Briefing by Department of Health Officials

To recap, witnesses can give evidence from committee room 1 if they prefer not to be in the Chamber. Mr. Jim Breslin has said he does not have a preference. I thank him for coming before us today.

I wish to advise the witnesses that by virtue of section 17(2)(i) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the provisions in Standing Order 186 that the committee should also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies. While we expect witnesses to answer questions asked by the committee clearly and with candour, witnesses can and should expect to be treated fairly. I will do my utmost to ensure that they are so treated, as, I am sure, will all committee members. I ask witnesses to bring any concerns witnesses have with regard to their treatment to the attention of the committee and they will be fully considered in accordance with the witness protocol.

Mr. Breslin can make his opening statement, followed by Dr. Tony Holohan. I remind members that every member is being afforded five minutes, and they can be given a further five minutes by a colleague who is further down the speaking list, subject to the proviso that members may have a maximum slot of ten minutes at any time to make statements and ask questions and, most important, leave time for receiving answers. I also ask witnesses to limit their opening statements to five minutes. We have received their statements and I thank them for taking the time to prepare and send them in advance.

I now ask Mr. Breslin to give an opening statement.

Mr. Jim Breslin

Do I remain seated?

Sorry. Finally, I would ask everybody to remain seated throughout. People are free to leave and I would encourage people to leave and come back to avail of their slot so that there are as few people as possible in the Chamber because the more contact we have with people, the more risk there is of spreading Covid-19 or, indeed, any other infectious disease. I would ask that people sit while addressing colleagues or witnesses and asking questions, and that they speak through the Chair.

Mr. Jim Breslin

I thank the Chairman. I am outside my usual habitat.

I thank the Chairman and committee members for their invitation to meet with the committee today. I extend my best wishes to the committee, and, indeed, the new Dáil, in its important work.

Just under 17 weeks ago, on 22 January, the World Health Organization, WHO, announced that there was evidence of human-to-human transmission of the novel coronavirus, Covid-19, in Wuhan, China. Since then, the Department of Health, the HSE, the wider health sector and colleagues across the civil and public service and community and voluntary sectors have put in place an unprecedented response to an unprecedented emergency. I am deeply proud of the way in which people in my own organisation have risen to the challenge, at great personal cost. We must particularly express our deepest gratitude to the staff of our front-line health service who have met this challenge head-on with what has been the most supreme determination.

In the period since we first learned of Covid-19, there have been more than 4.7 million cases confirmed worldwide and at least 315,000 people have died. In Ireland we have had more than 24,200 confirmed cases - that is the figure as of last night - and unfortunately, 1,547 deaths have been notified, each of them deeply mourned.

All crises come in phases. This public health crisis has a particularly prolonged acute phase. We have made definite progress in getting virus levels back down through stringent public health restrictions but the social and economic costs of Covid-19 have been huge and will be with us for some time. Yesterday saw the first easing of these measures under the roadmap. The bedrock of this progress has been the tremendous commitment on the part of citizens and communities to the behaviours necessary to reduce transmission. The progress is such that we can now collectively take some calculated risks in extending the range of activities it is permitted to undertake but we need to be aware that we will continue to be in the acute emergency phase of this crisis for some time, with further waves an ever-present danger. This is not a one, two or even three-day storm, after which we move to the recovery phase. The acute phase of this crisis will definitely be measured in months and, most probably, years rather than days.

Our health service has been tested to the limits but not overwhelmed, as the European Centre for Disease Prevention and Control, ECDC, and many of us feared. None of us has seen anything like this before – the scale of the challenge is unprecedented but so, too, has been the response. There has been a focus on moving quickly to utilise all available resources, recognising that our healthcare capacity is challenged even in normal times. For example, we have introduced payments to GPs for telehealth so as to avoid unnecessary visits to surgeries. The HSE has developed 29 community assessment hubs to avoid unnecessary hospitalisations. Private hospital facilities have been secured in preparation for the surge and they are now helping with the non-Covid care that has been displaced from our major public hospitals. The HSE, voluntary hospitals and other health agencies have worked with private nursing homes to support them in preventing or managing infection and continuing to care for our older people.

The health service has also been engaged in a massive effort to scale up our Covid-19 testing capacity. Covid-19 is a new virus. Four months ago there was no test for the virus, much less commercial supply of such tests and the infrastructure necessary to undertake testing at scale. The HSE has striven each week to increase testing capacity with the opening of 47 testing centres, commissioning 40 additional labs for the testing of Covid-19, and procuring supplies against a backdrop of global shortages, and also implementing IT systems to manage referrals and automating processes.

The plane has been in flight while all this necessary work to improve its efficiency and range has been undertaken. The issues that have been encountered along the way are well documented but, despite these, Ireland is positioned towards the top of the international testing league table. Ireland is fourth highest in the EU in terms of tests completed in population terms. To date, more than 280,000 tests have been conducted. There is much more work to do, in particular, in improving test turnaround times, but this week the HSE is on target to have a testing capacity of 15,000 tests per day with an average turnaround time from swab to result of between one and three days.

The scale up of contact tracing by the HSE has also taken place.

The median turnaround time for giving someone a positive result and commencing contact tracing is just over one day. There are outliers, and further improvements are planned and will be necessary to continue to improve turnaround and support any increase in contact tracing requirements associated with the greater circulation of people.

Congregated settings, by virtue of their physical nature and the susceptibility of those living there, are recognised by the World Health Organization, WHO, and the European Centre for Disease Prevention and Control, ECDC, as involving higher risk of infection. The deaths we have experienced in our long-term care facilities are the most difficult aspect of our experience with Covid-19 so far. The testimony of those who lost loved ones and cannot say goodbye in the normal way is truly heartbreaking. The international experience involving similar or in some cases worse problems than our own has been highlighted by WHO and ECDC, which made specific recommendations for this sector in the latter half of March. Our commitment to testing and recording of all deaths, wherever they occur, means our figures are much more representative and accurate than in many countries. We have also undertaken a comprehensive survey of deaths in long-term residential care to ensure that we are fully and transparently capturing the actual position. Since the outset of this emergency there has been a high level of alertness to the vulnerability of older people in general and those in long term-care in particular.

Important new and international information has emerged-----

I am sorry to interrupt, but I would ask Mr. Breslin to conclude so that we have enough time for questions.

Mr. Jim Breslin

We must be frank in acknowledging that the crisis is continuing and our conclusions must be tentative and preliminary. Because the virus is so new, there is much that we still do not know. A proven blueprint was not available at the outset on how this public health crisis would be managed. We are paying careful attention to international advice and experience. Decisions are being made in real time. The threat from the virus will be a reality for the foreseeable future and we must all protect the space for inquiry and learning.

I thank Mr. Breslin. I must ask him to conclude. We have his opening statement and we appreciate that he sent it to us in advance. I ask Dr. Holohan to give an opening statement and to limit it to five minutes, if possible.

Dr. Tony Holohan

I would like to thank the Chairman and the members of the committee for the invitation to appear today. I want to wish the committee well with the important work it is undertaking on behalf of the Oireachtas. The committee has indicated that its members wish to focus on three specific issues today. I am happy to offer a full briefing at any stage on the response to this whole pandemic on behalf of the National Public Health Emergency Team, NPHET, as I believe such an understanding will be critical to supporting the committee in its work.

I welcome the opportunity to explain our response. Maintaining open, clear communications with the public has been a central tenet of the health service's response to the Covid-19 pandemic, and to this end we have held 52 press conferences to date, among other things. Since Covid-19 emerged in China in December 2019, it has spread widely and rapidly around the world, as members have heard. As of today there have been more than 4.5 million cases worldwide, with 24,200 of these in Ireland. Sadly, 1,547 people in Ireland have lost their lives. We are acutely conscious of the grief that people have experienced over the past three months. I would like to take this opportunity to express my deepest condolences to all those who have lost loved ones.

We first heard reports of a novel coronavirus infection during the second week in January. Immediately, senior public health people in this country began to confer, monitor and collaborate with colleagues internationally. It became clear from an early stage that this would become a significant challenge for the world. It is equally true that the world's experience with this virus is still unfolding, with tragic consequences for many countries, irrespective of levels of preparedness, wealth or development.

While we had high levels of preparedness arising from our experience with pandemic influenza and other public health challenges, it was quickly clear to us that this virus was very different. The ease of its transmission and its severity, particularly for those who are vulnerable, combined with the fact that there is no natural immunity to this virus, no medicines available for its specific treatment and no vaccines, has presented an unprecedented global public health challenge.

To that end, on 30 January the WHO declared a public health emergency of international concern. The NPHET, which has been at the centre of our public health response, held its first meeting on 27 January 2020 and has held 31 meetings to date. Its role has been to provide clear advice to members of the public on how to protect themselves, their families and their communities, and when necessary to provide advice to the Government through the Minister for Health regarding wider societal public health measures.

