1.4 The spread of the disease in the United Kingdom was aided by the transportation of livestock around the country. Dealing outside the ring at critical large markets appeared to make the tracing of animals more difficult if not impossible. We were told by the NFU witness that the announcement of a nationwide livestock movement ban some days after the outbreak had begun meant that the expansion of the outbreak became inevitable. At the same time some submissions indicated that it would be unwise to interfere with the traditional process that has had stock migrating from the hills to the lowlands for finishing for centuries. But for the last 50 years the policy of paying support to farmers for the number of livestock on their land, irrespective of the environmental impact, has greatly increased animal movements as farmers adjust their own numbers in the run up to the 'counting day', currently the 1st March.

1.5 We find that there should be an immediate ban on animal movements from Day One of any future outbreak.

1.6 We find that, while acknowledging the practical and financial difficulties that may arise, a permanent regulation should be made requiring that all livestock which is susceptible to FMD, which moves onto a farm or returns to a farm unsold from market, or is rejected by a slaughterhouse, triggers a 21 day standstill for all relevant livestock on that holding. Exceptions could be permitted by licence which would include special conditions (e.g. quarantine, to slaughter, to holdings in the same occupancy).

1.7 We find that in principle a new culture needs to be developed around the marketing of livestock which effectively reduces or even eliminates trading outside the ring, the subsequent hawking of animals around the country and them changing hands a number of times in a very short period. (These may be long established practices but are clearly the prime cause of the difficulty in tracing stock and thus the spreading of disease.) Other countries demonstrate that this kind of dealing is not an essential part of a successful livestock industry. In any case every 'middleman' transaction increases the difference between the price to the farmer and the price to the ultimate consumer. (It has been represented to us that 'dealers' are not licensed and despite the difficulty of defining 'dealing' perhaps that would improve the 'culture'.) Regulations should be introduced that cause all buyers and sellers to register all transactions as well as movements immediately (there is currently a 3 day period of grace!). Multi-agency enforcement should accompany the regulation, and powers given to courts to ban individuals from trading if they are shown to have consistently failed to make and keep the necessary records. There is a particular need to improve the means of identification and regulation which will better control the movement and traceability of sheep.

1.8 We find that a study should be made of the feasibility of re-establishing the right density of local abattoirs and grant aid needed for that. The objective should be to enhance attempts to boost local consumer loyalty and reduce 'food miles'. Parallel efforts should be made to persuade large supermarkets who currently invest in a few large abattoirs that the same investment should be redirected to a network of small abattoirs instead, as a demonstration of their support for locally produced and processed meat.

1.9 There is evidence that the State Veterinary Service (SVS) had been run down over the last two decades and was thus greatly overstretched during the outbreak and its aftermath, the Inquiry was told, while the knowledge and experience of many local vets was not used. Retired vets, some with experience of previous outbreaks, volunteered their services but were rebuffed. In some cases the eventual hiring of vets from other countries, while very welcome at the time, created new problems arising from a lack of local knowledge and unfamiliarity with the language. (Since our public hearing a vet who worked in both the 1967 and the 2001 outbreaks has published his recorded comparisons of the methodology employed in each, including the time taken for similar actions. It underlines all that we have heard and provides factual support for some of the evidence offered to us (Richardson, A., Veterinary Times, 5th November 2001). An explanation of the policy decisions which drove the outbreak handling up such a different route in 2001 must be sought if the disaster is not to be repeated).

1.10 We find that the State Veterinary Service should be restored to a level which would enable it to respond more effectively to a future outbreak, and that the principle of 'retained vets' as Licensed Veterinary Inspectors should be enhanced so as to make them readily available to supplement the SVS force in any location in times of disease outbreak. We were told that precise precedent exists in other countries such as Australia and New Zealand and we can think of no good reason why such a scheme does not exist here.

1.11 All 'retained vets' should undergo regular training and refresher courses in the handling of animal disease epidemics.

1.12 On vaccination, there are two potential ways in which it might be used in a future outbreak, namely for eradication and containment. We find that the Government should set aside its perceived presumption against vaccination and explore how modern vaccination techniques could help tackle future outbreaks without resorting to the disastrous policy of killing and of contiguous culls with its attendant disposal problems that during 2001 brought both farming and tourism to their knees.

1.13 To this end we suggest that Government give much greater priority to more scientific research into vaccination backed with appropriate funds and contracts.

1.14 While we welcome the move by Government (since our Inquiry) to set up an international conference to discuss vaccination, it should go further and initiate international co-operation (beyond the EU) on vaccination by setting up an international partnership that would explore the issues, agree best practice, co-operate in vaccine development and production, and adopt a global strategy to which all livestock producing countries could sign up. This alone will create the level playing field for all producers.

