2. Professor Sir Smith

PROFESSOR SIR GREGOR SMITH (affirmed).

Questions From Lead Counsel to the Inquiry for Module 2A

Mr Dawson: You are Professor Sir Gregor Smith?

Professor Sir Smith: I am.

Lead 2A: I was planning on addressing you as Professor Smith,

would that be appropriate?

Professor Sir Smith: Absolutely fine, thank you.

Lead 2A: You have helpfully provided a statement to the Inquiry, Professor Smith, which is under reference INQ000273978. Is that your statement there?

Professor Sir Smith: It is.

Lead 2A: You’re familiar with the statement, and have had the opportunity to go through it in advance of giving evidence?

Professor Sir Smith: I have, yes.

Lead 2A: Has the content of this statement remained true and accurate as far as you’re concerned?

Professor Sir Smith: As far as I’m aware, yes.

Lead 2A: Thank you.

You are currently the Chief Medical Officer for Scotland; is that correct?

Professor Sir Smith: That’s correct.

Lead 2A: And you originally trained as a general practitioner?

Professor Sir Smith: I did, yes.

Lead 2A: You were formerly a medical director for primary care, I believe, in NHS Lanarkshire?

Professor Sir Smith: That’s correct.

Lead 2A: And you began working for Scottish Government as a medical adviser in primary care in 2012?

Professor Sir Smith: That would be correct, yes.

Lead 2A: I think there was an element of your work at that time that was the particular focus of your initial engagement relating to the Scottish GP contract; is that correct?

Professor Sir Smith: So during that initial period within Scottish Government up to 2015, I was a senior medical adviser in primary care, and part of the remit there was involved in the development of a new GP contract in Scotland.

Lead 2A: Thank you. You were appointed Deputy Chief Medical Officer of Scotland in 2015.

Professor Sir Smith: That’s correct.

Lead 2A: You were appointed interim Chief Medical Officer on 5 April 2020?

Professor Sir Smith: That’s correct.

Lead 2A: You were appointed to that role at the point when the previous Chief Medical Officer, Dr Catherine Calderwood, resigned?

Professor Sir Smith: Yes.

Lead 2A: And you subsequently became the Chief Medical Officer for Scotland on 23 December 2020?

Professor Sir Smith: That’s correct.

Lead 2A: Could you please give us a broad outline of the roles of both the Chief Medical Officer and the Deputy Chief Medical Officer, the latter being the role that you held at the beginning of the pandemic?

Professor Sir Smith: So in relation to specifically to the pandemic, the Chief Medical Officer was the principal independent clinical adviser to Scottish ministers and to officials. The role of the Chief Medical Officer in relation to the pandemic was to try to collate as much evidence as was possible about that emerging threat which had been identified relating to a novel coronavirus disease emerging in China at that point in time.

And the DCMO, the Deputy Chief Medical Officer’s role was to support the Chief Medical Officer in doing that, but also at that time a large part of my role was to take care of a lot of the other business that related to the office and to try to keep that business as usual, properly going(?).

Lead 2A: Thank you.

There is another prominent role within the advisory structure of the Scottish Government called the National Clinical Director; is that correct?

Professor Sir Smith: That’s correct.

Lead 2A: That post was held during the course of the pandemic by Professor Jason Leitch?

Professor Sir Smith: That’s correct.

Lead 2A: I believe that role to be a unique role when comparing the advisory structures in the United Kingdom. Could you please explain broadly how it is that the duties of the holder of that role fit in with the duties you’ve just explained, in particular focusing on the beginning of the pandemic.

Professor Sir Smith: Professor Leitch will be able to give you a much broader assessment of how his role worked at that point in time. From my perspective, the National Clinical Director’s role has always been complementary to that of the Chief Medical Officer, but focused on a slightly different remit.

The National Clinical Director’s remit has been broadly facing the NHS within Scotland rather than public health, up until that point, and at that early part of the pandemic response I am unaware as to the full extent of the National Clinical Director’s involvement in discussions with the CMO at that point in time.

Lead 2A: Right, I understand.

Professor Sir Smith: My understanding is that the National Clinical Director was very focused on preparation of the NHS.

Lead 2A: Right.

Given that you subsequently became the interim Chief Medical Officer, and then Chief Medical Officer towards the end of 2020, can you broadly explain for her Ladyship how it was that those roles developed as the pandemic went on and the requirements from medical advisers perhaps changed?

Professor Sir Smith: It was very clear to me that the scale of the threat and the response that was required to that threat required much more capacity clinically within Scottish Government advisory circles that we had at that point in time, so I recruited additional staff when I took over in April 2020, but I also sought to involve the skills that the National Clinical Director and, indeed, the Chief Nursing Officer, the third part of the senior clinician triumvirate which existed within those advisory structures, to try to make sure that they were very much more involved than perhaps they previously had been in sharing the advisory duties. That involved not only linking back to how we became involved with ministers in providing that advice, but also how we engaged with the public as well in relation to that advice.

Lead 2A: Thank you.

Would it be correct to say that the ultimate role of the Chief Medical Officer is to provide medical advice to the Scottish ministers to help them inform their decisions?

Professor Sir Smith: Ultimately I think that’s correct, yes.

Lead 2A: Although, as you’ve already helpfully explained, the Chief Medical Officer will draw on a lot of advisory systems and no doubt also on the Deputy Chief Medical Officer and National Clinical Director and others, the ultimate responsibility for that provision of medical advice to ministers sits with the CMO?

Professor Sir Smith: Ultimately the CMO’s responsibility is to offer that advice to ministers, from which they can then base decisions.

Lead 2A: Thank you.

We’ll hear some evidence later today from Professor Sheila Rowan, who is, as I understand it, a professor of physics and astronomy at University of Glasgow. She performed the role of Chief Scientific Adviser to the Scottish Government, at least for the early part of the pandemic before another person took that role over. We also know that there’s another post called Chief Scientist (Health), and I understand that that role was held predominantly during the pandemic by Professor David Crossman. Have I got at least all the personalities correct in the –

Professor Sir Smith: The personalities you’ve described there are absolutely correct.

Lead 2A: Thank you.

As far as scientific advice is concerned, is it correct to say that the Chief Medical Officer ultimately also provides advice to the Scottish Government on scientific matters, in particular insofar as they related to the pandemic, including in relation to the role of the things like vaccine, the efficacy and availability of testing, the efficacy and availability of PPE and the like?

Professor Sir Smith: Yes, the Chief Medical Officer helps to co-ordinate that advice from a variety of specialist advisers; you’ve mentioned some of them there, the Chief Scientific Adviser for Government is one. An important one – which again, going back to an earlier point that you made in terms of how we utilise all the assets within the team that we have, was the chief scientific officer for health.

Professor Crossman was a very able individual, who I thought was – could contribute much more than he had been able to contribute up until that point. And we used them specifically in relation to some of those questions that you’ve posed there in terms of the research and scientific basis for particular approaches such as testing.

Lead 2A: So just to try to make sure we have the structures correctly, the CMO works within the CMO department or directorate; is that correct?

Professor Sir Smith: So the way that this works is the CMO Directorate is a unique directorate within Scottish Government. It’s unique in some ways because it sits slightly to the side of other directors. What I mean by that is it has an independence which perhaps other parts of government don’t quite have. I think a really important aspect of the role is that independent clinical and scientific advice that comes through the office. But within that directorate, there are a number of clinical advisers that I am the line manager to and responsible for, one of whom is the chief scientific officer for health, we have already mentioned, another of whom, another really important figure in all of this, the Chief Pharmaceutical Officer as well, who is able to provide additional information and advice in relation to therapeutics.

Lead 2A: The Chief Scientist, as I understand it, effectively sits structurally in a different part of the Scottish Government, not under the ambit of the directorate of health and social care but of another directorate, I think it’s the economy directorate; is that correct?

Professor Sir Smith: I think that is correct, yes, economy.

Lead 2A: For present purposes it’s in a different part of the Scottish Government.

And is it correct to say that the post that Professor Crossman held was, to a degree, a bridge between the scientific side and the health side, in that he was Chief Scientist (Health) and therefore would have informed advice from both the Chief Scientific Officer and the Chief Medical Officer?

Professor Sir Smith: I would say that’s a very good way of describing the role of the Chief Scientific Officer in health, a bridge between many different parts of government, particularly in that research field. And an important aspect of research, of course, is to link back to other aspects of government such as economy and learning as well and to be able to bridge some of the kind of joint ambitions that the government would have in those areas.

Lead 2A: You’ve described the importance of the independence of the Chief Medical Officer’s department, but from an administrative perspective it struck us that these arrangements are perhaps slightly complex. Was it, to any extent, a matter which caused difficulty in accessing the right people, making the most and best informed decisions, that these structures existed somewhat in different parts of the Scottish Government, or did you not find that in your role?

Professor Sir Smith: I can very honestly say to you that I did not find that in my role, and that actually access to other parts of government, access to getting the right staff was never an issue.

Lead 2A: Thank you.

You sat on a number of advisory groups and attended a large number of meetings during the course of the pandemic in your three roles, including SAGE, the four nations chief medical and scientific officers group – could you just say “yes” if that’s correct, rather than –

Professor Sir Smith: Yes.

Lead 2A: Thank you.

The scientific influenza group on modelling, SPI-M?

Professor Sir Smith: Yes – no.

Lead 2A: No. The Scientific Pandemic Insights Group on Behaviours, SPI-B?

Professor Sir Smith: No.

Lead 2A: The Joint Committee on Vaccination and Immunisation, JCVI?

Professor Sir Smith: No.

Lead 2A: The Joint t Biosecurity Centre, JBC?

Professor Sir Smith: The JBC technical board.

Lead 2A: The group that we’ve heard of before under the acronym NERVTAG?

Professor Sir Smith: No.

Lead 2A: The UK Health Security Agency?

Professor Sir Smith: The UK Health Security Agency board.

Lead 2A: And you did sit on the Scottish Covid Advisory Group when it was formed?

Professor Sir Smith: Yes.

Lead 2A: What was your role when attending these groups?

Professor Sir Smith: So particularly in – if we start off with SAGE, I think SAGE is a good example. In the early part of the pandemic, as the Scottish Government began to receive invites to attend SAGE meetings, I attended SAGE as an observer to proceedings. My role there was to take account of the information and discussion that was being relayed over the course of those meetings and, where it was necessary to try to kind of ask questions on behalf of the Scottish Government, to signal those. You – generally they had to be signalled in advance of the meeting. Latterly, whilst DCMO, there were other mechanisms put in place to try to signal questions to the committee during its operation.

But that observer status during that period was essentially as an information gathering mission.

Lead 2A: To stay on the UK level, what about NERVTAG?

Professor Sir Smith: Yeah, I didn’t sit on NERVTAG at all. NERVTAG is a very technical committee, it’s generally staffed by people with expertise, deep expertise in infectious diseases and epidemiology. We had a representative on NERVTAG from other sources within Scotland who were able to feed back when it was relevant and appropriate for them to do so.

Lead 2A: Indeed, we heard from Dr Jim McMenamin on Friday, for example, who sat on that.

Professor Sir Smith: And Dr McMenamin is one of the unsung heroes in terms of the approach that was taken in Scotland, a man who I have enormous respect for.

Lead 2A: Thank you.

You also sat on the four nations chief medical and scientific officers group. Could you explain your role in that group?

Professor Sir Smith: The chief medical officers group – so I – I suspect that the group that you’re alluding to is the JBC technical board, which was staffed full of CMOs and the chief scientific officers, and this was a board which was examining some of the technical parameters under which JBC would develop data or information for use. A good example of that might be the data that was developed and the approach that was taken in terms of assessing risk of other countries as – of other countries at the borders with the UK and people returning or travelling to those countries. So we gave advice on some of the parameters which data would be useful technically to assess that.

Lead 2A: Thank you.

We’ll hear more, I think, later in the week, about the precise circumstances in which the Scottish Covid Advisory Group came together from other witnesses. But as far as your role on that group was concerned, what was your role? In particular, was this a group that reported effectively or offered its advice ultimately to Scottish ministers through you?

Professor Sir Smith: The group operated in a way whereby advice that came from that group was provided to me and to the Scottish ministers, and it was set up to – and it was set up in a way to try to allow a greater interrogation of the data and the evidence that they were considering. So whilst I was a member of the group, its extreme usefulness was – was an ability to be able to actually get into discussion with members of the group in a deep way at times. Sometimes that would be through the chair, sometimes that would be by attending the meetings himself and being able to kind of, in a two-way mechanism, being able to both relay information that I was party to but also hear the discussion and interrogate the discussion which was going on within that group as well.

The advice that advisory group was able to provide to us was incredibly useful. Much of it was based on the same evidence which was being considered in other places, but the ability to be able to kind of have that discussion in – first-hand with those people was incredibly valuable.

Lead 2A: Thank you.

Lady Hallett: Professor, if you could slow down a bit, I’m afraid you’re falling into the same trap the rest of us fall into.

Mr Dawson: Professor, there is a stenographer, obviously, who is attempting to keep up with your very useful evidence, so if we could just try to take it as slowly as we possibly can. I’m often admonished for the same thing, I have to say.

You have given some helpful evidence about the structures through which medical advice was able to be provided to the Scottish Government during the course of the pandemic and more generally. The Inquiry has already heard evidence about the structures which existed at UK Government level, and the key individuals involved, not least Professor Whitty, and Sir Patrick Vallance. These were individuals who, we’ve heard evidence, came from, in Professor Whitty’s case, a public health background; is that correct?

Professor Sir Smith: I think Professor Whitty’s background is both in public health and infectious diseases.

Lead 2A: Indeed. And I think the Inquiry has also heard evidence in the previous module that Sir Patrick Vallance came from – he’s a – as I understand it, a clinical pharmacologist who had experience of working within an industry relating to development of pharmaceuticals and the like. Also an element that was very relevant to the pandemic response; is that correct?

Professor Sir Smith: Yes.

Lead 2A: In Scotland, the three main individuals whom we’ve looked at who provided medical advice to the government came from different medical backgrounds; is that correct?

Professor Sir Smith: Yes, we all came from different specialities.

Lead 2A: You’ve already helpfully told us that you came from a general practice background and worked through various government jobs. Dr Calderwood, I think, came from an obstetrics and gynaecology background; is that correct?

Professor Sir Smith: That’s correct.

Lead 2A: And Professor Jason Leitch was originally trained in dentistry –

Professor Sir Smith: That’s correct.

Lead 2A: – before taking qualifications in public health at various university institutions after that?

Professor Sir Smith: That’s correct, as far as I know.

Lead 2A: Would it be fair to say that, given the particular requirements and difficulties faced in the pandemic itself, that the background and experience which you and your two colleagues were able to bring to bear to providing scientific advice meant that you required more perhaps than the UK Government advisers to translate the advice of others more expert than you in the matter?

Professor Sir Smith: I don’t think that’s correct, no. I had been working in population health and public health since probably 2006, in various leadership roles, between managed clinical networks to medical director roles, to subsequently ten years of experience within Scottish Government working at population health level as well. So I don’t think it’s correct to say that.

But what I will say is that the information and the knowledge which was used over the course of that response necessarily came from a wide group of very specialist people, both within the health protection community and the infectious disease community, and their input was incredibly valuable.

Lead 2A: But ultimately, as you have I think accepted and explained, the ultimate role as far as providing advice to the Scottish ministers are concerned falls to the Chief Medical Officer, and neither you nor Dr Calderwood were, like Professor Whitty, experts in public health and infectious diseases in that way?

Professor Sir Smith: My core speciality wasn’t public health but I would still regard myself as having expertise in population health and public health.

Lead 2A: I should say, Professor, I mean no disrespect at all in that regard, but the reason I ask the question is because during the course of the pandemic it was often part of commentary of people who were wondering whether they had to continue to adhere to restrictions that the medical advisers who would appear perhaps didn’t have the same level of expertise as the UK Government medical advisers. Was consideration given in the public communications strategy at least to the need to try to win the confidence of the public in order to try to maintain compliance and these particular comments, rather than criticisms, that were sometimes made?

