Congregated Settings: Nursing Homes

I now invite our witnesses, Mr. Tadhg Daly, chief executive officer, Nursing Homes Ireland, and Mr. Mervyn Taylor, executive director, Sage Advocacy, to join us. I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they 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 and with respect and consideration at all times in accordance with the witness protocol.

I now invite Mr. Daly to make his opening statement and ask that he limit it to five minutes. As we received the opening statement in advance, it has been circulated.

Mr. Tadhg Daly

I thank the Chairman and committee members for the opportunity to address them today. I am joined by my colleague, Ms Anne Costello, nursing committee director, Nursing Homes Ireland. The work of this committee will represent one of the most important analysis of a national emergency that will forever be ingrained in our country's history. I wish it well in its work in the weeks ahead.

Nursing homes are traditionally very positive settings and homes of inspiration and happiness to the communities within them. They are a home from home. Covid-19 has brought huge levels of upset, sadness and worry in through their doors. I now take this opportunity to call upon us to commemorate forever all those who, tragically, lost their lives in our nursing homes and in our country because of this cruel virus. We should take the opportunity to laud the considerable sacrifices of nursing home residents. The loss of a loved one's personal touch and, for many, the loss of friends has caused huge upset and worry for thousands of our most special residents. Under very pressurised circumstances, our staff have made extra time to sit with residents and have prioritised the use of technology to connect residents with loved ones, often taking time outside of working hours to fulfil such work.

We applaud the staff in our nursing homes, HSE, private and voluntary. These 40,000 people are on the Covid front line. They have made sacrifices willingly, and with great commitment they continue to provide person-centred care, comfort and support. I thank the staff in the nursing homes for the care and support provided to residents over the weeks and months, with much of it provided to residents with Covid-19. The recent months have presented a stressful and demanding time, and these people ensured residents received excellent care in the most challenging of circumstances.

Covid-19 has presented a tragedy for nursing home residents, but it should not be lost on us that four out of every five nursing home residents who contracted Covid-19 recovered from the virus. This is testament to the tremendous dedication and professionalism of the staff under extremely strenuous circumstances. There needs to be a greater appreciation that care of the older person is complex. Nurses in our nursing homes have very specific clinical expertise and a broad knowledge base founded on the science and art of the person-centred gerontological care model.

During the first three months of the year more than 2,500 people entered nursing home care under the fair deal scheme. Every month, 1,000 people transfer from our acute hospitals into private and voluntary nursing homes. During this national emergency, 7% of Covid cases entailed transfer of residents to hospital. As an easily transmittable virus, we knew in early January and February it could take the lives of nursing home residents in our communities.

Preliminary research indicates up to 40% of transmission is passed by asymptomatic persons. The mass testing of residents has seen asymptomatic residents and staff test positive. Nursing homes have huge levels of experience in managing the outbreak of flu and norovirus every winter and have extensive experience, both clinical and practical, in implementing infection prevention control measures, but a global pandemic is on a different scale entirely.

We were exasperated in early stages and felt the sector required a very specific plan. We knew Covid-19 had a disproportionate impact on older people. The planning and focus was almost exclusively on our acute hospitals. We were aware people in our nursing homes would be among the most susceptible to the virus and a national strategy and response was required. The challenges of personal protective equipment, PPE, testing, aggressive recruitment of nursing home staff and discharges from acute hospitals are well versed at this stage. Our decision to restrict visitors on Friday, 6 March was informed by our nursing committee, comprising clinical experts, and it was not taken lightly. It was taken on a Friday because we were conscious of the many visitors who may have come to nursing homes that weekend.

Key State organisations left the nursing home sector and its residents isolated in those early days, and the dismay will live forever with us. However, we welcome the lead of the Minister for Health, Deputy Harris, in eventually bringing senior officials from his Department and the Health Service Executive, HSE, around the table to support the sector and our residents in coping with Covid-19. The evidence from Ireland and internationally is no individual element of the health service can manage the global Covid-19 pandemic alone. The supports provided by HSE community services are appreciated and have delivered valued resourcing supports to residents.

Covid-19 continues to live with us. We give early welcome to the Minister’s commitment to establish a nursing home expert panel to support good planning and safeguards to protect people who call a nursing home their home. However, one significant voice is absent, that representing nurses from our nursing homes, who continue to operate very much on the front line.

Members of the Oireachtas will be aware that Nursing Homes Ireland has outlined annually a request that the Government should lead in establishing a forum on long-term care. That call has gone unheeded for almost a decade but today we reiterate that call. We wish to move forward but Covid-19 now lives among us. We are actively engaged with the Minister, Deputy Harris, his officials and colleagues in the HSE and the Health Protection Surveillance Centre, HPSC, in presenting measures that can ease visitor restrictions in our nursing homes. Clear policy is required and there is a requirement to balance delicately health, safety and risk to life against the mental well-being and happiness of residents. Social connection for nursing home residents is critical.

Lessons can be learned from closer engagement brought upon us by Covid-19. There is now a requirement for a better and more integrated working relationship between the State and the entire nursing home sector. The core focus must be on meeting the complex health and social care needs of nursing home residents. As a society, we will be stronger working together.

Mr. Mervyn Taylor

I thank the committee for this opportunity to appear before it. The mission of Sage Advocacy is to promote, protect and defend the rights and dignity of vulnerable adults, older people and healthcare patients. We support and advocate for people independently of family, service provider or systems interests. We have made a detailed submission to the committee, so in these opening remarks I want to focus on where we go from here. We see little value in shroud waving and comparing deaths in one nursing home with another. As Mother Jones famously stated, "Pray for the dead and fight like hell for the living."

I will first give some sense of what it has been like from the perspectives of residents, relatives and staff. "You have no idea how awful it is – it’s horrific." These were the words of a member of staff in a nursing home that experienced a serious outbreak and many deaths. The impact of an outbreak has been frightening for many residents, and for those with dementia, the arrival of people in full PPE was terrifying. Serious shortages of staff meant that there was little, if any, time to provide support to residents in facilities where many died. For families with relatives who were extremely ill or dying, the inability to visit or even to talk to their loved one by phone was a source of considerable distress and frustration.

Approximately 20% of older people need some form of support and care, of which less than 5% will live in a nursing home at any one time. Nursing home care is not long-term care. The average length of stay is just over two years. In 2016, Sage Advocacy, along with other NGOs, organised a forum on long-term care for older people.

The unanimity of opinion at that forum was summed up in a question. Why, despite decades of policy reports and recommendations to Government, is there still a systemic bias towards care in congregated settings and no formal legislative basis for support and care in the community? The report of the forum spoke of the need to develop a vision for long-term support and care which is as compelling as that of the hospice movement at its best.

At the core of this issue is the fragmented nature of social care for older people. This is not just about what did or did not happen in March and April. Home support services, such as they are, are not provided on a statutory basis or regulated and have no clear vision, other than the level of home care packages that can be provided in any one year.

Care in nursing homes is provided on a statutory basis and is regulated, but has an overly complex and ultimately dangerous architecture. The National Treatment Purchase Fund, NTPF, buys care from private providers without proper consideration of the range of needs. The HSE administers the scheme but - this is critical - the contract is between the older person and the nursing home. HIQA sets the standards, but has no role in setting the price, and inspects, but has no powers to investigate complaints. Crucially, as Sage Advocacy’s February report on medical care in nursing homes pointed out, there is no clear framework for the provision of medical care to the most vulnerable of our older people, nor are there ratios set for the level of suitably skilled nursing staff.

Over recent decades the State’s approach to the residential care of older adults has been one of retreat in favour of private providers, with the remaining public facilities providing care mainly to the more frail with complex care needs, sometimes in famine era buildings. Elements within the HSE, working with NGOs, put forward proposals for a change to a teaghleach or smaller-scale household model, but they were not supported. The State, having outsourced the service, practised social distancing while the public, notwithstanding the good service provided by many facilities, is increasingly questioning the morality of private investment in human vulnerability. Simply stated, we are talking of vulnerable people in a vulnerable sector.

Our detailed recommendations are set out in our submission. The five I would highlight are: an integrated system of long-term support and care spanning all care situations with a single source of funding; the integration of private nursing homes into the wider framework of public health and social care; clear guidelines on the skills and level of nursing staff and medical care required in congregated care settings related to the needs of residents; a wider range of service and ownership models for homecare and care in congregated settings; and legislation for adult safeguarding and the protection of liberty in places of care and legislative recognition for independent advocacy.

The Covid-19 public health emergency has shown some of the great strengths of Irish society. It has also shown weaknesses. We have a two-tier healthcare system and a two-tier siloed approach to the long-term care and support of older people which is biased towards congregated settings. We owe it to ourselves, and to those who have sacrificed so much, to do better. Let us shed a tier and set about building Sláintecare, a single-tier national health service with an integrated system of social care focused on home and a much wider range of options between home and nursing homes. I thank the Chairman.

I thank Mr. Taylor. I would now like to call on Deputy Louise O'Reilly, who is speaking for ten minutes.

I thank the witnesses for being here today and offer my sympathies to the families of those who have been bereaved and those resident or working in the nursing home sector.

I have some questions for Mr. Daly relating to his statement and correspondence we received today. It strikes me that the nursing home sector showed a degree of foresight and planning and tried to flag issues at a very early stage. The hundreds of pieces of correspondence we received at 9.30 a.m. today indicate that, as Mr. Daly said in his opening statement, a national strategy and response was required. The correspondence and letters from March show that Mr. Daly was begging for assistance and PPE and that, to use his words, he was pleading with the State to stop the aggressive recruitment of staff from the nursing home sector.

In short, it appears that nursing homes were flooded with patients and starved of staff, and yet there was no plan. Does Mr. Daly have any idea why no plan was forthcoming, when all of the international experience would tell us that there was a need for one? We know now that more than half of the deaths that have occurred have occurred in the nursing home sector. Why was there no plan?

Mr. Tadhg Daly

That is a question for someone else. The point we have been continuously making is that given the vulnerability of the age profile and the complexity of care of older persons, there should have been a national plan. From where I sit, what I have seen is an overt focus on the acute hospital sector to the exclusion of community care in general. Clearly, the discharge of large numbers of patients from the acute hospitals was an attempt to ensure the hospitals were ready. We heard that a good deal in terms of ensuring the hospitals were prepared. In fact, the surge that was predicted or expected in the hospitals materialised in the nursing home sector.

To prepare the hospital sector, large numbers of patients were discharged but they were discharged to the nursing home sector with no plan.

Mr. Tadhg Daly

From a nursing home point of view, it is important to state that the nursing home sector is a part of a well-functioning health service. In peacetime - in normal times, as it were - there would be regular transfers of people from acute hospitals. Our concern was that there was no plan. In fact, the issue of testing was critical in hindsight. The fact that residents who had come from acute hospitals were not tested prior to admission to the nursing home was-----

At the time those responsible were preparing the acute hospitals, they were transferring large numbers of patients from those hospitals to the nursing home sector. These patients were to become residents but they were not tested. Was any protocol given to nursing homes? Were nursing homes instructed that these people had to isolate for 14 days? Did those discharging people check in advance that nursing homes had single room accommodation or were people simply discharged to create space?

