Special Committee on Covid-19 Response debate -
Tuesday, 21 Jul 2020

Covid-19: Infection Rate among Healthcare Workers

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I welcome our witnesses in committee room 2. They represent Fórsa, SIPTU and the Irish Nurses and Midwives Organisation.

I advise our witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009 - I have just realised I am wearing my mask while making a contribution - witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and 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 way as to make him, her or it identifiable.

We will begin with the Fórsa trade union. I call on Ms Keogh to introduce the delegation and to briefly outline the key points of her submission to the committee, which has already been circulated to members.

Ms Catherine Keogh

I am an assistant general secretary in the Fórsa national health office. I am here with Mr. Éamonn Donnelly, our national secretary in the health division. The committee will have received our submission in advance.

The key point for Fórsa is the ripple effect infection rates among healthcare workers has had across the whole health service as we faced into the pandemic. Fórsa represents health and social care professionals including physiotherapists, orthoptists, and speech and language therapists. Our orthoptists were trained in swab testing and carried out such tests on the front line. Some were then infected with Covid and spent three months off work before returning to front-line testing straight away. We want to talk about the significant effect this had across the health sector, primarily with regard to our own grades but also for all others. A common refrain of the trade union movement is that an injury to one is an injury to all. In healthcare, particularly during a pandemic, an infection for one has an effect on everyone, both in the acute and community settings. Our submission reflects on that and on the rates of infection. I will pass over to my colleague, Mr. Donnelly, who has some opening remarks to make.

Mr. Éamonn Donnelly

In addition to what is in the statement, one of the key points we want to emphasise is that it is not just about the disproportionately large infection rates among healthcare workers, it is about the effect that has across the workforce in the health sector. We hope we will move from a world where we were dealing only with the response to the pandemic into what the HSE calls a co-Covid environment, where we are living with the disease and reopening health services that people need to access. We cannot keep health services shut down forever. What that means is that as community-led health services reopen, the people who have already been working in direct response to the pandemic, and to whom my colleague, Ms Keogh, referred, go back to substantive roles in the community. The example I cite in the statement is of a physiotherapist who will now have to resume treatment with somebody whose mobility has deteriorated alarmingly in the four months since the Covid response started.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Mr. Donnelly. We have his opening statement. I want to try to get to the other speakers and we will come back to Mr. Donnelly.

I thank Mr. King for appearing before us this morning. I ask him to introduce his delegation and make a short comment outlining the key points of his submission to the committee, recognising that we have received it already.

Mr. John King

SIPTU has approximately 43,000 members who work in the health service across a multitude of health service settings. We represent a broad range of workers right across the health service, from porters, attendants, kitchen staff and chefs to professional grades such as ambulance and paramedic staff and staff involved in radiography, nursing and midwifery, as well as a significant number of members in the mental health service.

We made a detailed presentation to the committee, which includes the findings from a survey of our membership. I am joined by Ms Michele Monahan, SIPTU honorary vice president, who is also a front-line worker employed in the HSE. Ms Monahan can give direct evidence to the committee on the effect of the crisis on healthcare workers. While the submission presents the findings, it also makes a number of key recommendations and we look forward to engaging with the committee on them today. They include a comprehensive review on the effects of the totality of the impact of the crisis on healthcare workers affected, but also on the staff who were not affected but were left working in that pressurised environment.

We also believe significant learning is needed on some of the policies and decisions taken to ensure we do not end up in this situation again. I refer, for example, to the decanting of acute patients into nursing homes.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I will stop Mr. King there. I apologise for cutting across him.

Mr. John King

That is fine.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Mr. King. We welcome back Ms Phil Ní Sheaghdha. I ask her to introduce her delegation and make a short comment outlining her key points, recognising that we have her submission.

Ms Phil Ní Sheaghdha

The INMO's submission today will focus on a matter briefly touched on during the previous discussion on childcare, namely, the high rate of infection among healthcare workers, which currently stands at 34% of all of those who have been infected with Covid-19 in the Republic. Of those, 32% are nurses and midwives. We believe it is time for the Health and Safety Authority, HSA, to be involved and that an examination of the high infection rate among healthcare workers must be examined by the statutory agency tasked with this particular responsibility. It is unfair and disrespectful to healthcare workers that the HSA has not been given the statutory authority to investigate the cause, identify the reasons and make recommendations. We have to do better.

I am accompanied by a staff nurse, Siobhán Murphy, who has been infected with Covid-19. She is currently on week 14 of an absence from work and she has had severe side effects as a result of being infected at work.

We know that 80% of all infections within the healthcare setting have been occupationally acquired. We have surveyed our members and we know their biggest concern relates to the fact that, as the committee knows, the pandemic is still within our health service. The idea that they have to face it again with the current level of support absolutely terrifies them. I will hand over to Ms Murphy for one minute to outline her personal circumstances.

Ms Siobhán Murphy

I worked on a Covid-positive ward since 24 March. We were catapulted into this pandemic but we faced it with strength as a team. We are nurses who work 13-hour shifts. We work days, nights and weekends. My experience was of overexposure and burnout due to the challenge we faced already pre-Covid, with understaffing and being overwhelmed with the ever-expanding role of being a staff nurse. As one cannot put a time limit on providing care to a patient, I suppose the exposure to Covid-19 as a nurse was profound. There have been psychological and physical side effects and symptoms that I still experience today. I am still off work at the moment, as are three of my colleagues, while four colleagues required hospital treatment due to contracting Covid-19. A total of 13 out of 20 of my colleagues contracted Covid-19.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Ms Murphy for her attendance today, which we appreciate.

I will move on to contributions from the members. Deputy Devlin of Fianna Fáil is first and he has ten minutes for questions and responses for witnesses. Witnesses should be aware that as it is sometimes difficult to communicate between the two rooms, they might hear the Deputies speak across them but they are only trying to keep things going. I call Deputy Devlin.

Deputy Cormac Devlin

I thank the Acting Chair. I thank the witnesses for their attendance and particularly Ms Murphy for her personal account. Like the public at large, we appreciate all that the witnesses and their members do daily, particularly during this crisis. There were a lot of challenges in advance of Covid and especially during Covid and the witnesses' submissions articulated that very well.

The million-dollar question, particularly if a second wave - God forbid - were to come, is what could we do differently and how could we do it. I would be interested to hear from the various organisations here. Perhaps the representatives of the INMO would like to answer.

Ms Phil Ní Sheaghdha

On what we can do differently, we can ensure that healthcare workers have the same status as every other worker in the Republic. Such a status would mean that if they go to work and become ill because of the job they do, they have the right to have that examined by the statutory agency holding responsibility for any other workplace accident, namely, the Health and Safety Authority, HSA. We urge this committee to ensure that the regulation preventing the HSA from doing just that is altered and the Minister with responsibility puts before the House the regulation changes. It is very simple. It is a statutory instrument and it needs to be done immediately because there is no way an employer in the public or private sector should be the only authority that determines whether it has acted in a correct manner when it comes to its workers' welfare. We do not believe that should be the case. It is not fair to healthcare workers. We appreciate, as we have said publicly previously, the applause and the well-intentioned thanks healthcare workers have received but right now, facing into doing this again, our members are saying they are exhausted and cannot endure this again with the protections that were in place. That needs to be examined by the HSA to ensure that correct protections are put in place.

Deputy Cormac Devlin

I thank Ms Ní Sheaghdha. Does any other organisation have recommendations on how we might do things differently?

Mr. Éamonn Donnelly

I agree with what my colleague, Ms Ní Sheaghdha, has said on burnout but if we get a second wave it will be very difficult to call on the exact same cohort of people to provide the same response.

I wonder about all of the excitement surrounding Be on Call for Ireland when it was announced. That campaign has since been stood down. To my mind, we will not be able to deal with a second wave without the ability to have a fluid migration of the workforce into the health services. We have to be upfront about that. We are in a better place to be able to deal with a second wave due to testing and tracing and so on but, for the reasons my colleague outlined, the workforce in health is pretty much at burnout stage. The HSE needs to be right at the top of the game in ensuring the health services are compliant with the return to work safely protocols. That is not the case and the HSE is behind the pace on that matter.

Mr. John King

I will be brief and will try to avoid being repetitive. I agree with my colleagues on the importance of the statutory agency assuming the required levels of responsibility. The figures speak for themselves. No other sector of employment has suffered the same infection rates as the health sector. The reasons healthcare workers are here is that they work in HSE and healthcare settings. For this reason, the HSE needs to be involved in making sure that all that can be done is done to protect healthcare workers in their employment.

I will make one additional point. As a society, we waited for the pandemic to arrive before we reacted. We have an opportunity, while Covid has abated to the extent that it has, to ensure the policies and procedures we implemented very early on are not repeated because in some cases some of those policies and procedures did not help with the level of infection rates that occurred. We have that opportunity now.

Deputy Cormac Devlin

SIPTU's submission caused a bit of a flurry in advance of this meeting. It was about certain workers presenting for work with potential symptoms in fear of losing overtime or premiums. I find that worrying and I am sure members of the public would as well. How widespread was that?

Mr. John King

We raised this matter extensively with the HSE and the relevant Department when this particular policy decision was taken. To understand the point we are trying to make, we have to go back to the context of what Covid was like in healthcare settings in February and March when we did not have the advanced levels of testing and so on that we have in place now. Staff in the health service, similar to staff in other sectors of the economy, require their total earnings to be able to survive. The point we were making in including this point in the submission was to draw attention to a policy that did not work because it served as a disincentive. It is not a question of determining how many cases there were or what was the prevalence. The fact is that it was a policy that did not work because it acted as a disincentive.

Deputy Cormac Devlin

Obviously if there is a second wave, we need to be very conscious of that. From my perspective, the message should be that anybody who shows symptoms, irrespective of monetary gain, should not present for work. I hope Mr. King, the other witnesses and all members share that view. While financial considerations are a legitimate concern, surely health would override those. I wish Mr. King good luck in SIPTU's discussions with the HSE.

On the discussions between the organisations the witnesses represent and the HSE, I presume they are ongoing in the face of a second wave. Will the witnesses elaborate on that issue?

Ms Phil Ní Sheaghdha

The discussions are ongoing in respect of opening up the health service to Covid and non-Covid services. The problem is that we are still awaiting a funded workforce plan. It is something we have sought and it needs to be put in place. We have guarantees, for example, that both Covid and non-Covid services will have to be provided.

