Consideration of particularly vulnerable people

¶10.5. As recognised by Public Health England in June 2020:

" [T]he burden of disease and mortality from COVID-19 is not evenly spread in the population."³³ INQ000268359_0020 para 2.2

¶Those at greater risk of direct harm were largely those who were most at risk clinically. People in later life experience a greater prevalence of chronic illness, reduced immunity and, more generally, frailty.⁴⁴ INQ000280058_0005 para 14 People with underlying health conditions were at greater risk of suffering severe illness requiring hospital admission and of dying from Covid-19.⁵⁵ Disparities in the Risk and Outcomes of COVID-19, Public Health England, August 2020, pp7, 60 (https://assets.publishing.service. gov.uk/media/5f328354d3bf7f1b12a7023a/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf; INQ000101218); INQ000280067_0005 para 10

Older people

¶10.6. From March 2020 to February 2022, 81% of deaths involving Covid-19 in the UK occurred in people aged 70 or older.⁶⁶ INQ000271436_0013-0014 para 43 The increased vulnerability of older people to respiratory viruses is well documented.⁷⁷ INQ000280058_0005 para 10 It is why older groups are recommended for influenza vaccination.⁸⁸ INQ000280058_0005, 0007 paras 10-11

¶10.7. Older people who were poorer or members of an ethnic minority were even more at risk.⁹⁹ INQ000280058_0007, 0010 paras 22, 30 Older people who live in deprived conditions suffer more illness than their better-off counterparts. The prevalence of disability and health conditions increases with age. Deprivation is associated with greater mental and physical ill-health. Older people did not just die in far greater numbers in the pandemic, as compared with any other group of people in society – they also endured loneliness and isolation, and many died in circumstances that were deeply distressing to their families.¹⁰¹⁰ INQ000248853_0006; Eddie Lynch 1 May 2024 11/20-25

Care homes

¶10.8. The impact of Covid-19 on those residing in care homes, residential homes and nursing homes (referred to collectively in this Report as 'care homes') was devastating. People who live in these settings are uniquely vulnerable. They may be dependent upon staff for almost every aspect of their daily care and for keeping them safe. The Inquiry is considering the impact of the pandemic on the publicly and privately funded adult social care sector, in the four nations, in Module 6: Care sector.

¶10.9. The virus presented a real danger to those in care homes during a pandemic. Prior to Covid-19, there were well-documented consequences of outbreaks of influenza in care homes.¹¹¹¹ 'Influenza in long-term care facilities', Louise E. Lansbury, Caroline S. Brown, Jonathan S. Nguyen-Van-Tam, Influenza and Other Respiratory Viruses (2017), 11(5), pp356-366 (https://doi.org/10.1111/irv.12464; INQ000269388) The age and health conditions of those who live in care homes render them vulnerable to dying from infectious diseases. Residents may live in close proximity and socialise together. Many residents receive personal care with close contact. There is a daily stream of visitors, including those who provide services or additional forms of care. There is a high turnover of staff, and individuals often work across multiple care home settings.

¶10.10. Across England and Wales, there were 35,206 deaths of care home residents involving Covid-19 between 13 March 2020 and 25 February 2022, which was around one-fifth of all deaths involving Covid-19 in those nations.¹²¹² INQ000271436_0017 para 52 In Scotland, there were 4,476 care home deaths involving Covid-19 between 13 March 2020 and the end of 2022.¹³¹³ INQ000584980 In Northern Ireland, there were 1,250 deaths of care home residents involving Covid-19 in the period from 18 March 2020 to 25 March 2022 – representing 28.2% of all Covid-19-related deaths in Northern Ireland.¹⁴¹⁴ Deaths of care home residents involving Covid-19 being defined as those who died in a care home, or whose death certificate recorded their address as a care home (INQ000584978_0017). It is likely that the actual number was higher in each nation because of factors like the lack of testing in the early stages of the pandemic.¹⁵¹⁵ Definitions used for place(s) of death vary across the UK in the datasets available (INQ000271436_0016 para 51).

¶10.11. In March 2020, a policy was implemented across all four nations to discharge patients to their homes or to the care sector, where clinically appropriate.¹⁶¹⁶ INQ000103691_0002; INQ000226942_0001; INQ000101020_0007; INQ000120717; INQ000325243_0001 The policy was implemented quickly as the focus of decision-makers in each nation was on increasing hospital capacity and reducing the risk of patients acquiring Covid-19 in hospitals.¹⁷¹⁷ INQ000232194_0011 para 43; INQ000370347_0063 para 129; Frank Atherton 4 March 2024 70/8-71/8, 72/10-20; INQ000120717_0006 para 13 (Guidance issued in Northern Ireland recommended in the absence of symptoms: "[N]o personal protective equipment is required above and beyond normal good hygiene practices.") However, there was no requirement to test patients for Covid-19 who were being discharged to their homes or the care sector.¹⁸¹⁸ INQ000251645_0103 para 7.133; INQ000273807_0135-136 para 9.41; INQ000101020_0007; INQ000226942; INQ000120717; Michael McBride 10 May 2024 186/14-19; Mark Drakeford 13 March 2024 92/3-17; Vaughan Gething 11 March 2024 123/8-124/23; INQ000222973_0002 Professor Whitty explained that it would have been ideal to test patients being discharged to care homes, but there were not enough tests to achieve this, and the testing turnaround time was not fast enough.¹⁹¹⁹ INQ000251645_0103 para 7.133; see also INQ000120705_0001 Sir Christopher Wormald, Permanent Secretary to the Department of Health and Social Care from May 2016 to December 2024, also confirmed that the lack of testing capacity was the main reason that testing prior to discharge was not required by the guidance.²⁰²⁰ INQ000280628_0095-0096 para 181 In Scotland, testing was directed for all hospital admissions that were suspected of being related to Covid-19 and all intensive care unit admissions where there was an upper respiratory-related condition. Testing a significant proportion of, or all, care home residents would have significantly exceeded the available capacity in laboratories.²¹²¹ INQ000222973_0002 para 11 Professor Sir Michael

¶McBride (Chief Medical Officer for Northern Ireland from September 2006) told the

¶Inquiry that, on 19 March 2020, Northern Ireland had a testing capacity of 200 tests and therefore "just didn't have the testing capacity".²²²² Michael McBride 10 May 2024 186/14-19, 190/19-20

¶10.12. A number of Welsh Government witnesses confirmed the limited testing capacity throughout March and April 2020, with tests prioritised for those with symptoms of Covid-19.²³²³ Mark Drakeford 13 March 2024 92/3-17; Andrew Goodall 5 March 2024 52/15-23 However, unlike the position in England, Mark Drakeford MS (First Minister of Wales from December 2018 to March 2024) told the Inquiry that the number of tests needed to test all patients before discharge to care homes:

