Public Accounts and Public Administration Committee

Before we come to that inquiry, we have a paper to note. The Welsh Government has shared with us a management response form in relation to the auditor general's statutory report on the Well-being of Future Generations (Wales) Act 2015, entitled, 'No time to lose: Lessons from our work under the Well-being of Future Generations Act'. The response sets out the Welsh Government's responses to the recommendations made in the auditor general's report. I therefore, please, invite the Auditor General for Wales to share any comments he might have on that response.

Thank you, Mark. We made just four recommendations to the Government's inquiry report, three of which have been accepted in principle and one rejected, so I'm a little disappointed by that and puzzled in some parts as well. That said, on the first recommendation, which called for a post-legislative review of the Act, I do understand the reasoning behind the Government's response there. With the upcoming election, I understand why a decision on that probably needs to be delayed.

The second recommendation related to funding arrangements and working with other public bodies to try to minimise uncertainty in that regard. We very consciously rooted that recommendation in recognising the constraints that the Welsh Government faces itself. But, our recommendation went much broader than just the annual funding cycle and was very exploratory in nature, aimed at stimulating conversation between the Government and public bodies, given that this is an issue that comes up repeatedly in our engagement with other parts of the public sector.

The fourth recommendation recommended to the Welsh Government they should review the accountability and performance framework that they use to hold other parts of the public sector to account, and specifically to try to ensure that they were rooted in the well-being of future generations Act—so, focused on indicators that were relevant to long-term thinking, prevention, collaboration and so forth. In its response, the Welsh Government focuses primarily on the public services boards, and so I'm a little confused by that, given that it wasn't an explicit part of our recommendation, which went much broader.

And that leaves the third recommendation, which related to prevention. That's the one that's been rejected. Again, our recommendation was very broad and exploratory in nature, encouraging the Welsh Government to engage with other parts of the public sector to see what can be done collectively to promote, encourage, incentivise and protect preventative action and spend. It was very definitely not a recommendation for hypothecation of that spend, and that seems to be at the root of why the Welsh Government has rejected it. So, clearly disappointed with that.

But, as for next steps, I know that the Equality and Social Justice Committee is close to completing its inquiry into the Act. We've shared this response with them as well, and I believe they've got the Welsh Government coming in to give evidence imminently. So, that would seem to be the most obvious, immediate route to test the Government's thinking in respect of this response. Thank you, Mark.

Thank you very much indeed. Before I invite Members to comment, I'll just very briefly refer to the conference Owain and I attended last Friday—the Commonwealth Parliamentary Association, British Islands and Mediterranean region, public accounts committees. A lot of the focus was on recommendations and the tracking of recommendations, but when I referred to the use in Wales of the third option of 'accept in principle', there was general surprise. It would appear that most Governments across the Commonwealth only accept or reject, but a lot of focus then on tracking, and some of the bodies have formalised tracking processes for recommendations, which, of course, we don't. Others, including the Scots, are looking at it. So, just a thought for the future.

But, Members, do you have any thoughts specifically on this, on the Welsh Government's response and Adrian's response to that response?

I'd just say it was hardly unexpected. I think we should again push back on 'accept in principle'. You're bored of me saying this, but I'll keep on saying it: 'accept in principle' means we don't agree but we don't want an argument over it, and I think that does no good to anybody. We're better off having the argument about it so they can actually explain why they're right and we're wrong, and we can try and explain why we're right and they're wrong. What you do against an 'accept in principle'? Yes, it does need tracking, and that will be a job for the next Senedd, whoever happens to be here.

Any further thoughts, Tom or Adam? So, you're content for us to respond along the lines described, but also picking up on Adrian's concerns.

Yes.

Thank you. Okay. I think, again, very briefly, on 'accept in principle', 'accept’ can actually address some of the 'accept in principles'. You may not be agreeing or they may not be agreeing to the specific action indicated or inferred, but they're still agreeing with the item and proposing an alternative way of doing it. It’s still accept. Or they're not going to do it—so, say so. Right, so we've agreed on the action there. So, we can have a very, very short, five-minute break and we'll reconvene at 09:35

Bore da. Welcome to our witnesses who have now joined us for this morning's evidence session. I'd be grateful if, perhaps, you could start by introducing yourselves and the roles that you hold.

Bore da. I'm Tracey Cooper, chief executive of Public Health Wales, and it's nice to see everybody again.

Bore da. Chris Williams, consultant epidemiologist at Public Health Wales.

Bore da. Meng Khaw. I'm the national director of health protection and screening services, Public Health Wales.

Thank you very much indeed. This is this committee's first oral evidence session as part of its consideration of the UK COVID-19 inquiry module 1 report, and we'll be hearing from the witnesses who are from Public Health Wales. As convention dictates, I as Chair will ask the first questions and then invite colleagues to question you further. In your view, how has Public Health Wales revised its pandemic preparedness strategy since COVID-19, specifically in response to the gaps identified in the COVID-19 UK inquiry module 1 report and the Welsh Government's response?

We took the opportunity to reflect on our arrangements immediately after the pandemic, learning the lessons we did around surge planning and capacity around addressing health inequalities, given the differential impact that COVID-19 had on the population. We also looked at our systems, processes and governance, particularly around de-escalating our response, where necessary. We immediately put those into the next revision of our emergency response plan.

When the module 1 recommendations came out, we then reassessed our actions and undertook further work to refine our processes, focusing on pandemic preparedness. So, we set up a pandemic preparedness sub-group of our emergency preparedness resilience and response group to get into the detail around how we might plan for a future pandemic in a different way, taking into account the recommendations. As you know, the module 1 recommendations placed the duty for Governments across the UK to respond to the recommendations, and we aligned ourselves with the Welsh Government response and worked closely to establish new arrangements. For Public Health Wales, we then derived a draft pandemic response plan that we then used in Exercise Pegasus.

Okay. We'll come on to Pegasus later. What do you consider to be Public Health Wales's role in implementing the UK COVID-19 inquiry module 1 recommendations relevant to Wales? In the context of that role, what progress do you believe has been made to date, and how is progress being monitored and reported?

