Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): I welcome the Minister, Robin Swann, and the Chief Medical Officer (CMO), Michael McBride, to our meeting. You are both very welcome this morning. Could you please go ahead and give us your introductory remarks?

Mr Swann (The Minister of Health): Thank you, Chair. I will keep the introductory remarks as short as I can so that we are open to questions and discussion.

Thank you, once again, for the opportunity to update the Committee. Since my last briefing, as we are all aware, there has been an alarming increase in the number of positive COVID cases across Northern Ireland. We saw another 424 cases confirmed yesterday, which is the highest daily total since the current testing model was rolled out. The day before was 320 cases, and that had been the highest ever daily rate. We face a very serious situation, and, as I said during the media briefing yesterday afternoon, as a country and as a society, we are now very much at a crossroads. If the current trends do not change and if attitudes to the virus do not toughen, in six weeks' time, our hospital inpatient numbers will exceed those witnessed during the first wave, and that is not even the worst-case scenario. Our Chief Scientific Adviser warns that it could happen in as little as three weeks. To all the doubters and naysayers, I emphasise that point: in three to six weeks, those will be people being hospitalised, not people simply testing positive, because the virus remains incredibly serious and incredibly dangerous.

The Executive recently took the difficult decision to implement restrictions across the entirety of Northern Ireland. That followed earlier localised restrictions, which have already resulted in improvements in some areas. Cases in Ballymena and BT43 have dropped by about 50%, and the Belfast rate has slowed. Unfortunately, the number of cases in the latter is still growing, and we are all aware of the particular problem in the Derry City and Strabane District Council area. What we are witnessing there is sustained transmission in the community, and the problem is not related to a few bad outbreaks. The problem is that the virus is in the community and is spreading rapidly within it.

We are now in a place where further difficult decisions are necessary, and, as you may be aware, I will go to the Executive later today with a set or proposals. As the Chief Medical Officer has said, there is a small window of opportunity for us to stop the spread of the infection. I make no apology, Chair, for again strenuously urging everyone to do what they can to prevent the virus spreading further. Those are the simple things that you and other Committee members have reiterated: keep washing your hands regularly; wear a face covering in enclosed spaces; stay at least two metres apart or one metre apart when a face covering is worn or other precautions are taken. We must all do what we can to stop this now.

I have made the Committee aware of my desire and commitment to restore services as quickly as possible. Last week, I informed the Assembly of the rebuild and restabilisation plans for cancer. It will not be easy, but I suspect that there will be political unanimity for what, I suspect, is a key priority for all parties. However, the pandemic will continue to impose constraints through the need to socially distance and to use appropriate PPE that will impact on the ability to increase capacity. The current rise in the number of COVID cases will also have a bearing on the level of services that can be delivered in the next three months. I am already watching with huge concern as beds and staff that should have been used for more and more elective services are now being stretched to capacity.

Achievement of the mission set out in the framework for rebuilding services requires my direct decision-making and authority, supported by my Department. As you know, that required my Department to make changes to the current governance structures, which impacted on the responsibilities of the Health and Social Care Board (HSCB), the Public Health Agency (PHA) and the health and social care trusts. That did not diminish the existing delegation of the Department's statutory functions to the relevant bodies but, rather, ensured that the direction and oversight of the Department's priorities for the next two years was made clear. That was done to ensure that the planning and delivery of services was designed to deliver the maximum local and regional resilience and that decision-making was as agile and streamlined as possible.

I therefore published a memorandum to the 2011 Health and Social Care (HSC) framework document, which sets out the changes to governance and decision-making processes for a period of two years. That became effective from June 2020 and is due to be reviewed on a six-monthly basis. When I published the memorandum, I undertook an initial sounding exercise, to which 35 responses were received. I gave the undertaking that my Department would undertake a full 12-week consultation exercise in line with its statutory obligations. That public consultation was launched on 14 September. I will be happy to provide the Committee with progress reports on that issue.

Chair, I am now open to questions and comments.

The Chairperson (Mr Gildernew): OK. Thank you very much, Minister. I begin by acknowledging the work that you and all of your team have been doing in the efforts to tackle the pandemic and the serious issues that are out there. There is clearly no respite in how it is progressing, and the pressures look set to increase, which is a concern.

On behalf of the Committee, I welcome your confirmation that a COVID life assurance scheme is now in place; that is very useful. I note that you are making further enquiries to ensure that that will not have an impact on benefits. I also welcome the written statement that was made to the Assembly. Those are useful to keep everyone updated and aware of what is happening at any given time. I understand that your time is tight this morning. We appreciate your coming here and will keep the session as tight as we can.