Mr. Tadhg Daly

The policy was evolving from public health on an ongoing basis, to be fair to public health, but clearly they were categorised as low risk in most cases. On the basis of the correspondence that I have seen from the acute hospitals, nursing homes would have taken those precautions in terms of isolation, where possible.

Nursing homes were not instructed to - that is my point.

Mr. Tadhg Daly

No. The current guidance says that a person coming from an acute hospital should be in isolation for a period of 14 days. That was not public health policy at the time, but it would have been practised in most nursing homes. This was compounded by the fact that if nursing homes had large numbers of asymptomatic residents, then we could have staff members caring for residents who subsequently tested positive. These staff members would also have been caring for other residents within a particular nursing home.

I am looking at correspondence sent by Mr. Daly on 10 March. He requested that all discharges would undergo a full risk assessment, a full medical assessment and be tested for Covid-19. I have been told by the Minister for Health as well that the protocol dictates that a patient discharged must have two negative tests prior to transfer. That did not happen in March. Am I right?

Mr. Tadhg Daly

No, it did not happen.

At the same time, staff were being aggressively recruited, to use the term Mr. Daly used. He called on the HSE to "desist from targeting the recruitment of staff from the private nursing home sector". These staff were being recruited by the HSE to go to the acute hospital sector at the same time as large numbers of patients were being transferred out. Is that right?

Mr. Tadhg Daly

Yes.

Nursing homes were losing staff at the same time as they were being asked to take on additional patients.

Mr. Tadhg Daly

We were.

None of these patients was tested. The medical assessment and risk assessment that nursing homes had looked for were not taking place in March.

Mr. Tadhg Daly

Some risk assessment was done but the testing was not done in line with what we would have felt. In recent times we have seen the European Centre for Disease Prevention and Control state that a more rigorous programme of testing would have been appropriate.

I am looking at correspondence from Mr. Daly. Chairman, I want to point out again, on the record, that we received a huge volume of correspondence at 9.30 this morning. It is not helpful. It is more helpful for us in doing our work if we get it in good time. I am looking at correspondence from Mr. Daly dated 17 March sent to the Department. Mr. Daly stated:

We require a commitment to constant two-way dialogue as we strive to protect the nation. In such regard I am following up again with regard to critical issues.

At the time we were looking at what was happening internationally. We could see what was happening in Italy and other countries where the surge was happening not only in the hospitals but in the nursing home sector as well. We knew that there was an acute issue in the nursing home sector. Yet, Mr. Daly was writing and requesting that there would be a constant two-way dialogue.

Is it fair to say he was right but was not getting much back in response? That is what seems to be in the correspondence: a lot of letters from Mr. Daly but not a huge amount by way of detailed correspondence-----

Mr. Tadhg Daly

Our first communication to the Department was in February. As to what we suggested at that time, I had come across some evidence from my colleagues in Scotland that we should replicate some of the advice and guidance there. That took some time to take hold. It is fair to say we had a good engagement with officials, but clearly we were also exasperated by the fact that we had not met the Minister at that stage. The meeting was, I think, at the end of March.

The first meeting was at the end of March, but how many times had Mr. Daly requested that meeting? We know that Nursing Homes Ireland issued a press release on 25 March, and we know from the correspondence that Mr. Daly made a large number of requests, but that meeting did not happen until the end of March.

Mr. Tadhg Daly

Yes, 30 March, but it is fair to say there has been very good engagement from the Minister, Deputy Harris, and officials since then.

That is fair enough.

Regarding the number of discharges made at the very beginning, is it Mr. Daly's opinion that it is possible that in some instances the virus may have come into nursing homes via those discharges because of the lack of risk assessment, the lack of medical assessment and the failure to test prior to transfer?

Mr. Tadhg Daly

I am not a public health expert or a virologist-----

I am only asking for Mr. Daly's opinion.

Mr. Tadhg Daly

-----but clearly the virus was very easily transmissible and, given what we know now about the levels of community transmission probably as early as February, yes, I would say that was a contributory factor.

Mr. Daly says in his submission to us:

Key State organisations left the nursing home sector and its residents isolated in those early days. The dismay will live forever with us.

I will come to Mr. Taylor as well on this, but could Mr. Daly briefly describe the impact of having to deal in this environment not just with the deaths that happen but also with caring for those patients? I refer to the impact that this has had on the residents and the staff and the fact that so many opportunities were missed. The staff and the residents were on the front line without as much as the comfort of their families, who were waiting outside.

Mr. Tadhg Daly

For the period of early March it was very distressing. I was getting calls from members and dealing with staff and with families. As I said in my statement, our first priority should be the residents because they have had a difficult period with no visitors. They have also lost friends and what they see as their family. It was therefore very difficult and we were exasperated by the lack of engagement, as we saw it at that time.

I like the Mother Jones quote to which Mr. Taylor referred, "Pray for the dead and fight like hell for the living." It is very important. He described the impact on the residents and the staff and the relatives of the staff: "You have no idea how awful it is - it's horrific." As to what was happening at the time, what feedback was Sage Advocacy getting from residents and their families, specifically relating to that period when, as Mr. Daly has described, nursing homes were being flooded with patients but starved of staff at the same time?

Mr. Mervyn Taylor

Sage Advocacy is an external organisation. It works with individuals and families, sometimes where a person lacks capacity, or their representatives. We do not have an operational role in the nursing homes. The Deputy will appreciate that because of the restrictions, it was very difficult to get contact. We did nevertheless have a lot of contact with some relatives in some cases but also with staff. In many cases we were acting almost like a sounding board for some people who are under an awful lot of pressure in the nursing homes. One of the key issues was that there is a belief that the hospitals were suddenly emptied out all into nursing homes. I would like to see the data on the transfers from the acute hospitals to the nursing homes because I think they are mixed. That is my very strong impression. I know there were some nursing homes that took in people and other nursing homes that closed down, restricted visiting and said they would not take anybody from acute hospitals-----

As is their right.

Mr. Mervyn Taylor

-----as is their right, one might argue.

I thank Mr. Taylor. I am sorry to cut across him but we are quite curtailed by time because we cannot be here for more than two hours at a time.

I welcome Mr. Daly, who is here on behalf of Nursing Homes Ireland, and Sage Advocacy. I pay tribute to all those who work in nursing homes, who give so willingly and so well of their time, their effort and their personal commitment.

I thank Mr. Taylor and Deputy Shanahan.

The sad fact that so many people have died in nursing homes is a tragedy for all of us. We must find not only accountability, but also the facts. Is it true that Mr. Daly first met the HSE's CEO in mid-February?

Mr. Tadhg Daly

We met on 19 February, but there-----

That is okay. I just-----

Mr. Tadhg Daly

-----was no engagement on Covid-----

Nursing Home Ireland's engagement with the Department began in late February. Is that correct?

Mr. Tadhg Daly

We wrote to the Department on 28 February.

There are 400 items of correspondence between Nursing Homes Ireland and the Department of Health. Is that correct?

Mr. Tadhg Daly

I did not realise the number was so vast.

It is. On 17 March, did Mr. Daly thank the Department of Health for regular and ongoing communications in the current unprecedented environment? Did Nursing Homes Ireland assure the Department of its support and state that they would work together? On 18 March, Nursing Homes Ireland wrote to the Department and thanked officials for their continued collaboration, stating that together they would have the commitment to ensure the care of 25,000 residents in private and voluntary nursing homes was addressed. Nursing Homes Ireland also wrote that it appreciated the round-the-clock engagement and availability in that regard.

Mr. Tadhg Daly

Yes.

On 19 March, Nursing Homes Ireland had a conference call with the Minister. On 20 March, it had a conference call with the Department of Health. On 24 March, Nursing Homes Ireland was looking for financial assistance. On 26 March, the Minister confirmed that to it and, on 29 March, there was a meeting. On 4 April, the temporary financial assistance scheme was launched. Correspondence shows that no one from NPHET asked Nursing Homes Ireland not to tell families where the cases or clusters were. Are all of these facts correct?

Mr. Tadhg Daly

No, they are not. The Deputy mentioned a number of items. We would have ongoing engagement with officials throughout the year. There are 25,000 people residing in our members' nursing homes, so we view it as an important role for the organisation to engage with officials throughout the year.

Mr. Tadhg Daly

My approach is to work collaboratively with people.

Okay. Chairman, I-----

Mr. Tadhg Daly

Regarding dates, the Deputy mentioned a conference call on 19 March with the Minister, but the first meeting with the Minister was on 30 March.

The conference call I talked about was on 19 March. Did a conference call take place?

Mr. Tadhg Daly

With the Minister, no.

My information is that it did.

Mr. Tadhg Daly

No. Our first-----

The main point I want to make to Mr. Daly-----

In fairness, if the Deputy asks Mr. Daly a question, he has to be allowed to answer.

Mr. Tadhg Daly

The first meeting with the Minister was on Monday, 30 March.

Thank you.

So Mr. Daly is saying that this conference call did not take place. Fair enough.

Mr. Tadhg Daly

A conference call may have happened, but we did not have a conference call with the Minister. I would have to check my-----

I believe Nursing Homes Ireland did have a conference call, but my main point is that Mr. Daly's statement, "Key State organisations left the nursing home sector and its residents isolated in those early days", is patently and obviously untrue.

My second point relates to Nursing Homes Ireland's directors. It has 12, all of whom are business people. I looked at their accounts and there are wealthy companies represented among those directors, who are very fine people in every respect. Some €23.3 million was the profit of eight of those directors in the last accounting year. I cannot get the accounts of the other directors because they are part of other companies. Is it fair to say that the nursing homes sector is a privately funded organisation and has a great deal of money to pay for, for example, PPE, testing, staff accommodation and extra staff in this crisis?

Mr. Tadhg Daly

Yes. The sector takes its responsibilities seriously. The issue with PPE is well rehearsed. The normal supply of PPE was unavailable to the sector. Most of the PPE being garnered for the country was being directed towards the HSE and the HSE alone. It was not an issue of finances, but of accessibility.

But Mr. Daly's-----

Mr. Tadhg Daly

Likewise, testing was being done nationally by the HSE.

What funds did nursing homes spend in addition to normal funding to get PPE and pay for testing, extra staff and staff accommodation?

Mr. Tadhg Daly

It runs into millions of euro. I can get those figures for the committee.

Please. I thank Mr. Daly.

Mr. Tadhg Daly

I had a call with the Minister yesterday. Under the temporary financial assistance scheme to date, €8.7 million has been drawn down. That spending was probably incurred in April.

That was Government money refunded to nursing homes.

Mr. Tadhg Daly

No. It is State money to support our fellow citizens.

Yes, but my point is-----

Mr. Tadhg Daly

It is a support that-----

-----that Mr. Daly asserted that nursing homes were not supported. I am saying that the facts point to the opposite.

Mr. Tadhg Daly

If I could, Chairman, please. The State scheme was announced on 4 April. The first money was only drawn down last week.

But who paid? Nursing homes were recompensed.

Mr. Tadhg Daly

No.

I am not saying it is a bad thing.

It got the money back that it spent. To say that its members were left isolated is not a fact.

