2. Professor Sir McBride
PROFESSOR SIR MICHAEL McBRIDE (sworn).
Questions From Lead Counsel to the Inquiry
Mr Keith: Good afternoon. Could you give the Inquiry your full name, please.
Professor Sir McBride: Yes, Michael Oliver McBride.
Lead Inquiry: Sir Michael, thank you for the provision of the two witness statements that you have given this Inquiry. They are INQ000187306, dated 12 May, and INQ000203352 dated 6 June. You’ve signed both of them and provided statements of truth.
Sir Michael, you are currently the Chief Medical Officer for Northern Ireland. You were appointed to that post in September of 2006. Before then, were you medical director at the Royal Group of Hospitals from August 2002?
Professor Sir McBride: That’s correct.
Lead Inquiry: Have you also during that period been the chief executive of Belfast Health and Social Care Trust, a position you held from December 2014 to February 2017?
Professor Sir McBride: Yes.
Lead Inquiry: So you were fulfilling that task whilst you were also Chief Medical Officer?
Professor Sir McBride: That’s correct, yes.
Lead Inquiry: I’d like to start, please, if I may, with the position of the Chief Medical Officer for Northern Ireland and the Chief Medical Officer Group, in the general scheme of things, in Northern Ireland.
May we have, please, our organogram, INQ000204014 at page 14. You will see there, in the middle of the page, the “First Minister and Deputy First Minister, The Executive Office”, and, towards the bottom of the page, the blue box, “Department of Health”, bottom right-hand corner, “Chief Medical Officer Group” and “Chief Medical Officer”.
It is obvious that the Chief Medical Officer is part of the Chief Medical Officer Group, which is part of the Department of Health. Could you please give us an overview of the Chief Medical Officer’s functions as part of the Department of Health?
Professor Sir McBride: Yes. As Chief Medical Officer my main role is to provide independent advice to the permanent secretary, to the minister, on professional technical matters and on scientific matters, and I’m supported in that role by a number of professional colleagues.
I also have responsibilities in heading up the Chief Medical Officers’ Group for, particularly, Population Health Directorate, which you see in the box. Population Health Directorate is headed up by the director of population health, who reports through to the Deputy Chief Medical Officer and in turn through to myself.
The Population Health Directorate has responsibility for a number of policy areas which are of relevance to the Inquiry, namely health protection, including screening and vaccination, and also emergency preparedness and response in terms of relevant policy and guidance.
It also has responsibility for health improvement policy, so that would be in relation to departmental policy on alcohol and drugs, on suicide prevention, and a range of other pertinent areas – you know, with respect to reducing health inequalities.
Lead Inquiry: That’s quite a lot.
Professor Sir McBride: That’s quite a lot.
Lead Inquiry: The CMO Group obviously, therefore, discharges functions beyond the individual functions of the Chief Medical Officer, so from what you’ve said it appears to be concerned with health protection policies, vaccination, infectious disease prevention and control, and health improvement generally.
Where, within that structure, that’s to say the CMO Group structure and the Population Health Directorate structure, does the specific issue of emergency planning in the health field come in?
Professor Sir McBride: Yeah. I should add, if I may, before answering that, that there are a number of other policy area directorates within CMO Group and that includes the pharmacy directorate, which is headed up by the Chief Pharmaceutical Officer and also –
Lead Inquiry: Chief Dental Officer?
Professor Sir McBride: Chief Dental Officer.
Lead Inquiry: And Quality, Safety and Improvement Directorate –
Professor Sir McBride: Indeed, indeed.
Lead Inquiry: All right.
Professor Sir McBride: The responsibility for the area that you mentioned resides within the Emergency Planning Branch within CMO Group.
Lead Inquiry: Do we have that in the blue box under Department of Health?
Professor Sir McBride: That is correct.
Lead Inquiry: Does the Emergency Planning Branch have day-to-day responsibility for that part of the Department of Health that’s concerned with the budgets for pandemics and civil contingency planning and preparedness, emergency planning, and that area?
Professor Sir McBride: It does. I mean, I can expand if that’s helpful, but yes.
Lead Inquiry: The Emergency Planning Branch doesn’t report, however, directly to you as the CMO, does it?
Professor Sir McBride: Ultimately it reports through to me, yes.
Lead Inquiry: Ultimately to you?
Professor Sir McBride: Yes.
Lead Inquiry: But does it report through, in fact, your deputy, the Deputy CMO?
Professor Sir McBride: It would report through the director of Population Health, and then in turn to the Deputy CMO and ultimately to me, so I would have overall responsibility.
Lead Inquiry: All right. So in truth you are two stages removed: the reporting goes through the director of population health, a Ms Redmond, and then, through her, to the Deputy CMO and then to you?
Professor Sir McBride: Correct.
Lead Inquiry: With the terrible travails of Covid behind you, is that a structure which worked, in your opinion, or would you say that the Emergency Planning Branch, given the importance of the matters which it addresses, should be closer connected to you, the CMO, in a more direct reporting structure?
Professor Sir McBride: I think the span of that area of work within population health was too large, I think I would absolutely acknowledge that. Since that organisational structure there we have subsequently carried out a review within Chief Medical Officer Group, we have established a separate Health Protection Directorate, and also, again to use that acronym again, the – a separate directorate for emergency preparedness, resilience and response, which is headed up by another director.
So we have, in essence, expanded those particular areas and reduced the responsibilities of the Director of Population Health accordingly. And appropriately, I would add.
Lead Inquiry: So to be clear about this, following Covid you in fact commissioned a review –
Professor Sir McBride: Yes.
Lead Inquiry: – in 2021 as to whether or not the current structure of the CMO Group was appropriate, in terms of its ability to prepare for emergencies and addressing civil contingencies, and that review recommended a new directorate which is not a subdivision of the director of Population Health Directorate –
Professor Sir McBride: Correct.
Lead Inquiry: – it is now its own directorate, the Emergency Preparedness, Resilience and Response Directorate?
Professor Sir McBride: That is correct.
Lead Inquiry: So may we take it from that that it now has a greater prominence and importance in the general scheme of things structurally within the Department of Health?
Professor Sir McBride: It’s certainly always had a prominence and importance. It certainly has now greater resource aligned to it, and I think that is – you know, it’s a distinction but, I mean, I think your point and the premise of your point is well made and I accept it.
Lead Inquiry: It’s a change that you wouldn’t have recommended and put into place unless it had intrinsic worth?
Professor Sir McBride: That’s correct.
Lead Inquiry: Right.
In your statement you say that the CMO Group is the sponsor branch for the Public Health Agency in Northern Ireland. What does that mean? What is the sponsor branch?
Professor Sir McBride: Yes. The Department of Health has a number of what we refer to as arm’s length bodies. Those arm’s length bodies are established in statute, so the Public Health Agency is established in statute. There are a series of agreements in place in terms of objectives, business plans, priorities which are set on an annual basis, in agreement with the PHA, which are set against their annual allocation in terms of their budget.
As the CMO Group and head of CMO Group, we meet with the PHA on a very regular basis through what are called sponsorship review meetings, so those are an opportunity from a fixed agenda for the PHA to raise issues that they have in relation to meeting their objectives, any resourcing pressures that they may be encountering, or areas where they require us to support them in engaging with other parts of the department, given that their responsibilities, particularly around health improvement, are cross-cutting and impact on a number of other policy areas within the department.
So those sponsorship review meetings meet – occur very regularly, and then they also feed into the mid-year and end of year accountability review with the permanent secretary, which I also attend, along with the chief executive of the PHA, Public Health Agency, and the chair of the board of the Public Health Agency.
Lead Inquiry: All right. We are, of course, concerned with the responses of the various bodies and the planning done by them in the context of infectious disease outbreaks. In the Northern Irish Department of Health structure, which body is primarily responsible for operational response in the face of an infectious diseases outbreak?
I ask because we have in this structure, and we’ve now heard, the Public Health Agency, but my Lady’s heard evidence that in the civil contingencies part of the Northern Irish government, the CCG(NI), there is a hub, there is also an emergency operational centre within the Department of Health, all of which would be expected to carry out operational responses.
So where does the PHA’s operational functions come in the general scheme of things?
Professor Sir McBride: The Public Health Agency will lead on the vast majority of outbreaks of infectious diseases. I mean, if I could give, for example, coming out of Covid we had a number of unfortunate occurrences where we saw higher than normal rates of infection. If you recall, we saw scarlet fever in young children occurring more frequently, and indeed in older people. We had an increase in a type of hepatitis, non-A, non-E hepatitis, again, which the PHA was leading the Northern Ireland response.
In both those cases the PHA was plugged in, as it were, to the wider UK response, so the UK Health Security Agency established an incident management team at a UK level, and then the Public Health Agency would manage the response at a Northern Ireland level but liaising with the UK Health Security Agency.
So in the day-to-day management of outbreaks, whether that’s food-borne, for instance, they would work with local councils in supporting the management of that outbreak, it would be the Public Health Agency. When it gets to a scale where it’s beginning to impact at a population level, then it’s at that point we make a decision within the department whether we continue to keep a monitoring brief or we need to lean in to support the PHA and the – in the wider response.
Lead Inquiry: Which you’ll then do by triggering the arrangements at a national level by virtue of the CCG(NI) Hub, by the operational centre within the Department of Health, where of course the emergencies are regarded as a – as requiring that sort of national response?
