Volume 7: Medicines and Cosmetics
9. Consideration of an audit of the uses of cattle tissues
Discussion
Why was an audit needed?
What happened
The consequences
The causes
The adequacy of the response
1. The MAFF response between 1989 and 1992
2. New MAFF proposals for an 'audit trail' in 1995
3. The DH response
Lessons

9.124 In this section we consider first why an audit was needed in relation to BSE, what happened to the proposal that emerged for such an audit and the consequences. We then look at the adequacy of the response by MAFF and DH respectively. We conclude, as in other discussion sections, by drawing attention to some general lessons for the future.

Why was an audit needed?

9.125 BSE was a TSE deadly to cattle. Potentially, it might also infect humans, millions of whom daily came into contact with some form of bovine product. As the disease spread, the Government found itself drawn into a series of major policy decisions affecting national economic and public health interests on a far wider front than that normally associated with an outbreak of animal disease. It needed a framework within which to work effectively and rationally.

9.126 An obvious first step was to map out the destination of each bovine product, and the processes and handling involved. It was essential to ensure no potential routes of transmission for the BSE agent had been overlooked.

9.127 Those responsible for ensuring the safety of each potential route of transmission could then be contacted and the risk assessed. Coordinated measures could be adopted. Once action had been taken, the map of identified pathways could be used to monitor the situation, identify any gaps and ensure new information was relayed as appropriate.

9.128 This overview needed to transcend departmental boundaries. The situation was extremely complex. Several freestanding pieces of safety legislation were in place across the huge range of products involved, in some cases with Scottish and Northern Irish variants. Many different Departments and public bodies had responsibilities for regulating, enforcing and monitoring individual activities.

What happened

9.129 We had expected to find that the policy divisions in MAFF and DH had needed no prompting to embark on the necessary information-gathering about potential routes of infection. As the narrative above reveals, the importance of doing so had been flagged up in 1988 at the first meeting of the Southwood Working Party and a year later it was identified by the Tyrrell Committee as a top-priority project. As such, it was endorsed by the MAFF Permanent Secretary and listed in the programme of work, though as we discuss below, with a degree of confusion surrounding who was doing it. When it failed to materialise, its importance was again urged in 1990 and 1991 by SEAC. Only in 1996, urged by SEAC, was the work eventually put in hand.

The consequences

9.130 We are in no doubt that the absence of this information-gathering exercise affected the speed and promptness of some of the action taken on BSE. As this and other volumes have shown, some matters, for example action on cosmetics and toiletries, were not picked up and dealt with as swiftly as they might have been. Moreover, the lack of an overall framework and direction meant that, even when they had been identified, action to block some potential pathways of infection was allowed to languish. The stories on advice of the Advisory Committee on Dangerous Pathogens (ACDP) to high-risk groups and DES advice on bovine eyeball dissection are examples of this (see Chapters 8 and 9 of Volume 6). In addition, there was inconsistency in the assessment of some risks under the different regulatory regimes. An area where, on the face of it, the approaches were inconsistent, is described in Chapter 6, namely the use of intestines for sausage casings (which was considered unacceptable) and for sutures (the continued use of which was permitted pending the production of clean stocks). The full range of uses of some basic products such as tallow and gelatin, and the need for a comprehensive assessment of such uses were not recognised until late in the day. Some potential pathways of infection through waste disposal were not identified at all.

9.131 While the absence of an audit of cattle products was not by any means the sole cause of all these failings, it none the less, in our view, played its part.

The causes

9.132 Why did so important a basic exercise languish? We identified some prior factors that influenced how the Tyrrell Committee recommendation A1d was tackled:

1. The ambivalent status of the project.
2. Its linking with cosmetics.
3. The battle being waged over research funding.

9.133 These might not have been fatal to the outcome had it not been for a fourth factor:

1. Lack of ownership.

9.134 We look at each of these factors in turn.

(1) Ambivalent status of the project

9.135 A problem from the start was how to categorise what was required for budgeting purposes. The project was identified in a report on research needs. But it was not scientific research in the sense attaching to most of the other studies proposed and certainly not the sort of item funded by research councils. Dr Pickles, when seeking to persuade one of the DH divisions to finance its modest costs, termed it 'soft research'. In a supplementary statement to the Inquiry, Mr Bradley spoke of 'a surveillance study rather than a scientific research study . . . . It would be a matter more appropriate for the policy side of MAFF, probably either the AHD or the MHD.' ¹ Dr Matthews in 1995 saw the revived audit proposal as a hands-on exercise that could be carried out with internal State Veterinary Service (SVS) resources, as had been done in the tracing of rendering practices as a pathway for disease (see paragraph 9.103 above). It was ultimately commissioned from a team of consultants.

