Scientific advice and evidence in emergencies






Scientific advice and evidence in emergencies  

Wednesday 20 October 2010

Professor Sheila Bird, Professor Neil Ferguson, Justin McCracken and Dr Peter Holden

Professor David Harper, Professor Sir Gordon Duff and Sir Liam Donaldson

Evidence heard in  Public Questions  1 - 59



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Oral Evidence


on  Wednesday 20 October 2010

Members present:


Andrew Miller (Chair)

Gavin Barwell

Stephen Metcalfe

Stephen Mosley

Pamela Nash

Alok Sharma

Graham Stringer

Roger Williams

Examination of Witnesses

Witnesses: Professor Sheila Bird, Vice President (2006-09), Royal Statistical Society, Professor Neil Ferguson OBE, Director, MRC Centre for Outbreak Analysis and Modelling, Justin McCracken, Chief Executive, Health Protection Agency, and Dr Peter Holden, British Medical Association, gave evidence.

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 y ou go through, tell me whether you had much interaction with each other during that p rocess, 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 CD-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 BSC and mad cow disease, and then the foot and mouth epidemic where, particularly myself and my colleague, Roy Anderson, were heavily involved, and then later the SARS epidemic. Yes, I interacted with many of these regularly, certainly Justin.

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 our 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, 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 design.

One of my other roles at the Royal Statistical Society is in terms of public understanding of statistical science. 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 it had waited a 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, you are looking in advance of an event, and you are saying, "What should the NHS prepare for without any knowledge?" That 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 entire 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 giving this example of 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 is 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 identify 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 integrals-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. 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 paralogued 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. 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. 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, 21 August, which is just when it was started, 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 transmissions have 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 vaccine, though, is 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 can we 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 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 the health protection organisations right across the UK. 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 which was through 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. 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 the 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 it was a sense of disconnectedness. Clearly, it wasn’t as bad as what happened in foot and mouth 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 than 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 A Reasonable Worst Case. 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 it 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.

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, wh o 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 an 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 on 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 confusion 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, w hose 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 thing 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 ha ve 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 yo u 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 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, 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 providing it 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. There was a Cabinet Office in this country, 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 see in the White House and then CDC. Similarly, there are 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 low level but classified 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. 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 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 preventing pandemic panic 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 Council sits. Yes, 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, the scientific staff in the Department of Health, providing the secretariat for all the Scientific Pandemic Influenza Advisory Committee 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.

Examination of witnesses

Witnesses: Professor David Harper CBE, Chief Scientist, Department of Health, Professor Sir Gordon Duff, Chair of the Scientific Pandemic Influenza Advisory Committee, Department of Health, and Sir Liam Donaldson, Former Chief Medical Officer, Department of Health, gave evidence.

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.

Sir Liam Donaldson: 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 led 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 committees. 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 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.