Professor Sir McBride: Certainly at the extreme end, yes.
Lead Inquiry: Escalation?
Professor Sir McBride: But there is a sort of in between level where the Public Health Agency may determine, for instance, look, this outbreak is now impacting on the health service, and they may say to colleagues in what was the Health and Social Care Board, “We need the resources of the health service to support us in managing this outbreak”. So a good example was Mpox recently, where the Health and Social Care Board had to come alongside the PHA to support the vaccination of those that were at significant risk.
At a further escalation, the PHA, the Public Health Agency, the Health and Social Care Board may decide to activate silver, and in that case we really at that stage would be thinking: look, this is perhaps something which is getting to the stage where it may be affecting the Northern Ireland population. Then we as a department would seek to support, provide strategic direction, provide advice and support. And if it really got to the level where it became a civil contingency emergency at that scale, then that’s what you would see the triggering of the Northern Ireland Hub –
Lead Inquiry: The national arrangements?
Professor Sir McBride: The national civil contingency management arrangements, et cetera.
Lead Inquiry: All right.
In your witness statement, there are references to two other groups that I want to ask you about. The first is the Northern Ireland Pandemic Flu Oversight Group. This appears to be a group that was established by you in 2018 to lead on health and social care preparedness and response, and one of the areas that it was addressing was the promulgation of guidance for surge capacity and also triage work by healthcare settings.
It seems to have been established by the Emergency Planning Branch, the body to which you referred a few moments ago, and it was chaired by the director of Population Health.
What was the need for that body? Why was it set up in 2018, shortly?
Professor Sir McBride: Well, in short, this was following on from Exercise Cygnus. It was identified at a UK level that there was a need for surge plans right across health and social care but with particular reference to secondary care and social care. There were five workstreams set up at a UK level in the summer of 2017. All of the devolved administrations were part of that work. To ensure that Northern Ireland played its full part in ensuring that we worked within that structure, we established a CCG – sorry, Civil Contingencies Group, a pandemic flu group, which over – to overlook those five workstreams. I’ll not go into the detail of those, but –
Lead Inquiry: This pandemic flu oversight group?
Professor Sir McBride: Beneath that then sat the Northern Ireland Pandemic Flu Oversight Group, with a specific purpose of developing surge plans in relation to secondary care and social care. As you say, it was chaired by the director of Population Health.
Lead Inquiry: I’m going to take the liberty of suggesting a correction in the nomenclature, was it the Pandemic Flu Northern Ireland subgroup?
Professor Sir McBride: Yes.
Lead Inquiry: Right.
That body, so the first one I mentioned, the Northern Ireland Pandemic Flu Oversight Group, was therefore formed to ensure that the workstreams, the recommendations, the learning from Exercise Cygnus were properly implemented, and it led to an additional group being formed called the Task and Finish Group, which I think you asked the Public Health Agency and the Health and Social Care Board to establish, and that was then put into place the following year in 2019; is that correct?
Professor Sir McBride: Yes. Could I take a moment maybe to clarify that, because – in case we’re confusing each other.
Lead Inquiry: Yes. Please.
Professor Sir McBride: So there was the Civil Contingencies Group, which was plugged into the Pandemic Flu Readiness Board, so that was overseeing all five workstreams, which the director of Population Health was also chairing, but the Department of Justice, TEO, were members of that.
Then beneath that was a health-specific group, which was the Northern Ireland Pandemic Flu Oversight Group, again chaired and established by the director of Population Health, established in March, and you’re quite right that beneath that again –
Lead Inquiry: Is that a subgroup?
Professor Sir McBride: Yes, that was a subgroup of the group I’ve just mentioned.
Lead Inquiry: Then there was a task and finish group as well?
Professor Sir McBride: We – yes, that group, the oversight group, comprised the department, senior executive directors within the Public Health Agency and the Health and Social Care Board.
I wrote personally to the then chief executive of the board asking them to establish a Task and Finish Group –
Lead Inquiry: All right.
Professor Sir McBride: – looking for the PHA to develop the said guidance.
Lead Inquiry: That was in 2019?
Professor Sir McBride: November 2018 was the date of my letter and the group was established in 2019.
Lead Inquiry: Yes. An important function of that Task and Finish Group was to review and update health and social care influenza pandemic surge guidance, but, as events transpired, Sir Michael, although a draft was drawn up, it was decided by officials in these relevant bodies that further work was required, but that work never came to pass because of, of course, the impact of the preparations for a no-deal EU exit and then of course Covid itself.
So the majority of the work that was due to be done by that Task and Finish Group, despite its title, was never completed, and therefore one may suppose that the structure of having a Northern Ireland Pandemic Flu Oversight Group, then a subgroup, and then a Task and Finish Group, alongside all the other groups, largely failed, at least in relation to that particular purpose?
Professor Sir McBride: I think – well, it’s absolutely correct to say that that work wasn’t finished, for the reasons that you’ve outlined, both at a UK and at a Northern Ireland level because resources were diverted to EU exit planning. The work was incidentally picked up again in January of 2020, but of course then events overtook us.
Lead Inquiry: Of course.
Professor Sir McBride: In the end, further work was carried out in February and we did have surge plans in place for the first wave of the pandemic. But, again, we’ll be looking at that in later modules.
Lead Inquiry: Indeed.
Professor Sir McBride: I think it was – I’m not certain that I would necessarily agree that it’s a structural issue in terms of complexity of the structures. You know, I think it’s actually all about function and structures matter less. There are some structures that matter – work better than others. We did, however, make significant progress in a number of areas: the preparation in the terms of the pandemic flu plan, there was significant progress made on that, but again it wasn’t completed. I think it’s fair to say –
Lead Inquiry: We will come back to the planning a little later.
Professor Sir McBride: Okay.
Lead Inquiry: Just remaining on the structures, the Inquiry is aware from your witness statement and other material that there were – I don’t know whether they are still in existence – a number of other bodies: the Health Emergency Planning Forum, the Critical Threats Preparedness Steering Group, the Joint Emergency Planning Board, the Joint Emergency Planning Team. There may be an appearance here of an overcomplexity or duplication of function or perhaps, to put it more charitably, a rather diffuse structure.
Has the structural system in Northern Ireland relating to healthcare been the subject of any type of overall analysis or rationalisation since Covid?
Professor Sir McBride: Certainly there is ongoing work in relation to review of the emergency response plan. There has been reviews of the business continuity plans across the system in terms of the structural elements that you’ve described and how they interrelate, no.
I have to say for those working in the system, who need to know how those structures work, we know how those structures work and how they interrelate, and I can explain, for instance, the various – the Joint Emergency Planning Board, the Joint Emergency Planning Team and how it supports the board. But I suppose really I absolutely appreciate from those looking in from the outside, it’s a reasonable question to say: is there a simpler way of doing this?
I think we structure the work in such a way that we get the work done, and we put around it organisational arrangements to ensure, in as far as we possibly can, notwithstanding that there are always other pressures, other demands and priorities, that we get the work done in as effective a way as we can.
Lead Inquiry: That’s the point, isn’t it? I mean, the overall worth of a system is surely not to be determined solely by whether or not its participants understand what they’re doing, it must also be determined by the outcome and the output, and –
Professor Sir McBride: Correct.
Lead Inquiry: – there are significant areas in which the work which was meant to be done by some of these committees, groups and entities didn’t come to fruition?
Professor Sir McBride: I think in the specific examples that you’ve mentioned, yes, however there are other examples where significant work was progressed and did come to fruition, and that work is ongoing on a, you know, daily, weekly, monthly basis. So, on those specific elements that you’ve mentioned, yes, where there was significant progress made. In some areas more than others there were aspects which certainly were not completed.
Lead Inquiry: All right.
Turning to another major issue in Northern Ireland, the collapse in the power-sharing arrangements. It is obvious, Sir Michael, from the evidence of Mr Swann last week and from the material before the Inquiry that the lack of an Executive, particularly between 2017 and 2020, had an adverse effect on, to use Mr Swann’s words, the preparedness of the health and social care system.
In terms of staffing, it led to inadequate staffing levels, because key decisions simply couldn’t be taken by ministers in the absence of a power-sharing arrangement, and the loss of strategic political oversight led to, to use the words of the permanent secretary, stagnancy on the part of the civil service.
To what extent, from your vantage point as the CMO within the CMO Group, did the collapse in the power-sharing Executive have an adverse impact?
Professor Sir McBride: Maybe could I answer that in maybe three parts. I think there’s sort of general context which I think is relevant. I think there is absolutely no doubt that the absence of ministers did have a significant impact on our ability to initiate new policy, develop new policy. We were not in a position to develop any relevant legislation, either primary or secondary legislation. And given that all of the work on what’s referred to as the “Programme for Government”, which is the cross-cutting work approved by the Executive where government departments put to ministers an agreed programme of work for government, we missed out and lost out on that – the benefits of that cross-government approach.
I think specifically in relation to health there is no doubt that the – it has been a very challenging resourcing situation over the last decade, and particularly so in Northern Ireland over the last five years, compounded by a reliance on annual budgets. So we were making decisions in terms of trying to live within budget allocations –
Lead Inquiry: So just to pause there so that we may be clear about what you’re saying, one of the consequences of the absence of ministerial oversight is there is nobody in position who can say, “Well, you can be permitted to move outside your budgetary constraints, we can take a different decision here in relation to resourcing or staffing levels because you’ve made a persuasive case that there ought to be a change”, so in essence you have to simply live within your means, and those means were determined, of course, before the collapse in the power-sharing arrangements?
