2. Dr Robert Orford
DR ROBERT ORFORD (affirmed).
Questions From Lead Counsel to the Inquiry for Module 2B
Mr Poole: Could you start by giving us your full name, please.
Dr Robert Orford: Yes, Robert Leslie Orford.
Lead 2B: Dr Orford, thank you for coming today and giving your evidence to the Inquiry. If I could just remind you to keep your voice up so we can hear you, but also so your evidence can be recorded. If I ask you a question you don’t understand and would like rephrased, please do ask me.
You have been good enough to provide two witness statements to this module: your individual witness statement dated 19 December of last week, we can see that displayed, and also a corporate statement on behalf of TAG and TAC, which is dated 23 November, and we can also see that displayed on screen.
You have signed both of those statements with a statement of truth. Can you please confirm that the contents of those statements are true to the best of your knowledge and belief?
Dr Robert Orford: They are.
Lead 2B: I’m grateful.
Dr Orford, you are currently the Chief Scientific Adviser for Health in Wales and you have held that post since 2017; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: As regards your professional background, you hold an honours degree and PhD in molecular biology, you completed a post doctoral fellowship with the Imperial Cancer Research Fund, before working as an investigator scientist with the Medical Research Council for five years. For eight years you worked for the Health Protection Agency, which later became Public Health England, and you are a visiting professor of evidence-based health policy at the University of South Wales; is all of that correct?
Dr Robert Orford: That’s correct.
Lead 2B: Throughout the pandemic, you were obviously Chief Scientific Adviser for Health in Wales. I understand that your roles and your responsibilities changed during the pandemic, we’ll obviously be looking at how they changed in due course, but in terms of your role as the Chief Scientific Adviser for Health and your key responsibilities at the start of the pandemic, would it be right to say that you play a crucial role in advising the Welsh Government on scientific and technical matters related to health policy and healthcare delivery?
Dr Robert Orford: That’s correct.
Lead 2B: And in terms of decision-making, part of your role is to ensure that the Welsh Government decisions related to healthcare are grounded in scientific evidence and best practices, is that right?
Dr Robert Orford: That’s correct.
Lead 2B: As regards your role when it comes to crisis management, such as pandemics or major disease outbreaks, would it be right to say that the CSAH plays a critical role in providing guidance and expertise to help manage and mitigate the impact of such crises?
Dr Robert Orford: I think prior to the pandemic, that wasn’t part of the role description, but during the pandemic it was.
Lead 2B: Would I be right in saying that although you are a member of the Welsh Government, you describe your role as being independent in the sense that you are free to provide advice without regard to government policy or direction; is that right?
Dr Robert Orford: That is partially correct, in that some of my role is more policy oriented, but the adviser part of my role was more an officer role, but part of my role, the adviser role, is exactly that.
Lead 2B: I’m grateful.
Now, you explain in your witness statement from mid to late February 2020 your work became entirely focused on Covid-19 and the scientific response to Covid-19; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: Now, a key part of the response was the development of TAC and TAG which the Inquiry has heard quite a lot about already and we’ll come back to that in the course of your evidence in due course. In addition to establishing and developing TAG and TAC, if I can just run through a few of your other key responsibilities during the pandemic. It’s right you represented Wales at SAGE meetings and meetings of subgroups of SAGE and other important four nation expert meetings; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: You had a significant role to play in developing scientific intelligence during the pandemic, so, for example, collating local, national and international information on the virus for use in various data dashboards and modelling forecasts; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: You chaired the Covid-19 Intelligence Cell, CIC, and were a member of the Health Protection Advisory Group outbreak subgroup; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: And you also led work to prepare for and deliver the First Minister’s weekly briefings, and in that capacity I understand your job was to ensure that they were significantly – sorry, scientifically robust evidence bases for all Welsh Government decisions; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: How did your role, Dr Orford, intersect with the Chief Medical Officer, Dr Atherton, during the pandemic?
Dr Robert Orford: Professor Sir Atherton and myself worked very closely together throughout the pandemic, we corresponded frequently. My role was to collate, synthesise, present understandable scientific technical information.
Lead 2B: You say in your witness statement that you did not work closely with the Chief Scientific Adviser for Wales, Professor Halligan, certainly in respect of the pandemic response, as it was agreed that you would lead from a science perspective; is that fair?
Dr Robert Orford: That’s correct.
Lead 2B: We understand that there were no governance arrangements in place at the start of the pandemic between the Chief Scientific Adviser and yourself. Did that present difficulties in terms of the share of responsibility between yourself and Professor Halligan at the start of the pandemic?
Dr Robert Orford: Fairly early on in the decisions around the formation of the Technical Advisory Cell I’d had conversations with Professor Halligan around who was best to lead that work and I was – had the best fit. We obviously kept in contact throughout the period of the pandemic, once a month.
Lead 2B: On 22 January 2020, you emailed the senior private secretary to the UK Government, Chief Scientific Adviser, Sir Patrick Vallance, asking to be included in the read-out of a precautionary SAGE meeting that was held on that day, 22 January. I don’t need to bring up the email on screen.
Did you consider it strange that you had to ask to be included in the read-out from that first precautionary SAGE meeting?
Dr Robert Orford: I believe there were two emails on that day. The second email was describing the devolved nature of health, and why it was important to be a member of that group.
Lead 2B: And so did you find it strange that you had to prompt the UK Government in order to receive a read-out of that first precautionary SAGE meeting?
Dr Robert Orford: Yeah, I think I found it slightly frustrating that it took time to access the group.
Lead 2B: I mean, I think I’m right in saying your first attendance at a SAGE meeting was not until 11 February, which was the sixth meeting of SAGE, and then that was at the invitation of the UK Government, and even then you were attending as an observer, which meant that you’re not able to participate in discussions. Is all of that right?
Dr Robert Orford: That’s correct, yes.
Lead 2B: Do you think you ought to have been invited to SAGE prior to 11 February?
Dr Robert Orford: I think it would have been helpful, yes.
Lead 2B: Would it also have been helpful to have been able to participate, so not simply attend in an observer capacity?
Dr Robert Orford: I can’t remember from memory whether I was knowingly quiet as an observer, I tend not to be, so I may well have not observed, solely observed. I mean, I did participate in those conversations, as did my colleague at the time.
Lead 2B: In terms of SAGE documents, did you have sufficient and timely access to SAGE documents?
Dr Robert Orford: Yes.
Lead 2B: At paragraph 41 of your witness statement, you say:
“SAGE tended to only be interested in the actions of the Welsh Government when there were differences in policy approaches …”
Then you give examples of the Welsh firebreak or local interventions in the autumn of 2020. Then you say:
“Unfortunately it appeared as though the devolved nations were a second order priority.”
Can you just help us with that, what made you form that view?
Dr Robert Orford: I think probably there’s two points there. Firstly, the priorities of SAGE were to understand what was coming, to be able to describe the nature of the onslaught that was going to arrive fairly swiftly with us. But also, you know, England is a lot bigger than Wales and the devolved governments, devolved nations, so very clearly there was a focus on challenges within England, as there’s not a separate administration of England, so as time progressed – and perhaps we’ll come on to that – there was more involvement with the devolved governments, with the chair seeking the opinion of the advisers in the devolved nations, but certainly at the beginning more of the emphasis was on the position in England and the UK, and I think that was probably the right thing to do for things like sentinel surveillance, where the numbers were bigger in England because of the size of the population.
Lead 2B: So although reference has been made to SAGE being too England-centric, from what you’ve just said, do you not necessarily see that as a – as too much of a criticism in the early stages of the pandemic, so February/March?
Dr Robert Orford: I think, you know, in the Civil Contingencies Act, where it describes SAGE as a UK forum, I think that really should have been a UK forum from the beginning.
Lead 2B: So you would have liked to have seen greater UK representation and governance on SAGE from the start?
Dr Robert Orford: Yes.
Lead 2B: You say in your witness statement there may have also been other political or civil servant influences on the UK nature of the science response as there were with other parts of the UK Government pandemic response. What do you mean by other political or civil servant influences on the UK nature of the scientific response or the science response?
Dr Robert Orford: So at different points of the pandemic, when scientific information became available, it may have been – it may have gone through other eyes, it may have gone through civil servant or ministerial eyes before it met advisers’ eyes. I hope that makes sense. So I would like to see unfiltered advice before it becomes public.
Lead 2B: I understand.
You say also in your witness statement:
“It might be helpful and timely to revisit the current SAGE guidance from a four nations perspective and also the UK Government scientific advisory code of practice to better reflect the extraordinary experience that the pandemic has brought to bear of the provision of scientific advice for government.”
To the best of your knowledge, has such a review of SAGE guidance taken place?
Dr Robert Orford: There has been a review of SAGE but I’ve not been privy to the findings of that. That may have been promulgated through the CSA network, but I’m unaware of that.
Lead 2B: Taking a step to the side and a few questions about NERVTAG. Wales were able to have an observer status on NERVTAG, but I think you say in your evidence it took several attempts to join. Can you help us, when were Welsh representatives permitted to join NERVTAG as observers?
Dr Robert Orford: I can’t remember the exact dates, it may have been around May/June, and those observers would have come from Public Health Wales.
Lead 2B: Do you know why it took so long for Wales to be permitted to join or have observer status on NERVTAG?
Dr Robert Orford: I think that question is best asked of the secretariat and chair of NERVTAG. I’m aware that there were sensitivities regarding leaks to the media and I think probably best to orient those questions that way.
