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

Examination of witnesses (Questions 32-59

Q32 Chair: Good morning, gentlemen. Thank you very much for coming to see us, and apologies for running slightly late. The previous witnesses have given us a lot of food for thought and I am sure you will as well. We will try and keep this relatively sharp, if we can. You are aware of the scope of our inquiry. We, clearly, wanted to look at the expertise that you bring to this debate.

First of all, can I ask how well did SAGE function in particular in the swine flu epidemic? How were the members of SAGE identified? Was there a relevant balance of expertise represented or was there too much emphasis on modelling?

Professor Harper: Thank you, Chair, and thank you for the opportunity to come along and talk to you this morning. I think, maybe, if I could start, very quickly, just by introducing my colleagues, and then I will come to the question, if I might. On my right is Professor Sir Liam Donaldson, who was formerly Chief Medical Officer in the Department of Health, and on my left is Professor Sir Gordon Duff who, amongst other roles that he has been playing recently, was the Chair of the SPI Committee, the Scientific Pandemic Influenza Committee, and also co-chair of SAGE. I am the Chief Scientist in the Department of Health and also the Director General for Health Improvement and Protection. So if, maybe, I could start, then my colleagues can pick up some of the points in due course.

  I think SAGE worked very well and it built on some of the lessons learnt from previous emergencies, not least going back as far as the foot and mouth disease crisis some years ago. Members were selected on the basis of their professional expertise and to try to cover a broad range of different interests, and in fact the majority of members were previously members of the committee that Sir Gordon chaired, SPI, and before that even members of the committee that I had chaired going back to 2005/2006, which was the Scientific Advisory Group set up to look at pandemic influenza preparedness.

  When it came to establishing SAGE, the membership was discussed, of course, with the Government's Chief Scientific Advisor, Sir John Beddington.

Q33 Chair: When the committee was in session, there must have been instances where there was, at least, a minority view, dissent in the ranks somewhere. How were minority views or differences of opinion transmitted to Government?

Sir Liam Donaldson: Would you like me to answer that?

Professor Harper: Yes, of course.

Sir Liam Donaldson: I have two additional points to make, Chairman. The first one is a wider point about modelling, which isn't specifically the question you asked, but I do think that the role of modelling during emergencies, as compared to planning emergencies, is quite different. I think we did have some problems with the use of modelling data during the emergency, even though it was of enormous value when we were doing our plans before all of this happened, but I will just leave that aside.

  On the meetings of SAGE, they were reported to the COBRAA Committee, the ministerial cross-government committee, every time it met, and the report was made by Sir John Beddington who was co-Chair of SAGE. My impression is that it was remarkable on how few occasions they disagreed. The only point I remember when there was quite a split in SAGE, and that was reported to the committee before COBRAA took its decision, was on whether anti-virals should be offered to all symptomatic patients or only high risk group patients. You can say, "Well, it's unfortunate that there was a disagreement", but the committee met, I think, something like 22 times, and there were only, really, one or two controversial sessions during that whole time. So I think that is pretty good for a scientific committee advising in a fast-moving emergency, but certainly the minority view was represented by Sir John before COBRAA took its decision.

Professor Sir Gordon Duff: Thank you, Chairman. May I revisit your first question, too, about the composition and the representativeness of SAGE or SPI, first of all? SPI, which arose from the previous Scientific Advisory Group that had started in 2005, was essentially a scientific group for preparedness for a pandemic. When I was appointed in 2008 as an independent chairman, one of my jobs was to increase the number of independent scientists on the committee. In doing that, I took personal advice from major institutions, including both the Royal Society and the Royal Society of Edinburgh. Most of the people on SPI were in fact independent academics at the top of their fields. When the pandemic arrived and the Scientific Advisory Group for Emergencies was set up, it was a smaller committee, the core of which had been members of SPI, augmented by one or two extra leading experts in necessary areas.

  With regard to your second question, Chairman, which was how dissent or disagreement was dealt with, I think what Sir Liam said was absolutely correct. We worked always very hard to achieve a concensus on all the difficult points. We were, I think, remarkably successful in that I only have a memory of one occasion when a majority vote was taken and, as Sir Liam said, that was from a total of 22 meetings during a time when there were quite a lot of decisions or recommendations that had to be formulated.

Q34 Chair: Am I right in assuming, Sir Gordon, that you periodically orally briefed COBRAA?

Professor Sir Gordon Duff: Yes. I attended most of the meetings as an observer, and on one occasion where Sir John Beddington could not attend I did the briefing as well.

