3. Professor Sir Horby
PROFESSOR SIR PETER HORBY (affirmed).
Questions From Lead Counsel to the Inquiry
Mr Keith: Good afternoon. Could you give the Inquiry your full name, please.
Professor Sir Horby: Good afternoon. My full name is Peter William Horby.
Lead Inquiry: Professor, thank you for the provision of your witness statement, and for attending today to give evidence. I’m sorry you have been kept waiting a little.
You are a professor of emerging infectious diseases and global health at the Centre for Tropical Medicine and Global Health at the University of Oxford; is that correct?
Professor Sir Horby: It was correct. I’m now the director of the Pandemic Sciences Institute, which is a slightly different organisational structure within the university.
Lead Inquiry: You are still a professor of emerging infectious diseases and global health –
Professor Sir Horby: Correct, yes.
Lead Inquiry: – and you specialise in emerging and epidemic infectious diseases?
Professor Sir Horby: I do.
Lead Inquiry: On account of one of the lessons and the pieces of learning that you include in your statement, I want to ask you about some of the other no less important roles that you have. Are you also the executive director of ISARIC, the International Severe Acute Respiratory and emerging Infection Consortium? Are you also or were you also the co-chief investigator of the RECOVERY Trial, which was – is the randomised evaluation of Covid-19 therapy trial?
Professor Sir Horby: Yes, I am.
Lead Inquiry: You were also from 2018, significantly, chair of the NERVTAG committee, and I think that as chair of the NERVTAG committee you attended 75 meetings of NERVTAG, all the meetings between January 2020 and June 2021?
Professor Sir Horby: Well, NERVTAG nerve convened 75 meetings. I’m not sure I was in attendance at all of them, it would have been the vast majority.
Lead Inquiry: We’ll excuse you those last few that you may not have attended, Professor.
As chair of NERVTAG, did you also attend SAGE and, in that role, your statement shows that you attended 89 of 105 SAGE Covid-19 meetings?
Professor Sir Horby: That’s correct.
Lead Inquiry: I want to commence your examination, please, about asking you some questions about the Centre for Tropical Medicine and Global Health at Oxford. It’s part of the Nuffield department of medicine, is it not?
Professor Sir Horby: That’s correct.
Lead Inquiry: And because you are a specialist in emerging infectious diseases, that comprises research and work in relation, in particular, to the emergence of diseases abroad?
Professor Sir Horby: That’s correct.
Lead Inquiry: The Centre for Tropical Medicine and Global Health has a very extensive research portfolio and it employs, does it not, a very significant number of principal investigators and staff both in the United Kingdom and abroad?
Professor Sir Horby: Yes.
Lead Inquiry: One of the points you make in your statement is that a major lesson that is required to be drawn from the pandemic is that there is an ongoing obligation to combine academic excellence, scientific and medical excellence, with public health and commercial capabilities, because that will deliver remarkable benefits at great speed?
Professor Sir Horby: Yes, that’s correct.
Lead Inquiry: Was the centre, and the University of Oxford more widely, concerned, as a result of that partnership during the pandemic, with, of course, as is very well known, the development of the Oxford-AstraZeneca vaccine, the RECOVERY Trial, which you’ve mentioned and which I’ll come back to in a moment, the ISARIC database, which is a worldwide clinical dataset – how many patient records does it contain now, Professor?
Professor Sir Horby: It now contains around a million patient records, with about half of them from low, middle-income countries.
Lead Inquiry: Was Oxford also concerned with the development of the NHS contact tracing app?
Professor Sir Horby: Yes.
Lead Inquiry: Just for a moment focusing on each of those particular achievements, ISARIC, the International Severe Acute Respiratory and emerging Infection Consortium, is it in essence a global network of clinical research networks, so providing a massive amount of data and information to enable countries to respond to diseases? Is that what it is about?
Professor Sir Horby: Yes, it was set up after the 2009 influenza pandemic because of the failure to do good clinical research on an epidemic infection that we knew was coming.
Lead Inquiry: I’m going to ask you, Professor, just to go a little more slowly, please, for the benefit of our stenographer.
So it was set up after the 2009 influenza pandemic, and on the commencement of the Covid-19 pandemic, was it apparent to you that the protocols and the procedures which ISARIC had developed over time would be required to be activated to assist the United Kingdom Government to respond to this pandemic?
Professor Sir Horby: Yes. So we had, with the World Health Organisation, written a clinical characterisation protocol, one of which was for acute respiratory infections, which was designed for exactly this scenario, so –
Lead Inquiry: What is – I’m sorry. What is a clinical characterisation protocol?
Professor Sir Horby: So it is a study that has ethical approval to get a good description from patients with a clinical syndrome, their demographics, their existing comorbidities, concurrent illnesses, their clinical presentation and the natural history of disease, because all of that information is critical both for clinical care but also for calibration of your public health response.
Lead Inquiry: So putting it in lay terms, and you’ll forgive me, were you making the point, in fact, to the Chief Medical Officer, that the government should activate this system of acquiring data about clinical features of persons suffering from the disease in order to better respond to the crisis and to inform the government’s response?
Professor Sir Horby: Yes, absolutely.
Lead Inquiry: All right.
Could we have INQ000221945, please.
You emailed the Chief Medical Officer on 17 January asking him, in essence, to activate this protocol so that information could start to be gathered on what it amounted to, what the pandemic amounted to, what the disease outbreak amounted to.
At the bottom of the page, in your email, in fact, to the then Chief Medical Officer, Professor Sir Chris Whitty, and also the Deputy Chief Medical Officer, Professor Sir Jonathan Van-Tam, you say:
“… we need two things to happen:
“1. 2019 [novel coronavirus] is designated as a priority pathogen of public health interest – I believe this is a [Public Health England] designation.”
What is a designation as a “priority pathogen of public health interest”?
Professor Sir Horby: Well, in this context, the National Institute for Health Research, which is a national NHS-affiliated research network, has a portfolio of studies that can be activated in a public health emergency but only if the pathogen is designated as a pathogen of public health interest. So we needed that to allow us to activate the protocol.
Lead Inquiry: The Inquiry is aware, as is the public, that there came a time in fact when the coronavirus was designated somewhat differently, with a different classification, known as a high-consequence infectious disease, it was so classified on 16 January. Can you assist the Inquiry as to whether that is the same designation of which you are speaking there or something different, and if it’s something different why was Covid classified on 16 January as a high-consequence infectious disease?
Professor Sir Horby: So they’re different classifications. This classification in this email is around activation of a clinical protocol. The other designation is around how the pathogen and patients who are infected with the pathogen are handled in terms of infection control and laboratory biosafety.
Lead Inquiry: So is that, in essence, a designation directed to the – well, directed by the government at the government to take particular precautions when dealing with such a disease?
Professor Sir Horby: Yes, and it’s the Advisory Committee on Dangerous Pathogens that advises the government on the designation of whether it should be a – designated as a high-consequence infectious disease.
Lead Inquiry: Once the outbreak had crashed upon UK shores in mid-March, Covid was declassified was an HCID, in fact it was so declassified on 19 March. Why, very shortly, was it deemed appropriate to declassify the virus as an HCID at that stage?
Professor Sir Horby: So the purpose of the classification is to mitigate the risk of transmission, either from patients to other patients, healthcare workers or visitors to hospitals, and to mitigate the risk of infection in a laboratory, of laboratory workers or escape from the laboratory.
Now, that only makes sense as a measure if there’s not already widespread transmission of the virus. Once you have the virus in the community, then those measures make a lot less sense. In fact, they’re counterproductive, because they inhibit your ability to manage patients and to do laboratory diagnostics, for example.
Lead Inquiry: A considerable amount of public concern was expressed about the de-designation of Covid as an HCID. Are you saying that there were good clinical practical reasons why the designation served no purpose after the epidemic, the pandemic had erupted?
Professor Sir Horby: Yes, absolutely, it would have been counterproductive, I think, to have maintained that classification.
Lead Inquiry: In fact, does Covid have a mortality rate that is somewhat lower than the sorts of diseases which often are classified as HCID, such as Ebola, plague, SARS, MERS and so on?
Professor Sir Horby: Yes, it does.
Lead Inquiry: And by the middle of March, had a specific diagnostic test been developed to test for Covid?
Professor Sir Horby: I’m not exactly sure of the timelines of when the diagnostics – I mean, the sort of advanced reference laboratory diagnostics were available, but the sort of point of care lateral flow devices that we’re all used to using at home were not yet available.