The official response from the Welsh Government is given every six months, and the latest response to those recommendations was published on 14 July this year. We have continued to work alongside the Welsh Government to inform the processes around risk assessment, and also worked alongside Welsh Government officials to drive the resilience strategy that was published in May. We're a member of the Welsh resilience forum and the Wales resilience partnership, and we are engaged at the local level with the local resilience fora and provide input into the local risk-assessment structures, which feeds into an all-Wales risk-assessment construct.

Chair, if I can build on Meng's comments as well, so, over the last couple of years, we've increased our emergency response team. So, we've added another four full-time members to that team. Whilst we've always provided a bit of a co-ordination around exercises, well pre pandemic, we've accelerated that. So, we led on eight system-wide exercises just last year alone. In the run-up to Exercise Pegasus, we did an exercise with LRFs to help prepare and test out the pandemic preparedness plans as well. So, our exercising at a system level has increased, even though we were doing it before COVID. But that's been a key role that we also see as part of our glue, if you like, between local authorities, health and Welsh Government as well.

So, to what extent—? You mentioned statutory bodies involved in this work, and a variety of statutory bodies. Are other sectors also included, given that so much care, for example, is provided in the independent or private sector, and even the third—well, all three sectors involved?

So, our role as a category 1 responder under the Civil Contingencies Act 2004 places a duty for us to work with other category 1 responders in emergency response. In the planning and preparedness phase, we meet as a local resilience forum. It is for the local resilience forum to then reach out to various partners to plan for future response. I think that's where the local presence and the local leadership around the system is really, really important. That varies between the four LRFs in Wales. So, we attend the LRFs and join the sub-groups, and we have a role in each of the four LRFs, whether it's around risk assessment, whether it's around leading the comms function. The head of EPRR is a deputy chair in the south LRF. So, we play a very critical role in that system-wide engagement.

The extent to which we work directly with third sector partners is an emerging piece of work. So, Welsh Government has set aside some contingencies for future surge planning and surge response. There is a team hosted by Cardiff Council that we manage on a day-to-day basis, and we're able to deploy that resource. Our ambition is to use that team to work on health protection inequalities during the preparedness phase. So, we will work directly with communities. At the last Wales resilience forum meeting, in the summer, I suggested that we included third sector organisations in developing our differential work with communities, to make sure that any future threats, whether it's a pandemic or any other hazards, don't have the differential impact that we might otherwise experience. So, that would involve directly working with vulnerable communities—however you define 'vulnerability'—and that would necessarily involve the third sector. Now, that work hasn't commenced, but we anticipate we will do so in the coming months.

Given the key role they played during the pandemic, and the lessons learned in their context, do care homes have a seat around this table, across sector?

So, our liaison with care homes is to support them in what they do. But we also have health boards who have the interface with care homes, whether it's around incident response to communicable diseases, whether it's norovirus or other gastrointestinal infections. That interface allows us to then identify what the support needs are. We do work with Social Care Wales to have programmes of development, and we host webinars to bring the care home sector in. So, most recently, we worked with Care Inspectorate Wales to share information with care homes about the rising cases of influenza, given that we are reaching peak activity in influenza, and Chris actually put together a briefing note that we then shared with the care home sector. So, this is ongoing work we do, part of business as usual.

I chaired a cross-party group inquiry into the impact of the pandemic on palliative care, and we had extensive evidence cross-sector, including care homes. Could I suggest that the lessons they have learned, both on that stand-alone but also working with the statutory sector, should be very much part of the design and delivery process, not a consultee further down the line?

Of course.

How will that be addressed?

I don't have access to those findings at this stage, but we will take it away and see what further work we need to do, but recognising that this is not a single organisation, but we need to work as a system to support the care sector.

Okay. To what extent are the financial and workforce resources available to you sufficient to deliver regular multi-agency exercises and to implement the UK COVID-19 inquiry module 1 recommendations effectively?

As Tracey said earlier, we have invested in our EPRR function in Public Health Wales, and through that expanded team, we've been able to deliver significant national multi-agency exercises, and often at short notice. So, in the advent of Mpox, which was a threat a couple of years ago, we put together an exercise that was attended by over 200 people across the system in Wales, to then engage in a discussion to assess whether we are sufficiently resourced, as a system, to respond to an outbreak of Mpox. In the event, clade 1 didn't affect us in the way that we might have expected, but nevertheless, it was a useful exercise so that we could test those arrangements. That was held at a national level, and what transpired afterwards was that, locally, at health board level, they were then also undertaking local exercises to test their own capacities and capabilities.

Are the financial and workforce resources sufficient for this multi-agency work you describe?

So, my sense, from a Public Health Wales point of view, is that we are sufficiently resourced. I lead that team, and I'm content that they have put in place a very comprehensive training programme for our strategic leaders and our operational leaders. They have led on the review of the governance and the emergency response plans, so I don't see any gaps currently in our provision. I think that the work that we do at a multi-agency national level is welcome and has been highlighted by Welsh Government as exemplars of good working.

Perhaps I should say I also chair the cross-party group on funerals and bereavement, and early in the pandemic, I was contacted regularly by the sector with major issues as they arose, which hadn't been planned for, but which were impacting on them. So, to what extent are they now, our funeral directors and the sector, involved in designing the planning for the future?

I don't know about their direct involvement, and this would happen at an LRF level. So, in planning for a pandemic response, clearly mortuary capacity is a part of that, and there will be sub-groups as part of the preparedness phase. So, that discussion would happen at a local resilience forum level, and we would be engaged in those discussions.

It would probably be through the local authorities' planning arrangements, I would have thought, that that would be taken into account. But it would be, as Meng says—. So, our role is that we'll bring the public health element to it, and each partner sitting around at the LRF has a specific role to play. So, I would have thought—and I could be wrong—that we'd expect that through the business continuity and the planning arrangements for the respective local authorities in that area.

How can you ensure that that is happening? The issues that were raised: yes, there was mortuary space, but there was also mislabelling of the deceased; a lack of PPE at the beginning, when they were not prioritised; and the impact on the funeral arrangements themselves, with a lack of clarity on how those would operate and the impacts on families before clarity was achieved. So, this is about proactive planning for the future. Rhetorically, is it not the case that they should be central to this?

