Joint Committee on Health debate -
Tuesday, 2 Feb 2021

Update on Covid-19 in Nursing Homes

Chairman

We have one piece of housekeeping before I bring in witnesses. Can I take it that the draft minutes of the last public joint committee meeting of Friday, 29 January, are agreed? Agreed. I remind members that we will be meeting in private session this afternoon at 3. 30 p.m.

I welcome the witnesses to our meeting this morning. They will be providing us with an update on Covid-19 in nursing homes: from Nursing Homes Ireland, Mr. Tadhg Daly, chief executive; Professor Dermot Power, gerontology expert; and Ms Deirdre Shanagher, strategic clinical nurse expert with regulatory compliance; from the Department of Health, Dr. Kathleen MacLellan, assistant secretary, social care division; Mr. Niall Redmond, principal officer, services for older people unit; and finally, from the HSE, Ms Yvonne O'Neill, national director, community operations; Dr. Siobhán Kennelly, national clinical and advisory group leader, older persons; and Ms Sandra Tuohy, assistant national director, services for older people.

Before we hear the opening statements, I need to point out to the witnesses that there is uncertainty as to whether parliamentary privilege applies to evidence given from a location outside the parliamentary 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 Mr. Daly to make his opening remarks.

Mr. Tadhg Daly

I wish the Chair and members of the joint committee good morning and thank them for the opportunity to meet with the committee today. Accompanying me, as the Chairman outlined, are Ms Deirdre Shanagher, clinical nurse expert with regulatory compliance, and Professor Dermot Power, Nursing Homes Ireland, NHI, gerontology expert.

We are here to represent over 400 private and voluntary nursing homes across the country which are integral for health and social care in Irish society. The past 11 months have represented a most arduous and upsetting time for all of us in the nursing homes sector.

The recent January 2021 data published by the National Public Health Emergency Team, NPHET, is a stark reminder of the indiscriminate nature of this deadly virus, with more cases of Covid-19 reported in January 2021 than the total number in the whole of 2020.

Nursing homes are home to people with the highest levels of frailty and with multiple underlying conditions. Worry and anxiety have been rife for the past year as staff and residents have lived with a virus that threatens their very lives.

Greater engagement and collaboration between the nursing home sector and our public health services has undoubtedly enhanced the supports available to nursing home residents and staff in the face of a global pandemic. This collaborative approach with key stakeholders, who are also attending this meeting, the HSE and Department of Health has included the provision of personal protective equipment, PPE, serial testing of staff and timely turnaround of results, provision of regular specialist Health Protection Surveillance Centre, HPSC, advice and guidance, the temporary assistance payment scheme, TAPS, and staffing when available.

The collaborative approach that was implemented following the onset of Covid-19, albeit delayed, remains in place, thankfully. However, the entire health service is under immense strain, with more than 6,000 staff absent due to the virus and in excess of 1,800 being unable to work within our nursing homes. Staffing is the predominant emergency that presents today across our health service. Within homes with outbreaks, available staff are going to extraordinary lengths at huge personal sacrifice to ensure continuity of care.

It should be noted that the majority of nursing homes, thankfully, are not experiencing an outbreak this time. Those that have outbreaks are severely constrained by the unprecedented circumstances, but thanks to the tremendous commitment by their teams, they are working through significant staffing challenges. The situation remains precarious.

The warnings from public health experts have been consistent and repeated. Heightened prevalence of Covid-19 in our communities presents an inevitable consequence for our health services and our nursing homes. In early December, the European Centre for Disease Prevention and Control, ECDC, warned about the epidemiological situation. Just two weeks ago, it highlighted that the new strains escalate transmissibility and, regrettably, bring with them higher mortality rates.

It is a great tragedy that Covid-19 has manifested again within our acute hospitals, nursing homes and all residential care settings, with tragic consequences for so many. Covid-19 is not particular to any class or type of setting. The new strains are highly transmissible across our health settings and within broader society.

A new beginning is slowly emerging. The roll-out of vaccination is bringing huge relief and hope within nursing homes. The biggest reaction among residents, staff and families is, thankfully, euphoria and it is important to acknowledge the contribution of the vaccination teams and all stakeholders in the roll-out. It has been a success throughout the country, with very positive feedback and very high levels of uptake being reported among residents and staff. However, we feel it is legitimate to ask if a critical window of opportunity was missed. With nursing home residents the most susceptible to the virus, just 10% of the initial 77,000 vaccinations administered by mid-January were within nursing homes. The committee will be aware that the national immunisation advisory committee agreed nursing home residents and staff would be priority 1. The first vaccines arrived in Ireland on 26 December, yet the first was only administered in a private or voluntary nursing home on 7 January. Every day is vital for our nursing home residents and staff.

A system also needs to be outlined with urgency for those residents and staff who missed the first dose of the vaccine due to having Covid and for new admissions to nursing homes from acute settings and the community. We remain engaged with a view to securing commitment from the HSE and public health to bring into effect immediately a policy to address this important issue.

Vaccination is bringing us towards a new dawn for the relatives and friends of nursing home residents. However, there is a way to go to protect our most vulnerable. The public health advice entails ongoing temporary but extended visitor restrictions, bringing tremendous pain and sorrow. Nursing homes have strived to ensure meaningful engagement has been supported through the homes and will continue to be guided by the public health advice. Based on our engagement with public health, the strong indication is enhanced infection prevention and control, IPC, measures will be required for some time. We cannot let our collective guard down as a society based on vaccination.

Today’s agenda encompasses supports for nursing home residents. I have spoken previously in the Oireachtas and to individual Members about the fair deal scheme, the requirement to publish the long-awaited pricing review which was due for publication in 2017 and reform of the funding model. HIQA needs to work with homes to better understand the severe challenges of the past year and those that present currently, and to work with providers and staff in a supportive and empathetic manner.

It is the opinion of Nursing Homes Ireland that an enduring legacy must emanate from the tragedy of Covid-19. Clearly, the enhanced collaboration and the teams of broader healthcare and social care professionals have come together in communities to support the delivery of highly specialised care to those in our nursing homes. Residential care of our ageing population cannot be allowed drift from the consciousness of the legislators responsible for health policy and resourcing. A number of significant issues remain in culs-de-sac and we look forward to engagement in the months ahead on the broad reform agenda. The necessity to more tightly integrate nursing home care into our health services, a core recommendation presented by the Covid-19 nursing homes expert panel, must become an immediate priority. Our organisation is engaged with the reference group under the Department of Health to ensure this happens.

I thank the staff across the entire health and social care service, particularly those in our nursing homes, for their heroism in providing care to our most vulnerable during this pandemic. Great pride is assumed by people within our nursing homes in providing person-centred, compassionate care. It is important, and I know this has been highlighted by committee members, collectively and individually, by the expert panel and by the HIQA review, to pay tribute to staff, managers and owners for their dedication. We also take this opportunity to extend our sympathies to the families and loved ones of all residents and staff who have lost their lives because of this awful pandemic. For residents, my wish, I am sure it is shared by committee members, is that they soon will get back to a familiar norm of open visits, hugs and hope.

Chairman

I thank Mr. Daly and now call Dr. MacLellan.

Dr. Kathleen MacLellan

I thank the Chairman and members. I am joined by Niall Redmond, who is principal officer in services for older people.

The year 2020 brought with it the most serious global pandemic in a century. Since its emergence, there have been more than 100 million Covid-19 cases worldwide, with almost 200,000 of these in Ireland where, very sadly, more than 3,000 people have lost their lives. One third of these lives have been lost in the past month. While there is much to be hopeful about, challenges associated with the pandemic will continue for the foreseeable future.

Nursing homes have been particularly affected by Covid-19 in Ireland and internationally, where residents and families, in balancing protective and supportive measures, have lived without the normal daily social and person to person interactions. It is with great sadness that 1,543 people have lost their lives to Covid-19 in nursing homes; 369 of these in the past month. It is important to recognise the continued and determined professional care provided by our healthcare workers in nursing homes 24 hours a day. The Government prioritisation of vaccination for residents and staff in nursing homes brings a strong sign of hope. Nursing homes are where more than 30,000 of our citizens call home. Residents of nursing homes are vulnerable to Covid-19 because of their age, underlying medical conditions, the extent of their requirement for direct care involving close physical contact and the nature of living in congregated settings.

The ECDC risk assessment in November reiterated the overarching message that residents of long-term residential care services are one of the most vulnerable populations and continued focus should be placed on preventing Covid-19 from being introduced into such facilities and on the control of outbreaks when they do occur. Consistent with the learning arising from the pandemic to date, the ECDC highlights that the probability of Covid-19 introduction into these setting depends on the level of Covid-19 circulation in the community. Consistent with the recent and current levels of community infection, unfortunately nursing home impacts can be seen, with a fivefold increase in open outbreaks from 34 in mid-December to 193 by the end of January. However, it is also important to appreciate that approximately 40% of our nursing homes remained Covid-19 outbreak free and many nursing homes that did experience an outbreak managed very well. The central focus of NPHET's response has been to control the spread of the virus in so far as possible to protect those who are most vulnerable from infection, as well as protecting against causes, situations, circumstances, and behaviours that may lead to the spread of Covid-19.

Sustained communication and inter-agency co-operation remain central to the response to Covid-19. Extensive, ongoing and problem-solving collaboration between stakeholders, the HSE, the National Treatment Purchase Fund, HIQA and the Department continues. The State’s responsibility to respond to the public health emergency created the need for the HSE to establish a structured nursing home support system in line with NPHET recommendations.

This has been a critical intervention in supporting the resilience of the sector in meeting the unprecedented challenges associated with Covid-19. Guidance, personal protective equipment, staffing, serial testing, infection prevention and control training, accommodation and financial support have been provided to the nursing home sector, both public and private. In addition, multidisciplinary clinical supports are in place at community healthcare organisation level through 23 Covid-19 response teams. HIQA has designed and implemented a regulatory assessment framework of the preparedness of designated centres for older people for a Covid-19 outbreak and an infection prevention and control assurance framework for nursing homes, which includes a self-assessment tool and support programme.