Lead Inquiry: On the topic of the understanding of, in the early days, the nature of the virus, one of the core participants has asked, through Counsel to the Inquiry, to what extent was NERVTAG in January aware of the nosocomial risk, the risk that this virus would be readily transmitted in hospitals and other healthcare settings? Was that a concern that presented itself towards the beginning of this chronology or was that something about which learning was developed later?
Professor Sir Horby: The concern was there right from the start, and I think, if my memory serves me right, there was an early email from the Deputy Chief Medical Officer, Jonathan Van-Tam, saying that hospital worker infection would be one of the red flags, that this was going to be a troublesome virus. So it’s always – and for me personally, I remember a conversation with somebody saying, “This is like flu”, sort of, you know, later on in the pandemic, and saying, “It’s not, we’re seeing healthcare workers dying”. That really is a red flag. So it was very much at the front of our minds that this is one of the flags that we should be looking for.
Lead Inquiry: Just two points on that. You were in a good position, on account of your many years of experience with emerging infectious diseases, particularly abroad, to understand that coronavirus was very much not an influenza?
Professor Sir Horby: It depends on the coronavirus. We have –
Lead Inquiry: Of course.
Professor Sir Horby: – endemic coronaviruses that cause the common cold and then, at the other end of the spectrum, we had the SARS coronavirus with quite a high case fatality rate, so there is a huge spectrum, and we didn’t yet know where on that spectrum we would land.
Lead Inquiry: I should have said this coronavirus. It became readily apparent to you that this coronavirus, SARS-CoV-2, had very distinct differences to the usual run of influenza?
Professor Sir Horby: Yes. I had personal professional contacts in China who were in Wuhan who we were in contact with, or I was in contact with, from 2 January, and it was clear fairly early that they were seeing severely ill cases, but one had to be cautious about assuming from that that it’s very transmissible or that the very severe cases are common amongst those infected.
So we had a suspicion that this could be a serious outbreak but not yet confirmation of that.
Lead Inquiry: At NERVTAG’s second meeting, which was in fact on 21 January, there was debate about the nature or rather the extent of the human-to-human transmission and a reference was made to the fact that the virus then in Wuhan or in China had been transmitted between a number of healthcare workers who had been in a neurosurgical unit where they had, regrettably, not worn PPE.
What impact on the thinking of NERVTAG did that piece of information have, that the virus then emerging in China had been transmitted, human to human apparently, amongst healthcare workers?
Professor Sir Horby: So it started to narrow down where on that spectrum of risk, I guess, we were. It did not yet indicate this could be a pandemic, because, for example, another coronavirus, Middle East respiratory coronavirus, MERS coronavirus, that is transmitted primarily from camels to humans, does cause quite significant hospital outbreaks, with infection of other patients and of staff and deaths in the vulnerable, but that has not – has not and had not at that time become a readily transmissible virus outside of that setting. So we could have remained either in that situation, where it was a MERS-like virus, or it could have been more like a SARS 2003 virus, which was transmitting a little bit outside of the hospital, or it could have been more like an influenza virus where it was readily transmissible in the community, and we didn’t know – so we’d narrowed it a bit but we didn’t know where we were still.
Lead Inquiry: Does that highlight the vital importance of data? So for any government seeking to respond to the possibility of an epidemic, what is vital is to understand the nature of the virus, its transmissibility, its features, what it is capable of, in order to be able to sensibly start making decisions?
Professor Sir Horby: Yes, absolutely, everything is dependent on that. And if I may –
Lead Inquiry: Yes, please.
Professor Sir Horby: – a good example is the H1N1 influenza pandemic which started in Brazil, and the very early data were that it was very severe because the initial cases had been detected in intensive care, and some of the initial estimates were that there was a case fatality rate of about 10%, up to 10%.
In the end that turned out to be wrong by 500 to 1000-fold, it was no more serious than a seasonal influenza. So you can get it catastrophically wrong unless you have really good comprehensive data, not just about the severe cases but about the whole extent of illness and infection in the community.
Lead Inquiry: You have referred to a particular piece of data, case fatality rate. Is it the position that, amongst the most important pieces of data are the infection fatality rate (what proportion of those persons who are infected will die), the case fatality rate (what proportion of confirmed cases will die) and also hospitalisation rate (what proportion of the infected population will require hospitalisation)?
Professor Sir Horby: Yes.
Lead Inquiry: Those are absolutely at the heart of a proper understanding of what the virus might do?
Professor Sir Horby: Yes, as well as the transmissibility, what we now know as the R number.
Lead Inquiry: They’re all linked, though, of course?
Professor Sir Horby: Yes.
Lead Inquiry: You need to know the transmissibility, the reproduction number, you need to know how it’s going to spread, likely to spread, in order to be able to see the extent of the infection and the risk of death or hospitalisation?
Professor Sir Horby: Yes.
Lead Inquiry: All right.
Lady Hallett: Pausing there?
Mr Keith: Yes.
Lady Hallett: We will now break.
Mr Keith: Thank you, my Lady.
Lady Hallett: 3.35, please.
(3.18 pm)
(A short break)
(3.35 pm)
Mr Keith: Professor, before the break, you were telling the Inquiry about the ISARIC system, the ISARIC procedure. Was one of or maybe the first – one of the first clinical descriptions of Covid-19 cases prepared by an ISARIC member, a country or a medical institute that is a member of ISARIC, and distributed through the ISARIC process? So was ISARIC right in there at the beginning with providing information about some of the clinical features of Covid?
Professor Sir Horby: Yes. So my first conversation on 2 January was with an ISARIC colleague in China, who I contacted, and it transpired he was actually in Wuhan, leading the clinical research response. And we provided support to him. So we provided him with the ISARIC tools, the case record forms, the sort of questionnaires that are filled in, and that format was used for the very first clinical description of what became known as Covid-19, which was, I think, published towards the end of January.
Lead Inquiry: It’s obvious, isn’t it, that, as professionals in this field, you were constantly looking abroad to see how this pandemic was developing, to try to see what information you could get, what data you could assemble? So is there any basis for the suggestion in some quarters that the scientists and the professionals involved in the management of this pandemic in the United Kingdom were not completely aware of what was happening abroad and what information and what data could be gleaned from the emergence of the epidemic elsewhere?
Professor Sir Horby: We were certainly extremely active, so from 2 January I was on the phone almost every night to colleagues in China and Asia, I was also on the phone to colleagues in the World Health Organisation in Europe and elsewhere on an almost daily basis, to try and get as good information as we could get.
Now, often it’s very partial, and we understood that, and I think it’s important that we had that appreciation, that we shouldn’t over-interpret the data. But that was – I mean, my very highest first priority was to get a really good handle on what we’re dealing with.
Lead Inquiry: That’s not to say that there weren’t very real difficulties in obtaining accurate, up-to-date information from, in particular, China?
Professor Sir Horby: Yes, very, very challenging.
Lead Inquiry: You’ve mentioned the publication in The Lancet, could we have INQ000222003. Just pause there.
(Pause)
Lead Inquiry: If we could have page 2 of 5, please. Is this the front page, the first page, in the bottom half, of an article published in The Lancet, I think on 24 January, talking about how Wuhan, Hubei Province, China, had become the centre of an outbreak of pneumonia of unknown cause?
Professor Sir Horby: Yes, it is. It’s one of a pair of papers. The first paper is the clinical description that used some of the ISARIC tools, and this is an accompanying commentary of which I’m a co-author.
Lead Inquiry: If we could scroll back out and then go to page 4 of 5, please, you can see that – well, you’ll be reminded, Professor, that your commentary talks of, in the left-hand column, around about halfway down, how:
“The increasing number of cases and widening geographical spread of the disease raise grave concerns about the future trajectory of the outbreak, especially with the Chinese Lunar New Year quickly approaching.”
On account of the millions of trips that would be made thereafter.
If we go to the last page, 5 of 5, did you say this in the last paragraph:
“We have to be aware of the challenge and concerns brought by 2019 [novel coronavirus] to our community. Every effort should be given to understand and control the disease, and the time to act is now.”
What did you mean by the appeal for the disease to be controlled?
Professor Sir Horby: So, in affected countries, to take strong measures to try to limit transmission, so that, ideally, we could contain and eliminate the virus and prevent it causing either bigger, country-wide, regional epidemics or a pandemic.
Lead Inquiry: Does that apply equally, therefore, that approach, to the United Kingdom?
Professor Sir Horby: It applies everywhere.
Lead Inquiry: To any country in which the virus has been able to gain a foothold?
Professor Sir Horby: Yes.
Lead Inquiry: That’s ISARIC.