We have sought that the workforce reflects that. If I was a nurse in an emergency department tonight, I would be providing either a Covid or non-Covid service. There are not two of me but there are two services. That is for the very reason the Deputy just outlined.

The important point about this virus is that it does not discriminate. Its aim is to infect people so we have to make sure we prevent it from doing that. If that means some members of the workforce having to remain outside it, the health service has to make provision to supplement the remaining workforce. What happened recently is that there was nobody to call on and, therefore, those who were at work were working short-handed. Ms Murphy can attest to that. There were 19 nurses on her ward. Twelve of them got infected and were absent from that ward, but the patient load did not decrease. We know from WHO statistics that infection rates are higher among those who are fatigued. The nurses who remained on that ward were exposed to a higher risk of infection purely because of fatigue. We need a funded workforce plan for nursing and midwifery. Fianna Fáil's pre-Government submission sought to increase the workforce quite substantially. We are eager to have that conversation. We are meeting the Minister this afternoon and will raise that with him, as well as with the HSE. That is the story in the public sector.

In the private sector, the workforce collapsed very quickly because its baseline was insufficient to begin with. We have to look seriously at reintroducing the public provision of care of older persons. We cannot rely on the private sector to the level we have. Some 82% of all care of the older person services is provided by the private sector and the workforce is not sufficient to endure another flu or another wave of Covid-19. It is simply unfair and inhumane to ask it to go back to that level of crazy staffing.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I call Deputy Cullinane.

Deputy David Cullinane

I welcome the witnesses. It is almost impossible to go through all the submissions in the ten minutes we have. I am sure all other contributors will have the same problem because there is so much that can be said. I thank them for their comprehensive briefing notes and opening statements. I commend all the members of their organisations and the front-line staff across all our healthcare settings on the huge sacrifices that were made and work that was undertaken over the past number of months.

I will start with the INMO. Ms Ní Sheaghdha referred to the international average of Covid-19 rates among healthcare workers. It is 1% in Singapore, 12% in Italy, 15% in Mexico, 22% in Spain, and 32% in this State, which is one of the highest percentages among the countries cited. Can Ms Ní Sheaghdha explain why that rate was so high in Ireland compared to other countries?

Ms Phil Ní Sheaghdha

Those figures have been collated by the International Council of Nurses, which looked at the numbers of healthcare workers infected as a proportion of the overall infection rate in each country. There are some caveats attached to that, for obvious reasons. However, we are satisfied that the figures we have received from the HSE reflect the reality. For example, the most recent figures collated last Friday show that 8,347 healthcare workers have been infected with Covid-19. Of those, the highest single group is nurses, with 2,711 infections. We have experienced that on our wards, and Ms Murphy experienced it personally. There are a number of reasons for the high infection rate. One is that there was a deficit of PPE to begin with, though that has improved and is no longer the issue. The biggest single issue is fatigue and the length of exposure of healthcare workers, such as nurses and midwives, to people with the infection. The longer someone is exposed to somebody with the infection, the more likely that person is to become infected. That has been proven.

We have to look at the idea that if we open up a Covid ward with a staff of 19 nurses and 12 of them get infected, we will have no replacements. It simply does not make any sense. It is causing the infection to increase.

Deputy David Cullinane

Ms Ní Sheaghdha also said that 73.25% of respondents in the survey indicated they found difficulty in accessing personal protective equipment. People will find it extraordinary that the number is so high and I am not disputing that it is the case. What time period are we speaking about? What was the critical time period when staff most found it difficult to get personal protective equipment? Has this issue now been fully resolved?

Ms Phil Ní Sheaghdha

There was great difficulty with getting personal protective equipment to begin with, particularly in the private sector. The biggest issue was the wearing of face masks. As the Deputy knows, there was a lot of debate about whether we should wear them. The HSE did not introduce until 22 April a policy that made it mandatory to wear face masks in healthcare settings. I gave evidence before the committee previously, and in our survey nurses give testimony on this point, of nurses being instructed not to wear face masks. This was simply the wrong policy. We knew from international evidence it was incorrect. They were instructed not to wear face masks. One nurse was actually disciplined for wearing a face mask. We now know, thankfully, that face masks contribute to the protection of healthcare workers.

There are various grades of face masks. If I am working in an intensive care unit or an area where I am engaging in aerosol generating procedures, I must have a higher quality face mask. All of this was too late. On 22 April, following the unions in this room requesting and constantly asking the HSE to change its policy, it eventually did so on 22 April. That was very late. Ms Murphy and her colleagues were working on a Covid ward from just after St. Patrick's Day. The point is that personal protective equipment was a big factor. It definitely has improved but we cannot risk the fatigue and exposure again.

Deputy David Cullinane

I might put a number of questions now because I will get caught on time and I want to cover as much ground as I can. I have another question which is specific to Ms Ní Sheaghdha and I have a general question for all of the witnesses to come back on, if they can.

My question for Ms Ní Sheaghdha is on the survey. It is very distressing to read what happened to front-line workers, it has to be said. We do not have time to go over all of the responses. I will refer to one respondent, who stated returning to work does not mean being 100% recovered and that employers should learn to accommodate staff returning from Covid special leave and support them to get back into shape instead of pushing them even more. Ms Ní Sheaghdha said in her opening statement and submission that a long-term process will be required to deal with the psychological impact that all of this has had on nurses and front-line staff, that it is in this phase that many staff will be running on empty and that it is important to be able to respond to the needs of staff and support them. She also said that if a new surge of the virus emerges, the health service must have the workforce to deliver services and adequate supports. Will Ms Ní Sheaghdha outline specifically what needs to be done to support front-line workers, whether because of the psychological impact, physical impact or whatever? What practical supports in the here and now will be needed?

I am not sure whether the witnesses saw the sessions we had last week with the HSE, when we spoke about capacity and the obvious fact that we still have to deal with Covid in our acute hospital settings. There may well be a surge but even the levels there at present require a lot of attention from front-line staff. We also have all of the ongoing non-Covid care. We have the programme to catch up on all of the missed care, which is necessary. How will any of this be done with the current capacity? It just cannot be done. Will the witnesses give us their view on what is needed in the short term in terms of beds, staff and other supports, such as physical infrastructure? What is needed in the coming months and the next year in our health service to ensure we can deal with Covid and non-Covid care and have some chance of dealing with the catch-up programme? I know it is a general question but it is an important one with regard to what is needed in the here and now.

My specific question was to Ms Ní Sheaghdha on the survey and the more general broader point on capacity is for all of the witnesses if they want to respond to it.

Ms Phil Ní Sheaghdha

In the here and now, the respondents to our survey made it very clear that a telephone helpline is not sufficient.

They want practical post-traumatic stress support. They describe what they are now enduring as post-traumatic stress. They are saying they are fearful of the ability of their employer to keep them safe. They are also quite determined that they will work and are happy to go to work but they must be protected.

We call on this committee to look to the Health and Safety Authority, which is the statutory body with responsibility to ensure workplaces are safe. We must have that comfort for the people we represent who are to the forefront of keeping citizens safe and making them better. The figures from our intensive care units and the recovery from this pandemic are down to the good work of those healthcare workers who spent their time beside the patients in those beds making sure they recovered. It is really important we do not forget that. Right now, what we need is the assurance that somebody other than the employer is determining that the workplace is safe. That is imperative and this committee has the authority to make that recommendation. We call upon the committee members to do so.

Deputy David Cullinane

I do not have another question; it is just a general question about the capacity needed in the here and now for all patients.

Ms Michele Monahan

I am a radiography manager so I deal with capacity issues every day. What will happen, as Ms Ní Sheaghda said, is that we will have two pathways. However, we have reopened emergency departments, EDs, which are now at the capacity they were pre-Covid. Pre-Covid we had TrolleyGAR, trolley watch, trolley everything, except one is not allowed to have that any more. What it puts back on the staff is that they work two streams whereby sometimes Covid-19 and non-Covid-19 patients are put through one piece of equipment - one CT scanner one MRI scanner - as fast as possible so no-one is waiting on a trolley and patients are admitted quickly so there is no crossover between Covid-19 and non-Covid-19.

We are not nearly at burnout, we are at burnout. One had to be there and to work through it. As Ms Murphy will attest, nobody can get what one had to go through except to be there. The first thing one learns as a healthcare professional is to leave emotions at the door and do not take patients home with us, but we did. We took every Covid-19 patient home with us because no family members were allowed in to see them. The burnout, stress and fatigue for those who did not get Covid-19 but had to do double shifts, additional call and additional everything needs to be recognised and a response needs to be put in. In one word, what we need to meet the capacity is "More". We need more staff, more equipment, more space and more everything as otherwise, it is not going to work.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Ms Monahan and Deputy Cullinane. We move on to the Fine Gael party. Deputy Colm Burke has ten minutes.

Deputy Colm Burke

I thank all the speakers this morning for all the submissions they already have made and for the work that has been done over the last four months in particular.

I wish to raise an issue from the HSE report about the breakdown of healthcare workers. One of the concerning figures is of the 8,260 workers - it is now up slightly from 8,260 - some 2,878 of those identified with Covid-19 had underlying clinical conditions. I am extremely concerned that a person working in the HSE with an underlying medical condition then appeared to have been put in the front line. I have evidence of that because a number of people contacted me over the past three to four months where they looked to be assigned to other areas rather than being on the front line and dealing with Covid-19.

Was that issue taken up by any union with the HSE during the course of the last four months, whereby staff with previous medical conditions and who were a high-risk category were required to work on the front line?

Mr. Éamonn Donnelly

I will deal with that because we were involved in the negotiations at that time. The HSE took a very severe position on that issue insofar as they required a consultant's certification that somebody had a vulnerable condition.

If the person did not have a certification from a consultant, he or she was asked to continue as normal or would otherwise not be paid. The practice of ignoring the validation from a GP that a person had an underlying condition seemed to present a significant problem. It is no surprise that a number of workers who were infected had underlying conditions.

Everybody needs to understand that when the outbreak happened in March, we were told that our workers were an army and a command and control model was put in place to mobilise the workforce to deal with the pandemic on behalf of the citizens of Ireland. That is what happened. However, that cannot be sustained in the long term. We cannot close down community health again.