Mr. Daly's organisation is the one that all the private nursing homes come back to. In the last report published on his organisation's nursing homes, how many of the 581 homes were fully compliant fully with HIQA regulations?

Mr. Tadhg Daly

I do not have those figures.

Mr. Tadhg Daly

There is another important qualification there. These are public, private, and voluntary nursing homes, which will also include-----

I am aware of that. The fact is that only 123 of the 581 nursing homes - public, private and not-for-profit - were fully compliant. Of those, there was a failure rate of 32% under governance and management, there was a residents' rights failure rate of 23%, for risk management it was 22%, and for infection control it was 18%. When that report was published, what was Mr. Daly’s response?

Mr. Tadhg Daly

I said two things. One was that the HIQA report for 2018 highlighted the high levels of compliance. HIQA is an independent body and it did highlight in its opening statement the high levels of compliance in the sector. The other thing I said was that the issue about compliance and inspection was what happens after the inspection. The inspection may highlight an issue where there is what could be seen as an area for improvement. All of the nursing homes, public private and voluntary, would then receive an action plan. The question then is to follow up on the action plan. If HIQA was unhappy, it could take corrective action.

Mr. Daly is right that the report highlighted that the compliance rates were very high, but what did the report actually say? It said that the compliance rate had gone down from 27% in 2017 to 23%. Mr. Daly represents an organisation whose members in the last published data have reduced compliance with infection control, and reduced compliance under all of these points-----

Mr. Tadhg Daly

That includes the HSE homes.

It includes everybody. I am not saying it does not.

Mr. Tadhg Daly

That is an important distinction.

Mr. Daly is making the point that the State, the HSE, the Minister or the Department did not assist his members. I believe that they did and I also believe that his organisation could have done much more for its members and it did not do that. The key point which we all want to ensure from here on is that Mr. Daly's organisation's members are compliant in every respect. There is only one nursing home-----

I remind the Deputy that our terms of reference are the State’s response to Covid-19.

If I can make this point, Chairman, and I am sorry if you do not like me saying this, but I am going to say-----

I have no problem but I am required to keep to the terms of reference and I have pointed this out to members previously.

-----this louder, and as loud as I can. It is exceptionally clear and it is something that I have said all of my life: the care of older people in nursing homes is not acceptable. The nursing home private sector is not compliant in the main, right across the sector. It comprises very wealthy companies which complain that the taxpayer is not doing enough for them. I wish to state exceptionally clearly that we need a total change in the way we look at the care of older people. We need the home care packages mentioned by Mr.Taylor, in the smaller units referred to, and to look after people with dementia. We need to stop this game of blaming everybody and to accept the fact that we are not doing enough and have never done enough. Unless things change now, we are going to go down the same road.

I respect Mr. Daly, whom I have met a number of times, but I want to make it exceptionally clear that it is not good enough that this system would continue, and the tragedies that have unfolded in many homes because of the deaths of loved ones. We have seen it every day on the television when it comes on about those poor people who have passed away. I knew many of them and I am saddened, and I know that the families are saddened by this. It is a scandal that this happened.

I point to a report in The Guardian about a British Parliament hearing. There is not one death certificate in all of Hong Kong for a person in a nursing home who had Covid-19 because not one of them there died. I just get so angry at this.

We need to move forward together but we must establish the facts. The truth is the truth and the truth will out. We have to change radically everything to do with older people.

Mr. Daly indicated he wished to reply.

Mr. Tadhg Daly

Yes, on a few points, please. The nursing home sector is arguably the most highly regulated part of the health service. HIQA will be appearing before the committee in the afternoon.

Not alone does HIQA have the authority but it also has the responsibility, if it sees standards that are not acceptable, to close a home. That responsibility rests with HIQA.

I have met many Members of this House over the last while. We hold an Oireachtas open day every year and we have met many Members at that. I spent eight or ten weeks last year coming in to meet Members one-to-one on the issue of a continuum of care. We need to develop a suite of care services for the older population and Nursing Homes Ireland members are doing it already in many cases and we will not be found wanting in our responsibilities.

I thank our witnesses for giving up their time and for coming in today. This awful pandemic has borne down heaviest on older people, particularly on those in nursing, residential and care homes. We have to be cognisant of the fact that 62% of all deaths that have happened so far have been in those settings and that 93% of all who have lost their lives so far are in the over 65 age bracket.

I have listened to the last speaker with interest and I want to bring the discussion back to the fact that there were failings over the last two months. We all realise that and it is important that we delve into it. It is also very important that we accept that four out of every five people in nursing homes who got Covid-19 recovered and I would like to thank the 40,000 staff in nursing, care and residential homes who have gone far beyond the call of duty.

I undertook a survey between 7 April and 8 April, in which I contacted 80 nursing homes in the south of the country. The results I got from them at that time bear out exactly what Mr. Daly said in his opening statement about the insufficient testing of residents and staff, a massive shortfall of PPE and an aggressive recruitment of nursing home staff. I want to point out that when I conducted that survey, at a time when I was being contacted by nursing homes all over Ireland as Fianna Fáil spokesperson for older people, 50% of the nursing homes that came back to me - and I got a 25% sample - had insufficient staff. That bears out what Mr. Daly said about staffing. On PPE, 30% of the nursing homes that came back to me had sufficient PPE. This was between 8 April and 9 April when we were entering the surge. However, 60% of the nursing homes that came back to me had no PPE and 10% had a three-day supply at that time. That testifies to the fact that nursing homes, whether they were public or private and whether they were care homes or facilities for people with additional needs, it made no difference. They did not have the staff during the Covid-19 pandemic and there was a shortage of PPE. I will stand over that assertion and I have all the emails to back it up.

Mr. Daly said that Nursing Homes Ireland sought detailed Covid-19 advice from the HSE in a letter on 28 February. I accept that it was 30 March before Nursing Homes Ireland met the Minister and his officials. After Nursing Homes Ireland requested dedicated guidance for residential care settings, when did it receive that advice?

Mr. Tadhg Daly

I will have to check the specific date but in the middle of March Nursing Homes Ireland and the HSE, through the national clinical programme for older persons, developed guidance specific to residential care settings but it took a number of weeks.

Would it be fair to say that Nursing Homes Ireland was initially disappointed? From the initial request on 28 February to 30 March, would it be fair to say that for Mr. Daly, as chairperson of Nursing Homes Ireland, which represents approximately 485 nursing homes in the sector, it was disappointing that it took four weeks for officials to meet with Nursing Homes Ireland?

Mr. Tadhg Daly

It is important to put on the record that we were engaged quite regularly with officials in the Department. Many matters were being escalated and we were hearing that NPHET was discussing certain matters but we felt it was important that the voice of the nursing home sector and the frustration that was felt by our members was heard at an official level. We were disappointed that it took almost a month before we got to meet with the Minister. I appreciate that he was busy in many other areas but I would highlight that given the vulnerability of older people, we felt this issue should have been higher on the agenda.

Does Mr. Daly believe that NPHET realised the gravity and urgency of the situation facing nursing homes in the early stages? I know there were many calls, including from my colleague, Deputy Donnelly, for nursing homes to be represented on the NPHET taskforce.

Does Mr. Daly believe it realised the urgency at the initial stage because we had all seen the pictures from Italy and Spain where older people were left in nursing homes without care?

Mr. Tadhg Daly

No, I do not, unfortunately. There was NPHET itself, a vulnerable persons subgroup and a nursing homes group. As an organisation and a sector, we had no representation on any of those three committees. That, to me, was more than disappointing. It was unacceptable in my mind.

I have another question on staffing issues during March and April. Mr. Daly mentioned in his opening statement that there was "aggressive recruitment of nursing home staff initially by the HSE". I have heard that from different nursing homes I spoke to. Can Mr. Daly expand on that? Was the recruitment above and beyond a general advertising campaign or did the HSE directly head hunt staff from nursing homes?

Mr. Tadhg Daly

Yes. We had written to the director general of the HSE and to the Minister. There were three letters on that occasion, on 9 March, outlining our concerns around that issue. What happened was people were on panels in some cases. There was also, we would suggest, a targeting of people who were working in the sector. We would have made the point that denuded one element of the health service to support another element, which was counterproductive. We would have asked for a moratorium on recruitment. This happens on an ongoing basis and people transfer for whatever reason. However, in the teeth of the global pandemic, we felt it was appropriate to ask the HSE to do that. It did not agree to do that at the time but there has been some improvements in that respect over the past number of weeks.

Now that we seem to have passed the peak, has the situation in regard to staffing in nursing homes improved? Are the nursing homes for whom Mr. Daly can speak preparing for a second surge?

Mr. Tadhg Daly

There are two things. Yes, the last number of weeks have been encouraging. Obviously, yesterday's announcement that there were no deaths was very encouraging for all of us, as a society. Things have definitely improved but we cannot afford to be complacent at all. I am aware there is some talk within NPHET and among others about a potential second wave. That is where the expert group the Minister has established is important because it will, hopefully, do what did not happen, maybe, back in February and March, and provide a roadmap for Ireland Inc. for public, private and voluntary nursing homes.

Mr. Daly, in his opening statement, spoke about the National Treatment Purchase Fund, the authority responsible for the commissioning of nursing home care. We all understand how it works but Mr. Daly said it fell silent as homes incurred considerable and responsible costs to manage the pandemic. I accept the Minister came on board with a package. I also accept the fact that any expenses incurred in March were not allowed and it was only the expenses incurred after 1 April. It is only fair to be clear about this matter. Many nursing homes incurred a lot of expenses in March that they could not recoup. What did Mr. Daly mean when he said it "fell silent" as homes incurred considerable expenses?

Mr. Tadhg Daly

The Deputy highlighted two issues. It is fair to acknowledge that on 4 April that was announced. We were very disappointed it was not backdated to 1 March, as the Deputy said. There are two issues here. There is an element of that scheme which talks about outbreak assistance, so there is extra funding, which is very positive, for those that had an outbreak. We would argue as well that those who spent considerable moneys to keep a nursing home Covid-free, in some respects, are not being recognised by the fact that the additional funding, in part C of that particular scheme, is only for those who had an outbreak. We were disappointed with the level of engagement by the National Treatment Purchase Fund at a very early stage.

I will wrap up my questions to Mr. Daly before moving on to question Mr. Taylor. We will never know how Covid got into nursing homes, hospitals, homes and communities. We can only surmise. During the first three months of the year more than 2,500 people entered nursing home care under the fair deal scheme. Every month 1,000 people transfer from acute hospitals into private and voluntary nursing homes. I accept that Mr. Daly may be unable to answer my next questions. How many people transferred in March after restrictions were imposed? How many of these patients from the acute sector were tested before going into the nursing homes? The crux of the issue is that these patients may have had Covid without realising it and may have, involuntarily, brought it into the nursing homes.

Mr. Tadhg Daly

I have some figures, but I do not have them in front of me, in terms of the number of transfers. The other question is more difficult to answer, in terms of the number of people who were tested.

Mr. Tadhg Daly

To my knowledge, from dealing with members, very few were tested.

If they were asymptomatic, it was not deemed necessary to take a test.

