Volume 6: Human Health, 1989-96
7. Human health developments from January 1996 to 20 March 1996
The storm breaks
Conclusion

Conclusion

7.456 We have reached the firm conclusion that there was no contingency planning to address the possibility that BSE would be shown to have transmitted to humans at any time before 8 March, either at MAFF or at DH. The contemporary documents paint a very clear picture.

7.457 The respective minutes of Mr Eddy and Dr Wight, which were intended to brief their superiors about what had transpired at SEAC's meeting on 1 February, provoked no reaction at all.

7.458 On 1 March Mr Eddy was alerted by Dr Wight to the fact that the CJDSU had obtained results which indicated that a new sub-population of CJD was emerging. He sent a minute to Mr Meldrum suggesting a meeting of MAFF and DH officials and press officers to decide how the news should be handled. He added that it was absolutely essential, in handling the news, to have some form of statement from SEAC (see paragraph 7.204). SEAC was due to meet on 8 March. No action of any sort appears to have been taken at MAFF or DH prior to that meeting.

7.459 SEAC met on 8 March. The same day Mr Skinner informed Sir Kenneth Calman and Mr Horam of the likely existence of a new form of CJD linked to exposure to BSE in the 1980s (see paragraph 7.215). Similar information was relayed by Mr Packer to Mr Hogg (see paragraph 7.217). At this point officials and Ministers in the two Departments began to move. The first decision was that a stop should be placed on the distribution of publicity extolling the safety of beef (see paragraphs 7.219-7.221). On Sir Kenneth Calman's instructions, Dr Rubery drew up her 'status paper'.

7.460 Thereafter, on 13 March, on Sir Kenneth Calman's initiative an interdepartmental meeting of officials with Professor Pattison took place (see paragraphs 7.235-7.248). Here, for the first time, there was discussion of possible measures to tighten up controls against transmission of BSE and the possibility of removing cows over 2 or 2½ years of age from the human food chain was mooted. Mr Packer reported this to Mr Hogg the same day (see paragraph 7.249). We think it likely that this was instrumental in the formulation by Mr Hogg of the 30 month scheme as his policy option.

7.461 By 18 March Mr Hogg had formulated his policy. Fundamental to it was his belief that it was not acceptable to have a policy which permitted animals with potentially infective tissues to be slaughtered for human consumption in reliance upon slaughterhouse operatives to remove all such tissues. While he may well have discussed his mistrust of slaughterhouses with his officials over the previous months, we do not accept that he had described his 30 month scheme. Nor had there been any discussion of the alternative option of deboning.

7.462 The attitude of Sir Kenneth Calman and Dr Metters appears to have been that there was no need to think about action unless and until SEAC advised that a likely link between BSE and CJD had been established (see paragraphs 7.181 and 7.185). We have observed that the language of Dr Wight's minute was a sedative, and this provides a degree of mitigation for those who were sedated.

7.463 In his witness statements Dr Metters suggested that there was nothing really that DH needed to do by way of contingency planning. It was for MAFF to weigh up the options, such as a cattle cull, that would increase the protection against the risk of transmission. ¹ So far as DH was concerned, there was no known treatment that would prevent infection or cure its consequences. So far as care of victims was concerned, there was no reason to think that the NHS would be unable to cope. ²

7.464 These comments exemplified the attitude of DH up to the last few days with which we are concerned. BSE was seen as being essentially MAFF's problem. To a degree this was realistic. The CJDSU was, however, very much DH's part of ship. By February the Unit's surveillance had produced evidence of a possible link between BSE and CJD. Despite the shortcomings in Dr Wight's minute of 6 February, it was on reading that minute - rather than six weeks later - that Sir Kenneth and Dr Metters should have considered the action that might be required should the scientists advise that BSE had probably been transmitted to humans. They should then have recognised the need for MAFF and DH to address the implications in conjunction. Sir Kenneth should also have alerted Mr Dorrell to the possibility that a link would be established between BSE and the young victims of CJD.

