2. Dr Joanne McClean
DR JOANNE McCLEAN (affirmed).
Questions From Lead Counsel to the Inquiry for Module 2C
Ms Dobbin: May I ask you to give your full name to
the Inquiry.
Dr Joanne McClean: My name is Joanne McClean.
Lead 2C: And you ought to have a witness statement in front of
you.
Dr Joanne McClean: I do.
Lead 2C: I think you signed it on 20 February of this year.
Dr Joanne McClean: That’s correct.
Lead 2C: Are you content that the contents of that statement are
true to the best of your knowledge?
Dr Joanne McClean: I am, yes.
Lead 2C: Thank you, Dr McClean. I think it’s right that you’re
the current director of the Public Health Agency in
Northern Ireland?
Dr Joanne McClean: That’s correct, yes, I have been the director of public
health in the Public Health Agency since September 2022.
Prior to that, I had been – immediately prior to that
I was working as an associate Deputy Chief Medical
Officer in the Department of Health, and that was from
June 2021 until my appointment with the PHA in
August 2022 –
Lead 2C: Just – I’ll stop you there. I’ll just take you through, if I may –
Dr Joanne McClean: Okay.
Lead 2C: – your career. I think that you are a medical doctor by qualification?
Dr Joanne McClean: That’s right.
Lead 2C: And I think, in fact, you’re still a clinician, you still remain practising; is that also correct?
Dr Joanne McClean: I am, yes, I graduated from Queen’s University in 1999 and I’ve remained a practising doctor since then and I’m on the GMC register as a consultant in public health medicine.
Lead 2C: I think you had a very early specialisation in public health; is that correct?
Dr Joanne McClean: I did, yes. After I completed several years of clinical training in junior doctor roles, I commenced the Northern Ireland public health medicine training scheme, in 2004 I think, and I then completed that and took up my first post as a consultant in 2011.
Lead 2C: I think it’s right that that was in the Public Health Agency?
Dr Joanne McClean: That’s correct, that was in the Public Health Agency.
Lead 2C: And I think it’s also right that in fact your specialisation is in children’s public health and the commissioning of children’s services; is that right?
Dr Joanne McClean: So public health training is generic, so you are trained right across the curriculum, including health protection, service, public health, health improvement. Prior to taking up my current post, my consultant post had had a particular focus on children’s public health, children’s services and the health and wellbeing of children.
Lead 2C: In fact during the pandemic I think, at the beginning, you remained in your role –
Dr Joanne McClean: I did.
Lead 2C: – in terms of commissioning children’s services, but at a point in time, and we’ll come to this, you in fact moved role, as it were, so that you could assist in the provision of advice in respect of care homes; is that right?
Dr Joanne McClean: That’s correct, yes. I – in the initial stages of the pandemic I helped and assisted with contact tracing, in those very early days, and then my focus was on my substantive post, and in that role I prepared mainly children’s services for the oncoming wave of infection.
I then went on and assisted in Public Health Agency responding to care homes. That was from around about April, early or mid-April 2020. I continued in that role and I also worked in the provision of highly specialised services, a role that I supported my colleagues in the Health and Social Care Board with.
And then sort of towards the end of the summer, in early September, then I was redeployed again, and at that point I led the Public Health Agency’s response to Covid infections in schools.
Lead 2C: All right.
Now –
Lady Hallett: Dr McClean, you’re like me, you speak very quickly. It’s very difficult to change one’s pattern of speech, I know all too well, but if you could slow down.
Dr Joanne McClean: I’ll try.
Lady Hallett: Sorry to interrupt, Ms Dobbin.
Ms Dobbin: No, no, I was about to say.
Thank you, Dr McClean.
Now I know that you’re obviously going to give evidence on behalf of the Public Health Agency, and I will ask a little bit about your experience in terms of providing advice in respect of care homes as well, but I’ll start, if I may, with the role of the Public Health Agency.
I think it’s right that the Public Health Agency in Northern Ireland – and if you need a place or if you want to look, it’s in your statement at paragraph 10, but it has three core functions, doesn’t it?
Dr Joanne McClean: So the Public Health Agency was established in 2009, and it was really established because of the importance of public health, and the main aim was to improve public health and with a particular focus on reducing health inequalities.
Within that there are three main areas of work that we have. They are – sorry.
They are health protection, which is responding to cases and clusters and outbreaks of infectious diseases, also pandemic preparedness and responding to threats to health that are posed by the environment, maybe water pollution, things like that.
We also have a responsibility for health improvement, and we lead and commission a whole range of programmes from encouraging people to stop smoking, to exercise more, but also really supporting communities who are disadvantaged to sort of take actions to improve their health, and that’s called our health improvement team.
And then we also have a team who focus on the provision of public health advice into the commissioning and delivery of health services, and within that team we are also responsible for the commissioning and quality assurance of population screening programmes.
And the agency also then has a lead function for research and development across the health and social care system, not just in public health.
Lead 2C: All right. So, of these three functions, it’s obviously the health protection function that came to the fore, during the pandemic, but obviously with some overlap in terms of the Public Health Agency’s role in respect of inequalities as well; correct?
Dr Joanne McClean: Yes.
Lead 2C: All right. I’ll ask you a bit more about inequalities shortly, I just want to stay, if I may, on the role of the Public Health Agency. It’s also right that it’s an arm’s length body of the Department of Health?
Dr Joanne McClean: That’s correct.
Lead 2C: And that the Chief Medical Officer’s group is the departmental sponsor for the Public Health Agency as well; is that right?
Dr Joanne McClean: That was right at the time of the pandemic. So from the establishment of the agency in 2009 right up until fairly recently – I think possibly, I can’t quite remember, but I think it may have been April or maybe January of this year – the sponsor branch has moved from the Chief Medical Officer’s office to another deputy permanent secretary within the Department of Health, and that’s quite a new arrangement, and that was just part of a wider reorganisation of functions and responsibilities within the Department of Health.
Lead 2C: I’m going to ask you to just try to slow down again.
Just coming back to the time – in fact I’m going to ask you a little bit more about the background to the Public Health Agency, but could you just help us in terms of the sponsorship role and what that was intended to provide to the Public Health Agency?
Dr Joanne McClean: So my understanding is that the sponsorship role is to provide direction, to make sure that the agency performs its statutory duties as they are supposed to, and also that the agency is delivering to a sufficient quality, delivering and delivering in line with the Department of Health and therefore the minister’s wishes.
The form that sponsorship takes is that there are regular meetings between the chair of the Public Health Agency and the chief executive with either the permanent secretary, the sponsor, within the department, where they go through a range of issues where the agency may escalate things that they believe are a risk or an issue, and the department may seek assurances on some part of our delivery.
Lead 2C: Dr McClean, I think you’re aware that, from around 2017, issues were being raised with the Public Health Agency by its sponsor about its capacity and capability to carry out its core functions; is that correct?
Dr Joanne McClean: I think the documentation that I have seen relating to that time mainly comes from the documents that are reviewed in preparation for giving evidence today, and most of that was around staffing within the health protection division, particularly staffing and the availability of consultant staff, specialist consultant staff to lead areas of work within that.
At the time of establishment of the agency there had been – I’m not sure of the exact number, but there had been maybe nine, ten consultants in health whose special interest was health protection, and that number had gone down as low as three, I think, not long before the Public Health Agency was established.
Lead 2C: All right.
Dr Joanne McClean: Or – or before the pandemic –
Lead 2C: The pandemic happened. So I’m going to start in 2017.
Dr Joanne McClean: Mm-hm.
Lead 2C: So I think the issues that were being raised in 2017 was, because of the depletion in staffing and experience, there was concern that the PHA couldn’t carry out its core functions; yes?
Dr Joanne McClean: That’s right.
Lead 2C: And again the following year, in 2018, the issue was raised again as to whether or not the PHA was going to be able to carry out its core functions; is that also correct?
Dr Joanne McClean: From the evidence I have seen in my bundle, yes, that is correct.
Lead 2C: And again I think that it’s right that between 2018 and 2020 the situation deteriorated still further in terms of that loss of critical staff and experience within the PHA?
Dr Joanne McClean: That’s correct. The numbers had gone down significantly for a range of reasons, mainly people had retired, come to an age whenever they retired. It is quite a specialist role so the staff who we need to fill those posts are highly specialised staff, they are consultants, like I am, in public health, but for them they would have chosen to maintain an interest in health protection. So at the point you achieve a certificate of completion of training in public health, that is across all the public health domains, but once you go into consultant practice, a lot of people – and certainly practice within the agency up until that point, was that you went and worked primarily in one of the domains, so health protection is what we’re talking about now. Other people chose to go, like I did, and work in service development and screening.
Lead 2C: I think the net result of that was that at the advent of the pandemic, I think there were very, very few people indeed within the PHA who had any sort of experience of dealing with a widespread outbreak of any infectious disease; is that right?
Dr Joanne McClean: I think there were a small number of very experienced consultants who had many years’ experience and would have had experience of dealing with significant outbreaks, including for example the swine flu outbreak in 2009, the pandemic in 2009, but their numbers were small, and just before the pandemic the agency had had some success in recruiting a number of locum consultants into the agency, so that was a good thing, to stabilise and improve staff as we went – phased into the pandemic.
Lead 2C: I think it’s right we’ve seen some email correspondence that there were possibly two people in the PHA who had had some role or experience of dealing with swine flu in 2009; does that sound about right?
