4. Professor Nick Phin
PROFESSOR NICK PHIN (sworn).
Questions From Lead Counsel to the Inquiry for Module 2A
Mr Dawson: Thank you very much.
This is the second occasion on which we have had two people give evidence together. I will, as I endeavoured the first time, attempt to direct my questions as best I can, but the Inquiry would be very interested to hear perspectives from both of you, so if there are observations you wish to make on questions I’ve addressed to the other, please indicate and I’d be very happy to hear from you on those matters too. You are Dr Jim McMenamin?
Dr McMenamin: Yes, that’s right.
Mr Dawson: And you are Professor Nick Phin.
Dr Phin: Correct.
Mr Dawson: And I understand you both have provided a number of statements to the Inquiry. In particular, Dr McMenamin, you have provided a witness statement under Inquiry number INQ000360968. The statement is dated 29 November 2023. Is that your statement?
Dr McMenamin: Yes.
Mr Dawson: Does the statement remain true and accurate as at this date.
Dr McMenamin: Yes, it does.
Mr Dawson: Professor Phin, you have also provided a statement to us, very helpfully. It’s dated 6 November 2023, under INQ000339576. Is that your statement?
Dr Phin: That is.
Mr Dawson: Do the contents of that statement remain true and accurate?
Dr Phin: They do.
Mr Dawson: As I understand it, having been briefed by your representatives, you were involved, Professor Phin, in the compilation of some corporate statements which were helpfully given to the Inquiry on behalf of Public Health Scotland. Is that correct?
Dr Phin: That’s correct.
Mr Dawson: And they are INQ000300280, a statement dated 2 October 2023, and a supplemental statement dated – INQ000361394, dated 23 October 2023, and a further PHS chronology dated INQ000176685.
You contributed to the compilation of these documents, as I understand it, although it was along with others, as I understand it?
Dr Phin: That’s correct, yes.
Mr Dawson: Do these remain true and accurate to the best of your knowledge and belief as at this date?
Dr Phin: They do.
Mr Dawson: Just to understand your respective roles here, you’ve both therefore provided individual witness statements to the Inquiry, and Dr McMenamin, I intend to ask you questions predominantly relating to your own personal experience of the pandemic but, insofar as it’s relevant to discuss PHS’s corporate position, I think, Professor Phin, you’re able to answer questions as best you can; is that roughly correct?
Dr Phin: That’s – that’ll be – yes, that’s the case.
Mr Dawson: And Dr McMenamin, that’s correct as far as your position is concerned? You were not, as I understand it, involved in the creation of the corporate materials, but you have very helpfully provided what is in fact a very lengthy personal statement and you can speak to that.
Dr McMenamin: Yes, that’s right.
Mr Dawson: Thank you very much indeed.
So to start with you, Dr McMenamin, I understand you are a consultant epidemiologist; is that correct?
Dr McMenamin: Yes.
Mr Dawson: And that you are the head of Health Protection (Infection Services); is that right?
Dr McMenamin: Yes.
Mr Dawson: And that you were the Public Health Scotland Covid-19 strategic incident director; is that correct?
Dr McMenamin: Yes, that’s correct.
Mr Dawson: And you have been the strategic lead for the respiratory team within PHS or its predecessors for the past 19 years?
Dr McMenamin: Yes, that’s right.
Mr Dawson: You were, as I understand it, during the course of the pandemic, a chair of a body which we will come on to called the National Incident Management Team.
Dr McMenamin: Yes, that’s correct.
Mr Dawson: You sat on a number of different bodies which provided advice to government, both UK Government and the Scottish Government, including SAGE.
Dr McMenamin: Yes.
Mr Dawson: And NERVTAG.
Dr McMenamin: Yes.
Mr Dawson: And the Scottish Government Covid Advisory Group.
Dr McMenamin: Yes, that’s correct.
Mr Dawson: Amongst others.
When the pandemic struck, Dr McMenamin, you acquired the role of public – I think Health Protection Scotland Covid-19 strategic incident director. What did that particular role entail?
Dr McMenamin: It meant overall co-ordination of, initially, the Health Protection Scotland response and, thereafter, the response (inaudible) Public Health Scotland.
Mr Dawson: Was it correct to say, as I said there, that that role was under the guise of Health Protection Scotland rather than Public Health Scotland?
Dr McMenamin: Yes, that’s initially –
Mr Dawson: Initially, yes, because as I think we’ve heard before from other witnesses there was an important reorganisation at around the time the pandemic struck of public health services in Scotland. I’ll try and narrate it briefly, but if I get anything wrong, please correct me.
There had been a number of agencies involved in the delivery of public health in Scotland, including Public Health Scotland before April 2020; is that right?
Dr McMenamin: Yes, correct.
Mr Dawson: And as part of strategic reorganisation of the way in which public health services were to be delivered, the Scottish Government decided to create a new body called Public Health Scotland.
Dr McMenamin: That’s correct.
Mr Dawson: And that body was incorporated in late 2019 as I understand it.
Dr McMenamin: Indeed.
Mr Dawson: And became operational in early April 2020.
Dr McMenamin: Yes, it did.
Mr Dawson: Which was a particularly important time as regards public health, because it was shortly into the first lockdown in the pandemic.
Dr McMenamin: Yes, that’s correct.
Mr Dawson: How did the role that you had of Covid-19 strategic incident director sit alongside other medical advisers who gave advice or provided assistance to the Scottish Government’s Covid-19 response, including, for example, the Chief Medical Officer and others?
Dr McMenamin: Thank you.
The principal route by which we offer advice remained exactly the same before and after to some degree, in that our principal contact through Scottish Government would be both through the offices of the Chief Medical Officer but also in reporting through our policy colleagues in Scottish Government.
The only additional reporting requirement that changed as of 1 April became that the co-sponsorship arrangement that we had for who we would report to meant that corporately, in addition to Scottish Government, there was also the involvement of our local authority colleagues and the body COSLA and Solace that were then a part and parcel of that combined reporting that we often did.
Mr Dawson: We’ll come on to some more detail relating to the National Incident Management Team of which you were chair in a moment, Dr McMenamin, but I’m interested to know, around that time at the beginning of the pandemic there must have been a clamour on the part of the Scottish Government for medical advice as to how they would handle the crisis. Did you find, from your perspective, and you’ve just explained how it fitted in with others, that the medical advisory systems at that crucial time provided clarity as to who it was that was to give the ministers who required it the ultimate medical advice, or was there a confusion perhaps of medical voices?
Dr McMenamin: I certainly don’t recall there being any confusion of medical voices, but rather a clear reporting arrangement where we were able to have an open door, effectively, to any urgent contact with the Chief Medical Officer, and that we had the opportunity through our Scottish Government policy colleagues to maintain the relationship with Scottish Government. And that was a very close working relationship that we had really from the first moments in January, when we identified there’s something not quite right happening in China, all the way through to the announcements by Scottish Government of the arrangements that were to be put in place for the emergency powers that Scottish Government would enact to support the response in Scotland.
Mr Dawson: Thank you.
Could I just ask you some details about your background, Professor Phin.
I understand that you joined Public Health Scotland as director of public health service on 6 January 2021; is that right?
Dr Phin: That’s correct, yes.
Mr Dawson: And in that role you were charged, along with others, with, as I’ve said, not only preparing the corporate response but collating together information to be able to respond to our questions as directed towards PHS; is that right?
Dr Phin: Yes.
Mr Dawson: Presumably that involved consultation with others because you yourself had arrived at PHS during the course of the pandemic.
Dr Phin: That’s correct, yes.
Mr Dawson: So, in as far as we are asking you questions, we have to understand that for the first half, if you like, of the pandemic, you were not personally part of Public Health Scotland; is that right?
Dr Phin: Yes, and if there are questions I think are – might be useful, I can involve my colleague.
Mr Dawson: I’m very much obliged.
Before that I understand it that you were the director of the Centre for Infectious Disease Surveillance and Control at Colindale.
Dr Phin: Yes, for three and a half years I was the interim director, I then became deputy director for the National Infection Service within Public Health England and part of that was dealing with emerging infections, et cetera. So my initial involvement, therefore, was I convened the first national – well, the IMT in London, within, I think, four or five days of us getting news of the developments in China.
Mr Dawson: So in the early part of the pandemic, before the role you took up with PHS, you were working within Public Health England?
Dr Phin: That’s correct.
Mr Dawson: As a result, in your witness statement you have been able to provide us with a number of interesting perspectives about the way in which things were approached differently in the two nations.
Dr Phin: That’s correct, yes.
Mr Dawson: Thank you.
We’ve heard some evidence from one of your colleagues in PHS, Mr Heald, already and so we’ve covered some of the functions, in particular the data side of things, but I wonder if we might just summarise what the role of PHS is and was.
I would attempt to summarise it along these lines: that during the course of the pandemic PHS received policy decisions from the Scottish Government and assisted with the medical side providing advice on the medical side of those; is that correct?
Dr Phin: Yes, I mean, medical but also epidemiological –
Mr Dawson: Yes.
Dr Phin: – statistical and other aspects.
Mr Dawson: It also had a role in issuing advice in the other direction, if you like, towards hospitals and the public and other organisations that might wish to receive advice about the policy of the government at the time.
Dr Phin: Yes, I think a key role was trying to translate some of those policy directions and aspirations into something that could be used, you know, by external organisations.
Mr Dawson: So in effect PHS was providing data and advice upstream towards the Scottish Government, but also it was providing it downstream towards institutions, organisations and the public?
Dr Phin: That’s correct, yes.
Mr Dawson: As we’ve heard from Mr Heald, an important part of that role was that PHS obtained, analysed and published data relating to the pandemic which was used both by the Scottish Government in its assessment of the threat but also by the public.
Dr Phin: That’s right.
Mr Dawson: And we’ve heard a good deal about that already from Mr Halliday and Mr Heald.
Did the nature of the role of HPS or PHS in any of these capacities change during the pandemic, or did it remain as that?
Dr Phin: From my perspective – bearing in mind, as I say, I came in 2021 – I can’t comment what it was like before then, but from 2021 onwards I would say that the role was pretty much unchanged. We continued to provide that advice, translate it into operational, if you like, guidance and provide intelligence and insight where appropriate.
