Covid-19: Final Report of Nursing Homes Expert Panel (Resumed)

We are back in public session. I welcome officials from the Department of Health and the representatives from the HSE to continue our consideration of the Covid-19 expert panel's report on nursing homes. From the Department of Health we have Dr. Kathleen MacLellan, assistant secretary, who is presenting from committee room 2. Dr. MacLellan is very welcome. By video link we have Mr. Niall Redmond, who is a principal officer in the Department. From the HSE, and also in committee room 2, we have: Mr. David Walsh, who is the implementation lead; Dr. Siobhán Kennelly, who is the national clinical and advisory group lead for older persons; and Ms Sandra Tuohy, assistant national director of services for older people. I welcome the witnesses.

Before we commence the formal proceedings I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter they must respect that direction. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

I invite Dr. MacLellan to make her opening statement. If Mr. Walsh has an opening statement or wants to make opening remarks, he will have an opportunity to speak after Dr. MacLellan. I ask that opening statements be kept to five minutes because we are operating to a strict two-hour sitting today.

Dr. Kathleen MacLellan

I thank the Chairman and members. This year, 2020, has brought with it the most serious global pandemic in a century. Since the emergence of Covid-19, there have been more than 28 million cases of the disease worldwide. Some 30,500 of these have been in Ireland and, very sadly, 1,781 people here lost their lives.

Nursing homes are where more than 30,000 of our citizens call home. Residents of nursing homes are vulnerable because of their age, underlying medical conditions, the extent of their requirement for direct care involving close physical contact and the nature of living in congregated settings. Nursing homes have been particularly impacted upon by Covid-19, both in Ireland and internationally. For the past six months, nursing home residents, their friends and families have sacrificed the normal daily social and person-to-person interactions. It is with great sadness that I say that 994 nursing home residents lost their lives as a result of Covid-19.

It is essential to recognise the continued and determined professional care provided by healthcare workers in nursing homes 24 hours a day.  It is also important to appreciate that approximately half of nursing homes remained free of Covid-19 and that many of the nursing homes which did experience an outbreak managed very well. The central focus of the response of the National Public Health Emergency Team, NPHET, has been to control the spread of the virus insofar as possible to protect those who are most vulnerable from infection, as well as protecting against causes, situations, circumstances and behaviours that may lead to the spread of Covid-19.

New cases, both across the whole population and in nursing homes, have steadily declined over the past few  months. Unfortunately, we are now seeing a gradual change in the epidemiological situation and nursing homes have not remained unaffected. Since the start of pandemic and as of 10 September 2020, there have been 281 clusters in nursing homes. More than 85% of those clusters are now closed, with 39 remaining as open clusters. The open clusters are in areas of high community Covid-19 transmission, including 27 in the east of the country, ten in the mid-west and two in the north east. In the 14 days prior to 10 September, the Health Protection Surveillance Centre, HPSC, advised the Department that 1,997 new confirmed cases had been notified, with 10% of those cases involving people aged 65 years and older. There have been four new clusters in nursing homes in this timeframe.

  It is of great concern that heightened community transmission may bring further unwitting transmission of Covid-19 into nursing homes, thereby impacting on those most vulnerable to the virus. Therefore, sustained communication and inter-agency co-operation must remain central to the response to the virus. Extensive ongoing and problem-solving collaboration between Nursing Homes Ireland, the HSE, the National Treatment Purchase Fund, the Health Information and Quality Authority and the Department continues. The State's responsibility to respond to the public health emergency created the need for the HSE to ensure a structured nursing home support system was in place in line with NPHET recommendations. This has been a critical intervention in supporting the resilience of the sector in meeting the unprecedented challenges associated with Covid-19. Guidance, personal protective equipment, staffing, serial testing, infection prevention and control training, accommodation and financial support have been provided to the nursing home sector, both public and private. In addition, multidisciplinary clinical supports are in place at community healthcare organisation, CHO, level through 23 Covid-19 response teams. 

HIQA has designed and implemented a regulatory assessment framework of the preparedness of designated centres for older people for a Covid-19 outbreak. In addition, the authority is in the process of developing an infection prevention and control assurance framework for nursing homes, which will include a self-assessment tool for nursing homes and will be supported by an outreach training and support programme by HIQA. 

In continuing to monitor the national and international experience of Covid-19 in nursing homes, NPHET outlined its clear view of the need to ensure that all actions that can be taken are taken to protect residents of nursing homes.  NPHET therefore recommended, on 23 May, that a Covid-19 expert panel on nursing homes be established by the Minister for Health. This panel was tasked with providing immediate real-time learnings and recommendations in light of the expected ongoing impact of the virus over the next 12 to 18 months. The panel has submitted its report to the Minister for Health, which included a substantial package of recommendations across 15 thematic areas. It contains 86 recommendations, with associated timelines, for implementation over the short, medium and long term by the HSE and associated agencies with responsibilities in this area. The report, which was published on 19 August by the Department of Health, also contains a specific chapter on the model of care.

The Department has strongly welcomed the report and is fully committed to progressing its recommendations. The Minister for Health has already established an implementation framework which will ensure a priority focus on key short-term public health and protective measures for nursing home residents over the coming months, with a particular emphasis on winter and ongoing preparedness against Covid-19. The framework includes an implementation oversight team and a reference group. The oversight team has met twice already and will report monthly to the Minister to outline progress and any challenges for escalation. The reference group will hold its first meeting next Monday.

Early progress on some recommendations has been made, including the commencement of a costing exercise, an additional funding allocation for infection prevention and control, plans to test the safe staffing framework, an ongoing commitment from the HSE and HIQA to implement the public health measures, commencement of the design of a visiting guidance framework, commencement of a review of the current HIQA regulations, and ongoing serial testing in nursing homes.

In conclusion, the Government's plan for living with Covid-19 places an important focus on supports for the nursing home sector. These supports include the continuation of the Covid-19 response teams, implementation of the safe staffing framework, an extension of the temporary financial support scheme and progression of the implementation of the expert panel recommendations, with particular focus on those recommendations requiring urgent and immediate attention in order to ensure all available measures to protect this vulnerable cohort are taken.

I thank Dr. MacLellan. I invite Mr. Walsh to make an opening statement if he so wishes.

Mr. David Walsh

I have a short opening statement. I thank the Chairman and members for the invitation to meet the Special Committee on Covid-19 Response. As noted, I am joined by my colleagues, Dr. Siobhán Kennelly and Ms Sandra Tuohy.

I wish to begin by taking the opportunity to again express my condolences to the families and relatives of those deceased as a result of Covid-19 and, in particular, those who were residents of nursing homes.

The Health Service Executive welcomes the publication of the report of the COVID-19 Nursing Homes Expert Panel Examination of Measures to 2021. The HSE is committed to working in partnership with the relevant public and private agencies to implement the recommendations within the report.

The report recognises the unprecedented effort made to support long-term care facilities and their residents, and the immediate responses put in place to support them whether under public, private or voluntary governance. These supports must now become more permanent in nature and work to achieve this has commenced across many of the recommendations. In particular, infection prevention and control infrastructure, PPE, Covid response teams and enhanced clinical supports are an immediate priority. The HSE winter plan, which is currently being finalised, will reflect how these supports will be embedded within services.

The continued development and implementation of the HSE's integrated care programme for chronic diseases, the integrated care programme for older persons and the further development of community healthcare networks, in partnership with general practice, form essential supports to all those who are vulnerable in our communities, including those in long-term care. As already mentioned, we have commenced work on the HSE actions in the report, and will work with the Department of Health and other partners to implement the recommendations that require either policy change or policy development. A comprehensive approach to addressing the future of how older persons' needs are met will require a whole-of-government and a whole-of-society approach with significant development of, and investment in, alternative care and housing models required.

The surest way of protecting residents in long-term care from Covid-19 is to work with communities to suppress the virus in the community. The public health advice and guidance to the population as a whole, along with a comprehensive testing and tracing strategy, form the core of the protective measures against this disease. The earlier phases of this pandemic showed clearly that where the virus is prevalent in the community the risk to those in long-term care in those communities rises commensurately. Suppressing the virus in the community protects everyone in that community.

In conclusion, I reiterate the support and commitment of the HSE to the implementation of the recommendations of this report. That concludes my statement.

I thank Mr. Walsh. Today, we meet in the Seanad Chamber. I remind members and witnesses that this session of our meeting must finish at 2.30 p.m. as the Seanad Committee on Procedure and Privileges is due to meet here at 3 p.m. Therefore, I must be very strict with people about time, including with myself who, as the first questioner today, has ten minutes. Can I assume that all of the witnesses or the key witnesses have read both the HIQA report and the report from the expert panel group? Yes.

Dr. Siobhán Kennelly

Yes.

I shall first direct my questions at Mr. Walsh. The HIQA report relays and outlines concerns that were expressed by the chief inspector in terms of nursing homes. Some of the concerns were as follows: the absence of clinical governance in most nursing homes; staffing levels not what they should be; a difficulty in maintaining staffing levels in the event of sudden and unplanned absences; the availability of resources such as PPE; access to specialist expertise; the layout of centres; and a history of non-compliance with relevant key regulations. As people will know, 39 of the 44 centres did not comply with more than one of the measures.

