Official Report: Minutes of Evidence

The Deputy Chairperson (Mrs Cameron): I welcome the Minister of Health, Mr Robin Swann; Professor Ian Young, the Chief Scientific Adviser; and Dr Michael McBride, the Chief Medical Officer. I acknowledge the incredible volume of work not just by you but by the entire healthcare system that is ongoing. In what are still difficult times, we appreciate that, and I am sure that you will want to update us.

I also acknowledge the recent announcement of the increased payments to those affected by the infected blood issue. That is important, and I welcome the fact that the payments will be in line with those in England, which is welcome news. We also welcome the return of services to the regional fertility centre.

I know that you are tight for time, Minister, and you have to get back to an Executive meeting. I invite you to give us your briefing, after which we will ask you some questions.

Mr Swann (The Minister of Health): Thank you for your comments, Chair, acknowledging the work of the entire health and social care system. Since we last met at the end of July, that work has continued at the same intensity. It is useful that we have come here today to provide you with an update on what has been happening and to answer questions. As this is the first briefing since the summer recess, I intend to keep my opening remarks brief to allow the Committee more time for questions. As you indicated, Chair, the Executive meeting that was meant to have been completed prior to the Committee session is resuming at 3:30 pm, so I need to get back in order to attend to business there.

It has been a long six months, and I understand how COVID fatigue has started to set in among some people. Some may even think that the worst of the virus has passed and that they no longer need to watch their distance or wash their hands. However, as I have said numerous times, they are wrong: this is still the biggest public health crisis in our generation. We face into what will, in all likelihood, be an incredibly difficult winter, and the prevalence of the virus is still increasing. However, it is important to express my gratitude, yet again, to all our health and social care staff who have been working in conditions that, in January, none of us could have imagined.

Our retail sector has reopened. The tourism and hospitality sector has largely reopened, subject to some continuing restrictions and social-distancing measures. One notable exception, however, is that "wet pubs" — those that do not serve food or have no outdoor areas — are not permitted to reopen. As members are aware, that is being discussed by the Executive. I am pleased to see that our children are returning to school. No one expected it to be easy, but, on the whole, I believe that the return to school has gone well.

The gradual reopening of society and, most recently, our schools, has unsurprisingly, placed increased pressures on our testing system. Our dashboard will have been published at 2.00 pm, and, today, we will have reported 8,013 individual tests across pillar 1 and pillar 2. A month ago, we were testing around a quarter of that number each day. We now test many more people per head of population than our neighbours. Chair, that is the highest number of tests we have completed in a single day. The demand for testing is increasing across the UK and across all channels. In all likelihood, that increase in demand will continue, and testing will continue to play a hugely important role in the weeks and months ahead. That is why I am also ramping up the testing options in pillar 1.

Chair, let me be clear: I am assured that we have enough testing capacity. Anyone who needs a test will get a test. I ask the few people who are experiencing difficulties when booking a test to leave the automatic system for an hour and try again later, because more tests are put online as demand increases. However, I will be concerned if an inaccurate public narrative develops that tests are not available or that people have to travel excessive distances. Such a misunderstanding could cause people who need a test not to come forward. For those who claim that we do not have enough tests available, I repeat the point: yesterday, we tested many more people than ever before, and the testing is there for everyone who needs it.

I take the opportunity to repeat the message that testing is available for all members of the public who have symptoms of COVID. The symptoms, as members well know, are a new continuous cough, a fever or high temperature, loss or a change of sense of taste or smell. If people have those symptoms, they should self-isolate and book a test. If people do not have those specific symptoms but have other COVID-like or cold-like symptoms such as a runny nose, they do not need to be tested or to self-isolate, and children can go to school if they are fit to do so.

Chair, the StopCOVID NI proximity app is working well. To date, there have been over 325,000 downloads, and, as of yesterday, 475 exposure notifications have been issued. Those are 475 people who have been identified via the app and told that they have been in contact with someone who is COVID-positive. They may have been picked up through contact tracing on our test, trace, protect system, but there may have been some who have not. The app is working for us.

Work continues in my Department on rebuilding Health and Social Care (HSC) services and increasing service capacity as quickly as possible across all programmes of care, with prevailing COVID-19 conditions. At the same time, we need to plan for potential future surges of the virus to ensure that we remain prepared, particularly as that may coincide with general winter pressures that we may face. Committee members may be aware that, yesterday, I announced the establishment of our second Nightingale facility, this time at Whiteabbey Hospital. My officials are developing the regional surge framework, which will provide a high-level overview of learning from the first wave and the regional approaches taken across key areas such as elective care, orthopaedic services and care homes to ensure that HSC is prepared for future surges.

As with the trust rebuilding plans, individual trusts will carry out their own local engagement with stakeholders and the trade union side (TUS) on their individual surge plans. However, I am keen to get opinion now on the regional surge framework, which is why, last night, I shared the draft with the key stakeholders, which included trade unions and the transformation advisory board (TAB) members before publication at the end of this month.

In concluding, I reiterate what I said in my last Committee briefing. Given the complexity and scale of the challenges that we face, it is vital that our health and social care system is given clear direction and that, in a fluid and changing environment, decisions are taken quickly. We will not be able to return to business as usual. The rebuilding of services will not happen overnight; they will require a rapid yet flexible response to ensure that the system can respond to further potential COVID-19 surges.

Chair, that concludes my opening comments. I kept them brief so that we can engage with members.

The Deputy Chairperson (Mrs Cameron): Thank you, Minister. We appreciate your keeping your comments to a minimum. It allows us to get plenty of questions in. It is great to hear that the app is working so well in conjunction with the test, trace, protect strategy. That is welcome news. I also welcome the news regarding the planned second Nightingale facility. I think that everyone was a little taken aback by it, but it is good to be cautious and to have those plans in place.

You removed car-parking charges for the staff members who were working in those difficult conditions, and they are back to paying charges. I declare an interest, as I have a family member who is a nurse and travels a considerable distance to her workplace and then has to pay ridiculous fees. If she does not do that, she has to take a bus and walk dark, lonely paths late at night after her shift to get back to her car for the long journey home. Are you looking at withdrawing those car-parking charges for staff members? I encourage you to abolish them altogether, if possible. That is my point on the two Nightingale facilities.

