National Assembly for Wales

Thank you. If I could make some opening comments, Chair, I'd be very grateful. First, I'd like to offer a few lines of advice and then a few words of reflection on the past six months, if I may. 

Yes.

So, as an opening comment, every person needs to be aware and consider their own risks. You need to be aware of the local transmission in your area. You need to know that you're more likely to infect or become infected by friends, family and those who you're close to and people who you work with. You need to know that by keeping your contacts low, you reduce the chances of larger outbreaks in your community, your village, your town, your county or country. You need to know that you can reduce your risks by adopting sensible behaviours. We do this every day as human beings—we assess and we manage our risks: we decide when to cross the road, when to fly, we decide when we need to have an operation or not have an operation. What we need is the information to make these risk-based decisions. We decide how close we are to others; we decide on the intensity of our local interactions, whether to drink sensibly; we decide on how much time we spend in different environments—we decide. We can be advised or mandated by Government, we can be advised by science, but in the end it comes down to personal motivation, opportunity and choice. It comes down to individuals and it includes all of us. 

My colleagues and I, alongside many individuals in academia, the national health service and civil servants, like ourselves, advise governments on what we know about the virus. Since February, we have worked continuously to ensure that the most up-to-date scientific, technical and medical information is captured, interpreted and shared with policy leads and decision makers. Our role is not to make policy, but to advise on policy.

Academic colleagues from Welsh universities have joined the collected efforts of our technical advisory group, and they've gone above and beyond what is expected of them in contributing their time freely in order to advance our knowledge and interpretation of the emerging science. We have worked at a frenetic pace. My colleagues who have led and administered the technical advisory cell have not stopped. To face the challenge, their work ethic has been determined, professional and relentless. Our primary objective is to reduce and prevent harm in Wales.

Our policy colleagues have also worked tirelessly in ensuring Wales has policies that are proportionate and clear, ensuring that as the science and advice changes, so too do their policies. Our decision makers have systematically and actively engaged in scientific discourse, reading and digesting papers that are presented with questioning and challenging the evidence, always staying close to the emerging evidence.

We've watched in admiration as the people of Wales have worked together to drive down the infection, generously yielding their civil liberties, so that their families and communities become safe. We've watched as these gains have been spent by others who have disinvested or tired of these behaviours in order to satisfy their own needs.

We have witnessed the growth of this insidious disease that attacks the most vulnerable in our society, that has thrived in care homes and has struck hardest in the poorest communities. A disease that evades early detection and spreads quickly between those who are less aware of the damage that it can cause. We have seen our health and social care system and our public health systems almost overwhelmed and the hard-fought fight-back from our health and social care workers, local authorities, scientists and many others to ensure that we are safe from harm.

We have seen the rapid development of a national testing contact tracing, local public health surveillance system and risk management architecture so that we can detect, assess and manage outbreaks quickly and effectively, where possible intervening locally with local intelligence and, where necessary, working at a regional and national level. We've worked collectively as a UK scientific committee. Wales has been a net beneficiary of the tireless and devoted efforts of the Scientific Advisory Group for Emergencies. We're incredibly grateful to Sir Patrick Vallance and Chris Whitty, alongside the SAGE secretariat.

We've also driven work in Wales in order to accommodate our own needs. There's been an incredible effort to keep up with the demand and the supply of scientific and technical information. Quite literally, hundreds of papers have passed through our hands and heads. Our knowledge and understanding of the disease has evolved quickly. As our understanding has changed, so too has our advice. The concept of just enough information to perform has struck home, with important decisions being based on rapidly emerging evidence. We've not pretended to know everything and there is still a lot to learn. We do know that by working together we've been strong and focused. We have challenged each other and avoided groupthink. We've been honest and clear in our advice and we have done this to reduce harm and suffering in Wales. Thank you.

Thank you very much, panel, for coming in and giving us evidence this morning. And thank you for your opening remarks, Rob; they were really appreciated. Some of the ground you covered covered some of the questions I was going to ask, namely the relationship between TAC and SAGE. And I think you turned round—. In your opening remarks you said 'the tireless and devoted efforts of the SAGE group' you were very grateful for and the literally thousands of papers that you've had to deal with. Can you inform the committee, with the benefit of hindsight—would you have done anything differently or interpreted anything differently from what we were when we started this pandemic in March?

Thank you. The retrospectivescope is an incredibly powerful tool and I'm sure we'll have a long opportunity to reflect on the decisions over time. Undoubtedly, we'll find things that have worked well and things that have worked less well. And we'll have uncovered things that we wish we would have known earlier. I'm sure there are lots of opportunities for us to say, ' I wish we had had this in place, I wish we had had this knowledge', but we didn't, and so we responded with what was available and what was in front of us. 

I think it's important to acknowledge that we're a small country and we're a small administration. We're not Whitehall and we don't have the resources that England have. But even given our small size, I think we've performed well with the resources that we have available. In some ways, our smallness has been an advantage. We're extraordinarily connected. We've moved quickly when we've needed to do so. So, I think, when we come to reflect on whether we would have done things differently, I'm sure we would have, but we didn't have the capability and capacity to deal with this one in a 100-year event, and I think there are lots of lessons learned that we will need to think about. It's an important part of the risk management cycle, in that we're continually asking ourselves, 'What could we do better? And how can we improve?' And we've tried to do that and reflect that in a paper that we've provided on preparing for winter. So, would we have done things differently? Almost certainly. And will we learn lessons? Definitely. And we need to continue doing this as we head into winter. I hope that answers your question. 

I certainly didn't pose the question trying to trip you up by saying that there were things that were evidently wrong that should have been done differently. I was trying to get some expert opinion from any one of the panel as to, looking back, what could have helped, given that all the talk now is the possibility of a second spike, and whether those changes have been made in the knowledge of what we know from the earlier six months that we've just gone through. So, it's not a trick question to try and pick up fault; it's trying to see what measures have been put in place that, with hindsight, we're able to iron those glitches out. 

Fliss wants to come in, but I think we've learned a great deal from the first wave. Responding quickly is one of them. Having a really good surveillance system in place, which we have, is another. Having adequate tests and testing in the right place are others. And these are all things that we've improved as we've gone along. Thank you. I'll bring Fliss in, if that's okay. 

Yes. Fliss, the floor is yours.

Thank you. At the very beginning of this, I think there are some things that we did absolutely right, although it takes time to understand. Some of the pieces of research that we stood up really yielded results very early, and I'd like to talk in particular to the COVID-19 Genomics UK Consortium and the tireless work of Professor Tom Connor—is he a professor yet? Dr Tom Connor, I apologise. Wales was, at one point, for about a month, the third in the world—not the UK, but Wales—in typing the genome of this virus. So, doing the ribonucleic acid phenotyping, and identifying and then publishing to the rest of the world what the sequences of the RNA meant. We identified very quickly that there was a change in the lineage that came from China, and when there was a clear understanding that the change in a single protein in that link, point 614 on the spike, actually made the transmission become faster, we were able to identify what that meant. And we're continually able to look out for new lineages as a result of that immediate work, and to put money into, resources into and time into sequencing and understanding the results of the sequencing of the genome. And that was swiftly taken up by the whole of the UK. I think we are still, as the whole UK, either first or second in the sequencing of genome—it's something that we're really good at.

Right from the start, the modelling was absolutely key. Although we were using pan-flu modelling, I'd really like to point out that we very early on looked at the history of every single other pandemic that we've seen that is like flu or like respiratory disease, and one of the first things you'll notice if you look at anything, even back to the Spanish flu, is that there is a second wave. It usually comes in the winter when people have the weaker immune responses, and it's usually more aggressive because the disease is better seeded throughout the community. So, we've said right from the beginning that although the key was, in those early days, to prevent significant harm and death from the first wave, we were looking to future waves and how we might survive this in the long term. And, indeed, SAGE commissioned the Academy of Medical Sciences to do a review for a month over the summer to talk about how all of the different countries in the United Kingdom could better prepare for the winter and the inevitable resurgence of this disease.

So, I think one of the things that we did straight away that I wouldn't change was go straight to all the virologists, all the epidemiologists, all the medical and public health experts and say, 'Although we don't know what this disease will do, what do we know about the progression of diseases like it and how will that change the way we need to plan?' It's a really bitter pill to swallow, knowing how dramatic the first set of restrictions where on all of us, every single one, and even those of us who haven't had the disease have been changed by it, but I can assure you, we knew the next one was coming, and the reason that we're doing local and much less restrictive restrictions in places like Caerphilly is because of all the work and the learning that's happened in the six months. Thank you.

Okay. Andrew R.T.

My final point is, obviously, there's been a change in direction—obviously, we went into lockdown as one country, and now the four component parts of the United Kingdom are doing things slightly different in various areas, yet SAGE is providing advice to your good selves. How has that advice been used in your situation, advising the Welsh Government with some of the differences that exists within Wales, to inform that decision making? So, with the devolution settlement that we have and, obviously, the SAGE operation being the central point of information in this exercise, how have you managed to interpret that into your advice that advises Welsh Government on the actions they should be taking?

Rob, go on then.

