Covid-19: Final Report of Nursing Homes Expert Panel

I apologise to the witnesses that we are a little bit later starting than anticipated. The Expert Panel on Nursing Homes was established by the previous Minister for Health. I welcome from committee room 2 Professor Cecily Kelleher, chair, Professor Cillian Twomey, member, and Ms Brigid Doherty, member of the Covid–19 Expert Panel on Nursing Homes.

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 or 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 Professor Kelleher to make her opening statement. It has been circulated, in advance, to members so I ask her to confine her statement to five minutes.

Professor Cecily Kelleher

I thank the Chair and members of the Oireachtas committee for their invitation to attend this morning.

COVID-19 presents, as we all know, a significant global threat to public health and the WHO declared a pandemic on 11 March 2020. As of 14 July 2020, for the purposes of our report, 79% of all notified deaths were in those aged over 75 years. The 985 deaths in nursing homes represented 56% of all deaths in the Republic of Ireland. We, as a society, mourn their loss and offer condolences to the families and loved ones of all those who lost someone during this period.

The four person independent expert panel was appointed by the Minister for Health on 20 May to examine the complex issues in this particularly vulnerable group of nursing home residents. We were tasked to provide assurance that national protective measures were in place in line with international guidelines and best practice; to review International evidence using a systematic research process; and, to report to the Minister on immediate real-time learnings and provide recommendations. The panel took an evidence-based and consultative approach to our work. This was an in-action and after-action review that took account of lessons learned and preparedness, and was forward looking.

We requested an analysis of available epidemiological data from the Health Protection Surveillance Centre and the Department of Health.

At UCD, my team undertook a rapid, systematic review of international literature on older people in long-stay care centres. We also undertook a three-part stakeholder consultation over the month of June. We held 13 meetings with 43 people from key groups and received a further 37 submissions. In addition, we received 53 submissions from nursing homes and 60 public submissions. Finally, we undertook three nursing home site visits, one actual and two virtual, with the person in charge and staff. Panel members also had engagement with several residents and relatives.

We know that 5% of those aged 65 and over live in communal establishments. HIQA, the Health Information and Quality Authority, is the regulator for this sector and, as of summer 2020, had 576 registered nursing homes, 444 of which were privately-owned, and 3.6% of the over-65 population reside there. The first notified case in the sector was on 16 March. As of 27 June, 252 clusters had been reported, which represented 18% of all clusters at the time and they were associated with 5,608 cases. Notably, the highest number of clusters were in the more densely populated eastern region. The estimated incidence rate, at 14.5%, was greatly higher than in the general population of comparable age.

The evidence review showed that, despite a limited database to date with a new disease, the importance of infection prevention and control measures was repeatedly highlighted. All stakeholders who consulted with us stressed the need for preparedness. This included discussion on timeliness of response both then and into the future, the challenges of managing a new disease, and the critical public health measures that must be in place. I stress, this is a highly contagious novel virus with continuously evolving understanding of its epidemiology. The significance of asymptomatic spread and atypical presentation in older people was not understood early in the pandemic. The rapidity of spread in frail, older people in a congregated setting was a feature in Ireland and elsewhere across the world. Consideration of the well-being of residents and their voices, and those of their family members, in management structures was emphasised. Preparedness for the next 18 months will be crucial, with a necessary focus on this sector immediately as part of winter planning.

There was also emphasis in the submissions on lessons learned about the model of care for older people more generally. Many submissions focused on the implications for a future model of care. The interdisciplinary co-operation in response to the crisis presented a model for future delivery. The importance of representation of older people in their care and the place of advocacy were stressed. Nursing homes into the future should be part of a continuous spectrum of care of the older person with provision of multidisciplinary support.

It was clear from a range of stakeholders we consulted that healthcare staff worked tirelessly for the residents and all parties, including carer staff, and they now require a range of supports, which we stress in our reports. Great value was placed on the services "stood up" to cope, especially Covid-19 response teams. These supports must be sustained and regularised over the next 18 months. This is a multifactorial challenge and we must be action driven. The recommendations must also reflect that systematic reform is needed in the way care is delivered into the future.

Each area of recommendation in 15 thematic areas has a suggested clear lead agency and timeframe for implementation. We list some examples for discussion in our presentation. This ranges from immediate and ongoing to within two years of the publication of the report. Public health preparedness right now is essential by individual nursing homes supported by the HSE and HIQA.

We have an opportunity to address health policy for older people, with nursing homes playing a key part. There is an implementation plan in train now by the Department of Health which will be crucial to the delivery of the recommendations in this report. I thank the committee.

I thank Professor Kelleher very much for her opening statement and for the report before us. She outlined the number of nursing homes. We discussed inspections previously at the committee with Nursing Homes Ireland and others and we had HIQA in recently speaking about the number of inspections it carried out.

Does she think there was an adequate number of inspections of all care settings during the initial stages of the pandemic?

Professor Cecily Kelleher

The committee has heard from HIQA, which is the regulatory authority. It does periodic inspections and those reports are all available to us. They cover areas relating to governance, staffing, management and infection prevention and control. The committee will be aware, from its evidence, that it necessarily suspended those inspections for public health reasons at the outset of this in March, and it recommenced them around the time of the preparation of our own report. We are forward looking in our recommendations, and we have made some clear recommendations to HIQA to strengthen those regulatory inspections, particularly around infection prevention and control. We have set out a number of those in our report. I draw the Deputy's attention to one specific recommendation we have made in regard to an audit of staff in current homes, which we think is a very important piece of work. We have also placed emphasis on staffing provision and how that might be put in place.

I thank the witness. Regarding staffing provision, a crucial issue that came to light in my constituency of Dún Laoghaire, and presumably throughout the country, which we are also seeing in schools now, is where somebody presents with symptoms, relief cover is needed. That is essential, particularly in a care setting such as a nursing home or other facility. Graph 3.3 on page 29 of the report refers to the incidence rates. A comparison is drawn between counties Cavan, Monaghan, Westmeath and Longford and the lower number of cases in counties Waterford and Galway. Equally, on page 41, table 3.10, reference is made to the high incidence among healthcare workers in counties Dublin, Cavan, Louth and Monaghan in comparison to counties Waterford and Galway. What, in Dr. Kelleher's opinion, was the difference between those areas?

Professor Cecily Kelleher

It is clear that incidence rates varied by region. The areas with higher incidence rates was reflected in our data in higher incidence in nursing homes. A key component is that it is important to keep the infection out of nursing homes, and when there is a number of possible exposures in that setting, that is something to be hypervigilant about. The first point I would make is that there is a regional variation. That is an important point, which we are again looking at now. In general, preparedness has to take account of means of keeping the virus out of a home, and to have infection prevention and control strategies in place, and indeed contingency plans for the cohorting of staff, and other responses that need to be made. We have made all of those recommendations in the report.

I turn to the discharges from hospital. The report states 10,710 individuals were discharged from nursing or convalescence homes, or long-stay accommodation and 401 had either caught or already had Covid, and 11 were probable cases. Can Dr. Kelleher elaborate on that?

Professor Cecily Kelleher

We were an expert panel tasked to ask those with that responsibility what the issues were in transfers from nursing homes. The committee will appreciate that we do not have direct oversight of that. We were very clear that we would like to understand whether transfer from nursing homes contributed in any way to this outbreak. We were assured that protocols were put in place rapidly in relation to testing that was appropriate, and that this needed to be in place. Again, we made clear recommendations around transfers from nursing homes, which is a key component of management going forward. I stress that we have also made recommendations in respect of a number of other factors, including the healthcare workers who are working in those facilities, the ongoing rolling testing that needs to be in place in that regard, and indeed any potential risk for entry into that setting. I could turn to any of my colleagues who would like to elaborate on that.

Another issue in this regard, which we have raised, is a unique identifier. It is very important that we would be able to track the transfer of patients into different settings, and to be able to do that robustly.

Professor Cillian Twomey

To follow up on what Professor Kelleher has just said, an obvious question to ask is whether it is likely or possible that the transfers that occurred from acute hospital settings to nursing homes in the month of February, predominantly, brought Covid-19 to the settings to which they were transferred. The short answer is that we are unable to say with certainty that they did or did not. That relates partly to the way in which data are accumulated and collected but the more likely explanation is multifactorial. It relates to staff working in residential care settings, some of whom were working in several settings at the same time, and residing in congregated settings. The possibility of staff transmission, therefore, is equally an important factor.

