Oireachtas Joint and Select Committees
Wednesday, 11 November 2020
Joint Oireachtas Committee on Health
HSE Winter Plan: HSE
I welcome our witnesses from the HSE, who will be briefing us on the executive's winter plan. This takes on a particular significance during these Covid times and will be in operation until April 2021. I welcome Mr. Paul Reid, CEO; Ms Anne O’Connor, chief operations officer; Dr. Colm Henry, chief clinical officer; and Mr. Liam Woods, national director of acute operations.
Before we hear Mr. Reid's opening statement, I must point out to the witnesses presenting remotely that there is uncertainty as to whether parliamentary privilege applies to witnesses giving evidence from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by the Chair to cease giving evidence on a particular matter, they must respect that direction.
Mr. Paul Reid:
I thank the Chair and members of the committee for the invitation to update them on the HSE’s winter plan. As this is my first time attending before this committee of the Thirty-third Dáil, I would like, on behalf of the HSE, to wish the Chair and the members of the committee well with their important work. I assure the committee that the HSE will assist it in every way we can. Colleagues joining me today are Ms Anne O’Connor, chief operations officer; Dr. Colm Henry, chief clinical officer; and Mr. Liam Woods, national director of acute operations.
On 27 March 2020, just as we were emerging from last year’s winter season, a decision was taken by NPHET to postpone all non-essential surgery, health procedures and other non-essential services on account of Covid-19. This necessary decision led to a near standstill of scheduled healthcare activity. Although activity has resumed, there have been enduring consequences for our health services. In the knowledge that we would be delivering services within a Covid-19 environment until after the development of a vaccine or cure, we published a strategic framework for service continuity. The framework outlines our key objectives, including the resumption of services, the retention of surge capacity and the adoption of new technologies. Our winter plan builds on this framework and aims to ensure that we are as prepared as possible for the anticipated seasonal pressures, which this year will be more challenging than ever.
We have been entrusted with €600 million in order to achieve these objectives which is the biggest allocation ever made for a winter plan. We are committed to investing this money in the places where it will have maximum impact.
Our core objectives can be succinctly summarised. First, we aim to avoid congestion in our hospitals. Second, we will resource community services to deliver more care than ever before. Third, we will ensure that lines of communication between these two pillars of our health system, acute and community, are seamless. Integration of services has always been problematic in practice. However, one of the few positive things to emerge from the pandemic is our capacity to operate as a whole system when the circumstances require it. Additional key priorities include supporting nursing homes, strengthening public health capacity and minimising the impacts of Covid-19 on our cancer services, including screening services.
Winter funding will only get us so far. Our success is also heavily predicated on the public continuing to take the necessary precautions as per public health advice and continuing the downward trend in community transmission of Covid-19.
A community first approach to the delivery of care will be central to delivering safe, efficient and effective services through winter and beyond. We are making substantial investment in reorienting our services into the community through: 4.7 million additional home support hours; enhanced home support packages; community specialist teams in 11 centres focused on older persons and chronic disease care; 530 community intermediate care and 631 enhanced community rehabilitation beds; GP access to more than 79,000 diagnostic procedures; enhanced homelessness supports; and making the flu vaccine available to staff and to the public.
With regard to our acute capacity, at the end of 2019, we had 10,988 inpatient beds, including 255 critical care beds.
The 2021 Estimates provide funding for the following beds on an ongoing basis: 1,146 incremental beds in acute hospitals; 66 critical care beds; and 135 sub-acute beds. The arrangement with private hospitals will also allow us to augment our existing approaches to Covid-19 and non-Covid pathways, particularly in the event of a surge in hospitalisations. Provision is also being made for additional consultants, the extension of renal dialysis satellite stations and home dialysis projects and for the use of new technologies in endoscopy. The waiting lists have stabilised, albeit at a much higher level. Extra resources for the National Treatment Purchase Fund, NTPF, will allow for additional insourced and outsourced activities to tackle waiting lists. Steady progress is also being made in the resumption of elective activity and the latest data show that we are almost in an equivalent position to the corresponding period in 2019.
I will inform the committee of the financial position. The HSE received its annual letter of determination 2021 on 4 November and is now engaged in the finalisation of the 2021 national service plan. In summary terms, the scale of the additional investment in the health service in 2021 is unprecedented when viewed in the context of any previous single year. Including moneys held back initially by the Department of Health, the national service plan 2021 revenue net expenditure allocation is €3,534 million or 21% above the national service plan 2020 allocation of just over €17 billion. The 2021 capital allocation is also more than 20% ahead of the 2020 level. This investment reflects a strengthened trust and confidence in the HSE and how our staff have mobilised and responded to the many challenges of this pandemic to date. We want to build on this response so far, so it becomes the foundation of a sustained and lasting improvement in our health and social care services of which we can all be proud.
Thank you. I remind witnesses and members of the challenges we face in terms of time constraints. The first session is ten minutes each, and that includes the replies. The following session is seven minutes each and, again, that includes replies. If we bear with that, we will get through the meeting. I call Senator Kyne.
I thank Mr. Reid and the team for their statement, and I acknowledge the work and effort of the many healthcare professionals all year round each year, as well as the high level of care and the positive experiences people have in the health system in general. There are always long-term challenges and some seemingly ever-present ones. Then there are sudden ones such as Covid-19. The winter planning is usually based on the previous winter, and the first couple of weeks of January are always the pinch point. What in particular will be done this year as opposed to other years?
There are 33,000 extra procedures promised. What is the role of private hospitals there? There was some concern about the previous agreement, but the agreement with private hospitals earlier in the year definitely saved lives. The most important criterion in respect of healthcare is the number of lives saved. I welcome the 33,000 procedures that have been identified. Is it ambitious? What impact has Covid-19 had on the screening programmes? Have the greatly reduced numbers of procedures been factored into these figures? Regarding the opening and operating hours of clinics, such as endoscopy clinics, if they could be increased from nine to 12 or even 15 hours, serious inroads could be made into waiting lists. Is that factored in here as well?
In primary care, there is an allocation which is a new feature of the winter plan. Mr. Reid referred to community assessment hubs. Where are these to be located or is that identified? What are the criteria for deciding these and what will be the role of GPs and the buy-in of GPs in these areas, because there has been concern about primary care centres? I note the report this morning of concern that there will be shortages in flu vaccines. GPs say there will not be enough vaccines for high-risk categories of patients. Perhaps Mr. Reid will clarify the current status of flu vaccine stocks.
Finally, with regard to additional capacity, obviously this will be dependent on recruitment. There are commitments, but are the numbers of nurses available? Are nurses and staff available to provide that additional capacity? It is dependent on recruitment and, in some cases, on physical infrastructure. Unfortunately, the experience in Galway on certain issues, such as the theatres in Merlin Park which had a leaking roof for three years and the unbearable delays in planning permission being lodged for a new emergency department, would question the ability to deliver such projects. It is frustrating that when a not-fit-for-purpose structure for the emergency department in Galway is identified there are delays in that regard. I have concerns about that.
Again, I thank the team and look forward to the replies.
Mr. Paul Reid:
I will try to be brief and will call on some of my colleagues to comment as well. First, I thank the Senator for his opening comments, which are appreciated by all our teams.
Second, in terms of what will be different in the first couple of weeks in January, it is particularly about what will be different as part of the overall approach to the winter plan and the significant extra investment, which Ms O'Connor can comment on briefly. There is our community investment, community investment teams, integrated teams and multidisciplinary teams working with our acute teams and with our community. There is a particular focus on home first and keeping people at home, but there is also investment in our hospitals in terms of emergency departments and having key decision makers available to make decisions. Separately, we have established this year much stronger working processes and pathways with GPs in primary care. The significant difference is our particular and strong focus on the investment in communities, especially on home first for elderly care. There are many new integrated processes between the acute system and the community system. However, I will call on Ms O'Connor shortly to comment on it.
Regarding the role of private hospitals, they will play a role. We have carried out a procurement process for private hospital groups. It is different from the first phase. There are two aspects to it. First, we already have a budget of €25 million, which some of the hospitals are drawing down for both diagnostics and services. Second, we have concluded a procurement process for a number of private hospitals to engage with us on, and we are finalising those in terms of some mini tenders which will be local, operated between the public hospitals and private hospitals for certain diagnostics and services. Part of that would include diagnostics access for GPs in the community. Again, that will be very different.
On the screening processes, in July we launched our outline plan for the relaunch of our four key screening services. That is mapped out and all of those have recommenced. At various levels they will start to call on people on a priority basis. I will not go through each of the programmes, but our winter plan has approximately €2.7 million to invest, particularly in the rapid access clinic. Our clinics have always been open but we are concerned to ensure that people who are symptomatic and need care come through. There is an extra investment in resources. There is also an extra investment in infection control processes for our screening services.
I will ask Dr. Henry or Mr. Woods to comment on the endoscopy clinics, but some of it is referenced in our winter plan. There are some new innovations in terms of endoscopy clinics and, indeed, endoscopy capsules that will be spread out to further hospitals as part of an acceleration plan for endoscopy clinics.
