Congregated Settings: Nursing Homes (Resumed)

I welcome our witnesses for our resumed hearing on Covid-19 outbreaks in congregated settings. We are joined by our witnesses from committee room 1 this morning. From the Department of Health we have Mr. Jim Breslin, Secretary General; Ms Kathleen MacLellan, assistant secretary, social care division; and Mr. Niall Redmond, principal officer of the social care division. From the HSE we have Mr. Paul Reid, CEO; Dr. Colm Henry, chief clinical officer; and Mr. David Walsh, national director of community operations.

I wish to 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 the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They 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, persons or entity by name or in such a manner as to make him, her or it identifiable.

Members are reminded of the provisions within Standing Order 186 that the committee shall refrain from enquiring 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. We expect witnesses to answer questions asked by the committee clearly and with candour, but witnesses can and should expect to be treated fairly and with respect and consideration at all times in accordance with the witness protocol.

I invite Mr. Breslin to make his opening statement and, as I have done previously, ask that he please limit it to five minutes as it has been circulated in advance.

Mr. Jim Breslin

Since its emergence, Covid-19 has spread rapidly, presenting an unprecedented global challenge. Of the more than eight million cases worldwide, some 25,000 have been in Ireland, where, very sadly, as of last night, 1,710 people had lost their lives. The deaths in our nursing homes are the most difficult aspect of our national experience, and each person who has died is deeply mourned by his or her family and all of us collectively. Nursing homes are what more than 30,000 of our citizens call home. Residents of nursing homes are vulnerable because of their age, underlying medical conditions and the extent of their requirement for care involving close physical contact. The National Public Health Emergency Team, NPHET, the Department of Health, the HSE and HIQA placed a focus on supporting older people from the outset of the pandemic.

Responding to Covid-19 involves an all-of-society, public health-led approach, with interruption of virus transmission the main goal. Suppressing the virus in the general population is a key action to limit spread to nursing homes and other settings. In addition, specific protective measures for nursing homes were introduced, including general infection prevention, social distancing, visitor restrictions, cocooning, guidance, training, testing and enhanced HSE supports for providers. The public health advice suggests that the key to protecting patients and staff in nursing home settings is to follow the whole package of infection control. Compliance with infection control standards forms part of the legal responsibilities of persons in charge of nursing homes.

Whereas Ireland recorded its first case of Covid-19 on 29 February, it was not until 16 March that the first case in a nursing home was notified by the Health Protection Surveillance Centre, HPSC. Cases peaked in the general population on 28 March but, around this time, cases in nursing homes commenced their increase in numbers. The peak in nursing homes occurred almost four weeks later on 22 April. Since then, the number of new cases has steadily declined and, today, 50% of all nursing home clusters are closed, meaning they have been Covid free for 28 days or longer. This has been a very challenging time for the residents, staff and families. Some 18% of the 30,000 residents of nursing homes have had a confirmed diagnosis of Covid-19. I want to recognise the enormous efforts of staff in nursing homes throughout the period and others who have supported them. Owing to their efforts, 56% of all nursing homes have remained virus free and the great majority of residents never contracted the virus. This is in the context of a highly infectious virus, much more infectious than influenza, smallpox or measles.

On 29 and 30 March, the Department convened a series of meetings to examine the disease trends in nursing homes, strategies adopted to date and further measures available. The Department, HIQA, the HPSC and the HSE participated. HIQA’s regulatory programmes provide it with a unique knowledge of the nursing home sector. In response to a specific request from the Department, on 30 March HIQA provided details of nursing homes considered potentially at risk, having been found in previous inspections not to have fully met regulations in areas such as infection control and risk management. On the next day, NPHET requested HIQA to risk assess all nursing homes and liaise with nursing homes and the HSE nationally and regionally as necessary. On 3 April, HIQA established an infection prevention and control hub and commenced a Covid-19 daily escalation pathway to the HSE, which has informed the HSE’s targeting of supports to private nursing homes.

Ireland is one of the few countries that have undertaken mass testing in nursing homes. More than 95,900 tests have been completed in long-term care settings. In addition, our commitment to recording all deaths associated with Covid-19 means our figures are more accurate than in many other countries. This was highlighted by Dr. David Nabarro, the WHO’s special envoy who appeared before this committee last week, who stated Ireland’s data were more "honest” than those of many other countries.

Guidance, personal protective equipment, PPE, staffing, accommodation and financial support issues have been addressed as speedily as possible. On 9 March, availability of PPE was provided by the HSE through local teams to private nursing homes. Up-to-date figures show that over the course of the pandemic, PPE of a value of €27 million has been provided. Furthermore, a €72 million temporary support package is in place. In the earliest period, the HSE experienced difficulties in securing supplies and scaling up testing and PPE operations. Such difficulties were experienced in many other health systems, sometimes with less success in overcoming them than the HSE achieved.

Ireland will continue to manage the impact of Covid-19. It has taken the efforts of the entire country to suppress the virus in recent months, and it will take great vigilance on all our parts to prevent a further surge in the future. The priority now is to maintain high-quality prevention measures in all healthcare settings. The recommendations of the Covid-19 nursing home expert panel established by the Minister will be available in the coming weeks to provide further guidance in respect of nursing homes.

The social care sector in many jurisdictions has been hit hard by Covid-19. There is a need for greater integration between health and social care. Hospitals tend to be better endowed with expertise and resources, while the continuum of care for older people is not sufficiently integrated. The HSE's mobilisation of 23 Covid-19 multidisciplinary response teams demonstrates the type of integrated approach needed. Integration of services and structures at the population level is key to the Sláintecare reform programme. It will be extremely beneficial in addressing the growing needs of our ageing population into the future.

I thank Mr. Breslin for his opening statement. I invite Mr. Paul Reid, chief executive officer, HSE, to make his opening statement. Again, I ask that he limit it to five minutes.

Mr. Paul Reid

I thank the Chairman and members for the invitation to meet the Special Committee on Covid-19 Response. I am joined by my colleagues, Dr. Colm Henry, chief clinical officer, and Mr. David Walsh, national director, community operations.

I express again my condolences to the families and relatives of those deceased as a result of Covid-19, in particular those who were residents of nursing homes. We have seen the impact of Covid-19 was greatest in such settings. The experience of the outbreak across these facilities and the immediate responses put in place by the HSE to support these services across public, private and voluntary settings were unprecedented.

I have submitted a detailed paper to the committee which captures the substantive ongoing level of engagement across the system between the HSE, HIQA, the Department of Health, as well as the private and voluntary nursing home representative group, Nursing Homes Ireland, NHI. In the paper, I have set out the different mandates of the HSE and HIQA in this sector. However, we are united in the singular mandate of safeguarding the health and well-being of older persons living in long-term residential care. A significant feature of the response to this pandemic has been the extent of the co-operation between HIQA, as the regulator, and the HSE. The knowledge of the sector, acquired by HIQA over many years through its inspectorate, has been used on an ongoing basis to inform the actions and supports provided by the HSE.

The HSE area crisis management teams, which were formed with a specific purpose of implementing the Covid response in turn set up Covid response teams. These enable the management of outbreaks of this insidious disease with absolute equity across public, private and voluntary operated services. These teams of clinical specialists provided a range of advice and support throughout the period, including on-site assessments of residents' needs. The HSE also had to provide additional staffing, not only to its own facilities but also to private providers.

Public health and other guidance was issued across a range of measures, sometimes on a daily basis. A full nationwide personal protective equipment, PPE, logistical distribution system was formulated and deployed to all providers in a short timeframe, making what was a scarce commodity both here and internationally available in a fair and equitable manner to support demand in as far as possible.

Through the work of the area crisis management teams and Covid response teams, it is fair to say that tremendous work was undertaken in conjunction with staff of these residential facilities preparing for and dealing with Covid-19 related issues. Over 80% of long-term care facilities registered with HIQA are operated by private and voluntary providers. However, the HSE’s local knowledge, supplemented by HIQA’s knowledge of the sector, and the support it provided through the response teams, was critical throughout the period concerned. It assisted greatly in ensuring many of these facilities are now functioning normally once again.

The HSE did not have the opportunity of a dress rehearsal to plan for and manage this crisis. Covid-19 is a novel virus. Information is constantly evolving on how it is transmitted, how it presents in different age groups and how it can be present in people without symptoms. As with any disease, decisions are made at a point in time based on the available evidence and knowledge. We were receiving international advice and learnings from other countries simultaneously with our own experience of its spread across our population. This knowledge was changing on an ongoing basis throughout.

The committee has inquired about the learning from the events of the past six months in order to inform how we, as a nation, are prepared to address further outbreaks of this or other diseases. I have addressed this in my submission. It is clear there is a requirement for significant changes in the models of care used in this country to care for our most vulnerable older people. These changes require a concerted effort across policymakers, regulators, providers and clinical experts to achieve a safe and sustainable model of care into the future. Significant areas for development include assessing the overall governance arrangements for private nursing homes, further development of HSE support structures, funding models for long-term care and alternatives to long-term care.

I pay tribute to all healthcare workers in residential care settings, the staff who volunteered to support these services at critical stages, as well as the co-operation of the representative bodies which engaged positively with the HSE to support the flexible deployment of staff of all grades and professions. I also pay tribute to the community and family volunteers who continue to provide a bedrock of support to older people both at home and in care during these difficult times.

While we have the virus under control, it has not gone away and there is the risk of a second wave as the country further opens the economy and society. It is, therefore, vital that all the public health advice and guidance are followed by us all so we can continue to do everything we can to prevent the resurgence and spread of this deadly virus.

That concludes my statement. We are happy to take questions.

The first speaker is Deputy O'Dowd from Fine Gael. He has ten minutes.

We need a national day of mourning and remembrance to remember all who have passed away, particularly the elderly in nursing homes. Many people were very worried and concerned about how their family members died. They did not see them when they were dying and, in some cases, they did not even know they were ill. They never got to see them when they died. Their friends could not comfort or hold them. We need to address that. I welcome the extension of the bereavement support line for families of those who died in Dealgan House nursing home but we need much more proactive engagement with all those concerned, who are suffering greatly. I am sure every Member is hearing this every day. There is considerable pain and suffering and we must address it.

I want to divide my time into two periods of five minutes, if I may. Given that the non-compliance rate of nursing homes – public, private and not-for-profit - was 77% in respect of all the regulations when they were last inspected, which had gone down from the previous year, is it good enough to wait for the report that is due on changes we have to make?

A representative of HIQA stated at our most recent meeting that the non-compliance rate of nursing homes regarding infection control was 8%. I queried that rate with the authority afterwards. In fact, the true figure for non-compliance in respect of infection control in 2019 was 22%. Of the 239 nursing homes examined, 52 were non-compliant. Why are patients going to continue to be sent to nursing homes that are either not fully compliant or, particularly with regard to infection control, not compliant? If more than 100 nursing homes did not have proper infection control in 2019, how can the witnesses stand over that? What are they going to do? How are they going to ensure the homes are compliant and that patients will not be sent to them if they are not?