You’ve referred to the RECOVERY Trial, I want to ask you some questions, please, about that. Was the RECOVERY Trial a sophisticated system or trial by which treatments for the potential benefit of persons suffering from coronavirus or Covid-19 could be evaluated?
Professor Sir Horby: It was. It is. It’s still running now.
Lead Inquiry: It the RECOVERY Trial enrol its first patient on 19 March 2020, so relatively early on?
Professor Sir Horby: Yes.
Lead Inquiry: Is it led by a number of institutes or is it purely a Nuffield Department of Medicine –
Professor Sir Horby: It’s an Oxford University study that’s led by myself but also my co-investigator, Martin Landray, who is from the Department of Population Health.
Lead Inquiry: I want to ask you about the RECOVERY Trial because was it the RECOVERY Trial that led to the breakthrough finding that there was a drug called dexamethasone which, in the passage of time, in the fullness of time, demonstrated itself capable of saving the lives of hundreds of thousands of people?
Professor Sir Horby: Yes, that’s correct. We found, I guess, the first life-saving treatment that actually, luckily, was a drug that is available worldwide.
Lead Inquiry: It’s a drug that is used, is it not, for patients who are seriously ill? It’s not used on people who have mild symptoms, it’s used on people who are on ventilators or who require oxygen, because it helps suppress the immune system and aids recovery?
Professor Sir Horby: Yes, that’s right. And it has a very significant effect on reducing the risk of death.
Lead Inquiry: All right, and did the RECOVERY Trial also expose how some other very different drugs which were paraded in the press from time to time and by certain notable global figures had very little by way of beneficial impact or medicinal purpose whatsoever?
Professor Sir Horby: Yes, our first result was that hydroxychloroquine is not an effective treatment for hospitalised patients, and our second result was the benefits of dexamethasone.
Lead Inquiry: Hydroxychloroquine was notoriously promoted by the then President Trump?
Professor Sir Horby: It was.
Lead Inquiry: All right.
That’s RECOVERY. Then can we come, please, to SAGE, of which you were a member by virtue of being chair of NERVTAG.
NERVTAG is a scientific advisory committee that reports, nominally, to the Department of Health and Social Care; is that right?
Professor Sir Horby: Yes, that’s correct.
Lead Inquiry: Why is it only nominally that it reported to the DHSC? Was that because in time, practically, it fed its learning and its reports to a considerable extent into SAGE?
Professor Sir Horby: Yes, so it’s a statutory committee in that it’s a standing committee that is sort of owned by the Department of Health and Social Care. During the pandemic it was quite early on agreed that NERVTAG should continue to operate, but it would report, almost have dual reporting, it would have responsibility to the DHSC, but also to SAGE.
Lead Inquiry: From whom or from what did NERVTAG receive its commission?
Professor Sir Horby: From SAGE. Well, prior to the pandemic, just from Department of Health and Social Care. Once the pandemic or the outbreak had begun and SAGE had been stood up, we took commissions from SAGE, from Department of Health and Social Care, and often from other sources, like Government Office for Science or Public Health England, but we did try to limit that and ask for it to be – all of those commissions to be screened through either SAGE or DHSC.
Lead Inquiry: NERVTAG is the New and Emerging Respiratory Virus Threats Advisory Group –
Professor Sir Horby: Yes.
Lead Inquiry: – I think.
Professor Sir Horby: It is.
Lead Inquiry: By the time Covid had come to the United Kingdom, by definition it was perhaps no longer a new and emerging viral threat; it had arrived?
Professor Sir Horby: Yes.
Lead Inquiry: Why was it necessary to keep NERVTAG going and to keep NERVTAG running at such a hot rate throughout the currency of the entire pandemic?
Professor Sir Horby: Well, I think there were advantages to doing that, and I think it was the right decision.
One is it’s a multidisciplinary committee, so it was set up and it has, you know, clinical, virological, sociobehavioural, modelling expertise, so it had, you know, quite a broad membership. Also it was a well established committee, so we were used to working with each other, and so it meant that we could operate effectively quickly, and much of the detailed technical work that SAGE would be looking for was within the scope of NERVTAG’s remit.
So we had both the background and the expertise to answer those commissions.
Lead Inquiry: Were those commissions always clearly identified or were there difficulties occasionally which required NERVTAG to push back and say, bluntly, “This question is too broad or too specific or we don’t understand what it means”?
Professor Sir Horby: Yes, definitely. And one can understand why that might happen in the heat of what was happening, but I think there were categories where it was too broad, you know – we were asked about, you know, what’s effective at preventing transmission, and that is a very, very broad question, it’s almost a PhD thesis, or were not really scientific, technical questions, they were straying into what is sort of standard knowledge and standard operational knowledge. For example, some of the questions around protective equipment and disinfection is not really a sort of difficult scientific question.
Lead Inquiry: Did the governance structures around NERVTAG work well, so your chairing of the group, your relations with government, such as they were, and your relationship with SAGE?
Professor Sir Horby: Yes, I think they worked well. It was very hard work, and I think we would have benefited from a better resourced secretariat, and probably some additional scientific – junior scientific support to help me prepare papers, et cetera. But the relationships worked well.
Lead Inquiry: By attending at SAGE yourself as the chair of NERVTAG, presumably you could see how the work and the learning that NERVTAG had provided was then discussed, debated and resolved in SAGE?
Professor Sir Horby: Yes.
Lead Inquiry: Where did the information or the conclusions go thereafter?
Professor Sir Horby: Thereafter, they went to government, and I don’t know much more than that. You know, it was very clear that the Chief Scientific Adviser and the Chief Medical Officer were often walking straight out of SAGE meetings into meetings with ministers, the Prime Minister, Cabinet Office, et cetera, and relaying the SAGE position or the SAGE advice to them. But we didn’t have – I personally did not have much visibility of what happened outside of SAGE.
Lead Inquiry: And to be absolutely clear about this, you never had any concerns about the ability, the scientific and professional, intellectual capacity of the CMO and the GCSA to faithfully represent the views of SAGE to government?
Professor Sir Horby: I think they both are incredibly talented, they’re great communicators, and I had absolute confidence in them.
Lead Inquiry: On SAGE itself, do you express in your statement – well, do you identify a number of areas in which you began to have concerns about the way in which SAGE was operating, in particular in relation to its role as a provider of advice to government, and this interface between the provision of advice and operational or proactive measures that were required to be identified?
Professor Sir Horby: I’m not sure I quite understand your question, Mr Keith.
Lead Inquiry: Yes. Well, I’ll put it another way. In your statement at paragraph 145, you identify that there may have been a problem with the ability of SAGE to provide advice because it didn’t know what the nature of the government’s objectives were, what its strategy was, and therefore it was unable to point its advice or to calibrate its advice to the best possible effect?
Professor Sir Horby: Yes, that’s correct.
I think it’s very difficult to provide science advice in a vacuum. It’s a bit like being asked to, you know, provide a map but you’ve not been told the destination that you’re heading to. So sometimes the scientific questions were obvious and the advice to give may be complex but it was straightforward. But other times, without understanding what it was that the objective, the policy objective, or the goal was, it became very difficult to give, I think, the most helpful advice.
Lead Inquiry: Did you get the impression that, whilst policymakers generally understood the advice that they were receiving, they may not have been provided with the answers that they were seeking, in part on account of this divide, this division of understanding as to what SAGE was there to do?
Professor Sir Horby: Yes. Perhaps sometimes they weren’t even sure what answers they were after.
I think it would have been beneficial to have a much closer dialogue between the policymakers and the scientists, so we could understand the thinking of the policymakers and what their direction of travel and what their goals were, so that we could craft the most useful science advice.
Lead Inquiry: Do you think that the division between the provision of scientific advice and the making of policy was understood by the public?
Professor Sir Horby: Largely – well, it’s hard to say, but I think that certainly there was some misunderstandings about what the scientists were doing and what the policymakers were doing and where the division lay.
Lady Hallett: Would you need the closer dialogue between policymakers and scientists if the CMO and the Chief Scientific Adviser were able to relay to you the government’s objectives? Surely they would be the source, under the system you’ve described?
Professor Sir Horby: I think it would have – it would have helped if perhaps the CSA and the CMO had a clearer steer from government as to what the policy objectives were in the short, medium and long term. But also, on occasions, I think it would have also helped to have had a roundtable dialogue –
Lady Hallett: Have everybody round the table?
Professor Sir Horby: Yeah – around specific really important questions so that we could get a really – a much clearer idea of the policy objectives, and maybe for the scientists to challenge the policymakers to think more clearly about what their policy objectives are, so that we could do the science advice as best we could.