On community assessment hubs, the plan facilitates a scale up from the current seven to approximately 20. We will monitor this closely. It is a process with good buy-in from GPs. The principle is to assess respiratory illness and try to filter out people who may need to go to a hospital, people who do not and people who can referred to other pathways. It worked very well for us during the Covid pandemic. The demand is not very high at present, so we will assess and monitor the best use of those clinics. However, there is good buy-in from GPs so far.
To deal briefly with vaccines, Dr. Henry was talking about this earlier this morning. We have now distributed almost 1.3 million vaccinations. We have distributed more as of this week than we did for all of the flu season last year. It is about 20% up on our total delivery and order. There is significant demand and we want to make sure it is prioritised. That was the principle of Dr. Henry's letter earlier this week, that it is prioritised for the groups who are defined as priority.
There is, however, very significant demand for private capacity for flu vaccine injections, and while that is under great pressure too, we are nonetheless significantly up on our volumes compared with last year. There are no missing vaccines. There is always a lag of GPs registering with the primary care reimbursement service, PCRS, for reimbursement but we want to see where the allocation is and how to prioritise the final distribution.
Recruitment will be a big challenge. We have recruited a net increase on our workforce this year of more than 5,000 resources, 1,600 of whom are nurses and 150 of whom are consultants. There are significant recruitment campaigns for each grade, although it will be a very significant challenge because there is a worldwide demand for healthcare workers. We have started that process and about 600 nurses from an international recruitment campaign are part of the process. As graduates come through this year, that will provide another 1,200 whole-time equivalents in the system.
With the Chairman's agreement, I might ask Ms O'Connor to make a brief comment, followed by Dr. Henry.
Ms Anne O'Connor:
On the winter planning, the Senator is absolutely correct. We usually see a big surge on the first few days of January once GP clinics reopen fully and people start attending and are referred to hospitals. The critical issue for us in respect of emergency departments and hospitals in particular relates to the flow that is created. Many people attending will be people who are either older or with chronic disease, which is why we have focused in our winter plan on the development of specific initiatives to support people to stay at home. I refer not just to home support, which is a significant investment and especially so in the first quarter, but also to integrated specialist teams for older persons and chronic disease management whom GPs can work with and access.
From our perspective, we want to ensure that people who attend an emergency department are turned around in order that as many people as possible can go home and be supported through our intervention teams and outpatient parenteral antibiotic therapy, OPAT, programme. A range of initiatives are focused entirely on reducing the need for people to attend the emergency department or, if they attend, to be treated in the emergency department and discharged. If such people require admission, the focus is on them being seen as quickly as possible through the hospital system, with good options at the end of their pathway of care from the hospital back out to the community and all those supports. More than half the funding in the winter plan this year is targeted at community investment, which is to avoid that congestion in January that we experienced in previous years. We have been building on the learning from previous years as to what has worked and what we will be aiming for in January next year.
Our guests will be aware we are under tight time constraints, so I would appreciate if our guests can respond to my questions as succinctly as they can. In some of my questions, I am merely seeking information. I will begin by putting a question to Dr. Henry about the flu vaccine. I understand he wrote to all GPs and pharmacists on Monday. Is that correct?
In that letter, Dr. Henry stated there were 1.3 million doses of the quadrivalent influenza vaccine, QIV, 700,000 of which had been administered. Some 600,000 doses had been distributed but not administered. Is that correct?
In his letter, Dr. Henry set out the high-risk categories, such as the over-65s, healthcare workers and pregnant women. Of the 600,000 doses that have not yet been administered, how can Dr. Henry guarantee that those high-risk patients will be prioritised? What checks or controls are in place? Can Dr. Henry guarantee that those who are deemed to be prioritised will be prioritised over others?
Dr. Colm Henry:
Based on the returns in respect of the 700,000 doses, we see they have largely been confined to the priority groups. Some 400,000 have been given to the over-65s, 35,000 to healthcare workers, 323,000 to 18- to 64-year-olds in at-risk groups, and there is the addition of the new, nasal vaccine to children. Based on patterns to date, it appears the strong message we have been giving repeatedly to pharmacists and GPs to confine the vaccine to priority groups seems to have been adhered to.
I apologise for interrupting but given that there is a significant demand this year, as Mr. Reid rightly noted, how can Dr. Henry guarantee that those 600,000 doses that have not yet been administered will go to the categories he outlined in his letter? He stated he wants to pause the remaining 50,000 to ensure they are prioritised, but how can he guarantee they will be prioritised?
Dr. Colm Henry:
I am not in a position to guarantee the behaviour of every pharmacist and GP in the country, as I am sure the Deputy will understand. Based on our strong and consistent messaging, however, and on our need to prioritise those groups with the stock we have, I am reasonably confident, judging by the information we have received to date, that those vaccines will go to those high priority groups.
We have sought a briefing not just on this issue but also on the potential for a Covid vaccine. We look forward to that briefing, which we hope will happen in the next couple of weeks. I wish the best of luck to the HSE in that work. It will be very important in the fight against Covid.
I turn to Mr. Reid in respect of hospital wait times. At the end of September 2016, some 438,267 outpatients were waiting to see a consultant. The figures for the end of September 2020 are 612,283, an increase of 173,000. Of that, the number of patients waiting 18 months or longer was 29,994 at the end of November 2016. As of the end of November this year, there were 149,491, an increase of 120,000 patients waiting 18 months or more on the figure for 2016. Why are outpatient wait times increasing year on year? The figure increased from 438,000 in 2016 to 612,000 this year.
I apologise to Mr. Woods but this is not Covid related. I will outline the figures year on year because it is not fair to say this is due to Covid. In 2016, 2017, 2018, 2019 and this year, the number of patients was 438,000, 493,000, 515,000, 568,000 and 612,000, respectively. Year on year, therefore, over recent years the numbers have been increasing. I am asking why.
Turning to the inpatient numbers, in 2019, some 67,985 people were waiting for inpatient procedures, whereas the figure is now 75,000. The numbers waiting 18 months or more have increased from 4,841 to 8,000, a difference of more than 3,000. They are very high numbers.
Mr. Liam Woods:
I agree that they are. The inpatient list was reducing, and while it grew as a result of Covid, it is now reducing again and the October figure is almost under 75,000. More generally, what will make a difference is there will be significant investment in chronic condition management outside of hospitals. Changing the model of care in order that more people are seen in the community by multidisciplinary teams is the way to address this. That will happen in areas such as cardiology and respiratory medicine, which will help address these lists. Significant initiatives, arising from the Covid response, are under way to do that. I should have highlighted earlier that the advent of virtual clinics as part of the Covid response has significantly assisted in addressing what was, as the Deputy rightly noted, a growth in numbers over recent months.
None of that answers my question because we need capacity. In regard to cardiology wait times in 2016, some 16,806 patients were on waiting lists, while in 2020, the figure was 27,000, a considerable increase. In 2016, some 1,875 people had been waiting 18 months, whereas the figure is now 7,963. I have dealt with a number of other cases that I will put to Mr. Woods. An elderly woman has been waiting to see a pain specialist for more than two years. The numbers waiting to see a pain specialist have increased sharply. The number waiting for pain relief this year is 12,289, while 4,000 patients have been waiting more than 18 months to see a pain specialist.
The number of children undergoing procedures for the treatment of scoliosis has dropped by 29% and the number of oncology procedures has also dropped by 29%. My point, therefore, is that despite all the spin and the rhetoric about all of the additional beds and staff, year-on-year, inpatient and outpatient waiting times are rising. Children with scoliosis are still awaiting much longer than they were in previous years for treatment; people are waiting on pain relief across all the specialties; and inpatient and outpatient waiting times are on the increase. There does not seem to be a plan. Given that those figures are not good, as Mr. Woods said, and they are going in the wrong direction, what action is going to be taken and how can we reduce those waiting times? We are told that with Sláintecare, people should not be waiting any longer than 12 weeks and yet we have hundreds of thousands of patients waiting more than 18 months simply to get into the system and to see a consultant. Can the HSE explain how those waiting times are going to come down over the next number of years?
Mr. Paul Reid:
The Deputy referenced Sláintecare in the last part of his question. Sláintecare is the whole-of-government plan to address the structural, infrastructural and funding deficits the health service has experienced over many years. The Deputy highlighted some of them there. I refer to what will make this better over the coming years. First, we welcome the significant extra investment of 20% for next year. That will provide extra bed capacity that we have not seen in a number of years, which the Deputy touched on at the end of his contribution. I will mention the other components of it. Sláintecare set out a requirement for at least 2,600 beds, incrementally brought into the system. That would be 7,500 if reform was not done at the same time. The 1,150 beds we have planned between this year and next year are welcome. It set out the need to look at elective hospitals because we know that the capacity and the organisation of the health system-----
I am sorry but I need to come back in again. Elective hospitals are a long way down the road and I want those hospitals to be delivered as quickly as possible. All elected representatives and members of this committee get representations. I refer to an elderly woman waiting for more than two years to see a pain specialist, children with scoliosis waiting longer for treatment, people on trolleys in record numbers and waiting times going up. Mr. Reid made reference to 1,150 beds. I refer to the baseline figures he is working off, namely, the 1,146 additional beds being in place by the end of 2021. Those beds are in addition to 2019 and not 2020. That is the reality. Most of them are already there and have been made permanent. I have spoken to hospital managers, including the manager in Waterford, who have told me that unless capital funding is provided, they will not have the space to open beds and yet there was not much additional capital funding in the budget. Therefore, of all these beds that are being promised, is Mr. Reid saying that they will only be opened using existing space or will capital funding be made available to hospitals where they need it, whether it is to build rapid build modular units or physical infrastructure? Despite all the numbers being thrown out in relation beds and staff levels, the waiting times paint a very different picture. Would Mr. Reid agree?