7.465 After the oral hearings, Mr Horam in a supplementary witness statement raised the possibility that Sir Kenneth had a discussion with him about the potential significance of SEAC's findings before 8 March and possibly even before 7 February. ³ We noted earlier that Dr Metters's minute of 8 February 1996 does not suggest that Mr Horam had learnt of the possibility that SEAC might be about to advise that there was a probable link between BSE and CJD. In his original witness statement Mr Horam had placed this conversation on or shortly after 8 March. ⁴ We believe that his original statement is likely to be correct. It certainly accords better with evidence given by Mr Dorrell and Sir Kenneth to the Agriculture and Health Select Committees on 27 March 1996. ⁵

7.466 Mr Dorrell stated to us that he could not recollect being told in February 1996 that there was a real possibility that SEAC was about to confirm a link between BSE and recent cases of CJD. He added that he would not have expected to be informed of this as he

. . . was interested in SEAC's actual conclusions, rather than speculation about what those conclusions might be. ⁶

7.467 We are in no doubt that the information that was discussed by SEAC on 1 February should have been communicated to Mr Dorrell and should, if he were not to be open to criticism, have led him to start to consider the implications of the possibility that BSE had transmitted to the young victims. As, however, he was not told about this, he escapes that criticism.

7.468 So far as MAFF is concerned, we have drawn attention to the contrast between those who told us that Mr Eddy's minute of 6 February put them on a state of alert as to the possibility that SEAC would conclude that BSE had been transmitted to humans - Mrs Browning, Mr Packer and Mr Carden - and those who said they saw no cause for alarm in Mr Eddy's minute - Mr Hogg and Mr Meldrum (see paragraphs 7.165-7.180).

7.469 We consider that Mr Eddy's minute should have put those who read it on alert in the manner described by Mr Carden. We agree with Mr Hogg that the terms of the minute suggested that Mr Eddy's concern was about the problems of presentation that the information to be published by Dr Will was likely to cause. Mr Packer told us, however, that he looked behind this at the substance of Mr Eddy's minute. The minute indicated that the problems of presentation would arise because it was impossible on the available evidence to rule out the possibility that the five young cases with distinctive pathology had 'caught' the disease from cattle. Further investigation was required which might, or might not, confirm that possibility.

7.470 Mr Hogg did not recollect reading the minute, but told us that he would almost certainly have done so. He said that it would have caused him concern (see paragraph 7.169) albeit that it was about problems of presentation. Mr Meldrum told us that he was personally concerned about the five young cases, but that Mr Eddy's minute indicated that SEAC did not consider that the situation was one of any urgency (see paragraph 7.179).

7.471 We are left in doubt as to whether Mr Eddy's minute put Mr Carden and Mrs Browning onto the state of 'high alert' that Mr Carden described. What is clear is that, as Mr Hogg observed, 'Meldrum and friends did not think that they had had enough information to come to me with recommendations or a form of concern' (see paragraph 7.173).

7.472 Despite the shortcomings in Mr Eddy's minute, on reading that minute Mr Hogg and Mrs Browning should have sought to discuss its implications with Mr Packer, Mr Carden and Mr Meldrum. Similarly, on reading that minute, those officials, after discussion among themselves, ought to have raised its implications with Mrs Browning and Mr Hogg. Each of these five individuals should have considered the action that might be required should the scientists advise that BSE had probably been transmitted to humans and they should have recognised the need for MAFF and DH to address the implications in conjunction, for example by seeking the views of Sir Kenneth Calman and by discussions between Mr Hogg and Mr Dorrell. They did not do so. Again, we have felt able to reach this conclusion for each individual on the basis of matters discussed at their respective oral hearings alone. In what follows, however, we look at the picture in the round. Mr Eddy's minute seems to have been treated by all simply as information of matters that called neither for action nor for discussion. We believe that the reason for this lies in the attitude to SEAC described by Mr Packer (see paragraph 7.408). SEAC was being relied upon to advise if and when the stage was reached that called for action and to advise what action should be taken. A few quotations from the evidence, in addition to those already cited from Mr Packer, will serve to illustrate this attitude.