Q35 Chair: So Sir John gave the routine briefing?

Professor Sir Gordon Duff: Yes.

Q36 Chair: But you were present at all times?

Professor Sir Gordon Duff: I was present pretty much at all times, not actually at every meeting. On occasion when he could not be there, I deputised for him.

Q37 Chair: Sir Liam, you weren't on SAGE?

Sir Liam Donaldson: No.

Q38 Chair: Should you have been?

Sir Liam Donaldson: No, Chairman. I think there is a potential conflict of interest there. I was the UK Government's Chief Medical Adviser and I had a responsibility, I think, to represent and comment on the scientific advice that was coming through. I think there are dangers in somebody in that role being locked into the main Scientific Advisory Committee. Nine times out of 10, I would, obviously, completely agree with the scientific advice, but sometimes in the world of public health, there are minority views that some people try to portray as crankish views. If we look back, for example, to the BSE crisis, what we saw there was scientific advice coming through at one point, which was absolutely crucial, which said there was no risk to the public from BSE. Now, I think in that situation it is the Chief Medical Officer's role to say to the Government, "Well, that is the mainstream scientific view, but you need to be aware that there is a minority view which holds a totally different position," and to be able to explain in simple terms what the pros and cons of those are. Now, in the situation of the pandemic, there wasn't an occasion where I disagreed with the scientific advice, but I think it was important that I had that distance.

Q39 Gavin Barwell: Professor Harper, you referred in what you had to say about the lessons which have been learned from previous issues which were applied this time. What would you change about the operation of SAGE going forward? What have you learned from this particular pandemic?

Professor Harper: I think SAGE operated well, as I said, to start with. I think one of the issues is, really, to pay particular attention to the links that Sir Liam and Sir Gordon have just alluded to, to make sure that where there are sources of advice that we are able to have the discussions properly within the framework and anticipate any differences of opinion that are almost inevitable with any high quality scientific discussion to be able to accommodate those properly in the framework.

  I think the other issue is really about communicating, and we might want to come on to this, or you might want to come on to it, later, communicating uncertainty, particularly with an issue such as pandemic influenza where, inevitably, in the early stages of the pandemic there will be great uncertainties. It is a new virus by definition. We don't know what the disease profile is. Sometimes getting across those messages requires particular communication skills, and I think, perhaps, SAGE could have played a different part in communicating to the professional groups out there so that we could help communicate some of those uncertainties.

Q40 Gavin Barwell: I have a question for all three of you. Going beyond just the role of SAGE, what lessons do you think the Government as a whole should draw from the pandemic, that it should apply to future outbreaks of pandemic influenza?

Professor Harper: If I start and then, I am sure, my colleagues will pick up. From very much a personal point of view, and I made this point in contributing to the WHO international review of how the pandemic was handled, I think there are three points that I would like to pick up. One is that within the UK we were able to adopt some containment. It was called "containment" in the early stages of the pandemic. Given you are the Science and Technology Committee, I should qualify that. It was always recognised that this, actually, was not containment. It was used as a shorthand for handling the initial phase of the pandemic. I think we have to be very clear in communicating that but also for the professionals involved in managing that initial phase of the pandemic, what the objectives are, what the scope of that phase might be. So that is one.

  The other two are closely related, really. It is the flexibility that, I think, we should look very carefully at for the future; flexibility for local response, flexibility internationally as well, given the leading role that the World Health Organisation played in the pandemic and the declaration of the pandemic and the criteria that we used to go into the decision to declare a pandemic. Some of the flexibilities around those areas are very important indeed, and I think we need to pay particular attention to that. I think the third point, which is linked to what I've said already, is how to communicate properly the uncertainty, but particularly where modellers are helping us in planning assumption terms, but when we talk about reasonable worst case scenarios, what does that actually mean, and try to get that message across more clearly. I think those are the three areas that I would pick.

Sir Liam Donaldson: Thank you. I think No. 1 priority should be to get a vaccine which is broad spectrum, and then we wouldn't have any more pandemics and, ideally, one that was cheap and easy to produce so that it would give long-term protection against all possible strains of influenza. That isn't impossible but it is, obviously, well on to the horizon and requires a lot of research. I would qualify that by saying that it may seem a dream but there had been very little research done on flu vaccines until avian flu came along because it wasn't in the interest of the vaccine industry, who were selling a new vaccine every year, to do a lot of research. Now we saw quite a lot of breakthroughs in the creation of vaccines during the phase of planning for a possible avian flu-related pandemic, and I think we should push even harder now to get that bigger breakthrough.