Mr. Jim Breslin

I might take that question. As the Deputy will be aware, HIQA uses three categories in the categorisation of compliance: full compliance, substantial compliance, and non-compliance. Sometimes the percentage for full compliance can be low but-----

With respect to information available, 52 were non-compliant. This meant a rate of 22%.

Mr. Jim Breslin

Yes, and I believe 18% was the figure last year. Zeroing in on non-compliance is really important. This is a standards-based approach and it is intended to have an improvement focus. Every time an inspection is done, the nursing home has to come up with an action plan on how to address the findings and improve. That does not mean that because a nursing home falls down in respect of one standard, HIQA believes it is unsafe for it to continue in operation. If HIQA believes that, it has the power to go to the courts to seek the deregistration of the home.

I absolutely agree with the Deputy that the infection-control standard in nursing homes, both public and private, is really important. The infectivity of Covid-19 has only emphasised this further. There is an all out focus on trying to ensure the standard is fully met, and the supports that are being put in place, including the multidisciplinary Covid-19 response team and the training, advice and guidance, are all targeted at ensuring the full implementation of infection control guidance. That guidance has been added to in the context of Covid-19 whereby we have learnt more about the virus over the period.

Will Mr. Breslin revert to us, through our secretariat, with up-to-date figures for 2020? I have asked for them and would appreciate it if they were made available to us. A key point is that if a nursing home does not meet infection control standards for Covid-19, it should not have patients at all because it is not fit for purpose.

My second question concerns the ratio of nurses and medical professionals to patients. We have huge conglomerates running massive nursing homes and we do not know the ratio between the number of high-dependency patients and the number of nurses who should be there to look after them. Is the Department going to do something about that? Will there be a new addition to the requirements so that nursing homes will have to have X number of nurses for X number of high-dependency patients, particularly given that 70% of such patients have dementia? What are we going to do in that regard?

Mr. Jim Breslin

Traditionally, as the Deputy knows, there is a regulation and a standard around staffing within nursing homes. They need to have both adequate staffing on a daily basis and a contingency plan in place. There is a set of requirements on a nursing home provider which includes that the facility must not be overly dependent on agency staff and must have contingency plans in place. Obviously, Covid-19-----

With respect, there is no definitive percentage or ratio-----

Mr. Jim Breslin

I will deal with that. I was about to say that Covid-19 placed substantial unprecedented pressures on staffing given the absenteeism that affected staff numbers. Going back to when the regulations were first done, the difficulty in specifying a particular ratio arises from the difference and variety among patients and the variety of accommodation and infrastructure available to any particular nursing home.

I would like to develop this point further with Mr. Breslin but, because of time constraints, I ask that he communicate with the committee on it.

Mr. Jim Breslin

We can write to the Deputy regarding the safe staffing framework.

I would like to see more defined and absolute criteria, which are not there right now.

My next question is on a separate area. I welcome all the work the Department and HSE have done in providing personal protective equipment to staff. As I understand it, €27 million worth of PPE has been provided by the HSE, since the first delivery on 1 March, to private and other nursing homes. How much, if any, money has been paid by private nursing home owners to the State towards that €27 million? I understand the sum is twice what the executive would usually spend on this equipment for all HSE institutions and hospitals nationally.

Mr. Paul Reid

The figure of €27 million is what the HSE has provided through funding from Government directly to the nursing home sector. Along with that, the temporary assistance payment scheme has been put in place to support nursing homes with other funding costs they will have had. There has been a further spend on that to date of approximately €11 million but we project that, up to 5 June, the probable spend will have been closer to €26 million. The spend we have provided directly to nursing homes was very significant. I will give the context, as I have pointed out before, that in any normal given year, the HSE would spend between €15 million and €20 million on PPE. That is in normal times.

With respect, I am under time constraints. Will Mr. Reid say how much the private nursing homes have paid towards that spend?

Mr. Paul Reid

That sum is directly paid by ourselves, not by-----

By how much have private nursing homes recompensed the taxpayer for that spend?

Mr. Paul Reid

That funding is directly provided by the State and taxpayers.

The private nursing homes have not given any recompense. Have they been asked to do so?

Mr. Paul Reid

Not at this stage. In our case, we wanted to-----

Fine. I will move on to my next question, to which I would like a quick "Yes" or "No" answer. The HSE provided 322 staff to private nursing homes, which is fantastic and welcome. Have the private nursing homes hired any additional staff that the HSE is aware of as a result of the crisis? I only have two minutes left so I ask for a quick answer because I have one other very important question to ask.

Mr. David Walsh

The purpose of the temporary assistance payment is twofold. Its first purpose is to enable nursing homes to hire additional staff and the second is to fund ancillary work such as cleaning, separation and cohorting that needs to be done and which may lead to additional costs. Nursing homes have brought in additional staff but I do not have the details of that.

My final question concerns a very important issue that was brought to my attention yesterday relating to dentists and the provision of PPE. The witnesses may not have the necessary information to answer it but I will put it to them. A dental practice in County Louth has sent a text to all its medical card patients informing them that, from receipt of that text, it will no longer provide them with dental care. It has caused absolute panic among a number of the people who got that text and who communicated their worry to me.

People who have long-term chronic illnesses such as diabetes, arthritis, cancer - and there is a disease called Elhers-Danlos syndrome - are extremely worried. I have been informed that they cannot get any other appointment with this dentist who is cutting them off immediately even though they are obliged to provide them with three months service after they terminate their contract. Is that not a serious crisis and is it happening elsewhere? The Dental Council of Ireland is investigating that this morning, and I welcome that, but it is unacceptable that any professional dentist would refuse to treat public patients because of the cost of personal protective equipment, PPE, or any possible dispute they are having with the HSE or the Department of Health. This has to be stopped immediately. People are entitled to be treated as human beings. I absolutely reject the treatment this dentist is meting out to medical card holders. It is arbitrary, unacceptable, entirely unprofessional and a disgrace.

Could I question whether that is about the subject matter-----

It is about PPE.

-----of this morning's session?

As I said, the witnesses may know about it. I am asking if they are aware of dentists-----

Would the Deputy accept a reply in writing?

I will, of course, yes.

I move on to Deputy O'Reilly. The Deputy is taking ten minutes.

Yes. This is my first opportunity to speak in the Chamber and I would like to express my sympathy, and that of Sinn Féin, to the family, friends and colleagues of Detective Garda Colm Horkan. Ar dheis Dé go raibh a anam.

I thank the witnesses for coming in again to give evidence this morning. I appreciate that it is a busy time for them. I express my thanks and appreciation for the work being done in the HSE and the Department of Health. We fully appreciate how busy they are at this time. Also, our sympathies are with those who are bereaved as a result of Covid-19.

My questions are mainly around the transfer of patients initially from the acute hospital sector into the private and the public nursing home sector. When Tadhg Daly was before the committee a couple of weeks ago, he said that there was no plan for the nursing home sector for the entire month of March. He also said that the sector was exasperated and that they were crying out for a specific plan but that there was none forthcoming. He further said that key State organisations left the nursing home sector and its residents isolated in those early days. Would Mr. Breslin agree with Mr. Daly that the nursing home sector was abandoned and left without a plan for almost the entire month of March?

Mr. Jim Breslin

No. I do not agree with that. I do note that Mr. Daly also commented very favourably at least half a dozen times on the extent of the engagement he had with the Department and the HSE over the period. The documents we have released to the committee - 160 separate communications - show just how much engagement and problem-solving was going on at the time. The fact that we were dealing in a national situation with the scaling up of PPE supply and testing did have implications for the nursing home sector but that was not the nursing home sector being discriminated against. It was quite the reverse. There was a clear focus on vulnerable older people, both in the community and in nursing homes, and a clear process in place to try to get as much support to nursing homes as possibly could be provided. That was continued throughout March and into April. We can see that in that as the situation worsened in nursing homes we were able to put further support in place, including further infection control advice and the community teams that were put in place on a multidisciplinary basis to respond and to get the situation back under control.

On 10 March, when Mr. Daly wrote asking that all transfers would be risk-assessed, medically assessed and tested for Covid-19 at the same time as the acute hospital sector was being emptied in preparation for the expected surge - very necessary work which we do not dispute - that was not done at that stage. In terms of the patients who were moved out, can Mr. Breslin timeline that for me? According to figures I have, 819 patients on the nursing homes support scheme were transferred from the acute hospital sector, which would be more than double the norm, so there was an escalated transfer of patients. In the month of March specifically, how many of those patients were tested for Covid-19 before they were transferred out?

How many were risk assessed and how many medically assessed? My next question might be one for Mr. Reid. On whose instruction were the patients transferred? It is my understanding that they were transferred without being tested. There was a big increase in the numbers and a concerted effort was made to clear the hospitals, so somebody was telling the discharge co-ordinators to discharge these patients to the care of nursing homes. Where did that instruction come from? The discharges could not have started spontaneously.

Mr. Jim Breslin

I will take the first part of the Deputy's question. Regarding engagement with Nursing Homes Ireland, Deputy O'Reilly mentioned 10 March. On the same day, guidance was issued by the HSE concerning the transfer of patients between acute hospitals and nursing home settings. I am sure representatives from the HSE can address that further.

No, I asked a very specific question about the numbers of people tested.

Mr. Jim Breslin

That guidance set out in detail the protocols to be adopted regarding testing and isolation of patients, depending on which categories they fell into.

Guidance is not a plan. I asked a specific question. How many patients were tested?

Mr. Jim Breslin

I am happy for the HSE to address that issue, but guidance is a plan. It tells a clinician and an institution how to put the procedures in place that are going to manage the transfer of patients. It is more detailed than a plan because it works at an individual patient level.

How many of those individual patients were tested?

Mr. Jim Breslin

I think the HSE has communicated with the committee on that matter. I am happy to have that answered.

How many patients were tested in March?

Mr. Paul Reid

Perhaps Dr. Henry might take that question.

Dr. Colm Henry

It is important, looking at testing at the time, to recognise it was based on our understanding of the case definition. The case definition at the time presumed the presence of symptoms for Covid-19. We know since then, because of evolving evidence that did not come through until the beginning of April when it was published in medical literature, the significance of asymptomatic transmission and atypical transmission.

I am sorry, but we are under extreme time pressure. This is not like a normal committee, so I am just looking for a number. Of the 819 patients transferred out in March, how many were tested? It is fine if the number is zero. I would just appreciate the number for March.

Mr. Paul Reid

I will come in on that question. First, the 800 figure refers to applications for the nursing home support scheme and, as such, they are applications from a range of sources. We cannot give a definitive number of people who were tested, but it can be assumed, as Mr. Breslin said, that guidance to our hospitals was very strong guidance. It was not a request but a direction. That was the protocol and process to test people on 10 March. That was the guidance at that stage.