The capacity issue is why we need inward migration in the workforce. It is no great surprise that the number of infections comprised workers in a vulnerable category because of the severe stance taken by the HSE in that regard.

Deputy Colm Burke

The figure of 2,878 is quite high. Is Mr. Donnelly aware of whether some of those people had requested not to be assigned to the particular roles they were asked to take on?

Mr. Éamonn Donnelly

There was a prescribed list of what constituted a vulnerable worker. It included heavy-duty stuff such as cancer treatment and so on. Issues such as blood pressure and diabetes were disregarded.

Deputy Colm Burke

I am aware of two or three cases where someone who had been through treatment for cancer had returned to work in the HSE, yet was required to work on the front line. Did the witnesses come across cases of people who had medical conditions and clearly indicated to management that it was inappropriate for them to be on the front line, but management ignored their requests to be assigned to other areas?

Mr. Éamonn Donnelly

It would be wrong to say that management ignored such requests. The policy that was handed down to managers ignored or ruled out such requests.

Deputy Colm Burke

Where did the policy come from? Did it come from HSE management or the Department of Health?

Mr. Éamonn Donnelly

The people who were in charge of the command and control model set down a policy of public health guidance. People from the Department of Health, NPHET and the HSE set down that policy. As far as we are concerned, the policy on vulnerable workers did not go far enough and has resulted in the high number of infections outlined by the Deputy

Deputy Colm Burke

I will move on to the wearing of face masks. I received quite a number of emails at a very early stage from people on the front line who wanted to wear face masks, but it appears that a decision was taken at a local level, by individual medical units, nursing homes or whatever, that masks were not required. Did the witnesses hear from people who had made requests that those in charge of a particular ward, hospital or nursing home ruled against that rather than there being a diktat from a central body such as the HSE?

Ms Phil Ní Sheaghdha

I will answer that. The policy of the HSE was quite specific on the wearing of face masks, and it was not broad enough. The policy was quoted to nurses when they sought to wear face masks and the wearing of face masks in the particular setting that they were in contravened the policy. At national level we had to change the policy. As I said, the policy was changed on 22 April to allow the widespread wearing of face masks, something that should have been the case from the beginning.

In respect of the question on underlying health conditions posed by the Deputy, healthcare workers got infected because of the exposure rate. They, no more than any other section of the population, include those with underlying health conditions.

The biggest issue we faced was nurses who were pregnant and attending work. We had a battle to ensure that they were not exposed. Pregnancy was not considered an underlying health condition. Some 34% of all of healthcare worker infections were among nurses.

Treating a pregnant woman with Covid-19 is very difficult and should never even be contemplated. We had a huge problem in trying to get pregnant nurses and midwives redeployed away from the front line. That problem was exacerbated because underlying staffing levels do not support redeployment.

We also had a call from the private sector to redeploy public servants, particularly nurses and midwives, into the private sector when it was short of staff. Personal protective equipment, PPE, was a problem in the private sector and policies and procedures, etc., were unfortunately absent in some cases. The exposure of healthcare workers is the point. It cannot be left to the employers and must be looked at by an agency with the statutory authority to examine it. An employer constantly suggesting reasons something has happened is simply not good enough. We must have stronger and better protections for healthcare workers on a legislative basis. They deserve the same protections as any other worker in this country and should not be treated less favourably.

Deputy Colm Burke

I will move on to consider how we go forward. Over the nearly six years from December 2014 to now, the number of people working full-time in the HSE, that is, whole-time equivalents, has gone from 103,000 to 123,000, which is an increase of 20,000 staff members. That increase obviously applies across all areas, including management, administration, care assistants, nurses and doctors. Where should the priority be in recruitment at this stage? Should it be care assistants and nurses or do we need an increase across all areas of the health sector? A question then arises regarding the kind of numbers should we be planning for over the next three years. We will be unable to introduce the necessary changes overnight but what should we be aiming for over the next three years?

Ms Phil Ní Sheaghdha

The health service has increased in capacity. The busyness of the health service has also increased in comparison to the time when the answer to the most recent recession was to introduce a moratorium on recruitment. Another moratorium was introduced in May of this year and really interfered with the ability of people to stay safe during this pandemic; there is no other way of saying it. There cannot be cutbacks on front-line staff in a service that is delivered by people. We have a shortage now that is estimated at just under 5,000 nurses and midwives. We know that maternity services are lacking. We should have one midwife per 29.5 births but we are close to 37 or 38, at best, in many locations. It is a known fact that we are short of midwives and nurses.

Each of the political parties addressed the matter in its election manifesto. Fianna Fáil said 4,000 extra nurses were needed. Fine Gael said 5,000 were needed. This is known. We know we need more front-line healthcare workers. We need more nurses and must do everything we can to retain those who have come through this pandemic so they do not leave. We also need to recruit more and increase undergraduate places. Some 5,000 school leavers looked to study nursing last year and only 1,700 places are available. That is a quick answer. Undergraduate places should be increased.

Deputy Colm Burke

What kind of numbers are we talking about over the next three years in real terms? How can 5,000 positions be filled over a three-year time period? That is the kind of time period we are talking about.

Ms Phil Ní Sheaghdha

We believe that can be done. There must be a funded workforce plan in place based on science which states that patients do better if there is a skill mix of 80:20 in an acute hospital and 70:30 outside of an acute hospital. That is what the science tells us and the numbers must reflect that. Otherwise, it is stating that it is okay to base our figures on unsafe levels of care and we do not accept that.

Deputy Duncan Smith

I thank the witnesses for their detailed submissions. There is so much in them that I wish I had more time to deal with them and the committee had more time to interrogate everything that needs to be interrogated. I hope the witnesses will forgive me for picking out a couple of issues from one of the submissions that caught my eye, namely, the quotes from SIPTU members. One of them said that at times there was rationing of PPE and workers were made to feel guilty for asking for it. Another said that it is now very difficult to get access to hand sanitiser and masks.

PPE is locked away in the manager's office and if that manager is not in, it runs out. This is quite shocking to hear given the assurances we have been given by the HSE and Government which suggested that this should no longer be an issue in light of the stocks of PPE available to be provided to all front-line and support staff. It seems to still be an issue. Based on that submission, I would be interested if Ms Monahan could give us more detail on her experiences in her work as a radiographer. She touched on this in her first contribution.

Mr. King mentioned at the outset that SIPTU represents a broad spectrum of staff. What has SIPTU learned that would be useful should there be a second wave of Covid?

Ms Michele Monahan

The situation with regard to PPE has evolved. The initial three to four weeks were a nightmare, as has been well documented. With regard to what came from China, the large size would fit a small person so some of us had no hope of getting into it. That was a very significant issue for staff. The issue with hand sanitiser arose because of reliance on a single source. Everything came from one place so, when that one place could no longer supply us, we had no other supplier available to us. The market was oversubscribed because the whole world wanted the same product.

I work in Connolly Hospital where we have a very good team so were not left without anything at any time. We distributed through the wards and became a team. If one area was running low on something one could go somewhere else for it. Everybody worked together. From speaking to my colleagues around the country, I know that this did happen, that things were locked away and that people did have to beg for PPE. That is just not right. The least staff working throughout this pandemic needed was the ability to do their jobs safely. An awful lot of them were denied that. That put them under a lot of pressure and stress. Many did not want to go back to work. People had full-blown panic attacks at work. They felt they could not go to work because radiographers carry out portable X-rays on every Covid patient and people just could not cope with doing that when they might not have PPE.

We really need to learn from all of this. We really need to look after our workers including those who get infected, those who are post-infection and those who are left behind working double and triple shifts and going to places where they do not normally work to pick up the slack while having to learn a new skill set on the job. We need to learn and learn quickly. We need that report and we need statutory backing for everything that happens because we cannot face another pandemic while addressing capacity issues at the same time.

Deputy Duncan Smith

I thank Ms Monahan. I really appreciate her comments but I have less than a minute left. I would appreciate it if Mr. King could answer my other question.

Mr. John King

I will be brief and avoid repetition if I can. I briefly mentioned earlier that society and the health system waited for the crisis to arrive before reacting. We are now in a position where we do not have to allow that to happen again. To give a very broad answer, it is a matter of our readiness to deal with a second surge when it comes. It is about ensuring that the health service has the capacity and the resources to meet that challenge when it comes. That includes issues such as that of PPE and proper policies and procedures that do not act as disincentives. There must be clear decision-making authority and so on. The point about the role of the Health and Safety Authority has been made so I will not repeat it.

One of the issues with regard to resourcing is that of staffing. This includes safe levels of staffing in all areas. Our submission highlights one matter with a view to highlighting it specifically rather than the story because we must learn from the story. It is then about applying what we have learned.

We have thousands of workers who come into health service settings every day of the week to do essential jobs to support the safe delivery of health services. They are not public servants and they do not have the same protections and terms and conditions of employment, such as the likes of death in service benefit, health and safety entitlements and so on. We believe that also needs to be examined if we are talking about a safe delivery of the health system in the future.

Deputy Róisín Shortall

I thank all the witnesses for their presentations but, more importantly, for all of the work they and their members have done over the past four or five very difficult months. I extend my condolences to them on the members whom they lost in the line of duty, and the many members who are still suffering the effects of the Covid infection. The point was made earlier that while thanks are important, there is a heartfelt view shared by the whole country that the way in which to give effect to that in meaningful terms is to introduce protections for workers in both ways.

It is quite remarkable that Covid-19 is not a notifiable disease. That has only come to my attention recently as a result of the campaign being run by the Irish Congress of Trade Unions, ICTU. It is incredible, given the deadly nature of the virus, and the fact that it has had such a devastating impact on healthcare workers in particular, that there has been a reluctance, to say the least, on the designation of Covid as a notifiable disease. I note what has been said about ICTU making an approach to the Tánaiste. It is unfortunate to say the least that the approach has not met with a positive response. It is certainly something we as a committee will take up in producing our report and recommendations. I wish to ask Ms Ní Sheaghdha in particular where we are at in the campaign to ensure that Covid is notifiable. Although the Tánaiste has not been encouraging so far, is she engaged in discussions at any level with the Government on this campaign?