Lead 2B: Catherine Moore, a lead scientist for Public Health Wales, describes that Public Health Wales’ role on NERVTAG was purely observatory but Public Health England were very active participants and this skewed the data being presented to very much a UKHSA view of the pandemic. Have you got any views on that comment?
Dr Robert Orford: I mean, Catherine was a member of the Technical Advisory Group and she was excellent, you know, she’s an international expert in virology. In NERVTAG they have the best people in virology, and it’s like drinking from a fire hydrant when you hear the conversations, so on those groups you absolutely want the best people there.
As to whether the conversations can be translated from what’s happening in England to what’s happening in Wales I think is – depends on the nature of the conversations.
Lead 2B: The Inquiry understands that from June 2020 a Science Co-ordination Group was established by GO-Science, the Government Office for Science in the UK. Can you help us, what was the purpose of that group?
Dr Robert Orford: So the Science Co-ordination Group was to understand what’s coming down the track and the type of papers that were in development, and the kind of conversations that would be had in forthcoming SAGE meetings and to generally share intelligence of what work is happening, for example, work that we were leading in Wales.
Lead 2B: What did that group add to the structures that were already in place at that stage?
Dr Robert Orford: I think they added more informal intelligence sharing, situational awareness of what was going to happen next.
Lead 2B: In terms of your liaison with UK Chief Scientific Advisers, so obviously outside SAGE, is it right that you had limited communication with Sir Patrick Vallance and Professor Whitty?
Dr Robert Orford: Yeah, most of my interactions with Sir Patrick and Sir Whitty were through SAGE.
Lead 2B: Was there any formal arrangement for meetings between yourself and Sir Patrick Vallance and Sir Chris Whitty?
Dr Robert Orford: No, but I’m, you know, fully aware of Professor Whitty having the dual role of Chief Scientific Adviser for Health and CMO at that point and most of those interactions happening between the CMOs.
Lead 2B: You met regularly, as we understand it, with Professor Young and Professor Crossman, so your counterparts in respectively Northern Ireland and Scotland. Are those the bi-monthly meetings that you mention in your TAC witness statement?
Dr Robert Orford: That’s correct.
Lead 2B: Were minutes taken of those meetings?
Dr Robert Orford: I don’t believe they were, unfortunately.
Lead 2B: Do you think it would have assisted to have minutes taken of those meetings?
Dr Robert Orford: I really like to have minutes of meetings. Unfortunately having the right staffing for secretariat support didn’t always – I mean, there were very many meetings and so to have the requisite number of administrative support people was not always possible. I would have much preferred to have minutes.
Lead 2B: Dr Orford, if I can just ask you, you’re fairly quietly spoken, so if I can just ask you to keep your voice up, please.
Dr Robert Orford: Of course, sorry.
Lead 2B: Thank you.
Now, the Inquiry understands that within the UK Government there are chief scientific advisers assigned to specific government departments, and those CSAs will advise ministers and officials within their own department. I think you’ve described that in your witness statement as a “CSA Network”, and you say that establishing meaningful connections between CSAs obviously should be of paramount importance, but am I right that the devolved administration governments, they’re not recognised within that CSA network?
Dr Robert Orford: They’re recognised as a department and so the CSA for government, Welsh Government, is the only member from Wales.
Lead 2B: What, if anything, is the consequence of that sort of, if you like, partial recognition?
Dr Robert Orford: I mean, the purpose of having a network is to ensure that you’ve got good connections between people within the network and on the network, and so take, for example, the Health and Safety Executive has a CSA, being familiar with that person and the work that they’re leading is, I think, probably better directly rather than second-hand.
Lead 2B: Has communication and co-ordination between all the UK chief scientific advisers for health changed since the pandemic?
Dr Robert Orford: No.
Lead 2B: To change topic slightly and ask some questions about the Covid Intelligence Cell, which I think you co-chaired with Fliss Bennee during the pandemic; is that right?
Dr Robert Orford: That’s correct.
Lead 2B: Just tell us briefly, what’s the purpose of the Covid Intelligence Cell?
Dr Robert Orford: So probably best described as a forum to provide an ongoing risk assessment narrative, so to be able to receive intelligence and data coming in from different parts of Wales, synthesise that and be able to produce an ongoing assessment of what will happen next, what’s happening now.
Lead 2B: Am I right the CIC was established in September 2020?
Dr Robert Orford: From memory, yes.
Lead 2B: Why was it established then? Was there a need, do you think, for it to have been established earlier in the pandemic?
Dr Robert Orford: I think it was established then as other parts of the machinery of dealing with a pandemic in a steady state were happening, so we were iterating our approach within government. The risk management part of Health Protection Advisory Group was being established alongside the Covid Intelligence Cell. Up until that time, most of the situational awareness that I was involved in came to the Technical Advisory Group, so it made sense to uncouple that conversation and bring it to one discrete forum.
Lead 2B: Now, you’ve mentioned the Technical Advisory Cell, so perhaps we can move to some questions about that. That was established much earlier, that was around 27 February 2020, I think I’m right in saying?
Dr Robert Orford: That’s correct, yes.
Lead 2B: If we can have a look at INQ000068504, please.
These are, in fact, the terms of reference for the Technical Advisory Group. If we can have a look at page 2 and the second paragraph there, we see a description of the respective functions. So TAG, the Technical Advisory Group, the group of scientific and technical experts who provide advice and guidance to the Welsh Government in response to COVID-19.”
Then:
“TAC is … the [cell] core team of public servants who … [Document read] … and evidence on COVID-19 to the wider public as needed.”
So they are the functions of the two bodies.
If we can please have a look at paragraph 3, just in terms of reporting and commissioning, so I’m right TAC sits within the Health and Social Services Group. As it says here, provides advice to the CMO, director general for Health and Social Services, and provided regular updates for the Minister for Health and Social Services and also the First Minister.
Then if we can have a look, please, at pages 3 and 4, I think it’s – yes, it’s paragraph 6 that runs over the page, we have there a list of TAG members.
Dr Orford, obviously neither TAG nor TAC had been established prior to the pandemic. Why was it thought necessary to establish TAG and TAC during a public health emergency?
Dr Robert Orford: As mentioned earlier, lots of the work – there’s far more capacity and capability within England to deal with these kind of events. Trying to understand the meaning of what was coming into a Welsh context was quite important. So when would the wave arrive? How big would the wave be? What kind of NHS capacity did we have available to deal with that? So it was important to be able to translate the really important UK level work into a Welsh-specific context. So the … yeah.
Lead 2B: I understand that April 2020 saw the first two TAG subgroups were formed and then we see gradual evolution. I think by the time we get to October 2020 there are nine subgroups. You say in your witness statement that each subgroup was limited to no more than ten experts in a given field. Can you just help me with why that was and how those experts were chosen.
Dr Robert Orford: So I think it’s probably that was an optimum level. The reason that came about, prior to my work in Welsh Government, I’d worked with Public Health England, with European Commission co-funded programmes on serious cross-border threats to health, on chemicals, and in that work we established networks of experts, and some of the work packages looked at the number of experts that you might need in a particular area to derive evidence and derive advice in a fairly swift manner to respond to emerging challenges. So, you know, whilst the ambition was to have a set number, I think there was some degree of variation between the groups as there was independence of the chair of the group to decide who they wanted and who they needed to help them best answer the questions that were posed of them.
Lead 2B: Did you ever find it difficult filling sort of the capacity? There was some evidence that the Inquiry heard at the end of last week that there weren’t perhaps enough scientists in Wales. Was that a problem that you encountered?
Dr Robert Orford: I’m not – I’m not sure. I think different groups had different challenges. Different groups had different makeup, just because of the nature of the material that they were talking about. For example, the socioeconomic harms group had more economic advisers from within government than perhaps external experts, whilst the virology and testing group had more Public Health Wales experts, because of the nature of the material and where those experts sat within – within Wales, whether universities or the public health authority.
Lead 2B: You mention there the economic harm subgroup. Something that you say in your witness statement is:
“One mistake I feel SAGE made was, unlike in TAG, economic and health, economic advice did not play a significant role. One of the key harms arising from the pandemic was economic damage and therefore economic evidence should have been a key consideration that was explored and shared publicly, as opposed to this being solely a consideration of the UK Treasury.”
Am I right in saying – thinking the economic harms subgroup was the group responsible then for providing economic and health economic advice to TAG?
Dr Robert Orford: Yeah, that’s correct.
Lead 2B: And did economic evidence play a significant role in the advice that TAG provided to the Welsh Government?
Dr Robert Orford: It did. I mean, if you look at the advice that we shared with policy colleagues and ministers, there was always – many times we provided information from the socioeconomic harms group and there were sometimes bespoke pieces of advice, for example the social cost of a case where we explored costs and impacts associated with the cases at different junctures of the pandemic. You know, papers on health inequalities were really important foundation pieces for the group as well that came from that group.
Lead 2B: The TAG Risk Communication and Behavioural Insights subgroup we understand held its first meeting on 22 July 2020, and provided advice to the Welsh Government for the first time in October 2021. Do you know why it took so long for that subgroup to produce its first advice to the Welsh Government?