Dr Joanne McClean: So I think that there were many more people within the agency who had experience of dealing with swine flu in 2009. I think the correspondence to – which you are referring to is from an official in the Department of Health who has made a comment that only two people in a very senior role within the agency were around in 2009, and that they, in 2009, had not been in very senior roles.
There were a significant number of staff who had been in the agency in 2009, including, for example, me, but at a much, much more junior level.
Lead 2C: Yes.
Dr Joanne McClean: I think what that correspondence goes on to talk about, I suppose, change at a senior level in the Public Health Agency, so I know we’re talking about consultants and specialist staffing, but there was concern around change at the senior level as well.
Lead 2C: But just coming to someone like you, for example, and whatever experience you had as a junior doctor in 2009, you would have been ten years qualified, I mean, would that – would your involvement at that stage in any way have equipped you for dealing with something much more significant than swine flu?
Dr Joanne McClean: I think there was learning for everyone, no matter what level of the agency that we were at at the time. I think that following that there were a number of exercises, because there were very few people, actually if any, across Northern Ireland who would have had to deal with something on the scale of Covid, because no one had.
Lead 2C: Of course.
Dr Joanne McClean: The sort of things that would have happened was we would have had significant outbreaks that would have tested us, and there’s learning in that in how you scale up staffing and things to respond to things, but nothing on the scale of Covid. And I think that’s true for a lot of agencies.
I think one of the ways that we prepared, in common with other agencies as well, would have been through exercising. So, at national level, local level, running pandemic exercises, testing plans. But that, as we learned, is very different to doing it for real.
Lead 2C: Yes, and I think we’ll probably find – we’ll look at what eventuated in terms of the PHA’s role, but, I mean, would it be right to say at this stage – and please say if you disagree – that any of those planning exercises proved wholly inadequate to the mammoth task that faced the PHA from January onwards?
Dr Joanne McClean: I think it’s fair to say that the PHA was not prepared in a number of ways, and I wouldn’t try to argue that we were. I think we had a number of strengths, but I don’t think we would have been prepared. But I think that was true probably of every public health organisation and body across the world, because it was such an unprecedented event.
Lead 2C: All right. Well, we’ll come and we’ll examine some of those issues in a little bit more detail.
I just want to go back to the role that PHA would ordinarily expect to play whenever’s an outbreak of an infectious disease. I think first of all its role in respect of infectious disease is actually a statutory one; is that correct?
Dr Joanne McClean: That’s correct, yes.
Lead 2C: So, by statute, part of its role is to respond, is that correct, to an outbreak of an infectious disease?
Dr Joanne McClean: That’s right. So most of our statutory responsibility and powers in relation to responding to infectious diseases comes from the 1967 Public Health Act, the Northern Ireland Public Health Act, so that talks about particular powers and it talks about the director of public health having particular powers with respect to a range of notifiable diseases, and it talks about powers to issue things like a notice to exclude someone from school, work, things like that. So that’s around responding to cases of notifiable diseases.
We also then, building on that, have responsibilities to try to stop the spread of infectious diseases within the community, and that, if you get more than one case, then that would be moving into an outbreak response, and we have a range of things that we do.
We discharge those responsibilities not by ourselves, so even to diagnose infectious diseases we rely on our colleagues in primary care to notify us, and the notifiable disease part of this is that if a medical practitioner – and I think the 1967 Act is written about medical practitioners.
Lead 2C: Yes.
Dr Joanne McClean: But if the medical practitioner suspects that an individual is suffering from one of a whole range of notifiable diseases, by law they have to inform – and the Act says – the director of public health. So then we receive those notifications and take appropriate action in relation to them.
Lead 2C: So within the PHA there’s essentially a team of people –
Dr Joanne McClean: Yeah.
Lead 2C: – and that’s their function within the PHA? And can you help the Inquiry in terms of the number of people who were in that team at the outbreak of the pandemic in January 2020?
Dr Joanne McClean: Yeah, so I’ll have to look at my notes for the exact number so I don’t mislead you, but in …
So within the public health directorate, in January 2020 we were divided up into four divisions. So there was health protection, which is that team that we’ll come to, there was service development and screening, health improvement and the R&D team. So the team who would respond to infectious diseases in the way I’ve described were drawn from the health protection team.
So I’m looking at my statement here, at paragraph 19 I think it is, there are some tables, and it says that in – 31 December 2019 there were just short of 40 whole-time equivalent staff within that health protection team.
Lead 2C: All right, so, I mean, a small team of people?
Dr Joanne McClean: Yes.
Lead 2C: Are they all clinicians, are they all doctors and nurses, or do you have other types of staff within that fourth group?
Dr Joanne McClean: No, within that there are a small number of consultants, most of whom are medical. We also have some registrars, who are in training in public health. We also have a team of nurses who have specialist expertise and experience in both health protection, public health, and infection control, and then we also have surveillance scientists, and we have project managers within the team and admin support as well. So that 40 includes a whole range of functions and any of the individual teams are quite small.
Lead 2C: All right.
Now I’m going to ask you a bit about the PHA’s role in silver within the orthodox emergency response. So first of all that’s within the Department of Health, isn’t it, they have a gold, silver, bronze response to an emergency?
Dr Joanne McClean: So the emergency response plan, sort of the health and social care system in Northern Ireland sort of organise themselves into to respond to issues is set up, and it’s – I think it’s standard emergency planning practice, I’m not an expert emergency planner, but this is a standard way to respond, that you have a gold command type level and that sits in the Department of Health, and then you have a regional layer which was silver, and that is made up of the Public Health Agency and our – where we take the lead in silver it would be mainly in response to something that was of public health nature, so infectious diseases like the pandemic.
Lead 2C: I’m going to ask you to stop, because I can take you to a document that sets all of that out. I suppose the question is really this: when those structures were stood up – that’s the term used – I think that was on 23 January 2020; correct?
Dr Joanne McClean: That’s correct.
Lead 2C: And the PHA formed part of the silver response alongside one of – it’s the HSBC(sic), isn’t it, the health service board?
Dr Joanne McClean: Health and Social Care Board, HSCB. And the other organisation that sits at silver level with us is the business support organisation.
Lead 2C: Can I just check, then, at that silver level, is it intended then that the PHA are part of the operational response or still part of the strategic response to the pandemic?
Dr Joanne McClean: So at that stage we are providing a strategic response, but I think we had two roles here. So at that time silver was set up and it was, my understanding is, a public health-led silver at that time, and that was quite early in the pandemic, in January, whenever we didn’t have any cases, even in the UK, but there was a lot of concern, there was a lot of information coming in from a lot of sources, and obviously then we need to be getting ourselves ready to provide an operational response within the Public Health Agency to deal with the cases, but then the other role of silver at that stage would have been to help our health service, our providers, our trusts be ready to respond, because they will have had lots of questions around how should they organise their services, what was the guidance if someone turned up who had been in one of the affected areas, what should they do with them, lots of other questions about how they operationally would implement the guidance. So the guidance was coming in from all sorts of areas and silver at that stage was very much focused on trying to collate, I suppose, curate the guidance and make sure it got out to the right people properly and that questions that came up were answered. At that stage that was the focus of silver.
Lead 2C: I’ll take you to the document and ask if it accurately reflects what the PHA’s role was supposed to be. If I could ask for INQ000325424. It’s the first page of this document. I don’t know if you’re familiar with it, Dr McClean. It ought to have been with your –
Dr Joanne McClean: I have seen it.
Lead 2C: You have seen it?
Dr Joanne McClean: I have seen it, yeah.
Lead 2C: Good. We can see that that’s dated 2 March. I think there may have been terms of reference before this, but this is slightly later on in the day. So it may give us a slightly more considered idea of what the PHA’s role was intended to be.
I think if we look at section 8 of this document, it sets out – I won’t read through all of them, but I just wanted to draw attention to some of them.
So the PHA was going to jointly run an operation centre; correct? I’ll ask you about it, I just want to make sure to ask you whether or not these were things that the PHA was intended to do as part of its role at silver.
Dr Joanne McClean: So these terms of reference are from a period whenever PHA were no longer in the lead for running the emergency operation centre. In the early days PHA was running the emergency operation centre because it was primarily about health information that was coming in. By this stage the focus was very much on preparing the service. So it would have been the Health and Social Care Board who were taking the lead in running the emergency operation centre at that time. We would have helped and assisted, but my understanding is that by March it was the Health and Social Care Board who were in charge of running the EOC and we were there in a supportive way. It was the opposite way earlier on.
Lead 2C: That’s what I was going to ask you, because that’s what I thought from your statement, but that helps to clarify that.
There was also going to be the provision of a joint situation report to the Department of Health as well?
Dr Joanne McClean: I believe that is the case, and I believe that that did happen and I’ve seen examples of that as part of my preparation.
Lead 2C: All right. Then the third point was that the PHA was going to maintain surveillance systems of Covid-19 cases and outbreak investigation, and again at that point in time was that the intended position, that that’s what the PHA would do?
Dr Joanne McClean: Yes, and that would be part of our core function in Public Health Agency. A really important part –
Lead 2C: Yes.
Dr Joanne McClean: – of responding to infectious diseases is knowing how many infections there are in the community and any changes in that infection, and the sort of technical term for that is surveillance, so that was a core bit of our function.
Lead 2C: Yes, so of all of the things that the PHA was going to do, at this point in the pandemic, would that have been the most important or the most significant?
Dr Joanne McClean: It would have been one of a number of surveillance – of important things.
Lead 2C: Then the next one was to adapt guidance on the management of cases and their contacts. Again, can I check, was that foreseen as being a PHA role?
