Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd
Health, Social Care and Sport Committee - Fifth Senedd18/11/2020
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Andrew R.T. Davies MS|
|Dai Lloyd MS||Cadeirydd y Pwyllgor|
|David Rees MS|
|Jayne Bryant MS|
|Lynne Neagle MS|
|Rhun ap Iorwerth MS|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Claire Morris||Ail Glerc|
|Dr Paul Worthington||Ymchwilydd|
|Lowri Jones||Dirprwy Glerc|
Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.
The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.
Cyfarfu'r pwyllgor drwy gynhadledd fideo.
Dechreuodd y cyfarfod am 09:30.
The committee met by video-conference.
The meeting began at 09:30.
Croeso i bawb i'r cyfarfod diweddaraf o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd drwy gyfrwng rhithiol. Gaf i, yn y lle cyntaf, estyn croeso i'm cyd-Aelodau o'r pwyllgor? Croeso i chi i gyd. Mae Andrew R.T. Davies a Lynne Neagle ar eu ffordd. Gallaf bellach nodi, yn naturiol, y bydd pawb yn ymwybodol taw cyfarfod rhithwir ydy hwn, gydag Aelodau a'r tystion yn cymryd rhan drwy gyfrwng fideogynadledda. Mae'r cyfarfod yma'n naturiol ddwyieithog. Mae gwasanaeth cyfieithu ar y pryd ar gael o'r Gymraeg i'r Saesneg, ac efallai bydd yna ychydig bach o oedi ar ôl i rywun fod yn siarad yn Gymraeg cyn i lefel y sain ddod yn ôl i'r lefel roedd o cyn hynny. Hefyd mae'r meiciau yn cael eu rheoli yn ganolog y tu ôl i'r llenni, ac efallai mi fyddwch chi yn cael neges ar y sgrin i ddadfudo cyn i chi siarad. Gallaf bellach nodi gogyfer y cofnod os bydd fy system rhyngrwyd i yn ffaelu, rydyn ni wedi penderfynu cyn hyn y bydd Rhun ap Iorwerth yn camu i mewn i'r bwlch, gan obeithio bod y system rhyngrwyd yn Ynys Môn yn gadarnach na'r un sydd yn y fan hyn yn Abertawe. Felly, fe fydd yn cadeirio dros dro nes y byddaf i'n gallu dod yn ôl. Allaf i ofyn a oes yna fuddiannau i'w datgan? Dwi'n gweld nad oes.
Welcome, everyone, to this latest meeting of the Health, Social Care and Sport Committee here at the Senedd in a virtual capacity. In the first instance, may I extend a warm welcome to my fellow Members of the committee? Welcome to all of you. Andrew R.T. Davies and Lynne Neagle are on their way. I also note that everyone will be aware that this is a virtual meeting, with Members and witnesses participating via video-conference. This meeting is, of course, bilingual, and an interpretation service is available from Welsh to English. There might be a slight delay after a contribution in Welsh before the sound level returns to the full level. The microphones are being controlled centrally behind the scenes, as it were, and perhaps you will see a prompt on your screen to unmute your microphones before you contribute. I also note for the record that if my internet were to fail, we have decided ahead of time that Rhun ap Iorwerth will step into the breach, in the hope that the internet on Ynys Môn is slightly more robust than the internet connection here in Swansea. So, he will chair until I'm able to reconnect. May I ask if there are any declarations of interest from Members? I see that there are none.
Felly, rydyn ni'n symud i eitem 2 ar yr agenda, parhad efo'n craffu ar ymatebion i bandemig COVID-19. Dyma sesiwn dystiolaeth gyda'r Athro Robert West a'r Athro Susan Michie. Croeso i chi'ch dau. I roi eich teitlau llawn: yr Athro Robert West, athro mewn seicoleg iechyd, Coleg Prifysgol Llundain, ac hefyd yr Athro Susan Michie, athro seicoleg iechyd a chyfarwyddwr y Ganolfan er Newid Ymddygiad, Coleg Prifysgol Llundain. Croeso i'r ddau ohonoch chi. Rydyn ni'n falch iawn i'ch cyfarfod chi, er yn rhithiol ac nid yn y cnawd, felly, ond daw hynny eto, efallai. Fe awn ni'n syth i mewn i gwestiynau. Mae gyda ni ryw awr, ac mae'r cwestiynau cyntaf o dan ofal David Rees. David.
So, we move on to item 2 on the agenda this morning, and the continuation of our scrutiny of responses to the COVID-19 pandemic. This is an evidence session with Professor Robert West and Professor Susan Michie. A very warm welcome to you both. Your full titles are: Professor Robert West, professor of health psychology at University College London, and also Professor Susan Michie, professor of health psychology and director of the Centre for Behaviour Change at University College London. A very warm welcome to you both. We're very pleased to meet you, although it's in a virtual capacity. Perhaps we'll meet you in person at another point. We'll go straight to questions, and the first questions come from David Rees. David.
Diolch, Gadeirydd. Good morning, both, and thank you for coming in this morning. Obviously, behavioural science is an important consideration as part of the modelling. We've had evidence on the data aspects of data modelling, but this, clearly, has implications upon that. Perhaps you could just give us a brief introduction as to how behavioural science plays into the modelling that's going on to look at the way the spread is happening.
Shall I start, then hand over to Susan? So, the reason why behavioural science is so important to understanding the results of the modelling, and ideally to feed into the modelling, of course, is that the mode of transmission is fundamentally dependant on behaviour, it's dependant on contact. The two modes of transmission are airborne, either through droplets or aerosols, or through fomites—contaminated surfaces. So, behaviour is obviously key. Now, as you've probably heard already, what they will do in the modelling is they'll model R0, which would be the rate of transmission, effectively, if you didn't do anything, if it was just allowed to go through a particular community. But then the job of the measures that we take is to get R below 1, so that we can reduce the rate and eventually, ultimately, get it to a level where it can be managed in a more conventional way.
What that means is, effectively, two things, really. In an ideal world, it means identifying people who are infectious and keeping them away from people who aren't yet infected. And the other side of this, of course, is the fomites, so the contaminated surfaces, to make sure that even if someone who is infectious is no longer in a particular vicinity, if they happen to have contaminated a surface or an object, that then is not picked up and transmitted through something else. So, the behaviour is really key to that, and I think you'll have probably also heard that, really, at the heart of this is keeping infectious people away from non-infected people. And the problem that we've faced with this particular virus is the fact that we don't know who is infectious because there is a fairly substantial rate of transmission from people who either will never have symptoms—and the current estimate of the transmission rate from those people is around 17 per cent, so 17 per cent of infections are judged, roughly, as far as we can tell, to be from people who will never show symptoms—but also a substantial amount of infection from people who haven't yet shown symptoms and will go on to. And what that means is that the test, trace, isolate and support system is absolutely at the heart of that, and, of course, behaviour is really important when it comes to engaging with that system and doing the things that are necessary. I don't know, Susan, if you want to add anything to that.
Yes, happy to. So, two ways in which behavioural science feeds into modelling: one is providing data on which the models are based. So, quite often, modellers will come to behaviour scientists and say, 'Can you provide us some evidence on what the current patterns of behaviour are?' This may be to do with adherence to various measures, it may be to do with types of travel, whatever they're taking into account in their models, because quite often—. Models are only as good as the assumptions, and often the assumptions are struggling to get good evidence to inform them.
The other way in which behavioural science routinely helps and interacts with the modellers is to evaluate different modelling scenarios in terms of the behavioural considerations. So, both Robert and I are on what is termed SPI-B—that's the behavioural science advisory part of the UK Scientific Advisory Group for Emergencies—and we are sometimes given several scenarios. And this is where modellers have looked at what would be the impact of having different measures in place—you know, schools, open or shut; restaurants and bars, open or shut, et cetera—and what might be the behavioural considerations. What do we think, for example, crucially, might be the adherence to a measure? Because you can have a measure that, if it was adhered to, would be more effective, but, if adherence is likely to be low, obviously that needs to be taken into consideration.
Another thing we may consider is knock-on effects, unintended consequences. So, for example, the measure that was brought into play in England of a curfew at 10 o'clock in the pubs wasn't actually brought to our committee, but had it been brought as, say, part of a modelling scenario, I think we would have pointed to the fact that people may start their social evening earlier, that they may not go straight home at 10 o'clock if they have established routines of Friday and Saturday nights out until 11 p.m. or 12 a.m., and go off in maybe less risky places.
So, those are examples where behavioural science can inform modelling. I would say that I think we could really improve what we're doing by having much closer interactions between behavioural science and modelling in the way that I've outlined, because, although these things happen, they don't happen nearly enough, and I think the modelling could be improved if it were able to be more informed by behavioural evidence, and also behavioural thinking, such as in the sort of systems thinking I was outlining in terms of unintended consequences.
Thank you for that. It was interesting that you mentioned the curfew agenda, and where it hadn't been brought to your sub-group to consider. Are there any other examples? I suppose in a sense what I'm trying to work out is what percentage of measures that are being taken actually are brought to the committee for consideration of behavioural attitudes.
It's difficult to put a figure on it, because, certainly, on SPI-B, it gets a lot of work—you know, there's a lot of commissions that come in and people work very hard to try to respond to those quickly. My personal impression is that some of the really key decisions, the really big ones, are the ones that, for some reason, haven't been brought to our attention ahead of time. And I think an absolutely critical one was when we came out of the first lockdown, and the messaging that accompanied that in England was, I think, as everyone—you know, you don't have to be a behavioural scientist to point out the flaws in that messaging. But it would have been appropriate to at least ask some advice on whether that messaging was likely to work, because it actually violated some really important principles.
And before handing just over to Susan on that, who may have a better memory than I've got on these things, actually, just yesterday, I think it was—was it yesterday—independent SAGE produced quite a nice report on messaging, and all the different time points when things happened and where messaging could have been improved. And messaging is not the only factor, by any means, but it is important and it's something that behavioural science can contribute to, I think.
Yes. I don't think I could—I don't have a sense of the overall volume of work, the overall contribution of the modelling committee. One of the things to say is that the way it's set up is that the behavioural science committee is one group and the modellers are a different group, and we don't have joint meetings. So, I think it's more of a process issue that I would draw attention to in this context, rather than the percentage that we have or haven't been brought into.
I think that one thing that—. Because I actually set up the behavioural advisory group back in 2009, when I was the only social and behavioural scientist on SAGE during the H1N1 pandemic. At that point, what we tried to do was to have a behavioural scientist who attended all the modelling meetings and, vice versa, a modeller would come and sit in on our meetings. So, I think it's that kind of cross-fertilisation and ongoing communication that is really important. But, certainly, SAGE is a huge organisation now with, I think, some, I don't know, up to 100 scientists, I think, or certainly more than 50, participating in the many different committees. And, obviously, everybody is there because they're experts in their field, which means that they have very, very busy day jobs, and we're doing this on top of the day jobs. So, I think there's a bigger issue about how one organises academic expertise, especially when it's in an ongoing way, rather than everybody coming together for a particular emergency that is very time limited.
Okay, thank you. It's also interesting with regard to the Government listening to the issues on behavioural aspects as well. But you talked very much, a couple of times, about the restrictions in England, and there have been variations, even in England, let alone variations within the UK. Have you looked at, or are you taking into consideration, the variation of those restrictions, and are they having an impact on people's behaviour? Because the media we hear, very much so, is London-centred media, and so, obviously, it does have different approaches.
I don't know—Susan, do you want to start this time?
I think that's a very fair point. As well as being on the Government's behavioural science part of SAGE, Robert and I also are involved with Independent SAGE, which speaks directly to the public and the press every Friday lunchtime. And during that, Professor Christina Pagel presents the data and does so separately with the four nations, so that we're able to have a look at what's happening at that point.
But I would say that, in terms of SAGE's work—and Robert may remember—I don't remember where we've been asked any questions comparing what's happening in the different nations. And the way that the committee works is that we only respond to commissions that come to us. We don't initiate; it's not a proactive committee. But I don't recall any work of that nature on the behavioural science group.
No, neither do I. But I think the general point that you raise is a very important one, and will be important as England starts to maybe come out of the lockdown and we go back to some sort of tiered system. Wherever you have a tiered system, you have to—. We certainly have discussed the issue of the pros and cons of having a tiered system, and those have been discussed in the media as well. And I think you also raise a very important point about a perception, which may be accurate—we don't know what goes on inside the minds of the politicians in London—but a perception, anyway, and the perception is important, that the tiered system is somewhat centred in terms of preferencing the economy and well-being of people in a certain part of the country. And if that perception—and that was always a risk, when you put in a tiered system, whether it's London or somewhere else, that it will cause resentment and division, partly, of course, because the boundaries between the different regions that may have different sets of restrictions have got to be somewhat arbitrary. And so you will always get people who are on one side of the street who are suffering from one set of restrictions and others who are not. And that's always a risk, which always has to be weighed against the fact that if you are in an area, and you're right in the middle of an area, with a very low community infection rate, then that appears unfair.