Dr Robert Orford: I mean, there’s two reasons there. From the very beginning stages of the SAGE group, probably the three most important groups were SPI-M, NERVTAG and SPI-B, and we had access to the outputs of those groups and as we were following a UK plan fairly closely in that period, then we didn’t really need RCBI at that point. But as we became different in our policy choices then we needed greater capacity and capability in that area, and I described the need for this broadened set of subgroups in a paper that was written in the summer of 2020 about the approaching difficult winter.
Lead 2B: Do you consider there to have been sufficient regard or focus on behavioural science and behavioural scientific evidence in Wales particularly during the first wave?
Dr Robert Orford: I mean, we certainly took the advice of SPI-B and SAGE very seriously in Wales, and you can see that in my briefing notes to CMO and officials and ministers throughout that period. Understanding what the public and the population would do during the first lockdown, for example, was, you know, ever so important.
Lead 2B: The Inquiry received evidence from Professor Ann John, who stated that across all the groups that she participated in during the pandemic response, including the RCBI subgroup and TAG itself, she said there was a lack of representation from ethnic minorities and from those of more deprived background. And she said as a result those advising policymakers had little direct understanding of experiences which may underpin behaviours and also their direct impacts. These included, for example, living in cramped conditions, being unable to order food online, not understanding perhaps the mistrust of vaccines and masks. And in her view this lack of ethnic and also social diversity can result in inappropriate policy responses.
I mean, do you accept those criticisms?
Dr Robert Orford: I do and I don’t. I’m not sure what the code of practice for scientific advisory committees says around this matter, which is an important matter. Part of Welsh Government is absolutely about co-production, doing things in partnership, and it’s really important that you do that on wicked problems, and usually policy formation happens slowly, not in a matter of hours and days, and we’ve got very good examples of patient public involvement in areas like genomics.
I think on the matter around the composition of the Technical Advisory Group, I’m not aware that there was a survey done on the breakdown of the background of the participants. I myself am from a working class background, I know my other colleagues were. In terms of ethnic diversity, again we didn’t survey the group or actively look. I think if I was to start again, ideally prior to a pandemic, I definitely would have looked at representation and a fuller understanding of how we would get that important information on these very difficult policy choices. But there was work looking, you know, with focus groups and different surveys that were done through Ipsos MORI and Public Health Wales to capture that type of information. But I think Ann John’s point was very valid, that we really need to think about the composition of groups.
Lead 2B: Dr Chris Jones, who the Inquiry heard from – sorry, the Deputy CMO, who has provided written evidence to the Inquiry, he has expressed discomfort at the number of government officials in TAG and the lack of independence that resulted from this. So he said in his written evidence to the Inquiry that each TAG meeting was chaired by Welsh Government officials with several officials contributing actively in the advice, and in his view that risked influencing professional and academic advice. Is that something that you recognise or what comment do you have on that evidence?
Dr Robert Orford: I’m not sure there was much active participation from policy observers. I actually think it’s really important to have observers, to be able to listen to the discourse and the debate and, you know, the weight of evidence. So I’m an advocate for non-scientists to be part of the conversations, however, not to be able to restrict the conversation with policy.
Lead 2B: Again, the Inquiry heard from Professor Gravenor last week, he and members of the Swansea modelling team were working voluntarily for a large part of the pandemic, as were a number of other members of TAG and TAC, so were having to juggle that work alongside their professional commitments.
Were you concerned at the time about the pressure that that may place on them but also how it may negatively impact on the quality or the timeliness of their work product?
Dr Robert Orford: You know, can I start by saying how grateful I am for Professor Gravenor’s work and all of the academic contributors to Technical Advisory Group, and there were over 200 who gave their time freely. In our lessons learned, we’ve identified this as an area that would require improvement, so we can reimburse people for their time. We were able to write ref letters to say that their research was contributing to policy and actions within Wales, which was important, but on the matter that Professor Gravenor raises around policy, we didn’t have a call-off contract in place that we could easily fund universities, and I think procurement was difficult, we didn’t have the staff to be able to put business justification cases in at that time, so that would be something I’d like to see addressed in the future.
Lead 2B: If I can just now identify some documents and TAG and TAC documents with you, as I understand it there were some three regular briefing documents that went to the Welsh Government, so I just want to identify what those are and ask you to perhaps briefly explain each of them.
The first is a document called a TAC summary of advice, so we’ve got an example up on the screen.
It’s INQ000066418. You see the first page of it there, and perhaps we can just go over to the second page.
This, as I understand it, is the TAC summary advice actually from 5 May 2020, but we’re not, for present purposes, concerned with the contents. I just want to know: what was the purpose of these advice summaries.
Dr Robert Orford: So there were actually two types of advice summary, there was an internal summary that contained more official sensitive information, for example unpublished discussions and papers from SAGE, and that went to the CMO, senior officials within health and across government and ministers, and that was a weekly publication.
It was a bit of a misnomer to say that it was a brief, that these would sometimes run to 50 or 9- pages long. And then there was a publicly accessible version, and this may be one of the earliest examples of a condensed public version that was able to share more broadly what we were observing and the information that was accessible to us at that time.
Lead 2B: So the internal, more expansive version, so say, for example, if it was commenting on SAGE, that would contain, would it, within that briefing pack, the particular SAGE minutes or the SPI-M minutes or documents?
Dr Robert Orford: Yeah, the key points from those papers. I mean, we were summarising and simplifying abstruse technical information that should be accessible for people without a scientific degree.
The first update to CMO, and my first SAGE meeting, this was really a continuation and an evolution of that update. I think there were 131 of them in the course of the pandemic.
Lead 2B: The second document was the Covid-19 Wales situational report. We’ve got an example of that on the screen.
What was the purpose of these situational reports?
Dr Robert Orford: So this again evolved over time where the TAC summary had more situational assessment information from a range of indicators. This then became the alert level assessment that then evolved into the Covid situational report, which essentially was a risk assessment bringing together different strands of evidence to say: this is the picture in Wales against these indicators and circuit-breakers.
Lead 2B: And is this an externally facing document or is this –
Dr Robert Orford: That’s correct, yes –
Lead 2B: – an internal Welsh Government –
Dr Robert Orford: – publish.
Lead 2B: If we can then identify perhaps the third document, the TAG contribution for 21-day review of measures, so we’ve got this at INQ000048838. We can just stick on this, which is the index page. What was the purpose of this document?
Dr Robert Orford: So this was the formal commissioning and questioning from policy colleagues involved in the national protections and policies that would then supplement and support ministerial advice and CMOs’ advice at that period.
Lead 2B: As well as these types of documents that we’ve just looked at, I assume that ad hoc requests could be made of TAG and TAC for advice; is that right?
Dr Robert Orford: Yeah, I think “ad hoc” is probably the right word at the beginning. That process, like these documents, evolved and were iterated over time, so a more formalised approach to commissioning was adopted over time.
Lead 2B: Perhaps you could just describe for me the relationship between TAG and TAC and the CMO. Was TAG and TAC independent of the CMO and his office?
Dr Robert Orford: At the beginning, you know, CMO had primacy as the lead official and so everything was routed through CMO, but conversations with my co-chair and myself, we thought there was a need to be – to be able to report to the director general of Health and Social Care in case our advice conflicted with the CMO, which it didn’t actually in that period. It was more detailed but it didn’t conflict.
Lead 2B: Do you think the difference between advice coming from TAG and TAC and advice coming from the CMO would have been understood by Welsh Government and Welsh Government ministers?
Dr Robert Orford: Do I think that the advice was understood?
Lead 2B: The difference between – so say if they received advice from TAG and TAC and they received advice from the CMO, would they think this was of a piece or would they think that these are different –
Dr Robert Orford: I mean, we met with ministers really frequently and Sir Frank and I and Fliss Bennee, you know, they knew that the advice was coming from ourselves and TAG and TAC or CMO, yeah.
Lead 2B: So I understand that TAC has been stood down and TAG has been repurposed; is that right?
Dr Robert Orford: I wouldn’t – well, the emergency response has obviously been rescinded, but at – the capacity and capability to respond is now within the science evidence advice division. TAG is still extant although not currently sitting.
Lead 2B: It is capable of being stood up in the event of a future pandemic?
Dr Robert Orford: In short order, yes.
Lead 2B: Dr Orford, I want to ask you some questions next about your initial understanding in January to March 2020. You say in your witness statement that you didn’t send any papers related to Covid to the First Minister in January 2020 because that was not within your roles or responsibilities during this period. As far as you were aware, did the First Minister have access to SAGE papers in January 2020?
Dr Robert Orford: Oh, I don’t know, you’d have to ask the First Minister.
Lead 2B: Now, Mr Drakeford said in his written evidence to the Inquiry that it was 24 January when Dr Atherton advised him that there was a significant risk that the virus would arrive in Wales.
Did you share the CMO’s view?
Dr Robert Orford: At that point, at that juncture, I wasn’t involved in health protection matters, my work was more facing the NHS.
Lead 2B: If we move then into February, 25 February you send an email to Dr Atherton in which you said, and we don’t need to get the email up on the screen you said:
“Based on current models demand will significantly outstrip NHS bed capacity for about 8 weeks during epidemic peak.”
Would it be right to say in late February – this is an email on 25 February – that you were concerned about the capacity in the health service in Wales, how it would respond to a high-consequence infectious disease?
Dr Robert Orford: Yes.
Lead 2B: Do you consider that Dr Atherton and the Welsh Government decision-makers took sufficient heed of warnings such as the warning contained in your email of 25 February?