" could have been small enough to accommodate, even with the limited number of tests [the Welsh Government] had".²⁴²⁴ Mark Drakeford 13 March 2024 218/24-219/12

¶10.13. Matt Hancock MP (Secretary of State for Health and Social Care from July 2018 to June 2021) told the Inquiry that, in his view, the decision to discharge patients to care homes without testing for Covid-19 was "the least worst of all the options".²⁵²⁵ INQ000232194_0012 para 46 Mr Drakeford maintained that, while he did not suggest the Welsh Government "did everything right and there wasn't a mistake that was made", the line of reasoning it followed at the time was:

" [T]he safest thing we could do was to remove people who didn't need to be in hospital out of hospital, given the impact that the disease was about to have on those hospital services."²⁶²⁶ Mark Drakeford 13 March 2024 90/9-91/21

¶Nicola Sturgeon MSP (First Minister of Scotland from November 2014 to March 2023) said that, in hindsight, discharge from hospitals into care homes without testing was a "mistake".²⁷²⁷ 'Covid in Scotland: "Mistake" to discharge Covid patients says Sturgeon', BBC News, 18 April 2021 (https://www.bbc.co.uk/news/uk-scotland-56791600; INQ000360030) Michelle O'Neill MLA (deputy First Minister of Northern Ireland from

¶January 2020 to February 2022) told the Inquiry that the lack of testing "did not serve those residents of care homes well".²⁸²⁸ Michelle O'Neill 14 May 2024 149/6-9; Robin Swann 13 May 2024 189/19-20

¶10.14. Limited choices were available in the spring of 2020, given the risk of hospitals being overwhelmed by Covid-19 patients, the risk of those remaining in hospital being infected by Covid-19 and the testing capacity that existed at that time. However, there was inadequate testing capacity because there had been inadequate planning.

¶10.15. During April 2020, increased testing capacity resulted in a change of policies across the four nations about discharges from hospitals into care homes. On 2 April 2020, guidance in England confirmed that "negative tests are not required prior to transfers/ admissions into the care home".²⁹²⁹ INQ000325255_0005 The UK government's COVID-19: Our Action Plan for Adult Social Care, published in mid-April 2020, noted a "move to institute a policy of testing all residents prior to admission to care homes".³⁰³⁰ INQ000233794_0009 para 1.30 However, this testing requirement did not apply to people being admitted to care homes from the community who, in accordance with the action plan, might be isolated for 14 days, although this was not mandatory. It was not until 28 April that sufficient testing capacity had been built up to enable all care home residents and staff (including those who were asymptomatic) to be tested.³¹³¹ INQ000232194_0083-0084 para 348f On 21 April, the Scottish Government announced that Covid-19 patients discharged from hospitals were required to have two negative tests before discharge.³²³² 'Coronavirus (COVID-19) update: Health Secretary's statement 21 April 2020', Scottish Government, 21 April 2020 (https://www.gov.scot/publications/coronavirus-covid-19-update-health-secretarys-update-tuesday-21-april-2020; INQ000292544) All new admissions into care homes, including those from the community, should be tested and isolated for 14 days on arrival.³³³³ 'Coronavirus (COVID-19) update: Health Secretary's statement 21 April 2020', Scottish Government, 21 April 2020 (https://www.gov.scot/publications/coronavirus-covid-19-update-health-secretarys-update-tuesday-21-april-2020; INQ000292544) On 22 April, the Welsh Government confirmed new policy instructions to all key stakeholders – including registered providers of care home services, local authorities and local health boards – that all patients should be tested prior to discharge from hospital to a care home setting.³⁴³⁴ INQ000336444 The Welsh Government subsequently published updated guidance confirming that all patients must be tested before transfer to care home settings.³⁵³⁵ INQ000081080_0003 On 26 April, revised guidance was published in Northern Ireland. This provided that, "ideally", patients who were Covid-19 positive or symptomatic should not be discharged to a care home that had no symptomatic or Covid-19- positive residents – unless that home was the patient's previous residence – and that all patients being discharged from hospital to a care home should be tested for Covid-19.³⁶³⁶ INQ000536254_0009 para 27

¶10.16. The experience of those in care homes illustrates the importance in any future pandemic strategy of providing for the identification and development of a plan to protect those who are likely to be vulnerable to the virus but also disproportionately adversely impacted by restrictions to control the virus.

Shielding

¶10.17. In March 2020, the UK government identified two groups that it considered were particularly at risk from Covid-19 due to comorbidities (the co-occurrence of two or more long-term conditions): the clinically extremely vulnerable; and the clinically vulnerable. Clinically extremely vulnerable people had medical conditions that were likely to make them particularly vulnerable to Covid-19.³⁷³⁷ INQ000273807_0084-0085 para 8.59 Clinically vulnerable people included those with medical conditions that might place:

" an individual at higher risk from COVID-19, albeit not with the same predictability or to the same extent as the clinically extremely vulnerable cohort".³⁸³⁸ INQ000273807_0085 para 8.63

¶10.18. Clinically extremely vulnerable people were advised to shield (stay at home and self-isolate to reduce the risk of infection) but clinically vulnerable people were not.³⁹³⁹ INQ000086747_0002, 0004; INQ000484783_0048-0049 para 206; INQ000273807_0085 para 8.64 In Module 3: Impact of the Covid-19 pandemic on healthcare systems in the four nations of the UK, the Inquiry is examining how the categories that made up these groups were determined, the support afforded to these groups and the communication with them.

¶10.19. By 23 July 2021, 3.8 million people had been identified as clinically extremely vulnerable in England.⁴⁰⁴⁰ INQ000410865_0023 para 62 By 29 June 2020, approximately 130,000 people were shielding in Wales.⁴¹⁴¹ INQ000066205_0001 At any given point, approximately 185,000 people were on the clinically extremely vulnerable list in Scotland.⁴²⁴² INQ000484783_0049 para 207 When the advice to pause shielding in Northern Ireland was given on 18 June 2020, 95,000 people were shielding.⁴³⁴³ INQ000207253 Based on Office for National Statistics population estimates from mid-2021, those numbers equated to roughly 6.7% of the population in England, 4.2% in Wales, 3.4% in Scotland and 5% in Northern Ireland.