By the middle of March it became evident that unprecedented action was needed to prevent the spread of infection, high rates of hospitalisation and intensive care unit admissions and significant mortality. Our collective actions have suppressed this infection, protected the health of people in this country and undoubtedly saved lives.

The cornerstone of the response in this country has been based on a public health evaluation of risk and public health-informed recommendations to Government as to what measures can be taken at each point to minimise the impact of this disease.

However, there is no certainty that we can keep this virus suppressed. The advice of NPHET is that we now ease restrictions in a phased risk-based manner, while maintaining close vigilance of the spread and impact of this virus to ensure that we can safely recommence work, social engagement, education and the day-to-day operation of the health service.

NPHET will continue to advise the Government, through the Minister for Health, to ensure that the decisions the Government takes are informed by public health considerations, while recognising that the Government will also need to take into account wider economic, social and other considerations as part of the phased unwinding of restrictions.

I thank Dr. Holohan for being so precise.

I welcome Mr. Breslin and Dr. Holohan to the Chamber and thank them both for the work they have been doing. I know they have been working flat out for several months and it is greatly appreciated. I wish them the very best with their ongoing efforts. As Mr. Breslin said, we are still very much in the emergency or acute phase.

We have ten minutes. I have five questions and I might ask both witnesses those questions, which should give them time to answer and if there is sufficient time we can go back and forth. I will start with testing and tracing. At last week's briefing, the health spokespersons from the HSE said that the median turnaround time from referral to getting a result back was five days. We heard from the Minister in the Chamber last week that the target time is three days, which still feels quite long. Mr. Breslin stated that in some instances this is now down to between one and three days. What is the current position and what is the target? Is it that we want to get a 24-hour turnaround across the board or for high-risk groups like healthcare workers, elderly people and so forth?

The second question I have is on the impact on the health system. Before the Covid virus arrived, the health system was struggling. The Covid virus has been catastrophic for healthcare facilities and ongoing work, but just as worrying are the medium-term impacts. Mr. Breslin said we could be dealing with this for months and potentially years. My understanding is that HSE hospitals used to have a bed occupancy rate of 95% but in the Covid world it will have to be no more than 80% in order that we can guard against a surge. Doctors have told me that the number of patients that can be operated on in a given theatre list is down by about half because of all the Covid hygiene and cleaning requirements. I believe it was discussed here last week, and other consultants have stated, that the number of patients that can now be seen by any given doctor and his or her team in an outpatient clinic session could be down by between 30% and 50%. On top of that, Paul Reid said an additional €1 billion would probably be required for PPE on an ongoing basis. Has an analysis been done on how diminished the HSE's healthcare capacity will be, how long is it believed that will be the case and what can be done about this extremely challenging situation?

My third question relates to private hospitals. The reason for taking over these hospitals made a lot of sense and it was a brave thing to do. We all saw the awful scenes from Italy and other places where patients who were critically ill were being treated in car parks. Clearly, the situation is not working at the moment. There seems to be a 30% occupancy rate and figures being collected by doctors suggest it has fallen since last week. Many of the operating theatres and diagnostic machines are not working as they could. About half the private consultants have signed up. It seems, at the same time, that we will use public healthcare money to treat private patients in private hospitals. This is money that would usually be provided by the insurance companies. The intention is noble on all sides in that we are trying to procure more healthcare capacity for public patients at this time, but it is clearly not working in terms of using the healthcare assets we have, nor in terms of public money. We are told the National Treatment Purchase Fund, NTPF, has identified about 5,000 public patients who could be treated in private hospitals, whereas €50 million in the pre-Covid world procured approximately 21,000 procedures.

I know a review is under way but, given that we are spending €115 million or more a month and that the assets are clearly not being used while men, women and children around the country are suffering, deteriorating and, in some cases, may lose their lives or be permanently damaged because this capacity is not being used, is it now time to quickly decide to cancel the contract while retaining an option for surge capacity in the future and to redeploy the money involved to the NTPF? This would mean that insurance companies would continue to pay for the private patients to be treated in private hospitals and that we could supercharge the NTPF, allowing us to make serious inroads into public patient waiting lists.

The Deputy has used almost five minutes. If he wishes to get two answers to each of these questions, it is a matter for himself as to how to proceed.

I will ask one more quick question, although the answer might be a bit long. What is the medium to longer-term strategy? Some people are saying we need to crush the curve as was done in Australia and New Zealand, allowing these countries to open up more widely. South Korea has taken a different approach that consists of very comprehensive testing, tracing and isolation. Sweden took a different approach, which was broadly to stay open. It has approximately the same fatality rate as Ireland. Has a strategy been decided on? Where is the thinking with regard to how we are going to deal with this over months and, as Mr. Breslin has pointed out, possibly years?

Does the Deputy wish both witnesses to answer each question?

I am satisfied with whatever way the witnesses want to answer.

Mr. Jim Breslin

On testing, the Deputy mentioned that it was taking five days last week. The target, which I believe we will achieve, is to reduce this to three days for 70% of all tests. There will be further improvements in this regard. One such improvement is to text people whose results are negative. This automation will speed things up. We want to continue to improve in this area. The system was patched together but it now needs to be redesigned end to end. The HSE is doing this and is working on its information systems and processing systems to get testing as close to real time as possible.

With regard to the impact on health services, on 5 May, NPHET advised that we could restart non-essential care within the health services. We are in the process of ramping up and planning for that in what will be a very different environment. It will undoubtedly take longer to do many procedures. To take endoscopy as an example, a single endoscopy is usually very quick to do. One will now have to put PPE on, do the procedure, take the PPE off again, decontaminate the area, and then bring someone back in. It will take longer and will cost more so there is a good chance we will end up doing less over this period. The way to buffer that is with innovation such as using technology, including telehealth and so on. The healthcare environment, however, will be very challenged for the foreseeable future.

On private hospitals, it is relevant that non-essential care was not taking place in either public or private hospitals up until the start of this month. We are, therefore, also in a ramping-up phase in private hospitals. A good deal more than half of consultants have signed up. We have made good progress in recent days. The Deputy is right however. Before the end of this month we need to stand back and review the situation in its entirety. One of the mandates we had in conducting negotiations was to prevent a situation in which, during the course of a pandemic, private patients could be in private hospitals because they had private health insurance while their care was paid for by the taxpayer. This would have undercut solidarity in our national effort. That was the motivation behind the arrangements we have put in place. It is important to acknowledge that a further wave or surge could happen at any stage and, in that case, we would need that capacity. The health system is not well-endowed with capacity.

I may return to the question of the medium to longer-term strategy as answering would eat into Dr. Holohan's time.

Dr. Tony Holohan

In the interests of time, I will not supplement Mr. Breslin's answers too much but I will say that testing and tracing should not be seen in isolation; it should be seen as part of a set of public health advice. Individual members of the public can help shorten the time to diagnosis by coming earlier. In addition to the enhancements that have been made to testing and tracing, we are advising individuals who are experiencing cold and flu-like symptoms not to put off the phone call to the doctor to see how they are until tomorrow but to make contact early. That gives us a greater chance, as do the improvements Mr. Breslin has outlined.

I could speak about the overall strategy at some length but I am conscious of the committee's time. Comparisons have been made to a number of different countries. With regard to New Zealand, western Europe has been the epicentre of this infection; New Zealand is on the other side of the world.

It is 2,500 miles from the nearest landmass. It is not part of a political, economic legal, social, cultural union with a number of other countries, like Ireland is. Direct comparisons - I am not suggesting the Deputy is making them - that others have made are not entirely valid. The spread of infection to that part of the world was a much later event and much smaller. They did take decisive action as I believe we did in this country. However, we were very close to the epicentre of this infection in a way that New Zealand simply is not.

Regarding Sweden, much has been said about mortality. I do not want to point unduly at comparisons between different countries, but we have to be sure we are counting the same things. We think in terms of direct comparisons. Admissions to intensive care are probably a more reliable measure of the burden of infection. Sweden has had a much bigger challenge than this country on that measure. When I checked yesterday it had almost 400 people in intensive care. If we adjusted for population that would be the equivalent of almost 200 people in intensive care here; we have 50.

I thank the Deputy and witnesses for staying in the time allocated.

I thank both witnesses for their evidence and for being here. We know how busy they are, and I thank them for giving us their time. I propose to do as was done previously. I will ask my questions and if we have time for an interaction, that is fine.