Following a NPHET recommendation in May 2020, a Covid-19 expert panel on nursing homes was established by the Minister for Health. This panel was tasked with providing immediate real-time learnings and submitted its report to the Minister for Health, making a substantial package of 86 recommendations across 15 thematic areas. The report was published on 19 August. The Minister for Health and the Minister of State with responsibility for mental health and older people are committed to progressing the recommendations and have established an implementation framework with a priority focus on those key short-term public health and protective measures. This framework includes an inter-agency implementation oversight team and a stakeholder reference group, which have met 11 times and seven times respectively. A second progress report is being finalised and early progress has been made on the recommendations, as I will set out.

An additional funding allocation for the provision of integrated infection prevention and control has been made to the HSE. There has been advanced planning for testing the safe staffing framework. There is an ongoing commitment by the HSE and HIQA to continue the public health support measures. Additional inspectorate staff for HIQA have been sanctioned to support increased frequency of inspections. A review of the current nursing home-related legislation, with a particular focus on enhanced regulatory powers and oversight, has been commenced and work across HIQA and the Department is ongoing. There is ongoing serial Covid-19 testing in nursing homes. A framework document on the roles and responsibilities of the various agencies has been published. There has been provision of extensive education, including a dedicated web page with all nursing home education resources in one place.

It is important that a paper reviewing Ireland’s actions in light of the key national options in mitigating and managing Covid-19 in long-term care provided by the November ECDC risk assessment has been developed and discussed by NPHET. The ECDC outlines the need to take a systems level approach to supporting the prevention, introduction and transmission of Covid-19, noting that no single intervention or response, but instead a co-ordinated package of interventions, is required to successfully tackle the virus. This paper has been published.

In summary, across all options identified by the ECDC, Ireland has in place a comprehensive set of public health measures, actions and responses that align with each of the ECDC options. These are either direct actions or supports undertaken by State agencies and public health authorities or are measures aimed at supporting and facilitating individual nursing homes. It is likely that the effect of these actions, building on the evolving knowledge of the disease, has had over time a positive effect on the levels and impact of Covid-19 in long-term residential care. As presented by the Irish epidemiological modelling group, the number of cases in long-term care was smaller in the second wave compared with the first. However, the number of cases linked to long-term care following unprecedented levels of infection in the community is now very high, similar to the numbers seen in April and May 2020. Nonetheless, when compared with the total burden of disease in the community and total cases per week, the level of infection is significantly less than in April and May 2020.

In conclusion, the Government's plan for living with Covid-19 places an important focus on supports for the nursing home sector, both in the short term and for the longer-term development of the future model of care. These supports include the continuation of the various supports I have outlined in the opening statement. The focus of the programme for Government has been on the development of the future model of care. It is very important today, as we reflect on what has happened during the pandemic, that we focus our efforts on supporting new and renewed models for older person care.

Ms Yvonne O'Neill

I thank the committee for the invitation to come before it this morning. Members have already been introduced to my colleagues, Dr. Siobhán Kennelly, the clinical lead for older persons, and Ms Sandra Tuohy, who is our head of operations for older persons. I start by acknowledging the professionalism, dedication and commitment throughout the pandemic of all healthcare workers and volunteers, particularly those working with older persons in nursing and care homes, whether public, voluntary or private. I extend my sincere sympathies to our healthcare workers who have lost colleagues and to all families who have lost loved ones to the virus, particularly today those who are residents of nursing homes where the impact of Covid-19 has been felt so severely.

When we attended in mid-June, a detailed paper was submitted to the committee which captured the roles and responsibilities and the substantive level of collaborative engagement across the system between the HSE, HIQA, the Department of Health, Nursing Homes Ireland and other providers, all with the singular mandate of safeguarding the health and well-being of older persons living in long-term residential care. At that time in June the virus was relatively under control, with the then risk of a second wave as the country further opened the economy and society.

Public health reported data in mid-June indicated active outbreaks in less than 6% of nursing homes, characterised by largely smaller levels of detection in residents and staff. The response now required to the outbreak levels experienced in the current wave since December covering nearly 30% of nursing homes has relied on continued and enhanced collaboration across these stakeholders to support all facilities now impacted by the increased rates and virulence of Covid-19 community transmissions.

We understand that the committee members want a specific focus today on a number of themes and so the remainder of this statement will follow in that order.

Evidence in Ireland and globally has shown that older people, particularly those who are medically compromised or frail, are at severe risk for poorer outcomes from Covid-19 and that congregated settings such as nursing homes have been particularly impacted. Throughout the pandemic nursing home residents, their friends and families have been severely restricted in their social interactions and personal contact. Both in our professional roles and our private lives we appreciate the impact of those restrictions on the well-being of our loved ones.

Approximately 32,000 of our older population live in one of the 572 nursing homes currently registered by HIQA, with 81% of beds operated by private providers. It should be noted that a considerable number of those have remained Covid free and for many which did experience outbreaks these were managed very well.

From our public health data we know that 81% of all notified deaths in health service settings in Ireland from Covid-19 occurred in nursing homes and, sadly, we have lost the lives of more than 1,500 nursing home residents as a result of Covid-19.

The pandemic continues to pose extreme challenges to the delivery of healthcare services nationally with the rise in community infections across the Christmas period compounding challenges with regard to maintaining a safe, effective service delivery across the nursing home sector where there are approximately 2,000 staff on Covid leave across the largest outbreaks in more than 100 facilities. At 1 February 2021, there were 193 reported open outbreaks.

The HSE has directed maximal efforts towards the management of these outbreaks. In line with recommendations from NPHET, the HSE has rapidly stood up and continues to provide a range of supports including clinical advice, infection prevention and control guidance, access to staff training and education, prioritisation of staff for testing, supply of personal protective equipment, PPE, temporary staff accommodation and redeployment of HSE staff in exceptional cases to ensure continued safe care. In the last reported week ending 21 January, 3,000 bed nights were provided in that staff accommodation, 60% of which related to a private nursing home staff.

Between the first and second waves a considerable number of webinars have been offered by the HSE and attended by hundreds of providers and their staff, in addition to a dedicated website for all related guidance. That is in parallel with continued operation of fortnightly serial testing of all nursing home staff, increased to weekly for the two weeks at the height of the current wave of Covid. The current seventh cycle of serial testing is indicating a detection rate of 2.3% of all staff tested.

During the first wave of the pandemic the HSE established a number of Covid-19 response teams with multidisciplinary specialist expertise who continue to work with all nursing homes - public and private - and play a critical role with the public health outbreak control teams in responding to, managing and containing outbreaks. There are currently 23 Covid response teams actively supporting nursing homes and these include infection prevention and control expertise, older persons service managers, consultant geriatricians and nursing staff. The Covid response teams can, if necessary, be flexibly enhanced with additional skill sets depending on the nature and setting of the outbreak in question, such as palliative care, and can also assist facilities with deployment of additional staff where necessary. Currently, there are nearly 200 HSE staff redeployed to older persons residential services and more than 60 of those related to private facilities.

The HSE has continued to supply PPE to all nursing homes in accordance with clinical guidance for both precautionary and Covid positive levels and also regardless of whether they are public, voluntarily or privately run. Measures are in place to increase PPE distribution for high demand items. The situation is monitored on an ongoing basis and guidance updated as required.

The very infectious nature of Covid-19 makes it difficult to prevent and control in residential care settings. In order to safeguard residents and staff, the HSE has, through the Health Protection Surveillance Centre, issued guidelines on visits. These guidelines are reviewed to reflect current public health advice and NPHET recommendations. As contact with family and friends is essential to residents’ well-being, these guidelines have at all times sought to balance competing challenges in order to serve the needs of residents, as well as incorporating expanded definitions of critical and compassionate circumstances based on experiences to date.

In addition to the previously outlined supports, the ongoing vaccination programme continues to provide a source of hope and positive development within older persons services during this difficult time. Today, 575 nursing homes across the country will have participated in the first dose programme of the vaccination with the plan for both delivery of the remaining dose 1 residents and staff who could not be vaccinated due to clinical presentation and the dose 2 programme to follow within the indicated timelines, dependent on vaccine supply.

While this continues to be a difficult time for all, it is vital that the work completed to date by our colleagues, clinical and non-clinical, is acknowledged. The HSE will continue to divert all of its efforts to managing the current crisis and maintaining safe, patient-focused service delivery.

Chairman

I thank Ms O'Neill for her opening statement. As was explained earlier, members are attending virtually from their offices on health and safety grounds. As a result, they cannot see the clock to monitor their speaking time. The first group of questioners has ten minutes and then seven minutes. I appeal to members to keep within these times. I will advise speakers when there is a minute remaining and ask them to stick to their time allocations in order to facilitate all members who want to participate in the meeting. I call Deputy Colm Burke.

Deputy Colm Burke

I thank all of our guests. It is important to acknowledge the work of everyone in the healthcare sector, in the hospitals, congregated settings and nursing homes.

Ms O'Neill stated 81% of notified deaths in health service settings occurred in nursing homes. That could be misinterpreted that 81% of the 3,000 Covid-related deaths occurred in nursing homes. The number of those who died in nursing homes is approximately 1,540. My understanding also is that a number of people died in facilities covered by the Mental Health Commission. Is there an actual breakdown of the number who died in home settings, hospitals, nursing homes and congregated settings, respectively? It is important the figures are clarified.

Ms Yvonne O'Neill

Yes, the 81% figure is of the deaths in all healthcare settings. That is across nursing homes and hospitals as opposed to 47% of all Covid-related deaths. We can provide the breakdown across all settings afterwards if that is helpful to the committee.

Deputy Colm Burke

Can we have a breakdown of the number of people who died in public nursing homes over the past two months? The last time the numbers worked out at 80:20. Up to 80% of nursing homes are in the private sector and 20% in the public sector. Has there been any variation from those numbers?