But I think the argument that's been put forward for a more blanket approach is a very powerful one, not so much on the behavioural side, but actually on the infection-control side more generally, and it's been borne out by the data, which are that we saw the infection rates rising faster in tier 1 than tier 2, than tier 3. And so the argument is, well, if you have a tiered system, then, effectively, the people who are currently in tier 1 will find themselves in tier 3 later—meantime, a whole number of people will have got sick and died. And there's an important—. I don't think that message necessarily has been getting across to the public. So, that would be an area where, I think, if you do decide to go down a particular route, whether it's a blanket approach or a tiered approach, you have to pay very close attention to the communication of that and the way that that's perceived.
Yes. So, the communication and the messaging, effectively, across a tiered system in particular is critical, because the behaviour will change depending on what people believe is the area they're in and therefore what they think they're entitled to do and not entitled to do.
Yes, absolutely right.
If I can add to that, I think there are several problems about the tier situation. One is the complexity—you know, the four nations doing different things, also different things at different times. And, certainly, the data over the last couple of months—the public are beginning to lose confidence in their ability to know what they should be doing. So, I think there's an information overload, complexity overload and confusion. And, obviously, once that sets in and people are no longer clear about things, clear about what it is and why, then adherence drops off. And, you know, it's not enough to say, 'Well, we can be simple; we'll just do the rule of six', because, yes, six is simple and that's memorable, but why six rather than five or seven? It begs questions. And we know that it's people understanding why they should be doing things that's very necessary for adherence, as well as 'what'. So, when seeds of doubt are planted, it's not helpful.
The other issue is about this issue about perceived fairness. If things are perceived not to be fair, to be unjust, then that also undermines adherence. And one of the problems, certainly in England, I think, with the way that the tier system was introduced, was there wasn't sufficient transparency or clarity about what the criteria were that would bring you from one tier into another. There was also, I think, resentment when different places in the same tiers had different levels of restrictions, and then, obviously, another factor that's really important is the support for businesses and individuals. Obviously, there was a real north-south divide that was very unfortunate, where there was less provision for quite harsh restrictions in the north, compared to what the furloughing had been. But then, as soon as it became a national situation, the north got what the south got. So, I think it's really important to think through all these issues when thinking about, obviously, the strategy of having a nationwide—even though there's variation within the nation—rather than a more local/regional tiered system.
Yes, thank you, Chair.
Reit, diolch, David. A symud ymlaen, mae rhai o'r cwestiynau hyn wedi cael eu gofyn a'u hateb, efallai. Rhun, wyt ti'n symud ymlaen, rŵan?
Thank you, David. Moving on now, some of these questions have already been covered and answered. Rhun, are you moving on now?
Diolch, Gadeirydd. A very good morning to you and thanks for being with us today. Let's turn to something that I think all of us can identify with on one level or another: pandemic fatigue. This is a phenomenon that has been studied—a major study by the World Health Organization. Tell us more about the impact of the fatigue, and how we're seeing that in action, if you like.
Well, it's not giving away any confidences to say that Susan and I have had discussions with the World Health Organization about that particular report, because whether you call it 'pandemic fatigue' or 'COVID fatigue' or 'lockdown fatigue', the problem with that generic concept is that it glosses over what are actually very distinct and different reasons for non-adherence to guidelines. So, Susan and I looked at this, and we published something in the British Medical Journal on it fairly recently, addressing the issue. If you were to take it as a sort of general phenomenon—people are just getting fed up with the whole thing, they're getting fed up with the disease, they're getting fed up with all the restrictions and so on, and that is causing a loss of motivation to adhere to guidelines—there's no evidence for that. That is not what we're seeing. In fact, the evidence goes rather against that.
So, what we saw from the studies that have been tracking this is that the adherence was high during the first lockdown, it then decreased at around the time of the Cummings incident and all the rest of it, and has been actually very stable since then, and, if anything, it's gone up a bit. Overall, when you look at all the different sort of behaviours that we're interested in, one key behaviour has been pretty low throughout, and that is the one that we most need people to do, which is to self-isolate if they've got symptoms. Now, that's been very low, but that was low at the beginning as well, and I think there's been a lot of discussion and analysis of data looking at why that is.
We'll move on, if we can, to that in just a second. Just before we leave the WHO's definition of 'pandemic fatigue', you have an issue with that, you're not comfortable with it, but the four strategies that are suggested as ways of dealing with what they call pandemic fatigue, I guess you would be pretty comfortable with.
Absolutely. Absolutely. It really was just a question of the framing. I thought, in all other respects, it was an excellent report and actually captured the structure rather well in terms of, 'You've got to make sure that people are capable of doing it, you've got to make sure that they have the material, financial and other resources for doing it, and then, of course, they've got to be motivated to do it.' So, I thought the way that they handled that was excellent. It was really just a question of the framing.
Okay, in which case, let's look at that issue that you naturally moved us on to, which is the self-isolation issue. I think SPI-B suggested that public adherence was as low as 20 per cent, which is pretty low when we're told how important it is for people to take these basic steps of sticking to the guidance. What's driving that? What's the major element that's driving that lack of adherence?
So, why don't I start off speaking to this, because this is actually data that's been produced by a study that I'm involved with, which was a weekly and is now a fortnightly—it may go back to weekly—survey that was commissioned by the Department of Health and Social Care, and actually had been funded previous to all of this, but on ice, so we started immediately that the pandemic started. We've been collecting a range of data. There's a lot of material there we haven't been allowed to publish, up until about a month ago, so that paper is actually just being revised and being resubmitted to the British Medical Journal. The updated data on that is that, actually, it's gone up now to 29 per cent as of a couple of weeks ago, but 29 per cent is a long, long way from what the modellers suggest is required for an effective system—80 per cent self-isolating to get the R down.
Now, when we look at the explanations for this, they range from leaving the house for caring responsibilities outside of the house to going out for medical appointments or to get provisions, and also for going out to work and to get income. This is really important, because these are solvable problems. Basically, financial and practical support could solve those problems. I'm on a The Lancet commission, and we have regular presentations from countries all over the world about their strategies for dealing with the pandemic, and I've been very struck by how different the approach to managed and supported isolation is in other countries, even relatively quite poor countries, and how much that seems to be associated with the countries that have handled the pandemic well, and also where the economies have been least impacted. These are countries not just in one part of the world—obviously New Zealand, Australia to some extent, then poorer counties like Uruguay and Cuba, Kerala in India, and then in Europe Norway is another example, and obviously there's China and the south-east Asia countries. In those countries, there's real variation in practice, but people tend to get either phoned or visited every day and asked how they are physically, whether they need any social or psychological support, practical help like taking out rubbish—do they need anything like that? Also, other countries are providing good compensation for lost income, so they regard it as a job. 'Your job is to stay at home, and we will pay you to stay at home'. I think it's £500 over two weeks, which is actually less than the minimum wage. It's not enough for people to pay their rent and feed their families, et cetera.
Is there also just a 'Behavioural' thing here, and people not understanding quite why they need to do it still and being bored, or whatever it might be, so that they're not happy to do this?
Okay, so, it's an interesting point, because another finding from that survey is that only about half the people, even now, are recognising the three core symptoms of COVID. So, if people aren't recognising the symptoms, then they're not going to get tested. If they're not going to get tested, they're not going to be in a situation where they're likely to be asked to isolate, or consider that they should isolate because they recognise those symptoms. I would say, though, the reason I'm talking about this enabled, supported isolation being associated, it appears, with good outcomes, is that the opposite can be really counterproductive. Again, this is another example of something we weren't consulted on; we just heard about it in the media. I think it's up to about a £10,000 fine for people not self-isolating. Now, given that, often, the reasons are financial that people are going out, to take this punitive approach not only can be alienating and therefore undermine the 'we are all in this together' kind of solidarity approach, but also can have this knock-on, unintended consequence, because if you don't want to risk having a fine for not self-isolating, the best way of doing that is to not get tested, to not go near that whole set-up. So, it actually could be quite counterproductive. I don’t think data are being collected on this, but it's really important how this is handled.
On the principle of supporting, my party—we're not party political in this committee, of course—is proposing a motion this afternoon in the Senedd on raising the level of support in areas of high incidence of the virus. Whereas, perhaps, months ago we would have talked about what further restrictions you can put on an area, let's talk about raising the level of support that you can provide to people. We've been discussing there support for self-isolation, but it could also, I guess, be support for doing all the other things—emotional support for not going to a house party, emotional support or communication to improve distancing between people. Is that fair?
Absolutely, and something that committee has been talking about the whole way along in order to improve adherence is supporting people, because when you look at the data, the overwhelming majority of people do want to do the right thing. And there's a group at Imperial that Helen Ward leads, and they found, for example, high intention for people wanting to self-isolate across all income groups, but when then you look at actually who is self-isolating, it's the people in the higher income groups and not the lower income groups, and those who are more able to work at home than not able to work at home.
The other thing as a general message we've been saying all the way along is the importance of engaging and consulting with and listening to communities, rather than having the top-down approach of, 'This is what it's going to be', is to have conversations, especially with the communities that are more challenged. We know young people tend to be in terms of adherence, especially young men, but there are other groups who find this more difficult. And the advantages of doing this is you can engage more with people's lived experience and actually find out what are the barriers and what are the solutions that, maybe, if you're sitting in whatever part of Government, you may not be so familiar with. So, you may get better strategies and solutions. And also, if people have been part of the conversation, they are more likely to own it and therefore more likely to adhere to it.
I've been trying to sum it up as helping people to help themselves, which I guess makes sense.
One last issue on self-isolation. Some countries—I know some Asian countries have done it, and I believe Italy have been doing it as well and maybe some other European countries as well—are getting people to self-isolate in, say, a self-isolation hostel or hotel. Is that an approach that you think might be useful here, Professor West?
Absolutely, and there are different models of this. Sometimes it's completely free and, again, some of the poorer countries are offering this free. Sometimes there are different grades. I think I heard of one country where you can isolate in army barracks for free; if you want more hotel accommodation, then you pay a small amount, but it's very subsidised. And other countries also have different tiers according to how ill you seem to be. If you have no symptoms, you're in one, but if you're middling, you're kept a watchful eye on, and then if you're more severe, obviously, you're in a more medical facility. But in our country, where we have so many people living in overcrowded houses, often multigenerational with vulnerable people at home, I think we're missing a trick in not doing more to help protect people within households from people who are potentially infectious. And there are very few households where people have got access to their own bedroom and bathroom, and have got somebody who can provide food and everything without any contamination. So, I think it's a very sensible idea.
I think Professor West wanted to come in there as well.
I think so. I think there are, obviously, practical issues that would have to be addressed, but in terms of the balance of resources, where one puts one's money, considering the vast cost of addressing this virus in the UK, I think there's a very good chance it would pay back, pay dividends. But there's one other thing, if I may, just very quickly. One of the problems, I think, is that when people find they have to self-isolate or would be required to, it kind of takes them by surprise. One of the things that we have been talking about is the idea of making sure that everyone has a sort of, you might call it a 'personal isolation plan', ahead of time. And this is where Government agencies could support people, because you could have a checklist, and you could say, 'These are all the things that would be challenges; which of these applies to you?' And then they could have a helpline, or something like that, which they could then contact to try to get those addressed in some way or another, either through local community action or something like that.
I was going to ask as a final question: with Welsh Government saying they are preparing a programme for supporting people to self-isolate better, what would be in that programme? I think you've outlined the kinds of things that you would like to see in that, but are you already at all seeing any signs that Governments—the Welsh Government is specifically of interest to us, but perhaps other Governments in the UK—are starting to get this right, are starting to say the right thing? Because we're seeing self-isolation payments—at a lower level than I'd like, but they are going out—but is there anything else positive that you're seeing out there?
Honestly, I don't think so. That's not to say that there's nothing, but I think one of the things that we've seen all the way along with this virus is the tendency to sort of underestimate what needs to be done and how quickly it needs to be done. And we end up having to do more and for longer. And I think that this is something that we could take a lot, lot more—. This is the critical thing, isn't it, really. It's probably the single most important thing we can do, so I think a lot more could be done, in my opinion.
I've found your responses very, very useful this morning. Thank you.
Symud ymlaen rŵan i gwestiynau gan Jayne Bryant. Jayne.
Moving on now to questions from Jayne Bryant. Jayne.
Thank you, Chair. Good morning. And, yes, your responses have been really helpful to us this morning, so thank you. Just looking at engagement with the public, you've touched on this morning how important that is, and you've also said that it's not just the simple messaging, it's also about people understanding why, as well as understanding what they need to do. You've touched on the paper, The Lancet paper, and the lessons learned from comparisons of countries and regions in Asia and Europe. Do you think many Governments have achieved this so far, that clear messaging?
