Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): I advise Committee members that the Chief Nursing Officer (CNO) is here, via video link, to brief the Committee on the experience of the nursing profession during the pandemic and on other issues relating to the pandemic.

Before we start, I declare an interest, as I was previously a social worker in one of the trusts. I am on a career break. Moreover, my wife is a nurse.

Charlotte, I invite you to go ahead and brief our Committee, please. Thank you.

Ms Charlotte McArdle (Department of Health): Thanks, Chairman, and thanks for the opportunity to address the Health Committee on COVID-related issues today. We would all agree that the past few months, particularly since March, have been one of the most challenging periods ever for our health and social care (HSC) service. There is, however, no doubt that, during this unprecedented period, nurses, midwives and allied health professionals (AHPs) in Northern Ireland have stood up to the challenges in a very positive, professional, creative and solution-focused way. Every time that I have had the opportunity to be out in the service during the COVID period, I have been completely overwhelmed by the way in which nurses, midwives and allied health professionals have responded to COVID.

As Chief Nursing Officer, I place on record my absolute admiration for the sterling service, professionalism and resilience shown by all our staff in health and social care, including volunteers and carers, in the face of COVID. Specifically, nursing, midwifery and the allied health professions were very proactive and responsive. Despite the workforce challenges that they faced, the professions put all their efforts, skills and focus into making sure that trusts and care homes were prepared and had a workforce that was ready to provide, and capable of providing, an exemplary service to the people of Northern Ireland at a time of greatest need. Being true to the values of professional practice, I have to say that they also rose to the challenges with steadfast resolve, delivering skilled, very compassionate care that has undoubtedly saved many lives. That is not to take away from the fact that it was tragic for those who lost their lives. All lives lost are most regrettable.

Throughout that period, the nursing, midwifery and allied health professional workforce developed innovative solutions to their practice and services in order to respond effectively to the needs of the population and to ensure that their patients, clients and residents received the very best, safest and most effective care possible.

I acknowledge the wider nursing, midwifery and allied health professional support teams, nursing and maternity assistants, and support workers from the allied health professional workforce, all of whom supported the professional staff in delivering that very skilled and high-quality care. Their combined contribution to the collective fight against COVID-19 has been nothing short of outstanding.

To give some examples of that, allied health professionals were essential to the respiratory needs of patients, to the nutritional management of patients in critical care and in supporting families and children with special educational needs (SEN). They provided resilience and support to care homes and to patients in their own homes. They continued

services during such a difficult time, stretching to pre-hospital paramedic care and to delivering radiotherapy and radiography services.

As the largest professional group, nurses and midwives have the ability, the flexibility and the agility to transform how care is organised, delivered and provided. They played a pivotal role in the pandemic response. The nursing and midwifery contribution encompassed all programmes of care: adult's, children's, mental health and learning disability services. The wide impact of nursing was demonstrated across all settings. For example, critical care nurses were at the forefront of intensive care, while district nursing services' work demands increased significantly. They supported the most vulnerable in communities, many of whom were shielding. In many instances, members of the profession put the care and well-being of the people of Northern Ireland ahead of their own needs and families. Indeed, many left the comfort of their own work environment and home in order to provide that care and to make sure that people were cared for.

I pay a particular tribute to the nursing and midwifery students. They are to be commended for their part in dealing with the pandemic and for the way in which they responded to the call for action. I realise that students had many questions and that it was very challenging for them. They had anxieties and fears, but they came forward to take up work placements. All the allied health professional students finished their programmes early in order to be in practice and support the workforce, and they made an absolutely amazing contribution. The feedback received from the service has been extremely positive about their contribution at such a critical time. It is fair to say that, based on the response from our students, in particular the final-year students, the future of our professions — nursing, midwifery and allied health professions — is definitely in safe hands.

Nurses and allied health professionals were instrumental in the opening of Northern Ireland's first Nightingale hospital at the Belfast City Hospital site. The 230-bed facility was staffed by a team drawn from across Northern Ireland to manage the anticipated surge in COVID-19 patients requiring intensive care. When I visited the Nightingale hospital with the Minister, the key role that nursing in particular had played in getting that facility up and running, turning it around within a week, was very clear to me. Ward sisters who came from other parts of the hospital to work in and lead intensive care teams really stepped up to the challenge and had an important role to play.

It is testament to the work of the health and social care system and the combined response to COVID that the Nightingale hospital was temporarily stood down in May.

We should not ever underestimate the emotional burden that that has placed on staff in caring for very acutely ill patients and in dealing with patients who did not have available to them the very good, strong family support that they would have had in normal circumstances. That has caused an emotional burden for our staff, given the number of COVID deaths during phase 1 of the pandemic, which were so regrettable and so untimely.

