Scientific advice and evidence in emergencies - Science and Technology Committee Contents

Examination of Witnesses (Questions 1-59)

Q1 Chair: Can I, first of all, welcome our witnesses here this morning and thank you for agreeing to attend? You are aware of the terms of reference of our inquiry. We are going far beyond your particular areas of expertise, looking more generally at the way that scientific advice has both historically been dealt with by Governments in emergency situations, and then we are going to look forward to things that, perhaps, haven't been as serious yet, but we will see.

I start off by asking all of you to explain very briefly your organisation's role in both the preparation for and the response to the swine flu pandemic, and also it would be helpful if you would, as you go through, tell me whether you had much interaction with each other during that process, either before or during. Who would like to start? Perhaps Professor Ferguson.

Professor Neil Ferguson: My centre, which is funded by the Medical Research Council, was founded in 2007 as a translational science centre, which meant that we did theoretical research on the dynamics of epidemics, but we also promised that we would apply it to emergency situations in particular, and that was part of our remit. In the context of pandemic influenza we had a contract with the Department of Health that we would provide real-time analysis and modelling support for them. We also had pre-existing agreements with the World Health Organisation and CDC—Centers for Disease Control and Protection in Atlanta—to do similar sorts of activities, so very early on we were called in to assist in all three of those roles. I should say that that builds on a long history of us providing scientific advice in such outbreak emergencies dating back all the way to BSE (mad cow disease), and then the foot and mouth epidemic where, I and my colleague, Roy Anderson, were heavily involved, and then later the SARS epidemic. I interacted with many of the other panel members here today regularly.

Dr Peter Holden: Good morning. I am Peter Holden. I am the British Medical Association's lead on emergency preparedness. You have the details of the organisation in the written submission. I am one of the GPs' leaders. I am a working GP. I am also trained as a medical incident commander for major incidents. My job was, essentially, to operationalise and galvanise 10,000 independent businesses, the front line of the NHS, aka general practice. Yes, we had on-going dialogue three or four times a week with many of the organisations you are going to interview.

Q2 Chair: Mr McCracken?

Justin McCracken: Justin McCracken. I am the Chief Executive of the Health Protection Agency that was established in 2003 to protect the population of the UK from a wide range of threats, but particularly infectious diseases. So we were closely involved in supporting the Department of Health in preparing for the threat of pandemic influenza, working over the last five years, and obviously in the response to this pandemic. Our role encompassed disease surveillance so that we, the Government and, indeed, everybody, could have a good view of the progress of the disease both in this country and across the world. The provision of diagnostic testing to support the response both locally with the NHS and, of course, nationally in determining our policy and reference microbiology services so, for instance, to check whether the virus was developing resistance to anti-virals and so on. We also provided a lot of advice and operational support to the NHS and to Peter and his members in terms of the front-line response to the pandemic.

  We provided information and advice to support Government decision-making based on the scientific work that we had done, and we provided advice to health professionals and the public in terms of appropriate response to the pandemic.

  We also had an important role in development of vaccines, so we developed the seed strains which were used by the manufacturers to develop the vaccine. We then did trials of vaccine when it became available and, indeed, provided much of the evidence that supported the JCVI advice to Government around vaccine policy. We were involved in the modelling work, and our team worked closely with Professor Ferguson's people.

  Last, but by no means least, we were involved during the so-called containment" phase—we had the operational lead in terms of the front-line response, working very closely with the NHS. So there is quite a wide range of roles.

Q3 Chair: Professor Bird?

Professor Sheila Bird: I was the Vice President of the Royal Statistical Society during the period of swine flu and was the Royal Statistical Society's appointed statistician member of the Scientific Pandemic Influenza Advisory Committee. As you are aware, that committee was in abeyance during the actual swine flu, and so my interactions during that time as a member of the committee were through email correspondence with colleagues in the Health Protection Agency and through the Chair to have input to the design of the FF100 cases and so on. My concern as a member of the committee had been on the use of representative sampling partly to reduce burden and to ensure that we had good surveillance designs.

  One of my other roles at the Royal Statistical Society is in terms of public understanding of statistical science. And so the Royal Statistical Society was very concerned about the public face of the monitoring of the swine flu epidemic, and that occasioned our President to write to Sir Liam Donaldson and we were very pleased that some of the suggestions were acted upon.

Q4 Pamela Nash: Good morning. Thank you for joining us. I just wanted to ask each of you if you felt that the Government was as prepared as it could have been for the onset of swine flu?

Dr Peter Holden: In a word, yes. In fact, there was a step change in preparations, particularly for swine flu, in 2005. In fact, we were involved from the BMA side, as was the Royal College of General Practitioners with DH and various other organisations within DH from that step change, and things were progressing really quite fast. The pace of work through '07 and '08 was proceeding quite quickly. Indeed, we actually issued our first specific guidance to general practice before swine flu hit us. If we had had another four months we'd have actually been completely ready. So I think yes, it was, but you can never say you are 100% ready. If ever you have hit a major incident and you say you got it right, it's time to retire. It's never going to be 100% ready because you never know what; you never know when; you never know how long it is going to last, how quickly it will recede and whether it will come back again. So as with all preparedness, you have to have a skeleton plan. What clothes you put on the skeleton, be it a T-shirt and jeans or full mountaineering gear will depend on the threat you get, and you've got to be flexible.

Professor Neil Ferguson: Like Peter, I was heavily involved in the pandemic preparedness efforts at the Department of Health and the NHS from 2005 onwards. Those efforts were well progressed. I would say that most people in DH might say that it would have been helpful if the pandemic had waited another year. There were a number of work streams which were coming up to completion at the end of 2009 and weren't quite ready. I think one important point to note, though, is the reason we prepared so intensely for a pandemic nationally was the potentially extreme in terms of consequences but unquantifiable threat of a lethal bird flu pandemic. So I think nearly all the preparedness had focused on that worst case scenario, and indeed that's what warranted stock-piling of anti-virals and the huge investment of money, time and resources.

  We had not considered as much as we might have done, first of all, how quickly we would be able to judge what the severity would be and how we would de-escalate the response to have a response proportionate to something less than that extreme worst case. I think that is really one of the lessons which, collectively, we are learning at the current time.

Justin McCracken: I think I would, by and large, agree with the other two witnesses, that the UK was very well prepared and certainly the WHO felt that we were among the best prepared countries in the world, and there had been a huge effort going on over about five years. Inevitably, that effort had prioritised what needed to be done so not everything was completely in place and ready. But, by and large, we were very well prepared and within what is always a resource-constrained environment, I think the degree of preparedness was excellent. So that enabled us, for instance, within days of the first case presenting in the UK, to have a diagnostic test capability at our Centre for Infections, and within a matter of a very small number of weeks we had rolled that diagnostic test right out across the country. None of that could have happened without the preparation that had been going on for some time. Although it is absolutely right that there are lessons to be learned because the pandemic that we got wasn't quite the one that we prepared for, I think the degree of preparedness was really very high.