I'll start and then I'll pass over to Susan. Yes, I think, if I may say, actually, it's all a matter of degree, and there's always more that can be done. And, if I may say, I think many of us have commented that we feel that, among the home nations, Scotland and Wales, in the major messaging that's been done, have done a good job, and England perhaps not so much. But, in other countries, again, from what we can see, countries that one would easily identify with as being somewhat similar to us in many ways, in terms of culture and so on, New Zealand, clearly, I think would be an object lesson for us. And I think part of it is not just about the information, and it's not just about saying to people, 'You have to do this for the community.' It's about what Steve Reicher calls the 'we' rather than the 'you'. It's not 'you' have to do it for the community, it's 'we' have to do it. And the messaging really gives a sense of this is a contract between us, and we will do our part, and you do your part, and we genuinely are in it together, that hackneyed phrase.
So, it's partly about the content of messaging, and it's partly about the tone. And I think that there are countries that have done a good job. And, of course, the other thing I would say, before handing over to Susan, is that, as far as we can tell, the messaging has been rather unsegmented, whereas what we know is that there are different parts of the community who require different messaging, and they have different people with whom they can identify, whether it's young people, or whether it's people from different cultural or ethnic groups. And I think we could have done a lot more, essentially, to engage with those communities, to identify what kind of messaging is likely to hit home and really resonate with them, and then to segment the messaging in that way. I think we could have done more.
And to build on that, I think much more use of role models who people identify with. I've said that young men, all the way through, have been the group that are least likely to adhere, and I really don't understand why more hasn't been done to engage the role models that they would look to—whether it's sportspeople, musicians, in film, tv, or whatever—to really drive home some of these messages. If you identify with the source of the message, you're more likely to engage with it, and it's more likely to translate through into behaviour. And it's used a lot in other kinds of public health messaging, and indeed advertising, but, strangely, it's been quite absent here.
In terms of the international comparisons that you asked about, the presentations that I've been part of, it's been very striking that the countries that I've mentioned that have been brought as good practice tend to have daily briefings by trusted people and very clear, consistent language—not condescending, but explaining what and why and also how things need to be done. And so people feel updated, people feel there's a place that they can go to where they will be able to find out what the current thinking is. And I would say that sounds like it's a formula that works and should be adopted.
That's really helpful. You've touched on how the public needs to be part of the response in feeling engaged and empowered and co-producing tailored solutions. How do you think it could be done? You've suggested one earlier, but how do you think it could be done, and would it be an effective tool for Governments?
I'll start. It's not something that I can cite evidence on, but I've had conversations with different people who've had expertise in citizen consultation, with different kinds of citizens panels and citizens assemblies. And I think these could be set up quite easily in localities, and I presume local government would be a good overarching agency to do this. If you want, I can follow up with expertise in this area, because there's a whole body of evidence on how to do this and how to do this well.
Thank you. Just finally from me, in terms of people's adherence to the restrictions, do you see that people are seeing this as targets to reach, rather than the limits, in terms of their behaviour?
That's a very interesting question. I don't know, honestly. But I think that—I have a sense that it's more impressionistic than that, it's rather vaguer. And one of the things, I think, that you always see in situations like this is what you might call exceptionalism, which is a generalised acceptance of the rule and the sense that, 'This is a good idea, and if it weren't for the fact that I've got to do this, or I've got this situation'—or whatever—'then I would of course obey it, but because of my own particular circumstances at this time'—or whatever—'then sadly I can't.' Again, it goes back to the communication, but one of the things that I think is potentially important that we've seen in other areas of health behaviour in addressing exceptionalism is to take it head on with the specific examples that people use themselves to say why they're different and why they don't have to do this because, in their circumstances, it doesn't make sense and so on. So, I think there are ways of addressing it that can work, but I think that's probably one of the key things.
And I think another thing is not just to think in terms of rules, but to think in terms of principles and how do people apply those principles to their own situation. I've been in discussion with colleagues when we've been thinking about how the coming Christmas holidays are going to be addressed. Obviously, that is a very complex issue. But people live in very, very different situations. So, some people, obviously, live on their own, some in very large, multigenerational households. We've got groups of students who are likely to be in halls of residence and not able to travel. We've got very different settings. And I think, in that sort of situation, really putting forward very clear principles as to what is going to reduce the risk of transmission—probably we haven't got time to go through them now, but there are six, 10, maybe—that people can then think about and say, 'How would I apply this to my situation?' Identify who the vulnerable people are; identify who the people are most likely to have been exposed for whatever reason, like work, to the virus; thinking about places and how to make those safer in terms of, you know, the basics: fewer people for shorter times, less close together, either outside or ventilation inside, making sure that you have access to soap, water, sanitiser, masks, tissues et cetera.
And I think this is a very good way of educating people. And I think, over this Christmas period, actually, if people were able to think about some of these principles—'How do I apply that to this period and keep my family and our loved ones as safe as possible?'—that would not only get maximum adherence, but also would be a very good educational opportunity. For example, people may be thinking that they could have smaller groups over a period of time and, for this year, not go for the big meal.
So, anyway, that's another approach to it, that I think we can sometimes do the rules thing too much, and sometimes just shift the focus onto the principles and applying principles to your situation to maximise safety.
That's really helpful, thank you.
Reit, rydym ni wedi cyrraedd yr adran olaf o gwestiynau nawr, ac mae hi o dan ofal Andrew R.T. Davies. Andrew.
Right, we've reached the last section of questions now, and those come from Andrew R.T. Davies. Andrew.
Thank you, Chair. Thank you, witnesses. Trust and trust in political leadership is something that's critical for people to accept the messaging that, obviously, has been given. And given the length of the pandemic that's ongoing now—and there's nothing really on the horizon to say that it's going to be shortened any time soon—many political leaders from across the globe have lost a lot of political trust, or the public have lost a lot of trust in them. How would you say that they could regain that trust? Because it's critical, given what we can see going forward—as I said, the pandemic isn't going to end any time soon—and so people need to have confidence that the messaging they're receiving from the political leadership is for their own good.
There are, obviously, a number of principles that generally apply when you're trying to secure trust, maintain trust—or regain trust, which is obviously harder. I think, looking at the pattern of evidence on trust over the course of the pandemic, what we've seen in the home nations is that trust has largely been—it started pretty high and has largely been preserved across all the home nations apart from England, where it took a bit of a nose dive.
So, I think, by and large, people are quite willing to give the leaders the benefit of the doubt. But obviously there's a limit to what extent people will continue to do that. But the key principles for regaining trust are very similar to those that you would use in the first place, and they're about what you might expect—they're about transparency and honesty and showing respect for your audience and the people you're talking to. And you have to come across as though you believe it yourself—you know, you're not just saying it. And that means admitting when you've made mistakes. I think one of the things that I thought was very helpful was when, in Scotland, they made a mistake around certain issues and Nicola Sturgeon was perfectly open about it and said, 'Well, I think we got it wrong.' Of course people are going to get it wrong, and people are remarkably forgiving if you say, 'Well, I think we got it wrong there, and this is what we're going to do to make it better in the future.' And so, I think we start from a positive place, because actually people are remarkably accepting and forgiving, because they need to be.
This is another thing that is a misunderstanding of what happens in pandemics. According to the Hollywood movies, society breaks down and crumbles and you get looting and pillaging and so on. Actually, the opposite tends to happen in pandemics. The people who weren't previously—. The leadership that wasn't particularly trusted previously becomes more trusted, and obviously there's a strong need from the population to feel that their leaders are doing a good job and they want to support them in that. So, from that perspective, I think that's quite positive, but it does mean that politicians and political leadership have to be honest, open, transparent and respectful, and, if they get it wrong, just say so.
Yes, again, other countries have really drawn attention to this about being able to say, 'We got it wrong' and 'We've made mistakes', and that engenders trust. And I think what we've had from Westminster, the kind of hyping up things too much, whether it's, 'The app is going to be the solution', whether its world-beating this or world-class that. That doesn't land well, especially when there is a mismatch between what's claimed and, then, what the reality is. So, I think to have some humility, to ensure that what one says matches reality—. It doesn't need to be spelt out, but that's not always the case.
Another important thing is not to blame. Again, I can really just talk about the Westminster Government. But blaming health workers for using too much PPE, blaming people for having too many tests, blaming young people for increasing transmission, this isn't good, neither for trusted leadership nor for building that sense of collective solidarity, which is needed. And, the final thing I would just repeat is that it is difficult to rebuild trust once one has lost it. Some people have a much better personal style, in terms of being direct, honest and open in the way that they communicate, than others do. But rebuilding trust, again means really listening to people, and, as Robert said, respecting people, and I would say, again, this engagement with communities, so it's not so much top-down communication.
Okay. And, once that trust is lost, obviously it's very hard, because, Susan, you used the word 'regain' several times in your presentation there. It is possible for leaders to regain it, would you suggest? Or, once it's lost, that's it, your credibility is shot?
I can't draw on any evidence to answer that question. But I think that there's a general thing where everybody has got the same goal of wanting to get out of this pandemic. People are looking for solutions. In that situation, people do look for leadership. Obviously people have memories, but I would say that, just as with personal relationships, they can go off kilter, they can be built back up again, so it can be with a relationship between governments and populations.
I think the idea of thinking about a social contract is a good one, that, 'We, as government, will do this on our part, if you, as the people, do that on your part' and we work together as part of this almost negotiated social contract. But I do think that—again, I'm talking about the Westminster Government—it requires quite a shift in direction, in emphasis, in ways of doing things. But there's plenty of material published on the Government website from our behavioural science advisory committee about how to build trust, how to increase adherence, principles of good communication, that could be listened to and implemented.
In the paper you submitted, you talk about obviously trying to break down the messaging into age groups, and in particular younger people, and that information for younger people should be led by 'trusted, non-governmental sources', I think is the way you word it in the paper. There's a balance to be struck, isn't there, because there's the political accountability and advisers advise, politicians decide, so there's that to obviously determine. But how would you suggest that route could balance those competing priorities? Because if that advice goes wrong, it's the politicians that end up being held to account for it, and the non-governmental organisation walks away, but yet you want that consistent messaging so that people buy into what's being asked of them, trying to suppress this virus, do you not?
You go, Susan.
Okay. I think, with everything, when one's working with different groups of people around policy and around implementing policy, a lot of it is about having good relationships, shared goals, shared incentives, and principles of good working together. So, I don't think there's any magical formula.
My own experience of working over decades with Government is that trusted personal relationships are really important, so I think it would be about finding the right groups and the right people, and ensuring that everybody is singing from the same hymn sheet—that one's signed up to a particular approach. And I totally agree about the accountability. I think that is something that, actually, if it were demonstrated more in practice, would also help with the trust issue.
I think I would only add that I can see that there might be concern if one were to hand over the messaging to an NGO or something like that. But, I think, another approach, of course, is that you still have your public health team and comms team working with NGOs to arrive at messaging, and then it's around the delivery of that—who delivers it, and who is seen to be on board with it—that would, probably, make the most difference, I think.
You're muted, Andrew.
I'm not quite sure what happened there—the host muted me, it did. So, is that indicating you want me to shut up now, Dai, because it's coming to the end of the session?
You can have one more question. Nothing to do with me, Andrew. [Laughter.]
All right. One final point, if I may, then. We're talking to society as a whole here, or politicians are talking to society as a whole. But yet, when you look at society, as advertisers recognise, you need to compartmentalise that messaging between young, middle-aged, old—all the demographics you can think of. Can you think of an example where the messaging could be improved and compartmentalised so that it is hitting home in a more powerful and trusted way? Or do we just carry on as we are and just hope that society as a whole absorbs that message and takes that advice and acts on that advice?
Well, I would say, if I'm thinking about—. One of our problems is we don't have enough evidence about where are the superspreading events happening. Where are the real problems? But if one's thinking that one problem that one doesn't see might be younger people socialising in each other's houses, then that would be a really good example of where very publicly working with young people to think about how to prevent that happening could be called for. But I can't summon up any example of that. Robert, I don't know if you can.
No. I think the general point is a good one, though. Actually, it's partly around the demographics of the population that you're addressing, and it's partly about the situations in which spreading events are occurring. And because, with this particular virus, what we're seeing is that the spread is not even—it's quite lumpy, with a relatively small number of situations creating a large number of infections. I think getting that right, that sweet spot, between the populations that tend to inhabit those situations and the situations themselves could be a very useful target for comms here. And I do think that it's worth investing in. I do think it's worth segmenting and looking at how one can best target messaging.
