Transcript of Module 2A Public Hearing on 22 January 2024

(10.00 am)

Lady Hallett: Good morning.

Mr Dawson: Good morning.

Lady Hallett: I’m grateful everyone’s managed to get through. By the looks of our public gallery, not that many of our normal attendees are present, but I’m grateful for everybody else who has obviously made a huge effort to get through.

Mr Dawson: There is one minor preliminary matter, my Lady, that I was just intending to deal with. This week your Ladyship will hear evidence from a number of medical and scientific witnesses. Your Ladyship will, however, not hear evidence from former Chief Medical Officer for Scotland, Dr Catherine Calderwood, who has been excused participation due to ill health.

The first witness this morning is Caroline Lamb. The questioning will be done by my learned friend Ms Arlidge.

Lady Hallett: Thank you.

1. Ms Caroline Lamb

MS CAROLINE LAMB (affirmed).

Questions From Counsel to the Inquiry

Ms Arlidge: My Lady.

You are Caroline Lamb?

Ms Caroline Lamb: I am.

Counsel Inquiry: You’ve provided the Inquiry with a number of witness statements in various guises in respect of your role at the directorate of health and social care. I’m going to have to take you to them all very briefly at this moment in time.

So if we first turn to your own personal statement, or your individual statement, that is INQ000315534. Hopefully that’s familiar to you.

Ms Caroline Lamb: It is, yes.

Counsel Inquiry: On page 12 is your signature and statement of truth. Are you happy that that statement remains true?

Ms Caroline Lamb: Yes, happy with that.

Counsel Inquiry: There are also – there’s a statement INQ000215470, and this sets out details about the roles of various directorate subgroups within the directorate. Again, are you content that that remains true and honest to the best of your knowledge and belief?

Ms Caroline Lamb: I am, yeah.

Counsel Inquiry: We then have an addendum statement dated 10 November 2023, INQ000343900.

Ms Caroline Lamb: Yep.

Counsel Inquiry: Again –

Ms Caroline Lamb: Content.

Counsel Inquiry: And INQ000215488.

Ms Caroline Lamb: Yes, correct.

Counsel Inquiry: INQ000346089 deals with care homes.

Ms Caroline Lamb: Yep, correct.

Counsel Inquiry: And finally, INQ000372948.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: They’re all familiar?

Ms Caroline Lamb: They are.

Counsel Inquiry: They’re all what you were expecting to come up on the screen?

Ms Caroline Lamb: Absolutely.

Counsel Inquiry: Now, you gave evidence in Module 1, so –

Ms Caroline Lamb: I did.

Counsel Inquiry: – you’ll remember we have a stenographer who is providing a live transcript and provides a transcript at the end of the day, so I’d just ask you to keep your voice up and remember that a nod doesn’t reflect on the transcript so easily.

You are currently Director-General Health and Social Care and the chief executive of NHS Scotland; is that right?

Ms Caroline Lamb: That’s correct.

Counsel Inquiry: And you started your role in Scottish Government as director of digital and service engagement at that directorate in December 2019?

Ms Caroline Lamb: That’s correct.

Counsel Inquiry: You then moved on to, in that role, expanded into various things that were Covid-related specifically. We’ll come to those in a moment. But in January 2021, you became Director-General and chief executive of NHS Scotland; is that right?

Ms Caroline Lamb: That’s correct.

Counsel Inquiry: So taking the first year of your role, from about – we’ll be discussing various of these roles in more detail during the course of your evidence, but from about mid-March 2020 until early May 2020, were you the delivery director for intensive care capacity expansion?

Ms Caroline Lamb: That’s correct, yes.

Counsel Inquiry: Thereafter did you become involved in the contact tracing system development in Scotland?

Ms Caroline Lamb: Yes, I did, I led the delivery of contact tracing.

Counsel Inquiry: And then after, from August 2020, you moved on to be delivery director for the vaccination programme; is that right?

Ms Caroline Lamb: That’s correct.

Counsel Inquiry: Then 2021, as we’ve just discovered, you became chief executive of NHS Scotland. Just for clarity’s sake, is it right you’re not a clinician or a doctor?

Ms Caroline Lamb: That’s correct.

Counsel Inquiry: You’re a leader in bringing things together rather than providing clinical advice –

Ms Caroline Lamb: Absolutely, yes.

Counsel Inquiry: – is that fair?

Just in terms of the sort of provision of advice to Scottish Government and to ministers, the witness statement – one of the corporate witness statements, INQ000215470, sets out how ministers – how advice is provided to ministers in the following terms. It’s paragraphs 39 to 40.

I won’t take you through the whole thing, don’t worry, I won’t read it all out, but effectively policy papers are drawn up by – within the directorate, passed to Chief Medical Officer, for example, their team, to look at it from clinical perspective, and bringing together no doubt a number of threads within a policy paper that is going up to ministers; is that right?

Ms Caroline Lamb: Yes, that’s correct, yeah.

Counsel Inquiry: In terms of the commissioning of that advice, is that something that the directorate itself says “Ministers need to know about this particular point, we’re going to produce a policy paper”, or is it ministers coming to the directorate and saying “We want to do this, can you give us a policy paper”?

Ms Caroline Lamb: It could be either. So it could be us, officials within the DG, putting advice up to ministers on something that they needed to be aware of. It could be ministers asking for additional advice relating to something that we’d already put up. Or it could be ministers asking us for advice in relation to, as you said, an intervention or a policy that they wished to pursue.

Counsel Inquiry: When that policy paper is provided, it goes to Cabinet via the CMO; is that right?

Ms Caroline Lamb: So –

Counsel Inquiry: In most cases?

Ms Caroline Lamb: During the Covid – during the period of the Covid pandemic, there were many papers going to Cabinet, so it would depend on the content of that. But there would be – the Chief Medical Officer, the CMO, certainly attended Cabinet meetings, and was there to provide advice on the papers that were going, not all of which would have been coming from the CMO, or indeed from officials within the DG Health and Social Care, they would come from across government.

Counsel Inquiry: And were the policy papers on the whole or entirely consensus papers or were they range of options and balance – and disputed …

Ms Caroline Lamb: Again, they could be both, so you will have heard about the four harms group that was set up in order to try to look at the impact of policy interventions in the Covid pandemic from a range of different perspectives, and that group was very much set up to enable discussion amongst officials from different perspectives in order to provide sort of holistic and comprehensive advice to ministers. So there would be disagreements within those areas, particularly about the relative balance between responding to each one of those – each one of those four harms. But the mechanisms for pulling together the advice were designed to try to enable us to provide the most comprehensive advice to ministers possible, and that would often include options for ministers to make decisions on.

Counsel Inquiry: You’ve mentioned the four harms, so if we move to the four harms just briefly at this point. When you became Director-General, is it right that you at that point became a member of the four harms group, so you were attending those meetings?

Ms Caroline Lamb: That’s correct, yes.

Counsel Inquiry: And that group, the Inquiry’s heard evidence, had been meeting since October 2020, so two or three months before you joined.

What sort of briefing were you given to explain what the purpose of that group was, as effectively a late joiner?

Ms Caroline Lamb: So I was already aware of the work of the four harms group because I was a member of the DG before I became Director-General. So I was aware that we would often discuss on our daily directors’ calls what were the topics that were going to be discussed at the four harms, what was the evidence that we were pulling together, particularly around harms 1 and 2, which were the health-related harms that were a particular focus obviously for people in the DG Health and Social Care. So I don’t think I really needed briefing about the purpose of the four harms, I was already well aware of it. And even before that four harms structure was formally established I think we were already trying to look across to other colleagues across Scottish Government in terms of recognising that, whilst obviously there was a very significant health impact of the Covid pandemic, that wasn’t the only impact.