Mr Keith: “Following the science” was that well known mantra; may we presume that you weren’t a devotee to that phrase?
Professor Sir Horby: It certainly was something that was unpopular amongst all of the scientists I spoke to, for two main reasons. One, science is rarely black and white, there are different interpretations of science and there are different degrees of interpretation, and you will see that throughout the Inquiry, no doubt. Secondly, it assumes that there is a direct relationship between a piece of science advice and a policy decision, where that’s not the case. There are many other factors influencing the policy decisions, around ethics, economics, politics, which are outside of the science advice.
Lead Inquiry: Did you ever feel that the scientific advice provided by NERVTAG and SAGE was cherry-picked or, to use a more pejorative expression, manipulated by policymakers, that they took from you what they wished and then claimed that they were following you?
Professor Sir Horby: I never had – I didn’t personally have a very strong feeling around that. I did feel that there were decisions made that did not necessarily fully align with the science advice, and for me one of the issues was there was not a feedback cycle, so where the policy decisions did not match the science position we didn’t really get feedback as to why that policy decision was made, which I think would have helped us feel more comfortable about what was happening.
Lead Inquiry: In your statement, you say that it would have been helpful to SAGE to have a greater expertise on it from frontline public health practitioners. Why do you say that?
Professor Sir Horby: Whilst there were people in the room with public health expertise – I mean, I myself, my medical speciality is public health, but I’m not a practising frontline public health worker, and also the deputy chief medical officers, you know, have public health training as well. But that’s different from being at the frontline running a public health department in a local council or on the ground. And I think one of the messages, I think from my evidence, is that, you know, science needs to be in context, it needs to be in the policy context but it also needs to be in the operational context, and so I think having those kind of people giving an input would have helped us to refine the advice we were giving.
Lead Inquiry: Was SAGE and NERVTAG, were they both too scientific, if you like, or too dominated by biomedics as opposed to pandemic management experts?
Professor Sir Horby: That is one of the dilemmas. As a science advisory committee, you want a table full of eminent scientists who people will recognise as leading experts in that area of science, but if that is not contextualised then you can get science that’s not meaningful or helpful or practical. So at some point there has to be that sort of ground truthing of it, and perhaps that’s at the committee level, NERVTAG or SAGE level, but perhaps it’s in a different forum, but it does have to happen somewhere.
Lead Inquiry: Another point you make in your statement is that SAGE spent considerable time reviewing international data perspective and lessons that might be learned, and you’ve referred already to your own direct contacts with, no doubt, a multitude of similar experts abroad.
Could we have INQ000106108, please. This is a document, it’s minutes, in fact, of a SAGE meeting on 11 February.
If we just go to the second page, please, points 1 and 7, just to get our bearings, this is around the time where there was a debate about what the reasonable worst-case scenario approach should be, and how in general terms the government should continue to plan, and you’ll recall, Professor, the reference to using influenza pandemic assumptions.
Further down the page, at point 7, my Lady will recall this from another witness:
“It is not possible for the UK to accelerate diagnostic capability to include Covid-19 alongside regular flu testing …”
Then on page 3, please, you can see two-thirds of the way down the page:
“Action: FCO and DfID to work with SPI-M secretariat to finalise the detailed breakdown of data required from Chinese and other national authorities, and the routes through which this data should be shared.”
So is this a good example of the constant steps that SAGE took to try to accumulate as much information as it could about the data which you’ve described as being of such great importance?
Professor Sir Horby: Yes. And you can see there that the request was to be issued to UK heads of mission, so really using the Foreign Office network as a way to gather intelligence to help the UK response.
Lead Inquiry: In broad terms, did SAGE and NERVTAG have difficulties in or encounter difficulties in being asked repeatedly to give advice in broadly the same areas? Were you forced to return to issues which you believed that you had already resolved, or asked questions or asked to address issues which were outside the strict remit of either committee?
Professor Sir Horby: On the second issue, yes. I think particularly, you know, my experience with NERVTAG, we were asked sort of technical operational questions that weren’t really requiring, you know, heavy scientific inputs.
On the first question, we were asked to revisit items, but I think often quite sensibly. And we come to this later, but the use of face coverings is one where it came back to NERVTAG, I think for good reasons.
Lead Inquiry: Do you believe that your learning, your meetings, your consultation was sufficiently transparent and known to the public?
Professor Sir Horby: For NERVTAG, I hope so. We had – the membership was publicly available, because it was a standing committee, the terms of reference of the committee was publicly available, and we endeavoured to write as detailed minutes as we could and to publish those as quickly as we could. There was a bit of delay initially just because of workload and for no other reason, but we got those out as quickly as we could. And I think, you know, that was very helpful.
But as you know, the SAGE membership and the SAGE minutes took a bit longer to be made publicly available.
Lead Inquiry: The Inquiry has heard a considerable amount of evidence about the way in which the documents, the minutes so-called of SAGE, in particular, reflected a consensus position.
You give an example in your statement at paragraph 101 in fact that at one particular meeting, I think it was 24 January, the debate had to a significant extent revolved around one of The Lancet papers to which you’ve taken us, one of the documents of which you were a co-author, but that the minutes of that particular SAGE on 24 January simply do not reflect that debate, indeed they make no mention of that Lancet article, either the scientific paper or your commentary at all?
Professor Sir Horby: Yes, I think that the SAGE minutes were focused on identifying the key areas of consensus, the key pieces of advice, written, you can see, more from the position of a briefing paper to a minister, in contrast to the NERVTAG minutes, which were written with a lot more detail, including when there was disagreement and discussion, as a sort of public record of how we reached the position.
And I must say, in retrospect, that’s been very helpful for me, because I can go back and see who disagreed with whom and why we reached a certain position.
Lead Inquiry: Did NERVTAG produce a report – perhaps not an annual report, but a report – subsequently detailing the majority of the work that it had done between January 2020 and June 2021?
Professor Sir Horby: Yes, NERVTAG traditionally has written an annual report, so although this covered a longer period, it was our attempt to do the annual report that covered the sort of first 18 months of the pandemic.
Lead Inquiry: Could we have INQ000221969, please, and page 3 of that document. It’s the fifth annual report. On the contents page, Professor, can we see or can we gain an understanding of the relatively large number of areas on which NERVTAG provided advice and which it reviewed, from clinical management of Covid, epidemiology of SARS-CoV-2, immunity, travel screening, SARS-2 in the care home sector, reinfection, variants, transmission, virology and the like?
Professor Sir Horby: Yes.
Lead Inquiry: How many papers did NERVTAG prepare and publish, do you recall, in total during that period?
Professor Sir Horby: I don’t recall, but it would have been well over 100, I would think. So each of the meetings would have several papers prepared for it or submitted to it, and with subgroups, et cetera, we produced a lot of material.
Lead Inquiry: Were the reports that were provided to NERVTAG, and which you debated, and the scientific learning that you had prepared for NERVTAG, was all that underlying material published or made available to the public by the government?
Professor Sir Horby: It was, unless there were reasons not to. Sometimes the data was in confidence or was pre-publication and academics didn’t want it to be shared until it had been through peer review. But our general principle was: be as open as we possibly could at all times.
Lead Inquiry: Does the evidence show that there were occasions when you even directed the secretariat to ensure that material of which you had become aware or reports that you had received from other bodies, for example Public Health England or ONS, be made public so that the public could understand the nature of your debate and why you’d reached the conclusions that you had?
Professor Sir Horby: Yes, on a number of occasions there were pieces of information that we saw as papers submitted to NERVTAG that we thought were of national interest and therefore we minuted that these should be made publicly available. We had no power to make that happen, but we could minute it and recommend it to DHSC and to government.
Lead Inquiry: Now, I want to ask you some questions about the chronology and bring you back to the beginning of January.
You say in your statement how planning for an extraordinary NERVTAG meeting began on 9 January, when the World Health Organisation announced that the cause of the outbreak was probably a novel coronavirus.
Professor Sir Horby: Correct.
Lead Inquiry: Was one of the first issues that NERVTAG therefore had to consider port screening?
Professor Sir Horby: That was one of the first issues we were asked to consider.
Lead Inquiry: It may seem self-evident, but the DHSC or SAGE wanted NERVTAG to consider this issue because one of the first steps the government might consider taking was imposing restrictions on the border?
Professor Sir Horby: Yes.
Lead Inquiry: In general terms, and mindful that at that stage, Professor, there was no sophisticated testing system in place at all, were there distinct restrictions or limits on what could be done by way of screening arrivals at the border?
Professor Sir Horby: So the only options in the absence of a test were symptom screening, really, so fever screening, which you can do through temperature monitors, or asking people to fill in a questionnaire about whether they’ve had a certain suite of symptoms or not.