I have a question for Mr. Taylor. I thank him for all the work he does advocating for older people. I have met him previously. Was he contacted by very many families, sons and daughters of people in nursing homes who are very concerned about their parents at this time? Unfortunately they have not been in a position to visit. I know nursing homes have done an awful lot of good work with FaceTime, phones and all that. Could Mr. Taylor explain the level of contact he has had from people who are worried?

Mr. Mervyn Taylor

It was considerable. I said on "Drive Time" before that one of my abiding memories of this crisis has been a sense of phones not being answered when a place went into crisis. It is important to say that in Deputy Butler's own area, in the south east, they got away relatively lightly. It was the north-east quadrant from Dublin across to Mullingar and up to Cavan that was very badly hit. In that area, there were nights one would put one's head in one's hands. There were people who were despairing. They could not get through because the staffing situation was so difficult. The nursing homes were really stuck for staff. Some places were down to absolute skeleton staff until the cavalry came. The fact of the matter is that they needed support. People were literally worn out. I think of one woman in particular who had a dying husband and a son who had lived in the same nursing home and had gone into a hospital and died. People were literally worn out and we were almost trying to pick up the phone calls for them because they were running out of energy. That is one of the key things. It sounds like it has nothing to do with clinical care but one of the most important things was the lack of ability to answer the phones. To think of a nursing home with 50 people in it, that is at least 50 families all trying to get through, and there is nobody able to answer the phone. All sorts of stories were magnified; that is one of the problems. It is about trying to separate fact from fiction in these situations. We heard of places where there were all sorts of allegations about numbers of deaths which were subsequently not true.

I would ask Deputies to, please, leave time for answers. If we continually go over time, the speakers at the end will not get to speak. I call Deputy Ossian Smyth of the Green Party.

I thank Mr. Daly and Mr. Taylor for coming in. I want to ask Mr. Daly about the distribution of PPE. I understand it was chaotic for a while and nobody was getting anything. Now I believe we are at a stage where some people are over-supplied and some are under-supplied. That is the experience of my colleague, Councillor Róisín Garvey in Clare, who tells me she went around with a supply of PPE and found that some nursing homes did not want it and some were desperate. Is that Mr. Daly's experience with his members?

Mr. Tadhg Daly

Yes. In the early stages, as the Deputy said, it was quite chaotic. Everybody was scrambling to ensure that they had enough supply. We made a suggestion in the early stage that every nursing home should have a three-day supply in-house so they could deal with either a confirmed case or, more important, a suspected case. We also felt that among our members, if we had a three-day supply people could share, maybe, in a given location.

Have the infection control rules that are apparently needed affected the operation of the nursing homes at the moment? We talk about congregated settings. Typically, people are sitting in sitting rooms, watching TV, sharing rooms on occasion or whatever. Nursing Homes Ireland has received guidance from the Department of Health on how they should operate from the infection control point of view. Does that mean that fewer people can fit in a nursing home? How is it affecting Nursing Homes Ireland members?

Mr. Tadhg Daly

That is the next question in terms of this expert group. It is looking at how we can plan for the next six to 18 months. Over the last while we have seen that people are practising cocooning, in effect. In the private and voluntary sector, the vast majority would be in single en-suite rooms. Unfortunately, as regards the social connectedness piece, people very often are staying in their rooms.

Are there very few new entrants to the nursing homes? Is it the case that people are not being admitted any more?

Mr. Tadhg Daly

It is mixed, to be honest. In some homes where there has not been a Covid outbreak and where an acute hospital is still discharging and they have taken the appropriate steps in terms of risk and testing, it is appropriate that a person would be transferred. In those cases, a person would be isolated for 14 days.

I think it is fair to say that many people, even before the pandemic, would have preferred to stay in their home than go to a nursing home. They might have had a fear but now that fear is much greater and it is among families as well.

Government policy is to move more towards home care and having a statutory home care package and away from relying on the fair deal scheme alone. This combination of fewer people fitting in a nursing home because of infection control rooms, fewer people wanting to enter them and the State supporting more home care would seem to add up to much less demand for nursing home spaces. I do not know whether this is how Mr. Daly sees it. If this does happen, will it lead to nursing homes either closing or having higher fees to stay in a nursing home with fewer people in it?

Mr. Tadhg Daly

The Deputy has raised a couple of points. Clearly, what we need to develop as a society is a continuum of care for older people. We always get caught up in the silos of home care, acute care, and housing with supports. We need to develop a continuum of care. There is a legitimate question on what we term the future viability of some homes, in particular smaller homes. We are very concerned about this with regard to maintaining service continuity. We have an ageing population and an increasing ageing demographic. It is also important to say the age profile of nursing homes is primarily over 80 and over 85.

Mr. Taylor mentioned that the average length of stay in a nursing home is two years. I am sorry to ask this but does this equate to life expectancy?

Mr. Mervyn Taylor

In general terms, yes.

If fewer people go to nursing homes and more home care is taking place, does Mr. Taylor expect that future nursing home stays will be shorter? Hospices have the shortest expected length of stay. Will future nursing home stays be shorter, for example, for one year? Will Mr. Taylor describe what fits into the gap between home care and nursing homes?

Mr. Mervyn Taylor

We need a continuum. Mr. Daly and I have been on the same platform regarding a continuum of care for a number of years. It is everything from home care, split housing and boarding out to supportive housing, mutual and housing co-operatives and housing with supports. There is a need for nursing home care but it is also how we try to envisage it for the future. We must bear in mind there is a wide range of nursing homes. I looked at the recent lists and 49% of nursing homes have fewer than 50 residents. This has its own issues. We want people to live in smaller more homely places but the fact is the trend is towards larger places. How do we get the balance right? It can only come with the continuum the Deputy is describing.

We need the documents from NPHET, the HSE and the Department which we requested.

They have been requested and that request will be reiterated.

We will send an email later.

I thank Mr. Daly and Mr. Taylor for coming before the committee. I will direct my first question to Mr. Daly. It has been pretty clear that, in his words during media appearances yesterday evening and this morning and in his opening statement, he has been shifting responsibility to the HSE. Is there anything he would have done differently with regard to his organisation earlier this year? Is there anything he would look back on and say he should have done this or that?

Mr. Tadhg Daly

Let me be clear that I am not shifting responsibility. We take our responsibility very seriously. I am highlighting the facts, which are that there were gaps in terms of the supports. It is not about supports for the private, public or voluntary sector; it is about supports for older people. Many of the measures we took on infection control, sourcing personal protective equipment, isolation within nursing homes and nursing homes being prepared with contingency planning could be improved but that is for another day. At this point, nothing stands out, to be honest, with regard to whether we would do things differently.

Is Mr. Daly satisfied with the larger corporate members of Nursing Homes Ireland? I know it also has members from the voluntary sector and small and medium enterprises. Nursing Homes Ireland's large corporate members have considerable experience of dealing with the HSE through the National Treatment Purchase Fund. The individuals involved are self-starters who have a lot of contacts, although they may not necessarily be living or domiciled here. Is Mr. Daly satisfied with their efforts?

Mr. Tadhg Daly

The virus is indiscriminate. It does not pick a public home or a private home, a large home or a small home. The efforts of all of the sector, public, private and voluntary, have been to try to suppress the virus. At this point, I do not have any concern but ultimately that is a matter for HIQA as the independent inspectorate.

Yes, and HIQA will appear before the committee next.

I agree the virus is indiscriminate but we are grappling with early figures that would indicate it more heavily affected the private than the HSE homes. We need to tease that out more.

Mr. Tadhg Daly

I do not think that stands up to scrutiny.

As a committee, we will be scrutinising that, but we are dealing with facts and data as we get them.

On the staff shortages, it is widely reported that the average pay in the sector is approximately €12 per hour for health assistants. Does Mr. Daly think this has had an impact on the staffing levels and the ability to attract staff? Nursing Homes Ireland has had its own recruitment campaign since 17 March, which would indicate this has not been successful. Mr. Daly said the HSE has been aggressive in its recruitment campaign but does he think the Nursing Homes Ireland structure in terms of pay for health staff has been a factor in this?

Mr. Tadhg Daly

Clearly, the sector is, as I said earlier, the most highly regulated, if taken from a standards point of view, but it is also regulated from a price point of view. The National Treatment Purchase Fund sets the fees and the fees, in turn, dictate the pay scales within the sector. We would love nothing better in the morning than to be on the same rates as the HSE but the State is not providing that level, despite the fact the fair deal is supposed to be a level playing field.

An awful lot of figures are being thrown around in regard to the industry and, as was said, everything from the voluntary right through to large corporates are involved. Given there has been an issue in terms of being prepared for this across the State, would Mr. Daly consider the setting up of a pandemic or crisis fund within the nursing homes sector, which he represents? I am referring to a sort of sinking fund into the future for those that can pay, and they would pay in so there would be a fund that could be drawn upon if there is a second or further wave of this crisis. This would mean that for those few weeks that were spent with the HSE, getting responses and not getting responses, it would not have to be such an issue because there would be that reserve, which would come from the nursing homes' own resources.

Mr. Tadhg Daly

Possibly, but the issue was not finance at all. The issue was PPE generally, as it just was not available. Members were sourcing it, they were buying it overseas and buying it locally. Finance was not the issue - let us be absolutely clear on that. The issue was that it was a scarce commodity in an international market and the source of supply had dried up, not just for nursing homes but for all elements of the health service.

Money must be an issue because there is now a €72 million support package and the nursing homes have drawn down €8.7 million. Money is an issue.

Mr. Tadhg Daly

The point I am making is that it was not an issue in terms of our preparedness because people had spent, and I can get some of the figures for the Deputy in terms of what members had spent in March. The point Deputy Butler made was that the scheme is from 1 April whereas, in fact, members would have spent quite considerable sums in March which are potentially not recoupable under the temporary financial assistance scheme.

I thank Mr. Daly.

I thank both witnesses for their presentations. Any examination of what has happened in the nursing homes must be viewed in a policy context. There is no doubt bereaved families and Irish society generally are paying a very high price for what I would regard as a confluence of policy failures in the care of older people which have been graphically and tragically exposed over recent months. It is important that we bear in mind what those policy failures are. The first is the two-tier health service. The second is in regard to social care being treated as the poor relation of the health service. The third is the fact that nursing homes are regarded as a good investment opportunity, as opposed to a central element of the healthcare service, and that the incentivisation of investment in nursing homes has led to the unrelenting privatisation of the sector. The fourth is the fact that older people themselves are incentivised to access nursing home care because of the lack of statutory entitlement to home care, in spite of the fact that home care is what older people want and is in the best interests of their health needs. The fifth area that has been absolutely exposed is the light-touch regulation of this entire sector.

I recognise that Deputy O'Dowd had to leave. I would make the point to Deputy O'Dowd and other Government Deputies that those points have to be made loudly as well and must be heard clearly. We are wasting our time examining this whole area unless we recognise that policy context and those policy failures.

I have a number of questions for Mr. Daly. The first relates to the staff ratios in operation across the sector.

What ratios apply in respect of nurses to residents and healthcare assistants to residents, and what is the policy in respect of casual staff?

Mr. Tadhg Daly

There are two things. One is that no ratios are set by the regulator-----

I asked what Mr. Daly operates in his sector.

