3. Mr Nigel Edwards

MR NIGEL EDWARDS (affirmed).

Questions From Lead Counsel to the Inquiry

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

Mr Nigel Edwards: My name is Nigel Charles Michael Edwards.

Lead Inquiry: Mr Edwards, whilst you give evidence, could you please remember to speak up and to speak as slowly as you are capable of doing. Thank you.

Thank you very much for providing a statement, which you have, it’s INQ000148416, and you have provided a signature and a declaration of truth at the conclusion of that.

Mr Edwards, your statement will be published and the Inquiry has read and considered it, and it will be the subject of further consideration in due course.

I want, therefore, to ask you some questions in a very broad sense about the state of resilience of the NHS and the social care sector in the United Kingdom, but primarily England, because that’s the focus of the Nuffield Trust, but not, whilst you do so, to delve into the detail operationally or otherwise of our NHS and social care structures, because they’re for later modules.

In essence, I want you to focus, please, on the extent to which the Nuffield Trust believes that those structures were capable and envisaged to be capable of responding to the severe demands of a pandemic.

What does the Nuffield Trust do?

Mr Nigel Edwards: We are a charitable foundation and we do research into health policy and healthcare delivery, largely with a focus on the UK, and we do that by using our own researchers, and working with published data.

Lead Inquiry: Are you the chief executive of the trust?

Mr Nigel Edwards: I am. I have been the chief executive for about nine and a half years.

Lead Inquiry: Is the trust a charity?

Mr Nigel Edwards: We are a charity. We have an endowment, which is the bequest of the late William Morris.

Lead Inquiry: Does it follow that you are, therefore, registered with the Charity Commission?

Mr Nigel Edwards: We are.

Lead Inquiry: I’m not going to go through the charitable objects one by one, but in essence does the Nuffield Trust carry out a number of important functions? You make available an evidence base, material, detailed information, that allows you and others to better understand the care structures in the United Kingdom, you provide expert commentary, analysis and scrutiny, and do you also bring together, for seminars, symposia and so on, policymakers and decision-makers in order to try to identify better ways forward and solutions for the problems that you identify?

Mr Nigel Edwards: That’s a very good summary of what we do.

Lead Inquiry: Now, in the years before January 2020, was pandemic planning or preparedness for pandemics something that the trust looked at specifically?

Mr Nigel Edwards: We didn’t look at this area specifically, for two main reasons. One is that we did not have the internal expertise or knowledge to really do that effectively, and secondly, from a number of sources it did appear that the UK’s general level of preparedness was satisfactory.

Lead Inquiry: Is infectious disease, being a form of health emergency, something in fact that the Nuffield Trust historically has looked at?

Mr Nigel Edwards: Not specifically.

Lead Inquiry: But presumably you would and you did nevertheless continuously look at the state of resilience of the system, that is to say the extent to which the systems would be able to deal with the sort of shock that a health emergency or a pandemic might bring about?

Mr Nigel Edwards: Yes, indeed. One of our main areas of focus over the years has been the ability of the NHS to deal with winter, which is a period where the NHS has historically come under a great deal of pressure, and indeed is something of a bellwether about the overall resilience and capability of the system, and this has been a focus of our research and – a significant focus of our research and commentary over the time that I have been at the trust.

Lead Inquiry: Does it form an important part of the trust’s functions to raise concerns where you discover there are problems or you discover there are systemic flaws in the system? So in relation to, for example, the ability of the NHS to cope with a severe winter, do you raise your concerns the government and with policymakers and so on?

Mr Nigel Edwards: Yes, we both raise concerns but also monitor the situation and try and make predictions about the future response and understand some of the underlying reasons why the NHS has historically struggled with dealing with even a relatively routine winter.

Lead Inquiry: Although the trust didn’t look specifically at preparedness or pandemic planning, did you after 2020 carry out some pieces of work which did happen to look at lessons which could be drawn from the pandemic in the particular context of infection prevention and building design in terms of the NHS and the social care structure?