Ms Phil Ní Sheaghdha

I thank Deputy Shortall. She is correct that the Irish Congress of Trade Unions had requested of the previous Minister, Deputy Humphreys, that the definition of personal injury in regulation 224 would be amended to include an occupational infection of this kind. We also wrote separately on behalf of our members and, as I understand it, a meeting is scheduled for this week with the ICTU and the current Minister, who is the Tánaiste, Deputy Varadkar, to deal with the issue. To date, the response has not included confirmation that the regulation will be amended, which is what is needed.

We also know that in the European Parliament, the definition in the biohazard directive now includes Covid-19 as an occupationally-acquired injury in category 3. As my colleague, Ms Siobhán Murphy, will be able to tell the committee, when one works on wards for 12-hour shifts, one knows all about it when one becomes infected. The long-term effect of this is quite severe. Ms Murphy has now entered her 12th week of being absent from work due to the after-effects of being infected. That cannot be described in any other way except as an occupationally-acquired illness.

Deputy Róisín Shortall

I thank Ms Ní Sheaghdha. I note the point she made about staffing levels. Covid has exposed significant failures right across the public services but nowhere more than in the health service. Ms Ní Sheaghdha made a point about being significantly understaffed as a result of large numbers of staff being out sick and the need to ensure there is a funded workforce plan. We very much take that on board as a committee.

In the couple of minutes remaining, I have questions for SIPTU and Fórsa.

There is an absence of protections for so many of our workers and a large number of healthcare support staff are in precarious, low pay jobs. This is a factor in healthcare assistants, for example, continuing to go to work when they had the virus because of the lack of statutory entitlement to sick pay. What percentage of staff in the areas SIPTU and Fórsa represent do they believe are in that category of precarious workers who do not have the statutory entitlements that many of the rest of us take for granted? Perhaps SIPTU can answer first.

Mr. John King

I thank the Deputy for the question. The reality is that healthcare workers and healthcare assistants who are employed directly by the HSE have a sick pay scheme and receive sick pay benefits under that. That is not the case in the private sector, particularly the private nursing home sector, where they do not have any advanced or reasonable collectively bargained pay, terms and conditions of employment that include sick pay schemes. That is also the case in the contract services sector, which does not deliver direct healthcare but does essential work to ensure healthcare can be delivered safely. This sector includes security, cleaning, private contractors and so on. The vast majority of them does not have a sick pay scheme. In such categories, there are very high percentages that do not have sick pay schemes.

Mr. Éamonn Donnelly

We have had a similar experience with regard to section 39 voluntary agencies representing workers without those type of protections. Within the HSE structure, we do not have experience of that in Fórsa. It is no new thing for healthcare workers to go in when they are sick during non-Covid times. They go to work when they have bad colds and that is normal. On this occasion, we were at greats pains to point out to people that, notwithstanding some of the choices one makes to go into work when one has symptoms, they must not present on this occasion. We were at great pains to point that out within the context of the public guidance.

Deputy Róisín Shortall

It is all the more regrettable that when we debated these issues last Wednesday in the Dáil, the motion to put a focus on the vulnerable nature of workers in the health sector in particular was voted down.

Deputy Richard Boyd Barrett

I thank all the contributors and pay tribute to Ms Murphy and all her colleagues for putting themselves in harm's way in very difficult circumstances to protect all of us over recent months. It seems from what the witnesses are telling us that the rhetoric we heard about the wonderful work of healthcare workers has not been matched by supporting front-line workers such as Ms Murphy in the way they should be supported. Listening to the witnesses' contributions, I find it shocking and frightening that they seem to be saying that healthcare workers on the front line are working unsafe hours with unsafe staffing levels and are being put under pressure to go to work even when they have underlying conditions, or for financial reasons. If that persists, we are in deep trouble if there is a second wave, as is likely, in the autumn. Is that a fair assessment of what the witnesses are telling us? I would like to hear from Ms Murphy on this. Does she feel the lessons are being learnt about what happened to her and the experience she has gone through? Are she and her colleagues prepared and, most important, are the HSE giving them the support to be prepared for what is coming in the autumn?

Ms Siobhán Murphy

First, I wish to point out that I am 27 years of age with no medical, previous or underlying health conditions. I unjustifiably contracted Covid-19 in the workplace due to, as was previously said, understaffing, being completely overwhelmed with the role of the nurse, extreme burnout and overexposure to the virus. I believe I was competent in my use of PPE; we had extensive training and education on the ward from infection prevention and control in the hospital on a daily basis, as PPE did change depending on supply.

On being prepared for a second surge, as nurses we are professionals. Speaking from the perspective of my own hospital, I cannot say that any of my colleagues presented to the ward with symptoms of Covid-19. There was a very clear pathway whereby a person isolated, he or she got a swab through occupational health in work, got his or her result and subsequently was off work for 14 days if not longer. In my case, it was for 12 weeks due to symptoms. Going forward, the psychological impact of Covid-19 has been detrimental to me and to my colleagues and I am sure I can speak on behalf of the nurses of Ireland when I say that. Being given a telephone number or an app to access from home for psychological trauma, for post-traumatic stress disorder, PTSD, which was mentioned, is just not sufficient.

We need significant debriefing going forward. Our mortality rate was incredibly high. We as nurses work to save lives but we were fighting a losing battle at the very start of Covid-19 and we do not want to see that again. I personally do not think I can walk into a workplace that is unsafe and that is how I felt at times, even though I was provided with PPE and I was, as I said, competent with it. To me, the workplace was a hazard. I ended up in hospital for a week due to my symptoms, which escalated out of my control and I had to be monitored and investigated as an inpatient in the hospital where I work, where just a week previously I would have been standing as a nurse at the bedside providing care to dying patients who succumbed to Covid-19. It was extremely traumatising and I do not know if any nurse could overcome that with just a number or an app. More needs to be done.

Deputy Richard Boyd Barrett

I wish to thank Ms Siobhán Murphy so much, on behalf of all of us, for what she has done.

Does she believe that lessons have been learned by the HSE and the Government from the rather harrowing experience she has clearly gone through? Does she get any sense that the problems will be addressed? What would making the situation different and better for her entail on the ground as a front-line healthcare worker in the autumn? Is it about more staff, working fewer hours, fewer periods of exposure and more support for the psychological impacts? I have a question for Ms Ní Sheaghdha as well, which must be quick as I am out of time.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

The Deputy's time is up.

Deputy Richard Boyd Barrett

Very briefly, what numbers do we need to recruit into the front line to be at safe levels for dealing with Covid and non-Covid healthcare come the autumn?

Ms Siobhán Murphy

To keep it brief, we definitely need increased numbers of staff nurses numbers permanently, not just agency staff that come in for a day here or there. We need to increase the number of nurses who are on a roster. We work seven days a week, 24 hours a day for 365 days a year and if someone falls ill, they have to be replaced. I will hand over to Ms Ní Sheaghdha for the remaining time.

Ms Phil Ní Sheaghdha

The figures we constantly quote are the figures that were in place before the first recession. We are still working with 1,000 fewer nurses today than we were in 2007 and the health service is much busier. In providing both Covid and non-Covid services, we need a minimum of 5,000 more nurses, including midwives.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Ms Ní Sheaghdha. I apologise for cutting across her but we are quite over time.

I thank Ms Murphy for outlining that post-traumatic stress disorder is a very serious clinical psychiatric condition and requires appropriate and urgent supports to try to help people through what can escalate and become a very difficult condition. Appropriate diagnosis at the earliest stage is key.

I thank her for outlining her experience so far. That phrase is also used too easily when it is a very specific clinical psychiatric diagnosis. It is very important that those at risk of acquiring it through trauma or developing it in the future get the correct diagnosis and treatment at the earliest stage in order that it does not escalate. I thank Ms Murphy for highlighting that.

I call Deputy Shanahan.

Deputy Matt Shanahan

I thank the witnesses, particularly Ms Murphy and all other front-line nurses. They have done an incredible job. At last Friday's committee meeting, I said that I thought a level of exasperation was quite evident over the course of the day. It has been evident at this committee for a while and is evident again here today. Anyone listening to the evidence and reading the submissions could not but be exasperated. We can all accept that there was a level of unpreparedness because no one knew what was around the corner.

What I am concerned with now is what we have learnt and what we are implementing before the winter. I have some background in infection control. Ms Ní Sheaghdha said the HSE asked for masks to be worn on 22 April. I asked for them to be mandated in the Dáil on 4 April. There were things we could have been doing regarding PPE. It was also stated that hand sanitiser is only available through one supplier. However, most of the distilleries in the country have been providing alcohol hand sanitiser, so there should be absolutely no reason not to have hand sanitiser in the healthcare sector. I encourage the unions that are present to get in contact with HSE procurement and to talk about these issues. I have worked with a number of companies in Ireland that are having great difficulty in bringing PPE into the supply network because of government procurement. These things must be addressed.

I have sat in hospital waiting areas and have looked at staff migrating through hospitals with their scrubs on, going down into community areas and back up to the wards. That must come to a stop, as must allowing public transit through all areas of a hospital. Infection control procedures must be put in place. They are the very first front-line policies, about which the witnesses must speak to the Minister very robustly.

I also previously mentioned temperature testing. Has the INMO any opinion on whether staff should be temperature tested before they start work in the morning, just as they are in other industries?

Ms Phil Ní Sheaghdha

There is no doubt that temperature testing has a place but we are more worried about asymptomatic presentations, that is, people who present with no symptoms but who are infectious. We and the other health sector unions have jointly asked the HSE to change its policy of advising staff who are close contacts of a case but have no symptoms to come back to work. We believe that is unsafe. We need swabbing and we need to know the status of workers. In the private sector, there is now mandatory staff swabbing but we do not have such a policy in the public acute hospital system. HSE officials will speak to the committee later and they will say, as they have said to us, that a swab is just a picture in time. However, we believe it is necessary because we know that asymptomatic workers in the private sector are being picked up as positive, and when they are asymptomatic and positive, they still pass the virus on to others. A temperature is one symptom that can have a number of different causes, but the swabbing of front-line workers must be mandatory in the acute service as well as the private sector.

Deputy Matt Shanahan

I agree with Ms Ní Sheaghdha wholeheartedly on that. I also previously brought up the donning and doffing of PPE at this committee and was told the HSE had provided videos on it. I was contacted by a nurse in Cavan hospital many weeks ago who highlighted the issue of donning and doffing of protective clothing and two weeks later, we had one of the highest spikes in the healthcare sector for that very reason. I again ask the witnesses to speak to the HSE about that because these are simple measures to implement. The very first priority is that workers need to be protected. Everybody accepts that. We cannot protect from everything but we can mitigate as far as possible.