Dr Joanne McClean: Because I wasn’t here at the time I feel I’m not able to comment in a lot of detail, but what I can say is that it would be my expectation that, as information on the infection came in, we would have had a role in disseminating that. We are not a provider of clinical care, so any provision of clinical guidance would have to be in consultation with clinical teams who look after patients. It wouldn’t be something that I would expect us to do on our own.
Lead 2C: Well, that’s what I wanted to check, because I think your witness statement suggests that in fact the PHA did not produce that kind of guidance.
Dr Joanne McClean: So I think there were different types of – lots of different types of guidance were produced during the pandemic, and I think at this stage there were, for us in public health, at that stage, I think they were in two main categories. The first would have been around guidance on how to manage cases from a sort of infection control point of view, and the first part of that is, first of all, how do you know you have a case? So that case definition, when is the case infectious? We didn’t really know at that time, but when is the case infectious? What should you do in response if you have a suspected case?
That to me is the public health management guidance, and that is something that we absolutely would be responsible for taking a lead on.
We don’t – we didn’t develop that by ourselves because this was now an emergency of an international significance, it was a huge, huge event, and in situations like this we look to sort of our colleagues in other parts of the UK who have a very large public health response team, so they’re really specialised –
Lead 2C: Sorry, I didn’t mean to cut across you, but is that Public Health England?
Dr Joanne McClean: Yes, that would have been Public Health England, so in terms of, we didn’t create guidance of a public health nature from scratch, because it – we couldn’t have done it, we wouldn’t have had the expertise, and we wouldn’t have added anything by doing it, because if you remember, and I think it does reference it in my statement as well, a lot of the information was emerging from other parts of the world, it was emerging from all sorts of places, we wouldn’t have that in-house capability, and because a lot of the information was coming from international partners, WHO and to an extent ECDC and other bodies like that, that sort of liaison at a UK level is with a single national contact point which is in Public Health England or was in Public Health England at that time.
Lead 2C: Can I ask you to pause there. Is it right then that Public Health England would have essentially taken all of that information, distilled it –
Dr Joanne McClean: Yes.
Lead 2C: – as it saw fit, and produced guidance, and you would then have essentially adopted that guidance?
Dr Joanne McClean: Yes.
Lead 2C: Other than doing that –
Dr Joanne McClean: Yes, we might have had to tailor it a little bit.
Lead 2C: Of course.
Dr Joanne McClean: To take account of our situation here, but by and large that was guidance that was rightly produced by people who are very specialist in that area. I wasn’t in this role at the time, but what does happen and has happened in other incidents that have happened since I have taken up post is that the people who do this in Public Health England do liaise with their colleagues in the devolved administrations, and even the English regions at times, so there was that communication. Guidance changed really, really rapidly, more quickly than anything I’ve seen before or since.
Lead 2C: Yes.
Dr Joanne McClean: So I hope I’m not diverting here, but this bit, the management of clinical cases and the clinical management of the illness might be something we would be involved in, in the Public Health Agency, but we would very much depend on our clinical colleagues to advise us, we might help corral that and get it into a consensus document, but at that stage both the public health guidance and the clinical guidance was very much new, it was not something that PHA would have developed from scratch and we would have done it with the appropriate partners, either Public Health England for the public health guidance, and then if there was a need for clinical guidance locally for anything to come out from the silver level, that would have to be done with clinical colleagues.
Lead 2C: All right. I’m going to try and just finish off this document, if I may. The other part of your role that was foreseen at this time was that you would provide timely and accurate information for public and health professionals on Covid-19 and the clinical effects of the infection.
Now, what we’ll come to and what we’ll look at is the provision by the PHA to data effectively at this point in time.
Is that what that’s talking about at this stage?
Dr Joanne McClean: It’s hard for me to know entirely because I wasn’t involved in formulating this, but I’m reading it and I’m thinking it probably is around providing information on the number of cases we have and how it’s spreading within the community. The clinical effects of the infection, that is something that would not be a primary function normally. Now, we do work closely with colleagues and can help disseminate that, but I’m not really sure what was meant by that at that time.
Lead 2C: All right, and I think provide advice on when to cease measures to slow transmission of the virus if they had been commenced?
Dr Joanne McClean: Yes.
Lead 2C: Again would that actually have been a role of the PHA at that time?
Dr Joanne McClean: (Pause). Possibly, but I’m very conscious that this was an incident that was even by this stage being managed very much on a UK-wide basis, so for something of this significance I’m not sure that … now I have the benefit of four years of hindsight, looking at this, but actually the point at which, you know, you have to change your strategy … possibly.
Ms Dobbin: All right. Maybe we can come back to that after lunch, if that’s a good point to break.
Lady Hallett: Yes, of course.
I am sorry, I hoped that you were warned that we would have to break in the middle of your evidence, Dr McClean, I’m sorry about that.
The Witness: No, it’s okay.
Lady Hallett: I shall return at 1.45.
(12.46 pm)
(The short adjournment)
(1.45 pm)
Lady Hallett: Ms Dobbin.
Ms Dobbin: Dr McClean, before the short adjournment we were looking at the document which set out what the PHA’s intended role was at the outset of the pandemic, and I just wanted to finish off quickly, if I may, on that.
I think we were looking before the break at the point at which it said “Provide timely and accurate information”, so we’d dealt with that, and we’d dealt with ceasing measures, and I think you’d said it was possible that the PHA didn’t have that role. And I think, as things transpired, it didn’t have that role, did it, as time moved on?
Dr Joanne McClean: I think that for something that wasn’t on the scale of Covid-19, so something that was a much more limited outbreak, something a bit more usual, if you had a wide – if you had an outbreak across Northern Ireland of something else, and quite often in an outbreak your overall objective will change through the course of the outbreak, I think if it was something more on what we would call a more normal scale, that may have been appropriate, but given what subsequently happened over the coming week to ten days, the scale of Covid I think made this quite a different scenario, even from perhaps what was expected whenever the terms of reference were drafted, which I think, from having looked at it just before lunch, was around the start of March.
Lead 2C: Yes, absolutely, and I’m going to come on and just ask you generally about these terms of reference, but just to finish off on this, so at that time, and again just focusing on early March, it was foreseen that the PHA would lead on the public health response; correct?
Dr Joanne McClean: Yes.
Lead 2C: And that it would lead the case management cell?
Dr Joanne McClean: Yes.
Lead 2C: And that it would undertake community surveillance and that it would provide – I’ll cut through this – mortality surveillance as well?
Dr Joanne McClean: Yes.
Lead 2C: And that it would also have a communications programme?
Dr Joanne McClean: Yes.
Lead 2C: And I think it’s right that very quickly it must have been realised that the PHA just wasn’t constituted to carry out a number of these –
Dr Joanne McClean: Yeah.
Lead 2C: – functions.
We’ll look at some of the functions that it did exercise during the early period, but I think a number of these things effectively fell away and became the responsibility of the Department of Health; correct?
Dr Joanne McClean: I think that’s correct, and at a strategic level even beyond the Department of Health, really at a UK-wide level for some of them.
Lead 2C: Right.
So I’m just going to look then at some of the things the PHA was doing at the outset. I think what you said a few moments ago was that the core role, as it were, of the PHA is to provide the surveillance about the transmission of a disease when there is an outbreak?
Dr Joanne McClean: So that is one of our core roles, is to provide infectious disease surveillance, that’s one of the things that we were set up to do.
Lead 2C: And I think it’s right that from the outset of the pandemic, in fact the PHA faced real challenges in its ability to access data so that it could provide that information onwards to the Department of Health about the transmission of the disease; is that correct?
Dr Joanne McClean: I think this was – first of all, it was a brand new infection. So if it had been something like – and I’ll use the example of flu. Had it been a typical flu, something that we have systems and mechanisms in place with our laboratories to count cases, with our GP colleagues for them to provide us with information about the number of people they are seeing with flu-like symptoms, they are pipelines and approaches that are in place. Covid was a brand new infection and so therefore there weren’t any ready-built things even within our lab to run the test, that was something that had to be developed, and the pipelines and the channels were new, it was – because it was a new disease.
Lead 2C: If I can just focus for a moment, because that’s really what I really want to get to and try to understand.
At the outset of the pandemic, so I mean January, February, March time, in terms of the sources of information available to the PHA, I think, am I right in understanding, that you had access to Apollo?
Dr Joanne McClean: Yes.
Lead 2C: So that is a mechanism that works the reporting back of some information about flu data; is that correct?
Dr Joanne McClean: That’s correct. So Apollo was a system that is used I think across the UK, and PHA started to use it in 2009 around the time of the swine flu outbreak, and Apollo gave – it has subsequently been replaced, or is in the process of being replaced, but it gave information around flu consultations in general practice.
And that’s for flu. That’s a really useful barometer of how many people in the community are experiencing flu-like symptoms. So in the winter time, you know, just because it happens that more people flu-like symptoms, so it’s important that we’re able to understand how that is progressing in the community. We don’t have widespread testing for flu in the community so we do depend on looking at how many symptomatic people are seeking healthcare and that primarily, for something like flu, is with primary care.
Lead 2C: All right. So presumably, then, that’s of limited use?
Dr Joanne McClean: Yes.
Lead 2C: Because it’s only telling you who’s going to primary care –
Dr Joanne McClean: Yes.
Lead 2C: – reporting symptoms of flu, so it in no way gives you an accurate picture of who might be reporting with a different virus?
Dr Joanne McClean: That’s right. So it looks for flu-like symptoms, so whenever they go to see their GP – GPs have very good electronic systems. When you go to see your GP they will put stuff up on the computer. And if they are coming in with symptoms that are typical of flu or another respiratory illness, that’s what it will pick up. But it is limited to primary care.