Turning to partnership working with the independent sector, the impact of COVID-19 has been devastating for many residents and their families and relatives and, of course, for the staff working in the care home sector. Based on their age and underlying conditions, many residents were, of course, at high risk from the effects of COVID-19. In April, the Department of Health, in partnership with the independent sector, established, at the Minister's request, a rapid learning initiative to understand the impact of the interventions implemented within care homes to prevent the further transmission of COVID-19. That partnership approach has allowed for joint learning to enable collective action across the statutory and independent sector, implement best practice and plan for a future COVID surge. I believe that the partnership that has been built during this very rapid period will provide the foundations for collaboration in the development of a framework for enhanced clinical care in care homes across Northern Ireland, which, again, the Minister has asked me to take forward. During the pandemic period, more so than at any other [Inaudible.]

As such, Northern Ireland must now seek to optimise the potential that has been demonstrated within the profession.

Turning to rebuilding and moving forward, these groups — allied health professionals, nurses and midwives — have been critical to the aims of delivering together and a road map for transformation of health and social care in Northern Ireland working across many different clinical pathways. That will continue. The leadership and expertise provided by nursing, midwifery and allied health professionals are essential to the rebuilding plan and to restructuring HSC post-COVID-19. That will include: strengthening community services; preventing hospital attendance and admission and supporting discharge; transforming elective outpatient services and elective care in general; and establishing urgent care services. There will be a new norm. I do not think that our health and social care service will go back to the way that it was.

While it is crucial that we continue to adapt our service and respond to the challenges posed by COVID, it is vital that the workforce continues to move forward. As I am sure that you are aware, in March, Minister Swann launched the 'Nursing and Midwifery Task Group (NMTG) Report and Recommendations', which sets out a road map to achieve world-class nursing and midwifery services in Northern Ireland for the next 10 to 15 years. That report will address the challenges faced by the workforce and highlights how the contribution of nursing and midwifery could be maximised to improve health outcomes for our population. It outlines the ambitions and commitments of the Department and the support and implementation of key strategic priorities. I will mention three main areas: stabilisation of the nursing and midwifery workforce and to ensure safe and effective care; strengthening the role of nursing and midwifery and the role that they play in population and public health planning; and enhancing the role that nurses and midwives play within multidisciplinary teams as part of the wider transformation of our health service.

COVID-19 will continue to present new challenges for all of us: nursing, midwifery and AHPs. However, the invaluable response of this workforce to date has proven that those challenges are not insurmountable. It is testament to the investment shown by the Department of Health in the long-term vision for these professions. The Nursing and Midwifery Task Group recommendations are now more crucial than ever. I will be developing a nursing and midwifery strategy to take forward the implementation of those recommendations.

Chair and Committee members, it is with great pride that I carry out my role as lead for nursing, midwifery and allied health professionals. I believe that I speak for all of us when I say that we will be forever grateful for and appreciative of the contribution that was made during this exceptional time. Thank you.

The Chairperson (Mr Gildernew): Thank you for that, Chief Nursing Officer. My first question is in relation to the allied health professionals, and you touched on it. We understand that your role as Chief Nursing Officer must have a heavy, heavy workload. In the light of that, are you confident that you will be able to fully represent the allied health professional perspectives on the new management structure? How do you intend to engage, or how do you currently engage, with the Chief Allied Health Professions Officer to seek her views in an appropriate and timely way so that the views of allied health professionals are hardwired into the process? How do you manage that?

Ms McArdle: In response to that, I would say that the allied health professions have been part of my divisional structure in the Department for many years — actually, since I came into post — so this is not a new development. The Chief Allied Health Professions Officer is a senior member of my team. We have regular meetings. We meet on a Monday with the senior team. I meet them, and we have regular contact with her. I am in daily communications with the Chief Allied Health Professions Officer, and any advice or information that I need to take forward to the management board will be provided by Jenny in her role. Should the management board require any specific and detailed information that is allied health professional-specific and that requires a more detailed response, of course the Chief Allied Health Professions Officer will be invited to attend those meetings.

After I leave the Committee today, I will be chairing the allied health professionals workforce steering group, in which we bring forward plans for each of the individual professions on workforce development and on the needs of undergraduates across all those different

professions. I am very closely linked in with allied health professions, both through the Chief Allied Health Professions Officer and through my connections with [Inaudible.]

You will understand that, in the trust structure, each of the directors of nursing also has some responsibility for the allied health professions, so when we meet as a group, allied health professional issues are also addressed. I am very confident that, going forward, I can hold that brief, and Jenny provides me with the necessary expertise to do so.

The Chairperson (Mr Gildernew): Thank you. I want to move on to the rapid learning initiative that you touched on in your remarks. Can you give us any information on when you expect the task force to report?

Ms McArdle: It is rapid learning — the clue is in the title — so it was a very short piece of work. I expect to have the report at the end of July. It will then, with the Minister's approval, move forward with the implementation of some of the recommendations. The early feedback that I am getting is that there are a number of immediate operational things that could be implemented, and then there are more strategic issues that will need to be addressed through other forums. That has also been raised with the management board.

