Chapter 8: Learning to live with Covid-19 (May 2021 to May 2022)

Chapter 8: Learning to live with Covid-19 (May 2021 to May 2022)

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Introduction

¶8.1. In late April and early May 2021, infection rates were low and the four nations of the UK began to emerge from the restrictions imposed in December 2020 and January 2021, in line with the published strategies in each nation.

¶8.2. The subsequent period from May 2021 to May 2022 was characterised by an attempt by the four governments to balance recovery from the effects of the first wave with the emergence of variants of Covid-19 and the continued need to manage the direct and indirect harms of the virus. The emergence of the Delta variant, first detected in March 2021, led to delays in the planned relaxation of restrictions. In the autumn of 2021, the emergence of the more transmissible Omicron variant caused an increase in infections and led to the reintroduction of restrictions. This period was characterised by a race between the rollout of the vaccines and the emerging variants.

¶8.3. By May 2022, about 1.75% of the UK population was still testing positive for Covid-19 at the time that all legal restrictions came to an end, but vaccines had succeeded in substantially reducing the rates of death and serious illness caused by the virus.¹¹ In Scotland, the population infection rate remained at over 2% in May 2022, the rates in the other three nations having been about 1.75% at that time (INQ000274150_0010). This chapter examines the events of the period between May 2021 and May 2022, the decisions taken in each nation in light of the evidence that was available to decision-makers at the time and whether such decisions were reasonable.

May to July 2021

¶8.4. At the start of May 2021, all four nations were still subject to strict restrictions. England was at Step 2 of the COVID-19 Response – Spring 2021 roadmap (discussed in Chapter 7: Further lockdowns, in this volume).²² COVID-19 Response – Spring 2021, HM Government, February 2021 (https://assets.publishing.service.gov.uk/ media/6033cfdae90e076607c1bf18/COVID-19_Response_-_Spring_2021.pdf; INQ000185087) On 26 April 2021, all of Scotland had moved to Level 3 restrictions.³³ 'Moving to Level 3', Scottish Government, 20 April 2021 (https://www.gov.scot/news/moving-to-level-3; INQ000369717) On 3 May, Wales had moved to Alert Level 3 (high-risk) of its system of restrictions.⁴⁴ 'Further coronavirus restriction relaxations brought forward', Welsh Government, 22 April 2021 (https://www.gov.wales/further-coronavirus-restriction-relaxations-brought-forward; INQ000055026) By the start of May, the Northern Ireland Executive had taken initial steps across a number of the pathways in The Executive's Pathway out of Restrictions and indicative dates for further relaxations in May had been identified.⁵⁵ INQ000212958; INQ000207213; INQ000212959; INQ000048525; INQ000212962

The emergence of the Delta variant: May 2021

¶8.5. A new threat began to emerge in April 2021, with a surge of cases in India.⁶⁶ INQ000369765_0061-0062 para 362 This variant – Delta – ultimately proved to be more transmissible than the Alpha variant.⁷⁷ INQ000251645_0150 para 8.82

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¶First identified in the UK in March 2021, cases rapidly grew throughout April and May 2021⁸⁸ SARS-CoV-2 Variants of Concern and Variants Under Investigation in England: Technical Briefing 10, Public Health England, 7 May 2021, p24 (https://assets.publishing.service.gov.uk/media/60953a8dd3bf7f288b4235ec/Variants_of_Concern_VOC_ Technical_Briefing_10_England.pdf; INQ000222014) and it went on to become the dominant strain throughout the UK.⁹⁹ Technical Report on the Covid-19 Pandemic in the UK, Department of Health and Social Care, 1 December 2022, p33 (https://www.gov.uk/government/publications/technical-report-on-the-covid-19-pandemic-in-the-uk; INQ000101642) This new wave peaked in the UK on 15 July 2021 with 62,000 cases.¹⁰¹⁰ INQ000283367_0005 At the peak, it is likely that over 1 million people were infected across the UK.¹¹¹¹ INQ000283367_0006

¶8.6. On 5 May 2021, the Scientific Advisory Group for Emergencies (SAGE) noted that there had been "a significant recent increase in prevalence of [the Delta variant], including some community transmission".¹²¹² INQ000119964_0001 para 1 Early indications were that it "may be more transmissible".¹³¹³ INQ000119964_0001 para 1 Modelling indicated that while Step 3 of the COVID-19 Response – Spring 2021 roadmap alone was "highly unlikely to put unsustainable pressure on the NHS", it was "likely to lead to R [the reproduction number] being greater than 1 in England".¹⁴¹⁴ INQ000119964_0001 para 3 It remained "highly likely" that there would be a further resurgence in hospitalisations and deaths, though "the scale, shape, and timing remain highly uncertain".¹⁵¹⁵ INQ000119964_0001 para 4 The resurgence would be smaller if baseline measures and sustained behavioural changes "which reduce transmission are maintained beyond the end of the roadmap".¹⁶¹⁶ INQ000119964_0001 para 5 Baseline measures included self-isolation, use of certification or 'test to enter', partial home working, good ventilation and face coverings.¹⁷¹⁷ INQ000119963 The speed of vaccine rollout was also a key factor. SAGE advised that, without interventions, a variant that substantially escaped immunity through the vaccines or was highly transmissible could lead to a very significant wave of infections, potentially larger than that seen in January 2021.

¶8.7. Subsequently, on 10 May 2021, the UK Cabinet approved the decision to move to Step 3 on 17 May.¹⁸¹⁸ INQ000088894_0005 Boris Johnson MP, Prime Minister from July 2019 to September 2022, noted that although new variants "remained a cause for concern", they did not prevent Step 3 from proceeding.¹⁹¹⁹ INQ000088894_0004 That same day, following advice from the Joint Biosecurity Centre, the Chief Medical Officers for the four nations and the NHS England National Medical Director announced that the UK-wide alert level should be reduced from Level 4 to Level 3.²⁰²⁰ 'COVID-19 alert level: Update from the UK Chief Medical Officers', Department of Health and Social Care, 10 May 2021 (https://www.gov.uk/government/news/covid-19-alert-level-update-from-the-uk-chief-medical-officers-10-may-2021; INQ000086792)

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¶Figure 28: Step 3, COVID-19 Response – Spring 2021 roadmap

capacity limits apply. - - subject to review.