Some of Mr. Walsh's colleagues were before this committee facing very tough questioning from its members. Senior representatives of the Department and HSE were playing down some of the issues arising in nursing homes and the fact that there was not a plan. Some of the issues being raised regarding access to personal protective equipment and the structural arrangement between the HSE, the Department and nursing homes were not as dramatic as made out. How does that now sit with the two reports we have, which clearly demonstrate there were failures and that we need to see very substantial changes in the clinical framework, governance and the relationship between the Department, the HSE and nursing homes? In Mr. Walsh's own words, could he explain the position of the Department and the HSE on the two reports, the recommendations therein and the issues that arise from them?

Mr. David Walsh

I will speak from the perspective of the HSE. The HSE clearly notes and supports the recommendations in the expert group report, which puts an onus on us all collectively to further develop and enhance the levels of interaction and support across acute hospitals, community services within the HSE, and the private and voluntary sector. Some of the developments over recent years within HSE services, including the integrated care programme for older people, of which Dr. Kennelly has been clinical lead, show the direction in which we now need to accelerate.

May I put a direct question to Mr. Walsh? One of the key issues arising from both reports concerns clinical governance and the role and authority of HIQA to examine issues in nursing homes. I am not sure whether Mr. Walsh saw the hearing last week when we had HIQA representatives before us. They outlined to us the many exchanges they have had with the Department, the HSE and Ministers calling for more powers, better regulations and changes to the Health Act. They have subsequently sent us a detailed note cataloguing all their requests, all of which fell on deaf ears. When the questions on poor clinical governance and the lack of a strong relationship between the HSE and nursing homes were put to the HSE, they were knocked back by very senior representatives of Mr. Walsh's organisation. Now that both reports have identified clinical governance weaknesses, people will want to know what the HSE and the Department are going to do about them. That is a very direct question for Mr. Walsh, and also for the Department.

Mr. David Walsh

I thank the Acting Chairman for that clarification. The HSE is fully committed to implementing recommendations in the expert review. The HSE does not have a role in regard to HIQA bar being regulated by it. At all times, in respect of HSE units, they are subject to-----

If that is the case, we need to go to the Department. We need to know if the system, whether it involves the HSE or the Department, will take the bull by the horns and deal with the issue of clinical governance once and for all. I do not have the time to go through the lengthy letter we got from HIQA that contains a long list of requests that have gone unanswered. Will the Department state whether we are going to get to a stage where we will improve clinical governance arrangements in nursing homes? Whose job will it be? Perhaps the Department will be able to answer that.

Dr. Kathleen MacLellan

I thank the Acting Chairman. The implementation oversight group has been established by the Minister for Health.

We know that. We know the groups that exist. We can have all the implementation groups in the world but we need to know whether there is a commitment by the Department to deal comprehensively, once and for all, with the clinical governance deficit in nursing homes and between HIQA and nursing homes. Is HIQA going to get the necessary powers in this regard?

Dr. Kathleen MacLellan

The straight answer is "Yes". There is a significant commitment, by both the Department and the Minister, to implement the recommendations.

While not picking out any recommendations, there is commitment to implement those with regard to clinical governance and supporting the HSE with the Covid-19 teams. The report did, however, point out that clinical governance responsibilities in the first instance are with the individual owner, as well as the person in charge, and with that they need support through the HSE. There is a commitment in the expert panel recommendation for that. We are committed to providing a framework around clinical governance, as well as engaging with GPs in building and enhancing their role in providing support for clinical governance across those nursing homes.

Is it the case then that the model being examined is that there will be an agreed clinical guidance framework, in which the Department will have a role in framing, and the responsibility for delivering that will be with the individual nursing homes? Will there be any role for HIQA in respect of that?

The most distressing parts of the two reports were the testimonies from family members and relatives of loved ones who passed away or who had experiences of being in nursing homes during a difficult time. We all accept that. It was difficult for the staff in those nursing homes as well. One issue which arose was that HIQA does not have the power to examine individual cases of neglect or abuse. We have seen several such cases raised in this committee, on the floor of the Dáil and elsewhere. There seems to be a weakness in that it is not clear how those individual cases can be dealt with. There is much to be learned about Covid but there are also those issues.

I thank Dr. MacLellan for her explanation of the framework. Those individual issues are rare. Most nursing homes provide an excellent service, as do most of the staff. However, when those instances of abuse and neglect occur, they need to be ruthlessly dealt with and there has to be a process in place. Does the Department support giving HIQA more powers to deal more comprehensively with those types of issues?

Dr. Kathleen MacLellan

The Department fully supports enhancing and building the powers of HIQA, as has been recommended by the expert panel report. Indeed, we have set up a bilateral project group to work across the Department and HIQA examining which of the regulations need to be strengthened, what powers could additionally be assigned and how quickly we can do that.

We work closely with HIQA and meet with the authority on a regular basis. We have ongoing engagement around regulations, powers it has and the form of regulation in place across our older person services. We are working with HIQA on home care services which do not have a structured, formalised regulatory system in place. We are fully committed to work on the legislative programme and to work through the recommendations which have been clear on the Department working with HIQA to assess what processes could be put in place around individual complaints. We also will work generally with HIQA on what additional powers could and should be assigned.

My colleague, Mr. Niall Redmond, wants to come in on this.

Before he comes in, as a member of the Oireachtas health committee which will be established in due course, I will certainly be asking that the committee keeps a keen eye on the expert panel report. As the Chairman of this committee said, we can have implementation teams and reports. However, they are only as good as their implementation. The health committee needs to keep a watchful eye on this.

I note there is a problem with the audio for Mr. Redmond. I apologise. I will go to Deputy Colm Burke while we get our IT people to sort out the audio problem. We will let Mr. Redmond back in then. He can take a note of issues which arise from Deputy Colm Burke's or other members' questions.

I call Deputy Colm Burke who has ten minutes.

I may not use them all.

I thank the witnesses for the work they have done over the past six months. It has been a challenging time for everyone. It is important that we work together to resolve outstanding issues and ensure our nursing homes and the care of the elderly are managed in the best possible way.

My opening question is on an issue I also raised with HIQA, which was mentioned in the presentation, and that is the planning for nursing homes between 1 January and the middle of April. While an approach had been adopted of getting people out of the hospitals to make room available in them to deal with people who need urgent care, there was a need for communication with nursing homes about how they needed to upskill and upgrade the service that they provided, particularly in the area of infection control. Was this issue examined by the Department to put more pressure on nursing homes, both public and private? I will give a simple example of what I am talking about. In one HSE facility as opposed to a nursing home, there were not even changing facilities for staff who came into work or finished work every morning or evening. Were those issues considered by the Department in the planning for dealing with this new challenge in our health service?

Dr. Kathleen MacLellan

I thank the Deputy for his question. Initial planning for infection prevention and control is through the public health departments in the HSE. These engaged very early, towards the end of January, with nursing homes and across the system. The initial guidance that was used was the influenza guidance, bearing in mind that many nursing homes already manage a number of different infections and outbreaks, including influenza, MRSA, and C. difficile infection. These were the first set of guidelines. There was very early engagement on infection prevention and control. That guidance and interaction between the HSE and education and support was built as we continued forward. Very helpfully, the expert report has clearly outlined specific recommendations around infection prevention and control, and processes and systems that need to be in place for nursing homes.

The other piece is that there were very particular recommendations-----

On that point, can our committee have copies of those communications because I have not seen any such written communications at any stage over the past three months from HIQA, the HSE or, indeed, from the Department?

Dr. Kathleen MacLellan

Certainly. Perhaps Mr. Walsh may wish to make a contribution.

Mr. David Walsh

I thank the Deputy. I thought that we had submitted an outline of all of the communications with nursing homes to the committee but if that has not happened, I will arrange for it to happen.

I am looking in particular for communications during the period between January and the end of March.

Mr. David Walsh

I understand.

I know that there were communications after that period but I am anxious to see the communications in that crucial time period. Perhaps they were submitted but I have no recollection of seeing any particular communications dealing with infection control.

Mr. David Walsh

The method used was to disseminate information via the HPSC website, where guidance was updated very often throughout the period and to then make this available through Nursing Homes Ireland, local engagement, and the HIQA portal as well. I will resubmit the timeline along with copies of the documentation for the committee so that it has a complete picture.

The second issue I want to raise was discussed earlier and relates to staff working in more than one nursing home. Was any guidance given to nursing homes or HSE facilities about the challenges that there would be in employing staff coming from another medical facility?

Some HSE facilities might have had difficulties in trying to get staff and that may have resulted in staff going from one medical facility to another. Were guidelines issued to nursing homes or HSE facilities? I also refer to mental health facilities because there were several adverse outcomes in those settings as well. Was any information sent out to such facilities at any stage warning of the dangers of taking in staff who were moving from one facility to another?

Dr. Kathleen MacLellan

I will come in first and then hand over to my colleague, Mr. Walsh. This issue was taken seriously by NPHET at an early stage because information was emerging internationally concerning the challenges regarding staff working in, and between, different facilities, as well as sharing residences. Swift action was taken and the HSE undertook some significant actions in this area.