Mr. Paul Reid:
I am trying to address the Deputy's question. To reassure members, I have no interest in spinning numbers. I am merely trying to set out the big structural changes required in the health service over the coming years. Ironically, we are in a much better place as a result of what has happened with Covid because one of the biggest changes we have to make is to release the pressure on our hospital system so that it can attend to elective care. As my colleague, Ms O'Connor highlighted, the right thing to do is to make a significant investment in community services, keeping people at home and in care outside of the hospital. This will give the health system a chance to address many of the issues the Deputy highlighted. I am not trying to claim that those issues do not exist, because they do, but what is required is the continued pathway that we are on now, which consists of investment in community services, integration between acute and community care, extra capacity in the hospital system and extra recruitment. These are the components of what we want to set out next year. I am not going to tell the committee that this problem will be solved next year, because it will not, but it is a pathway that we have to continue with over the coming years.
I have a number of questions I wish to pose to Mr. Reid. He might forgive me at the outset for jumping in and out, because I have ten minutes and I have a few issues I want to get through. With regard to the HSE's winter plan, what specific measures are being put in place to cater for the University Limerick Hospitals Group, especially University Hospital Limerick, UHL, and Ennis General Hospital? Statistically, on a multi-annual basis, this has been the hospital group which has been most impacted and adversely affected by patients waiting on trolleys and the pressure that mounts on accident and emergency departments in the winter months. I would like to hear what specific plans there are to address that.
Ms Anne O'Connor:
As Mr. Reid stated, beds are coming on stream in Limerick, and Mr. Woods can speak more to the actual capacity in the hospital. What is very important is that, as well as the bed capacity in the hospital, which has been a known deficit in that area for many years, there is very significant integrated working. At the risk of repeating what has been said, in Limerick there have been particular enhancements around the community intervention team and the integrated care teams. Again, it is about supporting the hospitals. This emphasis on community is about keeping people well at home but it is also very much about supporting our acute hospital system. I might ask Mr. Woods to speak on the specific hospital capacity.
Mr. Liam Woods:
In Limerick specifically, as the Deputy may be aware, 100 additional beds will come into use from mid-year to early January 2021. The 60-bed block will be gradually commissioned from November through to early January, and 24 and 14 bed additions have been made already. We are also looking at work in Nenagh to support further patient activity there. On the acute side, the 60 beds were planned pre-Covid, but are now coming on stream in a very timely way. The other two sets of beds, namely, the 24 and 14 additional beds, are a response within the Covid environment. That is where we are headed in terms of acute capacity. Clearly, the work done in respect of older persons and in primary care in the community will help. There is a very good community intervention team in Limerick opposite the hospital and that is being resourced-----
I refer to a short email I received from student nurse in my constituency during the week. She is required by the Nursing and Midwifery Board of Ireland to complete a minimum amount of clinical placement hours in order to meet the standards to qualify as a registered nurse. During previous years of training, the supernumerary status of her placement was upheld to the best of the ability of staff, but during the most recent clinical placement, this was not the case. She is a supernumerary student, and she claims that supernumerary students were being counted in the staffing numbers in an attempt to hide the excessive staff shortages due to Covid-19. I would like to know if that is the case. Are the supernumerary students being counted in staffing figures across hospitals?
During the initial Covid outbreak, or the first wave of Covid, the HSE belatedly paid student nurses some salaries as healthcare assistants, but that has now ended. Why has this ended? As we negotiate our way through the second wave of Covid, with the potential of a third wave in late winter or early spring, could the HSE outline how it is treating its student nurses? Is it counting them within the body of staffing, when it would not have done so in the months prior to this? I would like one of the witnesses to address the payment issue. Perhaps Ms O'Connor could respond to that.
Ms Anne O'Connor:
We very specifically count our student nurses as student nurses. It is important to acknowledge the very considerable contribution all students have made during Covid. We have a specific student count and one can see the numbers shifting as students graduate, usually around the month of September.
In terms of the payment of student nurses, the Deputy is right to say that has been an issue. They were paid during Covid as healthcare assistants and that ceased as they resumed their studies at college. It is an issue which has been raised and we are currently in discussions with the Department of Health. We are acutely aware that there are many different types of clinical students who do clinical placements across our system in terms of nursing, allied health professionals, radiographers, etc. It is currently a very live issue that is being discussed.
Ms Anne O'Connor:
They are currently not being paid as it is part of their clinical training. For any clinical professionals who do placements within any of our community or acute sites, they are not being paid, as it stands.
When students worked as healthcare assistants in previous months, particularly over the summer months, they were paid as healthcare assistants, but they are now back as part of their college year. I am aware this is a very live issue and it has been raised with the Department. Again, we have many different types of students working across the health system who are all doing clinical work, so that is a very big decision that would have to be agreed with the Department of Health and elsewhere.
My next question is on ventilators and is for Mr. Reid. At the very outset of the Covid pandemic there was a global rush to have more ventilator machines in the world's hospitals. We saw car manufacturers and other manufacturing plants across Europe diversifying and starting to make ventilators. It was reported week on week that Ireland's capacity per 100,000 of the population was one of the lowest in Europe. Heading into this winter, as we negotiate our way through the second wave of Covid and the potential for a third wave, have we added capacity for ventilators to treat people if their respiratory problems worsen due to Covid and how has that been increased since the springtime?
Mr. Paul Reid:
There are two aspects to the question: ventilators and total critical care bed capacity. I will take the latter first. We do have, as the Deputy said, quite rightly, a lower benchmark across OECD countries for our critical care beds. We had 255 at the start of Covid and we are now at 285 beds. We have a further 17 as part of the funding throughout the winter, which brings the total up to just over 300. The investment for the service plan brings us to 320. We do have a surge capacity which we would utilise and we had planned for in the first phase. Thankfully, we did not have to use it. That would bring us up to about 350 or 360, but that is using high-dependency unit beds and pre- and post-operative theatre beds that we do not really want to use as there is a higher level of risk involved, obviously, and there is the training of staff for those beds.
We saw footage on our TV screens in the springtime from Bergamo where ventilator machines had to be moved from patient to patient. Ventilators became a very fluid machine that would be trucked down a corridor to get a patient breathing again. What is our capacity specifically on those machines? Has it increased significantly?
Dr. Colm Henry:
It is important to emphasise what the CEO has just said there. We delivered, in the first phase and in the second phase, a great majority of critical care in conventional critical care settings. The mortality for critical care patients provided for in Ireland was of the order of 21%, which is about half of that in the UK and other countries. The reason mortality was much lower for the same patient selection was that we managed to deliver a greater majority of critical care in conventional critical care setting with trained expertise. When we talk about additional ventilators, it cannot be dealt with in isolation from dealing with the whole system of critical care and how it should be and how it is optimally delivered, that is to say, in conventional units in a critical care bed with trained nurses and trained doctors, and that is the capacity we are focusing on.
In the winter plan and budget 2021 there was a strong reference to rehabilitation beds. There is a figure for how many rehabilitation beds will be provided but no breakdown. I would like to know a little bit more. The witnesses may or may not have the statistics today as to where in the country we will see those beds.
Ms Anne O'Connor:
An additional 631 beds were referenced in the plan, and within that we can provide a breakdown perhaps. Certainly we are looking at the National Rehabilitation Hospital, NRH, and a number of other sites across the system. It is rehab beds related to our acute hospitals, and the NRH is a significant number within that. I can certainly provide the Deputy with a breakdown. I do not have all of the breakdown here.
I welcome Mr. Reid and his colleagues. I thank them for their attendance and for their ongoing work in this very important area. I just want to talk for a few moments about one of those few positives that came out of Covid, and that is the acceleration of some elements of Sláintecare. Earlier in the year, Mr. Reid referred to what was happening as "Sláintecare on speed". It is a very welcome development that there is a significant shift of activity away from hospitals to the community, which is what we should be aiming for anyway.
I want to make one point and then ask a question. The point I would make about it is that part and parcel of Sláintecare is the restructuring of the HSE combined with regional management and greater levels of accountability. I understand why the HSE had to park that earlier in the year and all of the focus was on responding to Covid. That is absolutely understandable. However, I made this point to the Minister last week and I want to make it to the witnesses today that I would strongly urge them to resume that restructuring reform programme relating to the structure of the HSE, and to do that as early as possible in the new year.
My next question relates to all of that work that is going on in shifting activity to the community, which is very welcome work. My concern is, though, about those areas, in my own constituency, as I wrote to Mr. Reid last week, but also in many other parts of urban and rural Ireland, where there is a poor level of GP provision. We know from various research that has been done that areas with the greatest level of health need are very often those areas with the poorest provision because of our two-tier system. Given the shift that is taking place, what work, if any, is being done to ensure that those areas which are very poorly served by general practice, with low numbers of GPs and other primary care staff, have sufficient numbers of GPs?