Thank you. As I said in my opening statement, we work at a frenetic pace. We receive SAGE papers every week and we're involved in SAGE discussions every week. We synthesise the information arising from SAGE and apply that to our own situation, and we share that with our policy leads and our Ministers in near enough real time. It's quite an operation to be able to that, and my colleagues work late into the night and early in the morning to achieve that. So, we take these scientific papers, we take the output, we think about how they apply to our own local situation, which is often different to England, and then we advise our Ministers accordingly. They don't just use scientific and technical advice—there are lots of other factors that are considered in decision making, which we're aware of, and perhaps some of the differences between our administration and others is because of the complexity of decision making. I hope that's an accurate—

Yes, fine. David Rees has a supplementary on this matter before moving on to your questions. David Rees.

Diolch, Cadeirydd. I just thought of one question. Obviously, you work very closely with SAGE, and I know, Rob, you actually attend SAGE, if I remember rightly from the last time we had this discussion. The committee has taken evidence from Independent SAGE, and David King was present. Do you also consider the reports of Independent SAGE in your collective ideas of advice and then coming to opinions?

Yes, absolutely. We'll consider any advice. As Fliss mentioned, the Academy of Medical Sciences, the royal colleges, the World Health Organization, other countries—we don't stop. We'll look at what anyone is doing. If we find better practice, if we find better evidence, then we'll use it. So, I'm very grateful for Independent SAGE thinking differently and challenging. That is the nature of scientific pursuit. We have to keep an active, open mind. As the evidence changes, then so does our advice. That's our role. Fliss wants to come in. Thank you.

Fliss.

Thank you. I absolutely agree with what Rob said. Obviously, we've been fortunate to have the two of us being able to attend almost every single SAGE meeting since its inception, and we are collectively, through the technical advisory group, members of every single sub-group of SAGE. The only real thing that prevents SAGE from having every scientist of repute on it is the sheer numbers and the inability to have discourse. To have Independent SAGE has been a huge benefit. The more people we have considering the evidence and the decision that we took very early on to publish all of our SAGE advice and all of our technical advisory group advice, as and where it became possible, are key because the more understanding that members of the public and Members of the Senedd and people who are responsible for changing people's minds and behaviours can have, the better they will be able to understand what the interventions and the path of the pandemic means for them and how they can help.

So, Independent SAGE, if we had 100 people in the technical advisory group, we would be able to send people to every single meeting. As it is, we try to consider their advice. The difference, though, with SAGE by comparison to others is that SAGE has the security clearance as a sub-group of COBRA to be able to see up-to-the-minute data that comes from health boards across the United Kingdom and from various other intelligence sources across the world. The only real difference is the fact that we've got access to the data that we can then interpret and consider.

Okay. David, moving on. 

Okay. Moving on, can I look at the winter preparations agenda? Clearly, yesterday, the Minister published his report on the winter protection plan, and perhaps in some ways of speaking—. I appreciate you give advice and it's his decision to make policies and decisions as to how that advice is implemented, but if you've had a chance to look at that plan, do you think it covers everything you would have given advice on, or are there areas that you think still need to be covered? 

Dr Orford. 

Thank you. I was really pleased to see the plan published yesterday. I've briefly read through it, as it only came out yesterday, and I've thought about that alongside the recommendations from the Academy of Medical Sciences, which very briefly—and we've included them as an annex in the paper that we've shared—are: minimising transmission of COVID in the community, and of course, we've got the coronavirus control plan as well; minimising infection in hospital settings and care settings and ensuring there are parallel streams; ensuring that there's adequate PPE consideration and things like point-of-care testing; ensuring that there's adequate testing and quarantining of patients; improving the public health surveillance system—not captured in the health protection plan necessarily but captured elsewhere—and also preparing for perhaps a resurgence in influenza in the winter. All of these elements are considered in the Academy of Medical Sciences plan and we recommend that these are really important considerations that have been thought about and considered by our policy leads in Welsh Government. 

Is there anything you think that is missing from that plan?

My personal reflection is if you look across the piece, if you look across the whole of the COVID response of the Welsh Government, I think there's been an incredible amount of work done over six months stepping up an excellent surveillance system that's able to detect infections in the community. There's a really strong testing strategy that clearly articulates the plan, clearly articulates our direction of travel and what we're trying to achieve. There is a test, trace and protect strategy that talks about contact tracing and how that will be scaled up through the winter. There's a plan around the NHS and all the different aspects of social care, primary care and secondary care. There is a national coronavirus control plan. The statistics flow freely from the Welsh Government on what is happening right here, right now. I think there's very clear risk communication advice coming from Welsh Government. So, my general feeling across the piece is that there's been an extraordinary amount of work that's been landed, and taken together there's an incredible piece of machinery within Wales to respond to what might be a challenging winter. So, I feel fairly confident that the work has been done—the hard yards have been done. There's more to do, undoubtedly, but people have recognised what the challenges are and they're working very hard to address them.

Okay. Well, the Academy of Medical Sciences paper that you've referred to as well highlighted a peak of, perhaps, cases in January and February next year, more than anything else. Clearly, there's a likelihood also of a peak of flu scenario as well. And based upon your own summary, which I saw yesterday from 11 September, which highlighted the capacity in our ICU level 3 and the number of COVID cases that are in those currently occupied beds, is there a challenge ahead of us that we still have enough critical care beds to deal with the increase in flu, the increase in COVID possibility and the normal winter challenges that are facing us? Do we still have the capacity? Because we talk about 5,000 beds, but I didn't hear about the critical care beds. Would we be increasing the number of critical care beds, for example?

Dr Orford first and then Fliss Bennee.

Thank you. I'll bring in Fliss now. There's an enormous piece of work that's been done and completed on the recommendations in our paper around planning for the winter and the modelling that goes behind it. So, I'll bring Fliss in if that's okay, and perhaps she can talk about our reasonable worst-case and some of the work around indicators and circuit breakers to give you some assurance that we've really carefully thought about this and included this in the planning.

Thank you, Rob. One of the benefits of being allowed to have robust scientific dialogue is, having commissioned the Academy of Medical Sciences paper, it's then possible for us to go through it and consider its defence. One of the things that we in SPI-M and in wider SAGE had significant discourse about is the modelling that they've put in to their assumptions. Actually, our reasonable worst-case scenario—and indeed the majority of our modelling—shows a peak at a different time, and we consider with a different number, because we've set our thresholds lower.

So, from a point of consideration, as with all modelling and as with all scientific consideration, while there is not perfect evidence, the Academy of Medical Sciences model is only one, and it is not the one which we agree nationally is the best fit. In the reasonable worst case for Wales, we've actually made use of a model that Swansea University, as well as some organisations such as Armakuni have done for us using the Oxford model. It's a point at which we start to diverge significantly from the wider UK model. So, at SAGE, we consider the UK model, and SAGE also runs those models for England, but the demographic in Wales, in Scotland, in Northern Ireland, is very different from something that has very large population centres in London, Birmingham, Manchester, Leeds, which would otherwise skew our reaction to it. So, our reasonable worst case that has a peak significantly earlier, I think, towards the end of December for COVID, which is slightly different, offset by a month or so from the traditional peak of the pan flu and influenza-type pneumonia responses and so forth. So, to answer your first question, I think this consideration of matching—[Inaudible.]—is a worry. Sorry, Chair. I'll get to the other point now.

In terms of thinking about the situational capacity for Wales, whilst, of course, Andrew Goodall, the chief executive of the NHS was responsible for the operational planning, the advice that we've been able to give is that the direct harm of COVID must be carefully balanced against the evidence we've had for the indirect harm if too much is set aside to deal with COVID, leading to an inability to cope with the harms that would be caused by people not being able to have access to urgent care and non-urgent care and so forth. And this was a significant consideration, which we modelled when the first restrictions were put in. We know that the time that was spent putting aside all of our hospitals for a potential COVID overwhelming meant that people who could have been diagnosed with cancer or could have been treated for things both urgent and non-urgent was pushed down the line, and the mitigation for that is reprioritising and treating them as soon as possible once the restrictions are eased.

That means that whilst we have a modelling for a total number of beds—and it's not 7,000 or 5,000; I will take a moment after this to look up the precise figure for you in my chart—but the recommendation we have is that they should work very closely to what we know to be tracking as the number of cases in hospital and later in ICU. As of yesterday, we had only three confirmed people in the ICU with COVID and another seven suspected across the whole of Wales. The whole point of being able to understand how many people have it much earlier on is to prevent the overwhelming of our health services, and that's why we've put the national thresholds in order. So, the thresholds are a combination of the number of positive cases per 100,000—I'll give you a caveat on that—and also the percentage positivity that we get from our testing. So, in the case of, say, locally for a local authority, we would have—sorry, please stop me if I'm going on too long.

No, it's okay.

So, we said at between 15 and 20 cases per 100,000, we would put a local authority, or part of a university health board, on the watch list. We would start to consider them regularly. The incident management teams would be stood up to consider the clusters and the cases themselves. I will go over to Marion in a minute to give us that run-off more clearly, but from a modelling point of view, when you get to 25 cases per 100,000 and up, that would be our amber stage, the stage at which you should strongly consider whether or not the combined picture requires restrictions at the local area. And above 50 cases per 100,000 we would say is a strong need for considering putting in restrictions immediately. The case positivity: our amber level is 2.5 per cent positivity and our red level is 5 per cent positivity. The reason that you can't just look at a single one is the thing that gets you more positive cases, straight away, is more testing. So, if you know that there's an outbreak in a food processing factory and go to the area with tests, then you are likely to get a massive increase in the number of positive tests you get. But if you know, through your soft intelligence, through your communicable disease control consultants and through your local intelligence, that it's confined to an area—and the Merthyr Tydfil incident was a very good example of this—you get everybody in the single institution where there's an incident, you test them, the number of cases per 100,000 goes through the roof for a couple of days as you identify them and get them to isolate, but it is not out in the community, and so there is not an outbreak that needs you to bring in local restrictions. And that's a really good example of how control works well. If you—

On the modelling, does your modelling take this into consideration? Because you talked about your various modelling for worst-case scenarios, and you also mentioned you were looking at modelling for regular services—of harm done by not addressing the non-COVID issues. So, that was included in your modelling, as well. So, you do have a model that identifies the position we could have if we don't address both simultaneously. 