9.136 This collection of perspectives seemed to us to reflect that what was required was not scientific research, but a systematic information-gathering exercise to assist policy-makers. Given the wide-ranging and in some cases unfamiliar areas needing to be tracked through, and the many parties involved, this clearly could not be done by MAFF in-house on its own. Collaboration with other interested parties and a modest amount of Departmental finance were going to be needed.

(2) The linking with cosmetics

9.137 We referred in the previous chapter to the confusion about follow-up action on cosmetics, arising from their linking with the audit proposal within the single recommendation A1d. We look further below at how this contributed to confused and unduly reassuring reports about what was happening on the twinned items. These repeatedly obscured the lack of progress.

(3) The battle over research funding

9.138 The Government's decision to cut money for agricultural research (see Chapter 6 of Volume 2) was causing MAFF much anguish. In summer 1989, they were in the thick of the fray with the Treasury about their future budget.

9.139 Within this fraught situation the audit proposal, listed by Tyrrell as a three-star item, had the advantage of being initially earmarked for funding. However, the downside was that it became swept up within the overall MAFF strategy for obtaining extra resources, and identifying projects that fell to others to fund.

9.140 The Permanent Secretary, Mr Andrews, had taken the wise step of asking an ad hoc group of scientific budget managers and key veterinarians to review what was already in hand on BSE and work out what extra funding might be needed to accommodate all the Tyrrell two-star and three-star recommendations. He asked them to split the items into two lists: those accepted for MAFF funding and those falling to other Departments or the private sector.

9.141 It would appear that before the projects were divided in this way, handling the audit proposal was already perplexing the ad hoc group. Dr MacOwan's initial assessment read: 'Advice should be sought from the Tyrrell Committee.' ² This was swiftly amended by Dr Shannon to say that routes currently considered important were being pursued, scientific progress might reveal the need for further action and the issue was of importance also to DH.

9.142 These were general statements of the obvious. They did not advance matters in any way on the proposal itself. However, a month later the two lists Mr Andrews had asked to be prepared were agreed and submitted to Ministers as the way forward. The audit was allocated to Table 2 as the responsibility of other Departments or industry alone or jointly with MAFF. This directly led to much of what followed. MAFF research staff concentrated on developing the projects set out in Table 1. The audit proposal was left adrift in Table 2. This was to prove ultimately fatal.

(4) Lack of ownership

9.143 The problems about the status of the project and how it was to be carried forward were not insuperable. They could have been speedily sorted out had the project had a champion. None emerged to press for the work to be done and secure action. The successive entries about it in the progress charts covering all the Tyrrell recommendations make plain that it was an unclaimed object.

• June 1989: Not in progress. Advice should be sought from the Tyrrell Committee. ³
• July/August 1989: Under the general annotation of: 'DH/DES or industry alone or jointly with MAFF'. Those routes considered important are being pursued. Scientific progress may reveal the need for further action. The issue is of importance also to DOH. ⁴
• March 1990: DH/Industry. In progress. ⁵
• April 1990: DH/Industry. Not in progress. ⁶ (Seen by SEAC in May 1990.)
• May 1990: DH/DTI/MAFF/Industry. In progress. Advice being given by DTI to trade associations. ⁷
• June 1990: DH/DTI/MAFF. Advice being given by DTI to trade associations. ⁸ (Dr MacOwan's minute of 21 June.)
• June 1990: DTI, MAFF and industry. In progress. Advice being given to trade associations in relation to cosmetics. Investigations under way to determine other outlets for bovine and ovine tissues. ⁹ (MAFF memorandum to Select Committee.)
• September 1991: Being examined in-house by MAFF and DH. ¹⁰ (draft section of report tabled for SEAC.)

9.144 The object of these charts was to present an up-to-date situation report. They identified the priority of each item, where it was being done, the research allocation and the current position, thus providing a form of accountability. In the case of the audit, comparison today of the entries not only indicates how rudderless it was; it also shows how the link between cosmetics and the general audit obscured the fact that no comprehensive audit was in hand.

The adequacy of the response

9.145 With these four factors in mind we reviewed the adequacy of the response:

1. by MAFF between 1989 and 1992;
2. by MAFF in 1995; and
3. by DH.