We have made a seriously strong recommendation with regard to data collection in order that in future, if the question is asked whether people who transferred from physician or hospital A to facility B had a higher of lower incidence of Covid, we will be able to answer that. We were not able to get that answer in the work that we had done. It is more likely that it was related to staff although much less, I suspect, visitors but that is another area in which potentially there might have been some transmission. There are deficiencies in the way in which data are collated as between the Health Protection Surveillance Centre, HPSC, HIQA data and mortality data. It needs to be tightened and we have made clear recommendations as to how that should be done as a matter of immediate urgency. That has been accepted by the various agencies concerned as something that should be done.

I thank Professor Twomey for that but in terms of the number of individuals who were transferred either from a hospital setting to a nursing home or a long-stay facility, was he able to establish if they were tested prior to leaving hospital, which for me would be a critical point?

Professor Cillian Twomey

We must bear in mind that we are talking about February. I suspect not everybody who was transferred in February was tested because the facilities for testing were not only not adequately available for the particular requirement the Deputy outlined but, similarly, they were not available globally or nationally. I suspect there were transfers in the early part of that process, in February, in particular, where testing was not universally done but I can tell the Deputy now that it is done in every case. Not only that, when somebody is transferred now from the acute sector to a residential care facility, he or she is quarantined for a period of 14 days so that, test or no test, such people are kept apart from the other residents for that period of time.

I know the committee has heard repeatedly that, inevitably, there has been a significant learning curve about this pandemic because it was new to all of us at the beginning of this year. There is no question that our systems evolved more efficiently as time went on. We were asked by the Minister what needs to be done to ensure, should there be another surge, that the sort of delays that occurred earlier in the process, in February in particular, would not recur. I believe our recommendations, if implemented, will ensure that they do not.

I thank Professor Twomey for that.

Professor Cecily Kelleher

On page 42 of our report we indicate that from 10 March, testing of people in line with national criteria and two negative swabs before transfer was put in place. The guidance was reviewed again on 6 April and subsequently again on 8 April.

I thank Professor Kelleher. On that point, it brings into focus chapter 5, which examined the learning from Covid to establish the extent to which nursing homes are better prepared. The witnesses might delve into the recommendations under chapter 5.

The supply of personal protective equipment, PPE, at a very early stage - Professor Kelleher mentioned February and it was new to everybody at that point - took some time to filter to either public or private nursing homes. The witnesses might comment on that, too, in response to my final question.

Professor Cecily Kelleher

It is a matter of record that there was a national issue around supply, that is, the appropriate supply of personal protective equipment and of the appropriate testing and contact tracing process. We have learned from that, which came out clearly in terms of the submissions that we had. We are absolutely clear, as a panel that recommends preparedness, that this now needs to be in place. We have made several recommendations on the HSE's support of that. We have asked that the Covid-19 teams would be continually stood up in that regard. It is absolutely crucial that it is now in place.

I thank the witnesses.

I welcome all the witnesses. I have read the report and my first question is for Professor Kelleher. To some degree, the report had to look back on the most recent events and how nursing homes dealt with Covid-19. However, the report concentrated more on the framework of care under which nursing homes do or do not operate, as the case may be. The essence of the report is recommendations that are forward-looking and looking at what changes needs to be made. Is that what the report sought to do in essence?

Professor Cecily Kelleher

Yes, that is very clear. Without in any minimising the trauma to this country regarding what we experienced so far with Covid-19, and particularly this sector, we were very much charged with looking forward and making those recommendations as to what needs to be done.

When the panel went about its work, did it interact with HIQA? Did the HIQA report have an impact on the report of the panel?

Professor Cecily Kelleher

Yes. In terms of our stakeholder consultation, our first ports of call were HIQA, the HSE, Nursing Homes Ireland and all of the stakeholders that have a statutory responsibility in relation to this area. HIQA told us that it had regulatory responsibility and wanted to see a strengthening of its own regulations. We also have made it clear in our recommendations that we both agree with that and want systematic inspections to be undertaken. For instance, we have responsibilities for HIQA in terms of compliance oversight where PPE should be made available, as we have just discussed. In terms of workforce and staffing, recommendation 9.1 in our report is that HIQA should carry out a detailed audit. Recommendation 14.2 in our report referred to a "deficit in infection control and risk management" and suggested "Mandatory training records including infection control should be included consistently". In addition, recommendation 14.5 states that the regulatory assessment should take specific account of "preparedness of designated centres".

My time is limited so I ask Professor Kelleher to confirm whether what I now say is correct. The report refers to very poor clinical governance across the sector and noted that in the HIQA report, there are no formal governance links between the HSE and that 60% of homes with outbreaks were not compliant with the existing clinical governance framework. Is that correct?

Professor Cecily Kelleher

The Deputy will have to indicate the source of that particular quote.

It is in the recommendations that talked about poor clinical governance. There is also talk about the structure and relationship between nursing homes, the Department of Health and the HSE. Is that something that the expert panel examined?

Professor Cecily Kelleher


What was the outcome?

Professor Cecily Kelleher

We have identified, as I think is clear, that the person in charge has a statutory responsibility in relation to the nursing home framework, particularly for those in the private nursing home sector. We have identified, as have others, that there was a gap in the public support for that sector and that was why the Covid-19 teams were put in place. That remains an absolutely crucial thing.

It also states there is not a clear delineation of roles and responsibilities of key stakeholders and communication between the sector - the HSE, HIQA and the Department - and it is not standardised or co-ordinated. Was that-----

Professor Cecily Kelleher

That is what we found and what the agencies indicated to us.

Okay. The report also states some homes did not communicate meaningfully with residents and families about lockdowns and visitation.

Professor Cillian Twomey

I might be able to help the Deputy by answering that question. He is quoting from submissions that came to us from relatives and the general public about their experiences. There is a chapter in our report which reproduces in summary form the totality of those submissions and many of them are making the statements Deputy Cullinane is now quoting. They are not necessarily comments that we have made or verified.

Does the report comment on the structural relationships between the HSE, the Department and nursing homes?

Professor Cillian Twomey


Yes, that is the point I was raising.

Professor Cillian Twomey

With good reason. If Deputy Cullinane remembers, HIQA told the committee some months ago that it felt the HSE did not know the private nursing home sector in its totality because of the sector's current construct.

Did the report comment on the view that some homes did not communicate meaningfully with residents and families? Did the expert panel offer an opinion on that?

Professor Cillian Twomey

The opinion I would offer is that in the view of the general public and relatives who responded to us their experiences reflected that very point.

Okay. The report also refers to an absence of an integrated infection prevention and control strategy linking nursing homes and the Department of Health and the HSE. Is that correct?

Professor Cillian Twomey

In my view it is correct. The policy decision was taken two or three decades ago to essentially move the oversight of care for older people in residential care settings from a State-controlled one to a slightly distanced one. Twenty years ago, 80% of all residential care facilities were publicly run while today the percentage is exactly reversed. When I was in clinical practice some time ago, that is a policy decision I did not support. I believe that decision needs to be reviewed because one of the consequences has been an inevitable separation from oversight by State structures such as the Department or the HSE by virtue of that new arrangement, where one has independent private providers providing care without any formal structure of communication. We have addressed that in the report and stated it is absolutely essential that some form of connection be established immediately by means of a memorandum of understanding of some sort and, formally, a more firm and permanent arrangement whereby that separation of responsibility is no longer a reality.

I thank Professor Twomey. This report is one of the best reports we have seen come before this committee or any committee. The work that was done and the very clear recommendations will serve us well if they are implemented. It is a very thorough report. To be frank, it is hard to disagree with any of its recommendations. We discussed the matter with HIQA last week and we got further correspondence from it. HIQA informed us a number of times when it was before the committee that it has been campaigning, agitating, urging and calling on the Government to change the legislation, improve clinical governance and give it more powers to be able to deal with some of the issues mentioned in the report but it would seem that those calls fell on deaf ears. On foot of the report we got in June 2016, the CEO of HIQA wrote to the Chief Medical Officer seeking amendments to the Health Act. In March 2017, HIQA produced a number of documents, again recommending changes to the regulatory framework. Again in 2017, the CEO wrote to the director of the national patient safety office providing an update on suggested amendments, but that did not happen. The chairperson of HIQA wrote in 2020 to the Minister for Health, Deputy Donnelly, on the issue of adult safeguarding. It is a very long letter that charts all of the recommendations that were made by HIQA to try to put in place better structures between the HSE, the Department and HIQA and to give HIQA the powers it needs. I do not want the witnesses to comment on HIQA's role and the requests it made or the Government's failure to act on them because that is a question we can put to the HSE and Minister.