Mr Nigel Edwards: Yes, indeed we did. We undertook two pieces of work, one funded by the Department of Health’s New Hospital Programme, and one that we funded ourself internally, the latter looking at the response of small hospitals, the former looking at what we should learn from the way that hospitals were designed and operated to make them more resilient in future, particularly as new hospitals are being constructed.

Lead Inquiry: Maintaining the focus on planning or lack of planning or preparedness or lack of preparedness, what did you find was the position in relation to the existence of pre-existing plans, pre-pandemic plans, designed, on the hospital front, to deal with the possibility of a sustained pandemic?

Mr Nigel Edwards: So the hospitals that we spoke to, and this was a sample, I should emphasise, had plans in place for dealing with influenza but not, we found, for dealing with a long-term sustained pandemic.

Lead Inquiry: Without going into the operational aspects of the hospital estate, and again focusing just on the degree of pre-planning that there was, was there a particular area, the supply of oxygen, in fact, in relation to which there appeared to be a marked absence of planning?

Mr Nigel Edwards: The requirement for high flow oxygen as a method for treating Covid-19 certainly came as a surprise, both clinically and also to state departments, who discovered that, in a number of cases, both the size of the pipework to supply oxygen and the machinery that’s used to condense oxygen to keep the supply going were inadequate for the scale of the task that was – that they were required to respond to.

They responded very well, but they had to make very major engineering and structural changes to be able to accommodate that.

Lead Inquiry: Does the fact that those changes had to be made of itself indicate that there had been an absence of planning for that eventuality?

Mr Nigel Edwards: I think it probably indicates a broader issue about the way that hospitals in the – in many parts of the UK have been designed and built over the years, which is to really strip out any kind of redundancy, to compress the spaces that are available, to save money where that is possible by reducing to the lowest tolerance that sits within the guidance.

Lead Inquiry: That would appear to be more of an operational aspect of the state of affairs in the NHS. Can you say whether or not you reached a view as to whether or not there had been an adequate or proper degree of planning, guidance and policy documents, drawn up to cater for that possibility?

Mr Nigel Edwards: I think, on the basis of what we saw, we can conclude that those plans were not adequate, and that partly reflects the nature of the treatment regime that was then required.

Lead Inquiry: All right.

Turning to social care and the social care sector, following the pandemic, did you – and do you continue to – carry out a study jointly with the London School of Economics, I think funded by the National Institute for Health and Care Research, as part of which you’ve looked at how well prepared the social care sector was for a pandemic?

Mr Nigel Edwards: Yes, indeed.

Lead Inquiry: In relation to three or four factors or three or four features of that study, firstly, the Inquiry has heard a considerable amount of evidence about the existence of what are called standards, assessments or tests, if you like, to validate the performance of the various bodies in the government structures. Is there a difference or did you find there to be a difference in the availability or existence of standards for the NHS to operate against as opposed to the social care sector?

Mr Nigel Edwards: The NHS typically has a much clearer set of standards defined than the social care sector.

I think it’s fair to say that we haven’t done a detailed examination of the standards, but the general principle of what you are saying is correct.

Lead Inquiry: You are aware, and of course the Nuffield Trust is aware of the fact that there were over the years a number of exercises carried out in the United Kingdom, dealing with a wide range of possible eventualities and different possibilities which might eventuate. Were you able to get an understanding of the degree to which the outcomes of the various exercises were implemented in the social care sector?

Mr Nigel Edwards: It’s not been an easy trail to follow. So-called Exercise Alice, which looked at the challenges associated with the MERS, Middle East respiratory disease, only covered health. The later Exercise Cygnus did look at social care. Our researchers did not find – were not able to find a great deal of evidence that the lessons from that were incorporated into social care, and the – in relation to the previous question that you asked, you know, that – this general lower level of requirement standards in social care continued after that, there did not seem to be a significant change in advice given to the sector.

Lead Inquiry: It is obvious, and the evidence plainly establishes, that such preparedness as there was was focused on the possibility of an influenza pandemic as opposed to a different type of catastrophic pathogenic outbreak. To what extent did your researchers see the consequences of that focus as they looked at the general state of health of the social care sector? Did they see evidence that non-influenza outbreak had been planned for to any degree at all?