Dr Robert Orford: At the time I didn’t have access, I wasn’t exposed to a Cabinet level or Executive Group conversation, so it’s very difficult for me to comment from my view at the time.
Lead 2B: Does it surprise you that if the First Minister is being told by the Chief Medical Officer on 24 January that there is a significant risk that the virus would arrive in Wales, that it takes until 25 February for Covid to be discussed at Cabinet level?
Dr Robert Orford: Again, I wasn’t privy to agenda setting with Cabinet, or those conversations. My advice was at that point being promulgated through the CMO, so I wasn’t privy to those conversations.
Lead 2B: On 27 February you sent an email to Dr Atherton.
If we could please display this, it’s INQ000087032. This is an email sent, as I say, on 27 February. If we could have a look at the fourth paragraph, please, of your email – yes – it reads:
“The SAGE papers add further detail on the [reasonable worse case] and start to quantitate the potential numbers of people at a UK level requiring hospital support and ventilation. Most of the pan-flu assumptions hold but some figures (eg duration of hospital stay) will have a significant impact on NHS planning when combined with the numbers of people requiring hospital support. If we estimate the numbers for Wales as being 5% of the UK totals we will see very significant impacts for NHS Wales that would far outstrip capacity for a number of weeks.”
So at this point, 27 February, were you clear that unless action was taken, the NHS in Wales would be overwhelmed?
Dr Robert Orford: Yes.
Lead 2B: The First Minister in his written evidence to the Inquiry has said that although the Welsh Government was aware of Covid-19 in January and February, it was not a priority. I mean, do you think that the Welsh Government appreciated the threat of Covid-19 in January and February 2020, or is that not something you can comment on?
Dr Robert Orford: Yeah, I guess, you know, those reflections are probably best placed with ministers and more senior officials, but certainly from my perspective the advice was: this is coming. How big will it be and when will it arrive were obviously first order questions for me at that point.
Lead 2B: In late January/February 2020, although you say that there was uncertainty about asymptomatic transmission and viral shedding before symptoms developed, you say in your statement that you considered it a possibility. That’s right, isn’t it?
Dr Robert Orford: Yeah, it’s … patients or people being asymptomatic and asymptomatic transmission are different. So I think we just need to be very careful in how we’re defining that.
Lead 2B: If we can have a look, please, at an update that you sent Dr Atherton on 20 February. This is following a SAGE meeting of the same date.
Yes, it’s INQ000310085.
The email at the top of the chain, fifth bullet point, please, it refers to the – yes, it says:
“From cruise ship – 30-50% asymptomatic-mild.”
Reference then obviously to the Diamond Princess cruise ship.
So is it right that by late February 2020 you and Dr Atherton were aware that there was asymptomatic transmission and that the rate might be as high as 30% to 50%?
Dr Robert Orford: Again, I think we need to be really careful here. So this information is coming from SAGE. This is saying whether people are infected, so testing positive, and whether or not they’ve got symptoms, and at that point we didn’t know whether people were – who were infected with no symptoms or pre-symptoms or paucisymptomatic, in that they had mild symptoms, were able to transmit. So that wasn’t until a lot later that there was sufficient evidence to say asymptomatic people could transmit, because certainly that was different from SARS-CoV-1.
Lead 2B: In your update to Dr Atherton of 20 February – if we could perhaps have this on display, INQ000310085 – sorry, it’s the same document. Seventh bullet point though now – you state that there was a 75 to 80% likelihood that the virus is already in circulation. In your view, what were the implications of this regarding next steps to be taken by the Welsh Government in response to Covid-19?
Dr Robert Orford: So, again, this is information flowing from SAGE and at the time the sentinel surveillance system was not particularly sensitive, so it was guesswork as to how many infected or infectious people were in the UK at that time. And I suspect it was from the genomic evidence there were probably a handful of people in the UK with the virus and, when was that, 20 February, so … so, yeah, it was a commentary on likelihood of people being, you know, the virus already being here in the UK.
Lead 2B: Sticking with this same document but going up to the fourth bullet point:
“Contact tracing to continue until trigger event detected eg local transmission not linked to travel. Number likely to be increased.”
Were you confident in the contact tracing arrangements that were established in Wales at this time?
Dr Robert Orford: So we had very few molecular tests to be able to detect people carrying the virus at that time, so, you know, to have the sufficient numbers of contact tracers available I think would have been difficult.
Lead 2B: In his witness statement to this module Dr Quentin Sandifer from Public Health Wales states that by 12 March it was clear that Public Health Wales’ capacity to conduct contact tracing was reaching a limit without a large expansion in the workforce to undertake this activity. Do you agree with Dr Sandifer’s assessment? Was this your view at the time?
Dr Robert Orford: Dr Sandifer would be far better placed than I to comment on the capacity of contact tracing in Wales at that juncture, so if he says it’s correct then I assume it is correct as I wasn’t directly involved in operationalisation of contact tracing at that point.
Mr Poole: My Lady, we’re about to move into March 2020, so that might be an appropriate moment.
Lady Hallett: Certainly. I hope you were warned you may go over lunch.
The Witness: Thank you.
Lady Hallett: 1.45, please.
(12.45 pm)
(The short adjournment)
(1.45 pm)
Lady Hallett: Mr Poole.
Mr Poole: Dr Orford, the UK Coronavirus: action plan was published on 3 March 2020. In your witness statement, you say:
“… prior to its publication I had commented by email on 1 March … that the document was Anglocentric and needed to better reflect the devolved nature of Health and the responsible organisations in Wales.”
First of all, I suppose, did the final version take on board your comments?
Dr Robert Orford: That’s a good question. I can’t recollect reading the last version, but I recollect seeing comments from other colleagues, a summary of comments back from devolved governments, making the same comment, that it needed to reflect the UK rather than the position in England.
Lead 2B: Why do you feel the action plan was Anglocentric?
Dr Robert Orford: I mean, quite often if you see documents that have been drafted fairly swiftly – I think that email probably came on a Sunday night to about 200 people – often you’ll find references to “the NHS”; well, there’s four NHS organisations within the UK, so unless you’re looking through a telescope from devolved government perspective, it’s not easy to capture all those nuances of the differences in devolved governance.
Lead 2B: On 12 March Wales like the rest of the UK moved from contain to delay and then on 17 March the First Minister advised that the public should limit non-essential contact, work from home where possible and avoid social venues. In your view, did that advice go far enough on 17 March?
Dr Robert Orford: I think probably from 17 – well, before 17 March it was looking pretty precarious and actually we probably should have gone further then.
Lead 2B: If we have a look please on 20 March, it’s a TAC Covid-19 briefing document. INQ000083241, thank you.
If we can look at page 1, first paragraph, TAC advised that the risk of exceeding NHS capacity was higher than previously considered.
Then paragraph 2, please:
“TAC [recommended] that further … [Document read] … and decrease the risk of exponential growth in demand.”
Picking up on your answer to the previous question and now having a look at this document, given the worsening clinical picture do you think the advice should have gone further than recommending further control measures simply being considered? Should the advice have actually recommended the introduction of further control measures at this stage?
Dr Robert Orford: That’s a good question. Hypothetically, should we have urged a lockdown sooner? I think that’s what we were saying here, that you needed to go sooner.
And just to try to fit this into context of what was happening, I believe there was a SAGE meeting on 16 March where there was a discussion that the doubling time was shorter than previously thought, and perhaps there were more cases in the community than possibly had been picked up through the ICU sentinel surveillance. So the picture was pretty bleak at this time that we were some way down the track.
Lead 2B: Could we, please, have a look at an email that you sent to Dr Atherton on 22 March. It’s INQ000350513.
This was an email in response to an email he had sent with information from Sir Chris Whitty on the UK Government strategy.
You say at page 1, first – or second substantive paragraph:
“I’m not sure I agree … [Document read] … needs to be done as soon as possible…eg tomorrow (2-3).”
Why did you disagree with the UK position on the second wave, the bounce-back as some have called it?
Dr Robert Orford: I’m not sure I’m disagreeing at that point. I haven’t got the document from Chris Whitty to refer to, but I think at that point I’m highlighting the need for more testing, more contact tracing, as well as the suppression methodology.
Lead 2B: As we know, the UK, including Wales, entered lockdown on 23 March. Do you consider the lockdown in Wales was imposed early enough?
Dr Robert Orford: At the time, the discussion was that we were possibly a couple of weeks behind London, and that London was further advanced than us because of the nature of the seeding of the infection into the UK. In hindsight, scientific papers suggest a week earlier would have been better, so if the UK had gone into lockdown on the 15th then that would have been better than the date it did go into lockdown, in hindsight.
Lead 2B: I think you refer in your witness statement to a modelling study that showed that introducing measures one week earlier would have reduced by 745% the number of Covid cases in England by 1 June. Is that right?
Dr Robert Orford: That’s correct, yeah. It’s not my work, but that is the finding of the paper.
Lead 2B: And that would have resulted in approximately 21,000 fewer hospital deaths and 34,000 fewer total deaths, and also the total time spent in lockdown would have been halved, from 69 days to 35 days?
Dr Robert Orford: According to the model, yes.
Lady Hallett: But what happens if you do then get another high wave?
Dr Robert Orford: I think we did get another high wave.
Lady Hallett: Exactly.
Dr Robert Orford: Yes.
Lady Hallett: So how does one look at those figures? If you’ve had those figures for the length of the lockdown and then you get another high wave, the number of deaths overall, can one say whether there was any impact on those?