This is my final question at this point.

Are they confident that the report's recommendations will be implemented, given HIQA has been calling for many of these changes itself, over a long period, and they have not been made? Are they confident that they will be made? How important is it, from their perspective, that the clear recommendations relating to clinical governance, the powers of HIQA, and a statutory framework that will work to protect older people and make sure they have all of the choices that they need regarding their care are delivered?

Ms Brigid Doherty

It is important that the regulations that are set out are assessed in great detail. Some of the regulations, in a sense, are still functional. There is more systematic and detailed exercise, for example as regards infection control, looking at training records, etc., and also that it is documented in detail and published in the inspection reports. There is an issue with staffing levels. There is no statutory requirement for either the number of staff or the skill mix. HIQA does not have any powers, and the regulation clearly states that it is down to the provider to decide the staffing level. That needs to change. The Department of Health is commencing the framework for safe staffing and skill mix. That is being introduced. It is crucial that it happens sooner rather than later, otherwise it is very difficult to assess whether there is an appropriate level of staff, and indeed the skill mix of the staff.

I thank Ms Doherty. I again commend the work that was done by the authors of the report. It is a comprehensive report, and if it is implemented, it will serve us well. I commend those who were party to this report.

The committee will publish its final report. The expert panel's report needs to be reviewed on a regular basis by the joint committee on health, when it is established. We need to keep an eye on these recommendations, and make sure, as quickly we can, that they are implemented. I propose that this would be one of the recommendations we make in our final report. This cannot be a report that sits on a shelf or is cherry-picked. We have to get under the bonnet of this and get it right. Significant changes have to be brought about. While the expert panel has done a first-class job, we will need to draw on its experience in the time ahead. The health committee has a big job of work to do to ensure that what is in this report is translated into action. I thank the witnesses.

Professor Cecily Kelleher

We wrote this report with a view to the fact that it would be implemented. That is why we have set out these recommendations clearly and with a timeframe, and that is why we understand that the implementation oversight group of the Department and the reference group will keep a vigilant eye to ensure these are implemented. This is about going forward.

Everybody who writes a report does so in the same hope, but very few of those hopes are satisfied in the end. Hopefully, this one will be the exception. I call Deputy Fergus O'Dowd.

I welcome the experts. I agree that this is an excellent report and that it is looking to the future, while also taking account of some of the issues that happened in the past. If I were to take one line from the report, it is that where the authors state, in a narrative that is hugely important, that high-dependent patients can live happily at home. What I take from all of this sadness, the Covid deaths, and all the issues that have arisen, is the fact that we should try, at all costs, to make sure that people stay in their homes for as long as possible. We need to provide them with the facilities and care in their homes. That is the happiest and the safest place for them. Even people who are frail can be looked after well at home. That is what I want to happen. If I am correct, in summary of all the recommendations, the panel is talking about a change in the model of care and making sure that people have better outcomes towards the end of their lives.

Unfortunately and sadly, that has not been the case in respect of some deaths that have occurred in nursing homes. I will not name them as they are well known to the public. One of the panel's recommendations, recommendation 15.3, deals specifically with families who have had no closure as a result of the deaths and have not had full explanations and 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." That is the case right now in respect of a home in County Louth and another in County Meath. What do the members of the panel see as a suitable structure for those aggrieved, for the families who have suffered grievously as a result of deaths which are to date unexplained and unaccounted for to them? How do they see it working?

Professor Cecily Kelleher

I will hand over to Ms Brigid Doherty on this point.

Ms Brigid Doherty

At present, any complaint made about care in a nursing home is dealt with by the home itself which is not generally satisfactory for the complainant, family members or the resident themselves. The HSE safeguarding service does not have legislative authority to investigate complaints in private nursing homes. It has no obligation, either legal or contractual, to do so. Therefore residents in nursing homes do not have the support a person would have were he or she in a hospital or at home. My understanding is that under the current legislation, HIQA does not have legal powers to carry out investigations of individual complaints either. Therefore, the only option open - and it can be a good and satisfactory option - is to provide independent advocate support to support residents or their families through the complaints process. However, my experience in the past has been that the really good investigations have been where an independent investigator is appointed to investigate complaints within nursing homes. We need an independent advocacy service for nursing homes and I understand the National Patient Safety Office is exploring the rolling of that out from their new service but we need a process of investigation that is independent of the nursing home provider, be it private or public.

It obviously be should independent of the HSE as well.

Ms Brigid Doherty

It needs to be independent of any provider-----

The question I am asking is-----

Ms Brigid Doherty

-----because in order to have the trust-----

The panel's recommendation talks about the timeframe for this being within 12 to 18 months. Can the panel tell me what progress has been made or would it be the Department that could tell me? The timeline should be immediate as it is hugely important for families. I understand members of the panel may have visited some of the homes I am talking about in their professional capacity and there is huge trauma for families attached to constantly fighting to get information and to get at the truth. As Ms Doherty noted, HIQA is carrying out inspections but a key problem I raised last week, about which I think the panel members agree with me, is that the authority can carry out an inspection but not an investigation. Consequently the families are really extremely distressed. The witnesses should respond to that point.

Ms Brigid Doherty

I agree with the Deputy about the families. The lack of information is frustrating for families or for whomsoever is making the complaint around the care. The onset of Covid has highlighted this even more. It has brought it to the fore because of families not being able to visit residents. There is, therefore, a huge gap in information about how the care is provided and certainly with end-of-life care as to how those last few days or weeks of life are. That is a huge issue and it will have implications for the grieving process on an ongoing basis but people will not begin to grieve for their lost relatives until they get the answers. I suggest that advocacy, which is there and is already set up, should be encouraged by the nursing homes and by HIQA to support residents and their families in investigations until the Department of Health has-----

I am talking about the one in County Louth. The Minister for Health has agreed, at my request, to meet the families. I welcome that. Mr. Ian Carter, the chief executive officer of the RCSI, for whom, I think, Ms Doherty works, will also be meeting the families. My key point is that those who have suffered most are the most frustrated by the current process. These people have lost family members and they keep coming up against bureaucracy, which is extremely unhelpful. That is why I welcome the recommendation. The timeline should be immediate and I will ask the Department of Health to give me more information as to what it has done on that.

I will make a point on the vision for long-term care. Sadly, most patients in nursing homes suffer from dementia. I have seen figures to the effect that between 70% and 80% of people in nursing homes have that diagnosis. We need fantastic home care provision, but that is not there at the moment. It needs to be far more integrated and less costly in terms of service provision than is the case at present. Do the witnesses have a view on that? Do they have a vision for the future of people with dementia living at home? Is there a model that we should be following? The one good thing that can come out of all this tragedy is that there is a huge opportunity to change forever the way older people are looked after in their declining years.

Professor Cillian Twomey

I thank the Deputy. On the previous point, Sage Advocacy has been involved in the case to which the Deputy referred and has provided independent oversight, which is very helpful. There are departmental advocacy plans. However, to come back to the Deputy's main point, there is a possibility - through Sage Advocacy - to do things more speedily.

The issue of complaints is complicated. Dementia is more common as people get older but there is a more fundamental point. In this society, we are, with few exceptions, either living at home and well - this is the case for the vast majority, young and old - or we get sick and go to hospital. Hopefully, we get treated and get better or we get treated and need ongoing supervision and care but get better and get home. However, there is a subset of people who have been completely healthy for 60, 70 or 80 years and who suddenly get a devastating illness such as a stroke. The system in place in present means they will either go home, if somebody can look after them, or they will go to a nursing home. It is my view that we have failed, with few exceptions, to develop the alternatives.

People with significant dependencies, including dementia, will do better in smaller congregated settings than in the institutional environment that any residential care facility inevitably is. We know from work done in other European countries, and there are some examples in Ireland as well, that people living in smaller settings, with maybe six or so residents, do infinitely better than those living in the larger ones. We have facilities in this country for residential care nursing homes that range in number from perhaps 30 to 180. I refer to the Years Ahead report of 1988, which the committee might like to have a look at because they will see resonances with what we are saying here. It was never envisaged that we would create large multi-occupancy residences like we now have. What we need, in my view, is a single integrated system of care for older people which allows the person to choose where they avail of that support and care. There should be a single source of funding which should allow them to be supported at home, if that is their wish, to be supported in one of an adequate number of smaller congregated settings - these are yet to be developed - or, if required, to be supported in long-term residential care.

