4. Professor James Nazroo

PROFESSOR JAMES NAZROO (recalled).

Lady Hallett: Professor. Thank you.

Don’t worry, you don’t need to take the oath again, I don’t think anything’s happened over lunch that I know of.

The Witness: Thank you.

Questions From Counsel to the Inquiry

Mr O’Connor: Professor, as my Lady indicated before you left that chair this morning, you’re still here because you have in fact prepared a second report to help the Inquiry, this one relating to the subject of later life; is that right?

Professor James Nazroo: Yes.

Counsel Inquiry: This report you prepared on your own, not with, as in the case of the ethnicity report, Professor Bécares?

Professor James Nazroo: That’s correct.

Counsel Inquiry: Can we call it up on screen, please. It’s at INQ000280058.

We can see there, Professor, the report is in fact entitled “Inequality, Later Life and Ageism”.

Professor James Nazroo: Yes.

Counsel Inquiry: We see your name at the bottom, and the date of 19 September this year. Is that your report?

Professor James Nazroo: That is my report.

Counsel Inquiry: Have you had a chance to read it through before giving evidence today and are the contents of it true?

Professor James Nazroo: They are.

Counsel Inquiry: Thank you.

It’s right, I think, Professor, that very broadly speaking, the subject of this report is inequalities faced at the outset of the pandemic by older people in this country?

Professor James Nazroo: Correct.

Counsel Inquiry: We can perhaps put a little more detail there. If we can go to the next page of the report and look at the very first paragraph, in fact I think it’s two pages on, sorry, and zoom in on paragraph 1, please, you say that in the report you summarise evidence produced prior to January 2020 on inequalities in health, social and economic factors experienced by older people and how that varies across the older population.

Professor James Nazroo: Yes.

Counsel Inquiry: So it is, if you like, a snapshot taken prior to the pandemic of the research that was available, the issues that might or perhaps should have been known to those who were going to go on and take decisions during the pandemic?

Professor James Nazroo: This is the evidence that was available as the pandemic emerged.

Counsel Inquiry: Thank you.

Now, you apologised this morning during your evidence for being definitional, I think was the word you used. I want to ask you very briefly about what we mean by “older people” or “age”. You address it at paragraph 5 of your report. Well, perhaps you can tell us in your own words: for the purposes of this report, what do you mean when you use the term “older people”?

Professor James Nazroo: So “older people”, the term – I use the term in an entirely pragmatic way in the context of this report. So the report primarily focuses on those aged 65 and older. This is a pragmatic division in order to be able to collate evidence. In some places I do talk about people who are a bit younger, so those aged 50 and over.

The importance of that – or the important consequence of that pragmatic decision, though, is that there is great variation amongst the 65 and older population in terms of the range of things that I discuss in the report.

Counsel Inquiry: Yes. So exactly as you say, although the age gives one a cohort, much of what we will go on to discuss will be about sub-groups within that larger cohort?

Professor James Nazroo: Yes.

Counsel Inquiry: In particular those who are vulnerable within the cohort, for example those who are economically disadvantaged; yes?

Professor James Nazroo: Yes.

Counsel Inquiry: Older people from ethnic minorities?

Professor James Nazroo: Yes.

Counsel Inquiry: And older people living in care homes?

Professor James Nazroo: Yes.

Counsel Inquiry: Thank you.

Let me ask you, again by way of introduction, about the geographical reach of your report. You explain in paragraph 6 of your report that the data which allows you to opine on these issues is much more detailed, much more reliable, relating to England than it is to the other nations of the UK; is that a fair summary?

Professor James Nazroo: That’s correct, yeah.

Counsel Inquiry: But you go on to say, and I’m not going to take you to the paragraphs of the report, perhaps we can deal with this by way of summary, but you go on to say that, in your expert view, the patterns, if you like, of inequality and the risks that may have been present probably are replicated or were replicated in Scotland, Wales, Northern Ireland?

Professor James Nazroo: Indeed. So –

Counsel Inquiry: Can you explain that?

Professor James Nazroo: Yeah. So for England we have a very rich data source that allows us to examine later life in a great detail. That’s the English Longitudinal Study of Ageing, which has been running for more than 20 years, and so you can see how things unfold for older people as they grow older.

There are parallel studies in some of the other nations of the UK, so there’s the NICOLA study in Northern Ireland, there’s the HAGIS study in Scotland, there is not such a study in Wales at the moment.

The issue with the data from the NICOLA study and the HAGIS study is that it’s relatively immature, so it’s not detailed enough to do this kind of work yet, though it will over time be able to do that.

The other sources of data really rely on surveys that have large enough samples of older people within them, and many surveys, most surveys, do not have large enough samples of older people within them, hence the specialist nature of the English Longitudinal Study of Ageing.

There are variations in circumstances across the different four nations of the UK, of course there are, including in relation to health. The points I’m making in this report are really about the level of inequality. So it’s not about the absolute level, it’s about the level of inequality. There is no evidence to suggest that the nature of inequality varies across the four nations.

I take some reassurance in making that claim, drawing that opinion, because there are a range of international studies that I can look to, to examine inequality in later life, and find that across a variety of national contexts very similar conclusions can be drawn to those that I draw here.

Counsel Inquiry: Thank you.

Perhaps we can just go over the page and zoom in on paragraph 9 to finish off this point. When you say in your report is, despite the imbalance in data, if we can put it that way, you say:

“… in [your] considered opinion it is very unlikely that there will be meaningful differences across the nations of the UK in relation to the issues discussed in this report, and that the … conclusions [you draw] are relevant for [all those four] nation[s] …”

Professor James Nazroo: That is my opinion, and in some places I do draw on evidence from other nations as well.

Counsel Inquiry: Yes, thank you.

I want to move on, then, Professor, and talk about the first of the topics that you address in your report, and that is the question of the vulnerability of older people to a pandemic caused by a respiratory virus.

You say, perhaps we can go over to the next page, at paragraph 10 of your report, that it is well documented that older people have increased vulnerability to a respiratory virus such as flu, which would of course have been the obvious benchmark if we are thinking of the position as at 2020 before the pandemic; is that fair?

Professor James Nazroo: Yes, exactly, and flu is the archetypal pandemic virus.

Counsel Inquiry: You refer, for example, to the well-known fact that older people are encouraged to have a flu jab?

Professor James Nazroo: Indeed.

Counsel Inquiry: Just before we move on, can you perhaps make it clear, the vulnerability that you’re talking about of older people to these types of respiratory diseases, is it a vulnerability to catching the disease or to experiencing severe symptoms and complications having caught it?