Professor Sir McBride: Yes, I mean, at that time there was limited ability for permanent secretaries to make those sort of decisions that you’ve alluded to, and that was guided by relevant court rulings and the Executive Formation and … Functions Act, so you didn’t have that same ability to move resources around and align them to priority.
That certainly impacted on decisions within health where we had to make savings, and obviously there’s limited opportunity to make savings in health, particularly where you have got inflationary pressures of 6% per year because of technology and ageing population and their needs, and we had in that – the five years running up to 1920 something in the region of a 2.90% growth on baseline each year, leaving a gap of 3% every year on year for five years.
Lead Inquiry: Meaning a deficit in your –
Professor Sir McBride: Yes.
Lead Inquiry: – resourcing every year, year-on-year?
Professor Sir McBride: You know, a gap between what we needed and what we had. So the resulting position was that we were having to make decisions which were not necessarily decisions that should be made but decisions that had to be made.
Lead Inquiry: In addition, the Inquiry’s heard evidence that the keynote report by Professor Rafael Bengoa, the Basque Country minister, he led, I think, an expert panel –
Professor Sir McBride: That’s correct.
Lead Inquiry: – review in 2016 called Systems, Not Structures: Changing Health and Social Care, which was I think envisaged to provide a framework for a significant reform in the Northern Irish health and social care system, that report couldn’t be put into place either?
Professor Sir McBride: That’s partly true. We were fortunate in that that report had been published prior to the collapse of the Executive, and in October 2016 the then health minister approved the Health and Wellbeing 2026: Delivering Together, which in essence gave the political mandate and the direction of travel for the transformation of health and social care services in Northern Ireland.
So we had a mandate within health, and we took forward, within the limitations of that mandate, a number of areas of work. So we developed a mental health strategy, we developed a cancer strategy, we published an elective care framework, we undertook a major review of unscheduled care services such as in accident & emergency departments, and that’s now going through to the first phase of implementation –
Lead Inquiry: Just pausing there, I’m sorry, Sir Michael –
Professor Sir McBride: No, you’re okay.
Lead Inquiry: – there is obviously a gap between planning and having mandates and reviewing the position, and of course implementation, which will depend, necessarily, on resourcing, and you’ve agreed that, of course, during the hiatus there was no ministerial direction on resourcing?
Professor Sir McBride: I completely concur with that, and it was the point I was about to make, which is that we put together the building blocks, we did some very good work in terms of what we would need to do, but there were clearly elements of this that required ministerial decision, and those areas that required a ministerial decision we were not possible – it was not possible for us to progress.
There was progress made, and I could give some examples, but I’m happy to expand if that would be helpful.
Lead Inquiry: The sum of that, Sir Michael, is that although progress was made and reviews and plans and guidance were drawn up, because, as you say, you had a mandate, overall there was a negative impact from the collapse in the power-sharing agreement because of the lack of resources and the sheer inability to be able to implement both that report and the other reforms and resourcing changes which were deemed necessary; that was the sum outcome, if you like, of the absence of ministerial oversight?
Professor Sir McBride: I think it had an impact, I don’t think there’s any question of that. Had we had ministers, I think it’s a reasonable question to ask whether we would have been able to take further all of that work any more quickly, because the work still needed to be done to inform ministerial decisions. But absolutely, we – there were significant elements of it that we could not implement without a ministerial decision.
Lead Inquiry: May I ask you about the Department of Health department risk registers?
Professor Sir McBride: Yes.
Lead Inquiry: Is that a process in which the CMO plays a significant role?
Professor Sir McBride: I certainly sign off on it. It’s developed by colleagues within CMO Group, the relevant policy areas, and certainly would be brought to my attention, and I would see the details of that, I would have an opportunity to ask any questions, seek any clarification, and ultimately, as the risk holder, would approve that to be considered by the top management group and subsequently by the departmental board.
Lead Inquiry: May we have, please, INQ000185379, which is the 2018/2019 Department of Health department risk register.
This is page 24 of the version, Sir Michael, so that you can get your bearings in relation to it, and it shows a particular risk, row DR6, in the bottom left-hand corner:
“The health and social care sector may be unable to respond to the health and social care consequences of any emergency (including those for which the [Department of Health] is the lead government department) due to inadequate planning and preparedness which could impact on the health and wellbeing of the population.”
Now, that, of course, doesn’t reflect the reality, it is the identification of a potential risk.
If we go back up, please, to page 24, the rating given for the residual risk and the risk once it has been treated, that is to say once it has been mitigated or thought has been given to how the risk may be reduced by a response, the ratings are assessed to be high and medium, both for impact and likelihood in both cases, that’s to say current and treated, and then a number of actions are identified: developing and reviewing strategic frameworks, developing a pan flu preparedness by participating in the Pandemic Flu Readiness Board, leading the CCG(NI) subgroup, and – over the page – work in relation to the contribution to the UK Draft Pandemic Bill, the development of pan flu guidance for Northern Ireland incorporating primary, secondary and social care, delivering a work programme to include training, testing and exercising, and then – at the bottom of the page – management of health countermeasure stockpiles.
Can you recall, Sir Michael, to what extent the identification of that risk was debated within the CMOG or the Department of Health in 2018, particularly from August, which is when I think that was published or made available?
Was there a significant level of concern that that risk identified in the left-hand side of the page was required to be mitigated and, in essence, things had to be done on quite a number of fronts in order to make sure that the risk could be properly mitigated?
Professor Sir McBride: I mean, I can’t recall the specific discussions at that time. What I would say is that, certainly going back as far as when I took up post in 2006, pandemic flu and the risks associated with it has always been on the departmental risk register.
The normal process whereby that would be assessed would involve my receiving the assessment of the risk, as I said, have an opportunity to engage with the team, it would then being discussed on more than one occasion in its development by the top management group of the department, which includes the perm sec in respect of policy leads, including myself, and in due course would be approved. It would be considered then by the departmental board, who would have an opportunity to interrogate it, ask questions, ask for further work or assurance –
Lead Inquiry: Then it is brought together and finalised?
Professor Sir McBride: Then in due course it would be reviewed on a quarterly basis by the risk holder, ie me, by TMG, by the departmental board, and then by – separate to that again, by the departmental audit risk and assurance committee, which basically provide assurances to the permanent secretary if there are any gaps in the risk register or in the controls within the risk register about which he should be concerned.
Lead Inquiry: So were you the risk owner for this risk, DR6?
Professor Sir McBride: Yes. These are all corporate risks, departmental risks, but the approach at that time was there had to be one nominated risk holder, and I was the nominated risk –
Lead Inquiry: Is that why your name appears in column 4 under SRO, for senior responsible officer?
Professor Sir McBride: That’s correct, yes.
Lead Inquiry: Why is the column “Actions completed, completion date and owner” blank on this 2018 to 2019 risk register? For this risk. Not, I should say, for other risks, but for this risk.
Professor Sir McBride: Yeah, because what we have here is a template for completion, as opposed to a completed template.
Lead Inquiry: But there are other risks identified on this document, for which there are completed actions?
Professor Sir McBride: Yes, but the point is that this is a living document and it’s updated on a quarterly basis, so that column to the extreme right, which is the action completed, would inform the column that you’ve highlighted in blue in terms of what progress had been made or why there had been no progress made in a particular area.
Lead Inquiry: So at the date of the making available of this variant of the risk register, this form of the risk register, there were no actions completed and therefore nobody could write into that column anything by way of actions completed, completion date or ownership?
Professor Sir McBride: No, I don’t think that’s a reasonable conclusion. I think that this – I mean, there will be completed documents where these actions are completed, and I’m sure they can be provided to the Inquiry, for any particular date. So, as I say, it’s a living document and this is a template for completion.
Lead Inquiry: By January 2020 and the eve of Covid, and the making available of the subsequent risk register, presumably for 2019 to 2020, do you know whether or not those actions which are identified as being planned were completed?
Professor Sir McBride: Some were completed, others weren’t. I mean, I can go through them if that would be helpful to you.
Lead Inquiry: Yes, that would be. Perhaps we can start with the pandemic flu preparedness programme?
Professor Sir McBride: Yes, that was completed. The emergency response plan was updated, signed off in January 2019 and published in February 2019.
Lead Inquiry: The pandemic flu guidance for primary, secondary and social care?
Professor Sir McBride: We’ve just alluded to that. That was progressed but not to completion. A draft had been received but it required further work.
Lead Inquiry: So it was not completed by January 2020?
Professor Sir McBride: That is correct, but – progressed but not completed.
Lead Inquiry: The work programme for training, testing and exercising?
Professor Sir McBride: That was completed. The training was completed in June 2018 with a full exercise of the emergency operations centre in November 2018.
Lead Inquiry: So that was the setting up and the running of the Hub or the departmental –
Professor Sir McBride: The departmental –
Lead Inquiry: – emergency operational centre?
Professor Sir McBride: Correct.
Lead Inquiry: That was in the context, was it not, of Operation Yellowhammer?
