, and also confusion about what local resilience fora were supposed to perform. You know, so there was misalignment and confusion about roles. That is something that emerges quite clearly from these statements.
I think another thing that is mentioned that is interesting for the expert advice system was that figures within HPA who were interviewed by Professor Berridge, the reports could never be published, their publication was, according to Professor Berridge, stopped. Also noted that it was difficult sometimes for HPA in wider expert meetings such as SAGE to assert itself because they were often presenting a corporate view of expertise as opposed to more independent statements by other SAGE members.
Finally, HPA also perceived it to be difficult, and this is something that emerges also in the Hine review, to sometimes reconcile its own forecasts of pandemic severity with reasonable worst-case scenarios that were frequently mobilised by the CMO of the time, Liam Donaldson, in warnings to the press, for example.
Counsel Inquiry: All right.
You conclude in your report that whilst the 2009 epidemic ultimately proved less severe than feared and showcased the startling potential of molecular diagnostics and vaccine design, it also revealed that well known problems of local and national co-ordination and resourcing had not been resolved, and to that, from what you have just told us, you would add a lack of clarity in terms of the roles that people were expected to fill during the course of the outbreak and in order to react to it?
Dr Claas Kirchhelle: I think that’s a consistent feature, yes.
Counsel Inquiry: All right.
Dr Claas Kirchhelle: Just one thing I would like to add, though, is this was not just something that was unique to swine flu, this was also highlighted by further reviews of the public health systems. So –
Counsel Inquiry: At the time?
Dr Claas Kirchhelle: Even before swine flu. So in 2007 the European Centers for Disease Control – and again you will find the references in the report – and I believe also Parliamentary committees were interested in these issues and highlighted the need to look further at local co-ordination.
Counsel Inquiry: Following on from the Hine review, the Inquiry has heard much about the 2011 United Kingdom pandemic influenza strategy, with its learnings and emphasis on individual behaviour. One of the criticisms that my Lady has heard is about the comparative lack of consideration of non-medical countermeasures, and that perhaps more should have been said in the strategy about the aspects of social distancing or school closure or even lockdown, which we know does not appear within the strategy.
Has your work, Dr Kirchhelle, shown that in fact some of those non-medical countermeasures, as you describe them, had been raised in previous papers and the reaction to the 2003 SARS outbreak and the 2009 swine flu outbreak, and that they were very much on the radar even though they might not have been considered and certainly not considered in detail within the strategy?
Dr Claas Kirchhelle: The non-medical interventions are a core part of pandemic planning from the 1990s onwards. It’s a core part of the 1997 UK multi-phase influenza plan. In 2003, in the case of SARS, with the plan that is released we have many of the interventions that are later rolled out during the Covid 2 outbreak happening, so from – and we also had during swine flu have school closure, we have border controls, we have – with Ebola later on too – travel restrictions or travel caution, we have hospitality sectors being concerned.
What is, however, new obviously in 2019/2020 with Covid-19 is the scale of lockdowns, the scale of societal closure that is considered. I don’t think that that was conceived of in the initial influenza plans, where the traditional emphasis of government has always been on business continuity, so minimising disruption to trade, minimising also disruption to the economy. That’s a core part of pandemic planning essentially from the late 1970s onwards.
Counsel Inquiry: I also want to ask you about another developing area of consideration in terms of pandemic planning, and it relates to behavioural science.
You say that within the United Kingdom the status of both epidemiological modelling and behavioural scientists in pandemic responses and in pandemic planning has received what you describe as a significant upgrade during the mid-2000s and ongoing from there.
I’d like to look, please, at a report which is called the MINDSPACE report – it’s at INQ000207450 – by the Cabinet Office and Institute for Government, which underlined the advantages of using what they described as low cost, low pain ways of tackling problems.
Let’s look, please, at page 4. This was a review that was prompted by Sir Gus O’Donnell, and we can see his signature there at the bottom, together with Sir Michael Bichard, and if we read into what the report was really set up to achieve:
“Influencing people’s behaviour is nothing new to Government, which has often used tools such as legislation, regulation or taxation to achieve desired policy outcomes. But many of the biggest policy challenges we are now facing – such as the increase in people with chronic health conditions – will only be resolved if we are successful in persuading people to change their behaviour, their lifestyles or their existing habits. Fortunately, over the last decade, our understanding of influences on behaviour has increased significantly and this points the way to new approaches and new solutions.