1. The MAFF response between 1989 and 1992

Who was responsible for action?

9.146 We have identified above the lack of ownership as a crucial factor. We considered who might have been expected to recognise the need for an exercise of this sort, with or without a recommendation from an expert committee, and who might have been expected to take forward the Tyrrell recommendation about it.

9.147 MAFF and DH had been partners in establishing the Tyrrell Committee. However, when the Interim Report was received, MAFF placed itself firmly in the lead on its handling. The Permanent Secretary, Mr Andrews, wrote in June to the CMO about the work he had put in train to deal with it, and set in hand action to identify resources. The MAFF Minister, Mr Gummer, put to colleagues in August proposals about the way the Report's recommendations should be handled, and eventually negotiated its publication. Mr Lawrence in MAFF had the job of regularly updating the progress chart.

9.148 Within MAFF, Animal Health Division, headed by Mr Robert Lowson, was responsible for developing policy on BSE. Mr Lowson worked to Mr Cruickshank, and subsequently Mrs Attridge, both of whom took an active part in advising Ministers about BSE policy issues. However, the role of working up policy proposals and submissions for Ministers, and setting up the arrangements to carry them out, was generally a Head of Division responsibility. Thus it seems to us that Mr Lowson had a responsibility to ensure as far as possible that the development of policy on BSE was properly informed by data from appropriate scientific research and field studies.

9.149 We do not think this responsibility lay with the CSG, whose concern was the effective deployment of the MAFF research budget within the resources available. Their recommendations about allocations depended on the strength of case and enthusiasm that policy divisions presented. Nor do we think it was the responsibility of the CVL. The CVL was a major research contractor, not a policy-maker. Once the allocations to Tables 1 and 2 were made, all its attention was devoted to the items in the former. As we have seen, the job of updating the chart as a whole, and thus monitoring progress in delivering the data needed by policy makers, rested with Mr Lowson's Division.

Animal Health Division policy development on BSE

9.150 Mr Lowson described the objective of BSE policy as being to take the action necessary to reduce as far as practicable the risk of exposure of, first, people, then animals, to the agent.

The fundamental objective of the policy was to do so to the extent to avoid disease being propagated. ¹¹

9.151 He agreed that it was desirable to have the best possible understanding of ways in which cattle, other animals and humans might come into contact with possibly infective material. He considered that what was needed for such an investigation was not scientific expertise, but knowledge of what happened in slaughterhouses and some knowledge of industries which made use of slaughterhouse products. ¹²

9.152 He did not need advice from scientists on the Tyrrell Committee to identify the need for an audit, nor from any other scientist as to how such an audit would be carried out.

9.153 Thus he was not disagreeing with our view that irrespective of anything the Tyrrell Committee recommended, it was part of the Animal Health Division policy role to consider whether a fact-finding exercise was desirable to map all the ways cattle products were used and their possible pathways for infection. Already MAFF was heavily engaged in developing new controls over high-risk bovine offals in human food. It was carrying out a joint exercise with DH to identify the use of bovine material in licensed medicines. Dr Matthews's initial discussions on 9 June 1989 with the HSE about following up the Southwood recommendations on occupational risk had led him to ask for a list of slaughterhouse products and their destinations (see Volume 6). Mr Lowson told us in oral evidence that when he saw Dr Matthews's request he thought this was a good idea. ¹³

9.154 The resulting preparation of a list by Mr Hutchins was subsequently to have an important influence on what was decided about the audit. Following the later hurried compilation of a list by Mr Rogers at Mr Lawrence's request in April 1990, a slightly expanded version of Mr Hutchins's list was put to SEAC. This in sum appears to constitute the 'in-house work' that was thought to make a full audit for the time being premature. It appears never to have got beyond the initial stage, apart from later ad hoc additions. This was scarcely a systematic investigation. As Dr Pickles pertinently observed, the purpose of a research study is 'to investigate more formally as to what actually happens, not what some of us think might happen'. ¹⁴

Carrying forward the audit proposal

9.155 Mr Lowson told us he had little recollection of the handling of the Tyrrell Report, and that so far as the audit was concerned he had reconstructed events from the written record.

9.156 We were curious as to his lack of involvement, given the responsibilities we have indicated above and his own manifest engagement in developing a variety of measures to protect against BSE risk. Mr Lowson explained that he was neither responsible nor involved at the time because the CSG was carrying out the research review:

At that time it was not the responsibility of my Division to commission research work and so to the extent that this would have involved formal research projects, I would have expected to have been consulted but would not have taken the lead on how any work flowing from this Committee's work was to be pursued. ¹⁵

9.157 He saw the audit proposal as being handled by others 'with relevant responsibility and expertise' and 'better qualified' than himself.