Yes. So, our reasonable worst-case scenario looks at the total number of excess deaths as a result of COVID-19. So, it doesn't consider—. Again, the importance of understanding at a reasonable worst case is what happens when we take the models, we run them on supercomputers, tens of thousands of different iterations of the model, to start to look at what is reasonable and what is not reasonable. The worst-case scenario is that something terrible happens and everybody in the country dies—that's not reasonable. So, the reasonable worst-case scenario is what happens when we take one or two standard deviations away from what we expect to be the worst case, and we say, 'This is our outer limit for planning purposes, you must be able to get to that point if you need to, but we expect, with mitigations put in place, that we should end up being much lower than that reasonable worst case'.

Dr Orford.

Thank you. Sorry, I was on mute. Also to come in, we also consider both the direct and indirect harms associated with COVID-19, so not just the harm from the disease itself, but the other harms associated with cessation of services or harms associated with the non-pharmaceutical interventions, like loneliness and isolation, as well as economic harm. So, it's quite complex, but we're trying to consider both indirect and direct harm for everything that we think about.

We'll come on to some of that now. David.

Just the final one from me on this point. Have you identified, therefore, triggers, which may actually—? In your modelling, what triggers were identified to say, 'Well this can spark off a need for an action to do something'?

Dr Orford first, then Fliss Bennee.

Thank you. With the surveillance systems, we look at a lot of different things. We look at GP consultations, NHS 111 calls, the number of infections, as Fliss described, in the community, and also hospital admissions and ICU admissions. So, there are lots of things that we consider. Now, we're also introducing waste water sampling that will, hopefully, give us an early indication of what's happening in different areas in Wales. So, there are lots of things that we are considering alongside the local intelligence that we receive through the COVID intelligence cell, from people on the ground that are reacting and observing, who are experts in their field of communicable diseases and are feeding that back very regularly. So, intelligence is absolutely key. Understanding outbreaks, incidents, clusters and how best to react to them is an important part of the response. Marion may want to say more about that, but it's a combination both of that kind of systematic surveillance and local intelligence. 

Can I ask, then, on these triggers—obviously, at the moment, we're seeing a number of patients who are younger people than we saw perhaps in February/March time—if it's managed correctly, and if the advice is such that we manage this correctly, could we actually see not necessarily the levels you are modelling on? Because we are being told now, effectively, 'Look, there's something coming but it's young people, and if we manage it well, it might not progress into the community progression and into older people.'

Unfortunately, in the first wave, it was in the younger people first—the more gregarious, outgoing people who like to mix and be out and about. I'm sure we all remember being that age once.

If we look at other examples, for example—

Some of us are still there—you never know. [Laughter.]

If we look at Florida and France, if we look at the mixing data, it's called the CoMix data, we can see that, unfortunately, the disease moves and transitions through the age groups, and we're seeing that now in parts of Wales where it's transitioning into older age groups. And that's partly because of the make-up of our society and the way in which our families are oriented. So, younger adults live with older adults, and older adults mix with even older adults. It's just the nature of the disease that it gets into those personal relationships, the people that are closest to you, the people that you live with and love. So, we thought about age segregation. It's really, really difficult. But young people, young adults, older adults, really need to think about their activities and really, really keep the number of interactions they have as low as practically possible. So, if the guidance is 30 people outside, it doesn't mean to say you have to achieve 30. You know, keep it low—that's really sensible advice. 

Fliss Bennee, did you want to come in at this point?

Thank you. I think Rob's covered most of it, and I should cede the floor to Marion for that sort of run-down. I just wanted to say with regard to the modelling and the threshold that it's absolutely the point at which it's not possible to trace contacts back. When it starts to become not incidents but outbreaks into the community, that's the point at which all of the triggers start to come forward, requiring policy interventions and non-pharmaceutical interventions in the wider community. But, they are triggered by local intelligence combined with the thresholds at local and national level. 

A good example is face coverings being made mandatory on a national level coming in because we hit that 20 per 100,000 threshold. When we hit the case threshold of 20 cases per 100,000 for Wales as a whole, that was the point at which we started considering, and then decision makers decided, that face coverings should be mandatory.

Dr Lyons, you've been invited to contribute, so the floor is yours. I understand shyness; I'm obviously beset with the issue myself. Dr Lyons.

I don't know that I have much more to add. Certainly, we have very, very good intelligence from our TTP. It is extremely effective, and I think it's effective because it's delivered very much at the local authority level and then supported by a regional model, which is the health board. Since it began in June, I think they have contacted 98 per cent of individuals who are positive and 94 per cent of their contacts were contacted. And it is that local intelligence, I think, that is critical. 

Somebody asked me about Neath Port Talbot yesterday and asked me why I wasn't worried, and I said I wasn't worried because I can account for every case there, and they consist of six small clusters of six individuals. So, it's not 36 cases in the community that I've just picked up at random and I don't know where they got it and whatever. It's different in Caerphilly and it's different again in RCT. So, the measures you apply are very much dependent on what you find when you look at your cases. And because of the success of our contact tracing, we know when things are just changing and we can react early.

And I am really pleased that the community in Caerphilly do understand it. It hasn't been a confusing message for them. They think, 'We want to keep our schools open, we want to keep the economy going, we want to get over this little bump', and they're stable now and I hope they keep going in the right direction. I think local knowledge is critical here and, as long as we can know what is happening on the ground, we can intervene early.

Can we suppress it? It would be nice to think that, at least for the moment, we can. If we could get past the flu vaccination programme, I'd be very pleased. As you know, we're expanding our flu programme this year. So, we aim to offer it much more widely. We really hope that those at risk and those over 65 increase the uptake, and we would like to also offer it, then, when we get the excess supply, to those down to the age, perhaps, of even 55 to 60. So, if we can keep going without huge surges and get that population vaccinated, I think it puts us in a better position. 

Great. David, are you done?

Sorry, Chair. I was muted. There's just one final point. I very much appreciate the news on Neath Port Talbot, by the way, which is my own patch, so it's nice to know that; it's very helpful.

But on the field hospital question, clearly, yesterday, in the plan, we actually heard from the Minister that the Dragon's Heart Hospital is going to be decommissioned and there'll be a new field hospital based next-door to the Heath, so they are going to continue. What's your advice, then, as to what role those field hospitals should play, because I'm deeply concerned in my own area about the issue of oxygen availability in these field hospitals? And what is their purpose? Is their purpose simply rehabilitation once you've got over the worst of it? Is their purpose to look after—? What's your advice on what those field hospitals should be doing?

Okay. Who wants to—? Dr Orford.

Thank you. I think this is an operational delivery question. I really believe that this is a question for Andrew Goodall and colleagues. We can advise on what the numbers will be, but, how the system operates at that level, I think that's for the chief executive of the NHS and the chief executives of the local health boards.

We'll ask him, then, don't worry.

Okay. Time is moving on, so we need to move on as well. One of the many high spots of any health committee meeting is when Lynne Neagle is asking questions. Lynne.

Thank you, Chair. Good morning, everyone. It's fascinating what you've said and it's really useful for us to get that kind of in-depth understanding of what's driving these decisions. So, based on the data you are looking at, then, can we expect the cancellation of routine operations in the autumn, now?

Fliss Bennee.

Thank you. Again, definitely an operational question rather than an advice question. But I would point to both the winter preparation plan and our previous advice that every attempt should be made to ensure that, short of total overwhelming of the NHS services, it should be possible, by any number of methods, such as separation of COVID-positive and non-COVID-positive patients, careful testing, tracing and isolation before operations and so forth, to ensure that prioritised care is run to mitigate that indirect harm from the previous closing of the health services. 

Okay, Lynne?

Okay, thank you. I was very interested in what you said about how much attention you pay to actually looking at the impact of indirect harm, and I'm particularly interested in the area of mental health, and Dr Orford referred to loneliness and isolation. I think in things like the excess deaths we've seen of people living with dementia, that is very clear evidence of the harms that are brought through coronavirus. Can you just explain in a little bit more detail how you measure those mental health harms in the advice that you give to Welsh Government?

Absolutely. Sorry, I hope you don't mind me coming in—I'm not used to waiting to be told to come in [Laughter.] I'm very shy and retiring, just like the Chair, I assure you.

Absolutely.

There are several different ways that we take account of this. We commissioned the scientific advisory group for emergencies along with Office for National Statistics economists and health professionals to do studies looking at excess deaths and excess harm from the four major kinds of harm that we identified. The British Medical Journal published way back at the start a huge list of potential indirect harms, many of them connected to mental health and well-being particularly, not only with dementia, isolation and loneliness, but also potentially abuse and modern problems like gaslighting and so forth, with people who become isolated. And the way that our health economists, like the fabulous Dr Brendan Collins, are able to provide a comparable consideration for when we're looking at measuring our ability to advise on harms, is by looking at quality years of life lost and that sort of measure of the quality of life that one can have, depending on things that are taken away from them.