“So whilst behavioural theory has already been deployed to good effect in some areas, it has much greater potential to help us. To realise that potential, we have to build our capacity and ensure that we have a sophisticated understanding of what does influence behaviour. This report is an important step in that direction because it shows how behavioural theory could help achieve better outcomes for citizens, either by complementing more established policy tools, or by suggesting more innovative interventions. In doing so, it draws on the most recent academic evidence, as well as exploring the wide range of existing good work in applying behavioural theory across the public sector. Finally, it shows how these insights could be put to practical use.”
So:
“This report tackles complex issues on which there are wide-ranging public views. We hope it will help stimulate debate amongst policy-makers and stakeholders and help us build our capability to use behaviour theory in an appropriate and effective way.”
Thank you. We can take that down, please.
Now, you observe in your report, Dr Kirchhelle, citing this MINDSPACE report, that the authors of the 2011 strategy hoped that there would be more of a consideration of voluntary responsible behaviour, that effectively behavioural science was being identified not only by those involved in drafting the strategy but also, as we can see, those who were looking more widely at the health of the United Kingdom, and that it was becoming an important consideration in planning or attempting to plan as to how best to tackle something like a pandemic when it was next going to hit.
Is that reflected in your knowledge and research of what was going on about this time? So we’re now talking ten years or so before the pandemic hit.
Dr Claas Kirchhelle: There’s a marked increase in interest in behavioural theory from around 2000 onwards. This is not just in the UK, this is also at the WHO level where there is a consistent focus on non-medical interventions but also focusing on vaccine uptake in the population.
Now, it’s a very interesting historical coincidence that this new emphasis that is placed on behavioural science, which primarily uses social cues to nudge people in the right direction – there’s also a nudge unit founded in the Cabinet Office during this time – it coincides with the election of a government which emphasises individual responsibility and market-efficient responses. Behavioural science at this time is closely integrated with market psychology, and – and I’ll slow down.
Counsel Inquiry: Sorry. Thank you.
Dr Claas Kirchhelle: – and it’s a core part also of the Hine review of 2009 that more use could be made of it.
The UK’s advice gremia, they start taking up on this from around 2005 onwards and start using behavioural scientists to draft, for example, business as usual messages for the UK Government, so to say, “Continue to go to work, the situation is under control”.
What is interesting what is missing from the behavioural science advice, that is response or representation from social sciences disciplines, which are more structural, so which try and understand the structural determinants of behaviour versus individual psychological determinants of behaviour, and obviously from 2015 onwards a large part of the research on social priming that underlies these hopes for behaviourist interventions at the scientific level experiences a crisis, the so-called replication crisis, where some of the assumptions about effects that can be scaled up to a population size are not replicable in repeat experiments, so the scientific advice and the state of science changes quite significantly during this time.
Counsel Inquiry: Right.
Does that mean that, in your opinion, enough emphasis was placed upon behavioural science in pandemic planning and in what we’re going to look at briefly now, in the exercises that were performed?
Dr Claas Kirchhelle: I think clearly no, because the emphasis here is on assumptions of the behaviour in a universal individual, with not enough regard to cultural and structurally determined aspects of behaviour. So how would ethnic minorities respond to public health interventions –
Counsel Inquiry: Sorry, I want to bring you on, please, to look at in particular the results from Exercise Cygnus, about which my Lady has heard much during the course of this Inquiry.
Just to set it into context, as we know, you’ve already mentioned the Ebola outbreak, which we know about, then there was the Exercise Alice exercise dealing with a MERS outbreak in 2016, and other such exercises, culminating in the large exercise of Cygnus, which my Lady has heard much about, and the report which came out of that exercise.
In your consideration of the report, you tell us that the exercise revealed significant pandemic vulnerabilities and that the final report warned that there is no overview of pandemic response plans and procedures and that the health system’s restructuring across all devolved administrations meant that key organisations referred to in plans and the 2011 strategy no longer existed.
But it’s the issue that you picked up about vulnerabilities and that in conjunction with behavioural science that I’m going to suggest might have been missing.
What do you say about the fact that vulnerabilities were capable of being identified during the course of that exercise and flowing from it from 2016, but may not have found their way into the pandemic plans, and how that sits with what you’ve just described as a lack of consideration of behavioural science?