Professor Sir McBride: It certainly would have been related to that, but again it was also related to preparation for pandemic flu. It so happened that Yellowhammer was going on in the background as well in terms of EU exit preparation.
Lead Inquiry: Was there specific testing of the operational arrangements, the emergency response arrangements, in the context of planning or emergency preparedness for infectious disease? Because I must suggest to you that although it’s clear that the Hub was operating for Operation Yellowhammer and also the departmental emergency operational centre, it doesn’t appear that they were operating for the purposes of readying the taskforce for pandemic planning.
Professor Sir McBride: I mean, the EOC operates generically irrespective of what the threat or hazard is. It isn’t a specific response mechanism or co-ordination mechanism to a particular threat. In many respects –
Lead Inquiry: But – I’m sorry, Sir Michael – that action planned was to deliver a work programme to ensure clear understanding of roles and responsibilities of key responders and familiarisation with key activities and processes in the context of planning and preparedness which could impact on the health and wellbeing of the population?
Professor Sir McBride: Yes.
Lead Inquiry: So rather different?
Professor Sir McBride: No, I think that’s the point I’m making, is that the activity of the EOC is agnostic to whatever the threat is. Its role, function, its communications in and out to the department from the health service, the sharing of information across government, its support to myself, if it’s activated, in chairing the strategic cell, is agnostic to whatever the threat is. So it’s about the process of informing – taking information in to inform strategic decisions by myself, if I was chairing gold, and sharing that strategic information out across other departments and back out to the health service.
So in many respects it’s neutral in terms of what the particular threat is, so it provides a generic function.
Lady Hallett: Mr Keith, is that a convenient moment?
Mr Keith: Yes, my Lady, it is.
Lady Hallett: I shall return at 3.15.
(3.03 pm)
(A short break)
(3.15 pm)
Mr Keith: May we have back up, please, document INQ000185379, page 14, and a different risk this time, Sir Michael, DR1, that available financial resources are insufficient and are not deployed effectively to ensure that essential services are maintained.
The risk is identified both pre and post mitigation as high, which is why it’s red. A number of actions are planned, with target dates and identification of ownership, and then, in relation to actions completed, completion date and owner, the essential position was this, wasn’t it, that, as you identified in your witness statement, there was a shortfall, so resources were simply not enough to be able to meet the anticipated demands of the Department of Health?
Professor Sir McBride: Correct.
Lead Inquiry: In your witness statement you say that that’s an acknowledged area of vulnerability for the department, and you also make the point that it was difficult then for the department to maintain readiness at a high level, in anticipation of future pandemics, and that it would be likely to remain so.
Can you just tell us, please, whether or not this position continued up to the time of the pandemic? This is a 2018/2019 risk register. Was it the same position throughout the entirety of 2019 and into 2020?
Professor Sir McBride: Yes, and probably has deteriorated since that time.
Lead Inquiry: In your witness statement, you also refer to a report from the Department of Health Emergency Planning Branch and a lessons learned review. It’s dated November 2021.
It’s INQ000188797, page 9, please.
Right at the bottom of the page, “Training, validating and review”:
“Despite training from Operation Yellowhammer during 2019, at the beginning of the response there were insufficient fully trained staff to cope with the volume of information or the pace of the pandemic.”
So there wasn’t just the resourcing issue, that had fed through to an absence or an insufficiency in the correct number of fully trained staff to be able to cope with the position as the department went into the pandemic?
Professor Sir McBride: Yes, there were probably two separate aspects to that.
We had 62 staff trained, but even that, given the demands of the pandemic, initially wasn’t sufficient and we had to go out for more volunteers.
The second aspect that compounded it was the remote working. We were not set up for the level of remote working that was required and that was an added problem. However, that was rapidly addressed.
So there is absolutely no doubt that there were very significant challenges during that period.
Lead Inquiry: So, in conclusion, whilst Operation Yellowhammer, the operation for dealing with the potential consequences of a no-deal EU exit, had some benefits in terms of interdepartmental training, training up members of staff who could be utilised to stand up for crisis management, benefits arising out of better developed supply chains, a better understanding of medicinal supplies and how to get medicine in the event of border problems, none of that could take away from the stark reality which was, in terms of resources and training and staff numbers, the Department of Health was in a pretty woeful position on the onset of the pandemic?
Professor Sir McBride: I wouldn’t use the word “woeful”, I think it was a very challenging position. I think the challenges of the pandemic were unprecedented. We had resource but we did not have the strength and depth that was required to mount what was an extremely sustained response to the pandemic.
Lead Inquiry: The lessons learned documentation shows there were insufficient staff numbers going into the pandemic –
Professor Sir McBride: Yeah.
Lead Inquiry: – and there was a resource shortfall in the two years leading up to it; that is correct, is it not?
Professor Sir McBride: I think it’s a fair summary, in – but I think this was a document that was written at the time with the experience of the first wave of the pandemic.
Lead Inquiry: So that we’re absolutely clear, Sir Michael, that paperwork shows that the pre-existing position on the onset of the pandemic was a shortfall in resources and insufficient numbers of staff. It wasn’t that the demands of the pandemic revealed that there wasn’t enough resources to be able to deal with the pandemic that ensued, or that there weren’t enough members of staff to be able to deal with the pandemic as it developed, it was that, objectively, the department was insufficiently resourced and insufficiently manned at the moment that the pandemic struck?
Professor Sir McBride: I think it is fair to say that there were very significant staffing problems, you know, I’m not – I would agree with that. There was capacity, there was capability, there was training, but, as we began to respond to the pandemic, even that was insufficient to mount the response that was required.
Lead Inquiry: Of course, because the scale of the pandemic –
Professor Sir McBride: Yes.
Lead Inquiry: – was outwith anybody’s imagination?
Professor Sir McBride: Yes.
Lead Inquiry: All right.
Another topic, please, which is the Health and Social Care Influenza Pandemic Preparedness and Response Guidance 2013.
Is this the document which was produced largely in reliance upon the United Kingdom 2011 pandemic influenza strategy, which was itself based upon the learning and the outcome from the H1N1 swine flu and the report from Dame Deirdre Hine?
Professor Sir McBride: In part, yes. So there were three inputs to that document. The first, as you say, was the UK strategy itself; the second was the recommendations arising from Dame Deirdre Hine’s review; and the third element was then a sort of lessons learned report that we did internally within the department, and those three elements contributed to that document, yes.
Lead Inquiry: We’ve noted that the document is very similar to the Welsh variant, that is to say the Wales Health and Social Care Influenza Pandemic Preparedness and Response Guidance. I’m not going to torment you by asking you which country prepared its guidance first, but one or both of the two countries must have had half an eye at least on the other one’s guidance?
Professor Sir McBride: I think it would be normal practice. We worked very closely together across the UK in terms of developing guidance and we will share documents with each other – I mean, that I think is a strength – and certainly we did share our document with colleagues in Wales. But, then again, we also benefit from colleagues in Wales and Scotland and England sharing their documents with us. So I think that’s a strength which I hope continues.
Lead Inquiry: But all those strategies were all themselves aligned to the United Kingdom approach in 2011, about which my Lady has heard a great deal of evidence.
Professor Sir McBride: Yes.
Lead Inquiry: Does it follow, Sir Michael, that because of that close alignment, the 2013 guidance may be said to have suffered from the same strategic errors – if that is what my Lady finds in due course – as the 2011 document: the absence of detailed consideration of the variable and inherently unpredictable characteristics of a pandemic, a zoonotic pandemic outbreak, an absence of any debate about the consequences of differing levels of transmission, of incubation periods, of viral loads, or asymptomatic transmission and the like?
Professor Sir McBride: I mean, I think, you know, the 2011 document makes passing reference to the ability to adapt the UK pandemic plan. I think it’s inevitably the case that, with the experience that we’ve now all lived through, that that document did not provide any effective basis for responding to the Covid pandemic. But you’re absolutely correct that our guidance was based on that and, you know – as I’ve said in my evidence statement and has been said by others – we absolutely do need a pandemic flu plan, but we also need something that is more generic, that is agile enough to be scaled up very quickly but then can be specific enough to be tailored to the particular pathogen, the particular virus or other agent, and then the particular control measures put in place depending on how it’s transmitted.
Lead Inquiry: And indeed the risk assessment process at United Kingdom level, and also nationally now, reflects the broader range of scenarios which were absent from that original strategy; and it had no consideration, did it, of the need for mass diagnostic testing or mass contact tracing, or mandatory quarantines or self-isolation, or any of the countermeasures which may have been thought appropriate for a non-influenza catastrophic pandemic?
Professor Sir McBride: I think that’s fair comment. I think it makes reference to contact tracing. However, I do not believe it was envisaged that contact tracing or indeed community testing would be taken to the scale that we did subsequently in the Covid-19 pandemic. So I would agree with that.
Lead Inquiry: Northern Ireland is of course in a unique position, because it is a separate geographic entity from the United Kingdom, it shares a land border with another country. Why was that – why were those specific characteristics of Northern Ireland not reflected in its own 2013 guidance? There is no consideration of what we may call the single island epidemiological issue. The strategy and the guidance was drafted very much as if Northern Ireland was the United Kingdom, but there are unique circumstances prevailing there.
Professor Sir McBride: Again, I suppose a high level point is that there’s and always has been and remains very close co-operation on a north/south basis in relation to a whole raft of policy areas, and also –
Lead Inquiry: And we will come back to that, Sir Michael.