Mr Dawson: Dr McMenamin, you may be able to assist with this as well.
As far as the way that advice was commissioned from HPS, or subsequently PHS, was concerned, from Scottish Government, how was that advice commissioned? Was it advice that was offered or was it specifically requested? How would that advisory function work?
Dr McMenamin: I think it would be fair to say that there was a mixture of different approaches that allowed advice and guidance to be offered, either through recognition, because it was fairly obvious that we would need to support our NHS board and local authority colleagues in the investigation and management of cases, but in particular once we reached the first cases being reported in Scotland and our Scottish Government colleagues increasingly moving towards a stepping up of their response on behalf of government and ultimately the emergency powers that were then enacted to support that, more and more of a transition from a health protection alone response into a societal response that our government colleagues were then very, very much at the forefront of, and in particular through the actions of First Minister, a co-ordination of that communication of messaging that was co-ordinated by our Scottish Government colleagues from some point in March onwards.
Mr Dawson: Okay.
Obviously, as we discussed with Mr Heald and Mr Halliday, there would be a situation where data was available upon which decisions might be made about the best thing to do to manage the pandemic which would emanate from PHS, and that that PHS data would form a subset of the entirety of the information available to the Scottish Government.
Dr McMenamin: Indeed.
Mr Dawson: What I’m interested in exploring is the extent to which PHS would form its own views based on its data, one assumes, about what to do, and the Scottish Government would make its mind up or take advice separately, or whether that was a collaborative exercise.
Dr McMenamin: It’s sometimes easy to forget that in the first days of our response, and indeed the first months, that we had no patients that were potentially presenting with infection and that our data then was a nil return thus far, for instance across the months of January and indeed across the month of February, that we had no cases, but rather that we were using the experience of others, whether that was from China or closer to home in Italy, across the month of February and then using the initial cases that were described in England. Our first approach to that was then to use whatever data was available to us to inform that, backed by this international data.
Professor Phin and I have had a long working relationship across decades in which making sense of those first cases using a First Few 100s approach was actually something which then was important that we were able to bring to the fore and work collaboratively across the UK to describe that first series of cases.
Mr Dawson: I think that’s a project, if you like, that the Inquiry’s heard some evidence about already in Module 2, so just to understand that, the position is that at the beginning – as regards access to information in particular – there was very scant information available and that therefore access to data and information was driven by the need to get one’s hands on whatever was available –
Dr McMenamin: Absolutely.
Mr Dawson: – to inform – best inform the response.
As the pandemic went on, one assumes more local data systems and testing and cases started to emerge, one could advise on and inform about a more local response; is that correct?
Dr McMenamin: And that the opportunity was afforded in the short interval to gear things up, to begin to be able to receive and process that information, recognising that this was in the days before declaration of a pandemic, it was very likely we were going to see an increase in cases and we would require to be able to report on all of those cases.
Mr Dawson: We’ve heard some evidence from the previous witness, who was a government civil servant, about difficulties that were experienced at a government level obtaining information from the UK Government.
You mentioned the fact that there was a necessity to try and rely on whatever evidence one could get, as hopefully reliable as possible, one would assume.
From a scientific perspective, was there over this period – and indeed any other period during the pandemic – any difficulty which was experienced gaining information on a scientific basis from the UK Government or from UK agency – English or UK based agencies?
Dr McMenamin: Not at all from our health protection colleagues. As you might imagine, in peacetime, outwith a pandemic setting, there was very good working relationship with our colleagues at what was Public Health England and what became the UK Health Security Agency, and indeed I have been a past chair of a multicountry group looking to harmonise some of our surveillance output. So we were using the relationships that we already had well established to make sure that we were keeping each other, and indeed the rest of the four nations – and indeed a fifth nation, the Irish Republic – very well aware of what was developing.
Mr Dawson: Sorry, Professor Phin.
Dr Phin: I’m just wanting to say, coming from the other perspective, when I was in Public Health England at that particular time we made every effort to try and involve the devolved administrations, as we called them, in both the information sharing and, where time allowed, the detailed development of policy and guidance.
I think it would be fair to say that we didn’t start off with no guidance at the beginning of a pandemic. We had the 2009 pandemic, and at that point I was leading the Pandemic Flu Office, and indeed we’d produced a suite of guidance around how we might manage various aspects of it.
So it was a case of getting that guidance out, dusting it off, looking at what we now knew about – what we knew about Covid, and seeing how we could adapt that existing guidance and use it in a rapid and helpful way with the response that we would – that potentially we could anticipate.
Mr Dawson: Thank you.
So her Ladyship will decide upon this in due course, but whatever the position as regards governmental information sharing or relations from a scientific perspective from both ends, your evidence is that that worked as well as one could expect?
Dr McMenamin: Yes.
Mr Dawson: I wonder if I could take you, in relation to this initial period, Dr McMenamin, to paragraph 14.18 of your witness statement. The statement is INQ000360968. We asked you some questions about this early period, which you have helpfully responded to in your statement. You say that:
“Early in the response HPS moved on to an emergency footing and instituted their Emergency Response Plan. Sustaining the response over the initial short period of months significantly taxed the capability of HPS to near breaking point despite the best efforts of our parent organisation, National Service Scotland, and the able assistance provided by our ARHAI colleagues …”
Could you tell us, first of all, which time period you’re referring to?
Dr McMenamin: So as an immediate response across the months of January, February and March.
Mr Dawson: And you say there that – this is obviously the period before the kind of April, PHS comes into existence –
Dr McMenamin: Yes.
Mr Dawson: – we’re still talking about HPS, that the position at that stage had stretched HPS to near breaking point. Can you tell us what you meant by that?
Dr McMenamin: I am indebted and will be forever indebted to just exactly how much and how wholeheartedly all of our staff threw themselves at addressing all of the issues of the day. It has become commonplace, I think, we’ve seen in some of the responses that it became common, regrettably, that colleagues were working 12 to 14-hour days for seven days a week and not necessarily having much in the way of opportunity for any downtime. So that continued sustained effort over an initial period, that didn’t start with a lockdown but rather started in January, was a significant effort by all of those staff that that meant then, for all of my colleagues then, I can offer nothing but thanks for all of the effort that they expended.
Mr Dawson: Could you just assist us with the acronym ARHAI?
Dr McMenamin: So Antimicrobial Infection and Healthcare Associated Infection is the acronym. I hope that the provision of the glossary in my own statement was then useful for that purpose to help anyone who might be reading that.
Mr Dawson: Yes, thank you.
Dr McMenamin: Those colleagues were part of our parent Health Protection Scotland organisation, but remained with our NSS colleagues at the creation of Public Health Scotland, so, if you like –
Mr Dawson: We’ll get on to that in a moment, but I was just keen to try to understand what the role of that particular body was. In particular, what was it doing specifically in the pandemic response and the process you’ve described over those early few months?
Dr McMenamin: Thank you. The principal role throughout this and the continued role that they had across the pandemic was in the provision of infection prevention and control advice for all of the NHS in Scotland.
Mr Dawson: Okay.
I’d like to ask you a few questions about the reorganisation. You’ve both given us in your statements helpful explanations of that but, broadly speaking, as I think you’ve alluded to, there was a reorganisation which meant a number of the public health functions which had previously been HPS moved to PHS; but one of the notable things that did not move was this ARHAI part of the operation, which stayed within – administratively within the ambit of National Services Scotland; is that correct?
Dr McMenamin: Yes.
Mr Dawson: Can I ask you whether, given the role that you have stated was played, an important role, by your ARHAI colleagues, that administrative separation between the two wings, if you like, of this public health response, or two of the wings, whether that caused difficulty when the separation happened? Because previously you were administratively together and you move to being administratively apart.
Dr McMenamin: So this might be considered akin to the most painless separation or divorce that I’ve ever experienced, because our colleagues continued on a day-to-day basis to work with us, night and day, to be able to deliver what we needed to do. So in those early days, certainly, and that first year of April 2020 to March 2021 was actually something which was barely visible to any external agency, let alone an internal one. We continued to rely on each other to assess the delivery of the things that we did.
Mr Dawson: But both parts, if you like, if I can describe it as that, played an essential role –
Dr McMenamin: Absolutely.
Mr Dawson: – over that period.
Dr McMenamin: Absolutely.
Mr Dawson: I think you recognise that in your statement.
Dr McMenamin: Yes.
Mr Dawson: Professor Phin, you in your witness statement, INQ000339576, at paragraph 11.1.2, comment under subparagraph (i) there that:
“In my view the separation of ARHAI from PHS should not have gone ahead at the start of the pandemic. Trained and suitably experienced health protection staff, familiar with working in the national health protection structure, were in short supply and leaving them in NSS impacted on the ability of PHS to mount an effective response at a critical time during the pandemic. It created artificial barriers to effective working at a time when this was desperately needed. Staff on both sides became distracted by trying to work through new arrangements etc. This was avoidable and unnecessary.”
In particular –
Lady Hallett: I’m sorry to ask, Mr Dawson. I think the public gallery look as if they’re being frozen. Can we please – one lady has already had to leave because she was so cold, and I’ve seen others shivering. If we could sort that out rather than – we don’t want to freeze our audience.
Sorry, Mr Dawson.
Mr Dawson: I did warn you about coming to Scotland …
Lady Hallett: I don’t think it’s meant to be that cold indoors, though.
Mr Dawson: Thank you, sorry.
Professor Phin, we were asking you about this administrative change, and in particular in light of the evidence that Dr McMenamin’s already given about the earlier period before April and the extent to which the pressures had driven the HPS service to near breaking point.
Could you assist us with your apparent view that you think this separation should not have gone ahead, in particular as regards the effect that you think this may have had on the effectiveness of the response?
Dr Phin: Yes, I think people maintained a very professional approach to this separation, they tried not to let it get in the way of any sort of barriers to useful working. However, what effectively happened was that Health Protection Scotland lost a third of its workforce in – when we became Public Health Scotland, and over the period of the pandemic we found ourselves going after the same groups of staff. So we were advertising to fill posts, and indeed there was movement from ARHAI, as we describe, ARHAI, to Public Health Scotland and from Public Health Scotland to ARHAI, which I don’t think was helpful.