And the other thing that we've seen in my other area of work, like tobacco control, is that it's making the messaging work together with all the other things that you're doing, and really having your strategy co-ordinated. When you can do that, the messaging gets people engaged and interested and so on, but you can also provide support and services to deal with specific problems as they arise. Then you get the best kind of result.
Thank you. Thank you, Chair.
Diolch yn fawr, Andrew. A dyna ddiwedd y sesiwn. Rydyn ni wedi’i hamseru'n berffaith. Diolch yn fawr i'r ddau ohonoch chi. Sesiwn arbennig; ardderchog, rhaid dweud. Perfformiad bendigedig gan y ddau ohonoch chi. Rydych chi'n haeddu cael eich sianel deledu eich hunain ar ôl hyn, os nad oes yna gytundeb yn y fantol eisoes. Diolch yn fawr iawn i chi. Yn ôl ein harfer, mi fyddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma, er mwyn i chi allu gwirio eu bod nhw'n ffeithiol gywir, ond gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i'r ddau ohonoch chi. Diolch yn fawr. Ac i'm cyd-Aelodau, mi wnawn ni dorri am egwyl rŵan, a dod yn ôl am yr ail sesiwn am 10:45. Diolch yn fawr iawn i bawb.
Thank you very much, Andrew. That brings us to the end of the session. We've timed it perfectly. Thank you very much to both of you. An excellent session, I have to say. And an excellent performance by both of you. You deserve to have your very own television channel from now on, if there isn't a contract already in place for you to have just that. But as is usual, you will receive a transcript of the discussion this morning to check for factual accuracy, but with those few words, thank you very much to both of you. Thank you. And to my fellow Members, we'll have a short break now, and return for the second session at 10:45. Thank you very much to everyone.
Gohiriwyd y cyfarfod rhwng 10:31 a 10:45.
The meeting adjourned between 10:31 and 10:45.
Felly, croeso nôl i bawb i'r sesiwn nesaf o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd drwy gyfrwng fideo gynadledda. Rydyn ni wedi cyrraedd eitem 3 ar yr agenda rŵan, a pharhad efo'n sesiynau tystiolaeth i mewn i ymatebion pawb i bandemig COVID-19.
O'n blaenau ni rŵan mae gyda ni sesiwn dystiolaeth gyda'r Athro David Heymann a'r Athro Devi Sridhar. Croeso i chi'ch dau. Yn benodol, i roi eu teitlau llawn, dwi'n falch iawn o groesawu i'n sgrin, felly, yr Athro David Heymann, athro epidemioleg clefydau heintus, Ysgol Hylendid a Meddygaeth Drofannol Llundain a phennaeth y Ganolfan ar Ddiogelwch Iechyd Byd-eang yn Chatham House, Llundain. Croeso i chi. Ac hefyd yr Athro Devi Sridhar, athro a chadeirydd Iechyd Cyhoeddus Byd-eang, Prifysgol Caeredin. Croeso i chithau hefyd, yr Athro Sridhar. Ac yn ôl ein harfer, fe awn ni'n syth i mewn i gwestiynau. Mae yna ryw awr a chwarter gyda ni i drafod materion o dan wahanol deitlau. Felly, fe wnawn ni ddechrau efo cwestiynau gan David Rees. David.
Welcome back, everyone, to the next session of the Health, Social Care and Sport Committee meeting here at the Senedd via video-conferencing. We've reached item 3 on the agenda this morning, and the continuation of our evidence sessions into the response to the COVID-19 pandemic.
Before us now we have an evidence session with Professor David Heymann and Professor Devi Sridhar. Welcome to you both. To give their full titles, I'm very pleased to welcome to our screens Professor David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine, and head of the Centre on Global Health Security at Chatham House in London. Welcome to you. And also welcome to Professor Devi Sridhar, professor and chair of Global Public Health at the University of Edinburgh. A very warm welcome to you, Professor Sridhar. And as is customary, we'll go straight to questions. We have around an hour and a quarter to discuss issues under different sections. And we'll start with questions from David Rees. David.
Diolch, Gadeirydd. Good morning, both. Perhaps we could start off with something very straightforward. The pandemic is global, we understand that, and we are seeing different countries react differently, and we're also seeing the way in which cases are rising in different countries vary. I suppose the first question is very simple. I understand that different social behaviours and social issues within those countries will have different impacts upon them, but where do you think—if we're taking everything into consideration—where do you think the countries are doing well, and where do you think the countries are not doing so well? And can I take—? Obviously, I do want you all to reflect, but, for example, we know Germany did well in the first phase, but in the second wave we seem to see Germany doing worse. So, perhaps, if you look at the countries that are doing better overall, rather than phase 1 or phase 2 at the moment.
Right, who wants to kick off? Professor Sridhar.
Okay. That's a great question. So, I would say, 'What does doing well even look like?' So, I think it's a combination of keeping your COVID-19 numbers low, your health services running, your economy, not having massive employment, keeping people in jobs, as well as schools open. So, I think there has to be, kind of, a holistic understanding of what is doing well, rather than just looking at one aspect of that.
If I look at regions of the world that are doing better, I think it's clear east Asia is probably the winner in this regard. Countries like Taiwan and South Korea are starting to see growth, they have managed to keep their numbers low and they've kept most of their society running without lockdowns. How they have done this is through three things. The first is through having very good voluntary guidance to their populations around avoiding this virus—or any viruses, to be fair. So, face coverings were introduced very early, avoiding crowded gatherings, getting outside, ventilation. So, they picked up very quickly that there were things they could tell their publics that they could voluntarily shift, which meant you don't need to put in harsh measures if people voluntarily shift their behaviour.
The second is they had strict border measures, so by 2 January, South Korea was already screening passengers from Wuhan. And if you look, as it evolved, later into January and February, most countries put in place very strict border restrictions. So, either testing or quarantine procedures. And I just wanted to emphasise, because there's been—it comes to the Germany point—there's been no country across the world that has sustainably suppressed this virus without checks on imported cases, because all you do with your lockdown measures is crush it, and then once you lift your restrictions, if you have people moving back and forth, you're just reseeding it. And I think some of the now sequencing coming out of Europe is showing that to be the case of Europe's challenge.
And the third thing is really good testing, tracing and isolation, and the key aspects of each were testing, results within 24 hours at some point—while we were still, in the UK, taking seven days, South Korea was doing it within four hours. Rapid antigen tests that have been produced, results within 15 to 20 minutes, though, of course, effectiveness is less than polymerase chain reaction tests in terms of picking up cases, and the isolation was managed isolation. So, people were supported financially, emotionally, but also practically—managed isolation in facilities where people could go—voluntary, but uptake was quite high. So, those are the components of what I've seen as an effective response.
And in Europe, just to end my comments there, yes, we've seen variation. I think you could see that probably the UK, Spain and France have struggled more than Germany, currently. Even if Germany is accelerating, their numbers are still far below, I think, other parts. There is variation within Europe. But I think the challenge for Germany is that it has borders with nine countries. They do have really good testing. They have good tracing. Isolation has been a problem in Europe. I think WHO has said that, because we haven't had the levels of isolation we need, which is probably over 80 or 90 per cent, to actually make sure people aren't infecting others and breaking chains of transmission. But also, even, I think, the German health Minister said tourism in the summer was a real issue when you had the movement of people constantly across. And so, I think as soon as the numbers start to take off, because this is a virus that is exponential growth—it spreads, sometimes, asymptomatically; it's a very tricky virus to manage, compared to other ones—then you have to put in place restrictions.
So, kind of the point I've got to, and I'll end there, looking around at the world, is either you go and you have an elimination approach, like east Asia and the Pacific, and you clear the virus and you get back to normal, you can lift all your restrictions, but you live within a bubble, or you live, let's say like in Europe, where you have open movement of people, travel slightly enforced, but not like putting people into quarantine in hotel facilities where they're not allowed to leave, as in Australia and New Zealand, but at that point we're going to live under restrictions. It's impossible, otherwise, to suppress this virus effectively with just test and trace, because the chains of infection move too quickly with a constant reseeding. So, I'll stop there. Thank you.
Professor Heymann, do you want to add anything to that?
Yes, sure, I'd be happy to add a little bit. Remember that these countries in Asia that responded very rapidly had had MERS and SARS coronavirus outbreaks previously. They were ready. They were alert. And when WHO announced on 5 January that there was a new respiratory virus that had not yet been identified in China, they began to intensify their alert, and by 20 January they were already detecting outbreaks caused by people coming in from China in most countries in Asia, and they were responding rapidly. That was the first thing that made it different in Asia than in Europe and in North America, where the same warning came out but the countries just weren't on the alert, and we now know that they did have cases come in at the same period of time. So, Asia got a head start because they were on the alert and ready. Early on in Asia they understood, also, through their outbreak investigation, that this was not transmitting like influenza, which Europe was still thinking by March that this was going to transmit like influenza, going directly into communities without a possibility of stopping outbreaks. In fact, in Asia, they began to stop outbreaks. They did contact tracing both forward and backward, and they were able to decrease transmission into the communities from massive outbreaks such as church outbreaks in South Korea, such as outbreaks amongst students in Hong Kong and various other places.
But they did one thing more: instead of just forward tracing, they also did backward tracing. They identified where transmission was occurring and they found in most countries that it was at nightclubs, in areas where there were students gathering and young people gathering, so they shut them down. They didn't shut down entire economies. WHO never recommended that. What they did was they shut down precisely where transmission was occurring and then they attempted to open it up again, to see if they had rectified the situation, and if not they closed it down again. And they aimed their compensatory funding, their resources, towards that rather than to the general society, which continued to function normally. I myself was in Singapore teaching in March, and it was as if I was in a country that was still functioning, except everybody was wearing masks, and in addition, they did shut down certain parts of the economy, but others were open. So, that was the second thing.
The third is the solidarity, and Devi mentioned a little bit to that. People in Asia understand not only how to protect others but how to protect themselves, and they practise it. They want to protect others because that's part of their culture. As you know if you've been in Asia during the winter months, when people have a respiratory infection, they wear a mask to protect others. That's just ingrained in most societies in Asia, so it was not too difficult for them to be able to do that, and as a result, Asia has been able to sustain in a longer term their transmission, although they haven't eliminated transmission.
I would disagree with Devi on elimination, because 'elimination' is not a good word. They still have transmission but they have it at a lower level of transmission, and it's allowed to come into their countries not overwhelming their health systems, except in New Zealand and in Australia, where there are elimination efforts. But in other parts of Asia, they still do have transmission occurring and they're keeping it at a low level so as not to overwhelm their systems. And most epidemiologists would tell you today that this virus looks like it will become endemic, as did four other coronaviruses, in human populations. And so, an attempt to get rid of it is probably not as strategic as an attempt to maintain it at a low level of transmission, moving forward.
Why did Europe go bad? Sorry, would you like to—?
No, it's okay. I was going to ask a question, but you keep on going.
Okay. One more thing. Why did Europe go bad? Europe went bad because they locked down, surprisingly, without an exit strategy. And so, when the exit occurred, it occurred overnight—nightclubs, pubs, everything were opened up and people breathed a sigh of relief; they went off on holiday and they were congregating where young people usually congregate, and they increased the transmission, which we're seeing now. So, the lesson from the first lockdown was: when you open up, open up carefully; open up the areas where there is not a lot of transmission and make sure that those areas where transmission is known to occur are locked down and that your resources are targeted towards them, so that they can be compensated for their lockdowns. Thank you.
Thank you. Obviously, that's very interesting. We had some behavioural scientists before, in the earlier session. And I suppose what you're saying here is that particularly those in Asia were able to draw on their experience, and their behaviours had already been modified, in one sense, from previous experiences of pandemics. But in Europe it seems that, because we hadn't really had that, the European attitude towards this was different. And as you already pointed out, I think, the summer holidays were a perfect example of where people thought, 'Here we are, free again. Let's go and enjoy our holidays.' From what I understand, a lot of infections came back into the country via summer holidays.
So, is Europe, do you think, now in a position—and we are part of Europe, in that sense, because we are part of western Europe—where we are now understanding the serious implications of our behaviour on the transmission of this disease? And, are we in a situation where we are ready to actually take on a more regular pattern of face mask wearing or other behaviours to ensure that we limit this transmission?
I'll just start and then Devi, I'm sure, will be able to supplement. What I would say is that there's nothing that replaces communication—clear communication and consistent communication. There's not been consistent communication in North America, in the United States, and there's not been continuous clear communication in many parts of Europe as well.
Asia: the secret in many countries was communication. In South Korea, they were doing it twice a day; they were reminding people, 'Wear masks.' In Japan, they instilled in people the honour of protecting the elderly by the youth not taking infection home to the elderly, and the Christmas warnings throughout the region now are talking about, 'Protect the elderly in your household, because that's where transmission occurs into the elderly populations.' And there are many other safeguards in the elderly care homes as well. But I think Devi would be able to supplement what I've just said.