Professor Sir McBride: I think in relation to the question that you ask, there are probably two main reasons for that. One is an issue of scale, and the second is, if I might put it broadly, a constitutional issue.
In terms of scale, we benefit hugely from being integrated into the UK system in terms of pandemic preparedness at all levels, both in terms of preparedness, planning and in response. We are a very small department, a very small group of departments. We simply could not replicate the expertise that exists or indeed the scale of work that takes place within the other jurisdictions, and we’re dependent on that at all sorts of levels.
We’re dependent on it from the point of view of scientific advice from SAGE and the various expert groups; we’re dependent on it in relation to the risk assessments from the UK Health Security Agency and from the National Security Risk Assessment; and we’re also dependent on it from the point of view of response, so in terms of the clinical countermeasures, management board, in terms of the procurement of PPE at a national level, the procurement of vaccines, antibiotics. And we benefit from it, as we discussed earlier, from all of the work that was taken forward, for instance, through the Pandemic Flu Readiness Board, in terms of the Pandemic Flu Bill.
So we could not, in our own right, replicate all that, and we are crucially interdependent on that work that occurs at a United Kingdom Government level.
Lead Inquiry: Why was it not open to the Department of Health to replicate that work, to take the advantage and the benefit of the scientific advice, the generic thinking, the guidance and the policies which had been no doubt carefully thought about in London and promulgated throughout the rest of the United Kingdom, and consider alongside that material the obvious fact that Northern Ireland is part of an island –
Professor Sir McBride: Yeah.
Lead Inquiry: – that no pandemic would respect a land border with the Republic of Ireland, and that there were obviously advantages in being part of an island and that proper sensible consideration of countermeasures would pay due regard to that feature, but that thinking is absolutely absent?
Professor Sir McBride: I think it probably comes on to my second point. I absolutely agree with you that – the premise of your question, that pandemics know no borders. The constitutional reality is that we are part of the United Kingdom –
Lead Inquiry: Of course.
Professor Sir McBride: – and in relation to, you know, reserved matters such as international travel, for instance, that was an important consideration in the pandemic, that is a matter which is reserved.
If one considers also then, as part of the response in terms of the funding, the procurement of vaccines, the funding of furlough, we are crucially dependent on the United Kingdom Government to provide that, and when the COBR is activated and the UK civil contingencies arrangements are activated, Northern Ireland is part of that.
So I think the question is probably not a technical issue for myself, rather a policy decision for ministers. As I’ve alluded to in my statement, I think there is real strengths and would be much merit in considering all of this at a UK and Ireland level. Indeed, one would extend that across to the common travel area. Because, again, pandemics don’t respect borders and there is freedom of movement of people within the common travel areas; there should be.
So I did allude to exercises which test that, not just at the operational level, not at just the policy level, but also at the ministerial level.
Lead Inquiry: Let me put the question a different way, Sir Michael: it is obvious, and there’s no significance in this feature –
Professor Sir McBride: No.
Lead Inquiry: – it’s well known that there are a number of sophisticated and significant cross-border entities which look at matters which cross the land border in the island of Ireland. You have given examples of bodies dealing with obesity prevention: the All-Ireland Food Poverty Network, the North South Alcohol Policy Advisory Group, the British-Irish Council workstream, there’s work on suicide prevention cross-border, and there is – as we’ve heard last week – the Cross Border Emergency Management Group.
So there’s no surprise –
Professor Sir McBride: No.
Lead Inquiry: – the existence of the Republic of Ireland and the southern part of the island of Ireland is an obvious feature.
So my question to you, though, is: given all that, why was there no consideration epidemiologically in that guidance – in the 2011 guidance, to the strategies, the policy documents that followed, the 2013 guidance in the case of the Department of Health – to the obvious feature that it is a single epidemiological island and that any sensible debate of countermeasures and the spread of a virus would have to take that into account?
Professor Sir McBride: Well, I think, if I may say so, I think it’s broader than the single epidemiological unit that is the island of Ireland. It goes much further, and I think that involves the UK and the island of Ireland, and I think that’s the point that I was making: that I think that is a policy matter for respective governments to consider. Although I’m well outwith my area of competence to speak on the responsibility of governments, but I do think that that is a matter for governments to consider those interfaces.
Now, there are mechanisms in relation to – you mentioned the British-Irish Council, et cetera – there are mechanisms in place, at a very practical level, in terms of – and answering the question about the common epidemiological approach – at an operational level, at a Chief Medical Officer level, we did take common epidemiological approaches to the border counties where we often had hotspots one side of the border, the other side of the border, and we requested – the Chief Medical Officer in the Republic of Ireland and myself requested the Public Health Agency and the Health Service Executive to work collectively along with local government, broadcast media, civil society, in addressing those hotspots.
So at a very practical –
Lead Inquiry: So once –
Professor Sir McBride: – that works.
Lead Inquiry: Forgive me. Once the pandemic had started –
Professor Sir McBride: Yeah.
Lead Inquiry: – you met weekly with your counterpart from the –
Professor Sir McBride: Yes.
Lead Inquiry: – Republic of Ireland in order to address that obvious feature of your joint position on the island?
Professor Sir McBride: Sure.
Lead Inquiry: So that only highlights, though, the absence of any sort of debate or formalised or regular –
Professor Sir McBride: Sure.
Lead Inquiry: – meetings to deal with pandemic preparedness in advance of –
Professor Sir McBride: But that wasn’t –
Lead Inquiry: – the pandemic?
Professor Sir McBride: I mean, the point I would make is we did exactly the same in 2009 during the H1N1 pandemic. So at that level there is very good and effective co-operation, always has been –
Lead Inquiry: At the operational level?
Professor Sir McBride: At the operational level, supported by respective Chief Medical Officers. I think the wider question in terms of: could we – could the improvement at a United Kingdom Government/Irish Government level, you know, I think is a matter for others. Because there are policy decisions in that space, and a good example of that was the alignment or non-alignment of international travel restrictions at various points in time.
I mean, I think of relevance – if I could give an example very briefly – was discussion at the Executive with the First Ministers of Scotland, Wales and the Chancellor of the Duchy of Lancaster about a sort of five nation, two island approach, and I think that’s the sort of space that we do need to think about for the future and any future pandemic preparedness.
Lead Inquiry: All right.
Chief Scientific Advisers. In Northern Ireland there is no general Chief Scientific Adviser for the Northern Irish government, for the Executive, but there are two CSAs, are there not, one attached to the Executive Office and a second attached to your own department, the Department of Health?
Was it apparent prior to the pandemic that there was a lacuna in the system insofar as there was no general unattached Chief Scientific Adviser for the government?
Professor Sir McBride: Just to take it back a little bit, there are two Chief Scientific Advisers, one within the Department of Health, and the second one within the department –
Lead Inquiry: Oh, DAERA?
Professor Sir McBride: Yes.
Lead Inquiry: I’m sorry, yes, you’re quite right.
Professor Sir McBride: The Department of Agriculture, Environment and Rural Affairs.
There is a second interim sort of chief government scientific adviser that has been appointed as an interim and, as you heard from Denis McMahon’s evidence, there had been a number of attempts to appoint a substantive Government Chief Scientific Adviser, but that – I mean, your – the point is well made that there is not a central government Chief Scientific Adviser. I think that is an inherent weakness.
Lead Inquiry: The CSA role was, at least pre-pandemic, part-time. It’s obvious that very little advice was sought from Professor Young, who was the Chief Scientific Adviser for the Department of Health.
Professor Sir McBride: No, again, I did hear that in questions and evidence provided during Robin Swann’s session. It is not accurate to state that the departmental – Department of Health Chief Scientific Adviser did not provide advice to the department. He provided it on an ongoing basis, on a number of really important areas such as the Health and Social Care Research and Development Strategy, the Northern Ireland genomic strategy, the Northern Ireland Rare Diseases strategy, but that advice was provided to the Department of Health. I think –
Lead Inquiry: So may not have found its way to the Executive Office and to the attention of –
Professor Sir McBride: Yes, and I think that’s the point that –
Lead Inquiry: – ministers there?
Professor Sir McBride: – Professor Young was making, that he had not been asked to provide advice directly to the Executive. It’s just a statement of fact.
Lead Inquiry: So there is a plan for the future recruitment of a chief governmental or a governmental Chief Scientific Adviser. Can you say to what extent those plans have developed?
Professor Sir McBride: I mean, that’s been taken forward by the Executive Office, as I understand, so I couldn’t really comment on the detail of that.
Lead Inquiry: All right.
Within the Department of Health, was there any contribution to the issue of pandemic preparedness on the part of the CSA within the Department of Health?
Professor Sir McBride: No, the contribution to pandemic preparedness, apart from myself, would’ve involved the two Deputy Chief Medical Officers, the senior medical officer for health protection, who would have provided specific scientific public health advice, and other colleagues within the Public Health Agency as necessary.
So the role of the departmental Chief Scientific Adviser was really in response mode, where with myself he would support me in providing scientific and public health advice to the health minister.
Lead Inquiry: And to what extent was the departmental CSA linked into the UK CSA network, or to the well known committees concerned with disease and emergency outbreaks, for example SAGE and SPI-B and NERVTAG and HAIRS and so on?