The INMO should also talk to the HSE about more flexible rotas. Perhaps nurses should only do four hours on and four hours off, with some kind of alternate shift change to reduce the level of fatigue and thereby reduce the rate of infection. I applaud everything the witnesses are doing. I feel sorry for front-line workers who have been caught up in this and I also feel sorry that we are not learning from the mistakes of the past. I hope they will bring these matters to the Minister, as I also intend to do.

Deputy Michael Collins

I thank the witnesses before us today. I will address my initial questions to Ms Ní Sheaghdha. How early was testing carried out of residents and staff in care of the elderly facilities? Should it have commenced earlier? Did the failure to carry it out earlier lead to staff and residents being at higher risk?

Ms Phil Ní Sheaghdha

I thank the Deputy for the question. The swabbing of staff in the private sector followed the presentation of symptoms. If there were symptomatic presentations then swabbing followed. In the public sector in care of the older person services, it depended very much on the availability of swabbing facilities. For example, Cherry Orchard Hospital has a laboratory on-site and swabbed its staff who presented with symptoms. It had a very good experience, if we could call it that, of Covid. In other words, the infection rate was quite low and the transfer of the infection to other staff was kept at a minimum. It also enforced quite strictly the policy of self-isolation for 14 days.

Even though the HSE's policy was that close contacts could be derogated to return to work, Cherry Orchard Hospital took decisions not to implement this. I know this because I spoke to one of the assistant directors who felt it was very important not to derogate staff to come back when they did not know their status and had not been swabbed. We have requested this policy to be removed. Today, if a member of the public is a close contact he or she will be advised to stay at home and self-isolate for 14 days. This should be no different for health service workers.

Deputy Michael Collins

We still have situations in community hospitals where the HIQA standards on single bed occupancy have not been met. Did multi-occupancy rooms lead to the spread of Covid-19?

Ms Phil Ní Sheaghdha

Our members will say one of the lessons learned is that the isolation of patients whose status is unknown should have been dealt with earlier. This is very difficult to do if one is awaiting swabs and the results are taking a long time to return. This has improved. We certainly have a huge problem with the availability of isolation facilities in acute and long-term care settings. We need more isolation facilities. We know from our figures, which we count on a daily basis, that we have overcrowding at present in our emergency departments. We do not know the status of a lot of the patients when the areas are overcrowded. This is a recipe for disaster.

Deputy Michael Collins

I understand that Ireland has the highest Covid infection rate for health workers in the world and that one in every ten Covid cases reported involves a healthcare worker. Given that more than €1 billion will be spent on PPE in Ireland this year, how is it possible that healthcare workers did not have access to adequate supplies of it?

Ms Phil Ní Sheaghdha

The best evidence of this is from Ms Murphy, who was in that situation. She was fully protected with PPE and still got infected, as did 12 of her colleagues. It is not just about availability. Availability was a real problem at the beginning. That improved, largely because of the work of the trade unions in this room. We sought that face masks should be mandatory for all healthcare workers. That is the point. The point is there are other reasons, and the HSA is the agency that should be examining what those reasons are. The committee can recommend that it now gets on this pitch. We have been asking for it. The Irish Congress of Trade Unions has been asking for it. The workforce is saying this is really serious. This is a hugely infectious pandemic and the agency that is entrusted with workers' welfare and ensuring that workers are safe when they go to work is not on the pitch. That is simply not fair.

Mr. Éamonn Donnelly

I would like to comment on this. During the spike in April, when almost 6,000 cases occurred among health workers, the numbers caused by deficits in PPE were surprisingly low. Most of the transmissions were through the workplace in the work setting, as Ms Ní Sheaghdha said, in a very risky environment. We were speaking about swabbing a few minutes ago. A number of our people who would not be considered front-line workers and stepped into the front line to do swabbing got infected.

It is a highly contagious environment but the numbers of infections caused by inadequate PPE, or a lack of PPE, were surprisingly low in that April period. There was a huge problem at the outset and, as Ms Ní Sheaghdha said, the trade unions moved assertively to try to correct that. The totality of the work environment needs to be observed. I would not want anybody to think that if we bulk up on their PPE arrangements this will be okay because it will not. There are a number of factors.

Deputy Paul McAuliffe

A number of questions I identified have already been asked so I will not ask the witnesses to answer them again. It is interesting to look back at some of the contributions and the words used. Ms Murphy used the phrase "catapulted into" and Ms Monahan spoke about the context and what Covid-19 was like. Looking back on the time when this happened, obviously, there are things we could not have changed given the speed at which it came on us. It is, however, exceptionally important we learn those lessons now so any future change in the Covid-19 rate is protected, particularly on masks, which we are all sitting here wearing today. It was not just Ireland but the entire world that got it wrong about masks. We must make sure we do not make that same type of mistake in other areas.

I want to thank all the workers. I am on the record as saying we need to make sure it is more than just thanks. I have no doubt that when Ms Ní Sheaghdha and her colleagues meet the Minister today they will be forceful in terms of the obligation the State has to the workers who have protected us.

I want to turn to the vaccination on influenza. I have said for some time that I am quite concerned we are going to have influenza and Covid-19 at the same time and it will lead to economic difficulties. There will be isolation where it is not needed. Equally, there is an increased risk for patients and healthcare workers. Can the witnesses talk about the availability of the influenza vaccination at this moment for healthcare workers?

Ms Michele Monahan

I work in Connolly Hospital, where one is almost mugged to get it because there are people on every corridor offering it and asking why one has not taken up the offer. It is readily available in the acute sector for all healthcare workers. I will leave the private sector to Ms Ní Sheaghdha, but certainly in the acute public health sector we are hugely encouraged to take up the flu vaccine.

Mr. Éamonn Donnelly

To complement Ms Monahan's contribution, I was on a call with the HSE last week in which we were informed that while the word "mandatory" might be a little over-assertive, there will be a new vaccination with four dimensions to it rather than the usual three which every healthcare worker will be "expected to avail of". That is encouraging and the trade unions have their part to play there too.

I wonder about the decision to stand down the Citywest facility, where there were 300 beds that we went out and had a look at. The construction of that facility was a phenomenal piece of work that showed everybody what could be done. When the numbers were reduced in terms of Covid-19 surely it would have been a way of anticipating a flu surge, for example, from the autumn onwards. I thought it was a strange decision.

Deputy Paul McAuliffe

Given the availability of the flu vaccine, both for healthcare workers and, I understand, target groups - we have identified 1.9 million vaccines - the HSE does not seem to be progressing a population-wide programme with the objective that everyone in the population will have the same level of access that healthcare workers have. That will have an impact on the number of people presenting to emergency wards and will put pressure on healthcare workers. Have the unions given any though to the impact of that on the already depleted levels of staff?

Ms Phil Ní Sheaghdha

The numbers from last year's flu epidemic indicated that the pressure on ICU beds was significant.

We know that those who get very sick with Covid-19 require intensive care beds and that we do not have a surplus of those beds in this country. That indicates that the private hospital facilities must remain available to the public health service. The intensive care beds and units are already staffed and they have ventilators. They must be available.

The flu epidemic has been a feature of every winter and our hospitals have been extraordinarily overcrowded every year right into February. There is no indication that will be any different this year, but what will be different is that we will also have Covid-19. We will have to redouble our efforts to make sure we have the necessary capacity and staff available.

Trade unions, including the INMO, agreed over the past two winters that our members would engage in a peer vaccination programme. That is a policy of the HSE. In other words, if a nurse works in hospital A or B in the public or private sector, he or she can vaccinate his or her peers. Our members now vaccinate their colleagues to ensure the greatest possible uptake of the vaccine when it is available.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

The Deputy can have more time if he wishes.

Deputy Paul McAuliffe

No, it is fine.

Deputy Louise O'Reilly

I thank the witnesses, in particular those who have come before us and have been generous with their time. The SIPTU submission states:

There is no doubt that the experience of the pandemic has taught us many lessons. These experiences must form part of our planning for the future. In many cases, services were unprepared and did not have the essential equipment or training to support and protect healthcare workers in the fight against Covid-19.

My questions are on the basis of that assertion. How much better prepared will we be in the event that there is a second wave, as much as we hope that does not happen? Will we be better prepared? Do we have the requisite number of staff in place? Will the necessary equipment be available? I ask these questions in the context of what was referenced by Ms Ní Sheaghdha, namely, the flu.

I am on the record as having said that we have had a succession of Ministers for Health in this State who seem to be surprised when flu breaks out at the exact same time every year. In the context of the potential for an increase in hospital attendances because of the flu and the reduced number of beds that will be available because of physical distancing, is there additional capacity in the system to take up that slack?

Mr. John King

I will take that question. I thank Deputy O'Reilly. The intent of our submission and contribution today is to challenge policymakers and committee members, as legislators, to ensure that we are in a state of readiness. Some of the experiences we continue to have leave a number of unanswered questions. We need to make sure we do not repeat the mistakes of the past.

We do not need to wait for the flu to arrive in order to get ready for it. We know Covid-19 is here and that there is a real likelihood of a second wave. We have touched on the issue of staffing resources. The fact of the matter is that there are not enough staff at any grade. There are real issues there, in particular in the context of dual pathways. There are issues around equipment and so on, and Covid and non-Covid patients arriving into those kind of situations.

Deputy Louise O'Reilly

I will pause Mr. King there for a moment. Have the trade unions been involved in planning for a second wave? In that regard, have they had sight of the additional capacity we all know is needed? Have they had sight of the additional capacity the HSE has sourced? Has it sourced additional capacity? What has been the level of engagement in terms of preparation?

Mr. John King

I have not had sight of that capacity. I am not sure about the level of engagement, even in terms of the contribution made by Ms Ní Sheaghdha on the funded workforce plan. The HSE has consistently been behind in dealing with that issue.

The issues about staffing and whether we will have the people and equipment to meet the challenges that are going to come are of deep concern. The trade unions engage with the HSE at a senior level on a weekly basis and many of these issues are discussed. The real challenge is to ensure that the correct policy decisions are taken to enable those discussions to deliver meaningful outcomes.