In the period up to 10 March, therefore, no testing was taking place, but Mr. Reid is stating that from 10 March the testing would have taken place. Is that the testing that was recommended, as I understand it, in April so that there would be two negative tests before a person would be transferred out, as well as the medical and risk assessment? It is my understanding they were not being carried out in March.

Dr. Colm Henry

It was. People were tested in hospitals settings and elsewhere based on the symptoms and case definition at the time. Regarding people who were Covid-19 positive within hospital settings and who were due for transfer, the direction on 10 March stated that there would be two negative tests prior to transfer out. Testing was, therefore, taking place. The point I was trying to make, however, and I will not labour it, is that testing was based on a case definition as the transmission of the virus was understood at the time.

People were not tested unless they were symptomatic or unless they fulfilled the case definition. If that is the case, I will go back to my original question. Somebody made a strategic decision to transfer the patients from the acute hospital sector into the nursing home sector. Who was that? Was it done by memorandum or how was it done? The numbers are significant. I appreciate they were only applications, but they were still way out of line with the normal level of applications.

Dr. Colm Henry

At that time, based on what we were seeing internationally, hospital systems in other countries were overwhelmed with Covid-19. There was no reason for us, other than the plan, not to have a similar eventuality. It was not just a case of getting people out of hospitals; it was a case of recognising that hospital settings were potentially hazardous scenarios, particularly for vulnerable older people. The reason for getting people out of hospitals was not just to create space in hospital settings for an anticipated surge in Covid-19 presentations, but also in recognition that a hospital setting could be potentially hazardous.

That is understood. Who made the decision to transfer out the patients?

It did not just happen. Somebody sent a memo or direction. Who was that and can we have a copy of the direction that was issued?

Dr. Colm Henry

It is my understanding that these decisions are made by clinicians on the ground and they are made, as happened well before Covid-19-----

They were made without any national guidance, individual clinicians made that decision. I must tell Dr. Henry that I find that hard to believe.

Dr. Colm Henry

As part of our overall approach we were of course trying to create as much capacity in our hospital system as we could. We were also trying to discharge people out of what was a potentially hazardous health care setting, namely the acute hospitals, as we were watching the experience of other countries.

I have only a few seconds left. No memo was issued to instruct the transfer out of patients to clear space in the hospitals, that was just done on a case-by-case basis by individual clinicians. I do not find that to be a very credible statement. It strikes me that the Department and the HSE had a plan to use the capacity in the nursing home sector but no plan to protect the nursing home residents. I do not hold any candle for the private nursing home sector. Anyone who knows me knows my views on that but the Department and the HSE had a duty of care to the patients - not to the private nursing home sector - but to the residents of those nursing homes, all of whom should be entitled to the full protection of PPE and the full protection of the State. I do not think that it is enough for people, by the way, who may or may not be complicit in the privatisation to say that somehow there could have been a hands-off approach. I have asked a series of very simple questions. It is clear that there was no plan to protect nursing home residents, there was only a plan to utilise that capacity.

I thank Deputy O'Reilly.

Deputy Butler is next, she is taking ten minutes.

Mr. Jim Breslin

If the Chairman will excuse me, Mr. Walsh wanted to complete the answer to Deputy O'Reilly and you cannot hear us on the microphone when everybody is talking.

Apologies. Mr. Walsh may come back in on that point.

Mr. David Walsh

I thank the Chairman. Perhaps I can clarify to Deputy O'Reilly that the HSE uses two mechanisms to assist with the discharge of people from acute hospitals. One is the nursing home support scheme that the committee is familiar with. The second support to that is the use of transitional care where people are going through the process of that scheme or, if they just need some convalescent time in a nursing home prior to discharge home, then they can access transitional care funding. Additional transitional care funding was made available to assist with the discharge of people who had completed the acute phase of their care to take people who were inappropriately in hospital so that they could be cared for in an appropriate setting, which is a nursing home.

I thank Mr. Walsh.

Mr. Reid stated in his opening statement that the HSE did not have the opportunity of a dress rehearsal to plan and manage the crisis and I believe everyone accepts that it was an unprecedented pandemic that bore down on our country. As we all know it bore down most heavily on our older population. Due to the fact that 64% of the 1,710 deaths - and we offer our condolences and sympathies to all those families - took place in residential settings including nursing homes, care homes and other residential facilities does Mr. Reid now accept that the wrong approach was taken in transferring patients in March and April, at the height of the pandemic, to nursing homes without testing them? Nothing will convince me that this was anything other than the wrong approach. The more I hear sitting in this committee for the past month and the more documentation we receive, the more I am convinced that this was the wrong approach. As we prepare for a possible resurgence of the pandemic does Mr. Reid stand over this approach and will the HSE take the same one if we have a resurgence?

Mr. Paul Reid

I thank Deputy Butler. I will make a couple of points on her comment that the wrong approach was taken. If one looks at what was happening and the timeline that it was happening on across Europe, what learnings were happening as the disease spread from China and particularly as it spread through Spain and Italy there were definitely indications that older people were more vulnerable. However there was limited information about the impact in longer-term care settings and indeed in nursing homes, right up to and including the middle of March and indeed later in March when it became very evident.

Evidence of the transmission of the disease, particularly as we experienced it in Ireland, was that people who were elderly and frail did not experience the symptoms that were projected as part of the normal case definition, that is, they were not symptomatic. The transmission occurred through non-symptomatic persons, residents and others.

I will comment on the overall approach. Dr. David Nabarro was before the committee last week. He outlined the approach we have taken in Ireland. He said that he could not think of more things we could have done to protect citizens and elderly people. As CEO of the HSE I am wide open to learning lessons. We will fully embrace the advisory committee or expert panel that has been established. We have to understand the lessons.

Mr. Reid was before the committee a month ago. I asked similar questions and I was not satisfied by the answers. Mr. Reid replied to me that "That is a process we would have done, and that was the right thing to do at the point in time of doing it." Does he still stand over that reply? I am very concerned that if there is a resurgence of the pandemic and we take the same approach of transferring patients from acute hospital settings to nursing homes without testing them, that approach will be wrong.

Mr. Paul Reid

No. As I said in my opening statement, we were making decisions at particular points in time.

I accept that and understand that there was a learning curve, but we must learn from the past three months. The purpose of this committee is to point out that we accept that everything was done in good faith, but if the HSE is going to take the same approach again, and 1,075 people lost their lives in nursing and residential care settings, I do not want to be part of that where we do not learn from our mistakes and test people at the right time. At the height of the pandemic the requirement for testing prior to admission to residential care facilities was removed, though patients did have to self-isolate. This has been changed to a requirement for prior tests as well as 14 days of self-isolation in a single room after transfer. Reports indicate that there was a 70% increase in the number of patients sent to nursing homes in March this year compared with March 2019, that is, 1,363 compared with 805. It is not known how many were tested prior to transfer, how many tested positive later in nursing homes, and how many died as a result of not being tested.

My question is simple and I ask it again: would the witnesses take the same approach again? Following up on Deputy O'Reilly's question, was it a combined decision by the HSE, the Department of Health and NPHET? We must get to the nub of this. Fantastic work was done in the past three months by health workers and care workers in nursing homes, hospitals, acute settings and the community. The response was fantastic but the disease bore down hardest on people in residential homes. Dr. Nabarro rightly said that we have done well in Ireland, but Mr. Breslin forgot to mention that he also said quite specifically that the number of deaths in residential settings was at the upper end. If there is another surge, will the HSE take the same approach or will it ensure that patients are tested before they go into nursing home settings? Many nursing home owners believe the virus was brought into their facilities through patients being transferred out of hospitals in advance of the expected surge. I do not want to labour the point but I feel very strongly about this.

Mr. Paul Reid

We are wide open to learning lessons. I said that we make decisions at a point in time. We did change our approach on testing and the case definition and how we ascertain it. Many of our top geriatrician consultants, one of whom, Dr. Colm Henry, is here with me today, were also quite taken aback at the presentation of positive cases and how asymptomatic people did not demonstrate any symptoms at all but may have just gone off their food. I spoke to GPs and geriatricians last week who spoke of how taken aback they were on this. As we learned more, our approach changed. I want to agree with the Deputy. As we have gone through the process, our approach has changed, and as we go forward, I have no doubt our approach will change. That is part of what we have learned about the virus.

Nobody is more upset than the healthcare workers who work in the system, both public and private, and have seen what has happened. Overall, I think our strategy approach was based on knowledge we had at a particular time and it did change as we gained more knowledge. I have no doubt learnings will be and should be made for the future.

I thank Mr. Reid very much. Mr. Breslin said in his opening statement: "The deaths in our nursing homes are the most difficult aspect of our national experience, and each person who has died is deeply mourned by his or her family and all of us collectively." We all agree with that. He also complimented the significant effort of staff in nursing homes. It does not matter to me whether nursing homes are public or private. During a pandemic what must be uppermost is the care of the patient. We compliment the staff on the work that was done. I have been calling for more than a month for more frequent testing for nursing homes, and I am pleased that the go-ahead for the testing of staff is to begin next week. Why are patients not also being tested at this time? Have we not learnt at this stage? Why was the decision taken to test staff only and what is the scientific evidence to support it? Those questions are for Mr. Breslin.

Mr. Jim Breslin

I will pick up on Deputy Butler's previous question too by saying I absolutely agree with both elements of what she said earlier. I welcome the fact that she said everything was done in good faith and that we have to learn for the future. That is our absolute focus as well right across the healthcare sector.

The current guidance reflects our knowledge now of this virus to a greater degree than was available at the start of March, and it reflects the fact that the HSE has done such Trojan work in getting the testing capacity in place. That means that all patients transferred from acute hospitals are now tested and all transfers are isolated for 14 days, so we are learning and we will apply the learning as we go ahead.

I have forgotten Deputy Butler's other question to me.

The question relates to the testing of staff in nursing homes from next week for four weeks in a row. I raised it with the Minister last week in the Dáil. My question is why only staff are to be tested not patients. Does it not make sense to test everyone in the facility?

Mr. Jim Breslin

I am not a public health doctor so I might ask Dr. Colm Henry to come in. The rationale is that the WHO recommends that staff be tested every week, but there is a testing regime for patients alongside that. It is based on WHO recommendations.

Dr. Colm Henry

There is testing of residents based on public health advice. Sometimes that is mass testing of one institution or sometimes it is based on clinical suspicion. That is happening all the time. From the evidence we have accrued internationally since the beginning of this crisis, the biggest predictor of outbreaks is community transmission. The level of community transmission is the single most important predictor of how residential care facilities are affected and, as such, while Deputy Butler characterised the outbreaks in nursing homes as a function of transfer of people who were not tested, the fact is that the important actions were advised. Testing enables the public health actions that are necessary, that is, isolation of patients and infection prevention and control measures. Testing is not an end in itself. Looking back now, with our awareness of asymptomatic transmission, it is certainly possible that some people who had no symptoms who were transferred from acute hospitals to residential care facilities took the virus with them. It is equally possible that asymptomatic people who were working in residential care facilities transmitted the virus. Hence the importance of focusing in this exercise in the coming weeks on the level of asymptomatic transmission of the virus among healthcare workers.