Are there any new challenges in the nursing homes that were not there in the first outbreak of Covid? Ms O'Neill referred to about 30% of nursing homes having had Covid outbreaks. Why does she think that occurred and what contributed to that?

Ms Yvonne O'Neill

The total deaths in nursing homes is across public and private facilities, so that is split. I will have to check afterwards in relation to how the deaths are recorded per facility and see if I can provide a breakdown between public and private.

On the Deputy's second question, I will hand over to my colleague, Dr. Siobhán Kennelly, but all statements reference the virulence of the current strain and the dependency between the rate of community transmission and the rate of transmission in our nursing sector. Unfortunately, that has led to the rate of increase. There have been huge developments in terms of infection prevention and control, IPC, efforts and adherence to the guidance by providers. The other thing that has probably changed, which is positive, relates to the regular serial testing of staffing. That leads to early detection and we have been able to work with providers on managing outbreaks through early detection in identification of staff.

Dr. Siobhán Kennelly

I thank the Deputy. Ms O'Neill has covered most of the points I would have made. Serial testing has made a significant impact on our ability to pick up asymptomatic infection, in particular on this round. The primary driver of the increased rates we saw was the very high rates of community transmission and the fact that our staff who work and live in community settings are unfortunately able to bring the virus with them into care settings and that causes difficulty.

The issues which have been highlighted through the nursing home expert panel report in terms of the risks that are posed by congregated settings for frail, older and vulnerable groups have not gone away. We will need to look fundamentally at the model of care in terms of provision for vulnerable groups and how they can be best cared for into the future.

Deputy Colm Burke

In the report Ms O'Neill gave this morning, there was a reference to where accommodation has been provided for staff. An issue that occurred in March and April was where, say, five people shared accommodation but they might be working in different healthcare settings. I presume it has been a challenge to try to deal with that issue.

Ms Yvonne O'Neill

Yes. That accommodation has been made available to all staff where they believe their home settings cannot give them the level of infection prevention control that they want. Other members of staff who have not taken up accommodation offers have, as Mr. Daly referenced, made sacrifices in their personal lives to minimise the potential for them to bring infection into the home. There have been multiple efforts, including accommodation provision and personal efforts by all our staff.

Deputy Colm Burke

Mr. Daly referred to the pricing review of 2017. On that issue and the challenges faced by private nursing homes, there are now increased costs in dealing with Covid. There is also the issue that when a patient is assessed under the fair deal scheme, he or she may be able to move around and is not in any way restricted. As such people remain in a nursing home for a longer period and as they get older, they need a higher level of care.

What are Mr. Daly's views on the challenges the failure to publish the review is posing for the private nursing home sector?

Mr. Tadhg Daly

As I said in my opening statement, this issue goes back to a publication from 2017. That it has not been published is an impediment to a mature debate and discussion on the future and sustainability of residential care services for our older population. We expected the then Minister for Health, Deputy Harris, to publish it in November 2019. He confirmed at our conference that the fair deal was not fair for private providers and that he would publish the review without delay. There has now been a further delay and that is having an impact.

It is important to acknowledge that the Department has put in place a temporary assistance payment scheme, although it is due to run out in June. It is a contribution towards the increased costs associated with Covid.

On the Deputy's point about dependency, at the moment there is a one-size-fits-all pricing model. The issue was raised recently in the Oireachtas by the Committee of Public Accounts, which some members of this committee are also members of. It highlighted in its analysis of the report of the Comptroller and Auditor General that there are significant challenges. We will work with the Minister, the Minister of State and the Department to ensure that the report is published as a priority.

Deputy Colm Burke

What problems with retaining staff do the financial challenges pose? Of the many people who have left the nursing home sector, will there be difficulty in getting them back, even when Covid is well under control?

Mr. Tadhg Daly

The other speakers have outlined, and many commentators have spoken about, the dedication and commitment of staff throughout the system. People who work in nursing homes are exceptional and we are hopeful the majority of them will return to the sector, although clearly that is a challenge. On the issue the Deputy raised about the sustainability of the sector, there is a significant discrepancy in the funding model, and until that is addressed, it will continue to impact on recruitment and retention. That needs to be dealt with as part of the review of the nursing homes support scheme.

Dr. Kathleen MacLellan

It might be helpful to give an update on the pricing review. As outlined by Mr. Daly, it was provided to the then Minister in late 2019. The report is complex and was given preliminary consideration by the Minister at that time. The report is now with the Minister, Deputy Donnelly, and the Minister of State, Deputy Butler, who are considering its content and the appropriate next steps. It is expected to be published soon.

We will have to give consideration to the impact of the Covid-19 pandemic. As was noted, the temporary payment assistance scheme has provided to the private nursing home sector additional Covid-related support to the value of €62.5 million to date. We will also need to give consideration to the Covid-19 expert panel recommendations in considering the pricing mechanisms within the nursing homes. Importantly, funding this year was provided for the recruitment of interRAI assessors, so we can move to put forward a standard assessment tool for the assessment of all older people, irrespective of whether they are going into nursing homes or will be supported within their own home.

Deputy David Cullinane

I welcome the witnesses. I wish to be associated with the expressions of sympathy to all those families who have lost loved ones in nursing homes, and I extend my solidarity and best wishes to all the staff who work in nursing homes throughout the island. I have a number of direct questions for Ms O'Neill and would appreciate short, sharp answers because I am just seeking information. As of today, how many confirmed outbreaks or open outbreaks are there in nursing homes?

Ms Yvonne O'Neill

The confirmed number today is 193 in nursing homes.

Deputy David Cullinane

That is a lot. How many positive Covid cases were there in January among either the staff or residents of nursing homes?

Ms Yvonne O'Neill

While I do not have that number in front of me, I do have it. One of my colleagues with the documentation might revert to the Deputy on it.

Deputy David Cullinane

If there are over 190 confirmed outbreaks, I would imagine that we are talking about thousands of positive cases. Would that be fair to say?

Mr. Niall Redmond

The figure I have for January is 4,300.

Deputy David Cullinane

Four thousand three hundred positive cases. Is that the number for staff? What is the breakdown between staff and residents?

Mr. Niall Redmond

I do not have the breakdown in front of me but the figure is 4,300 for staff and residents.

Ms Yvonne O'Neill

I can confirm the figure for staff. Thirty-seven per cent of the 4,000 cases relate to healthcare workers within the nursing homes.

Deputy David Cullinane

Those are very high numbers. We obviously have had very high levels of community transition but the number of outbreaks in nursing homes at the moment, amounting to over 190, is very high.

I wish to ask Ms O'Neill about crisis management. I have engaged with many groups that are raising concerns, from the Irish Association of Social Workers to Sage Advocacy and Care Champions. I want to discuss some of these concerns. In response to my first question, I do not want context or even the policy. Is there an outbreak management plan in place? Has the HSE an outbreak management plan, a crisis management plan, for all nursing homes, both public and private?

Ms Yvonne O'Neill

Yes. The outbreak control teams from public health and our own 23 Covid response teams operate according to a plan in responding to each outbreak when it happens, in determining what an outbreak is and in determining the level. The Covid response team works directly with the provider in respect of the impact and the supports that have to be put in place.

Deputy David Cullinane

Who is responsible for the implementation of the plan?

Ms Yvonne O'Neill

The Deputy will appreciate that the providers are ultimately responsible for the implementation of the plan in their response to an outbreak. That is supported by the public health and Covid response teams within the HSE.

Deputy David Cullinane

Am I correct that the HSE has responsibility for oversight?

Ms Yvonne O'Neill

The HSE has responsibility directly for its own facilities, the facilities it provides itself, and we work to support-----

Deputy David Cullinane

I am talking about private nursing homes.

Ms Yvonne O'Neill

-----private nursing homes in the implementation of their plans, as identified by public health officials having regard to the level of outbreak and risk.

Deputy David Cullinane

One of the things we have learned, from the expert panel report and the Covid committee when it was in place, is that the clinical governance arrangements between private nursing homes and the HSE need to be improved. We need consider that relationship very carefully.

On outbreak management and crisis management, I have been contacted by staff in many nursing homes who have expressed alarm over staffing levels in some of the homes. On the outbreak management and crisis management plan, what is the threshold or staff–resident ratio that would have to exist for circumstances to be considered to be at crisis point?

Ms Yvonne O'Neill

That is determined in relation to the level of outbreak, the number of residents affected by the outbreak and the number of staff on Covid leave. It is done in consultation with the provider, the public health team and the Covid response team. There is no one threshold because each outbreak has its own characteristics. The learning from the expert panel and the recommendations include the review of the staffing and skills mix for all providers. That will be a really important part of the learning from this. It is also a question of continued supports. I will ask my colleague-----

Deputy David Cullinane

I have a few more questions because I am not satisfied with the answer to the effect that it is more complicated than suggested. Most reasonable people would say there has to be a basic, minimum staff-resident ratio in any setting to ensure the optimum and highest levels of care. If the threshold falls below what I, Ms O'Neill and most reasonable people would consider to be a minimum, then we have a difficulty.

I want to put a number of questions and some of the experiences of families to Ms O'Neill, which come directly from all the groups I highlighted earlier. Families are struggling to get in contact and get through to nursing homes on the telephone. Has Ms O'Neill been made aware of the types of challenges family members have even to get basic information regarding their loved one in a nursing home?

Ms Yvonne O'Neill

Absolutely. We would be close to the challenges in dealing with any outbreak. We are supportive of any staffing that can be made available to any facility in an outbreak to improve and enhance communications with residents and families, which is absolutely-----

Deputy David Cullinane

The families tell me they cannot even get through on the telephone and get basic information. The loving and watchful eyes of loved ones and family members are not there. This is important when we talk about residents in care. That is not to say people do not get care when they are in nursing homes. Of course they do. We also know there have been instances of neglect and abuse. When one does not have that level of interaction between the loved ones and family members and the nursing home, it is a problem. It has been expressed to me that it is difficult even to get through on the telephone for basic information. The second issue is not being able to comfort a loved one who is passing away. I have heard from many families of residents who say they are only granted access when the person is no longer aware of their presence. I am sure Ms O'Neill can appreciate how traumatic that is. This is the experience of many family members.