I appreciate where you are coming from on COVID fatigue. We all see it, especially on social media. It is frightening to see the extreme gap between those who are terrified to leave their home and those who think that this is just the flu and we are all talking nonsense. That is a big concern.

There is an incredible amount of testing going on, which we welcome. We have come a long way from, I think, 40 —

Mr Swann: Forty-five.

The Deputy Chairperson (Mrs Cameron): — 45 a day. We are at well over 8,000, and that is to be welcomed. We understand the pressures with schools returning, but, hopefully, those fears will settle in the weeks and months ahead.

Rebuilding services is probably the most worrying element for me. I welcome the announcement of initiatives in elective care and orthopaedic surgery at Lagan Valley, Altnagelvin and Musgrave. Will you provide an update on that with particular emphasis on cancer services, day procedures and orthopaedic and outpatient appointments? Have you a timetable for full resumption? What proportion of services will trusts be able to sustain should a second wave of COVID-19 present itself in the winter months? I will kick off with that one.

Mr Swann: Just for a starter, Chair. We envisage that the Nightingale facility at Whiteabbey will be a step-down facility from the acute and social settings. It will not have the concentration of intensive-care units (ICU) beds that we had at the tower block at the City Hospital. That facility will still be there, should we need it. From what we saw in the management of the first surge and the number of ICU beds that we needed, it was decided that a step-down facility was crucial to support patients in their recovery. The development at Whiteabbey will be a specific site for that step-down service, and we will see where that can progress. That was announced yesterday as part of the engagement that we are having with TUS and TAB members to make sure that there is understanding.

I am aware of what asks there have been regarding car-parking charges. It is important to point out that trusts have different approaches to car-parking charges not only for visitors but for staff. We made an intervention during the first surge, and I am sure that we would make an intervention the second time, but trusts have to find £8 million. The Belfast Trust is carrying out a consultation at this minute in time. Centrally, we have reintroduced car-parking charges, but we keep that under review in respect of how we support our staff. The way in which trusts implement that policy is in their own hands.

You made a point about COVID fatigue. The noise that is now in the background concerns us — from the Chief Medical Officer and the Chief Scientific Adviser to anyone across the health service and you as members of the Committee — because its starts to instil the impression, as you indicated, Deputy Chair, that this is just a flu. As we said at the start, for the majority, this will be a flu-like virus, but it is more than a flu-like virus for the families of the more than 600 people who have passed away because of it. For anyone who has contracted the virus and come through it, it is still a concern. "Long COVID" is the expression that is being used to describe those who have had COVID but still suffer from some of its symptoms. When you talk to people who have spent time in ICU, you can hear them still having difficulty catching breath because of the after-effects of COVID. This is more than a flu, and that is why we are taking the steps in the direction that we are at this time.

As we have seen across the rest of the United Kingdom, as schools came back, there was increased demand for testing. If we follow the same trend here, that will start to die off. There is understandable nervousness among not just staff but parents and grandparents, so we have seen an increase in the numbers approaching our testing systems and COVID centres. We are working our way through that, and I ask everybody please to stick with the system. Additional tests do become available. It is a two-book system: you book in the morning for an afternoon or evening test; you book in the evening for a test the next morning.

We have seen some anomalies. Pillar 2 is a national testing system, and it is done online, so it directs someone to the closest available test centre. Unfortunately, especially if you live on the east coast or in the east of the Province, the computer may say that, geographically, your nearest centre is Scotland. I think that we had the reverse two and a half or three weeks ago, where some people in Scotland were being directed to test centres here. That is an issue that Gerry raised. That is how the system appears, but, if you go back into it, you will be directed to a more local testing facility. We are working with our partners in pillar 1, which is

in the west, as well as the Agri-Food and Biosciences Institute (AFBI) and Almac, to increase the pillar 1 testing capacity. Performing just over 8,000 tests yesterday is a large step, and we keep pushing the envelope to make sure that we get there.

We have had interaction with the Department of Education and the Education Authority (EA) to make sure that people understand that, if they have symptoms, they should get a test. If they do not have symptoms but are concerned, they should approach their GP and get guidance. That work is ongoing. Michael and Ian are meeting the Education Authority and the Department of Education twice weekly while we get through the reopening of schools. We are aware that testing pressures will come agin when we reopen the universities. That number of people going back to centralised locations will create pressures, but we have been building that into our system.

Your last point, Deputy Chair, was on service rebuilding plans. We have taken steps and made announcements, especially back in July, about orthopaedics and elective care, to put in place facilities to ensure that we continue to provide those services to the people who need them. I hope that we do not hit the same sort of surge as at the first point, when we had to close down services. It is about making sure that we have the facilities and staff available so that we can continue through that.

Rebuilding cancer services is one of the priorities that we are working on across all trusts. They are time-limited services and time-limited interactions, so we are working with trusts to build them in. Trusts' plans are due every three months. Their current plans run out at the end of this month, so trusts are already working on their October/November/December delivery plan and on where they foresee increases. Those plans are published online. There are also targets set for how many patients trusts intend to see in each service location, so it is about setting targets and trying to push them up.

We have seen an increase in our waiting lists. That was expected and is to be expected until we get back on top of where we were. It is a fragile system. It was fragile in January and through the first wave, but it is about trying to rebuild capacity so that we can start to claw back some of the operations and procedures that we need to get on with.

I think that that covers most of your points, Deputy Chair. Do you need further clarification of anything?

The Deputy Chairperson (Mrs Cameron): Thank you. Will the sick pay that has been paid out to care home staff continue to be funded? Is that now a permanent scenario?

Mr Swann: It is not permanent, but sick pay is being extended while funds are there, because we realise the value that it supplies and the reassurance that it gives to workers who need to self-isolate. The rapid learning initiative, which was drafted by the Chief Nursing Officer and published yesterday, points to a number of interventions that we need to make and supports that we learned from the first wave. That is how we will further support our independent care home sector, especially the people who work in it. That initiative is there.

It will be reported today that 21 care homes have confirmed outbreaks. That is being highlighted because of the testing of staff and the retesting of residents. Anywhere that has two positive cases will be declared a confirmed outbreak so that we can make sure that interventions are made quickly and that the virus does not spread in the home. Ian or Michael can give information on this, but what we are seeing is that those who test positive in care homes are asymptomatic. It is about early indication, and, if we can get asymptomatic residents or staff identified, isolated and supported, that will prevent further spread in that home. Ian or Michael, do you want to comment?