One of the key strands of work is the development of the acute care home model

care homes and the development of a new framework for the

health needs of people in care homes. It will link into that work. It is fair to say that I am very pleased with the response that I have had to the call for people to be involved in the rapid learning initiative. A call went out to all nursing homes — almost 500 — across Northern Ireland, and there has been a very good response.

In fact, I chaired two Zoom calls with the independent sector, and while we had 90 direct, individual links on the calls, for many of those, there were multiple people in the room, so I anticipate that, potentially, 150 people have had direct access for me to hear their views on the issues in care homes. Two surveys have been issued. The first was about patient experience and staff experience. That went to care homes, to residents and their families and to staff. The second was a management survey that looked at issues such as the management of infection control, the management of people through care homes and reducing footfall and the management of personal protective equipment (PPE). I expect that they will form the basis of many of the recommendations.

I should also say that the rapid learning initiative is being supported by the Institute for Healthcare Improvement (IHI), and it is saying that this is a unique approach. There is very little evidence from elsewhere of this approach being used to instigate rapid learning from the first phase of COVID in order to be prepared for any further wave that we might have in the future.

The Chairperson (Mr Gildernew): Thank you for that. I appreciate your setting out your engagement with the sector in that sense. Can you also give us information on how you are engaging with other stakeholders, in particular the trade unions? The initiative was set up in April, yet, in June, when the unions presented to the Committee, they still were not aware of the initiative. How is the workforce being represented on the task force? How are you engaging with stakeholders, including and in particular the unions?

Ms McArdle: There are four work streams under the rapid learning initiative, one of which is chaired by Brenda Rush, who is the senior professional nursing officer at the Royal College of Nursing (RCN); she is also the network lead for care homes. There is a direct link there to the RCN, and it has been fully engaged. UNISON was also invited to join but declined and said that it would rather provide evidence through front-line staff. The front-line staff have been involved in the initiatives directly, and the core subgroups are then supported by a steering group that is made up of the independent sector, care home managers and front-line staff, but also the Department of Health, the Public Health Agency (PHA), the trust, the Health and Social Care Board (HSCB), the Regulation and Quality Improvement Authority (RQIA), the Patient and Client Council and independent healthcare providers.

With the development of the plans for the new framework for healthcare leads in the care home sector, I plan to widen that to include the voluntary sector organisation representative voice of people in care homes. I also intend to discuss the plans with the Commissioner for Older People.

The Chairperson (Mr Gildernew): Before I go to the phones and then to members in the room, my final question is on strike pay reimbursement. I note from the Minister's letter that he refers to a paper that he brought before the Executive on 2 June, but the response to my Assembly question on that matter, on 26 June, stated that the Minister "will be bringing forward" a paper to the Executive. So I am wondering which it is, and, more importantly, when the staff who were on strike will see the money in their accounts.

Ms McArdle: The Minister has given his commitment to reimburse strike pay, and I understand that discussions are ongoing with the Executive about how that will be done. It is not an area that I provide advice to the Minister on, so there is not much else I can say about it, other than that it is in progress, and we understand that the Minister has made a commitment to ensure that it happens.

The Chairperson (Mr Gildernew): I understand that the money has been committed from Finance, so it seems strange that it has not happened. It is something that has come up a number of times at the Committee. I will cross now to the Deputy Chairperson, Pam Cameron, who is joining us on video link.

Mrs Cameron: Thank you, Charlotte, for your attendance at the Committee today. I appreciate the presentation that you have made and would like to hear a bit more detail about the Nightingale system because, should we have significant spikes, it could well come into operation again. It is very useful for us as members of the Committee, and even for the public, to know what it is actually like to work in those ICUs in particular.

I want to ask you specifically about the staffing of units such as Nightingale and ICUs in general. For a long time, banding has been a big concern of mine and how staff do not feel valued. Frankly, they are not being paid for the job that they do, and we know what an incredible job they have done and continue to do. Specifically, one of the recommendations of the nursing and midwifery task force is to develop arrangements for accelerated pay progression in band 5 to band 6 grades to take account of the years of experience and additional responsibilities undertaken by band 5 nurses, which is particularly evident during the pandemic. The implementation plan says that the Department will conduct a review to establish evidence of the cost and benefits of full implementation of the recommendation. I know that the Royal College of Nursing has expressed disappointment that the Minister has not accepted that recommendation. Why has that recommendation not been accepted? Is the review under way? If so, when will it be completed?

Ms McArdle: All the contributions that nurses have made during the pandemic, and before it, are absolutely valued by the Minister and the Department of Health and the health and social care system. There is no question about that. Many of them have fed back to me their pleasure at the number and volume of gifts, applause and thank-you notes that they have received from the population in Northern Ireland as a whole. Nursing is valued, and, as

trusted profession, it is well

value the work that nurses do. I certainly do value the contribution of all the health and social care services.