We hear regularly: "This is their home." It is their home in the literal sense but not like your home or my home and we have to recognise that the needs of people with significant disabilities, including dementia, require an alternative system of support to being congregated in large numbers. I am glad that, in the context of the commission on care referred to in the programme for Government, this is instanced as an important development.

I hope that we can introduce financial incentives now to develop these alternative, smaller congregated settings of support which are more locally-based and close to where people live, just as we did with the development of the private nursing homes sector 20 years ago.

That is a very important statement and I am very pleased Professor Twomey made it. That is where we have to go as a society.

I welcome the members of the expert panel and congratulate them on the panel's report. It is an excellent and comprehensive report which sets out a substantial number of recommendations, identifies the lead agency, which is very important, and suggests a timeframe.

There is no doubt that we need to substantially change the policy on elder care and move towards a new model of care. Deputies regularly deal with this issue. Approximately 6,000 people who have been approved for home care have not received it due to a lack of funding. Many of these people end up in acute hospitals or nursing homes where they do not need or want to be but that is the area for which funding is available. For this reason, I fully support the recommendations on changing the model of care.

It is very important that housing agencies are heavily involved in developing that new model of care. We have a small number of examples, which are very good, of local authorities providing sheltered housing. That could be developed much more widely. The ideal scenario is to have people stay in their own homes with support, although sometimes that is not appropriate. Local authorities have a very important role to play in providing sheltered housing that caters for a range of dependencies, from practically independent to more dependent, with the necessary supports. That requires different agencies to work together, which sounds easy but is often the main stumbling block. It is very important that this happen.

Members are not able to be present for the full meetings so I ask the witnesses to forgive me if this matter has been raised already. On the 88 recommendations, it is often said in this country that we produce many good reports but that we suffer from implementation deficit disorder. There is no doubt about that. The challenge for this committee and for us as public representatives is to ensure that does not happen with this important report. Can our expert panel give us its view at this stage on the response to its report and recommendations? Do the witnesses believe it has been adequate? I have a concern that the committee charged with implementing the recommendations is chaired by the Department of Health. That is an issue. Is the expert panel satisfied with the arrangements that have been put in place to date for the implementation of the recommendations in its report?

Professor Cecily Kelleher

I will first respond to the Deputy’s earlier point. We fully endorse what she is saying about taking an inter-sectoral approach to doing this. We have set out a number of the statutory care supports for older people. We are as concerned as the Deputy and others are to ensure this sector is protected into the winter. We have been giving very clear direction on this since we produced our report and we have had a positive response from the Minister. He has communicated very clearly to HIQA, the HSE and Nursing Homes Ireland that we need to be in implementation mode. It is very clear that from the core threat of Covid-19, we need to ensure the Covid-19 teams are stood up, are working, are supporting the individual nursing homes and have the preparedness and resources in place. We have set out a whole range of those resources. We want to ensure this happens.

I thank Professor Kelleher. It is important now that we look like being on the cusp of a second wave, regrettably, that all those recommendations are in place with regard to immediate concerns.

Regarding longer-term policy changes that are so badly needed, is she satisfied that a mechanism is in place to implement the recommendations the expert panel is making or does it have further recommendations to make in terms of what needs to happen?

Professor Cecily Kelleher

Certainly, we welcomed the implementation group being set up with those who have the statutory responsibility. A reference group is to be established that will have membership from this expert panel, which we hope will be vigilant with regard to this immediate short term. We think we have learned something very important about an area that has not been given as much attention as the acute sector to date. It is an endorsement of the need for an integrated care policy going forward and we absolutely would like to see these policy recommendations acted on. I will turn to my fellow member-----

I thank Professor Kelleher very much and I will pick up on a couple of points she made. She mentioned a reference group to be set up comprising members of her own group, which is important. Has she a timeline from the Minister for the setting up of that group?

Professor Cecily Kelleher

Yes, we have. We believe the first meeting is next Monday and I will chair that. I believe this afternoon there will be more information from the Department of Health on the detail of it.

Ms Brigid Doherty

The implementation group that has been set up has met twice. It meets every two weeks on a Wednesday.

Does the expert panel receive copies of the minutes?

Ms Brigid Doherty


I thank the witnesses very much.

I welcome the witnesses and thank them very much for their contributions. I particularly welcome the statement from Professor Twomey on the nature of the type of care we provide for our older persons. One thing is certain; we will all be there some day so it is important that we get the future right.

I would like to look back on the past and what the expert panel's report set out to do. I would Professor Twomey to comment because I believe his terms of reference were quite restricted in terms of what he could delve down into on what happened in the nursing homes. He was tasked to provide assurance that national protective measures were in place in line with international guidelines and to provide recommendations. He does not, however, seem to be able to move beyond that to say who or what was responsible for the spike in deaths or the 56% of all deaths in nursing homes. The report identifies some areas but Professor Twomey has said repeatedly that he completely disagreed with the policy decisions that were made over recent decades and that there was a significant gap in support for the care of our elderly, with 80% being in private settings where there was no oversight. I would like him to comment on the terms of reference. Would he have liked them to be expanded so he could make clearer and more concise recommendations about the nature of care going forward? It is well known that what is called the "grey rush" is now an investment opportunity for a large number of global corporations and it is exploitative of the care of our elderly. We need new ways to develop that. I, for one, will push that because we need to look at reversing the private-public trend that has developed over the past 20 years with 80% private to 20% public and voluntary homes.

There are alarming or worrying reports, and there was no doubt this was going to happen again, that the numbers of Covid-19 cases are beginning to increases in our nursing home sector. The expert panel has made good recommendations on issues such as access to rapid testing with fast-tracked results and ensuring all residents coming from the community or transferred from hospitals are tested. It is probably in the report that all staff should be tested.

Will our guests comment as to whether they are confident that the testing of staff, provision of PPE and the protection of the elderly in these homes, all of the recommendations the panel is making, are now happening? Our guests may not be able to answer that in detail and I acknowledge they have already given some answers about the near future to Deputy Shortall, but I am concerned about now and the return of Covid-19 to our nursing homes in numbers.

Professor Cillian Twomey

We can give some reassurance. A programme of ongoing testing of staff in all nursing homes is under way. Two such exercises have taken place already, one in June and the other over a four-week period ending in August. All staff in all nursing homes were tested. It is good news, though thankfully not surprising, that the positivity rate was very low, 0.1% to 0.2%. I am confident that the process is in place.

We are equally confident that there is a significant and real commitment to ensuring that every nursing home has a core supply of personal protective equipment and, in the event of a surge, will be able to access more without delay. Let us not forget that the PPE dilemma was not confined to nursing homes but was also a difficulty in the acute hospital sector. We all remember the aeroplane arriving from China with equipment that was unsuitable for either type of facility. I am confident on that score.

The Deputy asked if I am confident that the model will change. It must change. The 80-plus age group is going to treble in the next 30 years. Quite frankly, if, in 30 years' time, we have a model of care for older people that is three times the current one, we will have failed abysmally. For example, Denmark has not built a new nursing home since the late 1990s. Finland, which has a population a bit like our own although it is more scattered, has 7,000-plus residential care beds for older people. We have almost 32,000 beds. What is Finland doing that means not everyone requires to be institutionalised? That takes us back to the point I made earlier about the need to have alternative models. Let us be clear and fair that a considerable number of older people are being looked after in their own homes with the support and help of their families. That is to be commended and often occurs under difficult circumstances for the carers involved. That is where the majority of older people are. There are other models of care that will lighten the load on carers, such as the smaller congregated settings that I mentioned.

My nature is one of optimism - one might say it is utterly misplaced, but that is the way it is. I have been involved with reports in the health area for many years. I heard the pessimistic comments that the Chairman made earlier about reports generally. I understand that, but there is an urgency here. Perhaps one of the fortunate spin-offs of Covid-19 is that it has concentrated minds. Perhaps it will be the case that cross-departmental and cross-sectoral support will achieve the change that I believe absolutely must take place.

Professor Cecily Kelleher

I will come in on the points around the terms of reference because they are important. We were given those terms of reference to ensure that preparedness would be in place, based on international evidence. We did a wide stakeholder consultation with every agency that has a responsibility in this area. We also consulted the general public, nursing homes and the relatives and families of people who had been affected. We were very focused on the lessons to be learned and the preparedness that was needed in the work we were doing. We have learned a great deal more. We would all share the Deputy's hope that if we go through a resurgence of this virus, we will be prepared, understand the condition, know who the vulnerable patients and residents are, and have adequate PPE and other infection prevention and control pieces in place. The key things include having in-house capacity to take swabs, rapid testing and a responsive HSE. We are keeping a firm advocacy position on making sure that those things are being done.