Thank you. Actually, I don’t think David and I are too far off, because I guess, when I talk about an elimination strategy, I mean just trying to get to the lowest possible levels of transmission. I don’t mean elimination in the sense of no cases for 28 days. But I think, in Europe, there was a sense that there could be some level of endemic transmission and you could still keep your health services running. And I think what we’ve learnt with this virus is that it’s so transmissible and so infectious, plus the hospitalisation rate is such that, if you try to simmer it, all you’re going to get is continual take-offs and you’re forced into reactive lockdowns. Whereas, if you take the east Asian approach of almost a SARS approach, which is, ‘We’re trying to drive this infection to low levels’, it doesn’t mean getting to zero, but it means, ‘Deal with your flare-ups and go after cases; don’t just accept that there’ll be a certain level of infections.’ They seem to be doing better based on that kind of approach.
The second thing I wanted to mention on the messaging is I think, in Europe, we wasted a lot of time this summer having debates in the public space over, ‘Will we reach herd immunity? Have we reached herd immunity? Could we lift all restrictions and have we already all had it? Does testing matter? Do the tests even work or are they all false positives? If cases go up, but hospitalisations don’t, is this a problem?’ Where, we know that deaths come after hospitalisations, which come after cases, and there’s a lag. We’ve seen that across the world. So, I think, coming back to David's point, east Asia just avoided a lot of those debates. I think they find it quite astonishing. I was on a call with a colleague from Taiwan, and I was explaining a protest we had had recently in Scotland against face masks, and he said, 'Do you have protests against sunscreen?' You know, it's a basic public health measure. So, I think, this summer, that's been very hard with the communications, having also been involved with it. I feel that, sometimes, with the media, you end up debating something—'Are we at herd immunity with 15 per cent exposure?'—and we're debating that, instead of actually saying to people, 'These are ways we can get our economy going and get most of society up and running, how do we develop the public health preventions to be more precise in places where we know transmission occurs?'
And the last thing on travel, since you raised it—travel is a real issue, I think, because the lockdown measures we know work. We know what works to control the virus, but if you have absolutely no border checks, it's just—. The best graph, I think, has actually been from New Zealand. There's a paper in The New England Journal of Medicine, and what it showed is, like in all countries, the first introduction of infections were all imported cases. And they can do this via sequencing now. They have very advanced genetic sequencing there, and now, in Scotland, we're starting to see some of this as well. Then you go into community transmission, and your imported cases are negligible, because you have so much community transmission. So, even if a few cases are coming in, it's not going to fundamentally change your public health approach, which is getting on top of that transmission. And then, they crunch that transmission with a hard lockdown—as we did in Spain and the UK, in France—and then, all of a sudden, you see the imported cases rising.
But the difference in New Zealand is they caught those through testing in their quarantine facilities, and so they quickly caught those. And you could see if they hadn't caught those, you would have gone back into community transmission and they would've been back in that place. Iceland is the perfect example of this, because they also took an island approach, took a hard approach, cleared the virus, then opened up for tourism, but had two tourists come in who tested positive at the airport, and were asked to isolate, and they decided not to isolate and went on, and within a few days they had infected over 100 people. And part of that second wave in Iceland has been kicked off by two people going out, because they had gone back to everything open. So, it shows you the difficulty with the movement of people and why, actually, true elimination is probably impossible with this virus in countries, but an elimination strategy of actually getting to zero is probably the best way of staying out of lockdown. Otherwise, you're just in reactive cycles.
Thank you for that. I've talked about testing, and I know my colleagues will talk about testing in a little while. But on the data collection aspect of it, what you've been saying an awful lot is understanding where the virus is occurring and therefore the data is important in that. Are we collecting enough data at this point in time? Have we been lax in actually the collection of data to understand that transmission, and are we, at this point in time, getting enough data to understand it so we can take this agenda, if we think it's the right way to do it? Professor Sridhar first and then we'll go back to Professor Heymann.
I think there are all kinds of data that we need with this virus. So, one is where does it transmit. I think tracing data is probably useful there to understand, to ask people to explain where they've been. We need sequencing data from testing to understand what is the actual spread of different strains. Even there, I think one of the missed opportunities was that, because community testing stopped in March, there were probably a lot of people who were infected in March that we just don't know about and we weren't able to get that sequencing, which means there have been a few cases of reinfection, but we wouldn't necessarily know that if someone presents now and tests COVID positive they're actually reinfected or whether it's a primary infection, because of that lack of testing.
I think the third is, obviously, tracking, and I know all nations in the UK are working towards this—more precise regional lockdown measures where you can have different tiers in different parts of the country and be able to react. I mean, again, testing data is your best way of actually having regular surveillance. So, I would say I think the data systems are getting there, but we're probably not at the level of surveillance data that we need. We have the Office for National Statistics survey, we have the REACT survey, we have more and more coming online now, in a sense, which has helped our line of sight of what's happening with the virus. But I still think even tracing data is really difficult. And it's difficult in all places. New York City as well was saying, you know, when people say what they've done in a week, how do you know exactly where they were infected? Was it at the restaurant, was it at home, was it at school, was it at a park? It's hard because people have complex lives to pin down exactly where they were infected. But we have a general pattern, as David was saying, where we know where superspreading events happen, and we can give pretty good advice on how to manage those spaces and target financial support there.
Coming back to data, I would just say that there's a big misconception in the world, and that is that what's reported by WHO as cases is really the number of infections, and the number of infections depend on the testing strategies in countries. So, countries that are trying to open up their travel are having a very difficult time in understanding where there's an equal risk of transmission and an equal response capacity, which is what's needed in order to open up international travel. I actually chair a group at WHO that is advising the emergencies programme. We meet twice a week for two hours. At yesterday's meeting, we were addressing the issue of getting the right indicators for countries so that they can understand how they can compare to each other, because today, you can't compare the UK to Germany, because the testing strategies are entirely different, and they keep changing. Just as an example, the Liverpool study that England has done will be reported to WHO as cases, and that just skews the number of cases, because these aren't really cases, they're infections. And so, to compare countries, there needs to be a standardisation, and that's being done by WHO right now.
At the same time, the airlines are working with ICAO, which is the International Civil Aviation Organization, to develop strategies that they will use to make sure that travel is safe. Travel is quite safe now, as you know. What they're thinking about is testing before travel, testing on arrival and then maybe testing a few days later, five days later, and then permitting people to leave self-isolation. That's what some are talking about, because they want to get travel back into a more normal situation. Actually, Singapore has modelled what would happen if they did that, and they would have some imported cases, because their testing would miss some infections, but they're able to tolerate those. They're able to detect them and are able to respond to them as outbreaks.
Coming back to outbreaks, this disease still does cause outbreaks in all of our countries, and that's where the effort has to go to tracing and to tracking, but it has to be done at a local level. It cannot be done in the capital city. It has to be done by communities where there is trust and where people know how to trace for TB, for sexually transmitted infections, for HIV. They do a good job with that, and they would do a good job with COVID. But, unfortunately, the central level in many countries has taken that responsibility, and it just doesn't work.
I'm going to stop there, Chair, because my internet connection is unstable. I'm dropping out every now and again.
Right. Andrew R.T.—you had a short supplementary at this point.
Yes. It was just going back to Professor Devi there on the travel restrictions that you talked about. Very often, people think of travel restrictions as, obviously, national restrictions on the border, but under localised measures, particularly here in Wales, we've locked down counties on a county council basis. Now, we've moved back to an all-Wales travel area, even though infection rates are still very high in certain county areas. I think I heard you correctly in saying that you would never be able to suppress the virus unless you implement strict travel restrictions. I think I heard you correctly saying that. So, what is your view on the Welsh Government's current policy, which has moved away from its original policy of locking down county areas and is creating a national travel area, even though there are high instances of infection?
Well, it depends what the overall Welsh strategy is with this virus. If you actually want to take some kind of—I'm hesitant to use the words 'elimination strategy', but a maximum suppression strategy—I don't know how you can get there without having travel restrictions in place, because as soon as people move from a high-prevalence area to a low-prevalence area, you're going to keep seeing infections. We've seen this in Scotland, because if you look at some of the islands, they were completely clear for months, and then tourism started and, all of a sudden, they started seeing localised outbreaks. We've seen this in the highlands, and I'm guessing it's probably a similar picture in Wales. As soon as school-holiday season came up, all of a sudden, you're starting to see cases in places that never had infections before. And so, it's a real balance, because people want to move. They move to work, to see their family, they move for tourism. Some see it as a basic human right to be able to have your freedom of movement. They move for universities, and so how do you manage that movement?
It seems there are different models from across the world. So, Australia really had harsh restrictions within it between the different states, where you really couldn't move. It was enforced by the police. Then you have the German model, where they've also tried to say that, and tried to restrict travel, but it's been on a more voluntary basis—you advise. But again, I guess it comes back to what are you trying to do with this virus. If we're just trying to buy time until there's a vaccine or there's mass testing in place, to the spring, then it has to be done in a sustainable way, and you need to perhaps have more flexibility around travel so people can have more of their life back. If you're saying, 'Actually, we want to take a really harsh approach to this virus', and then want to protect that low prevalence through, in a way, bubbling yourself off, or fortressing yourself off, or testing at airports or, as Singapore's doing, at least catch a number of infections, you probably need to have testing for anyone coming in, and then you will have, probably, more strict restrictions during that period, and then you can release them and have more flexibility.
But even looking at east Asia—looking at Hong Kong, Singapore, Taiwan, South Korea—they all, from the start, have limited the movement of people. I think people there are not moving around as freely as before. They're starting to set up travel bubbles, but I think the movement has been—I don't know if David agrees with me—a real challenging area, because it's so ingrained that people can move around as they want even within a country, or across countries, given our integration.
Just to follow on from what Devi said—and it's absolutely right—many countries are suppressing with a political promise of a vaccine. That's the wrong way to go. There will be a vaccine, it's clear now, but we don't know whether that vaccine will prevent infection or whether it will only modify infection and cause less serious illness. And we don't know, if it does prevent infection, if it can prevent carriage of the virus in the nasal passage, even though a person is immune.
There's a lot we don't know about the vaccine, including how long it will last and whether or not there will be frequent need for boosters. So, in general—and I think there was an article circulated about living with the pandemic—it's not a good strategy, according to what the group that I chair believes, to just suppress, waiting for a vaccine. Suppression is to let the virus enter at a pace that the health systems and the people can keep up with, and that's where the monitoring needs to be, to make sure that that's occurred.
The political promise that this will all be over when there's a vaccine is not a promise that's valid. At the same time, there may be monoclonal antibodies, which are also very helpful, possibly even in using as prophylaxis in the elderly to provide a dose of antibody as they do for rabies today, and as they do for other infections, which can modify or even prevent infection. So, there are many things that are coming along, and to just put everything into a vaccine basket is not the right way forward at present.
Okay. We need to move on. Lynne Neagle.
Thank you, Chair. Good morning, both. I wanted to ask about pandemic planning. Professor Heymann, you highlighted the fact that they were better prepared in parts of Asia because they'd had SARS and MERS. We're told that there'd been regular pandemic planning exercises, et cetera, in the UK, but it seems that we weren't prepared for a novel virus like this, and that we were just prepared for flu. Is that your understanding, and shouldn't the UK have been better prepared for something coming left field like this? Do you think those lessons have been learnt going forward?
Thank you. I don't know if you know, but I was chair of Public Health England and the Health Protection Agency for eight years. I left that job two years ago, but I can tell you that there was pandemic planning, despite what the former chief medical officer might have said in the newspapers. There was planning for a MERS outbreak when MERS occurred and actually entered the UK twice, and there was also planning for other pandemics in addition to influenza. So there was preparedness, as there was in most countries, through exercises. I'm not just singling out the UK. Most countries had pandemic preparedness exercises. Why they didn't learn from those lessons, I can't answer. I don't know. But one of the reasons, clearly, is that there weren't the detection systems that could be sensitive enough to tell when a disease has entered, because the data is now showing that, even in France, the disease may have entered in December already. So, it just wasn't being detected for some reason. There were pandemic plans in place, but they just weren't being followed. Why, I can't answer. That's something that needs to be investigated clearly. Maybe Devi has an idea of—[Inaudible.]