Dr Claas Kirchhelle: So there are multiple things to unpack here with vulnerabilities. Right? There are health vulnerabilities which the committee has already heard from – the Inquiry – from other experts.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: I think that what’s quite remarkable about the tabletop exercises is that they assume homogeneity of the UK population which is being managed in response to an exercise. There are always calls for more research on how populations would respond to triage, to mass burials, et cetera, but there is very little – remarkably little – consideration given to the fact that the UK has become a substantially more diverse population in this time, that people with different cultural backgrounds, different experiences, will have different responses and expectations of what health services deliver.
Now, this is not in the report, this is something that however should be looked into more. With Ebola, anthropologists proved crucial in optimising responses in response to burial practices, but it seems that the UK was good at employing anthropologists for foreign responses. It would have been good to see more ethnographic and sociological studies of mixed responses within the UK population itself to restrictions, mask mandates, things like that.
Counsel Inquiry: All right, thank you.
So drawing those threads together, the potential to have more consideration to behavioural science, the potential to have more consideration to various vulnerabilities including health inequalities in pandemic planning, and –
Dr Claas Kirchhelle: If I may – I’m sorry, if I may just interrupt.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: So it’s not just the behavioural sciences, it’s actually the social sciences, so that we have an acknowledgement of structural variation within the UK population feeding into plans which are supposed to protect the health of this population.
Counsel Inquiry: All right, thank you for that.
If we look at paragraph 139 of your report, we can see your conclusions in this respect, and your comments on the tabletop exercises and the results of those exercises.
So it’s page 90, paragraph 139 in your report, which is INQ000205178. Thank you.
You say:
“The described exercises foreshadowed many of the key challenges that would emerge during Covid-19. Recurrent warnings about the same vulnerabilities also underlined the difficulties UK planners faced in moving from tabletop exercises and influenza plans to creating and sustaining the real physical infrastructures, staffing levels, and regulatory alignment necessary for an effective pandemic response. Although pandemic preparedness remained a frequently voiced concern, actual UK infection control capacity building between 2010 and 2019 was undermined by budget cuts, regulatory heterogenity …”
Can you explain to us what that is, please?
Dr Claas Kirchhelle: Multiple not homogeneous regulatory systems. So different –
Counsel Inquiry: Diverse?
Dr Claas Kirchhelle: Diverse, yes, that’s a good word.
Counsel Inquiry: All right, thank you:
“… repeated health services shake-ups, workforce shortages, and rapidly expanding public health remits. Following the 2016 Brexit referendum, there was also concern about reduced European coordination and a loss of British influence on European public health bodies.”
Thank you, we can take that down.
So all of the clues were there, some of them had been picked up and had formed part of the pandemic planning, but there were warnings and alerts which hadn’t been given perhaps as much emphasis as they might.
When one takes into account the issues which you’ve also set out in terms of funding and workforce capacity, how do you say that the planning and the issues that were affecting the United Kingdom in the run-up to Covid-19 hitting created a difficulty?
Dr Claas Kirchhelle: So I think what we see in this period are obviously the warnings, we see the tabletop exercises, but we don’t see a political – consistent political ownership of the issues that are raised.
Pandemic preparedness is frequently voiced in public. There are lots of Hollywood movies, in popular culture it also has a high place, but at the political level there doesn’t seem to be a consistent driver in terms of improvement of the capabilities.
This is caused by, I would say, budget pressures that are imposed, the need for efficiency, to manage reductions, and finally – and you have heard multiple witnesses testify to this – preparations for the real projected threat of the exit from the EU perhaps overshadowing resilience planning especially in the last three years before the pandemic.
Counsel Inquiry: You also refer in your conclusion there to the stark difference between considering an issue during a tabletop exercise and really being prepared for the reality when it hits. Do you think that the exercises about which this Inquiry has heard are effective, are worthwhile, could be improved, or is there always going to be a chasm between thinking about something within the clinical confines of a meeting room and the reality when it hits?
Dr Claas Kirchhelle: I think the truth of that is self-evident.
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: The exercises are important, they get people into contact who need to know each other. However, similar to the proverb about battle plans, the first thing that goes out of the window, within an hour, is the battle plan, and in that situation you need to have the resilience and the resources to pivot and adapt.
I remember statements from Mike Ryan from the WHO during the first month of the pandemic saying that you just need to – failure is okay, you continue, you just need to continue adapting. And for that you need to have the resources and the resilience in place, and you need to have the trust and the knowledge about who is responsible for what between key actors.