Yesterday we began the reopening of the economy. I am conscious that 100,000 construction workers are going back to work, which will pose a challenge for them in their workplaces and for their families when they go home. It will also pose a broader public health challenge. We are aware that specific guidelines for the operation of construction sites are in place. Later we will have a conversation with people about how they will be enforced. Is there a specific plan to test and trace those people who are now going back to work? I am sure the witnesses will agree testing and tracing are much easier when the country is on pause or shut down. Now as the economy begins to reopen, is a specific plan in place to cater for the numbers of people who will now be moving around and who previously had not been doing that?

We note the specific plan in place for construction workers. Is there similar guidance and advice for transport workers, postal workers and other people who will now be going to work and will have more work to do. Transport workers will be bringing people to and from work. It has struck me that - maybe it is necessarily so - some of the measures have been reactive rather than proactive. I would have thought the officials would have used the time on pause to make preparations for reopening the economy. I ask the witnesses to outline those specific preparations, in line with protecting the health, safety and welfare of those workers who will be returning to work out of necessity in the coming days. Indeed, some were back at work yesterday.

With regard to healthcare workers, the latest figure I had heard was an infection rate of around 25% to 30% among our healthcare workers. That is very concerning and I am sure the witnesses are also very concerned about that. I ask them to comment on how they think that happened, because it is not in line. I have heard members of the Government and others make comparisons between us and South Korea and other countries. We can make all the comparisons we like, but as far as I am aware nowhere else is that figure as high. I ask the witnesses to comment on how it got so high among our healthcare workers and what specific measures are in place. Is it due to the chronic understaffing we had as we came into this? Is that a factor?

I will not go over the reported tensions between the Department and the HSE. All those have been well ventilated in the public domain. I refer to reports following publication of the letter that there would be twice-weekly phone calls between the CMO, the head of the HSE and the Secretary General. Are those phone calls happening? Are the witnesses finding them useful? Are they minuted and if so, can they be published so we can all be up-to-date on it?

I have a question on nursing homes. According to the Minister for Health, on 19 February Paul Reid met the director of Nursing Homes Ireland. What actions were taken? It strikes me that some time was lost and that the measures put in place in the nursing home sector were, as I have previously described, reactive rather than proactive. It would seem the opportunity existed on 19 February.

Were the witnesses aware of that meeting, were they briefed and what specific actions were taken as a direct result?

Mr. Jim Breslin

I will take a couple of those questions and then ask Dr. Holohan to come in. On NPHET and the interaction with the HSE and what was put in place following the request from the HSE, we had a teleconference with the HSE chair, myself, the Minister, the Chief Medical Officer and the CEO of the HSE. We have agreed to have a regular weekly teleconference, which is minuted, where we go through all of the issues as a collective. It has been very beneficial over the period. The interactions are not just daily, they are almost hourly in between that, but as a centre piece where everybody comes together it is proving-----

Have those been published?

Mr. Jim Breslin

They have not been published yet but they are publishable.

Okay. If they could be provided to the committee that would be good.

Mr. Jim Breslin

On nursing homes, the Deputy asked about the meeting with the HSE CEO. The CEO will be before the committee later, but I understand that people touched base on the kind of preparations that the HSE was putting in place and Nursing Homes Ireland on its preparations and they agreed to keep in touch and provide the support to each other over the period. I can speak at more length about nursing homes generally but that is the position on the specific question.

I will ask Dr. Holohan to comment more.

Dr. Tony Holohan

On workers, we have done a lot of work with other Departments and the Health and Safety Authority, HSA, will be before the committee in the afternoon to provide an update on that work to ensure our public health advice is incorporated into the work that it does and support of and oversight of work and workplaces.

Any decision on testing and its role in a particular occupational setting will be taken on a public health assessment at a point in time if that is something that is valuable and worth doing. It will not necessarily be the case that particular occupational groups will be subject to a sweep of testing unless there is a public health rationale, and that might arise. That will be assessed on an ongoing basis over the course of the disease.

On healthcare workers, we have had a challenge. We have been honest and open about that. The figure is slightly over 30% - it is 31.5% as of yesterday - which is a high percentage. It should be borne in mind that we have prioritised healthcare workers for testing and, unlike many countries, we have completed a significant testing programme in residential care facilities. The staff in those settings were both tested and identified as positives and will be part of that figure. We have been proactive on this but there is no question that it has been a challenge. It reflects the fact that healthcare workers are in the front line. They are at risk of picking up this infection by virtue of the work they do. There is also the challenge that healthcare workers, when they are infected, are a source of potential infection both for the people they serve and the communities in which they live and are part of. That is a particular challenge and continuing cause for concern to address that. There has been a substantial fall in the rate of infection among healthcare workers so while the number is high, the incidence has been dropping significantly in recent weeks.

Does that include people working for private companies in the healthcare sector, specifically, contract cleaners, contract caterers, agency nurses, and agency healthcare assistants and carers?

Dr. Tony Holohan

All individuals who are healthcare workers who are identified as being at the front line, yes.

That would include contract cleaners?

Dr. Tony Holohan

Yes and it would include people in the community such as primary care staff, GPs, and anyone who is-----

They are very easily identifiable as healthcare workers. I am talking about people who are on contract working in hospitals for private entities: are they also included in those figures?

Dr. Tony Holohan

All healthcare workers, yes, at the front line.

That is not my understanding but I am happy to receive that information.

Dr. Tony Holohan

I am conscious of time. I could say a lot about nursing homes. Yes, the approach has been both reactive and proactive. Reactive is a necessary part of the response. It is the whole purpose of an epidemic response. We must react to an unfolding situation. What we decide to do today might, by virtue of what we know tomorrow, turn out to be something we need to supplement or change. That is the nature of a public health reaction.

The first confirmed case in this country was on 29 February. The advice that came a couple of days later from the European Centre for Disease Prevention and Control, ECDC, said there was no strong evidence of transmission of infection preceding symptom onset. That was the advice after we had had our first case.

We know that is no longer true. That is the advice we were acting on at that point in time, and I can go through-----

I understand that. I have one last question as I am conscious of time. All the advice I have read indicates that 72 hours should be the time for testing and contact tracing. How close to that are we? Is Dr. Holohan confident that as well as the capacity to swab, there is capacity to contact trace and follow up, specifically in the context of workers returning to work this week?

Dr. Tony Holohan

I think we can be confident of that. A huge amount of work has been done in the HSE, and I know its witnesses will be able to add much more detail. I am conscious of the time. The turnaround times have improved very significantly and the improvement in those has not finished. I believe that some of the innovations that have been introduced in that contact tracing, testing and sampling regime in this country are without precedent internationally. Now, people who are subject to testing get negative test results by text. With our positivity rate at the moment at 3%-----

I am talking about-----

Dr. Tony Holohan

-----97% of people are getting a result in that way. There was a challenge in getting negative results back to individuals, and that has been removed. There are other arrangements in terms of a telephone line arrangement for GPs. Where there is a challenge in getting a result to a patient, they can make same-day contact in regard to that.

It is still not 72 hours.

Dr. Tony Holohan

The majority of contact tracing is happening within 24 hours.

I call Deputy O'Dowd who has five minutes.

I propose to use two and half minutes. I have one question and I ask the witnesses to respond as they wish. First, I congratulate them on their excellent professionalism, their work and their credibility. I want to tell all the health workers who have given so much to all of us, and all the essential workers in the country, how much we respect them for what they have done.

I want to ask a question about all of those people who, sadly, have passed away in our nursing homes. I know it is not just in Ireland that this is happening but all over the world. If we want to benchmark the state of our nursing homes, public and private, the most recently published data, which are from August 2019, show there were 31,000 residents in 581 homes. Only 123 of those 581 homes were fully compliant with the HIQA regulations. Compliance was down from 27% in 2017 to 23% in 2018. Compliance with regulation 27, which deals specifically with infection control, was inspected by HIQA in only 215 of those 581 homes in 2018. Of those, 37 were found to be non-compliant. As such, non-compliance in providing very basic protection for residents in terms of infection control stood at 18%.

The HIQA report also found rates of non-compliance in the areas of governance management, fire precautions, residents' rights, risk management, and training and staff development of 32%, 34%, 27%, 22% and 19%, respectively. Were the witnesses aware of this or did HIQA advise them of it? What benchmark were they were given for the fight they had to fight, given that their hands were clearly tied by virtue of the fact that this was a new virus the world had never seen before? As they acknowledge, we knew that nursing homes were the most vulnerable. We knew from the evidence that this would be the case. My question is very clear. Can the witnesses give an absolute and categorical assurance to me now that all nursing homes, public and private, in this State are fully compliant in terms of infection control?

Who does the Deputy wish to answer that question?

Mr. Jim Breslin

I am happy to kick off. I thank the Deputy for the congratulations. What we have been engaged in is providing advice on an overall framework. All of the progress made has been made by the Irish people. There is no one actor in this. There has been cross-party support for it. Every sector has given support to it but, ultimately, it is down to the behaviour change that we have made and that we will have to sustain into the future.