So there was a seminal study that was presented to SAGE from—I'm going to remember the date, because I was looking at it—20 April, which considered the potential only, indeed, for excess deaths and for excess years of life lost. And that considered that the potential weight for isolation, in particular of individuals who were isolated, was so considerable that as soon as it was possible to lift the restrictions, investigations were begun on how to limit that loss. And that is what has led our advice and, I think, has led to policies such as the extended households and the importance of being able to have at least one person who is able to form a bubble or an extended household with individuals who otherwise would suffer extremely from isolation.

I know in places like residential homes, care homes, especially for the elderly, it's very, very difficult and completely heartbreaking not to be able to go and see and be with loved ones who are at the point where they will begin to forget. But the balance of harms, just from a pure mathematical point of view, says it is better for people to not be able to visit in the physical way but still to be able to visit in six months' time rather than, for many people, to lose to coronavirus their family before they have a chance to be reunited with them.

Okay. Dr Orford.

Oh, there we go. Sorry, I couldn't unmute. Just to support Fliss as well, the technical advisory group recognise how important this is, how important understanding and advising on indirect harms is, and it's remarkably complex and complicated.

To strengthen our response, as we've articulated in the paper that we've shared, we've set up a group specifically for looking at socioeconomic harms and considering all of the four harms, and also a group that's chaired by Professor Ann John from Swansea University on risk communication and behavioural insights. It's really important that we understand the challenges that people have, as we enter into winter, such that we can suggest ways to mitigate them and support people.

Okay. Lynne.

Yes. Thank you, and I'm delighted that Professor Ann John is now involved with the technical advisory group; I think that's very positive. Can I just enter into another area, then, of indirect harm, which is the restrictions that are still in place on maternity services and allowing partners into scans? In Gwent, they can only come into labour once a woman is 4 cm dilated, et cetera. Can I just ask you whether you've discussed that in the advisory group at all—the restrictions that are still in place there?

Who wants to crack on on that one? Dr Payne.

Thank you very much. It's a tremendously important question because, of course, pregnancy and maternity, you know, are vitally important times. It's not an illness, it's normality, it is what we rely on for our future population, and a wonderful event of personal and social significance. I know because I've had two lockdown grandchildren and I'm very conscious of this—one born just before lockdown but has lived through it, and one born during. So, yes, I have certainly been aware, at first hand, of the potential issues. I will say that it goes back to the basic considerations of reducing harm, infection control in terms of footfall in hospitals, where those restrictions have bitten—so, it's going into scanning and it's actually, as you say, having partners, once active labour is established but not before, and for limited periods after. So, it's potentially very distressing.

To answer your direct question, absolutely, we have considered it. We've considered it not only in—it's come through the TAC group. Unfortunately, just as with so many situations with children, young people and maternity services, there is actually very little research. We're certainly involved in commissioning via Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries and UK Obstetric Surveillance System research on what was the effect of COVID on pregnancy, because, of course, when this started, no woman had gone through a full pregnancy being exposed to COVID. We had no idea that it wasn't going to be like Zika. We didn't know. And so, on a precautionary principle, we made a number of recommendations about protecting pregnant women from the workplace and making sure that they had those protections.

So, yes, we—[Inaudible.]—the harms, and yes, we passed it on, and the chief nursing officer did actually put guidance out, but then it had to be interpreted locally in terms of infection control. The balance is always difficult to achieve, but we certainly considered it. Thank you.

Okay. Lynne.

Yes. I just—. It's been a priority area, hasn't it, for Welsh Government and for Public Health Wales, the first 1,000 days. It's about attachment, it's about bonding, it's about perinatal mental health, and those things are a strategic priority for Welsh Government. So, is it likely, then, that that is something that you'll be able to review, going forward?

It continues under review with the chief nursing officer, certainly. There is no additional evidence coming out about those particular aspects. The additional evidence is coming out about whether or not women are more affected during pregnancy, and they show fewer symptoms, but, if they get ill, they're again more likely to go into intensive care. So, again, it's a way of trying to reinforce the basic points about social distancing, about hand hygiene, surface hygiene and reducing contacts. Again, it is in the context of a series of controls. So, that's—. There isn't additional evidence relating to the question that you're asking, but we—. Of the 10,000 papers on medRxiv, we do keep monitoring any new evidence.

Thank you.

Lynne, happy?

Thank you.

Great. Moving on now to some questions from Jayne Bryant. Welcome, Jayne.

Thank you, Chair. Good morning. Just to take the questions on to local interventions, really, and, Dr Orford, you said about how intelligence is the key, and, Dr Lyons, you've talked about reacting in a really agile way to understand all the different clusters. I've certainly seen how that's been done in Newport in my constituency. How small do you think local intervention areas could be and have you looked at what's happening in Northern Ireland in terms of postcode areas and other examples?

Thank you. A local intervention area could be as small as a care home, I think. We've used these principles for a long, long time. Every winter, if I get an outbreak in a care home, we restrict movement into the care home, we stop visiting, we don't allow any discharges back to the care home until we're happy that the outbreak is over. So, it can be at any level. It can be even a house. We use these local interventions a lot in health protection where we have communicable diseases that can be transmitted to others.

Do we look at postcode data? Absolutely, we do. We don't publish it—it's not in the public domain—because, if you take, let's say, Hywel Dda, they only had 13 cases overall from Thursday to Tuesday last week, so, if I was to show that on a map, you could almost say, 'I know who that is', in rural areas, 'It's that farmhouse.' But we use it to support action locally, so when we have any IMT in an area, Public Health Wales will show a map, from the first infection that was in the area, and show where it has spread by individuals by postcode. That guides, then, where you might put your investment. So, for example, I can tell you that, in the RCT area, they have identified a cluster of cases from Tredegar who've travelled quite a distance to another MTU, mobile testing unit. So, now what they're going to do there—[Inaudible.]—

We've lost you.

Sorry—[Inaudible.]

Oh, you've gone again.

I think I'm—. Yes.

So, I was just saying that, and this is just in real times, in the last few days, I have identified that people are coming from that area of RCT to get tested, so they're going to actually put a mobile unit there all next week so that they have easy access, they don't have to travel any distance. It facilitates, it supports them if they have any signs of symptoms. So, we do use the postcodes all the time, but we don't put them in the public domain.

Okay. Jayne.

Thank you, Chair. Fliss, you've explained the modelling for implementing local restrictions earlier on, really, very clearly. Do you—? I think one of the other—. First of all, how do you feel that things have gone in, say, an area like Caerphilly? Dr Orford, you gave a bit of an indication, but how do you see—how quickly are you able to move into these decisions, and how quicky do you look at changing developments, and how agile can you be?

Thank you. Oh, sorry, Rob, did you want to come first?

Yes. I can tell you from first hand—I live in the Caerphilly area, so I saw how quickly those interventions came in, and I've also seen how quickly people have adopted those behaviours of not going into each other's houses. I know that's really difficult; it's tough that you can't go and see your friends and family as you might like to. I've seen real good compliance on wearing face coverings. I think people understand it and have bought into it. From a professional perspective of seeing the machinery work, these things are analysed every single day, and decisions and conversations are held every day. There are dynamic risk assessments that are happening at a local, regional and national level, and there are risk management conversations and decisions happening at those levels as well. So, I think that there's a fairly well understood process and processes in place now for us to be able to capture and interpret that intelligence, and then use that information to inform mitigation measures, which need to be appropriate. Some of the instruments are quite blunt, so we need to target them in the areas where we know there's evidence of disease transmission. Striking that balance is so important, because the measures impact upon people's freedoms. They're important to turn them on quickly and they're important to turn them off when appropriate as well.

Okay. Fliss, do you want to add to that?

Thank you, Chair. It possibly reflects poorly on us, or possibly it's just part of the psyche of the global community that, whilst we have said it is going to come back, and whilst we have said—. We have set out processes, but it is serious and it is returning. Nevertheless, I've felt that we were able to respond swiftly and in a measured way. But it did take many people by surprise, and it does need to be taken seriously if it's going to be dealt with well.

So, in the case of Caerphilly, I would say, as the lead, (1) it came absolutely in the right way—local intelligence over the weekend before last showed that we were going up above 25 cases per 100,000, that positivity was increasing. Mobile testing units came into place swiftly, in line with the local intelligence. By the time we came to Monday and the decisions were being made, we knew that the cases had gone over 50 per 100,000, which was into the red zone, and we swiftly mobilised. We were able to provide scientific advice and health protection advice to local and national decision makers, and the leaders of the community groups and the policy-making groups were able to suggest interventions that would be proportionate, and importantly—really importantly—mapped for what we were seeing on the ground. So, we knew in Caerphilly that this was being driven not necessarily by the night-time economy but by individuals having party groupings and having close contact within households, and that's why it needed to be the reduction in the number of household interactions that was going to have an effect on breaking the chain of transmission.

Member Neagle's point is really key here. Whilst we knew that this was going to have another rise, the well-being of individuals and of the community as a whole meant that it was necessary, and, indeed, the well-being of the economy and the social structure of the country meant that it was important to let people have as much of a break as they could whilst it was so safe and, with such good weather to be outside, to have the opportunity. Perhaps we let people think that it was more safe than we should have done. And, going back to Councillor Davies's point, looking in hindsight, perhaps we could have thought more about what behaviour would be in the long term, as we started to release those restrictions. Ministers have been very, very cautious in easing by comparison with other countries in the UK, and I think that that's one of the reasons why we're seeing controllable outbreaks now in Wales and we're able to keep ourselves so low down. 