Mr. Éamonn Donnelly

If I may, I will comment because I have been directly involved in the discussions to which Mr. King has referred. We have not had sight of any plan for a second wave is the explicit answer to the question. I earlier explained one of the reasons for that. When the national emergency struck, there was a command and control model and a mobilisation of the workforce to do something we had never done before. A second wave, if there is one, will come in different circumstances. On the positive side, we will be better equipped from the points of view of tracing and identifying contacts, and we know more about the illness. On the negative side, we have handed back 300 beds and do not have a workforce plan of which we have had sight. People would be wrong to think that it is possible to have a new command and control model that will have the same effect. The difference will be that there have been delays in cancer diagnostics for a number of months. Therapeutic interventions for vulnerable people have been delayed for a number of months and disability services have closed down for a number of months. The system will be unable to absorb that. We will go into a second wave while having to keep the other services I have mentioned open. It is beyond me how the HSE's Be on Call for Ireland initiative only yielded 125 staff members. That is staggering. It will not be possible to do the job and keep the health services live with an extra 125 people. If the civil and public service model and Be on Call for Ireland initiative are our staffing sources, those staff members need to go to areas of need. The HSE needs to get on top of that.

That is how we should prepare for a second wave. It is high time that preparation was tabled for discussion and not in a command and control manner. We should expect a second wave and expect to be able to deal with it alongside the provision of the rest of the health services.

Ms Catherine Keogh

I might come in on the question. There are two elements that to my mind seem to have been ignored. There is another front line about which people forget, namely, the front line in the community. Home help co-ordinators are represented by Fórsa and SIPTU represents home help workers who go into the home. They were the unsung heroes of the pandemic and kept many people out of acute hospitals. That element of the health service must be a part of any conversation about dealing with a second wave.

I also wish to draw people's attention to structural deficits that exist within the wider health service, including HSE hospitals, voluntary hospitals and section 38 and section 39 institutions providing disability services. As my colleagues have said, we now have a bit of time to plan how to properly approach a second wave. We must look at all those factors. We call on the HSE to do things, and that is important, but my colleagues who are involved in weekly meetings with the HSE know that we also need the voluntary hospitals, which are all independent bodies, to get on board. We need to bear those things in mind.

Deputy Louise O'Reilly

Ms Keogh is right that there must be a whole-of-system approach. Has Ms Ní Sheaghdha any observations to make?

Ms Phil Ní Sheaghdha

I have, and I thank the Deputy. The important point is that additional beds are needed and must be provided quickly. We are currently involved with a care of older persons service that has gone into liquidation. I do not think that case will be unique but will happen quite regularly, unfortunately. In its service plan last year, the HSE sought to remove 200 beds from care of older persons services. We wrote to the HSE and the Minister for Health objecting to that. We need to increase public service capability to provide care for our older persons. That must be a priority because we know that this virus has a much greater effect on the older population. Our population is aging. We also know that the flu takes a particular toll on our elderly population. For those reasons, we need to be increasing bed numbers in our care of older persons services.

We also need to look at ICU capacity. Three-month contracts were issued to staff to work in the health service during the pandemic and there is a constant requirement to repeat and seek approval for renewal of those contracts.

I have two comments to make on that. The first is that these should be directly hired. The second is that if there is any mention of another moratorium on hiring in the health service, we ask all Deputies who are listening to what is being presented today to oppose it.

Deputy Louise O'Reilly

There will certainly be very strong opposition to any suggestion of a recruitment moratorium from the Opposition benches. That is not acceptable. I was struck by what Ms Murphy said in her opening statement with regard to how she, in particular, and other staff are feeling overburdened, burnt out and overwhelmed. Those are very serious words. I sincerely hope the powers that be in the Department of Health and the HSE listen to those words and take them on board. If we are to face into a second wave, there has to be some acknowledgement of the residual impact of what all of us, but our front-line staff in particular, have just been through.

I will not ask Ms Murphy to comment on her own personal situation, but will she outline the residual impact with regard to any annual leave she or her colleagues might have used to take care of kids and what the impact of that will be as we head into a second wave? I also take this opportunity to thank Ms Murphy, Ms Monahan and all other front-line workers. The job they had to do for us was nearly impossible but they did it anyway.

Ms Siobhán Murphy

I have been off on basic-pay sick leave. It is counted as Covid sick leave so it is not taken out of my sick leave allocation for the year. I am, however, on basic pay so I am losing out on allowances for night shifts, weekends and bank holidays. We have had multiple bank holidays. My colleagues who have children have had to take annual leave to look after them at home. Again, they are on basic pay. It is not a choice. If I am sick, I am not going to walk back into the workplace until I am nearly 100% better. I have been told that could be October or November given what I have been through. I know the childcare issue is ongoing. I do not have kids myself but my colleagues do. That is a concern because it means more staff not on the floor because of the lack of childcare facilities. Again, their pay is affected.

Deputy Bernard J. Durkan

Like others, I compliment our witnesses on being here today, the replies they have given, and the tremendous work they have done throughout the Covid crisis. With regard to staffing levels, which has always been a sensitive issue, will Ms Ní Sheaghdha comment as to whether she is satisfied that nursing staff levels were increased proportionately when staffing levels throughout the HSE were increased? Did she feel that fewer nurses than other staff were appointed? Perhaps I can get an answer to that question first.

Ms Phil Ní Sheaghdha

The increase in the number of staff nurses, the front-line grade, has been quite modest. Some 230 were hired in the past year. We rely very heavily on our student population. We saw that during the pandemic when unqualified students were redeployed and worked as healthcare assistants while fourth-year students worked on the wards. Great thanks are due to them for doing so.

It is not a competition. The health service is short on staff at all grades, although most particularly those grades that work on the front line. We are certainly not satisfied that shortage is being measured properly. For example, staffing levels in services for the care of older persons are determined by cost of care, which is to say what can be afforded rather than what would provide the best outcome for patients. We now have two scientific policies, which have thankfully been adopted as Government policy. These determine scientifically the staffing, including the ratio and mix, required.

As I said earlier, in the acute hospital sector, 80% of staff should be nursing staff and 20% healthcare assistants. That kind of staffing results in better outcomes for patients. We are nowhere near that.

What the research into that scientific piece of work found is that it actually saves money because it increases attendance, cuts down on burnout and reduces the length of stay of patients because their outcomes are better, as the care gets to them quicker. We know what the answers are. We have the policies. What we need now is to ensure that the Department of Health, the HSE and the Department of Public Expenditure and Reform back it up and that they fund the workforce plans. They have to fund the workforce plans based on science, not availability of resources, because when it is based on availability of resources, that says to the front-line workers that the health service can only afford X number of us and we should get on with it. We do not accept that and we have never accepted it.

Deputy Bernard J. Durkan

Essentially, my question was to what extent Ms Ní Sheaghdha was reassured by the increased strength of general nursing staff in the period during which a considerable increase in health staff numbers took place throughout the country. Was she disappointed with the degree to which nursing staff increased or was she pleased that, proportionately, staffing levels in the nursing sector were adequately replenished?

Ms Phil Ní Sheaghdha

First and foremost, I do not believe that they were increased. We are working with 1,000 fewer nurses than we had in 2007, so they have not increased.

Deputy Bernard J. Durkan

That is not the case.

Ms Phil Ní Sheaghdha

We also know, for example, in the staff nurse grade, that since last December the increase, if one wants to call it that, was 238. We are still not at the 39,000 we had in 2007. We are more and more reliant on unqualified students to provide services when we know they should not.

Deputy Bernard J. Durkan

Out of the total number of new staff appointed before the moratorium, nursing levels were increased by a proportion. My question was and is whether that was sufficient or if it was lower than required. We believe that it was, but we have not seen the information to back that up.

Ms Phil Ní Sheaghdha

The HSE's statistics set it out, so the premise that they were increased is incorrect. They were not increased. We are still working with fewer nurses and midwives than we had in 2007, so they have not been increased.

Deputy Bernard J. Durkan

That is not true.

Ms Phil Ní Sheaghdha

It is.

Deputy Bernard J. Durkan

Deputy Colm Burke has already outlined the total number of extra staff employed by the health services. This is not a criticism of anybody. It is simply an effort to ascertain to what extent the staffing levels of nurses were increased, and whether that was in proportion to the general increase of 20,000 or whatever it was.

Ms Phil Ní Sheaghdha

Without labouring the point, I have the figures here. The total number of health service staff in January of this year in whole-time equivalents was 119,817. It depends on when one is measuring from. We are measuring from when we had 39,000 nurses. In the nursing category, between January 2019 and January 2020, the difference is 125. That still provides for a total number of nursing staff of 38,205 when we had 39,000 in December 2007, so we have not increased.

Deputy Bernard J. Durkan

I was not asking for a comparison with 2007.

Ms Phil Ní Sheaghdha

If Deputy Durkan is asking what is the proportionate increase, these are the HSE figures that are on the record: the number of consultants increased during that period by 172 and the number of registrars increased by 183. The biggest increase in the number of nurses was in the student nurse category and there were decreases in other categories. We know, for example, that the increase in the clerical and administrative grades, which my colleagues here represent, was 276. In the higher management grades, it was 309 for the same period that is reported upon. From a nursing point of view, we think that 125 in the staff nurse category does not come near what is required. It does not even replace those who are on maternity leave.

Those who are on maternity leave, for example, make up 3% of the entire workforce because 95% of nurses are women. We know we do not have enough replacements for maternity leave currently. What happens when a nurse is on maternity leave? The remainder work short.

Deputy Bernard J. Durkan

On the concerns expressed about staff in various situations throughout the country being reluctant to report with symptoms on the basis that they might be disadvantaged or that they might have competing needs, does SIPTU have documented evidence to that effect? If so, how widespread was that?

Mr. John King

We do not have documented evidence. We indicated to the HSE and the Department of Public Expenditure and Reform when they introduced that policy that it was wrong and could act as a disincentive. The context, in terms of what was happening in the HSE when that policy was introduced, does not reflect the context today in terms of testing capability and so on. One outcome of that policy and the ease with which people were being sent home and, in many cases, left at home for up to two weeks without being tested if they showed any symptom was that 97% or thereabouts of those sent home were shown not to have any symptoms. In those circumstances, people were financially penalised. The point of telling that particular story in the submission was not to labour that point but to say that policies such as that which serve to act as a disincentive when dealing with an issue like Covid-19 can be counterproductive. For this reason, we argue that such policies should not be in place.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I am struggling with that. It seems to me it would better to be sent home if there was a concern in relation to it. This session has been about concern for infection of healthcare workers.