Counsel Inquiry: Right.
Before coming to your conclusions as you set them out in the report –
Lady Hallett: Just before you do, can I ask roughly how long …
Ms Blackwell: I think I will be five minutes more, my Lady.
Lady Hallett: Because then Mr Lavery has some questions too.
Ms Blackwell: Right. I am happy to break now, if my Lady would prefer.
Lady Hallett: I think probably – unless it causes you any problems if we –
Dr Claas Kirchhelle: I would just make one final point, please, about – if I may?
Lady Hallett: No, whether or not we break now.
Dr Claas Kirchhelle: Yes, of course.
Lady Hallett: You can be back this afternoon?
Dr Claas Kirchhelle: Yes, I can do that.
Lady Hallett: Okay. We shall return at 1.50, please.
(12.55 pm)
(The short adjournment)
(1.50 pm)
Lady Hallett: Ms Blackwell.
Ms Blackwell: Thank you, my Lady.
Dr Kirchhelle, before we look at the conclusions that you draw in your report, I’d just like to ask you about the Global Health Security Index, about which the Inquiry has already heard, and the United Kingdom’s ranking in the category “Rapid response … and mitigation of the spread of an epidemic”.
Professor Mark Woolhouse has told the Inquiry that, in scoring considerably higher than any other nation, with the US coming in second in this category, there is a danger of a risk of complacency, that the government could reasonably claim that it was well prepared for a pandemic, citing that independent evaluation. Do you agree with that concern?
Dr Claas Kirchhelle: I think there’s a risk involved there.
Counsel Inquiry: Okay, but secondly, he went on to say that though the criteria used by the index seemed to be sensible, it proved a very poor indicator of outcomes in the face of an actual pandemic, not only for the UK and the US, but for other countries as well, and perhaps that indicates that we should not confuse preparedness and defined by the Index with vulnerability, and that the global health community needs to re-evaluate the relationship between the two.
He told the Inquiry that until that is done, it will be difficult for any government to make an objective assessment of either. Do you agree with that?
Dr Claas Kirchhelle: I think that’s true, yes.
Counsel Inquiry: Further, in his evidence, Professor Woolhouse told the Inquiry last week that the designer of the indices defended them on the grounds that they weren’t intended to be predictive, and he then asked rhetorically: well, if they weren’t, then what were they for?
Taking all of that into account, do you think that these types of international reviews are helpful or do they create the trap of complacency and fail to have any or any sufficient regard to vulnerabilities?
Dr Claas Kirchhelle: So I read the same article that Professor Woolhouse read, and I had the same thought with regards to the conclusion that the authors drew there.
So I think that international comparisons actually are incredibly important for public health preparedness. The question is what kind of comparisons we have. With the Global Health Security Index, it was a very specific form of evaluation that overemphasised technological preparedness, the capability to sequence and rapidly respond to outbreaks, but didn’t accurately take into account the overall baseline capacities of health systems and public health systems in these countries.
There is also an issue here at the international level with experts being drawn primarily from English and American settings, going to the same public health schools, and then perhaps evaluating quite a technologically – according to quite a technologically-based paradigm health systems performance.
So what you see with the Global Health Security Index was a simplification of what preparedness consists of, and it’s very much in keeping with this line of thought that I’ve described emerging from the 1990s onwards, this focus on upstream, top heavy epidemic intelligence, but it leaves out of the equation what happens when these centres of excellence are overwhelmed, when they fail.
So that was too reduced. Nonetheless, within the EU, when the UK was still a member, you had regular ECDC ratings of preparedness, and regular talking through of public health systems’ performance. Those were useful and they taken on board by the UK Government, some of the ratings there.
So international comparisons matter but we shouldn’t be overly focused that they actually paint a completely accurate picture.
Counsel Inquiry: All right.
Now to your conclusions. You say in your report that the past offers no simple and timeless solutions for the future of public health across the United Kingdom, but, having analysed eight decades of evolving infection control, you see that there are four central challenges going forwards.
First, declining attention.
Second, administrative misalignment.
Third, emergency priorities.
Fourth, what you describe as selective memory.
So just dealing with each of those individually, please.
First of all, declining attention. Is there a perceived problem that you have identified and you can now acknowledge as a problem going forwards that most UK citizens don’t perceive infectious disease as a significant threat to life?
Dr Claas Kirchhelle: That is true.