  The second thing is, just picking up Professor Harper's point on the public communication of risk, as the messenger for the 65,000 figure which came from the scientific modellers, is that there is a big question about the public understanding of science, clearly. I spent a long time in that particular press briefing with the journalists, slightly short of pleading with them not to put out misleading information. Apart from one correspondent, they didn't contextualise the figure at all. The modelling scientists would always say, "Well, even the 65,000 figure or figures like that held scientific water because those were the inputs that we had at the time", and then as they got more and more data, their number would come down and down and down. Unfortunately, that doesn't have much credibility with the public. They can't relate to that at all, understandably. So I think a great deal of care needs to be taken about the use of figures. I certainly felt that at the time. Even a back of the envelope calculation that I did suggested to me that we would get no more than a thousand deaths, but that was not the scientifically agreed figure. So I could hardly dissent from the bigger figure. So public understanding, particularly of that aspect of science, I think is quite important. If you become the subject of ridicule it can undermine public confidence in your whole programme.

Q41 Chair: Sir Liam, you are just describing things in terms of conventional historic ways of communicating to the public?

Sir Liam Donaldson: Yes.

Q42 Chair: Surely, had you had, right at the outset, a single flu portal, perhaps discussions with internet service providers to flag that up as the key source of information, you could have out-manoeuvred the red-top editors and have done a better job in managing public understanding?

Sir Liam Donaldson: With due respect, I think we did do a pretty good job on communication throughout. We had weekly press briefings. You won't find many journalists/health correspondents who would criticise. They were very open.

Q43 Chair: You have just said that only one journalist contextualised your answer.

Sir Liam Donaldson: That was on one press conference, on one out of 30 press conferences.

Q44 Chair: Had you done it my way through a single portal you would have been able to contextualise it in advance of the press conference?

Sir Liam Donaldson: Well, yes, possibly. First of all, we were only told a couple of hours ahead of the press briefing that we were entitled to release that figure, so it would have been difficult. So that was my second point on that particular aspect of public communication.

  The third one is that I think it would help to have more flexible vaccine contracts so that you aren't committed to so much expenditure based on a precautionary approach. I know that is quite difficult commercially to do that, but in the end we ended up ordering and paying for more vaccine than we actually used. So that would be my third point.

Professor Sir Gordon Duff: Chairman, if I might go back to Mr Barwell's question, which I think was not specific to the pandemic influenza experience but what was learnt from that that could be generalised. Of course, there are many things. I would say from where I was standing or sitting, the key thing was to have identified beforehand what the key information needs were going to be. In the period of preparedness you needed to make sure, as much as you could, that you would know what you needed to know and set up the machinery for acquiring it as rapidly as possible so that you could deploy your counter measures effectively. That is a generalisable situation. In the case of the pandemic it is all rather easy. The two things that we needed to know were how fast the virus was spreading, and how severe was the illness, with a sub-set of questions about were there special groups in each category, where it was spreading faster or it was more severe. I would think that that approach is highly generalisable across any national emergency.

  With SAGE I think we did pretty well in getting hold of the information on the spread. It took us a little bit longer to get hold of the information on how severe the illness was. We probably ought to have some legacy, ability, to track what is happening in the hospitals at the early part of an epidemic or a pandemic.

Sir Liam Donaldson: Could I just add something very quickly, Chairman? The amazing thing for me, having dealt with other emergencies over the years was there were relatively few surprises in this one. We had done the planning in advance for a more severe form of the virus, which is what was anticipated, but there were very few things that were unexpected apart from the mildness of the virus. That surprised me a great deal, because normally in an emergency you are being hit daily with twists and turns that you have got to react to and you hadn't expected. There wasn't much of that in this pandemic.

Q45 Stephen Mosley: One of the key features of the scientific advisory committees is that they are independent from Government and provide independent advice in a transparent manner. There is an impression that we have got, as the Royal Statistical Society has said, which is that when the SPI was suspended and SAGE was convened, that independent sub-committee effectively was in abeyance. The question that I would like to ask is, why was the SPI Advisory Committee absorbed into SAGE, and did it manage to retain its independence, and are actually are there any codes of practice out there that specify how the SAGE should act independently of Government?