I thank Dr. Henry very much.

My questions today are aimed at whoever of the witnesses feels most qualified to answer. I will start with the differences between outcomes for nursing homes in the public and private sectors. I understand that about 80% of older people are in private nursing homes. Has any analysis been done on the outcomes in terms of infection rate or mortality rate between the public and the private sector? Did this lead to a conclusion about which one was working better or whether we should have more public involvement?

Mr. Jim Breslin

I might take that question. I know the HSE has supplied a breakdown of figures as between public and private nursing homes. From our look at that, nothing obvious jumps out in terms of a particular trend. The expert panel that has been put in place by the Minister has commenced looking at this. I say this on a very preliminary basis. Our guess at the moment is that the biggest predictor of the number of cases in a nursing home is the extent of community transmission in that local area.

There is a range of other factors and we would be interested in finding out their ranking and order of magnitude. At the moment, however, I think community transmission rather than the size of a facility or whether it is public or private is probably the biggest explanation. We will certainly examine that in some detail. Dr. Henry might add to that.

Dr. Colm Henry

I totally agree. As I said in answer to the previous question, community transmission is the single biggest predictor we have. One of the fortunate things now is that we have very low levels of community transmission. Hence the greatly reduced number of outbreaks in all residential care facilities.

There are a number of differences, generally speaking, between public and private facilities which do not apply across the board, thus making comparison a little more difficult. Our public facilities tend to be older infrastructually, have different types of staffing and, speaking from professional experience, tend to accept more frail and perhaps dependent people in comparison with private facilities. That is not to say that private facilities do not accept frail, dependent and unwell people but there is a certain differential that makes it difficult to compare like with like.

There have been a number of changes to how we are dealing with the nursing homes. These emergency measures include, for example, greater subventions and the use of additional use of PPE, which comes with a cost. Given that we are relying on the private sector and private facilities must, presumably, ensure they earn enough money to be able to pay their staff, is this considered sustainable? Are we planning to continue with these measures forever? Do we have enough private operators to provide the capacity that has been predicted?

Mr. Paul Reid

The Deputy touched on a range of supports such as PPE. As we discussed, there are other supports in place, for example, staff supports and Covid response teams, which are integrated teams with various clinical and specialist skills. Those supports will continue. We will continue to do the right thing until such time as we have the virus under control, both in the community and in terms of these highly vulnerable and frail elements of the population. We will continue to provide these supports. Suffice to say, the schemes that have been put in place through the Department and the HSE are being drawn down significantly. The PPE we have acquired is very significant. We will continue to do the right thing for these vulnerable populations until such time as we are confident that the virus is under control. It is a significant cross to bear and there has been a significant increase in HSE expenditure to date. This will continue towards year end as we continue to do the right thing.

If we continue with the existing measures in nursing homes, for example, requiring that visitors do not have physical contact with residents and that all staff are masked and gowned and limiting group activities, it will seriously compromise the quality of life of people who live in nursing homes. Strict infection controls and measures for visitors' use of PPE could be acceptable in acute hospital settings where stays are for days or weeks. However, subjecting people living in nursing homes to those types of restrictions could make their quality of life very poor. A balance must be struck between quality of life and reducing risk. Have the witnesses considered that issue?

Mr. Jim Breslin

We absolutely agree with the Deputy. It is important to understand that these are people's homes. They are not places they are visiting but where they live, often for the rest of their lives. The connectedness between the people who live in nursing homes and their families is most important both in terms of what the family gets from it and what the resident receives from it. Good nursing homes understand that and ensure socialising between families and residents and among residents. Unfortunately, that has been interrupted by the virus. All of us are conscious of that and it was an influencing factor on decisions not to implement some of the restrictions prematurely. It is also part of the review of thee restrictions. This week, we have commenced, on a managed and precautionary basis, contact again between families and residents. One could create a sterile healthcare environment in these facilities but that is not where I would want to spend my last days. As such, it speaks to the model of care as well and how those facilities might look and feel in the future. They might well be quite different. In the past, we thought making big living rooms where people could have activities and socialise was the way forward.

We must rethink that now in light of this infection.

Is it planned to have physical contact between families and guests or visitors and residents?

Mr. Jim Breslin

It is difficult. We will have to judge that carefully. We are rolling out contact this week, which is not physical contact, and there will be much benefit in that. We will continue to assess this as we go along.

My first question is for Mr. Reid. What is the guidance for testing of staff in nursing homes? Mr. Tadhg Daly was on "Morning Ireland" this morning and seemed to imply this relates just to healthcare staff. Does the guidance for testing include support staff such as cleaners or caterers, or staff who may be working between different care home settings or different institutions?

Mr. Paul Reid

It is about healthcare workers. The common thread, as we have said this morning, is the strong evidence of community transmission being a big factor. It is to test healthcare workers within each of the settings. They have the highest risk and the most exposure. With regard to the second part of the question, we have worked with private nursing homes to have dedicated staff in order to reduce the impact of agency staff working between different nursing homes. Instead we were looking to have dedicated staff working in dedicated nursing home settings.

That is encouraging. The testing of any staff moving between nursing homes and institutions or who are regularly visiting them is a must. Even if improved efforts could be made in that regard, that work would go a long way.

I acknowledge a submission to the committee from former Senator Colette Kelleher, Dr. Maeve O'Rourke and their colleagues on a human rights-based framework not only for learning from what has happened but also planning for a resurgence or second or third waves. With due regard to that submission and Mr. Reid's opening statement, where he indicated that significant areas of development are needed, how will people who are currently living in the institutionalised care settings such as nursing homes be considered and heard with respect to developing improvements in this area?

Mr. Paul Reid

There will be a number of ways. With respect to the Deputy's general point on learning, this is related to Deputy Butler's comment. We need to ensure we learn from this and the HSE wants to ensure we can learn from it. I have just outlined some of the actions, and a number will be for the HSE directly. Our Covid-19 response teams have made an impact and we have managed to put our arms around all homes, both private and public, to a greater extent. It is a big lesson for us with respect to sustaining the integrated teams and the draw this will, quite correctly, have on us. We will continue with those teams.

Dr. Kathleen MacLellan

I thank the Deputy. The voice of the resident is something we take very seriously. We have already agreed with HIQA, the HSE and the Department that the national care experience survey, which the Deputy knows is conducted annually across acute hospitals, and which has been extended to maternity hospitals this year, will be extended to long-term residential care settings. This will provide a real structured approach to hear the voice of residents within those settings and to have that information used as it is currently used across our acute hospitals to provide quality improvement.

NPHET has published an ethical guidance framework for long-term residential care settings, including nursing homes, which takes into account a human rights approach. The approach has proportionate measures for protecting residents as well as trying to support those residents so they can have as high a quality of life as possible. It is something we will keep a focus on in as much as we can while being very conscious that these are people's homes and where they live, so we must try to open them as much as we can to people's families. We have seen significant innovation across nursing homes to continue contact with families, including the use of FaceTime and other types of technology. We really want to get back, as much as possible, to the type of visiting and supports described by the Deputy.

I thank the witness. I have a final question for Mr. Reid. Is he satisfied with the ability of the HSE safeguarding and protection teams to carry out safeguarding inquiries in private care homes? Have there been any cases where they have been refused entry or there have been difficulties in co-operation?

Mr. Paul Reid

I will ask my colleague to comment on that.

Mr. David Walsh

The capacity of the safeguarding teams to function, particularly in recent months, has been compromised by virtue of the disease. The HSE is currently working on a revised policy to address some of the areas of learning for the future on safeguarding. It is a huge area that warrants further consideration of how we operate within that hybrid model of public, voluntary and private to ensure the rights of residents, no matter what their care setting is, are looked after.

I thank Deputy Smith. I call Deputy Shortall.

It is important that we all recognise the Government policy context in which care for older people is being provided. In respect of nursing homes, as we are aware, that is largely privatised. It is an 80% privatised approach using for-profit services with no clinical oversight, and it is also a political context, which allows for poor staffing ratios and practices.

Many questions have been asked about learning from mistakes. The key learning needs to be at a political level in terms of taking a new approach to the care of older people and doing things differently. I hope that learning will be understood and followed by the incoming Government.

It is also important to recognise the need to free up hospital beds at a particular point in March and April in preparation for what looked like a huge surge coming towards Ireland. In fairness, that needs to be recognised, and freeing up as many hospital beds as possible was the right thing to do. Notwithstanding that, clearly there were issues, and mistakes were made. At this point, we had a situation a couple of week ago where Nursing Homes Ireland made an allegation that the transfer of patients from acute hospitals was a significant contributory factor to the ensuing appalling situation we saw in nursing homes in terms of prevalence and death rates. What analysis has been done of those patients who were transferred from acute hospitals? Can that analysis be made available publicly?

My second question, which I have received queries from families about, relates to what seems to be the current practice for families who are trying to get elderly patients transferred from hospitals to nursing homes. It seems it has gone to the opposite extreme in terms of being very tight. That is a good thing, but there seems also to be a requirement for a nursing home to be Covid-closed for 28 days, including patients not having any fevers. Is that the case? Can detail of that guidance be provided to the committee?

My final question relates to a previous comment made by Dr. Jack Lambert about the nursing home sector not being adequately prepared for a second wave. Is there a clear protocol on that, has it been published, and will that be made available to the committee?

Mr. Paul Reid

I thank the Deputy for her comments regarding the process we were engaged in at the start of this, and, as I keep saying, whatever learning we can develop we are certainly wide open to them.

There is no direct analysis that we have completed of all patients who would have been transferred at this stage. I will make the point - and I acknowledge that the Deputy quoted what Mr. Tadhg Daly had mentioned - that there will be learning as we move through, but the strongest evidence is of community transmission-----

I accept that, but does Mr. Reid intend on doing an analysis of that cohort of patients who were transferred? A serious allegation has been made in respect of that, and many things need to be accepted in the context of that, but surely, it makes sense to do an analysis of that cohort of patients.

Mr. Paul Reid

We want to collect whatever data we can on deaths, whether it is from testing or from www.rip.ie. We want to get the best knowledge and data possible. We are still living and working through this, but gathering all the data we can to help inform ourselves will definitely be of key importance. That data will be fed into the expert group.

Does the HSE have a timeframe for that analysis?

Mr. Paul Reid

We do not have a date.

The HSE should treat this as a matter of urgency.