I think a decision to defer that would have been useful at the time, and indeed there is a consultation ongoing at the moment which Public Health as a corporate body will be contributing to, and we will await the outcome.
What I’m expressing there, I think, is a personal view based on my experience of working in health protection over many years, and that ARHAI equivalent in Public Health England having – working extremely well within Public Health England. So again this is a professional perspective.
Mr Dawson: Because one of the things that the Inquiry is, of course, interested in is the extent to which it might make recommendations to try and make response in any future pandemic better, and I’m sure you are both also engaged in that process regularly. It did occur to us, on reading these comments and others, that this administrative separation – which of course had been pre-planned many months before, and no one knew there would be a pandemic – would be something perhaps that we might consider as being something that would improve any future response.
Would you agree with that, Professor?
Dr Phin: I would. I mean, if you look at health protection, health protection is an umbrella term describing all aspects. We cover vaccination, we cover infection control, antimicrobial resistance, we interact with animal health, we interact with the food industry, FSA. So health protection is that umbrella under which we all operate and we all work. Clearly people develop special interests, we hive off elements where it’s appropriate to develop and garner expertise, but ultimately working as part of that larger health protection organisation, we’re able to flex people to where they may be needed in the event of, let’s say, a large food-borne outbreak or, as indeed in this situation, in a pandemic.
So being able to have that overarching health protection structure I would say is a key issue going forward.
Mr Dawson: Thank you.
One of the things I just wanted to follow up on was that I think, Dr McMenamin, you said earlier that one of the important functions of ARHAI was development of guidance for infection prevention and control in hospital settings. Did that part of the operation also provide such guidance for social care settings?
Dr McMenamin: So, yes, they made a significant contribution potentially to anything that we were offering for setting specific information, but in the main the priority, as the name suggests, of – for their full name, for their abbreviation, was that their principal focus was always to be in the healthcare settings.
So outside of that, they were able to, where it was possible, begin to offer advice, but in the main it was a healthcare offer of that advice.
Mr Dawson: I think at paragraph 11.4.2 of the corporate statement it suggests that their role covered both health and social care, but is that to be understood with the limitation that they played some role in that, as I understand what you’re saying, but not their priority was hospital (inaudible)?
Dr McMenamin: We’re probably the wrong people to ask, because given that that separation from 1 April 2020 – but we can perhaps offer our understanding about that, but it would be good to confirm anything that we’re saying with our ARHAI colleagues.
Mr Dawson: Yes. The reason obviously I’m interested in that, to be candid, as you will have worked out, Dr McMenamin, is over the period that we are interested in at the very beginning of the pandemic –
Dr McMenamin: Yes.
Mr Dawson: – you will be aware that there were many, many infections and deaths in care homes in Scotland.
Dr McMenamin: Yes.
Mr Dawson: That’s an important part of the module that we’re addressing here, and we’ll come on to some elements of that in due course, but –
Dr McMenamin: Yes.
Mr Dawson: – I’m interested in the extent to which the reorganisation, or indeed inadequacies in the ARHAI role in providing guidance to, rather than to hospitals, to care home settings, created a potential problem, given, as we have heard from witnesses, including Donald Macaskill of Scottish Care yesterday, that there was a clamour really within the care community for guidance as to how operate effective infection control within an environment such as a care home, which –
Dr McMenamin: Yes.
Mr Dawson: – as I’m sure you’ll be aware, is difficult to do.
Dr McMenamin: Yes.
Mr Dawson: So can you help us, either of you, from a corporate view or from your own personal perspective, Dr McMenamin, as to whether there was a deficiency in the service being provided at that time with regard to guidance, which resulted either from the reorganisation or from the fact that it wasn’t clear that guidance to be provided to care homes was a priority in this public health service?
Dr McMenamin: So I don’t recognise that as being any deficiency. Our colleagues in infection prevention and control were able to make clear a very articulate recommendation about what would be advisable in the setting for health and social care, and they certainly were very much part of the guidance team and the offer of advice that covered this important period across March and April of 2020 onwards.
Mr Dawson: Just to be clear – sorry, before I come to you, Professor – there might be a difference in the type of guidance being provided, because guidance could be provided to government as to what they should do about it, but I mean guidance being provided to the sector itself.
Dr McMenamin: Yes, and indeed my infection prevention and control colleagues were making significant contribution to any of the guidance that was being issued either by Health Protection Scotland before the end of March 2020 or thereafter from Public Health Scotland.
Mr Dawson: Yes, thank you.
And, Professor, you have a view?
Dr Phin: Well, it’s just to say that, you know, we didn’t start from scratch when the pandemic started. Healthcare in social and healthcare settings have for many, many years been dealing with outbreaks of flu, norovirus, et cetera, in healthcare and in the community. So there are well established processes around infection control within the social care setting. In addition to that, we have local health boards which have got health protection teams, and we made clear in a number of iterations of the guidance that was subsequently issued that healthcare – social care settings should approach those health protection teams if there was any concerns or if they needed advice around the implementation or understanding.
So, you know, we didn’t start from nothing, there was existing principles, there were existing processes in place, and it was simply a case of trying to adapt those to the peculiarities of the themes or the things that were emerging from this particular pandemic.
Mr Dawson: There’s just one other aspect of the reorganisation which I’d just like to give you the opportunity to comment on. I think we may have touched on this already, but Chris Robertson – who’s the Chief Statistician, I think, at HPS – said in his witness statement to this Inquiry that:
“Almost certainly the formation of PHS in April 2020 initially had a major negative impact on the management of the pandemic in Scotland, as there was a whole new layer of senior management who the senior consultants had to report to. The management structure of PHS was more complex than HPS, and the whole organisation much larger. In addition, many of the senior leaders on the PHS board did not appear to have extensive experience in managing a pandemic response and were new and external appointments.”
So this is an aspect of the reorganisation which a witness who was involved is suggesting may have had an impact on the response, and one might reasonably think that such a reorganisation of senior management would have an impact on direction, control and the ability of the organisation to function as fully as one needed at that time.
I’d be very interested to hear your perspective on that, whether you agree with it or not, from a corporate or indeed individual perspective.
Dr McMenamin?
Dr McMenamin: I recognise everything that you’ve said that Professor Chris Robertson has written. In practice, I can see much of what Chris has written is something which was either being addressed but was perhaps interrupted, or at least the speed with which people could come to common understanding was interrupted because the pandemic was so demanding of our time. But nonetheless our chief executive and the interim clinical director in Public Health were instrumental in trying to overcome some of the immediate difficulties that we had, particularly about expanding our workforce. Which is always going to take time because you – the specialists that we needed to grow or acquire from elsewhere were going to take that time.
It’s certainly unfortunate about the timing of the creation of the organisation, but nonetheless important that we went ahead with that, and that as we pulled together, as the teams across all of those organisations coming together, we had very, very good buy-in from all of those team members. So at a practical level we could see the immediate benefits of having increased access to the same workforce who had joined us from NSS, who were part of an original organisation, Information Services Division, but also some of the expertise that our colleagues from Health Scotland were bringing to this, and in particular – and if opportunity arises in the discussion to talk about inequalities – their great experience was going to be very, very helpful over those coming months as we began to look at that.
Mr Dawson: Thank you.
I would like to just say to you, Dr McMenamin, that my question doesn’t seek to imply any criticism in any way. This was a pre-planned reorganisation which came at a really extremely unfortunate time. It is part of our remit, however, to explore as a matter of fact –
Dr McMenamin: Yes.
Mr Dawson: – whether that reorganisation did impact upon the response which this important organisation could provide, and support and advice that it was obviously was called upon to do.
Do you think overall that it did as a matter of fact, without suggesting any culpability or anything of that sort?
Dr McMenamin: It certainly may have affected some of our initial work, but work before PHS was formed had already been enabled by the appointment of a chief executive who was working in the background to make sure that that transition could be as smooth as possible. But I certainly could not disagree with you that that was challenging because we had to expend time and energy that otherwise we wouldn’t have had to – with getting to know new colleagues who were going to be instrumental in helping us doing things.
Mr Dawson: Thank you, Dr McMenamin.
Professor?
Dr Phin: Yeah, from a corporate perspective, although not around at the time, I worked extremely closely with chief exec and my other colleagues from January 2021 onwards. Looking through and talking to them, it was very clear that there was a recognition they were new to this, and therefore they followed almost to the letter the advice that Jim and his team was giving them about what was needed, what resources needed to be deployed, and I saw nothing to suggest that there was any reticence about moving people into support it.
So it’s not something I recognise in the sense that PHS actually provided greater flexibility. There were more resources to pull on, albeit not trained specifically in health protection, but everyone made a contribution and I would say that the establishment of that team across the wider remit actually helped bolster the response and, as I say, I saw nothing to indicate that the advice about how it should be structured, how it should be resourced was ever rejected, and in fact it was supported as best was possible at the time.
Mr Dawson: Thank you, Professor.
With my apologies for overrunning, my Lady, that would be a moment to break.
Lady Hallett: No, not at all. People probably don’t know as yet, we may have to sit a little later tonight. So I shall return at – we’ll have a slightly shorter break in case we need to have another break later, and I shall return at 3.20. And by the looks of it, we’re not freezing members of the public gallery any more; good.
(3.08 pm)
(A short break)
(3.20 pm)
Lady Hallett: Mr Dawson.
Mr Dawson: Thank you, my Lady.
Moving into a slightly different area, we are of course in this module concerned primarily with looking at political decisions made by primarily the Scottish Government but connected with Scotland, and we are asking you questions to try and understand your role in that process.
In your report, Professor Phin, you say at paragraph 1.4.4 of the report, INQ000339576, 1.4.4, where you say, reading from roughly the middle:
“PHS had therefore minimal opportunities to provide Ministers with a first-hand account of the thoughts of senior staff in PHS or to make them aware of the practical implications of policy decisions. The main mechanism by which PHS was able to provide advice to Scottish Government was through the NIMT.”
To which I will return imminently.
Do you think that PHS could or should have been able to provide more direct information and advice to ministers, given their central role in the public health response?