Ms Yvonne O'Neill

There is nothing in what the Deputy has described that we are not professionally, and in some cases personally, aware of. He will appreciate that we do not have a presence - legislatively, we cannot have a presence - in every nursing home because we are not the provider. We work closely with all providers to provide supports. When a nursing home has had an outbreak and there has been a level of concern about staffing levels, we have worked closely with it to identify agency staff. We have provided HSE staff directly into privately run homes.

Deputy David Cullinane

Can I ask Ms O'Neill a straight question?

Ms Yvonne O'Neill

I will hand over to my colleague to answer the Deputy's question on visits.

Dr. Siobhán Kennelly

The guidance on visiting has been reviewed on a number of occasions. There has been extensive collaboration with nursing home providers and the teams in the nursing homes. Clearly, we are aware of the issue, particularly when people are faced with outbreak situations with constrained staffing and very sick residents. As a geriatrician, I have been in a number of nursing homes when they have been experiencing these particular circumstances. I have looked after people who were dying in such circumstances. The situations described by the Deputy deeply affect the staff members who are looking after the patients and residents, as they do their family members. I am personally familiar with the efforts everybody is making at this time to try to support residents in their place of care.

Deputy David Cullinane

I appreciate that.

Dr. Siobhán Kennelly

I also want to emphasise-----

Deputy David Cullinane

My time is very short-----

Dr. Siobhán Kennelly

I am sorry for talking over the Deputy. I want to emphasise the role of the regulator in working with the providers on what their baseline safe staffing levels look like and how those are coming to light in the context of the pandemic. There is much work to be done to make sure there is sufficient baseline staffing in care homes for vulnerable people. We must look at the fact that 40%-----

Deputy David Cullinane

I must come back in because our time is very short. We have ten minutes to ask questions and we really need more distinct answers from the witnesses. We are raising important issues. I want to put a question to Ms O'Neill. I appreciate the responses I have been given. I must ask these questions on behalf of all the families and groups I have interacted with over the last number of weeks and months. Has the HSE engaged, or when was the last time it engaged, with the Irish Association of Social Workers, IASW, as one organisation? When was the last time it engaged or met with Care Champions, Sage Advocacy or any of those groups, personally? I ask the same of Dr. MacLellan. When was the last time any of the witnesses has met with those groups?

Ms Yvonne O'Neill

Meetings are held with Sage Advocacy a number of times in the year in terms of the service arrangements that the HSE has with the organisation.

Deputy David Cullinane

When was the last time the HSE met any of those groups?

Ms Yvonne O'Neill

I engaged with the CEO in the lead-up to Christmas but we have obviously not had meetings. The service arrangement meeting with Sage Advocacy was also just before Christmas, if I am not mistaken.

Deputy David Cullinane

I wish to refer to the Irish Association of Social Workers and Care Champions so the organisations that are representative of residents and their families. When was the last time that the HSE sat down and engaged with them, and heard their stories and experiences?

Ms Sandra Tuohy

The Deputy has commented that families have contacted him. They have also contacted my department directly in terms of not being able to get answers in respect of how their loved ones are doing. We are acutely aware of that. We have raised the matter through our response teams to see how we can improve the correspondence and communication between families and their relatives in nursing homes. To repeat, the challenges that we have-----

Deputy David Cullinane

That is not the question I asked.

Chairman

The Deputy has gone way over his time.

Ms Sandra Tuohy

We meet voluntary agencies once a month where we have a two-hour engagement with them about all of the issues pertinent to older people. We have that meeting every single month and that includes Sage Advocacy.

Deputy David Cullinane

When was the last time the HSE formally met representatives of the Irish Association of Social Workers and Care Champions?

Ms Sandra Tuohy

They are invited to this monthly meeting, Deputy.

Chairman

I suggest that the HSE supplies a detailed note to the Deputy. Before we move off discussing the issue of loved ones passing away, are the witnesses saying that there are different approaches in homes to someone in such a situation? Does each home have its own approach or is there a standard baseline approach?

Dr. Siobhán Kennelly

Everybody who is involved in trying to deliver care at the minute is acutely aware of the need to maintain contact but it is very determined in many cases. In all cases, as part of a set of preparedness actions that have been laid out by HIQA, which unfortunately is not represented here today, they are advised to put in contingency plans around how families will be able to make contact during an outbreak and during a pandemic. So there is a plan in place but it is very important that people understand the context within which people are trying to deliver services when a very severe outbreak hits. It will be very important in the context of the discussions we are having here that we understand the realities of the staffing issues and care needs. A structured engagement with families is necessary in all of these residential care units and they do their best to provide that. We cannot speak for private providers who are doing this and it might be that many of these questions might be more appropriately addressed to the people who are representing them here.

Chairman

The next questioner is Deputy Lahart and he has ten minutes.

Deputy John Lahart

I wish to refer to a question that my colleague asked as it may have been lost. Did I hear correctly that the Irish Association of Social Workers and the Care Champions are invited to the monthly meetings?

Ms Sandra Tuohy

Yes.

Ms Yvonne O'Neill

Yes.

Deputy John Lahart

Do they attend?

Ms Sandra Tuohy

I do not have-----

Ms Yvonne O'Neill

I am sorry but I do not know the answer; we can check in terms of the range of organisations that attend monthly meetings.

Deputy John Lahart

Given that such a large proportion of nursing homes are in the private sector, have all of the answers that have been given to date only concerned the public realm?

Ms Yvonne O'Neill

No. In terms of the reporting of the level of outbreak and types of supports that are in place, they apply to all providers irrespective of whether they are public, voluntary or private.

Deputy John Lahart

The witnesses mentioned HIQA and the private homes sector. I suggest that the committee looks for a report on some of the outstanding issues that cannot be answered by the witnesses present.

As this is obviously a fraught situation for everyone, I want to thank people for their work at the front line. I thank the nursing home staff and management who I imagine in the vast majority of cases are doing their absolute best. As it is clearly exceptionally challenging, I really want to express my thanks. I believe there are four nursing homes in my constituency. All are privately run. This may change after this meeting but I have not had overt criticisms or challenges to the manner in which they have been run.

I have several questions. We were given a percentage of residents who died Covid-related deaths in nursing homes. How many can the HSE say died with Covid, as opposed to from Covid? An elderly relative of mine died in a nursing home. She had a number of conditions but Covid in the last 48 hours was on the death certificate. Has the HSE any statistics on that?

Ms Yvonne O'Neill

We do. In respect of the numbers of deaths, we separate those that are Covid-related deaths. The Deputy's points are very important for us to understand because every death is a sad loss for families and is experienced deeply by other residents and staff in nursing homes. I will hand over to Dr. Kennelly but those data are recorded separately. In the month of January, 369 of the 1,000 deaths were Covid-related. Dr. Kennelly might describe the way in which they are reported.

Deputy John Lahart

I am sorry to press Dr. Kennelly but I ask her to keep her reply to a minute.

Dr. Siobhán Kennelly

I will not press it as Ms O'Neill has covered a lot of it. Essentially, Covid-related deaths are very specifically those deaths that occur in residents who have been detected as being Covid positive, either through serial testing or because they have been symptomatic. As the Deputy will be aware, all deaths in nursing homes are reported through the coronial system so there is a system of engagement between GPs, coroners and public health experts about what would be recorded as the cause of death within those settings and how that then gets recorded in our national system.

Deputy John Lahart

I thank Ms O'Neill and Dr. Kennelly. Have there been any new residents admitted to nursing homes over the period? Obviously there must be families with elderly relatives who require nursing home care and attention. How is that managed? Are there some who are resistant to that option now because of the experience of the high rate of outbreaks and so on?

Ms Yvonne O'Neill

Some of the opening statements will have referred to the fact that there is a large number of nursing homes who have not experienced an outbreak and so have been available for admission of patients. Obviously there are guidelines around admission including a requirement for isolation for 14 days on admission. Thus the move to a nursing home is currently difficult for anyone. My colleague, Ms Sandra Tuohy, might give the Deputy a quick note on that point. That would be helpful, especially in terms of how that activity has changed over the last number of months.

Ms Sandra Tuohy

On the number of people entering the nursing home support scheme, NHSS, we have seen a significant reduction in the number of applicants. However, that probably has more to do with the fact that we have increased the number of home support hours and the overall wraparound services we can deliver to people to maintain them in their own homes. Obviously the reform agenda of the HSE and the Department is to support more people to remain at home for longer so we are seeing the impact of that beginning to happen. We are trying to support people with home support at night in their own homes to reduce the overall number of people who must be admitted to nursing homes to receive the appropriate care. We still have access to private nursing homes and to public facilities. We are trying to do rehabilitation within them at the moment but as Dr. Kennelly has outlined, significant number of nursing homes are closed to admissions because of ongoing outbreaks. Nevertheless, we remain able to bring in some patients whose needs really could not be met in the community. We are getting access to some facilities but not all.

Deputy John Lahart

Will Ms Tuohy quantify, year on year if possible, how many new requests there would be for nursing home care at this stage in the year? She said there is a reduction. Can she quantify it?

Ms Sandra Tuohy

In 2016, a total of 9,996 people entered the scheme and long-term care facilities compared with 8,975 people in 2020. At the end of 2020, we had 22,755 people supported in the nursing home support scheme. This is a €1 billion scheme so those people are supported out of that budget.

Deputy John Lahart

That is clearly another challenge for the system and a significant consequence of the outbreak. Am I correct in saying there are some 2,000 staff on Covid-related leave in 100 facilities?