Professor James Nazroo: It’s to experiencing severe complications, illness, mortality, having caught it.

Counsel Inquiry: You explain, and I’m looking at paragraph 14 now, that there are three factors, albeit that they work in combination, to explain why it is that older people have this increased vulnerability to a respiratory virus or to experiencing severe symptoms of such a virus.

I’ll list them and then perhaps we can talk briefly about each of them in turn.

First of all, a greater prevalence of chronic illness amongst that group. Secondly, reduced immunity. And thirdly, the term “frailty”.

So can I ask you first of all just to expand a little on the point about greater prevalence of chronic illness, or I think as it’s sometimes referred to comorbidity?

Professor James Nazroo: Yes, so I think it’s very thoroughly established that the risk of illness is higher amongst older people, the risk of diagnosed disease is higher amongst older people, and the risk of chronic disease is higher among older people. And alongside that, as you indicated, there is a greater risk of having more than one disease.

Counsel Inquiry: That’s the first component, then. What about “reduced immunity”, what do you mean by that term?

Professor James Nazroo: So this is a consequence of biological ageing where the immune system performs less effectively and consequently people have reduced immunity and therefore are less able to combat an infection.

Counsel Inquiry: Then frailty, and that’s a word of course we’re all familiar with, but I think you use it as something of a term of art here?

Professor James Nazroo: Yes, so “frailty” within gerontology has a set of specific definitions. Here I refer to one in particular, produced by Ken Rockwood, who is an eminent gerontologist in Canada, and it basically talks about decline in biological systems across the spectrum, so physical, psychological and cognitive. And involves – like multimorbidity, involves many things occurring together and reduces vulnerability to subsequent adverse events.

Counsel Inquiry: Thank you.

So those factors, then, are the building blocks, if you like, the overlapping causes of this well known vulnerability of older people to catching respiratory viruses like flu or, as we shall see, Covid.

You go on to refer to the fact, and I’m now looking at paragraphs 17 and 18 of your report, that precisely that vulnerability which was known to exist in relation to flu demonstrated itself equally applicable to Covid within a fairly short period of the pandemic commencing.

Professor James Nazroo: Indeed, as soon as we had data from China, which was reasonably early in February, mid-February maybe, we saw very clearly that the risk of infection was not age-related, amongst the adult population, but the risk of mortality was very strongly age-related.

Counsel Inquiry: We see in paragraph 18 of your report the type of statistic that Mr Keith referred to in his opening a couple of days ago, ONS figures between March 2020 and June 2023: that of the deaths classified as being due to Covid-19, 59.6% of them occurred in the age group of 80 and over, 22.4% the cohort between 70 and 79, at 10.6% 60 to 69, and 6.6% in the age group 40 to 59, with less than 1% of those deaths occurring for people younger than 40.

Professor James Nazroo: Indeed.

Counsel Inquiry: Quite striking statistics.

Let’s move, then, if we may, to the second of the topics in your report, and this, as we said, we move from the general issues relating to the whole cohort of people of a certain age to vulnerable groups within that cohort.

You describe it as the patterning of inequality within the older population in your report.

Professor James Nazroo: Yes.

Counsel Inquiry: You refer in this section of your report to two segments of the older population that suffered greater ethnic inequality than others, first of all economically disadvantaged; yes?

Professor James Nazroo: Yes.

Counsel Inquiry: Secondly, older people from ethnic minorities?

Professor James Nazroo: Yes.

Counsel Inquiry: The issue that you are exploring in this part of your report is whether there were data available and research available in 2020 to suggest that those groups might be at greater risk to a pandemic –

Professor James Nazroo: Yes.

Counsel Inquiry: – such as occurred?

Professor James Nazroo: Yes.

Counsel Inquiry: I’ll start and in fact spend more time asking you questions about the first of those categories, the socioeconomic inequalities. Of course you have already touched this morning with Mr Keith on ethnicity. I’ll come back to it but more briefly.

Professor James Nazroo: Yes.

Counsel Inquiry: So as far as the economically disadvantaged cohort is concerned, you make the point, I’m looking at paragraphs 20 and 21 of your report, that in the period up to 2020 broadly speaking socioeconomic inequality amongst older people was marked, and in fact was growing; is that a fair summary?

Professor James Nazroo: That’s correct, yeah.

Counsel Inquiry: Then looking at paragraph 22, and perhaps we can bring this up on screen, you say:

“Socioeconomic position is strongly related to health, even in older ages, and consequently socioeconomic position is related to risk of complications and mortality in the context of a pandemic.”

Professor James Nazroo: Yes.

Counsel Inquiry: Can you perhaps expand on that a little?

Professor James Nazroo: Yes. So if you look at the patterning of health within the older population you see it’s strong correlated to markers of socioeconomic position such as wealth and education and so on, and as a consequence poorer older people are more likely to have the underlying diseases, comorbidities, that then lead to greater risk of death in the context of a pandemic.

Counsel Inquiry: Perhaps even, thinking of those other factors, lower immunity?

Professor James Nazroo: Indeed.

Counsel Inquiry: More frailty?

Professor James Nazroo: Yeah, indeed.

Counsel Inquiry: You have provided us with a graph which is actually on the next page of the report and I wonder if we can bring that up.

Tell me if I’m wrong, Professor, but I think the two graphs, first of all, they reflect women on the left-hand side and men on the right-hand side, you describe this in your report; is that right?

Professor James Nazroo: Yes, apologies, I should have put that on the graph.

Counsel Inquiry: Don’t worry. What they show, each of them, they represent a period of ageing between, you’ve got it in months at the bottom there, but it’s actually between the ages of 50 and 56?

Professor James Nazroo: No, no, so it’s people who are aged 50 and over and it’s a process of observing them over a six-year period, so over 72 months, sorry.

Counsel Inquiry: Yes, but would that not – if they started at 50, would that not be between –

Professor James Nazroo: Yes, but some of them are older than 50, so it’s 50 and older.

Counsel Inquiry: I see, all right.

But what we see, then – I mean, let’s look at the women, the graph on the left, first. Over though 72-month, six-year period, what we are seeing is essentially how many of them survive?

Professor James Nazroo: Yes, correct.

Counsel Inquiry: The different colour lines reflect the different quartiles of socioeconomic advantage, wealth?

Professor James Nazroo: The different quintiles of wealth, yes.

Counsel Inquiry: Sorry. The high level point to be made, if we’re looking at the left-hand table, is that we see the dark blue line, so that is the bottom, the poorest quintile, far more of those people die than the highest quintile, the green line at the top?

Professor James Nazroo: That is correct.