I will ask two shorter questions. Have our guests any concerns? They have outlined clearly that there needs to be testing and have said that testing of patients who are moving from hospitals into nursing homes is happening and will happen.

Do the witnesses have concerns that, should patients in the nursing home sector become very ill, they may be moved to a hospital setting for acute care? Even though the witnesses are very optimistic about changing the model for the future, as we speak planning permission is being sought and, in many cases, granted for large-scale nursing homes across the country. I refer to big corporations that are building the sort of capacity that was spoken about earlier - units of 100 or 200 beds, which are not appropriate. How are we to change that? There is also the question of other bodies concerned with the care of the elderly, such as Age Action and Sage Advocacy, not believing the report deals with the questions of families and some staff with regard to what happened in the nursing homes. Would the witnesses agree that, although the group's terms of reference did not require it to look at these issues, another body of work is required to deal with the concerns of families as regards what happened to their loved ones?

Ms Brigid Doherty

I will take the question regarding the families. I agree that something needs to be set up to investigate or talk through the care of residents in nursing homes with families. There is a huge gap in that respect. Sage Advocacy provided a lot of support through the first wave when nursing homes were closed and when families were having difficulties visiting at the end of people's lives. It was very traumatic when end-of-life visiting was not allowed. In the meantime, nursing homes are the providers and have a responsibility to meet families and to provide and release the information they hold under freedom of information legislation, if requested. I strongly support Sage Advocacy. It is a really good organisation and has a lot of experience. Its services should be promoted by HIQA and the Department of Health. When the Minister meets families, it may be worth him suggesting that the family bring an advocate. The advocates make sure that the voices of residents and their families are heard and that they understand what is being said. It is very important. There is a huge gap in that respect. I feel very strongly about that. If we do not deal with this now, it will have very long-lasting effects. It will come back for those people three, five or ten years down the road.

Professor Cillian Twomey

On whether we were concerned about people who are very ill being able to get to an acute hospital, I will mention one of the positives that emerged regarding the Covid response teams that we are now recommending, in recommendation 7.1, be permanently institutionalised as community support teams. This was reported to us by participants, including community nurses, geriatricians, infectious control staff, public health officials and so on. Heretofore the amount of support nursing homes got was decided somewhat haphazardly, perhaps more so in the private sector than in the public sector. These committees, however, were able to give support, including clinical support where necessary. This sometimes allowed the medical issue that had arisen to be dealt with satisfactorily in the nursing home. Equally, these teams were able to say that people needed to be transferred to an acute hospital because of the issue they had and to organise that transfer.

From now on, such community support teams need to be made permanent. This will lead to much better clinical decision-making about which patients or residents should be transferred and when. Sometimes nursing homes are worried about the publicity that might accrue to them if people who are close to the end of their lives and are dying die or if more than one or two such people die in a week. A support team would be able to say that a person is dying and that the humane thing to do is to support him or her where he or she is and where he or she has been looked after so well for so long, if that is the appropriate answer. A structure such as the community support teams which would support that kind of decision-making would make for a much more enhanced level and standard of care, while also providing reassurance to families, residents and staff in residential care settings.

I thank Deputy Smith and Professor Twomey.

I welcome our guests and thank them for their excellent work and the tenor of the report they have produced. It is very important that they have taken a forward-looking view and I accept that there may have to be some retrospective learning done at another time. We must now go about the business of protecting all of our aged in the future and making sure they have adequate resources in private and public nursing homes. I commend the quality of the report and its future perspective. It is to be hoped it will provide a template to deliver dignity, respect and resourcing to nursing home residents.

Early on in the Covid pandemic, I was one of those who engaged with nursing homes. I asked that swabs be taken in-house nationally when clinicians were capable of doing so and that a pathway be provided into hospital labs for PCR testing rather than having samples sent to the National Virus Reference Laboratory which was taking up to seven days to turn around tests. Thankfully, a lot of that was delivered.

I wish to discuss some of the issues for private nursing homes. I know they are vilified from time to time, but in my experience of Waterford county and city I can say that, without exception, tremendous care is given by the public and private sectors. Some of the issues highlighted at the time have probably not been fully dealt with. In terms of the Covid pathway, nursing homes are expected to provide isolation facilities which are taking up potential bed occupancy. This has a knock-on effect in terms of revenue. Another issue at the outset of the pandemic was the management of oxygen in nursing homes, which required sign-off by a palliative consultant, something which did not always happen as quickly as it should. Do the witnesses believe these issues will be dealt with following the report?

I refer to point of care testing. We have heard a lot about PCR testing in this country, but diagnostic testing is available in the United States, in particular. Has such testing been considered in order to allow for a faster turnaround time in nursing homes to allow isolation to take place immediately and contacts to be quarantined?

Professor Cecily Kelleher

All of the points the Deputy made about the earlier stage needed to be addressed and we recommend that they should be. It is very important to have capacity for in-house swabbing and rapid entry points into the laboratory information management system, LIMS, so that there is a quick turnaround in diagnostics.

We included in the report the recommendation that procurement should include the supply of oxygen as appropriate, and that should be the case. That is a key point.

I believe point of care testing has been reviewed and that a review is ongoing. PCR testing is currently being used and the National Virus Reference Laboratory is keeping a close eye on that. If point of care testing becomes a reliable means of testing, that will be recommended by NPHET.

I thank Professor Kelleher. She has answered my questions. Does she have an understanding of what the management of oxygen in terms of palliative care will be in the future if we end up with a second wave in our nursing homes? Please God, we will not. Will the Covid response teams that have been highlighted be assigned for that?

Ms Brigid Doherty

Very early on, the HSE asked all nursing homes to link with a palliative care team in their area. Palliative care consultants became part of the Covid response team. In our report, we recommend that continues so that every nursing home is linked with a palliative care team.

Nursing homes manage end-of-life care very well as they are used to doing it, as my colleague said. We had an increased number of deaths in nursing homes, including deaths that happened more quickly than expected. It is essential that palliative care teams are involved. We recommend that they are available 24-7 to support advanced care planning and anticipatory prescribing for symptom management, which would include oxygen if required.

The witnesses will be aware that at the start of the Covid pandemic many private nursing homes had to buy PPE.

They were not being supplied by the State. Subsequently, the State gave them support moneys but this was based on capitation grants and did not cover private patients in nursing homes. I hope this has been rectified at this stage and that in future there is modelling to provide PPE to private nursing homes. When I last engaged with them they had adequate amounts but that was based on very low rates of infection. Is there a pathway to ensure there will not be a delay and that the cost will be subvented to some degree?

Professor Cillian Twomey

The answer to both questions is "Yes". As I said earlier, it is the case that not just private nursing homes but also public nursing homes and acute hospitals had difficulty accessing equipment. Each nursing home is now assured of a core quantity of PPE and, in the event of a surge, having rapid access to additional equipment as required. This also applies to gowns, gear and masks as well as oxygen. Whether they are public or private this has to be done. What may need to be worked out is an arrangement between the public and private sectors as constructed on shared responsibility of the funding arrangements for the care and support needed.

Staff resourcing was a problem in the private and public sectors and possibly still is. I am aware of a number of nurses with foreign citizenship who are trying to get work here, and there are nursing homes that wish to recruit them, but they cannot get movement through the Department. Is there a crossover with the Department of Foreign Affairs and Trade on trying to fast-track some of these visa applications so we can get these people into position?

Professor Cillian Twomey

That is not something we have been particularly involved with or engaged in. We have to go back a step. Many overseas workers in residential care settings have working conditions that are inferior to those of colleagues working in other residential care settings. This in turn forces them to work in several settings at the same time. These hard-working staff very often live together and share accommodation with seven, eight or nine people. The danger with regard to Covid, and this is a serious issue, is the transmissibility potential that can occur. We have outlined that even agency staff should be assigned to a single nursing home and not work in several at the same time. It is a dangerous position in the current climate. The employment conditions of some staff in some nursing homes are a cause for concern. Certainly it was reported to our group that it is a major concern that needs to be addressed.

I also want to make the point that the care provided in public and private nursing homes is, by and large, of a very high quality. The staff are unbelievable. Residents have expressed this in the commentary submitted to us. In one of the nursing institutions I visited I met a staff member who had contracted Covid and had to take time off work. She felt very guilty about this fact and was very distressed because she knew that her being off meant the nursing home was down a whole-time equivalent. This was hugely devastating for her. I met her when she had just returned from her time off. She was much better health wise though not fully energised but she still felt guilty that she had to be off work because of her illness when she knew the nursing home required her assistance. In some instances, nursing homes were down many staff. We cannot overstate the devastation for the residents who died and their families but also for the staff during the peak period of deaths from mid-March through early April. It was hugely devastating. If any incentive is required to concentrate on implementing these measures it should be a reminder that we cannot go back to that.