Professor Sir Smith: So those comments that you have singled out there, I don’t particularly recognise as being something which was an issue which was raised at all. What was important was that credible and authentic clinical leaders were able to discuss with the public the requirement to undertake the very significant ask that we made of them, and to try to explain in very simple terms as to why that was the case.

I think it’s something that we did in Scotland very well. Certainly judging by the feedback that we had through some of the polling. Public confidence in that messaging was very, very high, and we saw really quite significant compliance from the public in relation to taking, as I say, those just quite incredible steps that we asked of them, to try and keep people safe. So I don’t accept that the background speciality that I have as a GP had any influence on that whatsoever at all.

Lead 2A: Thank you. You’ve referred to some polling as regards the communications strategy about which the Inquiry has already heard some evidence. Professor Paul Cairney, professor of political science, looked at this issue in an expert capacity and suggested to the Inquiry last week during his evidence that it was important to maintain a distinction between when people indicate a satisfaction with the way in which information is being presented as opposed to the possibility that may not necessarily indicate an understanding and hence compliance with it. Is that a distinction that you recognise?

Professor Sir Smith: I would be really interested in reading more about what he says there, and I think that we observed both a high degree of compliance and satisfaction with what was asked of the public.

Lead 2A: Thank you.

The phrase “following the science” is one which one hears often in connection with the pandemic and was used by a number of politicians to describe their response. Do you think that this is an accurate description of how policy decisions and ultimately strategy in fighting the virus were made within Scottish Government?

Professor Sir Smith: I’m not quite sure where that phrase originated from, but it’s one that certainly became quite commonly used over the course of the pandemic response, certainly in the media.

What I observed was a thirst for information and knowledge from those who were making decisions and they looked to science to try to provide that information and knowledge, so that they could try to make sense of the decisions that they were being asked to take. And what I found was a very receptive group of decision-makers who understood the limitations of some of the evidence and the science that was being presented to them, but also made great efforts to try to actually get under the bonnet and understand the science itself so that they weren’t wholly reliant on just people explaining it to them.

Lead 2A: What was it that gave you the impression that decision-makers ultimately understood the science itself?

Professor Sir Smith: The questions they asked me.

Lead 2A: Could you give some examples, perhaps, of the broad questions –

Professor Sir Smith: So the questions which began to be asked in relation to aspects of the response, whether that be modelling, whether that be transmission dynamics, whether that be even rudimentary epidemiology such as understanding of the R rate, over the course of that, even the early part of the response, the questions that came from those decision-makers began to become very insightful into not just information that was given to them but for the logical next steps that flowed from that as well.

Lead 2A: Thank you.

Given the complexity of the information, some of which we’ve seen presented in documents such as, for example, the SGoRR sitreps with which you’ll be familiar, do you think that there were stages of the pandemic in which politicians did follow the science in Scotland –

Professor Sir Smith: Yes.

Lead 2A: We’ll get on to the precision in a moment, I just want to finish the question. Were there times where you felt that they did follow the science and can you specify for us what time periods you think that might apply to?

Professor Sir Smith: One of the things which was very evident over the course of the discussion with senior officials and with ministers was an appreciation of what science could offer in terms of informing how to respond to the threat of the coronavirus. Some of that was about understanding the epidemiology and how it was likely to transmit through populations, and therefore shaped the type of response that was going to be required to reduce transmission. Some of that was about the clinical response that was going to be needed in order to treat people who had become infected with coronavirus.

There was a process by which we used that science and started to begin to integrate other fields of science into what, strictly speaking, would be health and public health research, and begin to integrate research from other areas such as behavioural science, how people might respond to a particular ask, how people might be feeling in terms of the degree of threat that they were facing. And the four harms process which subsequently became part of the way that we handled the pandemic in Scotland tried to take evidence from government advisers across four different aspects of harms that we’d identified and – and use science and research from those areas, evidence from those areas, to try to integrate a response that was balanced in terms of its approach and recognised the various harms that both the coronavirus itself would cause to the population but also the potential for the response to cause as well.

Lead 2A: Thank you.

You said, I think, that certain scientific disciplines were introduced into the analysis as time went on.

Professor Sir Smith: Yeah.

Lead 2A: You referred in particular to behavioural science. When was it that these – was it at the advent of the four harms strategy that these different scientific disciplines were brought to bear?

Professor Sir Smith: I would – I would recall it as far back as the March 2020 that some of these responses were beginning to be – become much more clearly integrated into the response. Understanding particularly in terms of the degree of the ask of the population how they might respond to that. And even at the very early stages of forming the C-19 Advisory Group, we made sure that we had representation from behavioural scientists on that group, which was further strengthened later on in 2020, I think.

Lead 2A: Does it mean that decisions before around the formation of the Covid-19 Advisory Group were not informed by this wide range of scientific disciplines?

Professor Sir Smith: I think that at the earlier stages of the response there was less emphasis given on the behavioural aspects of the response than perhaps there were by the time that we had reached some of the major decisions in March 2020. However, there was perhaps a greater reliance in those earlier stages of the type of advice which was coming from groups such as SPI-B, which had been set up as part of the SAGE infrastructure to look specifically at the behavioural response.

Lead 2A: Would it be fair to say that the logic of the position in introducing behavioural science around about the time of the formation of the Scottish Covid-19 Advisory Group was that it was important that there was a local consideration of the way in which Scottish people would react to restrictions which had not previously featured in the analysis?

Professor Sir Smith: I think that that was a helpful part of their involvement. I think that there was also insights which were developed from other places as well, and my observation would be that many of the political decision-makers who were present at that time were very good, in fact some were exceptional, at judging both the mood and response of the population.

Lead 2A: How did they go about doing that? Was it the polling that you’ve referred to, or something else?

Professor Sir Smith: I think some of the information came from polling, some of the information came from their own personal insights and discussions with both constituents and the many groups which they were in contact with.

Lead 2A: Was it ever part of – or if it was, when was it part of the Scottish Government’s approach to the fight against the virus that no death from coronavirus was acceptable?

Professor Sir Smith: It’s not particularly a phrase that I recognise. Certainly from a clinical perspective there was a deep realisation that tragic though it is, and it was an absolutely tragedy for some families, that it was almost inevitable, given the scale of the threat which was faced by a novel virus in a population that had no immunity to it, it was likely that there were going to be deaths. And what we sought to try to do was to try to limit the harm as far as we possibly could, to limit not only deaths as far as we could but also the other harms which arose as a consequence of illness from Covid-19 as well. We shouldn’t forget that Covid-19’s a disease which not only causes the risk of death, but also has long-term effects for many, many people as well.

Lead 2A: Indeed.

So to put my question in the context of the four harms strategy, which you’ve helpfully referred to, was it – and again if it was, when was it – part of the Scottish Government’s strategy to prioritise harm 1, which was, we recall from previous evidence, Covid-related harm, as opposed to the other harms?

Professor Sir Smith: As far back as I can remember it was the priority to try to reduce the direct harms which were being caused by Covid, that had been identified as certainly the most significant and pressing urgent threat to the nation, and there was a recognition that actually, left unchecked, the harms that the virus could cause would be far greater in the scale than the harms which would arise from some of the other four harms which have been identified. And by prioritising the direct harms, by reducing the displacement effect on the health services, and by trying to control and indeed suppress the growth of the virus, then that would actually allow the best chance to be able to reduce the harms in the other three areas as well.

Lead 2A: Thank you.

Was it the case – we know that the four harms group eventually formed in October 2020, though the four harms strategy, the framework had been laid out in April, over that period before October, was it the case that the priority remained harm 1 over the other harms?

Professor Sir Smith: During that period that you’re describing there from – probably from April through to October, it certainly appeared to be the case that harm 1 and harm 2 were given a significant degree of priority during that period. It was recognised that in the initial response there was a great deal of displacement in terms of other health need within the population, and during that period we started to try to recover aspects of the NHS at the same time to be able to try to address some of that unmet need that there was in the population as well. But it certainly was my view that during that period those two harms were given priority over the other two areas, though it has to be said that some of the responses during that time were still tempered by the recognition of potential harms in those other areas as well.

Lead 2A: And given the priority which you say was given to harms 1 and 2 over that period, when you were providing medical advice – if one might describe that as the policy of the government at that stage – did you tailor your advice to that policy?

Professor Sir Smith: The advice that I gave at that time was advice that was designed to reduce the harms in harm 1 and harm 2 as much as possible. It was for other advisers to give advice in relation to harms 3 and 4. It was the integration of the advice from a range of advisers which then allowed the policy to be developed and for decisions to be made by ministers.

But my priority, and I saw very clearly my priority was to give advice solely on the benefit to reducing harm 1 and harm 2.

Lead 2A: Those being harms related to health, broadly speaking?

Professor Sir Smith: Yes.

Lead 2A: You mentioned there the integration. To what extent were you afforded the opportunity to discuss and compare and contrast and integrate your views on harms 1 and 2 with the other advisers you’ve described as being more responsible for harms 3 and 4?

Professor Sir Smith: So very early on in the pandemic response, myself and the Chief Scientific Adviser had discussion about what we recognised was perhaps a benefit, in forming a whole new group for the chief advisers from different parts of government. Prior to the pandemic response, certainly didn’t seem that these chief advisers met on any kind of regular basis. But I saw and I think the Chief Scientific Adviser very clearly saw benefit as well in trying to bring people together in a forum that allowed us to consider a variety of types of evidence to look to see the broader impacts on society. That was a good forum for being able to discuss some of these impacts and really to gain a better and broader understanding of the impacts that we were beginning to see across different aspects of society.

It had always been recognised right from the beginning of the SAGE discussions that any response to try to control this pandemic was likely to have broader harms than simply the direct harms that we saw from the virus itself. So recognising then and understanding what those type of harms were likely to be and then trying to risk manage those, to mitigate and reduce the level of harm which we were seeing in those other areas, was an important part of that response.

And we should remember that ultimately any harm which befalls as a consequence of either social or economic detriment to the population also has a detrimental public health effect as well. If not in the short term, then it can perhaps be felt in the medium to longer term. So there was a benefit to being able to try to reduce those harms as much as possible, mitigate impacts, on a public health basis as well.

Lead 2A: So that was the theory; is that right?

Professor Sir Smith: That’s the theory.

Lead 2A: The Inquiry’s heard a considerable body of evidence, which might be summarised in an expression used by someone who appeared in the opening video that we played. He said that when Scotland tried to emerge from the pandemic, emerge from the lockdown in the period, I think, that we were talking about, he said “Nobody took a look around to work out whom we had left behind”. The way one might interpret that is that there continued to be a significant focus on harm 1 for too lengthy a period, and that the other harms, the harms caused by the countermeasures, broadly speaking, were not given sufficient attention over that period.

Would that be a criticism which you would recognise as regards the practical impact rather than just as regards the theory?

Professor Sir Smith: It is – it is a criticism, it is a story that I’ve heard from accounts of beforehand. Being part of those discussions when the variety of harms that we were seeing across the country were being considered, the way that that advice was then taken by decision-makers I think reflected where their perception of the greatest risk to the country existed. And ultimately any prioritisation of any harm over another probably reflected the risk thresholds of those decision-makers.

Lead 2A: The four harms group did not meet till October 2020; is that correct?

Professor Sir Smith: It did not meet on a formal basis in that time, but there were many discussions before that.

Lead 2A: By October 2020 Scotland had started to become overwhelmed by harm 1 again, hadn’t it?

Professor Sir Smith: What we saw in, starting generally from the early autumn period, was first of all significant outbreaks and clusters developing across the country. Largely inevitable as we still had a largely immune – sorry, a largely naive population in terms of immunity. And we saw more and more clusters developing over that early autumn period so that by the time we got to that kind of late autumn, early winter period, cases were certainly significant again, and there was a significant concern from a health protection perspective that if that wasn’t – that wasn’t controlled, if that wasn’t reduced, and if we didn’t manage to achieve lower case numbers and control over the prevailing R number in Scotland, and then entering that winter period, it was only likely to increase.

Lead 2A: We saw in some statistical evidence that the cases in Scotland started to rise significantly, I think from around August?

Professor Sir Smith: Yeah.

Lead 2A: And I think there is subsequent evidence from scientific study that suggests that that was in large part connected to people bringing the virus back from being away in continental Europe, in particular Spain?

Professor Sir Smith: I agree.

Lead 2A: Yes. What I’m suggesting to you, as regards the strategy, is that although the theory had been laid out in the framework in April, the fact that a committee had not met till October, a time at which Scotland had started, by circumstance, to become overwhelmed again by harm 1, the virus having returned, did this mean – was this the reason why people, like the gentleman said, were left behind and the other harms were not properly integrated into the response?

Professor Sir Smith: What I saw in that period that you’re describing between April and October was regular discussion in relation to the four harms and how they were integrated together. So the fact that a committee did not meet during that time shouldn’t – it shouldn’t being understood that there wasn’t a great deal of discussion about how you balance those harms in that –

Lead 2A: A great deal of discussion perhaps, Professor, but perhaps little effect?

Professor Sir Smith: I would think that you would probably observe that from the submissions which were made to kind of Cabinet, for instance, during that period that there was consideration of those four harms in that period as well.

Lead 2A: Could I turn to another subject, please. What was your understanding of your responsibilities with regard to the use of informal communications in the three posts that you held during the course of the pandemic as an employee, as I understand it, of the Scottish Government?

Professor Sir Smith: So informal communications, as I’ve outlined in my statement, have been used, when in a wave, largely for – to raise situational awareness, to kind of direct people towards particular pieces of information, to convey information about particular meetings which were taking place, which were used to try to arrange, in some cases, discussions or agreement around about particular situations.

The – you will see from some of the groups which have been submitted and that I was a part of, I have described that whilst these meetings are – that way of communication was useful for that purpose, that any information which was particularly pertinent or any decisions should be captured and put into email form.

Lead 2A: I think it’s correct to say that evidence has been given during the previous week that it’s not just a question of decisions being captured in that way, I think in order to put them on what’s called the corporate record, but that discussions engaged – in which individuals engaged in the pandemic response also required to be recorded that way. Is that not correct?

Professor Sir Smith: Pertinent information, yes. And I think you’ll see from one of the conversations within – and the advice I give to participants in one of the charts, that that’s how it should be captured.

Lead 2A: Could we look at INQ000334433, please.

This comes from a WhatsApp group chat, I understand, called “CMO weekly call”, and I’m particularly interested in going to this particular passage, which is from July of 2021. This is a conversation between yourself and Graham Ellis, in which he comments:

“Hope this isn’t FOI able?”

You say to him:

“Delete at the end of every day….”

And he laughs and puts his thumb up at that.

Was it your practice to delete messages at the end of every day?

Professor Sir Smith: Scottish Government advice in relation to this was not to retain information for longer than it was necessary, was to make sure that any information which was pertinent, as I say, any information, particularly discussions, which ended up in a decision was captured in – within the corporate systems. So my practice was to make sure that any information which was important in that way was then captured in email form on the system, was formally recorded so that it was an auditable trail. And I think you will see evidence of my approach to this within the conversations and within other conversations, that I exhort other members of those conversations to do the same. And – but my practice was, when information was – had been no longer useful, it shouldn’t be retained.

Lead 2A: My question was whether you deleted your messages at the end of every day?

Professor Sir Smith: If not at the end of every day then certainly on a frequent basis, I deleted information which was no longer needed to be kept.

Lead 2A: But your position is that, as far as you’re concerned, you would have, before doing so, on a daily basis extracted pertinent information from the exchanges, sent them on to the corporate record by email, and that those emails would then have recorded the information that was within the message before you deleted it?

Professor Sir Smith: So any important decisions that were taken wouldn’t be a verbatim account of a conversation but it would be the essence of any decision or any approach which should be taken on any information that had been given.