Yes. The three things that I think have made this pandemic really hard for European countries are, first, the case fatality rate of COVID-19 falls within the window where you could see it—and some have seen it, like President Trump—as a very bad flu, if you believe it's really 0.2 per cent or 0.3 per cent. Or it could be seen as being very serious, as the initial projections from China were that it was 2 or 3 per cent. But it's not near MERS, which is a third, or SARS, which is 10 per cent. So if every country had seen a virus coming out that killed a third of people, every country would have had the same strategy, which would have been what you call a SARS kind of strategy—maximum suppression, you cannot let this virus flow through your population. But because it kind of fell in this grey area, and then you add on top the second aspect, which is the randomness of who actually gets very seriously ill, and then we learn it's weighted against those who are elderly and vulnerable, unfortunately, I think what it's created is an idea of some kind of acceptable loss and that, actually, this is a bad flu that only really kills people over the age of 60 and those with pre-existing conditions. And then you add a third factor, which is asymptomatic transmission, which has been, I think, the Achilles' heel of the response, because usually in a public health response you have people who are symptomatic, and that's how you find them, because they report they are ill and then you can trace their contacts. But all of a sudden, you have people walking around feeling completely fine infecting others, especially young healthy people who have the most, probably, dynamic contacts and social networks. And you create a perfect storm for a very muddled strategy.
And what you see, if we play this out, are countries thinking, 'Well, actually, it's not that bad'. And we've had those debates, 'Could this be like a flu? Could we just let it go and shield the vulnerable and protect those most at risk?' And then we've seen the rise in hospitalisations, and the hospitalisations are also in younger people past the age of 20 and 30, who might just need oxygen, but they still need a bed. So it doesn't mean that the health service capacity doesn't matter. And then all of a sudden, you get into a lockdown, because your health services are strained and no advanced country wants to see its health services collapsing at that point, so they have to go into harsh restrictions to put a brake. And then all of a sudden you see a backlash about that, saying, 'Yes, but it's only people who are over 80 who are dying', or, 'My friend had it, who is 50, and they were completely fine and asymptomatic.' And so some of that randomness has created, I think, a very hard choice over what strategy you pursue.
At the start, I think also there was the idea that you could save your economy by going down a flu strategy. That, somehow, maximum suppression would cost too much in the cost-benefit calculation. And I think what's remarkable to see in 2020, looking at the economic analysis—the Financial Times has done this, Sir Nick Stern, Sir Tim Besley and other senior economists have written—is that actually those places that suppressed the virus have managed to keep their economies largely running, like David was talking about in Singapore. Whereas those that try to take a flu strategy because they ended up in a reactive way, have managed to crash their economies because they're in restrictions longer, and also they don't have a true exit, which means it's like a prolonged strangulation of the economy because you don't know how you're ever going to get your restaurants and your bars and sectors of your economy open again.
So, I think part of it is also that some people asked, and I don't know if David agrees with this, 'Is this disease x? Imagine this would have killed a third of people; how bad would it be?' And a part of me thinks that that probably would have been simpler, because every country would have run in the same direction and we wouldn't have had all these debates over what to do. We would have known what to do. We would have just gone and done it. But I really think that this is a truly tricky virus because of the aspect of one person's feeling completely fine and healthy is the other person's death sentence. And one person thinking, 'Actually, this is just a bad flu', which every day I hear that this is harmless to people under 55, but at the same time, we know that the hospitalisations mean that, if you don't get people oxygen, your fatality rate is going to jump up quite fast.
Thank you. It feels like a perfect storm, doesn't it, that we're in, really. Can I just ask you both, then, about the differing approaches across the UK that have been taken to control the virus—what your views are on those and whether there is any particular good practice that you think we should be following in Wales?
Well, I think that WHO, as I said earlier, never recommended locking down the economy. There were lockdowns that locked the whole economy, and people tolerated that very well the first time. People were afraid because they didn't understand this infection, and the lockdowns occurred. I think that, in retrospect, those lockdowns were probably not necessary. What was necessary was to do good contact tracing early on, find out where transmission was occurring and use a precision lockdown rather than an overall lockdown, as they did. This is all in retrospect, clearly. But those initial lockdowns surprised, I think, everybody, and many of the political promises were 'Well, we'll do this and then there will be a vaccine, and then we'll be able to unlock', which is not the case. This virus will remain.
And one other thing to add on to what Devi said is that, we don't understand the long-term sequelae of even the asymptomatic infection. We're beginning to understand that this virus may, in fact, cause long-term side effects in some people, although it's not clear yet; the studies are going on. But all of those things make it a virus that is very concerning to public health. But, at the same time, if we have to learn to live with this, we may just be able to tolerate some of those long-term effects and move on. And, so, it's really going to be a balance between the economies and the health of people. And, unfortunately, the medical community is not able to make those judgments. This has to be a consensus across Government, with other groups as well, because the medical community, as you know, takes an oath to save lives.
So, it's got to be a more cross-government approach to making those decisions, and not just a public health approach.
.Just to comment on what David said, and then I'll come back to your question. On the vaccine, I agree completely. A vaccine is a tool towards a strategy, and, in some way, mass testing, done frequently and accurately, could be more useful than a vaccine in the coming months than just waiting on a promise of a silver bullet. And I was struck, I recently participated in an Australian panel with the chief health officer of Victoria state, and he was saying they're going to use a vaccine for ring vaccination strategies, for flare-ups. They're not going for mass population vaccination. New York City—I'm on their COVID advisory group, and they're saying that they're going to use a vaccine for those who are young and healthy and most likely to transmit the infection if there's a vaccine that can stop transmission. So, they're not going to go after the elderly first and most vulnerable groups, but, actually, who's most likely to transmit it, to help with their suppression. So, it's quite interesting that, even with some more vaccines on the table, different countries will use them in different ways, depending on where they are with their COVID local epidemic.
On the different nations, I think the lessons that have come out—I'm probably going to repeat myself—are, first, really clear communications. I think the nations that have had daily press briefings, or even several times a week press briefings to explain what are the numbers, where are the clusters, what's the positivity, why are we opening schools or closing schools, or going into a firebreak, have done better. People want to understand, so communications is absolutely vital.
I think the next thing is having local testing and tracing, as David said as well, and that you embed this in your NHS, in your local health boards; you don't go for centralised services. And I think one of the challenges that there have been with the new rise of mega labs is the processing times. So, one of the challenges in Scotland, I think, has been that, if it takes five days for people to get their test returned from one of these UK centralised labs, your tracing teams are five days too late to be able to get on to where they might have been infected. So, you do your backward tracing, or even do the forward tracing of who they could be in contact with.
And the isolation, I think all nations of the UK have to work on, which is supporting people better; we need to pay people to stay home. The most effective way I saw this was there was an outbreak in a factory in Scotland, and they wanted everyone in the factory to isolate and they had problems with compliance. So, they actually paid people their full wages to isolate and compliance went up to close to 100 per cent. It just shows that, actually, you can't penalise people for an act of goodwill, which is that they are isolating not to infect others. They are already infected, so, for them, you have to almost reward isolation for the society.
And the last thing would be the travel restrictions. It just seems, among the nations, that it has become unnecessarily politicised over the movement, where I think we need to really address this like a public health issue. And this is about we want to protect areas of low prevalence, and we want to put in place measures in high-prevalence areas, whether that is restrictions, or mass testing, or supported isolation, to go after those and hit them. But there's no point hitting those high-prevalence areas if you're not having a strategy to protect your low-prevalence areas. Otherwise, it's just going to be constant reinfection over and over to different parts of the country.
Okay, thank you. And is there anything you'd like to add, Professor Sridhar, on the strategy of elimination, beyond what you've said already?
Yes. In the summer, as some of you might have noticed, I was very vocal that I thought that was an opportunity to really crunch the virus curve. Because if you look—and I think Wales was in a similar position, but Northern Ireland, Scotland, and England to a certain extent, were so low. The numbers of infection, if I think back to Scotland, we were at a handful of cases for weeks. Our positivity was close to zero per cent in terms of testing; some of those might have been false positives, because when you're at that level of prevalence—. But I think it has to be a four-nation approach. We need to have all four nations committed to going in that direction.
The word 'elimination'—and David might have a comment on this—seems to, in the public health community, people have a reverse response to it, because they mean, 'No, we're not going to get to zero cases; it's all over the planet, we're not going to get to that'. So I think we might need to think of a different term, whether it's 'maximum suppression', 'COVID-secure', 'COVID-free', 'zero-COVID', 'push to zero'. I think the term seems to elicit a problem. But I think it's completely right that it is worth considering that—if you want to save your economy, how do you get a drive to zero and deal with your flare-ups? It's much easier to deal with flare-ups, and go hard and sharp for a short amount of time, than to constantly have endemic transmission where you have to lock down the whole country over and over again. Otherwise, we're going to be in lockdowns again in January, post-Christmas—we can already see that happening.
Yes. Okay, thank you. And just finally from me then, you've both highlighted the importance of border controls. Obviously, we've just come out of our firebreak, England may come out of their lockdown at the beginning of December now. What should the approach of all four Governments be to international travel, following this period, and before we've got the vaccine and a longer term strategy?
You know, the key to international travel is equal risk and equal response capacity. And if the four nations in the UK, or if countries in Europe get together, and try to estimate, and do their own risk analysis and assess whether or not their risk is the same as in another country, and the response capacity is equally as good based on some of the indicators for contact tracing, for example, then a country should feel that they could open up. But if a country—. What happened in the summer, we know, is that people went to Spain—they came back infected, because they were on holiday and they went—[Inaudible.]. So if there isn't an equal response capacity, or equal response in all countries, then it would be foolish to open up between those countries at this point in time.
But the most important—and Devi said this, and I will say it again—is clear, constant communication that doesn't change, that explains to people what's going on. In the UK here—at least in England—the messages have changed periodically, without an explanation of why they're changing. And people are confused, they don't understand. There are simple messages—wear a mask to protect others and to protect yourself; you wash your hands; and you physically distance. Those are clear messages that everyone should understand, and should be practising. And they should be wearing them on the metro, on the subway, on the tube—whatever you call the public transport system—and they should make sure that others are doing it as well. There are announcements that some people can't wear them, and therefore they don't. But clear communication is the key to this, to opening up—constant communication, and the four nations having the same communication.
And I would just come back to elimination; I don't think it's a good name. I think what we have to do is live with the infection until we can do a better job at eventually making sure that it's not lethal to those people who are at greatest risk. But it will become endemic unless the scenario changes rapidly, and we just have to accept that. We don't want to be in a position like New Zealand; New Zealand can't shut off forever, and they have to depend on some good testing strategies, but also about a good system within the country when those accidental cases do enter. So it's very difficult for a country to remain zero in a country where, around the world, the disease is becoming endemic.
Okay. We need some agility now, in terms of questioning, because the time is marching on—a very interesting session. This morning's queen of agility is Jayne Bryant.
Thank you, Chair, and good morning. You've talked about some of the lessons that could be learned from the first lockdown. Do you think that they have been learned, or do you think that we're en route to making some of the same mistakes again?
Okay, I might just start and then I'm sure Devi will have some ideas as well. I think if the exit is done without a strategy of what to do next, then there's going to be a problem.
Ireland: I was talking with the Irish Government recently and they said there were two things that they felt they had done wrong. First was that they didn't have a strategy when they exited, they just exited. And second was that they let down their guard on their contact tracing during the time when there was lockdown, and they didn't continue, as did Germany, which continued to do it during their lockdown. And as a result, they had outbreaks occurring all over that they weren't responding to, and they didn't decrease the intensity of transmission by dealing with these outbreaks.
I think those are some of the lessons. And the third lesson is—. The United Kingdom has an excellent system of surveillance in each of the four nations—influenza-like illness surveillance. If that can be linked up, as Devi said, with rapid response testing, which means that you have a response in four hours, then you can begin to deal with this outbreak much better—when you detect it, you can then stop the outbreaks from occurring. But, until that occurs, and that has to be done at a local level, there will not be any successful identification of outbreaks early enough to decrease community transmission.
Yes, I think that's a great response from David. I think, looking back at the summer and coming out, the big things are around testing and tracing and isolation and making sure the systems are ready to go at a pretty large-scale level, and I think one of the problems has been that isolation has been so low. I think some of the surveys say that under 20 per cent of people are isolating. So, if you don't figure that out, it's very hard to open up.
I think the second big lesson is that there are certain sectors, which, through no fault of their own, are just riskier: nightclubs, live music, restaurants. It's no fault of these sectors; unfortunately, it's just the way the virus transmits and they're harder hit. I think, in the summer—I personally think the 'Eat Out to Help Out' scheme was a mistake. I think it should have been a takeaway scheme, it should have been an outdoor scheme. It should have been used to revive local businesses, but not through subsidising one of the riskiest activities, which is going into a restaurant with other people, because we know, even if you're 1m away or 2m away, if you're an indoor space that's unventilated, you're likely to be infected if someone's sat there, because of the aerosol and increasing knowledge around aerosol transmission.