Professor Harper: If I, again, could maybe start and I am sure that Sir Gordon, as the Chair of SPI and co-chair of SAGE, will want to add to this. Coming to the last part of the question, there are codes of practice produced. Well, there are guidelines, principles and a code of practice which in fact has just been refreshed and has been issued for consultation, I think, just last month in fact, from the Government's Chief Scientific Adviser, Sir John Beddington. These codes of practice and guidelines go back some way. I think the guidelines that have just been refreshed were published in 2007, and they are guidelines and codes of practice that are there to allow the framework to be created to preserve the independence of advice, which is very important given some of the changes that we are seeing currently in terms of our advisory non-departmental public bodies. So there are codes of practice and there is guidance there. Of course, as Chief Scientist in the Department, I work very closely with Sir John Beddington, as he works with other chief scientists and chief scientific advisers, to make sure that between us we have the right sort of relationships with our advisory committees and with our executive non-departmental bodies to be able to protect and preserve that independence. I think the one part of that I would question slightly is independence from Government. I think it is very important that we have independent scientific advice, scientific advice from independent scientists, however they might be defined, but scientists who are at the top of their profession, who have professional integrity and are able to play into that fairly extensive machinery across Government. Sir Gordon.

Professor Sir Gordon Duff: Thank you, David. The transition from what we call SPI, which was the preparedness committee, to SAGE, which was the wartime real committee for the pandemic, was done in a way where the independent academic voice, the independent scientific challenge, was retained, so SPI had three sub groups. One was called Modelling, which you probably know about; one was called Clinical Countermeasures, and the third was called Behaviour and Communication. Those sub groups were actually used by SAGE going forwards.

  The fact that I, as an independent, became co-chair of SAGE retains the challenge function. The challenge function is understood to be important but we also understand it to be only in the appreciation and interpretation of the scientific evidence. There is a distinction between that and its interpretation or translation into policy. So when it comes to challenging the scientific data and how it is being interpreted, I think SAGE had a very good and independent role in that and maintained that role throughout. I never really felt anything other than that the scientific advice that was coming through was the best possible scientific advice based purely on an appreciation of the data available.

Q46 Stephen Mosley: The other element to that is actually transparency. The SACs' guidelines and their transparency, their published minutes. There is an impression that SAGE is a lot more closed. Do you think that SAGE should be a bit more open to external scientific scrutiny, and also when it comes to you giving advice to the Ministers, do you get the impression that they do listen to your advice and, if not, do they give you an adequate explanation of why they have made their decision?

Professor Sir Gordon Duff: They are good questions. The first one, the way that SAGE had to work, I think, we have to put it in context, so we are talking about a preparedness committee that was meeting two or three times a year to, as it were, an emergency committee that was meeting weekly at the beginning and with sub-meetings in between. So the people involved had to be prepared and in a position to give up that amount of time. It was essentially a full-time job for the first few months. So that put some constraints on who could participate and who couldn't. Also the rate of progress, the rate at which things were going, made it quite difficult always to be as open, or appear to be as open, as we would like. We were most of the time adopting interim positions on a daily basis and it would have been extremely confusing to put out SAGE deliberations until they had crystallised on a given point. I think that is quite an important distinction between what happened between SPI and SAGE.

What was the second part of your question?

Q47 Stephen Mosley: It was more when you were giving SAGE's advice to the Government and the Government listens to that advice, and if they then make a decision do they actually give you an adequate explanation of why they've made the decision they did?

Professor Sir Gordon Duff: Don't forget, I observed rather than reported to the triple C, except when Sir John Beddington couldn't. My impression was that the scientific advice was taken extremely openly and given a lot of weight. I never heard a lack of response to the scientific advice. I'm not entirely sure that there was ever a time when the scientific advice was rejected. So I'm not quite sure whether I can answer your question, was an explanation given when it was rejected?

Stephen Mosley: Okay.

Professor Harper: Perhaps I could just add a few comments to Sir Gordon's. I think on the openness and transparency, the principle is absolutely beyond doubt, and that's the way that we encourage all of our scientific advisory committees to operate in the context of publishing minutes and maybe public meetings and so on and so forth. I think there is a difference that Sir Gordon alluded to here in the operational nature of SAGE and in its primary function of advising Ministers directly. I think the risk that needs to be balanced here is when we want open and honest discussion between scientists in the context of SAGE, we need to be careful, particularly if you look at reasonable worst case scenarios, whatever they might be, that information isn't available to a wider audience in—it sounds strange to say—less controlled way. One of the key features that you've already been focusing on is the need to put information to people in a way that they can understand it, that they can contextualise it and that they can appreciate the situation. There is a risk that needs to be counter-balanced there with high level, often very technical, complex scientific discussions. If the information is immediately available, there is a risk associated with that in this operational sense, but I stress it is in the context of SAGE working through the pandemic itself.