Professor Sir McBride: I mean, we benefit hugely from those expert committees, and our representation on them, in whatever capacity there, as observers or as full members. I think, as Sir Chris Whitty mentioned in his evidence, a very salient point, which is there is a difference in rigour and co-ordination in slow time, ie not in an emergency as opposed to an emergency situation such as the pandemic. They worked extremely well during the pandemic. I think there needs to be a further look at and examination of how they are co-ordinated in other times.
Lead Inquiry: Professor Young was able to get the benefit of SAGE because of course he became a full-time attendee from March 2020 onwards.
Professor Sir McBride: Yes.
Lead Inquiry: Prior to that time, Northern Ireland had only observer status, did it not, on SAGE, and wouldn’t necessarily be invited to attend?
Professor Sir McBride: Certainly I attended meetings in February of SAGE, a number of SAGE meetings. I think it’s fair to say that there were many demands for a number of meetings over that period. It was often difficult to attend meetings and also, I think as you’ve heard from other witnesses, initially those were on conference calls and the sound quality was not good. And certainly throughout the pandemic, and particularly after the return of the Chief Scientific Adviser from a period of absence due to ill health, the department was represented by either himself or his deputy, because we appointed a deputy for a period, at all of the SAGE – well, certainly almost all of the SAGE meetings.
Lead Inquiry: But it’s obvious, going forward, that in respect of any health emergency affecting Northern Ireland, there must be full participation by its officials on the relevant bodies including SAGE?
Professor Sir McBride: Yes, I mean – and I think Sir Chris covered this as well – I mean, the only person that is entitled to full-time membership is the chair and obviously it depends on the nature of the emergency. Certainly if it’s a health emergency I think – my belief is that there would be absolute requirement for us to be full members from the outset.
Lead Inquiry: Do you know what the position is in relation to the JCVI, the Joint Committee on Vaccinations and Immunisations, and also the Advisory Committee on Dangerous Pathogens: are they committees on which Northern Ireland has observer status or full participant status?
Professor Sir McBride: We have observer status on both of those committees. In relation to JCVI we, from 2015, we have both observer status and also an individual who is now a full member of JCVI and also able to attend subgroup meetings of JCVI. So we are well represented on JCVI.
Lead Inquiry: You, in April of 2020, established the Strategic Intelligence Group, chaired by the CSA –
Professor Sir McBride: Correct.
Lead Inquiry: – I presume, from your department, so the departmental CSA, and including members from a number of august universities and academic institutions and the PHA and also, I think, members of your own department as experts.
Why, if you were receiving sufficient scientific and technical advice from the UK bodies, was it necessary to set up the Strategic Intelligence Group?
Professor Sir McBride: I mean, it is good practice that the provision of scientific advice is open to scrutiny, and up until the establishment of the strategic intelligence group, the co-ordination of that advice to ministers was being provided by myself, with input from Professor Young and the two Deputy Chief Medical Officers. We felt that, without seeking to replicate or second-guess SAGE, we felt there would be much merit in a wider group of individuals considering not just the SAGE advice but other publications, other evidence emerging from other parts of the world, and actually to take that and apply it in the context of the trajectory of the pandemic in Northern Ireland.
So I have to say it was very useful. It applied, at one sort of degree of remove, challenge to us in terms of our thinking which then informed our advice to the health minister.
Lead Inquiry: What about forecasting and modelling? Was the system pre-pandemic adequate for the purposes of providing the Executive with sufficient information about modelling and forecasting in the event of a pandemic?
Professor Sir McBride: We certainly improved it. We did have full access to Northern Ireland-specific modelling from the subgroup of SPI-M, which is a subgroup of SAGE. That was specific to Northern Ireland but it wasn’t as current and real-time as we wished, so I asked the Chief Scientific Adviser on his return to establish a Northern Ireland modelling group, which he did. That continued then to provide as close to real-time modelling and various scenarios as we possibly could, and in due course I directed the PHA to build that capacity and capability into their organisation, which has now happened. So we now have that capacity within the Public Health Agency.
Lead Inquiry: But you ordered the capacity to be set up –
Professor Sir McBride: Yes.
Lead Inquiry: – under the guidance of the CSA and then latterly under the PHA –
Professor Sir McBride: Yeah.
Lead Inquiry: – because the provision of information that you were receiving pre-pandemic, or at least on the outset of the pandemic, was not sufficient for your purposes?
Professor Sir McBride: I wouldn’t go so far as to say that. What I would say is that it was sufficient but it wasn’t as real-time as we would wish it to be. What is really important, as we’ve heard from previous witnesses, is that we take the data that we have, which was Northern Ireland-specific, and we ensure that is as close to real-time and projecting potential scenarios as we can to assist ministers in their decisions.
Lead Inquiry: All right.
Exercises, and the outcome of SARS. Following SARS, did the Department of Health carry out a one-day exercise called Exercise Goliath?
Professor Sir McBride: Yes. I struggled to remember this earlier when you mentioned it.
Lead Inquiry: It was before your time, I should say, Sir Michael.
Professor Sir McBride: Well before my time, but it does take me back in time, because it was 2003. However, I was – and did take part in that exercise. I was then the medical director in the Royal Group of Hospitals Trust, as it was then, the predecessor of the Belfast Health and Social Care Trust, and did take part in that exercise.
Lead Inquiry: Now, its relevance is that within the lessons that were identified following the exercise was this lesson: that operational contact tracing mechanisms with the potential for scaling up need to be developed at board and trust level. A further recommendation revolved around the fact that there appeared to be insufficient discussion heard on primary prevention to avoid spread of the assumed SARS coronavirus, and also that participants in that exercise had voiced concerns about contact tracing capacity. Indeed, in the questionnaires filed by the participants, almost every participant mentioned the absence of sufficient contact tracing capacity.
That was a long time before 2020, of course, but many of the aspects of the system or at least the inadequacy in terms of sufficient mass testing, mass contact tracing and the need to prevent spread at an early stage of the outbreak, can all be traced back to some of the concerns expressed following Exercise Goliath, and I wanted to know, therefore, what you knew of the extent to which those recommendations and concerns had been acted upon?
Professor Sir McBride: I’m, as I say, not in a position to answer that. I would assume that, as is normally the case, that those recommendations would have been progressed and taken forward to updates of the emergency response plan, which I think was first developed in, from memory, in 2009. That is an assumption; I can’t say that with absolute certainty.
Lead Inquiry: But it didn’t provide for mass contact tracing or surge capacity –
Professor Sir McBride: Sure.
Lead Inquiry: – on the level which was anticipated in the recommendations from Exercise Goliath?
Professor Sir McBride: No, and I think therein is the difference, because again this was, you know, looking at it, rightly or wrongly, through the lens of a high-consequences infectious disease with very limited potential to become a pandemic. So it wasn’t looking at these requirements through: might we need this for a pandemic? It was looking at: are these needed now for this high-consequences infectious disease which has limited – compared to coronavirus, SARS-CoV-2, has limited person-to-person risk of transmission except particularly in those who are in close contact, such as in the healthcare environment?
So I think that that, I suppose, leap of thinking and challenge in terms of thinking did not occur, I can only assume, in terms of whether these are capabilities that we may need to deploy in a scenario where we are dealing with a novel pandemic virus.
Lead Inquiry: And this comes back to the original strategic error, if you like, in the 2013 strategy?
Professor Sir McBride: I think that’s a fair comment.
Lead Inquiry: What about Exercise Cygnus? Exercise Cygnus focused, for the purposes of Northern Ireland, on issues concerning communication with UK scientific experts, communication with the United Kingdom Government, and cross-border co-operation with the Republic of Ireland.
By the time of the pandemic, had all those issues or recommendations been implemented or were there still concerns, as the Department of Health saw it, by January 2020?
Professor Sir McBride: Well, certainly, as we covered earlier, there were a number of elements of work which informed the five workstreams under the Pandemic Flu Readiness Board, which – some of which had been progressed further than others, but certainly not all completed.
In relation to Exercise Cygnus, we did provide input back to inform the lessons learned report that was produced at a UK level, but we also developed our own lessons learned report, and we identified ten key areas to be progressed. Of those, six were completed. There were two that we didn’t complete and couldn’t complete because it involved – one of them, the recommendation 2, involved a review of the UK strategy of 2011. Recommendation 5 involved a completion of the communications around pandemic flu. Now, we had submitted our updated action in April 2018, and there was one recommendation which we will never complete because it’s about ongoing review and validation and updating.
Lead Inquiry: In relation to the health and social care system?
Professor Sir McBride: Yes. So we did make significant progress on the recommendations that we had identified, but there are a number of recommendations within Cygnus – which I think has been already covered in the evidence of others – that were not completed.
Lead Inquiry: Could we have INQ000188776, please. This is a report from November 2018 concerning the delivery of the Civil Contingencies Group Northern Ireland resilience programme progress report, it’s called a progress report template.
You can see there by November 2018 it asserts that good progress has been made on a number of areas but there are, at the bottom of the page, a number of issues still requiring resolution, excess deaths, and then over the page, that is on track.
Do you know whether or not that particular recommendation, that particular issue of excess deaths was completed?
Professor Sir McBride: Could we just go back, sorry?
Lead Inquiry: Yes, of course.
Professor Sir McBride: What was on track, sorry?
Lead Inquiry: Excess deaths.