Given the worrying times that we are in, I reiterate the messages that we have stated in the past: the simple but so important messages about washing hands, wearing masks, cough hygiene and social distancing. In fact, I ask people to abide by the regulations, guidance and advice as a minimum and, indeed, to go beyond it if they can. If you can do something further over the next period to reduce your contacts, which appear to be a key driver of the increases, I ask that you do it. I acknowledge the fact that most people have been doing that. That is important and will remain important in the time ahead.

While we are asking people to do everything that they can, it is important that we ask ourselves this: is the system doing everything that it can in what it provides to meet the needs that we face? I recently spoke with the contact-tracing team. I am concerned because they told us that, at times, between 5% and 30% of calls are not answered. The number that they are calling from is 02895368888. I ask that people bear that number in mind. People should be conscious that it could be a contact-tracing call that they are getting. It is very important information.

I am also conscious of significant and widespread issues — I am doing some work on this — in relation to testing and people not being able to get tested or get test results back in a timely fashion, and that is obviously creating a window of doubt. I know that the advice is that people should isolate until results come back, but it is crucial. In light of that, are you concerned about the ability of the test-and-trace system to cope? What steps did you take over the summer to ensure that we have a robust and fit-for-purpose system in place?

Mr Swann: I will start with test and trace. We have seen an enormous amount of cases come into that system. As you rightly say, each positive contact is followed up at least five times so that they can try to make contact with the person. We have 125 full-time contact tracers. A recruitment process was completed this week for another 30, who have completed their training, and a further open recruitment call should see another 20 come on board within the next week. We have taken over a second floor in County Hall in Ballymena. That facility has allowed us to utilise small offices so that individual teams can work as bubbles. One of our concerns, and I think Pat raised it in the Chamber, related to the location. If everybody were working in the same locality and a member of the contact-tracing team were to test positive, it could take out the entire system. We have, therefore, built in those protections.

One small change, which, we hope, will ease the number of calls, is the PHA's announcement, last night, that additional contacts will now receive a text message rather than a call. The person who tests positive will get the call, and they will provide their contacts' mobile numbers and those people will get a text message from the PHA, as happens with the app. They get the same sort of information.

Our app is working well. It is approaching 400,000 downloads and has activated just shy of 2,000 additional notifications for people to take the appropriate action. I am almost sure that, by the end of this week, the under-18 version will be launched. When we talked about the apps here, two pieces were critical to us: first, data protection, which we have secured; and, secondly, cross-border interoperability. As we see the increased numbers in Derry and Strabane and other border locations, the ability for our apps to talk with the app in the Republic of Ireland is crucial.

On testing, we keep pushing our internal pillar 1 testing capacity and using our partners that are there. We are also accessing pillar 2, which is the national testing. We are working to make sure that we get test results back from it as quickly as possible.

I will put things into perspective on where we are in testing. A piece of work on tests per 100,000 population, in response to an AQW, for the period between 9 September and 15 September, showed us sitting at 348 tests per 100,000, England at 325, Scotland at 289, Wales at 298 and the Republic at 220. For our testing capability, using both pillars, we are testing a high percentage of people. That is proving its worth in the positive cases that we see coming through.

The Chairperson (Mr Gildernew): Last night, I noted that the text system is coming into place. All the strands are useful, but part of the concern relates to the detailed information that you need. It is important to support people and have human-to-human contact. There was a recent case in the South, where they contact-traced and found, through rich detail, that that one case had generated a further 30. The entire system needs to be about find, test, trace, isolate and support. We need to have the capacity to track down and find that type of detail. Is it a sign that the system is under pressure that they have had to go to texting? Is that a sign that we face capacity problems?

Mr Swann: It is utilising the technology that we have to make that contact.

We have seen it working through the app, so the PHA decided to see if it would be useful to get secondary contacts as well. It is not a case of short-circuiting, but it takes time to make the five telephone calls. People may not answer a number that they do not recognise, but they will read a text. We will use any tool that we can get to make sure that anybody who is a secondary or tertiary contact gets the information that they need.

Dr Michael McBride (Department of Health): It addresses the problem that you mentioned, Chair, about the timeliness of the contact with individuals who need to self-isolate. We know from the contact-tracing service that 95% of index cases are able to provide contact numbers of their close contacts. We have that information, therefore it is important that we get it out to those who need to isolate. Text messaging and using SMS texts is a rapid means of doing that. Unfortunately, as you said, sometimes a high percentage of the first calls and, indeed, the second and third calls are not answered. This is a way to circumvent that.