Dr Michael McBride (Department of Health): Yes. On care homes, it is a different picture from the one that we saw during the first wave. As you know, we completed our first round of testing of all care home staff and residents as of the end of June, at the Minister's direction, and the next wave of that, based on the evidence from the Scientific Advisory Group for Emergencies (SAGE) and international evidence, commenced on 3 August. We have tested over 24,000 staff and residents. We have had excellent cooperation, I have to say, from the independent care home sector. There have obviously been some challenges with resources, and we are working with the sector to provide additional support.

Additional training on infection prevention and control has gone on over the summer, including a range of seminars, and trusts continue to support care homes where there are active outbreaks. A new portal has been launched by the Department of Health and Social Care (DHSC) for care homes that do not have outbreaks so that they can register in bulk their residents and staff for ongoing, regular testing. Obviously, we use pillar 1, as opposed to pillar 2, for care homes where there are active outbreaks, but, as the Minister said, we are now seeing the active case finding as a result of the testing programme, and that means that we can respond immediately to close down outbreaks. If we see two or more positive results, we test everybody: residents and staff. We then test at day four to day seven to make sure that we get on top of the outbreak. Again, that is everybody. Once the outbreak is confirmed as closed at day 14, we go back at day 28 and retest everyone, just to be absolutely certain that we have closed down the outbreak efficiently and effectively.

As I say, we know that the population in care homes remains vulnerable. We know that staff working in that environment feel very pressurised. They provide close, very personal care. The high standards of infection prevention and control and PPE will hopefully minimise that risk as far as possible, but it is likely that, as community transmission increases, we may potentially see further outbreaks.

In all of this, we will keep the frequency of testing of staff and residents under review. I hope that we can avoid getting into a situation in which we impose a blanket ban on visiting, because that is hugely detrimental to residents, many of whom are in the last months of life, and to relatives. It is something that we should try to avoid at all costs while managing and mitigating the risks of infection.

The Deputy Chairperson (Mrs Cameron): I am glad that you raised the issue of visiting. I was going to raise it, because the emotional and mental well-being of those in care homes is vital. Often, individuals are not in those settings for a terribly long time, so what time they have needs to be quality time, and they need to be able to see members of their family.

I have plenty more questions, but I will open it up to other members to make sure that everybody gets a chance to come in. Colin had indicated first, then Gerry and then Alex.

Mr McGrath: Thank you for coming along today. I commend you on the work that you are doing, Minister, and your leadership. I know, from the people whom I talk to, that you are certainly the most popular Ulster Unionist MLA in South Down, so I wanted to pass on some good regards to you.

On the issue of testing, you touched on the work that goes on with the education service. This is only the first week of schools being back, but there is lots of evidence coming through that schools are saying that, if a child has any symptom of any sickness at all, that child is to stay at home and is not allowed to return until it can be proved that the test is negative. Some schools are even suggesting that the whole family needs to be tested. I heard a figure this morning for the number of tests that have been completed versus the number of tests that would be required. Is there some way of ramping up the messaging to make it clear when a test is required and when one is not required? Maybe you can speak to the Education Authority again about sending out a clear and concise message to schools about when they should and should not ask for testing.

Sometimes people are not able to avail themselves of the online booking system, as you have correctly said. I have had two such cases. One person was told to go the Isle of Man, and the other was told to go to Scotland. They came to me to ask whether they could get on a boat if they had coronavirus. That has caused difficulties. Can you talk us through how the home testing kit is sent out? As a suggestion, if pharmacies had a supply of test kits, somebody could go to get one for somebody else and have it with them within an hour. Most people can get somebody to pop out to a chemist for them. If there were a supply of home testing kits available, they could be put in the post very quickly that day to get processed.

Mr Swann: To start with the message for schools, I can say that, at the Executive meeting earlier today — I do not think that I am breaking any confidences — there was a conversation between us and the Education Minister, and a number of other Ministers raised the exact point that you raise. We talked yesterday about symptoms. As a concerned parent — my nine-year-old and seven-year-old went back to school on Tuesday — I know what the sense of apprehension is like among many parents. For ease, they want to get a test, just to make sure. We are saying that, if you have symptoms, you should get tested and, if your child is ill, keep them at home, which is good practice.

We are working with the Education Authority and the Department of Education. There is a meeting tomorrow about communication to make sure that there is no deviation from or no ability to see confusion between what we say as a public health message and what the Department of Education or the Education Authority has put out to schools. We see very responsible messaging coming from the majority of schools. Again, the concern of parents will always be the concern of parents. It is about simplifying the message and having a conversation so that there is that continuity. Ian, do you want to pick up on the messaging?

We have not had a discussion with our partners in pillar 1, which is the national system, about making postal kits available in pharmacies. We are talking to the providers of a programme that would make 10 tests available to every school. A child can take one home — it is not to be used by the school — so that there is a quicker turnaround time, which should give reassurance. I do not know whether Ian or Michael wants to pick up on those specific issues.

Professor Ian Young (Department of Health): On the messaging issue, we absolutely accept that there is a lack of public understanding about when a test is appropriate. We are meeting the Education Authority tomorrow to discuss a really clear piece of messaging that can go out so that everybody is completely clear. It is the symptoms that the Minister referenced — new, continuous cough, loss of sense of taste or smell or an elevated temperature — that require a test. Other symptoms at the moment do not require a test.

That is kept continually under review as the scientific evidence changes, but, if there is any change in the symptoms that require a test, there will be clear messaging around that.

We have been asked questions. If a child gets tested, the rest of the household do not need to get tested unless they have symptoms themselves. If a child is a contact and is advised to self-isolate by the Public Health Agency (PHA), the rest of the household do not need to self-isolate unless the child develops symptoms, in which case the child needs to get a test and everybody isolates until the results of the test are available. We will try to answer all those questions and agree some really clear messaging and put that out very quickly. I hope that this will all settle down and everybody will get used to it in the next week to 10 days.