Dr Phin: Yes, I was contrasting the approach in Scotland with that experience then for the 12 months in England, and right from the start PHE – either myself as one of the incident directors, one of my medical director or director of health protection – would be involved in face-to-face discussions with the minister, they would be attending COBR, the COBR meetings, and there would be in the room present providing direct advice, based on largely our experience of: if you were to introduce this policy, this is what it could mean on the ground, these are the issues that we’d have to think through.
With the greatest of respect to colleagues in Scottish Government, they were working at a national level, they were not working – well, they, I’ve(?) understood I think what the local implications, the restrictions, the limitations indeed, on what could be done with the public health workforce. So very much being able to be in the same room, advise, point out the implications, I think, was really important.
Mr Dawson: Did that create a situation where decisions may be made about restrictions which might be incapable of being delivered on the ground?
Dr Phin: Yes, I think we’ve given a couple of examples, one around borders where there was an expectation that somehow we would be going out, checking up on people as to whether they were maintaining quarantine, and I think there was a reasonably robust exchange between our chief executive and Scottish Government saying that just wasn’t a feasible option, we didn’t have the legal powers, and in any sense, you know, it wasn’t something that we could do. But nevertheless we were instructed to try and enquire about people’s wellbeing and provide them with information, but equally if they didn’t respond there was an implication that we should somehow report this to Police Scotland. And again that is outwith anything that we would normally do, and had we been available we could have pointed out some of the limitations of that approach.
Mr Dawson: Do you think, other than just the practical issues and potential problems that that causes, do you think that that represents perhaps a gap in the knowledge base available to the Scottish ministers in making decisions, because it may be if they were aware of those practical limitations they would have chosen an alternative way of managing the pandemic, for example in the borders situation that you’re suggesting?
Dr Phin: It’s possible, and I would be speculating if I gave an opinion one way or the other. I’m simply noting that the difference, the contrast between England and Scotland where, if you like, the public health, the health protection advice was round the table, providing it directly. That’s not to say it was always listened to, but at least there was an opportunity to put those points across, and we were working, if you like, through a filter, you know, people were interpreting what they heard and they were then trying to then re-interpret that in the context of what they were being asked.
So being there, being able to clarify things at that point, I think could have been extremely beneficial.
Mr Dawson: I think you mentioned there was another example other than borders that you had considered.
Dr Phin: Yes, I mean … yes, there was another, and I’m trying to think what it was. Apologies, I can’t remember, but if it comes to me, I’ll –
Mr Dawson: Thank you, I appreciate that.
Just staying in your statement there, Professor, there was another issue I wanted to raise with you at paragraph 1.4.3, the immediately preceding paragraph. You enumerate(?) some of the challenges faced by those responding to the pandemic included the need for definitions used for certain key data items, their significance and the frequency of reporting to change over the course of the pandemic; and I think you highlight there, without going through all of the text, that there was an issue in this regard where PHS had suggested that a definition relating to deaths, mortality figures, would appropriately be changed in order to try to maximise accuracy and that that proposal was refused by the Scottish Government because they had become used to the way in which the definition had operated up to that point.
Can you add anything to that?
Dr Phin: Well, yes, I mean, that was one example you’ve given. Another example was in relation to our definition of a patient in hospital with Covid, which was – the definition that had been used was 28 days, so that was then used to understand occupancy, who was occupying beds in hospital. The reality was that, you know, 28 days is a long time, most people would have been recovered, therefore they weren’t occupying a bed because of Covid, and back in November, I think it was, 2022 we proposed the change to bring that down to 14 days. This was supported by CMO’s office but it wasn’t until May 2023 that that change was actually introduced. So that was nearly six, seven months, and we reckoned, we estimated that using that original definition we were overestimating the number of people in hospital by something like 24%, and if you’re trying to make planning assumptions, that’s quite a lot of people that you may be overestimating –
Mr Dawson: I think perhaps we touched on this with your colleague Mr Heald, it was because the definition of being in hospital 28 days after the test may include people who are no longer suffering from Covid –
Dr Phin: That’s right.
Mr Dawson: – but were in hospital for another reason. But the point here is that these were matters on which PHS made representations to the government to try to improve the system, but that these were rejected.
Dr Phin: Yes, they were eventually implemented –
Mr Dawson: Yes.
Dr Phin: – but it was after some time –
Mr Dawson: In the intervening period, PHS’s position would be that the data provided was not as accurate as it might have been?
Dr Phin: Yes.
Mr Dawson: I wonder if I might then move to the NIMT and I think, Dr McMenamin, in relation to this. You were the chair of this body. The PHS corporate statement states that:
“HPS set up a National Incident Management Team that met for the first time on 13 January 2020. The composition of the NIMT was dynamic and adapted to the evolving response to the pandemic. NIMT members include local health board directors of public health, Scottish Government policy and analytical advisers, the CMO and representatives from local government and PHS teams. Attendees changed over time between the initial set-up in January 2020 to the formalisation of the group and the agreement of the terms of reference in September 2020.”
Was the NIMT a body that was created simply to deal with the Covid crisis, or was it a concept that could be brought together to deal with an emergency of the nature of the Covid crisis, the idea of which already existed?
Dr McMenamin: Okay, so in reverse order, I think, to what you just asked me: the “Managing incidents of public health concern” which has been in place as a document that a number of stakeholders assisted us to generate from the Scottish Health Protection Network was a long-standing approach for how we dealt with any incidents, no matter their size, about what should or could be done and who might be able to assist you in delivering the response that was required to bring that issue under control.
Our initial incident management team met, as you said, for the first time in January and I think we’ve – we met something like 169 times. I think I might have been the chair 162 of those 169, and Nick maybe three or four of those, whenever I got benched to take leave or something else. So that group was really important in helping us to deliver everything that we then hoped to be able to deal with on a national basis, dealing with whatever the emerging issue was of the time.
And certainly from my perspective it was the privilege of my working lifetime to be able to be the chair of that group, because I don’t think I’ve ever come across a group of colleagues who were as dedicated to try and make sure that they managed Covid as best as was humanly possible to reduce the impact on the population.
Mr Dawson: Thank you.
Just to tie into one of the answers that Professor Phin gave a moment ago, my understanding is that the CMO sat on that group; is that correct?
Dr McMenamin: Yes, that’s correct.
Mr Dawson: And you mentioned earlier that one of the reporting mechanisms of PHS, or HPS as it was at that time, was through the CMO, and I think the passage we went to before suggested that because there was not direct contact with ministers, as there had been in Professor Phin’s experience in England, the NIMT was the main reporting mechanism.
Was it therefore the case that the CMO attended meetings and that whatever input the group could have the CMO then took away and fed into the Scottish Government machine?
Dr McMenamin: I think it was both directions, it was imparting any urgent issues for the incident management team to be able to address, but also hearing first-hand what the intelligence was that was being offered in each of the meetings about what were we seeing, what if anything was working in control of the cases that we were seeing, and instances where that was not the fact, but either that we were seeing an increasing number of cases, that’s to say that whatever policy issues had been implemented were not having the effect that they should or, particularly once we had the availability and deployment of vaccination, just what were we beginning to see. That allowed us to have the advice that we were offering from NIMT to come in through the formal four harms reporting arrangement, which I’m sure that we’ve been through over the previous days.
Mr Dawson: Yes.
Dr McMenamin: And offered that opportunity to also have in that four harms meeting that direct representative, the CMO, able to give an update to which I, as the chair, or whoever was attending on behalf of PHS, able to supplement that with any additional points that were felt to be important.
Mr Dawson: When you say that the NIMT was able to report and feed into the process local experience – you’ve talked about outbreaks, the effect of vaccination – was it possible through that mechanism to feed through local health experience, so in hospitals and the NHS, the frontline, if we can call it?
Dr McMenamin: Indeed. However, within the four harms exposure of all of that information, our representative colleagues, as directors of public health, or I think from one of the colleagues that you had yesterday on behalf of COSLA, Solace, hear that local representation about: yes, this is something that we agree with, or their opportunity to offer any contrary view.
Mr Dawson: I’m particularly interested in the extent to which it was possible to get frontline NHS information into the machine through that; that was part of it?
Dr McMenamin: Absolutely, yes, that is part of that. My principal role in garnering all of that advice then was to make sure that we had representation from all of our NHS boards and, through COSLA and Solace, opportunity to hear exactly what the intelligence was from those local areas about just exactly how bad a problem were they seeing, what was working, what did not, and that allowed us to contextualise any of the advice that we were then offering about the societal measures that were implemented at the time, or later the impact of vaccines.
Mr Dawson: Okay, thank you.
What prompted the NIMT to be set up on 13 January 2020?
Dr McMenamin: As part of our managing incidents of public health concern, there’s a set choreography for what we would do where: is there a problem? A problem assessment group, and that can be called by any of the constituent members – in this instance an internal issue within Health Protection Scotland – and thereafter say: we think that there’s something that at the very least that we need to begin to prepare for, where we can say there’s unusual infection in China which is unexplained, appears to be causing severe illness and was a recognised first step then where we implemented that to try and ensure that we were beginning to prepare for dealing with any increase in cases, should we see any.
Mr Dawson: So do I take it, then, that the instigation was from within HPS itself?
Dr McMenamin: Yes.
Mr Dawson: It wasn’t the Scottish Government or anything telling you to do that; you yourselves put that body together?
Dr McMenamin: That’s correct, and indeed that would be the normal circumstance for almost every incident management team that we’ve ever created.
Mr Dawson: What advice generally was being given over the period between January and February, to the end of February let’s say, through the NIMT to the government about the nature of the threat?
Dr McMenamin: So in I think almost a daily basis that we have opportunity, through our national incident co-ordination, to be able to meet with a variety of stakeholders which included government, not just for the Chief Medical Officer who you’ve mentioned already, but also for a number of liaison colleagues within the policy side of government to hear exactly what was the feedback from our NHS board or indeed local authority colleagues about just what they were seeing.
Now, I’ve already mentioned that early on, that we necessarily were investigating any returning traveller who might meet a case definition, but the first identification of a new case for the first time in Scotland was not until the report on 1 March of 2020.
Mr Dawson: So there was little local information one could give, but were you looking at other sources, for example you mentioned earlier getting information from England or internationally, you obviously –
Dr Phin: Indeed.