¶10.20. The Office for National Statistics concluded that "shielding was likely to have saved lives but with considerable associated psychological morbidity in some".⁴⁴⁴⁴ INQ000101642_0258 The psychological harm appears to have persisted over the course of the pandemic. Statistics from January to March 2021 revealed that 31% of clinically extremely vulnerable adults reported experiencing some form of depression, compared with 20% of adults who were not advised to shield.⁴⁵⁴⁵ INQ000184680_0012 While the overall percentages were lower in the summer of 2021, a similar disparity existed between the two groups.⁴⁶⁴⁶ INQ000271404 The obvious risk that shielding might be harmful to clinically vulnerable people was recognised. As Dominic Cummings, Adviser to the Prime Minister from July 2019 to November 2020, noted in March 2020: "[P]roper social isolation for vulnerable groups will kill many of them."⁴⁷⁴⁷ Dominic Cummings 31 October 2023 247/15-249/25

¶10.21. The position of clinically vulnerable people highlights the challenges that decision-makers face when having to balance the imperative to stop the spread of a virus – especially to those people more vulnerable to serious illness and at greater risk of dying – with the fact that any interventions may inflict other serious harms on them and on others.

People living with disability

¶10.22. The term 'disability', as defined in the Equality Act 2010, is a broad one which encompasses a vast range of different physical and mental impairments. Disabled people are not homogeneous.⁴⁸⁴⁸ See section 6 of the Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15/contents), which defines disability as a physical or mental impairment that has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities. Many disabled people object to being labelled as 'vulnerable' and see the challenges they face as part of a fundamental failing on the part of society to accommodate their differences. However, it is important to recognise that many disabled people faced an increased risk from Covid-19 and suffered more-severe consequences from the steps taken to limit its spread. Many lived in fear of becoming infected by Covid-19, lost support networks available to them, and felt forgotten.⁴⁹⁴⁹ Nuala Toman 30 April 2024 164/4-11

¶10.23. Disabled adults in working-age families were much more likely to be living in poverty than those who were not disabled, and nearly 50% of those people living in poverty were either disabled themselves or lived with a disabled person.⁵⁰⁵⁰ INQ000280067_0006 para 18 Disabled people were more likely to live in inadequate housing than other groups (a factor that is also associated with respiratory disease). Disabled people were also known to be at greater risk of sexual and domestic violence.⁵¹⁵¹ INQ000280067_0007 para 20 Added to this, disability is associated with age. Approximately half of people significantly affected by disability are aged over 60.⁵²⁵² INQ000280067_0004 para 7 Disabled people are often dependent upon health and social care services – and those were under considerable pressure prior to the pandemic.

¶10.24. Many disabled people are more susceptible to viral infections. Some groups with specific disabilities are more prone to respiratory infection and more likely to develop serious symptoms once infected. These include people with learning disabilities, and those with multiple sclerosis, acute and chronic spinal cord injury and rheumatoid arthritis.⁵³⁵³ INQ000280067_0005 para 9 This brings with it a greater risk of death.⁵⁴⁵⁴ INQ000280067_0004 para 8; during a 2017 to 2018 influenza epidemic, Dutch research demonstrated that excess mortality among people with learning disabilities was three times higher than in the general Dutch population, and it occurred more often at a young age and with a broader range of underlying causes.

¶10.25. Across the UK, disabled people were more likely to die from Covid-19 than non-disabled people. In England and Wales, the risk of death involving Covid-19 in March to July 2020 was twice as high for men who reported being limited a lot by their disability than men who reported no disability. Among women, the risk was 2.4 times higher.⁵⁵⁵⁵ INQ000412416_0002 In Scotland, from March 2020 to January 2021, men who reported being limited a lot by their disability were 3 times more likely to die with Covid-19 and women were 3.2 times more likely to die – compared with non-disabled men and women respectively.⁵⁶⁵⁶ INQ000184679_0006 In Northern Ireland, from March to September 2020, the risk of death where Covid-19 was the underlying cause was 1.7 times higher for men who reported being limited a lot by their disability and 3.3 times higher for women who were limited a lot, compared with non-disabled people.⁵⁷⁵⁷ INQ000396813_0013

¶10.26. The risk was particularly stark for people with learning disabilities. Data showed that they had a much higher risk of infection, severe infection and mortality.⁵⁸⁵⁸ INQ000280067_0012 para 39 Data from Spain and Italy in April 2020 showed a disproportionate mortality rate from Covid-19 for those with learning disabilities and/or autism.⁵⁹⁵⁹ INQ000049998_0001 Until 5 June 2020, a person with learning disabilities and aged between 18 and 34 years old was 30 times more likely to die from Covid-19.⁶⁰⁶⁰ INQ000089700_0039 para 2 A person with Down's syndrome was also over 30 times more likely to die from the virus.⁶¹⁶¹ INQ000280067_0012 para 39

¶10.27. Professor Whitty commissioned a report from Public Health England in June 2020 about the emerging data on different outcomes from Covid-19. The subsequent report, Disparities in the Risk and Outcomes of COVID-19,⁶²⁶² INQ000268359. This report was first published on 2 June 2020 and last updated on 11 August 2020. reviewed the data on inequalities to assist in formulating the future public health response, but it did not set out any analysis of the specific risks to disabled people.⁶³⁶³ Disparities in the Risk and Outcomes of COVID-19, Public Health England, August 2020, (https://assets.publishing.service.gov.uk/ media/5f328354d3bf7f1b12a7023a/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf; INQ000101218) Despite concerns about this omission, it was decided not to delay the report's publication and to focus on disabled people separately.⁶⁴⁶⁴ INQ000069420_0001, 0004

¶10.28. It was not until 12 November 2020 that Public Health England published a report that considered the disproportionate number of people with learning disabilities who had died from Covid-19.⁶⁵⁶⁵ INQ000417384_0001 One of its findings was that, for people with learning disabilities, the rate of deaths that were definitely or possibly Covid-19-related – after adjustment for under-reporting – was 3.6 times the rate in the general population. The report noted that it was not currently clear what was driving the increased risk. The gaps in data meant that there was insufficient information to inform Covid-19 policy-making for disabled people, and communications to mitigate the impact of Covid-19 on disabled people were being hampered. The report was explicit that if this was not addressed at pace, the UK government faced a wider reputational risk of being too slow to act in spite of several credible reports of significant differential impacts.⁶⁶⁶⁶ INQ000083918_0002

¶10.29. On the same day, 12 November, a submission from the Cabinet Office Disability Unit to the Secretary of State for Work and Pensions noted that data and analysis on the question of the disproportionate impacts of Covid-19 on disabled people had significant gaps.⁶⁷⁶⁷ The Disability Unit, part of the Cabinet Office, was responsible for the National Strategy for Disabled People and helping government departments to develop and monitor policies relating to disabled people. For example, the Office for National Statistics' mortality data did not identify what types of disabilities (or impairments) were associated with an increased risk of death from Covid-19.⁶⁸⁶⁸ INQ000083918_0001

¶10.30. Professor Tom Shakespeare and Professor Nicholas Watson provided expert evidence to the Inquiry on the pre-pandemic inequalities associated with disabilities (see Appendix 1: The background to this module and the Inquiry's methodology, in this volume).⁶⁹⁶⁹ INQ000280067 They explained that the higher risk that Covid-19 posed to disabled people could (and should) have been foreseen.⁷⁰⁷⁰ INQ000280067_0003 para 2 The Inquiry agrees that the fact that disabled people would be exposed to a range of different and higher risks should have been obvious.