Counsel Inquiry: As you just identified, harms 1 and 2 obviously of primary relevance and importance to your group, to your directorate. Professor Cairney last week gave evidence that his impression of the four harms group was it was about – it was a statement of the problem, it wasn’t a statement of the solution. So it was reminding those involved in decision-making of the balance, the trade-offs that existed, as you say, in terms of one intervention leading to harms in another area.

Was that something that you had a similar impression, as someone who was contributing yourself within that group?

Ms Caroline Lamb: My impression was that the four harms group was bringing together not just officials and clinicians from within the DG Health and Social Care, and indeed colleagues from the wider system through the National Incident Management Team, but also colleagues with an interest in the social impacts and the economic impacts, and I suppose there was very much that recognition of trying to understand what the impact was across all those four areas.

I think potentially it was simpler in the – particular in the early days of the pandemic to understand the health-related harms than it was to understand the social and economic-related harms, and therefore, you know, maybe there was more of a focus on just trying to understand what those social and economic harms were.

But it was absolutely about trying to provide advice to ministers that set out the broad context and enabled them to make the choices with advice around what some of the other impacts would be as well as just the health impacts.

Counsel Inquiry: And in your role, did you – was it your role to advocate for the – harms 1 and 2, or to take part in that balancing exercise yourself in terms of providing advice to the ministers?

Ms Caroline Lamb: So I think my role and the role of colleagues within the DG was very much to present the evidence that we had, which changed at different stages of the pandemic, to be really clear about what was – what – the impact around harm 1, so, you know, be really clear about the numbers that we had in hospital and intensive care, the people – the rate of Covid in the community, but also about the knock-on impact on harm 2.

Now, whilst we are, of course, extremely passionate about health and social care services and providing those services for the people of Scotland, I think our role was really to very much present that evidence and to be really clear about the impact in relation to harms 1 and 2 rather than particularly advocating for those harms as opposed to other harms that were undoubtedly occurring as well.

Counsel Inquiry: Because some might say trying to delineate between different harms broadly is not quite as straightforward as: this number of people dying from Covid, this number of people have Covid, this number of people aren’t able to access cancer treatment this week; because effectively they all link in with each other, don’t they?

Ms Caroline Lamb: Absolutely. I think that was both one of the – that was why the four harms was such a valuable forum to try to actually – for us as officials but also in presenting our advice to ministers, to be really clear about all the different aspects and all the different harms that were occurring. So I think that was really valuable. But yes, it’s undoubtedly challenging, because there are judgement calls and balances to be made about – and, as I say, I think probably particularly in the early stages the data and evidence that we had was more – was more relevant to harms 1 and 2 than it was to harms 3 and 4.

Counsel Inquiry: And to what extent did you sort of liaise with colleagues in different departments with different harms to hand, for instance? So, for instance, harm 2, the broader health consequences.

Ms Caroline Lamb: Yep.

Counsel Inquiry: You’ve got the direct broader health consequences of someone not being treated for cancer or the like at a particular moment in time. But that inevitably has an economic effect or a societal effect as well, doesn’t it, because firstly, from an NHS Scotland point of view, those costs are being pushed down the line and it’s more expensive to treat people who are sicker in the future? And those people who are sick may not be able to go to work so much, so there’s an economic impact.

So how did you in your role and your team’s role seek to advance those sorts of interconnected elements within the four harms strategy?

Ms Caroline Lamb: So I think we were – we probably started off in the early days being most concerned about harm 1 and about protecting, absolutely protecting people from Covid, and then as we sought to re-mobilise health services and to try to get back to a position where people were able to get screening appointments, for example, we were also, I think, hugely conscious of the backlogs that were building up and, as you’ve rightly pointed out, the fact that that ill health doesn’t go away and it gets more difficult to treat.

And equally I think we were also conscious of the economic impact in terms of the number of people who were economically active in society, but also what that means for people as well. So we have – I gave evidence in Module 1 about our focus on health inequalities and on the – all the factors that contribute towards good overall health that actually have nothing to do with health and social care systems, it’s all about whether people are able to get good employment, get good housing, whether they’re able to live in a good environment. So I think to characterise us as being narrowly focused on harms 1 and 2 doesn’t take into account the fact that we have been – had a commitment for many years towards trying to improve health inequalities, and critical to that is having, as I’ve said, good jobs, good housing, good education. So I think we’re always mindful of those other factors as well.

Counsel Inquiry: Over the course of your time on the group, did you find that there was a shift in focus, in terms of the group, the ministers’ approach to balancing the four harms?

Ms Caroline Lamb: I think that the shift in focus also related to the progression of the pandemic and where the pandemic was at any one point and, you know, again, as you’ll be aware, that went through peaks and troughs, so with – through the first wave and then into new waves and new variants. But I think there was absolutely an understanding of the impact that the pandemic and the measures that would be taken to control the pandemic were having on other aspects of social life and economy as well.

Counsel Inquiry: We move on to another element of your role in the first year of your time as a Directorate. From January 2020 to January 2021, Test & Protect steering group membership.

Ms Caroline Lamb: Yep.

Counsel Inquiry: I think you joined – you were chairman of the Test & Protect steering group from the outset; is that right?

Ms Caroline Lamb: So my recollection is that I first got involved in Test & Protect in probably mid-March, early April – no, sorry, let me correct myself there.

I think Scotland launched the Test & Protect strategy on 5 May, and that’s the point at which I was appointed delivery director for the contact tracing element of Test & Protect. Prior to that, I’d been, first of all, involved in ramping up our digital approach, and particularly the video conferencing near me that enabled online consultations, and then, as you said earlier, in the work around expanding ICU. But my engagement in Test & Protect really started formally from, I think it was actually 5 May.

Counsel Inquiry: So is it the case that you were involved with the Test & Protect for the app and the contact tracing we’ll come on to in a moment, rather than the setting up of the strategy about testing itself in the early stages of the pandemic?

Ms Caroline Lamb: Yeah, that’s correct. My role was very much on the delivery side, to make sure that our strategy could be put into practice and delivered.

Counsel Inquiry: There were various different testing groups or committees set up to deal with testing and strategising about ramping up testing capacity and the like. The Inquiry has a statement from David Crossman, who was Chief Scientist for Health. We don’t need to bring it up on screen, but for reference and for the transcript, that’s INQ000273976.

Now, he was involved in something called SABoT(?), and that was about testing strategies, making sure that people were physically getting the testing samples and the mechanisms as well as the operation – so the operationalisation of things as well as the strategy.

Did that interact with your steering group on Test & Protect?

Ms Caroline Lamb: Yeah, so the group that David Crossman chaired was a subgroup of the Covid-19 Advisory Group, and it was very much looking at the scientific, the technical evidence around different sorts of testing, and then using that to help inform our strategy around where we would prioritise our testing capacity, and then, yes, you know, how that would actually be delivered. And to bear in mind that that involved not just having the capacity in labs to actually perform the tests, but having the capacity to take samples from people, whether it’s in the community or in hospital setting or whatever.

So, yeah, there was absolutely a feed-through. I think the way that generally happened was from the group that Professor Crossman chaired feeding through into policy advice to ministers that became our testing strategies which then got operationalised through the Test & Protect strategy. Initially focused around testing but then extending into contact tracing as we had the capacity, the testing capacity to be able to do that.