In relation to the acceleration of pay progression, nursing has been in the agenda for change framework since it began in 2004. Many of our nurses have been sitting on band 5 salaries for quite some time, and the agenda for change framework has not done nursing any favours. As roles expand and nurses take on new and —

The Chairperson (Mr Gildernew): I am sorry, Charlotte. We have lost you momentarily. Charlotte, we are not hearing you.

The Chairperson (Mr Gildernew): We are now back in public session, so if you could pick up again, Charlotte, on your point about the agenda for change.

Ms McArdle: As a pay structure, agenda for change has not served nursing well in career development opportunities. More than half of the nursing workforce are band 5 nurses. The feedback that we got from the nursing delivery task group co-production in engagement sessions with nurses and midwives, more than a 1,000 of whom inputted, was that they wanted us to take forward work that would look at rectifying that position.

The RCN and the other trade unions have a key role to play in pay negotiations and working with government on how we recognise and reward nurses and midwives in particular. In relation to accelerated pay, the recommendation was that there would be a run-through from band 5 to band 6 to recognise expertise and experience and that many band 5 nurses are in charge of wards and departments. That was never intended to be the case, because it is an entry grade to professional practice. For many other professions, there is a run-through — midwifery being one, social work another — with specific requirements.

The Minister is unable to accept that recommendation at the moment because he had asked for more work to be done on making the case and outlining the benefit. The Department has committed to doing that. That has had to be paused due to COVID-19, but we will pick it up again once we get services restarted as time allows.

Mrs Cameron: Thank you for that, Charlotte. I am still concerned.

I should have declared at the start, Chair, an interest in that I have a family member who worked in the Nightingale hospital and could well be back there in the near future.

It is wonderful that we clap for ICU nurses, but it is pretty insulting if we do not pay them their worth. If an ICU nurse is a band 6 — is that right?

Ms McArdle: Some are band 5 and some band 6. Those who are band 6 are band 6 because they have taken on additional roles. ICU nurses generally are band 5, the same as other areas. In some cases, they have been uplifted to band 6 because they have taken on the team leader role or a particular area of practice in a unit. It is one area that we will consider in accelerated pay progression.

Mrs Cameron: In reality, there are band 5 nurses in ICUs, putting themselves and their families at most risk of COVID-19, who are not and have not been receiving a band 6-appropriate pay level that you would expect to receive working in that type of environment.

Ms McArdle: I think that it is wider than ICU. I think that there are many nurses who are working in very complex situations in many departments and in communities across Northern Ireland, and we need to consider all of that in the round.

Mrs Cameron: Did you say that half of our nurses are band 5?

Ms McArdle: Yes, slightly more than half.

Mrs Cameron: So is the real issue the fact that more than half of the nurses are band 5, and the worry is that it would simply cost too much to pay them as band 6?

Ms McArdle: I do not think that it is actually a costing issue, although you will appreciate that, with nursing and midwifery being the biggest workforce, as 35% of the overall, any change to their terms and conditions is a significant cost. However, I think that it is about demonstrating the outcomes and how it will improve care for people. It is about demonstrating and valuing the contribution that nursing and midwifery can make and making that argument to ensure that there is a clear career pathway.

For me, it is actually about keeping nurses in practice and allowing them to stay in their area and to develop their expertise at a higher level. Part of the problem with the career structure in nursing, as it has been for many years, is that, once you get to the band-7 level, which is a ward sister or a team leader role, there is not much more for you to do in clinical practice after that, and many nurses, as I did, move into management roles. I would like to try to reverse that with the development of very clear clinical career pathways. That work has begun with the Northern Ireland Practice and Education Council, and we are working our way through each specific pathway of care. You will be aware of the developments around advanced nursing practice, and those are higher level posts that enable nurses to stay in clinical practice and to work at the top end of their [Inaudible.]

I am very keen to promote that as the way forward across mental health, learning disability, adults and children.

Mrs Cameron: When are you expecting the review to be completed?

Ms McArdle: The review of?

Mrs Cameron: The review to establish the evidence of the costs and benefits of the full implementation of the recommendation.

Ms McArdle: The Minister has requested that that be completed in the next 18 months.

Mrs Cameron: OK.

The Chairperson (Mr Gildernew): OK. I am going to stay on the phones. Are you there, Pat, and do you have a question for Charlotte in this section? Go ahead, Pat — OK, we have lost you. If you can just pause for a second, we will see if we can get you back online. OK, I am going to have to pause the session again, and we will wait. We are having a lot of technical trouble today. I am going to pause the session, so that we can get this resolved.

The Chairperson (Mr Gildernew): Pat, go ahead with your question, please.

Mr Sheehan: Thanks. Charlotte, thank you for coming in today. I want to ask you about the issues surrounding the fit-testing certificates. We know that up to 3,000 staff have been identified as requiring a retest. Do you have the overall figures for the number of staff who have been identified as requiring a retest, who have contracted COVID-19 —?

The Chairperson (Mr Gildernew): We are going to have to pause and suspend the session again.

The Chairperson (Mr Gildernew): Go ahead with your answer to Pat, please, Charlotte.