And I think some other parts of the UK have – and that’s called syndromic surveillance. So syndromic surveillance is people who have the syndrome, so people have symptoms; it’s not based on laboratory data, it’s based on symptoms. It’s called syndromic surveillance.
At the start of the pandemic we had that in primary care through Apollo but we didn’t have it in secondary care set up within EDs. I think that is mentioned in the statement. Some syndromic surveillance had been set up at a point in time in the Public Health Agency but that wasn’t in place, certainly, at the start of the pandemic, and I don’t fully understand the reasons why that stopped.
Lead 2C: All right.
Let me just take it in stages, because I think as well, according to your statement, that you didn’t have any method of identifying hospitalisations with Covid-19 and you weren’t able to trace hospital-acquired Covid-19 until May of that year as well?
Dr Joanne McClean: Can I just check the paragraph number?
Lead 2C: So it’s paragraph 282.
Dr Joanne McClean: Sorry?
Lead 2C: Paragraph 282.
(Pause)
Lead 2C: Just so that I can orientate you in your statement, this is your entire section on data.
(Pause)
Dr Joanne McClean: Okay.
Lead 2C: So that would appear to be right, wouldn’t it, from your statement?
Dr Joanne McClean: Yes. I think earlier on in the pandemic, one of the – there were a number of things that were built to allow the surveillance team to count Covid-19-positive tests. So the first thing I think that they established was a reporting link with the laboratories, so the laboratories would tell them how many positive Covid tests there were, and in the very early days that number was very low because testing was limited.
Lead 2C: Yes.
Dr Joanne McClean: So the first thing that would have been built would have been a feed from the lab. It’s then a step beyond that to be able to link the feed that comes from the lab with electronic information from the patient administration system, which is the hospital system. That involves an electronic linkage. It wasn’t something that was well developed within the agency at that time.
Whenever the Public Health Agency was set up, the infectious disease surveillance sat within the agency, but the analysis and use of the hospital data, which includes admissions data, discharge data, that actually sat within the Health and Social Care Board. So their staff, in the Health and Social Care Board, were much better at using those electronic systems. And they’re not simple. You know, it does require experience to negotiate it, or to understand it. So they were in two different sort of – two different worlds, if you like, and I think it did take some time for the laboratory information to be able to sort of link and cut across so you could see how many people in hospital had had a positive test.
Lead 2C: The point that I’m trying to get to, it’s really just to understand in those early months how it was that Covid was actually being measured in Northern Ireland, because I think it’s right that, in fact, testing was extremely limited right up until March, and that a very small number of people had been tested even by – I think we get to around 7 or 8 March and the numbers of people that had been tested was small.
How was it up until it that point – or what was the most reliable barometer of what Covid transmission rates were like in Northern Ireland?
Dr Joanne McClean: So I don’t think we did have a particularly reliable barometer at that stage. We were – we were building links with the laboratories, so we were getting reasonably accurate information from the laboratories, but as you say, that was really only the tip of the iceberg, because only a very small number of people were eligible for the very limited number of tests at that stage.
In terms of deaths, for example, because that is mentioned on the – in the terms of reference document and it’s also mentioned in the evidence, to the best of my knowledge, prior to Covid-19 deaths were not reported to the Public Health Agency for us to publish data on.
Lead 2C: Yes.
Dr Joanne McClean: We would have been aware of deaths, say, for example, from meningococcal disease or another disease, and we would have that information for ourselves, but to the best of my knowledge we never received information routinely on deaths and we didn’t publish information on deaths, that was the role of the Northern Ireland research and statistical agency, NISRA.
Lead 2C: Yes. There’s a few things bound up in that, if I can just tease them out a bit. Obviously the – silver had been stood up from the January.
Dr Joanne McClean: Mm-hm.
Lead 2C: Can the Inquiry assume, then, that between the January and until we’re getting into the middle of March, that the work done to build up testing capacity hadn’t taken place within the PHA?
Dr Joanne McClean: So testing capacity was ramped up primarily – Public Health Agency does not run testing. Testing is delivered, first of all, by – it was the virology lab in Queen’s University – or not in Queen’s University, in the Royal Victoria Hospital.
Lead 2C: Yes.
Dr Joanne McClean: The regional virology lab very quickly actually got a test. So remember, this was a virus that hadn’t existed six months previously, so the virology lab in the Royal was actually quite fast, in UK-wide terms, in getting a test that was in place.
A lot of work then did go on and one of my colleagues in the Public Health Agency chaired the expert advisory group on testing on behalf of the department, and – of health, and that group sat within the Department of Health but relied on specialist skills from the PHA, and the remit of that group was to advise on testing and to be involved in the ramp-up of testing.
Testing went from not being able to do any tests at all, sort of at the start of the year, to, by the end of the year, doing hundreds of thousands of tests.
Lead 2C: Yes.
Dr Joanne McClean: And that was way beyond the capacity of the health service, and you’ll remember that we had the national testing initiative come in, so there were lots of different partners involved. There was the Royal, there was also the universities –
Lead 2C: Sorry, I’m just going to stop you, because I am really just focusing on the outset, and really trying to understand what work had been done within the PHA, and I understand the PHA wasn’t in fact administering the testing by itself, but, just trying to understand the work that had been done in those first few months on the understanding that there would have to be a test and trace capacity that didn’t exist, what your understanding is of the work that went on in that first bit of time within the PHA?
Dr Joanne McClean: So because I wasn’t physically there I’m really not over the detail of that and I don’t want to misrepresent anyone by saying – by maybe not describing something that happened. I hadn’t seen the note of every single silver meeting to be able to describe any discussions that took up – took place about ramp-up.
I think ramp-up was very quick. Perhaps in hindsight, and learning for a future pandemic, I would say that it is much more obvious to us now that testing capacity and the rapid expansion of that at the start needs to be a priority, and that is something that I would expect will be built into plans. But that is learning.
Lead 2C: All right.
Dr Joanne McClean: But perhaps, if it’s acceptable, if I undertake to look at the notes and provide the Inquiry with any additional record that I can find of specific actions that were taken by silver at that time.
Lead 2C: I anticipate there will be other witnesses who can help us with that –
Dr Joanne McClean: Okay.
Lead 2C: – and I’ll take you through to some other documents shortly that might help, but I just wanted to go to this first so that we could understand some of the practical difficulties there were at the outset.
This is INQ000445513. If we could go to page 2 of that.
And again, I think you’ve been provided with this, Dr McClean. This is an email that was sent by one of the advisers to Minister Swann, and it’s one of a number of emails at around this time that were sent to the PHA setting out the difficulties, and I think the minister had taken a personal interest in trying to ensure that he was providing accurate data whenever he was making announcements or speaking about the pandemic.
But we can see that at the second paragraph what the adviser was saying was that:
“There are serious discrepancies in what the Minister is being told and what is actually happening. I … continue to have serious concerns about the quality of information being published in the daily PHA surveillance report.”
Then there’s a reference in the next paragraph – I think the Hugo is Professor Hugo van Woerden; is that correct?
Dr Joanne McClean: Correct.
Lead 2C: “Hugo/Brid - the Minister & I both asked for clarity yesterday, and with all respect we didn’t get it. I was even told yesterday that it’s not the time to be getting into the detail. It is.”
Then he sets out some of the other issues that had been raised.
Can you help the Inquiry with that? I think it is right that there were real difficulties at that point in time with the PHA’s provision of information to the Department of Health and to the minister in particular.
Dr Joanne McClean: So because I recognised that this is going to be an issue that was going to be of particular interest, I have taken the opportunity to talk to some people who were involved, because I was not involved at this time, so my understanding is that a lot of the difference and the perception of discrepancies in the numbers was around the difference between the total testing capacity, the absolute maximum number of tests that the laboratories could run versus the number of tests they actually ran.
So, having looked at documents that were provided by the Inquiry around this issue and having talked to colleagues who were directly involved, what seems to have happened is that around about or just before this date, which was Sunday 28 March, but just before then I think an announcement or – it had been put into the public domain that we – our testing, our total testing capacity in Northern Ireland was now 600 tests per day. Which is a huge increase from what we’ve talked about earlier. Then I think there was frustration and disappointment expressed whenever reports from the Public Health Agency were coming that, well, we did maybe 380, 400 tests, and that number was fluctuating from day to day.
I think that the issue has arisen because there are two different things at play here. There is the total number of tests that the laboratory can physically do and then there’s the total number of tests that the laboratory receives, and that’s really the demand, the number of people who are coming forward to be tested.
It seemed counterintuitive at the time because there was such a clamour for testing, such a demand for testing, that information was being put out that there were now 600 tests a day now available but only 300 and whatever it was people came forward.
And I think there were a number of reasons for that. Testing at that stage was limited in who could come forward. Healthcare workers had now been prioritised, and that was to make sure that they weren’t bringing the infection into work and to make sure that they could safely return to work with symptoms. So they had been prioritised, and I think there was a frustration that we still had healthcare workers off work but not all the tests were being used. And I think at that stage the number of – the number of testing centres was limited so I think there were maybe two at this stage, one in the SSE and one maybe in Derry. So the number of people who came forward were that number. And people might not have come forward for a whole range of reasons, but the number of people who come forward, that is beyond the control or remit of the Public Health Agency. All we can do, really, is make sure that our colleagues in trusts and healthcare providers know that they are symptomatic staff, that they are eligible for testing and they should come forward. And I think it was the difference between those two numbers –
Lead 2C: There was a missing – there is –
Dr Joanne McClean: That is – so because I wasn’t there, I can’t be absolutely certain, but having spoken to people from PHA who were there and having looked at the various emails and documents, that seems to be the issue, that there was a frustration that there was a public announcement made that there were 600 tests available now but a much smaller number were actually being performed.