I guess it's probably beyond our remit around controlling that engagement, but what we can do is contact the chairs of each of the local resilience fora and just feed back to them that interaction that you have had through the cross-party group, and just flag with them the need to ensure that they're involved in the planning. Because it would be for the—. It wouldn't be our role, but as a member of the LRF, we can certainly raise it at the LRF chair level, just to—. Not for us to seek assurance, because our role isn't to seek assurance from them, but to ask them to satisfy themselves that that whole funeral director involvement, the mortuary involvement, which sits, probably, between health and local authorities, is taken into account for planning. So, if that's helpful, Chair, we can take that away as an action.

Thank you. I'll bring in Tom Giffard.

Thank you, Chair. I wanted to start by asking about Exercise Pegasus. So, what was Public Health Wales's specific role and contribution in Exercise Pegasus, and how are the outcomes of that exercise influencing preparedness and resilience planning?

So, Exercise Pegasus was a UK-wide tier 1 level exercise of significant proportion in terms of input from the four nations. There had been quite a long lead-in phase for planning and there was a distinction between the red team, who were in charge with the exercise materials, and the blue team, who were the focus of the response.

So, we played an active part, because in a pandemic response you would expect Public Health Wales, as a category 1 responder, to play a significant part. And as the public health organisation for Wales, we also have a role around surveillance and data collection and analysis and reporting. We also have a health protection team, which responds to local and national threats by establishing outbreak control teams, which actually plays to our business as usual, as we deal with communicable diseases on a daily basis.

So, our role was very much focused on the national response, working closely with Welsh Government. And, indeed, on the anchor days, we were co-located with Welsh Government in Cathays. But we also have a presence at a local level; so we played into the local strategic co-ordination groups, and also the tactical co-ordination groups. And within Public Health Wales, we also put in place our response command and control structures by establishing a strategic response group alongside a tactical response group, and we played in real time as the scenario unfolded.

Exercise Pegasus was held over a two-month period with three distinct phases: the emergence, the containment and the mitigation. In each of those phases, we played a different role in terms of our response to it. But we took the opportunity to be fully engaged in it. We deployed 145 members of staff to be engaged in the cells that we put in place to respond. So, that could have been around inequalities, it could have been around data, diagnostics and testing. And that was, then, all co-ordinated through a single situation report, which we then used as the basis for our engagement at a local and national level.

And what were the lessons learned? What were the outcomes for Public Health Wales as a consequence of your participation in it?

So, that's ongoing. So, Exercise Pegasus has just finished and we called endex last week. So, there have been various debrief sessions, and we have four of us attending the UK-wide debrief session on 9 December, and we're looking forward to that wider learning. But internally, within Public Health Wales, we have taken the opportunity to debrief after every phase, to pick up the learning that we will then incorporate into the next revision of our emergency response plan.

Okay. Concerns have been raised by COVID-19 Bereaved Families for Justice Cymru that Exercise Pegasus focused too narrowly on NHS preparedness and overlooked wider system resilience. So, what is Public Health Wales's assessment of those concerns, and to what extent did the exercise reflect a whole-system multi-agency approach?

Having been involved with emergency preparedness for decades, I would say, my experience of this exercise is it was a game changer. It was very, very different to previous exercises I've attended. And most of them have been compressed into a single day. Here, we're talking of a two-month period with three distinct phases so that we could test the granularity of our response. And what really struck me was the difference between this exercise and previous exercises, which did focus on the NHS and, more specifically, focused on NHS secondary care response and capacity.

But what we saw in Exercise Pegasus was a move into more of the public health and social measures that were anticipated, whether it's about school closures or whether it's about lockdown, stay-at-home policies. And that was the culmination of phase 3 of the exercise. So it didn't focus, actually, on NHS response, but much more around the cross-Government policy considerations.

If I could build on that, it was a civil contingencies response. So, there were strategic response groups in each of the four areas that we fed into. Local authorities were actively involved. So, it was a normal response in civil contingencies. Rather than health exercising with health, it was multi-agency, and, I think, if COVID hadn't have happened, it wouldn't have been like that. So it was very much all of the agencies were around the table—police, local government, et cetera. So, it was very much, as Meng says, the cross-sector response to something that could have a civil impact at different phases of the exercise.

There were some warm-up exercises earlier in the year, were there? SOLARIS, I read, and ALKARAB. Could you just tell us a little bit about that? And I was wondering if you could give us—. I think it's called a 'hot debrief' in the jargon. Just give us your early sense of the lessons from the warm-up exercise and from Pegasus, so that we can understand it. I know there'll be further work, but just give us some headlines, if you like, about things that surprised you, that are new, out of those exercises, or clear learning from those exercises, things that you were trying to test that were validated, or things that turned out differently.

We can prepare a fuller report than the summary that I will offer, but we took the opportunity to prepare our LRFs in advance of Exercise Pegasus by having Exercise SOLARIS, because Exercise Pegasus focused on the anchor days, which were held at a national level, and then the local exercise took place a few days after. But that was where, as Tracey said, it brought together all the organisations that usually meet as the LRF and the SCG. So, it familiarised partners that otherwise wouldn't be engaged in a multi-sector response. The feedback has been very positive, and I think it really helped the SCGs prepare for Exercise Pegasus. But we can provide more detail around the evaluation if that would be helpful to the committee.

Just in general terms with these tier-1 exercises, these Pegasus-like exercises, the commitment has been given, has it not, including by yourselves, to publish all of the findings absolutely transparently.

Yes.

I just wanted to ask as well about some of the commitments that flow from recommendation 5 of the module 1 report. In terms of the TARIAN system that you have, I think that you've identified the need to replace that, and also the Welsh emergency care data set. They're both sort of related to data. On the targets the Welsh Government have referred to in the autumn and winter of 2026, my initial response is that if they're necessary, why has it taken four, five years since the end of the pandemic to make those what are regarded as essential changes to data? How would you respond to that?

Shall I start, and then I might bring Chris in as well? TARIAN was a system we developed as a case management system for dealing with health protection issues, and it served us well for business-as-usual handling of outbreaks and incidents. It's our single source of information for how an outbreak was managed.

As we then emerged in the pandemic, obviously it wasn't designed for surge in the way that we experienced in COVID. So, it was clear that we needed a new system. That's why the investment into the new health protection information management system commitment is so valuable for us, particularly as it will cope with surge—the numbers we're talking about are significantly different to business as usual—and, also, the partners we would be working closely with, and their access to the system, because, up to then, it was largely an internal Public Health Wales system.