Lead Inquiry: Are people generally prone to want to declare that they’ve got symptoms of a new and emerging infectious disease?
Professor Sir Horby: I would imagine many are not.
Lead Inquiry: In relation to temperature screening or symptom screening, is that a particularly effective way of ascertaining whether or not people are infected?
Professor Sir Horby: It’s not, it’s very insensitive, particularly when you’ve got an emerging infection which is quite rare. The vast majority of people with a fever you’ll pick up will not have the infection, and so you will be quarantining and evaluating a very, very large number of people when there’s very few real cases, but you will also miss a large number of the real cases because they are incubating disease, so they’re infected but they’re not yet showing symptoms.
So, you know, the data is – you know, it varies, but, you know, for every case you’d detect you’d miss 15 to 20 of what you’re looking for, as well as having to evaluate many hundreds or potentially thousands of non-cases.
So it’s very widely regarded as a very poor measure, a very ineffective measure.
Lead Inquiry: So it’s ineffective, and presumably any kind of border restriction comes at considerable cost, and not just irritation and inconvenience to travellers but is a very difficult system to put into place operationally?
Professor Sir Horby: Yes, and costly, and also may divert resources from better activities like screening people who present to healthcare centres, asking them about their travel history and then focusing on those patients rather than screening a large, very large number of travellers.
Lead Inquiry: Could we have INQ000023107, please, on the screen. These are the minutes from that particular NERVTAG meeting on 13 January. If we look at the first page, we can see who was in attendance, the contents at the bottom, and then on page 3, please, paragraph 3.2:
“Members note that it has been stated that there has been no ‘significant’ human to human transmission, which implies there may be some evidence of limited human to human transmission …”
So by this time, the end of January, it was becoming apparent from data from China that there probably was human-to-human transmission?
Professor Sir Horby: I think the data, but also the careful use of “no ‘significant’ human to human transmission” which implies that it’s not none.
Lead Inquiry: Page 6, please, 3.9:
“The current PHE risk assessment for this virus was presented …”
Professor, what does the PHE risk assessment assess?
Professor Sir Horby: It’s a good question. We actually had debated this considerably in NERVTAG before the pandemic, and it’s very difficult to do a meaningful and informative and intuitive risk assessment, and actually in retrospect this risk assessment was, if anything, unhelpful. It’s a risk assessment based on the current risk today to, you know, the UK population, what’s the risk to someone on, you know, the Clapham omnibus or whatever, which at that time was very low, because there were no cases outside China, and the risk to a UK traveller is low because, you know, it wasn’t an extensive outbreak outside of the UK. But it can and was interpreted as us saying that the future risk was very low, which is a quite different proposition. But it became a distraction, unfortunately.
Lady Hallett: Isn’t the right thing to do to say “We cannot carry out a risk assessment until we know more”?
Professor Sir Horby: Well, I think we could make a comment about the risk to, you know, someone walking down Euston Road at that time, which was very low. We couldn’t make an assessment of the risk in the next six months, one year. I think we could have been – that should have been communicated better.
Mr Keith: The purpose of the PHE risk assessment process is to inform the public as to what the Public Health England, the government, believes is the then current risk.
Professor Sir Horby: Yes.
Lead Inquiry: Having a risk assessment process which focuses only on the risk at that particular day, on that occasion –
Professor Sir Horby: Yeah.
Lead Inquiry: – fundamentally invalidates the validity of such a public assessment, does it not?
Professor Sir Horby: Well, extremely limits it and, as I said, in the past at NERVTAG we have gone round and round with PHE trying to develop a more meaningful risk assessment, and this process was completely unhelpful actually, it was distracting, it gave the wrong message and in fact, you know, it might imply we weren’t doing much but we were doing an awful lot. So it didn’t actually even reflect into what actions were taken.
So one of my recommendations is that there needs to be a much more refined approach to risk assessments and communication of risk.
Lead Inquiry: Do you think that if at the end of January Public Health England had declared openly and publicly: there is currently no viral activity in the United Kingdom but that, given the impossibility of effective containment, given what we know about human-to-human transmission, given that we know that the travelling around China and the Far East of millions of people, including hundreds of thousands of infected people, there’s a very high risk that that virus will come here?
Professor Sir Horby: Yes, and I can’t be sure that wasn’t said, because I wasn’t following all, you know, the public communications from PHE or government.
Lead Inquiry: But there was no formal risk announcement that went to anything like that degree of alerting both the government and the population –
Professor Sir Horby: No.
Lead Inquiry: – that this highly dangerous, fatal viral outbreak was surely coming?
Professor Sir Horby: So we have one risk assessment framework which is the sort of government forward looking one, which –
Lead Inquiry: The national security risk –
Professor Sir Horby: The national security –
Lead Inquiry: Yes, we’ve heard a great deal about that. What was that?
Professor Sir Horby: The risk in the next –
Lead Inquiry: Yes.
Professor Sir Horby: – you know, five, ten years, and then we have this kind of risk assessment, which is what’s the risk now. What we are missing in the middle is, you know, what’s the risk in the next two, four, six, one year, and therefore what should we be preparing people for and preparing for ourselves.
Lead Inquiry: I was – I’ve now diverted you away from travel to the PHE risk assessment process. Could we have page 7:
“The current Public Health England travel advice was presented:
“Travellers should practice good general hygiene measures such as hand washing … travellers are advised to avoid consumption of any food … and follow the advice of local health authorities … there are no travel restrictions to or from Wuhan City … travellers developing a fever and cough within 14 days of travelling from Wuhan should seek medical advice.”
Then over the page on page 9, we can see action 2, DHSC to endeavour to establish if exit screening is taking place in Wuhan. DHSC, action 3, to raise the issue of advice posters at port of entry.
So the actions appeared to be designed to see whether there were any sorts of controls on travellers coming out of China, out of Wuhan, to see whether infected persons were being stopped?
Professor Sir Horby: Yes.
Lead Inquiry: And on the UK end, the DHSC wasn’t going to publish posters but it was going to raise the issue of whether or not advice posters should be posted at ports of entry?
Professor Sir Horby: Yes. I can’t remember the actual wording of the – in the more detailed minutes of action 3, but it – there were a number of measures recommended around highlighting to travellers the potential they may be infected and what they should do if they develop symptoms.
Lead Inquiry: Given what was beginning to be understood about the spread of the virus in South East Asia, human-to-human transmission, the beginnings of an understanding of the possible infection and fatality rates, do you believe that these actions were sufficient?
Professor Sir Horby: In terms of border measures, yes, because it was our belief and it was standard and there was a document with one of those first two NERVTAG meetings about the current position of the European Centers for Disease Control, the World Health Organisation and other bodies and other scientists around the value of symptom screening.
Lead Inquiry: Pause there. The WHO and the ECDC were recommending in general terms against the imposition of travel restrictions, weren’t they?
Professor Sir Horby: Yes.
Lead Inquiry: All right.
Professor Sir Horby: And travel screening.
So the settled position generally was that border symptom screening is generally ineffective and it is sometimes implemented but, you know, it is not the most effective thing to do.
There is another issue around preventing travel, so, you know, shutting borders, shutting flights, which is more effective, much more effective, but only if you do it at a very high level, and I think that’s in some of the minutes in one of the first two meetings, that you have to stop, you know, 70% to 90% of travel to even have a delay of one to two weeks. So it’s a very – it’s effective, but only if done at a very stringent level, and it’s not something we were asked about but we did comment on it.
Lead Inquiry: It’s well known that New Zealand was a country which did apply very stringent travel restrictions; it effectively closed its border by imposing mandatory quarantining firstly on all travellers and then only allowing residents in with quarantine.
By the time that New Zealand had done that, Professor, can you recall at what stage the United Kingdom was at in terms of the spread of the virus?
Professor Sir Horby: Yes, so most of the countries that introduced complete travel bans like New Zealand did so, you know, around, starting around sort of mid-March. So I think 18 March was when New Zealand introduced their complete travel ban. By that time, in the UK we already had extensive infection within the country, and it was now a domestic problem, it wasn’t an imported problem.
So stringent restrictions on people coming into the UK, they would have had to have been very high level, you know, 70% plus of all travel stopped, not just from China because the disease was seeded around the world – in the event we were seeded from Europe, not from South East Asia – and would have had to have been done very early.
It’s hard to see that that would have happened early enough because, you know, we didn’t have our first domestic cases until, you know, I think it was late February, by which time it was too late, and for the UK to have led the world and closed all the borders in – would have had to have been early February, I think it’s very difficult to imagine that that would have been done.
