Oireachtas Joint and Select Committees

Tuesday, 19 May 2020

Special Committee on Covid-19 Response

Briefing by HSE Officials

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I understand we are joined from committee room 1 by our witnesses. Is that correct?

Mr. Paul Reid:

Yes. Paul Reid, CEO of the HSE, here.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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We are joined by Mr. Paul Reid, CEO of the HSE; Ms. Anne O'Connor, also of the HSE, who is responsible for testing and tracing; and Dr. Colm Henry, chief clinical officer of the HSE. I thank them all for attending. There are three witnesses but we can only accommodate a maximum of two in the Chamber. The witnesses are therefore giving their evidence from committee room 1, where they can be sufficiently separated.

I wish to advise the witnesses that by virtue of section 17(2)(i) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of that evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the provisions in Standing Order 186 that the committee should also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies. While we expect witnesses to answer questions asked by the committee clearly and with candour, witnesses can and should expect to be treated fairly and with respect and consideration at all times in accordance with the witness protocol of the Houses.

I remind members that they have five-minute slots. If a member wishes to give another member his or her slot, members may speak for that time as well, subject to a maximum of ten minutes for any member. I will do my best to keep members informed of time. Without any further ado, we can begin the three witnesses' opening statements. I thank them all for the statements they have provided in advance. I appreciate that they are busy and thank them for taking the time to provide those statements. I ask that each witness limit his or her opening statement to five minutes to allow the maximum amount of time for questions and answers.

Mr. Paul Reid:

To respect members' time, we have just one opening statement. I will touch on some aspects of it but not maybe all of it. It is all on the record, obviously placed before the committee. I am grateful for the invitation to appear before the Special Committee on Covid-19. I am joined by my colleagues, Ms Anne O’Connor, chief operations officer for the HSE, and Dr Colm Henry, our chief clinical officer.

I am aware that the special committee wishes to discuss three matters: testing and tracing; congregated settings; and the reopening of the economy. The first two items are obviously specifically relevant to the HSE. I will make a few opening remarks before focusing on those two issues.

Members will already be aware that the health services have faced the worst pandemic in living memory. Since we became aware of the pandemic, the HSE has worked tirelessly to build our defences to protect the public from this potentially deadly virus. My first message today is that while we have collectively managed to significantly reduce the transmission rate of Covid-19, the HSE remains resolute in its work to combat the virus. However, we are still dealing with the virus and its potential impacts as we are here today, and we will be contending with COVID-19 for some considerable time to come.

Working with the board of the HSE, my primary focus as CEO is to continue the good work that has been completed to date in dealing with the impact of the virus and to ensure that we prepare for future potential surges. The public would accept nothing less of us.

It is important to cast our minds back to late February and early March 2020 and recall the worrying scenes that were witnessed from Italy and many other countries in Europe with intensive care units and hospitals becoming overwhelmed with the dreadful virus.

Having worked for 30 years in the private sector and for now nine years in the public service, I have never seen such significant and important change undertaken and implemented by so many dedicated people in such a short timeframe. I am extremely proud of how the healthcare system has responded in such difficult and worrying circumstances. I pay particular tribute to our front-line workers. I also recognise the contribution of the voluntary sector and many within the private healthcare sector who have collaborated with us in the national effort. This has been with the support of major Departments and State agencies. I also thank the political system overall for giving us its support throughout, particularly in the early phases of this pandemic.

I will reference some of the achievements we have managed to put in place in recent weeks to protect the public. We have strengthened our ICU capacity from a base of 225 beds to an operable capacity of just over 400 beds, putting in place a surge plan with the support of the purchase of extra ventilators. We have secured a large and sustainable supply of PPE and other equipment in a highly volatile global market. This has been achieved with the support of major State agencies, particularly IDA Ireland and the Department of Foreign Affairs and Trade.

We have put in place agreements with over 3,500 GPs across the country to support us on new pathways of care. We have had the mobilisation of the National Ambulance Service in a way that has never been done before. We have 47 swab testing centres across the country. We have moved from having one laboratory supporting testing to having 41 laboratories now involved. Some 1,800 staff have been trained in contact tracing. We have provided a wide range of supports to long-term residential care facilities. We have put in place innovative ways to support vulnerable groups. We have the use of telehealth, with new technologies deployed over a very short space of time.

This has all been achieved in a very short time and I thank all the agencies and Departments which have worked with us throughout this. I pay particular thanks to our front-line workers who have pioneered many new ways of working and have shown an agility and resilience that has been truly extraordinary. Many lives have been saved because of their skill, innovation and commitment. I am, however, deeply conscious that many have lost loved ones during the Covid-19 pandemic, including healthcare workers. I again extend my sincere condolences to all of those families.

Testing and tracing have represented a very significant mobilisation for the HSE overall. Last week, we published our change management plan to give us the capacity to process 100,000 tests per week. This involved 41 laboratories now for Covid testing, the availability of 47 swabbing centres across the country, and the deployment of new systems and supports to improve automation and turnaround times.

Along with the increased capacity we have recently introduced some innovations. These include a GP service called “Find my Test” for tests which go beyond the committed time frames; a 14-day active management of contacts of a confirmed case; automatic texting of confirmed negative cases, speeding up receipt of this result; automatic testing for contacts of a confirmed case; automated scheduling of appointments to reduce waiting times; automatic test referral for contacts of confirmed cases; improved notification of complex cases to our public health teams; and an automated IT solution that now transfers test results to our contact tracing teams in 90 minutes where previously it was 24 hours.

I am pleased to report significant progress which has put us in a much stronger position to achieve our capacity on targets for the coming weeks. Our focus now is to improve turnaround times significantly. We have committed to an average turnaround time from swabbing to test result-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I ask Mr. Reid to sum up if he can as he has gone over his five minutes.

Mr. Paul Reid:

Okay, I appreciate that. The position on congregated settings is on the record so I will make my closing remarks.

The entire health system has risen to meet many of the unpredictable challenges of Covid-19. I pay tribute to every member of staff for their professionalism, dedication and commitment and to their families who are supporting them. I would also like to thank the public for their tremendous support to date and for what they have sacrificed, which has been very significant. I again urge everyone to continue to support our front-line staff by following the public health advice to prevent the spread of the virus. It is really important that we all understand that we are still very much in the middle of this pandemic. We are not at the end by a long stretch. We continue to manage this crisis across several fronts, not least of which is the enormous additional cost associated with this pandemic.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank Mr. Reid and I thank him for providing his opening statement in advance. I will call Fianna Fáil first. Deputy Butler has ten minutes.

Photo of Mary ButlerMary Butler (Waterford, Fianna Fail)
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I welcome the witnesses, and thank them for giving their time. I thank them for their work to date and the response of the healthcare sector. I have four or five questions which I will put them to all three witnesses and whoever wishes to respond may do so.

This awful pandemic has borne down heaviest on older people, in particular those in nursing homes and residential facilities. Latest figures indicate that 62% of those who died were in such settings. I welcome that testing has been ramped up in nursing homes in recent weeks and all have been tested, staff and residents alike, but such testing should be carried out on a consistent basis. Regular testing in nursing homes will provide some reassurance for residents, their carers and families. Some felt badly let down at the outset. Is there a plan to roll out regular testing on a monthly or two-monthly basis in residential settings?

Nursing homes closed their doors to visitors on 6 March to protect residents and staff. How many patients were transferred from acute hospitals to step-down facilities - residential homes or nursing homes - during the month of March? Were they tested for Covid prior to their transfer? Of those transferred, do we know which patients subsequently contracted Covid and how many have passed away?

Deaths are highly concentrated in the three age groups over 65 years, which account for 93% of all deaths from Covid-19. Was this the expectation of the witnesses at the beginning? If so, why was the response very slow on personal protection equipment, PPE, and staff support in the nursing and residential home sector? While there were significant issues around sourcing PPE initially, the level of deaths among those over 65 years suggests the response was slow at the outset.

The restoration of BreastCheck and CervicalCheck are vital for the health of women. A clear plan needs to be put in place to address the backlog that has built up during the Covid pandemic, when, understandably, the screening services were suspended. The time has come to supercharge screening as a priority. Routinely, 34,000 tests are taken monthly. Figures published last week showed that no mammograms were carried out in April and that samples sent to CervicalCheck labs decreased by 93%.

In terms of my question, when can we see a resumption of those services and what plans will be put in place to deal with the backlog?

I turn now to the homecare sector and the wearing of face masks. Recently, the Health Protection Surveillance Centre, HPSC, issued guidance for immediate implementation that surgical masks should be worn by healthcare workers when providing care within two m. of a patient, irrespective of the Covid-19 status of the patient. Most people receiving home care will be older or more likely to have an underlying health condition and are obviously more vulnerable to the virus. Can Mr. Reid provide any clarity on that? Are face masks mandatory for a homecare worker who may be entering six or seven different homes on any given day?

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I ask Mr. Reid to reply to those questions. I am aware he cannot see the time limits we are operating under here in terms of the clock in the Chamber but there are six minutes remaining if he can reply to Deputy Butler's questions.

Mr. Paul Reid:

I thank the Deputy. I will reply to some of the questions and then call on some of my colleagues. I will be brief going through them to allow my colleagues make some comments also. First, in terms of nursing homes, I will make some general comments. We have said repeatedly that this is a novel virus and as it has spread across Europe, every country is learning about it. We, too, have been learning in terms of how it can spread, particularly in a congregated setting and among a vulnerable group. While we have been aware previously of symptomatic patients, what we have seen in the past few weeks of this pandemic in Ireland is that many in the more vulnerable and elderly population can be asymptomatic, thereby allowing the virus to spread within nursing home settings. We have had to learn from very different symptoms and, in some cases, no symptoms being shown.

On the specific question about testing and nursing homes, we have completed a very significant testing process throughout all of the long-term residential care areas. We have completed all of the nursing homes, both public and private, the mental health facilities and we are well advanced in the disability sector also. A very significant programme has been undertaken by our community and national ambulance services.