Related to that, obviously, was an earlier commitment to introduce salaried GPs. It seems that there has been no progress made on that at all. Related to that as well is the whole question of ensuring the fair allocation of resources. How does the HSE ensure that that takes place where there is poor provision at the moment?
My second question relates to the budget. An extra €3.5 billion is provided for the service plan this year. I do not want the details now but will the CEO send us the schedule of the breakdown of that €3.5 billion in terms of what element is going to Covid and what element is going to increased service provision?
My third question relates to the flu vaccine and shortages. I have been raising this with Mr. Reid since last July. I was assured at the time that the 1.4 million vaccines order was sufficient to get us up to 90% coverage. I doubted the figure at the time because it did not make any provision for additional groups or cohorts of people to avail of the vaccine as a health prevention measure. Why is it that only 1.4 million vaccines were ordered? Is the HSE now saying to people who are not in the at-risk groups that they cannot have access to the vaccine? That would be a retrograde step. Does the CEO accept that insufficient quantities were ordered initially?
Mr. Paul Reid:
I thank the Deputy. I will work through the questions and call on Dr. Henry especially on the flu vaccine. I thank the Deputy and her colleagues for their feedback on the health service and our workers.
On the acceleration of Sláintecare overall, I have just a couple of quick comments. As tough as Covid has been for the health system, I believe it has given a greater level of confidence to the health system, particularly around the area of integration. It has given a whole new level of care pathways so that we do actually invest in the community. Deputy Cullinane was talking earlier on about the capacity in the hospital system, and it is an issue, but we know a major part of that solution is in the community service. I know Deputy Shortall has been key in leading that whole report.
Specifically on the Deputy's point around regional management and prioritisation, that is ultimately a priority in terms of Government policy. The two elements of Sláintecare were regions and, separately, the significant focus on services. We certainly would be saying for now to continue the significant focus on services, but regions are still part of the Government policy, which we are implementing.
On the provision of GP services generally, that is a concern for me and for the health system. Areas of social deprivation suffer most in that context. In some hospitals where we see many people attending accident and emergency departments, that is largely down to areas where there is social deprivation and that do not have access to GPs and or that pathway. That is a concern for us. Regarding what would make the situation better, certainly the pipeline of GPs coming through the system has improved. Dr. Henry might also talk about that element. We regularly talk to representatives of the ICGP about how we, as a State, can improve the pipeline of GPs coming through training. It has been the experience, however, even during Covid-19, that areas of social deprivation suffer more in the context of health systems. That is well proven.
Turning briefly to the budget, what we have-----
I am sorry, but I asked what the HSE is doing to ensure there is an adequate number of GPs. It is fine to say there is a pipeline, but we know the current model does not support the establishment of GP practices in areas of high disadvantage. One proposal was to have salaried GPs and the HSE would provide premises. What is being done to address this issue?
Mr. Paul Reid:
I might ask Dr. Henry to come in because he deals with the ICGP on that issue specifically. It is about policy, ultimately. The new GP contract has helped us, especially regarding the capacity and capability of GPs concerning chronic illnesses and other aspects of healthcare. I will ask Dr. Henry to comment specifically on that issue, and Ms O'Connor might come in too. Returning briefly to the budget, the letter of determination arrived from the Minister, and our board-----
Dr. Colm Henry:
Regarding Deputy Shortall's questions, I will start with the flu vaccine. As the Deputy pointed out, we purchased 1.4 million doses of the flu vaccine, which was an increase of 20% on last year. If we look at the pattern we will see that of the roughly 1.2 million doses distributed last year, approximately 1 million were administered. We are seeing an increase in purchasing power this year, and also a major increase in uptake, which is welcome. I emphasise to the Deputy that the at-risk groups have not changed. We have been careful to be consistent with our messaging to the public and to GPs and pharmacists that the vaccine must be confined and preserved for and administered to at-risk groups, as clearly defined by and in line with WHO recommendations.
Turning to the Deputy's question regarding whether we have enough flu vaccine, it is too early to say. I was on a call to members of the ICGP and there were mixed messages from the primary care communities. Some are reporting they have enough vaccine, while others are reporting they are running short. That is why we are now pausing to find information regarding what has happened to those doses of the vaccine which have been distributed but not yet recorded as administered. We are doing that so we can direct our remaining stocks for use with those priority groups.
With all due respect, the HSE's calculation was based on increasing the uptake of the vaccine among the at-risk groups. There is no doubt that this is an important objective. However, does this situation now mean that the order put in by the HSE earlier in the year for 1.4 million doses will not cater for anybody outside those at-risk groups? Was that a mistake? Is the message to people outside the at-risk groups now that they should not get the vaccine?
Dr. Colm Henry:
That has been our consistent message all along. The vaccine is for at-risk groups and we have made that consistently clear in our public messaging and in our messaging to GPs and pharmacists. As I replied to Deputy Cullinane, the feedback we are getting, based on what has been administered to date, is that is the way GPs and pharmacists are prescribing. Our message has been very consistent on this issue.
Given the year that is in it, when people are conscious of health and taking steps to prevent getting any infections, including the flu, many people were of the view that this year they would get the vaccine. Dr. Henry is now telling those people, however, that there are not sufficient doses of the vaccine to allow people outside the at-risk groups to get it. Is there a question now about the sufficiency of the orders submitted earlier in the year by the HSE? I refer to ordering just 1.4 million doses of the vaccine.
Dr. Colm Henry:
Again, we always intended and still intend that the vaccine is only for those at-risk groups. That was our messaging, which has been entirely consistent and clear from the beginning. It has been in line with our public health advice regarding where vaccine stocks should be best administered to maximum effect.
That has not been the practice. Companies provide the vaccine as a preventative measure, as do the Houses of the Oireachtas. There has been a big shift in policy this year, if Dr. Henry is stating that people should not get the vaccine if they are not in the at-risk groups. I think that is a mistake.
Dr. Colm Henry:
I can only repeat my answers, which are based on all the public health advice regarding how we can best use and direct the resources and vaccines we get in respect of at-risk groups. I am aware of the practices of private companies and other facilities, but this is a HSE exercise based on a population vaccination for influenza. This year, we have added an additional stock of vaccine for 2- to 12-year-olds to increase protection for the overall population, including children.
We touched on this aspect slightly, but I want to spend more time on the treatment of chronic disease and how it interacts with the winter plan as set out. I refer to chronic disease as encompassing things such as diabetes, asthma, chronic obstructive pulmonary disease and cardiovascular conditions. A chronic disease management programme that was in the process of being rolled out before the Covid-19 crisis included things like patient education, preventative care, medication reviews and individual care plans. There was much emphasis on lifestyle and supporting patients. Chronic illness is a large spectrum. Some people have a management plan that is working for them, but there are also more complex cases. A modified and structured chronic disease management programme has been issued by the HSE. I would like to unpack that in respect of the winter plan, however. It is mentioned a little bit, and the key sentence I get from the document is: "Implement a structured programme for chronic disease management and prevention, with an anticipated 75% uptake". Can we unpack that sentence and get more information on how that is working? Is that happening through the community hubs? Have we any idea of how effective this programme is? It encompasses hundreds of thousands of people in Ireland.
Ms Anne O'Connor:
I will comment on how that programme interacts with the winter plan and Dr. Henry can contribute on the chronic disease management aspect. We are looking at implementing the chronic disease management plan in respect of the clinical model developed. In the winter plan, we have identified 18 chronic disease integrated management teams, which are multidisciplinary in nature. They have input from consultants, nurses and allied health professionals. The idea is that they will deliver on the plan in an integrated way absolutely in line with the model. I ask Dr. Henry to comment on the details of chronic disease management.
Dr. Colm Henry:
I thank the Deputy for an interesting question. If we look at chronic disease management as a spectrum without picking any one illness, we will see that it runs from prevention, in the first place, and promotion, to early intervention and what we call secondary prevention, which means that if somebody has an established disease such as diabetes, we treat blood pressure and make earlier interventions before things become really serious, to the end of the spectrum, which involves serious illness, hospitalisation and even intensive care and end-of-life care. Deputy Shortall will be aware of this information because it is a theme in Sláintecare. For too long, we have invested in the right side of the spectrum, namely, in the intensive side of care, in hospitalisation and in specialist care. This is unsustainable. When we look at the profile of chronic disease in Ireland and other western countries, we can see an epidemic of chronic disease, where upwards of 70% or 80% of GP consultations are with people with chronic disease, as well as up to 40% of attendances at accident and emergency departments.
What we are trying to do with this programme is to build on what has been essentially pilot work in setting up networks of care across the roughly 96 community care networks in Ireland. We want to expand them rapidly, beyond what has been a relatively small number to date, so they can provide loops, circuits and episodes of care that do not go through acute hospitals. We want to intervene and address problems earlier, such as blood pressure, and foot problems in people with diabetes, for example, instead of having a line of defence which is very deep and at hospital level. This is, therefore, a capacity-building exercise. It is a slow game, but it is essential to invest in this aspect now so that we do not have to depend continually on hospitals to deal with that right side of the spectrum of chronic disease management, which is the intensive and resource-heavy side.