Ms Yvonne O'Neill

Yes, that is largely correct. We have 193 outbreaks currently. We we have staff leaving on and returning from Covid-related leave so it is a very volatile number. Across our most significant outbreaks, we currently have approximately 2,000 people on Covid-related leave.

Deputy John Lahart

What have been the psychological and mental health impacts on residents and staff? I ask the witnesses to give us a picture of that. What recommendations, if any, do they have for this committee on additional resources they need or additional interventions the system requires?

Dr. Siobhán Kennelly

There has been a very severe impact across the board. A number of bereavement supports and programmes have been put in place by the Irish Hospice Foundation and others to help with some of the trauma related directly to the deaths and outbreaks as they have been happening. There will be a significant need, as highlighted in the expert panel report, for bereavement supports for many of the staff, residents and their families who have been impacted directly by outbreaks. Second, there has been the mental health impact and a physical health impact of a significantly prolonged period of isolation. If residents are isolated for a two-week period during an outbreak, they can become quite deconditioned. Many of them lose weight. We have quantified that with regard to the impact it has on mood, appetite and a significant number of physical and mental health parameters. We recognise that residents in these facilities are going to need a significant level of rehabilitation and support. Their families are going to need support and staff will clearly need a lot of support. We have provided a lot of education and training on post-Covid rehabilitation with staff across the sectors, but clearly they need time and resources to be able to provide that.

Deputy Róisín Shortall

I thank all our guests for attending and for their presentations. My first questions are on the roll-out of the vaccine programme in nursing homes. The original target date for having all residents and staff in nursing homes receive the first dose of the vaccine was more than a week ago. For various reasons, this has not happened and the Minister has told us that there are four nursing homes where no vaccine has been provided. In another 117 nursing homes, there are significant numbers who did not receive the vaccine, again for various reasons. What is the total number of people in those two groups, as between residents and staff?

Ms Yvonne O'Neill

I do not have that level of detail but it is available. I am aware the committee had a session on Friday on the overall vaccination programme.

Some 97% of the nursing homes have received the first dose, but, as mentioned by the Deputy, there are four that have not received it thus far. That is the-----

Deputy Róisín Shortall

I would like to come in again, if I may. We have been asking these questions of the Minister. I was hoping we might get answers this morning but Ms O'Neill does not have the number of people who have not-----

Ms Yvonne O'Neill

I do not have the number within the 117 nursing homes that have to be revisited in respect of the first dose who, because of clinical presentation reasons, could not receive their vaccine at the time.

Deputy Róisín Shortall

I appreciate that.

Ms Yvonne O'Neill

The vaccine has been rolled out to the 117 nursing homes. I cannot provide the figure today for the number of staff and residents not vaccinated.

Deputy Róisín Shortall

That is unfortunate. It is important that we know that number. We were told that there are significant numbers in that regard within the 117 nursing homes. Can Ms O'Neill get that number and come back to the committee with it as soon as possible?

Ms Yvonne O'Neill

Yes.

Deputy Róisín Shortall

We sought it last week from the Minister. If Ms O'Neill could provide it, we would like it now.

My next question relates to religious nursing homes. I have been made aware of four such nursing homes where there has been no roll-out of the vaccine. What are the arrangements for religious nursing homes?

Ms Yvonne O'Neill

The Deputy will probably be aware from the presentation last Friday by our colleagues that our chief clinical officer, in consultation with the Government, has produced a sequencing document around roll-out of the vaccine. There is engagement directly on identification of those religious communities where there are vulnerable older people and their carers. We are aware of, and have provided supports to, facilities where there are identified outbreaks. We are aware of outbreaks in a number of them and we are working with the stakeholder groups that represent them.

Deputy Róisín Shortall

I will pose that question again. What are the arrangements for roll-out of the vaccination programme in religious nursing homes?

Ms Yvonne O'Neill

That will align with the sequencing on the over 65s and vulnerable groups in relation to the wider sequencing.

Deputy Róisín Shortall

There are no arrangements to include them in congregated settings.

Ms Yvonne O'Neill

I will clarify that. They are identified as a vulnerable group within the over 65s. When supply is available they will be part of a determination of congregated settings.

Deputy Róisín Shortall

That is what I said. They are being included with the over 65s but not as a specific congregated setting. Is that correct?

Ms Yvonne O'Neill

We might be getting caught up in words. They are a vulnerable group because of the congregated setting in which they live. We are identifying them and they will be part of that prioritised group.

Deputy Róisín Shortall

When will the vaccination programme be rolled out to them?

Dr. Siobhán Kennelly

The prioritisation exercise happens through the national immunisation advisory committee, NIAC. There is an exercise under way between NIAC and the office of the chief clinical officer to prioritise other congregated settings, including the religious orders, in regard to roll-out.

Deputy Róisín Shortall

As of now, they are not among the prioritised as a specific group.

I want to move on now to the fact that we find ourselves yet again in a situation where there are extremely high rates of the virus and deaths in the nursing home sector. It is hard to believe we are back in this situation given the experience of last April and May. Yet again, NPHET is expressing serious concern about the very high numbers similar to last April and May and it has referenced a deteriorating epidemiological profile in long-term residential care facilities. Have we not learned lessons from that first wave, which was so tragic? There were three lessons identified at that point from that awful experience. The first was that there was no clinical oversight of private sector nursing homes and that the State was operating an arm's length approach to older people's care. There was a major gap in services and no clinical oversight of private nursing homes.

The second lesson that we talk about is the fact it is not an ideal situation for older people to find themselves in congregated settings. It is not ideal from a health perspective, certainly in a pandemic, and also not ideal socially. The third area was the chronic underfunding of home care. Those three lessons were identified by the expert panel and they have been known for a long time by many of the advocacy groups working with older people, particularly Sage. It was also recognised at a political level. Those of us in opposition have recognised these for a long time and it was recognised at Government level last summer that these were lessons that had to be learned, and that we had to find a new model of care for supporting and caring for older people.

I am asking about those three areas that had been well flagged and identified last summer: the lack of clinical oversight; the fact many older people are in congregated settings and we needed a new model of care and a statutory right to home care; and the underfunding of social care for older people. What has been done about those three major areas that had been identified last summer?

Ms Yvonne O'Neill

My colleague, Ms Tuohy, earlier referenced the significant investment in home care this year, exactly as the Deputy is describing as being required, which was 5 million additional hours in home care, which has allowed us to offer home care to a considerable number-----

Deputy Róisín Shortall

What was the additional number?

Chairman

The Deputy is way over time.

Ms Yvonne O'Neill

It is 1,200. That has meant a significant reduction in waiting lists for people for home care. The Deputy will know that our model of care is maintaining people at home and, thus, there is also additional investment in rehabilitation supports to maintain people at home. Deputy Lahart earlier referred to the question around the reducing number of older people in our nursing homes.

In terms of that model for congregated settings, we have responded to the learnings from the last time. I know my colleague, Dr. MacLellan from the Department of Health, who leads on implementation oversight for the expert panel, will also be able to respond around the-----

Deputy Róisín Shortall

With all due respect, we were supposed to have a statutory right to home care at this point. Why do we not see that? Why is it delayed?

Ms Yvonne O'Neill

I suggest that Dr. MacLellan responds.

Dr. Kathleen MacLellan

First, €150 million in extra funding has gone into home care this year to deliver an extra 5 million home care hours. Some €127 million has gone in to configure 1,250 beds for intermediate care to provide for a re-ablement model in the community. The ESRI is just completing a demand and supply model for us in regard to part of the basis for the statutory home care scheme. Significant funding has gone in for the establishment of a national home care office, which will underpin the statutory home care scheme, and that is scheduled as part of the national service plan, NSP, for 2021 in addition to the roll-out of the interRAI single assessment tool, for which funding has gone in for 128 assessors. There has been significant progress in terms of increasing the capacity and progressing the key elements of the statutory home care scheme.

We have taken significant lessons and learning from the evolving disease and what has happened internationally. One of the clear things for us, and the ECDC, NPHET and HIQA have all said this in their risk assessments, is that high levels of community transmission make it absolutely impossible to keep Covid-19 out of nursing homes, so our job-----

Deputy Róisín Shortall

What has happened in regard to clinical oversight?

Chairman

Hold on. Other members are looking to get in. We do not have the time this morning.

Deputy Róisín Shortall

Clinical oversight was the key area that was identified. What has been done about that?

Dr. Kathleen MacLellan

In regard to clinical oversight, the expert panel identified very clearly that the person in charge of the nursing home has responsibility for clinical governance within that nursing home, with the support of the GPs. Work has started to scope what that clinical governance model might look like, and the HSE is also working to scope how it might start engaging with the general practitioners. As the Deputy will understand, the key engagement with the general practitioners over the last period of time has been in regard to the vaccination roll-out, but it is a priority and it is part of the work of the implementation oversight team at the minute.

Chairman

I need to move on to Deputy Hourigan.

Deputy Neasa Hourigan

I will follow on from Deputy Shortall's question. I thank Dr. MacLellan for being here today and for her time. She mentioned the issue of statutory home care, the ESRI's report on demand and supply and the opening of a home care office. It sounds like things are in process. Could we have a timeline for completion of those issues? When does the HSE expect to see statutory home care in place?

Dr. Kathleen MacLellan

We are working with the HSE in respect of the establishment of the home care office, the interRAI assessors and those key elements that need to go in place. It is intended that they will be in place in 2021.

Deputy Neasa Hourigan

Does Dr. MacLellan mean the end of 2021?

Dr. Kathleen MacLellan

The timeframe will depend on the capacity with the current Covid-19 surge. However, it is absolutely intended that they will be in place by the end of 2021.

We are also finalising a draft scheme in respect of to the regulation of home care. We intend to bring a memorandum to Government to seek permission to draft it. That would relate to setting the minimum standards that need to be in place. HIQA has agreed within its business plan to start working on those minimum standards for care for home care providers, because they are not regulated at the moment.

Deputy Neasa Hourigan

Exactly. Will that be happening within 2021 as well?