Lead 2C: Because I was going to ask if we could go to a document that’s related to this, I think it’s page 1 of that document, sorry. Yes. Because we have the minister in fact stepping in now to say that the PHA in their reporting needs fixed and fixed now, “This is now a millstone around our necks, can we pull the daily surveillance report into the department”.
So plainly the issue is around the minister being concerned about the accuracy of the information that he’s providing, and did that in fact happen? Did the surveillance report then go in, was that taken into the Department of Health?
Dr Joanne McClean: So I can’t comment for the minister or what his frustrations were at that time, so I may be incorrect, but what I have seen in the documents was I think it was the mismatch between the tests available and the tests actually being done.
Lead 2C: Yes.
Dr Joanne McClean: PHA accurately reported the tests being done. The fact that they did not, were not the same as the 600 tests available seems to have been the issue. The surveillance, I know that some reporting did go into the department. I’m not entirely sure of what exactly went into the department, and what remained with the PHA. I don’t really understand the exact breakdown of it, but that did happen at a later stage, but …
Lead 2C: All right. I’m going to go to the PHA response to this, so it’s at INQ000389810, and if we could go to page 3, please, to begin with. It’s just to help orientate you in this, so I think we can see here that the director, and just to be clear, Professor van Woerden was the then director of the Public Health Agency, wanted to have a meeting about it. If we could then go to page 2, please, and this is from Mr Pengelly, who’s the permanent secretary to the Department of Health.
One can see there the frustration apparent on his part, and his annoyance that no meeting was needed, it was just clarity.
So again it would seem that at this point, and it’s 28 March, this was obviously an issue of some seriousness; yes.
Dr Joanne McClean: Yes, it obviously has been escalated to a very senior level. Because I wasn’t there, I really want – I don’t get the nuance, I wouldn’t want to misrepresent anything. I would make a comment, though, that this was an extremely difficult time for everyone, at all levels of society, and I think that people were working really round the clock, and I notice in some of these emails that they were sent on a Sunday, quite often late on a Sunday, and I think it is – it’s inevitable sometimes that frustration will spill into communication, and I can’t comment on whether or not a meeting was required. My experience in general is that if there was a misunderstanding and email correspondence goes forward and back, that can sometimes make things worse and sometimes a discussion to understand the positions is helpful. But I wasn’t there, so I don’t know.
Lead 2C: I think you will have been able to see from the correspondence –
Dr Joanne McClean: Oh yeah.
Lead 2C: – that we have sent that these problems endured, they didn’t go away. Perhaps if we could look at another document, this is INQ000389819, if we could go to page 4 again just to help you orientate yourself in it.
So I think we can see that in relation to this, the issue is around the numbers of people who had died, and that being part of the PHA’s role to report those by this stage as well, and I think if we go to page 4 of this – sorry, it is page 1 of that, I do apologise. We can see that there’s a lengthy explanation from Professor van Woerden about the deaths and how they were being counted. It would appear from this that there’s some resistance on his part to the basis upon which the PHA was being asked to provide information to the Department of Health about the number of people who were dying each day. Is that right?
Dr Joanne McClean: So this email is dated 6 May.
Lead 2C: Yes.
Dr Joanne McClean: I think some of the issues and differences around deaths pre-date that, and I think it’s maybe helpful to go back a bit earlier in the pandemic to sort of explain the story of how I think this unfolded.
I said a while ago that, to the best of my knowledge, and I’ve talked to my colleagues who have a special interest in surveillance, PHA has never had a role in counting deaths, receiving information about deaths and providing public information. That’s a statutory duty that sits with NISRA and the Registrar General. So there’s a law that you must report a death within five days in Northern Ireland.
Lead 2C: Yes.
Dr Joanne McClean: And the causes of that then are set out, and there are lots of rules around what you put on the death certificate, and that is looked after by NISRA, and that’s a really important accurate record of deaths.
Because there was an absolute recognition that people will want to know, including the department, including the minister, but including ourselves, for trying to understand how the pandemic is progressing, how many people are being admitted to hospital, how many people are dying, the surveillance team and the Public Health Agency established for the first time ever a system whereby clinical staff, so doctors in the main, consultants in hospitals, could report patients who died in hospital who had had a positive Covid test within the previous 28 days. The positive Covid test within the previous 28 days is a definition that had been agreed with other public health organisations as being the best definition we could use. That used a system called SharePoint, which is a very basic, I think it’s a Microsoft programme, and it allows you, it’s like a portal, so it allows you to put information in, maybe in a hospital, and then that would come into the PHA.
So the arrangement was, and I think the chief executive wrote to trusts’ chief executives and asked them to implement this in their trusts, the arrangements was that clinicians would report all deaths that had occurred in patients under their care by a certain time each day and that would allow the PHA to produce a count.
Now, there were a number of challenges with that. As I say, this was the first time anything like this had been set up before. It depended on very busy clinicians, busy clinicians who were looking after very sick patients, it required them to go and complete an administrative task, so there’s a little bit of a weakness there, that you could get under-reporting for very understandable reasons.
You could also get that the clinicians maybe didn’t get a chance over the course of a couple of days and might report several deaths maybe on one day, but they may have reported on different days. So it was – it was as good a system as could have been put in at the time, but it was certainly not a perfect system and it was certainly not at the accuracy that we would expect when deaths are being published in the way they are being published from NISRA.
I think there was some loss in confidence around the information that was being provided when it started to be used in the public domain and being used as a count of deaths because there was that risk of under-ascertainment of deaths.
There was also a risk that we obviously weren’t getting most community deaths, although sometimes I’m led to believe that maybe a GP would have phoned in and said “I’ve had a patient who’s died in the community from Covid”, that might have been added in to the numbers, so they just weren’t accurate numbers that we could really stand over in the same way that NISRA has accurate numbers. And I think there was some anxiety around that, and sometimes perhaps the department would hear – would say, “Well, the Public Health Agency said three people died in the Northern Trust on this day, but I know, because my neighbour died” – and there was just a bit of a shakiness of confidence.
But having looked at that, I would say this is because the information system that was put in place was the best that it could have been considering the circumstances, but it was never going to give totally accurate information, that rightly and properly rests with NISRA. So it was almost, like – it was information but it wasn’t complete information. It was useful information in that it gave you a bit of a trend. You would certainly expect day to day that you would see a reasonable trend, but it wasn’t perfect.
So I understand there had been some loss of confidence because of the issues, and again I think it was perhaps misunderstandings and perhaps not understanding the complexity and just what was involved.
This then, this email, which happens – which is sent in May, and I did take the opportunity to speak to Professor van Woerden about it, what he meant, this is – I think relates to a different issue to the death counting –
Lead 2C: Can I just stop you, sorry, you’ve spoken at length, and I am really just focusing on the language that’s used –
Dr Joanne McClean: Okay.
Lead 2C: I want to focus on the language that’s being used in this email.
Dr Joanne McClean: Okay.
Lead 2C: Because what he sets out in terms is, and it’s the third bullet point down, isn’t it:
“The data that is being reported to the public is completely misleading.”
So he is not saying it’s imperfect, he is saying it’s completely misleading, and I want to understand your evidence as to whether or not what he was saying in May, is that accurate, is that correct, was the data that was being reported completely misleading because, as you’ve suggested, it might have been an underestimate?
Dr Joanne McClean: So I think, I’m not sure, I would need to check this, but I think by May I think he is actually talking about information that is now being published as well by NISRA as well.
Lead 2C: Yes.
Dr Joanne McClean: I think whenever he said it’s misleading whenever I spoke to him I said what did you mean I think that what he’s referring to is the debate that we heard many times during the pandemic is: is death with a positive Covid test within 28 days the most accurate way to reflect the number of people who have died because of Covid? So an analogy that was used that used to be used sometimes in the media you would hear “Well, you could die of – you know, you could fall and hit your head and die from a head injury, just because you happened to have Covid a week previously you would be counted in the Covid death numbers”.
Now, there was a lot of public discussion around that, around what was death from Covid versus death with Covid.
Lead 2C: Yes.
Dr Joanne McClean: And I think what happened then was NISRA then moved and did publish quite detailed guidance on the attributable causes of death, so within the death certificate you’ve got various things and it talks about what the underlying cause is which starts to try to unpick it.
I can’t be absolutely sure what Professor van Woerden meant at that stage, but from having talked to him and looked at the chronology of the various things that have happened, I think that may be the issue. But, as I say, I’m not entirely sure.
Lead 2C: Should we take it from this that from that period until May there were still serious issues or serious concerns on the part of the PHA as to the accuracy of the data that was being reported?
Dr Joanne McClean: This is the opinion of Professor van Woerden, so I’m just careful about interpreting it.
Lead 2C: Yes.
Dr Joanne McClean: I think … my feeling about this was that he was worried that things were being presented as absolute certainty that this was a Covid death when other things may have been in there as well, is my understanding, and it was that thing sort of, dying because of Covid versus maybe having a coincidental positive test within 28 days, that is my understanding having tried to piece together the various bits of evidence and having spoken to him.
Lead 2C: I’m going to move on to ask you, I think you know that there was a rapid review of the PHA’s epidemiological function, if I could ask for that to be brought up, please, it’s INQ000001196.