Counsel Inquiry: So what we see is that over those 72 months, the least affluent, only 84% of the cohort survive, whereas with the most affluent it’s 96?

Professor James Nazroo: That is correct.

Counsel Inquiry: So a marked difference over that six-year period?

Professor James Nazroo: Indeed.

Counsel Inquiry: And the right-hand table reflects the experiences of men, otherwise it’s the same?

Professor James Nazroo: The same pattern but –

Counsel Inquiry: The –

Professor James Nazroo: – different because of differences in mortality risk for men and women.

Counsel Inquiry: Yes, so rather more of the men die, that’s 80 – sorry, 93% for the most advantaged and 80% for the poorest quintile?

Professor James Nazroo: Yes.

Counsel Inquiry: But a similar pattern nonetheless?

Professor James Nazroo: Yeah.

Counsel Inquiry: Is that then a reflection of what you were saying about a very marked relationship between affluence or economic advantage on the one hand and health outcomes and ultimately mortality on the other?

Professor James Nazroo: Indeed, this is a high-level summary of that relationship.

Counsel Inquiry: Just before we take that down, I think it’s actually on the previous page, but these were statistics I think that appeared in a report that you yourself wrote?

Professor James Nazroo: Indeed, using data from the English Longitudinal Study of Ageing.

Counsel Inquiry: Yes. So just remind us of the date of that study, or roughly the date.

Professor James Nazroo: I think these were published probably 2012, I’m not 100% certain.

Counsel Inquiry: No, well, we don’t need to worry about the exact date. The point I’m after is that this was data that was available in 2020?

Professor James Nazroo: Indeed.

Counsel Inquiry: I’m sure there was lots of data addressing issues like this or closely related issues; is that fair?

Professor James Nazroo: Indeed, there were a number of papers, reports and policy documents reporting this kind of evidence.

Counsel Inquiry: So is this, are these tables, these graphs that you’ve produced, reflective of what the mainstream data was showing –

Professor James Nazroo: They are.

Counsel Inquiry: – in the period prior to the pandemic?

Professor James Nazroo: They are.

Counsel Inquiry: Then towards the end of your report, you refer – we don’t need to go to it – to early SAGE meetings that took place in the very first weeks of 2020 and discussion there about trying to identify who might be the sections of society who were most vulnerable to a pandemic such as was at that stage developing, and looking at those graphs, is your view that that would have been relevant to answering that question?

Professor James Nazroo: I think it would have been relevant to answering that question. My report refers to my reading of minutes of those early meetings. I don’t know the full extent of how these issues were discussed in the SAGE committee of course.

Counsel Inquiry: Yes, I’m not trying to – perhaps I can make myself clearer. I’m certainly not trying to ask you to put yourself into the minds of those at SAGE and I’m not even asking really for you to comment on what SAGE did or didn’t do. It’s simply to address that very high-level question. If one was asking oneself from a position of knowledge and expertise at the outset of the pandemic “Who do we need to look out for?” would these graphs have given you part of the answer to that?

Professor James Nazroo: So this was not only – this kind of evidence was not only publicly available, it actually was present in government departments and very widely circulated.

Counsel Inquiry: Thank you.

I mentioned a few minutes ago that there were two segments or particularly vulnerable segments of society that I was going to ask you about. One was the socioeconomic disadvantage, which we’ve covered. The other was older people within ethnic minorities. As I said, this is an issue that you have already touched on with Mr Keith this morning, but can we go, please, it’s paragraph – if we can go to figure 4 in your report, which is just above paragraph 31. That’s it. If we could zoom in on that graph, please.

Now, Professor, this is a graph that you looked at with Mr Keith this morning, isn’t it?

Professor James Nazroo: Yes.

Counsel Inquiry: You have included it in your Later Life report because of its relevance to that as well as to ethnicity, intersectionality?

Professor James Nazroo: Indeed.

Counsel Inquiry: For our purposes, we are interested in the sort of right-hand corner of this graph, are we not?

Professor James Nazroo: Indeed.

Counsel Inquiry: Because that’s the sort of end of this table which informs us about, on the face of it at any rate, disparity in health outcomes or self-reported health towards the end of people’s lives?

Professor James Nazroo: Indeed.

Counsel Inquiry: As we saw this morning, the disparities widen generally as the age of the individuals increases?

Professor James Nazroo: They do.

Counsel Inquiry: So by the end of the – by the far right-hand side of the table, one sees some quite marked differences, with the Bangladeshi, Pakistani and black Caribbean cohorts really quite distinct from some of the others, including the white British?

Professor James Nazroo: Yes.

Counsel Inquiry: Now, on its face, and this is the point you make in your report, does that type of information also feed into the question of who might be vulnerable to a pandemic such as Covid?

Professor James Nazroo: It does. Just to divert very slightly to illustrate the point, I’d encourage you to look at the line that cuts across at 20% on the chart, the orange line, and see where the different ethnic minority groups cross that line, and that’s the age at which 20% of them report having not good health, and you can see that it’s much younger for some groups than for other groups, and that gives you a sense of how health vulnerability happens at a younger age for some ethnic minority groups than for white British groups.

Counsel Inquiry: Going back to my question, I was asking you the hypothetical or the high-level question about those people within society who might have been identified at an early stage as those who were vulnerable, particularly vulnerable, to Covid. We talked about the less affluent groups. On its face, and I’m going to come to ask you whether we need to qualify it or not, but on its face does this graph tell us something separate about those who might have been identified as being at risk from Covid?

Professor James Nazroo: Yes, apologies, I didn’t answer that correctly, but, yes, that’s what this graph tells us, that there are certain ethnic minority groups that were particularly vulnerable or appear to be particularly vulnerable to Covid.

Counsel Inquiry: As you explained this morning, we can see that these figures are drawn from the results of the 2011 census?

Professor James Nazroo: Yes.

Counsel Inquiry: And no doubt it takes a while for all of that information to feed through into the research. But similarly to the questions I was asking you about your own socioeconomic data, are you able to help us whether this type of table shows the general understanding amongst the academic community of these types of issues as at 2020?

Professor James Nazroo: It does. These analyses are not unique, there have been earlier analyses that have a very, very similar pattern. Using data that are earlier, of course. So these are the most recent available, but …

Counsel Inquiry: As at 2020?

Professor James Nazroo: Yeah.

Counsel Inquiry: But we then have to ask ourselves the question that you were addressing with Mr Keith, because we know that since the pandemic the ONS have produced further data, backward-looking data, which relates to this pre-pandemic period –

Professor James Nazroo: Yes.

Counsel Inquiry: – which gives different results. That data relates not to morbidity, which is a subject of this graph, but mortality. But in fact do those later figures at least cast doubt on the accuracy of the lines we see on this page?