Mr. Tadhg Daly

We do not operate. We are not the regulator. Ultimately, members-----

No, I asked about what Mr. Daly and his members operate.

Mr. Tadhg Daly

It depends.

What ratios does Mr. Daly work to?

Mr. Tadhg Daly

As per the regulations, it depends on the layout of the building and the dependency levels of residents. It varies across the sector depending on the complexity of care required and the layout.

Does Mr. Daly have recommended ratios for his members?

Mr. Tadhg Daly

We did. In 2009, when HIQA began, we submitted a paper at the time calling for ratios. That was not taken on board.

I accept the point Mr. Daly makes on different situations, but he must have an overall ratio in respect of nurses to residents.

Mr. Tadhg Daly

No, what one has in each nursing home is what one would call a person in charge, that is, a director of nursing who would then make that call in terms of both the numbers and skill set. The skill set is important as well. It is about numbers and skill mix in terms of nurses versus senior clinicians versus care assistants. It varies right across the sector.

So Mr. Daly does not recommend any particular ratios as regards nurses.

Mr. Tadhg Daly

The regulator does not permit-----

No. I asked if Mr. Daly does.

Mr. Tadhg Daly

No, the regulator does not permit us to do that. We would love to have them. If we had ratios in the morning, then we could go back to our friends in the NTPF and say it is a cost associated with it. We would argue, in fact, that the greyness around it at times is being used against the sector.

Presumably, Mr. Daly can set his own policies for his sector. I find it hard to believe that he would be precluded from having safe ratios as regards nurses to residents.

I will list the other questions I have for him and perhaps he could answer them together. What is the policy in Mr. Daly's sector on staff moving between nursing homes? How much of the €72 million support fund has been drawn down to date, and what have his members been using that support money for in the main?

I refer to the transfer of patients from acute hospitals, which we know should have happened anyway. We should not have large numbers of older people in acute hospitals when they do not need to be there. Mr. Daly identified this as the source of the virus in nursing homes. The CMO disputes that. Does Mr. Daly have data to support his contention?

Mr. Tadhg Daly

The Deputy raised three points. One was on the policy of the sector on moving staff between centres. A number of our nursing homes, particularly in rural Ireland, would have a steady state of staff. In urban areas, more so, there would be some movement of staff between centres. However, there would also be movement of physiotherapists and speech and language therapists, and of other professionals coming in and out of nursing homes. There is no absolute policy one way or the other.

On the €72 million, as of last Friday, €8.7 million has been drawn down and the majority of that has been spent on PPE and staffing.

On the issue of the transfer of residents, I am not saying it was the sole determinant. However, I am saying it was a significant contributory factor because, as we know now, there was much greater community transmission of the virus.

What is Mr. Daly's data to support that contention?

Mr. Tadhg Daly

What we saw was that the residents were not tested and-----

Mr. Tadhg Daly

-----40% were asymptomatic, so following the mass testing there was a significant increase in the number of positive cases in nursing homes.

It is a substantial claim to make and Mr. Daly's members would know the point at which his patients or residents were transferred to hospitals.

Deputy Shortall, I apologise, I must stop you.

What data does Mr. Daly have to support what he is claiming?

Mr. Tadhg Daly

We have the number of transfers from hospitals without testing, and we now know 40% of people were asymptomatic.

Thank you very much, Mr. Daly.

They are not the same people-----

Mr. Tadhg Daly

Yes, they are.

Thank you, Deputy Shortall.

Some 40% of people-----

Mr. Tadhg Daly

I am not saying that, I am saying-----

I am afraid cannot give Deputy Shortall time from somebody else.

Mr. Tadhg Daly

I am happy to come back to the Deputy on the specifics.

By correspondence, if necessary. Thank you, it is appreciated.

I call Deputy Barry.

I will start with a brief question for Mr. Taylor, requiring a brief reply. In his statement referring to outbreaks in nursing homes, he said that staff shortages in some cases led to risk-taking with staff in some facilities having to continue to work while ill and in other cases encouraging people back from isolation.

Can Mr. Taylor stand over that statement or back it up?

Mr. Mervyn Taylor

What we report is what we hear. These were statements made to us by staff who were isolating and who were feeling under great pressure to come back. One has to bear in mind that there were extreme shortages-----

I understand that. They were referred to in the passage I quoted.

Mr. Mervyn Taylor

Hard decisions had to be made.

Mr. Taylor is saying that was direct evidence given to him by staff.

My next question, also for a brief reply, is for Mr. Daly. I will read from the statement again: "Staff shortages in some cases led to risk taking with staff in some facilities having to continue to work while ill and in other cases encouraging people back from isolation." Does Mr. Daly think that is correct and could he comment briefly on it?

Mr. Tadhg Daly

I do not believe that it is widespread for several reasons. First, all nursing homes follow the public health advice. Second, in the case of an outbreak, public health are in the building every day. Third, there was a change in policy around the term "essential workers" on foot of some recommendations from the deputy chief medical officer.

It was not widespread but it certainly happened.

Mr. Tadhg Daly

I do not believe so.

How many people work in the private nursing home sector? Roughly speaking, how many of those would be covered by a sick pay scheme?

Mr. Tadhg Daly

About 30,000 people work directly in the sector. As to the number covered by a scheme, I would have to check for the Deputy. Some would be covered and some would not be covered.

Would perhaps 25,000 be covered and 5,000 not be covered or would the reverse be the case perhaps? I am not looking for an exact figure from Mr. Daly but a rough idea.

Mr. Tadhg Daly

I would have to do a survey of our members because each member is independent and members run their nursing homes independently of NHI.

Does Mr. Daly not even have a rough idea of the number of workers who may be covered by a sick pay scheme?

Mr. Tadhg Daly

I do not, to be honest, but I can get the figure for the Deputy.

I find it slightly incredible that Mr. Daly is not aware of even the rough figure. This is a key issue because if a person working in the private nursing home sector wakes up in the morning with a sore throat or a temperature, there may be something going on. If that person has take-home wages of less than €350 per week, there is an economic incentive or an economic pressure on him or her to go into work and take a risk. Does Mr. Daly agree with that analysis?

Mr. Tadhg Daly

No, because I place my trust in the staff of the sector, who care deeply for the residents they care for. They would not take that risk because we have had a heightened risk of Covid in the past number of months. I would not accept that at all.

To be clear, I too place my trust in the staff who have been on the front line and have done heroic work. However, it is not credible to argue that if workers were to suffer losses in pay, in some cases significant losses, this would not be a pressure point, at the very least, to take a risk in this situation. Does Mr. Daly not even accept that it is a pressure point?

Mr. Tadhg Daly

It is a big risk. I would say that nobody is prepared to take it given what we know now about the issue of Covid.

I lost 20 seconds at the start of my contribution as a result of the carry-over from the previous slot. I will conclude, however, by referring to the passionate speech made by Deputy O'Dowd in which he referred to the private nursing home sector putting profit before health and safety. The Deputy has since left the meeting but I point out to the remaining Government members that the reason for that is that we have gone from having a nursing home sector that was majority publicly owned 35 years ago to one which is overwhelmingly privately owned. The reason for that change was that a policy of privatisation backed up by massive tax breaks was pursued by Governments led by both Fianna Fáil and Fine Gael. There was, therefore, more than a touch of hypocrisy in the bit of outrage we saw earlier.

I call Deputy Shanahan from the Regional Group of Independents.

I thank the witnesses for attending today. On the temporary financial assistance payment, I understand the capitation payment is based on the number of public residents as opposed to private ones. Is that correct?

Mr. Tadhg Daly

That was changed last week following our engagement with the Minister. It is a positive move.

I would much prefer to concentrate on where we are going as opposed to where we have been.

On the facilitation of isolation protocols in nursing homes now, is there an ability for the nursing home sector to be recompensed for that?

Mr. Tadhg Daly

"No" is the short answer. Unfortunately, at the moment, if one does an isolation area and one does not take in new residents, it is a disincentive.

On Deputy O'Dowd's comments earlier, I met some of NHI's members in March. As somebody who has been involved in trying to help the HSE to source PPE through contacts that I have, I am well aware of the cost of PPE and of what was being paid by some of NHI's members and the difficulties getting it. I do not think Deputy O'Dowd was quite clear in highlighting the fact that NHI members are not being paid for those purchases made back in early March. That needs to be put on the record because at the moment the record reflects that is not the case when, in fact, NHI members have not been paid.

I wish to ask Mr. Daly about recruitment. Would Mr. Daly say it was a difficulty for the sector that the HSE was actively targeting healthcare personnel for recruitment, and that they were coming from some of the homes of NHI members?

Mr. Tadhg Daly

Yes, that was very challenging in the early period because losing any staff member even in ordinary times is challenging, particularly nursing staff. Nursing staff are a scarce commodity worldwide, so that put extra pressure on the sector. We asked for a moratorium on recruitment for the period of the pandemic at least.

I questioned the Minister on all of those subjects in the Dáil on 23 April, so I am glad that there has been some movement.

On future testing regimes of staff and patients, the ECDC is calling for weekly tests. Is Mr. Daly engaging with the Department at the moment on how this might be achieved?

Mr. Tadhg Daly

Yes, we have had twice weekly meetings with the Minister, which is very positive. That needs to be acknowledged, and we have met with officials in the Department. We have produced a paper, which we submitted last week. I understand that NPHET is meeting this Thursday. We concur with the ECDC's recommendation.

Some private hospitals are implementing their own PCR testing and they can turn around tests potentially in less than half an hour. Is this something that NHI might look at trying to facilitate for its members, both public and private?

Mr. Tadhg Daly

Absolutely. The challenge for us now is to navigate our way out of this particular pandemic and ensure the safety and welfare of both residents and staff. Any measures that we can take as an organisation will be taken.

On the isolation of residents at present, we know that four out of five residents who have come into contact with Covid have survived. We assume the science is not exact, but we know people have antibodies for a period. Is it possible that we could look at antibody testing to try to identify those nursing home patients and allow them to have access to their family and relatives, rather than continuing to be locked down?

Mr. Tadhg Daly

On the issue of easing visitor restrictions, we have submitted a paper to NPHET on that and I believe that is for discussion on Thursday. We have come through a very difficult period and I concur with the Deputy that we need to look at solutions so that we can move to the next phase because clearly the visitor restrictions are having an impact on residents.

On Mr. Daly's comments regarding the integrated model of care into the future and the clear guidelines for skills, everybody here would support that. We accept there are strictures imposed on the NHI by NTPF in terms of the overall burden of moneys there to assist that.

Mr. Taylor mentioned advocacy for those in residential care being framed in legislation. In 30 seconds, could he give a quick outline of how he sees that being developed?

Mr. Mervyn Taylor

I will do so very quickly, as I am aware of the time strictures. Legislation has been anticipated for safeguarding adults and the Law Reform Commission has a consultation going on regarding how such a framework might best occur. We believe that is a mechanism for framing legal recognition of independent advocacy. There is also a need for legislation on protection of liberty of people in congregated care settings because that is a serious issue. People have been transferred from acute hospitals to nursing homes on temporary transition funding. The question is: will they have a choice of staying there or getting the package they need to support them to go home? Legislation can come either way.