Mr Dawson: – somehow found out about the virus from China in the first place. So what was the tenor of the advice about the threat? I mean, it seems that there is other evidence which is available to this module from another epidemiologist who was expressing, he says, considerable concern about the threat over this period to the Chief Medical Officer. Was that the tenor of the advice being given by NIMT at that stage? Because obviously there was little local information.
Dr McMenamin: Indeed. I think across the UK, whether it was through Professor Woolhouse directly or whether it was from a variety of colleagues who were reporting to us, Professor Phin in his prior role, or indeed other colleagues in England, but also any feedback that we had from colleagues in the World Health Organisation or elsewhere, where this distillate of information was demonstrating a picture of gradually escalating, a ramping up of concern across the month of January and February, particularly once we saw that this was not just an isolated problem confined to the shores of China, but rather one which was beginning to hit home closer to home, whether that was Italy or elsewhere.
Mr Dawson: So by the end of February, what advice had been given by NIMT about the threat to Scotland to the CMO or Scottish Government?
Dr McMenamin: That there was this gradual escalation of threat that we could see and that the important grouping – that we haven’t yet moved on to consider – is the advice that was coming through from SAGE, the Scientific Advisory Group for Emergencies –
Mr Dawson: Yes.
Dr McMenamin: – along with any advice from the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), both of which bodies I was sitting on.
That international experience was feeding in through both of those groups, and was being fed in in parallel to anything that we were seeing locally, where that international concern fuelled by any of the modelling scenario output by SPI modelling group was certainly very, very influential in describing what was happening abroad and what might happen next.
Mr Dawson: Given that international perspective on the threat which you were also part of, as you said, on those committees, and indeed your knowledge about epidemiology, what advice was being tendered at a local level to Scottish Government about the need to consider precautionary measures that would need to be taken, for example the ramping up of PPE, the development of a testing regime during the month of February, let’s say?
Dr McMenamin: Well, I think, looking back on things, we had not the position that we perhaps enjoyed at the peak of where we were able to do a million tests a day, but rather that we had a limited number of tests from about the middle of February onwards from, you know, February 10, maybe we had to do – the capability to offer something between 350, 375 tests per day from a new testing system that was available to be deployed. And I think that that was reflecting in what we were advising, which was: we think that there is an escalating issue internationally. We at that point had not seen any human cases being identified in Scotland, but we had seen some cases identified in England, and indeed across the month of February we were aware of the first of the death reports that were beginning to come through about that. So the advice that we had then was: we need to be prepared to escalate. It was over to our government colleagues who, on a societal perspective, were beginning to put the machinery in place to begin to generate what you’ve then taken us into, which is: and what should we do about PPE which is already stockpiled, what should we do about any of the other planning that we need to have in place?
Mr Dawson: One thing that you’ve alluded on as being the actual course of events is it does take a while to ramp up testing, it takes a while to acquire PPE, one needs to work out what the current state of stocks and capacity is.
Given the emerging nature of the threat – as you said, the gradual nature, the emergence of cases in Europe, deaths in Europe – to what extent do you think that the message being given to government from any of these bodies on which you were sitting was one of urgency such that, even although the threat may not materialise, if it does, one needs to be more ready than we actually were in Scotland?
Dr McMenamin: I think that the primacy of the offer of advice here was one where we recognised that that prime influencer of what should happen next needed to be the SAGE group. They were informed by NERVTAG, informed by SPI modelling group, of course informed by any of the national health protection agencies across the UK, but the primary recommendations were going to stem from what our SAGE colleagues were saying.
Mr Dawson: Is that because those bodies had access to the best available information?
Dr McMenamin: It’s not just that they, like us, had access to that information, but rather that they had the brain power in the room to be able to make that determination and recommendation or advice that was then going to UK ministers or being offered to ministers across each of the devolved administrations.
Mr Dawson: Thank you.
I think the professor is keen to say something on this subject.
Dr Phin: I just wonder if a little bit of context might be helpful here.
We’ve got to just reflect back to the 2009 pandemic. During the 2009 pandemic many people, organisations globally were heavily criticised for overreacting to what turned out to be a relatively mild infection.
So in the people looking at this, there was the context: at what point do we say this is mild and it’s going to be a serious condition? So that was going through people’s minds.
The second thing is that the information we were getting out of China suggested that this originated in a wet market or seafood market – wet being, you know, live animals as opposed to wet in the sort of colloquial sense – and therefore people were watching and waiting: is this going to be something where there is evidence of human-to-human transmission? And once that started to emerge, that then started to build up a picture that concern should be taken.
The stocks were controlled by UKHSA, and I think it would be fair to say that in the early weeks UKHSA – or PHE, as it was at the time – would be the organisation that would take the national, the UK perspective. But as it gradually started to emerge, the DAs, the devolved administrations started then to take on responsibility given that health is a devolved, you know, responsibility in Scotland.
So I think in that context, there was a caution, there was an uncertainty, the information we were getting was coming out slowly and, you know, caution was the day.
The last point I wanted to make was about testing, because I think that was something that came up yesterday. Until we know the genetic sequence of the virus, you can’t develop a test. That came out in the middle of January. PHE Colindale worked tirelessly to develop a test. That then had to be field tested, you needed a virus to be able to test it against, it needed to be validated, and it wasn’t until 10 February that Scotland carried out its first test. And that validation is important, because CDC, you know, globally – you know, global body that’s held in very high esteem, developed a test which actually turned out to be faulty and did not deliver it. So these are high stakes endeavours.
So the first test was in Scotland on 10 February. 350 tests by the end of February, I think it was 1,900 by the end of March – pardon?
Dr McMenamin: Daily tests.
Dr Phin: Sorry, daily tests. These are daily tests, not weekly tests. Thank you.
So wanting to do some of the things that we love to do was constrained simply by the fact that there wasn’t the resource, there wasn’t the infrastructure and indeed, as the pandemic evolved in those early months into 2020, supply chains were stretched, we ended up not having enough sample kits because everyone was trying to get their hands on them.
So there were multiple factors here that delayed the introduction of testing, which I think we all accept now was an important part of our control response.
Mr Dawson: Thank you.
You mentioned in your response that the position was characterised as one of caution, based on the context that you set out, including 2009. Was it the case and was it important that advice being given to the Scottish Government and other governmental bodies didn’t only reflect that caution but reflected an element of precaution, given the possibility that the reliance on previous experiences such as 2009 may not turn out to be how this coronavirus manifested itself?
Dr Phin: I wasn’t party to those discussions, either in PHE or in PHS –
Mr Dawson: Of course.
Dr Phin: – but I was party to the discussions where we looked at the evidence, and there was this initial sense of caution: is this going to be the same as 2009? Have we got evidence that there is person-to-person transmission, which would be a key feature of an evolving pandemic? Once we were clear about that, I can’t comment on the mechanisms as to how that was fed into either Cabinet Office in England or in Scottish Government. I do know that the CMOs met regularly at that point to consider it, so I would have expected there to have been some information being fed in at that level.
Mr Dawson: I was holding off on your response, Professor, but perhaps more appropriately for Dr McMenamin: was it your experience, given your involvement in these advisory structures, that Scottish Government was getting a message of precaution as well as caution at this time? Or was, as the professor has suggested, what characterised the advice being one of caution based on the previous experiences to which he’s alluded?
Dr McMenamin: I think it would be fair to say that both things were happening, it was caution and precaution. Indeed, I caught part of the testimony earlier from Mr Thomson while we were in the waiting area, and I could see then that that gearing up that was being discussed was something that, certainly from the health protection side of public health discussions, was one that we could see that happening within the discussions we were having then with our health protection and director of public health colleagues, while at the same time any discussion that we had with Scottish Government colleagues, whether it was from the CMO’s office or from policy side, we could see that this was an escalating concern, and particularly became an escalating concern once we began to see our first home cases identified and, in particular, as Professor Phin has just taken us into, once we had demonstration of community transmission, onward transmission of this infection to others in the population, then, yes, that was coming home to then be truly something which was much more scary for us.
Mr Dawson: That’s a key epidemiological red flag, I suppose, is it?
Dr McMenamin: Absolutely.
Mr Dawson: When did that occur in Scotland?
Dr McMenamin: So I think the demonstration that we had is from our first case identification that we had on 1 March, the follow-up of those individuals, along with what our colleagues were doing across the rest of the UK, we were then able to demonstrate sustained community transmission by about the middle of the month of march. That meant then that with – despite anything that was being done in the background, meant that we had to have some serious discussion then about what further escalation needed to be in place and how incrementally could it be delivered.
Mr Dawson: You’ve mentioned your involvement in both SAGE and NERVTAG –
Dr McMenamin: Yes.
Mr Dawson: – Dr McMenamin. The broad question I’m interested in as regards those bodies is the extent which you and other representatives from Scotland were able to voice issues from a particularly Scottish context in terms of asking questions, seeking information, feeding information in, or whether you thought the Scottish participation was suboptimal from a Scottish public health perspective?
Dr McMenamin: I certainly don’t think it was suboptimal. Like any new group when it’s forming, of course there are teething difficulties or maybe from time to time, because of a delivery method for how you communicate, there can be interruptions in information provision or you drop off of an invite or something, but all of those things were really very quickly remedied, in particular for SAGE.
NERVTAG, my status in that group was as a member because I’m an appointed member to that group, whereas –
Mr Dawson: In private capacity, was it?
Dr McMenamin: That’s right.
Mr Dawson: Yes.
Dr McMenamin: So that throughout all of that, that group was very, very active in looking at any of the new information. For the SAGE status, I think I’m variably described either as a member or observer, but the key thing was that either of the health protection teams in each of the administrations, along with representatives of the chief medical officers of the UK and the policy side were part of those discussions, and I think that that was a full offer of observer status for those groups, and that I felt at no point any difficulty about being able to contribute, particularly when we had something key to raise, and that in particular when we began to describe the first of the vaccine effectiveness studies, that was very, very welcomed by that SAGE group, as we had something new and important potentially as a path out of the lockdowns that had been in place, and relaxation of societal measures.
Mr Dawson: Was that through the EAVE II project?
Dr McMenamin: Yes, that’s correct.