Counsel Inquiry: Right. Why is that a problem?
Dr Claas Kirchhelle: It’s multifaceted. Most UK citizens within their family have lived memories of multiple pandemics, including here, by the way, also the HIV/AIDS pandemic, which spread in the 1980s, and yet over the years we have seen a consistent decline of societal attention for infectious disease threats.
There are multiple connected reasons for this. The overall reason is obviously that the primary cause of death in this country has increasingly shifted towards non-communicable diseases. Parallelled with this, however, is a problem of investment and protecting the infrastructures that have allowed this decline to take place in the first place.
So the reason my report goes back to the 1930s is to showcase how these baseline infrastructures function. They run quite smoothly most of the time, when it comes to decreasing overall disease pressures on society. Ironically by functioning so smoothly attention for their maintenance declines, and this we can see with investment levels when it comes to protecting core capabilities such as local public health laboratories, local public health specialities, et cetera.
There is also, interlinked with this, the other issue of advocacy. So when we go, again, back to the beginning of this period, public health was very much focused on infectious disease control, but what we see now with public health is a very broad multidisciplinary family of approaches that focus on health improvement, prevention, et cetera, and infectious disease control, this core original capability, is no longer necessarily at the forefront of this thinking. We see it with the recruitment but we also see it with problems of advocacy within the public health community when it comes to protecting and prioritising infectious disease control.
To layer on to that, the final thing, if we then broaden the remit of the public health agencies that we task with protecting public health, more and more and more to cover more aspects, we will inevitably find that persistent lobbying for the protection of these baseline infrastructures will be drowned out by other issues over time.
So it’s a multi – it’s a staggered problem in many ways, but what needs to be done is to increase a permanent advocacy for the maintenance of baseline capabilities that protect you when technology isn’t available to curb an outbreak.
Counsel Inquiry: By doing that, visibility will be maintained and possibly even increased?
Dr Claas Kirchhelle: Ideally, yes, but we shouldn’t expect that societal memories of Covid-19 remain stable. History indicates otherwise. History indicates that forgetfulness will set in and that alternative priorities will come. So what you need is a persistent independent lobbying and protection of resources within government, and also within the profession.
Counsel Inquiry: What about the central challenge that you describe as “administrative misalignment”?
Dr Claas Kirchhelle: One of the leading historians of medicine always describes global health as essentially local. Nothing at the global level really matters if it can’t be put into action locally effectively. So public health continuously has a challenge of aligning health systems’ responses with public health surveillance and other local responses and integrating it nationally into a complete holistic picture and intelligence-led approach to public health.
What we’ve seen in the UK, already before devolution but accelerating after devolution, is an increasing – I lack the word – diverse set of administrative structures, at the local level and at the national levels in the devolved administrations.
This is complicated by the fact, in my opinion, that UKHSA is de facto an English public health administration, yet has obviously UK-wide remits. Other countries – I’m German – for example, have a federal system that is fully federal, where you have an administration that then navigates between individual state-led public health systems.
But in the UK this results in – the fact that we have a kind of hybrid system results in very difficult alignment processes. We see the evidence of this in the tabletop exercises and also in the very telling Department of Health review from 2017, where it said that people within Public Health England didn’t necessarily know who even to call or when to call devolved administrations. And if I’d looked in the devolved administrations, I’m sure I might have found similar references with regards to who is responsible for what within Colindale.
Counsel Inquiry: So ensuring a clarity as to role and responsibility would assist in terms of what you describe as administrative misalignment?
Dr Claas Kirchhelle: There is no optimal solution. All of the devolved administrations have experimented with different systems. We also see, historically, different systems in the UK. But I think what would help would be to avoid reformism, so to avoid changing everything up every ten years –
Counsel Inquiry: And changing the name of structures and organisations?
Dr Claas Kirchhelle: Which is interesting, because it seems to happen after crises, which seems to draw artificial lines after things.
So there is a clear need to either stabilise arrangements and make them work better, or to have a more participant-led discussion about how to structure, UK-wide, things going forward.
I draw here on the selective memory because at the moment most of the memories that are always drawn on are English memories when it comes to restructuring public health systems. So it needs to be, in my opinion, a more representative, a more diverse process, that is not just led from Westminster but has more active involvement of the devolved administrations.