The texts also provide a link to the COVIDCare app, which provides tailored advice on what to do if you have symptoms. The important message to get out is that, if you get that text message saying that you have been in close contact and are asked to self-isolate, it does not mean that you need to get a test; it means that you follow the advice, self-isolate and, if you develop symptoms, you then get a test. That is crucial. That information is in the link to the text, but it is important that we ensure that, as you rightly pointed out, with the pressure on testing, we prioritise testing for those who are symptomatic. We have been putting out that message for some time. It is when people are symptomatic or are advised by the contact-tracing service or Public Health Agency to get a test that they should get a test, not in other circumstances.

The Chairperson (Mr Gildernew): I am conscious of the pressure on time, but I and other representatives have questions in that, sometimes, do not get answered. We all understand that there is huge pressure on time. I have asked questions about memorandums of understanding because it is now clear now how vital North/South cooperation is. I have asked about surge planning. It is now 1 October, and we are looking at a worrying situation. What update can you give us on the work for surge planning for what looks like a difficult winter?

Mr Swann: We are looking to publish our next three-monthly surge plan by the end of —? Where are we?

Dr McBride: October.

Mr Swann: I am trying to remember what three-month period we are in.

Dr McBride: October to December.

Mr Swann: That work is, at the moment, with the management board to sign off, to make sure that we can keep open as many services as possible. That is why we did a piece of work on cancer, elective care surgery and orthopaedics, moving to that more regionalised —. I met the board of the South Eastern Health and Social Care Trust yesterday in regard to the work at Lagan Valley Hospital. Good reports are coming out of there on how they have been able to reconfigure buildings, services and people to make sure that, if we do need the bed capacity for COVID that we did at the start of the year, a lot of those services can continue. We learned that stopping those services completely made it hard to restart them, and we are all aware of the implications that had.

As I have said previously in the Chamber, when I took over in January, we were running a transformation health service to try to deliver some the changes of Bengoa while keeping the health service running. We are now trying to run three health services: we are doing some of the transformation work; we are trying to keep our health service going; plus we are doing a COVID service, all on the same footprint with the same number of people.

The surge planning is about that strategic look. Our regional approach and the network approach that we are seeing across the water and a lot the specialties, because of silos being broken down in the past six months, is really embedding and getting good feedback from staff and the trade union side, but also from patients, who are utilising the service.

The Chairperson (Mr Gildernew): I think everyone understood that unprecedented things had to happen at the start, but I think that there is an expectation, rightly, that lessons will have been learned and that we can do things better this time.

On surge planning, can you tell us today — or come back to us, if you do not have the detail — how many ventilators, which we have talked about before, have been ordered? How many have arrived and how many have been commissioned?

Mr Swann: Off the top of my head, I do not know. I know that we have nearly 200 in place and have 200 still in progress. We did not stop buying. We kept any orders that we had in progress.

Dr McBride: I am happy to provide a written update on that. We have capacity, through Nightingale 1, to significantly expand critical care capacity, with ventilators aligned with that. To correct my earlier comment, the rebuild plan is from October to December, and the surge plan is from October through to March. So, we are looking at the surge plan to get us through to the spring. Obviously, it will include issues such as Nightingale 1, which was the step up in intensive care, and Nightingale 2, which is the step-down facility in Whiteabbey, to make sure that we can maintain patient flows and then continue the separation between COVID-free elective care and other services that we need to maintain.

Unlike last time, we will seek, as the Minister said, to maintain routine services as far as that is possible while, at the same time, maintaining the services for those who need hospital care for COVID-19, with enhanced support to ensure that we can support people who are not ill enough to require hospital admission in their home environment, with, obviously, liaison with primary care and with respiratory units in our hospital settings.

The Chairperson (Mr Gildernew): Thank you. A detailed update on that would be useful.

Mr Swann: That is fine.

The Chairperson (Mr Gildernew): I will go across to members. Pam Cameron is our deputy Chair. Pam, are you able to hear us?

Mrs Cameron: I can. Thank you, Chair. Thank you, Minister and Dr McBride, for your attendance at the Committee today. At the outset, Robin, I welcome, in particular, your comments around keeping services open as much as possible. It is vital that that happens in the second wave that we are entering.

First, on the back of Colm's comments around the testing capacity, are you concerned that schools, children and staff are being tested unnecessarily and that that puts additional pressure on the testing systems? Secondly, you will be well aware of the attitude that some members of the community are taking to COVID-19, where complacency seems to be rife.

merits of a mask actually adhere to restrictions. A family member who works in ICU has told me what it entails, and, quite frankly, it is frightening. Dr McBride, will you outline the average experience in an ICU department for someone who is unfortunate enough to have to be admitted to receive that treatment, and can you outline how the virus attacks the human body? If it has to be graphic, let that be the case.