7.473 When giving evidence in Phase 2, Mrs Browning said:

In the last week or two, particularly before the announcement was made, we were quite desperate to get some definitive advice from SEAC. ⁷

. . . over a period of some seven weeks Ministers were placed in a position where they were required to await scientific advice which was anticipated would not be forthcoming until the spring. ⁸

. . . we had been given very clear advice at the beginning of February that we could not expect to get the definitive advice on exactly what we were going to have to deal with until the spring. We had to accept, however frustrating that was, that that is the way that science works; ⁹

. . . policy action in the main, in my experience, meant that the SEAC Committee would give Ministers advice in the light of new scientific evidence, and without exception we then put that into legislation and into the public domain.

There were issues around the handling of that process, vis-à-vis the general public and the media; but I am not aware that there was any advice that I was given by SEAC in my three years as a Minister at MAFF that we did not accept or we did not implement in terms of policy making. ¹⁰

7.474 In a witness statement Mr Carden referred to the fact that there were already in place precautionary measures to address the contingency that BSE might be transmissible to humans. It was not self-evident that SEAC would see a need for any new measures. He added:

We were therefore keenly attentive to indications emerging from SEAC, following their 1 February meeting, as to whether they thought new measures might be needed. It was certainly not apparent to me from Mr Eddy's 6 February 1996 report that they would recommend anything of that kind. As I said in my oral evidence to the Inquiry on 2 July 1998 'there was not much basis for thinking usefully about things that would have to be done if the worst case conclusion was reached. ¹¹

7.475 Mr Meldrum, in oral evidence in Phase 2, gave his perception of the situation:

I thought that is what SEAC was saying. This is immensely worrying, the number of cases in a short timescale in young people with different presenting symptoms. We were all much aware of it. And I of course, like everybody else, was waiting until SEAC came to a view. Because of the expansion of the committee, they were in a very good position to do so. ¹²

7.476 In a witness statement, Mr Packer told us:

We were waiting for SEAC's advice on transmissibility which only they were competent to give. Fortunately it was always likely that this process would be a matter of only a few weeks as proved to be the case. We were also awaiting SEAC's recommendations on the appropriate response to such advice. (I always thought it undesirable to proceed on any other basis (see for example the minute from Mr Strang to Ms O'Donoghue of 15 March 1996 (paragraph 2)). It was not clear that they would recommend any action; certainly there was no need for emergency measures.

7.477 He continued:

From 8 March 1996 circumstances changed again since a finding that transmissibility had occurred became significantly more probable. From that point policy was taken forward at the top level within MAFF, in close consultation with DoH and with SEAC notably the CMO and Professor Pattison. In effect these discussions constituted part of the planning process. Given the importance of the issues this was wholly appropriate. ¹³

7.478 This last paragraph is significant. The deliberations that took place after 8 March were, to a degree, contingency planning. SEAC did not advise that there was a probable link between BSE and the young cases of CJD until 16 March. SEAC did not advise on the action that it was appropriate to take until 20 March. At the interdepartmental meeting of officials which he called on 13 March, Sir Kenneth Calman commented that 'although the implications were stark, the options were very limited'. ¹⁴

7.479 We have concluded that the options could and should have been discussed within and between the two Departments on a contingency basis during the month of February and the early part of March. Dr Rubery's status paper of 12 March correctly noted:

MAFF needed to consider additional possible safeguards for the public with respect to exposure to Beef and Beef products. ¹⁵

7.480 Between 13 and 20 March whether and how the human food chain should receive further protection was the most important issue being considered by SEAC and government. It was being considered in a rush under extreme pressure. It should have received detailed consideration on a contingency basis before the storm broke in March.