Counsel Inquiry: In your roles – I appreciate you weren’t on the SABoT, for instance, and you were in the operationalisation of the contact tracing, but to what extent were the numbers of tests literally available core to the strategy in terms of contact tracing, in terms of Test & Protect going forwards? How did that change over the course of the first three or four months, say?

Ms Caroline Lamb: So that was absolutely fundamental to being – the number of test – having availability of tests and having a reduced amount of community transmission was really important to being able to build a sustainable contact tracing system, so – to – to get into contact tracing at scale, which is what we did from the announcement of the strategy to – it was launched I think about 28 May, we launched the Test & Protect, so the “protect” bit being the contact tracing and support to isolate element. It was important that we were confident that we had enough testing capacity then so that people who were able to get tested and to confirm whether they were in fact Covid-positive so that we were then able to kick off the mechanisms to trace their contacts and provide them with appropriate advice.

Counsel Inquiry: And at the start of the pandemic, to what extent did Scotland have its own testing capacity or was it reliant upon external, private labs?

Ms Caroline Lamb: So to a very, very – very small extent. Clearly at the very start of the pandemic then, first of all, an appropriate test had to be developed. In the early, very early days, we were reliant on sending tests down to, I think it’s Colindale. We then took measures to develop, I think as soon as a test was available, took measures to develop capacity. Originally we had capacity in Edinburgh and Glasgow. I think it was about 350 tests a day. We extended that into Dundee and then worked really hard to build our NHS Scotland capacity alongside also engaging with UK Government around the set-up of the Lighthouse labs.

Counsel Inquiry: Because there is effectively a need to get ahead of the game for two reasons. Or many reasons but let’s look at two here. One, because the whole world is about to want to get into testing, so, in terms of capacity, you have to be ahead of the game to ensure you have enough materials and enough capacity in that regard, don’t you? And then, secondly, in order – you have to get ahead of the game in order to physically have the number of tests to make sure that you’re putting the swabs where you need to put the swabs and tracing outbreaks?

Ms Caroline Lamb: Yeah.

Counsel Inquiry: Do you agree with both of those?

Ms Caroline Lamb: Yeah, so I’d agree with both of those statements. I think that having the actual technology to be able to do the testing was important, but also then having the facilities, the people on the ground to actually be able to carry out the sampling, yeah, absolutely, particularly taking swabs, yes.

Counsel Inquiry: The Inquiry heard evidence last week that there was some concerns expressed by some of your colleagues – Derek Grieve in the public health side of things – that there was insufficient urgency amongst some departments and some members of Scottish Government about ramping up the response to the threat posed by the pandemic.

Was the limited number of tests in February/March a result of that, in your view, or at least contributed to by that?

Ms Caroline Lamb: So I wouldn’t – I don’t think so. I think that we were – certainly given that our focus originally was on NHS Scotland and working with NHS Scotland to ramp up tests, absolutely NHS Scotland was very, very acutely concerned to get those tests ramped up. I’m not sure exactly what the context is of that statement from Derek, but my – my impression could be that that might be about the way in which Scottish Government was able to pivot to support the huge amount – the huge volume of extra work that was involved within the DG Health and Social Care to produce the advice, to produce – you know, to support delivery organisations to get all of this set up, but I’m –

Counsel Inquiry: Because something like this requires good funding, good focus, a concerted effort from multiple different departments and individuals, and lots of cogs in the wheel to get things moving at the earliest possibility – possible time?

Ms Caroline Lamb: Yes, it absolutely does. I think that I – you know, I said in my opening statement at Module 1 just how grateful I am to everybody who worked across Health and Social Care, in the DG, and in health boards and social care organisations, but, you know, people really went the extra mile to pull together – local authority colleagues as well – in terms of providing – you know, identifying locations for testing sites, identifying locations that would help us to get people who maybe would find it more difficult to travel to some of the bigger sites. It was an enormous team effort, yes.

Counsel Inquiry: And in terms of your role in Test & Protect, were you involved in discussions about prioritising those limited tests at the beginning?

Ms Caroline Lamb: I wasn’t directly involved in the discussions around prioritisation so I – you know, I was aware of the approach that was being taken, which was very much around prioritising, first of all, being able to treat people and be able to know who had Covid-19, and then move progressively towards protecting the vulnerable, and then out into trying to break chains of transmission. But I wasn’t directly involved at that point in those – in the provision of that advice or the co-ordination of that advice.

Counsel Inquiry: Was that advice that came from SABoT or your directorate?

Ms Caroline Lamb: So it was a – SABoT was providing advice and that advice was then corralled through the clinicians within particularly the Chief Medical Officer, Chief Nursing Officer and others within the DG.

Counsel Inquiry: And in terms of that corralling of that advice, who was making the decisions or advising about who to prioritise for testing, for instance?

Ms Caroline Lamb: So the advice around prioritisation came from clinicians, and was also, I suppose, you know, linked with advice from officials around how many tests we had, how quickly we expected to be able to ramp up that testing capacity, what was the likely demand for testing in each of those groups, so – and then – but – and the decisions around the apps, the prioritisation was – that advice then went to ministers and ministers made the decisions around the prioritisation.

Counsel Inquiry: In terms of sort of sections of society who could have been prioritised, or balancing all of those things into the mix, to what extent is it effectively determined by which clinician is shouting the loudest in those circumstances rather than a broader analysis? So, for instance – it’s in the title of your directorate, you’ve got health and social care.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: So to what extent is there someone in the room advocating for social care to have greater prioritisation in testing capacity usage?

Ms Caroline Lamb: So my recollection of the conversations at the time around testing and then, when I was more directly involved in the delivery of the vaccination programme, around, you know, how we approached our role out of the vaccination programme, was that absolutely our Chief Nurse particularly was a huge advocate for social care and for doing as much as we could to protect vulnerable. And actually some of the early decisions that were made around the prioritisation of our testing capacity as we started to ramp it up – but we were nowhere near the numbers of daily tests that we had later in the pandemic – some of the early decisions were around, first of all, around testing – testing people before they – who were being discharged from hospitals to care homes.

Counsel Inquiry: The Inquiry heard last week about various studies, for example, that have been gone into, the effect or otherwise of testing before release into care homes. But if we take it back a few months in the piece, say, lots of – there were lots of deaths in care homes from the very earliest stages of the pandemic, weren’t there?

Ms Caroline Lamb: Yes.

Counsel Inquiry: And the majority of deaths in the first wave were in care homes; is that right?

Ms Caroline Lamb: Yes, I believe that’s correct, yep.

Counsel Inquiry: So in terms of – and of course even from the very beginning everyone was conscious that some demographics were more vulnerable to either very serious consequences or death as a result of Covid infection, and age was a significant factor in that.

So with the social care hat of the DHSC element, some might say that department is in the best position to understand the number of patients being discharged from hospitals into care homes, for example, because you’ve got the hospital side of things and the social care side of things. You can understand how many patients are being discharged from hospitals into care in the community, and you can work out how many patients are coming into hospital with Covid from care homes or care – or who were receiving care in the community. And all of that would be useful information, wouldn’t it, to consider the risk profiles and to look at whether that particular cohort required prioritisation of testing?

Ms Caroline Lamb: So what I would say to that is I don’t think that we had the – we didn’t have as good data as we would have liked to have, particularly in those early days. So whilst we have good data on who’s in hospital, that doesn’t necessarily extend to knowing where they’ve come from. And we were – we did not have great data on exactly who was in care homes.