Mr Dawson: We’ve heard some evidence about that already. My broad understanding is that that was a project which was able to deliver early, very early, in fact the earliest, I think, information about the effectiveness of the vaccines in February 2021 –
Dr McMenamin: Yes, that’s right.
Mr Dawson: – because it was a mechanism that was able to access information quickly through its previous set-up, if you like; is that correct?
Dr McMenamin: Indeed, and that first demonstration of effectiveness is of somewhere between 84% and 92% effectiveness for one dose of vaccine on a national basis was really important.
And picking up on something that Nick said earlier – I beg your pardon, Professor Phin – that we had the forethought to set something up after the 2009 pandemic which was now bearing fruit and was looking at the whole of the Scottish population to use information to be able to demonstrate that effect.
Mr Dawson: The EAVE project involved reviving, as I think you mentioned, a previous project and scaling it up, as I understand it, to be able to access a huge amount of information to inform us about –
Dr McMenamin: Indeed.
Mr Dawson: – the crisis, and therefore it was in a position to be able to report quickly on vaccine effectiveness, as we’ve discussed.
Was it a tool that was used in order to affect the real-time response or did it merely use the same dataset as was being used in order to inform that response?
Dr McMenamin: Well, Professor Aziz Sheikh and Professor Chris Robertson are the key architects of this from the University of Edinburgh, and through Professor Robertson who worked with us but is a University of Strathclyde professor of mathematics. It was using near real-time data to be able to demonstrate what our vaccine effect was, but also even before we had vaccines be able to say something about who is most at risk of the development of complications of Covid? The identification of those groups most at risk led to refinement of the some of the advice that was then able to be offered on a policy basis. We were able to use that dataset for validation of risk groups across the UK and, more than that, it’s really important and I think it’s become important for everyone that they have confidence about: is the vaccine that I’m going to receive going to make me unwell? And it is important, then we were able to investigate on a whole population basis things that might not have been picked up in any of the initial trials of vaccines but, because you were using a whole population, and even though you might have a rare side effect, something is one in a million, you’re able to identify that using that whole population basis.
Mr Dawson: In the period before that, I think you identified that the project was able to achieve research benefit which would assist the general pandemic response by identifying things through the researchers’ efforts, such as particularly at-risk groups and that sort of thing, which might not have been something available elsewhere –
Dr McMenamin: Absolutely.
Mr Dawson: – of the EAVE II project.
Dr McMenamin: Absolutely, and that demonstration of this surveillance output and the evaluation of the health policy and health benefit of some of our routine approaches was then immensely useful. Not just for Scotland, not just for the UK but was internationally greeted with the broad consensus that this was a really dramatic development that globally was then captured in media reporting.
Mr Dawson: We heard from Mr Roger Halliday about the lack of research opportunities and access to data that might have benefitted on a wider scale the pandemic response in Scotland. Would it be fair to say that EAVE II is the exception to that proposition, very much so?
Dr McMenamin: In fact that I think went much further than that. It’s integral to what Professor Phin and I, with PHS, are looking at about what should be an important part of what Public Health Scotland is doing routinely in the future for the observations about the impacts and description of risk factors, in particular looking at the health inequalities issues that our own organisation is trying to do to not only identify what the inequalities are, but to assess the interventions that are there to try and address those inequalities.
Mr Dawson: Thank you very much.
I believe, my Lady, we are to have a short break at this stage for the stenographer.
Lady Hallett: Because we may be sitting later –
Mr Dawson: Yes.
Lady Hallett: – the stenographer literally just needs to move her fingers –
Mr Dawson: A short break –
Lady Hallett: – or she gets very tired.
Mr Dawson: – would be convenient.
Lady Hallett: So I’m not going to go very far, I suggest other people don’t go, and I shall return at 4.05.
Mr Dawson: Thank you, my Lady.
(4.01 pm)
(A short break)
(4.05 pm)
Lady Hallett: Mr Dawson.
Mr Dawson: I have some questions for you now, it’s about two things that I think are related, broadly speaking: care home related guidance, but also something called the policy alignment check which you cover in your statements.
In relation to the care home guidance, we’ve heard some evidence about this already from Donald Macaskill of Scottish Care, and I think it’s fair to say that our understanding of the responses you have provided in this area is that, as per your general position, Professor Phin, you have provided a corporate response but were not part of PHS at the time of the early pandemic; and, Dr McMenamin, your position, as I understand it, is that care home guidance was not a matter that you had direct involvement in, there were others who dealt with that, but that very helpfully you have attempted to answer the question by looking at contemporaneous materials to assist us as best you can with the thinking and process behind care home guidance being issued over that early period.
So have I got that correct?
Dr McMenamin: Yes.
Mr Dawson: And I think that’s an important caveat to your evidence, that you were not, Dr McMenamin, the person who was actually dealing directly with this, but that you are assisting us on an informed but slightly second-hand basis. Is that fair?
Dr McMenamin: Indeed.
Mr Dawson: Could I just ask you, first of all, about aspects of your statement to do with the concept of the policy alignment check.
In particular, Dr McMenamin, you raise in your statement at paragraph 50.8 some of the challenges that appear to have been experienced by HPS in the early stages of the pandemic, trying to reach consensus in a timely manner. In particular, you refer to some disagreements with the Scottish Government about what precise language there should be and indeed who should take the lead, if you like, in relation to issuing guidance.
I wonder if, perhaps in the specific care context a bit more generally, you could explain to us the issues that were experienced, as you understand it, by HPS and subsequently PHS in that regard.
Dr McMenamin: Guidance spanned the period from March of 2020 onwards. My colleagues within HPS and then PHS from 1 April were then working collaboratively with a number of stakeholders to look at whatever guidance was required in each setting. As you might have already gathered, that increasing appreciation about what steps would need to be in place, particularly across the month of March, as we began to appreciate just exactly what we needed to plan for for Covid, meant that very rapidly we were trying to come to a conclusion about what initial guidance might be provided. So, for example, for care home settings, a provision of an initial response in which we were in liaison with Scottish Government, trying to rapidly pull together something for advice.
That is something which Professor Phin and all of us working in health protection are very familiar with, whenever you have an initial incident response where you often are giving completely unacceptable timelines to colleagues to rapidly contribute to information, recognising that you’ll do the best that you can for the maximum good within the time available to you, knowing that you may yet have opportunity to come back under current revisions, over the course of the rest of that month or later, to try and identify any further wording change or incorporate any of the new things available.
And in particular we’ve already began to talk about what the testing challenge was for us in that the number of tests that were available per day, talking about the most good that you could make of those tests was something which was incredibly clinically challenging.
You might imagine if someone is being managed in an intensive care or in a hospital bed and clinically there are some decisions to be made about what medicines, et cetera, that they’re receiving, that having priority for testing in that limited testing environment available to you becomes important, as is the investigation of incidents and outbreaks.
That meant that it’s not just our colleagues in Scottish Care but in fact everyone involved in that process who is then saying: what can we do to improve the availability of tests? We might recognise that we might not have them this very moment to be able to help with the care home setting, but what can be done to maximise our availability of those tests, and recognise that in fact that, as it turned out later, that we began to incrementally introduce those tests not just to the individuals receiving the care, but to staff that were also involved to try and make sure that we, as it became available to us, could manage that risk.
Mr Dawson: You’ve helpfully told us about the prevailing circumstances with regard to care home guidance.
In trying to combine two topics at once, which was my fault, I don’t think we’ve heard from you about the influence, if any, of the policy alignment check, particularly on the care home guidance in March.
Is there, based on your researches, an effect on the quality or timing of that guidance being provided by HPS?
Dr McMenamin: Forgive me, but it does sound as though there might be a misunderstanding about something.
Mr Dawson: Thank you.
Dr McMenamin: I think within the – I’m straying into territory for Professor Phin. In the corporate response that we outline, the policy alignment check and the arrangements for that were really something which stemmed from the middle of May onwards, rather than in this initial period that you’re speaking to for care homes, was something which we were looking at from the middle of March onwards.
Mr Dawson: Right. So it wasn’t an issue, it was simply because there’s a sentence in the corporate statement that suggests that the PAC process was a direct consequence of the NHS in Scotland having been placed on an emergency footing during the period from March 2020 to April 2022, but that may just reflect the entirety of the pandemic, it may not be that March was when this was actually an operative issue.
Dr McMenamin: I think I would understand that the key point that’s been made there is that, rather than Public Health Scotland – or their predecessor, HPS – being the key body who was responsible for guidance, it changed potentially as of those emergency powers coming in, because the primacy about who had control about the final bit of sign-off then becomes the Scottish ministers, and that that is a key distinction to make between the period before the institution of the emergency powers and the period that preceded it.
Mr Dawson: So let me just get this right. The emergency powers came in in Scotland on 26 March.
Dr McMenamin: Yes.
Mr Dawson: Which by your interpretation means that that was the point at which the Scottish ministers took responsibility over lockdowns, restrictions and the like?
Dr McMenamin: Well, they always did have control about that.
Mr Dawson: Yes.
Dr McMenamin: But rather that they, for guidance purposes, what I’m talking about here, that they had the final say about –
Mr Dawson: I see.
Dr McMenamin: – what should be communicated.
Mr Dawson: Right.
Dr McMenamin: And communication, then – as a key part of what you’re trying to do with guidance – was then their responsibility. So that’s not to say that of course our government colleagues didn’t have a significant input to anything that we said about guidance as one of our key partners in that period before –
Mr Dawson: Prior to that period, 26 March, HPS would, with in consultation with others like the government, have issued guidance of this nature by its own action.
Dr McMenamin: Indeed.
Mr Dawson: But then subsequent to that, there was a requirement, given the slightly changed position of the Scottish Government in the management of the pandemic, for there to be greater Scottish Government involvement in the process and effectively an alignment check between what you were proposing and what they were prepared to have put out. Is that broadly the position?
Dr McMenamin: Broadly speaking, without the term “policy alignment check” having been formally coined, because that was not coined until some point about the middle of May.
Mr Dawson: So this did not have an effect on guidance being issued about care homes in March.
Dr McMenamin: Correct.
Mr Dawson: The first such guidance having been issued, I think, on 13 March and that having preceded that period, that was simply issued by HPS itself; is that correct?
Dr McMenamin: It was issued by HPS itself following discussion with a number of our stakeholders.