In regard to nursing homes, undoubtedly, anybody who has observed, as I have, nursing homes over an extended period will have seen the development of that sector. The Deputy mentioned the regulation of the sector by HIQA and the introduction of new standards and infection control guidance, which are particularly relevant in this situation. We have infection control standards in place. I believe the current version of the standards is from 2018.

That would be very consciously part of the responsibilities of the people in charge of those nursing homes, whether these are private or public. HIQA plays a very important role in reinforcing that responsibility. It has done so throughout the Covid-19 crisis. It is currently engaged in an assessment process on Covid-19. However, right from the start HIQA reached out and issued guidance and notices to providers about their responsibilities.

That is not to say that this is easy. The CMO can talk on that but this is a much more infectious virus than the typical flu that we experience and is much more severe in its impact and yet it is hard to keep flu out of a nursing home during the winter period.

Much work has gone into this sector. I will not say that all of it has been perfectly executed nor will I say that there has not been learning in this. There has been a great deal of learning. The CMO has talked about the fact that the WHO and the European Centre for Disease Prevention and Control, ECDC, have updated their guidance on this. There is no doubt that this is and continues to be an absolute focus of the overall public health effort as is the importance of ensuring that everybody who is running a nursing home is very clear on what his or her responsibilities are, on what good practice is, and has the support to do that in every instance. That will be to the fore as to how we continue to manage the virus.

I thank Mr. Breslin and now call Deputy Ossian Smyth.

I will start with Mr. Breslin. I want to ask about people who have cancer, people with chronic illnesses and people in pain who up to now have been attending private hospitals for non-elective and very necessary procedures. Their procedures were simply eliminated, or their appointments disappeared. Understandably, we needed, or thought we needed, the hospitals for the surge. What is going to happen to those people? When are they going to get treatment or are any of them getting treatment at the moment or is there an alternative path for them? People have been coming to me to say that they have no idea when this is going to happen. Is there a date when we will be returning to treating at least non-elective patients who require treatment? I presume that some of these people will die and that this will be seen in the mortality statistics at the end of the year.

Our hospital system is often at 100% capacity, not just our emergency departments but our acute hospitals also. In the future we will have reduced capacity. Due to social distancing we will be down to 60% to 70%. How are we going to cope in that situation? It seems that we need the excess capacity from the private hospitals but we need to obtain it in a different way. Deputy Donnelly referred to this. Is there a way that we can use a less crude method done than just sequestering the entire empty private hospital? Can we obtain the procedures that we need to meet that extra capacity that will be required?

Mr. Jim Breslin

I thank the Deputy for his question. On the activity that is currently under way in private hospitals, I wish to place on the record that 6,646 inpatient discharges have taken place. There have been 21,350 day cases, which might include chemotherapy, 26,386 diagnostic procedures, and 15,862 outpatient procedures. I expect all of those figures to increase as we go through this.

What period do these deparmental figures refer to?

Mr. Jim Breslin

Those figures are up to last week. One of the factors is that the whole health service was restricted in what it was doing because of the presence of the virus to the extent that it was within our community. That did affect private hospitals. We concluded the heads of terms of agreement with the private hospitals but there were protracted discussions with private hospital consultants. We have more than 280 private hospital consultants on board. More are finalising their position with us, which is the majority of the cohort. The private hospitals are happy with the sign up that they have at this stage and that it can work within their hospitals and that we have the manpower to do so.

On the continuity of care issues that the Deputy has referred to, that is dependent on the consultant under whose care the person is being treated. If that consultant signs up to the arrangements, all of his or her patients move across with him or her at the very point in treatment that they are at. They do not go back to the start of the queue or back to a GP. They stay with that consultant based on the point that they are at on the care spectrum. The one distinction is that they do not pay a fee to that hospital consultant nor does the health insurer. The reason is that we are going to pay a salary to the hospital consultant so he or she cannot be paid twice.

How many consultants have signed up to this deal at this stage?

Mr. Jim Breslin

More than 280 consultants have signed up. In the event that they do not sign up, arrangements are in place with the patient to decide if he or she wants to stay with that private hospital consultant. The patient might stay with him or her in his or her outpatient rooms, if that is the type of care the patient is receiving, or the patient may wish to move across. If patient moves across, he or she moves either to another private hospital consultant who has signed up, or to a consultant assigned from within the public system.

I refer to the point about how much activity that there can be in this period. We are organising and re-organising all of the activity, so many things that were happening in public hospitals have now moved lock, stock, and barrel into private hospitals. We want to keep it away from an area that might have Covid, and run it in the private hospital, and run it in a facility that is purpose-built for that. The private hospital facility makes an important contribution to how we meet healthcare needs at this stage. What we will have to review is the extent to which we continue with that. The point that I wish to make, and I made it earlier, is that the mandate that we started from was not to have a dual system of public funds going into a private hospital and then fee income coming in at the same time. We may change that, but the question that presents in that situation is whether there are different incentives for treating private patients in that situation.

If 280 consultants have signed up, how many consultants have not?

Mr. Jim Breslin

There are about 450. Some consultants have very sessional commitments as they are retired. We think there are about 450, and there is a good chunk who are in the process of signing up, on top of the 280.

I thank Mr. Breslin.

Deputy Duncan Smith of the Labour Party has five minutes.

I would like to direct most of my questions to the CMO. I wish to go back and forth on the questions as the answers should not take too long. I would like to thank the CMO and the Secretary General for all their work, and for the leadership that they have shown over the last number of months.

What was the CMO's thought process in terms of announcing the capacity for 100,000 tests per week on 17 April, given that it is a month later and, according to the Secretary General's statement, we are on the cusp of meeting that target? The statement from the director general of the HSE, who is coming to the next session, states that we are at that target today. I am still uncertain as to whether we have that capacity now. Either way we are close, but what was the CMO's thought process in stating that without first consulting with the HSE?

Dr. Tony Holohan

We are at that capacity now. We think that is the scale that we need for the various different categories, and I can explain what it is composed of. That number was arrived at as a result of the work that we did at the National Public Health Emergency Team, which is attended not only by people from the Department and a range of other organisations, but also by the senior leadership of the HSE. They are all party to our discussions. Our collective assessment was that was what we believed that we needed. That was the target that we set out to achieve, and it has now been achieved. However, it is not the only target that is important. The key target from our point of view is the turnaround, namely the length of time it takes to get a piece of information back to a patient, or in respect of a patient to a public health team to allow the necessary processes of contact tracing, or indeed clinical management if it is a patient who is unwell and where clinical management is needed for them. That is the critical thing.

I appreciate that.

Dr. Tony Holohan

I refer to what we might find as we go on and as this pandemic unfolds. I should make the committee aware, as it may or may not be aware, that this morning the ECDC published Surveillance of Covid-19 at long-term residential care facilities in the EU-EEA. It is hot off the presses this morning. It is recommending testing in respect of staff of long-term residential facilities at the rate of something like once a week.

I am not disputing the amount that is needed.

Dr. Tony Holohan

I am not suggesting that the Deputy is. There is a fixation generally on the number of 100,000. In fact, it may need to be fluid. We might find that we need more testing. We know that we are not using that volume of testing at the moment. We have more than sufficient capacity right now. However, needs will change.

That fixation was probably set by the statement on 17 April, but I am happy that we are at that capacity----

Dr. Tony Holohan

That has been the target for a month.

With all due respect to the CMO, I have two minutes left. How many members were at NPHET's first meeting and how many were at its 31st meeting, which I believe was the most recent one? How are the recommendations from NPHET communicated to the national crisis management team in the HSE? Is it in a report, or is it in the minutes of the meetings? If so, I ask if they can be published? I think that we are seven meetings behind now, or maybe more, for which the minutes have not been published.

How are members of NPHET appointed? Is there a specific protocol that the Minister has to sign off on? Who is the key decision-maker for appointing people to NPHET?

Dr. Tony Holohan

The Deputy asked a series of questions and to be honest, I have not internalised every single one of them. I have not come prepared with the specific pieces of information so I cannot tell him exactly how many people were present. However, the number was probably in the order of ten or a dozen. NPHET has grown over the period according to our needs. That is the nature of that particular team. We have used it on many occasions in the past as a structure to guide our response. Its composition, size, scale and expertise depend on what our needs are at a point in time. We have, therefore, brought on or co-opted people at various points along the way.

On the minutes, which the Deputy asked about, I do not think he is up to date. We have caught up in terms of the minutes, even in the past number of days. It is important, however, to understand the process that we use. I was asked how we capture decisions and conclusions. What we do, before the conclusion of each meeting, is agree on the conclusions and actions that form the basis of the advice that goes either to the Minister, and through the Minister to the Government, or to the HSE and its CEO. We agree that text in the meeting. The final part of each meeting is reaching agreement on that and it then frames the body of the letter. We do not wait until a set of minutes has been finalised before acting because we need to be in a position to act quickly. That is the whole nature of the exercise.