7.481 Mr John Major in a written statement to us put the matter succinctly:

It appears from Mr Hogg's evidence that there were indications prior to March 1996 that SEAC might reach the conclusions they eventually did reach. Given this, I would have expected that some thought was given to what would need to be done if those conclusions were reached. ¹⁶

Defects in the policy-making process

7.482 The policy-making process took place in a rush in the week leading up to 20 March. Largely because of this, it had the following unsatisfactory features:

1. No submission was made to Mr Hogg from his officials setting out the policy options and the pros and cons of each. The advice that he received from his Permanent Secretary was essentially that he should wait to see what SEAC had to say.
2. There was a failure to identify the relevant questions that needed to be considered when deciding what policy should be adopted and to identify which of those questions required advice from SEAC.
3. Mr Hogg's decision was based very much on his own appraisal of the situation. We asked him how Mr Meldrum viewed his policy. He answered:

   I do not know what Meldrum's view was. I may have known at the time. I cannot remember now. The truth to tell, at the end of the day it was for me to make my mind up. That was what I was paid to do; and I did not hesitate to do it. They could have all told me I was wrong. But the plain truth is, Lord Phillips, I was right, and nobody has tried to argue otherwise. I knew I was right at the time; and a whole choir of people could have told me I was wrong. Perhaps they did, I do not know; but it did not matter. I knew I was right. ¹⁷

4. Mr Hogg claimed credit for getting the answer right in the way that he did:

   . . . by 16 March I had come to a fully worked up policy. With the exception of two elements, that policy was ultimately accepted by the Cabinet colleagues, but they did not accept it on the 20 March, or the 18 I think is probably the more correct. They did accept it a few days thereafter. It is still the policy in place, subject to natural evolution. I do not think anybody in this Inquiry or at any other stage has said of my policy - because it is my policy - that it was wrong. Therefore one must proceed on the basis that it was right. And if it was right, I am not at all sure what the criticism is about. Why worry about the modalities when the policy is right?

   You really, if I may venture to say this Lord Phillips, should be applauding Ministers who are prepared to take the necessary action quickly and in a non-bureaucratic manner. That is what I did. ¹⁸

   For reasons that we have developed, we agree that Mr Hogg got the right answers. It would have been better, however, had he been able to demonstrate that his officials had placed before him the relevant facts and arguments and that he had made a reasoned decision in the light of them.

5. Mr Hogg did not involve Mr Dorrell, his opposite number in DH, in the formulation of policy. It seems to us obvious that Mr Dorrell and his Department had a vital concern with the issue of what, if any, additional steps should be taken to protect public health. Mr Hogg was asked whether it would not have improved the chances of having his policy accepted if it had been discussed in more detail with the DH in February. His answer was that it would not, because neither Mr Dorrell nor the CMO agreed with him. ¹⁹ Mr Hogg simply presented his policy to Mr Dorrell on 16 March, apparently confident that its merits would speak for themselves. It seems to us that Mr Hogg would have had a better chance of persuading Mr Dorrell of the merits of his policy had Mr Dorrell or his officials been involved in discussions when that policy was being formulated.
6. The Prime Minister and Mr Hogg's ministerial colleagues were not informed of what by then had become a crisis situation until 18 March. Mr Major was asked to comment on this and did so in his statement:

   I have been asked to consider the evidence Mr Hogg gave orally to the Inquiry concerning the events leading to the announcement on 20 March 1996 and, in particular, what he said about the extent to which he thought it appropriate to inform other Ministers and myself about the information he had received prior to sending his first minute on 18 March. Mr Hogg gave as his reasons his concerns about leaks and the fact that he did not like troubling people - and myself in particular - until he knew exactly what the situation was and what he proposed to do. I agree with Mr Hogg's comments about leaks. Clearly, the more people who have knowledge of a particular set of facts, the chances of a leak must be increased. It was important that the information came into the public domain through a clear announcement about the advice that had been received and the Government's position on the action to be taken, and not through a leak. Mr Hogg could, as he said, have telephoned me to discuss the matter informally, but did not. I do also understand the reasons he gave to the Inquiry as to why he did not wish to trouble me. In Government there will be at any one time a number of important issues with which Departments are dealing and which may eventually need to be referred to Cabinet for collective decision. It would not usually be sensible to refer such matters to Cabinet and/or the Prime Minister for discussion before they have been properly considered by the relevant Department: the discussion ought to take place against the background of a well thought through position by those who are closest to the matter. Whether and when to refer a matter in this way must be a question of judgment for the relevant Department in each particular case. ²⁰

   We believe that contingency planning could have resulted in a well thought-through position being presented to the Prime Minister before 18 March. In the event the position was not 'well thought through by those closest to the matter'. Mr Hogg had reached his own conclusions largely by a process of independent thought.