Deputy Fergus O'Dowd

Fáiltím roimh na finnéithe. Tá jab an-mhaith déanta ag na daoine atá ag obair sa health service an t-am go léir. I have a question about the flu vaccine in preparation for the possibility of an outbreak of flu and the return of Covid-19. Do the witnesses' organisations have a policy on mandatory flu vaccination of all healthcare staff?

Ms Phil Ní Sheaghdha

From the INMO's perspective, we have a policy of promoting the uptake of the vaccine. We have a clear policy on that. The previous Minister for Health, Deputy Harris, sought legal advice, I understand, on the status of a mandatory flu vaccination and we await the publication of that advice because we have not seen it. My understanding is that there is some difficulty with the introduction of mandatory vaccinations and that the legal advice obtained by the Minister set that out. We have not seen it but we have a strong policy of promoting the uptake of flu vaccination. As I said, it is not only that but we have also agreed with the HSE a programme of peer vaccination, which sees our members providing vaccinations to their colleagues in their workplace to ensure the uptake is increased. Dr. Kevin Kelleher has confirmed to us that this approach improved the uptake significantly last year.

Deputy Fergus O'Dowd

What was the uptake last year?

Ms Phil Ní Sheaghdha

It was just over 37% in the grades of nursing and midwifery.

Deputy Fergus O'Dowd

Is that not quite low? I appreciate Ms Ní Sheaghdha's point. I understand the issue of legally challengeable orders and I welcome Ms Ní Sheaghdha's commitment for everyone to get vaccinated.

Ms Phil Ní Sheaghdha

Promotion, yes.

Deputy Fergus O'Dowd

We all need to do more to ensure 100% uptake among those working in a health environment, particularly with vulnerable people and anybody in hospital is vulnerable in one way or another.

How can we accelerate uptake, notwithstanding the legal issue Ms Ní Sheaghdha raises? I accept her point on legal advice but what can she say on the medical issue?

Ms Phil Ní Sheaghdha

There are two things. One is that the statistics we have, and the HSE has accepted this, only reflect those who have been provided with the vaccine in the public sector. As such, we do not know if people go to their GP or get the vaccine elsewhere. It is our view that the figure is much higher than that and if we measure across the healthcare worker grades, public and private, it is higher. The simple point is the flu vaccination is promoted strongly by the INMO and it is our policy to promote it. We have also agreed that to promote uptake our members will participate in ensuring that healthcare staff do not have to travel to get the vaccine and will get it as close to their workplace as possible. That has proven positive.

Deputy Fergus O'Dowd

Research was recently published by the University of Edinburgh on the prevalence of Covid-19 in nursing home environments in particular. It referred to the high footfall of staff, including agency workers, cooks and maintenance engineers, going in and out of the largest homes. This is thought to be a key factor in the infection of elderly residents. I appreciate that Ms Ní Sheaghdha represents the nursing profession. Does Ms Ní Sheaghdha know if any analysis has been done to show what proportion of the people infected are agency nurses? Is that an important point to make or follow up on?

Ms Phil Ní Sheaghdha

There are a number of questions that we a have sought answers to from the HSE and that is one of them. We know, for example, that the statistics produced weekly by the Health Protection Surveillance Centre - this only started in the past month because the INMO sought these figures - do not demarcate the numbers beyond the broad categories of "nurse", "healthcare assistant", "doctor", "porter", "other healthcare workers" and "unknown". As such, we have asked for information to allow us to determine where the areas of most risk are. We know now, for example, that 34% of all of the infections are among the nursing grades. We have asked for a breakdown between public and private and also figures on those who are fully equipped with PPE, such as Ms Murphy who worked on a ward with 19 others, all of whom were wearing PPE and 12 of whom contracted Covid-19.

Deputy Fergus O'Dowd

I understand the Ms Ní Sheaghdha's point. That is why I raise this research which is, I understand, the first academic research concentrating on the issue. What it found is that in larger care homes - I am not speaking about acute hospitals - the likelihood of infection is 20 times higher than in smaller care homes. As such, my question for Ms Ní Sheaghdha is one that concerns me a great deal. It relates to the regulations for care homes and qualified or professional nurses. There is no relationship between the number of dependent or high-dependency residents and the need for professionally qualified nursing staff. That is a serious concern to me. It is unacceptable that there would not be an appropriate and proportionate ratio of high-dependency residents to qualified nursing staff and other qualified persons as well. Does Ms Ní Sheaghdha have a view on that?

Ms Phil Ní Sheaghdha

We do. It is a very strong view and we have made a number of submissions to Government in respect of it. We need dependency level staffing. We need staffing based on the scientific evidence that determines what is the best outcome for the patient. We have a cost of care model in Ireland. The INMO absolutely rejects it. We also have a real problem with the staffing levels in the private sector where pay rates and collective bargaining for trade unions are not facilitated. We are dealing with many of our members who work in the private sector who have terms and conditions of employment much different from members in the public sector. They are also trying and struggling to provide the service that is needed because there are not enough of them. It is not unusual to have one nurse for 30 patients. We saw the evidence of that during the pandemic. The ability to provide correct and safe staffing levels does not exist at the moment in the private sector.

That is unfortunate. We have called on HIQA to comment on staffing levels on numerous occasions. Right now, we need a Government policy that confirms that staffing levels in the acute sector and in the care of older persons, both public and private, must be based on the dependency levels of the patient. There is a tool for achieving that, which is Government policy. The Government has stated that it will fund it, but we have not seen any evidence in that regard. The funded workforce plan is required and we need engagement with the Departments of Health and Public Expenditure and Reform on it. The Deputy is correct because it needs to be based on science.

Deputy Fergus O'Dowd

I have a relative-in-law who is in a nursing home. He is being looked after extremely well and there is a very good mix of people working there. The problem is that when people are selecting a nursing home, they look for one near where they live and they do not know anything else about it. They go in and sign the contract of care, but there is no mandatory requirement on the nursing home, whether public or private, to say what its staffing levels are or whether there are other ancillary services such as speech therapy, physiotherapy, and so on. One will always find there is a charge of €10 or €20 a week for something that many people cannot avail of because 70% of the people in our nursing homes have dementia. There is a huge lack of transparency about the €60,000 or more that people pay for their care. People say the buildings are fine and they often look lovely, but the quality of care varies significantly.

I welcome Ms Ní Sheaghdha's comments and I suggest that if she has other views on the matter that she has not expressed, she should do so and we may include them as recommendations in our report. Until we get that certainty, quality of care and proportionality between qualified staff and medical and nursing need, there will not be proper and adequate care in these institutions.

Ms Phil Ní Sheaghdha

We agree wholeheartedly and believe that the private for-profit model is the incorrect one for our older population. We have made submissions to this committee and to the Joint Committee on Health in the previous Dáil on this matter. We raised the 200 beds that were earmarked to be taken out of the public sector last December in the service plan right across the political spectrum, with the HSE and with the Department of Health. The model in this country is to privatise the care of the older person, and that is the wrong model. The State has to provide care for our older population and base the number of nurses, healthcare assistants and other staff on the dependency level of the patient, not the for-profit and the cost of care model, because that model is incorrect.

Deputy Fergus O'Dowd

I totally agree with what Ms Ní Sheaghdha is saying. That is the future for good, high-quality healthcare.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank the Deputy. This committee is producing a report on Covid-19 in nursing homes, which will be circulated to members, and we will discuss it in a Microsoft Teams meeting on Thursday. If the witnesses want to make additional contributions on that matter, now is absolutely the time to do so.

I will ask the witnesses a few questions of my own. I return to the issue of preventing people from getting the flu. There is a contradiction in being able to present for work and the risk of Covid-19. What are the witnesses' views on making the flu vaccine mandatory? Ms Ní Sheaghdha talked about promoting it and she said she thought the real figure was higher than the stated 37%. In what circumstances would a healthcare worker not wish to have the flu vaccine? Is there something that is preventing people from getting it?

Is there something we are not aware of that would make it difficult to make it essential, if not mandatory, which has a different regulatory implication?

Ms Phil Ní Sheaghdha

I thank the Acting Chairman for the question. The first issue is whether the health care worker, no more than any other member of society, has an underlying health condition whereby a flu vaccine would be contraindicated.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

Will Ms Ní Sheaghdha give an example of this? What underlying conditions?

Ms Phil Ní Sheaghdha

That would depend on the underlying health condition. From our perspective, we are very clear on this. We promote the uptake of the vaccine to the healthcare workers we represent.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Ms Ní Sheaghdha. She did say that. I will be more specific in my question, if she does not mind, to help me with my own understanding. Will Ms Ní Sheaghdha name one or two conditions that are contraindications? Is diabetes a contraindication? Will Ms Ní Sheaghdha name one or two conditions where there is a contraindication with the flu vaccine?

Ms Phil Ní Sheaghdha

My understanding is that it is allergy based and it depends on the particular allergy and on the vaccine produced. As my colleague from Fórsa said earlier, the vaccine this year is slightly different to the vaccine last year. This is a constant matter that people must discuss with their GPs. The point is that my view, and the view of the union representing nurses and midwives, is that healthcare workers, nurses and midwives are encouraged to get the vaccine. It is promoted. They go further than this because they also contribute to the uptake by ensuring other healthcare workers can have the vaccine in their place of work and we provide this to them.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I fully understand and respect that. I am just trying to understand how the list of contraindications is communicated on an annual basis, how clear it is and what those barriers are. I totally respect there are some barriers for some people. Of course, the issue is that a healthcare worker who gets the flu will be deemed, I assume, to be at risk of having Covid-19 given the overlap of the symptoms. We have discussed today the risk of infection of Covid-19 for healthcare workers, and we have also discussed with Mr. King people staying home for various reasons or being required to self-isolate, and there is a clear overlap. What can we do additionally this year to try to ensure people get the flu vaccine?