Mr. Jim Breslin

I would like to comment on preparedness for a second wave. There is no complacency around this anywhere in the healthcare service, nor should there be. HIQA has put a quality assurance framework regarding preparedness in place, against which it is reviewing nursing homes. The infrastructure that has been put in place, including the multidisciplinary community response teams, is being maintained so that the HSE has support in place across the continuum of care. I also note the stockpiling of PPE and testing capability. We are more advanced in our preparedness than we could have been at the start of the year, but continued and sustainable focus on this will be needed right across the sector for the foreseeable future.

Will the Department of Health publish that guidance?

Mr. Jim Breslin

It is available. HIQA has published it. We will get that to the committee.

I thank Mr. Breslin.

In the short space of time available, I would like to make some observations. Although Mr. Reid continually repeats that we need to learn from what has happened in our nursing homes, the submissions seem to suggest that there were basically no mistakes, no delays in acting and no errors in dealing with the virus in the homes and that everything that could have been done was done at the right time. I do not believe this narrative. I struggle to see how the Department, the HSE and HIQA can say that they made no mistakes, or if they do not admit that mistakes were made, how they can possibly learn in time for a possible second outbreak of the virus.

That narrative is contradicted by some of the facts, such as the overall higher proportion of deaths in our nursing homes. It is also contradicted by my experience and that of other Deputies who were contacted repeatedly throughout March and April by members of staff and the families of people in those nursing homes. They were in absolute despair about the provision and use of PPE and the lack of testing for themselves and patients. At a briefing on 12 March, I asked if workers who look after our elderly were being tested. I was bluntly told that we do not do that. We are now beginning large-scale testing because we believe it is the best thing to do. If it we did not have the capacity at the time, that should have been the answer, not an assertion that we do not do that. I am not a healthcare professional but testing those working in the homes seemed eminently sensible to me. We were told that the virus was not brought into the homes by the patients because they were being isolated, which I do not accept. It did not come in with visitors because the homes were closed to visitors. Clearly it was coming in with the carers, and they were not being tested.

I refer to the issue of PPE. Although PPE was provided in large quantities, until 22 April the HSE guidelines instructed that members of staff should not wear masks unless they were showing symptoms. We now know that this was crazy advice. It was only withdrawn on 22 April. Now all members of staff wear masks regardless of whether they are symptomatic.

I turn to my question, about which I am always going to wonder unless there is an independent public inquiry into the level of care in the nursing homes, which I believe is needed. Very few people who contracted the virus and became very ill received care in emergency department or acute hospital settings. I know the answer to that point concerns the end-of-life care plan, etc. However, our nursing homes were without sufficient PPE and had low-paid staff who were not properly trained. Some 80% of them are run on a for-profit basis. I cannot help wondering if they were the best places to care for our elderly when their workers were screaming about the lack of facilities and PPE.

I agree with Mr. Breslin about one lesson that can be drawn from this. We cannot continue to have a split of 80% private nursing homes to 20% public nursing homes in this country.

We need to learn the lesson that the State should take responsibility for the care of our elderly. These people have worked and paid taxes all their lives. They do not deserve to be hived off to a for-profit system. Just because the State contracts out care, it is not absolved of its responsibility for the care of the elderly. That was clearly shown in the context of CervicalCheck and the Ruth Morrissey case. The State still has responsibility when things go wrong, even when it has contracted out care.

Staff in care homes have contacted me today to say that patients are coming in without being isolated and tested in advance. Many questions still need to be asked about what is going on.

St. Mary's centre in Telford is a nursing home for the visually impaired that has had no cases of Covid-19. I understand the centre is run by the Religious Sisters of Charity and is due to be closed. I have asked the Minister if the State will take over this facility and run it in the interests of public medicine for those who are visually impaired and elderly. The Minister told me bluntly that this was a matter for the board. That does not indicate to me that anybody in the Department of Health has learned lessons from the catastrophe of the privatised nature of the care for our elderly. If we want a testimony to those who died in nursing home settings throughout the country and those who looked after them, taking St. Mary's in Telford into State ownership would be a way to begin. We must stop the nonsense of contracting out the care of our vulnerable people.

I will direct questions to Mr. Reid or Mr. Breslin. Something that might come through here and be shown up by the expert panel is that one of the most likely vectors for disease has been agency staff who were transiting between different care homes. That is a function of the private nature of nursing home care. As previous speakers noted, 80% of such care is provided in the private sector.

I will talk about the support that was given to the private nursing home sector and support payments. I have previously raised the fact that significant costs were incurred and flagged within the private nursing home sector back in March. I do not believe those costs have been looked at since. The capitation grant was not given to private patients, even though they were in the process and were surely part of the risk metric. The cost of personal protective equipment paid by nursing homes in March has not been covered and repaid. Isolation requirements that the Department and the HSE are mandating on private nursing homes are reducing their revenue streams. That is an additional cost.

Another issue that was highlighted early on in the process was that the HSE was recruiting temporary staff who were largely coming across from private agencies that were supplying support to the private nursing sector. Have any steps been taken to mitigate the effects of those issues in future, in the context of the possibility of a second surge of the virus, and has consideration been given to how they might be dealt with?

Mr. Jim Breslin

I might answer a couple of the policy questions and will hand over to the HSE to respond on the question about agency staff. The temporary assistance scheme has been extended to include residents, whether they are under the fair deal scheme or are privately paying their own way. The available supports cover occupancy.

It remains the case that the scheme started on 1 April and a cross-Government policy decision was made as to when it should commence, given that various schemes were being mobilised at the time. That policy decision was made at the time. I will ask the representatives of the HSE to comment on the agency matter.

Mr. Paul Reid

The HSE issued a direction about agency staff very early on in the process. Our preference is that we have dedicated staff in dedicated settings, particularly in areas of high transmission in community. We have said this before, but it would still be unfair to pinpoint one particular cohort for the transmission of disease within these settings because it is never directly linear. That will be a part of the learning, however.

I will make a general point about costs and PPE. I made the point earlier that the HSE has been providing significant amounts of PPE to the public and private sectors, and will continue to do so at a scale that is required. That is our approach.

There are some learnings, as the Deputy and others have touched on, about staffing. The clinical advisory group on older persons of the Royal College of Physicians of Ireland, RCPI, has done a recent assessment and will draw learnings around staff, staffing structures, permanent staffing, particularly in private nursing homes. Those lessons must be learned for the future.

I will ask my colleague to make a quick comment.

Mr. David Walsh

On agency staff, the HSE issued an instruction to the agencies we deal with very early in this process not to facilitate agency staff working in multiple locations.

Regarding HSE recruitment of private nursing home staff, where I have been asked to by Nursing Homes Ireland, I have followed up in specific cases. We have a policy of not targeting private nursing home staff and where people were already in process, in some cases we have delayed that recruitment in order to facilitate the nursing home. However, there has always been an element of travel between public, voluntary and private across long-term care.

I thank Mr. Walsh for that. It is just that I am under time pressure.

I will direct a couple of questions to the Secretary General, Mr. Breslin. In terms of congregated settings, there is an outstanding issue which is between the section 38 and section 39 workers. Is there any opportunity or policy coming down the track which will redress the differences in pay, structures, etc.?

In the committee earlier this week, we heard from Sebastian Barnes of the Irish Fiscal Advisory Council. Mr. Barnes highlighted that the council's analysis showed that the Sláintecare implementation cost would be €3 billion - he did not say what would be the ongoing costs of that. Has Mr. Breslin any thoughts as to what provision within that budget might go into the older residential nursing care sector because it would appear that even a small amount of what we spend at present in the private hospital deals would have done much to mitigate what happened in the nursing homes?

Mr. Jim Breslin

In terms of the last question, core to Sláintecare is how we manage the population and the risk factors in it. When one looks at a population, older people are among the greater users of the health service. Therefore, any investment in Sláintecare will have to look at integrated approaches for older people right across the care continuum, most of which should be targeted at trying to keep older people in their own homes. That is why we are working on the statutory home care scheme.

The work that the HSE has done on the integrated care programme for older people will also be important. Indeed, many older people have multiple chronic illnesses. The focus in Sláintecare on chronic disease will be equally important.

I am sorry I forgot the Deputy's first question.

I asked about the section 38 versus section 39 workers.

Mr. Jim Breslin

With the help of the labour relations machinery, there is work under way between the Department, the HSE and the unions on assessing it. The issue is that in many cases the practice has been different over the course of the crisis and people had different things done to their pay.

I ask Mr. Breslin to provide a reply in writing to that.

Mr. Jim Breslin

We are trying to work through that with the agencies involved. The employees are not public servants but we recognise that there is a process under way.

I thank Mr. Breslin and call Deputy Michael Collins.

I thank our guests for coming here today.

I sympathise with the families of those who died in nursing homes and community hospitals due to coronavirus and pay tribute to the dedicated staff in each of these care facilities who are working under enormous pressures.

While we are concentrating today on nursing homes, we should not forget community hospitals that were not brought up to standard in 2016, which was the first deadline for them to be made 80% single-bed occupancy. I am blessed to have so many excellent nursing homes in my constituency which have been Covid free but they know this can never be taken for granted. I have spoken to these nursing homes - Cramers Court in Belgooly, Bushmount and CareChoice in Clonakilty, Deerpark in Bantry, Fairfield in Drimoleague and Skibbereen residential centre. I also spoke to those in the community hospitals in west Cork. I thank each and every staff member who fought bravely to protect their patients.

HIQA set standards of 80% single-room occupancy by 2016. The Minister signed a statutory instrument which extended this deadline to 2021. Maybe the Secretary General would answer the following question. Will the extended date of January 2021 be met in all of the community hospitals and nursing homes?

Mr. Jim Breslin

That will be difficult given what has happened with the construction sector over the course of this year. The HSE was already challenged to make it in respect of all facilities. Many completely new facilities have been put in place and many refurbishments have been undertaken, but to make it by that deadline is certainly not the most probably outcome at this stage.

Was a risk assessment done on infection control before the statutory instrument was signed?

Mr. Jim Breslin

Absolutely. The full extent of the knowledge, not just in Government but across the whole community, in respect of the infrastructure deficits within healthcare generally but particularly within our public nursing home sector was known at that time. The question that was facing Government was whether these facilities would be closed or maintained over a period as a programme was put in place to refurbish or replace them. Through regulation, HIQA was allowed to register them with conditions. The conditions require workaround solutions and that the best be made of the infrastructure. These are valued institutions in many localities and they deliver good care. The decision at the time was to sustain them and allow that programme of infrastructure development to be put in place.

Does the Department of Health accept that in the context of Covid-19, the statutory instrument which resulted in the date being pushed out has cost lives?

Mr. Jim Breslin

I do not accept that because, as we discussed earlier, there are multiple factors as to where cases broke out. Some facilities we are talking about had a good experience, while some modern facilities had a poorer experience. All of us have to work every year with the overall resource constraints we face and we have faced stop-go in respect of healthcare capital. We had a very good national development plan in 2007 but it was never implemented. In fact, only about half the money in general and much less for community services was available over the subsequent period. In 2016, some €500 million was put in place for the refurbishment and rebuild of these facilities. That programme of work is under way.