Professor Sheila Bird: I would just add to that, that the prior analysis of those past epidemics was largely led by Professor Ferguson's team and was done to a phenomenally high quality. We knew as much as we possibly could from the analysis of past epidemics. I think also there was tremendous preparedness in terms of the virologists, as you have heard. I think internationally the UK's contribution to that is actually widely recognised.

Q5 Gavin Barwell: I want to pick up some of the comments that Professor Ferguson made, and ask a couple of questions about regional worst case scenarios. As a starter, how evidence based was the Government's reasonable worst case scenario for swine flu?

Professor Neil Ferguson: Can I, perhaps, pick up on that first? I think, maybe, it might be good to put that into context because the Department of Health had a preparedness plan for dealing with a pandemic. In that context, the reasonable worst case scenario, of course, is defined in advance of an event, and you are saying, "What should the NHS prepare for without any knowledge?" That reasonable worst case scenario was based on the mortality we saw during the 1918 Spanish flu pandemic—namely a 2% case fatality rate and a rather pessimistic, but I think reasonable, estimate of what's called the attack rate, what proportion of the people might get ill. I cannot, off the top of my head, remember the precise number of deaths, but it was intended to be a worst case for NHS planning assumptions.

  Now, the term "a reasonable worst case" is, by definition, not an objectively definable term; it is a subjective term. One could take the other extreme, and I remember David King and Sir John Beddington challenging what we were doing by saying, "Well, if you look at bird flu, that has a 60% case fatality rate", so the reasonable worst case is, of course, that bird flu becomes transmissible and we get a 60% case fatality rate. That was felt certainly to be a worst case but almost unpreparable for. So from the point of view of something reasonable for the NHS to plan for and reasonable in terms of cost, that is why the Spanish flu example was used.

  Moving forward to the pandemic, and this is where the concepts became muddied, we went from using, right at the beginning of the pandemic, that pre-existing reasonable worst case, to giving, effectively, what was an upper statistical confidence bound on our assessment of what the severity of the current pandemic was. That did not, perhaps, communicate as clearly as it should have done what we were doing, particularly to the NHS. Those estimates got revised really quite rapidly, so within a month we were down from about that 2% level closer to 0.4% case fatality. Six weeks later it was down to below 0.1%-one in a thousand case fatality. So the estimates went downwards over time. I completely accept that that posed significant communication challenges for the Department of Health, the Chief Medical Officer and the NHS.

  A further problem was that there was about a three to four week lag between the group I was involved in coming up with new reasonable worst cases, and then coming into the public domain in terms of getting through the DH and Cabinet Office approval process. So what was in the public domain as a reasonable worst case was already behind the evidence, given how fast the evidence was building up.

  I think it is perfectly valid to also ask why we didn't provide a best guess, a best estimate of what the fatality was. That did start to be done from about July-August onwards but was not initially felt to be the priority. That, again, caused a little confusion because the reasonable worst case got viewed as a prediction, which it never was. I have talked for long enough.

Justin McCracken: I agree with that. There is no doubt that the planning assumption that was built into the general pre-pandemic plan was well evidence based and was a good reasonable worst case assumption. I think there is no doubt about that at all. Then as the evidence developed of the particular characteristics of this pandemic it was a real challenge to develop—to, as it were, refine the planning assumptions—because the reasonable worst case was one end of the spectrum that was being used to drive planning assumptions through the health system. Of course, one of the complicating factors early on was that much of the early evidence was coming from Mexico, and the initial information, both about hospitalisation rates and case fatality rates, turned out, in the event, to be higher than the facts ultimately support because of biases in the data coming from there initially. So there were huge challenges for the modelling teams. I think the process that was used of getting the expert modellers from all the key groups together under the chairmanship of the Department of Health, to develop, broadly speaking, consensus views about what the projections were and, therefore, what reasonable worst and reasonable best case scenarios were to drive the evidence, was a good one. It is already accepted, I think, that one should re-look at the process in terms of how one develops planning assumptions, and Sir John Beddington, as I understand it, has initiated work in that area. Clearly, the communication of the reasonable worst case and, indeed, the basis for planning assumptions is a challenge that probably deserves a little bit more attention, despite the huge effort that was put into communication with, I think, by and large quite a lot of success, but in this one area, probably, there was more that could be done.

Q6 Graham Stringer: Does that mean the Mexican health authorities were not telling us the truth?

Justin McCracken: Professor Ferguson can probably answer that better me, but I don't think there is any question of their deliberately misleading us. I wasn't intending to imply that.

Q7 Graham Stringer: But the information was wrong? That is what the answer means, does it?

Professor Neil Ferguson: Yes. We worked with the Department of Health in Mexico in the early stages. The real problem is that all the surveillance was focused in hospitals so, by definition, if you look in hospitals, you see sick people. We knew. It was not a matter of us näively saying, "Well, this looks really serious because we are seeing deaths." From the very first instant, we anticipated that this would be the tip of the iceberg and there would be lots of mild disease in the community. We just couldn't say how many and, therefore, we couldn't put those deaths into context.

Justin McCracken: To give another example, we sent a team out to Mexico fairly early on in the event. We were identifying British tourists coming back from areas of the country and they clearly had swine flu at a time when the Mexican authorities were claiming that those parts of the country were disease free. Now, I don't believe that they were deliberately misleading us. They simply, as Professor Ferguson said, didn't have the surveillance in place to enable them to determine how widespread the disease was.

Q8 Gavin Barwell: I will just ask some follow-up questions while no one wants to come in. Thank you for your answers, because you pre-empted some of my questions about how the scenario was revised and some of the communication issues. I have two questions. What lessons do you think we can learn for the future both in terms of whether we should communicate just a worst case scenario figure or a range of potential outcomes? Also I was particularly taken with the point you made about the delay, this three to four week delay, from your group revising the figure to that revised figure actually coming into the public domain. Was it also taking three to four weeks from your group revising the figure for emergency respondents to get your revised figures?

Justin McCracken: May I answer the first point? Actually, the question is predicated slightly on a misunderstanding, but it shows how difficult communication is because it was not just the reasonable worst case scenario that was communicated to the press. It was, actually, the range of both the best and the worst. But, inevitably, I think the figure that the press focused on was the worst case scenario. I was at the press conference when Sir Liam Donaldson communicated the figures. I am pretty confident in my memory on that point.

Q9 Gavin Barwell: So in future would you give a mid-range figure from what you learned?

Justin McCracken: The difficulty of giving even a mid-range figure is the degree of uncertainty that is associated with it, but I think there probably is a case for that. I don't think you can escape from communicating a reasonable worst case scenario that you are going to use for your planning in your health care system, but I do think that more emphasis needs to be given to what I would call the more likely expectation. Others may have different views.