Generally what I found was that the information systems like this were used to convey information about exchanges which were either already beginning on emails or information which was being passed on through emails. Documents were being passed on in that way.

Lead 2A: You referred again in your answer there to decisions, so does pertinent information, as far as you’re concerned, mean information which demonstrates that a decision has been taken?

Professor Sir Smith: The most important information which was – was about definitive information, which may include a decision. So once perhaps a consensus has been achieved, what that consensus was.

Lead 2A: I took from what you were saying a moment ago that there was a – someone had informed you that there was a need or impetus towards not retaining too much information, and that that was an important part of your thinking in this regard. And of course organisations like the Scottish Government can’t keep every piece of paper and every document or every WhatsApp message. Where did the impression of that being the impetus which should be an important part of decision-making in this regard come from?

Professor Sir Smith: So there was advice given to Scottish Government employees which specifically dealt with informal messaging and the need to delete on a regular basis any information which was not relevant.

Lead 2A: Can you remember in particular which advice? Because there were a number that you were relying upon.

Professor Sir Smith: I think this was advice which was – the one I recall was perhaps on the Saltire website which had been given out towards –

Lead 2A: There was one which was issued on the Saltire website in April 2020. Was that perhaps –

Professor Sir Smith: It would be towards the beginning –

Lead 2A: Yes, we looked at that with Ms Fraser on Friday, but that would be the one that would have –

Professor Sir Smith: That would be one, but there was also advice which was given and reminders which were given in discussions with the then Director-General, who again reminded us that official business shouldn’t be done within these mediums and that there should be regular deletion, partly for security purposes, from that medium as well, and that it shouldn’t be seen as a secure medium.

Lead 2A: At that time, just to be clear for the personalities again, the Director-General was Mr Wright?

Professor Sir Smith: It wasn’t at that stage. I don’t recall that instruction coming from Mr Wright. I might be mistaken, but I think it came from Ms Grahame(?).

Lead 2A: Thank you.

Could I move on to a separate area, please. Obviously as I’ve said at the beginning of today, the Inquiry will not be hearing from your predecessor in the post as Chief Medical Officer.

We are, of course, very interested in exploring matters pertaining to the early period of the pandemic at which time, as you’ve helpfully explained, you were Deputy Chief Medical Officer.

My understanding from your statement and from notebooks which you’ve helpfully provided is that you attended certain meetings at around that time, although, as you have set out, you also had considerable responsibilities for parts of the NHS that were not directly related to Covid at that time.

So would it be fair to say that there is a certain degree of limitation on what you can do to help us with the events of the period up till you becoming interim – Chief Medical Officer, but that of course, as you have done in your statement, you will help us as best you possibly can with your recollections of events?

Professor Sir Smith: I think that’s fair to say. I think that during that period I did have involvement and I participated in many meetings, even during that period, including incident management teams, including many of the SAGE meetings. I had quite a degree of involvement over that period. Where I had less involvement and where I may be able to help you less is in the direct discussions and the way that advice was conveyed to decision-makers.

Lead 2A: I think you say in your statement that Dr Calderwood undertook the majority of engagement with Scottish ministers and senior officials around that period. Did you have conversations with Dr Calderwood, as her deputy, about the emerging information, the strategy and ultimately what advice she would be providing to ministers?

Professor Sir Smith: We spoke on a regular basis in relation to the emerging advice, and we didn’t speak just as much in terms of how she would relay that advice, of what advice was provided to ministers. There were a couple of occasions where I was able to kind of have direct discussion with ministers myself during that period, but that was probably by March that I would be involved in that way.

Lead 2A: Would it be – we obviously, as I say, have had some access to some of your diary entries, including references to some of the SAGE meetings you attended. Would it be correct to characterise them, as you said earlier, as you being there very much in an observer role – it looks very much like you’re trying to extract as much information as you possibly can, your notes are quite full – and then perhaps take it back to feed into the decision-making system in Scotland; would that be a correct characterisation?

Professor Sir Smith: I think that’s a very correct characterisation. My role was as an observer at SAGE, was to try to glean as much information as possible. Perhaps there was a slight element of frustration that I couldn’t participate in any deeper sense and perhaps at that stage we were still to see the full usefulness of SAGE in terms of being able to actually become involved in the discussion at that point.

Lead 2A: Well, that was precisely the issue I wanted to hone in on, was the frustration. You mentioned, I think, earlier that when attending SAGE, representatives or officials like yourselves and others who would be there had an opportunity to ask questions but they had to be submitted in advance, was that something –

Professor Sir Smith: That’s correct.

Lead 2A: How long did that carry on for, that practice?

Professor Sir Smith: That practice probably carried on through the February and March period that I was involved there, but I think from that point onwards, probably late March, it became a much more integrated approach and it became much more – much easier to be able to actually get involved in discussion and ask questions within the body of the meeting.

There was one occasion in particular where – most of the SAGE meetings were attended remotely, and at that time this was before really we had any of the platforms which enabled video meetings, it was mostly done using kind of dialled in telephones. The ability to be able to communicate in that environment was, I think, difficult, and on one occasion at least I remember travelling to London specifically to attend a meeting in person just so that I could try to glean more information but also have discussion with people who were there –

Lead 2A: Just to be clear, the remoteness element you were talking about there, did that relate to the period before things got better towards the end of March, or was that the period after?

Professor Sir Smith: That would probably be – so the remote – the remoteness element would be during the initial stages of SAGE, particularly February and early March.

Lead 2A: But as far as the input or the output, if you like, from – for Scotland generally at that stage, you mentioned feeling a degree of frustration at your inability to explore things. Could you expand a little further? What were the effects of your inability to engage in the way that you would have wanted?

Professor Sir Smith: So, the impact of that inability to be able to explore during the course of the meeting meant that you then had to – rather than be able to deal with a particular line of inquiry or interest at the time you had to chase down someone afterwards to try to find out more information. It expanded on the amount of work which was necessary to try to get a sense of an answer to your question. And …

Lead 2A: What were the sorts of Scottish-specific, I assume, issues that you were wishing to raise, and you were having this difficulty in doing so, around that time?

Professor Sir Smith: So they were many and varied. And I wouldn’t characterise them as being particularly Scottish-specific, I think that these were just general epidemiology questions which you wanted to ask or particular clarifications about what data or modelling was suggesting, and these were – these were not issues which were, as I say, generally specific to a kind of Scottish situation, these were about the wider virus itself.

Lead 2A: Thank you very much.

Lady Hallett: Were there any other people from Scotland on SAGE at the time you were on it?

Professor Sir Smith: Yes, there was representation there. Again, Jim McMenamin was one of the –

Lady Hallett: I was going to say I thought there were others.

Professor Sir Smith: Yeah, and we used to compare notes afterwards, after a meeting, just to make sure that our understanding was broadly similar in terms of the approach. But, as I say, having the observer status at that point in time did feed a little bit of frustration.

That was corrected, though, and I should emphasise that that was corrected.

Mr Dawson: Yes, it was corrected, I think you say, towards the end of March. Thank you.

If that’s an appropriate moment, my Lady?

Lady Hallett: Certainly.

Mr Dawson: Thank you.

Lady Hallett: I shall return at 1.45.

(12.45 pm)

(The short adjournment)

(1.45 pm)

Lady Hallett: Mr Dawson.

Mr Dawson: Thank you, my Lady.

Professor Smith, before the break we were discussing some of the information that was available in the early part of the pandemic about the emerging threat, and I’d like to stay in that area, if that’s possible.

Could we have a look, please, at INQ000273978. I’m looking at paragraph 241.

And you were asked some questions about some early email exchanges between Professor Mark Woolhouse, who is an epidemiologist at Edinburgh University, who was in contact in January, and from then on with your predecessor, Dr Calderwood, and you say there that:

“I was aware that Professor Mark Woolhouse had contacted the CMO (Dr Calderwood) and had seen a content of an email which provided his view of a potential scenario. I was also aware that the CMO arranged to discuss this further with Professor Woolhouse and though I do not know the content of those discussions, I recall her taking these assessments, alongside information she was receiving from elsewhere, with a particularly significant gravity.”

If I could just take you to an email chain and see if this is the chain, it’s INQ000352450. If we go to page 7 of this document, please, this is a series of emails all in a chain – sorry, page 6. Yes. We could just go to the page before that to see the top of the email.

So this is the first email in the chain, the earliest chronologically. If we go slightly above that, yes, we see this is an email from Mark Woolhouse – sorry, a bit further down, please, to the email below that. Yes. The one dated 21 January. No, further towards the end.

(Pause)

Mr Dawson: So you can – this is an email – I’m looking at the email from Mark Woolhouse. You can see there there’s one – from the top part of the screen – dated 21 January from Professor Woolhouse to your predecessor. Although that’s the CMO address, that was to Dr Calderwood, I think.

Is this an email do you think you would have seen or would have known about from discussions? This is the first in the chain which starts to intimate some of the concerns that Professor Woolhouse had at that time.

Professor Sir Smith: So I certainly recognise the tone of the email, even from the read-through that I –

Lead 2A: This wasn’t to you, so I just want to be clear that it may be possible that the details are – you’re not entirely au fait with.

Professor Sir Smith: I know from this communication and from other communications from Professor Woolhouse around about that time that he did have significant concerns in relation to the potential threat that this virus could cause, even at that time, and the degree of uncertainty that still existed around about the potential that it did have.

Lead 2A: Yes. Just to be clear, he’s a witness who has appeared on a number of occasions in the Inquiry already, Professor Woolhouse is a consultant epidemiologist based in the Usher Institute at Edinburgh University?

Professor Sir Smith: That’s right, yes.

Lead 2A: If we could have a look at the email, at the bottom page that you can see there, at the top passage, he says:

“The obvious concern (increased by yesterday’s not unexpected announcement of human-to-human transmission) is that this become a pandemic, and therefore will affect Scotland. This is not yet certain, but in my judgement it is likely, certainly sufficiently likely that we should be prepared for the eventuality. Other colleagues share this view.”

There are some instructive parallels with the H1N1 pandemic in 2009-10. Indeed, one possibility is that this could turn out to be quite similar in some key respects: a widespread epidemic fuelled by mild cases but with mortality among vulnerable patients.”

So at that stage, as you say, Professor Woolhouse’s position in intimating his concerns to Dr Calderwood is that there are still some uncertainties about the position, but that he considers that a threat to Scotland is sufficiently likely; yes?

Professor Sir Smith: That’s certainly my reading of his email and also the discussions that I was privy to at that time with Professor Woolhouse.

Lead 2A: And I think what he has – a piece of factual information, if you like, rather than assessment or opinion, is that evidence had arisen the previous day of human-to-human transmission, that’s referred to in the email?

Professor Sir Smith: So that was at the stage where it was just becoming evident that there were – rather than transmission from an animal source to human, that there were – there was now evidence of distinct human-to-human transmission, ie the virus had now been able to evolve to an extent that it had the potential to certainly cause at the very least an outbreak, if not an epidemic or even a pandemic, in human form.

Lead 2A: Thank you for that. What I’m trying to highlight is that the evidence of human-to-human transmission is very significant in trying to work out the potential threat, isn’t that right?

Professor Sir Smith: That is correct.

Lead 2A: Thank you.

He also, and it’s fair to say that this is much more at the state of possibility rather than likelihood, says that this could be an epidemic fuelled by mild cases, with mortality amongst vulnerable patients like the H1N1 threat had been.

Would this tend to suggest, if the epidemic were to be fuelled by mild cases, that testing, though an important part of trying to contain the virus, may miss cases as mild patients may not report for – to undergo a test?

Professor Sir Smith: One of the key considerations at this stage would have been to what degree can viral substance be obtained in order to develop tests which would identify with sufficient confidence that the virus itself could be identified, particularly if there were mild cases which could mimic many other diseases.

Lead 2A: And in this email he also raises the possibility of the severity of any ultimate epidemic in Scotland, were it to arrive; is that correct?

Professor Sir Smith: So I recall both within – I can read within this email, but I also recall within other correspondence from Mark that he rose that it had the potential to do that, but again emphasised within each of those that there was great uncertainty about that.

Lead 2A: Yes. It is fair to say that there’s a degree of uncertainty; certain things are expressed at the level of likelihood and others at the level of possibility.

What I would be interested in knowing is what the response was within your office, if you like, on behalf of Dr Calderwood, and indeed what advice was provided to ministers to put this on their radar, if you like?

Professor Sir Smith: I would love to be able to answer that question for you with the degree of detail that I suspect you’re looking for, but I’m afraid that I wasn’t sufficiently close to those discussions that you speak about, what there existed between Dr Calderwood and ministers, to be able to give you that with any kind of clarity. What I do recall from the conversations with Dr Calderwood was the concern that she had that she was using this information from Professor Woolhouse to corroborate information which was coming from other sources and to try to gain a – a kind of – a sense, a better all round picture of exactly the degree of threat.

I think she commits, in this email chain, to kind of taking that in to further discussion with other CMOs, where again it was recognised that there was a threat here which was certainly emerging, and that that threat was at that stage being fully assessed through the NERVTAG, which is the appropriate committee for assessing the threat from emerging respiratory viruses.

Lead 2A: Whilst it might be entirely understandable, as you were not the CMO at the time, that you’re not across the detail of precisely what might have been said to ministers, are you at least aware of whether conversations took place with ministers about this threat at this time, by –

Professor Sir Smith: I’m aware –

Lead 2A: – Dr Calderwood or others?

Professor Sir Smith: I’m aware of the intention that she had, but I’m not aware of the timing of any of those conversations, I’m afraid. I’m afraid I would be speculating on those.

Lead 2A: So she intended to convey it but you don’t know whether she did convey these matters, either generally or specifically?

Professor Sir Smith: What I recall from the discussions was her concern and the discussions that she initiated across government with fellow health and social care directors and the regular dialogue which she was having, even at that time, with ministers, particularly the Cabinet Secretary, in relation to the degree of threat. But what was said in those conversations I’m afraid I don’t know.

Lead 2A: Are you aware of any information or advice being communicated around this period about the possibility of asymptomatic transmission?

Professor Sir Smith: There’s a great deal of uncertainty about asymptomatic infection and asymptomatic transmission, two separate things and which need to be taken as two very separate entities.

Certainly by the stage that we were getting towards the end of January we recognised that it was possible that there was asymptomatic infection. What was very unclear at that stage was whether that asymptomatic infection could actually lead to asymptomatic transmission. And even six months later, in July, we still had opinion from the WHO where they were still stating at that point that further research was needed to establish whether there was asymptomatic transmission or not. But asymptomatic infection certainly was considered a possibility at that stage.

Lead 2A: Are you aware of any advice being tendered to any ministers around this time, by Dr Calderwood or others, about the possibility of asymptomatic or mildly symptomatic transmission?

Professor Sir Smith: I am not aware of any discussion in relation to that at all, I wasn’t privy to that.

Lead 2A: These are potentially very, very significant revelations being made by Professor Woolhouse; is that not correct?

Professor Sir Smith: These are concerns which have been raised by Professor Woolhouse, which were being raised in a variety of different areas. You know, Professor Woolhouse had taken the time to express his concerns directly to the CMO, but I am aware that very similar concerns were beginning to be spoken about amongst other epidemiologists at that point in time, in fact were being reported through some of the discussion, even in the early stages of SAGE and NERVTAG, that this virus had the potential to be an incredibly significant development.

Lead 2A: Given that significance, if advice had been tendered by the Chief Medical Officer at that time, Dr Calderwood, or others, would that not have been done in writing?

Professor Sir Smith: I – I think you’re asking me to speculate on something that which I can’t answer.

Lead 2A: But you’re aware of the systems which existed for providing advice to ministers at that time?

Professor Sir Smith: I’m aware that sometimes that advice was given directly in conversations and sometimes that advice was given in written form.