Just while I have the floor, I'd like to come back—I promised Member Rees that I would come back. I have looked and seen that the planning is 5,000 extra beds on surge. So, 5,000 beds on surge and 350 in ICU. And our reasonable worst-case from Swansea at peak is 190 cases in ICU occupation for COVID alone. The SAGE model is higher—I think it's about 350—but we think that the demographics for Wales mean that it's going to be lower than that. That should allow for non-COVID cases to be in ICU at the same time as COVID cases, even if the worst comes to the worst. I hope that allays the Member's concerns. 

Great. Thank you for that. Dr Lyons.

On the issue of responding in an agile fashion, I think we're building on what's familiar. We have extremely good multi-agency outbreak control plans, which have been tried and tested, and are reviewed regularly and modified. For all that COVID is a new respiratory virus to us, it doesn't change that multi-agency working, and it has worked extremely well and effectively. I must say that the strategic co-ordinating groups likewise have been extremely supportive. I think this has facilitated that ease of action across the piece. I come from it as an ex-consultant in communicable disease control, so I just see it as an infection, but actually it impacts on society, it impacts on industry, it impacts on anyone who goes to the shop. So, all the partners need to buy into any decision making. And because we're building on what's familiar rather than putting in something new that has never been tried and tested, it is working very, very well. We've seen that for almost every single outbreak we've had. 

Okay. Jayne.

Great. Thank you. I am learning about SCGs and IMTs. [Laughter.] Lots of those. Just looking at easing restrictions locally, what are the criteria and will they be different in different areas, depending on the different restrictions, in terms of easing restrictions in local areas?

Who wants to kick off? Fliss—how surprising. 

Terms and conditions apply—your restrictions may go up as well as down, absolutely. The importance of putting any restriction in place is knowing how you'll come away from it, otherwise there will be despair and there will be harm as a result. So, if we put something in as a result of having an increased positivity above a certain rate, then, once the outbreak is agreed to be under control in the local area, back down to a number that is below the thresholds put in place for intervention, then the health protection advisory group, being informed by local and national intelligence, looks at those thresholds and says, 'Now'—to decision makers—'is the time to consider removing those restrictions.' It needs to be done with not only communication about the restrictions being removed, but the reasons why they're being removed, so that people can understand that what they're doing helps. It's too early to say, but in Caerphilly we're starting to see, in the Public Health Wales data available on the internet, that the positivity rate is starting to halt because we've had good compliance, good understanding, and good public behaviour. 

Good. Jayne. 

Thank you. Just finally, I know there's been some research on the impact of local restrictions in places like Leicester, and on how people behave or how people feel about those restrictions. Is that something you're actively looking at and tracking—the behavioural issues in terms of those restrictions and how they affect people? 

Dr Orford, on Leicester. 

Absolutely, we look and we learn from others. We look at Scotland, we look at England and we try to understand what is happening there and what's behind it. So, Leicester is different to Caerphilly and there are different challenges. We do the same; we have to consider what's in front of us and think about our interventions. But compliance is really, really important and something that we think about and talk about a lot. How we enable people to make the right sensible choices is really important and that's part of our considerations, and part of the risk communication behavioural insights group. So, it's no good telling people to do these things if they can't achieve it physically or they can't do it financially. So, these are really important considerations: how do you enable, how do you support people to make the right decision?

Okay. Jayne, are you done?

Yes, thank you, Chair. 

Thank you. If I start and then I'll probably bring in Marion, if that's okay. Absolutely, this is a really challenging thing to do. The UK Government are scaling up an operation that's never been done before, but I think the current capacity is around 370,000 tests a day, which is remarkable. There are significant challenges in doing that, in scaling up an operation of that size and meeting the demand from areas, with schools going back and lots of anxious parents and individuals that feel that they want a test. So, that is a challenge and I'm sure it will be addressed, and I know there's lots of discussions with policy officials and decision makers about this. 

I think we're very fortunate in Wales in that we have our own system as well. From the beginning, we've built a system with Public Health Wales and that is able to support us when we're experiencing these types of problems with the lighthouse labs. So, I think this will be a blip. There definitely needs to be work done to address it, but I'm confident that we are in a different position because we do have capacity in Public Health Wales as well. Marion may want to come in as well.

Yes, thanks, Rob. Yes, we're very fortunate that the NHS labs can step in. We have always said that we would use the NHS labs in any outbreak situation, because we want that quick turnaround time. So, we want the results back in 24 hours. If I had a resident in a care home, I'd want to know, 'Is this COVID?', if it was a respiratory virus, and I'd want to know quickly so that I could prevent further harm. So, in fairness to the NHS, they did step into the breach. We saw it at the weekend in Rhondda Cynon Taf when they wanted to do the enhanced testing, and while the Welsh Ambulance Services NHS Trust supported them, it was the NHS labs instead of the lighthouse labs utility that they used for the most part.

In areas where I have some concerns, not particularly concerns, but we put a lot of effort into protecting our care homes, and you will know that since 16 June we have been either providing weekly or fortnightly testing for our care homes. And we're very fortunate that with the challenge of the lighthouse support currently that we can use the NHS labs in areas like Caerphilly, in areas like RCT, to maintain that weekly testing of staff so that we don't reintroduce it. 

So, as Rob says, it is a blip; it will be fixed in time. It's a massive industry that they've developed at pace, but we have that extra layer of resilience that does protect us to a certain extent.

I know you've said today that you very much respect the advice that you're given by Independent SAGE as well as SAGE itself. They said, I think it was probably their fourth report at the beginning of summer, that,

'There is an urgent need to plan for migration of testing back from the...Lighthouse laboratories into a more integrated future "normalisation" of...increased capacity across our existing PHE/NHS laboratories'.

And it's actually been the other way that the traffic has gone, that Welsh Government has decided, 'No, it's lighthouse that we need to depend on.' And when we see caps being imposed by lighthouse on certain parts of Wales, as it seems, that's the lack of control that I am concerned about—and not just me, but others too. Dr Orford.

Thank you. We're here to advise, and I think we're at danger of straying into policy territory here, so I think these questions are probably best served to others within our organisation. Investment decisions have been made to strengthen our capacity in Wales recently, and those options, that capability, will be coming online as well. Our testing technical advisory group is very productive, it's very active in advising policy makers on testing. There's lots of work going on at the moment of where to prioritise testing, how to use near-patient testing. And we'll bring that to support our policy makers develop the right policies for us in Wales, but also working alongside our colleagues at a UK level, together.

And you're quite right to draw the distinction between the advice and the policy side, but as advisers you presumably will be waving all sorts of flags at Government, and saying, 'What we've seen over the past two, three weeks in terms of people not being able to get those tests quickly, not being able to get home tests, this is something that you should be addressing very, very seriously as policy makers.'

Fliss Bennee, you've been waving, I hope.

Thank you, Chair. I think it's really important to note that the evidence and the advice shows that testing is not a prophylactic. Just because you have a test doesn't mean that you can have a normal life in an abnormal situation. To succeed in breaking this pandemic, and breaking the chains of transmission, there's a calculation that involves three different factors at least. And I would say that those are: test, trace and protect; COVID security in locations, looking at the hierarchy of risks; and public behaviour. And I don't think that it is within our gift, or within the base of evidence that we have, given how successfully other countries are able to control this disease with a fraction of the tests, for us to focus too much of our energy on suggesting that giving everybody a test is the way to treat this disease. The evidence says that people need to isolate if they're symptomatic or if they're contacted. People do if they're going to survive.

I'll refer you to your own advice back on 7 August:

'all traced contacts should be tested...after exposure',

and routine follow-ups should be conducted with them to see if they have had subsequent tests. This was your advice; Government didn't take it. Are you concerned about that?

Dr Orford. Sorry, Fliss.

We can advise, we can advise based upon the evidence and what's written and what's observed in the science of how best to manage outbreaks and transmission in the community. And then there's the delivery, then there's the practicalities of actually having to be able to achieve that. So whilst we'll give this-is-best-practice advice, difficult decisions need to be applied of how best to achieve this. And there is a huge architecture and industry, lots of people involved, around delivering tests. From the beginning, we've always said testing has to have utility, it has to have purpose, testing has to inform action and decisions.

But as well—I'll come to you, Dr Payne, in just a second. But as well as publishing that advice on 7 August that you would like them to test traced contacts, whilst you're saying, 'Well, if they haven't got the capacity, fine', will you keep on reminding them that it's your view that traced contacts should be tested and that not doing that is sub-prime?

Unless the evidence changes, if you've got the capacity, if you've got the capability, then do as much as you can.

But they haven't got the capacity currently to even test bog-standard cases in my constituency. That's what worries me.

Dr Payne.

Thank you. On the point of testing, again, it's making sure that we don't divert testing to inappropriate places. And we have, again, given quite a lot of advice now that schools are going back, and keeping children and young people in schools is an absolute priority, underlined by the recent World Health Organization paper and our own policies as well. We've tried to give people information about what is not a core symptom of COVID, because there's an awful lot of anxiety out there. It's totally understandable, but people have, we understand, been taking up tests when they don't have COVID core symptoms. So, we've identified that and actually done something to try and improve public information about it. Because, whatever tests we've got, we do have to focus them to answer the right question: is this COVID or not? And that's got to be predicated on core symptoms.