Counsel Inquiry: Should you have –

Ms Caroline Lamb: We took measures to improve that really quickly, but we had to put that in place.

Lady Hallett: But going back to Ms Arlidge’s question, you would have had the data on people going from hospital to care homes, wouldn’t you?

Ms Caroline Lamb: We would have data on people being discharged from hospitals, but not necessarily what setting they were being discharged to.

Ms Arlidge: Would that not be considered of central importance in circumstances where patients were being discharged with – because if there’s Covid in people who are sick or exposing people to people who have been in hospital with Covid, is that not a key fundamental marker to understand where there is risk at its highest?

Ms Caroline Lamb: So I absolutely agree that we did not have as good a quality data around the social care, the whole of the adult social care sector, at the beginning of the beginning, as we would have liked, and I think that reflects the fact that whilst Scottish Government and Scottish ministers are responsible for NHS Scotland and for healthcare in Scotland, the statutory responsibility for adult social care sits with local government and it is a much more fragmented system than the way in which we provide healthcare services.

We worked extremely hard to try to improve the data that we had around care homes and around adult social care more broadly. In the first instance that we did that setting up the safety huddle tool which was designed not only to give better information at both a national and a local – by “local” in this context I mean NHS board level – but also to gather information around things like, for example, infection prevention and control measures, staff absences within those homes, because there are – I think some of the research that’s been done since the start of the pandemic would demonstrate that there are – there were a number of factors that influenced the extremely tragic death rate in care homes, and one of those was around admissions from hospitals, but actually there was a much stronger correlation in the Public Health Scotland report around the size of the care home, which probably linked to the, you know – and links as well, sorry, to the prevalence of Covid in the local community.

Counsel Inquiry: What consideration, therefore, was in – particularly in circumstances where you didn’t have the data that you would have liked, that – care homes are effectively a completely different kettle of fish than discharging into ordinary – you know, in a normal circumstance – because in a care home there is inevitable need for close contact with patients, lots of care home residents simply wouldn’t be in a position to function without that sort of care, some of the residents wouldn’t be able to understand why social distancing or PPE was required, and all that sort of thing. So having all of the particular features of a care home, at what point did your directorate sort of say “Well, hang on a minute, this is a perfect storm potentially brewing” and what efforts were made to do something about it?

Ms Caroline Lamb: Yeah. So I think first of all we absolutely recognise that the nature of a care home, as you’ve described, with people requiring, you know, very close intimate contact from staff, the sort of quite closed nature of the community, did present a heightened risk.

We – in I think it was middle of March, so around 12 March, Health Protection Scotland issued some guidance on infection prevention and control specifically aimed at care homes. We already had the National Infection Prevention and Control Manual, which dates back to 2012, and that contained relevant – information that’s relevant to care homes, but didn’t articulate, that didn’t give example – worked examples for care home settings.

So Health Protection Scotland, HPS, issued guidance on the 12th, that was followed up on 13 March, by our Chief Medical Officer and Chief Nursing Officer writing – issuing further guidance, which was to sort of extend into the more clinical zone, so not just about infection prevention and control, but also things around restrictions on visiting and isolation, and isolation for people who were admitted either with symptoms or even were already in the care home with symptoms, and other factors.

That was then – I think that guidance was then updated again at the end of March, and again later on, probably April or May, and the Cabinet Secretary made her announcement about testing on discharge in mid-April.

So there was a huge focus around what needed to be done to try to support care homes, to keep their residents safe, to support them around infection prevention and control and really good procedures around that and other things, and you’ll also be aware that the Cabinet Secretary asked directors of public health in NHS boards to convene multidisciplinary groups to ensure that support was provided to care homes.

Counsel Inquiry: But by the time this guidance starts coming in, people are already dying at a high rate in care homes, aren’t they?

Ms Caroline Lamb: So the first guidance was issued on 12 March, which was, you know, I – it wasn’t – it wasn’t that there was no guidance there before, there was guidance there in the National Infection Prevention Manual, which had been in place since 2012, the health and social care pandemic flu plan was clear about the additional risks in care home-like environments for elderly people and the increased infection prevention and control measures that need to be followed. But I think that wasn’t there was guidance and, you know, worked examples that were relevant to – more relevant to care homes. And I think as well that – maybe that what we hadn’t fully taken account of was the number of care homes, the range of – whether, you know, public sector, private sector, voluntary sector, the number of employers and, therefore, the additional challenges of making sure that staff are actually aware of the guidance and trained in it.

Counsel Inquiry: Moving on to the Test & Protect hat that you wore, as it were.

Ms Caroline Lamb: Yep.

Counsel Inquiry: 7 May 2020, the Scottish Government announced that they’ve managed to get to 3,500 tests a day and they’re trying to ramp it up to 8,000 tests by mid-May. How many tests did you need at that sort of time in order to make Test & Protect – we’ll go on to exactly what that means – a functioning system?

Ms Caroline Lamb: I’m sorry, I can’t recall the actual modelling that was done around that. What I do recall is that during May and as – no doubt as a consequence of the national lockdown, the rates of Covid reduced quite substantially. In fact when we first launched contact tracing for Test & Protect on 28 May, case numbers were very low.

Counsel Inquiry: Perhaps a simple question.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: The Inquiry’s heard evidence that the principle is test, trace, isolate.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: Sometimes it’s called “test and trace”. Why was it called Test & Protect in Scotland?

Ms Caroline Lamb: I’m not sure I can give you a direct answer to that. It started off – the policy was described as “test, trace, isolate, support”, so TTIS, and maybe Test & Protect was just thought to be a bit snappier in terms of communicating the public the intention, because the intention was to test people both in order to protect them and protect the rest of society. Now, behind that, absolutely, there were four pillars, one was testing – testing, contract tracing, isolated – isolating and – and providing people with support for isolation. So in terms of the delivery of the programme we were working across all those – all those aspects, but I think Test & Protect was just designed to be a name for the programme that the public could relate to and that they would engage with and – and, you know, be part of.

Lady Hallett: One could ask: why is it called Test and Trace in England?

Ms Arlidge: Test & Protect is announced on 6 May 2020, contact tracing goes live two days later.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: Prior to that, presumably there’s quite a lot of employing contact tracers, because at this stage, to be clear, this is not the app that –

Ms Caroline Lamb: Yeah.

Counsel Inquiry: So this is someone tests positive and someone has to give them a ring and say “Where have you been in the past five days?” Is that the position?

Ms Caroline Lamb: Yes, yeah, that’s absolutely correct. Contact tracing was based on people phoning up. So they would speak to – somebody tested positive, they would get a phone call, they would be asked to talk through their contacts. So you’re right, yeah.

Counsel Inquiry: So inherently kind of reliant on (a) the memory of the person who has tested positive, sometimes in circumstances where they might be quite unwell with their Covid infection; it relies upon the honesty of that person; and it relies upon the ability of the contact tracer to properly take someone through their story. Is that fair?

Ms Caroline Lamb: Yes, I think that’s fair, yeah.

Counsel Inquiry: So what training did contact tracers, for instance, have to undergo and how long did that take to set up?

Ms Caroline Lamb: Yeah, so we started – the way in which we approached contact tracing in Scotland was to build on the existing local health protection teams in our NHS boards, so we looked to scale up those teams, but to augment that with a national contact tracing capacity that could be used to support local systems where they were experiencing peaks in infection, and also that increasingly became an approach where the local health protection teams who had the sort of more detailed knowledge locally would deal with the highest risk cases from the highest risk settings, and the national team would deal with the, you know, more straightforward risks.