Mr Dawson: Thank you.
Professor?
Dr Phin: Yeah, I wasn’t there at the time but, like Dr McMenamin, I’ve looked at the notes that were available, and I think it’s important that the guidance that was issued in March was actually for a care setting. It wasn’t simply care homes. It covered services delivered in the home, community services generally. It was a generic document. It wasn’t until later, I think until April, that we actually issued specific guidance for the care homes, by which time we were into this situation where sign-off was by Scottish Government.
The policy alignment guidance was absolutely key to taking forward guidance because, prior to that time, the challenge that we had was trying to get agreement and trying to get guidance out in a timely fashion, and – I think as you will see from some of the evidence we submitted –there were substantial delays in getting sign-off, which actually resulted in three or four sets of guidance actually not being issued but as moving on to an updated set of guidance. So the whole idea of the policy alignment is to try and speed up, make the process more efficient, and to address any concerns.
I would say that there was an analogy with Public Health England where we had something called the triple lock, which was an attempt to try and make sure that the organisations were all aligned and so that any guidance that was issued, you know, had the support and clarity from all organisations.
Mr Dawson: Could we look, please, at INQ000101020. This is the report which her Ladyship has seen before, “Discharges from NHS Scotland hospitals to care homes between 1 March and 31 May 2020”, published in October 2020. This is a report that was compiled by Public Health Scotland in connection with the discharge from hospitals to care homes over that period; is that right?
Dr McMenamin: That’s right.
Mr Dawson: In this report, it is, I think, set out that guidance was issued by HPS first on 13 March 2020?
Dr McMenamin: Yes.
Mr Dawson: And that it suggested a number of things, including social distancing, essential visits only, accept admissions to the home if safe, and close the home if resident tests positive.
Dr McMenamin: Yes.
Mr Dawson: That’s broadly what the guidance was.
Now, you’ve given an answer to this, I think, already, but I just want to address it directly.
That guidance contains no guidance or suggestion about the possibility of people being tested, or the requirement for a test before being moved from a hospital to a care home; is that right?
Dr McMenamin: Yes, that’s correct.
Mr Dawson: What is the reason why there is no element related to testing in that advice from HPS, as you understand it, based on your researches, Dr McMenamin?
Dr McMenamin: Well, my understanding was about availability of the tests that would be able to support such an approach, not just about, as you’ve just taken us into, discharge from hospital or admission from home to a care setting, but also the thinking that was going on in the background about: what would we need to be able to test not just those individuals who were in that care setting but potentially the staff who would be involved too?
Mr Dawson: So the issue was that, as you said earlier in your answer, there were no tests and there were difficulties around prioritising testing at that stage; is that –
Dr McMenamin: I think it’s the latter, that there was certainly significant pressure on test availability, dependent upon the setting that we wished to deploy it, and that there had to be effectively a triage, the concentration of where did we think the maximal benefit might derive from that test offer.
That’s not just from HPS at the time, or ultimately from PHS, but rather across all of the clinical service, about what could or should be done there.
Mr Dawson: Some might suggest, and indeed have suggested – and I would like to give you the opportunity, both of you, to comment on this – that at that time it was known that where the greatest need was was care homes, because the most vulnerable were the elderly and it was known or ought to have been known that care homes were generally an environment which had poor infection control, not at the level of a hospital, such that if a positive patient were released they would be exposed to a number of elderly vulnerable patients whom they would be likely to infect.
I simply invite your comment on that, because it’s a matter that’s been said to us by several witnesses.
Dr Phin: Could I come in on that point? I think – I don’t know if you’re aware of it, but there was a consensus statement issued on 26 May 2022, and this was a consensus statement that was commissioned by the Department of Health and Social Care in England and it was an independent report involving care homes, NHS, et cetera, and this was looking at the discharge of patients from hospital with Covid into care homes. It was a fairly extensive review, it actually used the data that was provided by Public Health Scotland in coming to its conclusions, and I think it draws out a couple of really important issues.
I think it recognises that both in care homes and in hospital we have two things, we’ve got two high contact groups, in other words we’ve got people being provided by care, very close contact, therefore potential for transmission is high, and they’re both dealing with vulnerable populations.
The conclusion of this report – and I’m very happy to forward it to you if you’ve not already seen it – is an acknowledgement that at least some care home outbreaks were caused, partly caused or intensified by discharge from hospital to care homes, and I think that’s an important issue.
They also identified, as was the case in the Public Health Scotland finding, that there is an association between care home size and outbreaks. In other words, the bigger the care home, the bigger the interactions, the more potential for outbreaks to occur.
And then finally, which I think is a really key issue, is that there was an acknowledgement that hospital discharges to care homes without testing early in the pandemic is highly likely to have caused some outbreaks. However, looking at two outbreaks that occurred, one in the East of England and one in Norfolk and Suffolk, the conclusion was that this was not the dominant driver, and in fact in the East of England study just under 6% of cases were definitely linked to hospital, and in fact in the Norfolk and Suffolk outbreak two out of 89 cases were linked. And again the conclusion is that hospital discharge was not a prominent feature of transmission in the healthcare setting.
Instead, and it’s in the report so I’m not – this is not me saying this – that care home staff and visiting professionals were probably the cause of many of the introductions and the promulgation of infection within the care homes, and they cite a case in Norfolk where there were six establishments, genetic sequencing identified this was not in the hospital, it was not in the community, it was being transmitted within the hospital setting.
So I’m not sure if you’re aware of it, I think it’s useful, because I think it acknowledges that there was an element but it was not the key, it was not the dominant route of transmission.
Mr Dawson: Do we see in either of the boxes on 13 or 26 March, which helpfully summarise the guidance, the two pieces of guidance issued by Health Protection Scotland, guidance relating to what should be done to minimise the risk of transmission by care home staff or visiting professionals?
Dr Phin: Sorry, I didn’t –
Dr McMenamin: For visiting professionals?
Mr Dawson: Yes, I’m quoting what I understood Professor Phin to have said was the predominant cause of the trans –
Dr Phin: Yes. That was the conclusion from this consensus –
Mr Dawson: What I’m asking is whether any guidance was given by this public health body to try to minimise that route of transmission at that time?
Dr McMenamin: If you mean –
Mr Dawson: Because I don’t see it in the boxes.
Dr McMenamin: Okay. The context here was regarding the care homes, which is what you’ve put up on the screen. Professor Phin’s already taken us into that, there was broader guidance that was available for use across the NHS and other settings, and indeed for the clinical management of individuals in the community. I think that the guidance was perhaps updated five times across the month of March. I’m not quite sure across the month of April how many times. But perhaps either Professor Phin or myself would need to come back to you about the detail of that specific question that you just asked.
Mr Dawson: It doesn’t appear in those boxes.
Dr McMenamin: That’s correct, it does not appear.
Mr Dawson: Yes.
Just to be clear, there was a second guidance, I think, issued by HPS on 26 March. Did your researches, Dr McMenamin, reveal why it was that a second piece of guidance was necessary at that particular point? There was a significant change obviously on 21 April, but why was a second guidance issued at that time?
Dr McMenamin: I think it would be fair to say that I’d just covered part of that by saying that each and every opportunity was made to update any of our guidance, and that there were five updates to that across the month of March. Forgive me, but I don’t know what the driver was for –
Mr Dawson: Yes. If you don’t know because of your limited involvement, I understand that, Dr McMenamin.
The other major element of these guidances – other than the fact that they don’t require negative tests or, as was subsequently the case, two negative tests before a patient or a resident would be allowed to be transferred from a hospital into a care home – is that the infection control measures and social distancing measures which are recommended here are, according to those who work within the care profession, completely unrealistic.
For example, “essential visits only” is simply something that many care home patients, many of whom suffer from dementia, it’s simply not something that is tolerable. Simply also that the vague suggestion that there should be social distancing in a care home with many patients with dementia, for example, is something at the very least – if not impossible, is something at the very least on which further specification would be required.
Have your researches indicated that there was any consideration in the publication of these guidance or these very practical limitations on the ability of the care sector to minimise infection within care homes?
Dr McMenamin: I think, certainly from what I have been able to see as communications in the background and from my own recollection of some of the discussions with colleagues at the time, of course all of those considerations were articulated, not just by Scottish Care, but were certainly discussed in a number of meetings across that time, and there were very passionate presentation of those views by a number of colleagues, including by Donald Macaskill, in those sorts of meetings.
I think that there was much sympathy for all of those views, but in practice what we had at the time was something which was scary because of the large number of potential deaths that we may yet go on to see at that time point, and regrettably – and it is with much regret that everyone, myself included, in PHS offer our deep regret about each and every one of those deaths and that for all of the families of everyone who was affected by this dreadful infection, and for the care staff too who managed all of these much loved individuals in those settings.
I think it would be certainly an instinctively human reaction that of course all of those things were being considered in each of those settings, but the key driver was: do the most good that we can. Understandably our knowledge at the time was as whatever you’ve seen documented, and that what we were then offering was the best advice at the time to try and deal with it, and that that then dynamically had to change over time as more information became available to us, particularly once we knew about the offer of tests when that became available to us.
Mr Dawson: Are there any – given your answer and what we’ve looked at, are there any elements of the public health services and Scotland’s role in providing guidance and support over this period that PHS, as kind of a legacy body, is able to identify, and are there any further expressions of regret which the organisation would like to advance on behalf of PHS to those who lost loved ones as a result of that mass outbreak of care home infections?
Dr Phin: Yes, I mean, unreservedly. Clearly the pandemic had an enormous impact and, as you say, a key risk factor for Covid complications and indeed deaths was age, older population, those with comorbidities, those with existing vulnerabilities, and these were the types of people who actually lived in some of the settings we’re describing at the moment.
It’s – I can only offer my sympathy, my condolences. This was a situation unprecedented. We were desperately trying to get principles, guidance out to care homes that they could use and adapt, and I have to stress that we recognised at the outset we cannot provide a set of guidance that answers every question, because as you have said there were people with dementia, there were people with other conditions for whom different types of care were necessary.
So what we tried to produce were some principles, some key pieces of guidance, and advice, that could be adapted and used in the healthcare setting – sorry, in the social care setting, where the people looking after those people had the better – had a greater insight into what they needed and how to adapt those principles in a practical and sensitive way.
