Impact of High Levels of Covid-19 on the Health System: Discussion

I welcome our witnesses to our meeting this morning. They will provide us with an update on the surge in the pandemic and the consequent demands being made on our health services, especially on our acute hospitals. The committee will address the roll-out of the Covid-19 vaccine at its meeting on Friday, 29 January. I welcome from the Department of Health Dr. Ronan Glynn, deputy chief medical officer; Ms Celeste O'Callaghan, director, acute hospitals policy division; Mr. David Smith, director, governance and performance division; and Mr. Gerry O'Brien, director, health protection division.

From the HSE, I welcome Mr. Liam Woods, national director of acute operations; Ms Angela Fitzgerald, deputy national director of acute operations; and Dr. Vida Hamilton, national clinical advisor and group lead for acute operations. Before we hear the opening statements, I point out to the witnesses that there is uncertainty as to whether parliamentary privilege applies to evidence given from a location outside the precincts of Leinster House. Therefore, if witnesses are directed by me to cease giving evidence in relation to a particular matter, they must respect that direction. I call Dr. Glynn to make his opening statement and he is very welcome this morning.

Dr. Ronan Glynn

I thank the committee for the invitation to address it today. I am joined by Ms Celeste O’ Callaghan, Mr. Gerry O’ Brien and Mr. David Smith from the Department of Health, along with HSE colleagues.

It is almost 12 months since the establishment of the National Public Health Emergency Team, NPHET, and the beginning of our response to Covid-19. To date, approximately 182,000 cases of coronavirus have been confirmed in Ireland. Sadly, more than 2,800 deaths from Covid-19 have been reported. I extend my heartfelt sympathies to the families and friends who have lost loved ones to this disease.

Ireland is now experiencing a severe third wave of infection, as are many other jurisdictions. The country has experienced a dramatic increase in disease incidence, hospitalisations and mortality since late December, with 532 deaths notified with a date of death in January so far. While there are some positive signs in recent days that transmission levels are reducing, incidence rates remain very high, at levels ten to 15 times greater than those observed in early December. The situation therefore remains extremely worrying with older and vulnerable individuals at greatest risk. Numbers of cases in hospital are tracking close to optimistic model predictions but it is important to remain cognisant that, even assuming a continued reduction in case numbers, there will still be a very slow decrease in numbers in hospital. Similarly, the total number of Covid-19 patients in intensive care units is at a very elevated level and it must be noted that a significant number of patients are also receiving advanced respiratory support on general wards.

As well as the concern regarding the health and well-being of those hospitalised, there is a clear risk for the capacity and operation of the healthcare system more broadly. A priority for NPHET throughout this pandemic has been the protection of non-Covid health and social care services and, unfortunately, this has been very significantly impacted by the recent deterioration. It remains imperative that all members of society collectively adhere to the public health advice, as well as the restrictive measures that have been put in place by Government.

It is important to reflect that the basic objective we are trying to achieve is to interrupt transmission of this virus from person to person. It is clear that the vast majority of the public are playing their part to reduce transmission, which is perhaps best emphasised by the fact that the average number of close contacts per case has decreased from almost five at the end of December to just 2.1 today. These efforts are more important then ever at this time and it is vital that they are maintained over the coming weeks.

I am pleased to say that our Covid vaccination programme is now well under way. By Wednesday evening last almost 122,000 vaccines were administered, with 73,100 for front-line healthcare workers and almost 49,000 to long-term care facilities, where both patients and staff were vaccinated. This is the largest ever vaccination programme conducted by the State. Vaccinations will be offered free to all residents who are indicated and wish to receive it, and we hope to see full public uptake. On a particularly positive note, the proportion of people who say that they will definitely or probably take the vaccine when it is offered to them has risen from 76% to 85% over recent weeks.

However, while the vaccine programme is being rolled out, we must continue to rely on the tools that are available to us. The use of face coverings, social distancing, hand and respiratory etiquette, working from home where at all possible and, ultimately, staying at home unless it is essential to be out remain vital to suppressing this virus.

We are also continuing to monitor the prevalence of new variants of the virus as they emerge. Viruses change constantly through mutation. While most of these will not have a significant impact, some mutations may provide the virus with a selective advantage, such as increased transmissibility or the ability to evade the immune response. We are monitoring three variants in particular at this time, one each of which was first identified in the UK, South Africa and Brazil.

I reiterate that the Government continues to advise against all non-essential travel at this time, a recommendation the European Centre for Disease Prevention and Control, ECDC, yesterday identified as key to slowing down the importation and spread of new variants.

To conclude, I acknowledge that hardly any aspect of Irish life has not been impacted in some way by this pandemic, and I thank the public for their continued efforts. However, much more progress must be achieved and sustained over the coming weeks to bring this disease under control and to substantially reduce the ongoing profound impact on all key public health priorities. At this stage, we need everyone to stay at home, other than for essential reasons, in order that we can continue to suppress the virus and minimise, to the greatest extent possible, any further impact on public health.

I thank Dr. Glynn and invite his colleague, Mr. Woods, to make his opening remarks.

Mr. Liam Woods

I thank the Chairman for the invitation to appear before the committee. I am joined by my colleagues Ms Angela Fitzgerald, deputy national director of acute operations, and Dr. Vida Hamilton, national clinical adviser and group lead for acute operations. Dr. Hamilton is also an intensivist working in Waterford hospital. We understand that the committee wishes us to address capacity in our hospital system and the general demand, particularly relating to Covid patients, and to talk about the private hospitals and increased capacity available to us under the private hospital arrangements recently put in place. As the Chairman noted, the vaccine is subject to further separate dialogue next week.

As for managing demand, the experience of the pandemic over the past ten months, moving towards a year, has taught us a number of lessons. In March and April, the number of emergency department, ED, attendances fell sharply. Non-urgent routine care was suspended, in line with the NPHET guidance in late March, and we acquired capability of 18 private hospitals to provide assurance of protected space in which to provide non-Covid care. The private hospital capacity at that stage was proactively used for significant volumes of non-Covid care, namely, 60,000 day cases and 10,000 inpatients. Extraordinary measures were taken to deal with an extraordinary and unprecedented challenge at that time.

During the first surge, 2,200 beds were vacant to support anticipated need, although there were staffing challenges with that, and Covid patient numbers peaked at 825. The plan worked for two reasons, namely, the extraordinary efforts of staff and carers throughout the health system and the magnificent response of the public in reducing transmission. The lessons learned at that stage were how to manage care of all acute patients, Covid and non-Covid alike, the extension of telemedicine, which very much supported care outside of the hospital environment, community care being brought closer to individuals' homes, the use of remote monitoring for people at home, which is ongoing, and the increased delivery of home dialysis to keep patients away from hospital space where feasible.

In regard to additional bed capacity, by the end of 2019 there were 10,988 inpatient beds, including 255 critical care beds in the system nationally. In response to Covid, we opened an additional 426 beds and, based on the Estimates for 2021, we will open a further 720 beds during the course of this year. The additional capacity from the start of last year, therefore, will be 1,146 beds in total. The intention is that will allow us to operate at 85% occupancy, which is the international norm. In addition, the Estimates for 2021 provide for the opening of 66 critical care beds by the end of 2021, which includes permanent funding for 40 beds, funded temporarily in response to surge. To date, 33 of these beds have been opened, with a further seven expected to do so in the coming weeks.

As for the preparation for 2021, the circumstances we face now are very different from those of March, and in many ways more challenging. The disease is much more transmissible.

Backlogs have built up in scheduled care. Social distancing and increased infection control measures mean our existing capacity cannot deliver at previous levels and overcrowding in emergency departments has been reduced significantly. We cannot tolerate high trolleys due to the risk of infection.

Significant numbers of healthcare workers are absent due to infection, close contact or the need to care for others. In the acute hospitals alone, we have more than 6,000 workers on sick leave at present. Almost half of them are nurses. On a positive front, the availability of early roll-out of a vaccine will be a key factor in mitigating risk in the future relating to our staff.

We are currently in a new pandemic surge. Numbers infected and hospitalised on either wards or in ICU are at levels not seen before. The number of measures already invoked include strong guidance from our chief clinical officer, all non-urgent and non-time-dependent cases in the public sector have been paused in public hospitals and surge plans have been activated across the entire public hospital system, increasing surge capacity by 400 beds. For critical care, our surge plans aim to deliver 350 ICU beds. Derogation measures are in place to maximise available staff. Safety net arrangements have been agreed with 18 private hospitals and more than 800 patients have already been treated.

The private hospital support in 2020 provided access to their entire capacity for three months in the earlier part of 2020. Temporary mechanisms beyond that period saw private hospitals provide care right though to the year end. The new safety net arrangement, which will be in place for up to 12 months, allows us to trigger capacity by prior arrangement in the event of need associated with surge, which we are now in, and guarantees access to a maximum of 30% capacity and beyond by agreement with private hospitals. The HSE is paying commercial rates for activity already carried out. The focus for private hospitals is on delivering urgent, time-dependent elective care and unscheduled care. Continuity of care concerns are being addressed in two ways. Public hospitals will determine the patient profile that will transfer and private hospitals can continue to deliver care for their patients in the remaining capacity, much of which will be urgent and necessary.

In conclusion, I would like to stress two points. We need people to continue to use the health services during this time. We are alert to the fact that in the first phase of this, there was the risk of patients not attending emergency departments for strokes and heart attacks in particular. Meeting the exceptional challenges which present to acute care depends heavily on the public response and the management of the infection in the community. That concludes my opening statement. I thank the Chairman.

