3. Ms Stephanie Howarth

MS STEPHANIE HOWARTH (affirmed).

Questions From Counsel to the Inquiry

Ms Spector: Please could you give us your full name.

Ms Stephanie Howarth: I’m Stephanie Howarth.

Counsel Inquiry: Ms Howarth, thank you for attending today and assisting the Inquiry. Whilst you give your evidence, could you, please, try to keep your voice up. This assists people who are listening here but also helps the stenographer who is making a note of the proceedings. If I ask you anything that isn’t clear please just ask me to repeat.

You were asked by the Inquiry to provide a witness statement addressing your role as Chief Statistician for Wales, and we can see the statement that you were good enough to provide on screen before you. Now, you signed this statement on 15 January 2024. Is that true to the best of your knowledge and belief?

Ms Stephanie Howarth: It is.

Counsel Inquiry: If we could please start with a few questions about yourself. You are the Chief Statistician and head of profession for statistics in the Welsh Government, and that’s a role that you have held since July 2020?

Ms Stephanie Howarth: That’s correct.

Counsel Inquiry: What are your responsibilities in that role?

Ms Stephanie Howarth: So as the Chief Statistician I am the Welsh Government’s principal adviser on official statistics. I oversee the independent production of official statistics in the Welsh Government. I also have a role as head of profession then in building the statistical capability and capacity within the Welsh Government, and I oversee the implementation of the code of practice for statistics.

Counsel Inquiry: Is it right that you remain operationally independent in terms of decision-making around official statistics?

Ms Stephanie Howarth: That’s correct, yes.

Counsel Inquiry: Now, we’ll come to hear more about its work in due course, but does the Knowledge and Analytical Services, or KAS, within the Welsh Government sit within your directorate?

Ms Stephanie Howarth: It does. So Knowledge and Analytical Services is made up of two parts and the statistics part is the section that I lead.

Counsel Inquiry: Now, you have seen the statement that Glyn Jones has provided to the Inquiry on behalf of KAS dated 8 December 2023. Do you agree with the contents of that statement?

Ms Stephanie Howarth: I do.

Counsel Inquiry: So moving to KAS now, please can you briefly outline what KAS is and what its role is within the Welsh Government.

Ms Stephanie Howarth: So KAS is Knowledge and Analytical Services. It’s a part of the Welsh Government that brings together the analytical professions, so statisticians, social researchers, economists, to provide analytical evidence and advice for Welsh Government ministers and officials to enable them to do their roles.

Counsel Inquiry: To broadly summarise the work that KAS did during the Covid-19 pandemic, is it correct that it established new data collections, acquired data from other bodies and third party organisations, provided analysis and advice to ministers and officials on Covid data, including the compilation of weekly data monitors, published and communicated regular Covid-19 statistics, and contributed to the work of TAC, TAG, Public Health Wales and Digital Health and Care Wales on statistical matters?

Ms Stephanie Howarth: That’s correct, and also we maintained a range of our regular statistical publications as well, that might not have been specifically about Covid-19 but were still important to understanding what was happening in Wales.

Counsel Inquiry: Ms Howarth, is it right that prior to the first national lockdown, neither the Chief Statistician nor KAS, in general, were actively involved in reporting on or briefing on the spread of Covid-19 as this was being led by Public Health Wales and by TAC?

Ms Stephanie Howarth: That’s broadly correct. So from the start of March Knowledge and Analytical Services had started to become more involved in work around Covid-19, but most of this work, in terms of reporting on things like infection levels and deaths, was being led by Public Health Wales.

Counsel Inquiry: I’m now going to ask you some questions about the data compilations that were provided by KAS during the pandemic. Was the assembly of statistical information about Covid-19 a key strategic priority for KAS for the Welsh Government at the outset and during the pandemic?

Ms Stephanie Howarth: That was certainly one of our main responsibilities. And bringing together the wide range of data that was in circulation was a key responsibility of KAS, to bring all that into one place.

Counsel Inquiry: And one such repository of key data or key information for the Welsh Government was the Covid-19 analysis hub which was stood up on 23 March 2020; is that right?

Ms Stephanie Howarth: Yes.

Counsel Inquiry: Initially the hub published all new data related to Covid-19 cases and deaths, and this was then later progressed to topics such as care homes, testing and contact tracing; is that right?

Ms Stephanie Howarth: Broadly. So Public Health Wales led on the publication of rapid surveillance data around cases and deaths and ONS then on deaths data from death certificates. But the hub had a role in re-using that information and bringing it together for use within the Welsh Government.

Counsel Inquiry: How frequently was the data on the hub updated?

Ms Stephanie Howarth: It would really vary by source. So there was a range of data sources that we were using, some of these were daily so we would use the daily information that was coming from Public Health Wales on things like the number of cases and the number of deaths. There was also daily information around school attendance and the number of people in hospitals, but some other sources would be less regular, might be weekly. So, for example, some data around testing and contact tracing, those things tended to be slightly less regular than daily, but still much more frequent than we might have been used to prior to the pandemic.

Counsel Inquiry: Coming slightly later in the chronology was the Covid-19 data monitor, which I understand was produced on 3 April 2020. Ms Howarth, how was that different to the hub?

Ms Stephanie Howarth: So the hub was a structure, a team essentially, within Knowledge and Analytical Services that was co-ordinating the role of statistics in the pandemic. The monitor was one of the products that the hub produced, and it was a compendium of statistical information about the pandemic, so that that information was there in one document and could easily capture the trends around Covid-19 and its associated harms in Wales.

Counsel Inquiry: You’ve alluded to it already but am I right in saying that Public Health Wales also published their own weekly Covid-19 data, including their Covid-19 data dashboard, which was circulated around senior Welsh Government officials and ministers?

Ms Stephanie Howarth: So Public Health Wales would publish daily information on their dashboard around cases and deaths and testing. The Welsh Government – if we’re talking about the data monitor here, this wasn’t something that was initially published, this was something that was circulated within the Welsh Government, although in time it did become a public-facing document.

Lady Hallett: Can I just interrupt to say that I’m afraid you’ve both got the same failing I have, which is speaking very quickly.

Ms Spector: Yes, please do remind me of that as we go through.

Lady Hallett: I’m afraid it’s something I have to remind myself of on occasion. Thank you.

Ms Spector: Thank you, my Lady.