9.158 Whoever was sorting out the resource implications of the package as a whole, it seemed to us that Mr Lowson continued to have a direct interest in securing that the outcome adequately reflected his Division's needs, and that the agreed projects relevant to these were speedily carried through.

9.159 It is unclear from contemporary papers what part he played in the discussions in July 1989. In oral evidence he told us that after Tyrrell reported he would certainly have had an interest in seeing that this was carried forward. ¹⁶ He said his Division was involved in agreeing with the CSG how each of the proposals should be responded to in the light of how useful they would be to him in his work. He thought that he had wondered whether it was necessary to initiate a formal study and that either he or Mr Lawrence must have fed that view into their deliberations. ¹⁷ This then appeared in the advice CSG offered to Ministers. As we have noted in the introduction to this discussion, the allocation of A1d to Table 2 was to prove fatal. Thereafter the project gathered dust until the following spring.

How matters were handled thereafter

9.160 In March 1990, the dearth of action was revealed when Dr Pickles queried Mr Lawrence's proposed update of the Tyrrell progress chart. In oral evidence Mr Lowson aptly said:

One is not going to pretend that this is the tidiest bit of bureaucratic activity you ever saw in your life . . . ¹⁸

9.161 He told us that after SEAC had reaffirmed the high priority of the item he imagined he would have made enquiries of colleagues and discovered that the work had been done and that they had the basic information. ¹⁹ However, matters had apparently not advanced any further when Mr Gummer met with officials on 21 May to be briefed for a BSE debate in the House of Commons. At this meeting Mr Gummer said he wanted the audit to go ahead and that MAFF would pay for it.

9.162 As the chronology has shown, a protocol for the study was still lacking a year later, in April 1991, when SEAC called for a paper. On discovering that nothing had been done, Mr Maslin minuted that it had 'fallen through the cracks'. ²⁰ We explored why this had happened, given Mr Gummer's clear expression of his wishes.

9.163 Unusually, no record of Mr Gummer's meeting was made at the time. This led to misunderstandings thereafter about who was actually drafting the protocol. Dr Pickles told us that she told Mr Gummer she would start thinking about a protocol straight away, so that he could mention in all honesty to Parliament that all the work had started. ²¹ She believed it was clear to MAFF colleagues present that this was a device to ease a Ministerial statement, not a commitment from DH to sponsor the work. There was no suggestion that this would involve misleading Parliament. None the less, Mr Gummer was emphatic that he would never do this:

Now I do not believe that I would have been party to something which could properly be called a device. Either it was happening or it was not happening. I know I would not have been because it would have been unacceptable and certainly would not have fitted in with my way of looking at life generally and certainly this particular difficulty personally. ²²

9.164 Mr Lowson thought Dr Pickles had undertaken to follow up. However, on 4 June, Dr Pickles objected to the A1d entry in Mr Lawrence's draft chart for the Agriculture Select Committee, and told Dr MacOwan, in a minute copied to Mr Lowson that she was not doing the work. Mr Lawrence told Mr Lowson he was not aware of Dr Pickles's having done any work, but this did not prompt any contact with Dr Pickles to clarify the matter. She wrote a week later to Mr Bradley to say she presumed he had the work in hand and asking if he wanted help with the protocol. This letter does not appear to have been copied to Mr Lowson.

9.165 Meanwhile the DH Research Division, with whom Dr Pickles had previously been exploring the possibility of DH funding, had confirmed with Mr Lawrence her understanding that MAFF was paying for the project and that it would appear in the project list. The version attached to the MAFF memorandum for the Select Committee, which was copied to Dr Pickles, indicated it was in progress. Shortly after, Mr Bradley replied to Dr Pickles's letter saying he had not got far with the matter. He did not say in terms that he was not working on it.

9.166 In July 1990, SEAC was told that MAFF had sought information from slaughterers which would provide a comprehensive picture. A few days later Mr Lowson advised Dr MacOwan that Animal Health Division had kicked things off through an enquiry at slaughterhouses to establish what happened to the whole range of bovine tissues. ²³ Pending the results, there was no need to direct resources to this issue. However, this slaughterhouse enquiry, as we have noted above, did not appear to consist of much more than the Hutchins and Rogers lists slightly updated. It seemed to us that, after kicking things off, Animal Health Division was losing them in the long grass.