There are going to be many benefits for a pandemic response to have a new system in place. I don't think we're out of line in terms of timescale, recognising that this needs a lot of planning, and it needs a lot of building of the new infrastructure. And, more importantly, it needs service user feedback, to make sure that the system we have fits all purposes. And that can be quite complex with the system. But Chris will have more details around the technical aspects, and also the utility of the new system.

Thanks. I think the intention of the new digital health protection project is to replace, as you mentioned, TARIAN, but also adding the functionalities that will enable dealing with very large numbers of cases and contacts, as we had to do in the pandemic, and as we did with the commissioned CRM system. In addition to the developments in technology that enable us to put it on the cloud and things like that, it's also taken a while to think through what exactly is needed from individual cases, from a few of them to a few thousand, to hundreds of thousands. And those discussions have been happening at a UK level for a while. So, it's not as if we knew exactly what was needed straight after the pandemic, and then didn't immediately commission it. It does take a little bit of time to plan it, but we are involved and engaged in the development of that and what is needed. And it should be good when it's—.

We've done a lot of discovery work with partners to make sure that the design of it meets their needs as well. TARIAN is quite bespoke, but this is a 'local authority meets the whole of the health system' system. So, from procurement, which has taken a while, because it's a lot of money, which will be a game changer for us—. And then, obviously, we need the right governance to make sure that we're spending it well for public money. But it will take a bit of time to design, to be interoperable with the systems within local authorities. So, we're working with Data Cymru, and we will be working with the Welsh Local Government Association, and local authorities, as well as health boards so that there is an interoperability with legacy and enabling what we need for the future. So, it takes a bit of time to actually implement it, but, as we say, it will be—. TARIAN will continue until that point, but it will be massive for us to be able to scale.

And whilst we're talking about a pandemic, what also is on our mind all the time is an all-threats risk. So, if we had a significant environmental threat, then we've got an information system that can do that. And, again, whilst we're talking about pandemics, all of our planning is cognisant of it could be a chemical, it could be radiological, it could be a nuclear incident, so what are the systems that we need to have in place for that.

Thank you, Chair.

Thank you. Can I just interject, briefly? Professor Fu-Meng Khaw referred to wider engagement with bodies that may not normally be involved in this multisector approach. How did that include non-public sector bodies who played and would play a key role in this?

Commercial actors, industry, science, pharma would be organisations that we would naturally link with in the course of a pandemic, because of the input they would have in therapeutics and vaccination. And certainly during COVID, we led on the oversight of the vaccine trials, and Chris was directly involved in that. So, maintaining those links with the industry is a really important part of our response.

Clearly, with each pandemic there may be different sorts of industries, but one of the critical companies was around the science of the diagnostics, because we had the capabilities within Public Health Wales to undertake genomic sequencing and, in fact, reported many of the sequences that appear in the international database from our outputs.

We have an ongoing presence around Genomic Partnership Wales. We're one of three partners in that, and we're constantly developing and maturing our relationship with industry. For example, we have a memorandum of understanding with Illumina that really allows us to develop new technologies.

That's helpful. I was thinking more about those who provide direct healthcare services, whether that's cancer charities, Macmillan nurses, Tenovus, whether it's charities providing specialist provision for people with neurological conditions, whether it's the care homes, who did play a key role in this. And, of course, many of the lessons learned are coming from that sector because of their immediate interconnectedness with the NHS and the impact that had on their provision, and so on. So, how, if at all, have they been directly involved in Pegasus and the other exercises referred to?

For Exercise Pegasus, I'm not immediately aware that at SCG level, which is where you would probably expect those interactions to take place, they had a seat around the table. We can go back and verify whether that was the case, but I'm not aware that they were involved. That's something we probably need to take away, and at the same time as we're raising with the LRF chairs about wider involvement, it might be something for us to reflect on as part of our lessons learned from Exercise Pegasus, and I'll ask the question of the team.

Thank you. Tom.

On wider civil contingencies arrangements, based on recent incidents such as storm Darragh, how effective have Wales's updated civil contingency structures been in enabling timely co-ordination and decision making, and what lessons has Public Health Wales drawn from these events to strengthen its future preparedness?

Timeliness of responses is of the essence, and we knew that from the Manchester bombing incident. In response to that, the LRFs in Wales have phased in a notification system that has enabled us to respond in a more timely manner, and we've aligned our resources accordingly as well, which was one of the reasons for the expansion of our EPRR team, so that we were able to put in place an on-call rota that focused on receiving major incident notifications through a pager rather than what was traditionally a phone call. Practically, it would take the command arrangements—the secretariat—two hours to contact all the partners relevant to an SCG. So, that delay would then lead to a delay in our response.

In storm Darragh, which took place between 6 December and 8 December last year, there was a very rapid response to requests for SCG meetings. All partners engaged in those local meetings, and what was really important was that we had the right conversations about the communications we needed to put out there, the impact on business continuity. Within Public Health Wales, we had an impact on the services we deliver for screening, so we had to cancel clinics on the Friday of the storm.

Our response continued throughout the period, but it wasn't primarily a public health emergency. But, nevertheless, I feel strongly that, as a category 1 responder, I will commit to attending the SCG meetings and assess the risk to public health from the discussions. At any point where we didn't feel we make a direct input, we would then stand down from the SCG with the permission of the chair.

So, that happened in storm Darragh. We were able to support the communications around the potential health threats arising from the storm. Things happen during floods that, actually, people might not be immediately aware of. So, we have a standing communications message that we use for such incidents. What struck me also was that, soon after the incident was closed, the Deputy First Minister hosted a debrief that brought together all the response partners, and that was a very helpful session.

What role does Public Health Wales play in the development and implementation of the Welsh national risk register and the Wales resilience framework?

So, the Wales resilience forum was reinvigorated, and the First Minister chaired a meeting in late spring this year, following, a few days after the publication of the Wales resilience strategy, which, actually, was a clearer account of our response, and also, in terms of the Wales risk register, derived from the UK Government risk register, offered for the first time an opportunity to include Wales-specific risks, which were then included in the national risk register for Wales.