Professor Sheila Bird: Perhaps I could come in on that point. Of course, what was being given for each of the components was an extreme value. You can't multiply extreme values together unless you also multiply together the corresponding probabilities, and if you are not told what those probabilities are—Professor Ferguson referred to an upper figure of 95% confidence intervals—then you know that it is something that happens about three times in a hundred. If you multiply two of those together, then the joint rarity is actually nine out of 10,000, or 1 in a 1,000. And so that is the problem: if you are going to give extreme values you have to say how extreme each of these estimates is because the multiplication of extreme values has to be parallelled by the multiplication of the corresponding probabilities. As you would know if you were betting on the 2 o'clock at Newmarket that Hopalong was to come in on a 1 in a 100 chance, and also putting a bet on in York, on the 3 o'clock, that Sidekick was going to come in at 1 in a 100, the chance that both of those are going to be realised is 1 in 10,000. And so common sense as well as statistical science says, "Beware when you multiply extreme values."

Gavin Barwell: Thanks for the tips.

Dr Peter Holden: It actually gave us quite a major problem operationally in the consulting room. It is trying to get across to the public the concept of risk and the business of statistics. The whole problem with society is that it doesn't know how to live with risk, and it only reads what the press will print. It is about openness and communications. Certainly one of the issues we found with all this was that there is need not to panic everybody but, at the same time, there is a need to inform, and the question, is where does that balance lie? I happen to sit on PICO, the Pandemic Influenza Clinical and Operational Advisory Group from the CMO, and also EPCLAG, the Emergency Preparedness Clinical Leaders Advisory Group, and not even we had sight of the publicity campaign. So how on earth are we supposed, as front-line troops, to explain to people if suddenly something appears on a website? It is a problem of explaining to the public the whole business of risk and the whole business of statistics—so much so that the BMA is about to re-publish Living with Risk as soon as we can get it together because this is about that. It is about managing expectation.

I think the other thing we need to understand with these planning assumptions, and people can say that an industry was made out of this with these worst case scenarios, is that, on an operational front, we are operating with very little redundancy in the system. Therefore, we had to use the statistics to model different methods of how we would respond according to attack rates and according to mortality.

The other problem we've got is the just-in-time society. In 1957 most women didn't work; they stayed at home and looked after the children. In 2010, if we had had the same scenario, the health service would have been on its knees. Half its workforce is women. They would either have to choose between staying at home to look after the children because the schools had closed, or going to work. So we had to have all these scenarios. In an era of freedom of information, you have to be open. The problem is that the press only print what they want to print. I think that is where the Government has got to be quite clear in what it puts up on its websites, and it must put both sides of the argument. It's either both sides or nothing, and society will not tolerate nothing.

Q10 Chair: Those comments don't apply, I am assuming, to every risk that people face because people respond in a different way to the risk of a major disease problem from the world of medicine. Very few people take sufficient precautions against melanoma, for example. It is a risk they seem prepared to take.

Dr Peter Holden: Yes.

Q11 Chair: Is that a failing on the part of the medical professional in improving public understanding of risk, or is it that statistically it is impossible to communicate that in a way that is meaningful?

Dr Peter Holden: It's a bit of both, but it's also a little bit about the way the public views the learned professions and science. There is a temptation nowadays not to believe boffins and not to believe the learned professions. It is part of the way society has evolved. It is a communication issue, and it is one that we are seeking to re-address. Certainly in the medical profession, we resolved this year that we would completely revise and re-publish Living with Risk, because people have no concept about risk. That's what this is about. People had a concept that they were likely to get flu. What they didn't have a concept of was how bad it was going to be and what the results were.

I think the planning assumptions were right, and I saw most of them. I think they were right because even those of us who had spent time looking at this from an operational viewpoint had no concept of scale until we had looked at it and worked out what a 2% attack rate meant, and then all of the way down to 0.5%.

Q12 Gavin Barwell: I have a final question on this point about understanding risk. In our briefing we have the following sentence: "The Government's current risk assessment identifies as the 'reasonable worst case' a flu pandemic…with a clinical attack rate of 25% to 50% spread over one or more waves, and with a case fatality of up to 2½%." If I have understood that correctly, that is saying that is a pandemic which might kill about 1% of the population. "This is assessed to have a medium to high likelihood of occurring over the next five years." What is a medium to high likelihood?

Professor Neil Ferguson: Yes. The latter point, I think, is more questionable. Certainly the first description, I think, is perfectly reasonable. I would slightly challenge Sheila in the sense that that I don't think the 50% attack rate is at the 95% upper band. If you look at community illness, the 1968 pandemic had a really quite high clinical attack rate. It was probably close to that. The case fatality rate is more subjective; we don't formally use statistics. You can use statistics in a formal sense to try and estimate a case fatality rate but you are trying to estimate the overall attack rate in a pandemic, and that's even harder to do.

By late August we had a very good central estimate of what deaths would be in the UK. That was actually very readily calculable from what was happening in Australia, New Zealand and South Africa, in a rather simple way, but those estimates proved to be very reliable. Their pandemic was way ahead of ours. What lesson we learned is that it is probably more useful to try and project overall deaths, total numbers of deaths, than try to focus on multiplying two quantities together both of which are uncertain. So we have learned lessons there.

The other thing we are trying to focus on, more generally in terms of assessing risk early on, both in terms of ramping up surveillance and thinking about how to make better use of the data in generating estimates, is how could we do better next time in getting more reliable estimates of severity earlier on with less uncertainty? I am not sure whether that is possible, but certainly it would have been an advantage had we been able to do it.

Professor Sheila Bird: I think there are two points that I would hope that we would manage for the future. The first is to be clear about whether we are going to report suspect cases or virologically confirmed hospitalised cases. Different things happened in different parts of the United Kingdom on that. There is also, I think, a difficulty, in England at least, in being sure about the count of deaths because there is a gap in the registration system in England which does not apply in Scotland. In England there is no obligation that the very fact of death be registered if that death has been referred to the coroner whereas, in Scotland every death has to be registered within eight days of being ascertained, so that you know the fact of death, the date of death, the age of the person who died. You won't necessarily know the cause at that time. That may come later. But in England we don't have a complete registration system, which caused a great difficulty for our Chief Medical Officer, who had to make extraordinary personal efforts to try to establish swine flu deaths.

Dr Peter Holden: But there are enormous problems on the ground. People come in and think they have got flu, and they haven't got flu. How do you tell the difference between suspect versus confirmed? The confounder in this, of course, was the Tamiflu line. I laid a bet with my colleagues that it would take two days for the newspapers to tell you how to get Tamiflu and we were wrong—it was three. You answer the right questions, so you got your Tamiflu to take with you on holiday just in case. So that was a real confuser at the beginning. I don't know how we get round that.

Q13 Graham Stringer: Dr Holden, the BMA's evidence does not just refer to the difficulties in communicating with the public. It refers to the difficulties in communicating with clinicians, particularly about the use of anti-virals. How could that have been improved? In fact, doctors were reluctant to prescribe anti-virals to healthy adults, weren't they? Their advice was that they should.