Has the Department of Health considered doctors and nurses in nursing homes and community hospitals to do coronavirus testing?

Mr. Jim Breslin

I did not follow the question.

At the present time, people have to go to specialised centres to have coronavirus testing carried out. Has the Department considered having doctors and nurses in these nursing homes and community hospitals carry out coronavirus testing?

Mr. Jim Breslin

There is a programme under way for nursing homes to be skilled up to do their own swab taking. The swabs then go to laboratories. The HSE might want to comment on that.

Mr. David Walsh

In the serial testing that is about to commence across the nursing home sector, the majority of swabbing will be done by the staff in the nursing homes.

Does the Department of Health intend to keep flying coronavirus tests out to Germany at a cost of up to €200 per test when we can have them done in the Republic for less than €50 a test?

Mr. Paul Reid

We put together a capacity plan to have the capacity to deliver 100,000 tests per week. We have 41 laboratories in total and one laboratory has capacity overseas which we need for surge if we reach such levels. It is part of our strategy right now. The pricing on it is fairly competitive in comparison with overall pricing for testing across the country. It is part of what we need to sustain a capacity of 100,000 tests per week.

I thank Mr. Breslin, Mr. Reid and all of the staff from the HSE and the Department for the work they have done. I also thank the staff in all of the medical facilities in nursing homes, hospitals and care facilities. My understanding is that in February 2019, the number of deaths in nursing homes connected to the flu virus increased from about 600 per month, which would be the normal number of deaths in nursing homes across the country, to about 1,000. In view of that, would it not have been the priority of both the Department and the HSE to clearly see that this was very much a vulnerable group in respect of Covid-19? There are 23,500 people in private nursing homes. There is no one denying that there was communication with the nursing homes and Nursing Homes Ireland.

However, there was no involvement at any kind of committee stage where a representative from that group would have made a contribution. There was Alone, for instance, which deals with people in the community and is giving great support to elderly people, but Nursing Homes Ireland or any representative from the private sector was not involved in any committee. In hindsight, would it have been better to have had the private sector involved at an early stage rather than in April?

I turn to HSE facilities where there was a high incidence of deaths, such as those in Clonakilty, Portlaoise, Donegal and the Phoenix Park. In one of them, there were six beds per ward. No action appears to have been taken. In some of the facilities, no isolation units were available. If the facilities had been hit with the virus, what action was planned for dealing with it? It appears that very little would have been able to have been done to deal with it.

Some 56% of nursing homes are Covid-19 free. Of that figure, what numbers of patients were transferred from hospitals to those units over the past three months? Were there no transfers or, if not, can we have sight of the numbers transferred to Covid-free units?

Finally, can we have a breakdown of the total number of staff recruited by the HSE from 1 January 2019 to 30 May 2020 who were previously employed in nursing homes, either as nurses or care staff?

Mr. Jim Breslin

On the representation of Nursing Home Ireland and the HSE, the health and social care sector is a very large sector. When we put in place the preparedness structures for this pandemic, we did not seek to have a representative of every sector on the committees. We sought to put expertise in place and engage seriously with those experts from different sectors on an ongoing basis. As the Deputy noted, there has been very significant engagement with the nursing home sector, both by the Department and the HSE, and the record shared by the Department of 160 separate communications, which does not take account of phone calls late at night and so on, bears that out.

I accept that Nursing Homes Ireland wanted to be represented on those structures. A committee was set up specifically in respect of nursing homes, and while it might seem obvious that Nursing Homes Ireland should have been on it, it was set up to devise the temporary assistance scheme, that is, the financial scheme that benefits the sector. The view I took as Accounting Officer was that Nursing Homes Ireland should be consulted throughout that process, but due the design of it, it was not proper to have the beneficiaries of the scheme in the room.

Would Mr. Breslin accept that there was also expertise within nursing homes? There were 23,500 people in nursing homes, so a very large number of people were being catered for. It was 1 April or 2 April before consultation started with nursing homes. If they had been involved from 6 March, perhaps we would have been better able to deal with the challenges they had.

Mr. Jim Breslin

No, the consultation and engagement took place from the outset, once we saw what we faced. There was a significant level of outreach to Nursing Homes Ireland, and the HSE can comment on the level of outreach that took place throughout the sector. I do not think the engagement started in April. The work on the scheme took place towards the end of March, but there was a great deal of outreach before that.

Mr. Paul Reid

I will make a couple of comments and ask my colleague, Mr. Walsh, to add to them.

There was significant and wide engagement, not just in March but from January, in terms of guidance we would have been given and communications directly with private nursing homes and Nursing Homes Ireland. There was regular engagement throughout February and March. There were reasonably strong relationships between Nursing Homes Ireland, the HSE and the Department.

Not specifically on the facilities mentioned by the Deputy but generally on the actions taken, it would involve an outbreak management team. That is the first thing that triggers, once we have identified an outbreak in a long-term care setting or nursing home. That is largely led by our public health teams in the first instance. It involves public health specialist doctors advising on infection, disease, prevention and control. It also involves mobilising nationally some of our quality and patient safety crews. The Covid response multidisciplinary teams would go in, which may have some dedicated geriatricians, clinical nurse specialists or wider supports.

In a ward, for instance, with six patients, my understanding is that no action was taken until the outbreak started and there were no isolation facilities. There were no staff changing rooms. Staff came in from home and straight into work without any changing facilities available.

Mr. Paul Reid

I cannot comment on specific locations or nursing home facilities.

This indicates that there was no planning.

Mr. David Walsh

The Deputy mentioned four specific HSE-operated units: Clonakilty, Portlaoise, Donegal and St. Mary's. Without doubt, where there are multiple occupancy rooms, and where the facility is full or near capacity, then isolation is difficult. Following public health and other clinical advice, cohorting is advised. A feature of those four units was not only that there was significant public health input but the relevant consultant geriatrician from the local acute hospital was involved in each one of those units. The Donegal unit has since closed and will not be in further use.

On the 56% which showed Covid free and the transfer of patients to those, can I get the numbers of transfer patients?

Mr. David Walsh

I will do my best to get that information. It may take some extraction but I will start that process.

Can we get the numbers of staff recruited, both nurses and care assistants, who previously worked in nursing homes?

Mr. David Walsh

Across the HSE and the major funded agencies, there are many avenues of recruitment. Many of the larger hospitals do their own recruitment. I will speak to the national director of HR to see if that sort of analysis is possible and come back directly to the Deputy.

One of the problems nursing homes had, especially in February and March, was that they found the staff that they had were suddenly gone. Accordingly, they then had to recruit agency staff, which was a challenge in itself.

Mr. David Walsh

I have asked Nursing Homes Ireland on a number of occasions to flag such issues to me. To be fair to Nursing Homes Ireland, it flagged a maximum of ten such cases. In a number of those cases, the recruitment was stopped. I am happy to follow up on any other issues that arise. I am not sure of the scale of it.

I welcome our two witnesses. I again thank both of them and their staff for their service in what is still a difficult and challenging time. I commend Mr. Reid for his commitment to look at changes in protecting older vulnerable people. This might come down the track. If there are positive changes, he will certainly have the support of my party.

I want to ask some questions of Mr. Breslin on the nursing home sector generally.

This is not about a blame game. This is about whether, during the months of February and March, there was a comprehensive plan in place to protect older people, and it is about who should have been or was responsible for it. Is Mr. Breslin satisfied there was a plan in place for nursing homes to ensure the very highest levels of care and protection for older people in February and March? Is he satisfied, as head of the Department, that there was such a plan in place?

Mr. Jim Breslin

The overall plan was adopted by the Government in the middle of March. The nature of it was such that it was a crisis management response. Every day, we were taking actions. We did not go off and produce a plan right at the start. We mobilised and put actions and preparations in place. We went to the Government in the middle of March with an overall action plan for the whole health-----

Was there not a plan in place for acute hospitals? I commend the Department on it. I had very high-level engagement with the management of University Hospital Waterford in early March. It had a plan in place that involved shifting staff out of the hospital to a private hospital. It involved freeing up beds for Covid patients. In fact, we did not need the capacity in the end because of the low level of contraction in Waterford, but it struck me that there was planning at a high level. Considering that Mr. Breslin said there was a plan put in place in the middle of March, why was there not an overarching, comprehensive plan in place for nursing homes prior to that?

Mr. Jim Breslin

It is also the case that there was not a single plan in place for acute hospitals before that. There was what the Deputy talked about, whereby at every level, including service provider, regional and national levels, preparedness activity was under way and processes were in place, but the national action plan was adopted in the middle of March. There was not a separate action plan for acute hospitals in February, or indeed earlier than-----

The question, then, is whether there should have been a comprehensive plan. Mr. Breslin himself talked about the consultation and engagement "from the off". Maybe he will be able to enlighten me on what he meant by "from the off". I refer to when we first became aware that the virus was a real problem. Mr. Breslin says consultation and engagement were evident "from the off". First, when was that? The second question, which is more obvious, is whether Mr. Breslin accepts that the sector, or perhaps one element of it, had the polar opposite view on the levels of consultation and engagement.

Mr. Jim Breslin

Regarding the documents we have shared, the Deputy will see that from February onwards, there was very routine and interactive engagement, almost daily but definitely weekly, with the sector. On the perspective of the sector, if we had had knowledge of this six months in advance, the best thing in the world we could have done would have been to have formulated a clear plan and a full strategic framework. Instead, what we had to do was use the emergency plans we already had in place, use the guidance already in place in respect of infection control, and mobilise a whole set of additional activities.

I am not asking the witness to look back with the benefit of hindsight. I have said on previous occasions that people like Mr. Breslin and staff in the HSE were in a very difficult position when a virus came at us very quickly and real decisions had to be made in real time. Everybody accepts that, but we read hundreds of pages of correspondence, including emails, from March that seemed to be mostly one way. It seemed that the calls and demands being made by the nursing home sector were not being met. Very strong opinions were aired by the representatives of an element of the nursing home sector in this very Chamber a number of weeks ago. They talked about their being exasperated and said there was no specific plan, and they also said they felt let down by the Department and HSE. While Mr. Breslin has one view, the nursing home sector feels differently.

Let me outline to him where the sector feels there was a lack of support. It cites insufficient testing of residents and staff and a mass shortfall of PPE. We heard also that some nursing homes were forced to use painters' overalls. That was a shock to many. Also cited were aggressive recruitment of nursing home staff initially by the HSE and discharges from acute hospitals to nursing homes without testing. The sector seemed to hold a view that was the polar opposite of that of Mr. Breslin on both the level of engagement and the level of support being put in place by the State for nursing homes in what was a critical time, when patients needed to be protected.