As far as Ministers and Government is concerned and the advice that was coming from SAGE, I'm not aware, or I can't think offhand, as Sir Gordon says, of any occasion when there was a reluctance to accept SAGE's advice. Sir John, as you have just heard, or Sir Gordon, were present at the COBRAA meetings, at the Civil Contingencies Committee meetings, to be able to make the input directly as co-chairs or as Chair of SAGE. Ministers have, without exception, been, I think, completely committed to using the best science. Science based and evidence based policy making has been to the fore throughout pandemic influenza handling and long before that as well.

Sir Liam Donaldson: If I could just add, briefly, it is important not to forget when all of this was going on that the science was being used to make lots of policy decisions quickly. There was a huge amount happening across Government with different Departments doing things, but particularly in the NHS. So we would be having to decide, "Do we need more paediatric intensive care beds?", because if we didn't have enough then children might die. "What are we going to do with the GPs who are being overwhelmed in London and the West Midlands? How are we going to get the supplies of anti-virals out?" So all of these things were happening. What SAGE was doing was providing and underpinning, scientific advice for some of them, but there were other areas where there was no science available to aid the policy decisions, but certainly SAGE was not telling the Government or advising the Government what policies to implement. There was another step which was often played out within the COBRAA discussions on what to do about the scientific advice, which didn't always have clear cut answers to it.

Q48 Graham Stringer: Sir Liam, in one of your previous answers you talked about smarter purchasing of vaccines.

Sir Liam Donaldson: Yes.

Graham Stringer: How much do you think could be saved in the future by smarter contracts?

Sir Liam Donaldson: I probably couldn't put a financial figure on it, and Professor Harper might want to comment because he was primarily involved in this. I do think that substantial sums of money could be saved.

Professor Harper: Well, I certainly wouldn't talk about individual figures. It depends entirely on the context.

Graham Stringer: It would be much more interesting if you did talk about individual figures.

Professor Harper: It depends on the vaccine, on the circumstances. What I was going to say was that we must always remember that we are part of a global market, and what contracts are let need to be seen in that context, so it's not as though the UK is in some privileged position in negotiating with any of the manufacturers.

Q49 Graham Stringer: I understand that. But what applies to the vaccine, does it also apply to the anti-virals? Is there, potentially, a great deal of money to be saved here if we think hard about the contracts for future emergencies?

Sir Liam Donaldson: I believe there is, yes, but I couldn't put a figure on it.

Q50 Graham Stringer: On both anti-virals and vaccines?

Sir Liam Donaldson: Yes.

Graham Stringer: That is clear even if it is not quantified. Thanks. I want to go back as well, Sir Liam, to another one of your answers. You talked about the "65,000 deaths" scenario. The discussion about that has been addressed a bit, but I was surprised that you were only allowed to release that figure two hours before the briefing with the press. Can you give us some background into the discussion that went on to the releasing of that figure?

Sir Liam Donaldson: Yes. There were two elements to the cross-Government emergency planning meetings, as you probably know. There was an officials' group, and then there was the ministerial group and they met on the days that the ministerial group met. The officials' group had met earlier in the morning. So they had already considered the various matters that were going to be discussed by ministers, including reports from the scientific committee. So, essentially, given that we had a weekly press briefing, the COBRAA ministerial meeting on Thursday was receiving for the first time the data on these modelling estimates. So we had to decide whether we told the press about it on that Thursday's briefing, which was happening a few hours later, or whether it was held back for a later briefing. Our view, or the view of the Ministers, the two Secretaries of State for Health who chaired the committees, Alan Johnson and Andy Burnham, was generally to be as open as early as possible, because if it had leaked out to the media we felt it would be more sensationalised. Now, it was sensationalised but I did my very best in that press briefing to explain at great length to journalists the nature of these figures, how they arose and to contextualise it, but it was to a degree sensationalised.

Q51 Graham Stringer: Was part of the contextualisation the number of deaths that there had actually been at the time of that briefing, and what was that number at the time?

Sir Liam Donaldson: The number of deaths at the time of that briefing, I think, would have been less than 200. I can't remember the exact figure.

Q52 Graham Stringer: And that was part of the contextualisation?

Sir Liam Donaldson: It certainly was; yes.