By April 2020, if I were, say, a senior government official and I wanted to understand what was happening in hospitals, is it right that I could check the data monitor published by KAS or the Public Health Wales weekly dashboard or any of the other publicly available information from, say, the ONS?

Ms Stephanie Howarth: So for information about hospitals, that was broadly made available within the Welsh Government, so the data monitor would have been one of the main ways that we circulated that information.

Counsel Inquiry: Please can we have on screen INQ000271847.

This is the HSSG response to Covid-19 lessons learned document produced in August of 2020.

Ms Howarth, am I right in saying that KAS contributed to that lessons learned report?

Ms Stephanie Howarth: Yes.

Counsel Inquiry: If you look, please, at page 3, in the middle of the column, penultimate paragraph:

“Not always clear cut split in responsibilities within KAS between health stats and covid hub.”

In the next paragraph:

“Multitude of dashboards being prepared for different purposes sometimes with similar but slightly different data flows. In terms of [Public Health Wales], this was sometimes done without any regard to what else was happening in the system. This then leads to duplication of similar outputs between [Public Health Wales] and [Welsh Government]. Creates confusion in the media and the public.”

Was that a fair criticism of the way in which data was presented during the first wave?

Ms Stephanie Howarth: I think it’s certainly fair to say that data was available from multiple places, and part of the reason for bringing a product like the data monitor together, and eventually then publishing it, was to have one place that brought together all the key information. But that being said, there were times, and I think that’s what this information is referring to, where new things would be published by other organisations, for example Public Health Wales, that we weren’t necessarily aware of in the Welsh Government that were going to happen, which I guess was a missed opportunity to co-ordinate better and think about presenting one collective message so that you could avoid that potential confusion.

Counsel Inquiry: I’m now going to change topic and ask you about NHS management information. We will hear during the course of this module that hospital information was a key part of pandemic response and informed Welsh Government decision-making. Focusing on the early days of the pandemic and the first wave in particular, was data on hospital admissions to intensive care and admissions in general a critical dataset for Welsh Government decision-makers during that time?

Ms Stephanie Howarth: It was certainly one of the datasets that was used a lot and very significantly, yes.

Counsel Inquiry: We heard this from Professor Sir Ian Diamond this morning, but at that time there was no mass programme of community testing, meaning that hospital admissions was crucial for the government to understand the spread of Covid-19 in communities; is that right?

Ms Stephanie Howarth: Yes.

Counsel Inquiry: It’s understood that KAS received data from hospitals on admissions due to Covid-19, patients in hospital suffering from Covid-19, bed capacity, ICU capacity, ventilator figures and so forth. Is that right?

Ms Stephanie Howarth: Yes. Actually, can I just clarify? So we were one user of that data, so the data was collected by Digital Health and Care Wales and it was provided to the Welsh Government. Initially it was provided to the NHS performance team, which is part of the health policy area, but KAS was also a team that used that data. So it wasn’t coming directly into KAS.

Counsel Inquiry: We’ll look at some charts based on the data that was provided in due course but before then I want to ask, if I may, about some of the limitations of the KAS data received from health boards during the first wave.

First, the Inquiry understands that there were issues with precisely what was measured and what could be measured in hospitals. Andrew Nelson, the chief information officer at Cym Taf Morgannwg University health board, has highlighted the following three issues, and I’ll read those out.

Number one, before 24 March 2020 it was difficult for health boards to even work out the number of admissions to hospital due to Covid-19 as this was dependent on mining free text fields from the emergency department datasets, which would have been prone to error.

Number two, there was no data differentiating community-acquired infections from hospital-acquired infections, meaning that the case load of Covid-19 in the community could be overestimated or it could be underestimated.

And number three, data did not distinguish between the numbers of patients admitted due to Covid-19 compared to the numbers admitted for a different reason but who happened to have Covid-19.

Lady Hallett: Pause. The transcript is not running, I don’t know if it’s just mine or whether it’s because – no, it is back. I think it’s because you were speaking too quickly, Ms Spector.

So we have – the last one the [draft] transcript’s got recorded “… it was difficult for health boards to even work out the number of admissions to hospital due to Covid-19 …” and there we stop. So that was number one.

So can we finish number one and then go back to the others, please? Sorry about this.

Ms Spector: Madam, I think that might have been number three.

Lady Hallett: No, I think that was –

Ms Spector: For ease, I’ll go through all of them once again. Thank you, my Lady.

Number one, before 24 March 2020 it was difficult for health boards to even work out the number of admissions to hospital due to Covid-19 as this was dependent on mining free text fields from the emergency department datasets, which would have been prone to error.

Number two, there was no data differentiating community-acquired infections from hospital-acquired infections, meaning that the case load of Covid-19 in the community could be overestimated or underestimated.

Number three, data did not distinguish between the numbers of patients admitted due to Covid-19 compared to the numbers admitted for a different reason but who happened to have Covid-19.

Do you agree with the issues that Andrew Nelson has identified?

Ms Stephanie Howarth: Broadly, but I think there’s probably some nuance to some of those. So the second point, around hospital-acquired and community-acquired Covid-19, I know Public Health Wales did publish information around hospital-acquired Covid-19. And then the final point was around, I think, those who were in hospital for Covid-19 reasons and those who had incidental Covid, for want of a better term, from I think it was January 2022, so relatively late on. There was information available that made that distinction, but certainly for the majority of the pandemic that wasn’t in place.

Counsel Inquiry: Is it fair to say that each one of those issues had the potential to make healthcare data in the first wave less reliable for policymakers?

Ms Stephanie Howarth: I’m not a policymaker so I can’t necessarily comment on how the information was used for policymaking purposes, but I think there’s a couple of points here that – there was a range of statistical information. So you have things like the testing data, the hospitalisation data and the mortality data, and those things collectively tell you about the trends of what was happening in Covid-19. But then I guess what – was it Mr Nelson who made this statement? I think the point that he’s making here as well is about the underlying health data systems within Wales and that they perhaps do not offer the flexibility to collect information in new and changing ways, and that’s a point I would agree with. Some of these kind of legacy data systems potentially made that more challenging to do at pace.

Counsel Inquiry: Moving on from data gathering to data reporting. In a review that was undertaken by the Welsh Government in April of 2020 a number of matters were identified.

Please can we have that document on screen, INQ000066087, for those following.

It’s titled “Review of mechanisms for reporting Covid-19 deaths in Wales”.