Professor James Nazroo: The mortality data published as experimental statistics by the Office for National Statistics show the opposite pattern to these data. So in those data, white British people at older ages have a shorter life expectancy than ethnic minority people at older ages.

Counsel Inquiry: So, on the basis of that data, one would identify different groups of society as being at particular risk of a pandemic?

Professor James Nazroo: If those data were available prior to the pandemic, those analyses were available prior to the pandemic, and I would also qualify and say if those data had also received the approval as a national statistic, then they would suggest that the white British group were most at risk.

Counsel Inquiry: You had a debate with Mr Keith this morning about the reliability of that ONS data. I don’t want to go back over that territory, but maybe I can simply ask you this: do the same considerations then that you expressed this morning apply to this question of the reliability of this data as compared with the ONS data?

Professor James Nazroo: They do. The estimations of life expectancy for ethnic minority people at older ages according to the ONS analyses are, in my view, not credible.

Lady Hallett: Do we not also have a problem – sorry to interrupt, Mr O’Connor.

The graph that you showed us first, that’s based on self-reporting. That’s got problems too, hasn’t it?

Professor James Nazroo: Yes, so the graph that we have in front of us, figure 4, is self-reported health. As I described earlier, there is now a considerable body of evidence that shows that self-reported health does predict mortality. There does not appear to be a variation in that across different ethnic groups, even though of course it is a self-report. And I haven’t included it in this report, but I have similar graphs from other data periods which show something similar for things like diagnosed diabetes.

Lady Hallett: Thank you.

Mr O’Connor: Thank you.

Professor, I’m going to move on, and turn to another section of society again, one of those which I mentioned at the outset, one of those I mentioned as being vulnerable, which is older people living in care homes.

I’m now looking at topic 3 in your report, and in the broadest of terms – and we’ll look at this in a little more detail – I think the headline points that you’re making are that those in care homes or residential care were at an elevated risk of respiratory diseases essentially for two reasons: one, because they were very likely already to have some form of chronic illness, that’s why they’re there; and secondly, the environmental considerations associated with care homes, the proximity of other people, the risks from the staff and so on.

So is that a fair summary of the very bald aspects of that type of vulnerability?

Professor James Nazroo: That is a fair summary: increased risk of infection because of the environment in which they were living, and, once having an infection, increased risk of serious illness and mortality.

Counsel Inquiry: You have drawn our attention to an article in a learned scientific journal which addressed exactly these points, going back to 2017, which therefore perhaps is a useful benchmark to see how these risks were understood by the scientific community prior to the pandemic.

Professor James Nazroo: Yes.

Counsel Inquiry: It’s been helpfully brought up on the screen. First of all, the title “Influenza in long-term care facilities”; yes?

Professor James Nazroo: Yes.

Counsel Inquiry: The date, we can see right at the top, I mean, the exact date doesn’t matter, but it’s June 2017. Do you see that?

Professor James Nazroo: Yes.

Counsel Inquiry: Can you help us, I couldn’t actually find it on this sheet, what was the name of the journal that it appeared in? Or perhaps you can’t help us with that?

Professor James Nazroo: I can. I’m just looking it up, apologies. It’s called “Influenza and other respiratory viruses”.

Counsel Inquiry: I see. In fact we do see that. If anyone’s interested it’s at the bottom right-hand corner of this page.

Professor James Nazroo: Yeah.

Counsel Inquiry: Do you see it?

Professor James Nazroo: Yes.

Counsel Inquiry: So I hadn’t appreciated, that’s actually the name of the journal itself, is it?

Professor James Nazroo: Yes.

Counsel Inquiry: Thank you.

We can see the rest of the page now, because the next point to note about this article is who wrote it. Could we zoom out, please, and look at the top again. Yes. So we see three names listed along the top: Louise Lansbury, Caroline Brown and Jonathan Van-Tam. Perhaps it’s the third of those names which draws the eye: Professor Van-Tam as he was then, is now. I think I’m right in saying that at the time that this article was published, that’s June 2017, he was a professor of public health at Nottingham University, he hadn’t yet been appointed to the role that we will become familiar with him in, as the Deputy Chief Medical Officer; he was appointed to that role later in 2017, I think.

Professor James Nazroo: Yes.

Counsel Inquiry: With that in mind, what I want to do is just look at a few passages of this report and then ask you some questions about it.

Could we start, please, by just zooming in on the bottom right-hand corner where it says “The impact of influenza”. So we see the article says:

“Persons residing in LTCFs [long-term care facilities] present a population very susceptible to the acquisition and spread of infectious diseases and for whom the consequences of infection may be serious. Nursing home residents are at greatest risk due to their overall frailty, close quarter living arrangements, shared caregivers, and opportunities for introduction of healthcare associated infections and the spread of pathogens to other facilities through resident transfers and the movement of staff and visitors in and out of the home.”

I’m not sure we’ve got – yes, sorry, we have got the right part:

“Outbreaks of influenza caused by both influenza A and B viruses are well documented in LTCFs, and may be explosive, with high mortality, highlighting the need for early recognition and prompt initiation of control measures.”

Then two other passages, if I may. If we can go over to the next full page, and it’s the left-hand column starting at “Transmission”, about halfway down:

“Transmission of influenza from healthcare workers … to hospital patients, including those in geriatric facilities, has been well documented using epidemiological linkage, nucleotide sequence analysis and contact tracking data and case reports of outbreaks of influenza-like illness in care facilities indicate that staff can transmit the virus to residents.”

There is then a passage which goes into some detail about various studies and test reports and so on, but picking it up about eight or nine lines up from the bottom:

“The observed variability …”

That’s in these test results, of healthcare workers.

“… might be explained by [healthcare workers] being at higher risk of asymptomatic or subclinical infection, indicating that [healthcare workers] may act as an infective pool to transmit influenza to frail elderly people.”

Finally, if I can pick it up at the very bottom of that column and going on to the next column:

“Although the role of asymptomatic people and those with only mild symptoms in spreading influenza is uncertain, [healthcare workers] often continue to work despite having symptoms and may act as a source of infection to those in their care. Nursing home aides in particular have been shown in one Swedish study to be the occupational group at significantly greatest risk of continuing to work despite the feeling that, in the light of their perceived state of health, they should have taken sick leave. However, in reality the employment status of many LTCF staff is often precarious and taking unpaid sick leave may result in adverse economic consequences.”

One might think – thank you very much – Professor, that in that article in 2017 Professor Van-Tam was flagging certain risks, risks that in fact, as we shall hear, transpired with terrible results, very clearly?