I thank Mr. Taylor and Deputy Shanahan.

I welcome Mr. Daly and Mr. Taylor who are giving evidence today.

It has been a very difficult time, especially for those who have lost loved ones in nursing homes. I pay tribute to the staff in nursing homes who have worked incredibly hard. I know of their hard work because I contacted many nursing homes in west Cork, such as Cramers Court in Belgooly, CareChoice Clonakilty, Bushmount Nursing Home, Skibbereen Residential Care Centre, Fairfield Nursing Home in Drimoleague and Deerpark House Nursing Home in Bantry. Each of them has gone through a difficult time. Thankfully, the number of cases of Covid in west Cork has been very low, which is a blessing in its own right. However, there are questions that need to be asked and I must address them as quickly as possible in the time I have. Most of them will be for Mr. Daly.

Was a strategy in place to test patients who were moved from hospitals to nursing homes in order to free up acute hospital beds? If there was such a strategy, what percentage of those patients were tested and moved only on the basis of a negative result?

Mr. Tadhg Daly

In early March, there was no such strategy. We received communication from the acute hospitals and the HSE community healthcare organisations that the patients were deemed to be low risk, had not been in contact with Covid and would be transferred. There was no definitive strategy at that point.

Is there a tracking system in place to identify nursing home staff who are working in more than one nursing home?

Mr. Tadhg Daly

There is. All our members are logging that information on a daily basis with the HSE, HIQA and the public health authorities. The information is held centrally.

Mr. Paul Reid stated that the mass testing of nursing home residents and staff at facilities is complete. Is there a plan to ensure the safety of residents in every residential nursing home?

Mr. Tadhg Daly

The mass testing is complete. As another Deputy noted, the question is what we will do next and whether there will be a targeted testing approach. I do not believe that the HSE is planning mass testing. It is clear that there must be a roadmap for testing in order to ensure that nursing homes can take patients from acute hospitals and reopen to visitors.

Do nursing homes plan to test and monitor the variables within those settings, such as the testing of staff on a weekly basis, at least? From what I can gather, it currently takes two weeks for residents to be tested and ten days for staff to be tested. Is Mr. Daly aware that Animal Health Laboratories in Bandon, west Cork, is turning around Covid-19 tests in a day? If he is not, will he get Nursing Homes Ireland to avail of this incredible service such that testing can be carried out in our own backyard rather than samples being flown to Germany and all over the world?

Mr. Tadhg Daly

On testing, matters have improved greatly, to be fair to the HSE. Turnaround time has been reduced to approximately three days. We will be guided by the recommendations of the public health authorities in respect of the next wave of testing. We understand that will be announced before the end of the week.

Is Nursing Homes Ireland aware of the laboratory in Bandon?

Mr. Tadhg Daly

I am not aware of it. What we have been dealing with is a national response. Ultimately, the HSE is running the testing programme. We have asked that testing kits be made available to staff in nursing homes in order that they can take swabs themselves, which would be far quicker than having to wait for the National Ambulance Service to so do.

That leads me on to my next question. I and many professionals believe doctors and nurses should be allowed to take swabs, which could result in being able to get next-day results. Is Nursing Homes Ireland working towards that?

Mr. Tadhg Daly

Absolutely.

Has the HSE given any indication that it will allow that to happen?

Mr. Tadhg Daly

It is happening in some centres, which is very positive because it leads to a quick turnaround and it means that the resident is swabbed by a person he or she knows well. It can be very comforting for a resident to have a person who he or she knows doing the swab rather than an external person.

As already stated, everybody wants there to be quick results. It seems to me that it is taking between ten and 12 days to get tests completed. If it takes another three to five, six or seven days to get the results, it defeats the whole purpose. My point is that we need to look to local laboratories to carry out these tests. I urge Mr. Daly to consider using such laboratories.

I ask that Mr. Daly reply to the Deputy in writing on the matter.

Mr. Tadhg Daly

I will revert to the Deputy directly on that point.

I call Deputy Cullinane. Is he taking five minutes or ten?

I am taking ten minutes. I welcome our witnesses and commend them on their service and work in representing their members - Mr. Daly in particular -and patients. I also commend them on dealing with a very difficult situation where, as I am sure they know, staff were across different departments as well.

I will talk Mr. Daly through his opening statement in a few minutes. He will understand, however, that at the previous session we asked for all correspondence between NHI and the Department of Health. We got that today at 9.30 a.m. We have not had time to go through all that correspondence in detail, but I have isolated some items, which I want to go through because they illustrate exactly what is in Mr. Daly's opening statement.

I will start with No. 32. I will not name the individuals involved, but Mr. Daly wrote to a senior official in the Department on 16 March setting out his concerns. I know there was prior correspondence, but on that date, he emailed this individual seeking a commitment to a dialogue. He referred to critical issues he had raised previously referred to considerable anxiety, access to PPE and issues concerning essential workers, and he suggested that a working group should be established to co-ordinate activities in the home care setting. Does he recall that?

Mr. Tadhg Daly

I do.

Two days later, on 18 March, Mr. Daly again followed up with more questions in respect of the provision of PPE, oxygen and required supplies, which he stated was very challenging, to say the least. He also referred to exhaustion of stocks, stated that residents and staff were awaiting testing and that was a difficulty. He also stated that "Delays occurring can present cataclysmic consequences." In that correspondence, Mr. Daly again sought an urgent meeting regarding outstanding issues. Does he remember that?

Mr. Tadhg Daly

I do indeed.

Did Mr. Daly get that urgent meeting?

Mr. Tadhg Daly

I think we met within two days with officials.

Was that with officials in the Department of Health or with the Minister? Did Mr. Daly seek a meeting with the Minister?

Mr. Tadhg Daly

We did seek a meeting with the Minister. The first meeting with the Minister was on 30 March.

When did Mr. Daly first seek a meeting with the Minister?

Mr. Tadhg Daly

I would have to check my date properly.

Was it weeks prior to that?

Mr. Tadhg Daly

That is correct. Our first correspondence was at the end of February and-----

I thank Mr. Daly.

Mr. Tadhg Daly

-----we were engaging right throughout March.

There was a constant pattern here of looking for meetings, flagging issues and raising yellow and red flags. I will go to correspondence No. 42. This was sent directly to the Minister for Health. It was an urgent request for a meeting and a conference call. That was on 19 March, and there was no response to that until the end of March. Is that correct?

Mr. Tadhg Daly

That is correct.

In No. 43, Mr. Daly again raised concerns in respect of a number of issues. I refer to a letter he wrote to the Minister in which he states:" I am writing to you to request an urgent meeting or conference call to discuss important issues." Mr. Daly then set out all the issues again. He continued by respectfully requesting immediate engagement to ensure the NHI could continue to provide high quality. That was on 19 March. It was not until the end of March that there was a meeting. Is that correct?

Mr. Tadhg Daly

That is correct.

No. 46 is also correspondence from Mr. Daly, where he noted that the Department had established a working group on the nursing homes sector but the said that the decision to establish a group and exclude NHI "beggars belief, given that the sector provides care in a home". Mr. Daly, therefore, had outlined that issue right through the process. He wanted a working group in place, but his group had been left out of the process. Is that correct?

Mr. Tadhg Daly

Yes, there were two subgroups of NPHET. One was the vulnerable persons subgroup and a nursing home subgroup was established as well. That was the one to which I was referring. There was a specific nursing home group and we did not have a seat at that table. That was unacceptable.

It seems to me, reading all the correspondence, that this was Mr. Daly's organisation was crying out for help, almost daily, and not getting the appropriate responses. Is that a fair assessment?

Mr. Tadhg Daly

We had good engagement with officials, but what we were hearing was that matters were being escalated. It was not until we met the Minister at the end of March that matters took off.

In Mr. Daly's opening statement, he stated he was "exasperated". That is a very strong word.

Mr. Tadhg Daly

It was very challenging, because I was dealing with members and families ringing me daily. There was a lot of frustration and anxiety in the sector.

Mr. Daly referred to the sector needing a specific plan. That did not come until the end of March. Is that fair to say?

Mr. Tadhg Daly

Or even early April.

Mr. Daly also stated it was obvious that Covid-19 would have a disproportionate effect on older people and that the focus was almost completely on acute hospitals.

A national strategy was required but it took a long time in terms of all of the correspondence to get that national strategy. Is that a fair point?

Mr. Tadhg Daly

Yes. Our point was that the focus was almost exclusively on the acute hospitals and preparing for the surge in the acute hospitals, whereas the surge materialised in the nursing home sector.

Mr. Daly reiterated in his opening statement that there was insufficient testing of residents and staff, that there was a mass shortfall of PPE and that providers had suppliers that they would utilise to source such equipment but they were informed of a global shortage. I noted in some of the correspondence, which we are only now getting an opportunity to comb through, that some nursing homes were forced to use painters' overalls and supplies from a local school and a vet as personal protective equipment. Does Mr. Daly find it profoundly shocking that that is the situation that staff and managers in the institutions were left in? The sector was crying out for help day in and day out, week in and week out during that timeframe and nursing homes and the staff were forced to used painters' overalls and supplies.

Mr. Tadhg Daly

In regard to the issues around PPE, there was a national shortage. The HSE was doing its best at the time but we would have felt that some of the PPE should have been directed towards the nursing home sector given the vulnerability, age profile and complexity of residential care.

Mr. Daly took a decision early on. I appreciate that we can look back with the benefit of hindsight but in early March Nursing Homes Ireland took a decision to impose restrictions in regard to visitation. Is it not the case that NPHET met a week later and took a different approach? Mr. Daly mentioned in his opening statement that NPHET publicly challenged the decision that his organisation took.

Mr. Tadhg Daly

As I said in my opening statement, all through the first week of March our nursing committee was meeting on a regular basis. My colleague-----

Mr. Daly used the words "publicly challenged". In other words, the outworking of the press statement that was issued at the time as a consequence of that meeting was that it publicly challenged the decision that his organisation made, which was to keep people safe.

Mr. Tadhg Daly

Yes, and it did pose some challenges because we had people telephoning us saying that they had heard there was no requirement for visitor restrictions and that they wanted to gain access to homes. That was a particularly difficult week for the staff in our homes.

Mr. Daly further mentioned in his opening statement that the National Treatment Purchase Fund, which is the authority responsible for the commissioning of nursing home care, fell silent as homes incurred considerable and responsible costs. The statement that the NTPF "fell silent" is a very strong one. In what area did it fall silent?

Mr. Tadhg Daly

All through March people were making significant preparations and spending considerable amounts of money to source PPE and additional staff, isolation areas and so on. Given the role of the National Treatment Purchase Fund in terms of funding under the fair deal scheme, we would have expected it to reach out and engage with the sector in terms of what those costs would look like.

Mr. Daly also said - this is one of the most telling contributions of his opening statement - that key State organisations left the nursing home sector and its residents isolated in those early days and "the dismay will live forever with us." That is a very strong statement. It strikes me that Mr. Daly was very disappointed and angry with the State actors that they did not respond. Despite all of the telephone calls, emails and other correspondence and the yellow and red flags being raised, the organisation and its members and residents of nursing homes were not given the human and financial resources that they required because there was an absence of a plan. Would that be a fair assessment of what Mr. Daly was getting at in that sentence of his opening statement?