We are currently getting some guidance from our public health lead in the country who is developing a strategy that will be recommended to NPHET shortly. That will set out our entire testing process looking ahead to the coming weeks, both in terms of long-term residential care settings and other vulnerable groups and areas of people we would proactively test. That will be part of the recommendations that will go to NPHET. I might ask Dr. Colm Henry to make a couple of comments on that issue.

The second question related to the transfer of elderly patients from acute settings to nursing home settings. As I said in my opening statement, we should cast our minds back to the start of this pandemic. The experience, particularly across Europe, was that a massive surge had impacted hospital and acute settings. Where we needed to provide massive supports also was in acute settings. We would have had an ongoing process of what we would call delayed transfers of care where people are deemed clinically fit and not suitable to be in an acute hospital setting for the transfer of those patients, and in most cases elderly patients, out of that care. That is a process we would have done, and that was the right thing to do at the point in time of doing it.

Third, on the PPE and supply generally to nursing homes overall, as we said a couple of times, this is a very different way for the HSE to work completely with the private nursing homes to the way and extent we have done in the past few weeks. The supports we have put in have ranged from, in some cases, a very significant number of staff. More than 450 staff are now redeployed across long-term residential care settings, including private nursing homes. We have another range of supports in terms of clinical specialists including geriatricians who would go in. Generally, we have multidisciplinary teams who would go in and give advice around infection control. Where outbreaks have taken place, our public health teams have gone in directly to those locations, including private nursing homes, and obviously the State-funded support scheme for private nursing homes has been part of that. We would have put in a range of supports, including PPE. I would make the point briefly that in the past few weeks the vast majority of our PPE has been distributed not to our acute settings but to long-term care settings, primarily nursing homes and, increasingly, home supports.

I will make two brief comments and I will then ask my colleague, Dr. Colm Henry, to comment on screening services. We are anxious to get back to non-Covid levels of service in many of our services, in particular screening services. This will be a very difficult period because we have to restore some of our services in a way that protects the public. Nobody will thank us if we restore services in a way that means we see public health outbreaks of the virus. It is a big challenge to get back to previous levels of services, particularly in cancer treatment. I repeat that if people have symptoms or feel they have symptoms, the clinical pathway is to definitely go back to their GP. Referrals are still taking place for support for people with symptoms. Restoring screening services is one area that Dr. Colm Henry is leading on with my colleague, Ms Anne O'Connor. They will come back with recommendations on how we can restore the range of services in a way that is safe for the public.

I will ask Ms O'Connor to comment on masks but I will make a brief comment to give some context. The NPHET definition on the wearing of masks by homecare workers has changed. During this pandemic, we have been distributing approximately 200,000 masks per week to healthcare workers. Now that the definition has been extended to all healthcare workers, that figure has gone up and we are now distributing 1.2 million masks per week to healthcare workers across a range of settings, extending far beyond the HSE. I will ask Dr. Colm Henry to comment on screening and Ms O'Connor to speak briefly as well.

Dr. Colm Henry:

I thank Deputy Butler. Screening involves bringing large numbers of healthy people into a healthcare setting to have a test done to see whether they may have had some changes, whether to the breast, colon or cervix, that may lead to precancerous or cancerous changes. On 27 March, we had a directive from NPHET to stop all non-essential services in this country. Across the world - in the Netherlands, the United Kingdom, Australia and New Zealand - we see that screening services have been stopped because of the risk of bringing healthy people into a congregated setting and thereby running the risk of an outbreak.

In normal times, any screening programme has both benefits and risks. Currently, bringing people into a congregated setting, whether it is a van for breast screening or a waiting room, is something that we cannot do. We cannot go back to business as usual. We have to consider everything. For example, in the case of breast screening, a van could normally accommodate between 40 and 50 cases a day, but this number could certainly not be done based on Covid principles. With good prevention and control principles, one could not do more than ten cases per day. The same applies to the waiting room. A mammogram requires close contact between a radiographer and a patient and will require a new way of working. Our screening programmes are focusing on symptomatic patients, as are other programmes internationally. To give an example, in the case of suspected breast cancer this would include a new symptom that might suggest cancer. We are supporting the symptomatic services in their endeavours to get back up and running in a Covid environment.

As to when we will restore screening services to the way we knew them, it is far too early to say, not just for this country but also internationally. This is because the principle of screening involves large numbers of people being available for testing.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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My apologies to Dr. Henry, but I have to impose brutal time restrictions because we cannot be here for more than two hours and all members need to be able to ask their questions.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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On that point, if we are to stick exactly to the time frames, I ask the witnesses to use their phones to time each ten minutes.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am working to ensure the witnesses can see the time but until then, the Deputy's suggestion is a reasonable one. I ask witnesses who have a phone to note the time available to them at the end of each slot.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Gabhaim buíochas leis an gCathaoirleach agus tá fáilte roimh an Uasal Reid, agus roimh na daoine uaisle eile.

I welcome our colleagues from the HSE. I also echo the words of Mr. Reid by thanking and commending all of the healthcare workers who have delivered and served all of us incredibly well in recent weeks. When the story of this pandemic is told, we will find that, notwithstanding how bad Covid-19 has impacted on us, including in the coming months, it would have been much worse were it not for the dedicated healthcare workers who put themselves in harm's way every single day they go to work. My only hope is that we never forget that, particularly in future debates on the terms and conditions under which those great people work.

I have a number of very short questions and perhaps I could get some equally short replies. My first question is: how many tests were carried out yesterday?

Mr. Paul Reid:

I do not have the exact number of tests for yesterday. I can give the Deputy last week's figures, which were about 38,000.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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On the last day that we have figures for, how many tests were carried out?

Mr. Paul Reid:

Over last week, we averaged just over 6,000 laboratory tests per day.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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How many test centres were open yesterday?

Mr. Paul Reid:

As of yesterday, 29 were open.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Out of 47.

If we recognise that testing and tracing are going to be pivotal in terms of our recovery, those figures suggest we have a bit to go. When Mr. Jim Breslin was here earlier on, he referred to the fact that around 70% of negative test results are conveyed within 72 hours. Can Mr. Reid confirm that this is the case? Even with that, that would indicate that 30% of negative cases are not informed within three days. When is it expected that we will get that figure? When will we get to 98% of negative cases being informed within 48 hours, for example?

Mr. Paul Reid:

The Deputy will appreciate I am trying to give him quick answers, but I need to put things in context as I do so. We are meeting the levels of demand that we have. The capacity we have built up has the capacity to build 100,000 tests per week so it is purely a function of the demand levels at the moment in terms of the answer I gave the Deputy on the numbers tested and the number of swab-testing centres open across the country. As the increased demand emerges by new definitions, those centres continuously open up. We have the capacity to do that.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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In terms of conveying results, say, for example, we get to a point where we are delivering 100,000 tests per week, how long will it take for negative test results to be conveyed to those 100,000 people?

Mr. Paul Reid:

I will tell the Deputy exactly what has been happening over the last couple of week and what is happening this week, and including our targets. There are two levels of targets. One relates to the time elapsed from when the swab is taken to when the laboratory test is available. The second one is what we call the end-to-end, that is, from the time the person is referred for a test to the time the contact tracing is done.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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That was my next question. How long is the end-to-end, on average, now?

Mr. Paul Reid:

The end-to-end target is to have everything done, end-to-end, 90% of those-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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How long is it currently, rather than the target?

Mr. Paul Reid:

Currently, we are meeting the target. The target for last week was 85% to be done within five days. This week it is 90% to be done within three days. Specifically, in relation to the overall performance of our testing and tracing right now, I mentioned in my opening statement some of the initiatives. To get back to the Deputy's specific question about negative tests, what happens now is if we take all the tests that are done on a Monday, currently 97% of tests are negative. We have a 3% positivity rate. Those 97% will get their test result in two days or less. If it was a hospital setting, it will be less than a day. If it was a community setting, overall it will be two days or less.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Does Mr. Reid know offhand how many employers were informed of their employees' test results before the employees themselves?

Mr. Paul Reid:

This came up this morning in the committee's discussions and I am just trying work through the fine details of all of that, but generally, and ultimately our process is overall to inform the individual first-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I get that but the question I asked was whether Mr. Reid knew how many workers had their results conveyed to their employer as opposed to them.

Mr. Paul Reid:

I was coming to that specifically. In relation to some of those we have been proactively testing over the last few weeks, there is a responsibility and a derogation on the public health official to get those results out urgently. There is one case that we know of where the employer was notified of a significant number of positive cases and that is at the discretion of the public health official and the judgment he or she makes-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Does Mr. Reid agree with what Dr. Holohan said earlier on? I think his words were that this practice would clearly breach patient confidentiality. Does Mr. Reid not agree with that?

Mr. Paul Reid:

The way we want to do this is directly through the GP and the individual. That is the route we have taken throughout this process.

There are exceptional cases where public health officials have a responsibility and have a derogation in terms of managing a major outbreak. That would be a responsibility that they take in extremely exceptional cases such as in a pandemic or a major outbreak.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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We are in a pandemic. Does that mean that the derogation, as defined, applies to anybody?

Mr. Paul Reid:

No, it would not because throughout the vast ultimate majority of all of the cases we have tested the result is communicated back through the GP to the individual. That is our process. That is the way it works.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Does Mr. Reid stand over the position whereby, in some instances, employers are informed about their workers' health before the workers themselves?

Mr. Paul Reid:

No. Ultimately, that is not the way we want to see this done. We want to see it done directly through the individuals in the first instance. That is exactly the way we want to see it done. That is the way we have done it throughout this process.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Are you going to work to stop it then?

Mr. Paul Reid:

The Deputy specifically asked me about a case, the details of which I do not have but have been trying to get since this morning. I will get it. The Deputy specifically asked me about a case of a plant or a particular organisation, which I understand was on public health terms, the way that was managed, in the exceptional pandemic situation.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Today, we received guidance that I understand is from the HSE on the conduct of our meetings here. It states: "If a person develops COVID-19 any person who spent a cumulative period of 2 hours or more during a 24 hour period in an enclosed space", and this place apparently fits that definition, should be advised to self-isolate within 14 days. In other words, if one person in this room gets Covid-19 then all of us should self-isolate. Does Mr. Reid stand over that advice?