Lady Hallett: To repeat the word “rapid”, I am afraid you are going to get into terrible trouble with the stenographers, Dr McClean, can you try and slow down.
Ms Dobbin: If we could go to page 20, please, and it’s paragraph 9.4. I’m sure you’ve seen this, but this epidemiological review, and this was done at quite an early stage, forgive me, I’ve forgotten the date, but I will come to that, it was done at quite an early stage but we can see at paragraph 9.4 it expressly refers to the fact that there were difficulties and tensions around the reporting of the daily death figures.
“It seems clear from a recent feedback session, from this rapid review to the PHA board, for their individuals who attend PHA board meetings who still cannot grasp why it was so important to the Minister and the Department to have exact and reliable figures about the number of daily deaths. This was and is a matter of public confidence and a measure of the competence of the system to respond to the pandemic.”
So the criticism that appears to be being made in that review was the ability of the PHA to provide the accurate and up-to-date information. Do you agree?
Dr Joanne McClean: So … so the review, in my understanding, was undertaken by an individual who was a retired civil servant, so he will have fully understood the minister’s and the department’s need for accurate and up-to-date information, and indeed the public’s need, and I understand that. I can’t comment on his view that he makes about individuals who attend PHA board meetings. I wasn’t there, I will not comment – I can’t comment on that.
I think the report is titled “A rapid review of the epidemiological function of the PHA”, and what I’ve been trying to explain is that, prior to Covid, PHA has never had and even now still does not have the primary responsibility in reporting death numbers. That lies with NISRA, and it lies with NISRA for the reasons I’ve tried to explain, that it is a complicated system.
I think my colleagues in the PHA and surveillance, I think they did an excellent job working with the trusts to put in place a system where trusts could report deaths, the only way that we had at that stage was for people to report them. Other layers that were subsequently put in included linking death, the fact of death to information on the patient administration system. Even that method is not 100% accurate, the definitive source for the reporting of death numbers is still NISRA, but that – there’s an obvious lag there because I think you have up to five days to register a death, I think the median is about three, and then there is a process of checking, and I know that subsequently – that during this period I have seen in the evidence that the Department of Health had asked NISRA to report on a more frequent basis – to report deaths on a more frequent basis. They are asking PHA for it daily. I think they wanted NISRA, because they recognised that NISRA are the accurate source of death information, to report it more frequently, maybe twice weekly, and NISRA then wrote back and explained why that wasn’t possible for them.
So I think the challenges – while it might seem like a simple thing to do, the challenges of accurately reporting deaths are not insignificant.
Lead 2C: All right. That report was in July 2020.
Dr Joanne McClean: Okay.
Lead 2C: So that we have that for the record and I think what it suggests, and we can see this if we look, for example, at paragraph 9.5, that again reflects the concern that – about the ability of the agency to understand the department’s requirement for information, including the required frequency.
I won’t read out all of this, but it goes on at paragraph 9.6 again to consider those difficulties, and then goes on at paragraph 9.7 to set out a number of challenges which the PHA faced in being able to provide the sort of information that was being required. Correct? And it went back to the issues that I asked you about at the very outset: in other words, was the PHA adequately staffed in order to be able to provide that sort of service to the Department of Health; yes?
Dr Joanne McClean: It does, and I think we’ve talked about staffing issues, we’ve talked about staffing issues at consultant level, but public health is a multidisciplinary effort, in fact it’s a multi-agency effort, the PHA can do really nothing on our own, we need to work with lots of partners right across society, but in terms of staff numbers, we did have a very small surveillance team as well, and surveillance is a skilled task, so there are surveillance scientists who we employ who are really good and skilled at understanding information coming in from laboratories, understanding what a case is, what a case isn’t, lots of caveats of data. So I think there definitely was a shortage in the number of people who were employed by the PHA with those sort of skills, that has been addressed to some degree.
I think another area that required development and that is being developed now is our ability around automation and our ability to use digital data and things, so we have – over the course of the pandemic PHA has really developed capability and capacity around digital analysis.
Lead 2C: I’m going to stop you, because you’re rushing ahead to issues that I’m going to come to. I’m going to go through some of the tasks or functions that the PHA was asked to exercise in order to understand whether it was capable of doing them.
One of the other tasks at this early stage as part of the stand-up of the silver arrangements that the PHA was asked to do was to partake in surge planning as well. I think again PHA was asked to do that in conjunction with the board as well; correct?
Dr Joanne McClean: Yes, the Health and Social Care Board, yes.
Lead 2C: Yes, and again the evidence seems to suggest that there were problems I think on the part of both bodies to be able to provide that in a timely way as well; is that correct?
Dr Joanne McClean: I think it was a challenge. I think – I mean, as we keep saying, this was an unprecedented event that happened, and yes, I think it was a challenge to actually be able to, at speed and scale, provide a surge plan that would meet the needs of the population of Northern Ireland.
And one of the things that I think we forget four years on is really the lack of knowledge that we had. Guidance, information wasn’t just changing day to day, it was changing hour by hour, so really it was very difficult to know what it was that we were planning for. I remember people were not sure about the duration of the pandemic, would there be – I think initially there was a general feeling that there would be one wave and it would be a bit like flu, you would have one big wave and then sort of a series of smaller waves fizzling out. This played out in a very different way, but it was challenge – the surge planning, I think, was challenging as well for a lot of reasons, including the ones I’ve talked about.
Lead 2C: We’ve got some witnesses who can deal in a bit more detail with surge planning, but I think it’s also right that the PHA didn’t have any modelling capacity either?
Dr Joanne McClean: No.
Lead 2C: At that time you had no modelling assistance?
Dr Joanne McClean: The PHA’s – did not have any modelling capacity and, as I said earlier, our development in more digital analysis, data science, was behind what we would have ideally liked. We have done a lot of work to improve that, and I think – at the outset we talked about the change or the number of health protection consultants we had, but the PHA had also been without a permanent chief executive from 2016. I’m the fifth director of public health in – I think since the pandemic started. So that instability in leadership and uncertainty around what the future for the Health and Social Care Board would be, I suspect that that probably did not help sort of future planning, strategic planning, horizon scanning.
Lead 2C: Yes. Forgive me, I’m going to move on to the next –
Dr Joanne McClean: Okay.
Lead 2C: – part of the role, which was obviously surveillance.
Now, we know testing is an important part of surveillance, and I think it’s common ground that there was just very limited testing capability up until about the middle of March. Is that –
Dr Joanne McClean: So it ramped up, I can’t remember the exact times, but it did ramp up very, very quickly.
Lead 2C: I’ve certainly picked out from one of the documents that was in your bundle – and I won’t take you to it – in addition to that the number of cases that were actually being confirmed was quite low as well; is that correct? And certainly one of the figures that’s mentioned is that by 7 or 8 March there had been eight confirmed cases in Northern Ireland; is that correct?
Dr Joanne McClean: It sounds – I can’t remember exactly but it sounds about right, yeah.
Lead 2C: But that’s about right. So just then looking at the tracing capability – because that was held within the PHA; yes?
Dr Joanne McClean: Yes.
Lead 2C: But I think as you set out in your statement, that was also extremely limited as well; is that right?
Dr Joanne McClean: Yes. In the early days of the pandemic, we had a very small number of cases and the cases at the very early days, as tends to be the case with things like this, were imported cases, because they were coming in from elsewhere.
Lead 2C: Yes.
Dr Joanne McClean: So we had a small number of cases. And the strategy at that time right across the UK was to identify the cases, which in the main were coming in, they were imported cases because the outbreaks were in other countries, and was to identify those cases, isolate them, isolate their contacts, to try to slow down and prevent further spread.
That’s quite an intensive job, whatever you’re doing it for a prolonged period of time. So what happened in PHA, which is in line with our plans, is that other people, so health protection, the health protection part of the directorate that we’ve talked about, were initially in charge, and then they started to bring people in from other divisions, redeploy people in.
Lead 2C: I’m just going to stop you there, because obviously we know when we get to 12 March, tracing stopped in Northern Ireland. I think what’s less clear is whether or not the Public Health Agency had at that point gone beyond its capacities in terms of being able to carry on tracing, or whether you were still at a point where you could have carried on doing that at that time?
Dr Joanne McClean: So I was involved in tracing at that stage because I had been redeployed over to help with it. I think that it was a challenge because it was very intensive and it required us to work very long hours, seven days a week, and bring lots of people in because of the labour intensiveness of each one. I think that we were – we had got into a rhythm. I wasn’t working at director level at that stage so I don’t know what the corporate position was but certainly on the ground, involved in it, we technically probably could have kept going for a bit longer beyond 12 March. I think there’s a separate discussion around the utility of that. You know, would it have been worthwhile? I think in theory we could have kept going. It wouldn’t have been without its impacts on the staff, on the staff wellbeing, it was hard work.
Lead 2C: Right. But is it right that still at that stage there wasn’t actually a clear picture as to what the prevalence was in Northern Ireland?
Dr Joanne McClean: So at that stage people who were being tested were people who had returned from other countries or people who had been contacts of cases. I think, and I can’t remember at what point it was in March, maybe about the 8th, we started to see cases that were locally acquired, so they had – and hadn’t had contact with a case we’d known from outside. So at that point we had some level of community transmission in Northern Ireland, so at that point we certainly had gone beyond the point that we were going to contain it to only imported cases, I think that is true.
Could we have continued contact tracing for a few more days? Arguably, yes, we probably could have. Would that have stopped the pandemic in Northern Ireland? No, it wouldn’t, because we already had community transmission.