Lead 2A: So over this period, it’s at least possible that advice could have been tendered by Dr Calderwood to the First Minister or the Cabinet Secretary for Health and Sport orally about the matters contained within this email?

Professor Sir Smith: It is feasible that that could be happened, but, as I say, you’re asking me to speculate on something which I was not directly involved in and I’m afraid I can’t give you an accurate answer to that.

Lead 2A: In the email Professor Woolhouse points out, again on the second page, just below the passage we looked at before, he says:

“Such an epidemic would be difficult to track. As in 2009-2010 what would be needed is an integrated surveillance set up that combines clinical surveillance, genomic surveillance, and serological surveillance. (The latter requiring an appropriate test; we and, I am sure, many others are working on this already). This should be unexceptionable. My reasons for writing now is to emphasise that, that based on experience of 2009-10, that systems needs to be put in place in advance of the arrival of the virus, so the sooner the better. If we wait until after the virus has arrived then we will miss information of public health value and our efforts to prevent [or] control the epidemic will be compromised.”

So the general message that Professor Woolhouse at least is trying to convey is that his experience of dealing with epidemics, pandemics of this nature is that one needs to act decisively and quickly otherwise it will be too late?

Professor Sir Smith: Yeah, I mean, I think everything that Professor Woolhouse says there is … is straight out of the health protection playbook. It’s surveillance being a particularly important part of identifying the possibility of cases. To do that you can either try to identify them through clinical means, which is a syndrome of symptoms which are so specific and sensitive to that illness that they’re easy to pick up clinically, or a testing infrastructure which allows the disease to be identified by laboratory means. In this case, because the symptoms were relatively non-specific, it relies largely on the – particularly at this time of the year, when there’s so many respiratory viruses circulating, it relies on the development of – the identification of material to be able to develop a test which can then be used and deployed at scale to be able to identify the virus.

Lead 2A: When did a test become available to Scotland?

Professor Sir Smith: I don’t recall the first available date, but the first instances of us being able to test were led by our NHS laboratories, with two regional laboratories in Glasgow and Edinburgh being able to offer approximately 300 or so tests a day between them in order that we try to identify those.

Lead 2A: I think you’re referring there to facilities that were opened up in March in order to provide tests, but what I was wanting to know is: obviously one has to go through a process of genomic sequencing which leads to a test. That test needs to be put together and then it gets scaled up. When was the test first available, do you remember?

Professor Sir Smith: I don’t recall the exact date when the test was first available. I recall in the very early stages, when the first potential cases were identified, testing at that time was so limited that samples had to be transported through special procedures to reference laboratories, public health laboratories. I think there’s perhaps only one in the United Kingdom who was able to operate the test at that time.

Lady Hallett: Sorry, could I just ask a question?

Could I go back to the email where Professor Woolhouse intervened? He raised the possibility of a very serious threat to Scotland, and by the sounds of it this resonated with both you and your predecessor as CMO, because you’d heard similar concerns elsewhere. What I don’t understand at the moment, Professor, and I’m not sure if you’re the one to answer or whether it should be your predecessor, but why didn’t the CMO talk to you, her deputy, about this potentially serious threat to the country?

Professor Sir Smith: She did, my Lady.

Lady Hallett: She did?

Professor Sir Smith: She spoke to me on a regular basis about it, and we discussed Professor Woolhouse’s advice and we discussed both his advice in the context of advice that she was already receiving from other people and from other committees at that point in time as well. So it shouldn’t be misunderstood that this was happening in a vacuum at all, this was happening in a way where information was being developed from a variety of different sources. What I am unable to say is –

Lady Hallett: What she then said?

Professor Sir Smith: – is the timing and the exact nature of what she said to others.

Lady Hallett: Right. Sorry, I misunderstood.

Mr Dawson: Thank you, my Lady.

So the position is that you were party to discussions, so you know about the discussions, and you’ve outlined some of the content of those, but you weren’t privy to the actions which Dr Calderwood might have taken as a result of those discussions and these concerns. I think you mentioned that in your evidence earlier, that that was broadly your –

Professor Sir Smith: I would love to be able to expand on the detail of that, but I think those questions are best directed to Dr Calderwood.

Lead 2A: Is it the case that the types of surveillance systems which Professor Woolhouse was urging ought to be set up as soon as possible to try to get ahead of the virus started to be set up from this point or not?

Professor Sir Smith: The type of surveillance systems that Professor Woolhouse refers to, as I say, they can be done in two ways. They can be done by symptom surveillance, syndrome surveillance, we still have the mechanisms to be able do that. At that point in time, though, it was at the time of the year with high circulating levels of respiratory virus, so symptom surveillance would have added relatively little information in terms of the specificity of the threat that was presented to the country.

Lead 2A: But that’s not, I think, what Professor Woolhouse was suggesting.

Professor Sir Smith: The second mechanism at which you could have done that would have been to set up a kind of laboratory surveillance mechanism. Now, that relies on the development of tests which are then scaled to a sufficient level that you’re able to use and deploy that testing in that way, and unfortunately that takes time.

Lead 2A: But there are even – what I think is being urged here, Professor Woolhouse recognises that work is being done on a test, what he seems to be suggesting is that the systems which would go around the test once it becomes available could be put into place such that when a test does become available, those systems are ready to start the scaling up process that you’ve talked about. Was action taken at this time to put those systems in place?

Professor Sir Smith: So there are recognised surveillance mechanisms across the UK then Scotland and elsewhere in the UK whereby that type of surveillance was already used through GP practices, what we call sentinel surveillance. And once a test was available in sufficient numbers to be able to do that, people who presented with symptoms which may have been suggestive of the disease could have been tested for it in order to identify them.

The deployment of that test into that environment is probably a simpler process than the development of the test to get to sufficient scale that you have got sufficient capacity in the testing in the laboratories to be able to test in that manner. And that takes – that’s probably the real limiting step in terms of the approach here.

Lead 2A: It’s been suggested by reference to a notebook provided by a civil servant called Mr Grieve, whom you will know, that around this period, although he was attending various meetings, I think perhaps some of the ones you were attending as well, of committees, that there was a general lack of awareness within the department of – the directorate, sorry, of health and social care, and indeed more widely within Scottish Government, as to the urgency of the threat.

Would you accept that that was indeed the position, and would you accept that that is in stark contrast to what is being urged by Professor Woolhouse?

Professor Sir Smith: I am surprised to hear that, because certainly the conversations that I was party to during that time, particularly in late January and early February, was that this was a very urgent threat which had been identified and which people really needed to turn their attention to.

And I think the evidence of what I saw at that time was that certainly health and social care directors were very focused upon this. I can’t comment on other parts of government as to how significantly they took the threat, but my recollection, my observation from that time, was that health and social care directors were incredibly worried about the potential that this threat had. And let me assure you that Dr Calderwood left people in no doubt that that was the case. In the conversations that I was party to with fellow directors, it was very clear that she saw this as something which needed to be prioritised.

Lead 2A: But you can speak directly, I think, to conversations to focus, you’ve mentioned, to worry, but not to action?

Professor Sir Smith: The implication behind my remarks there is that action would then be taken in terms of getting organised and preparing, and at that stage –

Lead 2A: What action was taken to prepare? Action not worry, conversation or focus.

Professor Sir Smith: So one of the earliest aspects of this that I remember was ensuring that we had briefing mechanisms to make sure that situational awareness of the degree of threat was understood by aspects of the health service, that within – proper links were established between departments in Scotland and the rest of the UK to make sure that information was being shared between them, that Scotland was able to kind of – to be part of any moves to kind of deploy testing as it became available at that stage. As I say, first of all through the NHS laboratory system, then gradually, as it was recognised, just the degree of capacity that would be required, how other laboratory systems could come in and assist the NHS in that testing as well.

So a whole series of things which began to take place in order to try to prepare health and social care for what was likely to come ahead. And in the meantime to try to identify when there were cases, potential cases in Scotland, so that the right health protection measures could be taken around about them.

Lead 2A: It would have been predictable at this stage that if something of the nature of the threat which Professor Woolhouse was setting out were to become reality, there would be a number of logistical things that would be necessary to put in place to try to protect not only potential victims but also the healthcare staff that would be required in hospitals and in social care settings against the virus so that they could adequately deliver care to those who were sick. What steps were taken over this period to try to secure greater supplies of personal protective equipment for those people?

Professor Sir Smith: I don’t recall specifically how that was approached, I wasn’t directly involved in much of that stuff, although there were points in time when I was asked to communicate with the system, I think probably towards late February, early March, about the use of some of the equipment. But that was overseen by a particular unit of health and social care called “health resilience”, and I’m afraid I wasn’t directly involved in their work there.

Lead 2A: Thank you.

You mentioned earlier some difficulties which you had experienced with regard to getting access to information which you were, I think, primarily, and understandably, deriving from SAGE and NERVTAG at that stage. Was the type of information that you were trying to get the type of information that Professor Woolhouse was giving you on a plate?

Professor Sir Smith: No.

Lead 2A: Why?

Professor Sir Smith: No.

Lead 2A: What was the information you were having difficulty in getting?

Professor Sir Smith: The type of information which I was trying to glean more information about was the timing of interventions in particular, to try to understand from SAGE and the scientists who were engaged there, their best advice as to when particular approaches should be implemented in order to have their effect. And it seemed, particularly through the conversations in the early part of March, that it was at that stage less clear as to when some of those interventions should be brought into play.

Lead 2A: Okay, let’s explore that a little more. Are we talking about here what one might call non-pharmaceutical interventions?

Professor Sir Smith: Yes, we’re talking about the NPIs here, and –

Lead 2A: Yes, we have been through an explanation of what that is and the various forms that might take.

So you mentioned that you had been seeking advice about the NPIs and when they might be used profitably, in early March. Had you sought information about that before that point?

Professor Sir Smith: The – so the – in terms of the NPIs before that point, there was still much discussion about how NPIs should be used and what – whether non-pharmaceutical interventions could be used in isolation or whether they needed to be used in, if you like, baskets or bundles of different approaches together. So much of the discussion through SAGE, particularly through the modelling groups, with much of it coming from SPI-M, was actually how would you achieve the desired effect.

Once you began to understand the transmission rate particularly of the virus and the R values that were associated with it, how you would begin to slow that down to the extent that the NPIs could actually have the desired effect, or whether that was using one or two NPIs in isolation, or whether in fact it needed a much broader approach to try to reduce the scale of infection at that point in time. There then became the question as to when was the best point in time to try to deploy those NPIs, and a great deal of discussion through that group as to what the likely impacts of deploying those NPIs, either in isolation or collectively, would have both in halting the virus at that stage but also potentially simply saving up more impact and trouble with a bigger wave once those were released at a later stage. There was still some uncertainty through the modelling as to what the impacts would be.

Lead 2A: I think if I heard your evidence correctly that you mentioned some difficulty in ascertaining information about the best timing in early March. Could you expand on that a little? What was the difficulty that you experienced?

Professor Sir Smith: So what we heard at that stage was a lot of discussion which was about at what point and what would be the triggers for the deployment of societal measures which would be deeply unpleasant for society to experience and which we would need the significant support of the population in order for them to be effective and to be able to sustain those for a period long enough that they would continue to have their effect.

You mentioned earlier the role of behavioural science at that stage, and behavioural science was an important feature of the discussions at that point in time, when many papers were fed in from SPI-B as to what we might expect in terms of a response from the population to a variety of different approaches.

But what I wasn’t clear on at that stage yet and which – what I didn’t see from SAGE was formal advice as to really what the trigger might be for deploying those either singular or multiple interventions, and how we should watch for that.

Eventually it settled, as you know from papers which you’ll have seen. And there was a variety of triggers which were suggested. Most of the data that we were using at that point, of course, was unfortunately of lagged data, it was health outcome data such as either hospital admission, ICU admission or even the possibility of the number of deaths that we were likely to see. But that lagged data was one of the things which was suggested and proposed as a trigger event for the institution of those type of measures.

Lead 2A: What was your understanding of the role of behavioural fatigue in the advice and discussion that was taking place around that period?

Professor Sir Smith: So behavioural fatigue was something which was acknowledged. I remember discussions at SAGE at the possibility that the deployment of particularly severe restrictions on everyday life might lead in some parts of the population to behaviours and fatigue in terms of compliance with those measures, which could actually cause a wave to develop which would be, at that stage, fairly significant in terms of the impact on the population.

Lead 2A: So was it the case that you were under the impression that advice had been received from experts, including from SPI-B, relating to behavioural fatigue and that it should play a role in determining when and if a lockdown should be imposed?

Professor Sir Smith: I would characterise advice on behavioural fatigue as one of many aspects which were considered in the round in terms of the timing for the deployment –

Lead 2A: But did you understand that SPI-B had given such advice?

Professor Sir Smith: I understood that SPI-B had raised concerns that behavioural fatigue may be a consideration in terms of the approach. What at that stage was unclear was whether fear of the impact of the virus and the impact of that on the population, the impact of that fear in the population would outweigh the fatigue that they may experience.

Lead 2A: I think you also mentioned a moment ago that there was some consideration around this time that the possibility of a bigger wave of the virus was playing some part in the consideration about the timing of the imposition of restrictions or ultimately a lockdown. What was your understanding of the position in that regard? How important was that a factor?

Professor Sir Smith: I recall discussions through SAGE where what I heard recounted were concerns through some of the models which had been developed that actually by reducing the initial impact and mitigating that, if measures were not sustained for a long enough time then the release of those measures, either through non-compliance or because of the harm it was causing to other parts of socioeconomic infrastructure within the country, would release an even bigger wave of infection amongst a population that was still immune naive to a virus which was likely to circulate very quickly. A lot of the initial discussion centred upon how long would it be necessary for those measures to stay in place and would it be necessary to have some degree of braking, if you like, from spread on a periodic basis until either sufficient therapeutics were available to intervene or a vaccine was available to try to give the population protection.

Lead 2A: Evidence emerged of growing infection in Italy in late February, I think. Do you recall that?

Professor Sir Smith: I do, yes.

Lead 2A: Scotland’s international rugby team played rugby in Rome on 22 February, and the international women’s team had been due to play in Legnano just outside Milan in the Lombardy region the 23rd, that match having been cancelled due to local concerns about Covid. Do you recall the Chief Medical Officer or anyone in the department of which you were part being asked to give any advice about the advisability of that match continuing given concerns about infection rates in that very part of Italy?

Professor Sir Smith: I guess in the – that’s – all I can speak for is that I wasn’t approached for advice myself. That’s all I was –

Lead 2A: If such advice had been provided, would it have been provided in writing?

Professor Sir Smith: I would – in a situation like that there may have been verbal advice given, there may have been written advice given, but I can only speak from my own experience in relation that rugby match, in that I wasn’t asked to provide advice in relation to that.

Lead 2A: Would it have been the sort of thing on which advice would have been useful? Given the fact that you were accessing information via SAGE and NERVTAG about these emerging international cases, would it have been useful for that to have been communicated, whether it was or not, in decision-making about whether that match should have been allowed to go ahead?

Professor Sir Smith: So my own view is that the whole question of international travel at that point in time is something which I think would have been very important to have a very risk-averse position in relation to at that stage.

Lead 2A: A further international rugby match took place in Scotland, between Scotland and France, on 8 March. France, as I understand it, was the first country in Europe to have a death from coronavirus, and on the day of the match France reduced the number of people allowed at mass gatherings to 1,000, and I understand around 67,000 people attended the match at Murrayfield on 8 March. Again, are you aware of any advice having been tendered to Scottish Government by the Chief Medical Officer or your directorate about the advisability of that match being allowed to proceed on Scottish soil?

Professor Sir Smith: Again, I can only speak from my perspective, and I was neither approached nor did I give advice in relation to that rugby match.

Lead 2A: And again, would one have expected that advice, if given, to have been provided in writing?

Professor Sir Smith: Again, I think I have to say that that advice may have been given in writing but it may also have been given verbally. I’m afraid I don’t know whether that was sought or given.