I thank Mr. Woods for his opening remarks. Before I open up the meeting to members, I thank Mr. Woods on behalf of the committee for the work he and his colleagues have done, and continue to do, to address the onerous challenges posed by the spread of Covid-19. Our first questioner this morning is Senator Conway.

I thank the Chairman and reiterate his comments in terms of thanking our guests for the fantastic work they are doing on all our behalf. I have a couple of questions for Mr. Woods and then a couple for Dr. Glynn. I will start with Mr. Woods. I can only imagine it is worrying from his perspective that 6,000 staff in the acute hospitals are out sick at the moment. I imagine the vast majority of them are out with Covid-19, either self-isolating or with Covid-19 itself. Has the HSE done any work or analysis on the outbreaks of Covid-19 in the acute hospitals? Has it carried out analysis as to how it is getting in so readily at this stage? Has Mr. Woods figures to hand of patients who present to the acute hospitals with non-Covid conditions who are actually contracting Covid-19 within the hospital setting?

Mr. Liam Woods

I thank the Senator. In brief, in terms of staff absence the Senator is right in saying we are talking about both Covid-positive and Covid-contact scenarios. Indeed, there are staff who are cocooning because they are vulnerable to the condition.

In terms of infection, the Senator is absolutely correct. We have data on the numbers of outbreaks. Right now, for example, there are 120 open outbreaks in the acute setting. We have also got those data for community settings. We also look at hospital-acquired cases. By way of example, in the week to 17 January, we had 442 hospital-acquired cases of Covid-19.

We are also keeping a close eye on laboratory-confirmed positive cases. The measures in place to address that, without taking too much of the Senator's time, are very much the infection prevention control guidance that we have in place through Professor Martin Cormican and colleagues, a lot of training and support, as well as provision of personal protective equipment, PPE, that is thankfully at this stage available, whereas the Senator will recall we had struggled with that in the first phase. Of course, the infrastructure we are working in and the increasing modernisation of that infrastructure is of assistance but some of our infrastructure is quite dated and that presents additional challenges.

In terms of the private hospital capacity, does Mr. Woods have to hand figures on how much of the private hospital capacity the HSE is using at present either for Covid or non-Covid public patients? I understand that the HSE is at surge and I would be interested in those figures.

On a general point, is Mr. Woods confident that the high level of care that has been provided in our hospitals over the years is being maintained or has there been compromise to the care of patients due the enormous strains and pressures that are on the system?

Mr. Liam Woods

As for private hospital capacity, in the past week 800 patients were treated. That was the first week within which the arrangement was triggered. To give the Senator a figure, 30% of capacity is just under 600 beds. As I said in the opening statement, we have access to more by agreement with the private hospitals. Our purpose at present is to grow to the use of that capacity.

The kind of care being provided in the private system is primarily non-Covid. The intention is to move patients to the private system who need urgent surgery where the private hospitals have that capacity. We are not at present consciously sending Covid-related patients.

On the point relating to confidence, clearly in a system where we have significant staff absence, very significant surge and high community infection, we are concerned about risk. Staff across the system are working as best possible to mitigate that risk but it would be unrealistic to expect the same outcome as in previous times, as the Senator suggests. We are very alert to that. I might ask my colleague, Dr. Hamilton, if she wishes to comment on that as well.

Dr. Vida Hamilton

The Senator is absolutely correct. We are in surge capacity and, therefore, we have to deploy different methods of staffing to ensure best care. Our critical care nurse escalation plan is in place. We trained 1,600 non-critical care staff to support critical care services. We deployed them in a one-to-one ratio working directly with a critical care nurse in a buddy arrangement in the first instance. Then, as we entered surge, we had one critical care nurse supervising two, and then three, non-critical care nurses but maintaining a nurse-patient ratio of one-to-one for optimal safety. We have a daily critical care major surge working group with very close engagement with the National Office of Clinical Audit, NOCA, which is monitoring occupancy and staffing levels. We have daily contact with units that are not declaring capacity to ensure they have arrangements in place for further emergency admissions and we are very actively managing that situation. As to whether the care is of the same standard, the answer is "No".

Would it be correct to say then that no intensive care patients are getting one-to-one treatment and care from an intensive care trained nurse but that they are getting one-to-one treatment and care from nurses who are supervised by intensive care trained nurses?

Dr. Vida Hamilton

Where possible, we are retaining one-to-one critical care nurse-to-patient ratios for level 3 patients. For level 2 patients, the normal ratio is one critical care nurse to two level 2 patients but for units that are in surge, yes, we are using that escalation model as the Senator described.

That is fine. I thank Dr. Hamilton and Mr. Woods. I have a couple of questions for Dr. Glynn.

I thank Dr. Glynn for all the great work he is doing.

On 30 December, the restrictions in existence now were introduced by the Government. Is Dr. Glynn disappointed that there are still 2,000 to 2,500 cases a day given the fact that we are now over three weeks into new level 5 plus restrictions? Would he have expected that we would be in a better position on 22 January after these restrictions were introduced?

Dr. Ronan Glynn

I am disappointed at the high levels but I am not surprised. The Senator asked if we are surprised that we have not made greater progress. We are not. We saw levels of infection in this country that we have never seen previously and neither have many countries internationally. Unfortunately, when one gets to levels as high as what we have experienced, it will take a long time. The pressures that we are seeing currently in the hospitals and ICU are reflective of what we have seen in the community in terms of case numbers in recent weeks.

Would Dr. Glynn be surprised if schools are actually back in the main before St. Patrick's Day?

Dr. Ronan Glynn

NPHET met yesterday and gave advice to the Government based on the current disease indicators. In general terms, we have a long way to go before we get back to a level of reopening that we have seen previously. I would emphasise at all times that from my perspective I do not believe there is too much value at this point, given the pressures on our health service, of looking too far back in history or looking too far forward. At the moment, we need to focus on the next days and weeks. NPHET and society have a number of key priorities that we are trying to protect and keep going as much as possible. Education is one of those.

Is Dr. Glynn concerned there is still too much activity around, say, Dublin city centre in terms of traffic and movement?

Dr. Ronan Glynn

From a pure public health perspective, we would like if the entire country stayed at home for two weeks and did not leave their houses at all. That is not realistic in that there are essential services we have to keep going. Our best indicator of compliance and population buy-in is the average number of close contacts per case. That has fallen to 2.1 on average per confirmed case. The challenge is not so much to improve on that. It is how to sustain and maintain that over the coming weeks. That is going to be very difficult. The majority of people have stayed at home and have not met up with friends or family members. That becomes increasingly difficult as we move forward over the coming weeks.

Finally, just one-----

Senator Conway, you have run out of time. I am moving on to the next speaker.

-----we are all in our offices.

Can you cut him off?

I observed and I listened with great-----

Senator Conway, you have run out of time. I am moving on to the next speaker.

I welcome all of our witnesses. I commend all of those on the front line in our healthcare services who are doing a Trojan job. I also commend those in the HSE who are rolling out the vaccine and wish everybody well. Best wishes to Dr. Woods and his team and Dr. Ronan Glynn and his team as well.

I appreciate the point that Dr. Glynn made that there may not be best value in looking back too much at this point because we have a very real crisis in the here and the now. Everybody accepts that. I am sure Dr. Glynn will also accept, however, that looking back is also important to learn lessons. We went from a situation before Christmas from having some of the best data in the EU. We were one of the best performing countries in terms of having very low rates of transmission. Towards the end of December into early January, we went quickly to being one of the worst performing. As Dr. Glynn said, this involved record numbers that were not anticipated and numbers in the thousands every day which has resulted in transmission rates which are off the charts.

If I am to be blunt, we lost control of the virus. I have to ask whether losing control of the virus was as a result of a failure of public health advice that was given or a failure to act on public health advice. What Dr. Glynn said, and he is right, was that all of us need to follow the public health advice in the individual asks but we also need to stay at home. This is the best way to help those on the front line so we have fewer cases, less transmission of the virus and fewer hospitalisations. If that is the case now, surely it was the case before we lost control of the virus. My direct question is whether losing control of the virus was down to public health advice that failed or our failure, as politicians, to act on the health advice given.

Dr. Ronan Glynn

I thank the Deputy. It is clear that a number of factors played into the situation that led to where we ended up at the end of December and early January. To be honest, it is not for me and it will take time to look back and separate out the relative contribution of the various elements but there is no doubt that increased levels of socialisation, the opening up of society, the extent to which generations, families and households mixed and the introduction of a more transmissible variant at the end of December were all factors that contributed to where we ended up in early January. If there is a lesson to be learned - the Deputy's question was premised on learning lessons - it is a one that we have known previously and it is very important that we bear it in mind as we move forward. It is that when we have to act on this virus we have to act quickly when things are going wrong. On the other side of this, when we are coming out-----

I accept that, and Dr. Glynn has answered the question, but my point is we went from very good data and good numbers, or at least better numbers and having some handle on the virus and some control, to a situation where we lost control. If we do not learn lessons about why we lost control, we could lose control again.

With regard to public health intervention and the public health advice being given at present, there is a legitimate debate about whether we are doing enough about travel, for example, having mandatory quarantine for people coming into the State and onto the island. Is NPHET advising mandatory quarantine?

The secondary issue is that we have never got testing and tracing right. We have never used it to hunt down the virus effectively. Dr. Glynn said it will take some time to get to a point anywhere near where we were during the summer - that is because of mistakes that were made - and we hope the vaccination programme will help also. When we get to that point we will need to use testing and tracing very effectively. What more can be done in this area? Is NPHET advising the Government that we should have mandatory quarantine of people coming into the State and onto the island?