¶Source: COVID-19 Response – Spring 2021, HM Government, February 2021 (https://assets.publishing.service.gov.uk/ media/6033cfdae90e076607c1bf18/COVID-19_Response_-_Spring_2021.pdf; INQ000185087_0040)

¶8.8. On 12 May 2021, the Scientific Pandemic Infections Group on Modelling, Operational sub-group (SPI-M-O) estimated the Delta variant to be up to 50% more transmissible than the Alpha variant. It was uncertain whether this would apply to wider community transmission because the number of Delta variant cases was "small and relatively focussed".²¹²¹ INQ000351841 If it did, there were:

" still too few adults vaccinated to prevent a significant resurgence that ultimately could put unsustainable pressure on the NHS, without non-pharmaceutical interventions".²²²² INQ000351841

¶This was endorsed by SAGE on 13 May, which advised that it was "likely that progressing with step 3 alone", without further measures, "would lead to a substantial resurgence of hospitalisations … [p]rogressing with both steps 3 and 4 at the earliest dates could lead to a much larger peak".²³²³ INQ000120618_0001 para 9 SAGE reiterated the lessons learned earlier in the pandemic, emphasising that the:

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" 'earlier, harder, broader' principles of responding quickly, taking strong measures, and doing so over a wider geography than where the issues have been identified in response to outbreaks, remain relevant. Testing, tracing and, in particular, isolating cases remained very important."²⁴²⁴ INQ000120618_0002 para 14

¶8.9. On 12 May 2021, Dr Rob Orford, Chief Scientific Adviser (Health) for Wales from January 2017, updated the Welsh Cabinet about "concerns amongst the scientific community on the rapid spread of this [Delta] variant and the potential for any vaccine escape".²⁵²⁵ INQ000057741_0006 para 3.4 The Welsh Cabinet determined that it was too soon to make any further decisions on social distancing. However, it confirmed the move to Alert Level 2 from 17 May, which included the reopening of indoor hospitality subject to the 'rule of six'.²⁶²⁶ Under the 'rule of six', a maximum of six people could meet indoors (see INQ000057741_0004 para 2.15).

¶8.10. On 13 May 2021, the reproduction number (R) was estimated to be between 0.8 and 1.1 in England and Northern Ireland, 0.8 and 1.0 in Scotland, and 0.7 and 1.0 in Wales. R is an indicator that lags by two to three weeks.²⁷²⁷ INQ000120618_0001 para 1 The Joint Committee on Vaccination and Immunisation considered data that showed "evidence of vaccine effectiveness particularly after two doses against the variant".²⁸²⁸ INQ000354508_0003 para 13 It concluded that "bringing the second dose interval forwards from 12 to 8 weeks would be reasonable" and "the overarching priority was to vaccinate those in vulnerable groups who had not yet received their first dose of vaccine".²⁹²⁹ INQ000354508_0005 para 24 The following day, the UK government announced that the most vulnerable would be offered a second dose earlier.³⁰³⁰ 'Most vulnerable offered second dose of COVID-19 vaccine earlier to help protect against variants', Department of Health and Social Care, 14 May 2021 (https://www.gov.uk/government/news/most-vulnerable-offered-second-dose-of-covid-19-vaccine-earlier-to- help-protect-against-variants; INQ000548026)

¶8.11. On 13 May 2021 in Northern Ireland, Arlene Foster MLA (later Baroness Foster of Aghadrumsee), First Minister of Northern Ireland from January 2016 to January 2017 and from January 2020 to June 2021, and Michelle O'Neill MLA (deputy First Minister of Northern Ireland from January 2020 to February 2022) proposed a series of further relaxations. These were to come into effect on 21 June subject to ratification by the Executive Committee on 17 June.³¹³¹ INQ000212967 Professor (later Sir) Michael McBride (Chief Medical Officer for Northern Ireland from September 2006) and Professor Ian Young (Chief Scientific Adviser to the Department of Health (Northern Ireland) from November 2015) reiterated their preference for "an incremental approach to easing of restrictions".³²³² INQ000207216_0004 para 13 Following discussion and amendment to a number of recommendations contained in the Executive Paper, the Executive Committee agreed to a number of relaxations and mitigations, including increasing the number of people allowed for indoor gatherings to those permitted by a risk assessment or the venue. The Minister of Health and the Minister for Infrastructure did not support the Northern Ireland Executive's decision to increase the numbers permitted for indoor gatherings in this way.³³³³ INQ000207216_0004-0005 paras 15-16; see also INQ000207216_0013

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¶8.12. On 14 May 2021, the Scottish Government's Four Harms Group, an advisory group responsible for facilitating discussion of the four harms approach, noted that Delta could become the dominant variant in Scotland within a fortnight and agreed that it should be monitored.³⁴³⁴ INQ000233185_0002. The Scottish Government established the Four Harms Group in late October 2020, involving members from outside the Scottish Government as well as the Chief Medical Officer and other civil servants (INQ000375323_0013 para 38). On 17 May, the Scottish Government proceeded with the easing of restrictions, which it had announced on 11 May. Most of mainland Scotland moved from Level 3 to Level 2, which permitted indoor service in pubs and restaurants. The Scottish island regions moved to Level 1, which permitted higher numbers of people to meet for significant life events and outdoor events.³⁵³⁵ 'Next steps out of lockdown', Scottish Government, 11 May 2021 (https://www.gov.scot/news/next-steps-out-of-lockdown; INQ000548029); 'Coronavirus (COVID-19) update: First Minister's statement – 11 May 2021', Scottish Government, 11 May 2021 (https://www.gov.scot/publications/coronavirus-covid-19-update-first-ministers-statement-11-2021; INQ000354327) England also moved to Step 3.

¶8.13. On 18 May 2021, the UK Cabinet recognised that cases were "very low", although "everyone was acutely aware of the risks posed by [the Delta variant] and its prevalence in particular areas".³⁶³⁶ INQ000089033_0010. This confirmed that the Delta variant was prevalent in areas such as Bolton and Blackburn. Professor Sir Patrick Vallance (later Lord Vallance of Balham), Government Chief Scientific Adviser from April 2018 to March 2023, advised that the Delta variant was "more transmissible" and was replacing the Alpha variant. Professor (later Sir) Jonathan Van-Tam, Deputy Chief Medical Officer for England from October 2017 to March 2022, expressed confidence "that two doses of the vaccine could interrupt transmission, rather than one".³⁷³⁷ INQ000089033_0011 Mr Johnson insisted on a cautious approach being maintained.³⁸³⁸ INQ000089033_0011

¶8.14. By 20 May 2021, there was no evidence of sustained community transmission of the Delta variant in Northern Ireland.³⁹³⁹ INQ000065750_0002 However, there was a higher incidence of Covid-19 cases generally than in the rest of the UK.⁴⁰⁴⁰ INQ000375416 The Northern Ireland Executive ratified a series of proposed relaxations.⁴¹⁴¹ INQ000048525_0005; INQ000207217_0004 Robin Swann MLA (Minister of Health for Northern Ireland from January 2020 to October 2022 and from February to May 2024) advised that "[o]verall, there is no immediate reason based on current data not to confirm the proposed relaxations".⁴²⁴² INQ000212972_0002 para 7 However, the Executive Paper from the Department of Health observed that:

¶" The relaxations proposed by the Executive go somewhat beyond those assumed

in modelling or being implemented elsewhere in the UK or ROI [Republic of Ireland] at present, despite our higher incidence compared with the rest of the UK … In addition, modelling does not account for the potential impact of [the