Q53 Graham Stringer: Can we talk about communications within the medical profession itself? The BMA were critical in two ways, really, in their submission to this Committee. One was that they were being bombarded with information from all sides and, therefore, it was difficult for them to extract the appropriate information, and then, secondly, when it came to use of anti-virals, they were unaware, in spite of all that turbulence, of the evidence base, and their instinct was not to prescribe anti-virals to adults, who were otherwise healthy apart from having flu. Do you think the BMA's criticisms about the communications are fair?

Sir Liam Donaldson: I think they are a little unfair. We dealt, on the GP side, with the two main groups, the Royal College of General Practitioners, who we used very, very extensively to monitor the quality of the flu lines and the National Pandemic Flu Service, to talk to their members and fellows and give us feedback and criticisms which we looked at on a regular basis. We also had regular contact with the BMA GP committee. It is worth saying, just out of completeness, that the BMA relationship with the Department of Health was also contractual. There were protracted negotiations on payment for administration of vaccines and for delivering services. So they were both acting as a professional body and a trade union, and we were dealing with them in two different contexts at the same time. But I think the idea that we over-communicated with them is a little unfair because, really, at other times they were saying to us, informally, "We need to know more."

Q54 Graham Stringer: That really is the point. It is both too much information in some places and not enough in other places. That is poor communication, isn't it?

Sir Liam Donaldson: I don't think the communication with them was poor. We contacted them formally through letters from me. They were contacted through their representatives who were regularly briefed. As the pandemic was emerging, they actually requested that we set up the National Pandemic Flu Service because they were overwhelmed in volume of work in the West Midlands and in London. So I felt our relationship with them was good.

  Now, on the anti-virals, that is a whole subject in its own right, because the scientific evidence base for the use of anti-virals in a pandemic does not exist. There is some evidence about the use of anti-virals in normal seasonal flu but not the huge amount. So, to a certain extent, and we were guided by SAGE here, we were deciding policy with an incomplete evidence base. Further research is needed on all of that and, hopefully, after looking at some of the data coming out of the pandemic at greater length we will be able to say a bit more about it. But the issue, centrally, was whether to be very precautionary, because we knew that some people who had symptoms of flu and no other underlying conditions, like diabetes or heart disease, died, not many of them, but we are in the 21st century, and we don't want people to die if we can avoid it. We also knew that anti-virals would probably reduce the severity of the illness, so the precautionary approach was to use the anti-virals more freely.

  Now, it is fair to say that some of the opinion within the BMA was, "Leave that to the clinical judgment of GPs", but you can't really win on that. If you are less precautionary and give the anti-virals less freely, then your risk is that some people would die. I am afraid that in a situation like that certainly my view has always been to take the precautionary line, and that's why I strongly felt that we should be using the anti-virals. There were children involved as well, and some healthy children had died, and I just wasn't prepared to see us take risks with children's lives and adults' lives.

Q55 Roger Williams: I have a few questions on the way in which there was co-ordination with the devolved Administrations, and perhaps I could ask Sir Liam really. How did you co-ordinate with the chief medical officers of the devolved Administrations?

Sir Liam Donaldson: I know them all very well and we were always on very good terms. There is a regular quarterly meeting of the chief medical officers to cover all areas of mutual interest, not just this. It happened before the emergency. So we've been very involved with them. I had been very involved in working with them on the plans before all of this started, and during the pandemic we had regular teleconferences, usually, because it was very difficult to get everybody together face-to-face with everything going on. So that was the main way that we communicated. Occasionally, I would have one-to-one telephone calls with one or the other. As you can imagine, in a situation like this there are quite a few trouble-shooting things that arise and you want to know what somebody else is doing and get their experience. Generally, I think it worked very well.

Q56 Roger Williams: Presumably, the scientific basis on the decisions was the same for all the four devolved Administrations. So how come we had different strategies arising in different places?

Sir Liam Donaldson: I think that is the point I was making earlier, Mr Williams. On the move between the science and the determination of policy, there was a little bit of an area there where judgment was required, and I think that explains some of the differences which were not major. There were big discussions, particularly about the presentation and the timing of the presentation of information to the public. There were some heavy discussions at times on that, but I think on the scientific decisions there were only, really, two or three areas where there were, initially, quite big disagreements and then everybody, I think, reached a consensus. One was on whether to offer the anti-virals on a more precautionary basis, and part of that was determined by the fact that in England we were getting many, many more cases, whereas in Wales, Scotland and Northern Ireland they weren't, and they could still run the anti-viral prescribing through a conventional GP system. That explained that. Then when we get into the territory of negotiating with the BMA about vaccine payments and so on, then, as you can imagine, there were elements of frustration in that and differences of view on how that should be handled.