Lead 2A: Thank you.

Could I ask to have INQ000371227 put up on the screen, please. I’m looking at page 77.

(Pause)

Lead 2A: Excuse me just one second.

(Pause)

Lead 2A: Sorry, I’m looking, as it appears, at the top left corner where it says “CMO CALL”, just focus in on that. No, the top left-hand corner, “CMO CALL”.

We think that this entry comes from 16 March 20 – this is from your handwritten notebook, Professor. We think it comes from 16 March, where it says:

“WHO – general view that WHO been unhelpful; Test Test Test being a particular example of misrepresentation.”

Is that – could you explain what it is that you felt had been a misrepresentation of the “test, test, test” message?

Professor Sir Smith: So testing was an incredibly important aspect of the response and testing had to be ramped up really as quickly as we possibly could, both in terms of the infrastructure to be able to conduct testing but also during that period, while the capacity for testing was available, was to use it in a prioritised way, and it was the view of the CMOs that testing at that stage was most important in identifying people for clinical purposes to know whether they had Covid or not, to differentiate it from other forms of illness which may need treatment, but also then to isolate them in a way that tried to reduce that transmission to other people as well. And testing should be prioritised in that sense in order – whilst the capacity to test was increasing. And WHO certainly viewed testing as being very important, but perhaps in the messaging around about testing they were not perhaps as nuanced in their messaging in terms of how it should be used.

Lead 2A: Right. So that was what you considered to be a misrepresentation?

Professor Sir Smith: Yep. Testing – there was a strong clinical view, not just held by the CMOs but held across the profession, that testing was incredibly important to – so that when faced with a patient who had the potential to have Covid in front of them, first and foremost we had the ability to be able to determine whether it was Covid or whether it was another treatable disease. And then of course if it was Covid that takes you down a whole pathway of treatment which necessitates a different – a wholly different approach both in terms of isolation, contact tracing, et cetera.

Lead 2A: Was what was unhelpful about the WHO’s message that although it set out a clear priority that testing was necessary to try to combat this disease, that Scotland was simply not practically ready to undertake that testing? Was that what was unhelpful about this message?

Professor Sir Smith: One of the things that I think was misrepresented here by WHO in those early stages was actually the difficulties in trying to increase the capacity sufficiently quickly to develop a testing at scale.

Lead 2A: So they were saying “You should test, test, test”, and Scotland said “We couldn’t, couldn’t, couldn’t”?

Professor Sir Smith: I think that is perhaps a characterisation which is unfair. I think Scotland recognised the need for testing, and great efforts were made by the teams involved to try to increase the capacity around testing as quickly as possible. That involved using not only the NHS laboratory infrastructure but also in linking with other public health laboratory infrastructure and university infrastructure to try to kind of develop sufficient number of tests across the country using all means possible.

You’ll recall that at this particular stage there were all sorts of difficulties with even getting the testing reagents from around the world and procuring testing reagents that were necessary. But what I witnessed was incredible efforts from the teams involved in testing to try to make sure that Scotland and the UK were positioned as importantly as possible. I don’t think anyone ever underestimated the importance of testing, but it certainly wasn’t easy for these teams in developing it at that time. And I think one of the – one of the major lessons which certainly I would want to see carried through following this, and I’m very glad it’s been captured within the report of the Standing Committee on Pandemic Preparedness, is to make sure that we’ve got an infrastructure which is sufficiently agile enough, particularly around about testing, and a public health reference laboratory testing infrastructure would, for me, be ideal for it to be able to turn its attention to emerging threats as they were identified in a way which was different from our experience in February and March of 2020.

Lead 2A: So for future pandemic preparedness, you think it’s extremely important that the infrastructure is maintained to enable all of the testing that’s required to be put into action as quickly as possible?

Professor Sir Smith: That’s one of the major pieces of learning that I would certainly want to single out from this, is that there are particular parts of infrastructure which were put in place that, whilst we could never maintain at the levels that existed during the height of the pandemic, certainly need to be there in a way where we could pivot in as agile a way as possible –

Lead 2A: So one might say the core of that existing infrastructure needs to be maintained for future pandemics?

Professor Sir Smith: And some of that might be laboratory space and some of that might be laboratory expertise and resource in individuals, but I do think that it’s really important that as a country we have a laboratory system which is preserved and invested in in the coming years. But that’s one of the things I would like to see –

Lead 2A: I have one other question about testing but before we go off what’s on the screen, just at the same point there you make a note relating – I think it says:

“SAGE – masks

“– likely to recommend.”

Was it your understanding at that stage that SAGE was likely to recommend something to do with face masks? Is that what that’s referring to?

Professor Sir Smith: Yeah, at this stage it was very unclear just exactly how advice was going to be developed around about masks and coverings, face coverings, noting that there’s a distinction between the two. And eventually the recommendation from SAGE was that it was face coverings rather than face masks. But I think those are two separate items which you see on screen there, the two dashes.

Lead 2A: I see. So they were discussing masks but they were likely to recommend something else?

Professor Sir Smith: You know, with the passage of time I can’t speak with accuracy as to exactly what that annotated comment means, but I do remember there being discussion in SAGE in relation to – and debate as to whether face masks or face coverings were likely to be the preferred option.

Lead 2A: Right.

Just on testing again, could I take you, please, to – we mentioned Professor Crossman earlier, to his statement, which is INQ000273976. I’m looking at paragraph 10.

Professor Crossman played a significant role in the testing side of things; is that correct?

Professor Sir Smith: He did.

Lead 2A: Yes, thank you. He says there:

“From January until around the middle of March 2020, I was not involved in pandemic management. I could see that individuals with governmental advisory function in the other nations were having some role in pandemic response and I was aware that some strategies were emerging for example in testing for [I think it’s meant to be SARS-CoV-2] infection. I was not formally asked to expand my role but it was the absence of a SARS-CoV-2 testing strategy in Scotland when there was one in England and Wales that caused me to contact Catherine Calderwood (then CMO) and bring this to her attention as I was concerned that without the ability to test for the causative agent the pandemic would be unmanageable. At that stage I offered my services to the CMO to help with the response. The CMO responded that it would be helpful to have a strategy but if I was going to do this it needed to be done quickly. I responded and delivered the first strategy with a civil servant (Mary Stewart …) by the 28th March and this seemed to establish me as a useful adviser to the Scottish Government’s response …”

Could it be taken from that, do you think, that the Scottish Government had no strategy for testing until Professor Crossman helpfully offered his services?

Professor Sir Smith: I think that could be one reading of what Professor Crossman has said in his statement.

Lead 2A: If that were the case, would that be a fair reflection of the reality?

Professor Sir Smith: I think at that stage the Scottish approach to testing was very much mirroring those which were happening in other the UK nations in terms of the prioritisation of testing. However, I think what Professor Crossman and his colleagues did very successfully was to take what was a rather informal approach and to formalise that within a written strategy so that people could be very clear as to how testing was going to be developed and prioritised for different purposes.

Lead 2A: I think he describes it as the absence of a testing strategy. That doesn’t tend to suggest that there was one at all.

Professor Sir Smith: I think you would have to ask Professor Crossman in greater detail, but what I would take from that is that there wasn’t a written strategy.

Lead 2A: Thank you.

Lady Hallett: Except he contrasts it with the position in England and Wales where there was one, and you said that Scotland was then mirroring the rest of the UK.

Professor Sir Smith: That was my recollection of it, was that the discussion there that certainly happened in clinical circles at that point in time was that Scotland was taking a similar approach to other countries in the UK, but there was no written strategy that backed that up.

Lady Hallett: Well, we’ll check with Professor Crossman.

Mr Dawson: Thank you.

Moving on to a slightly different area but in the same time period, we’ve heard some evidence already from Dr McMenamin and Professor Phin about the well known Nike conference. I only want to focus with you on one aspect of that.

Could we go to INQ000225995, please.

This is an exchange concerning this very thing. It mentions you, I think, having some involvement. Do you recall discussion around this early period to do with the – what should be said about concerns that were arising around the Nike conference at this time?

Professor Sir Smith: Yeah, I mean, I recall coming into this at a kind of latter stage. I think by this point in time the first cases had already been identified and an incident management team was up and running in relation to it, and my recollection is that the CMO fed into that process. I came into it, as I say, at probably a later stage when there was beginning to be a little bit of concern as to what was being said –

Lead 2A: I think broadly what this is showing is this is the chief of staff of the First Minister, Nicola Sturgeon, looking for some advice about what should be said around it, because I think you’ve identified by this point, which is towards the beginning of March, there had been some efforts in connection with this event to try to –

Professor Sir Smith: Yeah.

Lead 2A: – we heard from Dr McMenamin – to try to trace cases and to try to work out what was going on.

Professor Sir Smith: Yeah.

Lead 2A: I think he described those as local efforts to try to deal with the situation.

There was, I think it fair to say, a question mark as to whether this should be publicised in particular. If we go back to page 1, please, I think we see Dr Calderwood’s response, relating to this. She suggests towards the bottom that her “strong advice would be not to say anything here specifically” and that “naming the conference risks breaching patient confidentiality as a delegate list will be available”.

So it seems that the chief of staff on behalf of the First Minister had been seeking some guidance, and that there is a medical aspect to this in Dr Calderwood’s view which connects to patient confidentiality and that her view is that, as a result of that, this shouldn’t be released publicly, what has happened and what is going on to try and control it.

What was the issue about patient confidentiality, in the sense that could information not have been released with any patient details completely anonymised in order to keep the public informed about this potential significant threat?

Professor Sir Smith: There was a great deal of concern in those early stages about the welfare for people who had been identified as having Covid-19 and a process, a well recognised process in outbreak management, which we call deductive disclosure which is about managing the tension that exists between not giving information which could lead to the deductive disclosure or identification of a person associated with that outbreak and fulfilling legitimate public interest in terms of public messaging and transparency about any outbreak as well. And that is a tension that exists not just in relation to the response which we saw during Covid terms but it exists with every public health health protection response which exists and a real fear amongst clinicians that inadvertently by issuing particular types of advice actually you remove a patient’s right to confidentiality in the illness which they might be experiencing.

So Dr Calderwood’s concerns here are something which we see and encounter regularly when managing outbreaks across the country. And different clinicians will have different levels of risk tolerance in order to that, and I know that Dr Calderwood in particular was very against any circumstances whereby she may be responsible for the release of confidential patient information, and a particularly high level of – a high risk threshold in relation to that.

I think when you speak to other clinicians they might have different levels of risk tolerance in relation to that. My own view in this case was that, and it’s probably recorded in some of the email systems, I suspect, is that whilst it was really important to maintain patient confidentiality at all times, that there was – in this case there was an interest, a legitimate public interest that meant that some information, some form of information –

Lead 2A: That’s precisely what I was getting at.

Professor Sir Smith: – could be released. But it had to be very, very carefully thought through, the implications of that, so as not – particularly when there’s such small numbers at this early stage of the outbreak being identified.

Another word on the Nike conference, if I can, because I think it’s really important that when we’re speaking about the Nike conference we commend and recognise the efforts of the health protection teams that were involved in dealing with this conference, because their actions at that point in time probably – well, we now know from the evidence from the genomic sampling –

Lead 2A: We went through that, although your tribute is –

Professor Sir Smith: Yeah, handled this outbreak so thoroughly that actually we were able to – there was no further examples of that lineage, that lineage died out in Scotland as a consequence.

Lead 2A: There were though, I think, in the same report, between 290 and 310 other incursions of Covid into Scotland over this period.

Professor Sir Smith: I think this is really important to understand, when you look at the way Covid was introduced to Scotland, and this is not just in the period probably February and March of 2020 but also later on that summer when international travel began to open up, what we saw the evidence for, particularly through this relatively new discipline of genomic sampling, which was a wonderful innovation used extensively during the early part of this response to understand transmission dynamics of the virus, but what we saw was that, as you say, there were several hundred incursions of the virus of different types across Scotland at that point in time. So rather than, if you like, a ground zero which occurred in Scotland, actually that multiple seeding through international travel that there was at that event made it very difficult to control the virus in those early stages.

Lead 2A: Dr McMenamin when we discussed this on Friday was at pains to – I’d suggested to him that perhaps a number of these strains had come from Spain and he was at pains to say that it came from a number of the major European countries, including Italy and France. And of course the Scotland rugby teams, international rugby teams, played rugby in Italy in late February, didn’t they, or one of them did?

Professor Sir Smith: And many people from Scotland visited for skiing in those kind of areas as well. And – and, you know, international tourism being as it is just now, there will always be a risk that as infection of one sort of another begins to show itself globally, is that there will be further and further incursions as a consequence of that.

Lead 2A: Equally, a number of people from France came to Scotland to watch Scotland play France on 8 March as well?

Professor Sir Smith: And as you say, there were tourists come to Scotland, and Scottish people visit other countries for a number of different reasons.

Lead 2A: But those events were predictable and might have been able to have been controlled?

Professor Sir Smith: I think that those are events that, with the benefit of hindsight, you’re right, they could have had an impact, but the degree to which they’ve had an impact is, at this stage, I’m afraid –

Lead 2A: Whether it’s necessary to rely on hindsight will be a matter for your Ladyship in due course. But as regards this very matter, I wonder if I could take you to your witness statement INQ000273978, to page 71, paragraph 280, where you give us some useful information about an important event. You’re talking here about the first person to test positive for Covid in Scotland and you say:

“The first person to test positive for Covid-19 in Scotland was on 1 March 2020. This person was a returning traveller. Subsequently, the first person to test positive through evidence of community transmission

(ie no exposure to known contact or returning traveller)

Lead 2A: was 11 March 2020. This was significant because it implied that Covid-19 was already spreading within communities and so the geographic element of the case definition was removed. It also heralded the move to delay phase of the response.”

Furthermore – so this gives some background – I understand on 13 March, an announcement was made by your predecessor – we can take that down, thank you – an announcement was made by your predecessor about the first death in Scotland from Covid, and what was said at that time by Dr Calderwood was:

“I am saddened to report that a patient in Scotland who has tested positive for Coronavirus has died in hospital. I offer my deepest sympathy to their friends and family at this difficult time.

“The patient, who was being treated by Lothian Health Board was an older person who had underlying health conditions. No further information will be available to protect patient confidentiality.”

It was subsequently suggested in the press that the person who had died was in fact a Frenchman who had attended the Scotland rugby game. That does not feature in the analysis given by Dr Calderwood. Is it your understanding that that is in fact correct and why did that not appear in Dr Calderwood’s announcement?

Professor Sir Smith: I have to say to you I have no knowledge of that whatsoever.

Lead 2A: I’d like to ask you some questions, please, about the circumstances in which you came to take on the post initially of interim CMO and subsequently as CMO in December.

Could I just ask you, before we get into the detail of that, why was it that you were appointed interim CMO for such a lengthy period and then took over as the full CMO, if you like, and did that have any practical significance at all?

Professor Sir Smith: So the reason I was interim CMO for, oh, that must have been approximately six months or so, was partly because I was managing a pandemic at that point in time and the appointments process to an office such as the CMO is a fairly rigorous one and one which is overseen by civil service commissioners, so it’s a competitive process through – with different stages, and I think in order to make sure that both – usually the appointment of a CMO is a process which takes several months from the point of identification of potential candidates, through advertisement, through to assessment centres which people participate in, and then interview. And, as I say, subsequently it was decided that sufficient stabilisation had occurred within the system by late 2020 that that process could be begun, and still at that point it probably took three to four months from advertisement through to appointment.

Lead 2A: But to all intents and purposes, am I correct in thinking you performed the role of the CMO, whether you were interim –

Professor Sir Smith: So the role of – I guess it’s important to point out at this stage that I wasn’t the first interim CMO that Scotland has had, there have been instances before, from the handing of one CMO to the next, whether an interim has been appointed. In fact before Dr Calderwood took office –

Lead 2A: What I’m trying to get at, Professor Smith, is I just want to know whether from 5 April 2020, irrespective of the title and the various procedures, which I understand need to be followed, you were the principal medical adviser to the Scottish Government on matters relating to –

Professor Sir Smith: So it was exactly the same.