Mr Nigel Edwards: No. Most of the focus had been on planning for an influenza-type outbreak, and the significance of that was that a number of the proposals for how to deal with that did not take into account the airborne nature of transmission for Covid-19.

Lead Inquiry: Did some of the employees and the managers in the social care sector to whom your researchers spoke express any view on the extent to which, both pre and post pandemic, the United Kingdom had availed itself sufficiently of learning or knowledge or experience from other countries who had had to deal with pandemic outbreaks in earlier times?

Mr Nigel Edwards: We couldn’t find direct evidence for that.

Lead Inquiry: All right.

The Member of Parliament Matt Hancock gave evidence to this Inquiry about the difficulties encountered by the Department of Health and Social Care during the early days of the pandemic in understanding the sheer number of social care providers, as well as the number of persons receiving care in the social care sector, as well as, I should say, the number of persons who required care but were not receiving care in the social care sector.

Is there, in the NHS, the means to identify centrally the numbers of persons receiving healthcare?

Mr Nigel Edwards: At a broad level, yes.

Lead Inquiry: Is there a comparable mechanism in the social care sector? Do they have comparable mechanisms for understanding how many people are being treated and how many people are receiving care?

Mr Nigel Edwards: No, and in fact the overall oversight of the sector in terms of even who is employed and who is providing care is also – the information on this is also patchy or poor.

Lead Inquiry: Is that because the majority of the providers of social care are local providers, instructed or paid by local authorities to provide care for their purposes, and therefore there are a very large number of individual fragmented providers?

Mr Nigel Edwards: That is correct, although the Care Quality Commission would have a register of all registered social care providers, but that’s a regulatory function rather than a managerial one.

Lead Inquiry: Now turning to resilience, which forms the majority of your statement. In the context of looking at the state of health of a health system or a social care system, why does resilience matter when it comes to examining the potential impact of a health emergency or a pandemic? Why can’t it just be assumed that a system of care will suck up whatever a health emergency presents it with?

Mr Nigel Edwards: One of the reasons for that is that some of the nature of health emergencies means that there is a very large surge in demand, many percentage points greater than the baseline level, and many health systems but the UK in particular has traditionally run with very low margins of spare capacity, which means that having a plan for how to deal with a sudden surge or emergency is very important, but it also of course limits the scope of that plan because the level of spare capacity in the system is relatively low.

Lead Inquiry: Do different considerations apply to whether or not a system is capable of recovering from a shock as opposed to dealing with the initial shock of a pandemic?

Mr Nigel Edwards: Our research internationally suggests that the ability to recover from a shock is very closely related to the overall level of capacity and pre-existing resilience in the system, so those countries which had higher levels of beds and staffing, more hospitals, better provided home care services, have recovered significantly better than those, like the UK, that do not.

Lead Inquiry: Was the Nuffield Trust – or is it able to reach a view as to general levels of resilience, firstly in the NHS and secondly in the social care sector, over the years preceding the pandemic? Is there a chart or a line or a broad degree of progress that you can identify?

Mr Nigel Edwards: If we start with bed capacity and the demand associated with that, the number of beds in the NHS has remained relatively static during the period leading up to the pandemic. The NHS has a very low number of beds per capita compared with other high income countries. It tends to run them at a much higher rate of occupancy, which of course means that its ability to absorb shocks or increases in demand is much lower. And although the number of beds has remained static, the population has both grown and aged over this period. So while demand has been going up by 2% a year, the beds have remained static, and the number of nurses have gone up by 0.2% over this period, which means that the system – the hospital system is highly constrained.

Lead Inquiry: So that’s beds and nurses. What about the state of resilience in terms of the workforce generally in the NHS over, for example, five years preceding the pandemic?

Mr Nigel Edwards: So the workforce has been growing, but the level of – so too has the number of vacancies, and there have been shifts in the way that people work for the NHS, more people working on temporary contracts and through the use of bank and agency-type staff, which, again, does affect the ability of the NHS to provide services that respond to these growing levels of demand.