Professor Sir Gordon Duff: With regard to that, after the early part of the pandemic when the efforts were aimed at using these counter measures to slow spread, once we had gone beyond that, all SAGE's advice on the use of anti-virals has always contained the scope for clinical discretion. SAGE would never have wanted to advise that a prescriber or a doctor should not be able to prescribe if, in their clinical judgment, it was going to do more good than harm, and at the same time they should not be forced to prescribe if, in their clinical judgement, it was going to do more harm than good. So that was built into the anti-viral advice pretty much as soon as we came out of the first stage of trying to slow things down.

Q57 Roger Williams: In the report that Dame Deirdre produced, I think one of the recommendations was that there should be a clarification of the way in which the devolved Health Ministers received the advice from SAGE. Was that a good recommendation? Why do you need the recommendation in the first place?

Professor Sir Gordon Duff: We would have welcomed the representatives from the devolved Administrations at any SAGE meeting. I have got a feeling that there was an open invitation. Certainly by the time that advice was transmitted to Ministers.

Professor Harper: Maybe I could say a few words in response to the question. Certainly with our expert committees, including the likes of the Joint Committee on Vaccination and Immunisation, which was one of the key committees as we moved through the pandemic, the advice that was provided was provided to the devolved administrations in just the same way as to England and to central Government. For the ministers, all of the appropriate ministers from the devolved administrations were involved in the Civil Contingencies Committee discussions, usually, in fact, almost exclusively, I think, by teleconference, but they were certainly involved. They heard the presentations from Sir John Beddington, from Sir Liam, Sir Gordon and others. So they were in possession of the same basic scientific and evidence base.

I think what Dame Deidre said in her report in fact-I know what she said-was that the model that was created of having the four nations ministerial discussions outwith the main CCC or COBRAA discussions was a very good model and it helped improve the speed with which some of the key decisions needed to be taken. She has held that up as an example of how to work in the future as far as the ministerial collaboration around some of these key areas is concerned.

Sir Liam Donaldson: The other thing to say, Mr Williams, is, obviously, as you can imagine, behind the scenes there were occasionally disagreements, but one of the areas which I think we hit for the first time in the relationship with the use of scientific advice was that there were a couple of occasions where Ministers, particularly from the devolved Administrations, felt that they had been given the advice in a very cut and dried way, without the chance to debate it. That is quite a delicate area, you see, because some people would say, "Well, for politicians to become involved before the scientists have given their advice is political interference." So there was quite a bit of tension at one stage. From memory, it was about the policy on vaccination because some of the Ministers held the view that they wanted to vaccinate school children and then others didn't, and the advice coming from the JCVI was, "No, there isn't a case for vaccinating school children." I think there was a feeling amongst some Ministers of, "Well, they've just told us this now. They have made their advice public. We're left with a fait accompli and we want to hear why they have decided this before they start telling the public what they've decided." So there was a little bit of a row behind the scenes about that. But I take the view that it is healthy that there is some disagreement and debate in these situations and there is not just a passive reaction to everything. That is the sort of territory that we hit for the first time-the idea of scientific advice being made public before Ministers had actually taken the policy decision based on the science-and it was a tricky area. It was only in certain conditions that it arose.

Q58 Roger Williams: In the previous Parliament, I sat on the Environment, Food and Rural Affairs Select Committee, and we did some very good and enjoyable reports on avian flu both from its agricultural perspective and its wildlife perspective, but also on the possibility of it crossing the species barrier and becoming highly infectious in humans. I remember the term "highly pathenogenic", well, certainly making you feel very poorly, anyway. I got the impression that the approach to the swine flu thing was ramped up because we were expecting an avian flu outbreak. I just wonder now, having dealt successfully with the swine flu outbreak, although there are some reservations, obviously, are we better prepared for an avian flu outbreak that could possibly occur?

Professor Harper: I think we are better prepared. As many people have commented, going through swine flu is the best possible test of how well prepared we were. A number of lessons were learnt, some of which we have touched upon, but I am bound to say, again, as we have already said, in the early days of a pandemic, with a completely new virus, with an unknown disease profile, it would be strange to think that the initial actions that were taken would be very different. In some ways, I am sure, there are refinements that could be made and we could talk more about that if you wanted to. But I think the principle is to try as hard as we can to get as much time as possible to be able to characterise the nature of the disease and so on, and that is as part of the global community, so that applies wherever the pandemic emerges, and, of course, it's conceivable that it could emerge in this country. I think with avian flu, in particular, the risk is more likely from those countries where there is close proximity of humans and birds, domestic fowl and the like.