If we look at page 1, paragraph 6:

“Following the identification on April 23rd of 84 deaths that had [now] been reported to Public Health by” –

Lady Hallett: “Had not been reported”.

Ms Spector: “… that had not been reported [my apologies] to Public Health Wales by Betsi Cadwaladr University health board … [Public Health Wales] and Welsh Government officials have sought assurances from across health boards and trusts concerning the robustness of the current process.”

Then if we move to under the heading “Inconsistent approaches across Health Boards” at paragraph 11, on page 2:

“For example, as a result of not using a single system, [Public Health Wales] have reported a number of generic issues during the past few weeks which include: delays by health boards in the reporting of deaths; reported ambiguity in the definition of what constitutes a death to be reported through surveillance and the inclusion of deaths occurring outside of a hospital.”

Then finally, under the heading “Multiple reporting streams and unclear reconciliation processes”, thank you:

“Health Boards are required to report data to a number of different organisations: [Public Health Wales], internal briefings to the Board and key local stakeholders, to the NHS Wales Informatics Service … and to the Office of National Statistics … These reports have different purposes and often a different basis, which can lead to inconsistency in the results being produced.”

Did KAS review and agree with each of those findings at the time that this report was produced?

Ms Stephanie Howarth: So this report was prior to me becoming Chief Statistician so it wasn’t something that I was directly involved in, so this was the previous Chief Statistician who led on this work, but my understanding is that he was involved in developing this report and so, I expect, would likely have agreed with those statements.

Counsel Inquiry: Please can we now look at, again, the HSSG lessons learned review document at INQ000271847, and the final paragraph in the central column of page 2:

“The issues that arose in mortality surveillance are well documented in the review but could have been avoided by greater roles and responsibilities and adherence to some principles around management of administrative data which KAS could have advised on. There was a lack of clarity on who was reviewing the mortality data and ensuring LHBs were submitting surveillance data.”

Ms Howarth, do you accept that finding, that KAS could have done more in those early days to ensure the quality and consistency of hospital data?

Ms Stephanie Howarth: So I think the point that this is making is about not hospital data but about mortality data, which was being collected through the rapid surveillance measures that Public Health Wales had put in place, so this wasn’t something that KAS were directly involved in, but it’s making the point that the types of quality assurance processes that we use within Knowledge and Analytical Services, these approaches, if we’d been asked to advise on it, would have avoided those kind of errors and that missed reporting happening.

It’s fair to say that in Public Health Wales they didn’t have government statisticians with the same kind of experience and background that we have in Knowledge and Analytical Services, and if they had they might have had greater awareness of the kind of toolkits that we use around the quality assurance of administrative data that might have better helped identify that some of these returns were not being made from some health boards on that rapid mortality surveillance.

Lady Hallett: On what basis do you work? Do you have to wait to be asked to provide a report or to analyse data or can you do something off your own bat?

Ms Stephanie Howarth: So do you mean in terms of working with Public Health Wales or more generally?

Lady Hallett: Yes.

Ms Stephanie Howarth: So I have a role as a – kind of a leadership role across the official statistics system but generally it would be that people might come and ask for our advice on particular topics, and that has happened on regular occasions. But throughout the pandemic it was perhaps more that we were proactive in giving that advice because of the lack of experience, I guess, in Public Health Wales in using the code of practice of statistics, for example.

Lady Hallett: So during the pandemic you became proactive but generally you would wait for the statistician at Public – or statisticians, I can never say the word, at Public Health Wales to come to you and ask for help, advice?

Ms Stephanie Howarth: In normal times, yes. We do have a regular six-monthly get-together of all the official statistics producers in Wales, which is an opportunity to understand what each other is working on in normal times. So yes, normally we would expect lead officials in each organisation to raise issues with the Chief Statistician.

Lady Hallett: I’m sorry to take you back to right at the beginning – I’m sorry about this, Ms Spector, I’m sorry to interrupt – but when – you didn’t get involved until the first lockdown, so the Public Health Wales statisticians were doing the work at that stage. Do you think it might have been helpful if you had been – if your department had been asked for its assistance earlier on?

Ms Stephanie Howarth: Potentially. I mean, the role of reporting public health statistics is a role for Public Health Wales, but I think this experience has shown that – the value that government statisticians can bring in terms of both the quality assurance of data and the ability to communicate that data as well, and understand user needs, and I think that there was potentially an opportunity that we could have got involved earlier, yeah.

Lady Hallett: Thank you. Sorry to interrupt.

Ms Spector: Not at all, my Lady.

I’m now going to ask about a different aspect of Wales’ healthcare data management.

The Inquiry understands that Wales occupies a unique position within the UK due to its Secure Anonymised Information Linkage (SAIL) Databank; is that right?

Ms Stephanie Howarth: Yes.

Counsel Inquiry: To begin, can you explain what that databank is and what it does?

Ms Stephanie Howarth: Certainly, so the SAIL Databank is run by Swansea University. It’s what’s known as a trusted research environment. So it’s a secure virtual environment where data can be deposited and researchers can apply to use that data for public good research purposes. And the thing that’s particularly unique about the SAIL Databank is that all these different data sources can be linked together in a secure and anonymised way so you can learn more about a particular topic than you can from using any of those individual datasets in isolation.

Counsel Inquiry: So the value is as much in the linking as it is in the collection of that data?

Ms Stephanie Howarth: Yes, definitely.

Counsel Inquiry: The Inquiry understands that during the pandemic many relevant datasets were supplied to SAIL to enable them to be linked, including data relating to social care workers, children’s attendance at schools, emergency department datasets, data from healthcare workers, risk assessments and the ZOE symptom tracker app; is that right, by way of example?

Ms Stephanie Howarth: Yes, I believe so. Not all of those would have come from the Welsh Government but that’s the kind of data that would be available in SAIL, yes.

Counsel Inquiry: Was KAS and TAC able to use this kind of data linking to support analytical work required in the pandemic response?

Ms Stephanie Howarth: Yes, it was used considerably.

Counsel Inquiry: What kind of work was able to be done with it?

Ms Stephanie Howarth: So there would be work carried out either by analysts based in the Welsh Government or through the academic community as well. We brought together this One Wales partnership, it was called, which was looking to bring together those with relevant experience in this area to support the pandemic.