Mr. David Walsh

Clear advice was issued through the management system in the HSE and that advice was also shared with Nursing Homes Ireland. The HSE's national director of human resources wrote to the agencies used by the HSE instructing them not to assign their workers to multiple sites. There were, however, tensions at times. I refer to when the HSE was asked to support some of its own units that were in trouble because of staff being off sick, or private or voluntary units with the same problem. Out of necessity, therefore, that meant transferring an employee from one service to another. It is important to note that aspect, but that had to be done on a risk-assessed basis to do the most good and the least harm. The instruction sent out was to not share staff across units and that instruction was also given to the agencies that we deal with.

I know of one facility with ten people where several staff unfortunately contracted the virus and were unable to turn up to work. It was impossible to replace them. Is a mechanism now in place to deal with such a situation? If an HSE or nursing home facility runs into a major problem with staffing, is a mechanism in place to enable that challenge to be dealt with adequately? In the facility I referred to, it was necessary to transfer people and, unfortunately, four of those ten people died. It was not a HSE facility or a private nursing home, but six of the patients ended up having to be transferred to a HSE facility. If there is another major challenge with staffing, do the HSE and the Department of Health have a mechanism to address that challenge?

Mr. David Walsh

The HSE has been working with Nursing Homes Ireland for several months, and nursing homes have also had the benefit of the temporary assistant payment scheme, which has allowed them to invest in an enhanced level of service to enable them to deal with those sorts of issues. We have requested every unit, which is reiterated in the report of the expert review team, to have a plan in place, from the perspectives of management and staff, to give the required resilience to manage if there should be another outbreak in a unit. There may be cases, despite a good plan being in place, where it becomes difficult to manage with staffing. The HSE and other partners will then do all in their power to assist.

There are difficulties, such as the one we mentioned earlier in this discussion in transferring staff from one facility to another and the risk associated with that. In the first instance, every unit should have its own plan and the HSE will do all in its power to back up those plans should the worst come to the worst.

I think the audio problem with Mr. Redmond has been fixed so I will give him two minutes to respond to some of the issues that arose in the first two contributions and then move to our next speaker.

Mr. Niall Redmond

I thank the Chair. I hope he can hear me now.

On the Chair’s contribution on clinical governance, it is important to reflect on the fact that HIQA has a substantial number of powers available to it at the moment in terms of clinical governance. Dr. MacLellan has outlined some of the work we will be doing over the next while, to which HIQA will be central. Aside from that, there are a number of other streams of work under way as well as part of that overall package and framework of clinical governance. Important in that is the work the Department has been doing over the past 12 months on an adult safeguarding policy for the health sector which would be the first national safeguarding policy for the health sector. That would have within its scope private and public facilities and nursing homes. That work is advancing this year with a view to going out to public consultation on a draft policy later this year or early 2021. That will be another important aspect of the clinical governance framework.

In the programme for Government, there is also a commitment to exploring the expansion of the role of the ombudsman to examine individual care concerns in relation to nursing homes. That will be another important aspect of that framework. I do not think there is one particular silver bullet. A package of measures is required to put together a robust framework around that.

The role of advocacy cannot be understated. We are doing some work around the programme for Government commitment to the roll-out of the patient advocacy service into the community, which will be another important aspect of the response.

I thank Mr. Redmond. We heard him loud and clear; he might need to adjust his volume a bit. Perhaps audio can have a look at that? The Fianna Fáil speaker is Teachta Devlin, who has ten minutes.

I thank the witnesses for their attendance today. I will start with a question for Mr. Walsh regarding his opening statement. He mentioned that the HSE actions in this report will be worked on with the Department of Health and other partners to implement the recommendations that require policy change and/or policy development. For clarity, how do the Department of Health and the HSE work together and what subtle differences are there between the two bodies that require co-ordination?

Mr. David Walsh

I will open on that and then hand over to my colleague, Dr. MacLellan. There are close and tight links between the Department of Health and the HSE. The Department has a clear role in the development of policy and the monitoring of the HSE's implementation of that policy. In every section of the Department, there are clear links to the corresponding section of the HSE and we work continually throughout the year on relevant issues. In recent weeks, it has been around the winter plan and the structures around the implementation of the recommendations of this review.

There are longer-term issues, such as the development of how we provide home support, which will be a key facet of how we alter the model of care for older persons in this country, and the Department has a key role in this. Its role is as key as that of the HSE in implementation. I will hand over to Dr. MacLellan.

In terms of the recommendations made in the report before us, whose ultimate role will it be to see its implementation? Is it the Department, the HSE or another?

Mr. David Walsh

The chief executive of the HSE is accountable for the performance of the HSE. My colleagues and I are accountable to him for our performance. The chief executive is accountable to the board of the HSE. The Minister has accepted the report and has tasked the Department to lead on implementation of the recommendations. I will ask Dr. MacLellan to outline how the Department is doing this in co-operation with the HSE and others.

In her opening statement, Dr. MacLellan mentioned the extension to the temporary financial support scheme. Specifically, what does this cover? Does it cover staff supports and staff cover, as the previous speaker asked?

Dr. Kathleen MacLellan

The temporary scheme was set up with two elements. One is with regard to supporting these nursing homes in their preparedness planning and having their contingency plans in place. The other element is to support additional costs these nursing homes may incur if they have an outbreak or cluster within them. My colleague, Mr. Redmond, will give detail on this, including the extent of the funding that has been given through the temporary scheme. It has been very much welcomed by the private nursing home sector and is very much seen to support the additional costs they have incurred in the management of Covid-19.

Mr. Niall Redmond

Approximately €37 million has been paid out. Actually, as of this morning, approximately €39 million had been paid out to providers under the scheme. To answer the direct question, the scheme covers a contribution towards a number of different costs related to Covid-19. These include additional staffing costs, additional cleaning costs, infection prevention and control costs and training. There is a broad range of inclusion criteria and my understanding of the funding paid out so far is that the vast majority has related to staffing costs. This may involve hiring extra staff to cover absences or to supplement the existing staffing complement in a nursing home.

Mr. Walsh referred to the winter plan. How confident are we as a nation that we have enough PPE for the winter months? How confident are we regarding its supply and distribution and ensuring it gets to the various services speedily?

Ms Sandra Tuohy

I will answer the question on PPE. Since the start of the pandemic, almost €70 million worth of PPE has been supplied to nursing homes throughout the country. Every crisis response team for our nursing homes has a PPE lead. We have assurances on the supply lines of PPE and ongoing supplies specifically for our nursing homes going into winter. I can assure the committee on this.

My next question relates to our earlier session with the expert panel. There were more than 400 discharges from hospitals into congregated settings, including nursing homes, care facilities and long-stay facilities. I need assurances that anybody discharged from an acute setting will be tested. I would like confirmation on this from the relevant witness.

Dr. Kathleen MacLellan

I will start and my colleagues from the HSE can come in. There is very clear guidance on the testing that needs to happen prior to discharge.

It was put together by the HPSC. In addition, the director of acute hospitals has assured the Department in the past few weeks that he has gone out to all of the hospital groups in order to be assured that the guidance is being followed. That assurance has been provided. I will hand over to Dr. Kennelly from the HSE.

Dr. Siobhán Kennelly

To emphasise what Dr. MacLellan said, testing guidance has been in place for quite some time. We know not just testing but also specific protocols around the isolation of people after they transfer from acute hospitals to residential care for a period of two weeks are now accepted as standard practice across the board. That is being implemented across private and public facilities.

Reference was made to the bilateral group. Is that the same as the implementation framework group or is it separate? How many meetings of the bilateral group have taken place to date?

Dr. Kathleen MacLellan

I will answer that question and then hand over to Mr. Redmond. It is not part of the implementation oversight group, but its work will be part of delivering the recommendations of that group. It is a separate process. The Minister asked for it to be established across the Department and HIQA. I will ask Mr. Redmond to comment.

Mr. Niall Redmond

That is correct. The bilateral group with HIQA and the Department is a separate group that is looking at some of the recommendations made by the expert panel on the regulatory framework. We will be working with HIQA over the next number of weeks and months to examine that framework and look at what we can do in the short and longer term around the regulations. I believe the Minister wrote to HIQA in the past week or ten days regarding the establishment of that group and we are hoping to have our first meeting next week.

I refer to services for older people. When will community social day care settings resume?

Ms Sandra Tuohy

We recently developed the reopening guidance for day care centres, along with our colleagues in infection prevention and control. We have expertise on that. It is quite complicated to reopen our day centres because many people who attend them are also depended on transport to get them there. We cannot have six or eight people in a bus being transported from their homes to day centres. We are examining how we might mitigate against that.

I wish to provide the House and Deputy with an assurance that those people who are not receiving day centre support are having alternative services delivered to them in their homes, such as meals on wheels and telephone support from people who provide services to them in day centres. We are committed to reopening our day centres, but we want to do that safely and mitigate against the risk of the transmission of the virus to a really vulnerable group.

The next slot is for the Green Party but there is no one from the party present. We will move on to the Labour Party slot.

I will direct my first couple of questions to the HSE. The report noted that the socioeconomic conditions that many essential front line healthcare staff are living under might be an essential barrier to effective infection controls, in particular staff who do not have access to sick pay, need to work in multiple facilities or live in crowded accommodation.

Public health officials are clearly on the record as having said that workers who need to self-isolate should have no fear about their employment and that economic circumstances should not be a barrier to people coming forward and getting tested. Has any consideration been given to providing some ring-fenced funding that will offer additional sick pay support for all nursing home workers as we approach winter 2020?