That is encouraging.

Dr. Tony Holohan

The administrative task of publishing the minutes has lagged a little behind and we are trying to catch up on that. We have had 31 or 32 meetings, with an average duration of between three and four hours. In some weeks, we have had three or four meetings, some of them until late into the night or the early hours of the morning. The challenge of keeping up to date with all of the administrative tasks associated with that is significant but it has not delayed our decision-making or our advice to Government.

If the committee could see that correspondence, it would be much appreciated.

I thank Dr. Holohan for his ongoing work. I have three questions for him. They concern the basis and rationale for decision-making and the need to be much more transparent about decision-making, not least to keep the public and everybody else with him. We are quite different from other countries in that we do not release much of the data, make the data open source or explain as we go along. For example, when the decision was taken to open schools in Denmark, a full risk assessment was done and the outcome published, so everybody knew that the R-nought number was likely to go up a small bit, as it did before coming back down again. Everybody bought in to the decision to reopen Danish schools. I am not specifically talking about schools but the need for very robust risk assessment and to be very open and transparent about it. What expertise and tools are available to NPHET to risk assess all of the major decisions that are being made?

The R-nought number currently stands at around 0.5. That is very hard to understand given the profile of the people who have been tested in recent times. In the main, they are people who had a lot of contacts and therefore, presumably, there was a lot of transmission. On what is the R-nought number based? Is it based on a theoretical model and, if so, can the model be published?

Dr. Holohan has talked a great deal about the need to understand the behaviour of the virus. What is his current estimate of the prevalence of the virus in the community? It is very hard to understand that. Last night, the figure for new cases was 88. It is fantastic that it has fallen so low. If 88 cases represent a 3% positive testing rate, the total number of people whose results we got yesterday was less than 3,000. That figure does not sit logically with the approach of needing to do 15,000 tests per day. How does Dr. Holohan explain what appears to be a disconnect there?

Dr. Tony Holohan

I will take the questions in reverse order, if that is okay. We are not testing at the scale of 15,000 a day at the moment. We know that.

One of the things we wanted to bring forward and that we would have been discussing this morning in the National Public Health Emergency Team, but that meeting is not taking place, is the question of what would be next in our priorities regarding testing and where we would direct that capacity. In broad terms, the 3% positivity rate reflects what we think is happening in the community, but there are other categories of testing that we will have to prioritise into the future in the healthcare environment, for example, in hospital settings, although it will not just be hospital settings. As we increase, it is hoped, the amount of non-Covid-19 care we provide, testing both patients and staff will become a feature-----

Yes, but it is based on less than 3,000 tested yesterday.

Dr. Tony Holohan

Yes, that is correct. There is also something of a weekend effect in that.

Dr. Tony Holohan

If I can add to that, one of the things that will help in our understanding of the community transmission, and I accept the point the Deputy is making, will be the decision we have taken to introduce this week, with the easing of restrictions, the testing of close contacts of cases, which many other countries are not doing. That will add significantly to our understanding of community transmission and asymptomatic transmission and give us a much greater response, as it were, in terms of our handling of that.

Regarding the R-nought, it is based on the summation of three models and-----

Will Dr. Holohan publish that model?

Dr. Tony Holohan

-----it is due to be published. I would have to check with the chair but my understanding is that the work is going through a peer review process at the moment. I cannot honestly tell the Deputy right now what the timeline is in that regard but the intention is to publish that.

It is important and-----

Dr. Tony Holohan

Absolutely, I agree entirely.

-----I wonder why it has not been done.

Dr. Tony Holohan

With regard to the expertise, we have a range of different expertise at the NPHET in respect of our public health assessments. There is a range of epidemiological and mathematical modelling expertise, public health, geriatrics, psychiatry and a range of other supporting specialties.

Again, would Dr. Holohan commit to publishing those risk assessments for the big decisions taken, for example, in respect of the construction industry, schools or whatever? It is important that we are aware of the basis.

Dr. Tony Holohan

Regarding those assessments, let us say an assessment relating to a school setting, some of that work in some of those circumstances will be done by the relevant sector. We give public health advice and we support other sectors in the decisions they have to make on the actions they need to take, internalising our public health advice into the way they organise the-----

Would Dr. Holohan favour publication of those risk assessments?

Dr. Tony Holohan

Any of the material we have available to us, which is our public health consideration, we frame it in the minutes and publish. I have no difficulty in making that available.

You said the assessment is being peer reviewed and you cannot tell us now what the timeline is. Can you let us know by correspondence what the timeline is likely to be?

Dr. Tony Holohan

I just wish to check with Professor Philip Nolan, who is chair of the group. He is leading that work. I just do not know that piece of information at the moment.

You can provide it by correspondence.

Dr. Tony Holohan

I know the intention is to publish that model.

You can let us know, roughly, what the timeline is anticipated to be.

Dr. Tony Holohan

Yes, I will find that out and let you know.

I call Deputy Boyd Barrett.

I thank Mr. Breslin and Dr. Holohan for all the work they have done. Nobody has doubts about that. Dr. Holohan said he has a concern about health workers. The infection rate among healthcare workers is very high - Dr. Holohan said it is 31%. Why is it so much higher among Irish healthcare workers than it is in other jurisdictions? It is one of the highest. Why is that the case? What advice did the HSE get on healthcare workers? I have been asking about this since the second week of March. According to the NPHET minutes the team got advice twice from the expert advisory group, on 7 March and 10 March, relating to healthcare workers. On 16 March I asked what those advices were and I still have not received an answer. I have asked repeatedly to see the advice, recommendations and minutes from the expert advisory group. This is terribly important given the high level of infection among our healthcare workers.

To bring Dr. Holohan up to speed on the position, and I do not understand this, an agency nurse who was recruited by a Dublin hospital two weeks ago has tested positive for the coronavirus in recent days. She was not tested when entering that hospital, where there are many elderly people.

I do not understand this. I would like to see the advice that was given by the expert advisory group in March about healthcare workers and I would like an explanation on why we have such a high infection rate among healthcare workers. How on earth can we have a situation where healthcare workers are coming in to work with vulnerable people two months into this crisis when we know there is a problem with healthcare workers' infection rate and that they are not being tested before they start work with elderly people? We then discover it two weeks later. Are healthcare workers who go to visit the elderly in their homes being tested before they do that work? Are there regular tests of healthcare workers when they are working to make sure they are not infected? I would appreciate answers to those questions. Could we please see the advice and minutes of the expert advisory group, for which I have been asking for two months?

Dr. Tony Holohan

Yes. I will engage with the chair of the expert advisory group group about when the minutes and advice can be provided. We have, for the most part, acted on all the advice the expert advisory group has given to NPHET. I see no difficulty in making that available to the Deputy. There is new guidance from the European Centre for Disease Prevention and Control, ECDC, from this morning about the question of testing. We will look at what that means for testing here, as will other countries. I cannot answer about the specifics of why an individual nurse is not tested, as the Deputy will appreciate.

We have had a significant programme of testing throughout the residential and community sector, including in nursing homes. Staff and patients in all settings have been tested. A public health-led set of decisions has determined who gets tested and when. The team at the Health Protection Surveillance Centre, HSPC, which is doing that work is continuing to assess how we should appropriately prioritise testing with regard to public health. The next meeting of NPHET was due to be this morning, and will consider the question of prioritisation, with regard to the next categories that we think are important for testing. What does the ongoing programme of testing for people who work or reside in long-term residential care facilities need to be? It will address people in exactly the categories about which the Deputy is asking.

We are signed up to the European project on convalescent blood plasma therapy. I asked weeks ago for a report on how that is going. The results are promising. I understand there are apheresis machines for the extraction of blood plasma in St. James's Hospital and that 500 people who have recovered from Covid-19 have offered to make donations, but those machines are not being used to extract that blood plasma. I would like to know what is happening there.

Dr. Tony Holohan

I was not aware the Deputy would ask that specific question so I do not have a specific answer, but we will get it for the Deputy and correspond with him on it.

I thank the witnesses for their attendance. I have some questions for Mr. Breslin and I ask him to leave time for the Chief Medical Officer for the last couple of answers. Who is responsible for managing positive tests and the negative tests? Deputy Naughten brought in information during the week about meat factories. We have had contact occurring with management in meat factories but not directly with the patients, to say that patients had tested positive. On the other hand, negative test results have taken more than two weeks to come back. There are significant issues which Mr. Breslin might address.