Ms McArdle: I was just explaining that I do not have that information in front of me. However, I know that those staff who required new fit testing have all but completed that in most circumstances. The numbers across the organisations varied. The greatest number of staff who needed fit testing were in the Belfast Trust and the South Eastern Trust. Then, in terms of a direct correlation to COVID-positive, the only trust that I am aware of that has identified COVID-positive members of staff is the South Eastern Trust, which had between 10 and 15 people who tested positive. It is unclear, however, whether there is a direct correlation between the fit test and the COVID-positive test. We would have to be aware that there is a possibility that that did happen. I know that the South Eastern Trust has put support in place for the staff who were affected.

Mr Sheehan: I want to follow up on that, Chair, if that is OK.

The Chairperson (Mr Gildernew): Go ahead, Pat.

Mr Sheehan: The Minister has said that the risk to staff was low. Can you explain how that assessment was arrived at?

Ms McArdle: The risk to staff was low because the mask provided some coverage; it just did not provide a tight seal. It is my understanding — this is a complicated process — that there are various steps in the process of fit testing; it is up to seven steps. The majority of staff would have passed elements of the seven steps but not all seven steps, which meant that they had some protection from the mask but not full protection. That is why we established that the risk was low.

The Chairperson (Mr Gildernew): OK, thank you. We will go to Órlaithí on the phone. Are you there, Órlaithí, and do you have a question?

Ms Flynn: Yes, I am here, Chair. Thank you, Charlotte. I just want to touch on the overall rebuilding plan, which the Chair mentioned in his questions earlier in the session. Do you have any examples of submissions that you have made as CNO to the overall plan?

The Chair also raised the issue of the voice and input of the allied health professionals. Schools are reopening, and the allied health professionals have a key role in children's speech and language and communication needs. How will the speech and language therapists and all the allied health professionals be supported to carry out those really important roles for children in the education system in the time ahead?

Ms McArdle: Thanks for that, Órlaithí. As the CNO, I am a member of the management board, and I am leading two of the prioritised work streams, which relate to surge planning for phase 2 and acute care at home and the initiative around developing the new framework. I have produced papers to the management executive on both of those — the project initiation document and the plans going forward, which have been signed off by the management board.

Allied health professionals have been working very closely with the Chief Allied Health Professions Officer in both of those because of the vital role that allied health professionals will play in surge planning for a further phase, particularly in recovery and in the organisation of the service and having allied health professional staff, as they did in the first wave, move into different roles to support the care of people. So, we are working very closely on that. The Chief Allied Health Professions Officer is a member of the project board for surge planning and will be for the new health framework. She is very much integrated and has very good opportunities to discuss those issues with me.

In relation to special schools, the Chief Allied Health Professions Officer takes a key role in that and in working with colleagues on the policy side on disability. A specific allied health professional post is in place now at the PHA. That is a very close working relationship to ensure that the allied health professional support required in special schools is available.

I work very closely with the Chief Allied Health Professions Officer to ensure that the necessary resources are in place in line with the available budget. I cannot overemphasise that the Chief Allied Health Professions Officer and I work very closely together and are in daily contact on these issues.

Ms Flynn: To go back to the rapid learning initiative, I am not sure whether you will have an answer to this question, but do you know who drafted the terms of reference for that initiative? It was due to report on 17 July, which was last Friday. Do you have a copy of that report? If so, can you share it with the Committee?

Ms McArdle: The draft terms of reference were drafted by the deputy Chief Nursing Officer who is taking the lead in carrying forward that work. The report is being prepared, and there will be a sign-off meeting on 29 July. Once the Minister has had an opportunity to review that and clear it, I will be happy to share it with the Committee.

Ms Flynn: Brilliant. Thank you.

Mr Carroll: Thanks, Charlotte, for your presentation. I have been contacted, as I am sure have others, about concerns about malnutrition amongst older people. The Dietetic Association has been in touch, and I was shocked to learn that, before COVID, one in 10 over-65s was at risk of malnutrition. That is likely to increase in this period. It is a scandal and a crisis in and of itself, but there are obviously associated health risks with that, such as muscle wasting, cognitive impairment and so on. What commitment is there to tackling food insecurity?

I have two quick points on top of that. There are concerns, as the Chair raised, about the new management board. There is no specific voice for AHPs, and it is no disrespect to you, Charlotte, but people feel that it is a bit of a closed shop. We are seeing documents being released in the press about the reduction of emergency departments, and there is a real question about transparency and the nature of that board. Will you comment on that?

Finally, it is important that nurses are paid properly and adequately, generally, but also that they are paid the strike pay that was promised to them. We all clapped for them on Thursdays, and Ministers clapped for them, but it is no good if Ministers clap for them but do not pay them what they promised and what they are owed. As Chief Nursing Officer, do you think that it is long overdue that those nurses are paid the strike pay that they lost out on because they were forced to take strike action earlier this year?

Ms McArdle: There are a number of questions there. If I understand you right, the first question is about nutrition and the commitment to food. Is that correct?