Several organisations, including SIPTU, raised recruitment concerns in nursing homes and said pay and conditions were a barrier to achieving safe staffing levels. The report recommends that contracts, pay scales and staff development in nursing homes require review and that there is an immediate and ongoing need to attract staff with career development opportunities. Are there plans to commission a full review into the pay and conditions of workers in the sector? When is that is likely to commence? Who will undertake the review? Will workers' representatives he included in the process?

Mr. David Walsh

I will start with that and hand over to colleagues in the Department of Health.

Within HSE facilities staff have access to the HSE sick pay scheme so I think the reference within the review related to terms and conditions in the private nursing home sector. To support those staff, over the last number of months the HSE have made available accommodation that would allow them to avoid the situation the Deputy described in his question. On pay and conditions, there are obviously very clear recommendations about that in the review. Dr. MacLellan will comment on the approach to addressing those recommendations.

Dr. Kathleen MacLellan

Within the responsibility of the Department of Health and the HSE, we have been able to put in place accommodation and accommodation supports for those working within the private nursing home sector. There is a recommendation in the report which is directed toward the Department of Enterprise, Trade and Employment. This is a cross-Government piece. The Department of Health will work with other Departments on education, training and the guidance related to that.

On the terms and conditions, this review is recommended to be completed within 18 months. A recommendation of significant importance is that when the Minister for Health brings this report to the Government for a full discussion, a cross-Government approach will be taken on how that review of employment terms and conditions in the private nursing home sector can proceed and be undertaken. It is of significant importance that we provide these terms and conditions to employees to ensure they do not feel they have to work when they are sick or feel they will not be supported where self-isolation is concerned. There has already been cross-Government support for supporting employees in those areas.

The officials will be aware that one nursing home was taken under operational control as a result of a catastrophic situation which unfolded in April. We still do not know what criteria triggered the RCSI to take control of the nursing home in question. For the sake of future planning and in order that we can learn from what happened, will the HSE advise what threshold applied to trigger such an unprecedented response from a hospital group?

Mr. David Walsh

I am aware that the matter the Deputy raises is the subject of direct correspondence with the CEO of the HSE. I am also aware that the CEO of the hospital group in question has written to the families of some of the residents in the nursing home in recent days. I am not sure what the status of that communication is but I will undertake to check and revert directly to the committee.

Dr. Kathleen MacLellan

If I may add to that, it is important to note that HIQA, as the independent regulator, regularly inspects all nursing homes. It is the eyes and ears of the State within the nursing homes and it has significant powers where it identifies that there are issues with quality or adherence to standards or regulations. Those powers extend not only to imposing conditions on the registration of such nursing homes but also to closing them down. That is a very significant power our regulator has. HIQA, through the Health Act, has the ability and the right to enter nursing homes in relation to their registration and registration conditions. As such, our independent regulator holds a very important function in this regard.

I thank all of the witnesses.

I thank the officials from the Department and the HSE for their attendance and presentations. I will follow on from an issue raised by Deputy Duncan Smith. Questions of low pay and precarious work are clearly very pertinent to this whole issue. I would like Mr. Walsh to go into a bit more detail about the comments he made about the accommodation many of the staff are living in.

It has been identified as a key issue that many staff are not only low paid but are often consequently living in poor-quality accommodation, in congregated settings and, in some cases, in direct provision. Given the growth of the virus, particularly in the Dublin area and the potential threat to residents in nursing homes, what is happening with regard to the issue of unsatisfactory housing conditions? Will the witnesses spell out what action is being taken in that respect? It seems it is the source of much of the spread of the infection. What arrangements are in place for care staff who are diagnosed with the virus to isolate themselves?

Ms Sandra Tuohy

I will take the question on accommodation. For a number of months, the HSE has been providing private hotel accommodation for staff who need to self-isolate from their own households as a result of outbreaks within nursing homes and for staff who are themselves living in overcrowded private housing. We will continue to provide such accommodation for people who are outside of the temporary assistance payment scheme, which is offered to the private nursing homes.

Approximately how many people have been involved?

Ms Sandra Tuohy

I do not have that figure right now but I can supply it.

Does Ms Tuohy have a ballpark figure?

Ms Sandra Tuohy

I understand the figure is in the hundreds.

Okay. On what basis is that provided? Is it that the HSE meets the cost?

Ms Sandra Tuohy

The HSE meets the full cost.

I am glad that is happening and that there is a contingency in place but this and so many other issues arising from the recommendations really underline the totally precarious nature of the funding model for nursing home care. It is very delicately calibrated to maximise the return on investment for the owners of the nursing homes while limiting the financial exposure of the State, neither aim having much to do with the care of older people.

My question is probably most suited to Mr. Walsh. Arising out of the very significant, wide-ranging and fundamental recommendations about the need to totally change the financial model as well as the model of care, what work has been done on estimating the potential cost of implementing the recommendations regarding the financial model for operating nursing homes?

Mr. David Walsh

I believe that is more of a question for the Department of Health so I might ask Dr. MacLellan to respond.

Dr. Kathleen MacLellan

We have commenced looking at all the recommendations and looking at those bodies which either have responsibility for their implementation or expertise with regard to them. The National Treatment Purchase Fund, which operates the nursing homes support scheme, is carrying out work on costing and the cost of care. The Health Service Executive is also carrying out work on costing. We in the Department are also looking at costing those recommendations. The cost of some of the recommendations will relate to continuing the supports already in place. Some of that will come through the funding in place to deal with Covid, some we will seek through the Estimates process and some we will seek from Government when the Minister brings the report to it. Significant work on costing has commenced.

Some of the recommendations apply to the short term and it is very urgent that cost not become a barrier to their implementation. Others, particularly those with regard to the model and cost of care, relate to the longer term. There is a significant amount of work to be done in looking at what model of care we want for our older people in future. Part of that will involve working with our colleagues across Government, including those involved in housing, to see how to develop and design, as quickly as possible, a model to support people living in their own homes for as long as possible. Significant work has been done across the HSE in looking at new forms and processes of home care. This work will allow us begin to move towards supporting people living within their own homes much better. I particularly refer to those who need more care than has traditionally been provided through the existing home care support scheme.

Home First is the new model at which we are looking.

I will ask Mr. Walsh a question about the need to change the model of care but, before I do, I will talk about changing the financial model around nursing home care, the dominance of the private sector, the tax-based approach, returns on investments and all of those kinds of things. Those kinds of issues work against quality care. Who is carrying out costings? What is the timescale involved for the return of that report?

Dr. Kathleen MacLellan

The work has not commenced on examining the model of care on the back of the recommendations within the nursing home expert report so the issue of costing does not yet arise. Mr. Redmond wants to come in and follow up on that.

Mr. Niall Redmond

I will just add to that. When considering the recommendations and the broader work that is happening, looking at and considering how to reform older-person services, we must consider some of the policy work around what the future model might look like and how its models of care and finance might operate. A significant amount of work needs to be done to map out and put granular detail around what that might look like before we can accurately predict what that model will cost in its delivery.

It is fair to say that the National Treatment Purchase Fund, NTPF, is doing a piece of work to look at the pricing system that applies to agreements with private and voluntary nursing homes. That work is ongoing. The Department is also doing a piece of work. It is particularly important that the care needs assessment becomes the critical foundation piece for both the delivery of services and how they are resourced and configured. The roll-out of the single assessment tool will be a key part of that and the Department is working with the Health Research Board at the moment to undertake a review of international evidence for how to take a care needs assessment and define and allocate resources across a range of care bands. That preparatory, evidence-based gathering work is well under way and we are looking at future models.

I appreciate that as it relates to the model of care but my question related specifically to the continuation of nursing home care. There will be some element of that, and hopefully a reduced one, but questions arise about the role of the State and private sector, tax breaks and all of that kind of thing. I was curious to know whether any of that work has started.

What is the level of financial support currently being provided to private sector nursing homes? Our guests said that there is approximately €39 million in the support fund and talked about providing residential accommodation for hundreds of vulnerable workers in the nursing home sector. I presume there are other costs involved in the provision of personal protective equipment, PPE. Do our guests have a total cost for the level of financial support being provided to private sector nursing homes?

Mr. David Walsh

I do not have a total cost in front of me. To the items that the Deputy mentioned could be added the costs of other types of support such as infection prevention control advice, other types of support and replacement staff.

Could Mr. Walsh get that information for us?

Mr. David Walsh

I will seek that information and send it to the committee.

I have another question for Mr. Walsh. I asked him earlier in the year about the number of people who have been approved for home care and are on waiting lists because the funding provided is totally inadequate. I regularly check how many are on those waiting lists and the last time I checked, there were in or around 6,000 to 7,000 people, predominantly on the north side of Dublin and the north-west area. What is the current number of older people who have been approved for home care and are on waiting lists?

Mr. David Walsh

Ms Tuohy has that information.

Ms Sandra Tuohy

We obviously had a large waiting list when we were most recently before this committee. It is now down to 4,550 people awaiting home support across the country. That figure is from July.

We have been working really hard to reduce that even further. We hope to have the August figures very shortly and we also hope that these will show a reduction in the number of people awaiting home support in the community. We hope to reduce the list of those waiting for home support to a very small number, if not to get rid of it entirely towards the end of October, because we recognise that is one of the fundamental ways of keeping people at home, keeping them safe and avoiding hospital admissions where we can.