¶10.31. Despite this, the Disability Unit and the Minister for Disabled People were not invited to play a direct role in the UK government's initial strategy from January to March 2020. Critically, neither the Disability Unit nor the minister had any part in the discussions about whether to implement a lockdown, how that decision might be mitigated or the policy on the discharge of hospital patients into care homes.⁷¹⁷¹ INQ000233735_0006 paras 15-16; INQ000174833_0004 para 5 Although the Secretary of State for Work and Pensions attended the General Public Sector Ministerial Implementation Group, which was responsible for oversight of vulnerable people from April 2020, the Minister for Disabled People was not a permanent member.⁷²⁷² INQ000087167; Justin Tomlinson 8 November 2023 169/4-11; INQ000182343; INQ000183934_0006 Neither the Secretary of State for Work and Pensions nor the Minister for Disabled People were standing members of the Covid-19 Operations Committee (Covid-O) or the Covid-19 Strategy Committee (Covid-S).⁷³⁷³ INQ000183934_0006

¶10.32. It was not until 21 May 2020 that the position of disabled people was first considered at an inter-ministerial level (at the General Public Sector Ministerial Implementation Group). It was then recognised that much of the data and insights available were anecdotal and that further data on the impact of Covid-19 on disabled people would be "key" in guiding the response. In a paper by the Disability Unit, it was identified that impact assessments and insights from stakeholders were required to understand the needs of disabled people.⁷⁴⁷⁴ INQ000083584_0005

¶10.33. Professor Sir Ian Diamond, UK National Statistician from October 2019, described the failure to collect real-time data on disabled people who died of Covid-19 in England and Wales as a "major data gap for our country".⁷⁵⁷⁵ Ian Diamond 29 February 2024 95/13-21 Data regarding the number of disabled people who died due to Covid-19 were not available in Scotland prior to 24 March 2021 and in Northern Ireland until late 2021.⁷⁶⁷⁶ Roger Halliday 17 January 2024 131/9-132/5; Nuala Toman 30 April 2024 163/6-9

¶10.34. In May 2020, the Disability Unit intended that each UK government department should develop a plan to address key evidence gaps about the impact of the pandemic on disabled people.⁷⁷⁷⁷ INQ000083584_0007 From May to October 2020, data on disability across the UK government were "fragmented" and did "not allow comparisons to be made across departments", and the information held by the UK government was mainly from anecdotal reports or charity sector surveys.⁷⁸⁷⁸ INQ000198850_0026 para 62; INQ000083956_0002 para 7 As a consequence, in October 2020, UK government departments were given the task of improving data collection about disabled people.⁷⁹⁷⁹ INQ000083956_0007 However, the initial responses did not identify sufficient steps to fill those data gaps about disabled people. 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, said that he was:

" deeply disappointed in the responses … Several departments have not responded to the commission; other returns lack ambition."⁸⁰⁸⁰ INQ000083956_0008

¶Collection of data about disabled people did not improve markedly across the pandemic – and on 30 March 2021, the Disability Unit remained concerned about a lack of disability data in general and sub-categories of impairment.⁸¹⁸¹ INQ000083885_0006, 0032-0036

¶10.35. These gaps in knowledge (together with any advice to decision-makers that rely on such knowledge), about the direct and indirect impacts that the pandemic was having on disabled people, were replicated across the UK.⁸²⁸² INQ000083956_0002 para 7; Ian Diamond 29 February 2024 95/13-21; Roger Halliday 17 January 2024 131/2-132/5; INQ000371664_0020 paras 98-101; Nuala Toman 30 April 2024 163/6-9

¶10.36. This incomplete knowledge contributed to the failure of the UK government to act sufficiently speedily to mitigate some risks to disabled people. In June 2020, having Down's syndrome was identified as high risk in relation to Covid-19.⁸³⁸³ INQ000221762_0003-0004 para 4.9 It was not until it was demonstrated, in September 2020, that Down's syndrome was associated with a potential 10-fold increase in likelihood of death that it was added to the Shielded Patient List for those who were clinically extremely vulnerable.⁸⁴⁸⁴ INQ000109794_0003; INQ000410237_0082 Even then, it took over a month for shielding letters to be sent out.⁸⁵⁸⁵ INQ000058508_0001

¶10.37. Similarly, in Wales, the setting up of the Disability Rights Taskforce – a key recommendation of the Locked Out: Liberating Disabled People's Lives and Rights in Wales Beyond COVID-19 report, commissioned by the Welsh Government – was slower than anticipated.⁸⁶⁸⁶ INQ000274189_0022 para 66 The Disability Rights Taskforce was constituted in November 2021, eight months after the report was presented to the Welsh Government.

¶10.38. Prior to the decision to implement a lockdown in March 2020, clear consideration should have been given by decision-makers, and planning ought to have taken place, as to how disabled people would be protected from both Covid-19 and the impact of restrictions such as a lockdown – if one were required. In circumstances in which it was foreseeable that disabled people would be particularly vulnerable to dying from Covid-19 and to being adversely affected by a lockdown, it was important that those charged with making decisions that would profoundly affect disabled people had ready access to expert advice (including advice informed by disabled people themselves). When it became clear that specific groups of disabled people were at even greater risk from Covid-19, this ought to have been acted upon and mitigated swiftly. The UK government should have ensured that those with particular responsibility for disabled people – the Minister for Disabled People and the Disability Unit – were fully integrated into those bodies charged with the policy on, and operational response to, the pandemic from January 2020.

Ethnicity

¶10.39. The statistics bear out the stark reality that the highest mortality rates for Covid-19 were among people of certain ethnic backgrounds. The first 10 doctors who lost their lives to the virus were from ethnic minority backgrounds.⁸⁷⁸⁷ INQ000274052_0005; INQ000223060_0002

¶10.40. In terms of risk factors, people from certain ethnic minorities suffer more illness.⁸⁸⁸⁸ INQ000252609_0006 para 2.16; INQ000280057_0007 According to Professor James Nazroo and Professor Laia Bécares, expert witnesses on ethnicity (see Appendix 1: The background to this module and the Inquiry's methodology, in this volume), this has been a persistent finding in research for several decades.⁸⁹⁸⁹ INQ000280057_0007 para 15 For example, evidence shows that prior to the pandemic, Pakistani, Bangladeshi and Black Caribbean people, and women from an Indian background, had higher rates of limiting, long-term illness. These groups also suffered from comorbidities that increased the risk of a more severe outcome from Covid-19.⁹⁰⁹⁰ INQ000280057_0007 para 20 For example, diabetes is more prevalent in Black and Asian communities; people of Bangladeshi and Pakistani backgrounds have higher rates of cardiovascular disease; and people of Black Caribbean and Black African backgrounds have higher rates of hypertension.⁹¹⁹¹ Disparities in the Risk and Outcomes of COVID-19, Public Health England, August 2020, p40 (https://assets.publishing.service. gov.uk/media/5f328354d3bf7f1b12a7023a/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf; INQ000101218) These health inequalities become more pronounced as people age.⁹²⁹² INQ000280057_0009 paras 23-24 Where multiple risk factors are present, disparities can be compounded.