Professor James Nazroo: I think the paper flagged those risks very clearly, yes.

Counsel Inquiry: First of all, he was flagging the basic vulnerability of nursing and care home occupants to a flu-like virus on account of their own frailty and their close living arrangements?

Professor James Nazroo: Yes.

Counsel Inquiry: He was also flagging the risk that healthcare staff might themselves transmit the disease –

Professor James Nazroo: Yes.

Counsel Inquiry: – firstly by moving themselves between different care facilities, secondly the risk in asymptomatic transmission –

Professor James Nazroo: Yes.

Counsel Inquiry: – by healthcare workers. Why is that of interest?

Professor James Nazroo: Because even though you are asymptomatic you could still carry infection and therefore can pass the infection on to other people.

Counsel Inquiry: And so –

Professor James Nazroo: If you’re in intimate contact with someone, caring for them, then that risk of transmission is very high.

Counsel Inquiry: The risk then, as with any asymptomatic transmission, is that the people who are doing the transmitting don’t even realise that they have the virus, there’s no reason for them to shield or to isolate, and therefore the risk of them spreading it is that much worse?

Professor James Nazroo: That’s correct.

Counsel Inquiry: Then also flagged is what’s described in the report as the precarious nature of healthcare workers’ employment, which in fact leads to the risk that even if they do know that they’re ill they might still carry on working. They don’t want to take sick leave, they’re worried about whether they’re going to keep their job; is that fair?

Professor James Nazroo: They’re worried about income in the context of having to take sick leave.

Counsel Inquiry: Finally, and perhaps bringing it all together, these risks generate risks of outbreaks of infectious disease in nursing homes, in care homes, that can be, to use the words of the report, explosive and involve high mortality?

Professor James Nazroo: They carry the risk of high mortality, indeed.

Counsel Inquiry: The word in the report was “explosive”; is that a word you’re not comfortable with?

Professor James Nazroo: I probably would not choose to use such an emotive word, but certainly a high risk of mortality.

Counsel Inquiry: One wonders, one doesn’t know, of course, but one wonders what the authors of the report meant by that word. Might they have meant that those – if you like, it’s a sort of tinder box, the coming together of frail people, living in close proximity to each other, and these transient workers who may have an asymptomatic virus and who may not be inclined to isolate even if they know they are ill, a risk of a sudden and extreme outbreak, would that be one way of understanding the word explosive perhaps?

Professor James Nazroo: So I initially qualified my response by saying I’m not an infectious diseases epidemiologist, but the example would be that one person becomes infected within the care home and, without adequate protections within the care home, then the illness will spread rapidly.

Counsel Inquiry: Yes.

Then finally with this document, could we have to the seventh page of it, please. It’s the paragraph headed “Conclusion” but the last few lines of it, we see about four or five lines up from the bottom, the sentence starting at the end of one of the lines:

“The prevention and control of influenza in LTCFs requires a multifaceted approach; vaccination and antiviral policies form an important part of this, but strong managerial leadership, outbreak planning, and a well-trained, educated and engaged workforce are pivotal to the successful implementation of IPC policies.”

IPC, infection …

Professor James Nazroo: Infection prevention control, I believe.

Counsel Inquiry: That’s right. Again, it would seem in this article to be rather prophetic as to what was needed in 2020; is that fair?

Professor James Nazroo: Indeed.

Counsel Inquiry: So just finally then before we leave this part of it, for the reasons really summarised in that article, that segment of the older population who were resident in nursing homes, in care homes, and in fact in your report you say similar considerations would apply to those who were in hospital awaiting discharge, were they another identifiable vulnerable group who were vulnerable, particularly vulnerable, to experiencing serious symptoms from Covid?

Professor James Nazroo: So my opinion is that the profile of the people who were medically fit, awaiting discharge, was very similar, is very similar to those who are in care homes, they’re awaiting discharge into care homes or into their own homes if appropriate packages can be put in place, which means they have a similar level of morbidity, frailty and so on, and then in addition because they are in hospital they are at a heightened risk of infection.

Counsel Inquiry: Thank you.

Finally, one more topic to address with you, Professor, and that is the risk of adverse outcomes resulting from non-pharmaceutical interventions during the pandemic, and how that relates to these inequality issues that we have been addressing together.

I’m now looking at paragraphs 46 and following of your report, and perhaps it’s worth me saying that, as with previous sections of your report, this is focused very much on the research that was available in 2020.

We will be hearing, my Lady, later this afternoon from a witness from Age UK who will tell us more about the impact that was in fact experienced by older people as a result of NPIs.

But at the moment I’m going to ask you questions, as I say, about what was known, what data, what research was available before the pandemic started.

But in summary, is it fair to say, Professor, that the evidence, the research that was available indicated that older people would suffer more than most from, for example, a lockdown, first of all because, because of the greater vulnerability, they would be more likely to have to isolate themselves, and that they would be more affected once they were isolating; is that a fair summary?

Professor James Nazroo: That’s a fair summary of the on-average situation amongst older people.

Counsel Inquiry: Focusing a little on various areas. First of all, the question of social exclusion. You refer in your report to the risk of social exclusion being higher for particular groups of older people. Can you expand on that a little?

Professor James Nazroo: Yes. So I offer a brief summary of what social exclusion might be, but in effect it means poor access to services, facilities, community and so on, and the evidence suggests that people who are poorer or people who are living in more deprived areas are more likely to not only be socially excluded at a particular point in time but over time they are more likely to move into social exclusion than richer people, and much less likely to move out of social exclusion if they’re already in it.

Counsel Inquiry: And those considerations are clearly of great relevance to the question of lockdown and how older people would fare in that situation?

Professor James Nazroo: Yes, absolutely.

Counsel Inquiry: I want to move to the question of digital exclusion.

Lady Hallett: I don’t know how much longer you have to go. We do have, I think, about 15 minutes of other questions.

Mr O’Connor: Yes. I probably only have another two or three minutes with the Professor, and perhaps if I finish with him and then we have a break before my learned friends can go to their questions.

Lady Hallett: Of course.

Mr O’Connor: It’s in fact – well, I’ve got two more topics. The first of those is digital exclusion, Professor, and I’m now looking at paragraph 56 of your report.

You say:

“Also relevant to social and psychological wellbeing, social distancing and lockdown measures have a particularly negative impact on those who do not have access to digital devices and high quality broadband, because they can be used to maintain connections …”

And so on.

I think it’s fair to say that not just maintaining connections with family but, in a distancing situation, necessary for much more than that?

Professor James Nazroo: Indeed, for connections with community networks and connections with services, amenities and so on.