Mr. Jim Breslin

I will come to the level of supports in a moment. Obviously, the Department and the HSE were working within constraints. In respect of the level of engagement, even the Nursing Homes Ireland representative who attended a meeting of this committee acknowledged that engagement. I have counted his comments in this regard and they number more than half a dozen. He told the committee:

It is fair to say we had very good engagement ... It is very important to put on the record that we engaged quite regularly with officials in the Department ... We had really good engagement ... We had very good engagement with officials ... I deal with officials in the Department on an ongoing basis ... We were not disappointed with the level of engagement.

That does not sound to me like officials were ignoring Nursing Homes Ireland but quite the reverse-----

With respect, the Nursing Homes Ireland representative may have said all that but he also said that the sector was exasperated, that it felt let down and that it was put in a very difficult position when, as he put it, nursing homes were "crying out for help" in a range of areas and that support was not forthcoming. I think what he was saying was that in the latter stage, from March onwards, there was a better level of engagement-----

Mr. Jim Breslin

No.

-----but prior to that, there seemed, from the perspective of the sector, to be real difficulties and challenges.

Mr. Jim Breslin

Absolutely not. I have read faithfully and accurately what he said. We have shared the records with the committee and they do not start at the end of March. They start much earlier than that. What I would have said, if the Deputy had allowed me to finish my answer, is that the supports the sector were critical of were given in a situation where the HSE, along with every health system internationally, was seeking to mobilise supplies that were not readily available. That problem was being experienced across all sectors within the health services. The constraints in regard to PPE and testing affected the nursing home sector but were not discriminatory to that sector. It was quite the reverse and the sector was dealt with equitably.

I will use one of Mr. Breslin's own analogies from a previous meeting in putting my next question. Does he believe that the HSE and the Department sent enough firefighters to support the residents of nursing homes? Does he accept any level of the commentary - criticism might be a strong word but, certainly, there were strong assertions - from the nursing home sector that there were real challenges in regard to a shortfall of PPE and testing and that there was, as nursing home owners see it, a lack of a comprehensive plan and no underpinning with funding and resources? There were an awful lot of very emotional things said by people who manage nursing homes and I am conscious that there are families who are bereaved. I am not putting the blame for this on any individual but it does strike me that the Department and the HSE are maybe being a little overly defensive on this issue. It is always better to acknowledge if there were mistakes made or there was not sufficient time or, for whatever reasons, the supports were not put in place. It should be acknowledged that this is what happened rather than just saying, "We did everything possible", when we have the nursing home sector saying that is not the case.

Mr. Jim Breslin

I am very much committed to learning. As I said in my previous answer, I had to recognise that we would have liked to have had more PPE and more testing to make available. I absolutely recognise that. However, it is also fair for us to say that, objectively, everything possible within those constraints was done. The committee had the benefit of hearing from the WHO envoy last week, who said:

As far as I can tell from the analysis that I have done, Ireland moved pretty quickly on a number of issues particularly trying to get personal protective equipment, PPE, in its various forms, to the staff in nursing homes and restricting visitation in nursing homes, recognising that visitors were a primary way of bringing in the virus. Ireland, possibly, might have been one of the faster countries to introduce this. At the moment I am not thinking that there is something that Ireland has not done. I just think that one, we have got a very honest counting of numbers and two, as with every country, this has been quite a struggle but it seems that Ireland did pretty well.

I thank Mr. Breslin. I want to put one quick question to the HSE representatives if I can. It is not Covid-related but a response might be given to me in writing. A question was raised by Deputy Shanahan at the latest session in regard to the second catheterisation laboratory for Waterford. There is a bigger issue here concerning the national review of cardiac services. That review has been going on for an awfully long time and there is no sense of when the work will be completed, when we will see an interim report and when we will see any finality in terms of that process. I am sure both HSE witnesses will know that it is a very important issue for people in the region. The witnesses will not have time now but they might provide an update to me in writing on this matter.

As this matter is not within the committee's terms of reference, the witnesses are not required to answer the Deputy's question. They are, of course, free to respond to him in writing if they so choose.

Mr. Jim Breslin

We will write to the Deputy on that point.

Mr. Paul Reid

Can I make a brief comment on PPE and testing?

If it is very brief, yes.

Mr. Paul Reid

I want to comment on the issue of Nursing Homes Ireland crying out for help and not getting a response. I may be paraphrasing it wrongly but I, too, strongly contend that we had engagement throughout January, February and March. I met personally Tadhg Daly and the chairman of Nursing Homes Ireland on 19 February. We engaged in ongoing communications and engagement throughout January, February and March. The Deputy is correct that there were issues in terms of availability in early March of testing reagents and kits, and it did significantly impact us on our testing across the country. That was a major factor globally. It was a major factor we struggled with in early March. Similarly, on PPE, we did struggle in terms of PPE across the system, and that was a factor. I would comment that in early March there were requests from private nursing homes for some PPE. On some occasions we distributed PPE. We closed down a testing centre and distributed to a private nursing home. When we got a significant delivery from China on 29 March, the first major delivery, that following week-----

I think we covered a lot of that in the last-----

Mr. Paul Reid

-----40% of deliveries went to nursing homes.

I do not want to speak over Mr. Reid but I think we covered a lot of that in the last session.

Mr. Paul Reid

I will revert to the Deputy on the question about Waterford and the cath lab.

I thank Mr. Reid.

I thank all of our witnesses not just for their time today but for the ongoing work they have been doing over the past few months on what is the biggest public health crisis the country has ever faced. This State has done incredible work in areas such as getting the hospitals ready for the surge. Our clinicians have done extraordinary work. The engagement with the public has been fantastic. The one area where we probably have not fared well is on nursing homes and because that is the subject matter of the session today, I want to focus on that.

We have had 1,710 fatalities to date from Covid-19. Our fatality rate is high by international and European standards. I have put that to various people previously and the answer has always been that we are not comparing like for like because we have a very good reporting regime. However, new analysis in The Sunday Business Post by Susan Mitchell and Rachel Lavin deals with that. It looks at excess deaths over the past five years and has been lauded by statisticians as robust analysis. We now have comparable data on Ireland's Covid-19 fatality rate versus that of other European countries and what it shows is what the other data showed as well. We have the eighth highest fatality rate in Europe. Many people have said that given that we are an island and therefore have less cross-border traffic than mainland European countries, and that we are on the western edge of Europe and therefore we had more time, we would have expected to be in the lower end of fatalities in Europe, but we are not. We are in the higher end; we are in the top third. If we had had the same level of fatalities as countries like Germany, Austria, Finland, Denmark and many others, instead of having 1,700 fatalities we would be down around 500, and if we were in the bottom third we would be lower again.

The reality is that two in every three fatalities have come from long-term residential settings in Ireland and the vast majority of those are from nursing homes. Have the witnesses and the organisations they lead - the Department and the HSE - looked at what those other countries did because they have a fraction of the fatality rate that we have and a fraction of our fatality rate in nursing homes? It is plausible that they took actions that we should know about that we did not do and from which we should be learning because we could be looking at a second wave. God knows, we could be looking at more than a second wave. Has the State looked at what the countries with much lower fatality rates did to protect their nursing homes? Are there actions we can take in the future? Is there anything we have learned from that and anything we are putting in place to improve our ongoing response?

Mr. Jim Breslin

I will take that question initially. Throughout the process, we have gathered evidence internationally and repeatedly as part of the NPHET process. I refer to what measures have been taken across all countries and what we can learn from them. That includes people to whom the Deputy referred. When I say the data do not give us a definitive picture, I mean there are things we can learn from everybody, and we have been doing that.

When it comes to the data, there are two main types. One is fatality rate, which is generally the number of cases and how that number converts into mortality, in other words, how many people got Covid-19 and how many died. The second type, which is what the Deputy referred to and The Sunday Business Post produced, is excess all-cause mortality over this period. Regarding the second type, it is important which time period is picked. We will learn more from this as time goes on. We went through our excess mortality period using the up-to-date data from the rip.ie website. We went through those data in March and April. That rate has now subsided, but other countries are continuing to have excess mortality. In saying that, I am not taking from the fact that we zero in on particular countries and particular measures that have been taken. The NPHET measures for nursing homes taken at the end of March and start of April were based on evidence gathered internationally on what others were doing.

I thank Mr. Breslin for that response. No matter how the data are cut, be that excess deaths, reported fatalities or data pulled from the rip.ie website, we have a very high fatality rate. As many people with expertise in this area have stated, we should have had a relatively low rate. In light of that, does the Department of Health, the HSE or NPHET have a team in place looking at what the Germans, the Finns and the Austrians did? Many countries around Europe have a much lower fatality rate than Ireland. It is not a little bit lower. For every one fatality those countries have had, we have had five, six, seven or eight. Is there anything we have identified and learned that we are now implementing to strengthen our response?

Mr. Jim Breslin

A whole range of lessons have been learned. The types of measures we have taken on testing and case definition have all been informed by international learning. I do not fully accept that we have a very high fatality rate. I believe Dr. David Nabarro was correct in stating that we have been much more comprehensive in our recording of deaths. In addition, regarding the proportion of deaths that have taken place in nursing homes, while I will not say we have been fully successful, we have put in place many measures to suppress community transmission that avoided deaths in the community. This leads to a higher proportion of deaths being in nursing homes. If we had twice the number of community deaths, the percentage of deaths in nursing homes would be 40%, not 60%.

I appreciate that, and it is a fair point, but the fact that we have multiples of the overall fatality rate definitively proves that other countries had much lower mortality rates in nursing homes. The statement from Dr. Nabarro to which Mr. Breslin referred was made in response to a question from me. I put that question and he answered in that way because we did not have The Sunday Business Post analysis at that time. He referred to the response to date, which has been that the data is not comparable. The reason The Sunday Business Post analysis on excess deaths is so important is because it moves beyond Dr. Nabarro's point and states we do now have comparable data. It is not just The Sunday Business Post analysis. We have had statisticians and mathematicians look at the data and say this is the right way to go.

I thank Mr. Breslin for his answer. I believe one of the reasons that not everything was done in nursing homes that could have been done was that the sector did not have a voice. I have listened to Mr. Breslin, Mr. Reid and others and read through all the correspondence provided. I appreciate there was engagement. I know Mr. Breslin, Mr. Reid and their staff were engaging because I have read through the multitude of emails. What I do not understand is why that engagement did not turn into action. The first time NPHET mentioned nursing homes was on 10 March when it told nursing homes to remove the visitor restrictions that had been put in place. The Government's national Covid-19 response was published on 16 March. It is a detailed document but it mentions nursing homes just once, and only in the context of being somewhere to discharge acute patients to.

We have the protocols now that show patients were discharged from nursing homes to hospitals with Covid outbreaks and the patients were not tested. The protocols also show that even if the patient was a defined close contact of a Covid case in a hospital where there was an outbreak, he or she still were not tested. The nursing homes wrote immediately saying they were not comfortable with this and that all these patients need to be isolated in the hospitals for two weeks. None of these things seemed to happen. While I accept that there was engagement, why does Mr. Breslin think that at NPHET and in the Government strategy that was published, there was so little action until close to the end of March, when the nursing homes were clearly raising a growing crisis much earlier than that?