Dr. Kathleen MacLellan

That will be happening within 2021, absolutely.

Deputy Neasa Hourigan

Does Mr. Daly wish to come in?

Mr. Tadhg Daly

I wish to make a point. Two issues were raised there, including one on clinical oversight. Clearly, there has been better collaboration in recent months but that needs to continue to improve. We highlighted in our opening statement the need for greater integration.

The issue of the care needs of an ageing population is relevant. We need to be careful here that we do not get into talking about home care versus residential care versus acute care. What we need is a continuum of care for our ageing population with all those elements playing a key role. Those who are in our nursing homes, as we know, are the most frail and vulnerable and have been assessed by a multidisciplinary team as requiring residential care.

Deputy Neasa Hourigan

We had a session on vaccines on Friday. I am trying to get a sense of what the interface with the information technology system is, especially in nursing homes as it relates to the private and public versions. I am asking for an overview. I am specifically interested in the fact that we have many staff on leave. We might have new service users. What is the access and interface between nursing homes and the vaccine IT system over the coming months? Will it pick up people who might have been missed in the first round? How is the HSE referring people to that? Could someone give me an overview of how that is happening?

Ms Yvonne O'Neill

Again, I have to confess that I am not that close to the vaccination IT system. However, what I do know is that it is available to all, irrespective of the location of where the vaccination is being rolled out. How this happened in practice was that the team was on-site at a public, private or voluntary provider of services for older persons, those with disability or in hospitals. The details of those vaccinated were recorded at the time of vaccination and then put on the system. That will allow us to identify the question Deputy Hourigan is asking, which is those to whom we have to return.

Deputy Neasa Hourigan

Who is inputting that information into the system?

Ms Yvonne O'Neill

The team of vaccinators who are present on-site during the vaccination.

Deputy Neasa Hourigan

If a staff member comes back from leave after that process, who then refers the staff member or a new service user to the vaccination programme?

Ms Yvonne O'Neill

There are two points on that. First, the list of those for vaccination, including residents and staff, is supplied in advance. That is loaded onto the system in advance of the vaccination team presenting. Second, there is a portal within the system that is made available for people to register. That will also allow people who have not been identified to register. The useful thing about it is that any worker, from an agency or otherwise, who is present is vaccinated.

Deputy Neasa Hourigan

To be clear, if someone is missed in that process, who refers that person to the system?

Ms Yvonne O'Neill

They are known to us.

Deputy Neasa Hourigan

If there is someone new who presents, who refers that person to the system?

Ms Yvonne O'Neill

When we have to return to a provider where staff were missed or new staff who have come in since the first dose, they will be identified in advance of the vaccination team arriving for the cover of dose one and the dose two programme.

Deputy Neasa Hourigan

To be clear, the staff member is referring himself or herself to the system.

Ms Yvonne O'Neill

No. We have an arrangement where in advance of the vaccination team presenting we work with the provider on the list of staff and residents in that facility.

Deputy Neasa Hourigan

Is it a medical member of staff of the provider who does the referring?

Ms Yvonne O'Neill

It does not have to be. Again, I am not entirely familiar but in terms of-----

Deputy Neasa Hourigan

It can be a manager.

Ms Yvonne O'Neill

In terms of a validation of list of residents and staff, absolutely. Yes.

Deputy Neasa Hourigan

I might have time for a final question.

Chairman

Go ahead.

Deputy Neasa Hourigan

I want to follow up on serial testing and, in particular, on asymptomatic transmission. Is testing and tracing happening where an asymptomatic transmission is found?

Ms Yvonne O'Neill

Yes. Regarding healthcare workers in our long-term residential facilities, all positives and all close contacts of positives are followed up and traced.

Deputy Neasa Hourigan

Back how many days?

Ms Yvonne O'Neill

There is a two-test system. If they have been in contact, there is a zero and ten-day provision. Am I correct on that, Ms Kennelly?

Dr. Siobhán Kennelly

Yes.

Ms Yvonne O'Neill

Zero and ten days.

Deputy Neasa Hourigan

Thank you.

Chairman

The next questioner is Deputy Gino Kenny.

Deputy Gino Kenny

Good morning everybody and I thank the witnesses for their contributions thus far.

It makes for very sombre reading when we hear more than half of the people who have died were in nursing home settings. It is a terrible situation in which the staff in nursing homes, residents and their relatives find themselves. I worked in a nursing home for a number of years and I cannot imagine the hurt and pain relatives are going through at the moment when they cannot see their loved ones in their time of need. It is pretty bleak to say the least. Our solidarity and support goes to all the workers and residents who are in that situation.

The public were shocked last year to learn that more than 50% of the people who died from Covid were in a nursing home setting. In January that figure has gone down to approximately 35%. We do not seem to have learned any lessons even with respect to the Special Committee on Covid-19 Response. It made a number of good recommendations, particularly related to staffing levels, retention of staff, agency staff and how people were discharged from acute hospitals into a nursing home setting. Hopefully all those recommendations can be adhered to. When the dust settles on this, members of the public will want a public inquiry into what happened in nursing homes. There is the disparate nature of nursing homes with 80% being private and 20% being public. Also, there does not seem to be a coherent plan for the care of our loved ones. When all of this is revealed, we will have to look at ourselves in the mirror. Would the HSE personnel support a public inquiry into what has happened during the past year, particularly with respect to nursing homes?

Ms Yvonne O'Neill

There is nothing in what the Deputy has said regarding the impact of the pandemic with which the HSE or any member of staff of the HSE would disagree. It is important for us to emphasise, as Dr. MacLellan noted earlier, that although there was an increase in the rate of detected infection in nursing homes, that rate was much lower than the community rate. I want to make sure that people understand this point. Certainly, in terms of our residents, their families and our staff, it is important to acknowledge that they managed to keep the rate of increase of infection in our long-term residential facilities at a much lower level than was the case in respect of community transmission. That is in direct relationship to the work and efforts and the infection prevention control measures taken by all of our staff and their adherence to those measures.

As I mentioned in my opening statement, the detection rate of 2.3% for the seventh cycle of serial testing is a very small proportion of how high the community transmission rate got at the same time. We need to acknowledge that in order to make sure there is a proportionate view of the level of outbreak in nursing homes. Certainly, the HSE would be very happy to contribute to any analysis that may take place in any forum in regard to the management and prevention of outbreaks in any of our long-term residential facilities.

My colleague, Dr. Kennelly, wants to comment.

Dr. Siobhán Kennelly

Dr. Mike Ryan from the WHO gave a very good presentation on a lot of the fundamentals around ageing and the exposé that Covid-19 has been in terms of ageing at a discussion organised by the Irish Gerontological Society, IGS, last October. He stated that 40% of deaths in older people very much reflected where they lived, particularly if they lived in a congregated care setting. We really need to look at the pandemic in terms of what it means for us in regard to how we address ageing within our society and the health and social care provision around it. That is part of the fundamental policy provision in terms of Sláintecare and trying to ensure that people can live within their own homes for as long as possible. The measures that are being taken through the enhanced community care initiatives and others are fundamentally underpinning the way the discussion moves forward.

I come back to Mr. Daly's point earlier around these issues being seen across a continuum. When one asks older people where they want to live, the huge majority of them want to continue living in their own homes. We need a model of long-term care that speaks to smaller, residential, household-type models in which the evidence internationally is increasingly accruing around less exposure in terms of pandemic and risk. The Deputy is addressing a number of really important learning points within his questions and they will need to be taken on by the system.

Deputy Gino Kenny

I have two further questions and they are for Mr. Daly.

Chairman

The Deputy will have to confine himself to one question as we are running out of time.

Deputy Gino Kenny

They are two very quick questions. Does Mr. Daly support a public inquiry into what has happened in nursing homes? I am not sure whether he will be able to answer my second question. Have new residents coming into nursing homes been given the first dose of the vaccine?

Mr. Tadhg Daly

I thank the Deputy for his questions. In common with all colleagues, whatever is decided by Government or by the Legislature in terms of the look-back at the pandemic, as it were, it needs, first, to be done in the round. Nursing Homes Ireland will participate as appropriate.

In terms of vaccinations, at this point in time, new residents have not been vaccinated. That is why it is important that we are engaged with the HSE on a policy, procedure and protocol to ensure that there is a robust system of making sure that all residents who discharge from acute hospitals are vaccinated, ideally before they come to the nursing home or, if not, within a very short period of their arrival into the residential care setting.

Chairman

Mr. Daly's last remark makes sense. The next speaker is Senator Kyne and he has five minutes. We are running down the clock.

Senator Seán Kyne

I welcome the witnesses. It has been a difficult 11 or 12 months for staff in nursing homes and I pay tribute to them. It has also been a difficult year for residents and their families, especially for residents who were used to regular visits from families or those who might have large families.

Mr. Daly mentioned that staffing is the predominant emergency. He also mentioned the significant progress in reducing processing times for the atypical working visa for non-EEA nurses. What are the turnaround times and how have they improved? Which countries in particular are providing most of the valuable nurses and care staff? What more can be done in this regard? Has the job situation resulted in an increased interest by people in this country to work in care homes?

Mr. Tadhg Daly

Back in December we were looking at a waiting time of 12 weeks and the good news with the atypical working scheme, further to our engagement with the Department of Justice, is that significant progress has been made on the scheme. In some cases the waiting time has reduced to seven days, which is very positive.

The main sources of candidates right across the health service, not just in nursing homes, are in India and the Philippines. We are working closely with the Royal College of Surgeons in Ireland on the clinical adaptation programme for staff coming from overseas because of the impact they have right across the entire health and social care service. That is very positive.

Senator Seán Kyne

What about the job situation among Irish people? Has there been an increased interest?