Mr. Paul Reid:

I shall pass the question on to Dr. Colm Henry, who is our lead on public health advice. The guidance is very clear. It is public health advice and it is clearly documented on our HPSC site.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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If one were to take that advice, does Mr. Reid accept that in the situation of a meat factory that if one worker contracts Covid-19 then under the definition that we have been supplied with here the factory would have to close immediately or close for at least 14 days?

Dr. Colm Henry:

The advice is as follows. If somebody turns out to have Covid-19 then anybody with whom they were in contact in the previous 48 hours, and as the Deputy described, in an enclosed setting for more than two hours they would be deemed to be a contact. The directive actually states, if we consider the detail on the HSE website, that a risk assessment is carried out by the public health department. In the case of a meat factory or any other congregated setting, or any enclosed setting, the public health department will carry out an assessment and decide based on their assessment and the analysis of the risk what actions will follow, who is go into isolation, who is to be deemed a contact and who is to be tested.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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We have been given guidance. This relates to a committee that is doing important work, we hope, in terms of getting answers relating to Covid-19. The guidance very clearly states that even asking people to leave a room for two hours will not change the assessment and that, in the context of the controls, people who have been in contact in a room for over two hours should be asked to self-isolate within 14 days. Has that advice been conveyed to employers and places like meat factories regarding an instance of an individual contracting Covid-19? Essentially, in those settings, that means everybody will be asked to self-isolate for 14 days.

Dr. Colm Henry:

I would leave these decisions to public health departments that carry out the outbreak management on all of our behalf. They carry out assessments of each individual area and each individual congregated setting whether it is a meat factory, a nursing home or a direct provision centre, and they will give the advice as to who should be tested, who should be isolated and who should be contact traced.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Only a few seconds remain. In terms of the advice that we were given, is that the advice that has been conveyed to employers this week as they reopen their businesses?

Dr. Colm Henry:

Deputy, there is no blanket advice given to every single setting. I am trying to convey the message to him that each assessment is different based on the public health department's assessment of each setting.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank the witnesses. I call Deputy Colm Burke. Is he taking time from somebody else?

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I shall take two and a half minutes from Deputy Brophy so I will speak for a total of seven and a half minutes.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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There is an additional two and a half minutes because the Deputy's earlier contribution was curtailed.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I thank the Chairman. I shall try to keep my contribution as short as possible because many people wish to speak.

I thank all of the people in the HSE for all of the work they have done over the last number of weeks and months in very difficult circumstances. Everyone appreciates the dedication and commitment by everyone involved in dealing with this crisis.

I shall revisit an issue that I raised earlier this morning.

It relates to congregated settings and setting out a list of where there were risks at an early stage. In a number of facilities there were more than ten deaths. In one of them that I am aware of there were six beds per ward. I note that Mr. Reid spoke in his report about mass testing in 372 mental health residential service locations and in 1,269 residential care facilities. What numbers of people are we talking about in each of these facilities, that is, the number of residents in the facilities and the number of staff? Second, has the HSE prioritised where there are no isolation facilities available if an outbreak occurs in one of the facilities? That happened in one of the facilities I know of and there were no isolation facilities available. Is a clear plan of action ready to be put in place if there is an outbreak?

The second matter I wish to mention relates to people working in the healthcare sector. Some 7,815 positive cases are in healthcare. Is there a breakdown of the number of people in the HSE and those in the private healthcare sector? Of that 7,815 do we know how many ended up having to be admitted to hospital and to intensive care? It is important that we get that information. What action is being taken to reduce the risk to healthcare professionals, be they care assistants, nurses or doctors? What has been identified that should have been put in place and must now be put in place to deal with and try to reduce the level of contamination of people who are working in the healthcare sector?

Mr. Paul Reid:

I will ask my colleague, Ms O'Connor, to answer the question on nursing homes and congregated settings.

Ms Anne O'Connor:

Regarding the congregated settings, we have been working since this started to examine the facilities we have in terms of the number of residents and the number of staff. As we previously mentioned about residential care, it is not just nursing homes. The mental health facilities and disability settings are also quite complex because we have houses and settings that are quite small with one, two or three residents. We have been working on the de-congregation of disability settings for a number of years, but we still have mental health facilities and disability settings where we have a small congregated setting of six or more and sometimes up to ten and 12 people in a house. In some respects they have been more difficult to manage but our services have been working to examine how they can spread the residents out more. We have moved people and we have looked at different ways of accommodating them. We have been working very closely with many providers across the disability organisations. That is a challenge for us.

Across all three we have prioritised facilities that have an outbreak. In the first instance we have been testing facilities with an outbreak or with suspected cases. They have now been completed. As Mr. Reid said, we have tested all residents and staff across all our nursing homes. We have also tested all staff and residents in mental health facilities. In disability settings we are more than halfway there. Our focus for this week and next week is to conclude the testing, with a particular focus on ensuring we have addressed all facilities with a suspected outbreak.

Mr. Paul Reid:

I will respond to the question on the healthcare workers and I will ask Dr. Henry to respond as well. I can briefly give the Deputy some figures he suggested. Among healthcare workers who have had confirmed cases the rate of hospitalisation and ICU admission for Covid-19 is much lower than for the normal population. Some 3.7% or 259 of the positive cases among healthcare workers have been hospitalised. This compares with an overall hospitalisation rate of approximately 13% for the confirmed cases in the total population. In terms of admission to ICU, 43 healthcare workers, or 0.61%, have been admitted to ICU, which is much lower than the rate for cases among non-healthcare workers in the population.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Are the witnesses satisfied that there are adequate facilities to isolate a case if one is identified in healthcare facilities, either mental health or disability services facilities?

Ms Anne O'Connor:

We are satisfied that we have processes in place in mental health settings. We are working with providers in disability services settings. Most disability services are provided through funded agencies. In some instances, people are easier to isolate than others for a variety of reasons, and we are looking at ways in which we can work with service users and their families. We have come up with different ways of providing services to be able to provide isolation. I cannot say that we are satisfied that we will not have an issue isolating somebody. However, we have worked a lot with services to see how they can isolate people when required.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Is a system in place to check whether fundamental changes made in the running of facilities are being implemented in full? Are these residential facilities visited regularly to make sure that all the changes that were made are being followed through?

Ms Anne O'Connor:

Our mental health and disability settings are regulated by external regulators. We are working closely with HIQA with respect to nursing homes and disability settings. The Mental Health Commission is also working with us on disability settings. Our services have been provided with advice. The staff in mental health settings, which are mostly HSE-provided, are involved in developing their own approaches to this with the guidance of public health information and the local area crisis management team. Likewise, the disability sector has availed of all advice and guidance.

On infection prevention and control, in the disability sector, most testing has been done by staff working in the sector rather than by external testing teams, and we will expand that. It is taking this as seriously as possible and doing everything that it can. Its first interest is service users and it is committed, across all of our services, to ensuring that we can continue to provide services that are safe and that do no harm to any service user.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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The Deputy has two minutes left. I can give that to one of his colleagues later.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I thank the Chairman.

Ossian Smyth (Dún Laoghaire, Green Party)
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Many people have been avoiding attending hospital. There are also people whose appointments have been cancelled and medical staff who are unavailable to work, especially in the private hospital system. People attend the private hospital system for necessary procedures which are important to their future health. To what extent are people who wish to attend and are willing to go to hospital, who require medical care that they had previously been getting through the private system, being provided for in any sense? Does Mr. Reid know the number of people who are being denied medical care as a result of large sections of these hospitals being empty?

Mr. Paul Reid:

The rationale for us making that arrangement with the private hospital groups was to give us surge capacity at the start of and during this pandemic. Thankfully, with the good actions of the public and healthcare workers in following public health advice, we have not seen that surge. We have a new scenario for how best to use that capacity in the coming weeks. We cannot just assume that the positivity rates or the transmission rates in the community will stay as they are. As restrictions are lifted and more people gather and engage with bigger groups, there is a severe risk of two things happening. One is an increase of the peaks and troughs of the transmission of the disease and the other is a significant surge, which has been the experience of some countries. We have to plan ahead in a different way to have capacity.

Clinical care pathways are still available in private hospitals.

If a person was being treated by a private consultant in a private hospital group, the fact now that we have procured their services does not take away from that clinical pathway for the person who is receiving that treatment. If they are still a clinical priority and the service that they were attending is still required, that can still be in place. If that consultant has not signed up for the type A contract, it can be carried on by another consultant who has or it can be done on a pro bonobasis, which has happened on some occasions. The clinical pathway is still there for the person-----

Ossian Smyth (Dún Laoghaire, Green Party)
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Is Mr. Reid saying that there are options for all patients in that situation? In other words, if one's hospital is closed and one's doctor is not signed up, is it the case then that everybody has some option as an alternative?

Mr. Paul Reid:

No. As I understand it, the Deputy asked me about a person who was receiving treatment in a private hospital group with a private consultant. The pathway is still available to that person through his or her private consultant, if the consultant has signed up for the type A contract. It is still there based on the clinical priorities, both public and private priorities.

Ossian Smyth (Dún Laoghaire, Green Party)
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To exit from this stage where we have this full lease of all the private hospitals, and presumably we are going to return to using a smaller portion of the hospitals and taking them on an as-needed basis, a procedural basis or a National Treatment Purchase Fund, NTPF, style approach to usage, how is the HSE going to get from one of those to the other? Does the HSE have an exit pathway or is Mr. Reid hoping to find a way, as he said earlier, to deliver Sláintecare at speed, that the conversion of consultants into public contracts is something that will last? Are those converted contracts something that are long-term or are they only for the duration of the surge?