Some 45% of our population has private health insurance and is, at present, excluded from accessing general consultants' work and any opportunity to have treatment. Mr. Breslin said that a significant number of doctors have signed up to the type A contract. How many surgeons have signed up to the type A contract? It is my understanding that in private hospitals, where much elective work is done, that if there is no surgeon to do it, there is not much point in having the other consultants on board. Some €115 million is going out per month to secure the hospital contract. I see in data from 18 May that only 30% of beds in private hospitals are taken up. Many of these are long-stay patients from public hospitals who have been moved out. The National Treatment Purchase Fund's annual budget is between €30 million and €50 million per year, and we are spending €115 million.

I would like see that contract revised.

On University Hospital Waterford, UHW, I want to put something on the record which is not quite Covid-related but is as a fact of it. We had a diagnostic cardiac lab facility on site there since September 2017. This was moved off the premises in recent weeks, however, as the contract was not extended. We are now back to one cardiac cath lab in the south east for 500,000 people. We have a hospital with 160 beds-----

Is this related to the Covid response?

Yes, I understand. I just will make the point if I may. We have 160 beds in the hospital but we have only three patients in there for Covid. I would ask the witnesses to reflect on that.

Can I ask the Chief Medical Officer if there is any update on hydroxychloroquine? Is there any update on the idea of using vitamin supplements, particularly vitamin D, and zinc supplements for the elderly? Does Dr. Holohan believe antibody testing can be used at any point in the future?

With respect to Waterford having the lowest incidence of Covid in the country, why can the regions not be allowed to open in advance of the major population centres?

I remind the witnesses that they are only asked to answer questions on Covid.

Mr. Jim Breslin

On the positive test - the Chief Medical Officer will confirm this - the procedure is contact tracing would take place with the individual. I cannot understand the issue that has arisen with an employer getting a result in the absence-----

It has been communicated to the Department.

Mr. Jim Breslin

-----of an individual. The policy is that it will go back to the individual who has been the subject of the test. As Dr. Holohan has referred to, there have been delays with negative tests. A negative test is the one less concerning to the contact tracer. As Dr. Holohan has outlined, we have now automated that, so that will flow very readily. Up to 97% of cases will go back with a text message.

On the private hospitals, I would not agree that 45% of people have been excluded. The private hospitals are open to the whole community at this stage. It is a clinical judgment as to who gets admitted. That will not be decided on somebody's insurance. That equally means, if somebody is insured and it is clinically necessary for them to be admitted, then they are eligible for admission.

On the number of surgeons, I do not have the exact number. However, I would not expect the type of huge bias that the Deputy is inferring. Surgeons need hospitals. In order to practise, they would want to have access to private hospitals. There are some other specialties which do not need hospitals as much. They can do much of their work in an outpatient setting. They may be less represented in the numbers which signed up. We have not experienced a major problem in terms of surgeons different from other doctors. We have had some delay in everybody signing up but not specific to surgeons.

I was not going to comment on the cath lab but I do know the full extent of the concern, the issues and all the work that has gone in both by the HSE and nationally.

Dr. Tony Holohan

To be clear, we have had some reports of employers receiving results in respect of individual patients. That is a breach of confidentiality.

We are over time. The other questions can be answered by correspondence. I am sorry I have to be ruthless with time to ensure everybody gets a fair crack of the whip.

I call Deputy Michael Collins for the Rural Independent Group.

I thank both gentlemen for being here before us today. It is important for questions that the public has and for which we need to have answers.

On testing, many samples have been sent to Germany at a massive cost. I understand a new plane was required to fly them in and out of the country. I have spoken to labs here about testing that could have been done in Ireland. Animal Health Laboratories Limited is testing for Covid-19. Tests go into the lab in the morning and the results come back in the evening. This company felt that if it had a few more resources, it could have done anything up to 5,000 plus tests a week. While it has been considered by private hospitals, it has not been considered by the HSE. Why did we go to the massive expense of flying our samples to Germany, waiting up to three weeks? I have had cancer patients contacting me who cannot have cancer treatment because they are waiting three weeks for results. We find out that this kind of test could have been done in Ireland and created jobs locally. It could be looked at going forward.

I am not trying to point fingers here because the witnesses have done some tremendous work and I do not want to be seen to be critical in any way. However, that is the point that I would really appreciate an answer on. The HSE has taken over the 19 private hospitals at a cost of €115 million per month. It is completely understandable that a deal had to be done initially to secure capacity in respect of Covid-19. No one knew where this would go initially and the HSE had to do so, but the light switch for medical care for all other patients has been turned off. There are now 2.2 million citizens with private healthcare who will have had no option but to join the public waiting list as of 30 April. The National Treatment Purchase Fund, NTPF, recorded 770,000 people in hospitals and clinics. Other countries have had to do something similar and they have reverted. I am asking the same thing. Are we considering the gradual reopening of private hospitals to people with private health insurance? It is important and there is fierce worry out there that people with serious health issues need to be seen. They are paying for private healthcare but that is not available at the present.

Did the HSE, in its consultations, remove elderly and sick people from hospitals and put them into nursing homes and community hospitals without testing them? There are other questions but I would prefer to have those answered.

Mr. Jim Breslin

On the German lab, I can say it is not more expensive than Irish labs, including some of those that we have introduced more recently. The number of labs that are now testing in the National Virus Reference Laboratory, NVRL, has gone from one to 41, so we have taken account of capacity where we have been able to find it. With reference to lengths of time, a backlog of tests went to Germany and therefore by the time those people got their result there was a delay. However, the results coming back from Germany are very much within the next day, so there is not that length of time. The HSE will always look commercially at where best to do this and have regard to the turnaround time. That will be a dynamic situation which we will keep under review as we go along. We have added significant private sector labs in Ireland. One of our biggest labs now is a private sector lab, so there is an openness in the HSE to try to secure turnaround and cost effectiveness, but also the quality that we need, which would be foremost.

I have said what I have said on private hospitals. I do not envisage that people will have to go right back to the start of a waiting list. That is not what the policy says. There will be a review before the end of the month. We will take everything into account, but one of those things will be the World Health Organization's advice that the most likely scenario here is for recurring waves. The idea that we had our experience and now we can move on is absolutely not the case. We could be subject to a further wave, in which case we would be back to looking at a modest amount of ICU capacity within our public health service and wondering if we will be able to cope in that situation. There are strong arguments for using all of the capacity that we have nationally and for reviewing it on that basis.

All labs and testing are contracted directly with the HSE rather than with the Department, is that correct?

Mr. Jim Breslin

Yes.

Deputy Collins has 15 seconds.

I appreciate the answers. Another question I have is on the many home helps who got personal protective equipment, PPE, very late in the day. It was a serious worry to them.

Mr. Jim Breslin

We have good relationships with the home help sector. It has played a very important role. There is a relationship with the local community health office in terms of PPE. It has also been flexible and has gone in and worked in nursing homes in the most critical phase.

Thank you, Mr. Breslin.

Mr. Jim Breslin

One of the things going forward will be to try to get that service back up and running. It is important that we have a home help service into the future to try to cope.

The next Fianna Fáil speaker is Deputy McGuinness who has five minutes.

Have the witnesses examined the role of carers in the home and how they are being supported in all of this? The section 39 organisations, which provide services for the mentally and physically challenged clients, were caught for cash and funding before this happened. Has funding been released to those organisations to ensure that they can expand the role that they have, and indeed, support what is now required because of Covid-19?

In terms of reopening the economy, have the witnesses looked at France and its red and blue counties and numbers, urban and rural, in terms of a response to either one?

It seems to be a plan worth looking at.

The private hospital deal of €115 million a month has been mentioned. Is it actually €115 million a month, or has it gone over that? If so, why? Are the consultants involved in the hospitals being compensated for the loss of their business plans, in terms of the rooms they rent, lease or have purchased and the staff they employ? Where have all those staff gone? Are they being compensated? Is there an overall plan for the use of private hospitals - a solid plan to which people can refer? As of last week there was not.

The loss of three months of normal service in these private hospitals is projected to cause 1,800 extra deaths from cancer this year. Is Mr. Breslin familiar with these figures? That amounts to 20 extra people a day dying from cancer. I would like clarification around all the services offered to them. How many patients in private hospitals had their appointments cancelled over the past week?

As regards the deal itself, would it not have been a better idea to have a contingency for capacity that would be made available should it be needed? There was only a handful of patients in some hospitals at the beginning of this particular with the Private Hospitals Association. Scopes have been cancelled in public hospitals, and there is now a backlog of more than 4,000. What is being done about that?

Deputy McGuinness should leave time for Mr. Breslin to answer the questions.