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Delta variant] (up to 60% increase in transmission), the possibility of reduced vaccine uptake or effectiveness, waning immunity or cross border movements, or poor adherence to remaining mitigations."⁴³⁴³ INQ000212972_0001-0002 para 5

¶In a pessimistic scenario, it was estimated that:

" cases would peak at 5000 – 15000 per day, and hospital pressures would be similar to or a little less than those observed in January/February this year".⁴⁴⁴⁴ INQ000212972_0002 para 6

¶8.15. On 21 May 2021, the Scottish Cabinet noted preliminary indications that the Delta variant would be unlikely to cause a significant increase in serious illness or mortality, even among older age groups.⁴⁵⁴⁵ INQ000214466_0005 para 26

¶8.16. In a meeting of the Four Harms Group on 25 May 2021, there was some concern about the Scottish Government's working assumption that Scotland would move to Level 0 (the lowest level of restrictions, permitting gatherings of up to eight people from up to four households in private dwellings) on 28 June, and beyond Level 0 at the regular review three weeks later on 16 July.⁴⁶⁴⁶ INQ000233258. This was reflected in 'Beyond Level 0', a paper commissioned by Ms Sturgeon on 10 May 2021; see also 'Beyond Level 0 guidance', Scottish Hockey (https://scottish-hockey.org.uk/covid-19/coronavirus-covid-19-protection-levels/beyond-level-0- guidance; INQ000651559). Nicola Sturgeon MSP, First Minister of Scotland from November 2014 to March 2023, wanted "to move away from Government direction to a point where people make decisions themselves", but stated: "[W]e are not out of the woods yet."⁴⁷⁴⁷ INQ000233258_0005 There was a tension between Ms Sturgeon's desire to move down in levels and the ongoing concerns about the threat of Covid-19, in particular the emerging information about the Delta variant and the ability of the vaccination programme to keep it under control. It was around this time that Humza Yousaf MSP, Cabinet Secretary for Justice from June 2018 to May 2021 and Cabinet Secretary for Health and Social Care from May 2021 to March 2023, expressed his view privately that Ms Sturgeon was worried about "losing the dressing room".⁴⁸⁴⁸ INQ000334792_0006 This suggested that there was some concern that the imposition of greater restrictions at this time would not be popular with the public.

¶8.17. On 27 May 2021, R was estimated to be between 1.0 and 1.1 in England, between 1.0 and 1.3 in Scotland, between 0.8 and 1.1 in Wales, and between 0.7 and 1.1 in Northern Ireland.⁴⁹⁴⁹ INQ000120619_0001 para 1 SAGE remained uncertain about how much more transmissible the Delta variant was, but, if in the region of 40%, it was likely that there would be a substantial increase in hospitalisations. It was expected that the uncertainty would reduce within a fortnight as data became available. Public Health England analysis also indicated some decrease in vaccine effectiveness. Data were not available with regard to the Delta variant's severity, but there had been no indication that it was more severe.⁵⁰⁵⁰ INQ000120619_0001 paras 7, 9 The number of people estimated to have Covid-19 in England was approximately half of the estimate in April 2021.⁵¹⁵¹ The Office for National Statistics' Coronavirus (Covid-19) Infection Survey estimated that 48,500 people had Covid-19 in the community for the week 16 to 22 May 2021, as compared to 90,000 people for the week from 10 to 16 April (see INQ000119963_0002 para 9; INQ000120619_0001 para 2). SPI-M-O's consensus view was that deaths across the UK would remain very low over the forthcoming four weeks, with the caveat that their projections and views did not fully reflect policy or behavioural change in the two to three weeks prior, owing to delays in infection, need for hospital care and deaths.⁵²⁵² SPI-M-O Medium-Term Projections, SPI-M-O, 26 May 2021 (https://assets.publishing.service.gov.uk/ media/60c0aa1be90e0743a7a709db/S1252_SPI-M-O_MediumTermProjections.pdf; INQ000548033)

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¶8.18. That same day, the Welsh Cabinet agreed that it should proceed to move to Alert Level 1 (at the time, the lowest level of Wales-wide restrictions, as outlined in Coronavirus Control Plan: Revised Alert Levels in Wales) on 7 June 2021, provided that conditions remained stable over the following week.⁵³⁵³ Coronavirus Control Plan: Revised Alert Levels in Wales (March 2021), Welsh Government, March 2021 (https://www.gov.wales/sites/default/files/publications/2021-05/coronavirus-control-plan-revised-alert-levels-in-wales-march-2021.pdf; INQ000066069); INQ000022537_0003 paras 1.9-1.10

¶8.19. In Northern Ireland, while a number of cases had been detected, there remained no evidence of sustained transmission of the Delta variant.⁵⁴⁵⁴ INQ000382157 The relaxations at the end of April had not significantly impacted transmission.⁵⁵⁵⁵ INQ000207218_0003 On 27 May 2021, the Executive Committee agreed to ratify some proposed relaxations and to lift the guidance (but retain mitigations) relating to Common Travel Area travel, aligning Northern Ireland with the rest of the UK.⁵⁶⁵⁶ The Common Travel Area is an arrangement between the UK, the Crown Dependencies and Ireland under which British and Irish citizens can move freely and reside in either jurisdiction and enjoy associated rights and privileges. However, Mr Swann remained of the view that the guidance should be retained:

¶" until the impact of the easement of restrictions from … 24 May could be

assessed, and in order to delay the importation of variants of concern … allowing time for wider vaccination roll-out and minimising any potential for community transmission".⁵⁷⁵⁷ INQ000207218_0009

¶Professors McBride and Young cautioned that removing the guidance on self-isolation on travel within the Common Travel Area "would accelerate the introduction" of the Delta variant into Northern Ireland.⁵⁸⁵⁸ INQ000207218_0009

¶8.20. A Scottish Cabinet meeting on 1 June 2021 concluded:

¶" [A] 'one size fits all' approach to the next review of protection levels due by

7 June was unlikely to be effective or credible at a time when there was very low incidence [in many areas]."⁵⁹⁵⁹ INQ000214573_0004 para 16

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¶8.21. On 5 June 2021, much of mainland Scotland was moved to Level 1 restrictions (apart from the Central Belt, including Glasgow, which was put at Level 2) and island communities were moved to Level 0.⁶⁰⁶⁰ 'Coronavirus (COVID-19) update: First Minister's statement – 4 June 2021', Scottish Government, 4 June 2021 (https://www.gov.scot/publications/coronavirus-covid-19-update-first-ministers-statement-4-june-2021; INQ000353712_0004-0005)

¶8.22. By 3 June 2021, R was estimated to have increased in England, Wales and Scotland since 13 May, but estimates for Northern Ireland remained similar.⁶¹⁶¹ INQ000120623_0001 para 1; INQ000120618_0001 para 1 SAGE confirmed that this did not fully reflect changes following the relaxation of measures on 17 May in England, or the recent rapid increases in transmission of the Delta variant. There remained uncertainty about transmissibility and potentially an increased risk of hospitalisation. There was no evidence of worse outcomes for those hospitalised with the Delta variant. Vaccination continued to reduce the risks of hospitalisation in older people. SAGE advised that "delaying further increases in contacts (e.g., step 4 of the roadmap in England)" for even a few weeks "would allow more people to be protected by vaccination before transmission increases further".⁶²⁶² INQ000120623_0001 para 7 This in turn would reduce hospital admissions and delay and reduce the peak number of admissions.