I completely agree around the move towards community care and that first side of the spectrum. I am trying to understand the process of that and where the community hubs or where community care sits in terms of the complexity of chronic disease. How do we identify complex places? How would that process work in the context of a health system that is constrained with Covid at the moment? It seems to me that much of this has moved online which say, for someone who needs help with his or her diet, might be appropriate but for more complex cases it seems that face-to-face would be quite important.
I was very glad to hear Dr. Henry's colleague refer to multidisciplinary teams. Taking diabetes as an example, the involvement of allied care professionals is so important. Where are we with staffing issues around dieticians, for example?
Dr. Colm Henry:
The structure of this is quite important. These networked teams are multidisciplinary teams which are linked to local hospitals but their focus is on providing a care earlier in the spectrum to people with chronic disease, diabetes being a good example, where we provide care in a community setting through multidisciplinary teams that might otherwise have to be given as outpatients which, by definition, is less community based and less accessible to patients in some ways. The spectrum of interventions range from screening to opportunistic intervention, to medication review to blood pressure measurement, to other actions taken at that left side of the spectrum which allow people with chronic disease to stay healthier, live healthier and have more accurately prescribed and suitable medications, and hopefully never to rely on hospitalisation if they become more ill. It is about resilience, building teams within the community that are linked to hospitals that are providing a range of care for that left side of the spectrum, for chronic disease, particularly diabetes, heart disease and lung disease.
Dr. Colm Henry:
A whole range of services converted to virtual, non-face-to-face, for a variety of reasons during Covid. Back in March and April, when we witnessed the scenes in Bergamo and elsewhere, we had to reconfigure an entire health system in preparation for that. As we redeployed people back to these services we are improving our resilience and our capability to deal with people, both in virtual consultations, which are now quite appropriate in some circumstances, but also in face-to-face consultation.
Ms Anne O'Connor:
We have commenced a recruitment process. We already have panels in place for the allied health professionals. That process has started. They are not scheduled to come into effect until the first quarter of 2021, so they will not begin before Christmas. Those teams are due to commence after January.
I wish to focus on issues around testing and contract tracing staff and the recruiting of staff for the winter plan. Some weeks ago, we were told that there are 274 staff in contract tracing and there was a desire to ramp that up to 800. That is quite ambitious. What is the average length of contract for the 800 new hires expected by the end of the year? How many of the planned 800 in testing and tracing will be hired through a private recruitment company?
How much has the HSE paid a private recruitment company to recruit staff for the winter plan? CPL has been recruiting on behalf of the HSE in recent months. Was this contract put out to tender prior to CPL's appointment?
Mr. Paul Reid:
To update on recruitment numbers, there are two aspects, namely, swabbers and contract tracers. There will be close to 350 swabbers this week, and we are at about 470 fully resourced contract tracers. There are many more than that from other parts of the workforce. The recruitment process is through a recruitment company. People primarily have contracts for 12 months. They are on similar terms and conditions to those in related grades in the health service. We are resourcing on the basis of seeing how we manage through the pandemic, as different volumes emerge. If a vaccine emerges things can change. I cannot give the commercial terms with the recruitment company but it would have been on a draw down basis for the procurement of contracts. I am happy to give the Deputy a note on that setting out more detail.
Mr. Paul Reid:
The HSE's human resources would have always had draw down contracts for procurement that they would continuously draw down. Those are procured and renewed at various stages. I can give a full note confirming this but my understanding is that it was drawing down on contracts that are already in place. I will send that through the chair.
About two weeks ago, the Irish Nurses and Midwives Organisation said that 50 nurses a week were out of work due to Covid-19. That is quite stark. Healthcare staff have been at the front line of Covid. How many health workers are out of work on a long-term basis due to Covid-19 in the health service? The narrative has been that healthcare workers in Ireland have been greatly affected, and its infection rates among healthcare workers is the highest in the developed world by percentage.
Mr. Paul Reid:
I will ask my colleagues to respond on specific numbers but I will make some general points. First, to restate what the Deputy said, our healthcare workers have played a phenomenal role in Ireland's response, and they continue to do so, and we are forever grateful to them. We want to give them the fullest protections we can. On the measurement of comparative infection rates of the Irish workforce, we want to move beyond that and see what factors were driving that in the early stages. Thankfully, the percentage of healthcare workers infected has gone down significantly. We want to move beyond that. As I said before, we count the whole healthcare workforce whereas many European countries count only doctors and nurses.
Ms Anne O'Connor:
At any one time, we have more than over 1,000 staff out on Covid-related leave. It is about 1,100 to 1,200. We also have a significant number of staff who are out cocooning because of their own chronic conditions, etc. We work on the basis of approximately 2,000 people being impacted by Covid and unavailable for work. Dr. Henry might respond on percentages.
Dr. Colm Henry:
It was mentioned that earlier in the phase, we saw a much higher proportion of healthcare workers affected but in recent times that has dropped. From 2 August to the end of October, out of a total of almost 36,000 Covid cases, the total number among healthcare workers was 2,000 and 39 were hospitalised. Thankfully, we have seen a significant drop off in the proportion of healthcare workers affected.
On long-term sickness, there is a growing awareness of the longer-term effects from Covid-19.
Such effects are easy to define in some cases, particularly those of people who have been quite seriously ill and have organ-specific illnesses. In many cases, however, they are less specific. This is often the case when people are recovering from a variety of viral syndromes. They have what we call "multisystem illnesses", which means they have various symptoms which are not linked to a particular body function or organ function; involve fatigue and malaise; and, in a small number of cases, cause people to be off work for a protracted period of time. We are learning from this as we go on, like other countries. Long Covid syndrome does not yet have a universal single set of definitions to which we can refer.
I thank Dr. Henry for the work that has been done over the last number of months. Hopefully, we will not face the same challenges in three or four months' time that we do now and we will have the vaccine in place.
We spoke about an extra 1,148 acute beds being put in place. I am concerned about the planning for the availability of diagnostic services. We already have a problem in some of the hospitals where there is a delay or it takes longer than normal to get results back from diagnostic services within the hospital system.
It is great to see an additional number of beds available but attention must be paid to the efficient use of them. What plan is in place to make sure additional diagnostic services will also be made available within the hospitals? For instance, will those diagnostic services be available on Saturdays and Sundays so there is extra capacity to deal with the additional beds in the hospital?
The second issue is totally different and concerns the availability of people for home care at weekends. I receive quite a number of complaints from people who are provided with home care during the week but have difficulty in the availability of home care at weekends in certain areas of the country. What mechanisms have been put in place to make sure all those who require home care can access it during the weekends? There will be huge challenges, in particular, coming up to the Christmas period. What planning has been done to make sure adequate home care is provided throughout the Christmas period?
The other issue that comes up is the number of home care workers who are still leaving nursing homes and leaving the private sector. That creates its own vacuum. Many more home care providers need to be made available. What is the HSE doing to encourage people to get involved in home care and be available to provide this service?
I will conclude by asking about people who are waiting for cataract surgery in County Cork. As I understand it, once a person gets on the list for the cataract procedure there is no delay. The problem is getting on the list for the procedure and the delay in appointments to see patients. In view of the fact that buses are still going to Northern Ireland for cataract procedures under the treatment abroad fund, even during the lockdown, should priority be given to making appointments for people to be assessed, put on the list and then dealt with? For instance, a total of 133 people are on the waiting list at South Infirmary-Victoria University Hospital, 90 of whom have been waiting three months. The rest of them have been waiting slightly longer than three months. The reason they are not on the waiting list is they have not been seen to be assessed. Can something be done on that issue?
Ms Anne O'Connor:
I will take the question on home support and hand over to Mr. Woods on diagnostics within acute settings.
Deputy Colm Burke is absolutely right that we have a significant dependency on providers in the home support area. In some parts of the country, we employ home support workers directly, and in other parts, we rely on funded agencies. Within our winter plan we have a significant dependency on home support. In terms of the Homes First model, which is referenced within the winter plan, it is critical for us that we maintain and significantly increase the level of home support. We are aware that over the last six months the home support levels dropped off. From April to June, we reduced our home support by approximately 22% so we saw a drop-off of approximately 11,500 clients. Some of that was at the client's own request in terms of having people coming into his or her home and some were reduced in terms of low-priority provision from our perspective. That number has reduced to 5,000 people so we are now bringing the level of home support back up. In some parts of the country, we see the challenge some agencies have in terms of securing sufficient workers. I am aware that a number of those agencies have proactive recruitment campaigns which include full training for the role and we are engaging with them.
In terms of that dependency in our winter plan, our local community health organisations, CHOs, have been working with the home support providers to prepare for this significant increase. We are aware that it is a challenge. We are also aware that in the climate we are in, people are not always willing to go into those roles for all sorts of reasons. The agencies are being challenged in terms of, for example, their insurance policies as they relate to communicable diseases. There are other challenges for these agencies at the minute which we are trying to work through with them. They are real challenges. We are looking at how we recruit home support workers while, critically, enabling the other agencies on which we will rely. There should be no difference in terms of weekend cover. If a need is identified for home support, that should be available at all the times it is required. From our perspective, that will certainly form part of our contractual arrangements with the providers. If there is a specific issue the Deputy wishes to bring to my attention, he should feel free to send me on something.