Was the MAFF response adequate?

9.167 Although we think the misunderstanding at the time over the protocol was understandable, it did not need to persist as long as it did. An inquiry about progress in the months that followed would have revealed the true situation. As Mr Lowson was himself to observe in April 1991 when faced with Dr Pickles's wrath on discovering that work had not begun:

I entirely agree that it is not satisfactory that this item on the Tyrrell shopping list should not have received the attention it deserved. . . . No doubt for our part we should have been more assiduous in trying to find out what was going on. ²⁴

9.168 When we asked Mr Lowson if he had any further observations on the adequacy of his response in 1989 and after, we were told that he was not involved in considering the Tyrrell Report and that it was reasonable for him to believe up to 1990 that an audit was not needed. Moreover, nobody had disputed the entry in Table 2.

9.169 We have set out our reasons already for believing the information was indeed needed. Our hindsight review of some of the consequences that flowed from its absence amply demonstrates this. But we think that it also should have been obvious at the time. We have indicated our view that, as head of Animal Health Division, it was for Mr Lowson himself to champion the case.

9.170 As to what happened after May 1990, we were told on Mr Lowson's behalf that other matters thereafter took a higher priority over consideration of a possible research project to analyse the fate of bovine tissues. It was put to us that as the work had been partly done already and was regarded by DH as a 'relatively minor matter' this reflected a reasonable judgement.

9.171 In oral evidence Mr Lowson told us that after the excitement of the cat in May 1990 the matter got put to one side not because it was forgotten but because they were reasonably reassured that there was no potential route of exposure that had not been checked off one way or another. ²⁵ It seems to us that unless a systematic approach were adopted, it was not possible to be confident of this.

9.172 In considering Mr Lowson's response on the proposed bovine audit, we are conscious that in June 1989 he had only newly taken up his post in Animal Health Division and was dealing with many unfamiliar and urgent issues. The apparent management by the Chief Scientists team of the next stages on the Tyrrell proposals may have falsely reassured him that no action from him was called for.

9.173 None the less, we consider Mr Lowson should have ensured the matter was promptly and properly addressed then and subsequently. As he said in oral evidence, the matter was not tidily handled. Nor was it ever brought to a satisfactory conclusion. It was of some concern to us that by the time Mr Lowson left Animal Health Division in 1993 no audit had as yet been carried out. We discuss elsewhere some of the omissions that might have been identified and rectified had such an audit been achieved.

2. New MAFF proposals for an 'audit trail' in 1995

9.174 We now turn to the way matters were handled after the review of MAFF research on TSEs in February 1995 identified an 'audit trail' of the fate of bovine and ovine tissues as an area where work was needed. A year later, SEAC was to endorse this as urgent and sensible and to be 'unrepentant' in the face of MAFF pleas about the difficulty of doing anything quickly.

9.175 In 1995, Mr Thomas Eddy was head of Animal Health (Disease Control) Division. Dr Matthews was still acting as an in-house veterinary adviser to the Division.

9.176 The initial suggestion in March 1995 was that the work could be paid for out of the CVL annual surveillance budget. However, Dr Matthews did not think it even needed this and considered that a team of VOs could do the job, with the cost contained in-house. The final version of the paper circulated in May 1995 identified it as an AHVG study coordinated by the policy division.

9.177 However, it transpired after some months that there were insufficient resources to tackle the job in-house and it was decided to use outside consultants. SEAC at its November meeting had failed to reach the research priorities item due to lack of time, but in January and February pressed for the audit to be done. There was some administrative uncertainty about whose job it was to carry matters forward and further argument about how it should be financed. Following the March statement on the emergence of vCJD, the difficulties were swept away and the project was commissioned in June 1996.

Was the 1995 response adequate?

9.178 Had an audit been properly pursued in 1989, this question would not have arisen. That was not the position, and in 1995 it was recognised that the complex and far-ranging exercise of BSE containment needed solid information to underpin it. As Dr Matthews observed in March 1996, detail was needed for risk assessments by SEAC.

9.179 Once again, however, there was uncertainty about the nature and thus the funding of the project. Its initial designation for priority research funding was changed on the grounds that it could be done in other ways under the heading of surveillance. Because of this, it went to the foot of the research priority list. By the time it was realised that the work could not be done in-house as planned, the research budgeting cycle had rolled forward and there was no money available. In the event this financial question was sorted out, no doubt assisted by the fact that the cost was relatively modest.