Mr. Tadhg Daly

Nurses are in scarce supply across the world due to the high demand. Even in recent days, I heard colleagues outlining the challenges when an outbreak occurs and a large number of staff are out sick due to Covid. Nursing is the single biggest issue. That is why we as an organisation engaged last year in a workforce plan. We will engage with the Department of Health on that. We must have a workforce plan for the entire health and social care service. People spoke earlier about increased home care, for example. Even if we have all the additional home care hours, we need the staff to be able to do that, both in terms of nurses and carers. The situation is still very challenging but that is something we collectively need to address.

Senator Seán Kyne

What about non-nursing staff? Is there an increased availability?

Mr. Tadhg Daly

There is, but I would also say that working in a nursing home setting requires a very special skill set. We hear that many people are now, regrettably, unemployed, having lost their jobs in other sectors, but the vast majority of them may not be suited to working in nursing home care. That is why we need to focus on career planning. Reward is an important part of it as well. That goes back to the point I made earlier on the review of the fair deal scheme. Recruitment and retention are a challenge for all of us right across the health and social care services.

Senator Seán Kyne

I thank Mr. Daly. I will open up my questions to other witnesses. Care in homes is not just confined to feeding, personal hygiene and rest. Extra services are provided such as physiotherapy, chiropody, and daily exercise routines. How has this been impacted by the pandemic?

Mr. Tadhg Daly

It has been hugely challenging on residents. Perhaps my colleague, Professor Power, will comment on that as well.

Senator Seán Kyne

In what way?

Professor Dermot Power

I am a geriatrician at the Mater Hospital and I do some work with-----

Chairman

We cannot hear Professor Power very well. His line is very bad.

Professor Dermot Power

I apologise. I do not know if that is any better.

Chairman

Yes, that is better.

Professor Dermot Power

I am sorry about that. When an outbreak occurs in a nursing home, visiting by both relatives and therapists is affected. The consequence is that the services to which Senator Kyne referred can be limited for a period.

Chairman

I am afraid the line is gone again.

Professor Dermot Power

I apologise.

Chairman

We might go back to Mr. Daly.

Mr. Tadhg Daly

Ms Shanagher or Dr. Kennelly might also wish to come in here.

Dr. Siobhán Kennelly

There has obviously been some impact because some of those staff are isolating or cocooning and cannot necessarily provide the services they would have been able to. Physiotherapy, chiropody and personal care services involve a lot of intimate and close contact with residents.

Within HSE services there has been a huge emphasis on the provision of multidisciplinary services which, in some cases, have been diverted to residents in those settings, in particular after an outbreak. There is an issue around the continued provision of services. In the drafts on visiting guidance issued from September and October onwards we made a very clear distinction between essential service providers, including those who provide all the services the Senator listed, and a number of other important service providers, such as those who provide supports like hairdressing that support the well-being of people in nursing homes. We have tried to cover that, but access is contingent on what is happening within a nursing home at any one time and the type of care that needs to be delivered for the residents. It is very much dependent on the service provider.

Chairman

Senator Kyne's contribution has come to an end unless he wants a written answer from the witnesses.

Senator Seán Kyne

Notwithstanding the excellent care that has been provided, is there evidence of people deteriorating more rapidly because of the pandemic due to the lack of interaction with family, loss of routine and mixing with friends? Are people losing the will to live?

Dr. Siobhán Kennelly

It has had a significant impact, as we said earlier, in terms of mental and physical health. Significant efforts have been made in terms of education and training provision. We understand an awful lot more about the indirect impacts the Senator is speaking to as the months have gone by. There has been a huge emphasis on learning from what the indirect impacts will be.

There will be a long tail to the pandemic in terms of the needs of residents, families and others in a residential care setting. We will need to do a lot more work and research to understand what the long-term impacts will be. They should inform the safe staffing levels we are talking about and the multidisciplinary needs of the model in terms of the multidisciplinary supports that people need and our entire social care system.

We must remember the direct and indirect consequences are similar for very vulnerable people who are living in the community outside of the nursing home and are isolated in their homes and experiencing equally deleterious effects. For those who are interested, there is a report on the impact of cocooning available on the HSE website. It outlines a lot of the impacts we have spoken about today and details the feedback from voluntary agencies, the nursing home expert panel report and others in a very detailed way to demonstrate our learning and the kind of positive impact that community and voluntary support groups have had in mitigating some of that impact. It is available for members if they want to read it.

Chairman

I thank Dr. Kennelly. We need to move on.

Senator Annie Hoey

I also want to be associated with the comments expressing sympathy to those who have lost loved ones in nursing homes during Covid. I am thinking about them as they try to move forward.

The Covid-19 expert panel's report for the Minister for Health was released a couple of months ago. It stated only 10% of nursing homes invited actually submitted a written response. Members of the public had only one week within which to make a written submission. There were only 60 submissions from members of the public. Given the very strong public feeling about what has happened in nursing homes, that seems to be an extraordinarily small number. Can anyone offer any commentary on that?

Reference has been made to the need for a public inquiry. Do the witnesses think there has been a proper and deep reflection thus far on the situation in nursing homes with the Minister? Have members of the public had an opportunity to engage in that process? Have there been adequate opportunities for that thus far?

Dr. Kathleen MacLellan

I might take that question and then ask my colleague, Mr. Redmond, to come in. The expert panel worked at speed. It was very conscious of the need to get as much learning as quickly as possible and to bring that back to all of us around the table so that any improvements that could be made, would be made. It engaged quite significantly and directly with nursing homes. Virtual site visits were conducted with a number of nursing homes so that the panel could hear directly what was happening within those homes. I might ask Mr. Redmond to come in to provide some more detail on that consultation piece.

Senator Annie Hoey

The detail is not necessarily. I am just wondering whether engagement with 60 members of the public constitutes an accurate reflection of how members of the public have felt. I remember at the time that not a single person I knew had heard about the opportunity to engage with the consultation, including people who had relatives in nursing homes who had passed away. Do the witnesses think that there was adequate opportunity for members of the public to engage?

Mr. Niall Redmond

Reflecting on the approach of the expert panel, part of what it needed to do was to try to gather a set of evidence and inputs as quickly as possible to round out a very comprehensive report. It engaged quite extensively with the various stakeholders and representative bodies, such as the patient advocacy service. It met with a number of those bodies as well as with nursing home staff and representatives of residents. It reflects the approach the panel needed to take in respect of using a good and robust methodology to deliver a report and the learning from that report as quickly as possible. It is important to say that throughout the implementation structures that have been established, there is a stakeholder reference group. Members include nursing representatives and advocacy representatives from the national patient advocacy service and Sage Advocacy. Therefore, there is an ongoing opportunity to feed in the views from the resident and family perspectives. That is an important part of that process as we move through the implementation and ensure that the voice of residents is represented in those structures.

Senator Annie Hoey

That is not quite what I asked, but I will move onto the next question. An article was published, which I am sure everyone has seen. It has also been referenced in respect of the fact that because of staff shortages, relatives are not going to be able to visit residents at the end of life stage. I know many references have been made to the funding model and all of those things. What actions have been taken to recruit and keep staff? Would the witnesses acknowledge that pay and conditions are probably the main barriers to keeping staff and attracting them into the sector? I know we have discussed the funding model. What actions have been taken since the beginning of the Covid pandemic in order to get people into the sector? Critically, people need to be with their relatives at the end of their lives. The article, which states that staff shortages are going to result in people not being able to be with their relatives, is alarming.

Dr. Kathleen MacLellan

The HSE can speak for itself. We have a significant recruitment campaign that is ongoing. Part of that campaign will help support some of the staffing levels that may be required during very high Covid surge times within nursing homes. I am sure Nursing Homes Ireland may want to speak on this issue. It has also been actively seeking to recruit staff for its nursing homes.

On the end of life issue, there has been significant support from the community palliative care teams and the Covid response teams to support end of life care as well as is possible, within these very challenging circumstances. When Covid rates are very high within nursing homes, it is difficult for them to facilitate as much visiting as they would like to. We have always supported nursing home providers and those nurses in charge to facilitate as much visiting as possible at the end of life stage. Indeed, the guidance includes a very specific risk assessment to support them in this. One of the recommendations from the expert panel is that we work with the Irish Hospice Foundation, which we are doing in respect of any improvements that can be made around end of life care. In addition, we have funded HIQA to look to develop an end of life survey, as part of the patient experience survey, so that we can gain learning from that to bring back into our practice.

Chairman

Senator Black is next.

Senator Frances Black

I welcome all of our witnesses and wish to acknowledge the fantastic work of the healthcare workers and their families. I also wish to send my condolences to all of those families who have lost loved ones. It has been a very difficult year for so many people. A lot of the questions I wished to ask have already been answered but I have one or two questions on the increase in the number of outbreaks in nursing homes during this third wave. This has really alarmed the relatives of nursing home residents. They fear that there will be delays in vaccination because it is not possible to vaccinate nursing home residents when the level of the illness is so high. This is a terrifying prospect for elderly residents and their families. I seek clarification on whether residents who do not display symptoms and test negative for Covid-19 can be moved off-site to be vaccinated.

Most of us will be aware of the nursing home in County Galway that has issued an appeal for qualified nurses to help it to fight a serious outbreak of Covid-19. It is heartbreaking to hear that the outbreak has taken the lives of 12 residents and that 35 out of 49 residents have tested positive for the disease. Perhaps Dr. Kennelly could outline to us the situation with regard to providing qualified nurses for facilities like the nursing home in Galway when they are engaged in an enormous battle with Covid-19. It all seems to boil down to staffing levels and what we can do about them. One of the main issues arising from today's presentations is the lack of staff and that is something we must focus on going forward.

Dr. Siobhán Kennelly

I will deal with the first question and then hand over to my colleague, Ms O'Neill, who will address the second question. The vaccination of residents in nursing homes where outbreaks are occurring has been taking place. Mr. Daly will be familiar with that as it is happening in both private and public settings. Obviously people cannot be vaccinated if they are Covid positive. They must wait for four weeks from the time of a positive diagnosis but are eligible for the vaccine after they have completed that four-week waiting period. Residents who are either negative or who do not have symptoms at the time of a vaccine roll-out have, for the most part, been vaccinated. That has been continuing over that time.