Thank you. You've sort of mentioned this already, but I will ask it anyway: has Public Health Wales engaged with or implemented red teaming practices to critically assess its pandemic response plans, and, if so, how are those assessments used to improve resilience?

So, we were invited to provide a couple of inputs from our subject matter experts into the red team, and they held that role throughout Exercise Pegasus. In fact, they were also observing our internal meetings. So, we found that distinction very helpful. I expect the red team also found the subject matter expertise input into planning the exercise helpful as well, and we were able to keep the red team and the blue team separate.

We have talked about whether or not we continue that practice of the red teams. Whilst we didn't call it a red team, in our last comprehensive review of our emergency response plan, it was externally reviewed, to have that external challenge, which I think is a big learning for everybody through COVID. So, I think it's probably a practice—. Because it worked well; it was interesting, wasn't it? Even in the debriefs, the red team played the red team in their feedback. So, I think that's a healthy challenge for us to consider as mainstreaming it, going forward.

Thank you. Just finally, you mentioned that the debrief of Pegasus, the formal one, was due to take place in December. That will obviously be while we're still doing this module. So, will you be willing to share the findings and the outcomes more formally than the informal ones you've given already with the committee so that we can consider them then in our report?

Yes. I understand, on the findings, there's a commitment to publish them within months of the end of the exercise. Now, I don't know if there's been an agreed date of publication, but, as you imagine, there'll be a lot of information to get through, to analyse, to come up with a meaningful report. But I think, for Wales, we would be very keen to understand what are the specific elements that we will take away as a system in Wales. So, Welsh Government has put in place a pan-Government pandemic preparedness group, to which Public Health Wales is invited, and I expect much of the discussion will happen in that group.

And we'd be very happy to come back, yes.

Okay. Thank you.

Thank you very much indeed. Adam Price.

I'd just like to ask, if I may, about what's your view on the key elements of a Wales-specific resilience model that would improve upon the previous emergency preparedness and response framework in light of the lessons from the pandemic. So, the key thing is what improvements, and the Wales-specific elements in particular.

So, in any response, architecture, there are merits in thinking about the rationale for that architecture and also, as four nations, it would be helpful to understand what the commonality is across the four nations, so that there is a generic architecture of response and a bespoke architecture. I think the context of the devolution of health in Wales is different to England, so, by necessity, it has to be bespoke to Wales. So, I know, for Exercise Pegasus, arrangements within the resilience framework have been adapted to meet with the needs of Exercise Pegasus. Without going into detail, that new arrangement worked well, because there was clarity of roles and responsibilities, clarity of the command and control structure, that enabled us, as a category 1 responder functioning at the national and local level, to then link in with the various elements, particularly in Welsh Government. So, the arrangements put in place around the structures in each of the phases, which did vary, actually, and were agile, and I saw that being developed, were really helpful.

So, the clarity of roles and responsibilities is key to success, because we don't have time or the resource to duplicate efforts. And with the command and control arrangement, which is necessary for any crisis response, it enables us then to provide a more efficient response and interface between Public Health Wales and other partners. And that happened well at a national level and also at a local level. So, at a national level, it wasn't just the liaison with Welsh Government, but also with NHS Wales Performance and Improvement, who played a critical role in co-ordinating the response around the NHS organisations, including health boards.

Can I build on that as well? As Meng said, the generic elements for us would be access to data, early access to niche evidence, say, for example, the Scientific Advisory Group for Emergencies—we want to be around the table, we need to know what's happening, when it's happening, co-designing guidance at the same time, so that we're not on the back foot. So, there are some elements of the evidence of whatever is transpiring that all devolved nations should be around the table at the same time for, so that you can adapt it and translate it accordingly.

Where there are UK-funded things like vaccinations, like some of the testing capacity, we would want to exploit that, but we would also need to have domestic self-sufficiency, domestic resilience in Wales. So, it's that kind of 'T', as I would say: the horizontal bit is what's the all-of-UK that's appropriate for all of UK, and what's the vertical bit is what needs to be put in place for Wales to control what Wales needs to control. If there is something like a chemical or radiological nuclear incident, then that does tend to be led out of some of the concentrated skill base that sits in England. But, nevertheless, Wales would still want to be leading the local response to that. So, we would never see a situation where a response to the scale that we're talking about would be run solely at a UK level.

Can I turn to how you, as Public Health Wales, get insight from local communities, voluntary sector partners and other external experts—we've talked about red teams, but I'm thinking in a more diffuse way, in a broader way—into your preparedness and resilience planning? You used the 'How are we doing in Wales?' engagement survey, didn't you, during the pandemic itself. What are you doing now to incorporate that wider information, knowledge, insight from broader segments of society?

Do you want to start, and then I'll carry on?

Yes. So, we have continued the interface that we've put in place to connect with people in Wales. We have the 'Time to Talk Public Health' survey that we send out regularly, and we are able to change the questions in that, and we have had some amazing insights around people's attitudes to vaccination, for example, that has then helped us plan our vaccination campaigns. Or it could be around screening, because we run the screening programmes in Wales, and that helps us then change our communication messages on an agile basis.

Now, the work that I mentioned earlier that we haven't quite embarked on yet is to get into more granular detail about working directly with communities, whether directly from the team or through our third sector partners. Because that's where the real feedback is derived. And it's really important for us to be cognisant of that very granular detail, because we're really committed to providing excellent public health services and one of the domains of excellence, which is built into the Wales duty of quality, is around person-centredness, and we don't believe we can achieve excellence without that feedback from communities and individuals.

Thank you for that. Can I turn to my last question? And apologies if I may have to leave this session before the end of the follow-up questions. You've mentioned health inequalities earlier in your evidence; I'm wondering if you could say whether the changes that you have begun to put in place in terms of what we're focusing on today, in terms of preparedness and resilience planning—. To what extent are you confident that they will lead to better outcomes in terms of health inequalities in the context, for example, of a future pandemic?