Dr McBride: Irrespective of how clear guidance is, it is only when you have walked through the experience that issues will emerge that have not necessarily been covered with sufficient clarity in guidance. We are seeing some of those issues emerge, and there is a lot of work going on to address that and provide that clarity. Ian and I have offered to do a series of Zoom calls with school principals next week and the following week to provide an opportunity for them to ask the questions that they want to ask that may not necessarily be covered in guidance. The PHA is also working with Education Authority colleagues to develop a "Frequently Asked Questions" section to put up on the website that will hopefully, again, address those questions.

I think, as you said in your introductory comments, it will be a bumpy couple of weeks, as parents, teachers, principals and everyone become used to children being back at school. It is just a reflection of the genuine anxiety that is out there, and that is understandable. We will continue to play our part to support colleagues in education, everyone in schools and parents.

Mr McGrath: On a different avenue, I want to ask about the definition of "clusters". Currently, two positive tests is considered a cluster, but is there some way of improving that messaging? I have had two examples over the summer — one in the Crossgar and Ballynahinch area and one in Newcastle — and there is a sense of panic that follows the news headlines that there is a cluster in an area. People literally close their doors, pull their curtains and do not move from the house. The biggest impact is obviously the economic one on businesses, which are losing out. Some of those businesses are right to the wire or are very close. People talk about the definitions on the website that suggest that it is done by council area. The Newry, Mourne and Down council area, where we are, goes from just south of Belfast to the southern parts of Armagh. Saying that there are 15 or 20 cases can sound like a lot, but that is across 60 or 70 miles. Is there any way at all of refining that message or increasing the threshold? Can we refer to "small clusters" and "large clusters"? Is there any way that we can create some perspective that would help businesses that really struggle with this at times?

Mr Swann: Colin, that is the balance of how you identify this and how granularly you put out your positive tests. The PHA does its weekly update with regard to district councils, and it does what you are asking for. It does outbreaks by district council and then outbreaks of more than five. There is that differentiation, but it does not go into pinpointing specific villages or towns. It shows what side, who and where. We have seen a good reaction to our test, trace and protect system. We are getting very good buy-in from the general public, because they are not being scared away from engaging with that system. There is a psychological concern that, if you start to identify certain areas, people become disenfranchised or do not want to engage with the test, trace and protect system. That is especially a concern with hard-to-reach individuals and our settled ethnic communities, whom we want to engage with our system. We have seen a cluster identified in a meat-processing factory and one in the Limavady area, where we saw difficulties in getting people to engage. Those are made public. Where we are seeing engagement with our test, trace and protect system, the PHA see the point that we would rather have people engaging with us on a confidential and reassured basis.

Our test, trace and protect system is performing very well at this minute in time. PHA put out the statistics: in the last week, we were able to get in contact with 273 of the 313 cases who were identified to test, trace and protect. That is 87%. Compared with other systems across these islands, that is a high percentage of people engaging with us. From those 273, they identified an additional 856 contacts. That is another 856 people who were identified as being at potential risk from COVID. Of those 856, 819 responded to test, trace and protect, which is a 96% return. We are getting good buy-in from that work. We are seeing the same with the app: there is good engagement with that too. That system — that ability to break the chains of COVID transmission — is working well for us. However, when somebody on social media — I remember the incident well — gets hold of a story and blows it out of proportion, there are adverse effects. If there is a need for an alert in a certain area, it will come from the Public Health Agency.

The Deputy Chairperson (Mrs Cameron): Thank you, Minister. Is the app now available to under-18s?

Mr Swann: The app is not yet available to under-18s, but it is in product development; it should be available in the next couple of weeks. An app available to under-18s will be a first. The reason for that is the data protection concerns. If someone under, I think, 16 downloads an app, they need parental consent. We are working through that with the Children's Commissioner to make sure that all those reassurances are in place. The Committee raised concerns about whether the app would be centralised or decentralised. The approach that we took has resulted in a large uptake. I think that, at the last count, 328,000 people had downloaded the app in Northern Ireland. That is over-18s; when we have the under-18 app, we expect that to increase significantly. It is working: 279 people have been identified via the app, and they have released another 475 notifications via the app.

The Deputy Chairperson (Mrs Cameron): Will it be a separate app or just a choice?

Mr Swann: It will work through the same system, but it will have different language and different parental consents, which are needed if people under the relevant age want to put it on their phone.

Mr Carroll: Thanks, Minister. You both, correctly, thanked the healthcare workers. We are really indebted to them for all the work that they have done to keep people safe and alive throughout this period. Minister, do you have any views on the Royal College of Nursing (RCN) call for a 12·5% pay increase? It is warranted in any case but especially because of the work that they have been doing throughout the pandemic. Considering that we are likely to see a significant pay increase for MLA constituency staff, it is only right, fair and proper that nurses and, indeed, all healthcare workers get a fair wage. I would like to hear the Minister's view on that.

We have had a lot of correspondence and heard issues and worries about dental services. Some of those issues remain. There is a real concern in my constituency about dental operators going private. One in particular has flagged up that it is going private, and there will, possibly, be more.

Obviously the R rate has shot up in the last few weeks and months. I think that there have been 400-odd new cases in the last week, and, obviously — tragically — there have been more deaths. My recollection from March was that we were led to believe that, if the R rate was above 1, we needed to rethink lockdown or elements of it. Does the Minister have any concerns that we are moving too quickly? From my perspective and that of others, it seems that things are moving too quickly. Effectively, everything is more or less open apart from wet bars, as you indicated. You said, Minister, that there was the potential for another full-scale assault. I am concerned that we have moved too quickly. The result of that has been the R rate increasing and the number of cases increasing, and tragically there have been some deaths.

Finally, what is the assessment, from maybe the Chief Medical Officer and the Chief Scientific Adviser, about the virus over the next few weeks? Obviously, there is an element of unpredictability about it, but there are patterns across the world. What is the view on how, potentially, the virus will spread over the next few weeks and months?

Mr Swann: With regard to RCN's position calling for 12·5% across all Agenda for Change staff, it is not just for Agenda for Change; it is a UK national call as well. We are prepared to be part of that conversation, and we are part of it. The recognition that we gave and still have to give to our healthcare workers through the pandemic means that it is vital that we keep them in the position that they rightly deserve. I have said before and have said to the Committee that, for too long, they were the Cinderella service that we relied on without realising their true value. When we reflect back to January, one of the important points in getting the Assembly back together was the pressure that came from that sector and recognising our heath service workforce and our nursing workforce. It is there, and it is the conversation that is being had at the national level, and it is one that I will continue to push for. It is also — I have said this before too — about the recognition that we have to give to our domiciliary and care home staff. For too long, they have been not left out but, often, left behind, so it is about making sure that we get them that recognition as well.