Mr Carroll: Malnutrition. Yes.

Ms McArdle: Obviously, dieticians have a key role to play in supporting people with very complex nutritional needs. However, there is a responsibility on all health and social care staff to ensure that patients and residents receive adequate nutrition. I am responsible for a nutrition strategy, and I have set up a group, which the Chief Allied Health Professions Officer is part of, and there is dietetic input to that. Each trust has a management group, chaired by the director of nursing because of the link between allied health professionals and nursing, to oversee nutritional management in the organisation, both in hospital and in the community.

Some years ago, work was done on identification of people at risk, and support plans were put in place. It is very much in the domain of nursing to assess those needs, both in hospital and in the community, and to put in place strategies and care plans to support people with poor nutritional needs, and then to refer on to dieticians for specific input, where required. Obviously, in areas such as intensive care, where many patients are receiving tube feeds, dieticians have a very key role to play in supporting that. It is the same with people with intestinal problems, who need specific calorific input, as well as vitamins and nutrition, from our dietetic teams.

There is a clear commitment to ensuring the nutrition of the population of Northern Ireland, in terms of healthy eating and weight management and, at the other end of the scale, where people are poorly nourished, that we address and identify those issues early on.

The second point was about the transparency of the management board. I hope that, through my evidence today, you can see the strong working relationship that I have with the Chief Allied Health Professions Officer. She is key to the decision-making in my team and is a senior member of my team, and she is well linked in to the management board, though she may not be there in person. I have given a commitment, as has the Minister, that, if specific input is required, that will be taken forward.

Can the Committee still hear me?

The Chairperson (Mr Gildernew): Yes, we are hearing you.

Ms McArdle: Good. As the work develops in the management board, the outworkings of that will become clear. As I said, Jenny, the Chief Allied Health Professions Officer, had input to the papers that I brought forward and is part of the structure that supported the development of those project initiation documents.

The third point was about pay. As I said, the Minister has outlined his commitment to ensuring that that happens as quickly as possible, and therefore it will happen in due course, as soon as it can be made available through [Inaudible.]

I understand that conversations are still happening at the Executive table about how that will happen.

The Chairperson (Mr Gildernew): OK. Thank you.

Mr McGrath: Thank you very much, Chair, and thank you, Charlotte. My question is about many of the nursing professional staff who were relocated to various centres during the response. For example, many staff from the Downe Hospital were relocated to work in the Lagan Valley and Ulster hospitals. I am not sure whether you are aware that initial ripples included them having parts of their pay cut because they were taking travel time to get from one place to another. When they arrived in their new work location, because the surge that was predicted did not arrive, many of them were left with no work to do and some were encouraged to take annual leave. Many of the services have not been returned to their original workplaces and many of the services that were cancelled have not been restarted. We had the chief executives with us earlier, one of whom mentioned, on at least two or three occasions, the images on television of Italy and other places that meant that everybody had to prepare their responses, but it became very obvious, quite quickly, that that was not what we were going to face here. Are you concerned that many of the nursing professionals are having their working arrangements completely up the left, and there is not much help or assistance to relocate them back to their original places of work?

Ms McArdle: I would first say that, though we are talking about nurses, everybody — midwives and allied health professionals as well — has changed how they work, for the benefit of patient care, and willingly moved location where they had to. We saw the biggest impact of that with nurses moving to ICUs to support teams there.

You are right that, through the good work of our health and social care teams and the obeyance of the public to the required rules on social distancing, hand hygiene, good respiratory etiquette etc, we did not see what could have been an even worse COVID pandemic, with many more lives lost. We prepared for the worst. If we had not prepared for the worst, I might have been at the Committee justifying why we had not. It is a fine balance to strike. Many people did move willingly. I am not aware of the particular issues that you refer to between the Downe and Lagan Valley. I do not really understand why people would have their pay cut, so I cannot comment on that.

I am not aware of issues about nurses not being settled back into their original place of work. It is crucial that that happens because we will not be able to rebuild our services without having people back. One of the examples is health visiting. A number of health-visiting staff were moved out of health visiting into other acute roles, but we cannot have children not having their health checks or those not happening on time. Many of our school nursing staff will need to be involved in the immunisation programme. It is important that they are back at their workplace planning for how they will take forward the immunisation of children for flu and COVID, whenever the vaccine becomes available. It is critical that we have staff in the right place doing the right job in order to rebuild our services. I am not aware of any of the particular issues that you raise.

Mr McGrath: May I say something in a politely challenging way? You built up there that you would have to come to the Committee to defend not doing something. Of course, I never suggested that you were not doing it. I actually said that we needed to prepare for the worst at the beginning; that is what we had to do. However, it became apparent very quickly, possibly about a month to six weeks into it, that we would not see the 15,000 deaths and that the Nightingale hospital would not be required. To me, at that stage, when it was starting to be suggested that we did not need the likes of the Nightingale and we knew that there was floor upon floor upon floor in the City Hospital that would not be required, the trusts should have been starting to flush their staff back out into their original posts and jobs. If that had happened at that stage, maybe we would not have the backlog that we are looking at now.