  With the great uncertainty in the early stages of a pandemic, it is very likely that we would be taking similar courses of action to try to learn as much as we could, as quickly as we can, about the disease.

Sir Liam Donaldson: I was just going to say, quickly, that I think there are two sides to it. I think, first of all, it has been extremely valuable in anticipating what might happen with a more severe strain of the flu. I think the particular value has been in testing the capacity of the NHS to respond because, essentially, we had anticipated in the planning that the NHS would be overwhelmed. Hence, we had to have some way of diverting the pressure with the use of the flu line, which was very, very effective. There isn't a completely right answer to that because people will always say, "Oh, you're giving anti-virals to people that don't need it. People are just taking them. You'll promote anti-viral resistance", all of this. We were in some cases quite close to the maximum on our intensive care beds, particularly for children.

Before we had all of this, NHS managers could not picture what it would be like to have thousands of extra cases flowing in. Now they can picture it, but what we would ideally like to be able to tell them, if we had a more severe strain, is, would it be five times worse, would it be 10 times worse, would it be 20 times worse? That's the way we've got to think about it, because if that NHS capacity failed then people would be dying, lying out in the streets outside the hospitals.

The other side of the coin, I think, is from the public perception point of view. They have been through a pandemic, they were warned that this was something very different, it was a pandemic, and they have concluded, probably, that it wasn't so bad. So will everybody take another pandemic seriously? So I think there are two ways of looking at it.

Q59 Roger Williams: It seems to me that preparedness for another pandemic is dependent on surveillance. As you rightly said, it is areas where contact between humans and birds is more close than it is probably in the developed world. Is there anything we can do on an international basis to improve surveillance and pick up any possible beginnings of an outbreak that could have severe effects in this country?

Professor Harper: This was part of the preparation, anyway, given the risks from avian flu. You will all recall, I am sure, some of the big meetings that were held as part of the international approach. Some of them were called "pledging conferences", where part of the objective there was to increase the resource available to those countries most in need, and part of it, under the auspices of the World Health Organisation, was to try to improve surveillance in those countries that perhaps didn't have the quality of surveillance that we have in the UK and in some of the other more developed countries. So that was always part of preparation. It will remain a big challenge because resources are limited and they need to be targeted. In some of the countries of most concern, most at risk for the reasons that you have just indicated, there are issues around health systems generally. It is about capacity and capability in a very broad sense, so surveillance is very, very important. I think we are better placed than we were and the recognition of that is clearer. The World Health Organisation has this key leadership role to play, as do some of the other international organisations, notably, the Animal Health Organisation-OIE-and others because this is very much an animal/human concern that we have. So those discussions are continuing.

The point that Sir Liam has made is a very good one. Having been through swine flu and it turning out not to be as serious as maybe some had anticipated, I think what Sir Liam was saying about the public in the UK is equally true of communities globally. So to have governments putting extra resource into surveillance of zoonotic infections in a country that has a huge number of other pressures will remain a big policy challenge.

Sir Liam Donaldson: The only thing I would add, and this is going a bit beyond flu viruses now, is that the area I do think does need more attention is the risks arising from a deliberately man-made, engineered virus that would be released and whether we have the security and policing of laboratories and of students to know whether that could happen. I do think that is an area which needs to be looked at more thoroughly.

Professor Sir Gordon Duff: Could I just go back to the very beginning of what you said? It is undoubtedly true that it was the H5N1 experience in the Far East that was driving the planning assumptions or the worst fears of a highly pathogenic, highly transmissible virus-a new virus. The problem is that decisions have to be taken at the outset of a new influenza before you have all the information that you need. So you have got to commission the vaccine as soon as you have got a vaccine seed before you know how devastating an illness it's going to be.

At the beginning of our discussions Sir Liam brought up a concept that I think is very key to going forward, which is more research, more support for research, for a universal flu vaccine. It wouldn't necessarily have to be a perfect vaccine in terms of protection, but as long as it would reduce both the transmissibility and the pathogenicity, the virulence, we would have no further need to plan for huge pandemics.

Chair: We will see later on this afternoon the probability of funding that kind of research. Gentlemen, can I thank you for your attendance this morning. It has been an extremely enlightening session. There may be a few follow-up questions we would like to write to you about following on from your evidence. Thank you very much for your attendance.

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