So, yes, we – you know, my condolences on behalf of the organisation to all those families and individuals who suffered.
Dr McMenamin: One further thing perhaps to add is: you may recognise from the evidence that we’ve submitted, Public Health Scotland’s role here is in provision of guidance, it’s our local authority and NHS board colleagues who had the relationship with the care homes and, as Professor Phin has just taken us into, that opportunity for those offering care in the community was to make a dialogue with their local health protection teams and their public health departments to go through any issue that they had. That was certainly a really important thing for those departments to be able to collect any of the valuable intelligence there and share that, and indeed the very welcome component of Cabinet Secretary announcement also was the role to try and co-ordinate activity by the department – by the department of public health directors locally to try and address such circumstance.
Mr Dawson: Those provisions, I think you’re referring to the 21 April announcement?
Dr McMenamin: Yes.
Mr Dawson: Which is reflected again here. Is there any reason for you to think that those provisions could not have been introduced much earlier, based on your knowledge of the way that public health and these organisations and agencies work?
Dr McMenamin: Yeah, I think from the review of the information that I see, an earlier step in retrospect, something which could potentially have been done was that earlier appeal for better co-ordination. That’s not to say that any of our colleagues were not doing their best, but rather it was unclear about who had overall primacy in being able to make sure that things were as best co-ordinated as they possibly could be. I’ve already said that HPS and PHS didn’t have – we certainly don’t have any legislative power to be able to do anything for those settings.
Mr Dawson: Yes.
Dr McMenamin: Another body that is there is able to say something about the care homes, which is the Care Inspectorate. So for them, working in conjunction with those agencies who are responsible for the care of the population, it’s the NHS boards and the local authorities.
Mr Dawson: Thank you for that perspective.
I’d like to ask you about one other area. I might be able to cover this without going to the detailed report.
You’ve helpfully given us some very detailed information about a particular aspect of the Covid-19 pandemic in Scotland, namely the significance of the Nike conference which took place in late February 2020 as regards the transmission of the virus.
As I think is reflected in reports which emanate from PHS and you, this is an event which has largely been portrayed as a superspreader event, but as I understand it the – HPS undertook an investigation into the extent, retrospectively, as to whether that had in fact been the case or not.
My understanding is that the broad conclusions were that that proposition was in fact not correct, and that the strain of the virus which had been introduced via that event could be shown to have died out and not caused a mass outbreak of infection as had been speculated.
Is that the broad conclusion of the report?
Dr McMenamin: Indeed, the Nike conference wasn’t a ground zero, it was one of at least 200 plus introductions of slightly different variants of the Covid-19 virus into the population. There was some remarkable detective work enabled by whole genomic sequencing, looking at the genetic fingerprints of the different variants at the time which allowed us to demonstrate that the public health actions that were taken limited the effect of the spread.
The spread within the Scottish and indeed the UK population was something that appeared to be limited to those individuals who attended or, for instance, to households of those individuals, and that that certainly meant that we instituted a number of local actions to deal with that.
It’s certainly fair to say that that was certainly assisted later by what we then have all come to see, which is either for Scotland, the rest of the UK or internationally, across the month of March into April, all of the societal measures that then kicked in to try and limit the spread of infection, but we’ve certainly not seen recurrence of any of that infection –
Mr Dawson: It was that aspect that, not so much relating to the particular conference strain but the wider investigation that I was interested in, because I think what the report shows is that in Scotland on at least 283 occasions during March and February, Covid, SARS-CoV-2 was introduced into Scotland.
Dr McMenamin: Yes.
Mr Dawson: And there is in fact a separate estimate from another group of 307 over that period.
Dr McMenamin: Yes.
Mr Dawson: And that the lineages which were introduced over that period could be traced to mainland Europe, particularly Spain; is that right?
Dr McMenamin: I think particularly Italy, Spain and other European countries, yes.
Mr Dawson: Yes, thank you. Spain is just mentioned, but that – it is effectively from continental Europe where Covid came into Scotland over that period –
Dr McMenamin: Yes.
Mr Dawson: – is that what we think?
And the study also helpfully indicated that there was community transmission which was likely to have occurred in Scotland undetected up to one to two weeks earlier than the first detected case which was on 1 March; is that right?
Dr McMenamin: Yes.
Mr Dawson: And also it suggests that, considering the 14 to 28-day incubation period before seroconversion, the report concludes that it was likely that the virus began circulating in Scotland in late February 2020?
Dr McMenamin: Yes, on that basis.
Mr Dawson: Yes. So it’s a helpful indicator as to what was actually going on at that time, although of course unknown.
Dr McMenamin: Indeed.
Mr Dawson: Could I ask you about one further aspect of that, Dr McMenamin? You have in your report some observations. Another aspect of the Nike conference which has caused some degree of public consternation is the fact that information relating to it which was available to HPS in its investigations but Scottish Government and other agencies, other public agencies, was not publicised at that time, which I think created or contributed to the creation of an apprehension that something was being hidden from the public and that it was significant in connection with the way in which Covid spread in Scotland.
You suggest in your report I think that there are some positive public health reasons for not publicising the name. I think they include at least the – your experience that if one does release details of things like that, that that might reduce the willingness of the agency involved or the company involved to participate in initial investigations, which you have said are important; is that broadly correct?
Dr McMenamin: That’s correct.
Mr Dawson: Would it not have been possible, however, to try to find a middle ground? Because the public health communications policy of the Scottish Government subsequent to this was based very much on the idea – the idea – that the Scottish Government was being honest with the people of Scotland, and the Nike conference experience in many eyes soured that relationship and meant that people did not trust the Scottish Government.
Would it not have been possible to deal with those public health concerns that you’ve pointed out by anonymising but still releasing information so that people were aware that there was a potential threat, and perhaps even to reassure them about the fact that HPS and your colleagues were doing everything they could to try and keep it under control?
Dr McMenamin: So in retrospect, yes, that’s one certain area that it could have been done, but with the agreement of the Chief Medical Officer of the time they agreed with our conclusion which was to keep –
Mr Dawson: Thank you.
Dr McMenamin: – to keep the information as it was.
I do take your point that that is a really important area of keeping the public with us in any of our communication, and certainly our government colleagues were supportive of this at the time too.
Mr Dawson: Thank you very much. Just bear with me one second.
(Pause)
Mr Dawson: Those are my questions. I’m sure I could go on for many hours, but we’ve reached the end of the day.
There is one Rule 10 proposal which we are just dealing with, my Lady, very momentarily, from one of the core participants.
Lady Hallett: Which I haven’t seen yet?
Mr Dawson: No.
(Pause)
Lady Hallett: Are you the source, Ms Mitchell?
Ms Mitchell: I had assumed that that would be sent. I had checked, it was sent to the right box.
Two in the one day, my Lady, but it’s just that I had an opportunity that my learned friend didn’t have to look at the document that was being referred to by Dr Phin in relation to outbreaks, and –
Lady Hallett: Ask your question, Ms Mitchell.
Ms Mitchell: I’m obliged. I’ll be very, very quick.
Questions From Ms Mitchell KC
Ms Mitchell: The report you referred to, just so we can be clear I’m talking about the right document, is the consensus statement on the association between the discharge of patients from hospitals and Covid in care homes published 26 May 2022; is that correct?
Dr Phin: That’s correct, yes.
Ms Mitchell: You clearly have a detailed knowledge of that report. The report indicates that in relation to the data from which – the information you gave about discharge into care homes, that has some important limitations; is that correct?
Dr Phin: Yeah.
Ms Mitchell: Can you identify what those limitations are? Would it be easier for me to point them out to you, at this time of day, perhaps?
Dr Phin: Well, I would be happy to take it and give a fuller response.
Ms Mitchell: Perhaps I can just put it this way: the limitations are, I think, broadly speaking, two-fold in relation to the data.
The first of these two, what are described as important features of limitations of the data, is that there was lone variable levels of testing in care homes’ populations in wave 1, with variations between areas depending on testing capacity. Typically, symptomatic residents admitted to hospital were tested but asymptomatic residents who were admitted for other reasons were not routinely tested. So there was a testing problem: if you couldn’t test, you didn’t know where Covid might have come from. Is that correct?
Dr Phin: Well, yes, generally, but the two instances are cited where a study was carried out in the East of England where they were able to demonstrate that 6% of cases were linked, and that is where whole genome sequencing would have been an important component.
The other one was an investigation of six establishments that were linked in Norfolk and Suffolk, where again two out of 89 were linked through this genetic fingerprinting –
Ms Mitchell: Indeed.
Dr Phin: – able to say these were exactly the same strain and there was nothing in the community that we were aware of and there was nothing in the hospital.
I think what these are is a consensus statement, these are a group of people both NHS, social care, scientists, and this is their conclusion, looking at a number of different studies, and … yeah.
Ms Mitchell: And indeed their conclusion, that the first part was that all analysis of the impact of hospital discharges are limited by two important features of the available data, the first which was identified, the second which is no UK country can easily and completely identify who is resident in care homes or who was discharged from hospital to care homes because sometimes the addresses weren’t changed. So that is another limiting factor of the data.
And in fact the report ends by saying none of these problems are fixable retrospectively, meaning that all of the analysis done are based in data that are less than ideal. Is that correct?
Dr Phin: That is the conclusion of that group. I would add though that they additionally looked at international studies, which actually supported the findings of their conclusion. So I keep going – I go back to it’s a consensus group.
I’m simply reporting and I’m – I think it would be obviously relevant to this Inquiry that they had a copy of that report, given it does highlight some of the issues that I think have been raised elsewhere.
Ms Mitchell: I’m obliged.
Lady Hallett: Thank you very much, Ms Mitchell.
Thank you, Mr Dawson.
Thank you both very much. Thank you or a second time, Dr McMenamin. I’ll try not to call you in every module, but thank you for your help. Thank you, Professor, for your help too.
(The witnesses withdrew)
Lady Hallett: And I hope that everyone gets as restful a weekend as possible, and I will see everyone at 10 o’clock on Monday. Thank you.
(4.48 pm)
(The hearing adjourned until 10 am on Monday, 22 January 2024)