Some examples of the kind of work that my team did were things like linking together the shielded persons list with other data sources like the school workforce census, for example. So that could tell us about the number of teachers and school staff who were on that shielded list, which you can then use to help inform planning for return to school.

Counsel Inquiry: For our purposes today, I want to look at the work SAIL was and perhaps was not able to do concerning Covid-19 datasets and some protected characteristics.

The former Chief Statistician Glyn Jones said in his statement to the Inquiry:

“A key challenge identified early on was the quality of data held by the NHS on ethnicity and the availability of Covid mortality data by ethnicity.”

Do you agree with what he has said in his statement?

Ms Stephanie Howarth: Yes.

Counsel Inquiry: To run through some of the challenges that he describes:

Data on ethnicity is not recorded on death certificates in England and Wales. We’ve heard about that already.

Many healthcare records do not record the ethnicity of the patient.

Initial reporting of Covid-19 deaths in confirmed hospital cases through the Welsh Clinical Portal surveillance form did not record ethnicity before May 2020.

And then there’s the “Is Wales Fairer?” report in 2018 which had already commented on the clear gaps in the data in Wales on protected characteristics. Is all of that correct?

Ms Stephanie Howarth: Yes, that’s correct.

Counsel Inquiry: What all of this meant in practice was that the data we’ve described on hospital admissions, on ICU admissions, deaths relating to Covid and so forth, none of that could be grouped by protected characteristics like ethnicity; is that right?

Ms Stephanie Howarth: Some of it could be but there would be some weaknesses in the data, and that’s where the acquisition of the 2011 census was so valuable. So the former Chief Statistician had made the case for that to be deposited in SAIL because it was so valuable in improving coverage of things like ethnicity within that dataset. So, as an example, I think I recall a colleague saying that it improved missingness within the ethnicity dataset from around 30% missingness to 10% missingness. So you’ve still got some records that do not have ethnicity data within them but considerably fewer than prior to bringing in the census data.

Counsel Inquiry: If that’s the census data, moving on from that, the evidence that the Inquiry has heard is that England has significantly more detailed information on ethnicity in other socioeconomic categories to link to Covid-19 outcomes, as much of this had been taken from English GP records. Now we’ve heard that Wales had the benefit of the SAIL Databank, why could this be done in England and could not be done in Wales?

Ms Stephanie Howarth: I’m not sure I’d agree with that because I think GP data is available within SAIL and a range of other datasets as well which bring together a whole range of different characteristics. That’s a very strong position in Wales, that we’ve had all this data available to link for a number of years. I think perhaps the question here is about where that data is held in different places.

So I know Ian Diamond talked earlier about not being able to carry out specific pieces of analysis within ONS because ONS didn’t hold that data but that data did exist in SAIL and it’s more that ONS hadn’t used the data in SAIL. It wasn’t that it didn’t exist in a linked format in some way. So ONS only had access itself to information about England.

Counsel Inquiry: So in summary, it was more of an access issue rather than not having a data or having not linked the data?

Ms Stephanie Howarth: Yes.

Lady Hallett: I’m sorry, I’m not following. Ms Spector’s question was: why is it England had better ethnicity data than Wales? Is that right, was that the question?

Ms Spector: My Lady, the question was more related to the fact that: why does it seem to be the case that that data could be extracted from English GP records when GP records exist in the SAIL Databank in Wales?

Lady Hallett: But was the introduction to that point that England had better ethnicity data?

Ms Spector: Yes, my Lady, yes.

Lady Hallett: I don’t think you’ve answered why did England have better ethnicity data than Wales, as far as I can tell. But maybe you have and I’ve misunderstood.

Ms Stephanie Howarth: No, that’s a fair question, and I don’t know if England does have better ethnicity data than Wales. My understanding was that if you’re looking at health records, for example, there are common challenges across both health systems, and that’s why linking data together is so beneficial.

Ms Spector: To perhaps put the question in a slightly different way, do any gaps remain in the KAS, in the SAIL datasets in relation to the ability to disaggregate health information by protected characteristics?

Ms Stephanie Howarth: There are certainly a range of issues related to availability of data on protected characteristics and they would affect data available in SAIL but also data that exists outside of SAIL as well, and we’ve already noted ethnicity being one particular example.

I think that’s particularly acute for Wales because Wales is a small nation with a small ethnic minority population, so if you are collecting data through surveys, for example, you have to have a very large survey in order to be able to break the data down by different ethnic minority groups. So that’s a particular challenge.

There are other challenges related to disability, for example, where most data is collected under the medical model for disability. We do not, as a statistics system across Wales or the UK, have an established method for collecting data through the social model for disability, although that is something we’re actively looking at at the moment.

Counsel Inquiry: Moving on now to data on social care.

Yesterday this Inquiry heard evidence from Helena Herklots, the Older People’s Commissioner for Wales, who described that initially in the first wave the data on deaths from Covid-19 did not include older people who died in care homes. Is that correct?

Ms Stephanie Howarth: So perhaps it would be helpful to set out the two different sources of data around Covid-19 mortality. So you have the rapid surveillance data that is collected by Public Health Wales that comes through their e-form that was used to collect this information. That information predominantly focused on deaths in hospitals. My understanding is it was never designed to be full coverage of all deaths, it was about being able to rapidly identify trends in mortality. So it may have captured some deaths in care homes, but it wouldn’t have captured all deaths in care homes.

The ONS data which comes from death certificates would capture all deaths and would be attributed to Covid-19 where that was mentioned on the death certificate.

Counsel Inquiry: Are you able to assist us with a date when the Welsh Government was in receipt of reliable and comprehensive data of all people who died in care homes due to suspected or confirmed Covid-19?

Ms Stephanie Howarth: That would have come from the ONS data, which would cover all care homes. There was also an additional source from Care Inspectorate Wales, so Care Inspectorate Wales is required to be notified of a death of a care home resident and the Welsh Government had access to that information from relatively early on in the pandemic. I know we began publishing it from early May but we would have had access to it internally earlier than that.

Counsel Inquiry: Now, the ONS has published a number of blogs and lessons learned reports during the pandemic, and one of these is called “Glimmers of light for adult social care statistics”, dated 8 July 2021, which you can see before you on the screen. That blog summarised the concerns that the ONS had been raising relating to adult social care in Wales and amongst all UK nations, it’s not unique to Wales.