Mr. Paul Reid:

To answer the Deputy's last question first, those contracts are just for the duration of the agreement. The heads of terms with the hospital agreement is very clear. It is for a specific period, and any decisions to renew that will be ultimately based on a recommendation from ourselves and the HSE board, as well as by the Department, ultimately the Department of Public Expenditure and Reform and the Government. It might be decided to go into some different arrangement in the future. These are all the considerations which will have to be made in the coming weeks.

Ossian Smyth (Dún Laoghaire, Green Party)
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What is the expiry date? Do they all expire on the same date?

Mr. Paul Reid:

Ultimately, the agreement for all the hospital groups was for three months, with the option for a five-month agreement. That was the nature of the heads of terms of the agreement. To extend it to five months - to extend it to July and August -needs a decision by the end of May. That is a consideration which will be given to relevant key stakeholders.

Duncan Smith (Dublin Fingal, Labour)
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I welcome the witnesses for coming to the committee today. Why did they CEO feel he had to write to the Department on 19 April on the Chief Medical Officer's commitments on testing capacity?

In a reply I received from the CMO this morning, I was told that the figure of 100,000 testing capacity, which we have reached this week after a month, will now be a fluid figure and under constant review. Is there a real impact on the delivery of services if the figure for testing capacity shifts? Is there a knock-on impact on what can be delivered if the capacity has to go up to 120,000 or is reduced to 80,000? Will that free up capacity or the delivery of other services?

We had four tragic Covid deaths yesterday. What is the proportion of non-Covid preventable deaths? Is this being tracked? Which is higher at the moment and is this something that is being measured?

Is any consideration being given to the provision of financial, medical and rehabilitative supports for health workers in the aftermath of the Covid-19 emergency, particularly with counselling? Is this being discussed as we seek to move out of this crisis, it is hoped later on this year?

Are Mr. Reid and his colleagues in the HSE concerned about the potential for under-reporting of symptoms or safe public health practices from residents in direct provision? It is well known that many asylum seekers fear speaking out because they are in such a vulnerable position and due to the potential ramifications of whistleblowing.

Mr. Paul Reid:

I will try to be brief. On the first question, the reason that I communicated with the Secretary General on communications and capacity specifically related to the agreement that we had all been working to and have recently delivered, namely a pathway that gets us to 100,000 tests to be completed within a week. Specifically, the engagement that I had over that weekend related to communications where that was announced as we were still in dialogue about our pathway to get there. That was the nature of the engagement and communications that I had, and members will have seen the letter which is publicly available. There will be many different engagements between myself and the Secretary General on a range of issues, but I felt that we needed to clarify this one. Subsequently, as members will be aware, we have engaged significantly and collaboratively on the change management plan that I launched last Thursday,14 May, which is the outcome of those discussions over the past few weeks. The issue was never about how we could get to the capacity for 100,000. The issue was our pathway and the process that we were engaged in to get there, and which we did finish out on. Thankfully, we have a good and agreed shared plan. That specifically is what I wrote about at that stage.

The second question was on whether other services will be impacted by testing and tracing. It is the very nature of what we are going to have to live with, definitely for the next year ahead but who knows, it may be longer. I cannot predict, but we are going to have to have the capacity for the testing and tracing process, while at the same time, as other Deputies have also asked, migrating back to non-Covid services. Unfortunately, it cannot be an either-or scenario for us. We cannot turn the dial down on one, because much of our workforce are workers that we have in the healthcare system engaged in swabbing centres, for example. It is an extra demand on us, but we will have to meet that demand while migrating back to a level of safe non-Covid services.

In terms of the non-Covid deaths, before I finish I will ask Dr. Colm Henry to come in because that is an issue that NPHET is looking through in order to assess the non-Covid deaths that have happened. Are these incremental or is it different? That is a process that the data is still being compiled on.

The provisional supports for healthcare workers is something that I am hugely committed to. We have put in a range of supports during this period which have, thankfully, been well taken up by our support workers. That can be in terms of support helplines, engagement sessions that they have, collectively or individually, through our employee assistance programme, or dedicated mental health and stress lines that we have put in place for our staff that have been significantly taken up. We are happy to share with members some numbers on that take-up. Who knows about after it, but certainly throughout this crisis I want to maintain and provide the wide range of supports for our staff that they quite rightly deserve.

In terms of concerns regarding non-reporting of symptoms, this week we launched a public media campaign on national and local radio to strongly encourage people to come back for care where they have symptoms that they believe need clinical care, whether that is back through our GP, hospital or community systems. What we want to do in that process is-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Thank you, Mr. Reid. Does Dr. Henry want to respond very briefly on the issue of preventable non-Covid deaths?

Dr. Colm Henry:

From the information available to us, any excess mortality we have seen this year to date is largely attributable to Covid-19 deaths, but that said, it does not take away from the fact that there is a morbidity building up through unaddressed illness, through people either not presenting with symptoms or not attending. That would not be immediately obvious-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am sorry to cut you short. I appreciate that it is difficult without seeing the time periods that we have available. You are hamstrung in your answers. I apologise. We are seeking to remedy this for future witnesses, but it does not help you.

I call Deputy Shortall.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I welcome Mr. Reid and his colleagues and thank them all for the work they are doing. I have four questions, the first of which is on the fact that we are now thankfully at a point this week where we understand there is a capacity to test and trace 100,000 cases per week. What does Mr. Reid believe is the main challenge to not achieving that figure in the event that the demand arises for that number?

What might prevent that being reached? Specifically, can Mr. Reid comment on the reliability of the source of the reagents?

Second, regarding the data the HSE is producing, it is quite frustrating and does not help confidence when we do not get regular data updates. I ask him to commit to publishing the number of tests undertaken on a daily basis, with a breakdown of where those cases are, whether in the community, congregated settings, among healthcare workers, and so on. It would be helpful and would help bring the public along if the HSE did that.

My third question relates to the comment Mr. Reid made a few weeks ago when he stated that we would need to spend approximately €1 billion per year on PPE. That is a vast sum which has huge implications for the health budget and the economy in general. To what extent has he, or anyone else at any level in the HSE, given consideration to sourcing that PPE in Ireland? That would entail setting up a whole new manufacturing operation, but surely given the scale of the cost involved, it would make sense to do that. Have any moves been made in that regard?

My final question relates to high-risk groups such as older people, those with certain conditions, people in congregated settings, meat packers and construction workers, for example. What system is in place to identify those high-risk groups and respond accordingly? We all accept there were unfortunate delays in respect of nursing home residents, but how can we ensure we do not have similar delays in tackling other high-risk groups?

Mr. Paul Reid:

I will try to take the Deputy's first three questions together. I acknowledge that it has been a very frustrating period for the public in terms of how we mobilised and got to our current capacity, because we did meet very significant issues. We encountered huge issues in the availability of reagents, test kits and setting up all the test centres across the country. Setting up the operation we did in eight weeks was not easy. We are dealing with a whole lot of legacy systems, from which we are now extracting these data and automating them. I will not go through the technical detail of it but it was a frustration for us as well as for the public. I just want to acknowledge that.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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What does Mr. Reid see as the challenges going forward?

Mr. Paul Reid:

Right now the challenges ultimately depend on the transmission of the disease. As I said to Deputy Carthy earlier, as we are dealing with a low positivity rate and a high negativity rate, the vast majority of those tests will now be automated and completed in less than two days because they are negative and texts are sent out automatically. Where we deal with more complex cases, such as testing in congregated settings and among vulnerable groups, the completion of that process and contacting that person and their contacts takes more time. Sometimes we are dealing with people in a congregated setting, an ICU or a non English-speaking community. More complex cases take more time, so as that positivity rate changes, we will deal with more complex cases.

The second part of the Deputy's question related to the availability of reagents, which have largely come from a few suppliers. Roche and Abbott are the two major global suppliers based in Ireland and we have made agreements with them. We have also established a supply line from overseas in China, which now supplies our 41 labs with a steady supply of reagents. That has put us in a much stronger position.

The Deputy also asked about data and reporting. I accept her frustration with this issue because she has been diligent with her questioning of us on it. We are in a much stronger position now and we publish an operational report every day that sets out the number of ICU beds, trends, positive cases, and so on. We are now including a dashboard in that report, which shows the numbers of tests done throughout the week, the referral times - that is, the time it takes from someone feeling symptoms to being referred by a doctor - and the time it takes from swab test to lab test, and we will have the complete end-to-end time shortly as well.

That dashboard went live last night and we will be building it further as we go along.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank Mr. Reid.

Mr. Paul Reid:

The significant cost of PPE is largely driven by the volume that we are supplying, the price on the global market and the reach that is required because the equipment needs to be provided beyond the HSE sector. Part of the strategy that we keenly wish to pursue is to get Irish manufacturers to recalibrate their businesses in order to provide PPE. We very much see that as part of stimulating the economy for the future.

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Mr. Reid rightly praised the healthcare workers earlier. We all praise our heroic healthcare workers. How does that correctly given praise tally with the decision to recruit healthcare workers and nurses who volunteered to answer the call from Ireland through temporary agency contracts provided by for-profit groups such as CPL Resources? Those contracts are the worst of all possible contracts. Under them, the company will not make any payment for a day on which an employee does not attend for work. This appears in these contracts under the heading "Sick pay". I mentioned earlier a nurse who, two weeks ago, was recruited, via CPL, to a Dublin hospital. She has since tested positive for Covid-19 and will not be paid under her contract. Is that how to treat our heroic nurses, particularly when we need permanent increases in healthcare worker, nurse and staff capacity? Who made the decision to recruit people via temporary agency contracts rather than directly through the HSE? The nurse to whom I refer has to self-isolate in City West. When she asked how to get to City West, she was told to get a taxi. When she asked if the taxi driver would have PPE, and know that his or her passenger was Covid-19 positive, she received no real response. That is not how we need to treat our healthcare workers.