Have I picked you up correctly? Do the trusts not engage with you if they are reshaping their services and moving nursing staff about the place? You are the Chief Nursing Officer. Would the trusts not discuss with you if dozens and dozens, if not hundreds, of nursing staff are having their working locations and jobs changed?

Ms McArdle: Absolutely. During the whole pandemic, I had three-times-a-week calls with the directors of nursing on Mondays, Wednesdays and Fridays, where we addressed many of the issues that you refer to as well as many others. What I am saying is that issues as you are describing them were not brought to me by the directors of nursing. While I accept that there will have been teething problems at the start, I am assuming that, in the main, those things have returned to normal because I am not hearing otherwise from any other source. The RCN would often be a source of letting me know when things are not good and nurses are feeling unsupported. There are also the directors of nursing, my visits out to wards and departments and my close contacts with the service. None of those avenues has raised with me the issue that you have raised today, but I will undertake to investigate that.

Mr McGrath: So, the unions have not approached you about this at all?

Ms McArdle: No, they have not.

Mr McGrath: Thank you.

Ms Bradshaw: Thank you. It is such a long session for you, Charlotte. My question is in relation to your role as chair of the Department of Health's steering group on the new cancer strategy. What work, if any, was carried out at the height of the pandemic? How are you picking up the pace to try to meet targets and move that work forward? Obviously, it is even more valuable now because we have had the drop in diagnostics etc.

Ms McArdle: We had a very successful engagement in January, I think, not long after the Assembly was reestablished. Then, we stood things down for COVID from March through to June. That has restarted. We had our first project board meeting in June. There was recognition from project board members about the work that we were planning to do on the cancer strategy. A significant amount of work has already been done. The development of the strategy was actually going extremely well. We had very good engagement and it has been co-produced from the very start.

The project steering board wanted to take stock, as it recognised that the starting place for cancer services now is different from when we started the work over a year ago and that we will have to take account of COVID-19 in the cancer strategy.

Yesterday at the management board, we had a long discussion about restarting cancer services. There was a recognition that the cancer strategy is a long-term development in cancer services to take us through the next 10 years and that it is crucially dependent on workforce issues, networks and how we re-stabilise cancer services post-COVID-19. Our attention now is on rebuilding cancer services. It will be very slow and will not get back to how it was pre-COVID-19 very quickly, but there is an absolute ambition to make sure that cancer patients get the right treatment as fast as possible. We will take that time while services are being rebuilt, bearing in mind that many members of our groups, work streams and the steering group, which is co-chaired by a person with lived experience of cancer, have had to shield during this period and that access to them has been very limited. We will pick it up now, but it has kicked us off our timeline significantly, and we will have to reassess all that. Our primary focus at this stage is on rebuilding cancer services.

Ms Bradshaw: I attended that event in January; it was an excellent example of co-production. The room was buzzing and full of people who were very enthused, so thank you for that.

My second question is about safe staffing legislation and how that is moving forward and whether you think that allied health professionals should be covered by such legislation. Thank you.

Ms McArdle: As part of the framework agreement following industrial action, the Minister agreed that we would take forward work on safe staffing legislation. Looking around the world, there are not many examples of where Governments have put safe staffing into legislation. Closer to home, Wales has brought it in, and Scotland is in the process of doing so. They have taken different approaches to it. In Wales, it is nurse staffing, whereas Scotland has gone for a much broader approach to include all healthcare professionals. The way that we will consider it will be to look at it more broadly than just nursing. However, given the issues with the nursing workforce and the fact that we have a very good policy on safe staffing called 'Delivering Care', which has been in place since 2014, nursing is probably a little bit better placed to be the first phase of the legislation. I absolutely agree than it needs to be wider than nursing and should include AHPs.

The Chairperson (Mr Gildernew): Thank you. Charlotte, by way of a follow-up to Paula's question: in 2016, the Department undertook to recruit 622 international nurses. How many have been recruited to date and what issues are affecting that recruitment?

Ms McArdle: I do not have the exact figure, Colm, although I am happy to get it. It has obviously been paused during the COVID-19 pandemic for a lot of reasons. One is the ability of people to travel from their home countries; two is the fact that the Nursing and Midwifery Council (NMC) stood down the processes that we had in place that would allow overseas nurses to register; and three is that our attention was on making sure that we could manage the COVID-19 situation. I think that we are pretty close to where we wanted to be, although the process has taken a bit longer. To date, I think that we have recruited 600 nurses. There has been a slight delay, and the programme has been extended because of COVID-19.