Dr. Ronan Glynn

NPHET has been clear in its response for the vast majority of this pandemic that travel poses a significant risk to the suppression and containment of the disease in our country. This is not simply NPHET's position, it is the position clearly articulated by the ECDC as recently as yesterday, particularly in relation to the emergence of new variants.

Sorry, Dr. Glynn, we have very short time. The question I asked is whether NPHET is in favour of mandatory quarantine. It is a very direct question. Dr. Glynn appreciates why I am asking the question because it is a source of public discussion and an important one. People have a reasonable expectation that we will do everything possible to prevent the virus coming in when we get the numbers down low. I am asking Dr. Glynn a direct question as to whether NPHET is advising mandatory quarantine with regard to travel.

Dr. Ronan Glynn

NPHET is in favour of avoiding all non-essential travel in the first instance. This is the most important measure. Beyond this, our advice is there and it is published. We have asked for mandatory quarantine previously and recently we asked for any element of discretion as it applies to travel to be removed insofar as is possible. However, we are not the experts on what is possible.

What we want is a situation where essential travel is reduced to the greatest extent possible, through whatever means are required to bring that into effect.

Okay. To be clear, what Dr. Glynn is saying is that NPHET has previously recommended mandatory quarantine and its position has not changed, and the reality of how that will happen has to be worked out by Government, but NPHET’s advice is there should be mandatory quarantine. Is that correct?

Dr. Ronan Glynn

Our advice is that the discretionary elements of travel need to be addressed to the greatest extent possible. Mandatory quarantine is one way in which that could be done, but there may be other ways that could be done that I am not privy to from a health perspective. As I said, the key is that as few people as possible come into this country for non-essential reasons over the coming weeks and months.

Thank you. I say all of that because it is important that we do everything we possibly can to have the strongest public health interventions to reduce the transmission rates and to reduce the number of people who contract the virus. That in itself will help our front-line healthcare workers and admissions in hospitals as well, which is an obvious point to make.

I will come to Mr. Woods. In regard to hospital capacity, how many critical care beds are open today?

Mr. Liam Woods

The last figure last night was 336.

What is the maximum capacity in the public system? What is the most that we can get?

Mr. Liam Woods

The base funded and staffed capacity is actually 287, so we are already ahead of that.

What is the maximum that we can have?

Mr. Liam Woods

The maximum capacity with reasonable quality of care associated with what Senator Conway referred to is identified at about 350.

Then we are very close to maximum capacity.

Mr. Liam Woods

We are indeed.

What did the bed capacity review, mentioned in the HSE report, recommend we should be at by the end of 2020?

Mr. Liam Woods

The wider review of ICU capacity suggests the figure we should be targeting is 460 nationally over the next three to four years. In terms of the actual numbers, 287 was to become 301 at the end of quarter 1 of 2021 and then to grow to 321 by the end of the year. That is contingent on training and recruitment, which is ongoing at the moment.

The cancellation of non-urgent care is obviously necessary because of the dire situation we are in. Would Mr. Woods accept that is going to present real challenges for hospitals when we start to reopen that care again and that we are going to need a very substantial catch-up plan? I say this because the front-line staff I talk to daily are exhausted and absolutely at breaking point - not near it, they are at it. They have had a very tough year, they are dealing with a very tough time, and they will now face into all of the catch-up care that will have to be done. First, what are we going to do to make sure we have all of the additional capacity we need to make sure they are protected? I want to ask a second question.

The Deputy has no time left.

Is Mr. Woods aware of any hospitals that are continuing to put patients in wards where there are confirmed outbreaks? As the Chair is telling me I am short on time, I have one last question. I want to ask about St. Brigid's Hospital in Carrick-on-Suir. I understand it has been closed without consultation with people in that community and they are very upset about that. Mr. Woods might answer those questions.

Mr. Liam Woods

I thank the Deputy. I absolutely share his view on the difficult year it has been for staff and, of course, there will be significant catch-up. We have learned that from the first phase, where there was significant loss of activity, which we are experiencing once again. We are looking to offset that as best we can into the private environment right now, but the Deputy is right in saying that when we get through this wave, we will still have significant catch-up. In terms of capacity, the 1,146 beds we are putting in is a contribution to that. Obviously, the NTPF has significant additional funds this year as well. I think its budget may be €130 million this year, and that can also support and assist.

I might ask my colleague, Ms Angela Fitzgerald, if there is anything further she would wish to add to that and I will come back in on Carrick-on-Suir.

I am sorry. I had a question about patients potentially being admitted into wards in acute hospitals where there are confirmed outbreaks.

Has the HSE been made aware of any situations that have arisen in that context?

Mr. Liam Woods

Personally, I have not. I will hand over to my colleague to speak on capacity.

Ms Angela Fitzgerald

Mr. Woods made the point about the plan in terms of the growth in activity. For context, in the bed capacity review, it brings us to where we should be by the end of this year. As we know, and the Deputy made the point well, that capacity will not give us as much as it would have before. In our plan this year, we are recognising that we will not get the same yield in our activity both in theatre and in social distance requirements. We have three plans: one, to grow capacity; two, to leverage the National Treatment Purchase Fund, NTPF, which, as Mr. Woods noted, has €130 million to spend this year; and three, a fund of €150 million coming through in the Estimates for the access to care plan. We are trying to use as much of it in the public system but the Deputy's point is well made around the fatigue in staff and the challenge in the short term of growing that capacity. We have a target of about €45 million to spend in the public system doing more public work through extended day and out-of-hours and using new capacity. We are also looking at using the private sector for a broader range of initiatives than we would have seen before.

The Deputy spoke of learning lessons. We have learned a lot about how we can work more effectively with the private sector. When our doctors work alongside their doctors, we get a better yield. That is a model that we will continue to use. Some exciting innovations are coming, which Dr. Hamilton may wish to speak on. For example, one challenge we face is endoscopy. No matter how fast we run, the growth in the waiting list gets ahead of us and Covid has made that a much more challenging issue. We are doing a couple of things. We are looking at rolling out PillCam, a camera that we can use, as part of our response. It has two benefits. One is to-----

Ms Fitzgerald will have to wind up please. I am sorry we have gone over our time. Can we have a written reply to Deputy Cullinane's question on the closed hospital?

Mr. Liam Woods

Absolutely. It is actually a community facility. I will arrange for that.

Great. I thank Mr. Woods.

I thank the witnesses for their dedicated public service. Has the Beacon Hospital actually signed up?

Ms Angela Fitzgerald

It has, yes.

The schools issue has created an awful lot of division, aside from everything else. The CMO is a very well-respected national figure. What he says never falls on deaf ears. I wonder why he did not make his presence felt. It would have made a significant difference in the past week or ten days.

Dr. Ronan Glynn

I assume that is a question for me. The CMO's position on this, as my own, has been articulated on a number of occasions. I refer the Deputy and others, as I have done previously, to our letter of 5 January. I will read out again what we said because our advice has not changed:

...while the experience from September to December 2020 has clearly demonstrated that schools are in themselves a safe environment, the current epidemiological situation has deteriorated to a point where the significant levels of mobility and linked activity that the full reopening of schools would generate, constitutes a very significant additional risk in the context of what are already unprecedented levels of disease transmission in the community.

In that letter we also pointed out that measures should be taken to limit the impact on the healthcare workforce and that specific measures be taken to ensure that more vulnerable children can be best supported over these weeks.

This is where the CMO's voice, with the greatest respect to Dr. Glynn as the deputy CMO, would be really important. Would NPHET favour the return to school and the facilitation of the return to school of children with special needs?

Dr. Ronan Glynn

Our understanding is that the number of pupils and staff encompassed by that would represent a very small proportion of the 1.1 million students and staff in total who would go back in a full reopening. From our perspective, would 3%, 4% or 5% of that full cohort going back have a significant impact on the very high levels of community transmission that we are seeing at present? No, it would not. That would not have a significant impact on mobility at community level.

I thank Dr. Glynn for that. The next question, and we are three minutes into my questions now, is whether NPHET favours the prioritisation of teachers and special needs assistants, SNAs, with regard to vaccinations or is it comfortable with the existing priority list?

Dr. Ronan Glynn

The prioritisation list was drawn up by the national immunisation advisory committee. It will look at that on an ongoing basis. It is up to that committee in the first instance to look at the prioritisation list and if there are any changes to that list, it will be submitted to NPHET in the first instance and then considered by the Government.

I am not trying to be clever but it is a question that has been asked and it is a question relating to a number of other areas as well. Pending the abundance of supply that may hopefully arrive at the beginning of the second quarter, does NPHET see some degree of flexibility or elasticity in that priority list as situations demand or as supply arrives?

Dr. Ronan Glynn

Clearly, as supply arrives there will be greater flexibility in rolling out the vaccine but in the first instance the prioritisation list has to be guided by our experience of the pandemic to date. It has to be premised on protecting those who are most vulnerable and who have suffered the severest effects of this. Obviously, that is older people and people living in residential care facilities. It also has to be premised on protecting our healthcare staff, both for their protection, and the protection of the health service, but also for the protection of the patients they care for on a daily basis. Beyond that, if there are any changes to the prioritisation list, even with volume the reality is that if we raised a group up a prioritisation list, there is no getting away from the fact that in doing so we are deprioritising another group. There are significant moral and ethical questions to be asked and decisions to be made in all of that. That is a process that needs to take place over time as more evidence becomes available and as we learn more about the volume of vaccines we are going to get and when we are going to get them and, crucially also, as we learn more about the impact of these vaccines on transmission.

I thank Dr. Glynn. I want to put on the record that if there was an unanticipated increase in the volume of vaccines available, together with the ability of human resources to deliver that vaccine into people's arms-----

Does Deputy Lahart realise that we will be dealing with vaccines next week?