¶10.41. People from ethnic minority backgrounds also disproportionately experience socioeconomic disadvantages. According to Professors Nazroo and Bécares, this is linked to the issue of racism across society as a whole, whereby the laws, rules or policies in society may result in – and perpetuate – unfair or harmful treatment of others based on race.⁹³⁹³ INQ000280057_0015 para 42 People from certain ethnic minority groups are also more likely to live and work in circumstances that increase their risk of exposure to infectious illness. For example, people from ethnic minority groups are more likely to be employed in higher-contact employment, such as transport and delivery jobs, or working as healthcare assistants, hospital cleaners, social care workers and in nursing and other medical jobs. People from Bangladeshi and Pakistani backgrounds are also more likely, in most regions of England, to live in urban areas with reduced access to green space; more likely to live in a deprived neighbourhood; and more likely to live in overcrowded housing.⁹⁴⁹⁴ INQ000280057_0013-0014 This question of occupational risk and other social factors is considered in greater detail below.

¶10.42. Professor Kamlesh Khunti (Professor of Primary Care Diabetes and Vascular Medicine at the University of Leicester and Chair of the Scientific Advisory Group for Emergencies' (SAGE) Ethnicity Subgroup from August 2020 to March 2021) explained that inequalities in health and access to care experienced by ethnic minority groups were well evidenced prior to the pandemic. So, too, were social inequalities. These factors made the likelihood of disparities in risks and outcomes as a consequence of the Covid-19 infection "somewhat foreseeable".⁹⁵⁹⁵ INQ000252609_0004-0005 para 2.11 What was not expected was the scale of the pandemic and the need to plan for potential disparities of this scale.

¶10.43. Data from England demonstrated that, when taking age into account, people from Black African and Black Caribbean backgrounds had the highest rates of mortality during the first wave of the pandemic. From the second wave onwards, the highest mortality rates were among people of a Bangladeshi background and then people from a Pakistani background. Black African and Black Caribbean men and women remained at slightly higher risk during the second wave.⁹⁶⁹⁶ INQ000089747_0021 Between March 2020 and September 2021, those from a Pakistani background were about 3.5 times more likely to die from Covid-19 in Scotland than those from a White Scottish background.⁹⁷⁹⁷ INQ000274150_0035

¶10.44. Data on ethnicity – in the context of death registration and in relation to the impact of both the pandemic and the interventions introduced to combat it (as opposed to vaccine uptake) – were insufficiently collated and analysed. Some data gaps were not resolved during the course of the pandemic. For example, in December 2021, the Minister for Equalities made 17 recommendations, of which at least 4 aimed to improve the recording and use of ethnicity data.⁹⁸⁹⁸ INQ000198850_0023-0024 paras 58i-l Professor Whitty explained:

" [E]thnicity is often poorly or confusingly captured, or not captured at all … NHS data on ethnicity is often patchy and does not always rely on self-identified ethnicity, although this is arguably improving."⁹⁹⁹⁹ INQ000251645_0205 para 11.15

¶10.45. Of the four nations, only in Scotland was a person's ethnicity on death certificates collected at the time of the pandemic.¹⁰⁰¹⁰⁰ Module 2 Hearings: Written closing statement on behalf of the Scottish ministers, 15 January 2024, pp13-14, para 39 (https://covid19.public-inquiry.uk/documents/module-2-closing-statement-on-behalf-of-the-scottish-ministers); see also INQ000300700_0040 para 107 (Northern Ireland); INQ000227599_0007-0008 paras 26-32 The lack of ethnicity on death certificates meant that any disproportionate number of deaths within a particular ethnic group could not be identified as quickly as it could have been were that data held. Since the pandemic, death certificates in England and Wales record ethnicity where it has been self-declared in the deceased's medical records.¹⁰¹¹⁰¹ An Overview of the Death Certification Reforms, Department of Health and Social Care, updated 14 August 2024 (https://www.gov.uk/government/publications/changes-to-the-death-certification-process/an-overview-of-the-death-certification- reforms; INQ000548292) This is significant progress in collecting data that provide an understanding of whether a pathogen is causing a disproportionate number of deaths in any ethnic group. However, a complete picture will only exist when there is full coverage within the health system and consistency across health and other data collation systems.

¶10.46. In Wales, there were no datasets that permitted any meaningful comparison for the impact of the pandemic on ethnicity, occupation, religion or disability status.¹⁰²¹⁰² Ian Diamond 29 February 2024 95/15-18; see also Stephanie Howarth 29 February 2024 129/12-25; INQ000251645_0205 para 11.15; Gavin Freegard 10 October 2023 190/16-23 In Scotland, there was also a lack of data relating to at-risk and vulnerable groups at the beginning of the pandemic.¹⁰³¹⁰³ Scott Heald 17 January 2024 114/1-16; INQ000274052_0005; INQ000371664_0020 paras 98-101; INQ000099698_0005 Professor Ian Young, Chief Scientific Adviser to the Department of Health (Northern Ireland) from November 2015, explained that not only was real-time data on disability overall lacking, but also it was not possible to look at ethnicity trends because of the poor recording of ethnicity in healthcare records.¹⁰⁴¹⁰⁴ INQ000409589_0023 para 63

¶10.47. A further lesson learned during the pandemic was that even when data are available, ethnic minorities should not be treated as a homogenous group.¹⁰⁵¹⁰⁵ INQ000251645_0205 para 11.15; Gavin Freegard 10 October 2023 190/16-23 As said by Professor Dame Jenny Harries (Deputy Chief Medical Officer for England from July 2019 to March 2021, Chief Executive of the UK Health Security Agency from April 2021):

" [D]isaggregating data robustly to identify population variation is critical in ascertaining where to provide appropriate intervention for improved outcomes."¹⁰⁶¹⁰⁶ INQ000273807_0150-0151 para 11.3

¶That lesson can also be applied in relation to disabled people.