I will have to wrap it up there.

That is good news. Has that funding been secured and what is the level of it?

Ms Sandra Tuohy

We received additional funding from the Department of Health for home support so as to manage more people at home throughout the pandemic and we have been utilising that money to reduce the waiting lists in conjunction with direction from the Department on that. We have also put in for additional home support to assist more people outside of long-term care into 2021 and we are awaiting feedback on that in the winter plan.

Could the witnesses send on a detailed note to the committee in respect of that matter and the previous one? It would be great if we could be given more information than it is possibly to give verbally. I must move on. I will try my best to keep people to time because we must be out at 2.30 p.m., and I want to be fair to everybody.

I thank all the witnesses for attending. I firmly believe the key issue, if not the cause, of the policy that worsened the impact of Covid-19 in nursing homes was the decision taken in the 1990s to contract out the care of elderly people to private, for-profit nursing homes. Some of the points made by the expert panel and in other reports support that view. The fact is that we have 80% of all beds in the private sector where there are long hours of work, precarious employment and low pay, as well as a skills shortage and a push to cut costs. That is the reason we saw the restrictions and lack of early use of PPE among other issues. That, combined with a failure of medical care and clinical governance, worsened the impact of Covid on the nursing home sector. I believe that this, as well as other issues that arose during the crisis, such as the lack of testing and other factors, laid the basis for the disaster.

I have a few questions which I want to ask together. Perhaps the witnesses will take note of the following four questions. Could they comment on the call by relatives and loved ones of those who lost their lives in the nursing home sector, as well as advocacy groups, for a full public inquiry into the deaths in nursing homes? Many of us feel that while the report from the expert panel is welcome it is not what is needed.

I seek assurances that all staff in nursing homes have access to a functioning sick pay scheme so that we do not have concerns that employees who are sick may feel compelled to continue to work if they are unwell. Could the witnesses also indicate, if they know, whether the use of agency staff is still as widespread as it was and whether agencies in general are being used widely in the nursing home sector?

My third question is an important one and is probably for Mr. Walsh. Who was it that changed the regulation referred to on page 96, in chapter 7, of the expert panel's report, which specifically meant that it was no longer a requirement for the person in charge on site in a nursing home to be a qualified registered nurse or gerontologist? What was the purpose of that change and what were the consequences when it came to the pandemic and elderly care?

Will the witnesses comment on the view expressed recently by Ms Phil Ní Sheaghdha of the INMO that we do not need an audit of the staffing ratios in the sector? We already know that the staffing problems are bad and we know how to address them. Specifically, how would it help to have a regulated and mandatory staffing ratio and skill set, as well as sector-wide pay and conditions applicable across all nursing homes and elderly care centres? There are four questions there and I am spouting them out together because otherwise I might run out of time.

Dr. Kathleen MacLellan

I will start and then hand over to my colleague, Mr. Redmond, followed by the HSE.

First, regarding those individuals who have lost loved ones in homes, all of us understand how difficult and how hard these last number of months have been. We are particularly committed to the recommendation within the expert panel report to build the advocacy services and ensure those individuals, families and residents have access to professional advocacy as we have seen has been provided through Sage Advocacy and the patient advocacy service. It is available across our acute hospitals and we are working to extend that out into the community as well.

Regarding the staffing, we are committed and the chief nurse within the Department has commenced the implementation of the safe staffing framework. Phase one of the safe staffing framework has been in acute hospitals, phase two in the emergency departments and phase three now is in older people settings. There has been significant evidence-based learning across older people settings with regard to staffing and the care needs of those older people. It is now being progressed through a draft guidance framework which is with the HSE and will be tested over the next number of weeks with a view to having that guidance on safe staffing available for the winter period. I will pass over to my colleague, Mr. Redmond, on the regulatory piece that was raised.

I thank Dr. MacLellan for the response. Before that happens, however, a direct question was asked on the Department's view on whether there should be a full public independent inquiry. I am aware that Dr. MacLellan referred to other matters but it was a distinct and direct question that deserves a distinct response. Could you respond to that please?

Dr. Kathleen MacLellan

Regarding the question raised, the Department considers at the minute that HIQA is the independent statutory authority. It is on the ground in many of those nursing homes that have been significantly challenged and where relatives and residents have-----

We are all aware of the role of HIQA. I need to press Dr. MacLellan on that point because a fair question was asked on whether the Department supports a full independent inquiry into what happened in nursing homes during the pandemic. It is a clear question. She may not be in a position to answer it but if that is the case just say so. We are all aware of the role of HIQA. It is a direct question that deserves a direct response.

Dr. Kathleen MacLellan

What I can say has to be with regard to awaiting the various inspection reports from HIQA and progressing the patient advocacy service on supporting those individuals and those residents. HIQA has significant powers here with regard to the review and examination of the carer and its meeting of standards in its inspection reports and, indeed, should HIQA decide to do an investigation it has powers under section 9 of the health Act.

Does the HSE wish to respond to those other issues? I will have to move on, unfortunately, to our next speaker.

Mr. David Walsh

Regarding agency staff usage, agencies certainly have a role in supplying staff right across the system in both acute and subacute hospitals, the HSE and the private sector. The task and the ask, however, really has been to ensure that we do not have agency staff moving from one location to another and then to another. That has been an essential plank in trying to reduce the risk of transmission.

Regarding assurance on the sick pay scheme and nursing homes, I cannot give that except on HSE operated or funded services. I cannot do so with regard to the private sector. I can confirm that I had no act or role with regard to altering the qualifications required to be a person in charge.

On Ms Ní Sheaghdha's comments on safe staffing, I know that the Irish Nurses & Midwives Organisation, INMO, co-operated fully and was a key partner in the development of safe staffing levels for the acute services. I expect it would be fully committed to developing similar models for the non-acute services.

If Mr. Walsh cannot answer my question about the change in regulations of the requirements of the professionalism of the person in charge, then who made the change and when? What Minister, what Department or who in the Department made the change?

If he cannot answer it now, will he please find out the answer and give it to me? It is referred to in the expert report on page 96, chapter 7, so I am surprised Mr. Walsh does not have the answer. It is a very clear move away from having highly qualified people in charge of nursing homes and deregulating them to an extent that I believe may show that patients, and residents as a whole, got sick and suffered because of the reduction in the level of qualifications of the persons in charge. Why was that regulation changed, by whom and when?

Mr. David Walsh

I commit to following up on that.

If he can do so, I ask Mr. Walsh to provide a written response to that issue with the other issues also. The next speaker is from the Regional Group of Independents, my constituency colleague, Teachta Shanahan. I will be keeping him to his five minutes.

I thank the Chairman. I thank our guests for attending, particularly those who have been with us a number of times. All of us welcomed the expert panel's report but it contains many recommendations and thresholds that need to be met in the future and the first question that would arise in anybody's mind is the level of sourcing that will be required. The Deputy who preceded me spoke about the difficulties relating to private sector involvement in nursing homes. I am aware of a nursing home proposition in our constituency that was refused by the banks because they said there was not enough profit in it. I am not sure that it is that profitable a business to be in. It may be for some but I doubt that it is for new entrants.

The bigger issue that all of this relates to is resourcing, either the lack of it or the drip-feeding that has gone on within the sector. All of us want to see an end to that but I will touch on a topic spoken about previously, which is community care. Significant reforms are needed in the area of community care, certainly for constituents of mine. We hear all the time of cases where people are allocated an hour but where the person who is providing the care might take 15 minutes to drive to the first client and another 15 minutes to go on to the next client. As a result, almost 30 minutes of the time is spent travelling. That is not sustainable. We have people who are hoping to get up and be showered but, essentially, what they are getting is a very quick wash from a hand basin, an egg and a bit of toast provided for them and then that person is gone out the door. If we are serious about looking after people at home, we need to reconsider the way we do that.

In terms of the multidisciplinary supports at CHO level, there are 23 teams. Can somebody explain how that process will work in the future for nursing homes that have potential cases of Covid-19 and they want to engage with the medics?

Dr. Kathleen MacLellan

I might start by dealing with the plans relating to home care. The Department's commitment - it is also a Sláintecare commitment - is the development of a statutory scheme for the home care services. There has been progress on that and further progress will be made towards the end of this year and into next year. We have looked at international models. We have been working with the ESRI in terms of examining demand. We have also been examining - my colleague mentioned it earlier - the standard assessment tool, which is critically important. It is about the importance of examining the type of care, and the Deputy raised that, in terms of whether somebody needs hours in respect of physiotherapy, the activities of daily living support or their shopping and how we can get the best and most tailored support in place. We have significant plans for the roll-out of a standard assessment tool and the utilisation of that tool to decide the type and volume of care that will be utilised. The roll-out of that will commence as we move towards the end of this year.

There is a significant commitment to look at the type and form of home care being provided. As the Deputy heard earlier, we have invested significantly to bring down the waiting lists and we are hopeful that we will be able to invest significantly over the winter and going into 2020 to introduce what will be a broader and more comprehensive home support system through a home first approach. My colleagues in the HSE might want to give some more information on that.

Ms Sandra Tuohy

I thank Dr. MacLellan. To pick up on the crisis response teams, CRTs, in the context of nursing homes, the Deputy asked what will happen in future should there be a confirmed outbreak in a nursing home. I can confirm that the CRTs for our nursing homes comprise nurses, public health experts, PPE leads, infection prevention control experts, etc.

