12 May 2022: Pickles - C

The afternoon shifted to the Advisory Committee on the Virological Safety of Blood (ACVSB). Dr Pickles established the group and attended the first meeting. No reason was known why such a group had not been set up previously. After each meeting there would be a “de-brief” to pick up on action points and anything requiring the attention of a Minister. As with Dr Rejman, the comment of Dr Perry about the number of DH staff attending, the lack of public health input, and the emphasis on achieving the best outcome at the expense of getting on with what could be done was also put to Dr Pickles. Rather than accept or reject Dr Perry’s statements, the witness went on a meandering journey around how people get selected for a committee. She did have an issue with the suggestion that the desire for the best got in the way of doing what had to be done. Dr Pickles stuck with the view that the science did not justify the use of the available tests, despite the impact on subsequently infected people.

The role of DH attendees did include participation in discussions, but not decisions. Those from Northern Ireland, Scotland, and Wales tended just to be silent observers. It was also clarified that a Minister was not required to follow the advice of the ACVSB. On confidentiality again, there would be reminders at the start of meetings on this requirement. Dr Pickles thought the confidentiality was to avoid mixed messages coming out, or of one robust but minority voice skewing the understanding of the nature of the debate. There were also concerns about commercial interests that might seek to influence decisions, which they could do if the minutes were published. Similarly, interest groups might also seek to exert influence. There was a nuanced different between imposed confidentiality and something being “in confidence”. The ACVSB was more the latter than the former. Counsel did point out the potential drawbacks of keeping things so secret, but Dr Pickles seemed satisfied with the justifications for doing so. No surprise there.

There were ACVSB recommendations which included making the case financially to NHS Management to allow for certain recommendations since it was “their money” and if Management spent some of it on one thing, that would mean something else would not be funded. The paperwork on cost-benefit calculations were fascinating because they gave an insight into how health economists attribute financial equivalences to the costs or savings of people being infected or not infected. Dr Pickles admitted that the model was not perfect, and could for example, be seen to value the life of a disabled person less than an able-bodied person. The budget also went down to the level of knowing the cost of having to recruit new blood donors if people stopped giving if they received a false positive, for example. There were some “unquantifiable costs”, such as the results of stigma on a person, but given the number of assumptions and aggregation of data to get to an actual amount, the whole process looked very much like the reverse of a cigarette packet exercise. How many key Government decisions are based on these snake-oil budget assessment solutions? And how many are manipulated – as they are clearly ripe for – to achieve an otherwise unjustifiable desired outcome. Statisticians and cost-benefit estimators may equally be open to an undesirable but unavoidable accusation of gerrymandering.

Again, as for Dr Rejman, Dr Pickles was asked about the apparent slowness to act towards screening in the UK compared to other countries. The witness could not recall her thinking from the time. She did recall seeking information how certain issues were handled in other places, such as false positives, but there was no information forthcoming – assuming it was even available. The same ACVSB committee members, including Dr Rejman, who were resisting screening, were tasked with attending the various conferences where these matters were discussed and using that to inform its forthcoming deliberations and recommendations. Perhaps that was risking a conflict between held positions and alternative options, with that established chestnut of “confirmation bias” likely to sway things in favour of people only seeing and hearing what they want to see and hear.

In the meantime, questions were being raised, including in Parliament, asking why the UK appeared to be moving too slowly towards screening. Other committees were highlighting the need for urgent action and how this must be understood and acted upon by Ministers. The conflict between the position ACVSB were holding on to and what different experts were saying was creating an irreconcilable tension. The public health emphasis on seeking to minimise transmission by introducing screening eventually triumphed, so the ACVSB had to find a way to interpret their science to allow a shift. The Economic Advisers’ Office seemed to find a way to justify, in financial terms, a new narrative to be prepared which helped the previously not recommendation position to be now recommended. It is amazing what some smoke and a few mirrors can do to help people understand what “the science” is saying.

The justification for a uniform start to screening, in hindsight, looks like the issue of urgency had still not percolated down to those charged with making it happen – who just happened to be the same people previously recommending not starting screening. Ouch. There was also a timing issue with new iterations of the tests (“second generation”) not yet being approved, and that added to the melting pot of affecting issues. Then there was Newcastle. The Northern Regional Transfusion Centre, led by Dr Lloyd, wanted to “break ranks”. The reaction was not at all to welcome this rebellion, even though it would start to “save lives” sooner. The majority view opposed the Newcastle move, and collectively they had clearly reconciled for themselves any appearance of being less concerned about minimising transmissions and so saving lives. History has not been kind to them. Seems like history is correct.

A hindsight question from Counsel about what was done was met with a rejection of any suggestion of complacency. Dr Pickles said there were disbenefits from acting too soon, and not just negative impacts of not introducing screening sooner. FDA approval seemed to be pivotal, and the witness was asked why that was. She suggested some explanations but could not claim to have the right expertise to say for sure. On the possibility of “sharp practice” resulting from appearing to show a preference for one product over another, the witness could again only attempt an explanation rather than a secure recollection. It included her raising the potential problems with the Haemophilia Society having Armour sponsoring the Bulletin.

Counsel mentioned to the Chair that she did not intend to put questions to the witness about CJD, even though Dr Pickles had been so involved in the BSE case. However, she was not in post during the key period and has helpfully provided very detailed responses in written answers to Inquiry questions.

Part way through this session, Sir Brian had to intervene because the witness kept predicting the questions from Counsel and starting to answer before the full question was out. This was making it impossible for the transcribers to capture what was being said. Maybe Dr Pickles just wanted to get this over with as soon as possible. That’s understandable.

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