7. SEAC was required to advise on policy overnight. It seems to us that this put members of the Committee under almost intolerable pressure.
8. The Cabinet was faced with taking a decision on the basis of SEAC's advice without the time or the information necessary to consider other matters of high relevance to the policy decision.

Would contingency planning have made any difference?

7.483 This question was raised more than once by Mr Packer when giving evidence in Phase 2. The propositions that he put to us can be summarised as follows. The Government would not move without advice from SEAC. It was undesirable to proceed without SEAC's advice. Mr Hogg attempted to do so and the policy that he proposed was rejected. ²¹ In the event SEAC advised and the Government followed that advice. Contingency planning would not have affected the end result.

7.484 When it was put to Mr Packer that MAFF should have been thinking about the possible options, he answered:

But we do come back to the question of outcomes, Chairman, and would the outcome have been different if pursued differently; and my contention is the outcome would not have been different or better. I think there is a lot of evidence for that in the papers before you. However it may be suggested work might have been done, the end result was correct, and that goes a long way towards validating the approach of those at the time. ²²

7.485 We do not agree with Mr Packer that 'the end result was correct'. The end result was a policy decision which almost immediately proved to be unviable and had to be abandoned, to be replaced with the 30 month scheme that Mr Hogg had initially proposed. Mr Hogg put the matter to us as follows:

. . . SEAC did in fact recommend a deboning regime; and indeed my colleagues in the Cabinet were foolish enough to accept it. But I knew it was wrong, I said it was wrong, I was not going to have it, and it changed. ²³

7.486 We do not endorse the adjective used by Mr Hogg to describe his colleagues' reaction. The Cabinet was confronted with an acute emergency. Mr Major and his colleagues learned on 18 March of SEAC's advice that BSE had probably been transmitted to humans. They appreciated that if the Government did not make this advice public others were likely to, and that the public would demand to know the Government's response to the advice. SEAC was pressed to give its advice as to the measures that should be taken to protect public health and did so. The Government accepted that advice.

7.487 Mr Packer had questioned the need to devote resources to contingency planning. He made the point that precautions were already in place against the risk that BSE might be transmissible. He commented: 'If you think matters are secure, then you can move in a more measured way', and questioned: 'What would lie behind this rush to do things before we were clear what water we were in?' ²⁴ In the event, the Cabinet found itself in very hot water. At that point the machinery of government moved impressively fast in reacting to the emergency. In the circumstances we do not consider that the Cabinet can be criticised for the decision that it reached, albeit that the decision proved to be wrong. The question that interests us is whether contingency planning might have resulted in the Cabinet reaching the conclusion that the de-boning option was not the correct policy decision and that a 30 month scheme should be introduced.

7.488 We now turn to consider major issues which should have been considered if a properly informed policy decision were to be taken on 20 March. We shall consider whether, if contingency planning had started in February, the Cabinet might have reached a different policy decision. In the course of our discussion we shall examine the extent to which it was appropriate to look to SEAC to provide the answer to the issue and the extent to which the answer should have been sought elsewhere.

Should additional tissues be banned?

7.489 The policy in place in February 1996 was designed to address a remote risk that BSE might be transmissible to humans. The method of addressing that risk was to seek to remove from the carcasses of cattle those tissues which, should the disease be transmissible, would carry a high titre of infectivity. These were designated as SBO. It was recognised that there were, in addition, tissues that might carry a low titre of infectivity, in particular peripheral nervous and lymphatic tissue, that were not proscribed as SBO. At the stage that beef was deboned, often in the butcher's shop, these would normally be removed in the course of dressing the meat. It had been considered disproportionate to proscribe these as SBO.