Dr Robert Orford: Depends when you intervene on that second wave, I guess.
Mr Poole: So timing of further restrictions in, say, autumn/winter 2020 would have been critical?
Dr Robert Orford: Yes.
Lead 2B: Before we leave March, can I just ask some questions about the advice you provided to the Welsh Government as regards transmission risks of allowing mass gatherings to go ahead.
If we could have a look, please, at INQ000271446, at page 13. I’m grateful.
So this is an email that was sent on 9 March from the principal private secretary to the First Minister. The email asks for advice in relation to cancelling major events due to coronavirus. Your reply is at the top of page 11, I think, and it’s dated 11 March.
So you send a technical briefing on mass gatherings, and we can see that briefing – I don’t – perhaps if we can bring up that briefing.
It’s INQ000271447.
Bottom of page 3 of this briefing, in answer to the question “Should I continue to attend or run sports events?” the briefing advises that:
“There is presently no scientific evidence … [Document read] … the situation evolves.”
Then over the page, page 4, first paragraph, in answer to the question “Why is the Six Nations [rugby] going ahead this weekend?” the briefing states:
“The 4 CMOs position on the science not supporting … [Document read] … bodies to make their own decisions …”
Is it right that the advice that you were giving and that TAC was giving at this time was based on the view that the events themselves would not be major vectors for transmission?
Dr Robert Orford: Yeah, that’s correct. The advice that I was giving – I’m not certain that this document is one that I drafted, I think it was probably drafted by comms colleagues with some advice from myself within it, and the advice that I gave was the advice of SAGE and the calculations from the modellers regarding the impact, the potential impact of those events.
Lead 2B: I mean, the events foreseeably entailed people travelling for the match, so we’ve heard that 20,000 Scottish rugby fans travelled to Cardiff in advance of the rugby match, and they foreseeably would have entailed people meeting in pubs and bars ahead of the match. From a public health perspective, would it not have been prudent to advise against mass gatherings going ahead?
Dr Robert Orford: I think in the benefit of hindsight, it would have made sense, just the optics of this, to stop the events going ahead. But from an epidemiological perspective, then perhaps closing all bars at the same time to stop displacement activities. So whilst the risk of these individual events were negligible compared to the whole population where transmission happens all of the time everywhere, actually what the – what they presented to the public was that these events are okay.
Lead 2B: Are you aware that the advice from Public Health Wales was that the match should be postponed or cancelled?
Dr Robert Orford: I don’t think I was aware at the time that that was their advice but, you know, that is their responsibility, to provide public health advice.
Lead 2B: The evidence that Sir Chris Whitty has given to the Inquiry on 21 November, he spoke about the consequences of allowing mass gatherings to go ahead.
If we can just, please, see a passage of the transcript of his evidence, it’s – I’m grateful.
So internal page 189, lines 13 to 19, so Sir Chris Whitty said there allowing mass gatherings and sporting events to go ahead “signalled to the general public that the government couldn’t be that worried”, and he stated:
“So I think that the problem was not the gatherings themselves, which I don’t think there’s good evidence has had a major material effect directly, but the impression it gives of normality at a time that what you’re trying to signal is anything but normality.”
Professor Whitty also stated that debating the closure of schools “whilst allowing sporting events to continue and mass gatherings to remain open” was, in his words “logically incoherent to the general public, quite reasonably”.
Do you agree with Sir Chris Whitty’s views –
Dr Robert Orford: I do.
Lead 2B: – as expressed there?
Dr Robert Orford: Yes, I do.
Lead 2B: We can change topic, Dr Orford, talk about testing. Now, from 22 March 2020 you were the senior responsible officer for testing; is that right?
Dr Robert Orford: That’s correct, yeah.
Lead 2B: If we could, please, have on display INQ000309871.
Which is an email of 22 March, Quentin Sandifer from Public Health Wales emailing you and Tracey Cooper regarding testing.
Now, in this email Dr Sandifer expresses concern about Wales losing out in relation to testing kits. Dr Sandifer says:
“Above all else I am really worried that National politics could trump public safety and need in Wales and we end up losing out badly in Wales.”
What did you understand to be Dr Sandifer’s concern about national politics trumping public safety?
Dr Robert Orford: That’s a really good question for Dr Sandifer. My understanding that the whole of the world were looking for tests for Covid, including UK Government, and including Welsh Government, including Public Health Wales, and Public Health Wales were concerned that an agreement had been struck with a company that wasn’t honoured because of other power plays going on at UK level.
Lead 2B: Did you have concerns at this point in time, so this is 22 March, about whether Wales would be able to rely on UK-wide initiatives to scale up testing capacity in Wales?
Dr Robert Orford: So I was unaware at that time if there was or wasn’t a UK testing plan, and so on 23 March, the next day, or on the 22nd, I asked who was responsible for co-ordinating testing in Wales, it turned out to be me, I was given that privilege, and by the 23rd we’d assembled a group, including Public Health Wales, to draft a high-level testing plan to scale up testing, partly because of this problem.
Lead 2B: On 27 March you were asked questions about the testing strategy on behalf of Mr Gething.
The email that I’d like displayed is INQ000383998, thank you.
So on the second page we can see there:
“The Minister [Mr Gething] … has a number of questions he would like answered before the testing plan can be published.”
And the email refers to concerns regarding testing capacity and concerns about being reliant on UK initiatives. Now, your reply is the text that we can see in red in this email.
Middle of that page, the email specifically references being let down by Roche, and that is what you’ve just alluded to a moment ago, if I can perhaps give a summary of the situation and you can tell me whether I’ve got it right.
There was an announcement made by Mr Gething on 21 March that the Welsh Government would have access to 6,000 Covid tests a day by 1 April. That appears to have been based on an agreement that the Welsh Government believed it had or at least was negotiating with the Swiss pharmaceutical company Roche, however Roche ended up supplying tests to the UK Government for use in England, and then, after agreement, with the devolved administrations. Is that more or less an accurate summary?
Dr Robert Orford: I think that agreement would have been with Public Health Wales and Roche rather than the Welsh Government, was my understanding. And I don’t think that was a written agreement, I think it was a verbal agreement.
Lead 2B: We have a look, please, at page – yes, page 2, paragraph 4 of – let me just check.
If we can have actually, please, INQ000309905 displayed. This is an email from Tracey Cooper to you and others – yes, I’m grateful, thank you.
So page 2 and paragraph 4 of this email, it is said there, I’m reading from (a):
“It is clear that the situation is rather chaotic and the … [Document read] … will be met.”
Would it be fair to say that there was little trust that UK-wide testing initiatives could be relied upon at this stage?
Dr Robert Orford: I think there was a great deal of uncertainty at that stage.
Lady Hallett: I think it’s right to say for those that haven’t followed this that this incident involving Roche and the number of tests has been highly controversial as to whose memory is accurate.
Dr Robert Orford: Yeah, absolutely.
Lady Hallett: Is that fair?
Dr Robert Orford: But I think Tracey’s emails are fairly – you know, are accurate at the time, they were captured with the knowledge at the time.
Mr Poole: Was there a concern that you would be competing with the UK Government in the supply of testing materials?
Dr Robert Orford: Yes.
Lead 2B: Now, we know that a testing plan was published in Wales on 7 April 2020. The Inquiry understands that the Welsh Government published the document “Test, Trace, Protect” setting out its strategy in relation to health surveillance in the community on 13 May, so that strategy was published four months after the global emergency was evident. Why did it take four months for that testing strategy to be developed?
Dr Robert Orford: So the first test plan wasn’t published but it was finalised and agreed by the then Minister for Health and Social Services on 27 March, so four days later than we brought the group together, and the principal objectives – they’ve had six work packages, with the first one being to scale tests. That plan was then shared with devolved governments and UK Government.
Lead 2B: Dr Orford, change of topic. I’d like to ask you some questions about discharging patients from hospital to care homes next and also the related question of testing as well.
On 13 March 2020 the minister for health and social care made a public statement announcing a framework of actions aimed at allowing health and social care providers to make decisions to assist with the timely preparation for the expected number of confirmed cases, and we can see that on the screen there.
At point 4 of that announcement we can see it said:
“Expedite discharge of vulnerable patients from acute and community hospitals.”
Then at point 7:
“Suspending the current protocol which gives the right of a choice of home.”
Is it right to understand the purpose of these measures was to ensure timely discharges and basically try to eliminate delays related to care home choice so as to maximise the number of hospital beds that were available in the event of a surge in hospital demand?
Dr Robert Orford: That would make absolute sense. I’d no involvement in writing these policies, so those questions might be best addressed to those involved in the policy decisions here.
Lead 2B: Do you agree though that expediting the discharge of vulnerable patients from hospital into care homes presents a clear risk that obviously had to be managed?
Dr Robert Orford: Oh, I think there were, you know, significant risks around hospitals and care homes throughout the pandemic.
Lead 2B: If we could, please, have INQ000336353 on screen, which is an email exchange on 31 March between the Deputy CMO, Dr Jones, and various HSSG officials.
If we can, please, go to page 3 – we’re there already, thank you – Dr Jones replies, right at the top of the page:
“I would think … [Document read] … be positive the next.”
Did you or TAG or TAC advise on this?
Dr Robert Orford: No.
Lead 2B: On 9 April 2020 Public Health Wales issued guidance on the admission and care of care home residents. The advice was that negative tests were not required prior to transfer and admission into a residential setting. Again, did you or TAG or TAC advise on that?