Okay; I will leave that.

With regard to messaging, I follow the daily press briefings but the messaging has not changed much, whether there were five people in ICU or 200 people in ICU. I mean this as a serious point but I believe there is a need to repurpose the messaging because NPHET has exhausted almost every adjective in the dictionary at this stage. The situation was viewed as grave a year ago when we were down at level 5, and I am not belittling all of this, but many people are not listening now. I live very close to the M50. Last year during level 5 lockdown, the M50 was like a quiet country road. One could hear individual cars on it. Today it is buzzing, and we heard figures this week of 60% of transport being on the road. What are Dr. Glynn's ideas about that? People have switched off. They often ask me why the daily briefings are continuing as it is too much to take in.

The recent message that this will go on for at least a year had a serious negative impact on people's mental health. I found it quite disheartening to hear. While we are at level 5 in theory, Dublin is not at level 5. There is a significant amount of activity. The city is quiet but there is much going on in the suburbs. That is not a criticism of the witnesses. Do they have any ideas on how the messaging can be changed to reinforce its impact?

Dr. Ronan Glynn

There is unquestionably more activity than there was last March and April. One of the challenges in this is that much of the messaging has not changed because the basic premise of the messaging has not changed. The underlying issue has not changed, namely, that this virus is dangerous and the way to stop transmission is to get people not to come into contact with one another.

We have a behavioural subgroup which does fantastic work behind the scenes. NPHET expects to receive a paper from it next week, specifically looking at how to sustain the high levels of compliance we have seen over recent weeks. One key thing the subgroup tells us is that we need to be careful about overemphasising the small minority of people who are not adhering. I take the Deputy's point that there is more activity on the roads but we can see from the close contacts that average confirmed cases have that the vast majority of people are complying to the greatest extent possible.

The natural reproduction number of the virus is probably between three and four. Approximately 60% of cases in the country are probably related to the so-called UK variant, B117, which is more highly transmissible. Despite that, we have managed to get down to a reproduction number which was estimated by Professor Nolan yesterday evening as being between 0.5 and 0.9. A key part of what we need people to understand is that they are not alone in doing the right thing. There are outliers and people who are not following the guidance but the vast majority of people in the country are still listening to the basic messages. It is incredibly difficult for them but they are sticking with it. Hopefully they will stick with it in a year that will be much quieter than last year, although unfortunately there can be no guarantees about that.

We are not here to criticise the witnesses. Part of the role is to reflect public opinion and what we hear as constituency politicians. When people who are making an effort see workers on a building site or a shop open, it can have a corrosive effect. It might be useful, if it is appropriate, for Dr. Glynn to share with the committee the behavioural paper to which he referred. We would find it useful to look at some of the background. We want to be helpful too.

I thank the witnesses for their attendance and the work they are doing. I have questions for Dr. Glynn. NPHET's most recent letter, which was published yesterday, is explicit about international travel and I welcome that. In the last couple of paragraphs, it refers to the current arrangements where a person is required to restrict his or her movements and there is no requirement for a post-arrival test. The letter explicitly states that we need to remove the discretion in both those areas. My interpretation of that is that if one removes the discretion, one is then calling for a mandatory arrangement. Am I right in that reading of the letter?

Dr. Ronan Glynn

As I said earlier, we are certainly not the experts regarding what measures or blend of measures might be usefully applied. Ultimately, we are interested in reducing non-essential travel to the greatest extent possible.

Mandatory quarantine is one potential solution there. There may be others. Ultimately, we want discretion removed so that as few people as possible, who do not need to be travelling, are travelling.

I am reading that as a comment on the arrangements that are there at the moment. For some reason, the Government seemed to think it was okay to introduce a regime whereby one had a pre-departure test, then it was discretionary and it was advised that people self-isolate. Most of us view that as totally inadequate in respect of safeguarding the country. I am aware that politics involved in this and NPHET is very careful not to stray into the political arena. It has been said before that while mandatory quarantining would be welcome, it is viewed as not politically feasible. Given the escalation of the situation and the new variants that have emerged, I wonder why NPHET does not come out and provide clear advice on what is in the best interests of the country in respect of international travel.

Dr. Ronan Glynn

NPHET has been as clear as it possibly can be on the issue of international travel. We do not want non-essential travellers coming into this country. We have been clear on that for months. It has happened, although obviously the volume of travel has been way down, which is welcome. There is no doubt that travel continues to play a role in the transmission of this disease in this country and will make it more difficult to maintain suppression over time. That is particularly the case in light of the new variants.

Essentially, the regime that is there at the moment is not sufficiently effective. That is my understanding of what Dr. Glynn is saying.

Dr. Ronan Glynn

The regime that is there at the moment will not stop all cases coming into this country.

That is particularly pertinent in the context of the failure to control the escalation of the virus, and also in light of the Taoiseach's comments yesterday that we are probably looking at a situation where pubs and restaurants will remain closed until the end of May. It is incumbent on political leaders to take a new approach. I welcome the clarification provided in the letter.

Dr. Glynn talked about the basic tools that can be used, and have been used from the beginning. I wonder why improving ventilation is not included as one of those tools.

Dr. Ronan Glynn

Ventilation is included. The Health Protection Surveillance Centre has had guidance up on ventilation for many months. We have been clear that ventilation does play a role. However, we need to be careful that we do not become too reductionist in our approach. There is no one measure that can stop this virus.

I appreciate that. I am just making the point that it would be helpful if NPHET representatives and the public messaging stressed the importance of good ventilation. It has been lost, and it should be more centre-stage, in my view. The general advice would concur with that.

On the question of when restrictions might be lifted, the approach that has been taken to date has been to introduce the various restrictions for a period of time. I recognise that NPHET had recommended that the previous level 5 restrictions be introduced with a view to bringing the incidence rate down to between 50 and 100. What is Dr. Glynn's view of the level of the virus at which it would be safe to lift the restrictions? I am talking about daily case numbers.

Dr. Ronan Glynn

Unfortunately, it is simply too early to give a firm view on that issue at the moment. We need to see how things play out with the E117 variant, which is the British variant, as it becomes even more dominant in this country. We need to see the extent to which we remain successful in containing the South African and Brazilian variants. In the first instance, we need to see whether we can maintain the current rates of improvement over the coming weeks. There is no guarantee on that. It is simply too early to talk-----

Does Dr. Glynn favour the approach whereby a target is set in respect of the level of the virus, rather than a time limit for restrictions?

Dr. Ronan Glynn

In an ideal world, at all times we would have liked to be able to say, "When we get to this point, we can do this."

I understand that it would provide great levels of clarity to everybody but, unfortunately, at no point have we been able to reduce down our recommendations to be premised upon one or two indicators. They were all a set of circumstances at the time that needed to be taken into account.

My last question is on the new variants. Will Dr. Glynn tell us the current view on some of the new variants with regard to reinfection? Obviously this poses a major challenge to us all. What is the current thinking on the South African and the Brazilian variants and reinfection?

Dr. Ronan Glynn

The British variant concern seems to be predominantly around transmissibility, with no obvious impact on vaccines or on reinfection. There is some very early suggestion that the South African variant in particular, and perhaps the Brazilian variant, may have an impact in reinfection and may have an impact on the effectiveness of the currently available vaccines. I stress that this is very early, and we certainly need more evidence before we could conclude on that. Clearly, we must adopt a precautionary principle and the key now is to stop these variants from being imported here in the first instance.

I thank Dr. Glynn.

I thank the witnesses. They have heard it a few times at this committee on health. We are very aware of the amount of work they are doing and how hard they are working. They are trying to deal with a very difficult situation.

I will return to the issue of beds and staffing. I want to unpack a bit around the bed and staffing outlook for 2021. In some of the opening statements today we heard there were 274 beds planned for 2021, which is reliant on staffing and recruitment. Could we hear a little more about this? Is recruitment increasing or decreasing at the moment? What happens in the event that we are unable to attract staff to those beds and at what level do we think this will hit those 274 beds?

Mr. Liam Woods

First I will make a general comment on staff numbers now versus the start of 2020. There are 6,300 additional whole-time equivalents, WTE, which is slightly more in staff numbers, in the health system currently. Of those, some 3,900 are in the acute environment. We can provide data separately on the balance of 2,288 because I do not want to read out numbers for too long here. There has been a significant increase in staffing. Some of that is associated with the capacity already open and the Deputy is right in saying that the critical dependency for 2021 is our ability to recruit. The service plan and the Estimate budget for 2021 provides for very significant recruitment.

On the acute side I will ask Ms Fitzgerald to comment on the beds. We have already opened some of those beds and they are staffed. We have opened six beds in the high dependency unit in Limerick, the latest beds opened, which is also staffed.

Ms Angela Fitzgerald

As Deputy Hourigan said I will "unpack" it. We started with a target of 11,046 beds in 2020. During the first wave of Covid we opened 426 of those beds on a temporary basis. Thankfully we are now in a position to keep those open. The link with staffing is very relevant. Obviously, if we know the beds are opened permanently then we can attract permanent staff. This is very important.

The second thing we did was to look to open the balance of beds. By the end of last year we had a total of 677 additional beds opened. That included the 426. This leaves us with a further number of beds to open this year, which is about 470. The plan is to try to open half of those in the first quarter and the remainder will be over the year. We have been successful in being able to get most of those beds open on time. To the extent there are beds in the back end of the year it is because they are largely dependent on capital works. The Deputy has raised an important point.