Its findings, as you can see on the screen before you, were that:

“[1] Adult social care has not been measured or managed as closely as healthcare, [with] a lack of funding [leading] to under investment in resourcing in data and analysis.

“[2] There is an unknown volume and value of privately funded provision of adult social care.”

Just moving on:

“Robust, harmonised data supply to ensure comparable statistics from both public and private providers is problematic, as data collection processes are not always standardised.”

And moving on:

“Data quality is variable within and across local authorities, with inconsistent interpretation of data reporting guidance by local authorities.”

The post goes on to say, just in the next sentence below:

“As data issues go, as the pandemic has highlighted, there is not so much a gap as a chasm, with consequences to our understanding of social care delivery and outcomes.”

Now, as I’ve said, those findings are not addressed uniquely to Wales, but is it fair to say that these problems persisted in Wales in March 2020?

Ms Stephanie Howarth: Yes, I think that’s a fair summary.

Counsel Inquiry: Now, in terms of listing the changes that have been made since then, the blog proceeds to list five tangible changes being made by the UK Government on this issue for data in England, such as the monthly publication of a statistics report on adult social care in England. Just regarding actions being taken in Wales, the post simply says “the Welsh Government remains committed to improving the data it captures on social care”.

So can I ask you: what is the Welsh Government, assisted by KAS, doing on this issue?

Ms Stephanie Howarth: So I think there’s probably two different strands to this: there’s things specifically related to the pandemic and then there’s social care data more generally.

So during the pandemic I’ve already mentioned the data that was available from Care Inspectorate Wales, so that was a new source of information that we began using to learn more about the pandemic and how it affected care homes.

We also stood up a weekly, what we referred to as a checkpoint survey of local authority social services. Social care and social services generally doesn’t have the same kind of timeliness of information that the health service has, and so this weekly survey was a way of understanding the demand and local social services’ ability to respond to that demand during the pandemic.

Outside of the pandemic, more broadly, we have been putting a lot of effort in recently into improving data around adult social care and adult social services more broadly. So this year, for example, we will start collecting what we’re calling an adult census of people who use social care services, so that will give us much more granular information about people who use local authority social care services.

Counsel Inquiry: Moving on now to occupation data.

Another group at higher risk of contracting Covid-19 were healthcare workers and social care workers.

With that in mind, please, can we look at document INQ000395589.

If we could please go to the bottom of page 4 and the top of page 5, this is an email thread between members of Public Health Wales about data reporting in Wales, and we can see that Dr Frank Atherton was copied in to those emails.

The first email in the thread was sent on 14 April 2020. If we look at that first sentence that’s highlighted in yellow:

“They [meaning the ONS] are looking at developing a new process for capturing deaths in HCWs [healthcare workers] and adult SCWs [social care workers] – this was discussed with the DAs at the weekend and is under review.”

Then if we scroll up to the thread on page 3 and an email sent on 15 April, again from a member of Public Health Wales, and if we look at the second sentence highlighted in yellow:

“DHSC/PHE are asking the DAs to confirm what they are doing about information about staff number deaths – would like an update on this urgently.”

In the next email thread, at the bottom of page 2, an email from a further member of Public Health Wales reads:

“In meeting with Minister [meaning Vaughan Gething] where he agreed we hold our line that there is no reporting on NHS staff deaths, in Wales, by [Public Health Wales].”

Then the final email in that thread on page 1 says:

“We do need a handle on HCW deaths ourselves.”

In March and April of 2020, do you know whether KAS was asked to assist Public Health Wales in identifying healthcare worker or social care worker deaths?

Ms Stephanie Howarth: I don’t know if we were asked in that specific period, it wasn’t something I was involved in, but I do know that Public Health Wales did add a flag around healthcare worker deaths and social care worker deaths in their e-form that they use for rapid surveillance and mortality purposes as a way of helping to collect this information.

Counsel Inquiry: Do you know when that took place?

Ms Stephanie Howarth: I think that was added in early May, from memory.

I do know also that colleagues in Knowledge and Analytical Services asked the Office for National Statistics as well to provide information from their mortality data that would tell us the numbers of healthcare workers and social care workers in Wales who had died from Covid-19.

Lady Hallett: Do you know what the argument was in relation to no reporting?

Ms Stephanie Howarth: I don’t know. My suspicion might be that it was because there would perhaps be very small numbers and you might not want to disclose some information about someone that wasn’t public, but that’s just a guess.

Lady Hallett: Thank you.

Ms Spector: In your opinion, was that an important dataset to try and receive?

Ms Stephanie Howarth: Yes, there was certainly a lot of interest in understanding the potential risk that healthcare workers and social care workers were experiencing and having reliable statistics on that was an important thing to be able to do. The differentiation, I should probably make, the ONS data doesn’t necessarily tell you about in-service deaths from Covid-19, so it would tell you whether someone had died from Covid-19 but not necessarily whether it was something that had been acquired in the line of work, for example.

Counsel Inquiry: Moving on now, we’ll look at some of the charts that you provided with your witness statement concerning Covid-19 infections and hospital data in Wales.

So first please can we have figure 1(a) in your witness statement INQ000399709.

This illustrates the weekly hospital admissions for Covid-19 and non-Covid-19 conditions in Wales from March 2020 to June 2022.

Are you able to explain to us what this chart shows?

Ms Stephanie Howarth: Yes, so this is the weekly hospital admissions for Covid. It includes both suspected and confirmed cases. And you can see that that blue line at the bottom shows the Covid-19 cases with some distinct peaks in the early phase of the pandemic in sort of March/April 2020, and then other peaks towards the end of 2020, early 2021.

Counsel Inquiry: If we could now, please, have on screen INQ000412041 and the slide on page 2.

This chart shows the number of beds available compared to the number of patients across hospitals in Wales, and we can see here that the pale orange line represents confirmed and suspected Covid patients; the orange line, designated Covid beds; the pale blue line, total patients in hospital; and then that dark blue line, all general and acute beds.

For clarity, am I right in saying that that red line for designated Covid-19 beds does not represent maximum capacity for Covid-19 patients in hospital because designated – beds that were not designated for Covid-19 could still be used for Covid-19 patients?

Ms Stephanie Howarth: Yes, that’s correct. Generally we would look at occupancy across the hospital as a whole rather than designated Covid-19 beds per se.

Counsel Inquiry: With that caveat in mind, are you able to talk us through what this chart shows?