Long Covid

¶8.23. It is well recognised that viral infections can cause longer-term illnesses, known as long-term sequelae. Professor Sir Christopher Whitty, Chief Medical Officer for England from October 2019, told the Inquiry:

" [I]nitial planning for COVID-19 took no account of the group of chronic (prolonged) syndromes which have subsequently become known as Long COVID. It was not that the possibility of some chronic sequelae was not accepted, but rather that the nature and scale of it was not foreseen."⁶³⁶³ INQ000251645_0206 para 12.1

¶8.24. At the outset of the pandemic, messaging also focused almost exclusively – and understandably – on the potential severity of becoming infected with Covid-19 and the risk of death. Even when it was clear that there was a risk from Long Covid, there were no public health campaigns focused on communicating the risks or the evolving understanding of the syndrome.⁶⁴⁶⁴ Lee Cain 31 October 2023 81/19-82/22 Dr Rachael Evans, expert witness with Professor Chris Brightling on Long Covid, underscored the need for distinct public messaging to distinguish Long Covid from the narrower risk profile of severe, acute Covid-19 infection:

" [A]ctually anyone can develop Long Covid. So anyone that's contracting the infection can end up unfortunately with this very prolonged illness."⁶⁵⁶⁵ Rachael Evans 13 October 2023 116/4-9

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¶8.25. In the absence of such information, individuals would have been unable to make their own, fully informed decisions about the levels of risk they were prepared to tolerate and the risks posed to others around them. Public messaging about the incidence and existence of Long Covid would likely have had a considerable, positive impact on those experiencing it and, perhaps, on those dismissive of symptoms. The UK government should have acknowledged Long Covid and made the risks clear in public health messaging. The potential for long-term sequelae arising from infection and any developing understanding should be communicated to the public in any future pandemic.

¶8.26. In May 2020, SAGE had noted the "existence of longer-term health sequelae" and "the importance of monitoring these impacts through longer-term cohort studies".⁶⁶⁶⁶ INQ000120513; see also INQ000061556_0003 para 17 Patient-led groups had begun to be formed in May and June 2020 to provide support to those affected and to promote public awareness of ongoing symptoms.⁶⁷⁶⁷ INQ000280197_0002 paras 4-5; INQ000280196_0002 para 3 A literature review and research into the long-term effects of Covid-19 were commissioned and funded.⁶⁸⁶⁸ INQ000251645_0208-0209 paras 12.8-12.14

¶8.27. In July 2020, the NHS launched the 'Your Covid Recovery' website and Matt Hancock MP (Secretary of State for Health and Social Care from July 2018 to June 2021) chaired a roundtable to consider the long-term impacts of Covid-19 infection.⁶⁹⁶⁹ 'NHS to launch ground breaking online COVID-19 rehab service', NHS England, 5 July 2020 (https://www.england.nhs. uk/2020/07/nhs-to-launch-ground-breaking-online-covid-19-rehab-service; INQ000205651); INQ000292628; INQ000274099 Guidance about the long-term health effects of Covid-19 was subsequently published in early September 2020.⁷⁰⁷⁰ INQ000272238 In October 2020, NHS England launched a five-point plan, including guidance from the National Institute for Health and Care Excellence (known as NICE), research funding and a Long Covid Taskforce, while Wales also funded a recovery programme and Scotland provided investment to the health boards to support local services for Long Covid.⁷¹⁷¹ INQ000280198_0008-0009 para 1.9

¶8.28. There was sufficient information available by October 2020 for decision-makers to understand that Long Covid was a significant policy and health issue to be tackled.⁷²⁷² See, for example, Christopher Brightling 13 October 2023 124/2-126/23 However, the UK government – in particular Mr Johnson – remained slow to acknowledge the seriousness and prevalence of the condition and to direct that greater attention be paid to how it could be addressed, mitigated and taken into account in decision-making on strategy and the imposition of interventions. In October 2020, Mr Johnson wrote "BOLLOCKS" on a box note relating to Long Covid.⁷³⁷³ INQ000251910_0009 He acknowledged that it took him "some time to recognise that long Covid was a serious condition", adding: "For some time, therefore, I was not convinced that long Covid truly existed."⁷⁴⁷⁴ INQ000255836_0191-0192 para 657; see also Boris Johnson 7 December 2023 162/16-24; INQ000251910_0009; INQ000214216_0052 Imran Shafi (Private Secretary to the Prime Minister for public services from March 2018 to March 2021) advised Mr Johnson in January 2021 that he was obtaining "objective clinical advice" on the extent to which Long Covid was a "reasonable policy consideration".⁷⁵⁷⁵ Imran Shafi 30 October 2023 200/1-8

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¶8.29. In response to a request from Mr Johnson, on 31 May 2021 Professor Whitty produced a note on Long Covid.⁷⁶⁷⁶ INQ000251916 His written advice outlined that there was "a large enough problem to be concerned about".⁷⁷⁷⁷ INQ000251916_0003 Professor Whitty's solution was to "stop people getting COVID; no COVID, no Long COVID".⁷⁸⁷⁸ INQ000251916_0003

¶8.30. Professor Brightling and Dr Evans told the Inquiry:

" [I]t was foreseeable that there was going to be long-term sequelae from Covid-19 extrapolated from previous coronavirus pandemics and previous knowledge of post-viral syndromes."⁷⁹⁷⁹ INQ000280198_0031 para 7.4; see also INQ000251645_0207; INQ000269203_0135; INQ000273807_0169; INQ000238826_0203

¶8.31. Professor Whitty acknowledged that the failure to recognise that "Long COVID would be a significant part of the disease burden of COVID-19 early in the pandemic however had important practical implications" for the management of the pandemic and consideration of the effects of Covid-19.⁸⁰⁸⁰ INQ000251645_0207 In future pandemics, consideration of long-term sequelae must be built into any strategy and supporting plans.⁸¹⁸¹ See also INQ000251645_0207; INQ000269203_0135; INQ000273807_0169; INQ000238826_0203; INQ000280198_0031 para 7.4