Counsel Inquiry: At paragraph 57 of your report you indicate that in the years prior to 2020 there had been a lot of progress, if one wants to call it progress, in moving many of the sort of essential services online?

Professor James Nazroo: Yes.

Counsel Inquiry: Then if we can look at paragraph 58, please, you say this:

“However, older people are more likely not to be using the internet.”

Then you have produced this data from 2020, an estimate that 13% of adults in the UK do not use the internet, so that’s a global figure, but then if one breaks it down, you say there is a sharp age gradient, so it’s 17% of – and these are figures of people who are not using the internet – 17% in the bracket 55 to 64, 30% in the bracket 65 to 74, and 51% for those aged 75 and older.

You say an ONS survey also from 2020 found that nearly 40% of those aged 75 and older had never used the internet, and Age UK report that many of those who had used the internet no longer do so.

Professor James Nazroo: Yes.

Counsel Inquiry: So 13% of the adult population but, as you say, a very sharp gradient when one gets to the older cohorts –

Professor James Nazroo: Yes.

Counsel Inquiry: – of people who don’t use the internet.

You then go on to, as it were, focus more precisely. You say at paragraph 60 in effect that the wealthier elderly, and I take it you mean of all of those cohorts, are more likely than the poorer elderly to use the internet?

Professor James Nazroo: Yes.

Counsel Inquiry: So this digital exclusion is something, therefore, that’s more keenly felt by the poorer elderly cohorts?

Professor James Nazroo: Yes.

Counsel Inquiry: You also indicate or suggest that poor health also shapes the trajectory of internet use?

Professor James Nazroo: That’s correct.

Counsel Inquiry: So in summary, are you saying that these sort of intersections, older, poorer and those with ill health, putting those all together, are the least likely to have or to be able to use, to be familiar with the internet?

Professor James Nazroo: Yeah. So socioeconomic position and health are related, as I described, as we discussed earlier, but over and above socioeconomic inequality, deteriorating health leads to less use of the internet.

Counsel Inquiry: That was the data that was available in 2020, and of course one might think that, if you like, those people you’re describing who are least likely to use the internet might have been amongst those who would most need it once the pandemic started?

Professor James Nazroo: That’s certainly possible. And the data were available before 2020, so much of this work was done before 2020.

Counsel Inquiry: Just finally on this, are you able to help us – this is not something that’s covered in your report, and you may not be able to help us, but are you able to help us whether there was yet another variation in the sense of whether older women were more digitally excluded than older men?

Professor James Nazroo: Older women are more digitally excluded than older men.

Counsel Inquiry: Was that something that was there on the research prior to the pandemic?

Professor James Nazroo: Indeed, it was available prior to the pandemic.

Counsel Inquiry: Thank you.

The last subject then, again, which is something that is not covered in your report, is the question of domestic abuse.

Was there in 2020 evidence showing any particular patterning or risks of domestic abuse within the older population?

Professor James Nazroo: So domestic abuse I think we need to define broadly, need to think about physical abuse, sexual abuse, psychological abuse, neglect and financial abuse I think are the main dimensions that are studied when people study domestic abuse of older people.

The evidence is intermittent. There was a large study done 2006/7, something around then, on domestic abuse amongst older people, that was a large representative study, which – I can’t remember the exact number, but something like 2% or 3% of older people reported experiencing abuse.

I think we have to put that estimate in the context of how easy it is to tell someone that you’re being abused, particularly when various dimensions of elder abuse are seen as normal, routine and so on. But nevertheless, a significant proportion.

In relation to your earlier question about gender, it seems that most of the elder abuse is conducted by partners. Well, maybe not most, but at least half of elder abuse is conducted by partners.

Mr O’Connor: Thank you.

My Lady, those are all the questions that I had.

Lady Hallett: Thank you, Mr O’Connor.

Are you all right?

Professor James Nazroo: I am indeed.

Lady Hallett: Thank you very much. I shall return at 25 to. Thank you.

(3.20 pm)

(A short break)

(3.35 pm)

Lady Hallett: Mr O’Connor.

Mr O’Connor: My Lady, as I said, I have finished my questioning of Professor Nazroo, but there were two representatives, Mr Thomas from FEHMO, and Ms Gowman from Covid Bereaved Families for Justice Cymru, who you had indicated you might be prepared to grant permission to ask questions of this witness.

Lady Hallett: Yes, I do grant permission.

Mr Thomas.

Questions From Professor Thomas KC

Professor Thomas: Thank you, Professor, I’ve only got one question for you, and it’s this: in your report you note, firstly, the complexity of the age and ethnicity intersecting; secondly, in particular heightened vulnerabilities of older ethnic minority people, notably the early onset of age-related illnesses compared with the white British group; thirdly, the significant presence of ethnic minority workers in the social care sector; and fourthly, the missed opportunities in treating older people as a monolithic group.

Here’s the question: given the above, can you share with us what your views are on the appropriateness of inviting older and/or retired health and social care workers from ethnic minority communities to return to active service during the pandemic?

Professor James Nazroo: I’ll speak into the microphone, sorry. I presume that’s appropriate, rather than …

Okay, so this is an important question, I think. I think it’s right to summarise my evidence as suggesting that older ethnic minority people are particularly vulnerable, and this will apply of course to former as well as current healthcare workers.

So for me the question then would be what kind of risk assessments should you put in place if you were asking those people to return to the frontline in the context of the need for additional labour. So the risk assessments would be crucial here.

Lady Hallett: Thank you, Mr Thomas.

Now, you’re going to have the same problem I have in seeing the next questioner.

Ms Gowman, there you are, I can see you.

The Witness: I can.

Questions From Ms Gowman

Ms Gowman: Professor Nazroo, I represent Covid Bereaved Families for Justice Cymru. I’m going to ask you questions on four topics, time permitting.

The first topic is the use of blanket policies and tools in healthcare. My Lady has granted permission for the Cymru group to ask a set of reformulated questions on this topic, having liaised with Covid Bereaved Families for Justice UK and Northern Ireland, and it is on behalf of all three groups that I ask questions on this topic.

At paragraph 77 of your report, you say that many hospitals used some form of triage to restrict intensive care for those aged 60 and over, modelled on a disseminated but not implemented NHS Covid-19 decision support tool.

It’s right, isn’t it, that the decision support tool was a points-based system, using a combination of four constituent scores across the domains of age, gender, level of frailty and medical conditions, that then subsequently recommended patients into particular treatment pathways?

Professor James Nazroo: That’s correct, though, as you said, this decision support tool was never implemented.

Ms Gowman: Yes.

Professor James Nazroo: Though it may have influenced decision-making.