Professor Sir McBride: I think while I wasn’t directly involved in that work – as you say, the Department of Justice is leading on it – I think significant progress was made. I’m not certain whether that was completed.
Lead Inquiry: Then “Sector resilience”, in the middle of the page:
“The Executive Office is in the process of collating information for issue to departments to commission resilience assessments for their respective sectors.”
What is sector resilience?
Professor Sir McBride: It refers to, in simple terms, the preparation for the non-health related consequences of a pandemic. So the impact across broader society, the impact on the economy, the impact on education, the impact on a range of other sectors. Again, that area of work and that co-ordination of work on the non-health pandemic consequences falls to TEO to progress.
Lead Inquiry: All right.
Then do we take it that the first bullet point, “Resilience in health and social care, the preparatory work to establish a group to draw up service-facing surge and triage guidance” was the work to which you made reference at the beginning of your evidence –
Professor Sir McBride: That’s correct.
Lead Inquiry: – which, due to the demands of Operation Yellowhammer and then the onset of the pandemic, was never completed?
The risk register for the Department of Health at the time, to which we looked earlier, made plain that the health and social care sector might be unable to respond to the health and social care consequences of any emergency due to inadequate planning and preparedness.
So may we take it from that that there was a general awareness that important parts of the post-Cygnus recommendations, because of the demands of lack of resource and insufficient staff numbers, were not being brought to fruition?
Professor Sir McBride: I make a sort of distinction, if I might, and I hope this is clear. The purpose of a risk register is to ensure that the objectives of the department are met, and clearly the department has a responsibility to provide health and social care services in whatever circumstances.
So the purpose of the risk register is to delineate some of the critical risks. It’s not to say there’s a significant risk that’s going to happen; it’s saying “This is a risk that we need to be very mindful of, this is a risk that we need to be prepared for, and we need to take a range of mitigating actions to prevent that from happening”.
Those that fall to health in terms of – which we’ve discussed earlier – are some of those mitigations. They’re not all of them, but they are some of the mitigations, because it’s not an exhaustive list, it’s some of the high level mitigations that went into the departmental risk register.
Lead Inquiry: But not all the mitigations were put into effect, for the reasons you’ve described?
Professor Sir McBride: Yes.
Lead Inquiry: So the risks of course continue to exist, because they were not all met by way of the mitigating measures, for the reasons you’ve described?
Professor Sir McBride: And the only other point I would make is that risk will always remain on the risk register, because this is a material risk that will continue to remain on the risk register, as it has done from 2008. It is a risk that we always need to be mindful of. So it’s never resolved, it always needs to remain as a risk and, as I say, there’s a need to update the actions that we will take to manage the risk.
Lead Inquiry: Quite. But, because it was a high level departmental risk register, the department at a high level was aware of the risks of course and the absence, in part, of the proper mitigating steps being taken to mitigate the risks?
Professor Sir McBride: In part but, as I say, there are a range of other mitigations that are in place that are not necessarily reflected in the department’s risk register but would be reflected in the risk register of other organisations who would be mounting the operational response. So this is a very high level departmental document.
Lead Inquiry: One of the other pieces of learning that came out of Exercise Cygnus was the need to collaborate on cross-border issues and “operate a joined-up strategy with the Republic of Ireland”. We have debated already some of the bodies –
Professor Sir McBride: Sure.
Lead Inquiry: – to which you personally were party. Did the system of cross-border collaboration improve after 2016 and the outcome of Cygnus, before 2020, or was it in a state of stasis?
Professor Sir McBride: I can only comment from my own experience and knowledge. You know, from taking up post in 2006, there has always been very effective working relationships between both departments, but that’s not really the question.
As to whether or not the recommendations in respect of cross-government collaboration were progressed and taken forward by the United Kingdom Government and they engaged with the Irish Government, I couldn’t say.
Lead Inquiry: All right.
Inequalities and data disaggregation. In your witness statement you refer to the development of a vulnerable people protocol –
Professor Sir McBride: Yeah.
Lead Inquiry: – to define vulnerable people, and I think it was your people that developed the protocol in order to try to identify persons who would need particular assistance, of course, in the event of a pandemic.
When was that protocol drawn up? It was pre-pandemic, was it not?
Professor Sir McBride: From memory, it was drawn up and completed in 2013 following a particularly severe episode of severe weather that Northern Ireland experienced at that time. So 2013, from recollection.
Lead Inquiry: Then was it subject to variation throughout and then operated, utilised at the time of the pandemic?
Professor Sir McBride: Yeah, I think it was updated in 2016. I mean, I don’t know if you wanted me to expand on the approach taken or …
Lead Inquiry: Well, I was going to ask you: was it a protocol that paid attention to the clinical needs of vulnerable persons, or was it a protocol that was able to identify vulnerabilities ethically and socially as well?
Professor Sir McBride: It was more of a generic document. So the approach – the initial thinking of this was that we could develop a list of lists, with the appropriate safeguard to data protection and personal information, of vulnerable people right across Northern Ireland. Obviously that wasn’t possible.
So, as it was developed, it was agreed that we would develop an approach which was based on those known to Health and Social Care as vulnerable. Now, that can be for a variety of reasons, it doesn’t necessarily relate to clinical vulnerability. There can be other reasons why people are socially vulnerable.
So those known to the health service, those known to utility services – for instance, heat, light and power – who would be on their lists as particularly vulnerable. Then we had a third category, which was the emerging vulnerable. Because obviously in any particular emergency situation there can be people who emerge, as the emergency progresses, who were not immediately obviously vulnerable at the outset.
So that was the approach that was taken.
Lead Inquiry: And who may not be known to the authorities and –
Professor Sir McBride: Who may not be known.
Lead Inquiry: – and who may need to be discovered?
Professor Sir McBride: Yeah.
Lead Inquiry: And was that protocol of great practical utility in the face of the pandemic itself?
Professor Sir McBride: I don’t believe it was of great practical utility, if I’m honest. I think the nature of the decisions that were made, the speed at which they were made, the fact that we were making decisions which were about saving lives, protecting the health service, meant that we had to make – ministers had to make decisions based on the advice that we were providing, which didn’t allow us the time to consider as fully as we, perhaps on reflection, could have; the impacts, the disproportionate impacts that some of those non-pharmaceutical interventions, the restrictions on people’s lives were having on those who were most socioeconomically disadvantaged.
Lead Inquiry: Because of course those countermeasures, the decisions, were taken at a very high, generic level?
Professor Sir McBride: They were.
Lead Inquiry: They applied across the nation, and it was simply not possible to have regard to the particular characteristics which might have underpinned a more vulnerable-centric approach to social restrictions?
Professor Sir McBride: I mean, I would agree with that. I mean, we did, whenever we reviewed the restrictions – which we did on a three to four-weekly cycle – we did give consideration to those who would be particularly adversely impacted, and there were certain mitigations that we put in place to try to address that. So we worked very closely, for instance, with the Department for Communities to try to provide the requisite financial support and other support to those who were vulnerable, those that were elderly, those who were living alone.
We worked – we identified, for instance, that school –
Lady Hallett: I think we’re moving on to response now.
Mr Keith: Yes.
Professor Sir McBride: Oh, okay.
Mr Keith: I was going to let Sir Michael finish that particular answer.
Finally, one last area, Sir Michael.
Much of your two witness statements are devoted to the important issue of lessons and, in essence, summarising what you say, you appeared to say this: that research capacity was of enormous utility, it was a great strength in the United Kingdom, and you were able to take the benefit of it in Northern Ireland.
For the future, the best thing that could be done to ensure that we have the capacity, the generic skills to be able to meet the next pandemic is to keep that research base in place, to make sure that we have the scientific wherewithal to be able to respond to the next pandemic, but also this crucially: the training of a core group of individuals with transferable skills who can then be used to – to use the current nomenclature – scale up to the next health emergency.
Is that the nub of it?
Professor Sir McBride: Yeah, there are a number of issues which we need to maintain capacity. I mean, the temptation is always, once an emergency is over, is to move on to the next set of challenges and the resourcing pressures are such that there’s a high risk that that will happen. Our science base or research base served us extremely well. One area where we are deficient, as you’ve heard already, is around diagnostics, the ability to scale that up at speed.
In relation to your question, there is a need for all of government to see this as part of the day job. This isn’t an add-on extra that those who are experts in emergency preparedness and planning response do. We will need those individuals, and continue to need those individuals, who have those highly specialist skills and experience and they need to be acknowledged, they need to be maintained. But we also need a set of generic skills right across government, in all government departments, so that an effective response can be mounted and we can dial that capacity up and dial it down as the need arises. Because unfortunately we will not be able to maintain the level of response, responsiveness at the level that it currently is, but we will absolutely need to be able to scale that up at very short notice when the need arises.
Mr Keith: Thank you.
My Lady, you have granted permission for two broad areas of questions, I believe.
Lady Hallett: I have.
Ms Campbell.
Questions From Ms Campbell KC
Ms Campbell: Sir Michael, my name is Brenda Campbell and, together with my colleagues here and in Belfast, we represent the Northern Ireland Covid Bereaved Families for Justice.
I have been granted permission to ask you questions across two broad topics, and I recognise from the outset that to some extent they have been covered, but I wonder if on behalf of the Northern Irish bereaved I might address some further issues in relation to them.