I'm grateful to you for that, and I would encourage you to press for even more communication on that. It happened in our family recently, when somebody had a cough, and said, 'Right, I want a test', and I said, 'Yes, absolutely, get a test if you need it, but there are serious implications for us as a family if you do need a test, in terms of isolation.' So, we did a lot of research and we found out pretty quickly that he didn't have what was defined anywhere as a new, persistent cough. But many people wouldn't have that information, so I would encourage more communication on that in order to limit unnecessary tests.

There's a lot in the pipeline, but, thank you, that's really helpful.

Could I just bring in Andrew R.T. at this point? We'll come back to you, Rhun, all right? Give you a bit of a break. Andrew R.T., you're fresh to this committee, we're looking for some innovative ideas. Andrew R.T.

I don't know about innovative ideas; I'm just after a point of information, because, as a politician, I talk a lot about testing and I listen to the news and I listened to the news this morning, and, actually, in many areas, capacity at the test centres doesn't seem to be a problem. From what contributors are talking about or what I heard on the radio this morning, it's about the ability of the labs to process the tests. I have no idea how long that particular test takes in the lab. Are any of you, as doctors, able to enlighten me anyway as to how long a test takes? Is it something that's relatively speedily done or is it something that's got to be cultured and it takes time? Because whilst I can take on board the physical nature of a testing station, I have no idea what goes on in the lab, to be honest with you.

Dr Orford, have you got a petri dish there or something?

I have. Fortunately, I'm trained as a molecular biologist, so I've got a little bit of understanding. It's a pretty well-trodden technique that's been around since the, probably, mid-1980s, in terms of the preparation of the sample, the extraction of the nucleic acid and then the mixing of that with other ingredients and the amplification of the material in that tube. And then a signal is provided if there's the presence of viral particles from the nucleic acid. That then is processed. We have a laboratory information management system that transmits that information to the patient's records. So, it's a very well-trodden, highly accredited process that happens in the laboratories of Public Health Wales, with a well-trodden, highly sensitive, highly specific test. The results from these tests are published, weekly, I think, are the turnaround times for the laboratories, and that's on the Welsh Government website.

Okay. Fliss Bennee, you had a supplementary to this.

Thank you, Chair. Whilst I'm not a molecular biologist, the behavioural and understanding point is well made. A lot of these kits are sent for home testing. When you go to a drive-through in order to protect staff, you're given an instruction booklet and the application of the test is not comfortable. I'm in quarantine at the moment because my son spent the last three days with a temperature above 40 degrees, and when I had to go to the drive-in and do the test on him, it was very, very hard to apply a swab, as a mother to a sick child, for 10 to 15 seconds on the back of his tonsils and then up the nose for a further 10 to 15 seconds. However, if you do not correctly apply the test in accordance with the instructions, if the swab doesn't get enough material or if you don't seal the bottle afterwards just as you're told, then all of the hard work that goes into doing that is voided. And the problem is that a lot of the home tests, if they're not well done, will result in a void. You could get up to, in a bad situation, maybe 5 per cent of cases being voided when they get to the lab because of leaks or dry swabs. If Member Davies wants to really drive home a message that will help his constituents, it is 'Make sure that if you do get a swab, you do it properly and carefully according to the instructions so that it can have the effect that is needed.'

Indeed, it is very uncomfortable and you will gag, although I would volunteer, Andrew R.T. for that course of action at the moment. Reverting to Rhun. 

Diolch, Cadeirydd. Picking up on something, Dr Lyons, you said on the importance of continuing with regular testing for staff at care homes, I am being lobbied heavily—well, I agree with the lobbyists, so they don't have to work too hard on me, but we have to put pressure on Government—to also extend that to domiciliary carers, to community nurses, to district nurses, to those working with vulnerable people in assisted living accommodation, and so on. These are workers that come into contact with a high number of vulnerable people. Would it be your advice that, in order to limit potential widespread spreading of cases among significant numbers of vulnerable people, it would be an idea to include them alongside residential home workers? 

Dr Lyons. 

Thanks. We all know the impact that COVID had on care home staff and residents, don't we? And I know that if I was to do antibody tests on staff and residents in a large care home that had a huge outbreak of COVID-19, I would expect that 60 per cent, maybe 80 per cent, would actually have antibodies, whether they presented with symptoms or not. Now, we don't know that about domiciliary care workers. I think we've got about 22,000 domiciliary care workers and I don't know how badly they were impacted by COVID-19 in the first wave. So, yesterday, all those domiciliary care home workers received a letter saying 'We're looking for volunteers, up to 30 per cent, to come forward so we can take antibodies'. And it won't help the individual, because you don't know whether they're protected or not, but it will be a sample size big enough—that'll be 4,000 to 6,000 domiciliary care workers—to tell us whether their prevalence of infection is higher than other population groups. So, we could compare it to the schoolteachers and school staff that we did prior to the summer, where we know now that the prevalence was 4.5 per cent.

Now, if we find, in our study, let's say, that it's twice that, we will want to work very closely with that sector to make sure that—I hope we don't have one—going into the second wave, they are well prepared, they have the proper PPE, and they have been supported in infection prevention and control training. So, this is why we want them to volunteer to do this study, for exactly the reasons you said. I want to know were they more harmed than others in the first wave. The health boards, each of them have a slightly different process, but hopefully by mid to late October we should have that information and intelligence. And, then, depending on what we learn from that, we can progress to other groups. 

But I don't have any evidence that people in assisted living had a poorer outcome than the general population. But we're taking it stage by stage. 

Dr Orford. 

Thank you. To come in there as well, there's been an enormous amount of research around COVID-19—an incredible amount. One of the things that we have really pushed is the use of links data, the use of anonymised data, building on assets that we have in Wales, such as the Secure Anonymised Information Linkage Databank down in Swansea. The use of SAIL and that type of infrastructure can help us answer some of these types of questions about how the virus is  circulating in different care settings, how it impacts patient- or non-patient-facing staff, and using that type of information will absolutely help us reduce those types of transmission events as we enter into winter. So, it's incredibly important that we do the types of studies that Marion has suggested—the serious surveillance type studies—and also use the data that we have and the assets that we have available to ask those questions in order for us to target our resources effectively.

Okay. Rhun.

Just briefly, one comment I'd make is that the domiciliary carers aren't so much afraid of getting it themselves; it's the danger of them taking it in to other people, having caught it outside their work. But when are we likely to get the result of that piece of work?

Well, by the time they have—. They've all got to book an appointment. They have to take a blood sample, so obviously they have to go to the hospital for it. They're setting up these clinics to support them with phlebotomy. I would think certainly by mid to late October we should have the first of the results.

Okay. Thank you. And finally from me, on face coverings, I don't think I've seen any piece of work anywhere, internationally, suggesting that face coverings are the silver bullet, that they are the solution to this COVID crisis, but, for some time, for a number of months, the balance that I've read has clearly been that they can be really useful. Can you explain the journey that you as a technical advice cell have been on? You said back in August that some of your members supported face coverings, but it didn't become mandatory until very, very recently. What happened there? Why were you at odds with what was, to me and others, pretty clear international advice by then?

Fliss Bennee.

Thank you. It's a really interesting question and probably one of the areas that's been most—[Inaudible.]—evidence and most debated at SAGE, at the technical advisory group and, as you say, around much of the world. I'd like also to approach again the concept of thresholds. So, by the time it was agreed that there was enough evidence to say that face coverings—. I say 'face coverings' here rather than 'face masks' because the majority of the evidence is weighted in terms of FFP3 or other clinical and surgical face masks, which we did not have enough of to be able to put outside of the health and social care vulnerable areas. So, the evidence that we needed to consider was what the proportion of aerosol-generated as opposed to heavy-droplet-generated transmission was likely to be. We needed to know that there was likely to be some—and the World Health Organization did eventually agree the admiral standard—a standard for face coverings that could be said to be able to prevent enough of the 5 nm and above particulate matter from being expelled. There is no strong evidence of protection for the individual wearing a face covering, even if it meets the correct standard. The only evidence that we have for protecting an individual is if they're wearing a clinical face mask, they have been trained to use it properly and they use it only for the prescribed amount of time and afterwards treat it as a piece of biohazard, closing it carefully and following a whole suite of principles, which is very difficult to achieve.

By the time we had reasonable evidence that there was a weak effect if the majority of the population was wearing face coverings of an appropriate fashion, the prevalence or the incidence of the infection within Wales was very low, and we come back to Member Bryant's point that there needs to be an endgame. So, the advice that we gave, and the advice that we put to Ministers was that if certain thresholds were met, then it would be appropriate to consider mandating face coverings, either at a local or a national level. But if it was mandated generally, while the prevalence and the incidence of the disease was very low, then what would be the exit strategy? When could people stop wearing face coverings? Is it proportionate to the risk? That is why, when the local—in Caerphilly—prevalence went above a certain level, face coverings were considered to be appropriate as an intervention that was made mandatory. And then the following day, when it became more than 20 cases per 100,000 in the nation as a whole, Ministers took the decision, based on our advice, policy advice and others, to make face coverings mandatory in the whole country.

[Inaudible.]—on its own mask journey, I think. Dr Orford.