9.180 We considered whether Mr Eddy should have perceived the importance of mapping the possible transmission routes of BSE and, once the research recommendation had been made in May 1995, ensured that no time was lost in getting the work put in hand.

9.181 He told us:

I would emphasise that the audit was not classed as urgent in the May 1995 conclusions of the research review and therefore the time-scale followed was not unreasonable for non-urgent work . . . ²⁶

9.182 We were not clear that Mr Eddy was correctly recalling his understanding of priorities at the time since it was at odds with Dr Matthews's reasoning, which he had set out in a minute abut the review findings copied to Mr Eddy on 25 April 1995.

9.183 What did happen was that with Mr Eddy's agreement, a means was apparently found to launch a surveillance study within available resources. The failure to get it in hand did not become apparent for a little time. Time had not allowed SEAC to discuss research priorities in November. However, the time lost after it was appreciated that the project needed funds was relatively brief. Once SEAC had given them their marching orders in February, officials lost no time in getting the project under way. In these circumstances we make no criticism of Mr Eddy.

3. The DH response

9.184 DH was only marginally involved in 1995 when the need for an audit was raised again in the context of the coverage of the MAFF-funded TSE research programme. However, in 1989 it had been much more directly engaged, in particular as a result of its joint sponsorship and secretariat of the Southwood and Tyrrell committees. We considered what role it played in the handling of the audit project and the adequacy of the response. We looked in particular at the actions of Dr Pickles who had the main DH liaison role with MAFF on BSE. Did she share Mr Lowson's responsibility for the failure to get the audit off the ground, and to follow up what happened to slaughterhouse products?

9.185 The picture that emerged at each stage, until her departure to a different post in September 1991, was that Dr Pickles pushed hard for the audit to be carried out. She had prepared the initial list of possible transmission routes that shaped the Southwood Working Party's priorities. Although at this period she considered that action was purely precautionary, she was involved in the Tyrrell Committee discussions that led to recommendation A1d in 1989. She sought to raise the matter with SEAC in April 1990 but, as we have seen, her paper was dropped in the face of Mr Meldrum's opposition.

9.186 She also took independent action in an effort to secure DH funds to break the impasse on the project and dropped this initiative only when Mr Gummer indicated MAFF would pay. She had raised directly with him the failure to carry out the project and that led to his instruction that it should go ahead. Thereafter, as already discussed there was confusion about the protocol. We do not attribute blame for that misunderstanding.

9.187 Should Dr Pickles thereafter, like Mr Lowson, have taken steps to check what was happening to the protocol? Her minute in April 1991, when she discovered the lack of progress, refers to her receipt of several assurances that it was in hand. As soon as she learnt the true state of affairs she energetically sought to get things moving again until the time she handed over the BSE work in autumn 1991.

9.188 Dr Pickles's robust and wide-ranging contributions to policy development did not always endear her to her MAFF colleagues. Taking account of the clear MAFF lead in following up Tyrrell, her own efforts to secure progress and the nature of the working relations between the two Departments, we do not think she should have done more than she did.

Lessons

9.189 There seemed to us to be several lessons to be drawn from this part of the BSE story that would apply pari passu to other major threats to human and animal health. Some are discussed in our chapters on commissioning research. We set out four that struck us particularly in considering the audit:

1. When faced with a deadly cattle disease potentially transmissible to humans, it should have been an immediate priority for MAFF to identify all the ways in which bovine material could come into contact with humans and other animals. This basic information was needed to map the territory that needed to be considered, for risk assessment and for the application of detailed measures. Fact-assembly of this sort ought not to have been confused with research.
2. An overview of cattle products needed to transcend Departmental boundaries. Even when the 1996 audit was being put in hand this was heavily orientated to MAFF areas of responsibility. It also needed to draw on a wider range of expertise than that available within Departments alone.
3. Overall 'ownership' of the exercise needed to be explicit and responsibilities placed on named individuals to direct and follow it through. As part of this, progress reports should not have been regarded as a low-level task to be automatically updated, but treated as a means of accountability. They should have made clear where there were any shortfalls, confusions or failings and who was charged with dealing with them.
4. Departmental financial arrangements needed to retain sufficient flexibility to cater for the immediate commissioning of 'soft' research where the need was urgent. This is part of a wider set of issues about the need for modest 'contingency funds' at Departments' discretion for meeting urgent research or consultancy demands.