It is important to note the resilience investment we have put into private nursing homes through the temporary assistance payment scheme to ensure they are readily prepared should there be a new or further outbreak of Covid-19 in a facility. The role of the crisis response team is to support the resilience of the private nursing home sector where it can in providing the expertise which those facilities may be unable to resource themselves. That will continue as per the expert panel report and those teams will remain in place for as long as we need to have them in place.

I referred in the earlier session to the question of ensuring there are adequate isolation facilities in place in nursing homes. Under the new regulations, nursing homes are required to maintain an isolation space in readiness for a Covid outbreak. I understand that the supports the Department were offering in this regard were based on capitation grants for public rather than private patients and possibly applied to private nursing homes only. Will the witnesses comment on that protocol?

My second question relates to the temporary financial supports that have been given. The witnesses signalled that there will be an extension of those supports. Can they indicate how far into the future that provision will extend?

Mr. Niall Redmond

I will take those two questions concerning the financial support scheme. Dealing with the second one first, the Government's resilience roadmap that was published yesterday outlines an extension to the scheme of nine months, from 1 October to June 2021 approximately. That commitment to an extension of the scheme is covered in the document.

On the Deputy's first point, it is true that at the commencement of the scheme on 1 April, the capitation rates related to nursing home support scheme residents. However, that was changed shortly afterwards such that all residents of a nursing home are included in the framework for calculation of the rates payable.

I thank the witnesses for coming in to answer our questions. For us, as Deputies, to be relevant, we must fight for and ask questions on behalf of the people who cannot fight and ask questions for themselves. I am talking about vulnerable elderly people. First of all, I regret that many such people died on their own without being allowed visits from family members and friends. If their families could not understand why they could not go in to see their loved ones, the elderly men and women who died on their own certainly did not understand why such visits were not permitted. I am still not happy with the number of visits that are allowed for the families of people in district and general hospitals and nursing homes. The severe restrictions that remain in place are not fair on the elderly people who gave so much to their country, their communities and their families. We need to facilitate visits for those people, whether by testing the people going in to see them or by some other means. We must do more for those elderly people who need company and who often have certain things they will talk about only with family members and not with staff or any other persons. I am asking that more be done to allow more visits for those people.

Most nursing homes and hospitals - probably 99% of them - are well run and people are well looked after in them, but we have seen what happened to that poor man up the country. One such case was too much and we do not want any more. I have been requested to ask in this committee about who oversees the nutritional and protein value of the food that is being given to patients. We know that HIQA is responsible for cleanliness, safety and many other issues, but who is responsible for the quality of the food?

I thank all of the wonderful home helps, as we call them in Kerry, for the wonderful work they do for people who want to stay in their homes for as long as possible. We do not have funding to employ enough home helps to give adequate time to the elderly people who want to remain in their homes for as long as possible.

The Deputy should allow adequate time for witnesses to reply.

I ask them to reply.

Dr. Kathleen MacLellan

I will respond first and one of my colleagues will answer on the business piece.

We have addressed some of the issues on home care on which we committed to providing additional information. There has been significant investment in this area. We are looking very closely at the establishment of a statutory home care scheme and building the capacity of the HSE for commissioning home care.

There is a standard in place for nutrition and hydration needs, namely, standard 2.2 of the HIQA standards. It is one of the standards that HIQA inspects against when its staff visit a home. Staff go through a number of elements in that standard, which I will not describe in detail in the interest of time. The standard includes residents being offered daily menus, catering, access to adequate quantities of food and the appropriate types of food. There is a particular standard in place because the importance of nutrition is recognised.

Everybody recognises how hard the visiting restrictions have been. These restrictions have been used internationally as a protective measure for residents. We have worked very hard to see how we can build and enhance the visiting in place. When we published ethical guidance through NPHET, it was around promoting proportionate visiting that strikes a balance between the protective measures and allowing for the health and well-being of residents. Dr. Kennelly will comment further.

Dr. Siobhán Kennelly

From our point of view, as clinicians, this is a critical issue. We recognise that there is significant morbidity and a significant impact arising from the visiting restrictions that have taken place, both at the height of the pandemic and as we start to open up. Clearly, it is about striking a balance, particularly in Dublin and elsewhere where there have been very high rates of community transmission, as alluded to previously. It is about how we continue to maintain the welfare of residents while allowing them to have visits on an ongoing basis. Significant work is being done by me and my colleagues in public health and in infection, prevention and control to achieve that balance in accordance with the Government action plan and its five levels and how the plan might translate over time. That is a critical factor. We hope that, even in circumstances were we will potentially have significant outbreaks, we will continue to have visiting at all times. It depends on the issues that arise for the nursing homes on different occasions.

I ask Ms Tuohy to respond to the home help issue if she is in a position to do so, after which we must move on to the next speaker.

I ask that action on visits to nursing homes be expedited as much as possible because elderly people do not have time on their side.

Dr. Siobhán Kennelly

We are very conscious of that. It is important to flag that much of the guidance on this was updated on the HPSC website in June. There has been an awful lot more flexibility around visits. It is important in our discussions with advocacy bodies, families and others that they are aware of the guidance, engage with nursing homes and advocate for visiting. Nursing homes are understandably cautious about visitations as they are permitted, particularly in different sectors. It is very important that people are aware of the guidance as it is updated, so that they can advocate and continue to see their loved ones.

Ms Tuohy must be very quick as I need to move on to the other speakers.

Ms Sandra Tuohy

With regard to home support and home help, people receive home support on the basis of their needs. That will continue. As I stated, we will continue to try to reduce the number awaiting home support or increased support hours as resources allow. As mentioned by the Department representatives, we are moving to the interRAI assessment tool, which will help us to understand comprehensively a person's needs so the correct number of hours can be allocated to address them.

We are now to have the three speakers from the three main parties. Sinn Féin is next, followed by Fine Gael and Fianna Fáil. The Chair of the committee wants to contribute also. We have 30 minutes remaining, after which we must conclude, unfortunately. I ask the speakers to spare a minute or two, if they can. I will have to be ruthless about time to allow the Chair to contribute. The next speaker is Teachta Louise O'Reilly from Sinn Féin.

I thank the Acting Chairman and the witnesses. My first question is for Mr. Walsh. If he cannot say who changed the criteria concerning a person in charge in a nursing home, could he offer a view as to the grade of the individual in question? Would they be in the Department or the HSE? The question deserves an answer. I understand Mr. Walsh does not have the answer today but he might have a view on the grade, group or category of the worker responsible for making the decision.

Mr. David Walsh

I just do not know. I would see it as a function of regulation. I do not know. I will have to follow up on it and revert to the Deputy. I have committed to doing so.

I thank Mr. Walsh. We would be very grateful if we received that correspondence.

I have some questions for Dr. MacLellan on March. I asked a number of questions of Mr. Breslin, the then Secretary General, on the transfer, and I also questioned Dr. Colm Henry at the time. We know there were 800 applications to transfer persons from hospitals to nursing homes. I have a series of questions and might ask them all at once. That might be handier. How many of the 800 patients were transferred? Of the 800, how many were tested once and how many were tested twice? Were they tested as a matter of routine, as per the regulations on 10 March, or were they tested only as per the case definition at the time, based on their being symptomatic? If a person was asymptomatic, would he or she have been tested in the first instance, much less tested twice, prior to transfer? I fully respect and appreciate the need to make space in our hospitals because of the mismanagement by successive Governments, chronic overcrowding and all that. My question is specifically on the 800 people in March.

Dr. Kathleen MacLellan

From 12 March, there was guidance on the testing of those who were being discharged to nursing homes. The guidance on the testing was in line with the case definition available in March. At that time, knowledge and information were simply not available suggesting that there was so much asymptomatic transmission and that the presentation of Covid-19 was atypical within older people and not in line with the traditional signs that were being examined.

With regard to the numbers being transferred out, there is a section in the expert panel report that points out that the hospital inpatient inquiry system, HIPE, data have captured those who would have had a Covid diagnosis in hospital at some stage. It is not necessarily related to whether they were discharged with Covid or admitted with it. With regard to those who were discharged from hospitals to nursing homes, four hundred would have been Covid positive and 11 would have been Covid probable. Our understanding, which would have been confirmed, is that the guidance of 12 March would have been adhered to but the clinical decisions on discharges are obviously made at local level by the clinical doctors. I am not sure whether Dr. Kennelly wants to follow up on that.

The decisions were made at local level but the guidance and case definition that applied at the time would obviously have excluded any person who was asymptomatic. I am referring, however, to the guidance that stated there should be two tests indicating "not detected" before a person is transferred out. Were the tests going to be carried out only on those who fitted the criteria at the time? I understand the knowledge is evolving but it was not a matter of routine in March to test twice; it was actually a matter of testing twice in line with the case criteria.

Is it correct that this would not have applied to anyone at that stage who was asymptomatic?

Dr. Siobhán Kennelly

The Deputy is correct. As we are well aware, the knowledge around asymptomatic transmission was not there. It was around 25 March that the European Centre for Disease Prevention and Control, ECDC, first highlighted the possibility of asymptomatic transmission. It was well into April before that was actually confirmed as a real route of transmission. Most of our guidance at the time was not based on knowledge or understanding of that particular aspect. As it became more understood, the focus on testing was re-emphasised.