I want to share with you the figures from the NMC report in July. They show that the increase of registrants in Northern Ireland was, I think, about 2·7%, and there is a direct correlation between that 2·7% and the number of overseas nurses who have registered in Northern Ireland. While it has been a bit slow to get off the ground, we have made very good progress, and I must pay tribute to the health and social care trusts, the Clinical Education Centre and Ulster University, which provides the objective structured clinical examination (OSCE) assessments. We have had a significant positive outcome, whereby almost 100% of overseas nurses get through the OSCE process the first time. Northern Ireland is unique in the UK with that.

So, we are on target and we will get there; it is just taking a little bit longer.

The Chairperson (Mr Gildernew): OK, thank you.

Mr Chambers: I want to make a few comments, Charlotte, and ask a few questions about childcare. Did the temporary childcare facilities that were made available by the Minister of Education over the past number of weeks go some way towards mitigating the concerns of nursing staff about childcare? Are there any concerns about childcare in the light of the proposed part-time and phased reopening of schools in August and September? Might that exacerbate childcare concerns, given that it will be a part-time situation? Will you encourage trusts to be flexible about shift allocations in order to ease the childcare concerns of individual nursing staff members?

Ms McArdle: Interestingly, I was on a Zoom call yesterday with a number of young nurse leaders. We were taking the learning from COVID-19 and one of the things that they said to me was that childcare was really important for them in order to make sure that they could be available for work when they needed to be. It was one of the top priorities, particularly for people with young families, and younger nurses and midwives. During the pandemic, they had not had the opportunity to have grandparents cover childcare for them in the way that they might have done in the past. Many of them said that their spouses and partners were either furloughed or working from home, which was a huge help. However, given that they were working extra shifts and longer shifts, the childcare facilities that were put in place helped a number of people, particularly single mums or mums with a lot of young children. I agree that that was a helpful initiative, but the uptake was not as high as we had anticipated, which may have been because many people had partners who were furloughed or who were able to work from home.

Flexible work allocation has always been the bedrock of nursing in order to accommodate people's needs, as have flexible shifts. I would absolutely encourage that to continue, particularly when we have some remaining challenges in the workforce. We want to keep the very good staff that we have and the expertise that they bring. If that means being a bit more flexible with their working life and their shift patterns, I would absolutely support that.

The Chairperson (Mr Gildernew): Thank you for that. I have another couple of questions, some of which are short and some of which you may not be able to answer. I appreciate that you have stayed on today and that you need to be away by 1:30 pm. I just want to ask about the rapid learning initiative. Did that consider the discharge policy in relation to admitting patients into care homes without testing? Is that part of the rapid learning initiative that you are doing?

Ms McArdle: Yes. Testing is

is part of that initiative

and so we consider discharge as well.

The Chairperson (Mr Gildernew): OK. I have another quick question. Have there been any attempts to develop a COVID-19 life assurance scheme? We heard in the early stages of the surge that there were issues with that. Has any work been done on that, and are you engaging with unions or the workforce in relation to it?

Ms McArdle: I am going to have to pass on that one. I am sorry; I do not have enough information to make any kind of informed response to it. I will certainly undertake to find out for you.

The Chairperson (Mr Gildernew): OK. My final question is about agency staff, which, as we all know, has been a perennial problem. There have been reports that a lot of agency work has dried up over the surge, with people being relocated and all of that. The terms and conditions of agency staff are also an issue. Has there been any success in bringing agency staff back in-house, and are there any plans to address that issue more proactively as we come out of COVID-19 — this spike of COVID-19?

Ms McArdle: A very good proposal had been developed in consultation with, and co-produced by, the trade unions pre-COVID-19 and was very near conclusion, led by my colleagues in the area of workforce policy. That will be recommenced now that we are through the initial surge of COVID-19. Again, that is as time allows because we do not know what the autumn and winter will bring, so we have to prepare for that, too. Therefore, it is very much back on the agenda, and the idea of that is that we try to attract people into full-time positions in trusts, enhance their payments through the bank and encourage the agency staff to go back into the work environment. I do not think that it is solely about the enhancements in pay. I think that it is about the experience of work-life balance, feeling valued and making a contribution in the workplace.

One of the biggest improvements in that area will be the increased availability of the nursing workforce as we go forward. We are beginning to see a little bit of light at the end of the tunnel with regard to the workforce challenges with, as I said, increased registrations at the Nursing and Midwifery Council by 2·7% and the huge improvement — an 87% increase from 2016 — in undergraduate places. Therefore, it is starting to trickle out, and I am very hopeful that, in the next couple of years, we will see those workforce issues reverse and, in doing so, make the working life of nurses much more attractive. That will help to retain the staff that we have.

The Chairperson (Mr Gildernew): Thank you, Charlotte, for your presentation, your answers and your commitment to providing those other bits and pieces of information to the Committee. On behalf of the Committee, I thank you for the work that you have done and continue to do. I also thank those whom you lead in the nursing workforce and express our ongoing appreciation and gratitude for what they have done at this time and for what they will likely have to do in the future. Thank you for that; we appreciate it. All the best. Slán leat.

Ms McArdle: Thank you.

The Chairperson (Mr Gildernew): Thank you.