The first is in relation to funding for the Public Health Agency or, perhaps more broadly, public health services in Northern Ireland.
I don’t know if you listened to the early stages of evidence that my Lady heard, but we heard from Professors Bambra and Marmot, are those names – you’re nodding –
Professor Sir McBride: Yes.
Ms Campbell KC: – so I’m assuming you tuned in to their evidence.
But in their report and in their evidence they told us that the UK fell from being ranked 26th globally in terms of life expectancy in 2010 to 36th globally by 2020, so one per year, if in fact it was not more rapid at different times.
They went on to say that life expectancy growth started to stall across the UK in 2011, something had changed in 2010 and 2011, and it coincided with a new government whose stated ambition was austerity. We heard some evidence in relation to that this morning from Dr Kirchhelle as well, and his reference to the King’s Fund.
Now, you’re nodding because no doubt those statistics are worryingly familiar to you in your role as the Chief Medical Officer, and indeed chief executive of the Belfast Health and Social Care Trust across that period.
When it comes to Northern Ireland, I wonder if we could put up, please, Dr Kirchhelle’s expert report, it’s INQ000205178, and I’m hoping it’s page 79, and paragraph 124 which deals specifically with Northern Ireland. So it’s INQ000205178, and paragraph 124, please. There we go. Do you see it? It just goes across two pages, I think.
So, Dr Kirchhelle in his report notes that:
“Between 2010 and 2019, the provision of Northern Irish public health services was subject to numerous reviews whilst suffering from stagnating or reduced funding and political stasis. Following its creation, PHA’s overall budget for health protection almost halved from £8.4 million in 2009/2010 ([which was] 15 percent of total programme funds) to £4.5 million in 2012/2013 (7 percent of total programme funds) before rising back to £7.7 million ([still only] 10.6 percent of total programme funds) in 2014/2015.”
He observed that:
“Budgets during the second half of the 2010s remained relatively static with the [Public Health Agency] at times resorting to voluntary redundancies to save costs, which negatively impacted staff morale.”
That chimes to some extent with the evidence that you were able to give us this morning, and should we understand that your evidence is that the situation has not improved since?
Professor Sir McBride: If anything, the situation has deteriorated since and –
Ms Campbell KC: Yes.
Professor Sir McBride: – I say, I don’t recognise the detail of those figures in relation to health protection, but I’m happy to talk generally about the public health budget allocation.
Ms Campbell KC: Well, that might be for a future module. But certainly where Dr Kirchhelle leaves off in 2019, the situation is that the Public Health Agency has suffered from real term reductions over a decade-long period, and what the bereaved families really are interested in is the impact of that on pandemic preparedness.
Did you hear the evidence last week from Mr Swann?
Professor Sir McBride: I did, yes.
Ms Campbell KC: You did, and he told us – and it was dealt with in some terms this morning and again in your evidence – about the need for transitional funding to be available in Northern Ireland, not just so that the health service could keep going but so that very much needed reform could take place, and you agree with that evidence, I’ve no doubt, in relation to –
Professor Sir McBride: I do, yes.
Ms Campbell KC: – Mr Swann.
What he went on to say was that the impact of that or the consequences of that were, whilst there was readiness for some aspects of pandemic planning, the aspects where we’d actually failed to invest and reform our health service had an adverse effect on how we responded as a Department of Health and as a society in regards to the additional supports that we had.
So although it was some readiness, essentially the health service was ill equipped to cope with the requirements of the pandemic.
Would you agree with that?
Professor Sir McBride: Plans and preparation are really important, but one of the most crucial aspects of the ability to respond to any emergency, particularly a sustained one or a pandemic, is the resilience of the health and social care system.
I think it is fair to – say, and this is a personal and professional view – that the health service in 2020 was not as resilient as it even was in 2009, with the H1N1 pandemic, and there are a number of reasons for that. We have alluded to some of them.
The lack of structural change, which was compounded by the resourcing situation and, as I said earlier, decisions that were made to live within budget allocation as opposed to decisions that should be made, and as a result that resulted in decisions that were short-term, and in the long-term counterstrategic and likely to cost more, particularly in relation to the priority that needs to be afforded public health.
Ms Campbell KC: Well, one practical consequence is that you’ve told us that, certainly as a significant part of your role in terms of planning, there was a recognition of a need for surge plans and for surge capacity within the health service and social care as well, and you’d agree with that?
Professor Sir McBride: Yes.
Ms Campbell KC: That there was a Task and Finish Group that was to review and update an influenza pandemic surge guidance, although that wasn’t quite completed?
Lady Hallett: Ms Campbell, I’m sorry to interrupt, but you do seem to be straying somewhat from – I think these are matters that Mr Keith has already covered.
Ms Campbell: In fact, my Lady, I hope I’m not straying too much, save to put it into the context of the evidence that we heard from Mr Swann last week.
If I may, it’s in fact the last topic under this heading and it was only, if I look at the question in particular, it’s about how the impact was mitigated –
Lady Hallett: Okay.
Ms Campbell: – with a focus on, and just to use the example of surge, given that it was both evidence from last week and evidence from today.
The surge capacity, we were told last week, in the event of the pandemic, had to come from re-directing or standing down other services –
Professor Sir McBride: Yes.
Ms Campbell KC: – so what you give to Covid, you take from other areas. And my question to you is this: given the recognition of this as an issue, what did you do to ensure that the impact was mitigated and that there was or would be additional surge capacity?
Professor Sir McBride: I think my concerns about the resourcing position in relation to the health service in Northern Ireland are a matter of public record.
My concerns about the lack of structural change or the slowness with which structural change had been progressed are also a matter of public record. I certainly raised those concerns with – within the department. There were difficult choices that needed to be made.
You’ve mentioned the PHA budget. Whilst they were not significant cuts per se in the public health budget they had to realise savings, so there were – they had to absorb, for instance, you know, 6% additional costs in their admin budget.
Now, when you talk about admin in the Public Health Agency, that’s professional staff who – their salary costs are not insignificant, so it’s not the same as admin costs elsewhere. And similarly they had to absorb a reduction of some 4.3% in the years running up to the period in question in the programme budget. Now, the programme budget is the things that you do in relation to alcohol and drugs, other interventions to address health inequality.
I can’t specifically comment on the – this figure in relation to health protection. It seems odd that it goes down in one year and up in the next, but again Public Health Agency colleagues may be able to enlighten you on that.
In terms of surge, I think certainly as Chief Medical Officer I was leading at that point in time significant elements of the Bengoa work, so I was the senior responsible officer for the establishment of the day elective centres to reduce the burden on the health service and to have more people having their surgery on an in – you know, day case basis. That was put to good effect during the surge because it meant that some of the red flags, et cetera, could continue and we weren’t having as much of an impact on routine elective, although we did significantly impact on people waiting for routine elective surgery.
I could give other examples, but I am conscious of time.
So I did what I could in terms of helping shape, influence and provide leadership to that system change to ensure that, with the resources that we had, that we were restructuring the health service to ensure that it was as robust as it could be to address any intended pressures.
I have to say, however, that was largely to deal with the here and now. You know, in Northern Ireland the health service struggles on a day in, daily basis to deliver what it should be delivering, notwithstanding the additional pressures created by the pandemic and surge. And you’re quite right, really what we had to do was turn off to a large extent all of that elective capacity, which had huge impacts right across the public, and people waiting excessive periods of time, even longer than they were before. The worst waiting times in the UK got even longer, people waiting in pain and distress, and we still are not in a position where we can recover that as quickly as we would wish.
Ms Campbell: Thank you.
Mr Keith: My Lady, I’m sorry to rise to my feet, I believe Ms Campbell may have had the ten minutes that it was agreed that she would have, and I’m very well aware that the Inquiry, for good practical reasons, can’t sit past 4.15 today.
Lady Hallett: Exactly.
What I’ll do, Ms Campbell, may I suggest that I ask the question that I gave you permission to ask, just to finish off? Because we are under pressure, I’m afraid, for different reasons.
Ms Campbell: Yes, of course.
Questions From the Chair
Lady Hallett: Sir Michael, were pressures on the PHA exacerbated by uncertainty about regulatory arrangements amidst the UK’s pending exit from the European Union, as described by other people including Baroness Foster, who’s talked about the focus on Brexit, and Dr Kirchhelle this morning?
Professor Sir McBride: Sorry, could you repeat that?
Lady Hallett: Were pressures on the PHA exacerbated by uncertainty about regulatory arrangements pending the exit from the European Union?
Professor Sir McBride: No immediate examples come to mind. There is no doubt, however, that their capacity was deflected, as everybody’s was, in terms of trying to plan and prepare for EU exit; but I can’t think of specific examples in response to that.
Lady Hallett: Well, I think everybody’s agreed there was an impact.
Professor Sir McBride: Oh, absolutely, without any question of a doubt.
Lady Hallett: Thank you very much indeed.
Mr Keith: My Lady, that concludes the evidence for today.
Lady Hallett: Thank you very much indeed, Sir Michael, thank you for your help.
The Witness: Thank you.
Lady Hallett: We may meet again in Belfast.
The Witness: I think we may.
(The witness withdrew)
Lady Hallett: 10 o’clock tomorrow, please.
(4.18 pm)
(The hearing adjourned until 10 am on Tuesday, 11 July 2023)