And a third thing, I think, over the summer is—. What I would have liked to have seen in the summer—I don't know how practical it is—is, when the numbers were low, that the UK had not encouraged people to go on holidays. And there would have been a short-term hit to aviation, there would have been a short-term hit to hospitality, but they would have really pushed hard to get the numbers low as a whole island. And then, at that point, protective acts, through testing at airports, though quarantine and release, so you ask people to come in, quarantine for five days and then get tested—so, test at the airport, quarantine five days, test again; if you're negative at both, you can go. It's not 100 per cent, but hopefully you'll catch—some of the modelling says—around 60 per cent of cases, 70 per cent. So, you catch some, and then support the people who are positive with supportive isolation.
I think, in the summer, we kind of just went back to normal. We said, 'Go back—everything back. We need to get the aviation industry supported. We need to get the hospitality industry supported', without a longer term plan, which means we head into winter and hospitality's been shut again. Furlough's been extended, but it's a question as to how long those businesses can survive, given that hospitality will be shut for a long time, given what we know about this virus.
And the other thing around travel is that I feel like we have introduced this quarantine procedure, as David has described it, based on high prevalence, but it's hard to assess, as he said, because you don't really understand prevalence in different places unless you can get to the heart of their testing strategy.
But I think, added to that, we're taking the costs, because aviation is, anyway, collapsing—business travel is down. If you look at traffic through Heathrow, through Edinburgh, through Manchester—it's really plummeted. So, you're, anyway, having the aviation industry struggling. At the same time, we're not actually tracking, when people come back into the country, if they're complying with quarantine. It's kind of an honour system for those two weeks. And this was flagged, at least, I'd say, in Scotland, because a lot of kids came back from places that were higher prevalence, should have been quarantining, but put their kids into school the next day. And all of a sudden you have cases in a school and the whole bubble has to go into isolation, because you want to keep the school running. And it just made me think that we need to do that better, and if better means harm mitigation, which is we test at airports and we test five days later, maybe people will do that. Because if you ask people just to come back and, with no checks, isolate for 14 days at home—people need to go back to their jobs, they want to have their kids in school, they want to go back to their lives.
Right now, what we're also seeing—. Perhaps some of the behavioural scientists—[Inaudible.]—at this, but an observation is that those most likely in the summer to go abroad on holiday were probably more risk-taking—so, they were younger and less adversely affected by this virus, were going to holiday destinations, going to nightclubs, having a really good time and then coming back—and those people are most likely, then, to go back into riskier settings domestically, which means going to house parties and going to pubs and restaurants. And so, all of a sudden, you get the movement of the people who are riskiest going across. And the most risk-averse people aren't flying, probably. Those who are in vulnerable groups have probably been very cautious, because they've shifted their behaviour. So, in a way, I wonder sometimes with aviation and international travel if we're taking all the costs, because we are seeing aviation hit, without getting the benefits of the public health benefit of actually stopping chains of infection coming back in. And how we actually correct that—it all comes back, I think, to testing and quarantine and managed isolation.
Thank you. That's really helpful. Just moving on, we're fast approaching Christmas, and something where a lot of people are going to be wanting to travel around and get back together, and I think people have different expectations about how they'll be able to do that and the want to do that. How do you see us in the next month or so, going up to Christmas and to new year and that period? How do you feel that we can take those lessons that we should learn and just some of the behavioural understanding about how people will want to get together? And how can you look at perhaps other places that have had similar times and how they've been able to manage people wanting to get together and travel?
I think in outbreak—in this outbreak, and in any outbreak—that people have to understand what to do to protect themselves and protect others, and if you can't instill in the population the fact that Christmas is a dangerous time for elderly parents and elderly grandparents, then it's been a failure in communication. So, that's the first thing that has to be done. People have to be trusted to do their own risk assessment, but they have to, at the same time, have the right messages so that they understand how to do their own risk assessment. That's the first thing.
The second thing is, that if people are travelling and they come back and they isolate for five days in their household or 10 days in their household and they're letting other people go out, which is what happens, it's really a loophole. I came back from France to the UK. My whole household could continue to move around while I was self-isolating. The most transmission occurs in the household. So, if I had been infected, the policy just had such a great loophole that it didn't even make any difference if I self-isolated or not, because, if I infected others, they were going out and taking the transmission further.
So, there needs to be a think-through of what the strategies are. But people need to understand, basically, that they need to do their own risk assessment; they need to be able to protect others and protect themselves at Christmas and all times.
Yes, I think that's right. I think we can look at what's happened in other parts of the world. So, Canadian Thanksgiving happened, and, if you talk to Canadian scientists, they say they think this really triggered an upswing in cases, and you are seeing in Canada acceleration about two weeks after their Canadian Thanksgiving. And I know in the United States there's a lot of concern about this as well, with Thanksgiving coming up, and the movement of people across the United States, as well as the gathering of big families across.
I think, then, looking ahead to our Christmas, there has to be a public conversation. Because the way I would put it is: either we have a relatively 'normal' Christmas, people get together, but we're going to pay for that in January, we're going to have rising hospitalisations, people will be infected, and we'll have to go into a second lockdown, I'm pretty sure, because we've already seen this play out in other countries, and we know the kinds of behaviours that will occur, or we can say to people, 'This is a pandemic, it's going to be really tough, but you can see people outside for walks, you're going to have to interact with, it's harsh to say, but with family virtually'—it's hard for me as well; my family is abroad—'and we're going to try to get through this, and there will be Christmases in the future where you can see relatives.'
My worry is, if Governments right now say, 'Okay, there's an armistice for Christmas' it's almost giving permission for people to meet each other, and, if elderly relatives become infected, does that make the Governments somewhat culpable, because they said, 'Actually, you can meet' and so people take that as, 'Oh, it's safe, right'? Or do you, as David said, advise people, which is their risk. Obviously, some people are willing to take those risks to see family. There are ways to mitigate those risks. You can see people outside. I think we know so much more about—you know, if you go for a walk outside, you have a meal outside, we see very little transmission occurring there, compared to inside. And also encouraging people, if they really, really want to see an elderly relative, to get tested and to quarantine two weeks. But I think—.
And if you talk to scientists, they take this very seriously. No-one is running off to go and see their elderly relatives, especially if you're mixing children who have just been in school with travel and with elderly relatives. It's a recipe for disaster. So, it's a really hard one. Everyone wants to see their family and get together, but, from a scientific perspective, it's quite a dangerous moment to have that happen over Christmas and the kinds of behaviour people will have.
That's really, really helpful. And do you think those conversations with the public—? You said that's really important, bearing in mind we're a month off it now. Do you feel that that's actually—that honest conversation's being had? And just also then, lastly, around the point you made around the vaccines, which is really important, about how different countries are looking to take that up, do you have any—? Are there any ideas that a particular way would be the better way of doing it? Or is it just, at the moment, we're not sure how that will go?
I think the first thing is to get the behavioural scientists involved in helping with the messaging, because they're best able to help people understand how they can deal with this virus. And they've been slighted in many countries—they've not been involved in the communications strategies and the various strategies that need to go forward.
But, with Christmas coming, it's going to be very, very difficult for a Government to do anything to stop people from meeting their families. It's going to be very, very difficult. And that's why it has to be on the families themselves to understand this. I think the young people just have to understand that they need to be very careful at Christmas time, because the elderly are at risk and they don't want to end up with a grandmother who dies because they infected her, or a grandfather who dies. So, I think any examples that are available now of when people went home and had their families affected would be very important to portray to the community, and let the people know that this is a very important time. I think the Government can do some things, but the Government can't do everything. If there's been one weakness in the response, it has been the Governments that have not been able to instill in their own people that ability to do their own risk assessments and to protect others.
If I could add on to that, I think two comments. The first is I feel like we've created almost a cat-and-mouse game with guidance currently and restrictions, where restrictions are put in place and then everyone figures out how to break them, which is the worst case. You'd rather have that you don't need to put in place any restrictions and everyone just knows what to do and just goes off and does it. And so there is a worry that we need to get our messaging better, which is that, actually, we're not putting in place restrictions to make people's life harder; Governments do this because they're trying to help advise and support people to make better decisions for their health and also for other people's health, because what you do affects others.
And coming back to David's point, the thing that I keep trying to say to people is that this seems endless, but in about four months I think we'll be in fundamentally different position. We're now having mass-testing trials, whether it's Slovakia or Liverpool or other places, we're understanding transmission better, we have several vaccines. Hopefully, one of them—we know they're effective—can actually be used for a larger distribution. So, if you can prevent infections now, you are giving a chance for people to live for potentially years or decades in a few months. So, that's been my message to young people—even to them, because young people can still get very ill from this. Around long COVID, some of the problems estimates, they're not insignificant: it's like 5 per cent or 10 per cent of even 20-year-olds can get chronically ill from this. And that's just been like, 'Yes, live your life, but it's not like this can be harmless to you either, and you play a role in passing it on.' I think that needs to be the consistent message, which is, 'You don't want to pass it on, and you don't want to get it. And these are ways you can do it.' And if people do want to meet, then at least open the windows, ventilate. There are things that we can all do just to lower that transmission risk. But, as David said, we've entered this weird cat-and-mouse game, so whatever we say to people to do, they all figure out how to find the loopholes so that they can be the ones that don't have to actually do that.
Thank you, Chair. Thank you.
Reit, mae'n amser symud ymlaen, a dal i ofyn am ystwythder yn y cwestiynu, ac mae Rhun ap Iorwerth yn giamstar ar hynny hefyd. Felly, Rhun.
It's time to move on now, and we will continue to ask for agility in the questioning, and Rhun ap Iorwerth is a champion of agility. So, Rhun.
Thank you, both, for your evidence so far. I'll just rattle through a couple of things. Most of them we've touched on already, but maybe just to look for a little bit more focus. On testing in particular, there are things that, clearly, I think, we should have done differently from the start. But we're not at the start now, we're here now, so what are the lessons, the main lessons that we should have learned, that should affect decisions made by Welsh Government now on testing; and what are the barriers preventing those lessons from being learnt, and change being implemented?
Certainly, a sound testing strategy is at the base of whatever a country does, and that testing strategy should have several objectives. Number one, it should be to rapidly identify people who are infected, so those people who come to attention because they're sick need to have a test that provides results within a very short period of time—hours rather than days. So, that's the first thing: a testing strategy that tests the people who are sick and gets a result very rapidly, so they can be managed properly.
The second thing is that to be able to understand where transmission is occurring, it may be that some of the antibody tests are very useful, looking at various parts of the country, although they haven't been shown to be successful yet. But the new antigen tests, those tests that don't determine the nucleic acid, the virus itself, but determine the protein of the virus, are also very important and will be important in testing strategies, but those strategies must be designed to understand what the risks are of false negatives or false positives, and that needs a scientific community to be evaluating those.
That has to be done by reliable modellers who can model what might happen if you miss a few cases, and I might just come back to modelling. Modelling has been the Achilles' heel of this, because the modellers have provided estimates that countries have believed are the reality, when actually they aren't reality; they're a model. And modelling was never intended for the general public or the journalists; modelling was intended for the public health leaders to decide what the worst-case scenario might be. And I saw a cartoon the other day—just to digress a bit—in which a woman was asking her doctor, 'When will the pandemic end?' and he said, 'I can't tell you, but ask the journalists.' And that's what's been driving the whole response has been the journalists and the modellers who have put this information out, and it's been interpreted many times in the wrong way.
But coming back to testing, a good testing strategy and the scientific community should be reviewing this. The most important thing, as Devi said earlier, is the time between a test and results if you want to contain this outbreak. And then, a decision on which tests you can accept.
Thank you for that. As a member still of the National Union of Journalists, following on from my career prior to politics, I'll think back at what you said there. Professor Sridhar, do you have any more comments on that real focus that the Welsh Government should have right now on decisions it could make differently on testing?
Yes, so I would say testing is one of the few ways to release lockdowns, and so I'll talk about what it can do and what it can't do. So, we have these rapid antigen tests now. South Korea's selling them, Slovakia bought 3.3 million of them, and they tested their whole population in a weekend. The way they did it is, 'You're in lockdown; if you want to be released from your lockdown individually, if you want to be able to move around, you need to get tested. If you're negative, you can go. If you're positive, you stay home for 10 days.' Isolation is just as vital; there's no point testing if you don't actually isolate people who are positive, otherwise it's a waste of time to test. And they're going to do that a week later because of the incubation period, because that means people could test negative, because these antigen tests are not good at picking up low viral loads. They're not good at picking up if you have, like, a stage of your viral load. They're not good at the front end, so you need to test again, because you could miss people, and they're doing that. They're going to test their whole population again in a weekend, and I think that's remarkable. I mean, these antigen tests are available; I think they're £3.90 each. I know there's a lot of scepticism about them and there's worry about false positives, but Slovakia seems to be doing really well, actually, but they are putting in place border restrictions as well—pretty harsh—to protect that. They're not trying to eliminate; they're trying to 'maximally suppress', as they call it, David—I mean, get their numbers down low enough so it's manageable.