¶10.48. The lack of comprehensive, equality-disaggregated data led to a general failure by the UK government and devolved administrations to understand who was most vulnerable to the pandemic and how the governments' interventions could be better calibrated.¹⁰⁷¹⁰⁷ INQ000309529_0024 para 80; INQ000260629_0048 paras 96-98

¶10.49. The pandemic exposed the urgent need for public authorities to update and expand data collection protocols to ensure that they collect appropriate, equality-disaggregated data. The absence of equality-disaggregated data during the pandemic also meant that the impact of measures could not be monitored in real time. The collation of relevant, equality-disaggregated data is necessary to enable both mitigation against unintended inequalities and the advancement of equality in the event of future pandemics.

¶10.50. The concern that Covid-19 might have a more severe effect on people from certain ethnic groups was raised at an early stage of the pandemic. On 4 April 2020, observational data from the Intensive Care National Audit & Research Centre showed that one-third of patients admitted to critical care units with Covid-19 were from ethnic minority backgrounds. The majority of these were patients of Asian and Black ethnicity.¹⁰⁸¹⁰⁸ INQ000099533_0004 On 17 April, further data were received from the COVID-19 Clinical Information Network study (Co-CIN).¹⁰⁹¹⁰⁹ This study collated clinical information from healthcare records of people of all ages admitted to hospital in England, Wales and Scotland to characterise the clinical features of patients with severe Covid-19. By 18 April, Professor Whitty considered that this issue required consideration by academic groups.¹¹⁰¹¹⁰ INQ000236611_0001

¶10.51. Provisional analysis of deaths in England and Wales published by the Office for National Statistics on 7 May 2020 showed that, when taking age into account, Black males were 4.2 times more likely to die from a Covid-19-related cause than White males, and Black females 4.3 times more likely as compared with White females. People of Bangladeshi, Pakistani, Indian and mixed ethnicities also had a significantly raised risk of death involving Covid-19 as compared with those of White ethnicity.¹¹¹¹¹¹ INQ000223073_0002

¶10.52. Public Health England's Disparities in the Risk and Outcomes of COVID-19 confirmed that death rates from Covid-19 were highest among people of Black and Asian ethnic groups.¹¹²¹¹² Disparities in the Risk and Outcomes of COVID-19, Public Health England, August 2020 (https://assets.publishing.service.gov.uk/ media/5f328354d3bf7f1b12a7023a/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf; INQ000101218) This was the opposite of what had been seen in previous years, when the mortality rates were lower in Asian and Black ethnic groups than White ethnic groups. After accounting for the effects of sex, age, deprivation and region, people of Bangladeshi ethnicity had about twice the risk of death when compared with people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had a 10% to 50% higher risk of death when compared with White British people. The report noted that the analysis of why people from certain ethnic groups were at a higher risk of becoming infected by, and dying from, Covid-19 did not include the effect of occupation. This was an important shortcoming, because it was known that some occupations had a high proportion of workers from ethnic minority groups. Furthermore, the report did not include the effect of comorbidities or obesity. Again, these were important factors because they were associated with the risk of death and were more commonly seen in some ethnic minority groups.

¶10.53. On 4 June 2020, SAGE concluded (with "high confidence") that the evidence suggested that ethnic minorities – particularly Black and South Asian ethnic groups – faced a significantly increased chance of becoming infected by Covid-19, of being admitted to critical care, and of dying. For hospitalised patients – even those with similar disease severity and duration of symptoms on admission, and after adjustment for deprivation and comorbidities – there was an increased risk of critical care admission for South Asian, Black and Other ethnic minority groups. Ultimately, the quality and granularity of data available were significant issues, but there could be little doubt as to the emerging picture.¹¹³¹¹³ INQ000223042_0001

¶10.54. Boris Johnson MP (Prime Minister from July 2019 to September 2022) told the Inquiry that, while Disparities in the Risk and Outcomes of COVID-19 identified Covid-19 disparities, it did not examine why they arose and made no recommendations. As a result, after its publication, Mr Johnson and Mr Hancock asked Kemi Badenoch MP (Minister for Equalities from February 2020 to July 2022) to lead a cross-government review of the effectiveness and impact of current action by relevant government departments, and their agencies, to reduce disparities in infection and death rates from Covid-19, including factors such as age, sex, occupation, obesity, comorbidities, geography and ethnicity.¹¹⁴¹¹⁴ INQ000584955; INQ000089741_0002

¶10.55. On 16 June 2020, Public Health England published another report commissioned by Professor Whitty.¹¹⁵¹¹⁵ INQ000248853_0096 para 6.37 It was entitled Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.¹¹⁶¹¹⁶ Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups, Public Health England, June 2020 (https://assets.publishing.service.gov.uk/media/5ee761fce90e070435f5a9dd/COVID_stakeholder_engagement_synthesis_beyond_ the_data.pdf; INQ000176354); INQ000196614 The report noted that Public Health England's data suggested that people of Black, Asian and other ethnic minority groups might be more exposed to Covid-19, and that this could be the result of factors associated with ethnicity, such as occupation, population density, use of public transport, household composition and housing conditions. The authors referred to many of the pre-existing health conditions that increased the risk of having severe infection (such as diabetes and obesity). They observed that these were more common in ethnic minority groups and that many of these conditions were linked to social and economic factors. The report noted that for many ethnic minority groups, especially in poor areas, there were higher incidences of chronic disease and of multiple long‑term conditions. The report provided clear evidence about the risks to which people from certain ethnic minority groups were exposed, because of their work in occupations with a higher risk of Covid-19 exposure. This included the health and social care workforce, as well as cleaners, public transport workers and retail workers. The report noted that the health and care workforce in England was significantly over-represented by people from ethnic minority groups: 40% of doctors, 20% of nurses and 17% of the social care workforce were from ethnic minority groups. In London, 44.9% of the NHS and Clinical Commissioning Group staff came from an ethnic minority group.¹¹⁷¹¹⁷ Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups, Public Health England, June 2020, p22 (https://assets. publishing.service.gov.uk/media/5ee761fce90e070435f5a9dd/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf; INQ000176354) Often, ethnic minority workers were in lower-paid roles within the NHS, which meant that these roles could not be done remotely.¹¹⁸¹¹⁸ Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups, Public Health England, June 2020, p22 (https://assets. publishing.service.gov.uk/media/5ee761fce90e070435f5a9dd/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf; INQ000176354)

¶10.56. The report set out seven recommendations. They included an acceleration of the development of culturally competent occupational risk assessment tools, which could be employed in a variety of occupational settings and used to reduce the risk of an employee's exposure to, and acquisition of, Covid-19 – especially for key workers working with a large cross-section of the general public or in contact with those infected by Covid-19. They also included the funding, development and implementation of culturally competent Covid-19 education and prevention campaigns. This report underscored the need to understand that, and act on the assumption that, people from ethnic minority backgrounds were being exposed to greater risk, in part because they were doing jobs upon which communities depended.