Ms Stephanie Howarth: Yes, so if we’re looking specifically at the Covid-19 series at the bottom there, it follows a similar trajectory to the admissions data in the previous slide. It shows that there were peaks in the spring of 2020 and again in late 2020 and early 2021, and that at times the number of confirmed and suspected Covid patients was close to or slightly over, in some cases, the designated Covid beds, although noting that there would still be other capacity available.

Counsel Inquiry: Can we also see that the availability of those Covid-19 designated beds was more limited in the second wave than in the first wave at times?

Ms Stephanie Howarth: Yes.

Counsel Inquiry: We’re going to hear about decisions that were made in Wales in waves 1 and 2 based on concerns about hospital capacity later in the next two weeks. This chart suggests that capacity was never near to being meaningfully exceeded in Welsh hospitals. However, the figures that we see are combining all hospitals and health boards. Are you able to assist us with whether there were certain hospitals or health boards that were more consistently near or at capacity during the Covid-19 pandemic?

Ms Stephanie Howarth: I’m afraid that’s not a level of detail that I can help you with.

Counsel Inquiry: If we now look at the chart on page 5, of INQ000412041, this chart shows invasive ventilated beds in Wales, April 2020 to June 2022. Just, again, are you able to talk us through what we can see in this chart?

Ms Stephanie Howarth: Yes, so there are two series here. The blue line represents the number of invasive ventilated beds that were available, these would typically be in a critical care environment but not always in a critical care environment. And then the yellow or orange line is the beds occupied, and that is for both Covid-19 and non-Covid-19 patients.

And similar to some of the previous series you can see some distinct peaks in the early and second phase of the pandemic.

If we look at beds available, there were a larger number of beds available that offered invasive ventilation earlier in the pandemic and then that drops after the first phase.

Counsel Inquiry: I’m grateful.

Finally I want to look at some charts concerning Covid-19 and discharges from hospitals into care homes in Wales during the pandemic.

Now, the ONS has published figures that there were 13,630 deaths in care homes overall in Wales during the Covid-19 pandemic. Just over 30% of those deaths were registered during the first wave, and 40% or so of those were registered during the second wave. Is that information correct?

Ms Stephanie Howarth: I don’t have the figures to hand, but that sounds correct.

Counsel Inquiry: We’ve discussed already a reason why those numbers might have been slightly under-reported in care homes in the first wave. Is it likely that official figures of deaths caused by Covid-19 in care homes in the first wave might be even lower still because there may have been undiagnosed Covid cases due to less testing and less clinical experience of staff in the early days of the first wave?

Ms Stephanie Howarth: That is potentially possible and I think that would be the same case for deaths outside of care homes as well, and that’s why sometimes it’s helpful to look at excess deaths overall rather than just Covid or non-Covid deaths.

Counsel Inquiry: Please can we now have on screen INQ000271757.

Now, am I right in saying that this is research that KAS conducted into discharges from hospitals to care homes between March and May of 2020?

Ms Stephanie Howarth: Yes, that’s correct.

Counsel Inquiry: We can see from the top of paragraph 2, page 1, KAS analysed 1,729 discharges from hospitals to care home settings, analysing how many patients were tested prior to discharge and how many of those patients subsequently passed away.

That number 1,729, can I ask, was that all discharges from hospitals to care homes in Wales, or was it a sample size that had been taken by KAS?

Ms Stephanie Howarth: This analysis was started before I was Chief Statistician so I wasn’t involved at that time, but my understanding is that should be all the discharges that were able to be identified at that point.

Counsel Inquiry: What this study did is it counted those who had themselves been discharged from hospitals into care homes and died rather than those who might have been infected from someone being discharged with Covid-19 into a care home and who then subsequently died; is that right?

Ms Stephanie Howarth: Sorry, could you repeat that?

Counsel Inquiry: I can. The study counted people who had been discharged from hospital with or without a test and who had subsequently died from Covid-19 rather than people who might have been infected by those people who had been discharged without a test?

Ms Stephanie Howarth: Yes, that’s right, it didn’t attempt to look at that issue around whether discharging from a hospital to a care home was related to an outbreak of Covid-19, it was simply looking to describe the number of discharges that happened and the testing activity associated with that. There was other work that had tried to look at that more complex question.

Counsel Inquiry: If we look at the final paragraph on page 1:

“Of the 81 discharged patients who by the point of data extraction on 30 June 2020 had died of COVID-19 related causes, 62 did not receive a test in hospital prior to discharge …”

If we then look at page 7 in the chart in the middle of that page, which is chart 3, that chart shows the proportion of discharges to care home settings where a test was taken in hospital prior to discharge and those that did not have the test, and we can see that dark blue there is “No test taken”.

If we focus on the week commencing 27 April, and that bar, we know that the Welsh Government announced on 24 April that mass testing would commence for all patients being discharged to care homes, which was followed by new guidance on hospital discharges on 29 April. But we can see in that bar for 27 April that the number of patients discharged without a test continued, given that we can see some navy blue space at the bottom of it, and we can see that that continued to the end of May; is that right?

Ms Stephanie Howarth: That is what the chart shows. I guess there could be some occasions when it might have been a data issue, that we couldn’t necessarily link a discharge record to a testing record, that could be a recording and reporting issue, but I couldn’t say that with certainty, but it does show within the data that there were some discharges that did not have a test record associated with them after that point.

Counsel Inquiry: If we then go to table 3 on page 8, that slightly breaks down the numbers of discharges that we’re talking about in the period that we’re looking at. We can see that for certain health boards the figure of discharges after the change of guidance was as high as 50% in April and 29% in May, so after the policy change; is that right?

Ms Stephanie Howarth: That is right, but it’s worth noting that there are some very small numbers involved there. So the Hywel Dda example in April, for example, is 1, which leaves a percentage of 50%, so it’s useful to look at the numbers as well as the percentages.

Counsel Inquiry: If we look at the numbers for Aneurin Bevan for May, that gives a slightly higher – not much, but a slightly higher – number of discharges, and we get the 17% there.

In terms of the conclusions that could be drawn from that table, what is it that KAS concluded, looking at those results, about the discharges that were continuing despite the change in guidance?

Ms Stephanie Howarth: I mean, I think our conclusion was that there were still some records where there appeared to be a discharge from hospital to care home without a test record after the point at which the guidance changed. That could be because it wasn’t possible to link a record, that could have been a data reporting issue, or it could have been genuinely that no test was undertaken.