Lead 2A: Thank you.

You were asked in your statement whether the resignation of Dr Calderwood had had an effect on Scotland’s response. You’ve already told us that she had been a pivotal figure, understandably, in the response up till that point. You say in your statement that:

“The resignation of Dr Calderwood did not affect Scotland’s pandemic response and [that] the CMOD continued to provide advice to policy colleagues and the Scottish Cabinet.”

In light of what you have already told us about the significance of her response, are you seriously suggesting this had little or no impact?

Professor Sir Smith: The biggest impact I had was in the workload for the rest of the directorate at that point in time. We suddenly found ourselves with an important trusted colleague who was no longer available there, who had developed relationships with ministers, and if there was any detrimental aspect of it at that point in time was that I – during that immediate period, it was about building relationships with those ministers in order that I could provide them with advice that they were seeking from me. Over the latter course of March, my time with ministers began to increase a little bit. I had conversations with the former First Minister on several occasions, I knew the Cabinet Secretary for Health well at that stage as well. And so by that point in time I was able to slip into the role without too much detriment.

You’ll recall that in that period the course was already set in terms of the approach, and it was – it was very much about being able to kind of give advice, develop advice as new evidence was coming in at that point in time.

Lead 2A: Is it correct to say that Dr Calderwood had a particularly close relationship, as you said, with the former First Minister, Ms Sturgeon, and the Cabinet Secretary for Health and Sport, Ms Freeman?

Professor Sir Smith: I think my observation would be that she had a good relationship with the former First Minister and with the Cabinet Secretary, and indeed with other ministers that she had contact with as well. She was an important figure and she was trusted, I think, by them.

Lead 2A: You presumably required to build a relationship, as you’ve described, with those two important figures in the pandemic response?

Professor Sir Smith: I believe that I had a trusted relationship and benefitted from a lot of contact with the Cabinet Secretary before that point in time, but I didn’t have quite the level of contact or relationship that Dr Calderwood had with the former First Minister.

Lead 2A: I think you suggested a moment ago that the course for the Covid response had already been set by that point. Did that mean that you inherited a plan that had been devised by someone else?

Professor Sir Smith: At that point of time we were, ultimately I would have thought, two weeks into what later became known as lockdown. Much of the discussion was about what impact was that lockdown having and how was it stabilising the drastic situation that we saw across the country, and we began to turn our attention at that stage to: if it was beginning to stabilise, then for how long did those drastic measures that we all experienced have to stay in place for and how would we begin to kind of gradually over time reduce that in as safe a way as possible?

Lead 2A: At the very moment of her resignation, a few days before on 1 April, Scotland’s confirmed cases of Covid-19 had passed 2,000, with 76 deaths in hospital that day, the Scottish Government had just announced its ambition to deliver 3,500 tests by the end of the month, construction had just started on the SEC in Glasgow to become the NHS Louisa Jordan, and the day after her resignation the Coronavirus Act was introduced, gaining Royal Assent on 31 March.

In light of these very, very important developments with regard to the strategy, it’s true to say, isn’t it, that this was the worst moment that one could possibly find for Dr Calderwood to depart the scene?

Professor Sir Smith: In the management of a pandemic, particularly in the early management of a pandemic, I don’t think there was any good time to lose an adviser, particularly an adviser who has built that level of trust and relationships across the system. So I don’t think that there is any good time at all.

Lead 2A: Is it correct to say that there were attempts made within the Scottish Government to keep Dr Calderwood in post despite the events which led to her resignation?

Professor Sir Smith: I wouldn’t be party to that, I wouldn’t know.

Lead 2A: Do you know when it was that the Scottish Government became aware of the matters which led to her resignation compared to when it was that she eventually resigned?

Professor Sir Smith: I can only tell you when I became aware, and I became aware on the Saturday evening, which I think would be April 4, perhaps.

Lead 2A: I think that’s right. I checked this earlier. I think April 5, the day of her resignation, she resigned late in the evening, that was a Sunday, so I think you’re absolutely right.

Professor Sir Smith: So I think it would be late afternoon, early evening on the – on Saturday the 4th that I became –

Lead 2A: The reason I ask is that there are – I won’t go into the detail, but that you will no doubt remember that obviously this was a difficult time for you and the rest of your team to have to take over responsibility, and there is some mention in some messages of the focus on Dr Calderwood being slightly difficult for the team, who was trying to keep the show on the road, understandably, and that there is a suggestion in those messages that – you refer to “the team who have been giving advice over the course of the week”. It tends to suggest, therefore, that perhaps the focus on having to deal with Dr Calderwood, in a more pastoral sense, which is also suggested, had been going on for some time before her resignation, through the course of that week, which then culminated on Sunday the 5th?

Professor Sir Smith: No, that’s an incorrect interpretation of that.

Lead 2A: Okay, thank you. But your first intimation of it was on the Saturday?

Professor Sir Smith: Yeah.

Lead 2A: Thank you.

I’ve asked you some questions already about your role on the Scottish Covid Advisory Group. One matter which has come up in our analysis of the group’s minutes is that you did not attend the third meeting, which took place on 2 April 2020, the fourth meeting on 6 April 2020, the fifth meeting on 9 April 2020, the sixth meeting on 13 April 2020, nor the seventh on 16 April, nor the eighth on 20 April.

You mentioned a moment ago the importance of creating relationships with your ministerial and indeed other civil service colleagues. Why was it that you failed to attend these meetings?

Professor Sir Smith: Because I would have had duties or priorities that sat elsewhere at that point in time. And I already knew many of the personalities who were involved in that group, I had established relationships with them, the chair in particular I had a very trusted relationship with, and we were able to use that trusted relationship to provide advice back and forward and for me to be able to get a full recount of the meeting from. And whenever I wasn’t able to attend a meeting itself I had one of my deputies delegating for me at that meeting. But really the relationships were already largely established with members of that group.

Lead 2A: Although no doubt these very eminent professionals were very well known to you, in this specific context, the context of a new group being set up to provide advice through you to ministers, which had been set up originally under the auspices of your predecessor, was it not very significant – was it not very important for you to attend these initial meetings to try to set up the way in which the group was going to function and to establish those relationships in that particular context?

Professor Sir Smith: That type of information was conveyed through the conversations that I had with the chair at that point in time. Unfortunately it just wasn’t possible for me to be everywhere at once and there were many, many calls on my time at that point in time, which just – I couldn’t be in two places at the one time.

Lead 2A: Thank you.

I’d like to ask you some questions – we’ve covered this area with a number of other witnesses including Dr McMenamin and Professor Phin – about the position with regard to the Chief Medical Officer’s office and the minimisation of infections within care homes.

We’ve looked in some detail, and I won’t take you to all the detail, Professor, with other witnesses, including Dr McMenamin particularly, at the report that was done by PHS in this regard which came out in October 2020, which helpfully sets out the pieces of published guidance that emanated from PHS with regard to the management of infection in care homes, and we’ve looked at the particulars of that, which I don’t intend to take you to.

What I would be interested to know is the extent to which the Chief Medical Officer’s office, because this was before you became Chief Medical Officer, was involved in the compilation and publication of the advices – of the guidance that emanated principally from PHS on 13 March and then later in the month, I think the 26th was the other date.

Professor Sir Smith: So I don’t recall any involvement. There was a separate structure which was set up to provide advice through that to develop that guidance. I know that Public Health Scotland and some advisers within Scottish Government worked closely together in relation to that guidance but I didn’t have any direct involvement in that.

Lead 2A: Right.

We’ve heard evidence or we have evidence that there were a number of versions of the guidance created, I think two were ultimately issued, but a number of versions existed. It creates an impression of a slightly chaotic picture in terms of the allocation of responsibilities for who is meant to put together and compile this guidance, whether it’s a government CMO type of exercise or whether it’s PHS or both.

Do you have any recollection of that characterisation being an accurate one over that period?

Professor Sir Smith: As I say, I wasn’t directly involved, so I couldn’t even comment as to how many iterations there were.

Lead 2A: Thank you, but there were other individuals effectively from within your directorate who were engaged in that process, along with Dr McMenamin and others?

Professor Sir Smith: There were other government clinical advisers. Whether they were within the directorate or not at that stage I cannot recall.

Lead 2A: We’ve heard evidence as regards this care home situation that there is a kind of cultural issue which exists within Scottish Government as regards its healthcare provision, that there is an instinct to look after hospitals and then to look after care homes, and, last, to look after those who are in residential care in their own homes. Is that a cultural issue which you recognise to any extent, and in particular relating to this very significant period?

Professor Sir Smith: So I have to say to you that I don’t recognise that as being a scenario which I ever saw play out, certainly in my presence. I think that there was – in the conversations that I recall from that period, there was general concern about the potential for the spread of infection in any closed setting, and I would put it as broadly as that. So I would also include in that not just hospitals, care homes, residential homes, but also prisons, places like that, where – any closed setting where actually there was a population who may be at greater risk and that the virus could spread within. And we’d already seen some of that play out in other countries, particularly Italy at that time, about the potential for them.

Lead 2A: Ms Lamb, who you will know, who gave evidence earlier, suggested that in this regard, as Dr McMenamin and Professor Phin had suggested, there was a need as regards testing for there to be a degree of prioritisation amongst groups who might be tested. Ms Lamb gave evidence to the effect that that prioritisation was a matter on which advice was given by the Chief Medical Officer or the Chief Medical Officer’s directorate. Do you have any knowledge of that advice and the basis upon which it was given as regards who should receive tests by way of priority over other groups?

Professor Sir Smith: So the only prioritisation that I recall at that point in time, particularly in those early stages, was that testing, where it was available, should be particularly prioritised for those with a clinical need, so to determine what illness they had, whether it was Covid or not, whether it was another treatable illness and how those patients should be managed. Beyond that as a first priority I wouldn’t be able to comment.

Mr Dawson: Thank you for that.

My Lady, if that’s a convenient moment, I’d be happy to break.

Lady Hallett: Certainly.

Mr Dawson: Thank you.

Lady Hallett: I shall return at 3.15.

(2.58 pm)

(A short break)

(3.15 pm)

Lady Hallett: Mr Dawson.

Mr Dawson: Thank you, my Lady.

Could I start by returning to an area we were looking at earlier and ask a question I forgot to ask you. You were giving some evidence about your involvement, albeit limited, in the advice that was provided to Scottish Government over the initial few months before the first lockdown, and you told us of course that the principal adviser in that regard was the Chief Medical Officer, Dr Calderwood, and you were not privy to a lot of the discussions, but you certainly discussed matters with her as her deputy. Would that be broadly correct?

Professor Sir Smith: Yes.

Lead 2A: I was interested to know whether, at that time, your understanding was that the Scottish Government had the legal power to impose restrictions on members of Scottish society or whether in having these discussions and providing advice you were under the impression that that legal power was something they did not have, which would later, of course, come through the Coronavirus Act. What was your understanding of the position?

Professor Sir Smith: So what I recall from that time is that there was – there was discussion between policy teams at that point to what extent Scotland had both the powers and the capabilities to support the population should an event like that begin to happen. I probably became more privy towards those conversations during the period of March than earlier than that. But as we were exploring what the possible responses could be, from the output of SAGE, it was becoming more and more evident that actually Scotland, although they had the powers to be able to kind of take that course of action, one of the difficulties in doing that was to be able to identify particularly the financial support for people – to support them during that period.

Lead 2A: The reason I ask is, of course, if one were in the position of Dr Calderwood at the time, giving advice about what options might exist, and you weren’t privy to the precise advice that was given, it would be important to know, would it not, what the range of legal options actually were, because you might wish to suggest something which simply couldn’t be done and therefore it would be a waste of time, whereas if the impression was that you did have the legal power to impose restrictions in the nature of a lockdown or something short of a lockdown, that would inform the matters on which advice from a medical perspective might be tendered, isn’t that right?

Professor Sir Smith: So within that context, I guess it’s understanding what powers were immediately available at that point in time and what powers could be developed through emergency legislation, and my understanding is that those areas were explored. But, as I say, not being privy to those conversations directly, I can’t give you –

Lead 2A: Of course we take your evidence in regard with that caveat, as I set out at the beginning.

To return then to where we were, which was discussing again an area you had a certain amount of involvement in, which was care homes, could I take you to INQ000371227. This, again, is one of your notebooks. Page 45, and I’m looking …

(Pause)

Lead 2A: Yes, it’s on the left-hand side there, you make a note – we think, from the previous entry, that this is dated – you can see on the right-hand side, there, there’s an entry of March – this is 2020 – on the left-hand side – we think this is dated 23 March 2020. So this shows some level of involvement or information that you have in the care homes issue at that time and you’ve written:

“CNOD view – if move to opening care homes to admissions when positive cases, it’ll need additional staff to care … for isolated patients and use associated IPC processes.”

Should that be CMOD?

Professor Sir Smith: No. CNOD –

Lead 2A: The Chief Nursing Officer –

Professor Sir Smith: So this looks – in this case, it’s information that I have jotted down that has been provided by potentially the Chief Nursing Officer or one of her staff in relation to their view who – the Chief Nursing Officer’s directorate is the lead directorate for infection prevention and control measures, and really was – provided significant clinical input into the development of approach to care homes.

Lead 2A: Well, can you tell us what you understand this to mean as being the CNOD view, rather than me suggesting to you what it …

Professor Sir Smith: What I read from this short passage which I’ve written down here which says – I suspect has been jotted down from a meeting at some point – that if admissions to care homes are contemplated when there are already positive cases within that care home, then we need to almost separate streams of staff, additional staff, just to look after the isolated patients and to take care of the infection prevention and control processes. I think these were ideas which were being bandied about round about capacity rather than any kind of definitive position in relation –

Lead 2A: Yes, I understand the context, but this seems to contemplate the possibility that there will be positive cases in care homes; yes?

Professor Sir Smith: I think it was always recognised that there would be the potential for positive cases in care homes. I think that we realised that it was – with ingress and egress from care homes, just with staff, with visitors, with other sorts, that it was always a possibility that someone could take infection into that environment, or it could come from other sources as well.

Lead 2A: Are you aware of the particular issue, I think, highlighted, as the Chief Nursing Officer Directorate is pointing out, that if positive cases did get into care homes then it would need additional staff in order to care for the isolated patients, because there would need to be a degree of isolation and – with various processes, infection control I think processes? Was anything done to try to address the fact that additional staff in care homes would be needed as had been highlighted, as far as you’re aware, over this period?

Professor Sir Smith: I’m afraid I wouldn’t be able to answer that question. I think that’s a question for people who were more closely involved in that work.

Lead 2A: Thank you very much.

If I could go on to some – a different area. I would like to ask you some – broadly some questions about various parts of the strategy for the Scottish Government’s fight against coronavirus and the various different phases that it went through.

Could I go to your statement, please, to paragraph 506 and page 126.

It’s INQ000273978, paragraph 506, please, page 126. Thank you.

This is a section of your lengthy report in which you are telling us – it’s a broad reflection, although in a particular context, about the differences in approach which emerged between the – in particular the UK Government’s response and the Scottish Government response. We heard some evidence about specific meetings around about the beginning to middle of May from Mr Thomson be the other day, leading to a COBR meeting which took place on 10 May, which he identified as being effectively a point at which you could recognise a significant – he didn’t like the word “divergence”, but divergence in the approaches.

You are comparing and contrasting, I think, here, at a general level the reasons why you think that those differences emerged and you say:

“It is my view that the differences in approach between UK nations were in part influenced by clinical and demographic considerations (Scotland has an older population, with greater levels of multimorbidity and therefore greater risk of harm from Covid-19) and in part by national tolerance of risk and harm in each of the four harm domains. This national tolerance of risk, in my view, is not as simple as saying Scottish Government’s tolerance of risk, as population polling and attitude surveys were used extensively alongside other sources of information to inform that understanding more fully.”