¶10.57. Professor Khunti identified the use of a "culturally tailored occupational risk assessment for covid-19" as one of five "immediate steps" the UK government should take.¹¹⁹¹¹⁹ Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups, Public Health England, June 2020, p10 (https://assets.publishing.service.gov.uk/media/5ee761fce90e070435f5a9dd/COVID_stakeholder_engagement_synthesis_beyond_ the_data.pdf; INQ000176354); INQ000223039 At the request of NHS England, Professor Khunti had previously chaired a group that developed a risk reduction framework, published on 12 May 2020. This was understood by Professor Khunti to have been "implemented in most clinical commissioning groups and hospitals but not all, and implementation has been varied".¹²⁰¹²⁰ INQ000252609_0005-0006 para 2.15 He considered that greater efforts could have been made to "implement mandatory occupational risk assessment for NHS and non-NHS staff".¹²¹¹²¹ INQ000252609_0006 para 2.18; INQ000223041

¶10.58. In Wales, a risk assessment tool for use in health and social care was developed and published online on 26 May 2020 by the First Minister's Black, Asian and Minority Ethnic Covid-19 Advisory Group (which was set up in response to the disproportionate impact of the pandemic on ethnic minority people in Wales).¹²²¹²² INQ000023242; INQ000366148_0032 para 99 This was understood by Professor Emmanuel Ogbonna, Professor of Management and Organization at Cardiff University and Chair of the group, to have been widely used throughout the pandemic.¹²³¹²³ INQ000366148_0032 para 99; Emmanuel Ogbonna 28 February 2024 58/1-59/2

¶10.59. The earliest indications in April 2020 that people from ethnic minority groups were at a heightened risk of becoming infected by Covid-19 ought to have been translated into swift action by each of the four governments. They should have had access to data demonstrating the extent to which specific groups were being exposed to greater risk and – crucially – why. There ought to have been clearer sponsorship, at the most senior levels of government, of a strategy targeted at reducing the risks to each of those ethnic groups shown to be particularly vulnerable. This required proper and sufficient expertise at the heart of the policy on, and operational response to, the pandemic.

¶10.60. This expertise was depleted in the UK government. Following the UK-wide lockdown in March 2020, members of the Race Disparity Unit and the Government Equalities Office, and the Director of the Disability Unit, were redeployed across government to assist elsewhere with the pandemic response.¹²⁴¹²⁴ INQ000198850_0013-0014 para 28 It was not until April and June 2020 that the role of the Disability Unit and Race Disparity Unit respectively were recognised by the Cabinet Office as 'business-critical functions' and added to the Critical Function list, which prevented the redeployment of staff and enabled the requisition of further staff. This was too late. Marcus Bell, then Director of both the Race Disparity Unit and the Disability Unit, did not return to post until mid-June 2020.¹²⁵¹²⁵ INQ000198850_0014 paras 30-31 He explained that this decision was taken on the basis that:

" At that time (March 2020) it was not apparent that ethnic minority people were disproportionately impacted."¹²⁶¹²⁶ INQ000198850_0014-0015 para 32

¶However, Mr Bell told the Inquiry:

" Once emerging data was clear about the disproportionate impact of the pandemic on ethnic minority people I returned."¹²⁷¹²⁷ INQ000198850_0014-0015 para 31

¶Mr Bell accepted that the redeployment of staff from the Race Disparity Unit:

" could have had a negative impact on our ability to respond, although it is difficult to quantify".¹²⁸¹²⁸ INQ000198850_0014 para 31

¶10.61. In future national emergencies, it is imperative that the response assumes that those who are already disadvantaged will be exposed to greater risk of infection and dying; that, in part, this may be linked to their occupations; and that these factors make it more likely that people from ethnic minority groups will be exposed to greater risk. There must then be a clear strategy from the outset to reduce the risks to which they are exposed.

Deprivation

¶10.62. In Disparities in the Risk and Outcomes of COVID-19, Public Health England noted that people who lived in deprived areas had higher diagnosis and mortality rates than those living in less deprived areas.¹²⁹¹²⁹ Disparities in the Risk and Outcomes of COVID-19, Public Health England, August 2020 (https://assets.publishing.service.gov.uk/ media/5f328354d3bf7f1b12a7023a/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf; INQ000101218) The mortality rates for both males and females in the most deprived areas were more than double those in the least deprived areas. Poor outcomes from Covid-19 infection in deprived areas remained after adjusting for age, sex, region and ethnicity. However, the report noted that the role of comorbidities required further investigation.

¶10.63. There are many reasons why people living in deprived areas suffered higher rates of infection from Covid-19 and were more at risk of dying from it. There is a long- established and clear correlation between deprivation and ill-health.¹³⁰¹³⁰ INQ000195843_0004-0005 para 4 The most deprived areas of the UK have worse health outcomes than the least deprived areas, across a range of indicators.¹³¹¹³¹ INQ000195843_0004-0005 para 4 (the indicators include, for example, mortality, life expectancy, infant mortality, cardiovascular disease, liver disease, diabetes and obesity) The least deprived areas in the UK have the best average health outcomes.¹³²¹³² INQ000195843_0004 para 4 This is true across the UK.¹³³¹³³ INQ000195843_0005-0007 paras 9-11; INQ000239587_0003; INQ000474457_0052

¶10.64. The need to work to support a family, and other social factors, such as living in multi-generational and overcrowded housing, combined to create a greater risk of becoming infected by Covid-19 and spreading the virus. People from certain ethnic groups are more likely to live in multi-generational and overcrowded housing. For example, Pakistani and Bangladeshi adults living in England have the highest rates of households of six or more people and the highest rates of overcrowding.¹³⁴¹³⁴ INQ000089744_0025 para 61 (3.5% of Pakistani adults and 32% of Bangladeshi adults; 24% of Bangladeshi households and 18% of Pakistani households in England)

¶10.65. The Office for National Statistics reported that men working in low-skilled occupations had the highest rate of death involving Covid-19 up to 20 April 2020. Men working in some specific occupations had significantly raised rates of death involving Covid-19, including security guards, taxi drivers, bus drivers, chefs and those working in lower-skilled occupations in construction and processing plants.¹³⁵¹³⁵ INQ000503378; INQ000118901_0035; Disparities in the Risk and Outcomes of COVID-19, Public Health England, August 2020, pp50-51, para 5.2 (https://assets.publishing.service.gov.uk/media/5f328354d3bf7f1b12a7023a/Disparities_in_the_risk_and_ outcomes_of_COVID_August_2020_update.pdf; INQ000101218) Men and women working in social care were also reported to have had significantly raised rates of death involving Covid-19.¹³⁶¹³⁶ INQ000101218_0051