Counsel Inquiry: Well, drawing upon your movement into the selective memory challenge, as well as what you’ve just told the Inquiry in terms of the devolved administrations and the UK-wide memory needing to be captured, is it also your view that there needs to be a proper representative amount of memory coming from different layers of public health?
Dr Claas Kirchhelle: Memory capture has been a formal part of pandemic planning since the 1990s, and yet while reading these enormous amount of reports as a historian since this time, I’ve been repeatedly struck at how narrow some of the capturing has been. Often enough it’s national institutions capturing memories that focus on national responsibilities that then results in new organisations being created or responsibilities shifted around between different ministries, but rarely have I seen memory capture exercises that actually have ample evidence from the local level.
I think this is something that relates to the key identified repeated weaknesses in the UK pandemic preparedness that comes out of the reports where local perspectives and local alignment seems to be one of the most sticky issues when it comes to preparedness.
So ensuring a representative participatory form of memory capture that draws on the DPH, the infection control nurses, the specialists at the local level seems absolutely central, and to add to this capturing in great detail the experiences of the devolved administrations, and – I think in the Inquiry this has come out repeatedly – capturing data that is comparable across devolved administrations is absolutely key to ensuring a more robust base of evidence moving forward.
Counsel Inquiry: Your final challenge going forwards you describe as emergency priorities. How can we best prepare ourselves for what might come next in terms of our emergency priorities?
Dr Claas Kirchhelle: I think there’s a philosophical dilemma here, because if you prepare for one emergency in a range of multiple emergencies, devoting all of your resources towards these specific scenarios might actually end up weakening your core baseline capacity.
So what we see from the 1990s onwards is a shift towards this top heavy upstream mode of epidemic intelligence and preparedness – this is not limited to the UK, it’s also in other countries – amidst a decline of the bread and butter public health capacity that you need when the centre fails.
This is, I think, a core theme especially in the case of England that is quite prominent from around 2000 onwards, and we saw it playing out with Covid-19 but we saw the warnings earlier about the repeated capacity problems and the fact that global reviews of the UK systems focused on these centres of excellence but perhaps might neglect the baseline hinterlands capacity of preparedness that I referred to in the Giants on Clay Feet article.
Counsel Inquiry: Yes.
Finally groupthink. The Inquiry has heard varying views on this and whether or not it existed and caused any difficulty in some of the scientific organisations and groups that were either permanently set up or stood up for an incident such as Covid-19.
As a historian, what is your view of groupthink and have you seen it present in some of the groups that you’ve looked into?
Dr Claas Kirchhelle: I think at the scientific level there is no evidence whatsoever of groupthink. There’s such a diverse planning landscape, and we see it with the WHO in 2018 putting Disease X formally onto pandemic planning landscapes. We see it with the planning for all kinds of high-consequence infectious diseases. We see it with the fact that the UK had a SARS plan, it had a MERS plan, there was planning across multiple pathogens. The fact that it still remained an influenza-based framework –
Counsel Inquiry: Yes.
Dr Claas Kirchhelle: – I agree here with Jenny Harries’ assessment, is that influenza was the most realistic disease to plan for.
Counsel Inquiry: Why was that?
Dr Claas Kirchhelle: We have the most robust data of pandemics based on influenza and they occur regularly. It’s not just 1918, the UK had a pandemic in the 1950s, in the 1960s, there was a major scare in the 1970s, another major scare in the 1990s, and a major scare – or an actual pandemic in 2009. So it’s realistic to see influenza as the most likely respiratory pathogen that can occur and that can spread.
There were obviously failures to update the plan for new knowledge emerging around asymptomatic transmission and aerosolised transmission, but it doesn’t mean that this amounts to groupthink. And I come back to the point I made earlier in my hearing, that a legal document is not necessarily representative of a very diverse ecosystem of thinking about pandemics. Again, we only need to look to popular culture, where actually there’s a huge amount of pandemic scenarios already embedded, with board games with multiple pathogens, and all of these things around.
So my point here is influenza is a realistic framework to base pandemic planning around, it’s there regularly. Moving forward it might be useful to perhaps have more generic names and prepare more generically for airborne pathogens, but I don’t subscribe historically to the argument that groupthink delayed preparedness. In 2019, December, we have the first phase one clinical trial of a MERS coronavirus vaccine, starting in Oxford and then in Saudi Arabia. This is physical evidence that groupthink was not present. The UK was preparing for multiple high-consequence infectious diseases with pandemic potential.