The objective is to get additionality, and one of the challenges we face right now is that, typically, in any one year we would have up to 100 out of our 11,000 beds closed, either because of infection control issues or refurbishment. At the moment, that number is 600, so while we are opening beds, we are also challenged every day by beds that are closed because of outbreaks. They are closed necessarily because of safety reasons. I hope that as we get ahead with this vaccine, what it will give us is that 1,146 beds. I am happy to give a breakdown on the 66 critical care beds, if the Deputy wishes. In summary, 40 beds were opened temporarily under the arrangements in March and up to May and we are opening those permanently. We have 33 of those beds opened permanently. As Mr. Woods said, we are stretching to open other ones on a temporary basis in response to the surge, but the objective is that by the end of quarter 1 we would have the 46 beds open. The 20 beds that are in the back end of this year are again due to capital works. The 66 additional beds will give-----

I am sorry to interrupt. That is fascinating. I thank Ms Fitzgerald. If she has more information about the numbers, she might send them on to me. She raised an issue I am generally interested in, which is permanence and attracting staff. In 2019, we had some of the lowest levels of acute care beds and ICU beds in the EU. As we move through this crisis, we have seen significant support for the health system and beds opening up, but what will we be looking at as the numbers, hopefully, continue to reduce? Are we going to be left with permanent beds or will we see beds closing?

Ms Angela Fitzgerald

That is a very important point. We have to acknowledge the collaboration with the Department. The 1,146 beds will be permanent beds. They directly align with the targets that are set in the capacity review, which set a very similar figure to have in place by the end of 2021. We are getting to a place. What that will do is allow us to operate at 85% occupancy, which is the international norm and it is what the bed capacity review recommends. That will allow for a safer and more effective flow of patients. It does drive other efficiencies because one can use one's beds more effectively. Deputy Hourigan is quite right.

To be clear, post-Covid, if there is ever such a thing, will we have an ICU bed capacity of 460?

Mr. Liam Woods

It might be useful if I ask Dr. Hamilton to contribute in a moment. The target at the end of this year in ICU capacity is to have 321 beds, from a starting base last March of 255. We can provide more data. I will not keep talking about numbers, but Dr. Hamilton might want to give more context around the ICU capacity and what that means.

Dr. Vida Hamilton

We very much welcome the increase in ICU capacity that will bring us more in line with OECD norms and will allow us to deliver the appropriate level of care to patients. Supporting that, we have the critical care programme and a very strong critical care nursing training infrastructure to ensure that we have a continuous supply of appropriately trained staff as those beds open. We are also working very closely with the Joint Faculty of Intensive Care Medicine of Ireland and the national doctors training and planning in workforce planning from the medical side also.

Mr. Liam Woods

We can provide analysis for Deputy Hourigan after the meeting on both the inpatient beds and the ICU beds.

I would appreciate that.

I am afraid Deputy Hourigan's time has run out, unless she has one quick question to submit for a written reply.

I am afraid there is nothing quick.

I am sorry about that. I call the next speaker, Deputy Gino Kenny.

I thank everyone for their statements and for their work thus far. I have two questions for Mr. Woods. In his statement, he indicated that 6,500 healthcare workers are on sick leave at present. That includes 2,500 nurses. That is a colossal hole in the public health service. At the apex of the surge in April and May 2020, what was the breakdown of healthcare workers out of work due to the pandemic?

What is the tipping point because obviously that is not sustainable? If it gets to the stage where so many nurses, doctors and other healthcare workers are out of work, it will have a very detrimental effect on doing the basics in our health system.

Mr. Liam Woods

The peak from April last year was about 5,700 as I recall, of which about half were in the hospital system with the balance in the community sector. We have now exceeded that. The Deputy asked about the implications and where the tipping point is. At the moment we have over 500 beds vacant in the hospital system which is primarily associated with staffing. As Dr. Hamilton said, we have also moved staff to support ICU and we have stopped non-urgent elective procedures and outpatient services. The system is focused on the core emergency flow and dealing with Covid.

As Dr. Glynn mentioned, subject to the current positive trend in reducing numbers of cases, although they are still very high, we think the service pressure as a result of patients with Covid in hospitals is peaking around now. The ICU peak may still be a week ahead; there is always a lag in the ICU pressure. We think we are very close to peak demand if the public measures remain in place. I acknowledge we are also at a point where what is being asked of staff is truly exceptional given the workload that is currently being undertaken.

I have a question on the private hospital deal. There are question marks over the colossal amount of public money that went into private hospitals last year. I think it was €113 million per month. How different is the deal this time? I understand the initial cost is €38 million. Is this value for money? What are the Covid and non-Covid capacity issues for private hospitals?

Mr. Liam Woods

The Deputy is right that there is a fundamental difference. For three months last year, the HSE took on the full capacity of the private system and paid at cost for that. The estimate for the full cost is about €300 million, but I would need to confirm that number. This time the arrangement is that we are taking on upfront 30% capacity and therefore it is not a cost-based arrangement. We are paying commercial rates. The key focus for us now is to move patients to the private hospitals from public hospitals to alleviate the pressure the Deputy mentioned in his first question. It is a key safety valve for us.

The other learning from the last time was that private hospitals are already undertaking significant urgent elective activity. It is not necessary or helpful to displace that activity. It is important that continues or it would potentially come into the public hospital system. We are working with the private hospitals right now to optimise the use of that 30% capacity. If we are at the ceiling of demand, we will continue to do that depending on certain trigger criteria which are set out and which are fundamentally based on the incidence of virus in the community and some hospital factors. There is a difference. The difference is that we have taken less capacity, but the private hospitals continue to do significant private work that is of benefit.

Can Mr. Woods comment on the costs?

Mr. Liam Woods

I think the Deputy gave an estimate. The estimate will fundamentally depend on the duration. The arrangement is for 12 months, but it is triggered when we hit particular surge points and we are in one of those right now. The cost will depend on how frequently it is triggered and how quickly it stands down. The figure the Deputy mentioned is an initial estimate of the first surge cost, but that could vary quite a bit, based on the degree of uptake of work in the private system.

My last question is for Dr. Glynn. While I am trying not to be political here, it is hard for Deputies not to be political. It is obvious that the Government's living with Covid policy is in tatters.

We are in the third lockdown and this is even worse than the previous two. The Government went against NPHET advice in late November and we are now living with the consequences. It is like living with an abuser; we cannot live with Covid. The policy of "living with Covid" simply do not work. How has this gone so terribly wrong in the space of six weeks? Ireland had one of the lowest rates of virus incidence and it now has one of the highest in the world. It is a result of the policy of living with Covid so we must do something different.

I can understand that the witnesses will be reluctant to criticise Government policy and I do not expect them to go into that area. Perhaps Dr. Glynn could reply to some of the Deputy's other remarks?

Dr. Ronan Glynn

In broad terms we need to keep adapting and we have learned much, although the basics have not changed. In the next month we will learn much about the future of dealing with the virus, particularly the extent to which the existence of these variants becomes known across Europe as more testing is done in member states and the extent to which we will be successful in containing or avoiding their import.

Just yesterday NPHET commenced work on where we go in the medium to longer term, looking at a 12-month view. In the first instance we would deal with the next four, six, eight and 12 weeks, an acute phase in which we try to manage what is facing us now. We need to build on that and put in play what we hope will be a very positive impact from the vaccines over the medium term. We clearly need to start talking about the longer term as well, as the one action we cannot take is go back to a position where we do not understand the very significant impact that globalisation can have on us in Ireland if we do not have enough focus on infectious diseases and their impact.

Looking at the global experience of this pandemic, Dr. Mike Ryan has said this may not be the big one and he may very well be right. What we have seen internationally with this pandemic is that experiences like this affect the most disadvantaged and vulnerable and those living on the margins of society. In the longer term, if there is to be any legacy from this, we must put in place a process that learns from the experience to ensure we can be in a better position in future.

I welcome Dr. Glynn, Mr. Woods and the team from the HSE. I acknowledge the exceptional work carried out by front-line workers and health officials over the past few months.

Christmas was always going to be a threat over any other time of year due to the nature of Irish people and the season coming after a difficult year. It coincided with the UK-identified strain of the virus arriving in the country. Was socialising through private gatherings and family homes the main source of infection that is responsible for our current position? Did we misread the threat or virulence of the UK-identified strain? The virus has mutated and new strains have been identified. There are different strains of flu annually so does Dr. Glynn anticipate there will be an annual vaccine for Covid-19 for older people or those with underlying conditions next winter and in following winters? Is this something that we hope will go away?

I have two questions for Mr. Woods afterwards.

Dr. Ronan Glynn

There is no doubt that when this virus gets into a household it is very difficult to stop it spreading within the household. If we listen to our clinicians

or GPs all across the country at the moment, any time one hears them speak it is very evident that containing spread within households had become much more difficult in recent weeks. That is most likely linked to the increased transmissibility of the new variant B117. However, to say that that was the primary factor, I do not think we could conclude that at the moment. What NPHET was clear about was that the significant risk was, which I am not attributing this to any particular sector or any particular setting, is in general terms we were worried that over the first three weeks in December there would be an opening up of society where, I suppose, younger people in the first instance would take advantage of that, would meet each other, would stick within the guidelines but there were far more opportunities for them to interact. What we were concerned about was that would lead to a volume of disease within a cohort of our population and then that would be followed through the Christmas and new year period by very significant intergenerational mixing where, unfortunately, that would lead then to very significant volumes of disease in those who are most vulnerable and elderly. Unfortunately, that has played out.

We can see from the mobility data that on 22 and 23 December we were back to levels of mobility in this country that were equivalent to what we saw pre-pandemic. That is the only time it happened since last February and that was in the week leading up to Christmas. Again, without being specific to a sector, and certainly not in any way seeking to attribute blame, I said in December that just because people could do something did not mean that they should do something. The reality is that people could do an awful lot. Unfortunately, we are where we are and it will take time to separate out the relative contribution of each of those elements.