However, our guidance did change, particularly around mid-March and emphasised the need for the isolation of patients for a 14-day period after they transferred out. The key around what came through in the ministerial expert report is that we do not know in terms of the people who did transfer out with Covid at which point in time in their hospital journey they had Covid. We do not know whether it was pre-existing coming into hospital or picked up subsequently in a nursing home because our systems do not allow for information to be communicated in that way.

It was clear to us in the context of testing and the nursing home outbreaks. This is why 14-day isolation is mandated. It is a difficult issue for many residents when they are being transferred because it is quite an onerous piece. It is important to emphasise that we do not over-rely on testing as part of the transfer function for these patients.

With regard to safe models of staffing, the trauma that staff working in nursing homes and right across the board experienced is accepted and acknowledged by the witnesses, some of whom I know are clinicians with a significant amount of experience. The level of deaths in the nursing home sector was significant. These are private sector workers, not public sector workers. Is there a proposal from the Department or the HSE to offer these people some kind of meaningful support as they head back into another winter?

Mr. Walsh alluded to the safe staffing model which has been agreed by the INMO. There is a recommendation that there be a review of the terms of conditions. This is to be carried out by the Department of Enterprise, Trade and Employment. I will not hold my breath on that. In the short term, would the model agreed with the INMO be easily adaptable in terms of safe staffing? Would a whole new model need to be agreed? If so, how long would that take?

Dr. Kathleen MacLellan

On the safe staffing model, the Department has already commenced phase 3. Phase 1 was in the acute hospitals. Phase 2 was in the emergency departments. Phase 3 is in the older person settings. The chief nurse working with the HSE has designed a guidance framework to be tested in several nursing homes within the next short while. It is evidence-based and will be based on the experience of the safe staffing within the hospitals and the emergency departments which obviously cater for an older cohort. It will be based on needs. It has commenced and it is with the view that there will be guidance available as we head into winter.

Is it envisaged that this will be put on a statutory footing? Guidance is fine and we would all hope that everyone would adhere to it. Guidance will be adhered to, obviously, in the public system. Given the wholesale privatisation of our nursing home sector - 80% of people will be in nursing homes in the private sector - without statutory underpinning of this guidance, does Dr. MacLellan think that this has a reasonable chance of being implemented? Would it be preferable to be belt, braces and baler twine about it and put it on a statutory footing?

Dr. Kathleen MacLellan

Part of the work we are doing in looking at HIQA regulations is how we can encompass the safe staffing framework within them. HIQA inspections are how nursing homes retain their registration. This could be an area inspected by HIQA. HIQA reports, as they are, comment on staffing and staff availability. We would like to see the safe staffing model. We will work to see how that could become part of the regulatory framework for nursing homes.

We will look to see if that would be feasible as that would give an extra strength in the regulation of those nursing homes.

I thank Dr. MacLellan and the Teachta. Our next speaker is Teachta Durkan. Given he is a stand-in chair in the Dáil and is ruthless in keeping people to their time, I am sure that he will have no problem in me holding him to the same standard today by keeping to his five minutes.

I will try to curtail my intrusion as much as possible. Arising from the discussions this morning and the questions to the expert panel, are the witnesses satisfied that adequate resources and information is available to public and private nursing homes, hospitals and the system in general, to deal adequately and early with an ongoing or upcoming surge?

Dr. Kathleen MacLellan

I will commence and then pass over to Mr. David Walsh. The expert panel has been very helpful in this by identifying clearly within the recommendations that we must continue the current supports that are in place. Those supports will be continued and the commitment is given to that. There has been a commitment on the availability of PPE, which is essential in protecting nursing home residents.

One issue we have not touched on so far is that serial testing within nursing homes has been operating as an early warning to us regarding Covid-19 entering nursing homes and giving us assurance that it is not within our nursing homes. The third round of this serial testing is commencing. It will continue for two weeks over the next month within those nursing homes. The frequency of that, whether it is to be increased or decreased, will be reviewed by NPHET. The resources and the continuation of those tests are in place.

We have also provided additional resources to the HSE to support infection prevention and control and these are already there, as well as towards the recruitment of 18 clinical nurse specialists in infection prevention and control across our community. We have just given sanction to HIQA to recruit nine additional inspectors so that there will be more inspectors available on the ground.

As we look at all of these recommendations, we will cost them to see if additional resources are needed. However, we are looking at the immediate and urgent ones to ensure those recommendations that need to be implemented or the resources that need to be in place are in place. I will pass over to Mr. Walsh now to see if he wishes to add anything to this.

Mr. David Walsh

I thank the Deputy. There is an absolute requirement to press on with the development and enhancement of our integrated care programme for older persons, which will bring more clinical expertise into the field to support people both at home and in long-term care. When those teams were available earlier in the year, they made a very positive contribution.

Dr. MacLennan mentioned the infection prevention and control plans, which have now been funded. The question then becomes whether people are out there who are qualified to take up those posts. We are currently trying to recruit those people but we need to, step by step, increase the level of that clinical expertise in infection prevention and control across the community, with very clear links back to the acute teams.

It is critical that we continue to develop home support, which a number of the committee member colleagues have mentioned, and to develop the structures around it in the way that we assess people and how we provide and manage that service.

Community health networks will be critical supports to general practice. General practice is the bedrock of health care in the community. We need to press on with our plans to develop these networks, which will lead to better availability of key skills in the community such as occupational therapy, physiotherapy and all the other therapies that will help keep people at home.

I thank Mr. Walsh but I will have to stop him there as I need Teachta Durkan to come in with his final question.

I understand that a rapid testing system with rapid results is operating in some countries. By "rapid", I mean results being provided within a few hours. How effective and reliable is this system? Can it be used at airports as we move into the new phase of living with the virus? How effective could a rapid testing system that produces results within one or two hours be if used in those circumstances?

Mr. David Walsh

I am completely unqualified to answer. The common test in use takes some time to analyse. I understand there are other options but I will defer to expert clinical advice as to their efficacy or appropriateness in any given setting. It might be better to get an expert response for the Deputy regarding that question.

I would be happy with a written reply.

If there is an expert in this area in the HSE or the Department, I ask that a written reply be provided to Deputy Durkan regarding international comparisons on rapid testing systems applicable to airports and other settings.

I thank the Acting Chairman.

Deputy McAuliffe has ten minutes but he might give some latitude to his colleague.

Deputy O'Dowd would like to contribute first.

I direct my first question to Mr. Walsh. What progress has been made on the fair deal scheme for home care?

Mr. David Walsh

I will pass that question to a representative of the Department of Health. Perhaps Mr. Redmond could answer.

Mr. Niall Redmond

One area of work we are looking at is a statutory home care scheme and its roll-out. I refer to regulation, a finance model and service configuration in the basket of services. Work is, therefore, ongoing on that scheme. We had hoped to be able to test some elements of it on a pilot basis this year, but that became challenging due to the impact of Covid-19 and we were unable to do it. We are, however, examining and planning the reinstatement of that testing programme, which will be evaluated as we go to inform the overarching development of the scheme. We are hoping to do that in 2021.

Several elements will be involved. We will be looking at the regulatory framework required, because the home support system and home care services are not currently regulated. Consequently, we will be examining putting regulation in place. We will also be looking at financial models and the type of modelling required, as well as future funding and service capacity requirements. Equally, we are exploring the type of service to be delivered on the ground and how that will be delivered. We are undertaking a fundamental examination of the home support service and what it needs to look like in future. There will be a greater focus on providing far more care at home and, in that context, we are looking at some new models. Those include the enablement model, and work is ongoing with the Health Research Board on an international evidence review. There is also some general work being done on needs assessment and care planning in the community.

How many people are working in that section? This issue has been ongoing for several years.

Mr. Niall Redmond

Between three and five people are working on this scheme in the Department, and then we have several experts working with us in the HSE, as well as in HIQA, to look at standards. As I mentioned, the Health Research Board is also doing some work. There is multi-agency and interagency collaboration, and several stakeholder groups are also involved. The core team consists of between three and five people, with several other people also plugging into that group.

I ask Mr. Redmond to listen to what I am trying to say or to Teachta O'Dowd, who is trying to come in. I know the sound is fading at times. That might be because Mr. Redmond is on-----

The question has been answered. Only a small number of people in the Department - between three and five - are working on this issue. The number of people working on this scheme should be increased. The scheme should have been finished, proofed and ready to roll at this stage. A huge change is necessary regarding the care of older people. Enabling people with high dependency needs to live at home is the key to the future well-being of older people. My challenge to Mr. Redmond and the Department, therefore, is to increase the number working on this scheme and not to stop the work on it.

I appreciate it has experienced a lot of pressures but I do not think the Department is putting enough care and attention into it. Have I much time left?

Just one minute, unfortunately.

Very well. I ask for a written reply in respect of recommendation 15.3 in the report, which states "The Department of Health should explore a suitable structure and process for external oversight of individual care concerns arising in nursing homes, once internal processes have been exhausted without satisfaction." What is the progress to date on that and what is the timeline for that change? Waiting 12 to 18 months is far too long. I thank the Chair.

I thank the Deputy. I ask the witnesses to answer that very quickly.

I thank my Fianna Fáil colleague for letting me in.