Dr Peter Holden: Now it is all over, I will tell that I prescribed zero. This is the problem of getting a liberal, self-governing profession to understand that this is command and control. It is quite a hard concept to get across to people who are used to being their own boss, who are used to taking autonomous clinical decisions. I think where the problem comes is that most doctors, if a thing does not ring true, will ask questions, and they will say "Show me the science". That is a perfectly proper approach under normal circumstances. If it is abnormal, I think, actually, this is about trust. You have to trust the scientific advice you have had and you have to trust the system that has been built, because there is no place on final approach for five captains in the cockpit. So the confusion came in when we built the information cascade. It was built on the assumption of using the internet, which I think is a faulty assumption. If you lose your power supply, how do you get into the internet? That is just a starter for 10.

To try to ensure that everybody was singing from the same hymn sheet, the four big players, the Royal College of GPs, the British Medical Association, the HPA and DH, all agreed that we would cross-link our websites and make sure it was the same hymn sheet. I think we came unstuck because we were so keen to be up-to-date and offer timely advice, and it was a fast moving scene. I can't remember whether it was the 6 June or 2 June—this is not criticism of the HPA—but on that day two different versions of an algorithm came out, and that really confused people because they didn't know which they were working to. We should have said, "This advice is valid for 72 hours and will be reviewed." The fact that there may be something in the last 10 hours of that 72-hour block that is not up-to-date is bad luck. If you look at any major incident, no matter whether it is Tavistock Square, Hillsborough or wherever, you see that the key thing in managing it is communication. If that fails it goes down the pan. I think we all tried to be too up-to-date and, therefore, I think what we should learn from this is that there is a review date on this advice, and you accept that the advice that may be on the website could be a few hours out of date in pure science terms.

  I think most doctors gathered fairly quickly that the places to look were those four websites, and they all carried the same information. Essentially, the HPA gave us the top line professional advice. The DH gave us the DH view on how we should operate, and that was informed hugely by the profession. The Royal College of GPs analysed what was there and put an international flavour on it. So you could look at all aspects. Now, many of us who are ordinary jobbing GPs found that all very interesting but actually we'd print off the nice coloured HPA flowchart that came out periodically because that would sit in your bag and in your consulting room.

  There is a real risk of over-information here, and there is an argument that we should have one portal in these circumstances.

Q14 Graham Stringer: Right. So, effectively, the advice to doctors was to prescribe anti-virals. The doctors in Wales, Northern Ireland and Scotland weren't doing it, and there was a reluctance to follow that advice here. It was slightly worse than that. The advice to midwives on whether they should be vaccinated was different from the advice that doctors were given; is that right?

Dr Peter Holden: The midwives came out ex cathedra without telling anybody about this, and I think this was a free-thinking set of loose canons, bluntly, in their profession, and they were stamped on pretty fast because they had no evidence for what they were saying.

Q15 Graham Stringer: So how long do you think that advice was being given, which was different?

Dr Peter Holden: Probably under a week, I think, but once we found out about it, things moved extremely fast. Quite hard words were said at fairly high levels to the midwifery leaders that, "This is not helpful" because there was no science to what they were saying. I think the issue about Wales, Scotland and Northern Ireland is that we have a devolved administration as far as health is concerned, and I think that English doctors—English GPs— feel, not only in retrospect but at the time, that we were too trigger-happy with Tamiflu. I am open-minded about that. I was party to a lot of evidence that the ordinary GP wasn't. I think there was a genuine view that, if nothing else, if it would shorten the course of the illness by one day, that meant you got 10% more people back at work, and in a just-in-time society—this is what people forget—we were looking at dislocation. If this had really taken off, there are four days' food on the shelves, four days' fuel and seven days' pharmaceuticals. If the trucks don't roll, this nation doesn't work.

Professor Neil Ferguson: Can I, perhaps, just interrupt slightly? I think there was more consistency in the scientific advice than in the clinical advice to all three countries than perhaps was anticipated. It was always a scientific and clinical judgment that the people who should be prioritised for the use of anti-virals strongly are those people who were in the clinical "at risk" groups. I think the wording in England, at least—I think similar wording was used in Scotland and Wales—was that it was up to the clinician's judgment as to whether to use Tamiflu in other circumstances. The reason we went for both the National Pandemic Flu Service telephone hotline and a fairly liberal use of guidelines for using Tamiflu was because we were concerned that it would be difficult for GPs to immediately make a judgment as to whether somebody was in a risk group. The critical thing in a pandemic, for the use of these drugs, is to treat people as rapidly after they develop symptoms as possible. That makes triaging more challenging when you are dealing with, potentially, millions of cases. But the fundamental goal was to treat people most at risk of severe disease. In some sense, the treatment of other people was the means of trying to achieve the highest level of coverage of those risk groups as possible.

Q16 Graham Stringer: That takes me on to the point of vaccination, Professor Ferguson. The strategy on vaccination was to start with the most vulnerable and that was started on 21 October, and then on 19 November it was moved on to vaccinating children from six months to five years, I think. I received advice from some of my local health professionals that they disagreed with the national strategy. They thought it would be better to vaccinate the children first because you would increase your herd immunity. I've got two questions about that. The decision on 19 November to vaccinate children, was that a change in the strategy from the beginning? Secondly, would it have been better to start with children as soon as the vaccine was available?

Professor Neil Ferguson: Can I deal with the second of those questions in terms of prioritisation? There was a lot of discussion—not just in this country, but in the United States and the WHO as well—about which groups prioritise for vaccination. You are completely right that if you have vaccine available really quite early in an epidemic, then targeting the people who transmit the disease, and in this case had we been able to target all school-aged children, for instance, all the way back in August, then we probably wouldn't have had an autumn wave to this epidemic. We would have stopped transmission.

  However, the reason we collectively advised on targeting clinical "at risk" groups is that it was always likely that we would be vaccinating in the teeth of the pandemic. In reality, by 21 October, which is when vaccination was started (though most vaccine wasn't delivered then), was approximately one week before the autumn wave of this pandemic peaked. In those circumstances, vaccinating the transmitters has very limited impact because a lot of the transmission has already happened and it takes vaccine between seven and 14 days to have an effect. So you are already on the downhill slope of the curve. What you can do in that case, though, is to reduce mortality in the people who are going to die in the tail end of the epidemic. That is the reason for prioritisation.

  On the former point, and the decision to vaccinate two to five year olds, I have to say that I was, perhaps, a little surprised by that. That was not something that went to the committee that I sat on, the SAGE Committee. It may have been discussed by other advisory groups in the Department of Health, but it was always going to be of marginal impact given that the epidemic was already largely over. I worried myself that it would lose credibility—that people would already view this not as a threat, so what was the justification for doing it? I felt that the justification in that context was a harder one to make for parents to vaccinate children in the general population. Clearly, in risk groups, if they enter into any of the clinical risk groups, they should be a priority.