What I am saying has important ramifications when we consider that the number of people on trolleys has risen to 114. We have been talking here about people being in the same room for two hours. There are 114 people in hospitals today who are in close proximity to each other and who will be waiting for hours for healthcare to be provided to them. Is it not the case that this is contrary to public health guidance and that there should be zero tolerance for people on trolleys in emergency departments? The only way to address that is by rapidly increasing the level of permanent staffing within and other capacities of our health service, and not via temporary agency contracts.

Mr. Paul Reid:

I obviously cannot comment on the specific case the Deputy mentioned. I will give an idea of the scale of the recruitment that has been happening in the past few weeks in permanent full-time employment in the HSE. A range of contracts have been put in place. A total of 2,367 positions have been filled across the HSE. Approximately 1,200 of the people who filled those positions were recruited directly by our HSE teams on permanent, full-time contracts. The Deputy will be familiar with the situation in nursing. Our student nurses in years one to three have been given healthcare assistant contracts for the duration of this period. There are almost 1,200 such contracts. Almost 1,100 others have been recruited through the Be on call for Ireland initiative, albeit just over 120 of those have started. Approximately 1,000 more are to come in as part of the initiative and they will be given contracts.

I have no doubt that some people have been recruited on contracts of a temporary nature because as we went into this crisis, we always expected a massive surge for three months and that after that period we may not need to retain the full numbers we had recruited. Some people are on contracts of a temporary duration and that will be reviewed. We are now, obviously, looking at a very different scenario and a review will take place in that context. To reassure Deputy Boyd Barrett, the vast majority of people who have been recruited over the past while have come in through direct contracts with the HSE and others have been recruited through various agencies and sources such as that mentioned by the Deputy. That recruitment took place on the basis that we were dealing with a temporary crisis that now looks as if it will last longer. We will have to review that.

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I hope all of those people will be made permanent. Does Mr. Reid agree that having people waiting on trolleys in emergency departments is incompatible with the public health guidance on social distancing and has to be addressed, and that there has to be a zero tolerance attitude towards it?

Mr. Paul Reid:

The reality for us is that we cannot have a situation where we end up in a winter crisis as happened last year, where significant volumes of people were on trolleys. As we head back into the non-Covid services to the best extent we can, we have to do so in a public health way that protects all of the people who come back to our hospital system. We have to go back to this very differently than we may have done in the past.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank Mr. Reid.

Matt Shanahan (Waterford, Independent)
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I wish to address Mr. Reid first. In terms of public policy communications, I have had representation from Conradh na Gaeilge asking that the HSE look to do some Irish messaging across the English radio and television channels and examine postering to make sure there is a representation of the messaging in Irish.

I refer to the policy on nursing homes. We know that the elderly are most at risk with respect to Covid. Has the HSE thought about any type of asymptomatic testing of staff in nursing homes? In other words, is it trying to find some way to carry out randomised testing of healthcare professionals to ensure they are not going to work as vectors of the disease? We have to go into the centres where people are most challenged.

The Chief Medical Officer was not able to give me a response to an earlier question. I ask Dr. Henry whether NPHET or any of the other medics are looking at the use of hydroxychloroquine, which has been used by a number of medics as a prophylactic. In terms of getting Covid, there is a lot of evidence building about supplemental vitamins, in particular vitamin D and zinc, for the elderly in respect of trying to stave off infection, and whether this should be a policy we consider. I believe Abbott has what may be an antibody test. An Israeli company has, I believe, developed a new generation saliva test. Do we have any information on those tests and when they might become available to us in Ireland?

Could the witnesses describe the difference between at risk and vulnerable in terms of our healthcare personnel? I know of a nurse who has diabetes and uses an insulin pump, and was described as at risk rather than vulnerable. She works in a setting where a patient tested positive. She had not treated the patient for 24 hours and, therefore, was told that she could not isolate and if she did she could do so using her holiday time. She was then asked to swab a patient who had a high temperature, which she did while wearing PPE, but she then had to wait a number of days for a test result to come back which was, happily, negative. She, like a lot of people, is confused about who is at risk and who is vulnerable.

There is a direct provision centre in the south west of the country where refugees have been placed in the past month. They have been largely isolating and have now come into the community. There is a lot of angst in the community that some of the refugees might harbour Covid and no testing regime has been implemented. Could we have some proactive testing in direct provision centres so that those living in them can mix without any issues of racism or anything else arising?

Mr. Paul Reid:

I thank the Deputy. I will pass him over to Dr. Henry.

Dr. Colm Henry:

On the testing of healthcare workers, we have some information that will inform how useful it might be in a residential care setting. A vast exercise was carried out on all residents and staff in nursing home settings. We know from the report presented to NPHET last week by Dr. Lorraine Doherty, clinical director of health protection, that there was a very low positive result for healthcare workers, in the order of 3% or 4%. It is likely that when there is a focus on healthcare workers in terms of protecting them, as well as staff, we will consider a range of measures, including infection prevention and control, hygiene, PPE and the screening of healthcare workers going into nursing homes. Testing will form one part of that. My assessment is based on the advice from Dr. Doherty. Testing will be focused rather than blanket, because blanket point-in-time testing yielded very little information apart from telling us that there was a very low prevalence of the virus at that point in time.

The Deputy's second question was regarding hydroxychloroquine, a drug used for other conditions. There have been some small studies done which to date do not show any direct benefit.

The current advice from the expert advisory group, in line with that in other countries, is that more research is needed before we demonstrate this is of any benefit in either the prevention or treatment of Covid-19. It is a drug that is not without side-effects, particularly cardiac side-effects. As such, we would not recommend it for prevention of Covid-19.

The third question the Deputy asked was on the salivary test. The current test we use for Covid-19 is a polymerase chain reaction, PCR, test which detects viral ribonucleic acid, RNA, in real time. It is very sensitive, not only to those who are actively sick but even those who are in a presymptomatic phase of two days. It picks up pieces of the viral RNA and obviously it correlates with their degree of infectivity. Other tests proposed include serological tests which look for antibodies. These are not so sensitive in the acute phase and tell us nothing about people's infectivity. We will carry out some so-called zero prevalence studies in this country where we will detect antibodies in two populations. We will, hopefully, get that study done in June. It will tell us something about the exposure of the Irish population in two random populations to the virus throughout this pandemic.

The Deputy asked about a direct provision centre. I will enunciate the same principles that I have enunciated, namely, that outbreak management is a function of public health and each situation is different. Our public health departments are trained and have experience in going into these settings, looking at the layout, congregation, isolation facilities and number of positive tests and giving specific advice along a given set of principles which do not apply in any blanket way across all healthcare settings. With regard to direct provision centres, in some centres there has been testing of everyone in the setting based on the layout of the particular centre and the number of positive tests. In others, not everyone has been tested, either because there has not been an outbreak or there has been a very small number of positive cases. We leave it to the public health departments which are managing these outbreaks to make those judgments on an individual basis.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank Dr. Henry. I call Deputy Michael Collins of the Rural Independent Group.

Photo of Michael CollinsMichael Collins (Cork South West, Independent)
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I thank the officials for appearing before us.

I will concentrate briefly on congregated settings. Community hospitals were meant to be brought up to a standard, as some were, of having up to 80% single-bed occupancy. At some stage, the HSE believed this target could not be delivered. It was a HIQA standard and the 80% figure was later reduced. Unfortunately, as I have seen in west Cork - it is probably the case throughout the country - this standard was not delivered. It is to be delivered going forward. Why were the standards announced initially not applied? Deadlines for bringing hostels up to standard were missed. Has this cost lives, especially in settings where there are multiple people in single rooms?

Was it necessary to remove home help from clients who were receiving only bare essential hours? In recent years, we have been fighting for greater investment in home help. It is proven that people who can stay at home longer are much healthier. Many people are very upset that they have lost their home help service and are trying to have it restored. That issue needs to be focused on.

I mentioned in an earlier discussion the budget available to the HSE. I note it has acquired a PC-12 aircraft to fly swabs to Germany for testing, which is very important. We realise now that these tests could have been carried out in laboratories here. As I said, Animal Health Laboratories Limited in west Cork has stated that, with a little investment, it could have carried out thousands of tests and the company has asked why we spent large amounts on having testing done elsewhere. The tests being carried out in Germany may not cost much but it costs a lot to get them there. We could have had next-day or same-evening results if we had invested in laboratories here. Maybe that issue will be considered.

Doctors and nurses from all over the world have practically given up their livelihoods to come home and help us save lives. What has the HSE planned to encourage them to stay in Ireland?

Ms Anne O'Connor:

On community hospitals and the investment programme, we have had a programme of investment in all our long-term residential care facilities and nursing homes, including the HSE community hospitals. That has been a staged programme in line with HIQA requirements relating to environmental conditions in congregated settings. We have developed that in line with available resources. Some of our capital programmes have concluded while others are in train.

There is a rolling upgrade to our facilities.

Regarding home help, prior to the emergence of Covid-19 we were providing home support to more than 51,000 people. That came down to 40,000. We saw a reduction of slightly more than 11,000 in the number of people in receipt of home support, but it is important to note that of those, 7,500 wanted to have the service suspended. The only services that were suspended were for priority 3 and priority 4 people, accounting for just under 4,000 people. Services were temporarily suspended for about 3,800 people. The community healthcare organisations are working closely with the providers throughout the country to ensure that people continue to be supported. We have also been signposting people to the voluntary sector and ensuring that we have telephone contact with them. In the majority of cases where service was suspended, this was at the request of recipients because they did not want people coming into their homes. We are working proactively. We have redeployed approximately 166 home support workers into residential care. As the situation in residential care stabilises further, those people will be redeployed to the provision of home support.

Mr. Paul Reid:

In response to the last question on laboratories, I note that the German laboratory is one of a total of 41 labs. The other 40 are Irish-based and include the Enfer Group facility in Kildare. That is our strategy. Our arrangement with the German laboratory is quite competitive, allowing for the transport costs which the Deputy quite rightly mentioned. We would not have entered it if we did not need the capacity and it did not meet our competitive tests. Our agreement with that laboratory is quite competitive in terms of logistics and test turnaround times. However, 40 of the 41 laboratories are in Ireland.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank the witnesses. I now return to the second Fianna Fáil speaker, Deputy Norma Foley. I thank her again for her patience in the first session.