June 2021

¶8.32. On 3 June 2021, the Welsh Cabinet followed public health advice to stagger the move to Alert Level 1 to delay the "most risky relaxations" and obtain data on the new variant.⁸²⁸² INQ000022537_0005 paras 2.1, 2.4 In the first stage, up to three different households could meet indoors and different events would be subject to maximum capacity levels.⁸³⁸³ INQ000022537_0005-0006 paras 2.6, 2.11

¶8.33. By 9 June 2021, R was estimated to have increased across the UK.⁸⁴⁸⁴ R was estimated to be between 1.2 and 1.4 in England and Scotland, 1.0 and 1.4 in Wales, and 0.8 and 1.3 in Northern Ireland (see INQ000120627_0001 para 1). It was difficult to separate the effects of the Delta variant's growth from recent changes in restrictions.⁸⁵⁸⁵ INQ000120627_0001 para 1 Modelled scenarios showed a larger wave than that modelled prior to Step 3 in England, owing to the emergence of the Delta variant. However, uncertainty remained about the impact on hospital admissions.⁸⁶⁸⁶ INQ000120627_0002 para 9 SAGE advised that a number of potential hospitalisations and deaths could be avoided rather than simply delayed if Step 4 of the COVID-19 Response – Spring 2021 roadmap was taken after 21 June. Modelling suggested that delaying Step 4 by four weeks beyond 21 June could reduce hospital admissions by around one-third to one-half (by allowing further time for vaccine coverage) and would move relaxations closer to the school holidays when transmission was expected to reduce. It would also allow time to better understand the risk and impact of the Delta variant. The peak was expected to occur around August 2021.

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¶There was considerable uncertainty about the impact on the NHS of taking Step 4.⁸⁷⁸⁷ INQ000120627_0002 paras 11-14

¶8.34. Discussions had been taking place within the UK government throughout this period on the impact of the Delta variant on Step 4. An update to the public was due on 14 June 2021, in advance of implementation on 21 June.⁸⁸⁸⁸ COVID-19 Response – Spring 2021, HM Government, February 2021, Executive summary (https://assets.publishing.service.gov.uk/ media/6033cfdae90e076607c1bf18/COVID-19_Response_-_Spring_2021.pdf; INQ000185087_0007) However, the rising rates of infections and scientific advice caused concern. On 8 June, Mr Johnson reiterated to the UK Cabinet the need for a cautious approach.⁸⁹⁸⁹ INQ000088958. See also INQ000198202 for meeting with the Covid-19 Taskforce earlier that day.

¶8.35. By 14 June 2021, there were around 8,000 cases a day in England – the highest since the end of February.⁹⁰⁹⁰ 'Vaccination programme accelerated as Step 4 is paused', Prime Minister's Office and Boris Johnson, 14 June 2021 (https://www.gov.uk/government/news/vaccination-programme-accelerated-as-step-4-is-paused; INQ000234938) Hospitalisations were doubling. Professor Whitty noted that "[w]ithin five to six doublings, the numbers would be at very dangerous levels".⁹¹⁹¹ INQ000146775_0008 The next phase of opening up would further increase doubling speed. Professor Vallance reiterated that a second dose of the vaccine was required to give more protection against the Delta variant and reduce hospitalisation. A four-week delay would allow further uptake.⁹²⁹² INQ000146775_0008; 'Vaccination programme accelerated as Step 4 is paused', Prime Minister's Office and Boris Johnson, 14 June 2021 (https://www.gov.uk/government/news/vaccination-programme-accelerated-as-step-4-is-paused; INQ000234938)

¶8.36. Following meetings on 13 and 14 June 2021, the Covid-19 Operations Committee (Covid-O) decided to delay Step 4 in England, with some limited exceptions, by four weeks to 19 July.⁹³⁹³ INQ000252914_0070 para 302; INQ000091961; INQ000146810; INQ000146775_0008-0009; INQ000217092_0006-0009 The emergence of the Delta variant meant that the fourth test in the COVID-19 Response – Spring 2021 roadmap – "our assessment of the risks is not fundamentally changed by new Variants of Concern" – was not met.⁹⁴⁹⁴ See, for example, INQ000092509_0006 In advance of the next review on 12 July, the time between the first and second dose of the vaccine was to be reduced from 12 weeks to 8 weeks.⁹⁵⁹⁵ 'Vaccination programme accelerated as Step 4 is paused', Prime Minister's Office and Boris Johnson, 14 June 2021 (https://www.gov.uk/government/news/vaccination-programme-accelerated-as-step-4-is-paused; INQ000234938) As noted by Professor Vallance, the interval between steps was an important opportunity to obtain and analyse data and information.⁹⁶⁹⁶ INQ000088958_0008 The advice was clear that there would be:

" an increase in the number of people hospitalised and dying, but this would be proportionately fewer than in previous waves. There would be a race between the number of people that the vaccination programme would protect against the growth of the virus."⁹⁷⁹⁷ INQ000088958_0008

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¶8.37. Similar advice about pausing restrictions to await vaccine uptake, in the wake of rising cases, was provided to the Scottish Government, Welsh Cabinet and Northern Ireland Executive.⁹⁸⁹⁸ INQ000212981; INQ000022540_0002 para 1.6; INQ000218171; INQ000218169 All three governments followed this advice. The Welsh Cabinet agreed to pause the move to Alert Level 1 until at least the next review, due by 15 July 2021.⁹⁹⁹⁹ INQ000022540_0002-0003 paras 1.4-1.5, 1.8; INQ000048533; INQ000357301; INQ000212981_0002 para 8

¶8.38. On 10 June 2021, Professors McBride and Young advised the Northern Ireland Executive that, in light of health service pressures, there was "little tolerance or capacity for significant increased Covid-19 admissions", and that if:

" admissions of the Delta variant are x2.4 and vaccine effectiveness more dependent on second doses then the Executive will need to factor this into the timing of decisions on any further relaxations which may be best deferred to middle to end of July".¹⁰⁰¹⁰⁰ INQ000357301_0005

¶In Northern Ireland, a new ratification date was fixed for 1 July 2021 for relaxations to take effect on 5 July.¹⁰¹¹⁰¹ INQ000048534_0002

¶8.39. On 18 June 2021, Ms Sturgeon announced a ban on non-essential travel between Scotland and parts of Greater Manchester and Salford from 21 June because of rising Covid-19 cases in the area.¹⁰²¹⁰² 'Coronavirus (COVID-19) update: First Minister's statement – 18 June 2021', Scottish Government, 18 June 2021 (https://www.gov.scot/publications/coronavirus-covid-19-update-first-ministers-statement-18-june-2021; INQ000353706) The Scottish Cabinet had not discussed the ban and there was no consultation with the UK government or with Andy Burnham (Mayor of Greater Manchester from May 2017). Mr Burnham told the Inquiry it was "[e]xactly what the Scottish National Party would always have accused Westminster of doing to Scotland".¹⁰³¹⁰³ Andy Burnham 27 November 2023 127/4-128/9

¶8.40. Several days later, on 22 June 2021, the Scottish Government announced the lifting of all Covid-19 restrictions (ie beyond Level 0) in Scotland for 9 August, but it delayed the move to Level 0 for the Scottish mainland from 28 June to 19 July.¹⁰⁴¹⁰⁴ 'Coronavirus (COVID-19) update: First Minister's statement – 22 June 2021', Scottish Government, 22 June 2021 (https://www.gov.scot/publications/coronavirus-covid-19-update-first-ministers-statement-22-june-2021; INQ000369676) The highest number of daily cases in Scotland since the start of mass testing was reported the next day.¹⁰⁵¹⁰⁵ INQ000243908

¶8.41. On 26 June 2021, Mr Hancock resigned as Secretary of State for Health and Social Care, apologising for breaching social distancing guidance.¹⁰⁶¹⁰⁶ INQ000174323 Sajid Javid MP (later Sir Sajid Javid) was appointed in his place and served in the role from June 2021 to July 2022.