Q17 Graham Stringer: That is interesting. Do I understand it correctly, that had vaccine been available earlier a different strategy would have been followed?

Professor Neil Ferguson: There could well have been. There is a lot of research and development going on about how we can speed up the manufacturing of pandemic flu vaccines. Currently they take six months to make and that is, basically, the timescale we had last year. If you could do it all in a month or two, and we were vaccinating in the summer instead, then the vaccination strategy may well have been quite different. That is not to say that we wouldn't have prioritised our clinical at risk groups, but there would have been, probably, a much bigger push to vaccinate school children before schools re-opened in the autumn. But we were never going to be in that situation, particularly given that vaccine was slightly delayed even compared with what we expected and only limited stocks were coming through in October. Most of the stocks came through later, and it made both epidemiological sense, from my perspective, and clinical sense to target those people who really had the highest risk of dying if they were infected.

Q18 Chair: Can I just pursue the issue about the different ways in which the nation states operate? There clearly are parts of the country—where Stephen Mosley and I live is an extremely good example—where the travel-to-work area is right across the border. Does it really make sense to have different health strategies to manage potential risk?

Dr Peter Holden: No. Disease does not respect political boundaries.

Q19 Chair: So why hasn't the medical profession made that abundantly clear?

Dr Peter Holden: We made it abundantly clear. The bottom line is that this is about political balls. That's the bottom line. Ministers were not prepared-you know. This was about countries reinforcing their independence in these matters. The medical profession always thought that a separate policy for each of the four countries was utterly crazy, and still think that.

Professor Neil Ferguson: There was a real attempt, at least at the high level, for co-ordination, though. The SAGE group, the Scientific Advisory Group, always had senior representatives dialling in mostly from Cardiff, Scotland and, indeed, Northern Ireland. Justin can talk to this. There was a real attempt to normalise surveillance protocols in the different countries. They were not always successful, but a lot of effort was put into that to try and get comparable statistics. They were not completely perfect, but I would say that if you have devolution, then that is an inevitable consequence. We are, at least, not in the Canadian situation where emergency management is really at the far extreme of that. So, from the point of view of dealing with emergencies, there clearly is a tension between command and control in devolved administration. I think the Canadian experience in the SARS epidemic in the provinces, which had a lot of autonomy which was then devolved down, was disastrous because they were basically unable to enact any sort of central control.

Justin McCracken: Perhaps I could just add to that. It is absolutely right that a huge amount of effort was put in right from day one to ensure, as far as possible, that there was consistency in approach right across the United Kingdom at all sorts of levels, so there were ministerial meetings, there were departmental official meetings and, indeed, the Health Protection Agency hosted daily teleconferences with health protection organisations right across the UK including the Devolved Administrations. So there was a huge amount of effort to make sure there was consistency. In, I think, the vast majority of areas, actually, the same approach was adopted at each stage in the different administrations. Anti-viral policy, when we moved on to the treatment phase, is something where there were differences, where decisions were made in the light, not just of the scientific advice from SAGE, as it were, the same to all ministers, but also the other factors which the different administrations had to take into account, such as capacity of health care system. My understanding is, first of all, that on the decision in England to offer anti-virals to all, I believe the Secretary of State did make it clear that that was a precautionary decision rather than one driven by scientific advice, and that it was also linked to capacity of the primary health care system in England, but I am sure there will be other witnesses who can help more on that point.

Professor Sheila Bird: I might just add that, on the design of the vaccine programme, as Professor Ferguson pointed out, if we were intending to vaccinate school children then, of course, the randomised controlled trials of vaccine would have had to weight their attention much more to children than to adults and senior citizens. And so the evidence base for the safety and efficacy of the vaccine also plays a part in public and professional views on the acceptability of that vaccine.

Q20 Stephen Metcalfe: You have mentioned SAGE a couple of times, which was obviously established once the emergency had been confirmed. How effective do you think SAGE was in advising the Government on swine flu? Did you think that the balance of experts on the group was correct and that they had a wide enough range of skills and disciplines to be able to come up with good advice for the Government?

Justin McCracken: Shall I start on that? I am sure colleagues will want to add.

This, I think, is the first time in an emergency that a SAGE has been pulled together as it was in this instance. This was a new part of the concept of operations in terms of the overall SAGE contingencies response. My own assessment, having been quite closely involved in this event and having been involved from different perspectives in a number of other events is that this was actually a significant improvement in terms of the way in which advice can be delivered to Government. On the overall assessment of effectiveness of SAGE, I think, my personal assessment would be that it really was pretty good. Perhaps more importantly, I think, that Dame Deirdre Hine in her review was pretty positive about it.

  I think in terms of the range of skills available to SAGE there was a wide range of different disciplines from modelling, virologists, epidemiologists and clinicians. So there was a wide range of skills available at SAGE. I think we were fortunate, the Government was fortunate, in the sense that there already was a Scientific Advisory Committee on Pandemic Influenza and it was, therefore, able, quite easily, if you like, to identify relevant experts to form a Scientific Advisory Group. So overall the advice was pretty effective.

  If one were looking to see how could one improve for the future, I think being clearer about the limitations of what science could and couldn't do, particularly early on but also at other stages, would be very important, as would making sure that there was even closer joining up, as it were, between the scientific advice from SAGE and the public health advice from the Chief Medical Officer. By and large, that worked well but there were one or two instances where there were differences. I think those would be the two things that I would pick out.

Professor Neil Ferguson: I don't have much to add. I think there is always a balance. SPI was formed—the Scientific Pandemic Influenza Advisory Committee, to give it its full name. It's a huge committee, I think it's 40-50 people, and has a huge range of expertise, all the way from the social sciences, through to virology, clinicians and, indeed, modellers. Clearly, in an emergency that is an impractical size of committee to operate. You need something which is smaller and more agile. I don't know precisely what process was used, but basically the people with most expertise to give and most prior experience of being involved in emergencies or responding to things were engaged in the SAGE group, and it still had a breadth of expertise from social scientists to clinicians, representatives from the NHS and modellers. It was really quite a balanced committee.

I would agree with Justin that expectations of what could be done and what was achievable—for instance, in modelling, my own group, but also from the surveillance side— were perhaps unrealistic. That probably emerged from the fact that we had all been planning for this severe epidemic, where case diagnosis and estimating case fatality would have been easier, but we were dealing with something much milder, and that posed challenges. I would also agree with Justin that where it really fell down—I warned of this in advance because I have memories of the foot and mouth epidemic, where it was equally an issue—was the lack of apparent co-ordination between the Chief Medical Officer's operations and the Chief Scientific Adviser's operations. I would, frankly, have liked to see a committee co-chaired by both the Chief Medical Officer and the Chief Scientific Adviser. I think that would have aided consistency within the DH decision-making processes and with communication.