I have evidence there is no home support in some areas at weekends. There might be home support for lunchtime on Saturday and Sunday but nothing in the morning, evening or night. I am talking about people who do not have family support or the back-up a family might provide. It is a huge challenge.
Ms Anne O'Connor:
Absolutely. The Deputy might send me more information about that. Certainly, from our perspective, we know there are challenges in some areas. It is generally a geographical challenge for us. Up until last year, for example, we had significant challenges in the south east in terms of securing home support workers. We worked with the agencies there and that situation improved. It changes in different areas, however. If people are in need of support but are not receiving it, by all means the Deputy should feel free to send me on something outlining where that is.
Mr. Liam Woods:
I thank the Deputy for the question. I have a couple of comments on diagnostics. There is investment in diagnostics and access to diagnostics for GPs in the winter plan and service plan. That will be somewhat supported by hospitals externally.
In terms of the resourcing of laboratories directly, we are appointing additional consultant staff to laboratories, including in County Cork, to support the increased workload and, of course, the additional bed capacity will bring with it a requirement for additional scientist and consultant staffing. That is part of the workload planning for 2021.
In equipment terms we have invested in and will continue to invest in laboratories to support the response to Covid-19 and other care. The Deputy referenced 24-7 access. We have already been using National Treatment Purchase Fund, NTPF, resources and, indeed, private hospitals to provide diagnostics. We have also done work to support 24-7 access to diagnostics. That was successful last winter and it is something we will seek to continue.
Mr. Liam Woods:
I will make the observation that it relates to ophthalmology. I note the Deputy's point. The outpatient list in ophthalmology has grown substantially during the course of this year and there has been much progress on the inpatient side for ophthalmology and cataract procedures, both nationally and in County Cork. We will have a dedicated plan to effectively address the outpatient list. We are resourced for that and will seek to enable that during the closing months of this year and into early next year. I can send the Deputy more detail on that.
Does Mr. Woods accept that patients were given their initial appointment to be assessed? Once they are on the list, we can deal with the list. The problem is they are not even getting on the list for the treatment.
I thank all the witnesses and express my gratitude to all healthcare workers and everyone who has been getting us through this crisis. It has not been an easy job. I will focus on two areas. I know a few questions have been asked about the flu vaccine but I will swing back to it if that is all right. There was a lot of coverage today and I am sure everyone's notifications were going off with news notifications. Obviously, the HSE has refuted the claims that supplies have gone missing but there is coverage around holding back doses until it is assessed where they are needed. I am a bit curious about the process by which this will be decided. It is my understanding that the HSE takes its lead on this issue based on information supplied by GPs. This is inputted from GP surgeries and that is how the HSE will be informed in this regard. This is put in in hard copy. I have heard from a number of GPs who have raised concerns around this process. It requires many hours of administration because there is no swift online system to do this. As has been noted, many GPs do not do the paperwork patient by patient as it is very time consuming. I know one GP who has had to hire extra staff simply to help with the administration associated with rolling out the flu vaccine this year, which I think we can agree is probably a slightly crazy use of resources when we are so tied for resources. Can the witnesses explain why in 2020 we still require GPs to do this in this way and why a swift online system of registering those who have received the flu vaccine is not yet in place? When I reflect on the GP who had to take on an extra person, I see that this form was handled four times - administration to the GP, back to the patient and back to administration to submit for payment. This seems wrong both from infection control and financial perspectives. If the information from GPs is going to be used to determine where the next round of flu vaccines will be sent, and right now, perhaps GPs have yet to even send their information to the HSE and might be doing it in bulk, using this administration system to decide where to send the last round of doses might not be a good statistics exercise.
Could the witnesses comment on concerns that private patients are getting the flu vaccine? Regardless of whether someone is a private or public patient, if one is vulnerable, one is vulnerable. What is the HSE doing to mitigate against this? Is there a contingency plan for buy more quantities of the flu vaccine if areas have been under-supplied due to this onerous system of registering the flu vaccine? I will ask my second question after that.
Dr. Colm Henry:
It has always been the case that GPs had apply for reimbursement after the vaccine had been administered. Clearly any system that would improve the timeliness and efficiency of this is something we want to promote. We are constantly talking to the GP community through the Irish College of General Practitioners, ICGP, about how we can support GPs in this important work.
As regards holding back, this has been the practice over the past few years. There has been a greater focus on it this year because of the great uptake of the vaccine, which is very welcome. I thank the Senator for giving me the opportunity to reiterate that no vaccine has disappeared. We are getting mixed reports from some GPs saying that they have enough vaccine for the at-risk groups - for which this vaccine is intended and prioritised - and other GPs, as the Senator correctly noted, saying that they are short. We want to find out where we can direct the remaining 50,000 to those who need it for priority groups.
The Senator is absolutely right; no distinction is made between public, private or otherwise. To reiterate the answer I gave to Deputy Shortall, the only criterion relates to at-risk groups in line with what the WHO advises and our assessment as to where this valuable resource should be directed. This makes no distinction between public and private patients.
I raised the issue of student nurses last week. We have been banging this drum for quite some time and the issue has been raised here. There is a lot of commentary along the lines that this issue must go to the Department of Health or that it must go back and forth. The Irish Nurses and Midwives Organisation, INMO, has said that it has been in discussion with the Department of Health but there does not appear to be any movement on this issue. I am being contacted by student nurses who are getting more and more distressed about the situation. As was rightly pointed out, it is not just about student nurses but all healthcare workers in training. Could someone offer some commentary? Do the witnesses believe student nurses and other healthcare workers in training should be paid for their time, for example, that on a sliding scale, as is done for other professions in training? We see that with gardaí and apprenticeships. Do the witnesses think they should be paid because nobody is giving an answer? I think they should be paid and the nurses and students in training think they should be paid. If these student trainees were taken out of the system, would the system be able to function? If student nurses were taken off the wards today, would the wards be able to function? If that is the case, is it not right that they should be paid? If they are paid a vital role in our healthcare system, be it in radiology or other areas, should they not be remunerated for doing that or is it seen as reasonable to expect them to do it without any pay?
Ms Anne O'Connor:
It is a very complicated issue. We have so many students in training. I am an occupational therapist myself and I trained in clinical placements. It is what all clinicians have done. As the Senator rightly said, there are many healthcare workers in training across our system. That is a very significant investment by the State in terms of paying students for their education. It is clinical training. Students have certain rules and responsibilities that are restricted in line with their experience and level of training. There are many medical students who work, particularly in the last year or two of their training, and provide critical service. In terms of whether they should be paid, I do not know. There are many students, and I presume there are many outside the healthcare sector, who would feel that they play a vital role and indeed they do but the decision in terms of payment is one that, unfortunately, is larger than the HSE because of the implications and ramifications across sectors. This is a discussion that is already taking place with the Department of Health and needs to take place at a wider cross-sectoral level.
I extend my thanks to all of the witnesses, everyone in the HSE and all the workers across the HSE, who are doing a fantastic job. We really appreciate the hard work and sacrifice across the board. A few members of this committee mentioned the flu vaccine. I refer specifically to the nasal flu vaccine available for two to 12-year-olds. I believe there is a surplus of this nasal vaccine and it has not been taken up in the manner the HSE hoped it would. Why was the decision made not to distribute this vaccine within the school system, as happens with other vaccines? Can this decision be reversed and the vaccine distributed in schools? Parents sometimes have difficulty taking time off work and many of the vaccination slots at the weekend have been taken up. Availability during the week is quite wide but, of course, children are in school and parents are at work. Can we distribute the nasal vaccine within schools over the next couple of weeks because I believe they have a relatively short shelf life? If the HSE has purchased them, can we not find a way for them to reach the people for whom they are intended?
Dr. Colm Henry:
Based on the returns to date, over 100,000 doses of the nasal vaccine have been given to children. It is important to point out that the campaigns were separate in time. That was important because it is a different vaccine with a different administration and a different age group so it is too early to say anything about the relative success of this campaign. It is a new nasal vaccine for children, which presents particular challenges in terms of communication and uptake. The uptake has been quite good to date but we are still advertising heavily, promoting it and encouraging parents to bring their children to pharmacists or GPs for the purposes of getting this vaccine.
As regards the Senator's comments about schools, a decision was made to do this through GPs and pharmacists. There is already a busy vaccination programme in schools that was paused during the lockdown. Our feeling is that we need to keep a distinction between that important rolling vaccination campaign and this new campaign, which is linked to the flu season and designed for a different purpose. It is too early to say. There has been a significant uptake but there is quite a bit to go.
I thank Mr. Henry. My next question relates to language access. I commend the HSE on using Irish Sign Language interpreters at all of the HSE briefings. That has been a very significant step in terms of access to very important information at a very serious time in our history and in the health context.
Unfortunately, the facilitation of Irish-language speakers in this country has not been great from the point of view of the HSE and the Department of Health. Irish is the first language of this country. To date, the correct information has not been available on the website in the Irish language. There has been a clear lack of investment in the distribution of Irish-language health information on the Government and HSE websites, which is really shocking.
