Written evidence submitted by Dr Jennifer Cole

Responses to further written questions following Dr Cole’s oral evidence on 7 September 2020.

1. How do you think the UK should adapt its approach to stockpiling in future, without running the risk of stockpiling the wrong things?

I would draw attention to the RUSI report on pharmaceutical resilience with regard to this question - https://rusi.org/sites/default/files/201305_cr_pharmaceutical_resilience.pdf. I think key takeaways from this were:

(a) Things that are stockpiled have a sell-by date. If one sell-by date passes and they have to be disposed of, it will inevitably be seen as money wasted and will be harder to replace. It's better to keep, for example, 6 month's supply of something you are definitely going to use than 1 week's but keeping something you may not use at all is largely wasteful. The six month's supply becomes a 'just in time' delivery issue, which can be dealt with separately or within the stockpiling question. Most hospitals etc don't have sufficient storage space to keep 6 months' supplies on site. Who is responsible for making sure private sector and subcontractors comply? Should NHS/govt stockpile for them or expect them to do it themselves?

(b) You can either stockpile the finished item (e.g. surgical masks) or the materials needed to manufacture them quickly when needed. An issue in the UK - relating to pharmaceuticals as well as masks etc - is lack of manufacturing capability in-country. When we import cheap goods from overseas rather than manufacture in-country it is hard to scale up manufacture. However, there are options to look at this more carefully - for instance, there are small-scale textile factories in the north-west of England that produce school uniforms, and high-end children's clothes producers in Wales, which could perhaps have been co-opted into manufacturing fabric masks quickly. Do we sufficiently understand at a resilience level where such capabilities lie and how to harness them? I suspect we could do better. 

(c) Not stockpiling the wrong things requires agility - this again suggests better ability to manufacture quickly is better than relying on imports. 

2. Do you think the preparations for Brexit in recent years have helped or hindered in testing the structures and capabilities needed for dealing with a severe biosecurity risk like COVID-19? As a new trade agreement is negotiated with the EU, what specific measures would you like to see included, from a biosecurity point of view?

Brexit preparations should have made everyone consider their business continuity plans and strengthen them. It didn't 'take the eye of the ball' of a biosecurity risk because that's not what we faced - a bad flu season could have had a similar effect. The biggest failing was the inability to protect elderly people in under-funded care homes, including lack of PPE for care workers. 'Blame Brexit' can't be used to explain away everything!

To be resilient, we need to be as resilient as possible at a local level. This includes not being dependent on other EU (or beyond EU) countries, but instead being able to stand on our own two feet, e.g. decent in-country manufacturing capacity. 

3. What are your views on the strengths and weaknesses of ‘Exercise Cygnus’ in 2016? Did it test the right things? To what extent do you believe that the Government learnt the lessons of ‘Exercise Cygnus’? To what extent did Cygnus’s focus on flu mean that we were left unprepared for other infectious diseases like COVID? Did Cygnus give us a false sense of security about biosecurity risks more generally? Is there any evidence that part of Government — the Cabinet Office or the National Security Council, say — was responsible for monitoring departments to ensure their preparedness plans were kept up to date?

Woefully underfunded; NHS so stripped back no-one had time to give any reasonable consideration to it. Just fund the NHS better and you don't need to exercise. 

Focus on influenza rather than a coronavirus isn't relevant - this is over-emphasized but the issue is the characteristics of the disease such as R0 (pandemic planning estimates of R1-2 broadly align with COVID19 more than its genetics. It's impossible to predict disease X so you have to plan using something as the causative agent - flu was as likely as anything. Whatever the disease was, it would have taken time to get a good grip on exact transmission mechanism, which demographics it did/didn't affect, IFR and so on. What might have been better to practice - but difficult to write into an exercise - was how to deal with that period of uncertainty but the UK did reasonably well with this, certainly compared with the US. The public needed to trust the experts to do the right thing and I think mostly they did.

Preparedness plans may have been focussed in the wrong place - dealing with cases/casualties rather than trying to stop the spread through track and trace etc. Were we thinking about new technology and non-pharmaceutical measures of disease control enough? Probably not. Did we consider how grocery deliveries would scale up in lockdown, for example? Probably not? 

The biggest issue is that people who are overworked anyway don't have time to play with what ifs? Just fund them better.

4. In your view, at what point should a public health issue become a 'national security’ concern, and bring into play all of the preparedness work that that entails?  Is there some sort of threshold — perhaps in terms of likely casualties or economic cost — that should be used, and, if so, what should this be?

Health should ALWAYS be a national concern, but not securitized. Prevention is better than cure - healthy people in good care have not been hit as hard as unhealthy people in poor care. Tackle the UK's disgraceful obesity problem; improve food systems; don't cut corners on elderly care etc. This is not about securitization, it's about human decency - caring about human beings and enabling them to be as healthy as possible throughout life.

9 September 2020