Did we misread the threat? To misread a threat one has to be aware of the threat and it was only notified by the UK authorities, and I would need to double-check for sure, but I think it was 19 or 21 December. We acted on that immediately. We can see from our own data that we had very low levels of the variant in the country. Looking back, there was probably less than 2% in the country up to 13 December, certainly less than 10% up to the week after that and then rising to approximately 16% in Christmas week, which is the week in which we first became aware that this variant was an issue. So there is no doubt that the variant is playing a significant role now and will be a significant challenge for us as we seek to achieve further suppression of this disease. There is no doubt that it played a role in making things as bad as they have got. Again, it was one contributor in a crowded field of contributors to the situation that we have found ourselves in.

Regarding the annual vaccine, on a positive front, the wonderful thing about the mRNA vaccines and the new technology we have is that it appears, in relative terms, that it is simple to swap out the key part of that vaccines and swap in other elements that can help to address the threats posed by other variants of this virus. That is not entirely clear at the moment but the scientific community seems reasonably confident that the swaps to update these vaccines will not be as onerous as the process that we had to go through to develop the vaccines in the first instance. In any event, this is not just about vaccination because were this vaccine to have the effect that we want it to have it needs to have an effect all over the world. If populations all across the world do not get this vaccine and are not immunised, we are going to see the emergence of new variants in other parts of the world.

They will eventually arrive here and will have very significant implications for public health in this country. It is in all our interests to do what we can to ensure that there is equitable access and supply across the world to vaccines.

The Senator has run out of time. Could he put his questions? We will get a written reply to the ones for Mr. Woods.

Yes. I am inquiring about the nature of the ICU beds required for those who have Covid but no other underlying conditions. Do they require the same level of support as an ICU bed that we would be more familiar with before this for somebody in post-operative care or stroke care? Are they more or less intense or are they patient-dependent? Second, how important are individual single-occupancy en suite rooms in the prevention of the spread of Covid? I am thinking of the new 75-bed ward in GUH versus a traditional ward in the hospital.

Mr. Liam Woods

I can answer quite quickly.

Please do.

Mr. Liam Woods

The answer to the second question is the single rooms are very helpful for infection prevention and control. On the first point on Covid-related patients, I might ask Dr. Hamilton to answer briefly because she is an intensivist.

Dr. Vida Hamilton

Patient care is directed on an individual basis but I would note that we have, as of yesterday, more than 330 patients on advanced oxygen-supply devices outside of the ICU. They have single organ failure. They are being supported outside of the intensive care unit but they are doing very well. We are providing ICU outreach to support the ones that are flagged by the respiratory teams to critical care. Does that answer the Senator's question?

Mr. Liam Woods

I think Dr. Hamilton would also indicate that the level of care for a Covid patient may be every bit as intense in an ICU bed as any other type of intensive care requirement.

I hope everyone can hear me. I reiterate what everyone has said. I thank all the witnesses so much for being here and for the work that they and their teams are doing. It is deeply appreciated by all of us here and, I am sure, many members of the public.

I will focus on two areas. The phrase "colossal health crisis" has been used in this session. We are obviously in a colossal health crisis but we arguably have an even more colossal health crisis coming down the line in dealing with the backlog that is being created and the knock-on consequences of Covid. We briefly talked about waiting lists. Has Mr. Woods any figures available - I would be happy to take them in writing - on how much the waiting lists have increased by? Before the Covid crisis we were constantly talking about waiting lists and the numbers going up. Has he figures for the waiting lists, particularly for cancer care and coronary care? For example, does he know how many cancer diagnoses there were in 2019 compared to 2020, which would perhaps tell us have we missed cancer care diagnoses? I had a meeting with the Irish Cancer Society over the summer and the society estimated by then that 600 cancer diagnosis had been missed. In the months following that, they estimated there would have been many more. Has Mr. Woods any thoughts on those waiting lists and those whose care we may have missed out on despite the best efforts to not do so?

Mr. Liam Woods

I thank the Senator. I will pass over to my colleague, Ms Angela Fitzgerald, in a moment. We can provide specific commentary back to the Senator in writing from the cancer programme on what has happened in cancer care and maybe, more generally, on waiting lists.

Ms Angela Fitzgerald

The Senator is quite correct. The effect of the decisions in March to curtail non-urgent elective care, which were appropriate because we were at a very early stage of understanding the disease, had a significant impact. While the system recovered, we have given ourselves a very big challenge. To put it into context, at the end of last year we had 66,000 patients waiting on our inpatient and day-case waiting list. At the peak in the middle of the summer, that rose to 85,000. That was largely because we were not able to schedule cases.

We are back down to 72,000, but 72,000 is obviously an unacceptable number. I mentioned earlier the access to care plan, but that is very challenged because, as the committee can see, alongside lockdown measures we also have to curtail elective care that is not time-dependent. It is important to say - and I think Dr. Hamilton will be able to come in on this - that we did, as far as possible, try to protect time-dependent care in two ways: not only in our public hospitals but also through the arrangement we had with private hospitals, which was intended to protect that care. While a lot has been said about the success or otherwise of the private hospital initiative, the committee will see in the pack and the opening statement we have provided the scale of work that was done in that time. Much of it was supporting cancer and other care. We did over 50,000 inpatient and day cases during that time. We also moved cancer care from public to private hospitals very successfully and moved the doctors with it. We saw that in St. Vincent's, in the Mater, in the Whitfield and in Cork. That will be an important part of surviving this current surge.

Regarding outpatients, which comprised a very challenging number to begin with, we had made significant inroads last year, although we were still at a very high figure. We went from a figure of about 565,000 at the end of last year up to more than 600,000 now. While typically none of these are patients waiting for cancer care, they are people who need to be seen and they pose a very significant challenge. One of the things we did successfully during the peak of the first surge was to shift some of our outpatient appointments to virtual appointments. At one point during the peak almost half our patients were being seen virtually. We would like to take that forward as part of the way we do our business but we also recognise that new patients need to be seen in person. At macro level the figures have deteriorated. Over the year we have seen them go, as I said, from 66,000 to 72,000 and from 560,000 to 610,000.

Regarding cancer, we have separate data coming through from the NCCP, and Dr. Hamilton may wish to comment on that, and our rapid access services, which are our early ways of detecting cancer, continued throughout. One of the challenges was that people were delayed in presenting because many people did not present. That is a challenge, and I think Mr. Woods made the point earlier that we see a direct relationship between attendance at ED and lockdown measures. People tend to stay away. It is a difficult message to get out. We are trying to prevent people from moving around unnecessarily but we still want people to present to their GPs and to the ED if they need to do so. The messaging that NPHET and others have got out on this is better and we are seeing better traction on it now. We are happy to share the detail of this with Senator Hoey if she so wishes.

It would be great if the HSE had any further figures to share.

I will bounce the second question off the witnesses and that will be my main questions asked, and then anybody else who wants to come in may do so. Could any of the witnesses offer their thoughts on the following? We have talked a lot about mandatory quarantine, and there has been comment from some political corners to the effect that it is not necessary and that we will not go down that route. I think it is important and necessary. Certainly, we in the Labour Party are supportive of it. What impact do the witnesses think not introducing mandatory quarantine will have on tackling the spread of this virus? We can say we do not want people travelling unless it is absolutely essential. Have we learned over the past ten months, however, that people will keep travelling and we simply need to go down the mandatory quarantine route, or what do the witnesses think the impact will be if we do not go down it? There was not a huge amount of support or calls for mandatory quarantine earlier in the pandemic. Do the witnesses think that was the wrong call? Perhaps the media portrayed things for which there was no support, and I recognise that the things the media report on have to be taken with a pinch of salt, but it felt like there was not a huge amount of support earlier in this crisis for mandatory quarantining. Do the witnesses think that has had a knock-on impact on the spread of this virus?

Dr. Ronan Glynn

Mandatory quarantine is one measure and it has clearly attracted significant attention and debate over recent days, and debate on any of these issues is welcome. Again, however, I would caution that the experience over the past year has been - and this is very understandable - that we typically bounce from question to question and from theme to theme as though if we could just do this or that one more thing, we could all go back to normal.

Unfortunately, that is simply not the case. We all want to go back to normal. From NPHET's perspective, we want any measure brought in that will suppress this to the level we saw last June. As I said, I am sure a variety of different measures are being considered that are way outside my sphere of understanding or expertise that might further help to reduce levels of incoming travel to this country. I remember voicing concerns before Christmas that incoming travel could contribute to issues we would see at this time so I am not downplaying it in any way but it is also worth again reflecting in these conversations that the vast majority of people in this country have listened to the advice and have restricted travel. Travel volumes are down very substantially on what they were previously. The one thing I do not want to happen in this debate is for people out there to feel they are in the minority or are the stupid ones for not booking their holiday this summer. That is not the case. The majority of people have listened to the advice. I know last summer was particularly difficult for people but they continued to listen to the advice and I do not think we should lose sight of that in the debates we have on this issue.

I appreciate and recognise that Dr. Glynn cannot give us the panacea we all want.

I thank the witnesses for all the sterling work they are doing. I cannot even imagine the pressure they must be feeling. I have more of a comment to make than a question to ask. I hope I have not misinterpreted the vaccine arrangement that NPHET thinks will allow travel. It is important to look at mandatory quarantine. I read a tweet that really impacted me this morning from a young woman who said that she put up on Twitter that she quarantined in a room by herself for two weeks after her husband died, meaning she could not go to his funeral and could not be comforted by anyone for two weeks right after the most traumatic day of her life. She then wrote "and you're all worried about inconveniencing tourists". I do not mean to trivialise the travel issue because I understand there are important matters-----

We cannot hear the Senator. Is it possible for her to put on her headset and speak into the microphone?