Are there any plans to hire a translator within the HSE specifically targeted at health information being translated into Irish and distributed in tandem with the English-language information? The level 5 information was not available in the Irish language.
Mr. Paul Reid:
I thank the Senator. I am taking on board her feedback as she has given it to us.
We want to continue to promote Irish Sign Language. It has been one of the very positive outcomes of Covid that a lot of Government and agency communications have used Irish Sign Language. I thank the Senator for her comment on that.
In our senior briefings, Dr. Henry is a Gaeilgeoir and takes a lot of our communications briefings with Raidió na Gaeltachta and other Irish-language channels in terms of communications. I am happy to take on board any feedback on areas we can improve on.
I appreciate that. I have heard Dr. Henry. Tá Gaeilge iontach aige. There has been significant feedback from the Irish-language community that there is a significant lacuna in terms of the information that needs to be provided in real time. Could Mr. Reid give serious consideration to hiring an interpreter or translator to provide information in real time and get it up on the website at the same time as the English-language information?
I will be in touch with Mr. Reid about this. It is an area of significant concern. I have been in touch with Irish-language speakers and their representative bodies.
I have a final question on maternity services. It is something I have raised directly with Mr. Reid in the past. Are there any plans to expand access for partners to scans, important visits, the earlier stages of labour and post birth?
Mr. Paul Reid:
The Senator, along with many other Deputies and Senators, has raised this issue. I appreciate it is very emotive. Our clinical lead for the women and infants programme engaged directly with maternity hospitals to consider a set of criteria that could support partner visits. One of the key issues, in particular given the high rates of the virus, is that we have to protect healthcare workers and settings. One or two maternity hospitals have made some further efforts to facilitate visits. It is an issue we have to keep under constant watch. We have asked maternity hospitals to take on board some of the wider aspects of care and for partners to have as much access as possible. Hospitals have to examine the risk criteria to make sure such access is safe.
I appreciate that. The health and well-being of workers in maternity services are a priority, but the women of Ireland would appreciate if there was a dedicated task force to deal with maternity services and a paper published. There must be a way forward because women feel they have been forgotten. It would be a strong signal if something concrete could be put forward in the near future.
I thank the witnesses for all of their hard work over the past few months. I can only imagine how stressful it was. I also thank all of our front-line workers.
I want to highlight mental health. Yesterday new research suggested that people who have survived Covid-19 are at greater risk of psychiatric disorders than those who have had other illnesses. A large study found that 20% of those infected with coronavirus are diagnosed with a psychiatric disorder within 90 days.
I was disappointed to note that there is no clear provision in the HSE winter plan for increased mental health supports, in particular community mental health supports including CAMHS. These services are under increased pressure because of Covid and this will continue over the winter and for many months to come. We are in for an onslaught. Community mental health services play a vital role in keeping people out of hospital and supporting and maintaining their recovery in the community.
I have a number of questions. I may not get through all of them today because I only have six minutes. I will ask some questions now and others later. If the witnesses could respond to me via email, I would really appreciate that because many different services throughout Ireland have a significant interest in this area.
Why was mental health not prioritised in the winter plan? Do the witnesses agree that this reflects the lack of parity of esteem between mental health and physical health in the winter plan? What measures are being put in place to protect the mental health and well-being of front-line workers and community care workers who are dealing with the enormity of the pandemic pressure? What measures is the HSE taking to ensure the gravely exacerbated suffering experienced by the homeless community is addressed? What individual supports are being given to these people at this time? If I have time, I will ask further questions.
Mr. Paul Reid:
I thank the Senator. I will try to respect her time and be brief, and pass her questions to my colleagues. Mental health is something which we are highly cognisant of and concerned about because our community and hospital systems are telling us about people who are presenting who have experienced anxiety, stress and mental health issues during Covid. We are always concerned about mental health.
On the winter plan, as part of the national service plan for 2021 the investment which we are working through at the moment provides for investment in mental health to be prioritised. It is obviously geared towards A Vision for Change and the new strategy for mental health. For this year and next year there are incremental investment targets for mental health which we fully support.
On the workforce, we have an extensive set of supports in place for our workforce around mental health, employee assistance programmes and other psychosocial supports. I have openly communicated with staff via video and have encouraged people to come forward when they feel stressed or anxious and avail of the supports there for them. It is something of which we are highly cognisant.
There has been significant investment throughout Covid in homelessness services. The winter plan involves work across agencies and Government Departments. Some of the successes during Covid were the protection of the homeless, finding accommodation for them and putting in place a wide range of supports around that. I will ask my colleague to address the other questions.
Ms Anne O'Connor:
In terms of mental health, we have a very significant focus on it and the priority for us was to secure considerable investment in order to be able to implement the new policy, Sharing the Vision. It is a refresh of A Vision for Change. We have now been allocated significant funding for the full year. It is more important for us to have secured permanent funding to deliver and develop teams.
From our perspective, the priority is, of course, to be able to provide early access to people in terms of mental health. We have worked throughout Covid to develop information and supports to people at the lowest level of complexity. We often focus on our very specialist mental health services for people who attend our specialist teams. However, we know there has been a gap at primary care level in terms of supporting the mental health needs of the population. We have developed a psychosocial framework that we hope to launch over the coming week or two in terms of supporting the general population, supporting people who attend services and, critically, supporting our staff. This looks at having an integrated response at a lower level, so in terms of primary care it is working with primary care psychology and with other disciplines and then feeding into the specialist services and having a clear pathway, as required. For us, this is going to be done on a population basis but it is a key priority for us.
We are seeing trends in terms of people whose conditions have deteriorated more or who are experiencing higher levels of anxiety than heretofore, so we are acutely aware of the need to progress that public-facing response. I think we have been doing it in a range of areas, and yourmentalhealth.iehas been updated on an ongoing basis throughout Covid. Critically, the support and the access to services is what we are focused on as we head through winter and into 2021.
In terms of the homeless, we are working with the providers. We have specific mental health services for homeless people and we are working with providers in terms of enhancing those services to those populations. We have been doing it through Covid and we will continue to do it.
That sounds very positive. I am still a bit disappointed it was not mentioned at all in the winter plan. I do feel it is important to reflect there is a huge connection between mental health and physical health, which I am sure the HSE is well aware of. This is particularly evident given the new research that came out yesterday, which suggested 20% of those infected with coronavirus were diagnosed with a psychiatric disorder within 90 days. It is a huge issue. I was disappointed to see there was nothing on it in the HSE plan.
I am conscious of the time. I might back to the witnesses with the other questions because they are very specific around CAMHS and mental health services that help to support and prevent people from ending up in hospital in the winter period. I will send those questions to the witnesses, if that is okay, but I would like to have answers to them.
Like others, I congratulate our health services and our witnesses today for the work they are doing and have struggled to do in the face of very severe challenges over the past six months or so. I have a number of questions and I will go through them quickly. Those that can be answered can be answered and the others that might have to be held over can be answered by way of written reply.
First, of the 2,000 staff currently out on sick leave due to Covid or Covid-related issues, what is the breakdown of those between medical staff, nursing staff and administrative staff? What is the number of GP appointments outstanding throughout the country? How many GP vacancies where there at the beginning of the year and how many are now filled or being filled? I know there are some in Kildare so I would appreciate a response on that.
The next question is an important one, namely, how do we handle or prevent the next surge? That is the critical question we all want to know the answer to. It is as simple as this. If another surge comes, the economic impact is going to be much more severe than anything experienced heretofore. It is repeating the same issue. The question I am trying to get at is this. Can we prepare now for that possible eventuality and prevent it by way of taking particular measures or putting a particular emphasis on certain of the restrictions without having to go into a lockdown when we come to the end of the current level 5 restrictions?
Our local hospital in Naas has ceased non-essential elective services as of today arising from staff shortages and staff being out on Covid-related leave. The question is how many staff have been affected by Covid and how many are affected currently, and how many are medical staff, nursing staff or administrative staff.
My next question is a continuation of an issue we often discuss at these committee meetings. Regarding the home care packages that are being prepared and that we are going to be relying upon very much throughout the winter, to what degree is it intended to regulate standards for those providing them in the private sector and the public sector? To have an equal standard across the board is important, and that applies without prejudice to anybody or anything.
My last question relates to the capital programme for Naas General Hospital. How is the proposed extension coming along? Is it being moved forward and can we rely on it arriving within a reasonable time to ensure we make progress? It is good for the morale of the staff that they know where we are going, it is good for patient accommodation, and it is good for the general service.
Mr. Paul Reid:
On the breakdown of staff, it is fluid. It is a smaller percentage than we were dealing with in the first phase, as Ms O'Connor said. We want to keep it that way and give the protections that are needed, but we cannot provide a breakdown because it changes, as I mentioned.
I will ask Dr. Henry to comment on the number of GPs. We saw an improvement last year in the pipeline of GPs coming through from training colleges, and that is one thing we want to keep going.