With regard to dental practices and the concern about PPE, we made a further intervention of £3·8 million to allow dentists to source their own PPE, because there are a number of avenues that they have been able to use. There have been ongoing discussions, and we have kept the emergency centres open but on a much reduced basis, as dentists start to reengage with their own patients. I do not know the detail of the one you were talking about, but, if you can give me the specifics, I will be more than happy to look at it. Dentists moving from being partly or completely National Health Service to private would be a concern, because most dentists work and survive on the balance of both. It would concern me if we further reduced our National Health Service dental provision, because it is vital for those who do need it.

With regard to R, we produce and release the R paper on a Thursday, as we said we would, and we are sitting at 1·3. That is steady from last week. It has not gone down but has remained steady for the second week in a row. It is above where we would like to see it, but, on balance and in proportion to the steps that the Executive are taking on restriction and regulation, I think we are proportionate in what we are doing. I do not want to go to a further lockdown, and I do not want to see the measures that we had to use previously reintroduced. That is when our continued ask goes to the general public to have social distancing, good hand hygiene and good respiratory hygiene and to wear a face covering where applicable.

The increase in cases over the last seven days is a concern, because what we now see and what is different from what we saw in the very early outbreaks is more of that younger cohort testing positive. That is reflective of complacency and of the fact that that is the age group that is going back into social interaction and going back into work. We ask people to be cautious and to use their common sense with regard to the asks that we make. With regard to that younger cohort, we have updated information that will be available from today's dashboard that will break it down into age group, and it will be done by a seven-day average. Over the last seven days, 60% of those testing positive are younger than 39, which is a complete flip from what we saw in the first outbreak. The message to younger people is, "Please take care of yourself, because, by taking care of yourself, you are looking after your loved ones".

Ian or Michael, I think, with regard to the virus and Gerry's last question.

Professor Young: We monitor carefully the progress of the epidemic. R is important, but we have been clear that, once cases are at a lower level, R is just one factor that we need to take into account. It is inevitable that, as we introduce relaxations and people interact more, we will see more cases, and that is unavoidable. Each time there are relaxations, we need a couple of weeks to assess their impact, to see what the new number of cases is, their age distribution and the extent to which they lead to impacts on the health and social care system.

At the moment, while the number of cases has gone up substantially — fifteenfold from early July — the number of hospital admissions and the number of seriously ill people have remained at a much lower level than during the first part of the epidemic. That is because, as the Minister indicated, at this time, the cases have switched round. We are seeing them in younger people, who may still suffer serious consequences from COVID — it is not a trivial illness — but, generally, they do not end up in hospital. Our big concern will be if we begin to see more cases occurring in the over-60s, in particular, because that it is what will lead to hospital admissions and deaths. We think that it is inevitable. Younger people mix with older people. They see parents who are older and they see grandparents, and that is why we need younger people just to be really careful.

Yes, we can open up, but we need to make sure that everybody sticks to the basic messages, that they become embedded and that we live with the virus, which is what is will have to happen through this winter. We will have to live with the virus; it is not going to disappear.

Dr McBride: The only thing to add to that is that it is very important that the virus has not gone away and is not going to go away. It is about adapting our behaviour to live safely with the virus and minimise the risk. These are finely balanced judgements for the Executive that we have discussed many times at the Committee.

The virus has had a disproportionate impact on socio-economically deprived communities, those from socio-economically deprived backgrounds and black and Asian ethnic minority groups. The virus disproportionately impacts on poorer people. It is important that we are mindful of the fact that there are significant health inequalities among the inequalities more generally in our society and those can only be exacerbated by the current restrictions that we have seen. It has impacted significantly on children's educational opportunities and, potentially, their life opportunities. Employment and livelihoods have been put at risk, as we have heard, so it is important that we take a balanced approach to this whilst trying to press down hard on the virus.

A couple of points to add are the fact that, at present, this phase is unlike the first wave. As Ian said, at this stage in the first wave, 40 to 50% of cases were in those over 60 years of age: we are seeing about 10% of cases among those over 60 years of age. That demonstrates that the behavioural aspects and the adherence to the messages are being heeded more by older individuals, who are at greater risk, than, perhaps, those under 39 years of age. That is not to demonise individual sections of our community; it is just a reality of the frequency of social contact.

The final point to make is that the Executive moved swiftly when we saw R go above 1 and reintroduced some of the restrictions in relation to household contacts and gatherings in private dwellings and gardens, with numbers of people and numbers of households going from 10 people from four different households to six from two different households and risk assessments carried out of all gatherings, either indoors or outdoors, of over 15, whereas, previously, that was 30. The Executive had considered the requirement for more localised restrictions, but, thankfully, up to this point, that has not been necessary. However, it remains something that the Minister and Executive colleagues will consider, if required.

The Deputy Chairperson (Mrs Cameron): Just before I go to Alex, in terms of the messaging, it is obviously complicated for people to keep on top of all the changes as we go forward and then back in steps. That is difficult, and it must be balanced against the obsession of listening to all things COVID 24/7, which is really unhealthy. How do you balance that? Is there a better way to get the message out without people having to be obsessed and constantly listen to the messages going out?

Mr Swann: That is a point, Deputy Chair. It is one reason why my Department reintroduced the weekly press briefings. Those are heard. We do one a week now. I do not say that that is enough, but it starts to reinforce the message that we need people to hear. We go back to the simple messages we used at the beginning: social distancing, good hand hygiene, good respiratory hygiene and, now, the addition of wearing face coverings. It is about getting that into people's heads and mindsets. We see an increase in people starting to do those things again.

I go back to Gerry's point about the increase in the R rate and what we are doing about it. There was the engagement as well. We have always had powers and regulations, but it was about the enforcement. The latest update we have is that the PSNI have now interacted and served 18 notices of prohibition on bars and licensed premises. That was not necessary before, but, now that that step has been taken, it emphasises the messaging.

Mr Easton: Thank you, Minister, for the presentation and for all that you and your staff are doing to keep us all safe.