Counsel Inquiry: Who did KAS send the results of this study to?

Ms Stephanie Howarth: So it wasn’t something I was directly involved in, but I believe that they were shared with senior officials in the Welsh Government working in health and social care in around late summer 2020.

Counsel Inquiry: Finally on this topic, the Vivaldi care home study was conducted by the ONS in the UK to measure the impact of Covid-19 in care homes in May to June of 2020, and am I right in saying that that study concluded that care homes using bank or agency nurses most days were more likely to have more cases of Covid-19, and care homes in which staff received sick pay were less likely to have cases of Covid-19 in residence?

Ms Stephanie Howarth: I believe that’s what the study found, yes. It’s a study that just covered England, however.

Counsel Inquiry: You pre-empted my next question. Is any similar study being undertaken in Wales or has been undertaken in Wales?

Ms Stephanie Howarth: So the report that you referred to with the bar charts in it does refer to a particular piece of research by Public Health Wales where they had looked at the risk factors associated with outbreaks in care homes, and I think they had found – if you’ll excuse me reading it so I don’t get it wrong –

Counsel Inquiry: Please.

Ms Stephanie Howarth: – but their conclusion was that they found that large care homes were at considerably greater risk of outbreaks throughout the pandemic and the exposure to discharge from hospital was not associated with a significant increase in risk after you take into account the care home size.

Counsel Inquiry: My final topic is about data sharing, firstly between KAS and the Welsh Government and the UK Government.

In terms of the speed of data sharing, Glyn Jones in his statement describes how for some areas the flow of data was generally slow or inhibited from the UK Government’s end to the devolved administrations, and he particularly cites the Department for Work and Pensions. Do you agree with what he says about that?

Ms Stephanie Howarth: Yes, I do agree with that.

Counsel Inquiry: Are there any other examples of areas that were particularly affected by delayed sharing speeds?

Ms Stephanie Howarth: I think the Department for Work and Pensions’ data sharing is probably the most noteworthy one. There were examples of very good data sharing; the Department for Transport, for example, was incredibly helpful in sharing data around mobility and trips that people were taking. Generally data sharing was quite positive, so those exceptions were few and far between. One other that’s worth noting perhaps is that we have been looking to acquire the data from the Covid-19 Infection Survey for SAIL, which is something we’ve not been able to do yet.

Counsel Inquiry: In terms of data sharing and conformity of datasets, we know that each of four nations had their own datasets and means of measuring Covid-19 cases and deaths. Especially at the onset of the pandemic, is it correct that definitions across the UK were inconsistent in their recording of deaths, for example, how data on Covid-related admissions and hospitalisations were measured for each nation, and the fact that Wales included suspected cases for some measures where other nations didn’t?

Ms Stephanie Howarth: On hospitalisations, yes, that’s correct. Broadly we were able to work together to understand the differences, but at the outset there, there were certainly differences there.

Counsel Inquiry: Were those differences that were worked out quite rapidly in the course of the pandemic?

Ms Stephanie Howarth: So I think perhaps those differences carried on throughout the course of the pandemic but we were able to understand where we could and couldn’t compare data better, if that makes sense.

Counsel Inquiry: Are any steps in motion to attempt to harmonise that kind of data collection for future –

Ms Stephanie Howarth: So I think we probably learned quite a lot from that experience. I think each nation in an attempt to be helpful moved quite quickly to start collecting its own data, but that then potentially meant that we had some small differences in the definitions we used across the UK. That’s something we’ve learnt from in, for example, the response to the Ukraine – the invasion of Ukraine and the data-related demands for that: we worked together across the nations to come up with a single set of statistics. So it’s about learning to take a couple of days to work together to avoid those kind of issues in future.

Counsel Inquiry: My final question is about the ONS. Professor Sir Ian Diamond earlier today was asked whether there were any changes in collaborating with KAS during the course of the pandemic and he said that there weren’t any. Is that something that you agree with?

Ms Stephanie Howarth: We certainly had very positive relationships with the Office for National Statistics. We were involved very closely in things like the development of the Covid-19 Infection Survey, they were very amenable to our requests for data and for additional analysis. However, I do think they were probably more closely embedded with the UK Government than perhaps the Welsh Government, and that potentially meant that UK Government requests were perhaps prioritised or understood more than requests from the Welsh Government.

Ms Spector: My Lady, those were all of my questions.

Lady Hallett: Thank you very much.

I think, Ms Gowman, you have permission for some questions.

Questions From Ms Gowman

Ms Gowman: Thank you, my Lady.

Ms Howarth, I ask questions on behalf of Covid-19 Bereaved Families for Justice Cymru.

Firstly in respect of the Covid-19 analysis hub established on 23 March 2020, just briefly, you’ve described today that the responsibility of the hub was to bring existing information together for use within Welsh Government. In other words, it provided Covid-19 statistical analysis to inform advisers and decision-makers in the Welsh Government; is that a fair summary?

Ms Stephanie Howarth: Yes.

Ms Gowman: So an important function?

Ms Stephanie Howarth: Yes.

Ms Gowman: The former Chief Statistician, Glyn Jones, states in his witness statement that the hub started life as a team of seven people; is that correct?

Ms Stephanie Howarth: That is correct, yes.

Ms Gowman: Initially did the staff in the hub act on a voluntary basis alongside other responsibilities?

Ms Stephanie Howarth: That is correct, although most of those other responsibilities were largely paused, which enabled them to contribute to the work of the hub.

Ms Gowman: And that may answer my next question, but do you question that the limited team of seven and the fact that staff were acting on a voluntary basis alongside other responsibilities, did that in any way impact on the hub’s ability to respond to requests in the early stages of the pandemic?

Ms Stephanie Howarth: So there were a range of other statistical and analytical staff also supporting the hub, so they weren’t the only people responding to requests. So if an example would be helpful, the team that leads on economy and labour market statistics would help contribute to work around that topic related to the pandemic. But that notwithstanding, I think it was a big ask for a small team to be able to accommodate the growing number of analytical demands during that time.

Ms Gowman: And certainly Glyn Jones suggests that by the summer of 2020 demand was outstripping supply; is that fair?

Ms Stephanie Howarth: Yes.