So, learning from the COVID pandemic and its differential impact—and we did some work during the pandemic to try and identify that differential impact, because there are weaknesses in our access to data that helps us with work on health inequalities, and maybe I can bring Chris in to describe the work we undertook as a proxy measure about the differential impact—what we feel is that this is a necessary part of our response and we need to build the systems that allow us to then understand further the differential impact and assess them. So, the work I described earlier will help us. But, Chris, I wondered if you might just give an overview of the approach currently on health inequalities, building on a programme of work we've launched in Public Health Wales through the health protection inequalities programme, which has started its work by providing staff with best practice guidance about how we deal with health protection inequalities. That's now in the system.

Yes. So, we're involved with that on the surveillance side and we have a programme to improve reporting on inequalities across our surveillance reports. During the pandemic, there were some gaps early on in knowledge about ethnicity in particular. We did contribute to the First Minister's group on that, using a proxy for ethnicity, and we were able to confirm some of the findings about differential impacts there. There's still imperfect data in terms of ethnicity across the NHS in Wales, but, again, we're trying to use workarounds to try and add that into our reporting using other sources. And also taking into account things you've mentioned, care homes—we're working with the care home sector to try and improve identification of cases and incidents in the care homes and also working with them on surveillance specifically in that sector.

And if again—. Sorry, Adam—

That's okay.

—if I could just add, of course, we know that any significant societal insult will have more harm if the health of the nation is poor. And obviously, as Public Health Wales, we cover the breadth of public health, and we're talking about more health protection and infection today, but—. So, we have a cross-organisational health inequalities group, which permeates actions across all of our strategic priorities, and one of our strategic outcomes by 2035 is improving healthy life expectancy, but reducing inequalities. So, that's key for us. And, as we've mentioned previously, we undertake health impact assessments, as we did through COVID, to engage with the public and inform Government and partners to say the impact of 'this' on mental well-being, the impact of 'this' on different population groups. So, all of that helps contribute to understanding and identifying recommendations to tackle those in the broader part of our work.

Okay, thank you. Thank you, Chair.

Thank you very much indeed. Mike Hedges.

On public messaging, one of the things that went wrong was that the names coronavirus, COVID and COVID-19 were used interchangeably. But there were people who said, 'Ah, they don't know what it is. It's either three different things, or they're not sure what it is.' Are you as convinced as I am that you just need one term?

Well, the whole public messaging during the pandemic was a challenge, wasn't it? It really was. Yes, I absolutely agree, one term. Obviously, as it evolved, the naming of it changed in those first few weeks or month. So, 'SARS-CoV', 'coronavirus', 'COVID-19', or 'the pandemic'. And, of course, most of the population just said 'COVID'. That's what it was termed. So, yes, absolutely. I think it took a couple of weeks for the world to decide what it was going to call it. And then, in technical documents, you'd have the technical term, and you just had to make sure that those didn't seep into public engagement.

But the whole public messaging was a challenge for a number of reasons. Obviously, the cross-border, where there was divergence in policy, restrictions, it was challenging to really engage with communities, because people trust people who sound like them, who live near them. And so we were doing a lot of work with different communities, the Chinese community, Muslim communities, et cetera, and through third sector.

And also, I think the third big challenge was misinformation and disinformation. So, we scaled up all of our social media teams to really try and survey what was being said and to try and counter those messages. We scaled up our behaviour science unit to try and engage with the public to understand the messages that would be more easily understood by different people. And we had WhatsApp groups with a load of third sector organisations to disseminate information. How we scaled that up very, very quickly was a real challenge.

But even 'Keep Wales safe'—that was our dominant message, wasn't it, which we aligned with Welsh Government on—and then it wasn't helpful when the England messaging changed. We did quite a lot of work early on trying to link in with Sky and the BBC, because it took them a couple of months to realise that there were four countries in the United Kingdom. So, the updates they were giving may have been an English policy, and not Welsh. It took a while for them to say 'in Wales', or 'in Scotland', or 'in Northern Ireland'. So, it was quite a challenge on a number of fronts, wasn't it?

Well, being on the receiving end of some misinformation from people, having been told by somebody, 'It's just a mild cold. Why are you making a fuss about it? It doesn't matter', or, as one person said, 'It's just a hoax. It doesn't exist.' So, I think you've got to build public trust, and it's very difficult.

I come from a generation—I think Mark might—where you saw people who'd suffered polio. You saw them on the street, walking around. You rushed to get your tetanus if you cut yourself, because we knew, not from personal experience, but from that of people, an older generation, or two older generations away, who knew that a cut on the leg or on the foot could be deadly, pre penicillin. So, we were brought up to know that there were dangers out there. We've got a generation that has not known about these dangers.

So, how do you build public trust to actually explain? And I ask you: should you be doing it now? Should you be talking about the success of getting rid of polio? Should you be talking about the success of getting rid of most other diseases? And should you be talking about the dangers of people not being vaccinated? We've seen that with measles, where somebody in Swansea died from measles. It is not just a childhood disease that makes you ill for a couple of days. Should you be getting that message across now, that this is what happens when you don't have a vaccination programme?

Do you want to—?

Yes, this is our 'business as usual'. So, we have a vaccine preventable disease programme that runs campaigns every year, throughout the year, on all the programmes that we have, whether they're existing childhood vaccination programmes or adult vaccination programmes, and new programmes like the respiratory syncytial virus in September last year, and for chicken pox in January of the coming year. So, we are very responsive to the ministerial policy around vaccination, and we use those opportunities to reiterate the importance of vaccination where it exists.

Now, the challenge with any pandemic is that, probably, in the first year, there won’t be a vaccine available. But I think it is right to be looking ahead to the time when we do have a vaccine, as we did in COVID very quickly, and Exercise Pegasus also had that assumption that a vaccine would be available within a year. But all our messaging, and all our actions were leading to the mitigations we have to put in place until vaccination.

And if I can build on that—I know Chris wants to come in—we can’t do that distantly. So, for example, with freshers' week, we have teams right across all universities in freshers' week, encouraging people around vaccination, and we do a huge amount around sexual health advice. We’ve invested in our digital media, because the generation, often, that we’re talking about, and the misinformation, disinformation, which, by the way, globally, is up there in the top global risks—. So, we meet with our counterparts in different countries around the world, talking about challenging that. So, there’s a digital social media element to it, but also there’s a face-to-face element. But I know that Chris wants to come in. Chris.