Absolutely and I strongly agree.

Professor Cecily Kelleher

To be clear, in the early stages of grappling with a pandemic of this scale there was a huge staffing crisis. We are recommending a preparedness plan.

As the committee is aware, we have also discovered the need to have an adequate staffing skill mix and we strongly recommend that be put in place.

I thank Professor Kelleher and Ms Doherty.

I thank the expert panel for its report and the comprehensive way in which it has approached its work. I will pick up on a point briefly addressed by Professor Twomey concerning the impact on staff. I do not want to dwell too much on this issue, but we know that 56% of total deaths from Covid-19 in this State, thus far, have occurred in nursing homes. Workers in that area are not unaccustomed to dealing with end-of-life situations. From talking to people in my community and some members of my family, I know that a degree of trauma - this is not exclusive to nursing homes - was experienced by staff in the healthcare sector as a result of how they had to deal with Covid-19. They were almost learning on the job. In nursing homes that was compounded early on by a flight from the sector into more mainstream healthcare areas. We know nursing homes were crying out for staff and that the Be on Call for Ireland initiative did not work or make a substantial difference. It was little more than a public relations exercise, a bit of spin and nonsense.

Regarding staff and how we can build in some resilience, because this situation is not over, do the witnesses have any recommendations regarding supports that could be put in place? The skill mix is important, but we do not need to review that because we have skill mix reports going back some 20 years. That aspect of the health service has been reviewed to death. Do the witnesses have views on the supports available to staff now and what else could be put in place? I ask that question because we owe our healthcare workers a little more than just a round of applause and a pat on the head. This crisis has had a mental health impact, and we have yet to deal with that. I address my question to Professor Twomey.

Professor Cillian Twomey

I will ask Professor Kelleher to respond because she has the answer at her fingertips.

Professor Cecily Kelleher

We agree with the Deputy's point. We make a recommendation, 5.8, regarding occupational health, human resource and psychological supports. We asked the nursing home providers to look at that. We have been clear with the implementation group and the reference group that the mental health aspects of this situation should and must be addressed. This applies to healthcare workers across the sector, but this group of staff is and was particularly vulnerable and we have made several other recommendations regarding employment supports as well. We have had some feedback, as part of the stakeholder exercise, that these supports were being put in place, especially in the larger units with the level of staffing to do it. It is, therefore, a recommendation that we have made.

I welcome the recommendation and that it has been made. To elaborate on recovery for staff, I believe that a comprehensive support package needs to be put in place across the healthcare sector, but specifically in nursing homes because of what people working in that area had to go through. Moving on to the issue of transfers out, an issue that may have been covered already, I am reasonably confident that I was the first person to raise this issue directly with the then Minister for Health. I refer to the need to have two "not detected" swabs before a patient was transferred out. Notwithstanding everything that has been said, we know that was not done.

Turning to what we can learn from what happened, and many lessons are being learned, are the witnesses confident that sufficient capacity exists as we prepare for a surge? We can see from the website of the INMO that the issue of trolley waits is back, not that it ever really went away, and some of our hospitals are nearing capacity. I know what was done the last time we had a surge and that we need to free up capacity in the hospitals. Are the witnesses confident that the required testing regime is in place to ensure that every person transferred from a nursing home into an acute hospital setting will be able to have the two "not detected" swabs before being moved?

Professor Cecily Kelleher

I would absolutely hope so. I take the Deputy’s point in respect of the beginning of this. There was a huge focus on acute hospital capacity. The nature of the illness was not fully understood at that point, nor was the position relating to asymptomatic, atypical or pre-symptomatic people. This has been in place since 10 March. The two tests need to be undertaken and we have strongly advocated that testing procedure should be in place and that all people transferred should be in isolation for 14 days. It absolutely should be in place.

Many private nursing homes do not have the space for isolation. When Professor Kelleher said that the regime has been in place since 10 March, does it mean that every patient who was transferred out from 10 March had two not-detected swabs before being moved?

Professor Cecily Kelleher

I think the evidence we were given was that that was put in place. I cannot answer whether every single one was the case but that was what we were given.

I would strongly disagree with that. I understand that might be the witnesses' position but it certainly is not the experience that has been relayed to me.

In terms of ensuring the resilience of the sector, we know there are obvious complications with a for-profit model for any form of healthcare. If one is chasing a profit all the time, it does not necessarily translate into good outcomes for patients, notwithstanding that there are many private nursing homes which are doing an absolutely fantastic job, thanks, in the main, to the men and women and staff working hard in them. On harmonising pay and conditions for workers, because we know what happened at the start where many people were transferred from the nursing home sector to the acute hospital sector, would Professor Kelleher see harmonising the terms and conditions, pay, etc., of those workers in the private sector – I mean bringing them up rather than bringing down those of the public service workers – as being important in terms of building resilience in the nursing home sector in the future?

Professor Cecily Kelleher

Yes. We had a number of submissions to that effect. It would be important that the terms and conditions of people employed across the sector, whether public or private, should be harmonised, and harmonised upwards and not downwards. We have made a number of recommendations around qualifications and support for that in the report.

On the level 5 qualification for the care assistants, clearly it would be ideal if they were all qualified to that level. There are many people working in the nursing home sector who perhaps started working a long time ago and who would not necessarily have that qualification but would have the experience. There is a facility there for one’s experience to be recognised in some way, shape or form. On bringing everyone up to the standard, would Professor Kelleher see that as being a viable option rather than asking people who perhaps 15 years' experience to go back into a classroom setting?

Professor Cecily Kelleher

That would be up to the specifics of those providing the programmes. However, prior learning is always a consideration in regard to the delivery of those kinds of qualifications. I think it would be very important to take account of that.

It would, because there is a danger that we would run towards a piece of paper when the experience and knowledge exist already. The piece of paper would not necessarily be that important.

On the panel's recommendation on reviewing the skills mix, there is model of safe staffing and that was agreed between the INMO, the other unions and the HSE. Would the panel see that safe staffing model as being transmissible to the private nursing home sector, even though I understand it might put pressure on costs? Could that easily translate or would the panel be in favour of developing a specific safe staffing model that would be very much focused on the care of the elderly setting?

Ms Brigid Doherty

The model being rolled out into nursing homes can be adapted to the requirements of nursing home care. However, we need to be able to assess the level of dependency in the nursing homes in order that we can match it with the right number as well as the skills mix of the staff looking after the elderly.

It is important, as we get older, that we be cared for by people with the appropriate skills.

Absolutely. There is sometimes a fear that the mention of a skill mix can signal a reduction in the number of higher skilled staff in favour of staff who are not as highly qualified. We need, however, to reclaim the phrase "skill mix" and take it for what it implies, namely, the skills appropriate to the level of dependency. I thank the witnesses for the report.

Professor Cecily Kelleher

To reassure the Deputy, we have recommendations on those, Nos. 5.3 and 5.4. The skill mix is really important.

I thank the witness.

I thank the witnesses for their presentation and the work they have done on preparing the report. A lot of hard work has gone into it. It is a very good report in terms of how we can plan for the future.

May I revert to the staff issue? It is important because the pressures staff are under in many nursing homes were really challenging. In the expert panel's investigation and work done, did it find any case where there was a lack of support for staff among management or the owners of the nursing homes or care facilities? Did staff receive sufficient support?

My second question is on infection control. This is dealt with in section 7.2 of the recommendations. Clear guidelines are set out regarding infection control and what needs to be done. This is an issue I raised with HIQA last week. Do the witnesses feel nursing homes were adequately prepared for what was a new virus that spread at a phenomenal rate, as implied in the presentation? Was there a sufficient briefing by the whole healthcare sector, including from HIQA to the HSE and from the HSE to the private and public nursing homes? Was the expert panel happy with it?

Third, last week HIQA compared the numbers of deaths in both public and private nursing homes. On the basis of the numbers, I understand that approximately 20% of all people in nursing homes are in public nursing homes and 80% are in private nursing homes. The numbers of deaths in each reflected these proportions. I believe about 23% of the deaths were in public nursing homes while 77% were in the private nursing homes. With regard to infection control, where do we fall down in getting the message to the people on the front line that Covid presented a new challenge and that it had to be approached in a different way?