In community services we have a much less clear view of what the capacity of the system is. There does not appear to be a very reliable way of quantifying that, but we do know that there has not been a growth in community services to compensate for, again, this growth in the age of the population and its high level of need, and as a consequence – I mentioned earlier winter, which I think is quite a good indicator of the resilience of the system. So, for example, in 2018, NHS England instructed hospitals to cancel all of their planned work to make space for emergencies in January of that year.

Lead Inquiry: What are community services? You referred twice to community services –

Mr Nigel Edwards: Yes.

Lead Inquiry: – by contrast to hospital services?

Mr Nigel Edwards: That is a much more complicated question than it might at first appear, but it would include some types of community hospitals, so hospitals which don’t –

Lead Inquiry: Slow down, please.

Mr Nigel Edwards: Sorry, I do apologise.

Lead Inquiry: It’s quite all right.

Mr Nigel Edwards: Hospitals which don’t manage emergency care –

Lead Inquiry: Right.

Mr Nigel Edwards: – maybe used for rehabilitation or for aftercare following a hospital visit.

Nurses and other clinical staff who provide care for people in their own homes, support patients with long-term chronic – with chronic conditions, manage their care and provide rehabilitation and aftercare in a home care setting.

Lead Inquiry: So you’ve touched upon, now, general workforce levels, general bed capacity. This is all in the NHS and non-social care. Again, without going into the detail and certainly not the operational side, what was the state of resilience in January 2020 of the capital infrastructure of the NHS, that is to say the buildings, the capital assets, the equipment, the hospitals, the wards?

Mr Nigel Edwards: As part of the approach to trying to keep NHS funding, at least keeping up a little bit with changes in costs, the capital budget had been reduced and turned to revenue, and one of the consequences of – so it’s an accounting shift, but the implication of it is that money that should have been spent on new equipment, on repairing – on repairs and maintenance, was shifted to keeping everyday operations going, and as a consequence the backlog maintenance bill of the NHS has grown very substantially over this period, which is another indicator of a problem because it means that a significant amount of the estate is really not fit for purpose.

Lead Inquiry: So in other words, and forgive me for oversimplifying it, there is a certain amount of money that goes into the NHS pot, money that might have been used to improve the infrastructure was used instead for its current account, that is to say for its trading, for keeping the system ticking over?

Mr Nigel Edwards: That’s correct.

Lead Inquiry: And that means that we’ve fallen behind in terms of the maintenance of our infrastructure and our capital expenditure?

Mr Nigel Edwards: That is correct.

Lead Inquiry: All right.

That’s the NHS. Could you give us, by reference to, firstly, places, then the general workforce numbers, and then, again, the capital infrastructure, the analogous position for the care home sector?

Mr Nigel Edwards: It’s not so easy to do this for social care. We can talk generally about what had happened to funding over this period.

Lead Inquiry: Yes?

Mr Nigel Edwards: So funding comes from councils, as you mentioned, and many of them had a significant reduction in their – the grants that they were receiving from central government, so they had – the spending in 2019 in real terms was actually less than it was – it was only just at 2010/11 levels, but the demand for social care and the need for it had significantly increased over that period, with the consequence that many local authorities were reducing the – what is called the eligibility criteria, so how much care – how much do you need to demonstrate a need for care to be able to be entitled to receive it from local authorities. So we’ve seen a constriction in the number of people offered care and the level of care that was available.

In the nursing home care sector, the consequence of that squeeze was that many nursing homes were having financial difficulties. Those with a strong self-paying component, so – were using that to subsidise the local authority residents who they were often housing at a loss. So there was –

Lead Inquiry: Can you just pause there?

Mr Nigel Edwards: Yeah.

Lead Inquiry: By that do you mean that, in order to balance their books, because obviously care has to be paid for and money needs to be paid to care home providers to provide the service, persons who pay privately get charged more to make up the deficit because the councils are paying relatively little to the care home providers to provide the service for their local authority care home residents? Is that the nub of it?

Mr Nigel Edwards: That’s absolutely correct. And one of the consequences of the financial squeeze is – although this is harder to quantify, is that this sector was also reporting that its investment in physical infrastructure, technology and other improvements had been severely limited over this period.