Ms Gowman: When assessing levels of frailty, the clinical frailty score, also known as the Rockwood frailty score, is also used as a prognostic indicator; is that right?

Professor James Nazroo: That’s correct.

Ms Gowman: Do you agree that the blanket use of the decision support tool and the clinical frailty score, insofar as they were used, and other similar tools, are potentially discriminately, and if so why?

Professor James Nazroo: They are discriminatory, in my view, so long as they restrict entry into care. My opinion is that they are useful tools for identifying those who need care, rather than the opposite.

Ms Gowman: Yes.

Insofar as the scoring systems are concerned, could they be used to impact on the prioritisation of treatment, and in turn mortality rates?

Professor James Nazroo: So my opinion is that they could be used to encourage treatment of people who are particularly vulnerable rather than to discourage the treatment of people who are particularly vulnerable. So my view is that the use of something like an age threshold or a frailty threshold or a multimorbidity threshold to identify people who need treatment is appropriate to identify those as people who are not worth treating, I think is the wrong use of such tools.

Ms Gowman: So they should be used to identify effectively the most vulnerable and deserving of treatment as opposed to eliminate treatment being given to those vulnerable individuals; is that fair?

Professor James Nazroo: The people who most need treatment.

Ms Gowman: Yes. And it’s also correct that there has been a long-standing concern about poor practices regarding the blanket use of Do Not Attempt Resuscitation notices. Is that your understanding?

Professor James Nazroo: Sorry, I’m afraid I haven’t seen detailed evidence of this, so all I can observe is the anecdotal evidence that has appeared in various reporting suggesting that that was the case.

Lady Hallett: Don’t worry, we’re going to deal with it in some detail at some stage. It’s one of those issues that I’m very conscious of.

Ms Gowman: If there is a blanket use of such notices, it follows, doesn’t it, that that would disproportionate affect the older population?

Professor James Nazroo: It would disproportionately affect the older, iller population, yeah.

Ms Gowman: From your perspective, based on the anecdotal evidence, did the pandemic expose and exacerbate issues surrounding the Do Not Attempt Resuscitation process?

Professor James Nazroo: Anecdotal evidence suggests that the Do Not Resuscitate notices were not used, in my view, appropriately. But I haven’t done research in this area, this is my understanding of the anecdotal evidence.

Ms Gowman: Finally on this topic, Professor Nazroo, are you aware of any alternative approaches to clinical decision-making that reduces the risk of discrimination against older and/or disabled people in particular?

Professor James Nazroo: As I’ve tried to identify in my report and in response to your earlier questions, there are clearly groups of older people who are more in need of treatment, of protection against infection and treatment once they receive infection. I think those groups – we had evidence on how to identify those groups prior to the pandemic.

Ms Gowman: Thank you.

The next topic is the vulnerability of older people in care homes and awaiting discharge from hospital, which you’ve already covered to some extent with my learned friend.

At paragraph 89 of your report, you identify, in respect of those living in care homes and medically fit and awaiting discharge, that there was a missed opportunity to implement recommendations of the review paper that we have already referred to. You have been taken to the risks in respect of those residing in long-term care facilities, but I want to ask you about the recommendations that emanated from that article.

It’s right, isn’t it, that the article makes several recommendations in respect of control measures in respect of long-term care facilities?

Professor James Nazroo: That’s correct.

Ms Gowman: If I summarise them in the following way, you can tell me if that represents your understanding: firstly, it recommends routine and pre-outbreak prevention measures comprising of planning, training and education, vaccination of residents and staff.

Secondly, it emphasises the need for early recognition, including by way of testing.

And, thirdly, it makes recommendations for outbreak control measures comprising respiratory etiquette, appropriate use of PPE, isolation of infected residents, and the minimisation of transmission opportunities, closure of care homes to new admissions, limitation of visitors, rostering vaccinated staff to care for residents, and hand hygiene and enhanced environmental cleaning.

Do you agree that those represent a summary of the primary recommendations made in that article?

Professor James Nazroo: I agree. I would add perhaps one more, which was around the staffing of long-term care facilities.

Ms Gowman: To ensure that there was effectively sufficient levels of staffing; is that right?

Professor James Nazroo: To ensure that staffing was sufficiently secure that the risks of precarity in the labour force, working in more than one care home and so on, were minimised.

Ms Gowman: You have already indicated in response to questions by my learned friend in respect of the impact on such patients, but is it right that the recommendations also represented the thrust of scientific thought on control measures at the time?

Professor James Nazroo: Sorry, I missed the: also represent?

Ms Gowman: The thrust of scientific thought?

Professor James Nazroo: They do, yes.

Ms Gowman: So this wasn’t a minority view?

Professor James Nazroo: No, no, this was an important review paper.

Ms Gowman: Can I ask, was the article publicly available?

Professor James Nazroo: Yes.

Ms Gowman: To your knowledge, it may be that you can’t assist with this, were the recommendations ever noted and implemented by any policymakers in advance of or going into the pandemic?

Professor James Nazroo: I cannot answer that question, I don’t know. The impression is that it was not, but that strictly is an impression.

Ms Gowman: So when you cite in your report that there was a missed opportunity –

Professor James Nazroo: Indeed.

Ms Gowman: – is that what you mean, ie –

Professor James Nazroo: Indeed.

Ms Gowman: – a missed opportunity to implement clear recommendations emanating from the article?

Professor James Nazroo: Indeed, and missed opportunity in the sense that this was well established evidence and could have been considered in the early days of the pandemic. I don’t know to what extent it was considered in the early days of the pandemic.

Ms Gowman: But your impression was that it was not?

Professor James Nazroo: My impression is that it was not implemented.

Ms Gowman: The next topic is the fragility of the domiciliary care sector. Within your report you identify that the social care system, in particular the care home sector, was in a fragile state on going into the pandemic. What comment, if any, can you make in respect of vulnerability and fragility of the domiciliary care sector in particular on going into the pandemic?

Professor James Nazroo: So again I have not reviewed the evidence in relation to domiciliary care, but the papers that I have seen suggest that there are very similar issues around underfunding and security of employment, and so on, that mean that there was a substantial risk of domiciliary care failure within the context of a pandemic.

Lady Hallett: Just so people understand, domiciliary means care in the home.

Professor James Nazroo: Indeed.

Ms Gowman: Thank you, my Lady, I was about to ask that follow-up question to clarify.

In terms of the issues that you identify with social care more generally that may have direct applicability to domiciliary care, your report identifies low pay and lack of resilience, carers moving from setting to setting, dependence on private agencies, problems sustaining packages of care and lack of PPE, and I think your evidence is that those issues applied equally to domiciliary care provision?