I have major concerns about COVID in one area. I will try to be diplomatic in saying it. The message that we are getting out is not listened to by a significant minority of the population. You see it with face masks. If you go into a shop, you will see any number of people just ignoring that. What concerns me even more is that, when we get a potential vaccine, I will be first in the queue to get it, so I volunteer. That is because I want to protect my mother and father, who are elderly and are not well, and I have faith.

Can you tell us where we are with the vaccine and how we will get that message out? I put it out publicly that I would take it, but the reaction I got from a significant number of people was that it will not be safe, it will cause illness, it has not been tested for long enough, even down to conspiracy theories of control. Some of it was absolutely crazy. We will have a big problem selling the vaccine. What plans have we to do that? The only way we will get on top of this totally is through a safe vaccine.

Mr Swann: Thanks, Alex. I assure you that some of the messaging that you got when you said you would take the vaccine was mild: you should see some of the stuff that I get [Laughter.]

It is amazing what conspiracies are promoted, sometimes by elected representatives.

Mr Easton: Not me.

Mr Swann: No, not you. It is a concern. It is not even in the message, but, sometimes, the messenger can cause difficulty and undermine the messaging that the Department and the Executive are putting out. It is that significant minority. You phrased that well: it is a significant minority, but they are vocal. I share your concern that they will start to undermine the core message that we put out of the importance of good hand hygiene, social distancing and all that. We cannot say it often enough.

With regard to the vaccine, it has been made clear a number of times that the only way we can get back to any sort of normality is through a widespread vaccine. If you do not mind, Chair, I will use the opportunity to push the flu vaccine, when it starts. We are doing a lot of work with GPs and community pharmacies in a number of settings to make sure that we get as high an uptake of the flu vaccine as we can. We are already aware that flu and COVID at the same time will be highly damaging and challenging for the health service. I use the opportunity you gave me in regard to the flu vaccine. The specifics of the COVID vaccine I will leave in the hands of Ian and Michael. They will talk about its efficacy, where we are in its development and how we ensure uptake.

Professor Young: There are around 170 vaccines in development worldwide. The UK Government have signed up to purchasing four separate vaccines in advance of the results of the significant clinical trials coming through. Fairly large-scale clinical trials of a small number of the vaccines are under way, and it is intended to start trials of vaccination in the UK in the next few weeks. I have signed up to participate in the clinical trials, which I absolutely would not do if I did not think it was safe. Certainly, I will also be very early in the queue, once a vaccine is properly available.

Dr McBride: Behind me [Laughter.]

Professor Young: It is likely that, when a vaccine becomes available for widespread use, we will require two doses of vaccine about a month apart to achieve significant immunity, according to the early studies. We are not sure how long that immunity will last, as, indeed, we are not sure how long immunity lasts for those who have experienced COVID. We know that there have now been several cases worldwide of people getting COVID for a second time, which indicates that immunity is not long-term. The fact that people have had the virus does not mean that they are safe from getting it again. We have still a lot to learn about it.

We do not think that a vaccine will be available in significant amounts before some time in 2021, so it is very unlikely that we will have a vaccine available for this winter. That is why, as I have said, we need to find a way to live with the virus, allowing as much activity as possible but with everybody remaining as careful as possible not to become infected by using the mitigations that we have described. I hope that as many people as possible will take up the opportunity of vaccination when it becomes available. We will certainly use very positive messaging around that, but there will have been substantial assessment of the safety of the vaccination before that point is reached.

Dr McBride: The only thing to add to that is about the safety of the vaccine. There will be no vaccine available until it goes through the proper and appropriate regulatory framework — the Medicines and Healthcare products Regulatory Agency (MHRA) approval system — and recommendation by the Joint Committee on Vaccination and Immunisation, which is a scientific body that is independent of government. It advises all UK Ministers on how vaccines should be administered, for instance, to a particular group in the population who would benefit from it most. Those approval processes will be in place, and, as some of you will recall, we had the same discussion back in 2009 and 2010 about the H1N1 swine flu vaccination, when the same concerns were voiced by the public around a new vaccine. That is understandable, and it is up to us to provide assurance to the public about the rigour of the testing and the trials that are under way and the approvals system.

We are fully linked into a UK-wide vaccine programme board, and I chair our Northern Ireland equivalent. As the Minister said, that oversees the seasonal flu vaccine programme, which will be really challenging this year. We have purchased a million doses of vaccine — over a quarter of a million more doses than we would for a normal seasonal flu — and we have the prospect, as Ian has said, although it is not likely, of potentially having to roll in very quickly and roll out a COVID-19 vaccine early in the new year. It will be immensely challenging. You have already heard general practitioners' concerns about the administration of the seasonal flu vaccines to tens of thousands of individuals in a socially distanced way with personal protective equipment. That will be challenging enough, but we will also have to catch up on existing immunisation programmes in schools and elsewhere and, then, mount what will be the phenomenally challenging exercise of administering a new vaccine for COVID-19.

The Deputy Chairperson (Mrs Cameron): Thank you for that, Dr McBride. I am concerned about time. We have only about 15 minutes left if the Minister has to leave at 3:15 pm.

Mr Swann: It is an Executive meeting, Chair. I will push it as long as I can; it is important for us to have this engagement.

The Deputy Chairperson (Mrs Cameron): I appreciate that very much. Four members have questions, so I suggest that each member has four or five minutes. I am sorry to do that, but I want to make sure that everybody gets a question.

Ms Flynn: Thank you, Chair, and I will try to be quick.

My first question is around the announcement of the new step-down facility at Whiteabbey and the specialist centres at the Lagan Valley and Ulster hospitals. Will the Department be able to provide us with the criteria that were used to determine where those facilities would be placed? Are there plans for an additional step-down facility later in the year or next year elsewhere in the North?

Mr Swann: Yes, Órlaithí, we can provide that information, and we will provide it as part of the rebuilding structure as well. That is no problem.

Ms Flynn: Brilliant, thank you. That was quick [Laughter.]

My second question, which has already been touched on, is around the winter pressures and the messaging. I heard Dr McBride on the radio this morning. Obviously, the important thing is being sensible in the actions that we take as individuals. I am concerned. We have seen an increase in the number of people coming forward for tests, which is a good thing if they are concerned but a bad thing if they do not require the test, because they might be taking it away from somebody else. Is the Department tracking the number of people who should be self-isolating after having a test or travelling in and out of the country? Is it possible, even through the contact tracing team, that, when we know who should be self-isolating, we can follow up on that more extensively? The worry is that there definitely is complacency at some levels and that people who should be self-isolating might not always do it. Once we hit the winter season, that could have an impact on a surge or a further spike. I do not know whether you are looking into that or whether something can be done about it.