Can the committee hear me now? Is that any better? I will turn it up.

Yes. We missed a lot of what she said.

Will I say it again? Can the committee hear me?

Go ahead. It would probably be helpful if the Senator had a headset on.

I do not have any headset. I will repeat what I said as quickly as possible. I was talking about the importance of mandatory quarantine. I did hear what Dr. Glynn said about NPHET's current position on travel, namely, that the regime is not sufficient. I heard him say that earlier to Deputy Shortall. I wanted to put on the record that I read a tweet this morning from a young woman who said she quarantined in a room by herself for two weeks after her husband died, meaning she could not go to his funeral and could not be comforted by anyone for two weeks right after the most traumatic day of her life. She then wrote "and you're all worried about inconveniencing tourists".

I do not want to trivialise this in any way with regard to travel. I understand there has to be essential travel. However, I do believe mandatory quarantine is important. We see that it has worked in Australia. It leads to reduced numbers and that is really important. I do not really have a question as such because Dr. Glynn has answered many of the questions around that.

There is another question I would like to ask. Before Christmas, Dr. Holohan was asked about alcohol and the role of alcohol in spreading the virus. Has there been any more information around alcohol and how it can spread or has spread the virus over the Christmas period? We all know how alcohol can lower people's inhibitions. I hope the committee members and witnesses were able to catch all that. I wanted to ask Dr. Glynn about the role of alcohol in spreading the disease.

Dr. Ronan Glynn

I will keep it brief. There is no new quantitative information. What we have heard over and over again throughout the duration of our response to this pandemic are the granular qualitative stories, narratives and data that our public health doctors and their teams have given us. It is difficult to put all of that into a weekly or regular report. However, time and again they have told us about the extent to which socialisation has an impact on this, whether it is extended family gatherings, friends meeting up or, in particular, hospitality settings. Again, this is not in any way seeking to attribute blame. The reality is that when people consume alcohol, they drop their guard. That is precisely what this virus wants us to do. It is difficult enough for a person to remember to keep a distance of 2 m, avoid touching his or her face, wash hands, wear a mask appropriately and avoid crowds at the best of times. I do not believe there is anyone who can say with confidence that they can do all that appropriately having consumed any significant level of alcohol. It is a factor. It is one more factor that we need to continue to address. Again, I am simply trying to reflect. Dr. Holohan was trying to reflect the concerns expressed to us by those who are at the coalface dealing with the impact of this on families and communities throughout the country.

I wish to ask one final question but I am unsure whether Dr. Glynn can answer it. We have seen a large amount of misinformation online in recent weeks on vaccination. How can we communicate to those people and others that the reality is that the vaccine is safe? That is all I have to ask.

We will be dealing with that next week, but Dr. Glynn may wish to respond quickly.

Dr. Ronan Glynn

There is one key message to get across - I know I have said this before. We should not overly obsess over or give a platform to those who are seeking to promote misinformation. The reality now is that 85% of people in the country are saying that they will probably or definitely take the vaccine when it is offered to them. That does not mean they do not have questions or concerns. Our job in the coming weeks and months will be to answer those questions and concerns and not worry too much about those on the extreme who will never be convinced by anything we say in respect of these vaccines.

My thanks to all the witnesses for the work they are doing. My thanks as well to all the staff across the entire health service. It has been a singularly challenging time during the past ten months.

I will open on the issue of messaging. I am concerned because there are several instances I have come across where people seem to be totally blasé about the issue of Covid-19. I am unsure whether we are getting the message out strongly enough. One case involved someone who went into a medical clinic without advising that he was awaiting the results of a Covid-19 test. After the medical clinic was over, he made a call saying that he had tested positive. The following day he was contacted by people from the facility. His friend picked up the telephone and handed it to the person who had identified as positive for Covid-19 because the person was driving.

People, therefore, are just not following the guidelines and it is something that we need to really work on. Maybe the witnesses might give some comments on how we could focus on getting a stronger message out there.

The second issue I want to raise is nursing staff, who have had huge challenges over the last ten months. The HSE representatives have given the figures on the number of them who are out. Over 6,000 are out due to being a close contact or actually having Covid. Can we get the figures of the people who have left the health service over the last ten months? This may have been for various reasons, including family reasons and the difficulties they now face in trying to deal with it. I have heard of quite a number of nursing staff who have resigned from the service. When people are leaving the HSE who have resigned, are they being asked to fill out a questionnaire so it can be established why they have left?

The final thing I want to ask about is people who are coming back from abroad who are qualified nurses trying to get registered with An Bord Altranais. I have one case at the moment where the person has been waiting for 16 weeks to get registered. She trained and worked in the UK, has come back, self-isolated, put in an application and 16 weeks later still has not received her registration. Can any of the witnesses deal with why it is taking four months for someone to register as a nurse here?

Mr. Liam Woods

Maybe Dr. Glynn will reply to the first point and then I will come in.

Dr. Ronan Glynn

The messaging is a constant issue and as I said earlier there will always be people who do not take the guidance on board. We have been as explicit as possible that people who have symptoms, think they might have Covid or have any suspicions should stay at home and contact their GP by phone in the first instance. However, I absolutely take the Deputy's point that we need to continue to look at the messaging, try to freshen it up and try to target different groups of the population whether by age or by geography. One of the ways in which we are doing that is we have asked our behavioural subgroup to bring a paper to NPHET next Thursday. I am sure we can share it with the committee following on from that NPHET meeting. There is no doubt however that it is an ongoing challenge, accepting again, as I always emphasise, that the vast majority of people are listening and are trying to do the right things.

Mr. Liam Woods

With the Chairman's permission, I will take the other part of the Deputy's questions. On the number of nurses who have left, we can and will give the Deputy a report on nursing retirements. I know he is also referring to nurses who have left without retiring and I will talk to HR colleagues and see if we have anything on that. One of the challenges in that analysis will be that one of the big causes for leaving is movement to somewhere else as well, in normal times. I understand that the Deputy is not referring to that but I will certainly see what data we have that would point toward this. I think it would be usual that there would be exit questionnaires, as the Deputy referred to, or dialogue at least. We may therefore be able to tap into some of the reasoning behind that but there is not a system that does that as a singularity. Of course, half of the staff we are referring to will be in voluntary entities but again, we will have some data around that, particularly in retirement instances. We would also potentially have some data, if we can obtain it, on age of retirement which would be an indicator in terms of what the Deputy is referring to.

On the An Bord Altranais issue, I will follow up with HR colleagues; I was not aware of that. I am aware that under the existing legislation brought in earlier last year there is an exemption from registration fees for Covid response but I was not aware of that kind of delay. I will certainly follow up with my HR colleagues.

Can I come back in on the exit survey when staff are leaving without retiring? Why is a comprehensive exit survey not done? The stories I am getting back from nurses who walked away from the system describe situations where they feel that the issues they raised were not being taken on board.

I am a bit concerned that we do not have comprehensive exit surveys because it is only by conducting those that we can deal with the challenges that nurses are facing on the front line and that is extremely important.

Mr. Liam Woods

I thank the Deputy, agree with him and share his concern that we must understand the reasons people would leave the health environment. I acknowledge that nurses, like all front-line staff, are working under enormous pressure at the moment and have been since 29 February last year in response to this pandemic. I will dialogue with our colleagues in HR to see what is available. I did not want to mislead in my reply, but there may be some information available which we can provide on that matter. That information would certainly exist at a local hospital group and local hospital level.

I have a further question about private hospitals. We have agreed that the HSE can take over 30% of capacity in private hospitals. What happens in areas where there is greater demand? In Dublin and Cork, for example, there are quite a number of private hospitals whereas in other areas, there might be only one facility. Is there any provision whereby the HSE can increase the volume of work that can be put into that private hospital beyond the agreed 30% because of the demands on the local HSE facility? Is there such a mechanism in the agreement that has been reached?

Mr. Liam Woods

There is an arrangement within the agreement that allows for going beyond that 30% where both parties consent. It is also the case that the distribution of private hospitals around the country is variable, as the Deputy suggested, with a larger number in Dublin, Cork and Galway. Patients are, in some instances, moving across facilities and are not necessarily limited by geography, depending on their particular requirements. There is a basis for extending beyond the agreed 30% should it be required.

I will also ask about patients who are attending hospital on a regular basis, dialysis patients in particular. It is a considerable challenge because many of them are attending a medical facility three times a week and many of those patients and their families are extremely concerned. What additional mechanisms have been put in place to make sure that those vulnerable patients do not contract Covid-19? What can be done to assist them? My understanding is that they are down the panel for vaccination. We are talking about quite a small group of people, in real terms. What is planned to deal with that situation?

Mr. Liam Woods

As part of the response to the first wave of the pandemic, the HSE, through Dr. Vida Hamilton and Professor George Mellotte, the clinical lead for renal services and dialysis, invested in moving as much care as we could off hospital campuses to community-based facilities and homes. When it came to access to hospital sites, the HSE ensured, to the greatest extent possible, separate entrances and egresses, and strong compliance with infection prevention and control guidance. Dr. Hamilton may wish to say a bit more about that issue.

Dr. Vida Hamilton

We are very conscious of the vulnerability of those individuals. As the Deputy said, they cannot cocoon in their homes and have to leave to access dialysis. We work closely with the dialysis programme. We increased our dialysis delivery in satellite centres, away from the main hospital, by 20% in March 2020 in order to move people away from hospital settings for haemodialysis. We also increased the number of individuals who could avail of home dialysis and provide their own care in the home.