Professor James Nazroo: I understand that they did.

Ms Gowman: Do you consider that there were missed opportunities by decision-makers in relation to the domiciliary care sector specifically?

Professor James Nazroo: Yes. I think the issues that you have just raised could have been considered at the beginning of the pandemic. The extent to which they were is not clear to me. That they did not lead to action does seem to be the case.

Ms Gowman: And should have been considered?

Professor James Nazroo: Should have been – should have been considered and should, in my opinion, have led to action.

Ms Gowman: The final topic, I think I have time, namely the disparities between the devolved nations. At paragraph 9 of your report, you state that it’s very unlikely there will have been meaningful differences across the nations, and you were taken to this section of your report earlier in your evidence.

The nature of inequalities may be similar across the four nations, but do you agree that the impact and extent of the health inequalities might differ between nations depending on the population make-up?

Professor James Nazroo: So I think the – for me the crucial point is that the level of risk of illness will vary across the four nations. I think that’s very well established, that it varies across the four nations.

Ms Gowman: Yes.

Professor James Nazroo: It also varies within the nations as well geographically. And so in terms of planning, you may well want to consider the absolute level of risk within the nation, but the inequality in risk, which is what I focus on here, I believe did not vary particularly across the four nations.

Ms Gowman: And one final question on –

Lady Hallett: No, I’m afraid not, Ms Gowman. I’m afraid you’re out of time. Apart from anything else, I can’t find that I had given approval for these. Anyway, we’re going to stop there.

Ms Gowman: Certainly.

Thank you, Professor. Thank you, my Lady.

Lady Hallett: Thank you very much indeed, Professor.

Those are all the questions, Mr O’Connor, for –

Mr O’Connor: No, no further questions, I’m very grateful –

Lady Hallett: And thank you for being so patient with us today.

The Witness: No, thank you, my Lady, I appreciate the opportunity to give evidence.

(The witness withdrew)

Lady Hallett: We’ve just got a wait a second, I’m afraid, until it’s all cleaned.

Mr O’Connor: My Lady, just before the witness is sworn, I wonder if I could just invite the witness to sit down for a moment, because I was in fact intending to take one other matter before I invite you to call her, which is the narrative, similar to the narrative that Mr Keith –

Lady Hallett: Of course, yes, absolutely, the summary.

Mr O’Connor: It’s useful for her to be – I’m sorry, I was distracted. But even before I do that, and just while Professor Nazroo’s evidence is fresh in our minds, perhaps just for the record I can make it clear to everyone who’s listening and who may read the transcript that the terms of Professor Nazroo’s instructions did not extend for us either showing him the evidence that has been provided to you about the government response or inviting him to provide any evidence, far less expert evidence, on what should or shouldn’t have been done, but I think in answering questions he made it clear that he was really speaking from his own sort of –

Lady Hallett: Yes, I was getting a little concerned at that stage.

Mr O’Connor: – impression. But to be clear, that wasn’t part of his formal function in either drafting his report or providing his views.

Lady Hallett: I think when you’re talking about expert evidence, we have got to be pretty clear.

Mr O’Connor: Yes.

Summary of questionnaire responses

Mr O’Connor: As I say, I wonder – I’m sorry, it’s going to take a few minutes, but I think it’s – since I’m going to, as Mr Keith did, just summarise the questionnaire responses that we received relating to the issue of later life, I think it would be more sensible to do that before Ms Abrahams gives evidence rather than afterwards, so that we have them in mind when she gives evidence. So I’m just going to read those out. It will take me two or three minutes.

As Mr Keith explained, we sought questionnaire responses from a range of interest groups within the field, in this case of later life, and received very helpful responses. Amongst them were – I’ll start with in fact a passage from Age UK’s questionnaire, which is the organisation we’ll hear that Ms Abrahams is part of, and their response included this passage:

“It should have been apparent from the very beginning that older people would be at the eye of the storm. Age was identified early on as a major risk factor for critical illness and mortality. The risk of living with pre-existing health conditions, disability or care need rises directly in line with age, including the majority of people advised they were clinical or extremely clinical vulnerable. Older people have greater likelihood of social isolation and digital exclusion. Older carers are more likely to be providing intensive informal care and there was a predictably high risk of losing and not regaining mobility, cognitive function, strength and balance or cardiovascular fitness amongst older people. In addition, the experiences of other countries that were ahead of us during the pandemic, such as Italy, demonstrated the vulnerability of older people, especially those living in residential settings.”

Then we have identified two broad themes that were addressed in these questionnaire responses, the first of which was a lack of understanding of the sector by those making decisions.

The National Care Forum stated this:

“One key overarching theme spans our submission, which is the lack of understanding of the care and support sector and those who are supported through it. This lack of understanding can be compared to the absolute primacy given to the NHS in all aspects of the government’s response to the pandemic, which is a far better understood institution for policy and decision-makers.”

Care England said this:

“Decisions were made during the pandemic, particularly within or during the first wave, that protected the NHS with little or no regard for the adult social care sector. Decision-makers did not have a clear and sufficient understanding of the social care sector, lack of central understanding of the diversity of the adult social care sector, particularly for those with learning disabilities and/or autism. Care England members operating within the younger adult sector found themselves having to rewrite guidance as a result of its predominant focus on older people living in residential care homes.”

The second theme is of longer term impacts. Age UK said this:

“Research suggests that older people who previously did not need support to maintain their independence are now requiring care and support for the first time, and much earlier than would otherwise have been the case. Those who were already struggling to carry out activities of daily living such as walking, eating, showering and getting dressed, are now finding things harder. The significant drop in activity levels amongst over 50s, and only a third of people aged 75 and over have been active during the pandemic, this has impacted on older people’s mobility, strength and balance and left them at greater risk of frailty and falls. The Carers UK survey in 2021 said that 72% of unpaid carers had not had a break since the pandemic began. The 2021 census shows the number of unpaid carers providing over 20 hours of care per week increased by 260,050 hours by 152,000. The more care provided, the more likely it is that someone will have to give up work to care, the more likely they are to have ill health, increased loneliness and isolation as well as financial hardship.”

Then, finally, Homecare Association Wales stated that:

“Recovery did not end in spring 2022. Workforce wellbeing continues to be important. The Welsh Government began discussions about recovery in 2020 and produced a Covid-19 recovery framework in July 2021. However, the guidance [they say] for social care only really reached a new normal during the spring 2023 when testing was finally stepped down.”

My Lady, those are the summary of the questionnaire responses, and may I now invite you to call Ms Abrahams. Thank you.

Lady Hallett: Thank you for being patient.