Ms Phil Ní Sheaghdha

The HSE has done a good job of promoting the vaccine. We would encourage an escalation of this, have it done earlier and more broadly, and educate people about the nature of the vaccine and the type of vaccine it is. There is huge concern among the population, and we hear it every year, about vaccines in general. We do not subscribe to this. Our members who work as public health nurses are on the front line of providing childhood immunisation and meningococcal vaccinations. We promote vaccines. We believe the health service must give correct information and contradict, perhaps, the information out there that is not based on science.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I agree completely with Ms Ní Sheaghdha on this.

Mr. John King

I do not want to be repetitive but just to say the responses given by our colleague, Ms Ní Sheaghdha, on the work all of the unions do to encourage the uptake of the flu vaccination is also something we promote and advocate in SIPTU.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

That is great.

Mr. John King

With regard to the specific question raised by the Acting Chairman on the flu vaccination in the context of a second surge of Covid-19, we intend and hope to have intensive engagement with the HSE on this.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank the witnesses.

To go back to some of the data from the HPSC, it may have been helpful to set out very clearly at the outset that we have all been using the same data from 11 July. Of the 26,076 Covid cases, 8,347, or 32%, were healthcare workers, with 319 hospitalised, 49 admitted to ICU and, very tragically, seven deaths. We are agreed that 30% of the cases were in nursing homes, residential institutions and community hospital long-stay units. We are all working from the same figures. Only 8.6% of cases are linked to an outbreak in a hospital. I wanted to set out these figures. In another submission, we have information that the difference between hospitals and the other settings is likely due to more robust supply chains for PPE in hospitals. I am very sensitive to the presence today of Ms Murphy who, along with her colleagues, was using PPE but contracted Covid-19 at some point. She said that 12 out of 19 of her colleagues contracted it in circumstances where they had been using PPE in a hospital. I want to ask a policy question and perhaps come back to Ms Murphy afterwards.

We have separate data which show that 56% of our nursing homes have no cases of Covid-19. Can we talk about those congregated settings or those intensely populated settings? We also have the prisons and the Central Mental Hospital where there have been no cases. Has any of the unions received feedback from members in other settings about how they managed those protection processes better or was it something else?

Ms Phil Ní Sheaghdha

I have been in direct contact with the Prison Service. I said at the last presentation to this committee it is to be commended in respect of that fact the prison population was protected to such a degree. That is not an accident. That is a policy where temperatures are taken and where all the precautions prior to attending work are to ensure one is not in any way symptomatic.

In the health service, by contrast, the big issue we had was with the derogation of staff who were asymptomatic but had been notified as close contacts. A person could get a phone call to say he or she is a close contact and should self-isolate for 14 days. That person could then get a call to say we are very short-staffed and he or she must come in. If the person is asked if he or she has a temperature and says "No" they are asked to come back to work. That flies in the face of the public health advice. We have sought the removal of that policy. That policy is still there and no healthcare worker should be derogated by a manager to return to work because they are short-staffed even though they have been a close contact and have not had a test. It is simply wrong.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

How long is it taking at the moment for healthcare workers to get results of test? Are they all back at this stage within 24 hours for healthcare workers?

Ms Phil Ní Sheaghdha

It is much quicker. It has improved significantly but again, it depends on where one resides and where one has the test. In general terms it is very quick.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

Ms Ní Sheaghdha mentioned that Cherry Orchard Hospital had a laboratory playing a positive role. Are all the acute hospital laboratories being used in this way? Is there any update on that?

Ms Phil Ní Sheaghdha

All of the laboratories facilities are working flat out. My colleagues in SIPTU might be able to give the Deputy a better indication as they represent the laboratory staff.

Mr. John King

In all fairness, that is correct. All of the laboratory facilities are working flat out. As Ms Ní Sheaghdha said, and as is evidenced in some of the contributions we received back from our own members, the situation as it is today is much improved from what existed at the outset.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

This may be a question better targeted at the HSE at the second session this afternoon but I will elicit an opinion from Ms Ní Sheaghdha's own perspective. At this stage, have all the student nurses who will qualify this year been offered full-time positions that are not via agencies? Have other healthcare professionals like physiotherapists, occupational therapists and all those who are coming out of universities this year been offered positions?

Ms Phil Ní Sheaghdha

We have an agreement that they will be offered positions but it is still a process that has not been completed. The important thing for the student nurse population is that, from our survey, many of them were traumatised by the experience of going through Covid-19 without supports. We really must make sure they do not leave the profession before they qualify. That is my aim right now. We are trying to get the HSE to understand it must support the student nurses who are in training because 1,700 of them are graduating this year and we need every single one of them to remain in the public health service.

We are short of our colleagues who come and help us every year from the Philippines and India. We have a reduction in the number of registrations which I presented at the last committee. The Nursing and Midwifery Board of Ireland, NMBI, figures show we are quite significantly reduced from this time last year. Every year the health service and private and public sector relies on overseas recruitment to supplement our workforce. We need to make sure that when they qualify our students are protected, supported and have permanent jobs.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

We are learning more and more every week and some weeks ago Dr. David Nabarro spoke to the committee about the long-term implications of having had and having recovered from Covid-19. He has recovered loosely because one of the ongoing features is long-term fatigue. Ms Murphy alluded to that initially and I may come back to it. From a policy perspective, does Ms Ní Sheaghdha feel there is a need now to review the work rosters or structures so the 12-hour shift arrangement recognises the ongoing nature of fatigue in this illness?

Ms Phil Ní Sheaghdha

What is required are frequent breaks within the roster and that is what the WHO tell us. We need frequent breaks. Ms Murphy is better able to describe this than I am.

What is required is that when someone is working and wearing PPE, he or she should be frequently relieved to hydrate and get a break from wearing it. Those committee members who have experienced wearing masks for the first time will understand that it is not very comfortable and one feels quite restricted. They can imagine what it is like wearing PPE for four hours and then being relieved for a break. The break period is the important point.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

As a simple example, I have had to take three breaks from wearing my mask to have some water. I totally respect what Ms Ní Sheaghdha is saying. I will deliberately put policy aside as I come to Ms Murphy. I am last with questions, and that is why I have left what I want to say until the end of this session.

The committee has had 16 public sessions and it is my understanding and that of the secretariat that Ms Murphy is the first person to come before the committee who has survived and recovered from Covid-19. It is remarkable that it has taken this long for us to speak to somebody who has had Covid-19. I thank her for coming before the committee. I do not want to ask her overly personal questions about her experience of the illness, but I recognise that her colleagues, including people she knows well, have had similar experiences.

For the benefit of the committee, the record of the House and those who may be watching and thinking about their movements and interactions with other people, I ask Ms Murphy to give us a sense of her general experience, and that of her colleagues to whom she has spoken, of having the illness.

Ms Siobhán Murphy

I thank the committee for giving me the opportunity to be here today and to share my experience. I am sure what I will say today will resonate with a lot of nurses across the country. I hope I will have made some impact on how we can improve the service if, God forbid, there is a second surge.

We went from being a 31-bed surgical ward to a Covid-positive only ward overnight. Only Covid-positive patients were admitted to our ward. We took on the task of the full multidisciplinary team as it did its remote reviews of patients. We were on the ward, at bedsides, 24 hours a day. It was an honour to care for patients. We love our job; that is why we are there. We bridged communications between patients and families using iPads, something we never had to do previously. The list is extensive; I could go on and on.

I will discuss the biggest change for me and my colleagues who contracted Covid-19. I contracted Covid on 30 April, six weeks after we became a Covid ward. I became a statistic when I tested positive for Covid-19. Initially, I was upset and quite angry, and that was the experience of my colleagues across the board. As I said, I followed hospital protocol and was competent in the use of PPE, but the emotions I initially felt were buried by the physical impact of Covid-19. I was crippled with fatigue, bed bound with headaches and had extreme shortness of breath, which caused great distress as I felt like I was suffocating. Many of my colleagues had the same symptoms.

I could not talk to my family or friends over the phone. I was in complete isolation. I lost my sense of taste and smell. Simple tasks such as washing and dressing or making a snack for myself were unachievable as I was completely debilitated. I presented to the emergency department about a week later because I was deteriorating at home. I was terrified. I have no underlying conditions, as I said, so it was a huge shock for me to be a patient in the emergency department in the hospital that I work in.

I was subsequently admitted for what I thought would be one or two nights' observation, but I was kept in for a week. I had a series of blood tests. I underwent a chest X-ray and a CT scan of my lungs, kidneys and other organs to rule out any damage that can be caused by Covid-19. As I said, there is no pattern. I was on a heart monitor 24 hours a day for six days because my heart rate increased to 170 bpm. Medical staff told me this was one of the post-viral effects of the illness.

I was negative for coronavirus at that stage but still had post-viral effects. The normal heart rate would be 60 to 80 bpm. I was on intravenous fluids to rehydrate me and received daily injections to ensure that I did not develop a blood clot which my experience as a nurse tells me can be potentially fatal. That was a worry.

The days and nights were extremely long in isolation. My concentration was massively affected and I was unable to pay any attention to a television that was playing in the background. I was relieved to get home about a week after I was admitted. Recovering in isolation is challenging both physically and mentally, as I have stated. I was unprepared for the psychological impact of contracting and living with Covid-19. It has definitely prolonged my road to recovery but I know I will get there and, hopefully, go back to work with my health at 100%.

For the first time, I experienced acute anxiety and panic attacks. I have ongoing insomnia. I can sleep for eight hours some nights but others I only sleep two to three hours, and I do not know why. I had vivid hallucinations at the start, as did some of my colleagues. That is not spoken about as a side effect. Everybody tends to speak about the physical signs and symptoms but the psychological effects, as I have said, are just as detrimental to recovery.

Twelve weeks on, I still have not returned to my pre-Covid health and still experience some fatigue. I will be fine one day and have to take an afternoon nap the next. Shortness of breath comes and goes. I am awaiting a lung function test to rule out a lasting impact from Covid. I am also very lucky that I have had physiotherapy input. I liaise with the hospital physiotherapy service to regain my strength and that will help to get me back to work eventually.

Acting Chairman (Deputy Jennifer Carroll MacNeill)

I thank Ms Murphy for outlining that for us; the committee really appreciates it. It is probably appropriate to leave it there for this session. I again thank Ms Murphy and all the witnesses.

Sitting suspended at 12.22 p.m. and resumed at 12.47 p.m.