If I had one thing I'd really hope for, if you were looking at where you're going to buy, is looking at buying these rapid tests and thinking of where to use them. And they're not silver bullets, right? They're not going to take away your—. They don't seem to catch asymptomatic transmission that well, because the viral load seems also to be low there. But, they're better than nothing, and then if you get your isolation policies in place, you could actually be running quite fast. So, I'm quite excited about this, and I think a lot of places are looking at Slovakia and wondering, 'Is this going to work?'
In Liverpool, it seems one of the issues has been take-up. A lot of people don't want to get tested, and the reason is, if you get tested and you're positive, you have to isolate. So, there's a deterrent to getting tested, because if you feel fine, why would you want to know you're positive? You want to go and have your household out. So, I think that's where we might get into a harder time in the UK, because I don't know if people would be willing to accept that kind of thing, which is, 'You're locked down.' And that way, I think, the release way creates an incentive, saying, 'Everyone stays home, but you don't have to stay home if you get tested.'
Yes, good idea. And mass testing in an area of particularly high prevalence, like Liverpool, say—we have some of those areas in Wales—might be useful if accompanied with the appropriate support mechanism, and so people know when they do get a positive test, they will be given the support they need—emotionally, financially—to stay at home. Is that a fair assessment?
Yes. So, I think the best example of this for, like I say, a nation closer to the UK is New York city. So, their isolation rate is around 98 per cent. So, I asked them, 'How did you get there?' And they said they've done three things. They pay people really well. They've spent a lot of money on their test, trace system and isolation. It seems like if you almost make it people's job to stay home. The second thing is they give emotional support. They give you a stay-at-home kit with essential foods, they call you every day and they'll even have someone come to your front door at a distance to make sure you're okay. So, people feel like someone's actually watching them and caring for them during that time. And the third thing is they offer hotel rooms. David was saying when he came back, what was the point if he's infected, he's going to infect the rest of his household. I do wonder sometimes if we've accepted too easily that if one person is infected, everyone is infected. I know, for example, if I was positive and I was going back to my flatmates, I would not want them to be infected. I'd say, 'Take me to a hotel room.' And, actually, it seems like uptake of hotel rooms has been very high; people seem to like staying in New York city hotel rooms. And so, if you have empty hotels, you can offer it as well. And I think—David will know better—but my sense is that east Asia has also been using isolation outside of the home for people who are positive.
And a very useful economic tool in terms of supporting the hospitality sector as well, I'd guess.
The final question, perhaps to you Professor Heymann: what are the key indicators that we should be looking out for in terms of looking for signs of success? Hospitalisations, deaths, positive cases—I guess not, because the more tests we do, they continue to go up. What are the one or two main things that we need to look at?
I think you need to be watching the severity of illness, as you said, and hospital admissions and severity of those are very good indicators of what's going on in the general population. And the second thing is, in addition to watching illness, watch hospital beds, of course. Because you don't want to lock down to preserve hospitals, you want to make sure that hospitals are well protected in advance.
I'll just come back to one other thing about what Devi said about Slovakia. It is a very interesting study that's going on to see if they can keep it down, but what do you do afterwards? So, it's important that you not just have an idea and do it, but you look at the long term. In the short term they'll lock down their borders; in the long term, what is their strategy? And I don't know if they have one in the long term. But New Zealand—I've been on a couple of teleconferences with various groups in New Zealand, and they really are very concerned about having to open up, because tourism is their major source of income, and they just can't open up because they have no virus. And so, they're trying to develop the right strategies. But, I think, as you move forward, it's not just enough to say, 'We'll do this as a reaction now', it's to look at the long term, 'What am I doing this for, what am I waiting for?' If you're waiting for a vaccine, then you need to tell your people you're trying to do that, and hopefully there will be that vaccine that comes in. But, I think it's, 'We're building the ship as it sails.' Every country is trying something a little bit differently, and I think Slovakia has a good experiment going on, but in the long term, what will their strategy be? And that's what is really important for the four nations here: if you're doing something in isolation from the other three, it's going to be very difficult to keep that suppression, or whatever you're trying to do, in the long term.
Thank you very much. Thanks, Chair.
Reit, ni wedi cyrraedd yr adran olaf nawr. Andrew, mae gyda ti gwpwl o funudau i gloriannu popeth. Andrew R.T. Davies.
We've reached the final section of questions now. Andrew R.T. Davies, you have a few minutes to ask your questions. Andrew R.T. Davies.
I'm conscious of the time, so I'll try and be brief. Sweden, for example, took a very different approach at the start of the pandemic, and the rest of Europe decided to do its own thing. Now we're seeing increased numbers in Sweden, and they're having to introduce other measures now to obviously reflect those increased numbers that are coming through. What lessons can we learn from what Sweden did, if indeed we can learn any lessons?
The Swedes have said the lessons won't be visible until five years hence. That's their reply.
Sounds like a politician's reply, that.
What's important in Sweden is that they did mitigate early on. They did close down mass gatherings; they just trusted their population to do the risk assessments necessary and follow the Government guidance. I think it's still too early to say, really, what has happened in Sweden. They were counting on developing some type of herd immunity. We don't know whether herd immunity is even possible with this virus. They only have, officially, about 9 per cent of their population that's been infected, so they haven't had a lot of people infected, but they will tell you that their major problem was in the elderly care homes where they didn't shield properly, and they have excuses for that as well, that the people who worked there didn't understand Swedish and they didn't realise it. There are all kinds of things that the Swedish will tell you, but again, I don't think the jury is finally out on what will happen. They had a lot of deaths at the start. Now, they've come down to a lower level of deaths, but they're increasing and at the same time their cases are increasing. So, you know, it was an experiment. They want to continue with it, and so we'll just have to wait and see what happens. I don't think anybody can make a judgment at this point in time.
I might be a bit harsher than David's answer on Sweden, which I think is quite balanced. I think Sweden took a gamble, and I think their gamble was that there was a large iceberg of people who would not be that badly affected, or already might have been infected, and that the fatality rate was closer to flu. If they had gambled right, they would have looked great, right, because all these countries like Spain and France, we would have all—Denmark, Norway—prematurely locked down, overreacted, and in the end this wouldn't have been that bad. They took the gamble that, actually, this wouldn't be that bad and they could front-load the deaths and get them over with, and I think one of their advisers wrote a piece in The Lancet early on, explaining their strategy, and said, 'Look, every country's going to take the same number of deaths, it's going to be based on their health service capacity, and so whether you take them now or in two years, you might as well keep your economy and society running; you can't crash everything chasing one virus.' I think it was a gamble because of three things that we've learned.
The first is that front-loading deaths makes no sense because, now, if you're in hospital, you're twice as likely to survive, because of dexamethasone and doctors have better therapies. So, even if New Zealand has to open up today, they're going to lose fewer people because their doctors know how to clinically manage this better and they have survived in a world with better therapeutics, and as vaccines and testing come along it's only going to get better, plus the genetic work being done trying to understand why, genetically, some people seem more susceptible to having more severe outcomes.
The second thing is they banked on some kind of herd immunity building, but learning again from New York city, what struck me is that they say that in certain boroughs, there's over 50 per cent seroprevalence, right? So, they have been hit pretty badly—you know, death rates on par with 1918. They are still seeing acceleration in those neighbourhoods. So, even at 50 per cent it's not like all of a sudden you get a flattening off, and that really worried me, because I'm looking at the UK and I think Wales is probably like Scotland, and there are some places with 1 or 2 per cent exposure. So, to get to 50 per cent, the amount of death you would see and hospitalisation would be pretty catastrophic. New York has been scarred by this experience. That's why, even though their positivity is super low, their schools are only back, I think, one or two days a week, because they're terrified of any kind of transmission of this.
The third thing is around long COVID. When this came out in east Asia—. I don't know if David might disagree with me here, but I had never heard of long COVID. They didn't talk about it. They talked about hospitalisations and deaths, but it hadn't yet emerged there was a chronic condition that people have and they suffer from. I think 180,000 people have come out in Sweden saying they suffer from long COVID, and that's worrying, because people die, it's tragic, but from an economic perspective, they die. But if people are sick, they're costing your health service and your economy, so it's much worse to have young people who are disabled from a virus.
And finally, I think the idea that you could save your economy—. What you saw in Sweden is mobility actually came down voluntarily, which is good, because you don't need to put in harsh restrictions, but at the same time it doesn't save your economy because people are not going into restaurants and shops and consuming. So, you take the same economic hit, you just take it for more deaths, and if you compare the Scandinavian countries, that's the story. They all have a similar amount of economic loss, but the deaths, I mean, are much higher in Sweden. So, I do wonder, sometimes, whether it was a gamble. I don't want to be unfairly harsh, but I think buying time, especially if there's a vaccine—. The countries that only took 15 deaths or 20 deaths or 100 deaths are going to look much better than the ones that took tens of thousands of deaths because they couldn't buy that eight months of time, or a year of time, until a vaccine.
Okay, thank you.
I'd just add that things have changed now since there are feasible vaccines out there. This was a decision made before it was known whether or not immunity would protect. And it's very difficult to look back in that context, which is important to do as well, because this was early on. I'm not defending Sweden in any way, and their GDP is just as bad off as in other countries. Clearly, they didn't succeed in what they were trying to do.
But I would say just one word on long COVID. It's important that cohorts are followed through, clearly, because some of the psychologists are saying that some of the long COVID might also be due to the confinement and the lockdowns that have occurred, because of putting people in a very different state for a period of two or three months. So, all these things have to be sorted out. There clearly is something physiological about long COVID, and there may be some psychological effects as well, from the lockdown, but that's being sorted out in long-term cohort studies going on here in the UK and in many countries around the world.
Okay. Thank you. I’m conscious that we’ve hit 12 o’clock and I think we’ve taken the evidence around the vaccine. In particular, what I found interesting was around the approach that New York is looking at, and Australia with the state of Victoria—I found that very interesting, on the basis that some of their approach is going to be quite different to what we're looking at doing here when the vaccine arrives in the UK. So, with that, Chair, I'll hand back to you.
Diolch yn fawr, Andrew. Cwestiynu da iawn ac yn brydlon. Rydyn ni allan o amser, fel mae Andrew yn ei ddweud, felly, dyna ddiwedd y sesiwn. Allaf i ddiolch yn fawr iawn i'r ddau ohonoch chi? Sesiwn bendigedig—ardderchog, a dweud y gwir. Rydyn ni wedi mwynhau. Diolch yn fawr iawn i'r ddau ohonoch chi am eich presenoldeb. Yn ôl ein harfer ni yn y pwyllgor yma, mi fyddwch chi yn derbyn trawsgrifiad o'r trafodaethau er mwyn i chi allu gwirio'i fod yn ffeithiol gywir. Ond, gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi. Dyna ddiwedd yr eitem yna ac rydych chi'n rhydd i fynd. Diolch yn fawr iawn i chi.
Thank you very much, Andrew. Excellent questioning. We've run out of time, as Andrew has said. That brings us to the end of that session. May I thank you both very much? An excellent session. We've enjoyed your contributions. Thank you very much to both of you for your attendance. As is customary, you will receive a transcript of the discussions for you to check for factual accuracy. But, with those few words, thank you very much to you both. That brings us to the end of that item and you're free to go. Thank you very much.
I'm cyd-Aelodau, rydyn ni'n symud ymlaen i eitem 4 a phapurau i'w nodi. Mi fydd Aelodau wedi darllen y llythyr gan Gadeirydd y Pwyllgor Plant, Pobl Ifanc ac Addysg ynghylch cyllideb ddrafft Llywodraeth Cymru ar gyfer y flwyddyn nesaf. Ydych chi'n hapus i'w nodi? Dwi'n gweld eich bod chi.
To my fellow Members, we move on to item 4 and papers to note. Members will have read the letter from the Chair of the Children, Young People and Education Committee regarding the Welsh Government's draft budget for next year. Are you content to note? I see that you are.
bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(ix).
that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(ix).
Cynigiwyd y cynnig.
Mae hynny'n mynd â ni ymlaen i eitem 5 a chynnig o dan Reol Sefydlog 17.42(ix) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn. Ydy pawb yn gytûn? Dwi'n gweld bod pawb yn gytûn, felly mi awn ni i sesiwn breifat nawr i drafod y dystiolaeth. Felly, dyna ddiwedd y cyfarfod cyhoeddus.
That takes us on to item 5 and a motion under Standing Order 17.42(ix) to resolve to exclude the public from the remainder of this meeting. Is everyone agreed? I see that everyone is indeed agreed, and so, we'll go into private session now to discuss the evidence that we've heard. So, that brings us to the end of the public meeting.
Derbyniwyd y cynnig.
Daeth rhan gyhoeddus y cyfarfod i ben am 12:02.
The public part of the meeting ended at 12:02.