Lead Inquiry: So just to pick up on a couple of points there, did subsequent genomic sequencing analysis show that there had been hundreds, if not thousands of individual seedings, that is infection points, within the United Kingdom in particularly the later part of February and the beginning of March?
Professor Sir Horby: Yes, from Italy, France –
Lead Inquiry: From Western Europe?
Professor Sir Horby: – yeah, Spain.
Lead Inquiry: And that the majority, as it transpired, of those infections had gone unknown –
Professor Sir Horby: Yes.
Lead Inquiry: – because they were asymptomatic?
Professor Sir Horby: Yes.
Lead Inquiry: So the position at the end of February was the infection had already taken hold, there was sustained community transmission, but that our ability to be aware of that was significantly hindered?
Professor Sir Horby: Yes, we didn’t have good awareness of what was happening in the country, which meant that by the time we knew that, it was too late for travel restrictions to have had any significant impact.
Lead Inquiry: Coming back to the issue of what NERVTAG was doing otherwise, and mindful of that index of the areas that you looked at, was NERVTAG asked to look at social distancing or was that a matter for SPI-M?
Professor Sir Horby: We were asked about the 2-metre rule and the basis for 2 metres as opposed to 1 metre or 4 metres, but we weren’t asked about social distancing as a population level intervention.
Lead Inquiry: But you were presumably, as chair of NERVTAG and therefore an attendee on SAGE, aware of the general flow of the debate about the extent of human-to-human transmission, the extent of asymptomatic infection, and also the debate about the impact on the NHS at the beginning of March?
Professor Sir Horby: Yes.
Lead Inquiry: When did you in general terms become aware, Professor, that the figures for the infection fatality rate, the case fatality rate, the infection hospitalisation rate, indicated numbers of deaths and hospitalisation in such large numbers that the NHS would become overwhelmed?
Professor Sir Horby: I would have to go back and look at the – I know at one of the NERVTAG meetings we were asked to give opinion on those very parameters for SPI-M modelling, in which we gave some indication of where we thought the most reasonable numbers were, and I believe that was towards the end of February, early March.
Lead Inquiry: I ask you because your statement makes the point that the situational awareness of SAGE and of NERVTAG was poor in February until, as you’ve described, more data became available. But the data that was absent, what sort of data was that? Was it data that disabled you and SAGE from understanding the likely impact of the virus on hospitals, and what the numbers of deaths and hospitalisations would be, or was it the more sophisticated data that was absent concerning the detail of latent periods and incubation periods and the more nuanced information about the virus?
Professor Sir Horby: So, I think there are a number of layers to the underlying question about whether we should have acted earlier. What we were facing was becoming very apparent toward the end of February and, from those parameters, were we to get extensive transmission in the UK it would be very serious, there would be a very large number of hospitalisations and deaths that would quite feasibly overwhelm the NHS.
What was missing was when that was going to happen. Was it going to happen next week, one month, two months, four months? And you can see from some of the earlier papers there was uncertainty. I think one of the pieces of evidence you showed me earlier said that it would be two to four months from domestic transmission in the UK to the peak, which turned out to be wrong; it turned out to be one month.
So I think we were becoming aware of what to expect, and that was becoming very well known, and that was discussed at SAGE and was known to NERVTAG and was in the SPI-M modelling. But we didn’t know when it was going to happen, and also we didn’t know what we should do about it, because the more nuanced data you were talking about is important if we’re deciding how long you quarantine people for, how long you need to get your results from test and trace back to reduce transmission.
So, yes, we knew what was coming, but there were other things that we didn’t know, and they were the things that became apparent in March.
Lead Inquiry: A considerable amount of time was spent debating the nature of what possible interventions could be applied, in modelling terms what might be the impact of whatever measures the government sought –
Professor Sir Horby: Yeah.
Lead Inquiry: – saw fit to impose. But to what extent, if any – and I genuinely put it neutrally – did the focus for those early weeks in March on the modelling, the working out of what possible interventions might have the best effect, the consequences of NPIs, concealed the reality, a much more brutal and less scientific reality, which was just the numbers of the virus and the epidemic would be bound to lead to the NHS being overwhelmed?
Professor Sir Horby: I don’t think it concealed it. You know, it was a fairly straightforward calculation to see that, you know, with a 1% fatality rate and 80% of the population being infected, you were going to see a lot of people dying and you would see a lot of people in hospital. And so the work that was done in March to improve the situational awareness, to try to understand when that was coming and how fast it would come, and to try to design the best interventions, I don’t think hid it, but you might not see that from the SAGE minutes.
Lead Inquiry: To what extent, if any, Professor, do you believe that the decision-making process that led to the first lockdown may have been too slow?
Professor Sir Horby: I think it could have been done earlier. There’s a scientific question about how much earlier. When did we know that we could identify when the peak was going to happen, that it was going to be in a month, not in, you know, two to four months, which we’d previously thought based on our earlier data? And that was probably, you know, a week or ten days earlier than the lockdown that we thought we knew enough scientifically.
Then there’s the question about – which is not my area – when politically would it have been acceptable? And I think it is important to think about the number of cases we were having in the UK at that time, which, you know, was quite low. We only had the first UK domestic case identified – because there were actually a lot – in late February, and so the numbers were creeping up. So at which point it would have been seen as a measure that could be taken at a political level is a different question.
Lead Inquiry: I now want to look at some of the important areas, other important areas that NERVTAG provided advice upon, not directly related to the lockdown decision or NPIs.
NERVTAG played a very considerable role, as you’ve described, in advising on the efficacy of face masks, on the protection of the vulnerable and in particular those in care homes, and also on the issue of contact tracing.
So just dealing with those three in order: in relation to face masks, from late January, as you’ve already described, NERVTAG was tasked to provide advice and specifically on the efficacy, the utility of face masks. Is this the position: that by mid-February NERVTAG recommended that wearing a face mask by symptomatic people is recommended, if tolerated, but that the wearing of face masks by well people living with symptomatic people is not recommended, and also not recommended is the wearing of face masks in public?
Were there a number of meetings of SAGE and NERVTAG through February, April – 7 and 19 and 13 April and then 14 April – at which NERVTAG and SAGE returned repeatedly to the issue of face masks?
Professor Sir Horby: Yes, that’s right, and this is one of the issues I said I think rightly came back round again.
Lead Inquiry: On 7 April, the SAGE minutes show that NERVTAG had concluded that the increased use of masks would have minimal effect.
On 9 April, the NERVTAG minutes from that day, NERVTAG 13, showed that Sir Jonathan Van-Tam had asked you to return to the issue of face masks because other countries had introduced what’s known as soft advisory positions in relation to the use of face masks, and he was concerned that NERVTAG and SAGE should re-examine the issue; is that correct?
Professor Sir Horby: That’s correct.
Lead Inquiry: Was there then a very considerable consideration provided by a paper dated 13 April called “Face mask use in the Community”? Did that paper summarise all the evidence which had gone before, set out a number of policy options, and basically conclude that there was weak evidence that the use of face masks by symptomatic people may reduce transmission?
Professor Sir Horby: That’s correct. It summarised the evidence as we saw it, which is something we might want to discuss.
Lead Inquiry: How did you see it, as NERVTAG, by 16 April?
Professor Sir Horby: So NERVTAG had looked at the issues of face masks in the past, pre-pandemic, and had taken quite a stringent scientific view that the highest quality evidence is randomised controlled trials, where people are randomised to have a face mask or not – not other sorts of studies, not just observational studies, which have many biases, or physical studies, how much virus is filtered – and that data was fairly clear that there may be some small benefits, but it wasn’t clear and the evidence was weak. And we maintained that position on how we saw the evidence, focusing on the data from randomised controlled trials. Others placed more weight on the physical evidence of filtration and the observational data.
Lead Inquiry: To what extent was the argument for the wearing of face masks strengthened by the application of a precautionary approach: well, it may not have much practical benefit, and there’s only some weak evidence to support the beneficial consequences of wearing a face mask, but it’s a good thing to do?
Professor Sir Horby: There are two considerations there. One is there was an issue early on about the availability of face masks and using them for a setting where they’re less effective and less useful. The second was around communicating doing something when the evidence wasn’t strong. But the reason it came back to us – and I think it was right – was the context had changed. The threat was much greater and more present than when we made the first recommendation. There was emerging data, observational data, which is sort of non-trial data, from places like Hong Kong, and there was more data about asymptomatic transmission.
So the context, the evidence hadn’t really changed. It had a bit, that we now had some Covid data rather than flu data, but the context had changed dramatically.