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¶8.42. Vaccines were, as predicted, disrupting the connection between infection and serious illness, hospitalisation and death. The median age of those hospitalised with Covid-19 had reduced from people in their mid-60s to those in their mid-40s, due to vaccination coverage in older people.¹⁰⁷¹⁰⁷ INQ000088958_0008-0009

Increasing cases

¶Figure 29: Estimated percentage of the population testing positive for Covid-19 from 1 May to 31 July 2021 across the UK

¶

• 21 21 21 21 21 21 21 21 21 21 21 21 21 — 1

• 20 20 20 20 20 20 20 20 20 20 20 20 20 — 02

t2 ay ay ay ay ay ne ne ne ne ly ly ly ly us M M M M M Ju Ju Ju Ju Ju Ju Ju Ju 3 10 17 24 31 7 5 12 19 26 Au g

¶
• 14 21 28 — 2

¶Source: Coronavirus Infection Survey from 1 May to 31 July 2021. (Modelled estimates, 95% confidence intervals not shown). For raw data, see the Coronavirus (COVID-19) Infection Survey: England, dataset, Office for National Statistics, 10 March 2023 (https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/datasets/ coronaviruscovid19infectionsurveydata/2023)

¶8.43. At the beginning of July 2021, although the rate of infection was growing across all parts of the UK, there were differences in prevalence between the four nations.¹⁰⁸¹⁰⁸ INQ000120629. R was estimated to be between 1.2 and 1.5 in England, in Scotland and in Wales, and between 1.3 and 1.6 in Northern Ireland. It had not changed significantly in the preceding weeks. By 1 July, there was an early indication of increased hospital admissions in Northern Ireland.¹⁰⁹¹⁰⁹ INQ000212984_0002 para 5 It was estimated that there might be 2,000 to 3,000 cases per day by the end of July, with significantly greater numbers in August.¹¹⁰¹¹⁰ INQ000212984_0002 para 5 The Department of Health advised delaying any further relaxations to reduce the risk of even greater increases.¹¹¹¹¹¹ INQ000212984_0002 para 5 Nonetheless, ministers agreed that, from 5 July, relaxations, including for mass and outdoor gatherings at domestic settings, would take effect.¹¹²¹¹² INQ000048536; INQ000357302_0001

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¶The Northern Ireland Executive published Building Forward: Consolidated Covid-19

¶Recovery Plan.¹¹³¹¹³ Building Forward: Consolidated Covid-19 Recovery Plan, Northern Ireland Executive, July 2021 (https://www.executiveoffice-ni.gov.uk/topics/building-forward-consolidated-covid-19-recovery-plan; INQ000101002). It set out an action plan to promote recovery in areas including economic development, inequalities and health.

¶8.44. By 5 July 2021, some Scottish health boards were experiencing "considerable pressure" – if cases continued to grow, there would be a need to consider "standing down elective services".¹¹⁴¹¹⁴ INQ000247795_0024-0025 There had been a 61% increase in Covid-19 hospital bed occupancy in one week.¹¹⁵¹¹⁵ INQ000247795_0021 However, overall hospital occupancy remained considerably below the January 2021 peak.¹¹⁶¹¹⁶ INQ000247795_0004

¶8.45. On 5 July 2021, the UK government published Covid-19 Response: Summer 2021.¹¹⁷¹¹⁷ COVID-19 Response: Summer 2021, HM Government, July 2021 (https://www.gov.uk/government/publications/covid-19-response-summer-2021-roadmap; INQ000180301) This was not a roadmap akin to the COVID-19 Response – Spring 2021 roadmap. It was a much shorter document, which set out at a high level the government's new approach and intentions for the summer. It did not, for example, contain triggers or tests to be met for the imposition of restrictions or specific responses. It explained that Step 4 would mark a new phase in the response, "moving away from stringent restrictions" towards an advisory approach with targeted interventions to:

¶
• reinforce vaccine defences through booster vaccinations;
• enable the public to make informed decisions through guidance rather than laws;
• retain proportionate test, trace and isolate plans;
• manage risks at the border; and
• support a global response to reduce the risk of variants.

¶Contingency measures would be retained to respond to unexpected events, while accepting that further cases, hospitalisations and deaths would occur as the country learned to live with Covid-19. The most significant risk was a 'variant of concern', which fully or partially escaped immunity otherwise conferred by past infection or the vaccines. Contingency plans would be maintained but such "measures would only be re-introduced as a last resort to prevent unsustainable pressure on the NHS".¹¹⁸¹¹⁸ COVID-19 Response: Summer 2021, HM Government, July 2021 (https://www.gov.uk/government/publications/covid-19-response-summer-2021-roadmap; INQ000180301)

¶8.46. That same day, the Welsh Cabinet discussed Technical Advisory Group advice that indicated "a significant weakening of the link between infections and serious illness", which might lead to a shift in the balance of harms. The Cabinet therefore agreed that a baseline alert level should be created to represent a final set of restrictions.¹¹⁹¹¹⁹ The Technical Advisory Group's advice on 9 July 2021 formally introduced a fifth harm from Covid-19: "harms arising from the way COVID-19 has exacerbated existing, or introduced new, inequalities in our society" (see Chapter 10: Vulnerabilities and inequalities, in Volume II).