That is not to say that there wasn't co-ordination. Clearly, David Harper, the senior civil servant sitting on that SAGE group, talked to the Chief Medical Officer regularly and there was a lot of cross-briefing from the secretariat, but there was still a sense of disconnectedness. Clearly, it wasn't as bad as what happened in foot and mouth disease in 2001 with the Chief Veterinary Officer and the Chief Scientist barely being able to speak to each other, but had the situation been much more serious and we had been really facing something more like what we were planning for, those, let's call them, slight tensions and that lack of connectedness would have been much more serious and might have degraded our ability to give a coherent response.

Q21 Chair: Professor Ferguson and Dr Holden, please move out of the sun if you want to. It is not our intention to interrogate you quite in that manner.

Professor Neil Ferguson: Yes, it is quite bright.

Dr Peter Holden: I would actually echo what has just been said. I have one caveat and one additional point, because I sat on PICO, which was the clinical end of what were the three big committees. However, if you did just merge the three committees, the problem is, at the end of the day, the operational people—the guys who have got to deliver—and ourselves rely on the science. You mentioned about committees being too big. It was getting quite big at 24, and there comes a point where somebody somewhere has to make a decision.

There is one other point I would like to make about the expert committees in general. The workload on them was utterly phenomenal and we were all still trying to do our day jobs. This only ended just in time before some people would have broken. I'm afraid the Government has got to understand that if it wants these senior people to work on these committees, at a much earlier stage they have to be relieved of their routine duties. Any incident commander will tell you, "Divide your force in two and tell the first half 'Go home and go to bed for 24 hours. I'll call you then.'" You can't keep up indefinitely the pace that we kept up for nine months. I think there is a very real issue there for these very senior committees. They were working all the hours God sent. The meetings were being squeezed in between our other commitments—on the telephone, in person, and all the rest of it—and I think you really need to look at that, because we got away with it this time, but if that had gone on for 18 months you would have had people going sick—key people going sick.

Q22 Stephen Metcalfe: Having made that point to—

Dr Peter Holden: It is in one of our submissions. We don't make it quite as bluntly as I do. Normally I'm not allowed out without a choke chain round my neck.

Q23 Stephen Metcalfe: You mentioned the limitations that science has in these areas. I think, from what you said, you were confident that you were putting across the fact that this was all within the limitations of what you can predict and what you can say. Do you think those limitations were being heard by Government? Do you think they understood that as well, that there was enough two-way communication?

Professor Neil Ferguson: I think it was certainly understood by Sir John Beddington, who is a very eminent scientist. I think it was very well understood by Liam. I think there was a degree of frustration that more wasn't possible. In communicating to Ministers and COBRA and otherwise, it posed a significant challenge both for Liam and for John in saying, "Well, we've got the best scientific advice, but I'm afraid we can't really tell what you want to know." That's always a challenge. I think the limitations were well understood.

I mentioned before the agility of the policy-making process in emergencies. Clearly it is more agile than normally, but still, with the need for DH approval and Cabinet Office approval for revisions, how long it takes papers to get to ministers and the ministerial meeting cycle, that means that as you go further up the chain for approval, delays come into the system. That gives a potential for inconsistencies. I can remember one instance in June last year. We published a scientific paper on what our best assessment of the severity was from UK data. That coincided with Liam publishing updated reasonable worst case numbers. One was more up-to-date than the other, and it posed challenges. I got it in the neck, I think. I won't say from whom as I wouldn't be so undiplomatic. Those are the things which, if we think about a really major crisis where we have tens of thousands of people dying, we need to have greater policy agility and a better, more streamlined way of adjusting the operational response.

Another example about SAGE, and I am sure that Justin diplomatically might back this, is the containment policy which was adopted. There was limited scientific advice. SAGE had not been created when that policy was adopted. I might have advised that the name be different as we were never going to contain this virus. But the policy went on, I think, for a good three to four weeks longer than it scientifically and epidemiologically was justified, and it was posing a large burden on lab capacity and NHS responses. There were reasons for that. We can talk to them in a policy sense, but I think, again, had there been that greater flexibility and agility, we might have ramped down faster just as Australia and some other countries—including, frankly, the US—did. They did a rather faster job of ramping down their initial high level response and intensity.

Justin McCracken: Perhaps I could just follow up on that. Neil is absolutely right. First of all, the name "Containment" was a misnomer. It was never expected or intended that it could prevent the spread of the virus around the country. It was about delaying in order to enable the rest of the health care system to be more fully prepared for when there were a larger number of cases. It is absolutely right that the policy was pursued for longer than was justified by the science in terms of whether there was evidence of sustained community transmission, which was the trigger that had been decided.

Also, we hadn't anticipated the degree of variability there would be in terms of intensity of disease activity around the country. So we had hot spots in Birmingham and in London. Although I agree with the point about flexibility in terms of speed of policy making, a bigger issue was flexibility in terms of recognising that you could have different approaches in different parts of the country without being inconsistent. So if you have got a different situation on the ground, you don't necessarily want to apply the same policy right across the country. Undoubtedly, huge pressures were put on both health care and public health staff in the areas where there were hotspots. I think that is one of the areas that has come out of the review that has already been done, and that needs to be considered carefully in planning for the future, both recognising the need for the more flexible response but also having clearly agreed beforehand what the triggers would be to move from one area to another. As Neil will remember, there were lots of discussions about precisely what the trigger levels should be, because that was a bit of the planning that hadn't been completed.

Professor Neil Ferguson: Can I add one tiny thing to that because it may put into context why the UK was so conservative? This is a justification to some extent. It turns out that because we had the most advanced epidemic in Europe, the World Health Organisation's decision to move to phase 6, declaring a full pandemic, hinged on whether and when the UK declared it had sustained community transmission, because that would fulfil the slightly arbitrary criteria that the WHO set. So Department of Health officials and ministers were very conscious that the rest of the world were looking and, therefore, were being, I think, overly conservative in saying, "What is the level of evidence required to demonstrate this fact?" It went all the way through to mid-June when, in reality, I think there was a lot of evidence back in mid-May. I say that, because I was involved, as Maria Zambon was, in that emergency committee, so we heard both sides of it.

Professor Sheila Bird: If I can come in on the issue of the membership of SAGE, the science of statistics is about efficient data collection as well as about analysis. I think there was a gap because there was not a statistician member of SAGE. The information, the consensus statements and so on, which went to SAGE, which are now in the public domain, show that percentages, be they fatality rates or whatever, were quoted in those summary documents without there being an annex which summarised the basic data that underlay those estimates. Now, if I tell you that 11% of the population believes such-and-such, it matters whether I have surveyed nine people and one out of the nine told me they believed it, or whether it is a Gallup survey of a thousand. So I think that is important for us all, actually. If a professional statistician cannot appraise the precision of a percentage without knowing either its denominator or the standard error, then neither can anybody else. We need to know those essentials.