Lady Hallett: I’m sorry, I’m not following, Sir Peter. If there’s a possible benefit, what’s the downside?
Professor Sir Horby: The downside is you might divert face masks from healthcare workers and those who need them most, and those in who they’re most effective, so sick people or the clinically very vulnerable.
The second downside is that you are making a population-wide recommendation based on weak evidence, which may weaken trust in your scientific independence and integrity, and you can see that face masks are still a controversial issue with different interpretation of the data. So we were trying to be, I think, very scientifically clean.
Mr Keith: At that time, so in April, it was very apparent to NERVTAG, wasn’t it, that the government had real concerns about – this is your second point – about the availability of masks? If NERVTAG or SAGE were to recommend the wearing of face masks, the government was concerned that that would take limited number of masks, such as there were, away from the healthcare sector?
I don’t know whether we have this in the system, INQ000102697, page 33. This is a page from a WhatsApp group including Mr Hancock, and you can see at about the tenth or eleventh entry, 16.04 – 16 April 2020, 22.03.53, Matt Hancock MP:
“WE DO NOT HAVE ENOUGH MASKS TO SAY THESE THINGS.”
Then:
“Talking about this before we are ready risks taking masks from nurses and social care workers who really need them. It is self-indulgent and dangerous.”
Now, that wasn’t a remark made specifically in relation to the NERVTAG consideration but it shows, doesn’t it, that the government was concerned about the practicalities?
Professor Sir Horby: Yes, I mean, it’s the first time I’ve seen that, and it – we were not – in no way were we pressured by anyone from government to make any advice based on the availability of masks but, as we had healthcare workers on the committee, it was a clear issue about the availability of PPE for healthcare workers, and raised by committee members that it could divert stocks away from places where they’re more effective.
Lead Inquiry: In the event, Professor, following the advice given by NERVTAG and adopted by SAGE, the government advised on 11 May the public to consider wearing face coverings. and then in June they became mandatory in public transport, and then in July in shops?
Professor Sir Horby: Well, I would say it wasn’t just on the basis of NERVTAG, and I think this was – you know, this is an example of effective challenge where DH or SAGE commissioned other expert groups to look at the data. The Royal Society and the DELVE group produced a paper, and also there were some other groups that looked at the data. So there was an attempt to get differing scientific views of the value of it, and it was those, all of those inputs I think that changed the position, not just NERVTAG.
Lead Inquiry: But NERVTAG was not an outlier, was it? The general consensus was, from those other no less worthy scientific groups, was that there was some weak evidence to support the wearing of face masks and that in all the circumstances it was something you could recommend?
Professor Sir Horby: Yes, that’s correct, and that matched what others were doing. So we were seeing WHO and the United States shift their position at the same time.
Lead Inquiry: The WHO changed its recommendation in June, did it not?
Professor Sir Horby: Yes, I believe so, yep.
Lead Inquiry: Contact tracing, shortly.
Did NERVTAG and SPI-M hold an extraordinary meeting on 26 April where it considered issues such as what sort of people should be contact traced, should they be the self-diagnosed contacts of an index case or a confirmed case, people who had confirmed – were confirmed to have coronavirus, and issues concerning how long the period of quarantine should be, what advice should be given to contacts, and whether or not testing of asymptomatic contacts was advisable?
Professor Sir Horby: Yes.
Lead Inquiry: So NERVTAG was at the heart of the debate about the nature of the contact tracing system which the government sought to build in those late spring months and then through the summer?
Professor Sir Horby: I believe the government, Public Health England, had an idea of what they wanted to put in place, and they were asking NERVTAG to give a scientific opinion on the validity of what they were proposing to do.
Lead Inquiry: Finally, care homes, as I mentioned. In light of the time, I’m going to deal with this fairly shortly, Professor, but it is an extremely important issue and I don’t think anyone to think that, because of the shortness of time, that less importance is being paid to it.
NERVTAG, from April onwards, discussed measures for the care of staff and residents in the care sector, did they not? From April did your committee raise very significant concerns about the likely impact of the epidemic, the disease, on care homes and on what could and should be done to afford them a greater level of protection?
Professor Sir Horby: Yes. We were not commissioned to do that. It was actually a very operational, not a scientific issue, but it became apparent during our review of data as part of our scientific activities that there was a problem, and although it really sat outside our remit of giving science advice, it was something we felt that we should raise with Department of Health and Social Care.
Lead Inquiry: On 24 April, your 15th NERVTAG meeting investigated the well publicised outbreaks of the infection in care homes over Easter, and you expressed full concern, didn’t you, about the high rates of positivity, tests showing positive tests in care homes amongst residents and staff, even though many of those individuals had been asymptomatic at the time of testing?
Professor Sir Horby: Yes.
Lead Inquiry: Did, therefore, you ask Public Health England to bring a paper to your next NERVTAG meeting to answer specific questions you had about the management of SARS Covid positive people in care homes?
Professor Sir Horby: Yes, we were in a sort of dilemma in that we were not commissioned to look at this, it was not scientific advice, but it was something that was worrying us as a committee; and so in a way that was a vehicle to bring it back on to the NERVTAG agenda, was to ask PHE to see what advice they might want from us.
Lead Inquiry: In light of the answers provided by PHE at the next meeting, did you agree that more stringent measures were needed for nursing homes to improve shielding of vulnerable individuals, because they’re naturally highly vulnerable?
Professor Sir Horby: Yes.
Lead Inquiry: And you made a specific recommendation that your comments be relayed to the DHSC, in particular that positive but asymptomatic staff should not provide care or have any contact with vulnerable individuals?
Professor Sir Horby: Yes.
Lead Inquiry: You again, at a later meeting, asked for more reassurance that your concerns had been acted upon, and eventually you wrote to the CMO, as the chair of NERVTAG, pointing out that you’d highlighted high rates of transmission in care homes, that you had asked for reassurance about the measures which would be applied, and that you were unclear on what practical steps the government was actually taking?
Professor Sir Horby: Yes, I mean, we have a number of routes available to us. One is minuting our concerns; number two is a formal minuted action to pass a concern on to particular individuals in DHSC; and the final route open to us is to write a formal letter from the chair to the Chief Medical Officer who, you know, is the responsible person for the committee within the Department of Health.
Lead Inquiry: I don’t know whether we have this on the system, INQ000221994. I think we do, thank you.
Sir Chris Whitty replied on 26 May. In that letter which comes from, we can see from the heading, the Chief Medical Officer and Chief Scientific Adviser, Professor Chris Whitty, within the Department of Health and Social Care, he referred to – he referred back to the government’s published adult social care action plan. He summarised what the approach had been in that action plan. He said:
“We have been working on the next steps of interventions.”
Then he referred again with these words to that plan:
“This care home support package sets out steps that must now be taken to keep people in care homes safe.”
There’s a reference to funding on 13 May.
Then over the page, what is been done in terms of tests being made generally available, clinical support, local authority care home support plans, building the workforce.
Did that letter, Professor, address the concerns that you had raised repeatedly in your communications within NERVTAG and to the government?
Professor Sir Horby: Yes, I felt it did, and particularly the – setting up the care home subgroup meant that we felt there was a group dedicated to addressing this problem and monitoring it and evaluating the measures, so we felt satisfied that this now was being taken care of.
Lead Inquiry: NERVTAG believed it had done all that it could –
Professor Sir Horby: Yes.
Lead Inquiry: – to ensure its concerns were met?
Professor Sir Horby: Yes.
Mr Keith: Thank you very much.
My Lady, those are all my questions.
Lady Hallett: I think I’ve agreed to – I think it’s Ms Stone going first.
Questions From Ms Stone
Ms Stone: Thank you, my Lady.
Good afternoon, Professor. I ask questions on behalf of Covid Bereaved Families for Justice UK. Could I ask you some questions, please, about the definition of Covid mortality and see if you can help us with that.
To contextualise, at NERVTAG meetings from at least, I think, late March, you received and discussed regular surveillance updates, and that included data on mortality, did it not?
Professor Sir Horby: Yes.
Ms Stone: So at that stage, so March into April 2020, what was your understanding about how Covid mortality was being defined and measured, please?
Professor Sir Horby: I would have to go back and look at that, but it was – you know, I believe it was around, you know, deaths within 28 days of a Covid diagnosis.
Ms Stone: So was there also an element about Covid-19 appearing on a death certificate?
Professor Sir Horby: I don’t recall us ever discussing that.
Ms Stone: Thank you.
To move on, please, to May 2020, because at this stage one of NERVTAG’s subgroups appears to have grappled with this question of definition, and that’s the clinical risk stratification group –
Professor Sir Horby: Yes.