Mr. Jim Breslin

We have to go back in time as regards the private hospitals. As we moved towards the end of March, we were beginning to experience some of what we had seen in Italy and France, and based on the trajectory of admissions into ICUs in public hospitals, they were going to rapidly fill up. We would have exceeded our ICU capacity within a week. That was the focus of the arrangement we put in place. We needed immediate access to those facilities. We will obviously review that as we go forward, but as I said earlier, we could find ourselves back in that situation quite readily. The other thing I should stress is that during that period, non-Covid care fell off across all healthcare services and sectors, in both public and private hospitals. We saw it in emergency departments-----

I am sorry to interrupt, but I am watching my time. I asked specifically about the contract, the consultants and their business plans. What is the position on that?

Mr. Jim Breslin

The consultants received a type A contract and are remunerated for that. In some instances where there is a business case in which their outpatient rooms would need to be used for the delivery of public care, paid for by the public purse, the HSE has been given the authority to enter into arrangements as long as there is value for money. That does not underwrite all the business losses that somebody suffered. Whole sectors of the economy are experiencing such losses and there are arrangements in place to address that separate from the health service.

Can Mr. Breslin deal with the other questions I asked regarding the cancellation of private appointments and the funding for section 39 organisations?

Mr. Jim Breslin

This afternoon, the HSE will outline the very close working relation it has with section 39 organisations. Arrangements have been put in place on a case-by-case basis where they have been affected by Covid. They may be taking on extra duties or may have incurred extra costs and the HSE has a process for that. The Government has put in place a scheme for charities in general as well.

Could I ask that some of the questions that were not answered, which are particularly relevant to consultants and the operation of their business, be answered in writing?

Mr. Breslin-----

Mr. Jim Breslin

I think I covered all the consulting questions but there are one or two-----

Mr. Breslin has not done so. He was very flippant about the consultants, their business plans and how they are going to be written off.

Is Mr. Breslin happy to answer the questions? We can recap them if necessary after the meeting.

Mr. Jim Breslin

Surely.

I thank Mr. Breslin. We can go back over the debate to see what was asked. We are over time. I appreciate that Deputy Cullinane is taking Deputy Carthy's time but I ask him to limit his contribution to seven minutes.

There has been a second speaker from Fianna Fáil. Does the sequence not mean that a Fine Gael speaker is due to ask questions now?

The next speaker is from Sinn Féin and Fine Gael will follow. Somebody in Sinn Féin gave up time, unlike Fine Gael. I ask Deputy Cullinane to limit his contribution to seven minutes because, otherwise, other people will not get to speak at all.

We will not quarrel in public; we can deal with that matter later. I will proceed.

I welcome the two witnesses and thank them and the teams behind them for their work. I send my best wishes to those teams and commend them for the work they have done. I will put my questions distinctly and I know that our witnesses are experienced and will respond equally distinctly. This is our first opportunity to look back, although it is also important to look forward, which I will do when I talk about testing and tracing. There are questions that need to be put about nursing homes and congregated settings. I will firstly put questions to Dr. Holohan.

My understanding is that when Nursing Homes Ireland first responded to the Covid-19 crisis on 4 March, it imposed nationwide visiting restrictions on private facilities. Is that correct?

Dr. Tony Holohan

I cannot confirm that it was 4 March but it was in the early days of the month.

It was in the early days of March.

Dr. Tony Holohan

I have no reason to dispute that it happened on 4 March.

On 10 March, on Dr. Holohan's advice, the blanket restrictions were lifted and that advice was given to nursing homes. Is that correct?

Dr. Tony Holohan

It was not given to nursing homes. It was a broader piece of advice, given in public, that related not only to nursing homes but a range of different actions that were happening over the course of that week. That was the advice we gave in public. We talked about it at the meeting of our National Public Health Emergency Team on that date as it related to nursing homes because we had a substantial concern that there was a lot of unilateral action taking place over the course of that week. A lot of organisations were taking their own decisions about what public health actions they needed to take, not informed by our advice. Our clear concern was to ensure that all of the organisations in the country were operating in step with our advice. That was, ultimately, what happened when the advice that we gave to the Government was implemented on 12 March.

On 10 March, the advice was that there should not be restrictions because they were too restrictive. Is Dr. Holohan saying that advice was given in broad terms?

Dr. Tony Holohan

That is not correct and I have been quoted as having spoken in those terms. If the Deputy checks our press release at that time, we said that visitor restrictions in respect of nursing homes "are not necessary at this moment in time". That is a totally different thing to the way it has been interpreted by many people as saying-----

Was advice given to nursing homes? Was there any communication between Dr. Holohan's office and Nursing Homes Ireland on any of that?

Dr. Tony Holohan

No. There would have been engagement between Nursing Homes Ireland, the Department and the Minister to which I was not a party.

There is disagreement as to whether that was an instruction or advice from Dr. Holohan, however it was presented in the public domain.

Dr. Tony Holohan

It was public advice.

Dr. Holohan may have a particular view of it. I think it was three days later, on 13 March, that the visiting ban was imposed, or reimposed. Is that correct?

Dr. Tony Holohan

On 12 March, we made a series of pieces of advice around school closures and a range of measures across society which included a recommendation that visits to nursing homes and healthcare facilities would cease. It was a change in our assessment of the disease on 11 March that led us to that point. Up to that point, we did not think that we should introduce such arrangements because we understood that these were restrictions on people visiting their loved ones in places where they live.

I should point out that, in terms of cross-country comparisons that we have done, when considering the length of time between a country reporting its first case and implementing visitor restrictions in the way that we did on that occasion, we were the quickest country in the world. No country-----

How many clusters of infection do we now have in nursing homes? How many clusters have been identified in nursing homes and residential settings? It is in the hundreds, is it not?

Dr. Tony Holohan

It is over 200 at this moment.

We can all accept that is very high.

Dr. Tony Holohan

It is, but it does not-----

Deputy Cullinane should allow the witness to answer questions.

Dr. Tony Holohan

That figure does not relate to visitor restrictions. We know that the point at which visitor restrictions were recommended by us, which was on 12 March, there were no reported clusters. No country made a such a recommendation, relative to the path of infection, earlier than we did. That is in comparison with a range of countries. I do not want to waste the time of the committee but I have that data here.

Dr. Holohan can forward that information.

Dr. Tony Holohan

It shows comparisons with New Zealand, Australia-----

I want to put a follow-up question to Mr. Breslin.

Dr. Tony Holohan

-----Canada and a range of countries across Europe. They all took a substantially longer time to implement that. We did that before the advice came from the WHO and European Centre for Disease Control and Prevention to introduce those recommendations.

I thank Dr. Holohan.

Dr. Tony Holohan

We were very responsive to the disease.

I want to put a question to Mr. Breslin. There was correspondence between NHI and his Department around that time. We have heard from the NHI that it sought meetings with the Minister or officials. If there was correspondence between the NHI, Mr. Breslin's office and the Minister, what was the nature of that? Can he share that correspondence with us? The NHI will come before the committee next week. My understanding is that it raised concerns about the lack of an overall comprehensive plan for nursing homes. As we all now know, there has a been a high incidence of Covid-19 in nursing homes. What was the nature of the correspondence at that early stage in March that took place between the Department and NHI?

Mr. Jim Breslin

I am happy to share the correspondence. There is a great dealing of tick-tacking with NHI, as the representatives of the sector, across a range of issues. During this period, that range of issues was connected with Covid. It related to specific issues and also their seeking engagement and representation on various structures. At the time, NHI sought representation on subgroups in NPHET that had been set up. Some of those subgroups had been doing the work of designing financial support schemes for the sector, so we did not consider that that was the appropriate course. NPHET is an expert group, and has HIQA on it as the representative of the regulator of the sector.

Is it not also true that it had appealed for specific guidance on what to do in nursing homes and how they should respond to this crisis, predicted that nursing homes would experience severe staff shortages, and raised concerns about PPE?

Mr. Jim Breslin

There has been a huge amount of guidance issued to residential-----

At the time, they were not clear about the position because they were looking for specific guidelines.

Mr. Jim Breslin

As I referenced earlier, there is already infection control guidance for the sector from HIQA. The HPSC issued guidance in early March, setting out how to manage Covid-19 both to prevent it and if there was an infection in a nursing home. Guidance, which is continually updated, has been issued to the sector. As the Deputy will no doubt hear from the HSE later today, a huge range of supports have been put in place to try to help the sector. The sector is a mix of publically operated and privately owned facilities. It is not line managed in its entirety by the HSE; much of it is outside the HSE.

I ask that all correspondence related to NHI, the Department, Dr. Holohan's office and the HSE be forwarded to this committee in advance of next week's sitting if that is possible.

Is that possible?

Mr. Jim Breslin

Yes.

Deputy Colm Brophy has five minutes.

I thank the Chairman. I endorse the comments of my colleague. I thank Mr. Breslin and the Chief Medical Officer for their service. I want to address the Department specifically in my first question.