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¶8.47. On 7 July 2021, SAGE advised that modelling scenarios showed an "extremely high prevalence of infection lasting until at least the end of August".¹²⁰¹²⁰ INQ000120629_0001 para 2 This presented four "major risks".¹²¹¹²¹ The four major risks were: an increase in hospitalisations and deaths; more Long Covid; workforce absences (including in the NHS); and the increased risk of new variants emerging (see INQ000120629_0001-0002 para 9). SAGE warned that the "combination of high prevalence and high levels of vaccination creates the conditions in which an immune escape variant is most likely to emerge".¹²²¹²² INQ000120629_0002 Furthermore:

" If the aim is to avoid the NHS becoming overwhelmed … it is important to understand the impact of different levels of admissions on NHS function and have appropriate contingency plans in place … at any point that cases are still increasing exponentially, admissions can be expected to at least double once more regardless of any measures put in place at that point."¹²³¹²³ INQ000120629_0002 para 12

¶On Step 4, it advised:

" Although a further delay to step 4 could have some additional positive impact by allowing more people to be vaccinated, the effect of this would be much smaller than the effect of the current delay and it would push the wave further towards the autumn and winter."¹²⁴¹²⁴ INQ000120629_0002 para 14

¶SAGE emphasised that the peak of the resurgence would be much lower if the return to pre-pandemic behaviours was "gradual" – a very rapid return could lead to a peak in hospitalisations similar to (or possibly even higher than) previous peaks.¹²⁵¹²⁵ INQ000120629_0002 Baseline measures would assist in reducing transmission and hospitalisation.

¶8.48. On 8 July 2021, Professor Young advised the Northern Ireland Executive Committee that rates of transmission were increasing in those over the age of 60. Hospital admission rates were increasing; however, intensive care unit occupancy remained low compared with earlier in the pandemic.¹²⁶¹²⁶ INQ000048537_0002 The Executive Committee agreed to extend the restrictions and scheduled a further review four weeks later. It voted against proposals for certain venues to be permitted to open from 8 July and against increasing the number of households permitted to meet in a domestic setting from 8 July. An indicative date of 26 July for these relaxations was retained.¹²⁷¹²⁷ INQ000048537_0005

¶8.49. At a Covid-O meeting on 12 July 2021, James Bowler (Second Permanent Secretary to the Cabinet Office and Head of the Covid-19 Taskforce from October 2020 to August 2021) advised that the benefits of a further delay were "unclear, and could compound risks by pushing the third wave into the winter", although it was acknowledged that the country would be opening up against a backdrop of increasing and high infection and prevalence rates.¹²⁸¹²⁸ INQ000092214_0005 Once again during this period, the Secretary of State for Health (which was now Mr Javid) and Michael Gove MP (later Lord Gove), Chancellor of the Duchy of Lancaster from July 2019 to September 2021 and Minister for the Cabinet Office from February 2020 to September 2021, were urging a more cautious approach, with Mr Johnson and Rishi Sunak MP Chancellor of the Exchequer from February 2020 to July 2022) in favour of loosening restrictions and opening up more quickly.¹²⁹¹²⁹ Sajid Javid 29 November 2023 128/1-25, 131/7-22; INQ000273901_0614 Covid-O agreed that, as recommended by the Covid-19 Taskforce, the four tests the UK government had outlined for easing Covid-19 restrictions had been met. However, the confidence that test three – which related to the risk of pressures on the NHS – had been met was not as high.¹³⁰¹³⁰ INQ000092214_0005, 0009. The four tests had been outlined in the spring 2021 roadmap: "a. The vaccine deployment programme continues successfully. b. Evidence shows vaccines are sufficiently effective in reducing hospitalisations and deaths in those vaccinated. c. Infection rates do not risk a surge in hospitalisations which would put unsustainable pressure on the NHS. c. [sic] Our assessment of the risks is not fundamentally changed by new Variants of Concern" (COVID-19 Response – Spring 2021, HM Government, February 2021, p4 (https://assets.publishing.service.gov.uk/media/6033cfdae90e076607c1bf18/COVID-19_ Response_-_Spring_2021.pdf; INQ000185087_0008)).Show full note The priority was to avoid a return to pre‑pandemic behaviour. Messaging would be crucial and should be focused on a gradual and cautious return and reopening.¹³¹¹³¹ INQ000092214_0005, 0010 Mr Johnson announced on the evening of 12 July that Step 4 of the COVID-19 Response – Spring 2021 roadmap would go ahead as planned in England on 19 July.¹³²¹³² 'PM statement at coronavirus press conference: 12 July 2021', Prime Minister's Office and Boris Johnson, 12 July 2021 (https://www.gov.uk/government/speeches/pm-statement-at-coronavirus-press-conference-12-july-2021; INQ000086709)

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¶Figure 30: Step 4, COVID-19 Response – Spring 2021 roadmap

¶Source: COVID-19 Response – Spring 2021, HM Government, February 2021 (https://assets.publishing.service.gov.uk/ media/6033cfdae90e076607c1bf18/COVID-19_Response_-_Spring_2021.pdf; INQ000185087_0043)

¶8.50. In Wales, while community transmission was high, the "pressure on the NHS in Wales was stable and it was experiencing the lowest levels of COVID-19 since reporting had begun".¹³³¹³³ INQ000129973_0003 para 4.3 Vaccination coverage in people aged over 40 was also high and

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¶"this … appeared to have altered the relationship between community transmission and harms".¹³⁴¹³⁴ INQ000129973_0003 para 4.4 Dr (later Sir) Frank Atherton, Chief Medical Officer for Wales from August 2016, advised that this:

" indicated that the current epidemiological picture changed the balance between direct and indirect harms and made it increasingly difficult to justify the stringent use of public health powers to continue restricting economic, social and cultural activities".¹³⁵¹³⁵ INQ000129973_0003 para 4.5

¶Reflecting these assessments, the updated Coronavirus Control Plan acknowledged that "other harms from the pandemic … are beginning to outweigh the direct harms from the virus".¹³⁶¹³⁶ Coronavirus Contral Plan: Alert Level Zero, Welsh Government, July 2021 (https://www.gov.wales/sites/default/files/publications/2021-09/coronavirus-control-plan-alert-level-zero-0.pdf; INQ000066070) The Welsh Cabinet agreed to make a number of relaxations from 17 July 2021, including a move to Alert Level 0 on 7 August.¹³⁷¹³⁷ INQ000129973_0003-0004 paras 4.8-4.11, 4.15

¶Figure 31: Alert levels in Wales in the summer of 2021

¶17 July Alert Level One

• 7 August Alert Level Zero -

¶ate 90 indoors in private homes and

¶Source: 'Most Covid rules set to be lifted in Wales on 7 August', BBC News, 14 July 2021 (https://www.bbc.co.uk/news/uk-wales-57823021; INQ000548025)

¶8.51. On 13 July 2021, the Scottish Cabinet considered that pressures on NHS and care staff would remain at excessive levels unless cases could be reduced.¹³⁸¹³⁸ INQ000214642_0003 para 12 It noted that Covid-19 was becoming a disease that was more likely to be caught by younger people and that increasing knowledge of "'long COVID' … should also give pause for thought".¹³⁹¹³⁹ INQ000214642_0003 para 13 This was the first discussion of Long Covid in the Scottish Cabinet. Despite the recognition that the number of cases had to be reduced to protect the NHS, the Cabinet agreed that, from 19 July, Level 0 should be applied across