Thank you. I think Fliss has covered many of the points. I think it's fair to say we've discussed this at length. We've avoided groupthink where we've had—. We could spend the next two hours arguing the case for face coverings as a prophylactic measure—

I hate to say, 'No, we can't', but, you know—

Okay, I'm glad about that. Thank you. And also as a more reactive measure—. At the moment, the decision is to use them very similarly to seatbelts on aeroplanes. When your pilot tells you to put them on, you know it might get bumpy, and that's the signal that we're conveying with face coverings: now is the time to put them on and the reason that you could put them on now or you should put them on now is because the likelihood of you coming into contact with somebody that's infectious or you being infectious yourself is higher, and it will also be a signal that when that reduces and there's less likelihood, then that's the time to take your seatbelt off. The other thing that we've considered—

If I may say, passengers are told to keep their seatbelt on at all times if possible.

We're in danger of getting side-tracked in metaphors here, but, carry on, Dr Orford. 

Maybe we go on different air carriers. So, just in terms of risk mitigation measures, there's a hierarchy of risk control, and the things that have the most impact are the things that you do first and the things that have the least impact are the things that you do last. Face coverings are an imposition and, by mandating it, people have to wear them. I've got two here. Do I like wearing them? No, I do not. But do I wear them? Yes, I do, and that's a choice that I've made up until now because it's been recommended and we've always recommended wearing them, but now it's mandated, so I have to wear one when I go into a shop.

Just in terms of the hierarchy of risk control—the things that are most important and have the greatest impact, and, if I may, Chair, I'll very briefly go through them—the first thing is don't do it. If you don't need to go out, don't go out. The next one is substitution. If we don't need to meet in person, then we can meet online and, by doing so, we've completely reduced the risk of transmitting the disease back and forth to each other. So, they're really important. So, rather than seeing my mum in person, I can contact her by Facetime and we can interact that way. It's not the same as meeting together, obviously. The next one is engineering controls. So, if you go into a shop, for example, there are plastic screens; there is no way that I can cough on you if there's a plastic screen in place. The next one is administrative controls, keeping those 2m apart. Ten metres is better; 2m is good. Again, it's not an absolute cut-off, but that will reduce the risk of me passing the virus on to you by coughing, through droplets and so forth. Staggered starts in schools, keeping bubbles of children small—these are all effective means of control. And the last one is personal protective equipment and then face coverings. So, it's the last thing we turn to, but it's a tell that things are not going the right way at the moment. 

I could also discuss this at length, and I'm really interested in what some of your own scientists were saying. You say there was a debate and you had disagreement within the group, and you say, 'Wearing a face covering was seen to mitigate a perceived relaxation of social distancing'. It kept us thinking it was serious. There was a really interesting report from Italy, I think it was, at the end of spring that said that if people wore a face covering, it made them behave in a more responsible way because they remembered all the time, and I can't help thinking that in places like Caerphilly and Rhondda Cynon Taf, having those face coverings before the increase in cases might have helped avoid it. But, hey, here we are. I've made my opinion clear, but we all know there are differing bits of evidence. 

We've reached that part of the health committee now where I utter the dreaded words, 'We need some agility now, team' in terms of both the length of questions and answers, and the queen of agility is Jayne Bryant. 

Not so agile as to unmute there. Thank you, Chair. Just on returning to workplaces and to offices, what role do workplaces play in the transmission of COVID-19 and how confident are you in the advice and measures that have been put in place?

[Inaudible.] Fliss Bennee first, then Dr Lyons. 

So, it's entirely dependent on the size and shape of the individual workplace, the make-up of the people and the behaviours within it. We've got—. I'll pass to Marion.

We've had, as you're probably aware, five or six large outbreaks, most of them associated with food packing plants, and sometimes the environments there are challenging in that they can be wet and cool and cold and—you know, the right environment. I think we've learnt over time what it takes to do it safely and do it well, and I can tell you that HSE, on visiting some of the plants—I think we've got 56 like plants across Wales—have been very, very impressed with the control measures in place. I know some of them have reduced the number of people on the floor by 50 per cent—one-way systems, no loitering in the locker rooms, and really good controls.

I think, as Fliss says, it is also dependent on the behaviour of individuals. So, we have seen, for example, in some of our loveliest industries—I'm not talking about food packing plants—where individuals do the right thing at work all day, they're minimised from their colleagues in the office, but they will eat together at lunchtime, go down to the coffee shop outwith the building, and don't social distance. So, often, what we link to a workplace actually is the behaviour of colleagues out of the workplace, whether that's on a Saturday night, meeting up to go to the pub, or whether it's going out at lunchtime, or, more commonly, car sharing. That has been a challenge for some of our industries, because they can be industrial sites away from the centre of the town; people work shifts of funny hours when public transport may not be available.

So, we're finding increasingly that, actually, it's not the behaviours in the workplace. I think both HSE and environmental health officers have been very impressed with the controls put in place right across industry, and that includes the hospitality industry. There have been very few very, very exceptional times when they would have to use the regulations to enforce the controls. I think people—they've learned, they've adapted; it's becoming the new norm to do it right and do it well. So, what we have found is that most infections in Wales arise from your household contacts, your close friends or their close friends. And very few are infected by strangers. The workplace, as I said, they've had some large outbreaks earlier on, but I think things are improving.

Fliss, briefly, and then back to Jayne.

Thank you, Chair. There are six gatekeepers for COVID: there are, really, multiple gatekeepers for any pandemic or mass contagious infection. The Government making regulations, the NHS providing support, can be nothing without the public being responsible for their public health, and employers can work hard to be COVID secure, we can implement test, trace and isolate procedures, but, without public behaviour, without the understanding that the effect, even if you think only of the effect on yourself—whether you think the risk is low that you will suffer, the likely effect on the community is a significant if even only 10 per cent of people in the community choose not to abide by those behaviours.

Okay. Jayne.

Thank you, Chair. Have you seen any difference, or do you have any advice on the difference, in messaging between England and Wales? Because, obviously, in east Wales, there are a lot of people who commute to work in England, and those workplaces, obviously, they've been given different messages to go back to work, and, obviously, there's different guidance there. Have you been looking at that?

I do know that the local authorities and the DPHs are working very, very closely together. We have had imported cases from England, and likewise, they have imported cases from us, because, sometimes, some of those industries draw from the same population groups. So, there is very, very close collaboration. I think, when it comes to safety in the workplace, the guidance isn't any different; it's the behaviours outside of it. I think all of industry have tried to improve that, so you won't find a smoking shelter now that doesn't have its seats bolted down 2m apart. Nearly all of our large industries have put up CCTV, so they can monitor it. But then, once they go outside and hang around at the bus stop, the controls are slightly more—it's difficult to implement the same controls. But I don't think there are such huge differences in the workplace on what good practice and good behaviour is, because most of our industries across the border are similar. What we don't have—or have very, very little of—are the huge agricultural industries, where they had large outbreaks in England, but we imported a couple of cases as a consequence.

Okay, I think Jayne's point—and I'll bring Dr Orford in on this, because it's based on what you've said a couple of times—is that, if you don't need to go out, don't go out, and I presume that you still adhere to the fact that, if you can work from home, then you work from home; I think that's what Jayne is trying to drive up. Because, obviously, in England, there's been an encouragement to repopulate city centre office space, but obviously you don't dictate policy for England, but, however, you do in Wales, Dr Orford. 

Thank you. I'm not sure we dictate the policy; we certainly advise policy. And it's the advice of SAGE as well to keep your contacts to a minimum, and, if you can work from home safely, then it's good to so to reduce the likelihood of transmission. Again, it's a really good substitution activity. I would say, if you do work from home, you can be extremely effective, and you do need to look after yourself. Whatever we do, going into winter, we really need to look after ourselves and practice good work hygiene at home—having sensible breaks, getting up, moving around. It's very easy to sit in front of your computer and not move. I appreciate there are other economic considerations that need to be thought through here around the high street, but also around local economies, around public transport and around the environment as well. So, it's not a straightforward subject, but, certainly from a public health perspective, the advice of the technical advisory group and SAGE, is, if you can work from home, best work from home.

Thank you. Fliss on that point—or whatever point it was.

Thank you, Chair. Good work hygiene is important. Dr Orford would not say it himself, but he's had seven-day-a-week work since pretty much January of this year, leading the science advice on this. In fact, I'm fairly certain that in 2019 his beard was a beautiful golden colour. [Laughter.]

We'll make sure that's registered in the minutes of this meeting. Jayne Bryant, have you—

No. Thank you, Chair. That's it, yes.

Excellent agility, that's what I like to hear. Right, education now. Lynne, you've got some questions.

Thanks, Chair. Yes, I'd like to ask about higher education. SAGE has said that there's a significant risk that universities going back could amplify local and national transmission. How concerned are you, and how confident are you, that appropriate steps are being taken to mitigate that risk?

Fliss.

Sorry. Thank you. It is a serious concern. The migration of around 400,000 people from different parts of the UK to other parts, some with significantly higher incidence, is, of course, a concern. However, there is an even greater concern over the livelihoods, and the economic scarring and the mental scarring that will occur if further education and higher education is not opened well points to a significantly higher harm. The Minister for Education and the entire policy department for education and further education have been working pretty much non-stop with whatever advice TAG can offer to identify ways to pursue this.