Ms Gowman: What impact do you think that that had on the hub’s ability to respond to policymakers to inform decision-making?

Ms Stephanie Howarth: So I think we did – the key information was made available and we were able to work with policy officials, but perhaps the thing that we were less able to do was be more proactive. It was much more reactive to the kind of demands that people had for statistics during that period, rather than more closely embedding yourself with the policy team.

Ms Gowman: And in future, what lessons do you think that can be learned from that scenario?

Ms Stephanie Howarth: I think it shows that you need suitable analytical capacity within an organisation to be able to work collaboratively with policymakers. I don’t necessarily feel like there was a deficiency in the use of analysis, but I think that we potentially could have gone further in anticipating some of those demands. But also it creates a significant impact on the small number of individuals concerned in terms of their own wellbeing, and I think a large capacity can help avoid some of those challenges as well.

Ms Gowman: Avoids burn-out?

Ms Stephanie Howarth: Yes.

Ms Gowman: Yes.

Secondly, we know that five new analytical posts were agreed in June 2020 for the hub, and six new posts were agreed in November 2020. What isn’t clear from the evidence at the moment is whether those posts were filled. Are you able to assist?

Ms Stephanie Howarth: They were, but it took a period of time for them to be filled.

Ms Gowman: Do you agree with your colleague, Glyn Jones, that, notwithstanding these vacancies having been advertised and indeed, as you’ve set out, eventually being filled, recruiting sufficient specialist resources remained a constant challenge throughout the pandemic and, secondly, that this meant that certain projects could not be adequately resourced?

Ms Stephanie Howarth: It was a challenge to resource analytical roles. There are only a finite number of analysts within government. We benefitted from being able to bring in, for example, colleagues from arm’s length bodies, we had a small number of loans from the Office for National Statistics, but it was a continual challenge to be able to fill the analytical capacity that we needed.

Ms Gowman: And in terms of the second part of the question, did that mean that certain projects couldn’t be adequately resourced?

Ms Stephanie Howarth: There were – generally I think it probably meant that we were slower to do things than we might have liked rather than they couldn’t happen, but there were some examples where – one particular noteworthy one was the Technical Advisory Cell had a dashboard, an internal dashboard, that they had brought together to interrogate some key sets of data, I would have liked that Knowledge and Analytical Services together with our digital colleagues would have been able to do that, but we didn’t have sufficient capacity to be able to do that, so that was something that was contracted out.

Ms Gowman: And aside from that example that you’ve given, how else, if at all, did the resourcing constraints impact on policymakers during the pandemic?

Ms Stephanie Howarth: I think broadly we were able to meet policy demands, I can’t think of a specific example that impacted policymaking, but it did often mean that people had to go above and beyond and work long hours to do so.

Ms Gowman: Thank you, Ms Howarth.

Those are my questions, thank you, my Lady.

Lady Hallett: Thank you very much.

Mr Gardner, I gather there’s a question the Children’s Commissioner would like asked.

Mr Gardner: Thank you, my Lady. I wonder if I might lean forward and obtain a …

Lady Hallett: A lectern for one question, Mr Gardner.

Mr Gardner: My eyesight, my Lady.

Lady Hallett: Actually it’s user technology, isn’t it? I hadn’t thought about that.

Questions From Mr Gardner

Mr Gardner: Ms Howarth, the Inquiry has just heard from Professor Diamond. I don’t need you to turn to it, but in his first statement at paragraph 166 he refers to a school infection survey and notes that that was an England-only study. Are you able to confirm if any equivalent study was taken during Covid relating to Wales?

Ms Stephanie Howarth: There wasn’t an equivalent study in Wales, no. I recall that we had discussions with ONS about their survey to understand how it worked, determine if it might be possible to extend to Wales, but from memory I recall it was quite an expensive survey to get up and running and there wasn’t necessarily the funding available to do that.

Mr Gardner: So you wouldn’t have been involved in risk profiling, but – correct me if I’m wrong?

Ms Stephanie Howarth: No.

Mr Gardner: But the result of that would be that those who were making decisions about risk profiling wouldn’t have had data available to them specifically about schools in Wales, then?

Ms Stephanie Howarth: It depends what data you mean. So they wouldn’t have had that specific data from the infection survey but there were other sources of data. Colleagues in Swansea University, for example, had linked together a range of data to understand transmission in schools. So there were a range of different data sources but the school infection survey run by ONS was an England-only survey.

Mr Gardner: I’m grateful. Thank you, my Lady.

Lady Hallett: Thank you, Mr Gardner.

I think you have one further question that John’s Campaign wishes you to ask. Yes, Ms Spector.

Further Questions From Counsel to the Inquiry

Ms Spector: Yes, I do, my Lady, thank you.

Ms Howarth, you confirmed that the rapid surveillance data did not cover all deaths, it did not capture all deaths in care homes, but that ONS would have captured all of those deaths. How did the publication of that data work?

Ms Stephanie Howarth: Of the ONS data?

Counsel Inquiry: Of the ONS data, yes.

Ms Stephanie Howarth: So ONS published that data on a weekly basis, I think it was, with an approximately ten-day lag, I believe, from memory. And I think as part of that they would regularly break down data by place of death.

I think it might also be useful to add that we shared data from the Welsh Government with ONS, the Care Inspectorate Wales data I mentioned, which helped them to produce their analysis around deaths of care home residents as well.

Counsel Inquiry: Sticking with the ONS data, would earlier figures that may not have included care home deaths have been updated retrospectively when the complete ONS data was received?

Ms Stephanie Howarth: So I’m not an expert in ONS’s mortality data but my understanding is it should cover all deaths that have a death certificate. So that would be regardless of where the death occurred, so they should all be in there, is my understanding.

Counsel Inquiry: Forgive me, I think the question simply is about whether earlier figures would ever be corrected to account for later figures?

Ms Stephanie Howarth: I’m not clear on how the ONS mortality data works, but I imagine that there would be updates for any late returns, for example, or delays in registration that were received.

Ms Spector: I’m grateful, my Lady.

Lady Hallett: Thank you very much indeed, Ms Spector.

Thank you very much indeed for your help, I’m very grateful to you.

The Witness: Thank you.

Lady Hallett: We’ll break now, I think, we might as well between witnesses, and I shall return at 3.15.

(3.00 pm)

(A short break)

(3.15 pm)

Mr Poole: I call Dr Robert Hoyle, please.