7.490 Once it was recognised that transmissibility was not a remote possibility, but a likelihood, the question arose of whether additional tissues should be proscribed as SBO. While this involved an exercise in proportionality, the question was one in respect of which SEAC's advice would naturally carry much weight.

7.491 SEAC considered the matter and concluded that, in the case of cattle over the age of 2½ years, the beef should be boned out in order to remove the nervous and lymphatic tissue trimmings, which would be treated as SBO. That conclusion was incorporated by SEAC in the advice that it gave to the Government on 20 March.

Additional measures to ensure proper removal of SBO?

7.492 There was a more fundamental issue. The policy in place in February 1996 envisaged the possibility that animals would go to be slaughtered for human consumption that had certain tissues, which, if eaten, might be potentially lethal. This was considered only a remote possibility, and in those circumstances it was considered satisfactory to rely upon the removal of those tissues by the slaughterhouse in order to protect human health. Once one postulated that it was probable that tissues of some animals entering the slaughterhouse would be potentially lethal, the question arose as to whether it was still satisfactory to rely upon the slaughterhouse to remove those tissues. This issue, also, was considered by SEAC. In its advice to Government, SEAC gave a conditional reply. The risk from eating beef would be likely to be extremely small provided that:

1. The SBO ban was properly enforced; constant supervision to ensure the complete removal of spinal cord was recommended;
2. The carcasses from cattle aged over 30 months were deboned in licensed plants supervised by the MHS.

7.493 This conditional advice from SEAC required further input from MAFF into the policy decision. How confident could one be that all spinal cord would be removed from every carcass? Shortcomings in this area had been disclosed in 1995 and steps had been taken to address them. MAFF officials do not appear to have advised on the degree of confidence that could be placed on those steps to achieve the desired result. Mr Hogg had, however, no doubt as to the answer:

. . . by the end of 1995 I had come to one very important conclusion as to the ability of abattoir owners and the slaughterhouses to deliver 100 per cent compliance. I was absolutely certain that they could not. And the reason for that was that I had seen them on a number of occasions personally, face to face; I had been to abattoirs; I had seen the audits; I had talked to the CMO, as you know. Above all, I had seen them and I had formed a very, very, very clear view that there were no circumstances in which I would base public safety on 100 per cent compliance in the abattoirs.

It was all right to accept a degree of default when you believed that the thing was not transmissible, but it was not all right to accept default when you came to believe that it was transmissible. And there was no prospect of my ever accepting a deboning regime voluntarily. It was forced on me for a few days by the Cabinet colleagues, but I would never have accepted it voluntarily because it would have meant putting my trust in people in whom I did not have that confidence. That is another point I think of importance. ²⁵

7.494 Had Mr Hogg sought advice from MAFF and from the MLC on this point, he would have received confirmation that 100 per cent success in the removal of spinal cord had not yet been achieved. We note that between 1 November 1995 and 20 March 1996 there were 19 instances where State Veterinary Service (SVS) staff found spinal cord had not been removed of which, in 11 cases, the health stamp had been applied. ²⁶

7.495 So far as the deboning option is concerned, SEAC stipulated in its advice that deboning would have to take place in licensed plants supervised by the MHS. As to this requirement, Mrs Browning commented to us:

Clearly there were limitations on the capacity of the industry to bone out all carcasses over 30 months of age, because it is a technique in the abattoir which has to be learned. It is a very specialised skill. Some abattoirs, a few, had this ability to do this. They had staff ready trained. There would have been a difficulty in terms of timing, in order to train sufficient staff. ²⁷

7.496 In his statement to us Mr Major remarked that the Cabinet agreed that the recommendations of SEAC should be accepted in full, although the detailed implementation would inevitably take some time. ²⁸

7.497 It does not seem to us that the Cabinet had the time or the information fully to appreciate the practical implications of the deboning recommendation.