The advice from SPI-B, the advice from the behaviour and risk communication group, and the advice from the technical advisory group has been very clear, and I've relayed this not only to the National Union of Students, but all the vice-chancellors and appropriate Minister and all policy makers. Each individual university and educational establishment is going to have a different situation; they will need to consider rationing their contacts if they are to make sure that they do not, and they will need to consider spread into the community.

But the three key messages are that the interventions that they choose will not work unless they co-produce them between administrators and teachers and students; they need to work together to agree what their behaviours will be and what their priorities are. Also, if somebody gets sick or if there's an incident at a university, the worst thing would be to send everybody home. They need to make that, if possible, they contain it there and they look after each other in that place, rather than spread the infection away. And, finally, when people need to isolate—and people will need to isolate—it's important that the community of students has support from the universities and colleges to ensure that those people do not end up suffering because they're isolated. Whether they choose to have isolation wards or bits of housing where people can isolate but not be isolated, that's fine. There's going to be 5 per cent of the population suffering from similar symptoms, whether they're COVID positive or not at the time. I'm confident that university students will be able to go back. It will have an effect, but I think that there are appropriate mitigations in place.

Okay, Lynne.

Okay, thank you. And in terms of—I mean, SAGE and yourselves have been very clear about the harms of missing out on education at whatever age. Have you done any analysis of potential harms for people going back into face-to-face contact in terms of mental health, et cetera, as well?

Who wants that one? Fliss, go on.

I'll start; I'm happy for others to come in. There has been a consideration, and I believe that policy colleagues are looking at needing to increase the amount of funding and resource that's available to look at mental health. The likelihood is that there will be somewhere up to a 60 per cent increase in the mental health issues for people under the age of 18 associated with the general lockdown and the severe restrictions that we had to put in place. But the majority of those individuals will bounce back relatively quickly and it's expected that the benefit of being able to go back face to face will wipe off most of the harms that happened over the last six months.

Okay, Dr Orford.

Thank you. This is an enormously challenging area, but there's been some considerable work that's been undertaken by both SAGE sub-groups and the group that Heather chairs on schools and education. There's quite a bit of advice on the indirect harms associated with education and withdrawal of education and some good advice on mental health harm and other types of harms. Heather may want to come in on that.

She definitely does—Heather.

Yes, thank you. Again, it comes back to the same basic principles that we have been repeatedly mentioning, which are understanding the direct and indirect harm and the COVID and non-COVID harm. Because children and young people—. First of all, there is the science that relates to children and young people who have been less affected and less susceptible and less likely to transmit the virus, so that's one consideration. Higher education, of course, is young adults, but there's a lot of crossover between them, especially in further education. So, it is actually back to the same basic principles: first, do no harm. And of course, children and young people were proportionately more disadvantaged by restrictions because they were less susceptible in the first place.

So, again, it's been getting that balance, it's been keeping a very clear focus on the absolute need, and this has been underlined by today's—yesterday's, sorry, the fourteenth; two days ago—WHO statement on education, saying it's really important to people that kids, young people and young adults are kept in education. It's a top priority.

So, it's that agile response of saying, 'Well, what's the risk? What's the intervention? How do we put them together to get the best outcome?' So, we've been focusing on the horizon and saying, 'How do we stick with this objective of keeping young people, children and young adults in education and how do we get the balance right?'

Mental health and support for them—again, that's absolutely been identified as being really important. Everybody has taken that on board. That's all in the planning, because it's clear it's going to be a problem. So, again, we remain focused on the ultimate objective of the well-being of children, young people and young adults.

Okay, Lynne.

Thank you. Final question from me, then: what is your view on universities setting up their own in-house testing of staff and students, as we know is planned in Cardiff?

Who wants to kick off on that one? Dr Orford.

Yes. Cardiff University are developing some in-house testing, but I must say we have robust systems in place for supporting individuals who may well become infectious. Universities generally are places where we should do research. They lend themselves to technological development in diagnostics and others, and I'm sure there is a lot to learn from the types of development that Cardiff University and other universities are developing. Our knowledge and our ability to detect this disease earlier in different populations will grow in the coming weeks and months to come. So, there's no magic silver bullet—testing is not a silver bullet. I think people need to adopt the same sensible behaviours as they would in the workplace, as they would at home. So, it should be no different, really.

Thank you, Chair. Just a couple of quick questions on public transport. Obviously, it was the first area in which face masks were required because of recognition of the social distancing challenges that using public transport would bring. I'm sure that situation is—[Inaudible.]—but where do you see the future of public transport in relation to spreading the virus, or perhaps minimising the spread of the virus?

Right. Fliss.

Thank you. This is a really difficult area, not least because, for many people, public transport is the only way they have to go and do things like get themselves food or visit other people. The benefits of behaviour that we have evidence for say that people, because they know they will be surrounded by strangers and because they know that they may not be able to distance themselves there as with other places—the hygienic COVID-secure behaviours that they display are much better on public transport. Far harder is, for instance, a school bus setting where very young people who might not understand so well the implications of their actions have to be in a smaller area. By and large, I think the importance of ensuring not only face coverings, but, far better, those higher up the hierarchy of risk areas that Rob was talking about—so trying to make sure that there's a physical divide between the conductor or the driver on a bus is better than having them wear a face covering and not having a physical divide. 

We know that it's safer to be outside than it is to be inside with the virus. So, trying to find a way to check tickets outside rather than inside a train—all of these things can lead to making it far safer for people to be less than 2m away. There is, of course, also the administrative practice of facing away from each other rather than into each other's faces, if you have to be closer. So, I think there are lots of things we can do to make it safer, but it's not safe; it's a risk calculation, just like getting in a car without COVID.

Okay. Dr Orford.

Yes, thank you very much. There are things that are far more risky that you can do and there are sensible precautions that you can take. Ensuring that public transport has good ventilation: there is some evidence around aerosol dissemination of the virus, so having a good breeze going through is very important; having your face covering on, stopping you transmitting those particles to other people; and good hand sanitiser—we know that it doesn't like hand sanitiser, it doesn't like soap, so washing your hands and not fiddling with your face. It's remarkably difficult not to do that. I have to constantly wring my hands together so that I'm not touching my wonderful beard. That's really important. I must stress—I'm sure we will see really good examples of people that are infecting each other by being close together in cars; I'm sure we will see friends and family that are close together on other forms of transport. It will be between the people that we know and love the most that we will infect the most.

David.

I appreciate that, because in the early stages of the virus, back in February, March and April, there were many workers on public transport that actually contracted the disease, and unfortunately some severely and some passed away as a consequence of that. So, are you confident that the guidance coming from Welsh Government reflects your advice about ensuring the safety of the drivers and conductors from passengers, and the passengers themselves? As you say, facing away from each other—there are measures that they can take to minimise it. Are you confident that that advice is being given in the guidance by the Welsh Government?  

Okay. Dr Orford.

If there's any new evidence, we will provide that to our colleagues. At the moment, we're giving sensible, risk-based advice about what we know about the disease—how it transmits, the main routes of transmission, through aerosol, through droplets, through contact transmission. As we receive new evidence, as more advice is commissioned by different departments, then we'll provide that advice and guidance to our policy makers and our policy leads so that public transport can be as safe as is practicably possible for people that are having to use those forms of transport to undergo their daily lives.

Dr Payne.

Thanks. I would just add that there's the advice and there is the communication of it. And we do have, as Rob has mentioned, the communications sub-group, chaired by Professor Ann John, but we certainly have been working on trying to be absolutely clear. If you cast your mind back to 'stay at home', that was a really simple message to give and it was very easy to comply with. It was obvious what it meant. Since we have been unlocking, it's been much more difficult to convey a simple, coherent message. But the idea is that it's simple, consistent and encourages collegial behaviour—you know, solidarity with the rest of the community. So, that's actually what we're also actively aiming at and Ann John will be able to tell you more about that.

Can I ask, then, because you just mentioned school buses and school transport? I had a constituent raising this issue with me; he was a bus driver on school transport. When we notice that children are—[Inaudible.]—sent home and a child is identified as being positive, we've seen classes, we've seen whole years being sent home, basically. The bus driver asked the question, what'll happen to them? Because sometimes, they have buses in which these children are sitting on for an hour plus, travelling to and from school. The guidance currently says that that's fine to the bus driver; he can stay in work. But is your advice that, in those circumstances, whenever a bus driver is in contact with a child for a long period of time, in a bus environment, which is a closed environment, they should also be wary to ensure that they are protected?

Okay. Dr Orford.

These are really important workplace questions about workplace safety, and it's really important that we consider these seriously. The advice that we provide, the types of advice around studies, sero-surveillance studies, to understand what infections have looked like through the previous months for us to understand if there's a disproportionate amount of infections, of historical infections, in this cohort of people, is really important. We've advised that. In our advice, we look at high-contact occupations and then we advise accordingly on the relevant levels of PPE or engineering controls, or other mitigating factors like really good ventilation, keeping all the windows open on the bus, that type of thing. So, there is evidence that we can collect. We can look at the number of people who have tested positive that have been bus drivers or taxi drivers, or any other high-contact occupation, of which there are many, and then ask whether the relevant engineering controls are in place. Workplace safety should look at that as well. So, we can provide advice—[Inaudible.]—looks good, and we can provide advice on any emerging evidence or any best practice that we might see within the UK or any other countries. So, all of the advice, everything we do is kept under constant review, and if the information and the evidence changes, then our advice changes pretty swiftly. 

Okay, thank you.