Norma Foley (Kerry, Fianna Fail)
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I would like to begin by welcoming the witnesses and expressing unreserved gratitude for the superb work of the HSE and its staff in the past several months and on an ongoing basis. I wish to acknowledge that many lives have been saved as a consequence of that work. However, it would be remiss of me if I did not shed light on what my constituents regard as shortcomings within that service. My constituents believe that actions or inaction in recent weeks have resulted in the loss of lives. I refer to a direct provision centre at the Skellig Star Hotel in Cahirsiveen, County Kerry. I wish to pose some questions about this particular facility and about direct provision centres. I ask the witnesses to answer and I will then have two further points to make.

I note that the Department of Justice and Equality claims unequivocally that the HSE failed to inform its officials of a positive case of Covid-19 at a Travelodge hotel in Dublin on 8 March. This Travelodge was home to a large group of asylum seekers. Is it true that the HSE failed to inform the Department of Justice and Equality? The Department of Justice and Equality also claims that the HSE signed off at national level on the movement of people from that same Travelodge to the Skellig Star Hotel in Cahirsiveen, a five-hour bus journey, without testing the group prior to leaving Dublin or on arrival in Cahirsiveen. Is this true?

Is Mr. Reid aware that the HSE Cork Kerry local health office expressed serious concern and misgivings about the movement of a large group of people during a pandemic, and that it expressed grave reservations about the suitability of Cahirsiveen as a location for a direct provision centre due to a lack of primary care facilities in the area? Clearly, these concerns were overruled. I would like to ask Mr. Reid exactly who overruled them. Was it the HSE or was it the Department of Justice and Equality?

There is evidence of what I consider to be not best practice at this direct provision centre, at which there are now 26 or more confirmed cases of Covid-19. Residents who are not blood relatives continue to share rooms, although this is not best practice. Given the size of the premises, there is absolutely no social distancing. There is a shared laundry room, small public spaces, a shared lift, etc.

Equally, there was absolutely no professional deep cleansing of this facility at any stage following the confirmation of the 26 cases, and residents continue to live there. Could Mr. Reid explain also, as the body charged with public health, how from the first diagnosis of Covid-19, it took the HSE 39 days to have a public health presence on the campus of the Skellig Star? I will allow him to answer those questions and then, with your indulgence, Chairman, I have two further points to make.

Mr. Paul Reid:

I will make a few comments and then I may call on one of my colleagues. I thank the Deputy for her opening comments, which we will pass on to everybody. I am sure they have heard them.

Second, regarding the Skellig Star in Cahersiveen, we have been working very co-operatively with the Department of Justice and Equality in recent weeks, specifically on the location the Deputy mentioned. It has been the subject of joint engagements between the public health teams, the local community teams and with officials from the Department of Justice and Equality on a national level. It has also been the subject of discussions between me and the Secretary General of the Department of Justice and Equality. It is true that there has been a lot of engagement and collaboration in terms of working with us to try to address the issues.

Specifically in relation to our role in that regard, we give public health advice very clearly and such advice is very well publicised. There is an obligation on the operators of direct provision centres to implement the advice. On many occasions we go into centres. In that specific case, our public health teams would have gone in and given specific advice on the location, both advice for staff and residents of the direct provision centres. There would have been a lot of engagement in recent weeks. I have been engaged locally with the teams down there as well. As I understand it, there has been significant engagement by the HSE.

I cannot comment on the particular positive case and the testing the Deputy mentioned. I do not know the detail of the case but I am happy to get back to her about it. Our Cork-Kerry community-based teams and the public health teams put significant supports in place there, not just in terms of advice. The implementation of public health advice is the responsibility of centres themselves. We will go in and support them in terms of what they need to do, but there is an obligation on the centres to implement the advice.

Separately, in terms of clinical care for anybody, we have been providing that pathway through our own public health teams as well.

Norma Foley (Kerry, Fianna Fail)
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Could I just conclude?

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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The Deputy can ask one very brief question.

Norma Foley (Kerry, Fianna Fail)
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Yes, just on brief question. Could Mr. Reid revert in writing in response to the questions I posed, as they are hugely important to the residents and to the community of Cahersiveen?

As HIQA has no overall remit in this regard, I ask that at the very least he would call for an unannounced inspection of the premises in question. On foot of such an inspection, which from all I know I am confident the centre will fail, as a matter of public health and safety and the welfare of everybody concerned, will he will call for the immediate closure of the centre should the public health inspection be failed?

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Is Mr. Reid happy to answer any questions that have not been answered by way of correspondence?

Mr. Paul Reid:

We will ask the local community teams, through our officials, to make sure we get a local response on the issue.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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Can I assume that all correspondence given will be circulated to the committee in response to questions asked?

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Yes.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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Mr. Reid is very welcome. We thank him and the people he represents for all the work they are doing day in and day out. During the course of this pandemic, I have remarked on the manner in which HSE staff have stepped up to the plate. They have changed their work practices in the blink of an eye. I well remember politicians and commentators long bemoaning the fact that staff were the biggest obstacle to change in the health service. I think we have successfully busted that myth now and I sincerely hope nobody ever goes back to it because we saw staff stepping up to the plate in a way that has taken our breath away. They have been absolutely outstanding. Mr. Reid confirmed that.

This morning, I asked the CMO about the specific guidelines in place for construction workers and I asked if similar guidelines were in place for other workers. We now find out that we in this Chamber have very specific guidelines in place for health and safety reasons, which is important. However, I cannot understand where the line is being drawn between what happens in here and what happens somewhere else.

If two hours is the rule, two hours is the rule. If everyone has to self-isolate, they have to self-isolate. It should not matter whether they work in politics, in a meat factory or in a shop. How is that being managed and how are these guidelines being conveyed to workers?

While I am on the issue of workers, healthcare workers account for 31.4% of infections. Does this worry the HSE? Are there plans in place to reduce this figure? Are specific plans in place to protect workers? It is very worrying.

My last point on workers is that nurses are due a pay increase. Some of them have got it and others have not. Can the witnesses tell me what the delay is and where the blockage is?

Mr. Paul Reid:

I thank the Deputy. I will be brief; I am watching the clock.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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While I agree with the Deputy that the issue of nurses' pay is very important, I am not sure it is relevant to the Covid-19 response.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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It is fine if Mr. Reid declines to answer. I doubted that he would.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I just wish to say that the witnesses are not compelled. They may not wish to answer that question as it is not within our terms of reference.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I will not compel Mr. Reid to answer.

Mr. Paul Reid:

I thank the Deputy for her comments about our staff. In all my comments I refer not only to HSE staff but to healthcare workers in general across the country, including GPs. All our healthcare workers have done a phenomenal job with us, for us, and for the public.

With specific regard to the public health advice, I will say two things. The first is that the advice on the Health Protection Surveillance Centre, HPSC, website is public health advice for all workforces and all organisations. As Dr. Henry said with regard to how that advice is applied, managed, monitored and implemented, our public health teams provide significant amounts of advice - particularly in recent weeks and again this week - to different sectors that contact us about opening arrangements. Our teams provide them with a level of advice separate to what is available on the site. The Health and Safety Authority, HSA, is playing a lead role and takes a big lead from our public health advice. It is directly engaged, even today, with our teams with regard to the application of public health advice. There are a number of significant working groups led by the HSA and our own teams which inspect sites for other reasons. For example, our environmental health officers may be carrying out particular inspections and, while doing so, they may take cognisance of the wider public health advice. All of that is being worked through with the HSA.

On the Deputy's questions with regard to healthcare workers, we are concerned about any positivity rates across the healthcare system and about how the infection may transmit further. Earlier I mentioned that hospitalisation rates and rates of admission to ICU were falling as a result of a number of actions we have taken, particularly some of the actions taken in congregated settings and nursing homes. In some cases agency workers may work between a number of different settings over a period of a week or, in some cases, a day. We took very early actions so that employers and agencies would ensure that staff were assigned to dedicated locations so that they would not have the opportunity to transmit the disease to other locations. That was one action.

A second action relates to accommodation. Significant numbers of staff and healthcare workers, both HSE and non-HSE, were provided with accommodation. Ms. O'Connor will provide details on this in a few minutes. Healthcare workers who shared accommodation with other healthcare workers were put into other locations to reduce the risk of the virus spreading between healthcare workers.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I asked Mr. Reid whether he was worried about the rate of 31.4%. That does not seem to be in line with the rate in other jurisdictions. I also have other questions. I am well aware of the measures that are in place, although it seems they are not enough if the rate of infection is 31.4%. We are very constrained on time, for very good reasons.

I will switch to the issue of nursing homes. People in my constituency and elsewhere have expressed to me the view that it was at the very start, when hospitals were cleared and people were transferred into nursing homes, that the virus was brought into those nursing homes. What specific actions were taken arising out of Mr. Reid's meeting with representatives of Nursing Homes Ireland on 19 February? Was a plan - not advice and guidance, but a plan - put in place with regard to the human, financial and other resources that would be needed following the meeting?

Mr. Paul Reid:

I will say two things and then may ask Ms. O'Connor to give some wider evidence.

On the first assertion the Deputy made that the transmission of the disease can be tracked back to - I am paraphrasing, excuse me, but this is what she may have said - people moving from a hospital setting to nursing homes, there is no evidence whatsoever for that. I think it would be misleading to say that that is where one can track back transmission in these in nursing homes to. It would be unfortunate that that would be perceived because there is no evidence. In fact, the evidence in terms of where the transmission within nursing homes can be identified or tracked back to is still something that NPHET is working through and trying to get a better level of understanding. It is not just us in Ireland. Just today the ECDC published a report on transmission of the disease in congregated settings. It too is learning. In every country mentioned in that report today there are learnings about how the disease may-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I appreciate that. I am not suggesting that is the case. I am saying that has been suggested to me.