Dr Robert Orford: No.
Lead 2B: On 17 April 2020 there was a meeting of the closed settings group which was a Public Health Wales group as I understand it, albeit, I think I’m right in saying, it had some overlap with TAG and TAC membership; is that right?
Dr Robert Orford: It’s possible that members of that group – I’m not sure who was on the group, so it’s difficult for me to answer but, you know, we’re a relatively small organisation, so there may have been some overlap.
Lead 2B: If we could, please, have INQ000336421, thank you.
This is an email sent following the meeting of that closed settings group on 17 April. Page 2 of the email chain, at “Action 3” reads:
“[Welsh Government] Policy officials verbally outlined a clear … [Document read] … communication. Lead WG policy officials.”
Did you agree with the change of policy regarding the testing of patients discharged from hospitals to care homes?
Dr Robert Orford: Again, I wasn’t involved in these policy discussions, I’m not sure I was included. What was the date, sorry?
Lead 2B: The date of this is 17 April.
Dr Robert Orford: No, I was no longer involved in testing at that point.
Lead 2B: Please can we have INQ000228309 displayed, please.
This is an email thread from 31 March and 1 April between you, Dr Thomas Connor, Chris Williams, Public Health Wales, and other members of TAC. We can go to page 6. We can see that the conversation begins with you explaining that the issue of nosocomial transmission has come up at SAGE and that it had come up in relation to Wales due to the Aneurin Bevan outbreak.
If we can, please, go up to page 3 of this email chain, there’s an email from Dr Connor. He writes, I think it’s the fourth paragraph, second line – second line in – thank you. So, second line:
“In this case we have a cluster of 50-70 … [Document read] … such testing has to be rapid to be useful.”
So Dr Connor’s there saying that weekly testing might have missed all of the transmission of a particular outbreak, isn’t he?
Dr Robert Orford: Yeah.
Lead 2B: Then if we can go right up to the top of the chain, page 1, you state, first paragraph:
“As Tom suggests a sequential approach to testing … [Document read] … if sounds like a sensible approach?”
I just want to take you on the same theme just to a document that you emailed two hours later – or, sorry, Chris Williams emailed you this document two hours later. It’s the CDC, Centers for Disease Control, prevention study.
I’m grateful, we’ve got it on the screen there.
That study looked at asymptomatic and presymptomatic Covid-19 infections in residents of a long-term care nursing facility.
We could have a look, please, at page 2 of that study, looking at the top left-hand box:
“What is already known? Once Covid is introduced in … [Document read] … contribute to SARS-Cov-2 transmission.”
Now, this is the report that Mr Hancock in his evidence to Module 2 described as a game-changer in terms of the scientific evidence underpinning testing policy advice in the UK.
This was emailed to you. Did you view this study in the same way as Mr Hancock, namely a game-changer as regards asymptomatic transmission and the need to introduce routine testing, especially in environments such as care homes?
Dr Robert Orford: So, you know, tend not to have game changing papers in science, it tends to be the accumulation of pieces of evidence to then form a consensus, and then you can say whether you’re confident in that consensus or not.
Just on the practicalities, if I can go back ever so slightly, I think probably around that time there were in the region of a thousand tests a day available in Wales within hospitals generally. There are 105,000 staff in the NHS in Wales. 36,000 of those are nurses and 9,000 of those are doctors and dentists, and 15,000 are allied health professionals and healthcare scientist, who I’m responsible for. There are 23 – sorry, there are 10,000 beds within the NHS. There are 80,000 social care workers and 23,000 residential beds. So that’s excluding other key workers. So there would be a huge demand for tests to test everyone.
So the conversation with Chris Williams and colleagues was more about how you can create a web that acted as a kind of surveillance system, where you didn’t have to seek – test everybody once a week, so you could pick up where outbreaks were and manage them effectively. So I think Chris’s sharing of this paper was more about how you establish that sentinel surveillance system within staff groups rather than asymptomatic or presymptomatic testing per se. But there were plenty of papers that came through NERVTAG around asymptomatic and presymptomatic people and testing.
Lead 2B: Now, on 16 April England introduced mandatory testing of all patients prior to discharge to a care home, and as we know that policy was not introduced in Wales until a couple of weeks later. I just want to show you if I can the ministerial advice that was submitted to Mr Gething on 30 April.
If we could have a look at page 2 of the ministerial advice, it’s the fifth paragraph and the second bullet point, right down at the bottom:
“We also intend to increase testing within care homes … [Document read] … capacity becomes available.”
Then page 4, please, paragraph 16, impact of asymptomatic care home residents:
“Whilst it is unclear what … [Document read] … half of residents with Covid-19.”
Were you aware that that study had been discussed in the Public Health England meeting on 20 April and, later, a NERVTAG meeting on 24 April?
Dr Robert Orford: Yeah, I think that was the “Easter six”, it was called the Easter six care home outbreak analysis that was brought from NERVTAG to SAGE a couple of days later.
Lead 2B: And the preliminary results were that 75% of residents were positive for Covid but only 25% were symptomatic, and 50% of staff were positive but only 29% of those were symptomatic. You were aware of those preliminary results?
Dr Robert Orford: Yeah, and again the conversation around whether somebody could be asymptomatic and transmit hadn’t quite been landed. I think probably WHO advice was still the same around symptomatic individuals and a case definition was still around people with the cardinal symptoms of Covid-19.
Lead 2B: We can – back to this ministerial advice, if I can, please, ask for page 5, paragraph 19 to be pulled up, thank you:
“The current position in care homes was to isolate … [Document read] … everyone was positive for Covid.”
Then the ministerial advice expresses concerns about the number of tests that would be required to test care home residents and staff on a routine basis, which is I think something you’ve also just alluded to.
Is it right, policy decisions on testing are obviously constrained by capability – capacity? Is it your view that had capacity been increased, there would have been a sound evidential basis for regular testing of asymptomatic care home staff and residents? In other words, would the policy have been adopted sooner if capacity was greater?
Dr Robert Orford: So hypothetically would we start at the position we ended at? I mean, logically, I would say yes. However, there was much more testing in the UK than there were in other countries. So, I mean, the logistics at the time, not just the scale of the need, was actually to bring testing to care homes themselves where we couldn’t reasonably expect care home residents to go to testing, as well as knowing who lived in care homes and who worked in care homes. There was quite a demand, a logistical demand and a digital demand, on colleagues to operationalise the policies that came thick and fast. So it was a real challenge for colleagues.
Lead 2B: Dr Orford, was the change in policy on care home testing driven by what was happening in England rather than the scientific advice provided in Wales in your view?
Dr Robert Orford: That’s a very good question and I think probably best aimed at colleagues who were leading on testing at this time, which, you know, again was a significant operational challenge with many people needing to work together at a national level to get things right.
And again, you know, comparing England and Wales is difficult because there’s greater capacity and capability in England as it’s 20 size – times bigger, but I honestly don’t know the details around any differences in that policy and the timings of the policies therein.
Lead 2B: We move into August. That saw the start of the Eat Out to Help Out scheme, and we know that’s a scheme implemented by the UK Government. Were you asked to advise on that initiative?
Dr Robert Orford: No.
Lead 2B: I want to ask you some questions next about firebreak. Before, I would just like to ask you a question about data, if I may.
On 18 September 2020, the ONS released data that demonstrated that 68% of deaths from Covid-19 between 2 March and 14 July 2020 were among disabled people. Following the release of those statistics, was any research carried out in Wales as to why that mortality figure was so high?
Dr Robert Orford: We wrote several papers on mortality statistics, working closely with colleagues in Knowledge and Analytical Services, as well as papers on health inequalities of the absolute and relative impact on different population groups.
Lead 2B: On 18 September TAC advised that more needed to be done to bring the R rate back down below 1. We can see the summary advice of 18 September on the screen. If we have a look at page 2, the fourth bullet point, please, it says:
“A package of non-pharmaceutical interventions (NPIs) on local and national scale may be needed to bring … [Document read] … length of time for which they are required.”
So TAC there advising action would be most effective if implemented early; correct?
Dr Robert Orford: Correct.
Lead 2B: Circuit-breaker or firebreak, so in other words, as we all know, a short period of lockdown, that was recommended by SAGE on 21 September. I don’t think you attended, but Fliss Bennee attend on behalf of TAC. We can see those minutes there.
If we could have a look at page 2.2, please:
“SAGE advice was that a package of interventions would need to be adopted to … [Document read] … to low levels.”
If we can have a look, please, at point 6 on that page:
“The more rapidly interventions are … [Document read] … geographical area.”
Presumably, as Fliss Bennee attend on the behalf of TAC, you were made aware of that SAGE advice?
Dr Robert Orford: Absolutely. I may well have been at SAGE, that meeting, but it’s not recorded.
Lead 2B: Four days later, so this is 25 September, the need for early intervention was reiterated by TAC. I don’t need to go to the advice, I’ll just read a summary:
“If the current measures do not bring R below 1 then further restrictions will be needed to control the epidemic in … [Document read] … the more effective they will be.”
Then on 2 October there was a rather more stark warning from TAC. We see the advice there, if we can have a look at page 2, please, fifth bullet point:
“Unless measures bring R below 1 … [Document read] … scenario planning levels.”
So, in other words, the NHS would become overwhelmed; correct?
Dr Robert Orford: Yeah.