Stephen Metcalfe: Thank you very much.

Q24 Alok Sharma: Can I just turn to the question of how well the Government communicated scientific advice both to the public and also to the responders? I will read you a small extract from the BMA, who stated the following. I don't know, Dr Holden, whether you actually wrote this. They said: "Doctors felt overwhelmed by the volume of information about the H1N1 pandemic issued by various bodies, including Government. Key advice was lost within the large quantity of emails received which often duplicated information." Could I turn to you, first, Professor Ferguson, and just ask you, as a member of SAGE, did you actually feel comfortable in communicating openly with the media about the swine flu pandemic?

Professor Neil Ferguson: Absolutely. There were no restrictions put on me. I was asked to inform the Department of Health if I was doing so. I was so busy, frankly, that I actually did relatively little of it. It is very easy in such circumstances as an independent scientist to become a regular on media programmes. As you all know, even a five-minute slot on the Today programme takes nearly two hours out of your day to do. So I did it very infrequently. Overall, and I did talk informally to journalists on the phone quite a lot, I was quite impressed with the media coverage. There were some outliers but, generally, I thought the way the risk was presented was not inflammatory or exaggerated. It represented the uncertainty and it communicated policy decisions fairly well. What I am not privy to, and I had no sight of, was the torrent of emails that, I am sure, were going to GPs and clinicians in the NHS. I really just saw the public face of communication. I had a few concerns about the weekly CMO's briefings, similar to the Royal Statistical Society, in what they focused on and the presentation of certain numbers as if this was the number of cases in the country. I don't want to go into the technical details. I think those lessons have been learned, but you do need to have a consistent face for the media, and I was satisfied with the CMO being that role.

Q25 Alok Sharma: So you don't think, then, that SAGE itself should be providing advice to the public? I understand that you are now-

Professor Neil Ferguson: Individual members of SAGE did, myself included on occasion, talk to the media. I prefer talking to the media about things I feel particularly competent about rather than just acting as a generic source of scientific expertise to the media. That's an interesting question. Sir John Beddington and Sir Gordon Duff, the co-chairs of SAGE, did relatively little media work during the pandemic, and it was mostly the Chief Medical Officer. I think there are reasons to support having a single source, but maybe there were instances when a greater public visibility might have been good. Certainly it might have good that the public knew we existed and what we were doing, and that, perhaps, wasn't entirely apparent.

Justin McCracken: If I may, just to add to what Neil has said, I think there are two separate issues there. One is communication to professionals and, as Dr Holden has said, the four big organisations did try very hard to get our acts together. I think there are more lessons to learn about that because, quite clearly, despite all our best efforts, there was, frankly, an overload for front-line professionals.

The second point is to do with SAGE and the communication to the public. There was a huge effort put into communicating with the public. We had, initially, daily reports, then weekly reports. From, and I forget exactly when, a few weeks into the pandemic, the Chief Medical Officer instituted his weekly press briefings and we made sure that our weekly reports went out at the same time to avoid any confusing overlap. I think there would be benefit in considering—this links back to the point of closer communication between SAGE, the Chief Scientific Adviser and the Chief Medical Officer—linking some of the evidence that SAGE has considered to make sure that that is part of the same communication process. I think openness about SAGE, about who the members are, their conflicts of interest and the evidence which is presented to it, can only be helpful. I would distinguish between that and their advice to ministers in terms of policy; it would probably not be helpful to make that public contemporaneously.

Q26 Alok Sharma: So just following on from that, Dr Holden, whose job do you think it should be to co-ordinate the difference sources of scientific advice to clinicians?

Dr Peter Holden: I, first of all, would associate myself with all the remarks that have been made; I agree with them entirely. Yes, I did write that, or say it and it got reported. Normally, I believe in complete freedom of information. Part of my job as a doctor is to put a patient's fears at bay because they come in with information that they do not have the knowledge, experience or expertise to put into context, and context is everything. In a scenario like this, this is command and control. You have to accept that. I think, in fairness to ministers, that is why we have got four nation approaches. It is very fundamentally anti-democratic to go command and control, but if that is the survival of the nation, that's what we have to do. If you're in that mode, there is an argument that says that during the emergency there is a common portal of information in and out, to the profession and to the public. We will have the row afterwards. We have this sort of enquiry afterwards to sort out whether it was reasonable, but at the time there is not time for a discussion except among the experts as to what should be going out—what is reasonable. And at the end of the day under these circumstances, you've got to trust the experts. If we get it wrong/right, you can sack us later, but you've got to trust the experts. But I do think you very much risk a Tower of Babel unless you have the coms right. Coms are everything. Every major incident report that has ever come out of Parliament will tell you communications, in whatever way—whether there were not enough radios or we had too many sources of information—is where it goes wrong every time. So, yes, a single portal, I think.

Q27 Roger Williams: Perhaps I could ask Dr Holden a question. He said that the public have a very poor understanding of risk. I guess GPs, perhaps, have a very poor understanding of risk. I tell you a little anecdote, just to draw out the point. The daughter of a constituent of mine was showing symptoms of fever, upset tummy and pain, and was told not to go to the doctor's surgery because it was likely to be swine flu. The doctor then refused to come to visit because it could have been swine flu. In the end the constituent took her daughter to the district general hospital and in two hours she was being operated on for appendicitis. It is a two-way process between the public and the medical profession. I don't know if you would like to comment on that.

Dr Peter Holden: It certainly is, and there were other cases which will limit my comment because I am acting as an expert witness where there are legal implications. But I think what people need to remember is that general practice, in particular, is about balancing risk. If I took the "You can't be too careful" route, I could fill the hospital in two hours, never mind whether it is flu. It is about balancing risk. It is about common things being common and what's most likely in that patient, in that age group with those symptoms. I just hope the patient is better.

Q28 Roger Williams: Better now, yes

Dr Peter Holden: One of the problems is that there was a degree of confusion out there about whether you should visit or shouldn't. I took the view, as did quite a lot of my colleagues, that I came into medicine and I knew there was an infection risk and with infection risk comes the risk of harm to yourself. Many of us just got on with it. The reason that the advice was given about not visiting was, firstly, to dampen the public's expectation that a visit would always be forthcoming, because of the logistical problems, if the pandemic had hit us, of visiting everybody, because we could not have done that. There was not a chance in hell of doing that. So, yes, they got it out of perspective. It's a judgment call. I'm sorry for the patient.

Q29 Stephen Mosley: In your previous answers you talked a bit about the reactions of other countries. You have also talked a bit about the international dimension through things like the World Health Organisation. Do you feel that there are any elements of international co-ordination that could have been improved, and do you think there are any important lessons that we could have learnt from what happened elsewhere?