Lady Hallett: Can I just check, you started off by talking about nursing homes; are you using nursing homes and care homes interchangeably?

Mr Nigel Edwards: I am, yes.

Mr Keith: There are different types of –

Mr Nigel Edwards: Yes.

Lead Inquiry: – social care homes, are there not?

Mr Nigel Edwards: Yeah, they have –

Lead Inquiry: What are the broad groups?

Mr Nigel Edwards: They have two. There are those that provide an element of nursing care and which some of the care is provided – is paid for by the NHS, and the hotel component either by the individual or by local authorities, and then there are care homes which do not have a nursing – a healthcare component and are more, you know, sometimes called residential homes.

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

Can we now look at data. So, as I said, Mr Hancock referred to the very real difficulties that the Department of Health and Social Care had had in trying to get on top of the numbers in the social care sector, and my Lady has received evidence from Professor Woolhouse, who spoke of difficulties in trying to get access to data for the purposes of legitimate and important research that he was conducting.

Is the NHS’s ability to collate and provide data relatively good in the opinion of the Nuffield Trust?

Mr Nigel Edwards: Broadly. I mentioned a concern about the data on community, these community services, which are an important component of care, but for hospital services the availability of data is pretty good.

Lead Inquiry: Does the Nuffield Trust have a view as to the extent to which concerns about data protection and privacy have prevented the proper utilisation and dissemination of data?

Mr Nigel Edwards: The problem of privacy are more relevant to the use of data, for example, to identify people at risk or to – and sometimes to do planning. Most local authorities have found ways to work with other agencies to do that, but there are some bureaucratic hurdles which the current legal framework can put in the way. But from the point of view of administrative data about pure numbers, there’s no particular reason why data protection or protection of privacy should affect the ability of the system to understand the broad – the broad trends and movements. It’s only at the point where you are trying to maybe look at a population and say “Who do we think is most at risk, and where should we intervene?” that the need to have some form of semi – what’s called pseudonymised data, which had – might relate to personal details. But from the point of view of planning, long-term forecasting, understanding capacity, there was no – there is no, as far as I’m aware, no particular data protection or other constraint.

Lead Inquiry: So just to pause there for a moment, there’s no problem in gaining access to pre-existing data, what has happened to whom and where and what services they’ve been provided with, and what services they may need on a historical basis. What is much more difficult is looking to the future prospectively and saying: who in number 13 or 14 or 15, the close in a particular area, is going to require a special need or a special service or is going to require being looked after on account of a pre-existing vulnerability or need? Is that the issue?

Mr Nigel Edwards: That can be the issue. I think in our evidence we gave an example from West Berkshire where that evidence – where they had very successfully managed to bring data from different sources to do precisely that sort of very detailed forecasting.

But from – just to –

Lead Inquiry: So just to pause there.

Mr Nigel Edwards: Yeah.

Lead Inquiry: For the purposes of preparedness and planning, it’s forecasting that matters, it’s the ability to be able to plan for all eventualities and to make plans to make sure that individual members of the population receive whatever services they’re going to need. That system of forecasting, is that in a good state?

Mr Nigel Edwards: I think we should just – perhaps I will clarify, if I may, a point here.

I am making a – we can make a distinction between sort of broad strategic planning to ensure that you’ve got a viable system which is resilient and that you – is using resources effectively, and that allows you to think about the sort of overall shape of the system, does not require that level of detail about the individual. The –

Lead Inquiry: But specific planning identification of individual needs does?

Mr Nigel Edwards: Yes. Yeah.

Lead Inquiry: To what extent, in your experience, does the NHS provide for that level of data?

Mr Nigel Edwards: The NHS has, with some issues about community services, generally got fairly good data to allow that sort of planning and capacity planning. However, the fragmented nature of the social care market, the fact that there are different purchasers (there’s local authorities and there are individuals), the problems that local authorities have experienced due to spending cuts that they have been subject to, and in fact the fragmented nature of the social care market means that the data to be able to do that is much less readily available, and I think at the level of the Department of Health has been broadly poorly understood in recent years.