Just on vaccination, and also inequalities, there’s a lot of really good work going on in reporting on inequalities and vaccination, and trying to improve any gaps. And, actually, although there were lots of difficult messages during the pandemic, and misinformation, I think some of the work that some of my colleagues have done has shown that the inequalities were lessened, particularly in comparison to other areas with similar pressures.

Can I just continue by saying that I think you did a good job? I think that, sometimes—. I used to teach in a college, and sometimes somebody would give you a very good piece of work, and you’d say, 'You missed that, and you missed that', without actually saying, 'You did well.' And I think that, for me, you did well.

Just continuing on that messaging, I think the first thing is that there was a fear amongst pregnant women that COVID could be dangerous, and you never really got across that it was more dangerous to have COVID than to have the vaccination. And the other thing is that, if penicillin had come out at the same time, without any further developments, we would have had people avoiding penicillin and dying as a consequence.

So, with any therapeutic intervention, there’s always a need to understand the risks of complications, et cetera. And what emerged in the early implementation of vaccination was that these risks were starting to emerge. And, I think, whenever the science is emerging, there’s always this risk of misinformation, and I think we saw some of that happening during COVID. But I don’t know whether, Chris, from your experience—.

I'll just take the point about pregnant women and COVID, and also the immunisation. So, I was involved in some of the early immunisation trials. When you first do the trials, you specifically exclude pregnant women, because you're not sure about the safety profile of the vaccine. So, at the beginning, you’re not able to recommend it, and, obviously, when the trial was widened and it was rolled out, then pregnant women were encouraged to get the vaccination. And that’s also very much a feature of post-pandemic, with the vaccination against RSV for pregnant women, which is protecting infants. So, we are able to move people to acceptance and uptake of vaccines.

The final thing on public messaging from me: you didn't get your message across to GPs and nurses completely. And there were nurses and GPs who were sceptical about the COVID vaccine, and that scepticism they passed on to their patients. I don't know if anybody's done a study of which medical practices had the poorest vaccination uptake, and why, because I think that's really the lesson for the future. You've got to get doctors or GPs buying in, and you've got to get nurses buying in before you can get the general public buying in.

If I start, and Chris may want to say something. Yes, we're seeing similar challenges now about the flu vaccination, interestingly enough. The uptake during the first number of vaccination cycles was high, and then, of course, people start to get into vaccine fatigue and it starts to drop off. But, of course, an employee of an NHS organisation, if they're offered a vaccine should take the vaccine. So, health boards scaled up. I think they did a very good job in Wales. In fact, they accelerated faster than any other country in diversifying offers for COVID vaccine, not only to their staff but also, obviously, to all of their communities. Literally, as a member of the public, you'd have a phone call, 'Can you come along this afternoon?' So, I think that there's an onus on health boards to push the message to their own staff. But we're seeing a similar—. Last year, there was a low uptake in flu vaccinations for NHS staff. So, we're actually working with Health Education and Improvement Wales, which provides all of the human resource support, to do a joint action with all colleagues across health boards and NHS organisations to understand. Our behavioural insight team are doing work with NHS staff now to understand the reluctance to take on the vaccine, to try and address that. And that will be good learning, if we get into a situation of a pandemic. But it was variable. I don't know, Chris, if you want to say anything.

Just to say that, currently, our surveillance of vaccine coverage does include right down to the practice level, and we try and work with individual practices. There is something around attitudes of healthcare workers towards promoting vaccination, but also I think accessibility to vaccinations through really good delivery is a very important aspect.

I'm not going to ask you two questions on co-ordination and collaboration unless you want to answer them, because I think you've talked in great detail about these up till now. Is there anything else you want to say about working with local resilience forums, and anything else you want to say about cross-border working?

So, I think our work with LRFs on an ongoing basis is strong. We've got good relationships at an operational and strategic level, and we have arrangements where people know who to contact for subject matter expertise. At a cross-border level, I think Exercise Pegasus and the learning from that will give us a bit more of an insight into what worked well and what could be improved, going forward. It's premature for me to say what they are at this point, but certainly the Public Health Wales experience is that, although there were cells that were put in place, our interaction with those cells could have been stronger and could have been on an equal level, so that we were co-producing rather than commenting on the things that were developed from those cells, whether it's guidance, products or whatever.

The only thing I would add to that on cross-border, the learning through COVID, is data, data, data. So, we had challenges, didn't we, in getting data from results of Welsh residents whose samples had gone to lighthouse labs. There were some times where it was slow to get that data, and then when it was international travellers returning or coming to Wales, it took us a while to get data from the Home Office. So, there are things that we're looking out for, as it were, around areas of improvement, and some of this was about devolution and non-devolved functions. So, there was a lot of learning, but the data was an area for us to be absolutely watching out for, which is what we did with Pegasus, because if you've got someone coming into a country, coming into the UK landmass with onward travel to another nation, you need to share that data in a timely way. We got there eventually, but it took us a little bit of time.

Thank you very much indeed. I was thinking back to March and April 2020, when Members here were offered COVID-19 tests, and we refused until we knew NHS staff had them. I was one of several Members who then suffered symptoms, but we couldn't have a test to tell us whether we actually had COVID-19, but it wasn't very nice. But after I was vaccinated, I had COVID three more times. It was a lot milder, but then the COVIDs were milder also. So, just for the record's sake, I think it's a rhetorical question again: can you confirm that the vaccine was never intended to stop you getting COVID, it was simply to hopefully control the worst symptoms and reduce mortality?

So, with any vaccine, it depends on the pathogen you're vaccinating against as to how it responds to the vaccine itself. So, the efficacy of the vaccine does vary from organism to organism. The SARS-CoV-2 virus was quite a clever virus—there were lots of antigens that you had to then target—and we also saw, didn't we, through the course of the pandemic, various variants then emerge, various mutations then emerge, which then signals how a virus can adapt to the environment. So, the vaccines and the targets that they were targeting did then vary, so the efficacy varied. And we built on the science and the learning of that and were then able to provide messaging to say, 'Actually, this vaccine is not going to be long-lasting, but it will protect you against really bad symptoms that require hospital admission, say, and it will make the infection milder.' But I wonder whether, Chris, there is anything you want to add.