Mr. Paul Reid:

Okay.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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When Mr. Reid has said he can be confident that has not happened, he is talking about a report being done. It strikes me that he could not be confident as yet. Specifically, from his meeting on 19 February with Nursing Homes Ireland, what plan in terms of the human resources, financial resources and other resources that would be necessary was put in place immediately following that? There does not seem to have been a plan. If there is, maybe Mr. Reid can share it with me.

Mr. Paul Reid:

Sorry, I may have misquoted the Deputy, but equally she may have misquoted me. I did not say I am confident. I said there is no current evidence that demonstrates that was the case in terms of transmission and transfer of patients across.

Specifically, on the meeting with Nursing Homes Ireland, I would meet and discuss with Tadhg Daly on a reasonable basis throughout this whole process - in the pandemic over the last few weeks. There have been very good relationships between Nursing Homes Ireland and the HSE throughout this period. On the Deputy's question of 19 February specifically, I can remember the meeting clearly. I have met a wide range of stakeholders since I took over the HSE. That was my first meeting with Nursing Homes Ireland. It was my first meeting with Tadhg Daly and its chairperson, Maurice Pratt. It was really geared towards an informal welcome and discussion-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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Therefore Covid-19 was not discussed at that meeting.

Mr. Paul Reid:

We had a brief discussion about how this may impact on Ireland. There was a very brief discussion between both of us. I would be doing it an injustice and indeed the HSE an injustice to say it was an in-depth discussion because we were just learning at the start of this - 19 February was very early stages. The world's focus and Ireland's focus were on how this may impact on our acute and ICU-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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Come on. Less than two weeks after that meeting, Nursing Homes Ireland imposed visiting restrictions in nursing homes. Did the HSE consider doing the same for public nursing homes? It was clearly thinking ahead. A couple of weeks later it was able to impose the restrictions. Mr. Reid is saying he had an informal meeting with its representatives in the middle of the preparations for the pandemic, but it was not mentioned, or it was not the focus of the discussion.

Mr. Paul Reid:

I do not believe there will be any disagreement between us and Nursing Homes Ireland on-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I am not suggesting there is. I am asking Mr. Reid.

Mr. Paul Reid:

I am clearly saying to the Deputy that at that stage of it the world's focus and Ireland's focus were on how this could impact on the acute settings. It was a general discussion and was about things we might need to be thinking of in preparation. That was the extent of it. Then we discussed a wide range of matters in general about nursing homes and how they interface with the health service on all of these supports.

I might just ask Ms O'Connor to make some general comments.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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Time is very tight. When Nursing Homes Ireland introduced visiting restrictions, did the HSE give consideration to doing the same in public nursing homes? Did Mr. Reid request a report? Did he-----

Mr. Paul Reid:

Throughout this whole process we have taken guidance and direction from NPHET in terms of the instructions and directions that have come from it. That is where we got our direction.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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As someone who is responsible-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Thank you.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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Sorry, Chairman, you did indulge others. I am in the middle of a question.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am sorry too.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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As someone who is-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am sorry too. Many people have had less time.

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I do not mean this disrespectfully, but others have been allowed the facility-----

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am sorry, I am not going to-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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----- to go over their time. Indeed, my colleague cut his time short the last time.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am-----

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I will ask one very brief question if I could.

Arising from that meeting, and in the intervening time the HSE did not commission a report or ask anyone to investigate if it would be a good idea to restricted visiting in public nursing homes; it waited for advice. Is that right?

Mr. Paul Reid:

As throughout all this whole process, we take all of our public health direction from NPHET. That is where we get our public health direction.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank Mr. Reid. I now call Deputy Carroll MacNeill. Is she taking time from somebody else?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I will take the additional two and a half minutes from Deputy Burke, but I will leave time for Deputy O'Dowd, if there is time at the end.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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It will be Deputy McGuinness and then Deputy O'Dowd.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Understood.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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The Deputy has seven and a half minutes.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I thank Mr. Reid and his colleagues for coming today. I know they put considerable work into preparing to appear before the committee and it is really appreciated.

As we are beginning to learn how to live with Covid and doing so safely as we reopen our economy, we must try to establish confidence in the economy and also in healthcare settings and so on. Bearing that in mind, can Mr. Reid be clear about how many health-acquired infections there have been, that is, people who were in acute hospitals and acquired Covid? Can Mr. Reid break those figures down into those who recovered or died as a consequence? There is one very sad case in my own area. It is a matter of confidence over time. I imagine, subject to Mr. Reid correcting me, that the incidence rate will decrease over time as the reaction, use of PPE and management practice, improves. It will be important for the public to have clarity on if we are asking them to return to hospital settings for treatment of non-Covid illnesses.

On reopening healthcare settings more generally, I refer to paediatric care and clinics. On reopening hospitals, care applies to everyone but it is particularly difficult with children, in relation to social and physical distancing but also often diagnostics. I am particularly concerned about the opening of standard clinics, including diabetes clinics. Picture the management of the standard outpatient clinic in Crumlin hospital on a Tuesday or Thursday afternoon. How will that be managed? I cannot see a way where it returns to its previous form at any time in the future. Is this an opportunity to break that into something that is easier for parents generally to manage, where they might turn up at a specified time with a likelihood of having the appointment within that time. That is an important opportunity that might come from this.

On nursing home testing, Dr. Holohan referred to the European Centre for Disease Prevention and Control, ECDC, technical report which was published today. I do not wish to catch Mr. Reid on the hoof on this but it focuses on the rapidity of testing. Will Mr. Reid confirm two things? There was an ongoing concern on nursing homes in my area about their ability to test patients and staff rather than waiting for a scheduled test, either waiting for GP referral or for a public health authority to come and test or to schedule a test. Nursing homes are capable of doing it and some are beginning to do it but as recently as last week, nursing homes in my area have raised this with me. Linked to that is where those tests go. There was concern that the batch of testing went to more than one laboratory resulting in staggered results back to the nursing home. That creates operational difficulties when one is trying to operate isolation in a confined congregated setting such as a nursing home. Will Mr. Reid confirm that he expects this will happen or that it is already happening, where nursing homes are entitled to do that testing themselves where there is a suspected patient and that any batches will be tested in the same laboratory to accelerate the process?

The ECDC report goes through European countries, Belgium, France, Germany, Ireland, Norway, Spain, Sweden and the UK. All but two have data from as recently as 11 May. Anyone reading it will notice that our data relating to long-term care facilities is from 13 April. I want to flag that with Mr. Reid. There may be a reason for this and I would be delighted if he could provide that to me. If that is not possible now, he might do so later.

Returning to normalisation, the decision to take over private hospitals had to be made at the time it was made, in the expectation of a surge and the pressure on intensive care units. It is incredibly welcome that it has not been needed as expected. It would have been unforgivable not to make those decisions at that time. However, now that we have overcome that first really dangerous period and it looks as though we will experience a series of waves, as described earlier, does Mr. Reid have in mind an appropriate proportion of space that must be retained over time in private hospitals in order to account for those waves? Will he give the committee some information on that? That is enough.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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That is a lot of questions.

Mr. Paul Reid:

I thank the Chairman. I will try to be brief going through the questions. My colleague, Dr. Henry, might mention one of them. The first question related to transmission in healthcare settings; I think it mentioned hospitals and transmission of the disease. The learning from the early phases and the work NPHET has been doing over the past while demonstrates that certainly the early transmission of the disease was happening within the community. That was where the major transmission of the disease took place. Obviously, the work and protections we put in with regard to our own healthcare workers were geared towards stopping the transmission of the disease, particularly in hospitals, and then in nursing homes also.

The second point, and I will answer briefly, was on the opening of outpatient departments, and the Deputy gave some examples. The chief clinical officer and the chief operations officer, who are both here with me today, are working through a plan on how we get back to non-Covid-19 services in a very safe way. The Deputy gave an example of an outpatients waiting room, which cannot be the case any more. We cannot have the numbers of people waiting for the various patient services they would come forward for congregated together. We have to go back to this in a very different way. It may not be the most efficient way but we have to go back to it in a very safe way. That is the work we are doing now. What would be the priorities about the services we would restore, and we spoke earlier about screening services and other services? What are the risks we have to manage for each of those services? What are the equity issues we need to put in place and the various risks? That plan is currently being finalised by my two colleagues who are with me here today.

The Deputy referred to the European Centre for Disease Prevention and Control, ECDC, report. I briefly went through that this morning. The Deputy is correct. It does reference the various countries, approaches to it and the data collection. I cannot comment specifically on the issue the Deputy referenced at the end of her contribution about the data for our own long-term care settings but I can come back to that.

On private hospitals, and I might ask my colleague to come back on the nursing homes, the Deputy is correct. I want to say again that it was procured for a particular reason. Thankfully, we have got through that. The biggest caution we have to put in place, and this is WHO guidance, is that a healthcare system needs to keep 80% capacity levels. We all know that, traditionally, the Irish health system operates at 95% on a normal day. We cannot go back to the way we were so we have to keep extra capacity. The thought process now is that: first, if we meet another surge we still have to keep capacity; second, even as we head into a winter we have to head into it knowing that we have to create capacity; and, third, what mechanism or way would we create that capacity in the future? That has to be part of the consideration being given to the current usage of the agreement we have with the private hospitals. Would we keep that for a further period as part of the agreement? Would we only keep some of it for a period of the agreement or would we go into something in a very different way? Ultimately, that is a decision for our policymakers in government.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank Mr. Reid. I will move on now to Deputy McGuinness who has five minutes.

Photo of John McGuinnessJohn McGuinness (Carlow-Kilkenny, Fianna Fail)
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Various consultants who contacted us over the past few weeks have pointed to the fact that the current arrangement with private consultants in private hospitals is inefficient and a waste of taxpayers' money. That could have been done differently, it could have been done better and it could be modified now. Who is giving us a look-back on how this contract has worked up to the point of its extension, if it happens, at the end of the three months? A consultant radiologist, for example, tells me that they would normally read 200 patient scans a day and that has gone down to zero. Is that true? Is that a fact of this arrangement the HSE has with the private hospitals? Is that a consequence of it?