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¶Scotland, but with a number of modifications.¹⁴⁰¹⁴⁰ Such as restricting gatherings outdoors to 15 people, 1 metre distancing indoors and a delay to live events of up to 200 people (INQ000214642_0007-0008 para 24). See also 'Level 0 from 19 July', Scottish Government, 13 July 2021 (https://www.gov.scot/news/ level-0-from-19-july; INQ000369713); 'Covid restrictions ease as Scotland moves to level zero', BBC News, 19 July 2021 (https://www. bbc.com/news/uk-scotland-57878745; INQ000357720); 'Rangers granted permission for 17,000 fans at league opener with Livingston', BBC News, 20 July 2021 (https://www.bbc.co.uk/sport/football/57901573; INQ000357832); INQ000214642_0003 para 14Show full note

¶8.52. England moved to Step 4 that same day, at the same time changing advice for the clinically extremely vulnerable (see Chapter 10: Vulnerabilities and inequalities, in Volume II), who were to follow the same guidance as the rest of the population.¹⁴¹¹⁴¹ 'Moving to Step 4 of the roadmap', Cabinet Office, 27 August 2021 (https://www.gov.uk/government/publications/covid-19- response-summer-2021-roadmap/moving-to-step-4-of-the-roadmap; INQ000136725) This was widely publicised as 'Freedom Day' – to the dismay of many vulnerable people, who continued to face increased risks of serious illness and death.¹⁴²¹⁴² INQ000273800_0044-0045 paras 130, 132; 'Does 19 July really represent "Freedom Day" for people with MS?', Multiple Sclerosis Trust, 8 July 2021 (https://mstrust.org.uk/news/stories/19-july-represent-freedom-day-people-ms; INQ000280373) It was marked by what became known as the 'pingdemic', as a consequence of the high number of infections and prevalence, which resulted in the NHS COVID-19 app (launched in England and Wales in September 2020, with a Bluetooth-based contact tracing functionality) notifying large numbers of people to self-isolate.¹⁴³¹⁴³ For further information regarding the NHS COVID-19 app, see 'Epidemiological impacts of the NHS COVID-19 app in England and Wales throughout its first year', M. Kendell, D. Tsallis, C. Wymant, A. Di Franca, Y. Balogun, X. Didelot, et al., Nature Communications (2021), 14(858) (https://doi.org/10.1038/s41467-023-36495-z; INQ000575411); 'NHS COVID-19 app launches across England and Wales', Department of Health and Social Care, 24 September 2020 (https://www.gov.uk/government/news/nhs-covid-19-app-launches- across-england-and-wales; INQ000237570).Show full note This had significant impacts across the economy and more generally.¹⁴⁴¹⁴⁴ INQ000092196_0006

¶8.53. On 22 July 2021, SAGE noted that levels of hospitalisations in England were broadly in line with the COVID-19 Response – Spring 2021 roadmap modelling. It reiterated the importance of contingency plans and the threat of new variants. It welcomed a report, commissioned by Professor Vallance, on preparing for winter and advised that the report's recommendations should be considered by government departments.¹⁴⁵¹⁴⁵ INQ000092856 The previous day, following a policy meeting to review risks for winter, Professor Vallance recorded in his evening notes that nobody had looked at the report and "once again DHSC [the Department of Health and Social Care] had done nothing".¹⁴⁶¹⁴⁶ INQ000273901_0489. The report was considered in later Department of Health and Social Care and Covid-19 Taskforce contingency planning documents, for example, INQ000257037. The report warned of the potential for Covid-19, a flu epidemic and a rise in other seasonal illnesses arising in the winter. It set out a detailed plan of action.¹⁴⁷¹⁴⁷ COVID-19: Preparing for the Future. Looking Ahead to Winter 2021/22 and Beyond, The Academy of Medical Sciences, 15 July 2021 (https://acmedsci.ac.uk/file-download/4747802; INQ000387464) SAGE advised that, while there was "an understandable and intense desire for 'normality' to return", efforts needed to be sustained "to limit the spread of the disease and the harm it can cause this year and beyond".¹⁴⁸¹⁴⁸ 'COVID-19: Preparing for the future. Public summary', The Academy of Medical Sciences, 15 July 2021 (https://acmedsci.ac.uk/file-download/38576298; INQ000591889)

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¶8.54. From 22 July 2021, Covid-O considered the response to the high prevalence of infection in the summer. The main risks identified included pressures on the test, trace and isolate programme and genomic sequencing capacity, travel and borders, high-risk settings and NHS pressures.¹⁴⁹¹⁴⁹ INQ000092555 Long Covid was noted in the context of workforce absence.¹⁵⁰¹⁵⁰ INQ000092058_0002 para 1(d) NHS pressures presented both demand and supply challenges, with a resurgence of demand on urgent and emergency care pathways. There were further pressures from increasing hospital admissions, the backlog of electives and on the ambulance services.¹⁵¹¹⁵¹ INQ000092226_0004; INQ000092555

¶8.55. In Northern Ireland, on 22 July 2021, case numbers and hospital inpatient numbers were increasing rapidly.¹⁵²¹⁵² INQ000065680_0002 para 5 A lower percentage of the Northern Ireland adult population had received a first dose of vaccination compared with the rest of the UK.¹⁵³¹⁵³ INQ000065680_0002 para 6 Consequently, Northern Ireland was "at risk of a bigger wave proportionally than the rest of the UK, by as much as 50%".¹⁵⁴¹⁵⁴ INQ000065680_0002 para 6 There was "considerable uncertainty" as to whether it was following the central or pessimistic modelling scenario and sufficient data and analysis would not be available until the end of July.¹⁵⁵¹⁵⁵ INQ000065680_0002 para 5 The Department of Health (Northern Ireland) advised that it would be preferable to wait until it was clear which trajectory Northern Ireland was following before deciding on further relaxations.¹⁵⁶¹⁵⁶ INQ000065680_0002-0003 para 9 Nonetheless, the Executive Committee decided on 22 July to ratify three further relaxations from 26 July. For example, up to 15 people from different households were permitted to meet outdoors.¹⁵⁷¹⁵⁷ INQ000065680_0005 On 26 July, ministers agreed the relaxation of a further five restrictions to take effect on 27 July.¹⁵⁸¹⁵⁸ INQ000236737; INQ000065584_0002 para 4 Professors McBride and Young cautioned that:

" [T]he risk of relaxations needs to be considered in the context of COVID prevalence, which is currently close to an all-time high."¹⁵⁹¹⁵⁹ INQ000065584_0002 para 4

¶8.56. Cases in Wales had increased rapidly since the beginning of June, but data suggested that rates might be beginning to decline by 29 July 2021. Pressure on the NHS remained below previous waves. On 2 August, Dr Atherton advised that the rate of infection was stable. A total of 80% of the Welsh population was now fully vaccinated. The Welsh Cabinet confirmed the move to Alert Level 0 from 7 August.¹⁶⁰¹⁶⁰ INQ000022545

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