Counsel Inquiry: But going forwards there needs to be a flex, doesn’t there, there needs to be an ability to adapt whatever preparedness follows from this Inquiry and in the days forwards, there has to be an element of adaptability?
Dr Claas Kirchhelle: Yes. I mean, while writing the report I asked myself the one counterfactual question: would the UK have performed better had it been the classic influenza pandemic that hit the country in 2020? And I think there were serious doubts about the ability to handle that. The PPE levels had fallen precariously low. The resourcing at the local level was not there. The communication pathways had not been addressed, et cetera.
So yes, we dealt with Covid-19 as a novel pathogen. Would the UK have performed so much better had it been a classic, still novel, influenza strain? I have my doubts.
Ms Blackwell: Thank you very much, Dr Kirchhelle.
My Lady, you’ve provisionally provided permission for Covid Bereaved Families for Justice Northern Ireland to ask questions on a topic. May that now be done?
Lady Hallett: Mr Lavery.
Questions From Mr Lavery KC
Mr Lavery: I think that’s working now, my Lady.
Lady Hallett: It is.
Mr Lavery: I think I’m jinxing the system.
Dr Kirchhelle, my name is Lavery, and I represent the Northern Ireland Covid-19 Bereaved Families for Justice, and as you’re aware her Ladyship has permitted me to ask a couple of questions about your report and about your evidence.
The first question I want to ask you about is about Operation Cygnus, which you referred to in your report, and there’s a section in that which is about the four nations’ response and one of the lessons identified, lesson 4, says that:
“Meetings of the four health ministers and CMOs should be considered best practice and included as part of the response ‘battle rhythm’.”
And the report also notes that:
“… the Devolved Administrations reported that they felt that they had been left out from some key decisions taken during the exercise, such as the decisions around activating the Relenza stockpile.”
Do you agree that the lack of formal involvement of the Northern Ireland Executive had a negative impact on the Executive’s ability to prepare for the pandemic? First, in relation to that, the first part is about whether meetings between the four health ministers and CMOs of the four nations, formal meetings, should be considered.
Dr Claas Kirchhelle: I mean, it’s always difficult to judge from an absence what the likely reaction would have been. It is remarkable that more formal meetings didn’t necessarily take place. I believe the Inquiry has already heard evidence that representatives of the Welsh public – and also of the Scottish public health system were on committees like NERVTAG more in the function of their expert qualifications rather than as a formal part of the process.
I think as a historian it struck me as remarkable that there’s no more formal representation of devolved administrations there. I can’t comment on how that affected performance in Covid-19.
Mr Lavery KC: Because in your evidence earlier you talked about the value of informal relationships, in particular within the devolved nations, and would you agree that if there were more formal structures there and contact that that might lead to informal relationships?
Dr Claas Kirchhelle: So the informal relationships are extremely important between the public health establishment, and in all of the oral history witness seminars that I’ve attended participants have stressed that that is extremely important to overcome administrative misalignment in crisis situations.
I have, however, no doubt that more formal discussions at the administrative level would also improve co-ordination between all four nations. The more one talks about common challenges the better the solutions will be that come out of them.
Mr Lavery KC: Would you agree, then, that – you complained about this being Westminster-led, the preparedness, that if there was such a formal arrangement that it might be less likely to be Westminster-led?
Dr Claas Kirchhelle: That is a decision for the UK populus to make, how they want to organise living together between the four nations in the UK. I think that there is, historically speaking, a bias towards English experiences in the memory capture and that that memory capture has informed pandemic planning moving forwards, and I think that’s all I can say there. I think it – necessarily more diverse views will likely create more resilience within the system when it comes to thinking through how the same crisis can have different impacts in different territories of the UK.
Mr Lavery KC: And that England might even learn from the devolved administrations? I think you said that there were some ambitious initiatives from Northern Ireland which foundered because of a lack of government there?
Dr Claas Kirchhelle: Northern Ireland is a very, I think, specific historical case, in terms of the overall political environment, in which health systems reforms have been attempted. I think that the UK almost provides a natural experiment for different forms of public health systems, with each devolved administration having slightly different approaches towards public health, and I think that the UK might profit from looking in more detail at how public health can work as an NHS-only operation or within the Northern Ireland context of an integrated health and social care system. Lessons can be learned from every case study.
I come back to the one point that is very important here, it’s that learning lessons also requires comparable data, and that is a big problem.