So in terms of training, public health, we worked with Public Health Scotland to develop the core scripts for contact tracing, we worked with NHS Education for Scotland, who are our education board, to put in place training packages. As you say, all of that stood up – stood up really, really quickly. So we went through a process – we also stood up the actual contact tracing system itself to enable all of that to be – to be logged. And it was important to us to have that as a national system so that it would be public for the national contact tracing facility to actually step in and support – support board, because everybody was working off the same – off the same system.

So the education and training packages were put in place during the course of May. The – when contact tracing first launched, a lot of boards had – because we were still – we were – not all NHS services were operating, so a lot of boards re-deployed existing members of staff into their health protection teams to provide that additional support. It was an online, an internet-enabled service, so it didn’t mean people had to be sitting in a call centre, they could work remotely, which was, again, incredibly helpful in terms of getting that set up.

Counsel Inquiry: Going back, taking that in stages, you say that was basically happening in May?

Ms Caroline Lamb: Yeah.

Counsel Inquiry: Lockdown comes 23 March. It’s known that pandemics, whichever kind of pandemic, testing, tracing, isolating contacts is a key part to try and get on top of the spread of a virus. Why was contact tracing only stepped up in May and not on the agenda getting things moving three months earlier?

Ms Caroline Lamb: So it absolutely was on the agenda. So it absolutely was on the agenda, and we were talking about it from, I think, April, early April, possibly earlier, but my – I’m speaking here very much from my experience, so I was brought into the process on about 5 May. At that point, Public Health Scotland had already been working up the, you know, what were all the different workstreams that needed – were needed, so, you know, the thinking on that was already well advanced. I think it was a combination of getting to the point where we would have the testing capacity available. And also, again, my understanding is that contact tracing, you know, WHO would indicate that there is a level of transmission within the community at which contact tracing is not really viable and not the best use of resources. So we had to get back to having a lower level of transmission in the community, and then be ready to launch that – launch the process, which we were.

Counsel Inquiry: So it goes live on 28 May. About a month later, on 21 June, I think leaflets are sent out to the public sort of explaining what it’s all intended – sort of why it’s happening and sort of giving more detail. Was it being found that people were simply not understanding the principle of Test & Protect?

Ms Caroline Lamb: I’m sorry, but I can’t recall the reason why those leaflets were sent, what I do recall is that from the first few weeks of operation of the Test & Protect system, there were, as I’ve said before, extremely low case numbers. And, whilst that might be a really good way to test a brand new system, actually in terms of that wider public knowledge of that, maybe it probably meant that there wasn’t a huge amount of activity going on for the first couple of weeks.

Counsel Inquiry: Fast forward a bit longer to when it moves from contact tracers and then moves into producing an app?

Ms Caroline Lamb: Yeah.

Counsel Inquiry: So 10 September, I think, is when the Protect Scotland app goes live. It’s – again, just so we’re clear, this is sort of the “ping” –

Ms Caroline Lamb: Yes.

Counsel Inquiry: – “pingdemic” and all of the things that were in the press at the time, designed to work on phones to physically locate you next to someone and so trace contacts in that –

Ms Caroline Lamb: Yes, that’s correct, yeah.

Counsel Inquiry: Did the human contact tracing then come to an end at that point?

Ms Caroline Lamb: No, it didn’t. We very much regarded the app as being an additional tool in the tool box around contact tracing, and it was, you know, very much there to, you know, support people to look after themselves as well in terms of, you know, knowing that they’d been in contact with somebody.

So, no, the human contact tracing continued and we also continued to develop our digital approaches to contact tracing, which included being able to send digital forms to people for them to fill in with their contact details.

Counsel Inquiry: And the app launches on the 10th, within 24 hours 600,000 people have downloaded it, and within a week I think it’s – about a week, there are 100 people that are told to self-isolate. What studies were going on to make sure that it was actually working?

Ms Caroline Lamb: I’m sorry, I’m not sure I can answer that. By the time we got to that point, I was actually working on the vaccination programme, so my recollection – obviously I was aware of the app being developed and my digital directorate would have been very involved – would have been very involved in that, but I’d need to refer you elsewhere for details around –

Counsel Inquiry: You may, therefore, not be able to help with the next question, but I’m going to ask it anyway –

Ms Caroline Lamb: Okay.

Counsel Inquiry: – and if you can’t help us, say so.

11 November it’s been announced that there has been a coding error in the app and so the estimation is about half of those testing positive, their contacts aren’t being traced properly, so there’s a chunk of people who have just gone missing under the app. Do you have any insight into that? Can you recall that?

Ms Caroline Lamb: I can’t – I can’t specifically recall that. What – I guess what I would say is that the fact that we still had the physical contact tracing capacity in place – so we were – at no point were we relying just on the app.

Counsel Inquiry: I think the next day, so 12 November, there was an announcement that it was felt that something like 8% or three and a half thousand people had not been traced by contact tracers since the beginning of July. So that combination of the app perhaps not working so well or something going wrong in the coding and the contact tracers not making contact with three and a half thousand people does suggest, doesn’t it, that there were people falling through the gaps, and that inevitably led to infections that – because people weren’t isolating because they didn’t know they had to?

Ms Caroline Lamb: So I absolutely accept that, and I do recall, you know, our concerns about the – when the contact tracing centres were making multiple calls to people who were contacts but had not been able to – had not been able to trace them, had not been able to speak to them. So yeah, there were issues around – and particularly as, you know, life got a bit more back to normal and people had more contacts.

Counsel Inquiry: And as life got back to normal and sort of more people moving around as well, we hear the phrase regularly, the virus doesn’t respect borders, but it’s right, isn’t it, that Protect Scotland was a different app to the app that was in England, and so if people were crossing the borders or contacting people from England or vice versa that app wouldn’t necessarily pick up those contacts; is that right?

Ms Caroline Lamb: So it was a different app, we took a different approach to information governance around the development of the app. I think we worked pretty hard with the other UK nations to try to make sure that they were compatible, but, I’m sorry, I don’t know the detail of the extent to which they were compatible or not.

Counsel Inquiry: Again, because you had moved on to different roles, it may be that you’re not able to help so much in terms of the Status app, so that was the – I appreciate you were involved in vaccines at the time, so it may be that you’ve got some oversight of this. But in September 2021, so some time later, there’s the COVID Status app is produced or set out, and that’s effectively the vaccine passport; is that right?

Ms Caroline Lamb: Yeah, that’s what it came to be called, yeah.

Counsel Inquiry: Colloquially called the vaccine passport. And that was released at a time when infections were getting higher and higher in Scotland, September 2021, hit by the Omicron wave.

Was there a risk or did it occur that the vaccine made everyone “Oh, look, I’ve got a vaccine, you know, this is my passport to freedom” in circumstances where society is opening up, but infections are climbing rapidly?

Ms Caroline Lamb: I think you’d probably need to ask a clinician for a view on the extent to which maybe that – or a behavioural – I think that it was the case that I think one of the reasons, one of the – part of the thinking behind having the vaccine Status app was to, absolutely, to encourage people to take up vaccination because that was, you know, our single route towards protecting – protecting people better.

Counsel Inquiry: Can we now move to a completely different area.

Ms Caroline Lamb: Okay.

Counsel Inquiry: Shielding and the involvement of your department in shielding broadly, not in a clinical sense at all, but in terms of the impact of shielding on decision-making by ministers in Scotland.