We put in robust guidelines on the management of patients while receiving dialysis, including instigating the use of masking during haemodialysis. With their agreement, our patients stopped eating and drinking during the dialysis period so that they could maintain masking and robust infection prevention and control practices.

We have audited our outcomes in terms of the acquisition of Covid-19 and outcomes from Covid, and they benchmark very favourably internationally. There have been low acquisition and mortality rates compared with international comparators in that vulnerable group of patients.

We are very conscious of their vulnerability and we continue to work actively with the relevant doctors to increase the number of home dialysis solutions and other solutions.

An additional challenge has been the difficulty in delivering transplant services for patients with renal failure due to the increased risk among transplant recipients if Covid-19 is acquired in the post-transplant period. That has put additional pressure on our renal services, but we are managing this extremely carefully.

I would like to ask a question. Afterwards, colleagues who have already asked questions will be allowed one question each.

Yesterday, during Leaders' Questions, the Tánaiste said 30% of cases arise in the hospital setting. I heard Dr. Colm Henry state this morning that great efforts were being made to make hospitals as safe as possible. We are talking about 2,000 people in the hospital setting with Covid. One third of that figure is 666. I heard Dr. Glynn state this morning that he wanted people to continue to use health services at this time. Clearly, however, we have a problem with our hospitals. Dr. Henry said this morning that there were difficulties with the way hospitals are designed and so on. I am aware of the sacrifices staff have made. We are already aware that 600 staff are out sick and that this is causing difficulties. What could we be doing differently? We have identified a cohort with a considerable rate of infection. What can be done differently within the hospital setting? I am aware that PPE and so on have a role but people are using such equipment. In the first lockdown, people were talking about the possibility of looking for accommodation for staff in the health service. Are we considering that? What are we going to do differently because of the rise in the number of cases?

Many of us feel hopeless. We are following all the guidelines. I am not talking about the hospital setting, in particular, but it would be really helpful if people were told each week where there is a rise in the numbers. I refer, in particular, to the track and trace system. It would be helpful if we were told how people are getting infected. It was mentioned this morning that infections are occurring in the home and that people may be going out partying. There was a suggestion that people are going to shebeens. It would be helpful if people could take ownership in respect of what they want to avoid doing. If I knew infections were occurring in Tesco or Dunnes Stores down the road, I would avoid going there. The same would apply to a certain shopping centre or other locations. It would be really helpful if we could circulate the message on what people can do themselves aside from avoiding social contact and washing hands. My key question, however, concerns what we can do in the hospital setting that we have not been doing to make hospitals safer for staff and patients.

Mr. Liam Woods

I will take the first question. With regard to infection in hospitals, the key control is the infection rate in the community. It is very visible that where there is a high rate of community infection, there are genuine challenges in the hospitals. There are many measures in place within hospitals to control infection but the reality is that hospitals are treating vulnerable patients and doing so in a way that complies as best as possible with all the policies, including those on the use of PPE, handwashing, social distancing and all the other measures that we could talk about. Fundamentally, however, the control concerns reducing the virus in the community.

Once the incidence of the virus in the community is high, it is a battle in hospitals to minimise its impact. Hospital staff, however, live in community.

To the point about hospital staff who need to self-isolate, there has been provision in Citywest, as an example, where a facility is provided for such staff. In fact, its use is now quite high. Some recently concluded studies have identified trends in this area and the strong indication is that one of the key drivers is the community infection rate, which brings us back to the core requirement to manage this pandemic, namely, compliance with the public health rules.

Dr. Glynn may wish to comment on the Chairman's broader points, which were about messaging.

Dr. Ronan Glynn

There is not much more that people individually can do, unfortunately. To a certain extent, we are asking them to do less, that is, to stay at home. I absolutely take the point that it would be great if we could say to avoid a particular shop or building. Unfortunately, however, with the presence of transmission that is in the community at the moment, everyone needs to assume that the virus is all around them, that anyone they come into contact with can infect them and that they themselves are potentially infectious. As we have said on many occasions, the single biggest issue with trying to control the virus is that many people are infectious before they are symptomatic, so they can pass it on to others before they are symptomatic. People can access the Covid data hub, which offers significant information on the incidence of the disease at a local level.

On messaging in general, people may be aware that we monitor public behaviours over time through a tracking service. To focus on the positive, in our most recent survey, which was conducted on Monday last, 88% of respondents said they were staying at home rather than going out. I acknowledge that the immediate response to that is "Of course that is what they will say because that is what they want you to hear." In fact, if we look back through the responses from August, September, October and November, the percentages were down in the 60s and 70s. The most recent occasion on which the figure was above the current level was in April, and even then it was at 90%. The vast majority of people are doing exactly what we want them to do. The challenge is to sustain that over the weeks ahead.

I had a technological battle this morning whereby the system decided to change my passwords, which made it very difficult to get reorganised. I apologise for missing the original presentations.

To begin in the political arena, I disagree with a point made by Deputy Gino Kenny, although normally I agree with much of what he has to say. We need to recognise one matter. We are not unique in the globe in having a serious problem with this virus. Throughout the world at present, an emergency battle is taking place. There has been surge after surge, and some of the countries that at the beginning were the leading lights in this area fell down, as we did too. It is not fair, therefore, to say the system or the people involved in the system have failed or that we are worse or better than anybody else. This is a battle that has to continue.

To be fair to the front-line workers, they have put their lives at risk and continue to do so. Many of them have lost their lives in the course of their duty to the system. We need to recognise that and to recognise that when we criticise the system, we may be criticising them indirectly and that is not fair.

At what stage can we expect the level of vaccination to move from 20%, to 30%, to 40% and so on? To what extent has it been calculated the degree to which the rate of infection is likely to drop in line with that, proportionately? It would be helpful if we had some figures on that because at least we would have something to look forward to.

We have all received emails, including in the past week, from allegedly well-informed personae to the effect that there is no virus at all and that this is a figment of the imagination of some very creative people.

There are many pages of this. It is doing terrible damage. It is doing damage and is disheartening for the people who are providing frontline services. We must all cop onto ourselves. In case anybody doubts, there are people who have made huge sacrifices in terms of de-congregation, avoiding meetings in the home and so-----

Deputy Durkan must wind up. I am sorry.

I know but I want to finish.

Can we save the vaccination question until next week?

How many seconds have I?

The Deputy has run out of time. His three minutes are well gone. Does he want a reply?

I will take the reply in writing. I was on the road at 7 a.m. this morning, in the frost, and I do not intend to go home without saying my piece. I will conclude by saying simply that I will avail of the replies by written means if necessary. I have two other questions. The first concerns the degree to which the service can avail of extra staff in the event of further emergencies. Deputy Colm Burke made reference to it already. Are they there, are they available, have they offered their services and are they awaiting inclusion?

Second and last, in the event of there being a further surge upon a surge, do the services have available to them the necessary beds to meet that surge? In other words, outside the private hospital system, is it possible to set up field hospitals and so on and are we prepared for that in the event of it being necessary? I thank the Chairman and apologise for coming in late. It was not my fault but the fault of technology. I am sure it was not his fault either but the fact that I sat here for the entire duration does not mean I have nothing to say.

Some of Deputy Durkan's colleagues, who are not members of the committee, wanted to come in as well and I will not be able to take them. Maybe we can just get a quick reply to his remarks and questions there from Dr. Glynn and others.

Dr. Ronan Glynn

There was a question on the impact of vaccination which I hope can be specifically covered at next week's meeting.

One point is that when we sit here and look at the evidence, graphs, charts and data, we are always conscious of the reality that we are not on a hospital ward nor in a GP practice; we are to a certain extent protected from what is frankly an enormous challenge for individuals working on the front line. I echo the Deputy's comments that at this stage, while I say there is no room for blame in relation to the vast majority of what happens in this pandemic - it is an extremely infectious disease - as far as anyone who denies its existence or seeks to downplay the impact it has on individuals and families across this country is concerned, there should be no place for them at this stage given the impact it is having on families across the country.

Mr. Liam Woods

Maybe I will address the other elements of the Deputy's questions. On the piece about extra staff, outside the private hospitals there is no magic bullet in terms of staff available for nursing or other services. We should of course acknowledge that the Army and the military generally have given us assistance in various areas of this, as have other staff cohorts but for direct service provision there are very few options and we are at the limit of that. The Deputy was projecting what would happen if there were a surge on top of the surge - our entire hope is that we are levelling off and beginning to see some decrease in total volume. Dr. Hamilton might comment on the field hospital idea.

Dr. Vida Hamilton

Given that our rate-limiting step in opening beds is staffing it is more prudent to retain our staff in our existing infrastructure, change day beds to stay beds and expand our capacity that way. The advantage of the private sector is that it comes with staffing so opening a field hospital is not a feasible solution.

I thank the witnesses. I apologise to the members who were trying to get back in, Deputies Lahart and Hourigan, and in particular Deputy O'Donnell.

If Deputy O'Donnell could forward his question, we will send it on within the system. I apologise again.

The committee will meet again in public session at 10 a.m. next Friday, 29 January, when we will give an update on the roll-out of the Covid-19 vaccine. Representatives of the Department of Health, the HSE and the special task force on the roll-out of the vaccine will be before the committee.

I again thank our witnesses and apologise for cutting them off in mid-sentence, or whatever else. I again express the appreciation of the committee and its support for the work our guests and their colleagues are doing. I thank them for their statements this morning.

The joint committee adjourned at 12.10 p.m. until 10 a.m. on Friday, 29 January 2021