Mr. Tadhg Daly

When I was preparing my opening statement I was thinking back on the early period during March when we were getting many calls from members and families and how exasperated they were. I was trying to reflect in my opening statement the challenge that we all went through at that particular time.

What about Deputy O'Dowd's assertion? He gave a very robust defence of the Department. When Mr. Breslin was here last week I put questions to him on some of these issues and he said that there was guidance and a plan throughout February and March, contradicting much of what is stated in all of the correspondence and Mr. Daly's opening statement. How does Mr. Daly respond to the questions that were put to him by Deputy O'Dowd and to the head of the Department downplaying the issues that he has raised throughout all of the correspondence and in his opening statement today?

Mr. Tadhg Daly

The correspondence speaks for itself. We had very good engagement with officials. I deal with officials in the Department on an ongoing basis.

My natural modus operandi is to work with people.

Did Mr. Daly feel let down?

Mr. Tadhg Daly

It is not about me.

No, but on behalf of his members did he feel let down? This is about patients in nursing homes.

Mr. Tadhg Daly

Yes, this is about residents. Absolutely.

Does Mr. Daly feel those patients were let down?

Mr. Tadhg Daly

I do. As a society, we did not pay enough attention to the care needs of those in residential care.

Is Deputy Carroll MacNeill taking five or ten minutes?

If I take five minutes, will Deputy McGuinness come after me?

There are ten minutes for Fine Gael and ten minutes for Fianna Fáil.

Grand. If I take five minutes, my colleague can also take five minutes.

I thank the witnesses for attending. I acknowledge the phenomenal and committed work of individuals in the sector who have worked really hard. I have stayed in touch with those in my area and last week we raised the issue of testing and tracing. I will be raising a significant matter that arises with respect to insurance but Mr. Daly is representing Nursing Homes Ireland, a representative body of for-profit and private nursing homes. Deputy O'Dowd has, over the course of his career, expressed concerns about how older people are cared for. The purpose of this committee is to assess the State response, and as Mr. Daly indicated, it is one of the most important analyses that may be conducted. It is in that vein that I wish to interrogate some of the matters raised by Mr. Daly.

The most important statement made by Mr. Daly, both here and in the media over the past couple of days, is that the sector felt isolated in early March, that this was distressing and that there was a lack of engagement. I will go through this as we now have the benefit of the correspondence between the Department and Nursing Homes Ireland. I apologise if this is dull but it is important to be careful.

Going back to the beginning of the year, there were two items of correspondence, with one relating to insurance and a second concerning a former Deputy, Mr. Jim Daly, who was not running for re-election. The correspondence of 28 February related to a call of thanks with respect to guidance on Covid-19. From 28 February onwards, there was very significant engagement on a daily and often multiple times daily. This was at assistant secretary level with Dr. Kathleen MacLellan. It is important because of what the witness said to go through some of the correspondence and I will give Mr. Daly the opportunity to respond at the end. Correspondence from the Department on 2 March states: "Thank you for your email. We continue to ensure members are appropriately informed.". The reply from Dr. MacLellan states: "Tadhg, many thanks for keeping me updated." I imagine some in the media will go through this correspondence but it is important for the committee's purpose for it to be done. On 4 March Dr. MacLellan wrote:

Tadhg,

... Yes I can confirm that there [are] a number of subgroups being established under NPHET. I will be chairing the Vulnerable People subgroup

Dr. MacLellan is the assistant secretary in the social care division and she indicates that she is chairing that subgroup and is the primary point of correspondence with Nursing Homes Ireland. Is that correct?

Mr. Tadhg Daly

That is correct.

Was Nursing Homes Ireland disappointed with the level of engagement on the part of Dr. MacLellan?

Mr. Tadhg Daly

We were not disappointed with the level of engagement. The issue was with the national plan that was coming. I was hearing that matters were being escalated. Looking at the correspondence, one can see we were being told the matters we were raising were being escalated to the working group.

On 5 March, Dr. MacLellan indicated: "There is a Department briefing ...and I have asked that you are invited - I hope to see you there." The reply from Mr. Daly states:

Thank you Kathleen,

I acknowledge commitment to ensure that residents and staff in the private and voluntary nursing home sector are encompassed in all Government planning.

There is some correspondence back and forth. On 5 March, Mr. Daly states:

Thank you for [the] invitation to [the] stakeholder briefing in the Department tomorrow. I can confirm that a number of our members participated in a conference call with Dr. Siobhán Kennelly [in the] HSE this afternoon ... I would appreciate a quick [update].

The correspondence continues and I do not want to take the committee's time by going through this in detail that is too great. On 10 March, however, there is a letter from the Secretary General of the Department of Health, which states:

I refer to your letter of 9 March.

As part of preparedness planning for Covid-19 we are examining a range of work force issues and I have asked relevant officials to look [at that]

This is in early March, when Mr. Daly indicates that his organisation felt isolated. There is correspondence on 10 March at 7 p.m. and 8 p.m. The correspondence continues, indicating that guidance was issued on 10 March and Mr. Daly thanks Dr. MacLellan for the correspondence indicating that guidance was issued. How is it precisely that Nursing Homes Ireland felt isolated? All this correspondence is from a period between 2 March and 10 March. Was it the particular engagement of the Minister that Mr. Daly sought?

Mr. Tadhg Daly

It was not that I felt isolated at all.

It was the sector I represent which felt isolated. My emails reflect my approach to working collaboratively with people, and what I was looking for was guidance, advice and an escalation of matters. On the issue the Deputy referred to in terms of the Secretary General responding, he stated that it was escalated to other officials in the Department. I still have not had a response in respect of that particular matter.

Correspondence dated 13 March states: "Dear Kathleen ... Thank you again. We wish to acknowledge your engagement ... We are committed ... and thank you for your participation." I appreciate that there is back and forth and clarity in respect of PPE and that that was an issue. I appreciate that testing was an issue. I appreciate that these were issues, collectively and nationally, not just for the sector but also for the State. Mr. Daly said he felt isolated. It is a really important statement. When he engaged with Deputy Cullinane, he stated that he sought a meeting with the Minister on 19 March. To correct the record, he had a conference call with Department officials on 20 March. Is that correct?

Mr. Tadhg Daly

That was a conference call with the working group and it took place on the basis of an outbreak. That was a working group of which our organisation was not a member.

Deputy Carroll MacNeill has used the five minutes.

Okay. That is no problem.

Other members will not have time. I am sorry. I cannot make time. Is Deputy McGuinness speaking for five or ten minutes?

I will speak for five minutes.

From reading the correspondence we received today and having listened to Mr. Daly's replies to various questions from members, it is clear that this is a huge scandal. As a country, we will reflect on what has happened with great sadness and shame. How best can we deal with all of the correspondence Mr. Daly has submitted to the committee and been asked about today?

Separate from this committee, is it the case that we now need a general inquiry at some stage into what happened so that we can understand clearly and have the time to tease out the step-by-step failings that have occurred? Whether it is the Minister, the Department or whoever, we are talking about the care of the elderly and a significant number of deaths that may or may not have been avoided. Does Mr. Daly see the need for a more substantial inquiry into all of this?

Mr. Tadhg Daly

It is important, in terms of the State's response, that the committee does its work first. That would inform the next steps. Similarly, the expert group that has been appointed by the Minister has an important job to do. I would not like to prejudge what is going to come out of those two groups but, clearly, there are lessons to be learned. The challenge for us, as a society, is to ensure that we continue to develop high-quality care-----

That is putting it mildly. What happened here is a complete failure of policy and a disregard for the care of older people. There are significant lessons to be learned from this, but the fact is that there is conflict, in the context of some of the issues raised, between Mr. Daly and the Department of Health, NPHET and so on. That conflict needs to be resolved. As policymakers, we need to be clear about where the failures occurred and also about the evidence Mr. Daly has for some of his statements. I would want to be clear on the direction nursing homes will take for the future because it is, without doubt, a shame on all of us that this happened and that there was not the type of response that there should have been from those who were central to delivering such a response in respect of the queries that were made. Mr. Daly is the one who is highlighting all of this and saying it.

Mr. Tadhg Daly

Absolutely.

He should not dress it up.

Mr. Tadhg Daly

The point I am making is that there was a very ambitious and necessary plan for acute hospitals. It is clear that that happened. Our position is that it did not happen for community care. That is a failure to my mind.

Did nursing homes withhold information from family members in respect of care and the issues the sector faced?

Mr. Tadhg Daly

No, the issue there was-----

If Mr. Daly says no, that is fine.

Did the nursing homes prevent the testing of staff within the homes? Was there a question around that? Did nursing homes try to avoid the testing of staff at some stage? Did some of them?

Mr. Tadhg Daly

No. We were calling for testing.

Can Mr. Daly check that out?

Mr. Tadhg Daly

I can. We were calling for testing. We called for robust elements of testing.

Is it not another scandal where the information required by families to make informed decisions about the care of their loved ones in these nursing homes was withheld from them?

Mr. Tadhg Daly

That did not happen. On 1 March, when the first case broke out, the National Public Health Emergency Team issued a statement saying that all of the information would be handled centrally. In the early stages, what we said to members was that speculation about the number of cases and clusters was unhelpful; the same point Mr. Taylor made earlier. I have made the point-----

So nursing homes withheld the information.

Mr. Tadhg Daly

No. Two calls would happen in what I would term ordinary times. One would be to the ambulance, potentially, if someone fell, and the other to the family. I am absolutely 100% confident, and can stand over the fact, that families of those who had residence in nursing homes were kept informed at all stages. There were challenges in terms of staffing, no doubt, in terms of answering all the queries.

What are the current guidelines?

Mr. Tadhg Daly

The current guidelines are the same as they have been for the past nine weeks. Basically, the family should be informed at all stages. That has always been the case.

My thanks to Mr. Taylor and Mr. Daly for coming to the committee this morning and for their contributions.

I want to go back to the issue of the roll-out of swabs being taken by staff. Is it not now a priority that every nursing home would have a person assigned to be able to do that on an ongoing basis? Is there now a discussion with the HSE for that to be put in place and for it to be done within a particular timescale? Surely, we could set a timescale of the next 14 days for that to be in place in every nursing home throughout the country. Is that physically possible at this stage?

Mr. Tadhg Daly

Yes, absolutely, and that would be our request. As I understand it, a paper is going to the National Public Health Emergency Team on Thursday on that basis.

Does Mr. Daly expect a time period for that to be put in place?

Mr. Tadhg Daly

The only information I have is from the European Centre for Disease Prevention and Control, which says it should happen on a weekly basis.

Could we actually have every nursing home being able to take the swabs? Can we have that structure in place within 14 days?

Mr. Tadhg Daly

Yes, absolutely.

Would Nursing Homes Ireland look for that kind of period?

Mr. Tadhg Daly

Yes, absolutely. Many of our members are doing it already.

Many people have raised the issue about staff pay in nursing homes. Approximately €1 billion per annum is being assigned for the fair deal scheme. What proportion of that goes to the private nursing home sector?