So a shielding programme is implemented in mid-March 2020. When was shielding first on the agenda, as it were, in the department?

Ms Caroline Lamb: I think there were discussions from quite early on as it became clear that the threat that we were facing from the pandemic about how we could protect the most vulnerable, so … aware of conversations particularly around, you know, the CMO, the CNO and then the four CMOs – in my understanding four CMOs worked together to develop the list, the definition list of those who were felt to be most vulnerable to the virus. We worked with Public Health Scotland, with colleagues in local authorities to try to come up with as complete a list as possible, and clinicians locally had the ability to add to that list. So if they felt that – you know, if a general practitioner felt that they had somebody who wasn’t on the list but should be, then they could add those on to the list.

So it was – formed part of our discussion from a pretty early stage, both in relation to identifying and categorising that shielding list, but also then what were we going to put in place to support those people.

Counsel Inquiry: And again, sort of expanding into the social care side of the DHSC title, you’ve got people who are clinically extremely vulnerable as a result of their pre-existing conditions or treatment that they’re undergoing, but you’ve also got people who are vulnerable because of health conditions that wouldn’t necessarily make them more vulnerable to the virus but are unable to access society in a result of things like lockdown and the like, and perhaps feel more vulnerable, whether or not they are in the clinically extremely vulnerable list.

So practicality in sort of shielding policy and ensuring access for people, the Inquiry heard last week that effectively a two-tier approach to shielding developed almost accidentally, because highest-risk list were given access to services with a priority for online delivery slots and prescription deliveries and that sort of thing, but people who were not at the highest risk under the clinically vulnerable analysis but still vulnerable as a result of, for instance, their disability, meant that they were in a second tier, they didn’t have that priority access and they didn’t have the – they were reliant still on other people to assist them and give rise to greater risk for them.

So was there any thought put to the fact that people might be de-prioritised under the shielding, because of the overly – not necessarily overfocused but the focus on shielding necessarily meant that services might be being removed or made harder to access to others?

Ms Caroline Lamb: So I suppose to respond to that in a couple of ways. Firstly, I don’t think there was any – ever any intention or to somehow sort of ration support that was available and to focus that at the clinically vulnerable group. Our local authorities worked through their local resilience partnerships and through – using their – I can’t remember precisely what they call them, but their lists of the most vulnerable people that they would use in relation to other, you know, civil emergencies, et cetera. They worked, I think, really hard, as did many voluntary organisations and others. So I think that, you know, the shielding list was very much about those who were clinically vulnerable, but there were other support mechanisms that, you know – like I say, I know – I don’t know the direct details but I know local authority colleagues worked really hard to put in place around people who weren’t clinically vulnerable but would be vulnerable for other reasons.

Counsel Inquiry: To what extent did things like the data issues that we’ve already covered cause problems in making sure that those vulnerable – not the clinically extremely vulnerable, the vulnerable people – didn’t fall – or did that lead to them falling through the gaps?

Ms Caroline Lamb: I don’t think I could answer that one, because that will depend on how good the data was that was held at a local, local authority level and that may well differ from one authority to the other.

Counsel Inquiry: You spoke earlier about the recognition of inequalities and – inequalities in health, inequalities in socioeconomic status and the like.

In one of the corporate statements, INQ000215470, paragraph 46, you say that the advice was based – CMO’s advice was based on what was considered best for Scotland having regard to health status of Scottish population and its characteristics, noted that it’s an older population than the average UK – it’s all right, you don’t need to go through it line by line – and multimorbidities, more multimorbidities. So greater vulnerabilities, greater risks, different socioeconomic risks, different ethnic group risks than in the UK as a whole.

You say in that statement that:

“Where there was a divergence of approach to NPIs in Scotland compared with other UK nations, this was driven by differences in the Scottish population and other factors. Advice was given solely on what was genuinely considered to be appropriate for Scotland. Where it was possible to achieve consistency with the other UK nations, that was desirable, but it was not always possible.”

Why wasn’t it always possible?

Ms Caroline Lamb: So, I think that, for two things. One, you referred to the different characteristics of a Scottish population, and I think as a result of those characteristics (older population, more multimorbidities), we were inclined probably to be more cautious, because of the nature of that population. I think the second area is, you know, there are also things that are just different. So, for example, school terms are different in Scotland than in England. So, you know, so there were some things around decisions around schools that just needed to be different because we have a different system.

Counsel Inquiry: The Inquiry has been provided with various papers in this regard, a presentation from – again, it doesn’t need to come up, but just for the transcript – Scottish Government’s Communities Analysis Division, which is the “Impact of Covid-19 on Equality Groups: Disability analysis”, was undertaken in October 2020, and there was a report from the Scottish Government titled “Coronavirus … impact on equality (research)”, September 2020. So there’s research being undertaken about the unequal impact of the virus and the underlying inequalities.

What concrete measures were being put in place to combat those inequalities in the second and third waves of the pandemic when, looking back and – because you see these reports, so what are those reports being operationalised into, in order to protect those who are more vulnerable for the various inequality reasons?

Ms Caroline Lamb: I would say that, look, the key aspect of that was in relation to the vaccination programme, with vaccinations being the thing that we could most positively do to protect everybody, and we – the vaccination programme had its own separate workstream around equalities, and that was all about trying to ensure that we didn’t just – you know, it wasn’t good enough just to hit the standard level of take-up for vaccinations, we needed to push it as hard as possible and we needed to try to ensure that we removed as many barriers as possible in relation to people from different communities, whether they be ethnic minority communities, whether they be Gypsy and traveller communities, whether they be some of our more socially disadvantaged communities, in ensuring that vaccination was easily available and that people were supported to get vaccinations.

The testing, our approach to testing also developed in relation to, you know, understanding some of those inequality impacts, again with mobile testing units with very local testing units and again trying to ensure that as far as possible we were reaching every corner of Scottish society.

Counsel Inquiry: Because some communities might be less likely to come forward for tests and some communities might be less willing to come forward for vaccinations?

Ms Caroline Lamb: Yeah. That’s absolutely right.

Counsel Inquiry: Turning then to NHS capacity in Scotland. At the start of 2020 you were involved in ICU capacity development, but I want to look at it in two stages, very briefly: there’s the ICU – develop ICU capacity and then there’s broader NHS capacity issues, both of which I think fall within your pile of things that you have to get through on a daily basis.

It’s an often repeated comment, both in this Inquiry and in broader circumstances, that the lockdown was to prevent – to stop the NHS being overwhelmed, and there was ICU – that relates to both ICU capacity in terms of just simply not having enough ventilators, et cetera, if the virus became – if everyone needed a ventilator –

Ms Caroline Lamb: Yeah.

Counsel Inquiry: – there simply weren’t enough ventilators to go around. Equally, not everyone needed a ventilator, but needed a bed and varying levels of clinical assistance in hospital settings.

In the first three months, so when you were looking at ICU capacity, what was being done in the non-ICU capacity expansion plans?

Ms Caroline Lamb: So in terms of the non-ICU capacity, I think two things. First of all, recognising that we had – we have the physical infrastructure that we have, we were concerned obviously about the number of beds but actually probably more concerned about the people to staff those beds as well, particularly when, you know, healthcare workers are not immune from becoming ill with Covid as well. So that is why we were focused on really trying to preserve the capacity that we had in the NHS for the people who would be – who would most need it. So we knew that we needed to obviously support people with Covid but on top of that retain the capacity to deal with emergency unscheduled care and also to keep cancer treatments, for example, going. So as a result of that we stood down a lot of our elective capacity, so the – a lot of the planned care didn’t happen during that period, in order to protect that capacity and to enable us to – enable the NHS boards to deploy staff who would maybe normally be involved in elective care to be able to staff both ICU and to provide extra capacity in emergency and unscheduled care as well. There was also the Louisa Jordan development as well.