Lead 2C: How many people were involved in tracing at around that point in time?
Dr Joanne McClean: So I would need to refer to the rotas and things we had –
Lead 2C: Can you give us a rough idea?
Dr Joanne McClean: On any – so I’m – from memory here, we were running a seven-day service, we were running it from about 9 to 8 in the evening, and at any particular time there might have been, this is a total guess, maybe 20 or 30 people in a room, so – but many more people contributing to rotas. But that is something that, from our records, I may be able to give a better idea. We were mainly relying on redeployed staff from other parts of the PHA.
Lead 2C: I want to move forward, as it were, because obviously efforts were then made to ramp up test and tracing, and I think you know that there’s an issue about the information that the PHA provided about the capacity to expand the number of tracers who would be available.
If I could ask to be brought up, please, INQ000353669. I think we need to go to page 7 of this, please. No, that’s fine.
We can see that this is an email again from Professor van Woerden, and he’s writing, isn’t he, to the Chief Scientific Adviser – this is on 20 April – to say that over 500 contact tracers who had been identified and were being trained – and I think that that’s in reply to an email from the Chief Scientific Adviser. We might just need to go up a bit, if we can, please. Yes, it’s the email that was sent at 9.18.
Yes, so it’s in response to the Chief Scientific Adviser saying that contact tracing and testing was likely to be a “key component” of the strategy going forward; yes?
Can you help, the evidence of the CMO and the CSA is that that information was what they understood the position to be, that there were 500 people who were being trained. Was that in fact the position?
Dr Joanne McClean: So, again, this is an area that I have had to look into and speak to people around, because I wasn’t there. I have spoken to people and tried to understand where the 500 figure came from in Dr van Woerden’s email. I think it may have related to – at that point in time, there had been a suggestion that 500 environmental health officers, or people who weren’t working in environmental health, officers who weren’t really doing environmental health things, because restaurants and things were shut, could be loaned into the PHA to help with contact tracing; that possibly seems to be where the number 500 has come from. Those staff did not come across to the PHA and, to the best of my knowledge, at this point in time, in April 2020, that number of people, 500 people, were not being trained, it was a much smaller number.
Over the course of the pandemic, how contact tracing was approached and delivered changed. I’ve liaised with colleagues who were involved in the operation –
Lead 2C: I’m going to stop you, and of course it’s understood this is not your email to answer for, but I think what you’re saying is it was not the position that 500 people were being trained, and that the email is misleading in suggesting that?
Dr Joanne McClean: At that point of time, to the best of my knowledge, 500 people were not being trained.
Lead 2C: I want to just stay on this, if I may, and ask if another email could be brought up, please. This is INQ000353671.
I think we need to go to the next page to orientate ourselves. We can see again it’s from Professor van Woerden, and we can just see that he’s setting out – we’re obviously a bit later in time, it’s gotten to the autumn, and Professor van Woerden is setting out that Professor Young had indicated that the PHA would need to be able to manage 500 cases a day and 5,000 – I think that’s probably contacts a day.
Dr Joanne McClean: Yes.
Lead 2C: And that this would require 300 to 600 staff.
I think if we go to the very bottom, under “Reflections” he’s effectively saying that he would have to double the size of the PHA, so that – effectively, that was just not realistic; is that correct?
Dr Joanne McClean: I think, again, not my email, but that would seem to be what he was suggesting.
Lead 2C: And I think if we could go up, please, in this email chain to page 2, thank you, the email at the top is from, we can just see, the Chief Medical Officer, and he says:
“Perhaps ground hog day for PHA and DPH.”
Can you help me as to who DPH is, please?
Dr Joanne McClean: So that will have been Professor van Woerden at that time.
Lead 2C: Thank you.
What he says is:
“We provided this modelling update to PHA in March/May time at a meeting in Castle Buildings which Liz and I attended and at which Hugo was also present. We experienced significant incredulity and push back from PHA colleagues as I recall which I challenged ahead at the time and we have repeatedly challenged since.”
Then he sets out that he had in fact “directed PHA to double their contact tracing capacity”.
So again, Dr McClean, just taking his words and his reference to incredulity and push-back, was that right, was there push-back on the part of the PHA? And again, understanding that you were not the director at that time, about the extent of contact tracing that would be required?
Dr Joanne McClean: So I wasn’t the director at that time, but again I’ve tried to explore with colleagues who were there what this referred to.
I think that there may have been individuals who were involved in planning the contact tracing service – I wasn’t – who felt that between 300 to 600 contact tracers was a very large number to trace a thousand cases a day, that you wouldn’t have needed that many. And I think at various points in emails an ECDC document is mentioned where it sets out some different scenarios for the type of staffing you would need, and it would depend on how long you took per case, how long it took to contact a contact, whether or not you used digital self-trace, SMS message, all that sort of thing. So it wasn’t a very fixed number. I think the difference in opinion may have been around the number of staff required to trace that number of cases a day, but again, that is from the discussions and what I can ascertain has happened.
Lead 2C: Because it’s not really – it’s not a disagreement, I think, in this email.
Dr Joanne McClean: Yeah.
Lead 2C: The Chief Medical Officer is saying that he had directed PHA to double its capacity –
Dr Joanne McClean: Yes.
Lead 2C: – and that that hadn’t been done, effectively; do you agree?
Dr Joanne McClean: I think that that seems to be a fair conclusion.
Lead 2C: But is there also an issue, then, as to whether or not the PHA just had that capacity or ability at all to ramp up in order to be able to provide that level –
Dr Joanne McClean: I think that – I think that very quickly after this there was – there was a period I think in late September, early October, where PHA capacity to keep up with the number of cases and satisfactorily trace them and complete them was challenged, and having looked at the activity data for the service I can see that there was a period where on many days we weren’t hitting the sort of 80% of cases done that we would have wanted to.
I think then changes were made and the model was changed and – or the model was further improved, I’m not sure operationally exactly what happened, but very quickly the number of contact tracing hours that were available increased really rapidly and then that – once that was in place.
So I think there has – I mean, I think it’s fair to say there has been an issue for a period of time where perhaps a course of action was taken that – and we ended up in a situation where capacity was not enough. It was rectified pretty quickly, and I think I would just want to acknowledge the efforts of people within the PHA who did ramp up a huge contact tracing service, and I know that because I’ve asked about the number of staff who were involved. And I think rather than talking about individuals or whole-time equivalents, we learned that actually planning the number of tracing hours you needed day to day was more helpful. So – and they were planned based on the number of cases that we expected to get, and that worked much better, sort of beyond the middle of October. But I did ask how many staff actually did we have, and over the course of the pandemic I’m told around 600 staff were trained in contact tracing. Not all of them traced all the time, some of them would only have traced for maybe a small number of days at a very busy period –
Lead 2C: So that was the eventual –
Dr Joanne McClean: Eventually we got the 600 – it wasn’t 600 whole-time equivalents, but it was across the pandemic – in total, at different times, we had 600 people contributing to the contact tracing hours.
Lead 2C: I want to go to another topic and it’s an important one. I’m going to try and take it as quickly as I can.
You were obviously involved in care homes and I think controlling outbreaks of Covid-19 in care homes and providing advice; is that correct?
Dr Joanne McClean: So I was involved in working primarily with colleagues in nursing and social services around trying to put some measures in place that would support the sector in a number of ways.
Lead 2C: All right. And I think it’s right, this is a matter for a number of – another witness, but the guidance that was given by the Department of Health at the very outset of the pandemic was to the effect that capacity in hospitals should be freed up by making as much use of care homes as possible; is that right?
Dr Joanne McClean: So I believe that that would have been the position. I think there was a real concern early in the pandemic that hospitals were going to very quickly be overwhelmed, and I think you may be referring to a letter sort of preparing the system –
Lead 2C: Yes.
Dr Joanne McClean: – for Covid, and I think there’s also reference in that letter to perhaps almost field hospitals, real concern that we would run out of capacity in our hospitals to look after all the people –
Lead 2C: Yes.
Dr Joanne McClean: – who needed to be there. So I think the driver there is that we need to make sure that people in our hospitals are people who could only be cared for in a hospital. I think that’s where that comes from perhaps.
Lead 2C: Yes, so I think we understand the rationale for it but the direction was to utilise as much –
Dr Joanne McClean: Yes.
Lead 2C: – spare capacity in the care –
Dr Joanne McClean: Yeah, that seems to be the direction.
Lead 2C: – sector as was possible?
Can you just help me then, in terms of the testing of people who were going from hospital into care homes, certainly from the material, and I think that it’s in your bundle, I think initially at least was the direction given to care homes that they should test people who were symptomatic within the care home?
Dr Joanne McClean: That is my understanding, that’s not the part of care homes that I was involved in at the time, testing policy was being led by the expert advisory group on testing, but I think testing at that time was being reserved for symptomatic people.
Lead 2C: Yes, it in fact took a considerable period of time, didn’t it, before there was asymptomatic testing within care homes?
Dr Joanne McClean: It did. It did.
Lead 2C: I think that it was raised first of all in the April, is that right, or guidance was suggested in the April that –
Dr Joanne McClean: I can’t remember the dates exactly, but I know that, I think it was recognised that care homes were a very important place to get testing into, and available to, and I think then there was a plan, and it was around Easter, which is possibly early April, from what I remember, that testing started to go into care homes, and I remember that we did have an initial round of testing – after testing for the asymptomatic – or the symptomatic cases, there was work to sort of establish how feasible it would be to go into a care home and test every single resident and every single member of staff, because while that’s something that became very normal during the pandemic, at the outset there was very much: would that be acceptable, would it be fair to go round and test every single resident, would it be fair to test all the staff?