Mr. Niall Redmond

Work needs to commence on that as part of the package of recommendations that the expert panel have made. It is one of those areas that will most likely require a legislative footing and that is reflected in the expert panel's own suggested timeline for that, which takes into account some of the complexities involved.

As was mentioned earlier on, we have commenced work looking at the regulatory framework with HIQA and at how we can improve that. That part of the work has commenced already but there are other commitments in the programme for Government, such as looking at the role of the ombudsman. There are a number of avenues which the State is exploring in relation to that recommendation.

Perhaps Mr. Redmond will provide us with a written response on that, as well. That would be helpful. The next speaker is Teachta McAuliffe. He will take seven minutes to leave some time for our Cathaoirleach.

I am happy to yield three to the Chair.

There is a huge array of recommendations here and I will focus on those on visiting nursing homes. The first recommendation in that section refers to balancing personal freedoms and public health measures. However, in the plan published yesterday, it seems clear that at a particular point in the scale, there will be suspension of nursing home visits. In the second recommendation in that section, there is reference to additional facilities. Has consideration been given to how we would do that? How, for example, would a large number of private operators be supported in doing that? We do not want to waste much-needed public resources. How can we ensure we continue to have visits to nursing homes in what might be an extended level 3 period in Dublin or any other county?

Dr. Kathleen MacLellan

In relation to visiting, everybody is understanding of and concerned about the effect of the visiting restrictions in nursing homes. However, they are a protective measure. We have ethical guidance on this issue through NPHET and what has happened to date is an attempt to promote and design a visiting framework that will be proportionate in protecting residents while supporting visiting in order that visits can continue appropriately. It is also important to say that the guidance has at no stage said there should be no visiting in relation to critical or end of life. We need to support our nursing homes in this and much of that is dependent on local risk assessments in relation to those nursing homes. In line with those local risk assessments, those nursing homes need to work to find processes and facilities that allow them to support visiting at those critical stages in life. Dr. Kennelly articulated earlier the ongoing work within the HSE around looking at a new framework for visiting and enhancing and expanding the visiting processes that are there. The guidance has been updated as we go along in line with public health guidance and there have been significant additions to the ability of nursing homes to provide and support visits from relatives. We are all conscious of the impact of where those people in our nursing homes can see their friends and family.

To be more specific, the report talks about additional facilities and such facilities would need to be funded. What model and level of funding would be applied?

Dr. Kathleen MacLellan

That is one of the recommendations currently being examined in respect of the implementation oversight group. We will look at how that can be funded, what type of funding should be available and what funding may already be available through various means. There is a temporary finance assistance scheme in place, which will be extended.

There will be opportunities to look at what supports can be provided to nursing homes should they need them and to put additional processes in place to facilitate this.

It would be incredibly important. I know from my own family and from many other families that visiting other people with PPE and protective gear makes the visit almost more traumatic than the absence of a visit. We need to make sure that whatever facilities there are ease some of these concerns or make PPE less necessary by having physical barriers. We want to make sure any facility put in place can be turned around to be a non-Covid facility afterwards. This is crucial.

We have spoken about end of life. We saw harrowing scenes during the very early days of the pandemic with people saying goodbye through a glass window. What arrangements can be put in place in the short term for people who are in a situation where a relative is due to pass away and they have a short period of time to say goodbye?

Dr. Siobhán Kennelly

What is useful about this stage of learning about the pandemic is that there is very little evidence that visitors introduce Covid infection to nursing homes. We have a bit of confidence on this with regard to our understanding that much more of the risk is through staff transmission. This was certainly one of the things we learned from phase 1. The early lockdown with regard to visiting means we have not necessarily tested this but international experience is that visitors, once the appropriate precautions are applied, probably constitute less of a risk than was the concern at the start of the pandemic. My clinical colleagues who are engaged in this and I will use that as an important reference point.

With regard to end-of-life care, there are very specific criteria on end-of-life visiting and how it can be facilitated. Much of this is predicated on the nursing home itself. PPE, particularly if there is an outbreak in the nursing home, is an obvious requirement in protecting people who are visiting. What we have seen from the private and public nursing home sectors is that there has been a lot of learning in this respect. There has been a lot of flexibility applied as-----

I am surprised that visitors are not necessarily a source of infection but as part of the Government's plan published yesterday, it is very clear that under level 3, visits, aside from critical or compassionate circumstances, would be suspended. My worry is that if we were to be in level 3 for a long time it would have a significant impact on people in nursing homes. I have run out of time and I will ask for a written response on this.

Dr. MacLellan and Mr. Walsh were both members of NPHET. Are they still members of NPHET?

Dr. Kathleen MacLellan

Yes.

Mr. David Walsh

I am not.

Who instructed the acute hospitals to discharge patients to create capacity for the anticipated surge?

Dr. Kathleen MacLellan

The discussions in NPHET were on preparedness and what the expectations would be. With regard to the question, perhaps the HSE could add something on it. There was certainly no directive given that all hospitals would be emptied into nursing homes. There was a considered approach whereby for older people in our hospitals who were ready for discharge, could be safely discharged and would be more appropriately managed in a nursing home setting that this would happen in as safe as possible a way.

Dr. Siobhán Kennelly

I want to bring us back to where we were in February and March and what we were seeing in acute hospitals in Italy, Spain and elsewhere. Key considerations in some of the decision-making that happened in this regard were the risk issues pertaining to older people in acute hospitals who themselves might have become victims of Covid introduction to those hospitals. Two facets of these hospital discharges were very much being balanced at the time. These were the risk to older people who would be inappropriately in hospital and exposed to risk of infection and the need for them to be cared for in a more appropriate place. Lessons learned about asymptomatic transmission, testing protocols and isolation protocols have all been introduced since on this basis.

Clearly, there has not been a substantive link made between those transfers and evidence of wholesale transmission into nursing homes of Covid-19. It seems that local community transmission of Covid-19 and staff transmission rates probably played a more important role in terms of how infection was introduced.

Who gave the direction that people were not to be transferred from community hospitals and nursing homes to acute hospitals?

Dr. Siobhán Kennelly

There was never any such direction given. There was very clear guidance, given that all decisions about transfer were to be clinically based using appropriate clinical judgment. There was never any directive around people not being transferred from private nursing homes or community hospitals.

Will all guidance, directions and communications at that time between the Department of Health and hospitals be provided to the committee? I refer to correspondence on discharging patients, creating capacity and what was appropriate in terms of transferring patients or seeking to have them admitted to acute hospitals.

Dr. Siobhán Kennelly

It has been provided. It is all a matter of public record and was published on the HPSC or HSE websites. We would be happy to provide the information again.

There is nothing further to be provided other than what has already been provided.

Mr. David Walsh

If it is helpful, we will put it into one pack and send it to the committee so it can see it in its totality.

I do not wish to overburden the witnesses. It might be helpful to ensure that nothing has fallen between the cracks.

The committee published an interim report. One of the key recommendations it contained related to care facilities that repeatedly fail in the context of HIQA recommendations - as opposed to being substantially compliant with them - and the fact that the practice of the HSE paying for and sending new patients to these facilities under the fair deal scheme should cease. Do the HSE or Department of Health have any view on that recommendation and its implementation?

Dr. Kathleen MacLellan

We would strongly respect the power and role of HIQA in regard to its inspection reports. HIQA has significant powers. If it has significant concerns about any of its regulations it can impose conditions on those nursing homes up to and including closing down a nursing home. It already has significant powers it can use should it have concerns about any of the standards it is regulating or assessing.

What about cases where it has deemed a facility to have failed an inspection and the HSE continues to send new residents to stay at that facility and pay for their care there? HIQA has not taken the step of closing them down because we know that is legally difficult and burdensome in terms of judicial reviews, etc. The HSE is sending patients into and paying for facilities which have repeatedly failed HIQA inspections. Is there any indication that the Department of Health will adopt a policy of ceasing to do that or will the HSE somehow deem it inappropriate that taxpayers' money be used to pay for patients in facilities which are failing inspections?

Mr. Niall Redmond

The regulatory framework in terms of the registration of nursing homes delivered by HIQA will determine whether a nursing home meets the registration criteria. If HIQA has concerns in respect of nursing homes on an ongoing basis, it has those powers. Obviously, there are natural justice processes in place.

We know that. Do not tell us what we know.

Mr. Niall Redmond

In terms of the fair deal, in many respects the fair deal scheme is the epitome of the money following the patient. The prospective resident of a nursing home makes the decision as to what nursing home to live in or transfer to. It is not the case that the HSE or Department makes a decision; rather it is the decision of the individual or family as to what nursing home a person may attend. I again stress that for any family considering what is a very significant life decision in terms of putting someone into nursing home care, all of the HIQA inspection reports are available online and they should pay close attention to them in terms of making those decisions.

I think we got the crux of it. The money follows the patient rather than the other way around. The Acting Chairman has indicated that we need to finish.

I thank all of the witnesses for their attendance and the information provided to the committee, which will feed into the its final report. The report will be presented to the Dáil at the end of September or in early October. I also request that all follow up information in written form that has been requested be sent to the committee within ten working days. On Friday, 18 September we will examine the impact of Covid-19 on sport. Throw-in for that will be 10.30 a.m.

The special committee adjourned at 2.35 p.m. until Friday, 18 September 2020 at 10.30 a.m.