Mr Swann: Órlaithí, on self-isolation, if people come through the contact tracing system — test, trace and protect — there are occasions when we or the PHA make follow-up calls. It is a check-in to see how people are rather than enforcement to make sure that they are actually there. One concern that we had about making that an enforcement issue, whereby you must self-isolate or be subject to a penalty, was that it would prevent people coming forward if they thought that they would be locked in their house. It is about that voluntary side of the general test, test — test, trace and protect. We have to find an easier name [Laughter.]

Dr McBride: Test, trace, protect.

Mr Swann: Yes, it is one of those that just does not stick.

We want to make sure that people engage voluntarily as much as possible. Enforcement is for those travelling in from red countries. That is where you must isolate for 14 days. Follow-up calls are made, and we have already seen one of the newspapers carrying a report this morning from the PSNI about a £1,000 fine levied on somebody who broke that rule.

It is about two different avenues of enforcement. If you come through the test, trace and protect system, you have done it voluntarily. We want to encourage people to do that. If you have come in from a red country, there is an enforcement part. We are seeing good engagement with the voluntary side of self-isolation. People who go forward for a test do so for the right reasons, so they are engaging with the rest of the advice as well.

With regard to concern about messaging for the winter, it is important that we get that message back into people's heads. It is for the Executive, the Committee and MLAs to keep rehearsing and repeating the message. We cannot repeat it often enough.

Ms Flynn: You made a point about catching COVID-19 versus catching the flu. Whatever way you can put that to the public, you must show the seriousness of COVID. There are myths out there that it is not dangerous or deadly and that it is just like having flu. It is just to try to do away with some of the complacency that might have set in at this stage.

Mr Swann: I appreciate that.

Mr Sheehan: Minister, there is no doubt that the increase in the number of infections is worrying. Earlier, Colin raised issues about testing for kids, when kids should get tested and about kids going to school and so on. Those are issues that constituents have raised with me recently, but I have a long list of other issues that have been raised.

Someone who had a highly elevated prostate-specific antigen (PSA) test at the start of the lockdown has still not been able to get the further investigation that he requires. Another constituent had an electrocardiogram (ECG) carried out by his GP. He was told that the results normally come back within three to four weeks but, because of COVID, it might take seven or eight weeks. He has now been waiting for 13 or 14 weeks. A 78-year-old constituent with chronic diarrhoea cannot get any further investigation. There is a young woman who needs surgery for endometriosis, and another young woman needs surgery for scoliosis. Another woman, who has suffered chronic bladder and kidney infections, has contracted sepsis on a number of occasions and has had her breastbone broken while CPR was being administered, has not seen her consultant for two years. While we are focusing on COVID, all those other conditions get worse, and people are not getting the treatment that they need. I am not asking a question; I am just making a statement. We need to focus on those other issues too.

I have two quick-fire questions. The first is about Muckamore. We saw in the press this week that it has cost an extra £12 million to put emergency measures in place as a result of the scandal there. Minister, when you were the leader of the Ulster Unionists, you signed a petition that called for a full-blown public inquiry. Is it not past time that you announced a full-blown public inquiry with powers to compel witnesses and documentation, to allow the families to find out what went wrong, who was responsible and where the fault lay in the system?

Secondly, Tony Stevens has been appointed interim chief executive of the Regulation and Quality Improvement Authority (RQIA). You are probably aware that the RQIA has been tasked to carry out reviews of the issues around neurology in the Belfast Trust. I do not want to impugn Tony Stevens's professional integrity in any way, but he was the medical director in the Belfast Trust when many of those misdiagnoses took place. Is there not a conflict of interest in having the former medical director of the Belfast Trust as the chief executive of the RQIA, which is involved in carrying out the reviews of that scandal?

Mr Swann: Pat, the number of individuals who are waiting longer than they should is a concern to us all. If you want to pass the details of any of those cases to us, we will get them to the trusts. That will allow us to look at them and make sure that they get the attention that they deserve and are not lost in the system.

I have visited Muckamore, I have met the families, and I signed that letter as party leader. I know that Paula has tabled a motion on Muckamore and that there will be a debate on Tuesday. I will respond to that debate because I do not want to take away from giving the House its place. It is not that I am denying you, Pat, or the families. I have said that I would follow up on an inquiry, and I will make an announcement to the Assembly on where we are with that. I am waiting for further advice coming back, and, from today, a number of cases are with the Public Prosecution Service (PPS) as a result of the PSNI investigations. I made that commitment, Pat, and you should know me well enough by now: when I make a commitment or promise, I will stick by it; it is not in my nature to do anything else. I will come back to you, and I am sure that you will be there on Tuesday when Paula brings that motion to the House.

Tony Stevens's appointment in the RQIA is temporary. He will be there for three to six months while we appoint a full-time chief executive. As you said, you know Tony, and I know him well from his work in the Northern Trust. There is no way that it is in his character to jeopardise any work that the RQIA is doing. I will seek reassurance that there is a separation between his post and any involvement in the concerns that you have raised. As the post is temporary, I do not think that there will be any question of any sort of interference, nor should there be.

The Deputy Chairperson (Mrs Cameron): OK. We have Paula next. We are not getting any response. I think that you are muted, Paula.

Ms Bradshaw: Hello, can you hear me now?

The Deputy Chairperson (Mrs Cameron): Yes. Thank you.

Ms Bradshaw: Thank you. One of the benefits of speaking late in the meeting is that some of my questions have been asked. Apologies for not being there. I have a head cold and do not think that you would appreciate me sneezing on you.

Minister, first, I return to the issue of fair pay for nurses. You promised that the nurses who were on strike earlier this year would have their docked pay reimbursed. When will they get that money?

The second issue relates to the house parties that have started now that students are returning to the Holylands and parts of inner Belfast and the fact that the police are having to respond. How will you work with the universities on robust messaging and follow-up testing? The threat of community transmission when students go back to their communities at the weekend is vast.