7.498 Mr Major commented in his statement, with hindsight, that had the matter been raised with him earlier, SEAC might have been asked to consider the matter with greater urgency. Had SEAC been invited in February to advise on a contingency basis, it is at least possible that the practicalities of 100 per cent enforcement of the SBO ban and of deboning in licensed premises under MHS supervision might have been explored before 20 March. Mr Hogg's personal reaction that de-boning was not a viable option might then have been supported by data. It might even have been shared by SEAC.

The issue of public confidence

7.499 We have no doubt that the primary consideration of the Government, when facing the crisis, was to ensure that any measures necessary to protect public health were put in place. They had, however, a powerful, and legitimate, secondary consideration. They wanted to mitigate, insofar as possible, the effect that the SEAC announcement would have on the beef market. To this end, considerable thought was given as to what should be said to the public. The Cabinet did not, however, consider whether it might be desirable to take more drastic action than that recommended by SEAC in the interests of the beef market. The reason that the policy that they selected proved unviable was because it was not acceptable to the market.

7.500 Mrs Browning explained the position to us as follows:

The overwhelming reason why the scheme was not put into practice and the 30 month slaughter scheme was implemented was because within 24 hours of the announcement on 20th March the retail trade, mainly the large supermarkets, made it absolutely clear that they were not going to sell meat over the age of 30 months. That was a view endorsed quite vocally for example by the leader of the NFU. It became quite apparent that in order to maintain public confidence post 20th March in British beef, that the decision by the supermarkets to say they would not sell it was instrumental in maintaining confidence in British beef. I have to say they were absolutely right to do so. It is to their credit that they pressed for that decision. However difficult the crisis was for the farming industry post 20th March, that action and that position did help to maintain confidence in British beef and allow the market to recover, as it has now recovered. ²⁹

7.501 In his statement Mr Major said this of the decision to abandon deboning and introduce the 30 month scheme:

Subsequently the Government did take further steps, but these were justified by the need to restore public confidence in the beef industry which had been affected severely by the media response to the announcement. We did, of course, anticipate the possibility of a highly adverse public reaction, but in Government decision making cannot be driven by concerns which appear to have no solid foundation: by contrast, the steps that we have agreed upon were firmly founded on the scientific advice we received. ³⁰

7.502 We have some difficulty with the logic of this part of Mr Major's evidence. It seems to us that the speed with which the Cabinet had to act precluded any informed consideration as to the effect that the alternative options were likely to have on the market. For this reason we make no criticism of the failure to take this into account. Had time permitted, however, it seems to us that the requirements of market confidence should have received careful consideration and been taken into account when policy was formulated.

7.503 We observe that this is a matter that received some embryonic consideration. On 15 March, Mr John Cowan, the Head of Beef Division, at the request of his superior, Mr Geoffrey Hollis, Head of Livestock Products Group, provided costings for two scenarios. One was that it proved necessary to take out of the human food chain animals over 2 ½ years of age, essentially cull cows. After advising on the very considerable costs that this would involve, he concluded with the following observations:

In addition to the direct costs of removing cull cows and adult bulls from the food chain, one has also to consider the likely consumer reaction. It is inconceivable that a ban on cow beef will not adversely affect consumption of all beef. That effect will be catastrophic unless we are in possession of convincing, indeed compelling, scientific arguments for taking such a draconian step only in relation to animals above a certain age. We should also have to face the argument that banning the consumption of muscle (which has never shown evidence of being susceptible to BSE infectivity) casts doubt:

a) on the measures we have in place currently;

b) on the safety of all beef muscle; and

c) perhaps most worrying, the safety of the most important cow product, milk. ³¹

7.504 A few days later he produced a note on the implications of a severe collapse of the beef market. This incorporated part of his paper on the effects of a ban on the sale of beef derived from animals aged over 30 months. He appears by this time to have had further thoughts on the effect that such a ban would have on the market, for he concluded his note:

The industry might, however, see some attraction in a voluntary ban on the sale of cow-beef, provided that the market for it could be supported through some form of intervention or compensation. Those slaughterhouses which supply the major supermarkets would undoubtedly be in a better position to do so if they could guarantee that they were not slaughtering cows. It would not be difficult for the MHS to enforce such guarantees, and they might serve to protect the market for steer beef from the long-term effects of this scare. ³²

On 18 March this note was forwarded by Mr Packer to Mr Hogg. ³³

7.505 At the Ministers' meeting on the following day Mr Hogg is recorded as saying

. . . that he believed that the panic which would ensue from any statement would destroy the beef industry. He believed it might be possible to save it if a firebreak could be erected and he had offered the best advice he could. He commented that the difficulty was that we knew that SBO controls were not wholly adequate and in the changed circumstances of the new information this made the Government's position untenable. ³⁴

7.506 This indicates that one consideration that Mr Hogg had in mind when urging the 30 month scheme was that this might have a beneficial effect on the market.

7.507 Having regard to the enormous cost of the 30 month scheme, it is not realistic to suggest that the Government would have adopted it simply on the basis of speculation that it might be beneficial to the market. We question whether, had time allowed, confidential soundings could not have been made which would have brought home to the Government that the de-boning option would not be acceptable to the market. In this context we have in mind evidence from Mr Hogg (see paragraph 7.383) that suggests that he had excellent contacts with some in the industry:

. . . I used to see Tom Viner and people like that - he was the Chief Executive of Sainsbury's, as you may remember - and others, we used to dine together sometimes and lunch together sometimes, not very frequently, and they used to come up to the office. I was absolutely delighted when the NFU and Sainsbury's, Tom Viner in particular and others, came to see me in my office after the Cabinet colleagues had rejected my policy, and pressed me to do exactly what I wanted to do. An enormous smile came across my face, and I told them how sensible and wise they were. But I do not actually remember talking to them in great length about the 30 months scheme beforehand. I think I was a bit surprised actually that they were pressing me to do exactly what I wanted to do. ³⁵

7.508 With hindsight it is clear that deboning was not a viable option and that Mr Hogg was right to opt for the 30 month scheme. His reaction to de-boning reflected that of the supermarkets and their customers. Had contingency planning begun in February and proper consideration been given to the various options, we think it possible that the Government would have opted for the 30 month scheme in the first place, rather than for a de-boning scheme which could not be implemented in the short term and which was perceived as an inadequate response by the NFU, the meat industry and the consumer.

7.509 Mr Hogg made the point that his policy had included a prohibition on the export of beef and beef products that did not comply with the 30 month rule. He went so far as to suggest to us that if this had been adopted in the first place the European beef ban would not have been imposed. ³⁶ We do not find that suggestion realistic. It does, however, lead us to a more fundamental observation in relation to contingency planning.

7.510 We have observed elsewhere that throughout the period with which we are concerned public pronouncements tended to convey the impression that BSE was not transmissible to humans. While most of those making the statements were aware of the possibility that humans might have been infected before precautionary measures were introduced, this matter was not put before the public. Public pronouncements did not lay the ground for the possible contingency that, in due course, BSE might be shown to have been transmitted to humans. Had this message been conveyed it might have proved easier to persuade the public that the early cases of vCJD did not cast doubt on the safety of the beef that was being sold in 1996.

The position of children

7.511 We have identified one other area where contingency planning might have proved beneficial. The young cases of vCJD raise the obvious question of whether children might have a particular susceptibility to infection with BSE. That question had been raised but not answered when Mr Dorrell made his statement to the House on 20 March. Following Sir Kenneth Calman's statement, Mr Dorrell was constrained to say that parents would be concerned about implications for their children and that he had asked SEAC to provide specific advice on that issue following its next meeting. ³⁷ This statement must have alarmed many parents. SEAC subsequently advised that there was no reason to believe that children were particularly susceptible. Had that advice been obtained before 20 March parents could have been reassured rather than alarmed.