There are two aspects. One is that the vaccine wasn't what we call a 'sterilising vaccine', as in, say, for the measles vaccine: so, you have it, you're immune and then you can't in general catch the disease or pass it on to someone else. It does reduce the severity, but as Meng has said, it's not lifelong—it's not long-term immunity—so your immunity needs to be boosted, either through vaccination or through exposure to natural infection, which is generally what happens for most respiratory viruses: the common cold viruses and that kind of thing. We catch them every year, we're a little bit boosted, but it never protects us for a lifetime. So, yes, it wasn't going to be a vaccine that was going to do that, but it was very effective in reducing the severity of disease.

Thank you. We come to the final short set of questions. I'm sorry we're a few minutes over, but we'll be over this very shortly. What were the key barriers you faced in collecting, analysing and sharing data during the pandemic, particularly between devolved and UK-level bodies and across agency levels?

I'll come in on this. So, we were fortunate early on. We've got a good system in Wales, where we collect all the laboratory results and they go into the same data system, and we're able to analyse that fairly rapidly. As Tracey said, there were some additional sources, so the lighthouse labs, which took a little while in order to feed in, and there were some deficiencies in terms of what sorts of attributes we have, like, particularly, ethnicity, occupation, et cetera, which didn't come in with the early data. But we were able to, fairly early on, analyse the data and put up, rapidly, a public-facing dashboard, showing exactly what was happening with the trends of infection.

The main flow problems, as has already been mentioned, were around some of the travel data, around some of the data from different laboratory testing sources, and that also hampered some of the whole-genome sequencing efforts, because not all of those were done. Mortality reporting was difficult, particularly in the early part, because of the ways that the data was collected and reported. But, in general, I think we managed to get things flowing in the first few months.

And in terms of interaction with other devolved Governments and UK bodies, were there barriers that affected decision making, and are there any other structural changes made since to improve data interoperability and comparability?

I don't think that the limitations majorly changed decision making, particularly in the early part, because it was mainly about the trends, and also information, where it was available, was shared through the UK incident management team structures. Since the pandemic, we have set up some data sharing agreements and increased information governance around that for the four nations, with a four-nations data-sharing framework and addendums for different areas of disease.

Within Wales, there's been some improvement of vaccination coverage reporting, so we're adding in influenza to the Wales immunisation system, which worked for COVID-19 vaccinations. So, there have been some improvements made on that. And also, lastly, just through the pandemic surveillance oversight group, we're trying to plan for the next pandemic, looking at the different data streams that will be required and then working through how we're going to share and work across the nations on those.

Can you specify further what further developments are needed in data infrastructure and sharing?

It's a large piece of work, so there will be other bits of data that we need to bring in. I think, although my colleagues are not here on this, genomics is one where we had a really good platform during the pandemic for sharing all the genomic data, and we do have international platforms. We recently uploaded influenza samples, so that, globally, people can see what's circulating in Wales. But there isn't really a UK platform as yet to put in all of the genomics data that we'd probably like there to be.

It was there when COVID was there—

It was there when COVID was there.

—and it's fallen away now.

Yes.

Are there, finally, any other barriers to sharing or adopting best practice where it's occurred, and how can those be mitigated?

I think organisations are sometimes reluctant to share data across sectors. We have that between, I won't name sectors, but between different parts of the system. But I think we are working to overcome that and also implement the sort of information governance documentation and safeguards that are needed for that.

Okay. Well, that brings us to the end of the formal questions. Before I conclude, are there any further points you would like to add that we haven't covered?

If I may, can I just make one point? I mentioned it a bit earlier, and it may be way beyond the committee's remit, but just about, as I said earlier, we're talking about pandemics, but we are very conscious of the other threats: a geopolitically unstable world, a cost-of-living crisis, with a climate crisis. We're part of what's called the International Association of National Public Health Institutes. I'm on the board and Meng chairs the global pandemic preparedness committee, which is going to be moving to an all-threats committee, likely. So, at some point, we'd be very happy, be it with yourselves or others, to have a conversation about what does all threats look like, because we're probably as rehearsed now for another pandemic, tragically as a result of the last pandemic, but we're working with our public health agencies across the UK, and our head of EPRR chairs that network, and I for one want us to be exercising a chemical, radiological or nuclear exercise next year, because that hasn't happened. We did an exercise after the Salisbury incident of novichok. We did three exercises across Wales immediately after it, but we just need to be cognisant that otherwise we're almost doing what the inquiry has complained about, through the lens of flu versus a pandemic. We just need to not look at pandemics versus other threats. So, just to leave that with you.

We have raw sewage going into rivers, raw sewage going into seas, the fact that when we have substantial flooding, the sewerage system can't respond effectively, and you end up with raw sewage in the roads. And it happened in Swansea at Cwmbwrla roundabout, where you had some sort of water that was very deep, but it contained raw sewage as well. Do you include that in your potential concerns?

Not as far as, I would say, a significant threat to the whole population. However, I mean, we were talking earlier, we've had a number of SCGs that we've been involved in in Wales where there's been water disruption, and industry obviously sit around the table; in fact, they chaired one SCG. So, they tend to be more local, albeit—. You know, it's about infrastructure and environmental protection, so we get involved around the health harms of that. I guess, my point is that on a larger scale, and how prepared are we from a UK perspective around some of those big climate crises, and some of that's about infrastructure as well, which I think is your point.

Can I just come in briefly? So, we have done some work to look at this with our own surveillance data. There's not huge amounts of evidence of harms, but we're also working with colleagues in Bangor on a wastewater side to look at those genomic links between that. And in terms of the all threats, we're also exercising around invasive mosquitoes and the threats of vector-borne disease. So, we are thinking more widely.

Well, it happened twice in my garden last year, and I had to clear up the raw sewage. Fortunately, I didn't catch anything from it. It is becoming very common. And perhaps we could capture the issue highlighted for the legacy report, in terms of the future work our successor committee might want to do on this.

So, I conclude by reminding you that a record of today's proceedings will be shared with you in advance for you to check for accuracy. And otherwise, that brings our formal session with you to a close this morning. So, thank you very much, all three of you, for being with us, and may you have a positive day for what remains of the time.

Diolch yn fawr iawn. Thank you. Nice to see you.

Okay, well, I propose that in accordance with Standing Order 17.42(ix), the committee resolves to meet in private for the remainder of today's meeting. Are Members content?

Content.