Lead 2B: Are you aware at this stage of any planning undertaken for further restrictions to be implemented?
Dr Robert Orford: I mean, I can’t remember the interactions with the Covid policy colleagues at that time regarding – sorry, I can’t remember the conversations that were going on at that time.
Lead 2B: If we have a look at 9 October, please, this is another TAC summary advice we can see at INQ000066397 – thank you very much.
If we have a look at page 2, “Current situation in Wales”, in the middle of the page:
“For the first time in this … [Document read] … test positivity.
“We are continuing to monitor how the … [Document read] … planning scenarios.”
Notwithstanding the clear direction from SAGE that we saw in the minutes a bit earlier, the obviously deteriorating picture, why at this stage wasn’t TAC clearly recommending the need for a firebreak?
Dr Robert Orford: So can I go back to the last question, please? Is that okay?
Lead 2B: Of course.
Dr Robert Orford: At the time there were local interventions, so understandably there were challenges around national interventions and concerns and there was a great deal of interest around hyperlocal interventions and local interventions to reduce harm, reduce economic harm, and not to put areas that had lower incidence into protected measures at that time.
So, you know, I can’t remember which local authorities were in what state during that period, but there was a lot of policy activity around intervening and monitoring and measuring, but still the epidemic was growing in Wales.
Lead 2B: Reference to local interventions, we know that in sort of late September early October there were effectively local lockdowns within Wales within some of the councils there?
Dr Robert Orford: Yes.
Lead 2B: Is that what you’re referring to by local –
Dr Robert Orford: I am, yeah. And there was work done that was led by Fliss Bennee in Wales looking at the impact of those local interventions to see whether or not they were having the desired effect. So, you know, to be able to change policy, realistically you need to bring evidence to show whether or not things are working.
Lead 2B: The First Minister in his written evidence to this module has described those local interventions as – his words were a “failed experiment”; do you agree with that?
Dr Robert Orford: I’m not sure where the origin of the idea around local interventions came from, whether that was UK Government or Welsh Government, but certainly I felt it made things more complicated, that you had to have more legislation, more policies in place, across different local authorities. So I think in hindsight, you know, perhaps they weren’t the best idea.
Lead 2B: Whilst I appreciate there may have been different policy initiatives being pursued, so we have local lockdowns at this time going on, but looking at what we’ve looked at so the SAGE minutes, the TAC advice that’s getting more and more stark, culminating in this advice of 9 October, so, going back to my question, why wasn’t TAC recommending clearly at this stage the need for a firebreak lockdown or a short lockdown across the whole of Wales?
Dr Robert Orford: I think they had, through this period, you know, the preceding documents had said we need a national intervention and a SAGE document said the same thing and I think broadly throughout the pandemic Wales followed SAGE advice.
Lead 2B: Can we, please, have INQ000385719 displayed.
Which is an email sent to you by someone at Public Health Wales on 11 October. So this is shortly ahead of a scheduled meeting to discuss Welsh strategy and a potential firebreak. The email highlights key areas for discussion at this meeting.
Do you agree that there remained – just looking at this email that starts, “I have put some high level points that will help us focus the discussion” – there remained a lack of clarity in respect of what the strategy for Wales should be at this point in time and who was responsible for identifying that strategy?
Dr Robert Orford: Yeah, I think this email’s from Giri Shankar, who was a member – he’s director of health protection in Public Health Wales and, you know, a really excellent member of the Technical Advisory Group. Not being able to remember word for word the policies, but certainly lots of conversation around balancing harm, that every intervention had associated harms and benefits, so whether that was relieving pressure on the NHS but that would incur economic harm and other associated indirect harms. So I think it would have been very difficult for a minister to stand up and say “These are the absolute levels of harms that we’re willing to tolerate or that we’re working to”, so I think it was very difficult to be clear on what balanced harms look like.
Lead 2B: Can I ask you to have a look, please, at an email of 15 October that you sent to the First Minister, Mr Gething and Dr Atherton as well as some others.
Yes, thank you, that’s the email on the display.
You effectively provide a summary of the epidemiological modelling work that had been undertaken to analyse the effect of a firebreak, and in that second paragraph there we can see you say:
“There are some key conclusions that we would like to share … [Document read] … message is the need to find ways to sustainably lower R following any firebreak.”
So although your email comes with the caveat that this is a work in progress, is the reason that you’re sharing this with the First Minister and the minister for health and social care because the situation in your view called for immediate action?
Dr Robert Orford: Yeah.
Lead 2B: This is 15 October.
Dr Robert Orford: Absolutely.
Lead 2B: Now the Inquiry understands that the Firebreak Implementation Group was established on 14 October and the purpose of that group was to consider advice regarding a potential firebreak in Wales.
If we could have a look, please, at INQ000315913.
It’s an email from you to Reg Kilpatrick on 18 October. The subject is “Covid Fire Break [Implementation Group]”. You open by saying that:
“The other side of the firebreak needs a look a lot different to now re: testing and isolation.”
And then point 5 you say:
“Would very much welcome sight of a … [Document read] … been missing this.”
So do I take it from that that your view was that economic considerations had not been factored into decision-making regarding the firebreak up to this point in time?
Dr Robert Orford: So can I just go back on the phasing of the firebreak? Is that okay?
There was some advice around, and I think it came from SAGE, around the timings of firebreaks, that if you got them to coalesce with harm term or school holidays then you’d lessen the educational impact, and so there was some logic in phasing the Welsh firebreak around autumn half term. And that was something that we’d considered much earlier in the pandemic, around school holiday phasing, but I think the way in which the pandemic was progressing, in terms of its doubling time, where small numbers become very large numbers very swiftly, that phasing didn’t – obviously didn’t work as well as it could have.
The affordability of turning the economy off was a separate set of conversations that I was aware of, but being presented with the economic argument that those figures weren’t as easy to come by as perhaps projections around direct harms.
Lead 2B: From a public health perspective, did you consider that there was any other option than to impose a firebreak at this point in time?
Dr Robert Orford: No.
Lead 2B: There was advice produced, further advice from TAG produced on the firebreak measures on 18 October. I don’t want to go that to advice, other than to just note that TAG recommended a two to three-week hard firebreak to bring R below 1 in order to lessen the impact and slow the growth of the epidemic in Wales, and then a firebreak was announced on 19 October.
Given everything we’ve just looked at, the increasing infection rates, the anticipated impact on health services, do you think a firebreak should have been implemented earlier than it was?
Dr Robert Orford: I think with the benefit of hindsight, yeah, earlier would have been better. It would have got the prevalence lower, but, you know, it did what it intended to do and pushed the epidemic back.
Lead 2B: Do you think the firebreak was of sufficient duration?
Dr Robert Orford: I think that’s a question around – in the modelling there was some difference between two weeks and three weeks, there were marginal gains of having three weeks, and four weeks was better than three weeks, so that was from the modelling. But from the actuals, from the observed information post-firebreak, it probably worked as well as a three-week firebreak in that it pushed the pandemic back probably 38 days in Wales and then slowed the next period of growth for the next couple of weeks.
Lead 2B: In your – one of your witness statements, your TAG and TAC witness statement, you describe the period leading up to and after the firebreak and the subsequent lockdowns in England and Wales as a key moment where there was a significant difference between Wales and England. You then go on to say:
“England did not follow SAGE’s advice to intervene early and also did not support Wales to do so financially. Given the subsequent number of infections, hospitalisations and deaths in the autumn/winter of 2020/21 arising from the circulation of [different variants, including] Alpha variant the policies proved to accrue significant harm in Wales.”
Can you just explain how the different approach in England accrued significant harm in Wales?
Dr Robert Orford: Well, if money had been made available to extend the firebreak, I mean, that’s what I’ve been led to believe, then perhaps we could have had a three-week firebreak, and certainly from the advice that we were given it was better to be in lockstep across the UK with clearer public health messaging, that probably would have been better if everybody had followed the SAGE advice at that point, but I’ve not seen the economic argument from the Treasury, say, on not having a firebreak across the UK at that point.
Lead 2B: You say in your witness statement that the advice or your advice was not reflected in the ministerial advice that was prepared regarding regulations that would come into force after the firebreak period ended on 9 November.
If we can just have a look at that ministerial advice, please – thank you.
If we have a look at page 4, paragraph 17, the advice refers to keeping the virus at a manageable level, which it describes at or below Rt 1.2.
Do you consider or did you consider an Rt value of or at below 1.2 keeping the virus at a manageable level?
Dr Robert Orford: No, and I think Professor Gravenor gave a good explanation of what R of 1.2 meant, it still means you’re in exponential growth. I think our advice was to keep it at or below 1, which would have been difficult as well.
Lead 2B: I mean, why do you think the virus was not held at a sustainable level following the firebreak lockdown?
Dr Robert Orford: Because there were too many relaxations and there were more opportunities for mixing over the general population.
Lead 2B: TAG published a statement on 7 December on NPIs in the pre-Christmas period.
We’ve got that at INQ00035042.
If we can just turn to the bottom of page 2, please, it’s the penultimate bullet point on that page:
“Policy modelling suggests that introducing Tier 3 restrictions prior … [Document read] … patients, and deaths.”
Now, no further restrictions were imposed following this advice. Why do you think the advice of TAG was not acted upon at this time? So this is 7 – sorry, 2 December.