Mr. Tadhg Daly

I do not have the figure in front of me but I think one third of the budget goes on two fifths of the residents. The significant proportion of the €980 million is actually spent in the public system.

In other words, per patient there is less coming to the private sector. Is that correct?

Mr. Tadhg Daly

Yes, the discrepancy is something of the order of a national average of approximately 62% per resident per week more in the public system than in the private system.

Does that mean a 62% additional cost in the public sector per patient?

Mr. Tadhg Daly

That is correct. That is per resident per week.

In real terms - in money terms - what is 62%? Is it €200, €300 or €400 per week?

Mr. Tadhg Daly

It is an average of approximately €500 per week. It is something in the order of €980 on average per week in the private sector as against €1,400 or €1,500 in the public system. Perhaps I can get those figures for the committee as well, afterwards.

There will be an additional cost because of personal protective equipment and all of the other costs associated with Covid-19. What additional cost does Mr. Daly believe will now be incurred per patient?

Mr. Tadhg Daly

At this stage of the game, it is very early in terms of putting a figure on that. Clearly, however, the announcement by the Minister of a temporary additional scheme was welcome. That was for three months. It is supposed to end at the end of June. The next question is what happens after the three months. We raised that with the Minister yesterday. That will be part of what I hope is our constructive engagement with the Minister and officials as we go through this.

In any event, there will now be an additional cost.

Mr. Tadhg Daly

I have no doubt. Yes, absolutely.

I want to go back on the issue of deaths in nursing homes. Life expectancy in this country has increased by seven years since 2000.

In other words, people are living seven years longer now compared with the year 2000. Nursing homes have made a contribution to that increase in life expectancy. On average, how many deaths are there in all the nursing homes across the country per month? Have we a figure for that?

Mr. Tadhg Daly

The HSE would be in a better position than me to comment, but the figure from the fair deal scheme is something in the order of 7,000 to 7,500 people annually, so perhaps about 600 people per month. This goes back to the point Mr. Taylor made about the complexity of care and the reduced length of stay in nursing homes.

Has there been at any stage, outside of Covid, a sudden increase in deaths in the nursing home sector?

Mr. Tadhg Daly

In February 2018, as I recall, there was a particularly bad flu and, I think, more than 1,000 deaths.

That was a jump of 400 in one month alone.

Mr. Tadhg Daly

I do not know the exact figures, but yes, there was an increase in that month, as I recall.

Finally, I wish to ask about the forum, which is an issue I raised in the Seanad. Who should be on the forum that Nursing Homes Ireland believes should be set up? Mr. Taylor might also come in on that.

Mr. Tadhg Daly

Our position on the forum has been on the record for a long number of years. We feel it should be Department-led because that is the whole policy. Going back to the remarks many of the speakers have made, it should be about policy. The forum should include the likes of HIQA, the HSE, Nursing Homes Ireland and, critically, representatives of older persons themselves.

Mr. Taylor has ten seconds; otherwise, I ask him to reply with correspondence.

Mr. Mervyn Taylor

Roughly 24% of people die in nursing homes.

The question is who should be on the forum. Otherwise, I will have to ask Mr. Taylor to reply with correspondence.

Mr. Mervyn Taylor

We had a forum in 2016. The issue is implementing the policies that have been talked about for the past 30 years.

I thank Mr. Taylor and Mr. Daly for coming and for their work in the past few months advocating on behalf of older people and residents and staff within the nursing homes. What has happened is tragic and heartbreaking. It has happened in a lot of other countries, although notably there are countries that managed to act decisively and early and avoid the outbreaks we have seen in our nursing homes. Both Mr. Daly and Mr. Taylor have laid out that older people lack a voice generally in policymaking and that nursing homes - really, we are talking about the residents and the staff when we talk about nursing homes - have also lacked a voice in this crisis. The Government's Covid action plan for mid-March refers to nursing homes only once as somewhere to send hospital patients. The plan makes no reference to any supports or risks that need to be examined for nursing homes. Mr. Daly has said that the first time he managed to get a meeting with the Minister was 30 March, when we were well into the crisis in the nursing homes. The first time the National Public Health Emergency Team even mentioned nursing homes in its minutes was in the minutes for its 12th meeting on 10 March. Its recommendation was that the restrictions that the nursing homes themselves had put in place should be relaxed. The National Public Health Emergency Team therefore held two positions in the same week: one, that schools should all close, and two, that nursing homes should be more open, which I find absolutely extraordinary. Would representation on the National Public Health Emergency Team and closer contact with senior officials and Cabinet have made a difference? The Minister's position, which he has outlined repeatedly to me, is that HIQA, the regulator, represents nursing homes at the table. Do the witnesses believe HIQA can represent nursing homes at the table? Critically, looking forward, do the witnesses believe that nursing home residents and staff and older people have a sufficient voice now, be it on the National Public Health Emergency Team, in senior policy settings, in senior HSE areas or at a senior political level, in order that we can properly prepare for the potential second wave which may come and make sure we do not see these outbreaks and tragic deaths occur again in our nursing homes, and indeed for older people in other settings?

Mr. Tadhg Daly

Regarding representation, yes, I believe having a voice for the sector, whether a nurse working on the front line, staff working in the sector or indeed older people themselves, on NPHET would have made a difference because it would have raised the issues on the agenda.

The Deputy pointed out that the first discussion was on 12 March. I contend that having a voice for the sector and older persons on NPHET would have been important.

HIQA is the independent regulator for public, private and voluntary settings. It is on NPHET, but so is the HSE, which is a provider of care through its own public facilities. Clearly, the private and voluntary sectors were not represented on NPHET. HIQA can speak for itself this afternoon, but its role is more about regulation than representing the voice of the sector.

Regarding the Deputy's third point, I have spoken to many parliamentarians over a long number of years about the voice of older people. In my role, I represent the providers of care, but-----

In the interests of time, I will ask a specific question. The Minister and I have discussed the matter repeatedly in this Chamber. The answer he keeps giving me is that nursing homes and their residents and staff do not need any representation because they now have regular access to him. We are still in the middle of this crisis and are planning for a second wave. Does Mr. Daly believe that nursing homes have sufficient voice at the right political, administrative and official levels?

Mr. Tadhg Daly

To be fair to the Minister, we meet him twice weekly. That is important and encouraging. He is very engaged and all the points we raise are being addressed. However, I would still argue that a voice for the sector needs to be on NPHET.

I thank Mr. Daly. Does Mr. Taylor believe that, in dealing with this crisis, older people now have sufficient voice in the various fora they need to have it - politically, administratively and in the State sector?

Mr. Mervyn Taylor

No. There is little time available in the meeting, but the simple fact is that, more than any talk of forums or public inquiries, we need integration of the private nursing home sector into the wider framework of health and social care. There has to be some link on clinical governance and nursing support across each of the six new HSE regions planned under Sláintecare. There was a constructional problem with private nursing homes, in that they were literally outsourced and forgotten about. I am clear on that.

Regarding a voice, I look forward to legislation that will legitimise the role of independent advocates. I remember private nursing homes throwing our staff out and not allowing them to contact residents. That is a rare occasion, but it has happened. When we talk about a voice, we need to talk about a right for independent advocacy and recognising that practice in law.

I thank Mr. Taylor and Deputy Donnelly. I have a couple of questions for the witnesses before they leave. Earlier in the meeting, there was a dispute concerning a teleconference. We have found a reference to it in what the Department of Health provided at 9.30 a.m., but the document is heavily redacted. Unfortunately, Mr. Daly is the only participant in it that we can identify.

Mr. Tadhg Daly

Okay.

I appreciate that Nursing Homes Ireland has far fewer resources than the Department, but does it have records of meetings, emails and other correspondence with the Department of Health? If so, could it provide them to the committee?

Mr. Tadhg Daly

Yes. I was not aware of the volume of correspondence that had already been provided, but I am happy to supply whatever is required.

Whatever correspondence Nursing Homes Ireland has. I do not wish to overburden it because I appreciate-----

Mr. Tadhg Daly

We do not have the same resources.

I understand.

Mr. Tadhg Daly

I am happy to talk to the secretariat about what will be made available, but as far as I am concerned, anything that is on the record is available to the committee.

I am sure that there are good reasons for the heavy redaction by the Department of Health and that it will provide them. We will ask for those reasons.

The Care Quality Commission is the United Kingdom's equivalent of HIQA. It required that every care facility identify a clinical lead by 15 May. In Ireland, some HSE facilities have a medical officer who is responsible for the care of all staff and some do not. In many HSE and private facilities, there are many people under the care of many different GPs and there is no one person responsible for the care of everyone. Would a similar approach to the UK's be beneficial in Ireland if a clinical lead had to be appointed for every care facility?

Mr. Tadhg Daly

Absolutely. We have made that point. We felt it was a missed opportunity in the revision of the General Medical Services, GMS, contract last year.

We are on the record in outlining that there should be a requirement for a specific GMS contract for residents in nursing homes.

The only other point, Chairman, is that the current standards speak of the resident retaining the right to his or her own GP.

In addition, perhaps.

Mr. Tadhg Daly

Well, yes. That may be.

Or is that instead of?

Mr. Tadhg Daly

No, currently the position - which is the point being made by the Chairman- is that many GPs are in and out of care facilities because of the right to retain one's own general practitioner. It is important to put on the record that general practice is a great support for their patients who are our residents.

Was there something that Mr. Taylor specifically wanted to come in on?

Mr. Mervyn Taylor

In February of this year we published a discussion document, Delivering Quality Medical Care in Irish Nursing Homes. One of the things that led us to develop this work, in which we collaborated with Nursing Home Ireland and the Irish College of General Practitioners, ICGP, was our concern that it was unclear what the clinical leadership is in nursing homes, particularly in private nursing homes. Some residents are being charged €25 and others €40 a week for a GP service when the fact of the matter is that they should be entitled to this anyway because of their age. In some places there would be a very good structure while in others it would be very difficult for GPs to come in. I want to quote very briefly from this report:

The point was made that nursing home staff may not have the exposure, experience and training available in acute hospitals. It was also suggested that skills sets of nurses working in nursing homes may have gone down in recent years with a concomitant fear of making decisions in potentially crisis situations.

The difficulty here is that if a nurse needs support and there is not strong clinical support, then there is a real weakness in the system, and there has to be clinical leadership.

Mr. Tadhg Daly

It is important to put on the record that the nurses in the nursing home sector are very well qualified and caring professionals with deep gerontological experience. They do have the support of GPs but they are very able and have great experience.

Mr. Daly had an introductory meeting with Mr. Paul Reid, the CEO of the HSE, on 19 February. Was Covid-19 a concern at that time or did it emerge later?

Mr. Tadhg Daly

No, it was not discussed. In fact, as we were getting up to leave, we were talking about matters overseas. It was not an agenda item at all.

Thank you very much for your help and for answering my questions as well as those of the committee. We look forward to receiving the documentation. I am sorry it is probably extensive but we will accept as much as Nursing Homes Ireland can provide.

Mr. Tadhg Daly

I will be happy to talk to the secretariat to clarify which departments are involved.

Sitting suspended at 1.08 p.m. and resumed at 2 p.m.