Another consultant informs me that a significant number of private hospital appointments have been cancelled. Does Mr. Reid know how many have been cancelled for the months of May and June? Another consultant says that because three months of normal service has been lost, the projection of 1,800 extra cancer deaths is now a figure that is known to the Department. I want to know where that figure came from, does it stand up, and if Mr. Reid has any comment on it?

The other issue is the contract itself. Mr. Reid offers contract A. I want to know if there was a greater saving to be made or a greater use of the time of consultants in terms of contracts B and C.

Is it true that someone informed the State Claims Agency to contact pathologists to say that the cancer biopsies from private hospitals from consultants who had not signed contract A were not to be read? was that a means of forcing those consultants to sign contract A?

The other issue is also referred to in a consultant's letter IN which he states that there are no pathways for him to look after public patients or for the consultant’s patients to be added to public waiting lists. That would seem to contradict what the HSE said earlier. The witnesses cannot ignore the feedback from the consultants in these cases who are pointing to failures within the system and to a lack of governance in the spending of taxpayers' money. Will the HSE tell us how many tests are undertaken in each of the 47 test centres? Do they run on a seven-day basis, how many tests are carried out in each centre, and what are the costs involved?

Ms Anne O'Connor:

On the issue of consultants and private hospitals, the decision was taken to go with an A-type contract. Clearly, everything is going to be reviewed, and as Mr. Reid said earlier, there is going to be and there is already a review under way to determine whether this would be extended beyond the current agreement.

On the use of the private hospitals, the core principle is that people will be assessed and seen on the basis of clinical need and that the continuity of care is maintained. For private consultants who have patients already, they can continue to see them. For us, the important bit is that we get to see the sickest people who may have had their treatment deferred or cancelled as a result of the work that we had to do to be able to cope with the potential surge.

We are looking at all of that and at the level of activity in the private hospitals. We know that from an inpatient perspective, that is at about 44-45%, but the day case occupancy is now up to over 80%. We are seeing a higher level of activity. We, along with the Department of Health, did engage and will continue to engage with the consultant bodies as part of this process.

In terms of the activity that we need to continue, it is going to be very important for us that we maintain a flow. Certainly, in terms of the prioritisation of people in line with the waiting lists that we have, we are going to continue looking at that with the National Treatment Purchase Fund, NTPF.

For us, this has not been a simple matter. It has been in response to an extraordinary situation and we are evaluating it in terms of the service response, the impact on people who need health services, and of course the value for money as part of that.

Photo of John McGuinnessJohn McGuinness (Carlow-Kilkenny, Fianna Fail)
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The HSE says it listens to the radiologists and to the cancer services. Like this morning, and it is no fault of our committee or indeed of our witnesses, it is very difficult to get the specific response required. Will the witnesses please look at the transcripts and give us the information arising from the questions that members have asked?

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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The Chief Medical Officer undertook to answer any questions that were unanswered and I am wondering if the HSE will do the same. If there are any unanswered questions, can we send them on to you to answer by return?

Mr. Paul Reid:

Absolutely.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Thank you very much. I call Deputy O’Dowd, who has five minutes.

Photo of Fergus O'DowdFergus O'Dowd (Louth, Fine Gael)
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The Chairman is very kind and has been very fair. I want to back up Deputy McGuinness in what he has said. The fact is that there is a person in my constituency who has cancer and who had a procedure cancelled two weeks ago. He and his consultant are both at home and there is nobody in the operating theatre where this procedure could have been done. That is not acceptable. It is hugely important that, whatever else we do, we ensure that people who had operations and procedures booked and were expecting them to take place have those proceeded with.

The other point I want to ask the HSE, and I want to say very clearly that there is great support for the fantastic work that it has done, is regarding the concerns for the future if Covid-19 comes back. What additional actions can or will the HSE carry out to ensure that the nursing home deaths are not as high as they currently are? While I accept and I said earlier that we know that older people are very vulnerable, particularly people in nursing homes, a nightmare scenario happened in a nursing home in my own constituency of County Louth, where there were more than 80 patients and there have been 22-23 deaths now.

Some 60% of the staff were sick and could not come in. Where there were 24 nurses at one stage, there were later just six trying to look after all the patients. It is an impossible task.

When did Mr. Reid first decide to intervene in the nursing home sector? I would like to know. I am not being critical or negative. We need to know when the requests came in for PPE from around the country. What was going on at the HSE's senior administrative level? When did it make the decision to intervene? I want to repeat publicly that the head of primary care in CHO 8 was exceptionally helpful when I made the case to him about the home to which I refer. There was a significant and immediate intervention. I do not know what went on with the complaints which we read in the national press about PPE not being supplied to private nursing homes. It was on Facebook pages. I received questions about why a nursing home was not getting PPE. The HSE told me clearly that if a request was made, nursing homes would get PPE immediately. There is a significant amount that we do not know, and we need to know more. The best way forward is to plan for the future as "Team Ireland", with the HSE, Nursing Homes Ireland and all the other agencies working together on a plan for the winter. We can only base that on the knowledge of what happened in the past, when the HSE knew and when it acted.

Mr. Paul Reid:

I ask Dr. Colm Henry to take the question on cancer services and private consultants.

Dr. Colm Henry:

On the issue of nursing homes, this is a novel virus and evolving information is coming through week by week. On 12 March, the ECDC described a case report of asymptomatic transmission. The question is what we have learned that we can apply in the context of future prevention. The most important lessons as we garner knowledge about this virus are the atypical presentations in older people and the importance of asymptomatic transmission. Even though that mass testing exercise has been reassuring in that it showed quite low levels of the virus among patients and staff, today's ECDC report had new guidance for residential care facilities, including a more aggressive testing strategy, bearing in mind that there is asymptomatic transmission and atypical presentation. I expect that will inform our own testing strategy in residential care settings from here on.

Wider measures include wider provision of the flu vaccine which, in line with other countries, we are now making available to younger age groups for this coming winter to reduce the reservoir of flu in the wider population, which would certainly challenge us on top of Covid-19 services. Ms O'Connor might address the timeline of providing PPE.

Ms Anne O'Connor:

Nursing homes would respond to infection anyway and have a regular supply of PPE. We became aware of significant challenges in the third week of March. It was well aired in the media that certain sites had struggled. At that time, we faced significant challenges in securing PPE in general. We were struggling to maintain a supply of some items. However, from late March through to early April, we significantly increased the supply of PPE. We had to prioritise supply across all sites. The area crisis management teams looked at all of the long-term residential care facilities, not just nursing homes, and what the supply requirement was. At the time, with the supply available, we had to prioritise and distribute PPE accordingly. The PPE supply going to residential care settings has now gone down to 31% of our PPE supply, whereas home support receives more than 32%. We supply a significant amount of PPE to hundreds of sites every day, including nursing homes and other long-term residential care facilities. There are different timelines for various facilities and areas, but, in the main, it was a challenge in late March.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am sorry to cut Ms O'Connor short. We have just a couple of minutes left before we reach our two-hour threshold. I have a couple of questions. How much has been spent on testing to date?

How much is envisaged to be spent on testing based on the contracts that have been signed to date? Are there any plans for antibody testing, which has been suggested as one of the means of opening countries in general?

Mr. Paul Reid:

On the antibody tests, I might ask my colleague to comment in a moment, but we are obviously staying very close to this in terms of what is on the market and learnings from other European countries, but there has not been a significant level of success with antibody testing. We see it having a role in the future and we want to monitor how it progresses. Some of the major global players are running some pilot projects and tests to support that overall.

On the overall cost of contact testing and tracing, it is something on which we are still in dialogue with the Department of Public Expenditure and Reform. As we brought our proposals to the Government in the last couple of weeks we set out the strategy and targets that I discussed earlier. Part of that was the funding requirement for it in the coming year.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am not talking about the funding requirement but how much has been spent to date.

Mr. Paul Reid:

The total contact tracing spend to date is in the region of about €2 million.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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That is contact tracing.

Mr. Paul Reid:

There are various aspects of it. My apologies, that is for contact tracing. I will come back to it momentarily, but overall it is something that would be a very significant cost for the HSE for this year. In a nine-month period it will be several hundred million. We are just working through the costings on that.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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You think it will cost several hundred million. How much has been spent up to now?

Mr. Paul Reid:

I can come back to you shortly, Chairman. I do not have the cost in front of me.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Perhaps you will be able to provide an answer by correspondence.

Mr. Paul Reid:

Yes, I can refer back to you.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I thank you, Mr. Reid, and your colleagues, Dr. Colm Henry and Ms Anne O'Connor, chief operations officer of the HSE, for attending today and for answering our many questions so fully. My apologies again for the fact that you could not see the timelines under which we were operating.

Mr. Paul Reid:

I have the cost so far for testing. It is roughly €35 million between testing and tracing.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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It is €35 million up to now but you think it will cost a couple of hundred million.

Mr. Paul Reid:

It will be a few hundred million based on the volume we are projecting for the rest of the year.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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Is there a breakdown available for the companies? Various companies have been engaged to do that testing. I am not asking you to provide that breakdown now but can you provide a breakdown of the companies and how much they have been paid?

Mr. Paul Reid:

The majority of the laboratories would be Irish based and there is one overseas. Our swabbing centres are primarily our HSE-funded and staffed centres in general.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I do not wish to use any more time but is a breakdown available of how much has been paid to whom up to now?

Mr. Paul Reid:

Sure.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I am not asking for the breakdown now. You can send it to us.

Mr. Paul Reid:

I know. You will get that.

Photo of Michael McNamaraMichael McNamara (Clare, Independent)
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I reiterate my thanks to you and your colleagues for coming here and answering our questions. I also thank my colleagues in the Chamber.

Sitting suspended at 4.05 p.m. and resumed at 4.30 p.m.