Counsel Inquiry: We’ll talk about Louisa Jordan in a moment.

Capacity is effectively multifactorial, isn’t it?

Ms Caroline Lamb: Yeah.

Counsel Inquiry: It’s having physical beds, it’s having ventilators, it’s having the staff, sufficiently trained stuff to man the ventilators, to treat patients. It’s having enough people to, you know, repair the ventilators and to clean them and to do all of the backroom efforts as well.

But presumably some of those factors are an awful lot easier to predict and manage than others, because, as you say, doctors and nurses and staff get sick themselves. So when you talk about expanding ICU capacity and indeed just general NHS capacity, how do you bring in extra sort of human capacity as the pandemic progresses?

Ms Caroline Lamb: Yeah. Yeah, so what we did in relation to that was we – essentially we issued a call to people who were, you know, recent retired, people who maybe had been working in the healthcare professions and weren’t any longer. The regulators, the GMC, the Nursing and Midwifery Council supported all UK governments in terms of being able to get people back onto the register. We had – one of our health boards supported us to set up a portal which enabled people to register their interest and desire to come back and support NHS Scotland. Not just NHS Scotland but also social care as well. And through those portals, NHS boards were able to – and social care organisations would be able to identify people who were able and willing to come back into the system of support. So we did track new staff in the early stages of the pandemic. We also brought students. So final year students, medical students and nursing and AHP students, came into the wards to work as well.

Counsel Inquiry: So you stepped up that capacity in the early stages by – and by closing down wards, as you’ve already said, and closing down electives.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: That occurs sort of fairly early on in matters, and when everyone is in sort of crisis mode, I suppose is the way of putting it. But the capacity issues continue for some time, don’t they, because – if we have up, please, INQ000274150.

Which is a slide that we looked at last week with the statisticians. So I’m not going to take you through the statistics in that way.

It’s page 15, please.

What we see here is the number of patient – or per capita rates of Covid-19 patients in hospital. So we see the peaks of the early pandemic, when capacity is being increased. We’ll ignore the change in methodology for this purpose, we don’t need to get into that.

October 2020, there’s the second wave, as it were. And then what I want to look at is effectively the third wave, the October 2021 peaks that we see there. Because I’ll come on in a moment to what that looked like on the ground, but we see, don’t we, that in Scotland in that period from sort of September 2021 onwards there is a large part of the time when there are more patients per capita in hospital in Scotland than there are in the UK with Covid. So there is all of a sudden higher rates of Covid in hospitals in Scotland – not all of a sudden, but for quite a sustained period, at the back end, second half or back end of 2021.

If we therefore can have up, please – and before we do, I appreciate of course that this is only to deal with Covid patients. There’s a whole load of other patients that require treatment at the same time for different things. So this doesn’t tell us how full the hospitals are, it tells us that there are more people in hospital with Covid than elsewhere in the country.

So if I take you, please, to INQ000360218, it’s a series of – I’ll take them very briefly, I was just going to say. We’ve got problems in capacity in terms of ambulances not being able to – so ambulance service is stretched to breaking point, we see that in that article, and they have problems with not being able to – so the ambulance service themselves are struggling, but equally one of the problems that is attributed to that is they can’t offload their patients in hospital because A&E wards are – A&E is stretched past capacity.

Is that fair?

Ms Caroline Lamb: Yes, absolutely, the system was under – that’s about the time the Omicron wave hit Scotland and you see from the earlier graph that Scotland had a much more severe increase in that period than England. I think England then sort of caught up with us around Christmas time, but essentially we went into winter earlier than we have gone into winter previously, in terms of pressures.

Counsel Inquiry: It meant various very drastic steps had to be taken in hospitals, so non-urgent operations were cancelled, I think, in a number of trusts, the public was asked only to ring 999 in circumstances of immediate life-threatening emergency, and subsequently the military were drafted in to assist with things like ambulance driving; is that right?

Ms Caroline Lamb: So if I just say, we had already – through Covid, we had introduced a reform of urgent and unscheduled care, so we were already trying to ensure that people who maybe didn’t need urgent care were effectively triaged through our NHS 24, our 111 service, and therefore kept away from the front door of our hospitals. We also had a significant extra investment going into the Scottish Ambulance Service, which – as I say, unfortunately Omicron hit us a bit before we would normally expect to get into winter pressures. But yes, it was an extremely difficult period. It wasn’t – it wasn’t consistent across the whole of Scotland, so I think Omicron tended to focus across the central belt of Scotland. But our systems were, had been trying to get back a bit more into business as usual, so hospitals were very full, hence the difficulty with offloading ambulances, yeah.

Counsel Inquiry: And the Royal College of Emergency Medicine I think in September said “We need more beds, we need a thousand more beds in order to try to get us over this issue”. Were those beds forthcoming?

Ms Caroline Lamb: The approach that we’ve taken to increasing capacity in NHS Scotland is to focus that capacity on where people need it. So with the – I suppose, the mantra behind that being about we only want people to be in hospital if they absolutely need to be in hospital, so we have focused a lot on what we can do to support people not to turn up to the front door in the first place, either through being triaged in 111 or the ambulance service, who do an amazing job of actually seeing and treating people rather than conveying them to hospital. We’ve also worked on Hospital at Home, so in response to your question, Hospital at Home provides that level of service to people in their own homes rather than in hospital. And I can’t recall exactly what capacity we’re at on there, but it’s something like the equivalent of three district general hospitals. So we have increased capacity, but we’ve not always done it in the acute hospital –

Counsel Inquiry: And the acute hospital settings were being overwhelmed for – not blanket across Scotland –

Ms Caroline Lamb: That’s correct.

Counsel Inquiry: – but there were a number of trusts who were on critical footings in October 2021 –

Ms Caroline Lamb: Yes, there were periods –

Counsel Inquiry: – and were not able to provide the service as a result of multifactorial issues, but Covid being part of that 18 months into pandemic; that’s right, isn’t it?

Ms Caroline Lamb: So, absolutely, Covid is part of that. There is a new infectious pathogen in our system that we didn’t have before. We were also coping with the impact of the first waves of Covid, and particularly seeing that people who were presenting particularly at A&E were sicker than they had been previously. So what impacts on hospital occupancy is also the length of time that people spend in hospital, and we have seen that occupancy rise, so people spending slightly longer in hospital. Which is partly a factor of that demographic of people being older, frailer, more multimorbidity, but no doubt Covid’s had an impact as well.

Counsel Inquiry: Were lessons simply not learned in the first two waves such that by the third wave, when you had those warnings, the capacity simply hadn’t been increased sufficiently?

Ms Caroline Lamb: So I think lessons were absolutely, absolutely were learned. Omicron I think did – the severity of the Omicron wave and – and the time it took, which – it hit earlier than we were expecting it.

Ms Arlidge: My Lady, is that a convenient moment?

Lady Hallett: Yes, of course. 11.35, please.

Ms Arlidge: Thank you very much, my Lady.

(11.21 am)

(A short break)

(11.35 am)

Lady Hallett: Ms Arlidge.

Ms Arlidge: Thank you, my Lady.