Mr. Jim Breslin

Part of it is terminology. Whereas the term "nursing homes" might not be used, if one looks at the national action plan, there are quite a number of references to long-term care for older people and care for older people, transitional and long-stay beds. Simply using "nursing homes", therefore, would not give the full spread of actions that are in that action plan. As to NPHET, again while the words "nursing homes" might not have been used, there were ongoing reports in to NPHET from HSE community operations, that is the non-hospital side of the HSE, which would have extended to nursing homes and issues of preparedness and long-stay facilities.

I thank the witnesses for their responses.

I thank Deputy Donnelly.

I have a number of questions. I will try to keep them short and I would appreciate it if the witnesses could keep their answers short as well, if possible. In response to Deputy O'Dowd, who pointed out that 22% of nursing homes were not HIQA-compliant, Mr. Breslin pointed out that there is a power to seek deregistration in the courts. In the meantime, however is it correct to say that the HSE are still funding those nursing homes through the nursing homes support scheme, the National Treatment Purchase Fund, etc.? If so, is that satisfactory, or are there any plans to change that arrangement?

Mr. David Walsh

There is not a direct link. The key to enabling the HSE to pay in respect of care is that the nursing home be registered and as long as it is, then-----

Even if it is registered and failing, the HSE continues to pay them?

Mr. David Walsh

Well-----

Mr. David Walsh

If we ceased to pay, then care would cease, so HIQA goes through a process of trying to improve standards within the home through its mechanisms-----

Does the HSE pay for new patients in nursing homes that are not HIQA-compliant and are failing infection-control guidelines?

Mr. David Walsh

I am not sure if there are many nursing homes that are 100% compliant. I am sure there are-----

Does the HSE pay for new patients going into the 22% of nursing homes that are failing?

Mr. David Walsh

If a person is approved under the nursing homes support scheme and the nursing home is a registered nursing home, unless some impediment is put in place through a condition of registration by HIQA, then the HSE is obliged to-----

Merely failing infection control is not, therefore, an impediment. Mr. Walsh mentioned discharge, and said individual clinicians were discharging people who were inappropriately in acute hospitals. Can he confirm that only people who were inappropriately in acute hospitals were being discharged?

Dr. Colm Henry

I am not sure what the Chairman's reference was to, but I earlier referenced the discharge of people from acute hospitals when it was deemed that their journey of clinical care was finished there. As happened well before Covid, patients are discharged once the clinician managing their care feels they no longer need to be in an acute hospital. As I referenced earlier, throughout March, there was an acute awareness of the impact that Covid-19 was having on acute hospitals in other countries-----

I get all of that. My question was: is it only people who were inappropriately in acute hospitals and whose planned treatment had been completed who were discharged? Can Dr. Henry confirm that or not?

Dr. Colm Henry

No, not at all. It was anyone whose course of treatment had finished.

Was it only people whose course of treatment had finished who were discharged?

Dr. Colm Henry

Yes, that has always been the way. They are either discharged home or they go back to where they came from, which might be a residential-----

The witnesses may or may not know this. How many people on any given day are still in acute hospitals even though their course of treatment has finished?

Mr. David Walsh

The figure for those who have completed their treatment and await an onward placement is around 400.

Some 400 people are taking up beds in acute hospitals, whose treatment is complete and they are waiting for somewhere else to go. The only reason they are there is because they have nowhere else to go, even during these times of Covid.

Mr. David Walsh

Sometimes where people are listed for long term care or for assistance at home for home support, they become unwell again. There may be an impediment to them moving, but at any one time there is a time lag between being declared fit for discharge and the arrangements being put in place.

Four hundred is the answer. Mr. Walsh mentioned international comparators and how we needed to be able to free up our acute hospitals because we did not know what was coming at us. Everyone accepts that. The lack of ventilators in Ireland was pointed out at the time. How many have been bought since 1 March?

Mr. Paul Reid

We had an initial stock across all our systems of about 1,100. We aimed to double that but late into the stage we stopped the procurement. Approximately 700 ventilators were bought.

Deputy Colm Burke mentioned that about 56% of nursing homes had no incidence of Covid, which is obviously good news. Did anyone look at why that was and, in particular, whether there is any correlation between the 56% and nursing homes that did not receive discharges from acute hospitals?

Dr. Colm Henry

The biggest single correlation which we have seen so far, bearing in mind that we are still at the early stages of the pandemic, is the level of community transmission. Where there are high levels of community transmission-----

No, I heard that and appreciate the answer, but did the HSE look at whether there is a correlation between the 56% of nursing homes that had no incidence of Covid and those nursing homes that did not receive discharges from acute hospitals?

Dr. Colm Henry

A range of correlations have been examined so far. We are still in the middle of analysing this-----

Has that correlation been looked at?

Dr. Colm Henry

No, no such correlation has yet been shown. The most significant level of correlation is with community transmission.

I understand that. Has the HSE examined whether there is a link between the 56% of nursing homes where there is no incidence and the number of nursing homes where there were no discharges from acute hospitals?

Dr. Colm Henry

A direct study of that nature-----

Not yet.

Dr. Colm Henry

-----looking at a single correlate has not been carried out to my knowledge.

That has not been looked at? That has or has not been looked at?

Dr. Colm Henry

Not at this stage, no.

Media reports suggest there were 240 deaths in the ten worst affected nursing homes. Is that correct? Were those ten worst affected nursing homes on the list HIQA sent to the HSE, expressing its concerns?

Mr. David Walsh

I have two separate streams of communication from HIQA, one on HSE or section 38 homes and, daily since the beginning of April, I have also received updated lists from HIQA on the totality of registered nursing homes, public or private. From those lists, it is clear that, as Dr. Henry has said, there is no direct correlation between-----

The question was more specific. HIQA sent the HSE a list, or it told the committee it did so, of nursing homes that it had specific concerns about in the context of Covid-19.

Mr. David Walsh

Yes.

First, is it correct that in the ten worst affected nursing homes there were 240 deaths, as reported in the media? Second, were those nursing homes on the list sent to the HSE by HIQA which was concerned about specific nursing homes?

Mr. David Walsh

On the HSE or section 38 nursing homes notified to me, a significant number had no deaths whatever and some had significant numbers of deaths.

They were not the highest number of deaths. Regarding private nursing homes, it is important to say that the data that were published were not validated data in terms of confirmed deaths from Covid. Once again, there was not a direct correlation between the nursing homes that HIQA would have had most concern about and those nursing homes with the highest number of RIPs.

I thank Mr. Walsh very much. Mr. Breslin talked about resuming visits to nursing homes. I heard on "Morning Ireland" on Monday, or perhaps it was Tuesday, the suggestion that people would visit their loved ones in nursing homes through a Perspex screen. Is that actually happening and is it satisfactory to the Department of Health and the HSE?

Mr. Jim Breslin

Dr. Henry might speak to this issue. A set of precautions is in place at the moment to facilitate visits.

Is that through a Perspex screen?

Dr. Colm Henry

Yes, we have advised nursing homes on the resumption of visiting and the advice pertains not to Perspex but to the number of visitors and the time that they can spend with their relative in nursing home settings. As was cited by a Deputy earlier, this is a critically important component of their care. The isolation has been, to say the least, damaging for people.

I thank Dr. Henry. So there are no Perspex screens then. Is that what I am hearing?

Dr. Colm Henry

The advice did not specifically refer to them. It is possible that some nursing homes may introduce them but the advice given was in terms of distancing, the number of visitors and the time spent with the resident. If nursing homes choose for whatever reason to use Perspex screens-----

As somebody who has taken legal instructions from people through screens in prisons and visited a loved one for a considerable period of time in a nursing home, I personally would have concerns about Perspex.

Mr. Jim Breslin

Dr. MacLellan might have something to add.

I do fully accept that precautions have to be taken but screens seem to me to be somewhat dehumanising.

Mr. Jim Breslin

Excuse me, Chairman. Dr. MacLellan will just add something.

Dr. Kathleen MacLellan

The visiting guidance here is very much around the fact that the person in charge would plan visits and that where social distancing cannot be maintained visitors would be required to wear a surgical mask. The facilities themselves would provide the mask. The visit should occur in the resident's room, if the room is a single room and if it is a multi-occupancy room the visit would be a room away from other people.

I thank Dr. MacLellan. It is noteworthy that the advice is entirely compliant with WHO guidelines. Mr. Breslin mentioned that he is looking at RIP.ie for excess deaths. Given that the Oireachtas beefed up the power of the registration service for deaths, births and marriages, why is he looking at RIP.ie data rather than data from the register of births, deaths and marriages?

Mr. Jim Breslin

The legislation on the registration of deaths in this country allows a three-month period for a death to be registered. In normal times that is probably fine although it does leave a lag for the information to be available, but in the context of a pandemic where one wants the information to be as up to date as possible, that is quite a lag. In Northern Ireland, for example, a death must be registered in five days. We are in discussions with other Departments on that but to get around the issue a full analysis is being done on RIP.ie and it is a very close approximation of the total number of deaths.

I thank Mr. Breslin. I have two final questions. I do appreciate his forbearance. He mentioned the expert panel report that is being led by Professor Kelleher. As a committee we hope to look at that. When does he expect the report?

Mr. Jim Breslin

The Minister has asked that the panel would come back by the end of June. The panel is independent so it will try to work to that deadline but I have not had confirmation yet that it will meet it exactly. It is our wish that the panel would complete its report by the end of June.

My final question does not relate to nursing homes but to something that was in the media today. Good results seem to be coming from the use of the steroid dexamethasone, which is not a particularly expensive one, but it is not yet used in Ireland. Could anybody explain why that is or what the plans are around it?

Dr. Colm Henry

The drug is widely used in Ireland. These are early trial results on a very select number of patients who are high-ventilatory support and highly dependent. We have sent an alert out to our own clinical community. As with any other drug that is licensed and available, it will be based on individual clinical judgment in the appropriate critical care settings.

I thank Dr. Henry very much. I have gone over time. I thank the witnesses very much for answering all of the questions and for their patience and forbearance.

Regarding the 56% of nursing homes that are Covid-free, could we have the number of patients transferred to them?

Yes, could we get the number of patients? That is a very reasonable request by Deputy Colm Burke. If possible, could we get by correspondence the exact number of patients that were transferred to the 56% of nursing homes that are Covid-free?

Mr. David Walsh

Yes, we will work on that.

Is ten working days a reasonable period?

Mr. David Walsh

Yes.

I will now suspend the committee until 2 p.m. I thank all the witnesses very much.

Sitting suspended at 1.10 p.m. and resumed at 2 p.m.