1.15 But, in the short term, the use of vaccination to contain the disease and thus reduce the pressure on the system of slaughtering and disposal must be considered.

1.16 We find that the whole question of using vaccination in the interest of temporary containment must be explored in the context of 1.12 above. DEFRA should recognise that farmers routinely inject stock as part of their livestock husbandry. The ridiculous and dangerous situation brought about by attempts at last-minute training of vaccinators at Hatherleigh should never be repeated because there are clear alternatives.

1.17 Many witnesses concurred in their opposition to the so called 'contiguous cull' which was imposed on Devon farms after the toing and froing of the weekend of 24/25th March (when policy about it appeared to change four times). No one argued against the culling of identified 'dangerous contacts', but the arbitrary and pedantic way in which 'contiguousness' was determined on maps in remote offices called the whole exercise into question, and it had horrifying consequences for many farms. That and the reports received by the Inquiry of insensitive and even belligerent operatives and bungled culls do little to enhance the professional reputation of all those involved, from Ministers downwards. Culling on or beyond confirmed infected farms should be confined to dangerous animal contacts identified on the ground by vets (see 1.18 below). The actual process of killing animals must in any case be handled more sensitively and more humanely. The inquiry heard graphic descriptions of grossly incompetent attempts at slaughter so exposed that amateur videos were able to be made of the events in Knowstone parish by witnesses. Extracts were shown on national TV broadcasts.

1.18 We find that contiguous culling should be confined to 'dangerous contacts' identified by vets on the ground, and then only after vaccination has ensured that slaughter rate and disposal rate can be reconciled. The evidence presented to us is overwhelmingly critical of the balance of effective need against unnecessary killing of healthy stock under the contiguous cull policy as carried out by MAFF (after modification on 24/25 March), and we so find.

1.19 We find that training in slaughter management is needed. It should include clear instruction in the assessment of the likely impact that slaughtering will have on farmers, their families and other witnesses of it. This of course will not be necessary if slaughter is discontinued in future policies. It also seemed strange to the Inquiry that amateurs were used in spite of experienced and trained slaughtermen being available.

1.20 The disposal of animal carcasses featured in a large number of submissions and we are aware of the miscalculations which led to the creation of the still unused pit at Ash Moor, its capital cost and continuing maintenance expenditure which we deal with in paragraph 1.21 below, but there were still large numbers of carcasses to be dealt with. While we accept and support the Environment Agency's established order of preference for disposal, namely render, burial and burn, the availability of all facilities clearly proved a stumbling block in the speedy removal of carcasses from farms. We understand that rendering plants are few and far between and that even maximum use of current facilities would be unable to deal with the vast numbers involved in this crisis. However, on-farm burial was not seen to be given serious local consideration in specific cases, and we do understand, in recording that, that the integrity of ground water in the vicinity of a burial must be maintained. Though in that respect we were concerned to learn that in a large area of north west Devon there was no comprehensive record of private sources of water (apparently quite legitimately) with consequent effects upon the task of identifying 'safe' burial sites - or other potential pollution sources for that matter.

1.21 We do not find in favour of large-scale burials and the problems relating to the siting, construction, cost and aftermath in human terms of the Ash Moor Pit project at Petrockstowe drive us to this conclusion. That the pit cost £5.6 million to construct, costs £20,000 per week to maintain and is empty, says a great deal about the miscalculation of carcass numbers and the subsequent misapplication of public money that the handling of the Devon outbreak involved. The effect on the local community is all the more regrettable given that the pits were in fact clearly not needed. (Explanations for decisions made are still needed and restoration of the site is vital if confidence is to be restored in the way bureaucratic decisions affecting the human environment are made). Small, on-farm burials must be given more careful consideration than was apparent from the witnesses we heard.

1.22 If the slaughter policy survives and rendering and small on-farm burial capacity is exceeded, then locations for large-scale burials must have already been identified and published in any future contingency planning. It is vital that full and open consultation must be undertaken with the public and local authorities, including an Environmental Impact Statement (EIS), as part of a Crown Notification of Proposed Development (NOPD) if the problems that have been associated with these sites are to be avoided. The crisis that a major outbreak generates is not an excuse for Government and its agencies to override the welfare of individuals or communities or to ignore the long established rules for the management of the environment. As in the contiguous culling operation, the insensitive treatment of individuals and communities confronted by events outside their control did nothing to foster a united front or provide community leadership against the common enemy - the disease itself.

1.23 Burning of carcasses on huge pyres was described to us as "barbaric and medieval" which is certainly the image that was conveyed. We recognise that the urgent need for disposal at the time may have been weighed against the effect on the environment and those communities living in the vicinity. But the disastrous effect of television and newspaper images of the pyres on tourism and other businesses, both nationally and internationally, certainly was not given any consideration in advance.