¶10.66. Research confirmed that occupational exposure to Covid-19 was a key risk factor in relation to the risk of infection and onward transmission but also in subsequent hospitalisation and mortality rates.¹³⁷¹³⁷ INQ000269856; INQ000269865; INQ000300548_0013-0015 Conversely, those people in professional occupations and the sorts of jobs that require higher qualifications had greater opportunity to work from home and consequently were less exposed to risk.¹³⁸¹³⁸ INQ000224407_0006 para 4

¶10.67. As Professor Neil Ferguson, Mathematical Epidemiologist at Imperial College London, explained: "[T]he poorest in society had the least ability to comply with measures, to work from home, [and] were most exposed to the virus."¹³⁹¹³⁹ Neil Ferguson 17 October 2023 210/3-5 Transmission and infection reflected "the amplifying effects between the working environment, crowded housing, job insecurity and poverty".¹⁴⁰¹⁴⁰ INQ000224407_0001

¶10.68. The pandemic also saw significant increases in the numbers of people who required income support.¹⁴¹¹⁴¹ For example, between February 2020 and February 2021, there were large increases in the proportion of working-age adults claiming Universal Credit. In February 2020, 3 million people were receiving Universal Credit and this rose to 5.9 million by February 2021. In February 2022, 5.5 million people were receiving Universal Credit: INQ000584979. In terms of those who remained in lower-paid and insecure employment during the pandemic, a factor contributing to the risks they faced was the ability to self-isolate without financial support. Such support was considered key to the success of test, trace and isolate systems across the UK, in order to reduce the risk of people either not taking tests – for fear of testing positive – or not reporting positive tests, to allow tracing.¹⁴²¹⁴² INQ000273901_0164; Anthony Costello 16 October 2023 168/24-169/2; David Halpern 1 November 2023 202/1-10; INQ000273842_0077; INQ000119872_0004; INQ000137934_0001, 0008 Statutory sick pay or individual payments were potential mechanisms of support. Professor Whitty observed:

" [S]ome of the highest incidence of Covid was in areas of relative deprivation, where there were higher rates of people who were not in continuous employment and therefore covered by ordinary sick leave."¹⁴³¹⁴³ Christopher Whitty 22 November 2023 145/2-21

¶10.69. Despite clear scientific advice, and despite many considering that the provision of financial support to encourage adherence to testing and self-isolation policies was necessary, the Inquiry heard that such provisions were "heatedly debated in government".¹⁴⁴¹⁴⁴ The likely impact of the financial inability to self-isolate was known prior to the pandemic and had been explicitly identified before the first lockdown in England. Christopher Whitty 22 November 2023 145/2-9; 'Influenza in long-term care facilities', Louise E. Lansbury, Caroline S. Brown, Jonathan S. Nguyen-Van-Tam, Influenza and Other Respiratory Viruses (2017), 11(5), pp356-366, p358 (https://doi.org/10.1111/irv.12464; INQ000269388_0003); INQ000250232_0010-0012 para 3.3; Lucy Yardley 18 October 2023 141/2-4; Gerry Murphy 1 May 2024 53/16-54/2; INQ000177806_0015-0016 para 56.Show full note Professor Whitty summarised:

" Treasury were generally not convinced by these arguments in favour of payments for working people who were self-isolating and who were not otherwise paid for that time."¹⁴⁵¹⁴⁵ INQ000251645_0172 para 8.138

¶Rishi Sunak MP, Chancellor of the Exchequer from February 2020 to July 2022, confirmed to the Inquiry that he was:

" sceptical that [financial provision] would make a significant difference to the levels of people self-isolating".¹⁴⁶¹⁴⁶ Rishi Sunak 11 December 2023 210/8-13

¶10.70. Financial disadvantage was identified in a Scientific Pandemic Insights Group on Behaviours (SPI-B) paper titled 'The impact of financial and other targeted support on rates of self-isolation or quarantine', in September 2020, as one of the four primary factors associated with the risk to adherence and compliance with non-pharmaceutical interventions.¹⁴⁷¹⁴⁷ Professor Lucy Yardley (Professor of Health Psychology at the University of Bristol and the University of Southampton, Co-Chair of SPI-B from April 2020) explained: "[B]efore lockdown we pointed out that it would be a problem, and we continued to point it out throughout."; Lucy Yardley 18 October 2023 141/2-4; INQ000250232_0010-0012 para 3.3; INQ000137934_0002 Professor James Rubin (Professor of Psychology and Emerging Health Risks at King's College London and Chair of SPI-B from February 2020 to June 2021), and others concluded in November 2020:

" [M]otivation to self-isolate is high in all groups; ability to self-isolate is lowest among the poorest sections of the population."¹⁴⁸¹⁴⁸ INQ000196988_0001 para 3; see also INQ000137934_0008

¶Many of those in low-paid professions had no option but to go out to work, and they faced additional risks of becoming infected by Covid-19.¹⁴⁹¹⁴⁹ David Halpern 1 November 2023 202/1-10; INQ000221436_0059 para 275; Dominic Cummings 31 October 2023 252/14-24 They then faced financial hardship if they self-isolated.

¶10.71. For people on low pay who struggle to pay for the basics, these hardships – or their consequences – should not be underestimated. They also had significant public health implications with regard to potential onward transmission. As early as July 2020, studies demonstrated that, in England, "care homes which paid members of staff when off sick or self-isolating had lower rates of transmission than those which did not".¹⁵⁰¹⁵⁰ INQ000251645_0172 para 8.138; Christopher Whitty 22 November 2023 146/4-8 There was "direct evidence of the link".¹⁵¹¹⁵¹ Christopher Whitty 22 November 2023 146/7-8

¶10.72. The problems persisted throughout the pandemic.¹⁵²¹⁵² Lucy Yardley 18 October 2023 140/1-141/4 This undermined infection prevention and inevitably contributed to the disparities and unequal impact evident during the pandemic.

¶10.73. Occupational risk and the nature of insecure, and low-waged, working conditions are relevant factors that the UK government and devolved administrations ought to have taken into account in pandemic planning (as set out in the Inquiry's Module 1 Report), given the known disproportionate impacts on infection rates, morbidity (illness) and mortality. From an infection control perspective, such consideration is essential when thinking about how to limit transmission. Mr Hancock acknowledged:

" [T]he lesson for the future is that self-isolation payments, rapidly delivered, are a necessity when self-isolation or indeed mandatory isolation is required."¹⁵³¹⁵³ Matt Hancock 1 December 2023 110/4-7

¶The Inquiry agrees: governments must ensure that planning is in place for adequate financial provision to ensure that people have the economic ability to self-isolate, along with mechanisms for payments.