Allowing for Mr. Breslin's opening statement and the preceding media coverage of it, we are facing into a crisis that may last for years rather than months. I want to comment on one particular aspect regarding the private hospitals and private health insurance. Is it effectively irrelevant for people to have private health insurance now? If one takes the position outlined by Mr. Breslin, which is that the Department wishes to retain private hospitals under its control for the duration of the risk of the Covid-19 pandemic, which by his statement will be years, then effectively there is no private healthcare in Ireland and for most people that means an end to private health insurance. There is no logic in paying for private health insurance. Indeed, there is even a questionable logic in continuing to pay for this year's private health insurance.

Mr. Breslin said that someone who is in the system will obviously maintain his or her place in the system. Am I correct in understanding that for somebody with a new complaint there is now no such thing as private healthcare? Does that position have Government or departmental endorsement? Are we happy with a process whereby we say to people who paid tens of thousands of euro over their lives for private health insurance in this country that themoney was, in effect, wasted?

Mr. Jim Breslin

The Deputy has extrapolated. What I set in place was the policy that motivated the putting in place of the arrangement. The arrangement is in place for three months. The HSE has the option to extend that for a fourth month and, by agreement with the private hospitals, by a fifth month. That is the arrangement that is in place.

We are now coming up to the end of month two when we will do a review, which will decide what we do after month three. We will have to take-----

In answer to colleagues' questions, Mr. Breslin twice said that, because of the risk of a surge capacity, the HSE needed to maintain that capacity. Let me take his answer through to its logical conclusion. If the HSE needs to maintain the surge capacity and there is no vaccine or treatment, while the pandemic risk remains the same in terms of surge, am I correct that means we permanently have to maintain that capacity?

Mr. Jim Breslin

I would not reduce it down to an either-or option. There will likely be different options at which you could look at where we are and what the future might hold. It is not simply: do you continue with the deal that you did the last time or do you not do the deal? You could look at different options within that.

Can Mr. Breslin reassure people that he is not envisaging a situation which effectively amounts to the abolition of private health insurance?

Mr. Jim Breslin

The health insurers have given a rebate on insurance for the period.

For a short period. Effectively, if we keep the hospital system the way it is, it is a rebate. I want to conclude-----

Mr. Jim Breslin

It is by agreement. The State did not impose this.

I appreciate it is by agreement but their subscribers, who were paying their hard-earned money into private health insurance for many years, have also got views on this.

I refer to a secondary area. Apologise for having to be so blunt but I have a second question that is primarily for the Chief Medical Officer on advice in the area. When we were initially on this committee, we were told we could be broad-ranging in our questions to him. I accept it is not in the core area.

I want to specifically ask about the underpinning medical advice to the 14-day quarantine on entering the country that has come into play. As long as that remains in place Ireland is an effective lockdown zone as regards reopening for tourism, the commercial life of the leisure industry, etc. It has significant implications. It seems to many a displaced point that one has Northern Ireland with an open border with people going back and forth as we all want but people are landing in Dublin Airport faced with a 14-day lockdown, which effectively will kill our tourist industry. What is the medical advice that underpins the advice to Government on that?

Dr. Tony Holohan

It is public health advice. It relates to our assessment in relation to the potential incubation period of this virus. There is pretty much international consensus on 14 days. Few countries are at variance with that particular measure. It is to try and ensure that we limit travel from overseas and have people coming in who do not spend a period of time. The reason it does not exist for travel on the island is that our assessment is that, in broad terms, the island is behaving as one from a disease point of view. In Northern Ireland, the incidence is broadly similar.

I accept that. While it is valid now, has Dr. Holohan any idea of when that will be lifted or when it will be considered?

Dr. Tony Holohan

I could not give a commitment in relation to that. In general, which, I know, will not answer the question, no measure that we have recommended of this kind will be in place for any longer than we believe it is necessary. It is simply too early to make an assessment, given - even on the island of Great Britain and in many other European countries let alone the United States and the rest of the world - the state of infection of how long we need to have that in place.

I am conscious that both Sinn Féin and Fianna Fáil have had more speaking time than Fine Gael. I will not be able to get to Deputy Foley but I ask Deputy Colm Burke to limit his contribution to two minutes. I am sorry that Fine Gael has had less time in this session. It will be borne in mind.

There are a number of points I wanted to raise but I will touch only on one that relates to congregated settings within the HSE. I was in contact with someone who was, in fact, affected by Covid-19 and works in a facility where a number of people died. The person highlighted the simple fact that there were no changing facilities within the facility for staff when they came into work in the morning. A number of people died. Within a few days, all of what the staff were looking for was put in place. I am wondering at the very start of this process whether an audit was done to see which congregated settings were in danger. For instance, in the setting to which I refer, there were six psychiatric patients per ward. Once the virus got in there, it was high risk. I am wondering was there a list of those places made. We have a number of HSE facilities where there have been more than ten deaths. Was a list made? It would appear from the evidence I have that no action was taken to deal with a crisis in those facilities.

I thank the Deputy and apologise for curtailing the speaking time. We must learn from our mistakes.

Can we make up from it in the next session?

We will certainly try to. I do not want to take the time.

Mr. Jim Breslin

Guidance was issued to all those sectors. As stated earlier, each is unique in terms of its local infrastructure. In many cases we have multi-annual capital programmes in place to improve the infrastructure. This means that what one person in a particular centre will have to do will be different from what someone is doing in another. As the regulators, HIQA and the Mental Health Commission have risk-rated individual settings and kept in touch with the HSE where they have concerns. That process is continuing.

Nothing has been learned from this. I was speaking to a staff member in the past few days. While certain new procedures have been put in place, they have now disappeared again. For instance, each member of staff was given a scrub suit to put on when he or she came in. There are none available now when staff members come into work. Nothing has been learned from the process. This needs to be challenged.

Mr. Jim Breslin

From what the Deputy says, that centre is regulated by HIQA or the Mental Health Commission. The HSE, HIQA and the Mental Health Commission will be very interested in those issues if they are of concern.

I thank Mr. Breslin. To conclude, I have two questions. We have a road map made up of phases which may be brought forward or may take longer than we anticipate. Have we outlined objective criteria that will allow us to move from one phase to the next? I refer to the transmission rate, ICU capacity, etc. Is it possible to publish those criteria? These questions are for Dr. Holohan. What is the position regarding transmission rates throughout the country? Have we managed to limit sustained human transmission to certain areas?

Dr. Tony Holohan

In broad terms, we have effectively extinguished it from the community in general, right across the country. Much of the caseload that is now being reported is seen in the context of particular settings. We are still seeing some positive numbers in residential care facilities, though the number has reduced very substantially, and in some occupational settings. That is not to say that there are not some cases, but we have effectively extinguished it, which was the strategy from the very start. We have to start with suppressing this infection across the community before we have a chance of protecting nursing homes or other specific settings.

On the specific question around criteria and measures, the actual threshold may change from time to time. How we view, say, a figure of 30 people in an intensive care unit at a certain point will depend on whether the number on the previous day was 29 or three. As such, the particular number very much depends on the context. We have a series of criteria that are set out in the Government's Roadmap for Reopening Society and Business. These refer to the disease and a range of other metrics concerning testing, contact tracing, health service capacity and the broad impact of the measures on the health and well-being of the public. All of these are taken into account in the staged recommendations and advice to the Government around easing restrictions.

Mr. Jim Breslin

I had one point to add.

I am afraid I need to get us out of here. Can I take from what Dr. Holohan said about transmission that we no longer have sustained human transmission in all areas of the country?

Dr. Tony Holohan

No. That is an absolute statement. I could not say that in absolute terms. We have effectively brought it down to a very low level. We do not have sustained widespread community transmission. We know that because we are not seeing a caseload which would reflect that, in spite of the fact that we have very substantial testing capacity in place. We are testing large numbers of people relative to the number of positive cases that are being identified. We can be assured about that.

I thank Mr. Breslin for his forbearance.

Mr. Jim Breslin

I wish to add that in addition to the advice on criteria that Dr. Holohan has referred to, the Government published public health advice, an economic assessment and a social assessment on Friday. We pass the advice to the Government, which pulls in multiple perspectives to make a decision.

I was interested in the medical criteria that will enable us to move forward or prevent us from doing so. I thank the witnesses and committee members, especially Deputy Foley. I apologise to Deputy Foley and to Fine Gael. That will be borne in mind during the next session. We need to learn not to take so much time in private session

We will need a couple of minutes in private session at the start of the next hearing because the way the timing has worked out is unsatisfactory. I appreciate the Chairman's efforts, but it is absolutely unsatisfactory.

I accept that it is unsatisfactory.

One party enjoyed 17 minutes of questioning. That cannot be allowed to happen.

Deputy Brophy's party got 12. I appreciate that. I thank the witnesses very much.

Sitting suspended at 1.05 p.m. and resumed at 2 p.m.