1.24 We were persuaded that particulate matter, spread from pyres in poor weather conditions, might well have contributed to the spread of the disease. We find that large-scale pyres should never be used again and if burning persists as an available tool then the use of numerous, small-scale, high temperature pyres must be tested and adopted if found viable.

1.25 As we have seen in 1.21, the volume of carcasses involved in Devon in 2001 and its gross miscalculation in advance on at least one occasion revolves around two things: the so-called contiguous cull and the separate welfare motive for culling. The contiguous cull (based on a computer model) appears to have been implemented by officials poring over maps in remote offices so that only holdings were considered, not the topography, the disposition of animals upon it nor the distances between them. One witness described the process as "carnage by computer". In many cases according to farmers and vets the risk of transmission was nil, yet all the animals on contiguous holdings were slaughtered.

1.26 Any future cull adopted to contain the spread of disease must be applied by experienced local trained operators who act on decisions made by locally-based vets, after assessing the risk according to local information and to the physical conditions as they apply at the time (as they were in 1967).

1.27 We hope that sufficient thought applied to the whole area of animal welfare brought about by movement restrictions applied in a blanket fashion could resolve the tragic problems that it caused. This should especially preclude any future need for culling simply on welfare grounds and serves only to underline the blunt instrument which movement restriction at the extremely local level became.

1.28 We find that it should not be beyond the combined wit of DEFRA, the Police, Highways Authorities, the RSPCA and local vets to arrange and supervise, if necessary, movements, across roads for example, to maintain health and safety among lambing flocks and calving cows in all cases where there is no risk of contagion. Powers for closing roads to enable stock movement are already within the remit of the above organisations.

1.29 We find that a national contingency plan should recognise the need for community support and part of the plan should be dedicated to enhancing local support networks and making adequate funds available to support their activities during times of crisis.

1.30 Farmers living under DEFRA's Form D restrictions on animal movements are the forgotten victims of this whole tragedy. There were 4,500 in this position in Devon alone. They had no prospect of trade, they had pressing animal welfare problems and for those that remained under restriction, the prospect of worse to come as winter loomed, and yet they have received not a penny in compensation.

1.31 The Government must provide rapid financial assistance to farmers and their families on Form D restrictions.

1.32 The Government could, if the will was there, devise a method for providing financial assistance to farmers and their families who were on Form D restrictions. (It is not acceptable simply to say 'it is not government policy to provide compensation for consequential losses...' (DEFRA answer to Q.7, Annex 4). The whole purpose of this exercise is to get government to change policies, and slaughter is a consequence which is compensated).

1.33 A possible way forward could be for DEFRA to create a comprehensive list of all farmers who were subject to Form D restrictions (except perhaps some dairymen) - to include the period for which the restriction was in force. Compensation payments could then be based on a daily rate relating to the number of livestock on the farm during the period that the restriction was in force (example with simply illustrative numbers: 100 days x 100 animals x 50p per animal day = £5,000). It would be necessary to restrict the definition of 'livestock' to say cattle, sheep and pigs - with a different rate for each type of animal. The procedure should be comparatively straightforward to administer as the livestock numbers would be supported by records.

1.34 In addition, a farmer ought to be able to show what he would have sold in normal circumstances and the Government could reimburse him the difference between that and what he has since received together with the interest accrued. This option would also apply to the non Form D farmers who were financially affected by restrictions and should compensate for losses due to beef animals ageing beyond 30 months.

1.35 More than one witness involved in the process of closure told us that the blanket ban on the use of public rights of way or open access land such as Dartmoor and Exmoor was in retrospect a mistake, although based on regulation by the then Ministry of Agriculture, Fisheries and Food, itself based on scientific advice. This led to the "Devon is Closed" tag and had a catastrophic effect on tourism and associated industries. It was, we recognise, in the absence of a risk assessment system, an understandable immediate reaction to the need to contain disease and remove all unnecessary risks. The psychological benefits at the time were clear but with hindsight were outweighed by the longer term situation.

1.36 We find that more research is needed on the transport of the Foot and Mouth virus by boots, clothing, tyres, hooves and any other passive agent so that the degree of selection which might be applied to the closure of rights of way and the type of access may be determined to enable supportable local decisions to be made.

1.37 Until that is done, those managing access, unitary, county and national park authorities aided by parish councils should be trusted to apply restrictions in line with veterinary advice in a pragmatic way. This could be done via joint liaison groups set up as part of the contingency plan, which might be an extension of the function of local access fora (under the Countryside and Rights of Way Act 2000) in times of emergency.