Professor Cecily Kelleher

The Deputy raised a number of points, all of which we believe are important. The sector has been used to dealing annually with infection prevention and control, including in respect of periodic influenza outbreaks. Covid-19 represented an unprecedented challenge across the healthcare system. It certainly would have been an unprecedented challenge in this healthcare environment, which is not set up for the level of hospital-based prevention and control that the contagious organism required. That is the first point.

Second, we all acknowledge that there was a major issue concerning preparedness, particularly regarding the rapidity of spread during March, the issue of having adequate personal protective equipment supplies and all the things we discussed earlier. I hope many of these issues will have been addressed comprehensively and more fully for the next stage. It is crucial that this be the case.

The Deputy raised recommendation No. 7.2. We are very much of the view that, because this can be managed in an acute scenario, the staffing needs to be thought through in regard to having the necessary supports and somebody available 24-7 for advice and guidance in this area. It is a specific recommendation we have made. I will pass over to my colleagues.

Professor Cillian Twomey

Regarding the preparedness of the community support teams, I do not think anybody was adequately prepared in February because we were just beginning to learn about what was about to unfold. However, we learned very quickly, maybe more quickly than some in other sectors did. A group we have not yet referred to in the context of the community support teams is that of general practitioners. The person in charge in a nursing home is the person HIQA identifies as such and, in a sense, that person is responsible for the totality of care in his or her institution. It is an onerous responsibility and assuming the role can be quite a lonely place for a person to be. If we expect people to take on that type of responsibility, we must have supports in place to ensure they can undertake it without being overly stressed. The role of the general practitioner is very important in this regard.

We currently have a situation where most residents in nursing homes have a GP assigned to them. Depending on the size of the residence, there could be ten, 12 or 14 GPs visiting the larger facilities and two or three visiting the smaller ones. There may be an urban versus rural factor in this regard. Those GPs provide care to their patients in the nursing home setting. We are strongly of the view that there needs to be a medical oversight role incorporated into the governance structure in nursing homes whereby the person in charge, who usually is a nurse, would have the support of a senior medical person, who should be a GP. We are suggesting that where GPs visit nursing homes, one of them would be identified as the GP lead in that facility and would be the go-to person for the overall review of adherence to all the standards HIQA has laid down and so on. Similarly, there needs to be a GP on the community support teams because GPs are the key medical link between the patient and medical care in the first instance. We recognise that this will put an additional onus on GPs who are currently overstretched in a context where there is not a sufficient number of trainee positions or established GPs. In recognition of this, we say that more places must be made available for general practice training and more GP positions must be created. This cannot be done haphazardly; it must be done properly.

Professor Twomey referred earlier to the structure of the nursing home sector. Is it not the case that the sector developed in the way it has because we had a situation in the past where only one person in a household was working, whereas now, almost every family has both partners working and they are unable, therefore, to give support to their parents in the same way that was possible in the past? Another factor is that a lot of people have gone abroad and the type of family support that used to be there is no longer available. This lack of family support is one of the challenges we now have in trying to develop community support.

The other issue in regard to the structure of the nursing homes sector is that it was set up as a separate entity. For instance, I am aware that elderly people in nursing homes are required to attend outpatient departments in certain cases when it would be a very easy prospect for a medical person from the HSE to attend a nursing home on, say, a monthly basis to review the requirements of residents. That type of arrangement was never set up and there is no structure for the connection between the HSE and the private nursing home sector. As a result, we have ended up with the difficulty we now have in regard to the lack of connection between hospitals and the HSE, on the one hand, and the private nursing home sector.

Professor Cillian Twomey

It is not true to say that nothing has been established. In my own clinical practice, for example, prior to Covid, I had assigned to me two community hospitals in the Cork city and county area which I visited on a regular basis. My colleagues in geriatric medicine in Cork continue to do the same. Admittedly, this related to HSE-funded facilities but it was an innovation that was introduced with benefit 15 or 20 years ago.

Covid-19 broadened that out considerably because it made clear that it is not good enough to have that sort of support provided to HSE facilities but it also needs to be provided to the private nursing homes. The Covid response teams did not distinguish between a public or a private residential care setting. The work that they did, which was hugely applauded, and we have an article in our report commenting on its success, did provide that necessary medical support. The person who, historically, would have had to inconveniently come from a nursing home to an outpatient clinic and wait for hours to be seen and then go back again can now be seen in that new format when the community support team visits the nursing home. We have now recommended that this model should be applicable to all residential care facilities, both public and private but there is a resources element to that. If we are asking general practitioners and geriatricians to be lead participants in it, as well as the other consultants like those in palliative care, public health and so on that are in our report, then we have to provide the resources for that to be realised. It is not impossible to do it but it absolutely must be done.

As regards the model, whether it is public or private my argument is that we should not have a huge number of large congregated settings for older people's long-term care residential needs. I am putting a strong case for a revised model, which is smaller congregated settings with a maximum of perhaps six people living in them. They can be managed much more easily, even in the context of someone being the father or mother of sons or daughters who are at work or who have gone abroad. It is about providing it in a more homely and humane way. To my mind, that will be much more a home than the institutions we have tended to generate over the past two decades.

Professor Cecily Kelleher

If I make a couple of other points, in terms of the demographics, there has been a change in family units and support that can be given to older family members but we also have a significantly aging population and the older one is, the more likely one is to be in a nursing home facility. We need to see in a comprehensive way how a community support could be put in place for our oldest old.

To go back to the Deputy's earlier point on the management supports, that did not come out clearly through the stakeholder consultations. I believe most of those were focused on the supports that should be coming from outside of it but, again, management support is a key point that we have recommended in respect of HIQA to ensure that the regulations, as well as that support, are in place.

Once again, I thank the expert panel for their work and their comprehensive report. To reiterate the headline figures, which are stark, 56% of total deaths as a result of Covid-19 occurred in nursing homes. That must point to a systemic failure of the highest degree because behind each of those deaths was a grieving family and the real life of a person who, undoubtedly, had come through hard times in his or her own life and then ended up being failed at his or her end in this State. To contextualise the greater anxieties that were caused to families who also had other members in nursing homes, whether they contracted Covid-19 or not, the restrictions that were in place led to enormous anxiety and fears, some of which have not dissipated.

I also note from the committee's report that there are strikingly high rates in particular regions and counties. The report pinpoints counties Cavan, Monaghan, Westmeath and Longford as having particularly high cumulative incidence rates of death that warrant further examination.

I note also that in the Department of Health's opening statement, if I read it correctly, that there are 39 remaining open clusters. I gather those are in nursing homes, and I seek clarification on that, and that four new clusters in nursing homes have occurred within the past fortnight. My first question to members of the panel is whether they are confident that the lessons have been learned with regard to visitation, the transfer of patients from other health services into nursing homes, the transfer of staff, particularly agency staff, across nursing homes, and the practice of the HSE actively recruiting staff from nursing homes to other areas of the health services?

In terms of all of the internal systemic problems in nursing homes, have lessons been learned to such a degree that we can say with confidence that we will not see a prevalence of deaths occurring in nursing homes over the coming months?

Professor Cecily Kelleher

I sincerely hope that lessons have been learned and we will not see a recurrence of what we have seen already. Four things really drove the vulnerability of this particular sector and they are the seriousness of the disease; the frailty and vulnerability of the population in question; the fact that a congregated setting is a very risky environment for the transmission and management of the virus where it is the home of the people concerned; and, the preparedness and response component. We discussed the latter earlier this morning. This rate is a very high rate. It is a deeply regrettable rate but our international review has shown that across the globe we are learning this lesson in terms of this setting. It was not just in Ireland that this situation occured that has thrown up the important questions that we need to address here.

Are we confident? The committee will meet representatives of the Department of Health later on. Earlier we talked about the nature of the current clusters and how many may be picked up now by the rolling testing process, which is a difference from where we originally started. The whole infection, prevention, control and preparedness piece is very important. We said earlier that the incidence on the east coast was higher and hence that drove risk in the congregated settings in those areas. We are trying to do everything we can to keep it out because that is what we absolutely must do to be vigilant and protect people. Essentially, we need to roll out what we have set out in this, and is what the stakeholders told us, in order to have as much confidence as possible.

How much time do I have?

One minute.

On page 93 of the report it states: "Other factors at play include the profile of workers in nursing homes and the interaction with other

cluster risk situations such as family members, shared accommodation and contact with other high-risk areas such as the meat packing industry." However, it has been cited that there is a particularly high incidence rate in nursing homes located in counties Cavan, Monaghan, Westmeath and Longford. In terms of what has happened in the North, there is similar data. Outside of Dublin the highest incidence rate seems to be centred around the Armagh Council District, which also happens to be a focal point in terms of the location of food factories in the North. Does the panel intend to recommend that a further examination of the link between the situations is carried out?