So eventually we did get to a position, by sort of testing that that was possible, first of all, then we rolled out testing starting off with a single round of testing, from memory, in homes where there had been an outbreak.
Lead 2C: Yes.
Dr Joanne McClean: And that was around – into them first, then also homes who had never had an outbreak. And then the regular programme of asymptomatic testing, which I think remained in place possibly for the next year, 18 months, then came after that.
Lead 2C: I think it wasn’t until the November that there was weekly testing in care homes of asymptomatic people, does that accord with your –
Dr Joanne McClean: I think regular testing started, I can’t remember the dates, I’d need to see my timeline, which I don’t have, but there certainly was a round of testing which completed I think by the end of June and then there were recommendations about introducing a regular testing programme. Prevalence in the summer of 2020 was very low, testing residents is – and we’re very conscious of this – testing residents – anyone who had a Covid test will remember, it was quite unpleasant, so you didn’t want to test people unnecessarily, so I think that the testing during the summer was less frequent and then it was increased in frequency perhaps in the autumn, but I think regular testing started in the summer, but I may be incorrect.
Lead 2C: Just if we stick for the moment at the outset of the pandemic, so looking at early spring, I think it’s right that the growth in cases became – and you’ve said this yourself in your statement, that most of your work from the March onwards was dealing with outbreaks in care homes, and I think we’ve seen already in the data that the highest number of deaths in care homes in Northern Ireland was in April 2020; correct?
Dr Joanne McClean: Yes.
Lead 2C: In terms of the role of the PHA in dealing with that, I don’t think any of your staff were able to actually go into homes to observe whether or not or what testing was taking place or what separation there was of people who were infected from those who weren’t?
Dr Joanne McClean: So the role of the PHA, so PHA has a role in supporting care homes and before the pandemic, the sort of outbreaks we got, the more common ones would have been GI, sort of gastrointestinal outbreaks, but we would have had a small number of respiratory outbreaks every year. However, if a home had some sort of outbreak, our nursing colleagues – primarily our nursing colleagues within health protection would work with the home to give them advice around infection control, isolation, all the various things to manage an outbreak.
Why we didn’t go into care homes routinely during the pandemic, we did have a programme of education and learning that would have happened before the pandemic, and actually continued on during it. I do think that in those weeks in April where there were obviously lots of outbreaks with very high mortality rates in care homes very high attack rates, we worked collectively with nursing and indeed colleagues in the department and other places to try and put in place a range of measures that would help the care home sector. I do recall a letter that was issued I think jointly by the Chief Medical Officer and Chief Nursing Officer, it wasn’t in my bundle but I do remember this letter was issued, PHA – we don’t have a team of infection control nurses who would routinely go out and perform inspections and support that sort of setting, at the time we didn’t, and I remember the letter that went out from the Chief Medical Officer and the Chief Nursing Officer asked trusts who would have more capacity in this area than we did to make sure that whenever there was a care home outbreak notified, we would tell trusts and then the letter had asked trusts to use their care home support teams and IPCM have a knowledge of the home and go into the home and observe practices if necessary, and I think that is in a letter which we can find and supply.
Lead 2C: I’m going to move on, if I may, to another –
Lady Hallett: Just before you do, and I’m sorry to take up some of your time, Ms Dobbin.
You seem to have moved from testing on discharge from hospital to testing in care homes of residents and staff. Could I just check what was your evidence on testing on discharge from hospital: when did any testing on discharge from hospital start, roughly?
Dr Joanne McClean: I’m sorry, I can’t answer that now, I would have to check that and come back, I can’t remember.
Lady Hallett: Initially it was for symptomatic patients?
Dr Joanne McClean: Yes.
Lady Hallett: Do you know when, if at all, testing for asymptomatic patients on discharge from hospital started?
Dr Joanne McClean: I’d have to – that definitely did come in, but I’d have to check the date that that actually started, I’m not sure.
Lady Hallett: Finally on this subject, who was making the decision as to when testing would occur on discharge from hospital?
Dr Joanne McClean: So my understanding is that advice on testing was considered by the expert advisory group on testing, that was chaired, as I said, by someone from the Public Health Agency on behalf of the department, that group included public health people, it included virologists, it included infection control people, and they provided the best advice that they could come with collectively and they provided that advice to the department, their role was to advise the department then on testing policy, so testing policy was policy that the department made, is my understanding.
Lady Hallett: If you can find the dates, I’d be really grateful –
Dr Joanne McClean: Okay.
Lady Hallett: – for the asymptomatic and symptomatic, because practice seems to have varied around the United Kingdom.
Dr Joanne McClean: Okay.
Ms Dobbin: What we do have, but it may be that the CMO I think will be able to help us on this if you don’t have the date to hand.
Dr Joanne McClean: Yes.
Lead 2C: I think certainly what the Department of Health suggests is that from 12 April 2020 Covid-19 testing arrangements were put in place for all symptomatic resident and staff in care homes, so that’s not dealing with the hospital, that’s dealing with the care homes. I don’t want to put you on the spot, if you can’t remember any specific dates but –
Dr Joanne McClean: I can’t remember exact – it sounds roughly right. I think it was post Easter and I think Easter in 2020 was early April.
Lead 2C: All right.
I had wanted to ask you about one more specific and discrete area, I’m conscious that we’re under a time pressure.
It’s really the role that the PHA has in health inequalities as well. Now, in terms of its broader remit, it has both a health inequalities role and a risk assessment role as well when it comes to outbreaks of disease. At any stage, and I’m thinking in particular about the early stages of the pandemic, did that role intersect, as it were, so that the PHA was providing guidance, for example, about the particular risks that might accrue to disabled people, whether because of their clinical risks to Covid-19 or more generally because of the risks that disabled people are at in terms of their health? I hope that makes sense.
Dr Joanne McClean: Yeah. No, it does. So I think, I can’t specifically remember what advice we might have given to disabled people. Are you thinking about shielding, or …?
Lead 2C: It’s not necessarily advice, I think it’s trying to understand whether or not the PHA played any sort of broader risk assessment role about the particular vulnerabilities, for example, of disabled people in the community and helping to inform decision-making.
Dr Joanne McClean: So to –
Lead 2C: Because of its very particular remit.
Dr Joanne McClean: To the best of my knowledge in those early stages of the pandemic, I don’t think that we did do a lot of that. I hope I haven’t misrepresented work that maybe went on and I just am not aware of. As the very early stages, there were lots of things going on, we were getting used to remote working, it was very – I think for most organisations it was a little – it was hard.
Certainly later on in the pandemic there was very much a recognition that that I think was probably obvious from the outset, I mean, in Northern Ireland we have, like many countries and like the rest of the UK, quite shocking health inequalities, particularly, you know. If you think about two boy babies being born in a hospital in Northern Ireland today, one born to parents from an affluent area, one born to parents from a very disadvantaged area. At the moment that they are born, their life expectancy differs by five years, two newborn babies, that’s unfair and that is unacceptable. And that is the situation that we went into the pandemic in that we had those inequalities and I have used an inequality that was between disadvantaged groups, but also disabilities, ethnicity, gender, lots of other things cause inequalities. I would say at the start of the pandemic, do I think that we looked at it as much as we could? No, I don’t, and I think that is learning for the future, that we have to be so conscious of those pre-existing health inequalities, and how we mitigate in future. I would also say as director of public health that this is not just about the pandemic, it is unfair that we have those health inequalities in our society. The Public Health Agency and indeed the health service overall cannot fix those. 80% of those are about how much money people have, their level of education, and I think there is an absolute onus on society and on the Executive and on government to realise that these are unfair inequalities that need to be tackled, not just because they caused an issue in the pandemic but just because they can and should be tackled. And I think if there was anything around the Executive and around coming together, that is a message that I think that we need to go in, this is not just about pandemic preparedness, this is about health inequalities in a broader sense.
But coming back to our role in PHA, I would say that as things went on, I mean, I’ve explained that we have a health improvement team who were involved helping us with doing many of the health protection type things at the start that we recognise that they have particular skills and particular contacts and I said earlier that the Public Health Agency, we can’t do anything by ourselves. We need to have partnerships at all levels of the community right down to sort of grassroot community level. And I think where that team really did make a difference was the connections that they had with councils, the connections they had perhaps with groups of migrant workers, with community groups who represent them.
And, for example, we had outbreaks in factories that have lots of migrant workers, trying to go in there, explain isolation, eventually explain vaccine, trying to make sure that vaccine came to them, we did do work on that later on. But in the early days and particularly thinking about perhaps people who were disabled or had other types of – faced other types of disadvantage I think that is something that I hope I haven’t misrepresented and missed things that we did but I think it’s something that I would want to improve on for the future.
Ms Dobbin: I’m grateful to you.
Those are all my questions, and I understand there aren’t any other –
Lady Hallett: I don’t know how much of your thunder Ms Dobbin has pinched, Mr Friedman?
Mr Friedman: None of my thunder pinched, I want to thank her for asking the questions and the answers that have been given by Dr McClean.
No more questions from me.
Lady Hallett: Thank you, Mr Friedman.
Thank you very much for your help, Dr McClean.
(The witness withdrew)
Lady Hallett: We will break now and we shall return at 3.15.
(3.00 pm)
(A short break)
(3.15 pm)
Lady Hallett: Mr Scott.
Mr Scott: Good afternoon, my Lady. May I call Jenny Pyper.