With regard to the prevention of the next surge, I will make some brief comments. Obviously, there has been learning both from what happened in the first phase and what is happening in this phase. One of the strongest messages is that the public health measures are the strongest first line of defence. Quite often, we talk about building hospital capacity and ICU capacity, which is important, and we talk about building our testing and tracing capacity, and they are important. However, our first line of defence is our public health measures and what we, as individuals and a society, take on board. There are learnings from the first phase, where we exited and the economy opened up in May, June and July, and then we saw a significant increase in August, September and particularly in October. The one thing that holds true, as we look forward to the next phase, is the public health measures around social distancing, infection prevention and control, how we mix with our families and how many households we mix between. Those are the part of our measures that will remain very consistent and strong, regardless of what level the economy is at or what level the Government decides we are in. That is the biggest line of defence and the biggest armoury we have against further surges in the community. Of course, there are learnings in terms of how we protect the vulnerable and nursing homes, and we have seen some of those learnings in this phase.
Strictly on Naas hospital, we are dealing with a very significant issue there and, indeed, in another couple of hospitals around the country. In terms of outbreaks, I do not have the numbers per sebut it is a very live issue, a very real issue, which we are dealing with, literally as we are sitting here and before we came here, and we will be dealing with it afterwards because they are under significant pressure in Naas.
I will ask Ms O’Connor to comment on the home packages and perhaps Mr. Woods will comment on the capital programme for Naas overall.
Ms Anne O'Connor:
We do not really regulate in terms of standards. We will absolutely be setting standards as part of the contract in terms of what we expect from providers, but clearly the function of regulation would sit outside of ourselves. I am certainly aware that, as we move towards a statutory home support scheme next year, that would be part of the discussion. Clearly, where we have a statutory scheme, we need to ensure the standards are implemented uniformly, but that is currently in development with the Department of Health.
Mr. Reid, Ms O'Connor and company have done a great job. It is important that we keep acknowledging the job they have done over the past number of months.
My first question is a straightforward one. Hopefully, it will be a straightforward answer. Has anybody in this country been reinfected with Covid-19 since this pandemic began?
Dr. Colm Henry:
There are no reports in this country. There have been individual reports - one, I think, in The Lancet- on a patient in Nepal. It was 28-year-old man who was reinfected. A typing of the virus demonstrated it was a true reinfection, with the second infection being more severe. That raised some concerns as to the sustainability of immunity once somebody has been infected, but, to my knowledge, we have not had a report of reinfection. That is not to say it has not happened but it has not been reported.
Dr. Colm Henry:
Looking at the proxy for this which is how long immunity lasts, we know that antibodies, particularly that spike protein, the bit that clasps the virus onto surfaces, can sustain for six months or so. The neutralising antibody, which is the really effective antibody against the virus, seems to wane so much after a few months. This may inform how we vaccinate people when, and if, this population-effective vaccine comes out.
It is too early to say. There is certainly antibody production, which seems to be quite sensitive. As for how long that lasts, what immunity that gives an individual and what protection it gives in respect of somebody not getting reinfected, it is too early to say, except, as I said to the Senator, that there have been reports in the medical literature on individual case histories that state a small number.
On the vaccine, obviously, the HSE has an arrangement with our colleagues in Europe. Have we had to put money upfront? Have we had to pay any money in advance? Have we had to make a deposit in order to buy into that system?
Dr. Colm Henry:
That would be a departmental Government issue. We in the HSE are working closely - I am sure the CEO can update the Senator - not only within the HSE but with other Departments in what will be a huge exercise for all Governments as vaccines come off those phase 3 trials. Ten of the vaccines are on phase 3 now, with a number of likely candidates that demonstrate safety, efficacy - the most recent being the interim report from Pfizer yesterday which was well publicised - and are proceeding rapidly to production. However, of course, there is licensing first, and then there is the logistics of a new vaccination programme among populations to reach a herd immunity level of 60% to 80%, according to what the WHO says, which is a considerable target.
I listened carefully to other contributions on the screening programme. I am concerned, because of my own life experience, about the diabetic retina screening programme. Can the HSE give me a quick update on where we are with that because that has prevented blindness and has been quite successful?
Dr. Colm Henry:
That is a very important screening programme given its impact on the target population. As the Senator will be aware, the screening programmes were suspended during that lockdown when all non-essential services were paused. Since the recommencement of the diabetic retina screening programme 25,123 participants have had routine digital screening and 2,624 have had digital surveillance screening nationally. We expect 37,000 clients to be screened by the end of March 2021.
How all the screening programmes are impacted by Covid and infection prevention and control requirements that Covid demands of healthcare settings depends on the nature of the test and where it is carried out. Fortunately, that is one of the programmes we were able to re-establish fairly quickly on a good footing. Hopefully, we will maintain what is a really important screening service for a very important target population.
I appreciate Dr. Henry's commitment to that. By the way, I also acknowledge that all the HSE's documentation has been provided in braille and large print, which is useful for the visually impaired community in this country.
My final question is for Mr. Reid. At present, in Dublin, there is a trial in the hospital group of a so-called "eye care liaison officer" where somebody who has been diagnosed with sight loss has a step-down person to talk to in terms of the support structures. I had a motion in the previous Seanad looking for that to be rolled out nationally. The then Minister, Deputy Harris, came in and committed to it. I wonder is Mr. Reid aware of that programme and how successful it has been and is the HSE committed to rolling that out to the other hospital groups around the country.
Mr. Paul Reid:
Briefly, on the Senator's first question which I did not come back on, there are negotiations, to reassure the Senator in terms of ourselves, through the Department and Government, on an advance purchase arrangement for vaccines. Part of that will be, as Dr. Henry stated, on the distribution for our population, and it will be on a pro ratabasis of the Irish population versus the EU countries. That is part of the advance purchase process. There is a whole-of-government task force being established - the first meeting was this morning - to focus on vaccine procurement, distribution and immunisation programme. It is early stages on that one.
I have not been made aware of the eye-care programme. It sounds like a very valuable programme. I might ask Mr. Woods to make a quick comment.
Mr. Liam Woods:
I am aware of it. It is not rolled out across the country, which is the point the Senator is pursuing. From our point of view, in terms of looking at 2021, we have now got significant resources to pursue areas of care such as this. I would certainly take it on board in our considerations for the service plan for 2021.
I have a number of questions but I will not have time to get into them today. Part of what we try to do here is reassure the public. We have heard this morning about the flu vaccine. Mr. Reid was talking in terms of minimising the impact of Covid on the cancer services and screening. In the final minute or two, he might expand on how that his happening. The big message people want to hear is reassurance that we are learning from the mistakes that have been made in the past and we will do things differently. I refer particularly to mistakes that were made early on in this Covid pandemic, to the difficulty to date of a big organisation showing flexibility and changing in midstream and to some of the things that are not working. People want to hear that the HSE is capable of doing that and that we are learning, as I say, from mistakes in the past. I, again, thank the witnesses for all their contributions here this morning. Mr. Reid might sum up.
Mr. Paul Reid:
If I can, I will quickly respond on the cancer screening services. I was making the extra focus, not the distinction, that we have also in terms of rapid access clinics. Positively, we have seen our rapid access clinics restored to a much stronger level and part of our winter investment is to support them again. There is €2.3 million for our rapid access clinics.
Separate to that are four major screening programmes. The Senator was pitching on one of them there, namely the diabetic retina screening. The others, BreastCheck, BowelCheck and CervicalCheck, have all been restored. Obviously, some are more challenged than others. For instance, BreastCheck, because we must put in place many infection prevention and control measures, is not as efficient as it would have been, but we are providing extra resources in order that we get back to the reasonable levels we desire and can sustain. Obviously, our key message to the public in this regard is that if someone has symptoms, he or she should please come forward. I would separate that out from the screening programmes, which are, in essence, testing healthy populations to get early signals.
Specifically, on the learnings from the first phase, we in the HSE have been very open, and so we should be, to what learnings can we take from each phase. From me, here are a few brief reflections on the first phase. Obviously, in the nursing homes and long-term care for older people, we all have to stand back and ask what could have been done differently. There have been many learnings on that. One certainly is that as the virus presented itself and affected people who were asymptomatic, once it got in it caused a huge risk across the nursing home setting. That is one that we built some more protections on in this phase. Certainly, that had to be a huge learning for all of us.
There was a second learning from nursing homes.
Congregated settings are not ideal and not the solution for the future in terms of long-term care, particularly for vulnerable groups and older people. Ultimately, that is a long process of change but it is not the way we would organise for a pandemic because one is at higher risk.
The third point from my perspective is that as we look into the utilisation of private hospitals, this time we will do it in a very different way. That is not to say it was wrong. We all watched what was happening in Bergamo, to which some members referred. We just had to get capacity into the Irish hospital system. Thankfully, the way the Irish public responded we did not utilise that to the extent we thought we may need it. Looking back now, we will do it very differently in this phase, which will be very targeted in terms of procurement and some phases. We have had learnings and we are very open to more.
I thank Mr. Reid and his colleagues for their helpful engagement with us this morning. I wish them all well. This meeting is adjourned until 11.30 a.m. next Wednesday, 18 November, when the committee will get an update on the progress on building the new children's hospital and representatives from the National Paediatric Hospital Development Board and Children's Health Ireland will present to the committee.