Just before the break we were talking about capacity. I just want to touch very briefly on the Louisa Jordan, if I may. 20 April 2020, Louisa Jordan was opened in Glasgow SEC. This was – I think, had 300 beds as an initial capacity, with the option of scaling it up.

In terms of the – I appreciate you weren’t in that particular post at the time – but in terms of actual use of Louisa Jordan, what was it – what was the hospital in fact used for?

Ms Caroline Lamb: So fortunately we never had to use it in relation to sort of, you know, overflow because other facilities were unable to cope. What we did use it for, NHS Greater Glasgow and Clyde used it for outpatient clinics once we started to get back a bit more to business as usual, and then it was used intensively as a vaccination centre as well.

Counsel Inquiry: How was it staffed, in light of what you said earlier about the ability to bring in staff and –

Ms Caroline Lamb: So when NHS Greater Glasgow and Clyde were using it for outpatients, that was NHS Greater Glasgow and Clyde staff who were deployed, and obviously it was a site that was away from areas where people with Covid were being treated.

Counsel Inquiry: When it was being set up, how was it intended that –

Ms Caroline Lamb: Oh, how was it intended? My apologies –

Counsel Inquiry: No, no, I was going to come –

Ms Caroline Lamb: Yeah, my apologies.

It was intended that we would use the – use some of the staff that we were getting through the – through the portal but that – also that we would use staff from within our other boards, and again that might have been redeploying them away from what might have been their original duties, given that we weren’t undertaking planned care at that point.

Counsel Inquiry: Why was the decision taken to decommission Louisa Jordan in April 2021?

Ms Caroline Lamb: I think the main reason – so at that point it was being used as a vaccination centre but it was part of releasing the SEC to get back to business as usual, particularly in advance of hosting COP26.

Counsel Inquiry: The issues of capacity we were talking about just before the break, was ever thought given to recommissioning it or doing something similar in order to assist with the overwhelming of the NHS in the later half of 2021?

Ms Caroline Lamb: I think – just relate to my earlier question, I think in terms of the issues that we have around managing hospital capacity, the focus there needs to be on making sure that we’ve only got the people in hospital who need to be in hospital so ensuring that once people are ready to be discharged they are discharged, so we do still have challenges around delayed discharges. And building more out of hospital capacity as well, particularly through Hospital at Home.

Counsel Inquiry: Another topic very, very briefly. Nosocomial infections.

Ms Caroline Lamb: Yeah.

Counsel Inquiry: The Inquiry of course is, will be looking at healthcare in more detail in future modules, so this is very much a sort of narrow issue in terms of Scottish Government decision-making in this regard.

There was a review group established in May 2020, wasn’t there, to look into nosocomial infections? Why was it formed then?

Ms Caroline Lamb: I think it was formed then – so we already have in place processes, advisory groups around nosocomial infection. I think that particular group was put in place to bring some additional capacity into that, into that work.

Counsel Inquiry: Because in, as the pandemic progressed, people were still getting Covid in hospital settings, despite the fact that infection control and the like were – would be better there than anywhere else, or should be better there than anywhere else in the community; that’s right, isn’t it?

Ms Caroline Lamb: Yes, that’s correct, and I think there’s a role for everybody working in health and social care to stay vigilant around infection prevention and control. We launched a campaign around – I think it’s called “It’s kind to remind”, which was about just remembering that infection prevention and control is just as important in the non-patient-facing areas in hospitals as the patient-facing areas.

So, you know, we spent a lot of time trying to ensure that people understand and are able to comply with infection prevention and control. But it is something that, not just Covid but for other infections people absolutely need to stay alert to.

Counsel Inquiry: The Inquiry has evidence, and there has been evidence heard elsewhere about, and again this is something that will obviously be covered in more detail in future modules, it arises in this regard out of evidence given last week by Dr Jim Elder-Woodward and the concerns in the disabled community, DPOs in particular, in relation to access to treatment and DNACPR, so do not attempt cardiopulmonary resuscitation.

The Inquiry has heard evidence and seen evidence that one of the health boards in Scotland published a Covid triage document online for a period which set out sort of how patients would be triaged in terms of accessing healthcare. Can you comment on that?

Ms Caroline Lamb: I’m sorry, I can’t, I haven’t seen that document.

Counsel Inquiry: Okay.

I want to take you back – not back, but … you say in your statement, paragraph – or page 11, INQ000315534, page 11, paragraph 35, you’re talking about ramping up infrastructure and ensuring that there is infrastructure in place in the course of a future pandemic or in terms of testing, vaccine – necessary infrastructure at the time had to be largely built from scratch, and I think what you’re saying here is: make sure it doesn’t have to be built from scratch again, keep the structures in place, to some extent?

Ms Caroline Lamb: Yeah. Absolutely.

Counsel Inquiry: You then say at paragraph 37 of your statement that:

“Better management of any future pandemic,

regardless of the particular characteristics of that

pandemic, will rely on the ability to ramp up key public

health infrastructure.”

You then say:

“Much of this has already been stood down as

a result of the withdrawal of UK Government funding.”

But it’s right, isn’t it, that the way funding

works, Scotland gets a block grant for health, and

Scottish ministers determine, decide as part of their

role how that funding is allocated, don’t they?

Ms Caroline Lamb: That’s correct. I think my – but I think we also have

to pay attention to the fact that during the Covid

pandemic there was additional funding made available

specifically for areas such as testing and the

Lighthouse labs, et cetera.

Lady Hallett: Sorry to interrupt. I thought the block

grant was block grant generally and then the Scottish

Government decided. I think your question said a block

grant for health.

Ms Arlidge: Sorry.

Funding is allocated in a block, and it is allocated

by Scottish Government to whatever areas they choose to allocate it to. So whilst you say that this has been stood down as a result of UK funding withdrawal, some of this infrastructure, what steps have been taken within your directorate and more broadly to maintain the level of capacity that you think is appropriate?

Ms Caroline Lamb: So I’m sure you will have seen evidence that Scotland’s established a Standing Committee on Pandemic Preparedness, and that has issued its draft report. It’s due to issue its final report this year. That is looking at the establishment of a Scottish centre for pandemic preparedness or planning, I can’t remember exactly what it’s due to be called.

I think in terms of what we have done so far is we have tried to, as economically as possible, maintain the sort of core capacity to be able to ramp up, but a lot of that is around some of our digital capacity, some of our data flows.

But the fact remains that were we to need to go back to sort of mass population level testing again, then that is something that would need to be funded on a four nations basis.

Counsel Inquiry: But it doesn’t preclude the infrastructure remaining in place –

Ms Caroline Lamb: It –

Counsel Inquiry: – so it is not a question of going back to zero?

Ms Caroline Lamb: I think you can keep some of the infrastructure in place

but it would still require significant additional

investment to ramp that up and get it going.

Counsel Inquiry: A ramping up phase.

Ms Arlidge: My Lady, have you got any questions?

Lady Hallett: No, I have no questions, thank you very much.

Forgive me. (Pause).

Thank you very much indeed, Ms Lamb, for all your

help for the second time. I’ll try not to call on you

too often but I can’t guarantee there won’t be

another –

The Witness: Yes, I expect we’ll be meeting again.

Lady Hallett: Thank you very much indeed.

(The witness withdrew)

Ms Arlidge: I’m grateful, my Lady. We now play a bit of

musical chairs in the bench.

(Pause)

Mr Dawson: My Lady, the next witness is Professor Sir

Gregor Smith.