Dr Robert Orford: I can’t quite remember when the tiers were brought in, but certainly that advice came from SAGE advice around the analysis of the impact of tiers, which I – from memory, I think 40 out of 43 areas in Tier 3 showed a reduction in transmission and prevalence in those areas. So that was the advice.
But as to why Cabinet decided not to or policy colleagues didn’t put that as their policy recommendations, I don’t know. I can’t quite remember the phasing of post lockdown restrictions, but I remember there being discussions around alert levels and what would be the sufficient – what would be the right tier to go into.
Lead 2B: If we can have a look, please, at some TAG policy modelling advice that was published on 1 December 2020. It’s INQ000321023. If we can have a look at the bottom of page 1, the advice there states:
“The most efficient way to reduce harm from covid-19 and pressure on the NHS is to … [Document read] … restrictions as soon as practically possible (high confidence).”
Now, we know Wales entered level 4 restrictions on 19 December. Now, having regard to mounting concerns throughout November and December 2020, do you consider that there was avoidable delay in the Welsh Government’s decision-making over moving to alert level 4, effectively a lockdown?
Dr Robert Orford: Again, some of these questions are for ministers and policy colleagues, but the advice at the time, based on the modelling, was: go earlier. As it was throughout the pandemic. But again, very difficult decisions.
Lead 2B: I’d like to ask you some questions now about the winter of 2021 into May 2022, and you’ve dealt with the advice provided by TAG and TAC during that period in your witness statement, and obviously we will have regard to that so just a few questions, really, about the Omicron variant.
We know that was identified as a variant of concern on 27 November 2021. Eluned Morgan, in her written evidence to the Inquiry, has described the decision to reintroduce some restrictions in response to Omicron as an example of a decision that may have been taken differently had more information been available.
She has said in her statement that:
“At the time there were information gaps in relation to the efficacy of the vaccinations deployed through the vaccination programme … [Document read] … available earlier.”
Do you agree with that view? Were there gaps in relation to the efficacy of the vaccination programme at that time?
Dr Robert Orford: Yeah, I agree. I think whenever a new variant emerged, trying to characterise it in terms of impact on vaccination status or the case – case to hospitalisation ratio, the number of people that became infected that would then go on to be hospitalised, there was some degree of uncertainty. I believe, from memory, there was a high scenario of a 2.5 case hospitalisation ratio and a low scenario of 1%, that these were just in the bounds of, you know, reasonable scenarios. So there was some uncertainty. And then new evidence came available, probably from UKHSA, at the time, to say that the lower estimate was more likely. So whilst we would have a significant number of cases, which we did, which would obviously impact Long Covid too, the stress on the NHS would be lower. So then there was a change in advice when the lower estimates became the more likely estimates.
Mr Poole: Dr Orford, thank you. They’re all the questions I’ve got for you, but there are some questions from core participants.
Lady Hallett: Ms Heaven.
Questions From Ms Heaven
Ms Heaven: Thank you, my Lady.
Just to say that, no criticism of Mr Poole, but he’s asked my question, so I’ve agreed with him to ask the same way but in a slightly different way, so you’re not surprised looking at the spreadsheet.
Good afternoon, Dr Orford, I represent the Covid-19 Bereaved Families for Justice Cymru.
Can I just go back to the firebreak, then, please. We obviously understand that that specific request came from you to Michael Gravenor and his team on 11 October to model a firebreak.
Now, if I – before I ask you the specific question, if I can just fill you in on some of the evidence my Lady’s heard.
So Michael Gravenor told the Inquiry that if there’d been a longer firebreak, this would have resulted in very low prevalence of the virus into December. He said, in effect, it would have pushed it deep into December. He said a four-week firebreak would give a seven to nine-week suppression time period, which of course would have meant that Wales would have faced a period of high winter transmission, plus the emergence of the Alpha variant, from a starting point of much lower community prevalence than it in fact had to face in December 2020. And of course that was bringing it much closer to when the vaccine arrived in December.
I asked Michael Gravenor if the Welsh Government had – knew of his modelling results, and this is what he said. So he said the report for the five to seven weeks and then the three to five weeks was in the report that went in for the two to three-week firebreak, but it did not include his results for the four-week firebreak.
But when I asked him about the Welsh Government would have known about the effects of a four-week firebreak, so that’s the seven to nine-week suppression time, he essentially said they had all the evidence, it was easy to extrapolate to a four-week firebreak, it was a matter of common sense.
Of course CTI has asked you a bit about this a moment ago and you just indicated that you knew that four weeks was better than three weeks. So can I just check with you, then, was it your understanding, and indeed did you know, as a result of Michael Gravenor’s modelling, that four weeks would push the virus deep into December, seven to nine weeks? Was that your understanding?
Dr Robert Orford: That was my understanding, and I’m pretty certain that was shared with policy colleagues around that time, and then there were separate requests that came for further modelling.
Ms Heaven: So that was going to be my next point, just to be very clear on what the Welsh Government knew. You have been critical in your witness statement about Welsh ministers departing from TAG/TAC advice in the easing of the firebreak, and we’ve just seen the email that you sent to ministers on the 15th where you said the take home is act sooner for longer, three weeks rather than two. TAG then recommends two to three weeks.
So, just so that my Lady’s absolutely clear on your evidence, were Cabinet ministers, and in particular the First Minister for Wales, Mark Drakeford, and Vaughan Gething, told in no uncertain terms that an autumn firebreak for four weeks would reduce community transmission deep into December, seven to nine weeks, and closer, of course, to the time when the vaccine would arrive? Were they told that in no uncertain terms?
Dr Robert Orford: I’d have to go back and check on the modelling papers and the internal TAC summaries that were shared around that time. However, separate conversations that considered not just the science, the affordability for example, would have been had within government. So perhaps those questions are best addressed to policy colleagues who are responsible for developing those policies and advice to ministers.
Ms Heaven: Just to push you a little bit though because we’ve seen your email to ministers though where it says two to three weeks. Did you specifically say to ministers, “But four weeks would push it deep into December”; do you recall?
Dr Robert Orford: I’m pretty certain we had advice going through at that time – so I’ve not got it in front of me – with different policy modelling outputs. So I’d have to go back and check what the papers were at that time, but there was more than one policy model made at that point.
Ms Heaven: Okay, thank you, my Lady, that’s my question.
Lady Hallett: Thank you, Ms Heaven.
Yes, Ms Foubister. You haven’t been negotiating with Mr Poole about your question?
Ms Foubister: Thank you, my Lady. No, I haven’t, just the one from me.
Questions From Ms Foubister
Ms Foubister: Good afternoon, Dr Orford, I represent John’s Campaign and Care Rights UK.
My question is about evidence and decision-making. So I would like to refer you to your individual witness statement, which is the one dated 19 December 2023, that’s INQ000390618.
Hopefully we can turn to paragraph 190.
190 is at the bottom of the page and it goes on to the next page a bit unfortunately, so hopefully we can see all of it.
While we’re getting there I’ll tell you what I’m going to be directing your attention to, and that’s that at paragraph 190 you refer to a paper called the Executive Committee in April 2020.
If we can just zoom in to paragraph 190. Thank you very much.
So you refer to the paper which is focused on “How can we use evidence better, to inform effective policies”, and then if we can go down the page a bit, it’s over onto the second bit of the page, to (IV), where you note that one of the recommendations of that paper was that the Welsh Government needs to embed a better culture of evidence use within policy development.
So my question to you, Dr Orford, is for your views on what specific changes have been or should be made to ensure that the views and evidence from stakeholders and experts are taken into account by core decision-makers?
Dr Robert Orford: Thank you. So this work has come from the – so this was April 2022 – from the Strategic Evidence Board, so there’s a recognition by the executive group of Welsh Government the need for more evidence to be embedded within policymaking. And I think that observation – you know, the chief science adviser, Sir Patrick Vallance and Angela McLean currently, are doing work to ensure there’s greater scientific literacy within the civil service, where there’s a relatively small percentage of civil servants that have a degree in science, broadly they have degrees in humanities. Some of the work that we’ve done in the Health and Social Services Group is to develop a division called SEA, Science Evidence Advice. Within SEA there are important functions like SPI functions, which we call science policy interfaces, so people who are able to support policy colleagues, ask evidence-informed questions to support them in developing and evaluating their policies. So there’s work like that going on throughout Welsh Government about how we improve our analytical capacity and capability as an organisation. So that work is ongoing.
Ms Foubister: Thank you very much.
Thank you, my Lady.
The Witness: Thank you.
Lady Hallett: Thank you very much.
Thank you very much, Dr Orford, that completes the questions we have. I’m not sure whether we’re going to have to ask you to come back. I’m sorry, it’s the nature of the module –
The Witness: No problem.
Lady Hallett: – system that we’ve introduced, because we have so many issues to investigate. But thank you for your help so far anyway.
The Witness: Thank you, your Ladyship.
(The witness withdrew)
Lady Hallett: Mr Poole.
Mr Poole: My Lady, I’m in your hands whether we, before the next witness, we take our 15-minute break now or we hear 15 minutes of evidence.
Lady Hallett: It’s now 3 o’clock, so what’s better for you?
Mr Poole: I think probably, to allow arrangements to be made, if we take it now.
Lady Hallett: Very well, back at 3 o’clock.
(2.45 pm)
(A short break)
(3.00 pm)
Lady Hallett: Is anybody else feeling the chill? Could we sort out the temperature, please.
Mr Poole: Could I please call Dame Shan Morgan.