Professor Neil Ferguson: Could I start? I am sure Justin will follow up. There was a good deal of co-ordination. The World Health Organisation is a strange political body in some ways, but I would say that the UK is disproportionally represented. It was certainly true on the emergency committee. We had more members, advisers on it, myself included, than any other nation. Also that is true of the lower level committees. The United States and the United Kingdom pull well above our weight in that international co-ordination. I think, generally, the exchange of information through teleconferences, both bilaterally between countries and expert groups, experts such as myself included, and multi-laterally organised by the WHO, was excellent. The one failing, and we particularly experienced this, is that while Governments and countries are happy to share analysis—their view of the situation—they are rarely willing to share the detailed data they are collecting in real time, or at least some of it. So that put me in a position where we had very detailed data from the US CDC, data from Mexico and other countries. We couldn't share it with the other partners we were working with. We could only share a kind of synthesis. Again, it was not so much of an issue last year because it was relatively mild, but there were instances where, had we been dealing with something more serious, it could have posed some problems and we could have lost some efficiency about that inability to share raw data.

Justin McCracken: Just to add to that, generally, I do think that there was extremely good international co-operation and sharing of information. We heard promptly about the initial cases, once they came to the United States. From Mexico, obviously, information came through a little more slowly. We had really good co-ordination across Europe. I think we were very lucky that the flu expert at the ECDC, the European Centre for Disease Prevention and Control, is a former employee of the Health Protection Agency. He joined SAGE. We had very good sharing of information, much more broadly internationally, so we were able to send somebody to Australia to observe their flu season before we had our winter season here. There was very, very good sharing of information and, as Professor Ferguson has said, it is probably true that the UK played a very important role in that and really punched above our weight. Obviously, Neil has much better information than I have about the details of the raw data. I'm sure it would be preferable if more data could be shared more quickly. I think within the constraints of what is possible internationally, it is quite remarkable how much was shared how quickly.

Professor Neil Ferguson: Just going back, there is one thing which I think would have been helpful. In this country the Cabinet Office prepared a SITREP, a Situation Report, which came out initially daily and then weekly, which was a very useful synthesis of information, which my colleagues—I was out in the States a lot last year—would have been interested to share with the White House and CDC. Similarly, there were similar high level documents, situation reports from the US, which I also got to see which I think would have been helpful in the UK context. A lot of the information flowed in the informal ways, but the formal sharing of those confidential documents proved impossible. With time, we could have had those formal agreements in place to allow that even closer sharing. It was probably easier between the UK and the US than many other pairs of countries.

Q30 Stephen Mosley: Dr John McCauley, who is a Director of the World Health Organisation's Collaborating Centre has said that he was surprised that the WHO CC didn't have a representative on SAGE giving that international perspective direct to SAGE. Have you got any comments on that?

Justin McCracken: I was not aware of that comment, first of all. My perspective is that SAGE had very good information about the situation internationally, both that collected through the Health Protection Agency with our contacts, both formal and informal, with health protection experts around the world, and also through the direct input from the European Centre for Disease Prevention and Control. So my feeling is that SAGE at no stage lacked the up-to-date information about what was happening around the world.

Professor Neil Ferguson: I should say that Maria Zambon, who is head of the Centre for Infections in the HPA, was a member of the Emergency Committee of the WHO, and I advised that committee myself, and provided that international perspective. She just pointed out that John Skehel, who is the ex-head of the National Institute for Medical Research, which houses that WHO Collaborating Centre, was also a member of the SAGE group. So I would say that it was a slightly unfair criticism.

Professor Sheila Bird: I would like, if I may, to make two remarks on the international situation. Australia and New Zealand did a magnificent job in reporting in the New England Journal of Medicine on all of their confirmed swine flu cases that were admitted to intensive care. That paper was very valuable for us ahead of our second wave of infection.

  The other remark that I would make is that almost every country, at the start of a pandemic, is doing virological testing to confirm its cases for a short period. Thereafter, there is overload on its virologists and it declares that, from a certain point onwards, we are not going to do confirmatory testing. Now, when WHO reports the number of confirmed cases around the world, it does not pay any heed to the fact that the United Kingdom was doing confirmation for six weeks, another country was doing confirmation for two weeks and another country was doing confirmation for 10 weeks. We would have a better appreciation of those numbers confirmed if people understood that routine confirmatory testing has to stop at a certain point because of overload, and the numbers of confirmed cases are not going to continue to go up because we're not doing the testing. That is not reflected in the international reporting, which is remiss.

Q31 Chair: My final question to you, if I may, is that, obviously, this particular emergency was nowhere near as serious as it had the potential to be. With hindsight, is it your judgment that there is sufficient scientific expertise within the civil service, or do you detect a problem? Secondly, would it be your view that things would improve if the Government Office for Science was located in the Cabinet Office?

Justin McCracken: Shall I start off? I am sure that my fellow witnesses will want to contribute. First of all, I can't think of any instance during this pandemic where any lack of or shortcomings in the quality of scientific expertise in the civil service were a limiting factor in terms of the scientific advice available to Government. I thought that the Scientific Secretariat to SAGE that was provided from the Department of Health did an absolutely outstanding job throughout. We talk about people being under pressure. They were under extreme pressure. So, in that sense, I do not think that there are problems in terms of quality or quantity. People had to work extremely hard. The Department was flexible at pulling in extra resource because it was in, as it were, crisis mode, but we would expect that to happen, I think. Equally, I'm not aware that the position of the Government Office for Science   was a problem in terms of this particular incident.

Professor Neil Ferguson: I would reinforce much of that. I think that the DH Secretariat for SAGE was truly excellent. Partly because of the real investment in previous pandemic planning we had before there was a cadre of very senior civil servants in the Department of Health who had a very comprehensive knowledge of the science themselves and really were experts in their own right, and some very expert junior staff.

  I would add to that. I think the creation, several years ago now, of the Civil Contingencies Secretariat in the Cabinet Office aided the response considerably as well, because now you have in the Cabinet Office a set of, maybe, less subject specialists but certainly people with a good scientific background in the understanding of risk and management of crises. The Cabinet Office briefing reports and situation reports were, I always thought, excellent documents put together by that team. So I think we are much better positioned now than, for instance, 10 years ago when I was dealing with foot and mouth disease.

  In terms of location—I don't think it is my place to say—I can see advantages both ways. The home in BIS is relevant for the Chief Scientist's role as the face of science in British Government because that is where the Research Councils sit. Yet, in dealing with emergency response and in advising the Prime Minister, I could imagine that sitting in the Cabinet Office would be equally useful. I suspect that he spends half his time there, anyhow.

Professor Sheila Bird: I wasn't on SAGE but, obviously, the secretariat for SPI, many of whom transited to do the secretariat work for SAGE and were scientific staff in the Department of Health, providing the secretariat for all the Scientific Pandemic Influenza Advisory Committee and were excellent and, as colleagues have said, very well versed in the science.

Chair: Can I thank you all for very frank answers. We have slightly overrun because of the importance of your evidence. We may well follow up some of the questions in a little more detail. Thank you very much for attending this morning.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2011
Prepared 2 March 2011