Ms Yvonne O'Neill

I will not speak about any particular outbreak if that is okay. The HSE works very closely with all care providers, including any facility that is experiencing a high level of outbreak like the one the Senator described. The Covid response teams work with providers in the identification of agency staff. Where that is not possible, they have supported facilities experiencing outbreaks with redeployed HSE staff. We operate on the basis of shift to shift and day to day. We are literally in that level of close contact with providers when they are experiencing challenging outbreaks. By and large what we are able to do, particularly while staff are on Covid leave, is to stabilise shift and rostering levels to get the facilities through the worst days. There is very strong guidance on this and providers are, largely, very responsive to it in terms of cohorting residents to reduce the wider impact when significant numbers of residents test positive. Mr. Daly may wish to speak on this too.

Mr. Tadhg Daly

As I said in my opening statement, staffing is a challenge that is shared across all of the settings. Over the weekend we heard acute hospitals appealing for staff. This problem is not unique to nursing homes, unfortunately, given the circumstances in which we find ourselves. It is the single biggest challenge. That the existing staff are working above and beyond the call of duty, working additional shifts and additional hours, is keeping us all going at this point. It is important to acknowledge that.

The other point that the Senator made with regard to vaccinations is critical. We need a very extensive protocol to ensure nobody is denied vaccination, particularly those in the most vulnerable categories.

We need to be very careful about moving residents off-site. We are looking at the most frail and vulnerable people here so we would expect that vaccination would happen on-site and every effort needs to be made, in the first instance, to go down that avenue.

Chairman

Before I bring in Senator Conway, I will go back to an issue raised earlier by Deputy Cullinane about engaging with stakeholders. I think a representative of the HSE said that those engagements were happening monthly. Has the Irish Association of Social Workers been asked to engage? Has it engaged?

Ms Sandra Tuohy

I will submit a list of all the voluntary agencies that have been invited to attend those monthly meetings with the HSE. The monthly engagement is an opportunity for us to be updated on outbreaks and matters related to Covid-19. Additionally, it is an opportunity for those agencies to offer advice to the HSE on direction of travel and how we might do things differently. The meetings once a month are very much collaborative. Those meetings were occurring every two weeks at the beginning of the crisis but it became more and more difficult to get people to attend. I will get a list of the relevant agencies and send it to the committee.

Senator Martin Conway

I welcome our guests and commend them on the work they are doing during this pandemic. I will ask first about the 193 outbreaks that were identified in nursing homes, as of yesterday. Has the HSE done any tracing in terms of those outbreaks? What percentage of them is a result of community-based transmission and what percentage is a result of infection in acute hospitals? Has any research been done on that yet?

Ms Yvonne O'Neill

The numbers that relate to an acute hospital admission would be very small; it would be a tiny number. Our public health outbreak control teams do that level of tracing but I do not have the Health Protection Surveillance Centre, HPSC, data in front of me. Those data are made available to explain the underlying cause of an outbreak. I cannot tell the Senator about the data around the current 193 outbreaks but community transmission would probably account for 90% of it. A very small number would relate to outbreaks in acute hospitals and associated discharges.

Senator Martin Conway

That coheres with the message that community transmission ends up in nursing homes, whether we like it or not.

The Covid-related temporary assistance payment scheme, TAPS, was set up to support nursing homes. How much has been paid out through that scheme to the private nursing homes to date?

Ms Yvonne O'Neill

I will hand over to Ms Tuohy on that question.

Ms Sandra Tuohy

To date, the TAPS has only been for private providers and does not apply to HSE facilities. Up to Friday of last week, €66.9 million had been paid out to providers. In excess of €100 million has also been spent on personal protective equipment, PPE, staff redeployment, staff accommodation, serial testing, cleaning and the like, in addition to the TAPS. That money has been given to providers to try to maintain the welfare of residents in those facilities.

Senator Martin Conway

That is a total of just under €170 million. When the first wave of the pandemic hit us, PPE and so on were the big issues for the 400 members of Mr. Daly's organisation. Was that €170 million enough to ensure that Nursing Homes Ireland could cover its Covid requirements in terms of the range of services it provides, PPE and so on?

Mr. Tadhg Daly

The figure relating to PPE is system-wide and does not apply only to private facilities. The TAPS is, clearly, a welcome development, to be fair. We are seeing that those facilities with big outbreaks are exceeding the thresholds. The scheme is a contribution towards the significant additional costs associated with Covid. It is very welcome but we are working with the Department on an ongoing basis to continually tweak and amend the scheme, as appropriate.

Senator Martin Conway

Since that scheme was put in place, have there been any asks from Nursing Homes Ireland that were not granted and that would have reduced the number of cases or fatalities among its 400 members?

Mr. Tadhg Daly

It is difficult to say whether more funding would have made a difference. Everything that could be done has been done. As I stated in May in my opening remarks to the Special Committee on Covid-19 Response, money is not a barrier. The temporary assistance scheme is a support mechanism to offset some of the costs. We were initially disappointed with regard to the issue around isolation beds. That was subsequently dealt with in November. In December, funding was made available in respect of the issue of visiting. I do not wish to be negative about it but we would liked to have seen those elements happen much more quickly. The total budget provided was €92 million. Only €62 million has been drawn down to date.

Senator Martin Conway

I think everybody present is glad to hear that.

Chairman

I ask Senator Conway to conclude his contribution or his colleague, Deputy Durkan, will not have time to come in.

Senator Martin Conway

I will ask one more question, if I may. Mr. Daly wanted his organisation to be represented on NPHET. What is its relationship with NPHET like at the moment? Does it have a relationship with NPHET? Mr. Daly made a very strong case in the media that private nursing homes should be represented on NPHET.

Mr. Tadhg Daly

At the outset of the pandemic, we believed there was a blind spot in terms of residential care for the older population. That is still the case. History will speak for itself in that regard. Our relationship with the system has been greatly enhanced. We do not have a direct relationship with NPHET but we are working closely with Dr. MacLellan, who is a member of NPHET, and we work with other members as individuals. However, we do not directly engage with NPHET.

Deputy Bernard J. Durkan

I appreciate the stoicism and dedication of all elements of the health services, front-line and otherwise, in the context of the tremendous work they have done and the resolution with which they have taken on the task at major health risk to themselves. What action on detection takes place in the event of an outbreak in the workplace, the community, public or private nursing homes, hospitals or other areas? What has been learned in the context of this surge in comparison with previous outbreaks? Has something been learned that needs to be incorporated more into services? Has the appropriate action been taken? Is it possible to take the appropriate action in every case? When the bells ring and there is an outbreak in a particular place, is there a systemic reaction and is it universal?

Is the provision of vaccines to patients and staff, etc., in nursing homes and hospitals being reviewed on an ongoing basis? Can it be improved? If there is any information that cannot be provided in the time available, I would be happy to take a written reply on the matter.

Ms Yvonne O'Neill

I thank the Deputy. I will deal with his questions in reverse order. The roll-out of the vaccination programme to nursing homes was accelerated. In the month since we received the vaccines, we have basically administered one dose in all of the 578 nursing homes bar four. As was stated, those who could not receive the first dose for clinical reasons will receive it when the programme for the second dose is rolled out. The only dependency is the supply of the vaccine.

The nursing home sector remains the priority in the roll-out of vaccination.

We talked a little about the Covid response teams in our reply to Deputy Cullinane earlier, so I will ask Dr. Kennelly to respond to the specific question on what actions happen as soon as an outbreak is detected.

Dr. Siobhán Kennelly

There is a very close relationship between all the public health teams on the ground and their colleagues in nursing homes and across many of the workplaces the Deputy outlined. Those public health colleagues will link directly with the care provider in the nursing home. They will establish where the positive cases are and what is the safest way of cohorting, which means grouping together residents who are positive into one area, and having as many staff work with them as closely as possible so there is less mixing of staff with residents who are not positive. There is usually very significant testing of all the residents in an affected area along with all the staff in those areas. Much of it depends on the size of the nursing home and the size of the outbreak, but it is very closely monitored with public health colleagues. They in turn link with us clinically, such as with my colleagues, geriatricians and others, to get palliative care advice. A number of reflex clinical actions arise.

Then there is the operational part Ms O'Neill spoke about in terms of the types of supports that are needed, be it for PPE, infection prevention and control, surveillance and assistance with that. They are well outlined and are available to all the care settings when it happens.

Ms Yvonne O'Neill

With regard to the third question on the lessons learned, the expert panel's report was a major opportunity for reflection on the first wave. The lessons we have learned about asymptomatic presentation have informed a number of the additional interventions. In particular, the serial testing has offered another way of early identification and mitigation of outbreaks. I see Dr. MacLellan has her hand up, so she might wish to say more on that.

Chairman

I will not be able to let Dr. MacLellan contribute. We are under strict instructions here and we are working to a tight schedule as well. I am thinking of the health and safety of staff here.

Thank you for your contributions this morning. I also wish to associate the committee with the messages of condolence. I offer thanks to you and all your staff, as you are working with the most vulnerable in society. We will return to the issue with HIQA, which is developing new oversight proposals for nursing homes. The suggestion of the vaccination of new residents is something we will follow up. We will also examine the implementation update for the expert panel report. Mr. Daly will be following up on the fair deal proposals with the Minister.

Again, thank you for your contributions. There is a great deal of information that we need to assess. Hopefully, we will move forward on many of the issues highlighted.

The committee will meet again in public session next Tuesday, 9 February, at 10 a.m. when we will discuss an update on protection and support for Covid-19 front-line healthcare workers with representatives of the Irish Hospital Consultants Association, the Irish Medical Organisation and the Irish Nurses and Midwives Organisation, who will make presentations to the committee.

There will be a private meeting of the committee at 3.30 p.m. today.

The joint committee adjourned at 12.04 p.m. until 10 a.m. on Tuesday, 9 February 2021.