Lead Inquiry: In your statement you address the impact of leaving the European Union, and I absolutely stress you make no political points about the merits or otherwise of leaving the European Union, but do you identify that, even whilst the terms of the departure were being negotiated, so pre-pandemic, the fact of the exit of the United Kingdom from the European Union began to have an impact on the resilience of the health and social care systems? That’s a yes or a no.

Mr Nigel Edwards: That’s a yes.

Lead Inquiry: Did you do so and did you identify three areas in which that impact began to become apparent: workforce, especially in relation to social care; the resilience of supply chains; and the ability to access medicines and supplies?

Mr Nigel Edwards: That’s correct.

Lead Inquiry: We’re not concerned in Module 1 with the resilience of supply chains and the ability to access medicines and supplies, that’s for later consideration, but in terms of the resilience of the sector, the social care sector, how significant was the impact on the workforce of the pre-pandemic commencement of the exit process?

Mr Nigel Edwards: There was a substantial drop in migrant – so it’s worth saying that the social care workforce, particularly in some parts of the country, particularly the south of England, has been highly dependent on migrant workers. A significant number of those had been coming from the EU, and there was a distinct drop off in that from 2016, for the two or three years following 2016, which started to be made up from – with migration from non-EU countries, but there was a hiatus between the drop-off from the EU and the recommence – the ability of the system to change the rules, to introduce new approaches to issuing visas. And there was also a problem which – at this point social care was not on the shortage workforce list of the Migration Advisory Committee.

Lead Inquiry: All right, we don’t need to go into the detail of it. It seems obvious, though, Mr Edwards, that the government, as might be expected, did start to take steps immediately to try to increase recruitment from other parts of the world in order to make up that looming deficit?

Mr Nigel Edwards: In health, but there was, I believe – I would have to maybe come back to you on the exact timing of this – but I think there was a hiatus between understanding the implications for the workforce in that particular sector and then changes in the rules to allow for people to be admitted from other non-EU countries.

Lead Inquiry: All right. Well, a hiatus may be forgiven, perhaps, but they took steps to try to ameliorate the problem as they saw it?

Mr Nigel Edwards: Yes.

Lead Inquiry: But to what extent – and we’re now, again – we’re still concerned, of course, with pre-pandemic state of affairs, so the state of preparedness and what sort of state of resilience the sector was in. By the time of the pandemic in January 2020, had that anticipated deficit been made up or were we in a position in which there was still a shortfall in terms of the numbers in the workforce at the moment of the impact of the pandemic?

Mr Nigel Edwards: There was still a shortfall in the social care workforce. I don’t know to what – it’s probably of only academic interest – extent that reflects the issues around funding, the impacts of Brexit and other factors, but the fact is that, in common with the health sector, the social care sector went into the pandemic with a significant number of vacancies and problems with both recruiting and retaining its workforce.

Lead Inquiry: Finally, a discrete and separate topic, pre-existing vulnerabilities of different groups.

You’ve given evidence, Mr Edwards, about how post pandemic the Nuffield Trust carried out research work in relation to the NHS and social care sectors, with a view on what sort of state they were in at the time of the pandemic and on the degree of planning retrospectively that you were able to ascertain.

To what extent did you find that there had been pre-existing planning for the needs of those persons who have particular non-clinical vulnerabilities? So that is to say persons who have vulnerabilities on account of social or ethnic considerations as opposed to purely clinical vulnerability. Did you see much by way of planning for their needs in the context of a planned health emergency?

Mr Nigel Edwards: No, I don’t think that came up in our research at all.

Lead Inquiry: All right. Does that mean you didn’t look for it or you didn’t see evidence of it?

Mr Nigel Edwards: I don’t think we found evidence of it.

Mr Keith: All right.

Mr Edwards, thank you very much. Those are all the questions that I have for you.

There are no applications under Rule 10.

Lady Hallett: Thank you very much for your help, Mr Edwards.

The Witness: Thank you.

(The witness withdrew)

Mr Keith: My Lady, the next witness is Dr Richard Horton, please.