Mr Lavery KC: Well, in that context, the next question I wanted to ask you was: you noted at paragraph 138 of your report that there were very few exercises which were UK-wide in scope, so is that part of the impact of that, or what was the impact of that?
Dr Claas Kirchhelle: Again I wish I’d had more time for the report and for the archival investigation. The devolved administrations have lots of tabletop exercises themselves. Pathogens cross borders without thinking of them. So obviously any UK-wide health threat, even a small outbreak, will probably trigger some kind of wider UK response. So it seems logical, and I’m thinking here of Sir Oliver Letwin’s evidence to the Inquiry, to formalise UK-wide preparedness planning going forward.
Mr Lavery KC: Then also, well, at paragraph 139 you referred to:
“… the difficulties UK planners faced in moving from tabletop exercises …”
Which you discussed earlier in your evidence:
“… and influenza plans to creating and sustaining the real physical infrastructures, staffing levels, and regulatory alignment necessary for an effective pandemic response.”
Does the fact that similar concerns about the UK’s pandemic preparedness were repeatedly raised throughout the relevant period indicate that a stated commitment to pandemic preparedness was not reflected in the action taken by government in the public health sector during the relevant period?
Dr Claas Kirchhelle: I think there is a mismatch between public warnings about pandemics and structural permanent reforms that are put in place.
Mr Lavery KC: You talked about the need to adapt but also about the need for resources. Was the position similar throughout the UK or did it vary across Northern Ireland, Scotland, Wales and England?
Dr Claas Kirchhelle: I’m not sure I follow the question.
Mr Lavery KC: Well, your concerns about – during the relevant period, that the pandemic preparedness was not reflected in action, tabletop exercises were not reflected in real physical infrastructure, staffing levels and regulatory alignment?
Dr Claas Kirchhelle: Yes, so I mean, again, as I said earlier, you know, it’s one thing to have a tabletop exercise, it’s another thing to have consistent policy implementation focus, either at the UK level or within the devolved administrations. Some devolved administrations clearly pay more attention to this than others, and again we come back to the point about diversity and perhaps a lack of a whole UK-wide approach to these issues.
Mr Lavery KC: Finally, then, Dr Kirchhelle, what was the impact of austerity policies on this? Ms Blackwell in your evidence earlier put to you the declining funding of public health, and I think you described it as a yo-yo effect, reacting to different situations. Was there an impact of austerity on these?
Dr Claas Kirchhelle: I’m very sure that austerity and, I think, the overwhelming body of evidence collected by this committee speaks to that – or by the Inquiry speaks to it, that there was a negative impact on public health levels. The King’s Fund has published data also measuring life expectancy changes during this time, changes in developments of life expectancy.
So I think there is quite a large body of evidence with which I would agree that austerity certainly didn’t have positive impacts on pandemic preparedness. The yo-yo effect is an interesting one. Often after health emergencies you get high levels of very targeted but often very short-term funding for public health, and it comes back to the point about that this funding rarely builds what Philip Mortimer was already warning about in 2003, the long-term capacity in the system, because it goes away after a while and it’s often too selective to build this core baseline capacity.
Mr Lavery KC: In your summary you say that in Northern Ireland there was, if you like, a double whammy impact of fiscal pressures and sustained and regular periods of breakdown of government, Stormont stalemate?
Dr Claas Kirchhelle: I draw here on the secondary literature, so this is both from the European Health Observatory but also from social scientists assessing it, to describe Northern Irish health policy in between the sitting of Stormont as managerial drift, and it’s very difficult to prepare for the future as a public health agency if you’re faced with significant political uncertainty, both about your own administrative arrangements within Northern Ireland and then, obviously, in the Northern Irish case specifically, also the pending exit of Britain from the EU, which in the annual reports also causes consternation.
Mr Lavery KC: Together with fiscal pressures?
Dr Claas Kirchhelle: Together with fiscal pressures, yes.
Mr Lavery: Thank you, my Lady.
Lady Hallett: Thank you, Mr Lavery.
Ms Blackwell: My Lady, that concludes the evidence of Dr Kirchhelle.
Lady Hallett: Thank you very much indeed for your help, Dr Kirchhelle, you kept saying several times if you’d had more time to do more research, you’ve done a huge amount in the time you’ve had. Thank you very much.
The Witness: Thank you very much.
(The witness withdrew)
Mr Keith: My Lady, the next witness is Professor Sir Michael McBride.