The third issue relates to the new Nightingale step-down facility in Whiteabbey Hospital. While I think that it is a great idea, I wonder what happened with the step-down centre at the Ramada Hotel in Talbot Street? As you know, it cost £150,000 to refurbish and then to reinstate it as a hotel, and it was quite problematic. Was there a robust business plan? A lot of public money was spent. Why was it closed down? Are we certain that Whiteabbey Hospital is the best place for the new facility?

Mr Swann: The first issue is currently with the Executive. I think that it was Gerry who asked me when we were last in the Assembly what the position was and where that decision stood. There is a repercussive nature of a change in policy should a Department reimburse strike pay. The way such a decision would work out is that, if any other Minister wanted to reimburse strike pay, the Department of Health would carry the financial burden. My officials and I are responsible for the health budget, and we want reassurance from the Executive that the Department of Health will not carry the repercussive costs should that happen elsewhere or at another time.

The issue of the students returning to the Holylands — I do not think that I am breaking any confidence — was raised at the Executive this morning. Health, Economy and Justice had a discussion on the proactive, coordinated steps that could be taken by the PSNI, the PHA, the universities and Belfast City Council to get the message out to the students. While wet bars are closed, which is the right thing to do, students will have house parties. Well, they will have house parties even if the wet bars are open, but it is how we get the message through to them. Our student population needs the messages, the support and the encouragement to be responsible. We are seeing students moving into accommodation a fortnight in advance of their return to university. If we can get them as they come back to their residences, that would be the proper thing to do.

The Ramada step-down facility was a project taken forward by the Belfast Trust; it was not a regional facility. If you want, we can follow that up with the Belfast Trust.

You may recall that, when we were looking at the first Nightingale facility, we had looked at the Eikon Exhibition Centre and other possible locations. Whiteabbey is part of our estate, so it is about utilising what we have. As I said in response to Órlaithí's question, we are quite prepared to share what information we have on that. Going forward, robustness is part of our planning.

Mr Chambers: Minister, I could not start to compete with the number of negative emails and social media comments that you and your team have received over recent months. There seems to be a small army of people spending every waking moment, maybe styling themselves as barrack-room lawyers, looking for loopholes, contradictions or difficulties in the enforcement of all of the regulations that you have been bringing through to try to protect the public. There are two issues: the letter of the law and the spirit of the law. Most of us recognise that the regulations have been brought in in emergency circumstances and were not subjected to the usual scrutiny, but they are there to protect the best interests and health of the public.

There is another small army of people who, I notice, write letters to the papers and go on demonstrations. They were demonstrating in Dublin last week, and they demonstrate in London. They seem to think that the whole COVID thing is a worldwide governmental conspiracy despite the fact that the latest figures show that maybe 25 million people throughout the world have contracted the virus. Do you have a message for those people?

This point is not related to that, but I want to ask about the pubs. I know that the police have served, I think, 18 closure notices. There are publicans throughout the country who are really driving a horse and cart through the regulations, and I have no doubt that the police may, eventually, work their way round to serving a closure notice on them. Is there a message for publicans that, if they continue to break the rules, even if the police do not knock their door and serve a closure notice on them, it could have long-term implications for the renewal of their licence?

Mr Swann: On the question of the letter or the spirit of the law, you have hit the nail on the head. The vast majority of people in Northern Ireland always do the right thing. They want to do the right thing because they know that it is about saving lives and protecting their loved ones. To use Alex's phrase, that "significant minority" will always be there. I say this to them: think of the danger that you are causing. When I see people protesting — they have the right to protest — and they are less than 2 metres apart or not wearing face coverings, my automatic reaction is to think, "Do you not realise the danger that you are doing not just to yourself but to your loved ones?". That is what carried the majority in Northern Ireland to the position that we got to a few months ago. In July and August, we had a very low number of positive cases and hospital admissions. That was because people were doing the right thing. They did not need to read the regulations or the letter of the law, because they knew what the spirit of it was: to save lives. That is where we want to be.

By saving lives and supporting our COVID response, we can get back to addressing the issues that Pat raised about all those who need follow-ups, scans read and surgery done. I say to that minority that their influence and their actions have an effect on other people's health, directly or indirectly. I will paraphrase or, actually, quote the Chief Medical Officer and tell them to "Wise up". I will ask them to wise up. I will say to them that they should have respect for other people. My social media accounts will have gone through the roof, now that I have told them to do that, but it is the right thing to do, Alan. It is what I do as Health Minister. That is the message that I need to get out there.

On the question of pubs, especially wet bars, the people whom I feel for most are the responsible publicans who are closed and are seeing their business suffer because they are doing what they are meant to do at this minute in time. If there was a way that I could reverse and close down the rogue elements who are open at this minute in time and allow those legitimate and responsible pub owners to open, I would do it. The Executive are re-engaging this afternoon, and the matter is being discussed. It is not up to me to pre-empt any announcement from the Executive, but it is something that we have to take notice of. Some of our local pubs are not just for people to go and get drunk in; there is a social aspect to them, especially in small rural communities where the pub is the only means for social interaction that people have.

People have broken the law, and the police have enforced 18 notifications. Members of the public are reporting pubs that break the regulations. There are also other publicans and bar owners who are reporting publicans because they know that that is having a long-term adverse impact on their businesses. Again, it is about being responsible and working with the Department of Health and the Executive so that we can get as much of society reopened as possible because we know the good that it brings.

The Deputy Chairperson (Mrs Cameron): Thank you very much. Minister. Your time is up, but that is a good note to end on: the message that, if we follow the guidelines and the regulations and do what, we all know, we need to do, that will help the economy. It will allow you to open more and resume health services, which is vital.

I thank each of you for your time this afternoon. It has been very useful. I know that there are many subjects and questions that we did not get through, but, no doubt, we will get you in the long grass with those. Minister, I wish you all the best for the rest of your Executive meeting today. Thank you all very much.

Mr Swann: Chair, I thank the Committee again. We will probably be back at the Committee sooner rather than later, because we need to bring back a number of issues and discuss them with the Committee. I thank the Committee for its support not just of the Department but of our whole health and social care family. I also thank members for continuing to push out the message that we need people to hear, because it needs to be heard. Chair, thank you very much for your support for the work that we have been doing.

The Deputy Chairperson (Mrs Cameron): Thank you very much.