There is a consistent theme amongst the evidence in written form given to this Inquiry about this issue, that Scotland had a different tolerance to risk, and I’d like to explore that with you a little bit.

First of all, there seemed to be two major components of what you’re saying here, is that there were clinical and demographic reasons why a different tolerance might be applied, and I’ll ask you about that in a moment, but there was also some additional factor, which you describe as there being some different national tolerance of risk, which I think you’re suggesting is evidenced by polling and attitudes surveys.

Can you tell us, please, precisely where it is that this “national tolerance of risk”, and the impression of it, in particular around this time, from May onwards, where that emanates from, as it seems to be a rather abstract concept which is hard to grasp hold of.

Professor Sir Smith: I agree that the whole concept of risk is sometimes difficult to grasp, and I guess the starting point for this is to understand –

Lead 2A: Just to be clear, Professor, it’s more the national tolerance element I’m interested in.

Professor Sir Smith: But I think that the concept of risk is also difficult to grasp in this context as well.

I think perhaps I’d best start with the clinical aspects of this, if I may, and that’s to explain why I think this is important, because Scotland does have an older population than other parts of the UK, and we knew even by this stage that it was very clear that older groups of people were at greater risk from the effects of the coronavirus. But not only is it an older population but it’s a sicker population, and it’s a sicker population for many reasons, but the development of what we call multimorbidity – that is the people having multiple medical conditions, chronic medical conditions that impact on their health – is more evident in Scotland than in other parts, and not only is it more evident but it also tends to occur at a slightly earlier age. And a lot of that is influenced by the health inequalities that we see across the nation as well. So, again, a piece of – strong piece of learning is about – one of the ways to make a country more resilient against any pandemic is to improve the general health of the population, but particularly those who experience inequalities.

Lead 2A: Is it correct to say, Professor – we’ve heard quite a lot of evidence about the health inequalities, and some specific characteristics of that, as well as the fact that Scotland has an older population and particularly from our statistical witnesses. You are saying here, I think, that the different approach taken from May onwards was driven in part by the different morbidity levels, the health inequalities. Was it the case that Scotland had greater health inequalities, worse wealth and an older population throughout the pandemic?

Professor Sir Smith: So we had worse health and greater inequalities leading into the pandemic –

Lead 2A: Yes.

Professor Sir Smith: – which was perpetuated through the pandemic.

Lead 2A: Yes.

Professor Sir Smith: So what it does is it places our population at a much greater risk –

Lead 2A: Yes, I understand. What I’m trying to establish is whether these factors remained a constant such that Scotland had these factors to take into account which were not as great a factor in other nations of the United Kingdom; is that correct?

Professor Sir Smith: So, yes, and one of the reasons for spending some time just to explain this is because I think that that begins to – you begin to explain and understand why the risk thresholds in Scotland was perhaps set slightly higher, because of the perceived additional risk to the population because of these increasing burden – or increased burden of disease that existed within the population.

Lead 2A: Was it your advice to the Scottish Government, based on these considerations, in May 2020 that it ought to ease the lockdown more slowly, thereby diverging from the UK Government’s approach, because of this higher level of multimorbidity and the older population?

Professor Sir Smith: So my advice, you’ll recall, at that point in time, would be taken in the context of the four harms, which was already established at that point, so –

Lead 2A: But as far as the harms you covered.

Professor Sir Smith: But my advice in terms of the health-related harms was that – was that actually the risk to the Scottish population was greater because of the demographics and the burden of disease that existed within the country.

Lead 2A: The Scottish population had these different characteristics at the time of the first lockdown, but no earlier restrictions were imposed; isn’t that correct?

Professor Sir Smith: That is correct.

Lead 2A: They had – the Scottish population had these characteristics in the summer of 2020 when the borders were opened to allow tourists to go to Spain and return, eventually causing these older sicker people considerable harm, isn’t that right?

Professor Sir Smith: That is correct.

Lead 2A: At the time of the circuit-breaker lockdowns in Wales and Northern Ireland and England between September and November 2020, when no Scottish national lockdown occurred, these factors also existed?

Professor Sir Smith: These factors existed throughout that time. The Scottish population has continually, as I say, demonstrated that it’s been a little bit older than other parts of the UK and has this heavier burden of disease.

Lead 2A: These factors existed when Scotland went into its second lockdown, no earlier than England’s second lockdown, isn’t that right?

Professor Sir Smith: It is.

Lead 2A: From summer 2021, when infection rates were the highest in the UK due to the Delta wave, and no lockdown took place, these considerations were also part of the picture?

Professor Sir Smith: It is.

Lead 2A: And in late –

Professor Sir Smith: What we should recall –

Lead 2A: Sorry.

Professor Sir Smith: If I may, what we should recall is that risk is dynamic, and over that period which you are describing with a we saw, very importantly, was also the introduction of additional therapeutic interventions and, most importantly, a vaccination programme which began to reduce the level of direct risk from the virus as a consequence. So it is not true – whilst the risk – or whilst the burden of disease and the elderliness of the population was a fairly constant during that time, the degree of risk that they faced was altered and influenced by the therapeutics and the vaccine which came into play at that time.

Lead 2A: This difference remained in late 2021 into 2022 when the infection rates in Scotland were the highest in the UK due to Delta and Omicron, and no national lockdown took place; is that not right?

Professor Sir Smith: As I explained, risk is dynamic.

Lead 2A: But these factors still existed at that time?

Professor Sir Smith: The elderliness of the population and the burden of disease, which by that point was influenced – the risk associated with them was influenced by the protective nature of the vaccines and also the therapeutics that were available.

Lead 2A: How were you able to measure the level of protection that was given by the vaccines over those later periods?

Professor Sir Smith: So the type of protection which the vaccine offered was monitored through what was, I think, one of the most important developments in terms of data over the course of the pandemic response: what became known as the EAVE II platform. Led by the Usher Institute in Edinburgh but really a kind of a collaboration between a number of institutes, including Public Health Scotland and Strathclyde University as well. But really the data which they were able to produce looking at the degree of risk to the population from a variety of different sources, whether that be new variants or the protection which was offered by the vaccine, became an incredibly important part of the information which was used to kind of associate risk within the country.

Lead 2A: What we’re trying to do here is work out why it is that Scotland took the same approach at certain times but a different approach in May 2020. You’ve introduced the concept of the vaccines offering a protection and the EAVE II study, again which we’ve heard about from other witnesses, but that protection was afforded to the people in the other nations of the UK equally, wasn’t it?

Professor Sir Smith: It was, yes.

Lead 2A: So that was a factor, as regards to the comparison, which was consistent, although the inconsistent factor remained Scotland’s multimorbidity and elderly population?

Professor Sir Smith: So again – just to emphasise again, risk is dynamic. Over that point in time we would see the same level – risk is dynamic in other countries as well, but if there is an approach to risk within this country it would be influenced by the confidence that the protections that the population was having from these other sources was going to have the desired effect and could replace some of the non-pharmaceutical interventions which were in play.

Lead 2A: Thank you.

The second component, you’ve taken them quite rightly, I think, the other way around, with the clinical and demographic considerations first, but I was also interested in trying to explore with you what you mean by what appears to be the other component of the decision-making process, which is the national tolerance of risk and harm, which I think you are suggesting is demonstrable through population polling and attitudes surveys. If I may say so, Professor, that seems like a rather unscientific concept. Could you help us with that?

Professor Sir Smith: Yeah, what we saw was the level of fear and anxiety through some of polling and attitudes survey was really quite significant and fear of the virus in particular was evident through that. We also heard it very clearly and strongly from many public groups as well who were expressing concern. There was, I think it’s fair to say, a real anxiety, concern, particularly for those who had been identified as the highest risk groups, so the group which, at the beginning of the pandemic, would have been known as the shielding group, but those at greatest risk. There was a particular anxiety that they would be left behind and that some of their needs would not be particularly catered for. And I heard some very compelling stories from some of those people in groups when either they wrote to me or spoke to me about their experience as well.

And so all of that begins to create an impression that actually the Scottish – there was a significant aspect of the Scottish public that was very cautious and fearful in their approach and was perhaps more risk-averse than we were seeing in other places, and I think that was reflected in attitudes of some of the decision-makers as well.

Lead 2A: Was that not the case then at the other times that I’ve mentioned when Scotland didn’t take greater restrictions? So, for example, you mentioned the shielding category. Was it not the case that people who were shielding were concerned about the virus when cases started to rise in August 2020 at exactly the same time that the shielding restrictions were lifted on 1 August by the Scottish Government?

Professor Sir Smith: And I think what we saw there was increasing confidence that actually the level of harm which was likely to be experienced by anyone had dropped to a level because of – although case levels were rising at that point, they were still at a very, very low level compared to before.

Lead 2A: But in essence, whether people in the public’s attitude to risk was one thing or another is not really the most important thing to weigh in the balance, is it, it’s what the science tells you about what the risk is. And of course members of the public didn’t get the SGoRR sitrep with all of its information in it. So whether people have a certain attitude, what your job is to give advice as to how they should be protected, whatever their attitude was; isn’t that right?

Professor Sir Smith: Which I continued to do, but I didn’t make decisions –

Lead 2A: Of course.

Professor Sir Smith: – (inaudible), andso the – whilst the advice that I may have given during that time remained fairly constant, and – it was always influenced for the decision-makers by advice which was coming from other areas of government and particularly took into account the impact on the other harms.

Lead 2A: I see. So in the period where one might say there is a closer alignment after having been a period of divergence, to use the phrase Mr Thomson doesn’t like, over, say, May to August, one sees these phenomena such as shielding being lifted across the United Kingdom on 1 August, that’s a common thing that happens, and then from then on the various things that happen tend to suggest that Scotland’s restrictions are either less than or equal to the rest of the UK. In that period, is your position that you continued to give advice that one needed to be focused in particular on the first harm but decision-makers made decisions with more regard to the other harms?

Professor Sir Smith: So my role was consistent during that time. As we’ve explored before, my role was to give the best advice that I could in terms of preventing harm 1 and harm 2 and that advice had to be taken and integrated into the advice that was being received from other parts of the government as well and other advisers within government, and I think what we can see in the decision-making there is a changing approach to the relative importance of each one of those harms, as time went on.

We should remember that whilst the harms relating to Covid changed over time as well, because of the influence of vaccines and therapeutics, the harms which people suffered economically also changed over time as well. So whilst some people might be able to cope, albeit with difficulty, with a short period of economic instability and difficulty, the longer that that goes on the greater the impact that that has as well. So the whole concept of risk, whether we’re talking about health harms, whether we’re talking about the society harms or whether we’re talking about the economic harms, none of that is static and constant. That is all dynamic.

Lead 2A: Thank you.

You mentioned earlier, I think, somewhat in passing, the position with regard to borders. I was interested to know – we heard some information, again from Mr Thomson, helpfully, about the way in which borders were controlled and although he insisted that the distinction was not a blurry one, there was a slight complexity with regard to the way that borders were operated because borders were a reserved matter for the purposes of immigration and nationality but, as far as the pandemic was concerned, it was a devolved matter because the control of borders pertain to a matter of public health, which of course, as you know, is a devolved matter.

When there were significant and frequent changes to the rules about which countries – what the countries were from which people would be allowed to enter Scotland or vice versa, over the period in particular for a period in 2020 and again in 2021, when advice was being tendered in this regard, was advice sought from you about whether you thought countries were too risky or not, or was advice sought from elsewhere? Because there were divergences in the approach, but our understanding from other evidence we heard last week is that the evidence base as to what the risk was in any given country was the same as between Scotland and the United Kingdom.

Professor Sir Smith: So the evidence was produced by the JBC, we’ve referred to the JBC before, and they produced really helpful evidence packs where they would be examining the information that was available in relation to certain countries and either their levels of infection, hospitalisation, or the emergence of potential variants within those, and I would be involved in giving advice to ministers with teams from both health policy but also from travel policy, in relation to those countries, and participated in ministerial calls across the four nations in relation to that as well. And again I think what you see in terms of the occasional divergence of the – and it didn’t happen terribly often, but occasionally, there was a divergence in approach between the four UK nations where risk appetite probably influenced the – how quickly the response was made.

Lead 2A: But if the evidence base was the same, what was the reason why these divergences started to occur?

Professor Sir Smith: I can only assume that in the decision-makers and perhaps even in the advice that was given, that is – the tolerance for risk was greater in some countries than others. Certainly from my perspective I was always very, very aware and cognisant of the evidence that had been produced about the multiple incursions that there had been both in the early part of the pandemic but then again in the late summer of 2020 and which had caused rising cases from some countries with greater levels of infection than we had. And whilst I think it would have been impossible to kind of keep infection out of this country completely from other sources, because of a reliance on goods coming in from other countries, my view was that where there was clear evidence of an increased risk in a particular country, and the ability for that country to then amplify what was already happening here, is that we should take action against that.

Lead 2A: Okay, thank you.

I’d like to go briefly to something I think we’ll cover with other witnesses but upon which you make a very helpful – that’s the concept of zero Covid around this time. This is the – this is a fairly well known concept that around the time, I think probably the summer of 2020 –

Professor Sir Smith: Yeah.

Lead 2A: – the cases had come very significantly down in Scotland and the narrative, certainly from the Scottish Government, is that that is associated with this strategy of easing the lockdown more slowly, which was successful in that it got cases down to a much lower level, and there was – there were a number of statements made, including by the First Minister, and indeed by other academics who were involved in advising the government, that zero Covid elimination was a feasible option and was indeed a laudable goal.

One of the things that we have struggled with is whether this was actually ever a policy. It may be a matter of semantics, but in your witness statement at paragraph 479 you helpfully say that your position on the matter is that:

“In my view it would have been impossible to achieve a ‘Zero COVID’ strategy without strict controls of every land, sea and air border alongside quarantine and high levels of co-operation of the public in adhering to restrictions in place. Regional co-operation in trying to achieve this aim (and most likely a wider degree of co-operation than UK nations alone) may have made this slightly more likely, but with a high dependency on these borders for essential goods and materials it would have been very difficult even with this.”

So, for the reasons we were just exploring to an extent, and I assume also the land border with England is a part of this, your view was that although elimination as an ultimate goal was a good thing, because it would mean suppression of the virus down to low levels at the very least, elimination was not something that could ever have been achieved; is that right, broadly?

Professor Sir Smith: So I think “elimination” was used as a term sometimes colloquially rather than scientifically, and certainly from a scientific perspective –

Lead 2A: Yes.

Professor Sir Smith: – looking at epidemiology, I didn’t think that elimination of the virus was a feasible option. However, if it led to an approach which tried to keep the numbers as low as possible, then I think that that was something which was useful –

Lead 2A: Yes?

Professor Sir Smith: – and something which was worth pursuing.

Zero Covid, as far as I’m concerned, was never a formal policy of the Scottish Government, but keeping the cases and the harm which was caused by those cases to as low a level as possible was something which we’ve stated in many documents. If we touch upon the environment, the circumstances that would have been necessary to achieve zero Covid, I really do think that it would have been almost impossible for Scotland to be able to achieve that as a country by itself. Even on a UK level I think that that would have been a very difficult thing to try and achieve, despite the fact we’re an island nation, but perhaps because we’re an island nation and are so reliant on things coming from outside. But with greater level of regional co-operation, and probably at a European level, I do believe that we could have sustained lower levels of Covid, perhaps not eliminated but certainly got very close to that, and dealt with sporadic cases much as we do with other diseases such as measles.

Lead 2A: Was your view on the matter, which I have set out and you’ve helpfully added to, a matter on which you provided advice to the First Minister and other ministers at that time?

Professor Sir Smith: It was a discussion that we had on a regular basis.

Lead 2A: Yes, that was your position?

Professor Sir Smith: And I think it was well recognised that that was my position, and I wrote one or two pieces on it, some of which appeared in popular media as well.