Ms Stone: – which is one of the ones that you refer to in your statement.
So this was a group which was established in response to a commission from DHSC and the CMO’s office, the objective being to produce a risk prediction algorithm to estimate hospital outcomes and mortality outcomes in the adult population, and that was to be rolled out in healthcare settings.
That’s the summary, I think, from the annual report that you referred to earlier.
Professor Sir Horby: Yes.
Ms Stone: Is it right that that ultimately, the product of that group, became QCovid?
Professor Sir Horby: That’s correct.
Ms Stone: So that was the risk prediction tool that was in operation.
Professor Sir Horby: Yes.
Ms Stone: So you tell us in your statement, Professor, that you attended meetings of this subgroup, at least initially, until it was set up –
Professor Sir Horby: Yes.
Ms Stone: – and then you left it to others, I think?
So in that context, can I ask you specifically about a discussion which took place at the first meeting of that subgroup about definitions in respect of Covid mortality, please.
I’d be grateful for INQ000221965, please. Thank you. So we can see this, Professor, on the screen. It’s a minute of a meeting which took place on 20 May 2020, and we can see that you’re amongst those who are noted to be present.
Professor Sir Horby: Yes.
Ms Stone: If we could go, please, to page 2 and section 2, and this deals with development of the model. The Inquiry’s heard quite a lot about modelling this week, but in essence this tool was a form of modelling, of model, was it?
Professor Sir Horby: Yes, it was. It is.
Ms Stone: If we can look at paragraph 2.3 in particular, we can see there that the group discussed possible outcome measures, and most agreed that the risk of death if positive for Covid-19 should be the primary outcome measure, noting that a definition of Covid-19 positive death was required; and then there’s an action point which says that:
“All to contribute towards developing a precise definition of Covid-19 mortality, ideally to match the figures which the government has been publishing.”
First question, please, Professor, is: why was a definition of Covid-19 positive death required in this context?
Professor Sir Horby: Because the objective was to try and get more refined estimates of individual risk of dying if they had a Covid infection, and dying due to the Covid infection. So the first thing is to be very clear about what your definition is comprised of.
Ms Stone: Can you help us with how it was proposed that all members of the group would contribute to that exercise?
Professor Sir Horby: Unfortunately I can’t, because I wasn’t chairing the meeting, and the development of the tool and the models was under Professor Hippisley-Cox’s management, and I hadn’t been involved in developing these kind of tools before.
Ms Stone: I see.
Can I ask you then, please, if you can help us with the significance of the final words there in that action, which are “ideally to match the figures which the government has been publishing”?
Professor Sir Horby: That’s a very good question. I don’t recall that statement or remember why that was put in there.
Lady Hallett: I think we’re going to have to move on, Ms Stone, I’m afraid.
Ms Stone: Yes.
Lady Hallett: I have been asked to take a break, and I am anxious to try and complete the professor’s evidence, so could you move on, please.
Ms Stone: Of course, my Lady.
Does the fact that this was being raised as an issue indicate that there wasn’t a standard definition of Covid mortality by May 2020?
Professor Sir Horby: I think that’s correct, it’s difficult to define causes of death, but it’s incredibly important, and there are many different ways to define a cause of death, and it’s not straightforward, but it does need to be discussed transparently and agreed.
Ms Stone: And finally, how was the definition agreed in this forum going to be used? Did it have any wider application than the risk stratification tool?
Professor Sir Horby: Not that I recall, but the use of the risk stratification tool was used for, I think, vaccination policy, so it did have material implications.
Ms Stone: So it was policy going forward, was it, including vaccinations?
Professor Sir Horby: It was used as a tool, I think, for people being prioritised for vaccination.
Ms Stone: Yes, thank you, Professor.
Thank you, my Lady.
Lady Hallett: Thank you, Ms Stone.
Mr Metzer, I think you can just complete the questioning.
Mr Metzer: Yes, of course, my Lady. There are a small number of questions which I understood were going to be put, which I think – subject, of course, to my Lady – were going to be put by Mr Keith.
I will be very short, but I do need to ask permission to go a little wider than the questions I have permission to ask. I shouldn’t be too long.
Lady Hallett: Well, we have to finish by 5 at the very latest, Mr Metzer, so I’m sorry, you’ve got your five minutes.
Questions From Mr Metzer KC
Mr Metzer: Professor Horby, first can you confirm that NERVTAG confirmed that identifying the end of symptoms may be very prolonged or very difficult to define on 6 March 2020, and specifically discussed ongoing clinical issues post-Covid and the potential need for a clinical forum on 15 May?
Professor Sir Horby: Yes, correct, we did.
Mr Metzer KC: Thank you.
Can you outline NERVTAG’s discussions on Long Covid and the outcome of the discussions? We note – and I’m not going to take you to them – the minutes of NERVTAG show that Long Covid was only first mentioned on 4 September 2020, and that during the course of that meeting the issue of Long Covid was raised, and the minutes note:
“Should NERVTAG look at this and have a view?”
The question is: the action was for you, Professor Horby, to discuss with Jonathan Van-Tam whether advice was needed for NERVTAG on Long Covid; is that right?
Professor Sir Horby: I believe so, yes.
Mr Metzer KC: Thank you. And why, when discussions on clinical issues post-Covid were identified by NERVTAG back in May 2020, was Long Covid only discussed in September of that year?
Professor Sir Horby: So the quotes that you gave from May were really about when we should define a point for quarantining or isolation of patients, the start of illness or the end of illness? Should somebody stay in quarantine for seven or 14 days after start of illness or, you know, four to seven days after end of illness? And the clinicians amongst us on the committee noted that there can be long-term symptoms like chronic cough, et cetera, fatigue, which make it quite difficult to define an end point.
So that was the context for that discussion. It wasn’t a context about: what are the longer term complications of Covid? And, you’re right, that wasn’t really raised until quite a lot later.
Mr Metzer KC: Thank you.
Are you able to comment on the ISARIC Long Covid study, when it was established, whether it was launched in response to SAGE 29’s discussions, and why you didn’t mention ISARIC’s work on Long Covid in your witness statement?
Professor Sir Horby: Yes. Thank you for that, it’s a good point.
We did start to engage on Long Covid through ISARIC towards sort of late summer, we engaged with the Long Covid survivors group, and they were co-developers of the Long Covid protocol, which we have established and is – data is being collected on that. But you’re right, it’s an omission from the evidence statement.
Mr Metzer KC: Thank you.
Lastly, areas that were given permission for previously.
Professor Brightling and Dr Evans in their expert report on Long Covid commend ISARIC’s study as a hibernating observational study of people hospitalised for an acute infection that was trial-ready at the onset of the pandemic.
Do you agree that the focus of ISARIC, WHO(?), the CCP, and on ISARIC 3C, were on patients suffering from acute Covid-19?
Professor Sir Horby: Yes, that’s correct.
Mr Metzer KC: And could surveillance of long-term sequelae have been built into the sleeping observational study that was trial-ready at the start of the pandemic?
Professor Sir Horby: Yes, it could have done and we intend to do that in the future. It was an omission.
Mr Metzer KC: Thank you.
Lastly, Professor Brightling and Dr Evans also gave evidence to the Inquiry that the risk of long-term sequelae was foreseeable before the Covid-19 pandemic based on evidence of post-viral sequelae from both MERS and SARS.
If ISARIC was developed in 2012 and activated for MERS, do you accept that the absence of monitoring long-term sequelae initially was a blind spot of ISARIC’s?
Professor Sir Horby: Having personally seen SARS cases and avian flu cases and worked closely with people who’ve seen MERS cases, long-term sequelae were not highlighted as a common or major problem, they were recognised but weren’t seen to be a major common problem. So I think at that time we may have underappreciated it, but I don’t see that we were missing sort of historic data that made us think that this would be a major issue.
Mr Metzer: Okay. Thank you very much, Professor Horby.
Thank you, my Lady.
Lady Hallett: Thank you, Mr Metzer.
Mr Keith: My Lady, we’re back on track in terms of timetable. That concludes today’s evidence.
Lady Hallett: I’m sure we all send our apologies to our stenographer.
I’m so sorry, thank you so much, Professor Sir Peter, I’m really grateful for all your help.
The Witness: Thank you.
Lady Hallett: And for all that, obviously, you’ve done to try and assist in this kind of pandemic and indeed others. Thank you.
The Witness: Thank you.
(The witness withdrew)
(5.00 pm)
(The hearing adjourned until 10 am on Thursday, 19 October 2023)