18 November 2022: Van-Tam - A

Celebrity medic, Professor Sir Jonathan Van-Tam, was the final oral evidence witness of the Inquiry. He was certainly used to speaking in public about viruses. There was the usual review of his CV, beginning with his graduating in medicine in 1987. He has a background in public health and epidemiology, focusing on influenza and respiratory viruses. There was a spell working in the private sector, then lecturing and committee work. He was on SAGE during the swine flu pandemic, then again due to SARS-Cov-2. In 2017, he was appointed Deputy Chief Medical Officer (DCMO). After Covid he went back to academia. He now also contributes to journals, primarily on Covid matters.

Prof Van-Tam was invited as an individual to speak to the Inquiry about public health and decision making at senior levels. As a junior doctor he spent some time working on the HIV outbreak. He served under two CMOs (Dame Sally Davis, then Chris Whitty). During his time as DCMO there were two DCMOs. His was the health protection remit. The other DCMO covered health improvement. The team included the CMO, the two DCMOs, a small staff of about four or five private secretaries and a similar number of admin roles. The CMO is basically the head of the public health apparatus in the UK. The deputies allow for reaching into areas of specialism, sometimes using their own knowledge and sometimes accessing their deep connections with the Public Health England (PHE)/UK Health Security Agency (UKHSA) “empire” who are very specialist advisers. Many of these people were located in the same building, but if required the DCMO can seek out wider networks, even internationally.

The role of “administrative” civil servants is to implement Government policy. The medical civil servants are primarily involved in expert advisory roles. The Covid pandemic was not typical in relation to the normal connections between CMO and Ministers. Pre-Covid, the CMO might have contact more days than not with Ministers, but not daily. DCMOs were often in contact with Ministers, but the normal arrangement was for things to go through the CMO. During Covid the contact was “near constant”.

On the balance between proactive and reactive ways of working, it was hard for the witness to describe the split, but it was a role covering both. There were no constraints if there was an issue emerging which might need to be brought to the attention of Ministers. The CMO role is statutory and independent, so they can issue communications at their own behest, but in the normal course of events there would be liaison through policy or other channels. When asked if the advice from CMOs to Ministers should be published, he said, “I don’t really think I have an answer to that question”. (Perhaps he has one eye on the Covid Public Inquiry to come his way.) On giving Ministers advice they want to hear or telling the hard things, he said there were ways to make sure any unwelcome news was passed on. On the Minister automatically accepting the advice of a CMO, he said it would not look good for a senior medical professional’s advice to be ignored.

Counsel asked about the liaison between the CMOs of the four nations. He was occasionally asked to attend these meetings but not all. There were these formal meetings, but also lots of informal contact. It was seen as a meeting of equals, bearing in mind that the local political landscape might be different. The witness said it would be quite unusual (he had never seen it) for there to be disagreements on matters of public health principles. During Covid, there was a much raised level of communications between the four CMOs.

Guidance to doctors from the CMO will have been agreed between the four nations, and sometimes signed by the four. Operational instructions would come from the NHS related to “command and control” matters, not the CMO. There is no actual restriction on what the CMO can write out about, but there is the understanding of what would be appropriate. Awareness raising to the public would not involve the CMO writing to the patients of other doctors (i.e. the general public), but rather a media campaign might be required. When an outbreak only affects a certain cohort of patients, such as for Monkeypox, it would be normal to use existing channels to communicate with those who needed to be apprised of the issue related to them.

The general clinical practice issues such as informed consent would not likely be the kind of thing a CMO would communicate with doctors about. It was seen as being on of the things that are “hardwired” into every clinician as a way to work. Counsel mentioned the Cumberlege Review as an example which raised difficulties which might need to be highlighted to all clinicians. He thought the CMO might get involved in such things, but it might be better for, say, the MHRA to direct communications. On the matter of communicating to the public, pre-pandemic, there may be matters big enough to require a CMO-level input to public communications. However, the Covid situation including the daily updates and other actions was seen as something comletely new.

The best ways to communicate information on a public health risk matter was to be done “proportionately”. Consideration of what is to be gained from raising an alarm has to recognise the possible setting off of hares running. The language must be accessible and there must be information not just for understanding but also information for action (what the member of the public can do about it for themselves). When there are gaps or uncertainties, the witness said it was important to be candid with a patient and the public about the limitations about what is known. On the balance between communicating something which might raise a panic and the option not to communicate, he said, “I don’t think there are ever excuses to not communicate and to not explain”. There should not be platitudes like “Don’t worry”.

The precautionary principle appears to have started in environmental decision-making and moved into public health. He thought it was a consideration, but the influences around when the precautionary thinking stops action being taken and when it does not it is not a blanket issue of always assuming precaution means not doing something.

Expert groups and committees should see themselves as having the Government as their customer. They “serve” the Government as the Government “sets the homework”. Groups should not be there to pontificate, but to answer difficult questions and give the Government its best thinking. It is healthy to have a diversity of views, including personalities (so long as they are capable of working collegiately), specialisms, and diversity in terms of protected characteristics, as appropriate. When there are dissenting views which go beyond the common position being sought, the record should note the differences and the report going to the Government should reflect that. There should not be a restriction on a dissenter expressing their alternative view, so long as they do not represent that as the collective view.

The Inquiry’s Expert Group on Public Health and Administration had highlighted the issues of complexity and fragmentation. Prof Van-Tam recognised how larger bodies such as the NHS do have to overcome these factors. The NHS itself is part of the bigger picture of the public health sphere. He went on to review the way sections of the health services were set up and changed over time to seek to provide the command and control required. The structures of national and local arrangements are part of the picture for the NHS, but it is underpinned by a strong health protection system which runs alongside it. On the communication aspect, say between the local public health teams and the local NHS bodies and clinicians, he sees the link as close but did introduce a hypothetical example when there might be problems, such as a cluster outbreak and the possibility of it becoming a national concern.

The witness was asked about the frequency of NHS reorganisations. They do not automatically stop the work going on and can produce benefits, by design. But it was agreed that they can be unsettling and disruptive.

The possible difficulties related to the links between the four nations was considered to be a non-issue and one he was strongly minded to refute.

As the Hearing Room emptied for the morning break, Professor Van-Tam walked towards the door to the private room the witnesses have with the biggest grin on his face. It did not appear to be connected to his performance thus far as a witness, but it seemed it was just him being him.