Lead 2A: Was there an appreciation at that time that the use of the concept of “zero Covid” or “elimination” in public pronouncements may as other witnesses, including Professor Stephen Reicher, are suggesting (their evidence to the Inquiry), create the impression amongst the public that, effectively, “Covid is over and we can go about our business as normal”?

Professor Sir Smith: I’m not sure that the public would ever have believed that that was ever a possibility at that stage in time, given the kind of feeling of anxiety that existed within the general population, and I think everybody certainly that I knew of was constantly watching both the UK and international picture to see where the next threat might arrive from. But I do think it was useful in terms of achieving a collective response from society with an aim to try to reduce the harm as much as possible across society.

It touches upon the point that Mr Reicher has spoken about on several occasions, which is actually appealing to the altruistic nature of humans and that collective societal response, and I think one of the things that it was helpful in doing in that respect was actually giving them an aim round about which we could try to coalesce.

Lead 2A: But it was a scientifically unachievable aim, isn’t that right?

Professor Sir Smith: I think that elimination, as it’s defined scientifically, is something which would have been almost impossible to achieve.

Lead 2A: Thank you.

I’d like to ask you about some brief questions, I hope, about the slightly later period. Obviously as we’ve discussed, evidence suggested, which we’ve analysed with statisticians, that cases started to go up in August. We have talked about the reasons for that. On 7 September the First Minister announced that there would be a slowing down of the easing of restrictions because of this, and consideration was given, in light of advice that had been tendered by SAGE, about which we are already heard evidence in Module 2, that there might be, by the time of September, a circuit-breaker or firebreak lockdown to try to break this increasing trend.

In around – on 18 September, you submitted an advice paper along with the Chief Nursing Officer and Professor Leitch, the National Clinical Director, which can be found at INQ000326427. I’m looking at page 4, paragraphs 21 and 22.

So this was an example of a situation in which you appear to be providing written advice, but along with your colleagues, who are providing a sort of joint opinion, if you like.

Just as we’re getting that up, this was a suggestion, this was effectively – you were looking at various options, various things that you might do, and the conclusion I think is reasonably expressed in these paragraphs whereyou say:

“However, we do not believe that these measures are sufficient.”

You’ve listed a whole load of potential measures immediately before that in a bullet point list.

“Therefore, we recommend that we introduce a general ‘stay at home’ order for 14 days from 12 October. We fully acknowledge the seriousness of this and we have discussed at some length whether we could recommend a less stringent ‘fire break’. Ministers will decide whether there should be specific exceptions from a four harms …”

Could we just have that back down to the original thing, and over the page:

“… perspective; from a public health perspective, to have the fire break effect, we require the most decisive action.”

Could I take you to another document, please, which is INQ000326426. I’m looking on page 1 at paragraph 6. This is an advice again by the three of you which was issued, it appears, later that very same day where you say:

“We remain of the view that a ‘fire break’ amounting to a general stay at home order may be required to be implemented quickly if our recommended measures do not have the desired effect. We do not propose at this stage a planned ‘fire break’ during the October school holidays but such a step may be required. With or without a ‘fire break’ we may have to consider tightening travel restrictions further during that period to reduce circulation of virus.”

So it looks like an advice was given that there should be a firebreak and then later on a shorter advice was tendered the same day by the same three people which moves the position slightly. We’re interested in exploring with you why it was that the advice that was being tendered had changed in that apparently significant fashion over the course of that day?

Professor Sir Smith: So the only reason that that might have happened is in terms of drafting and the strength of the recommendation that all three advisers were content with. It’s the only way that I could assume that that would happen.

Lead 2A: It does look like there’s a significant change. You say there’s decisive action, quite forceful, and you recognise that it might be resisted, I think, and then your position becomes that you’re no longer recommending within the course of it. So it’s not just a tweak. So are you saying that the first advice didn’t reflect your opinion and the second advice did, or what happened over the course of –

Professor Sir Smith: What I’m saying is that it appears that in that – if that is the order, I actually don’t know – I don’t particularly remember this submission that went up, but occasionally the process of drafting those submissions would be drafted by other people and we would comment on them, on the language that was used, and if we were unhappy at the language that was used in them we would change them.

Lead 2A: So you changed it from –

Professor Sir Smith: – that reflected our position on them.

Lead 2A: So you changed it from “You should have a firebreak lockdown” to “You should not have a firebreak lockdown”?

Professor Sir Smith: I don’t think that’s what it says.

Lead 2A: Well, what is the change?

Professor Sir Smith: It says –

Lead 2A: “We do not” –

Professor Sir Smith: – “school holidays”. So it’s the timing of it rather than whether it might be necessary.

Lead 2A: Are you suggesting it continued to be the position that there should be a firebreak lockdown?

Professor Sir Smith: But such a state may be required.

Lead 2A: But not at that time?

Professor Sir Smith: But not immediately at that time.

Lead 2A: But decisive action had been required, in accordance with the previous advice?

Professor Sir Smith: So, as I say, I’d – the only reason that that may have been included would have been in the drafting of the submission from whichever source, which clearly the three advisers have not agreed to.

Lady Hallett: So did the first advice go to ministers?

Professor Sir Smith: It doesn’t seem so. I wouldn’t have thought so.

Lady Hallett: So the first advice is drafted and you say that somebody, one of your number, decided that they didn’t like the advice as it was drafted. What was your opinion? Did you recommend a firebreak at that stage or didn’t you?

Professor Sir Smith: So what I recall at that stage was that it was – I don’t remember the exact dates, but I remember the discussions around about we were heading towards requiring some sort of firmer action and the timing of that firmer action was to be determined, some of it was determined by the modelling and there was still hope that the October school holidays might influence and bring down things naturally. We very often found that during periods when schools were not in session is that that influenced …

Lady Hallett: Did you advise a firebreak or was it one of your colleagues who advised a firebreak in the first advice?

Professor Sir Smith: I … I have to say to you that I don’t know where that first advice came from. So what I’m saying to you is I can only assume that that’s how it’s been drafted and that it has been altered when the three chief advisers have looked at it.

The process of drafting submissions was very often done by policy officials who interpreted our position and – from – just in the conversations that we had.

Lady Hallett: You can’t interpret “We say we need a firebreak now”. That’s not interpretation, Professor, is it? That’s straightforward. Either that’s what they understood you were saying. It’s not an interpretation, it’s quite a dramatic change.

Professor Sir Smith: It’s the only way that I can think that that has happened, but …

Lady Hallett: Sorry for interrupting, Mr Dawson.

Mr Dawson: Not at all.

This is potentially quite complicated, this, but what we did was we looked at the advice and then we compared and contrasted what the advice was with what we thought the actual outcome was, and this was quite an interesting illustration where you then go on to tell us, in this advice, having said “We now” – well, “We do not [I should say] recommend a firebreak lockdown”, that various things should in fact happen to try to reduce R below zero, strengthen FACTS, et cetera, et cetera.

So we did a comparison here, I won’t go through the detail of it obviously, but as a broad proposition what appears then to happen is that in this list – which goes on a bit further than one can see there and over the page – some of the things which you recommend with your colleagues should be done are accepted and some are not, and it’s – the basic question is: in circumstances where, having come to the view that there should not be a firebreak lockdown by this point, and then having come up with what I assume is quite a carefully planned series of things to try and work out, well, what’s the best thing, where is the virus coming from, what do we need to do, and in the circumstances where what eventually happens is some of them are accepted and some of them are not, in these sorts of circumstances, would you ever have the opportunity, having tendered this written advice, to discuss with the ultimate decision-makers which bits they really should keep in and which bits they should jettison?

Of course they are, as you have said on a number of occasions taking into account a number of different factors and harms, but to what extent is there a system whereby in that list you’re able to say to them, “But if you’re going to do anything, you absolutely have to do that; but if you’re going to not do that, that’s okay, that’s not going to make much difference”?

Because it seemed to us to be slightly odd that some of the things are accepted and some are not without, as far as we can tell from the paperwork, any further discussion about what the most important elements from a harm 1 perspective actually are.

Professor Sir Smith: So there are probably two things I would want to kind of emphasise in this. The first of all is that there’s a full realisation that the role of an adviser, whether it be a health adviser, an economic adviser or so forth is simply that: it’s to provide advice, and that that advice is received and acted upon according to how the decision-maker wants, so that’s the first aspect.

The second aspect was my experience, whenever one of these submissions was sent to the decision-makers, to the ministers, to speak about, they would – they would then organise a call, either in person or at the very least using a video platform to discuss the advice that was contained within it, and there would then be a back and forwards in relation, just as you describe, about what were the particularly important elements of it, or to explore some of the reasoning behind the proposal in further detail; and that was a process which we became very used to, all the way through the pandemic, but very, very regularly a submission such as this would then provoke a kind of call of some sort or a meeting of some sort to discuss the advice further.

Lead 2A: Did that happen on this occasion?

Professor Sir Smith: I don’t recall any occasions when it didn’t happen.

Lead 2A: There’s no document – this is very clearly set out as to what your position was. We’re not aware of there being any documentation we’ve seen about that process, so you’re saying that’s an oral process or a meeting takes place and –

Professor Sir Smith: Yeah, it was an oral process, yep.

Lead 2A: Right. Because, for example, just to look at these things, for example, the “Strengthen FACTS” message, we think that did happen, but “limit unnecessary domestic and foreign travel” didn’t.

So other things like non-essential car sharing did come in, but restricting non-essential travel to 30 miles limit did not.

Other measures that did not included a message to underline the seriousness of the situation, protecting the NHS, preserving care; that did not happen.

So would you have sat down with the decision-maker and gone through every element to make sure that they were pushing the emphasis on the right parts? And how does the public know what that process involved?

Professor Sir Smith: So I don’t remember the particular conversation that relates to this paper, because there were so many conversations which happened which were similar to this, but generally what it would involve is looking at the proposals which were contained within the submission and walking through them as to what we thought that they would achieve, and again taking into account the advice from other parts of government as well as to what potential harms they might cause as well.

I think I have to convey that this was all part of that four harms approach we were looking at, the impacts on society as a whole rather than simply just as a health impact.

Lead 2A: Thank you.

So moving into a different later period, I would just like to ask you broadly about one, really, area. We’ve seen in the evidence that from around August 2021 – sorry, from around July 2021, there was a significant increase in cases in Scotland, I think associated with the Delta variant, and that because the Omicron variant then arrived towards the end of the year and then quickly became the dominant stream, effectively Scottish infection cases remained very high over that period.

We have also explored that over that third wave period there was very nearly as much mortality in Scotland – despite the impression that Omicron is a less virulent strain of Covid – as there had been in both waves 1 and 2, there was roughly 5,000 deaths in the first, 5,000 in the second and about 4,000 in the third.

Over that period, that period might be said to be characterised by very much less stringent restrictions, the main protection, it would appear, against the virus being the vaccine, as you have said earlier, and in particular the vaccine passport system, although it had a different name in Scotland, that was what Ms Lamb told us it subsequently became known as.

Over that period, given your predominant responsibility for providing advice on harms 1 and 2, to what extent were you providing advice that more needed to be done to address harm 1, greater restrictions needed to be applied, and that the vaccine and the vaccine passport were clearly not protecting the people of Scotland?

Professor Sir Smith: So during that period one of the most important things was, as you say, was that we had a greater level of protection from both vaccine and therapeutics, so there were multiple medications that we could now use to treat people who had become ill, and the vaccine was proving that it was able to offer particular protection against the most severe consequences of Covid, particularly against mortality and serious illness.

What it was able to do less well was to reduce transmission, although it did have an impact on transmission as well. And in terms of the vaccine certification or passport, as it became known as, whilst I was supportive generally of the approach, I would have preferred to have seen a slightly more stringent approach which was deployed in relation to it, and I gave advice that actually vaccination by itself wasn’t sufficient to render an environment safe, and that – but that vaccination plus testing in combination would certainly give an additional degree of protection.

Lead 2A: So were there measures that you suggested should be imposed, further restrictions, over that period that were not?

Professor Sir Smith: I don’t recall the specific detail, but I remember during that period there were times when I would have been more content if a stronger position had been adopted to protect some of the environments where we knew that transmission was likely to take place. So by that point it was very well established that indoor places with poor ventilation where people were coming together were likely to be places where transmission was much more likely to occur, and if we were going to kind of use vaccine certification in that environment also testing at the same time as relying on vaccination would have given an additional degree of protection.

Lead 2A: But there wasn’t that level of testing; is that what you’re suggesting?

Professor Sir Smith: Yeah.

Lead 2A: So given your responsibility in that position, you would have provided advice that that was necessary?

Professor Sir Smith: I recall doing that.

Lead 2A: Thank you.

Could I just ask you one final question, it’s about one of the helpful lessons learned and recommendations that you’ve set out. In paragraph 720 of the report, you talk about:

“This pandemic, in common with many others, reflected and in many cases exacerbated existing inequalities. Research on where the disparities were, what their causes were and how best to reduce them needed to begin from the outset of the pandemic. A wide range of qualitative and quantitative research methods were needed to understand disparities. Continual dialogue with local communities was important in understanding risks and vulnerabilities, and to co-design effective responses at a hyper-local level that might not be picked up in larger, national data sets or research.”

So I think here you’re addressing a theme about which we have heard a considerable amount of evidence.

Is it correct to say that you’re accepting there that there wasn’t enough done to understand the way in which the pandemic was exacerbating existing inequalities, and that that is a matter which not only could have been done better during the pandemic but must be done better in future?

Professor Sir Smith: So the whole issue of health inequalities is one which I think is worth exploring in quite a bit of detail, because just in terms of lessons learned, one of the most important things that we as a nation could do in order to prepare ourselves for the inevitable next pandemic which we face is to raise the health of all the population, to make it a much more health resilient nation and population in terms of meeting whichever disease comes to us in pandemic form in the future.

Now, to do that we need to understand the nature of health inequalities and we need to prioritise action against health inequalities that exists within our society. So both during the pandemic and outside the pandemic, spending as much time and research as possible to understand the impact on people’s lives of those inequalities that they face and how that impacts on their health is something which I think is incredibly important. We see it in society even before the pandemic came, is that health inequalities were stark. I see a renewed focus since the pandemic in terms of trying to address some of those health inequalities and we should be very, very clear that the way that we address those is not through a healthcare-related model but actually is through a kind of cross-government, all-society approach in terms of what we understand by inequality across society. And if we can do that, if we can improve both the economic and social capital of communities, that leads to a kind of better level of health within all these communities, I think that we’ll be in a far stronger position to be able to meet Disease X when it appears in the next pandemic.

Lead 2A: That’s a very laudable aim, if I may say so, Professor, but is your position that that did not happen sufficiently during the pandemic?

Professor Sir Smith: I think attempts were made to do that, and it was often very difficult to get the right data and information to understand exactly how it impacted on particular communities. I think changes were made during the course of the pandemic which helped us to understand better. I think it’s worth singling out the huge efforts which were made, albeit slower than I think people would have liked to have seen it, to understand the impact on particular BAME communities and those who had lived with disabilities of one sort or another. I think although strides were made during the course of the pandemic to understand that better, preparing ourselves so that we’ve got much better data resources that relate to some of these communities and characteristics is going to be really important for us to –

Lead 2A: Were those data sources at least lacking in the pandemic?

Professor Sir Smith: I think they were lacking at the beginning of the pandemic, yes. I think they were developed over the course of the pandemic, but certainly at the beginning I don’t think they were as strong as they subsequently became.

Mr Dawson: Thank you very much. Excuse me just one second.

Those are my questions, and there are no core participant questions, as I understand it.

Lady Hallett: Thank you very much indeed, Professor. Thank you for your help and for being here virtually all day.

The Witness: Thank you.

(The witness withdrew)

Mr Dawson: The next witness is Professor Sheila Rowan, and my learned friend Ms Arlidge will be asking the questions.

Lady Hallett: More musical chairs.