Professor Cecily Kelleher

Speaking to the section referred to, this was information that was repeatedly given to us at an anecdotal level so we asked for systematic evidence to link that observation. Obviously there are geographical associations and what we were told by many, as we have said, around the staff who work in the nursing home sector, where they may have shared accommodation or other reasons, that they were associated. I do think it is a very important issue that needs vigilance. We know that rolling testing was also being done in the meat packing industry as well as the rolling testing that is being done in nursing homes. We have recommended that the data sets be linked so that we could have a more systematic report on the risk factors for outbreaks in those settings, which are important to record.

I suggest to our secretariat that that be included for consideration in our report.

I thank the Deputy.

Like other speakers, I welcome the witnesses and thank them for their report. One question arises immediately which I know has been referred to previously. In the event of the report being carefully implemented, are the witnesses satisfied that that will adequately address the issues that came to the fore in the recent pandemic?

That is my first question.

Professor Cecily Kelleher

We have done our level best to make the recommendations that we think could ameliorate what we saw already, but we are in an uncharted situation here. We are dealing with a pandemic of a condition where every day we learn more about its impact and effects. We have seen that Covid-19 is a highly contagious condition and that it can have long-term sequelae, so we have to continue to see what the impact of that might be in the population. We are trying to control the pandemic in this country and doing everything we can to keep it minimised and contained. We endorse that insofar of its importance. I hope the recommendations we are making around what we are learning about this particular sector and what we owe older people in policy terms will mean that we can see a change in that in the long term.

Professor Cillian Twomey

We need testing and rapid turnaround of results needs to be applied, not just in the nursing home sector we are discussing in terms of staff and residents but, as we have heard in recent weeks, it is a challenge to apply it nationally as well. If there is a suspicion, a person must have a test as quickly as possible and get the results as quickly as possible. It would be nice to think the testing arrangement that was very publicly promoted and mentioned last evening could be applied across the country. What we need is that level of promptness so that if there is somebody who is positive one can get on with contacting the individuals that person was in touch with. That is a seriously important part and it requires funding and setting up. There are places available to do it, but we have to be vigilant and we also need to crank that up in the event of anything like a surge re-emerging.

Ms Brigid Doherty

It is in our recommendations but what is very important with the winter ahead is to encourage everybody to have the flu vaccination. We hope all healthcare staff and anybody working in a nursing home will take up the flu vaccination. We need to encourage everybody, including members of the public, to take up the flu vaccination because otherwise we will possibly have residents requiring admission to hospital. We sincerely hope that could be avoided.

The recommendations have to be implemented. They are very clear. They are achievable. I believe we have the will of all the stakeholders to implement them now.

May I ask another question, Chairman? How many minutes do I have left?

Yes. The Deputy has a minute and a half.

That is very tight.

I am told we have to be strict on time because the Seanad will sit in this Chamber at 2.30 p.m.

That is fine. I have a number of questions but I will ask them quickly. Nursing homes have been mentioned many times in the debate on this issue over the past six months and there has been implied criticism. We all have nursing homes in our constituencies, both public and private ones, and without exception the quality and standard of service provision are excellent. From my experience, I certainly could not point the finger at anybody. Like everyone else here, I deal with the nursing and management staff fairly regularly. One can gauge from the opinions one gets that they do their utmost to give the best possible quality of service.

Have public or private nursing homes been in a better or worse situation in the pandemic, given that it was identified from the outset that nursing homes would be vulnerable for two reasons, namely, congregation and age profile?

Professor Cillian Twomey

The answer is there is no difference, but it was not the nursing homes that were the issue. It was the frail older people who are in nursing homes and happen to be at risk. The concern is greater if one has a setting in which there is a larger number, such as in a bigger facility in which more frail older people are congregated.

If the virus gets in, that is the key issue. If the virus gets in, it is almost impossible to stop it spreading, unless one is right on the case in terms of the preparedness we discussed earlier. I agree totally. It is not the case that public was better and private was worse. Both were equally affected. But in my view, by having people who are vulnerable and frail in large congregating settings in the first place, public or private, that puts them at risk that need not be, if we begin to think of alternative models for the future.

At the very beginning of your answer to Deputy Durkan, did you say there is no difference between public and private?

Professor Cillian Twomey

In terms of the outcome of mortality, broadly, there was no difference between the two.

In terms of preparedness, I think was Deputy Durkan's question.

Professor Cillian Twomey

Preparedness was different. There was not full preparedness everywhere on 1 February this year, because we were only beginning to get on top of it.

For the last question, the witness can send me a written reply. In relation to rapid testing and rapid results, to what extent does the witness believe that can address the issues now arising with the second surge?

Professor Cillian Twomey

By definition, if one has rapid testing and rapid results, one is able to get on top of the case more speedily. If it takes three days to have a test and another three days to get the results, that is six days lost. Then one is having to isolate staff while waiting the six-day period. That was one of the things-----

I am sorry to be rushing you. I have three questions, and I would appreciate succinct answers. I am sorry for my time management failures.

One of the key recommendations this committee made in its interim report was that the practice of the HSE sending people into nursing homes which have failed HIQA inspections should cease. The HSE sends them there and pays for them with taxpayers' money and through the fair deal scheme. Is that a recommendation that the panel would agree with?

Professor Cecily Kelleher

We did not make that recommendation, though we are very clear that the HIQA reports have to be adequate in relation to compliance with legislation, in order to answer that question.

I suppose the witness cannot answer on behalf of the panel when it did not make that recommendation. Is it a recommendation that the witness personally agrees with, that we have to cease sending people into nursing homes which have failed inspection? There is compliant, substantially compliant, and then fail, which is a different category to-----

Professor Cillian Twomey

The inspection process that HIQA very importantly has to undertake is serious. If a facility continuously fails to meet the standards that are set, generally speaking, it is given the opportunity to correct the areas that are deficient, and it is then revisited. If it is persistently failing on a multiple number of standards, then HIQA, under its regulation, has no option to say that it is an unsafe place for a person or people to be looked after.

Does the witness agree with the HSE sending people into these facilities?

Professor Cillian Twomey

The HSE does not send people into these facilities. The future existence of facilities that are substandard, and repeatedly so, and do not meet standards, has to be questioned. In fairness, there has been an incident or two of nursing homes that have been closed.

There has but the fair deal scheme is still being used to fund people going into these facilities, as we speak. Unless the committee is going to hear something different from the HSE or that practice has very recently ceased, the fair deal scheme and the National Treatment Purchase Fund are still being used to put people into these facilities.

I want to move on to my next question, and I have two left. The Care Quality Commission of the United Kingdom recommended that a clinical lead be appointed by 15 May in respect of each nursing home. Some HSE facilities have a medical officer. By dint of history some do not, but the majority do. However, private nursing homes, be necessity, have no medical officer who is responsible for the medical treatment of the entire community. Is that something that the witness would like to see happen? I am referring to something like what happened in the UK, where there is a clinical lead to be appointed, who is responsible for-----

Professor Cillian Twomey

It is one of our key recommendations that there will be a GP lead in every nursing home, and there will be a GP lead as a member of each community support team.

I thank the witness. This is my last question. I am going to go back to the opening questioning of, I think Deputy Devlin, who talked about the testing of people, in February and particularly in early March, who were being discharged from acute units into nursing homes. Was there an unusual level of people discharged, at that time, from the acute units into nursing homes?

Professor Cillian Twomey

There was. At the time, we were looking at the television screens as to what was happening in Italy, Spain and so on and there was a real concern that the acute hospital system would be overrun.

Was there a policy of discharging patients from the acute hospitals into the nursing homes?

Professor Cillian Twomey

I am not sure whether you would call it a policy but there was a reality of an urgent requirement to make available acute bed capacity, which did not exist, and, therefore, a significant number of-----

Is Professor Twomey aware of that urgent requirement having been communicated to acute hospitals?

Professor Cillian Twomey

I am not aware of what communications have taken place between the HSE and the acute hospitals but it was from the acute hospitals that the patients were transferred to care facilities based on the requirement to create capacity. That all happened in February. That is why it happened.

I thank the witnesses for answering my questions and those of committee members. I apologise again for the slight delay in getting started earlier.

Sitting suspended at 12.06 p.m. and resumed at 12.30 p.m.