Mr Swann: Pam, I will let Dr McBride pick up on that last one from a very specific medical point of view. On teachers and pupils, we have done work, even recently, on making sure that we are getting the right message through to principals and parents on testing to provide the reassurance about what steps they could take. The Education Minister said at the start that there would be bumps, and there were bumps regarding that guidance and advice. That is why the PHA set up that specific call cell that school principals could use should they need to seek further advice.

If someone has symptoms and needs to be tested, I advise them to get tested. However, as the Chief Medical Officer said, if the guidance is that you should self-isolate for 14 days before symptoms appear, that is the guidance that we ask people to follow. That guidance was developed to ensure that our testing capacity is there for those who need it when they need it. We have done that work with schools and with parents, and we have a clear flow chart of what steps parents and teachers should take to seek a test and when to seek a test. Michael, do you want to pick up on the ICU experience?

Dr McBride: Yes, I am happy to do that. It is very difficult for people to imagine what it is like to fight for your breath and not to be able to breathe and how scary that experience is. It is doubly frightening to imagine what it is like to be separated from family and friends, from your normal sources of support and those who provide resilience and encouragement at such times. If you are in a ward environment, the only interaction that you may have with those individuals is via technology — Facebook or some other means — by which the ward staff of doctors, nurses and all the allied health professionals (AHPs) are trying to ensure that you can maintain contact with your family and friends. You will be in a ward environment in the first instance, and you may have support with your breathing. We talk about continuous positive airway pressure (CPAP), which helps to ease the work that you do to get air into your lungs. That in itself is a traumatic experience, because a mask is tightly fitted over your face, which many people find quite claustrophobic. You need to maintain that mask over your face, because, otherwise, the amount of oxygen — your oxygen saturation — falls very quickly. It is a bit like facing into a wind tunnel with air coming at a high pressure, forcing air into your airways. It is a very unpleasant experience. As a patient and a person sitting there, you know that that is the difference between you staying well or perhaps being transferred to intensive care. All the time, you are surrounded by nurses and doctors. Their hands are gloved, their faces are behind face masks and they are wearing PPE. Despite the best efforts of staff, it can feel very impersonal at a time of significant anxiety and fear.

Despite the efforts of medical teams and the use, perhaps, of new drugs that are effective for people who require oxygen therapy, such as the dexamethasones and the prednisolones, and new investigational drugs such as the remdesivirs, there will, sadly, come a time for many individuals when there has to be a conversation about being transferred to an intensive care unit, because the early ventilation of patients who are deteriorating is important. There then comes the conversation with those patients that, once they are ventilated, they may never wake up again because it may never be possible to take them off a ventilator. Those patients then have a conversation with their family, which has to be done remotely rather than directly in order to protect family members. That happens with members of staff wearing full PPE. There is a detachment, although there is still a hand to hold and a smile behind the mask. It is a very scary experience.

When individuals are paralysed and ventilated, they and their relatives do not know whether they will wake up again. Sadly, too many people do not. For some, the course is one of improvement, but many people are left with long-term sequelae both psychologically from a mental health point of view and with respiratory problems. We have heard of long COVID. Sadly, many people in that situation have other syndromes that are associated with SARS-CoV-2. In addition to respiratory problems, they get an immune response to the virus with chemicals called cytokines and others that flood their immune system. They develop clotting and renal problems, and, sadly, people die, despite the best efforts of the skilled multidisciplinary team in intensive care.

That is the reality of COVID-19. We saw it in the first wave. None of us should lose sight of that reality. As the Chief Scientific Adviser said yesterday, we are a few short weeks away from that reality again. As the Minister indicated, we are at a crossroads. We have weeks to intervene — this goes back to your point, Pam — and we all need to do the right thing. As you said, Chair, it is about reducing our social contacts. We are not powerless in all this, and it is not inevitable, but, unless we all act now, the consequences and what we will see in the weeks ahead are very clear.

The Chairperson (Mr Gildernew): No one should take any chances on experiencing that, and no one should pass on the potential that others might experience it.

Mr Carroll: Thanks, Minister and Michael. I would like you to comment on a couple of things. We had a discussion last week about the neurology review, and a few patients have been in touch with me and with other members. They are still concerned that there has not been a follow-up meeting with the Department. They expressed their real trauma to me, and, I am sure, to others, about hearing of Dr Watt's resignation. There is a concern that they are not being listened to, consulted with or talked to. I am relaying that concern. A response from the Minister would be useful.

I have also been told that there may have been an increase in the number of assaults on staff working in the learning disability sector. I seek clarity on that. I am not sure whether the Minister or the CMO have any figures, but that concern has been relayed to me.

On maternity services, a lot of people have been in touch with me, concerned that partners are unable to attend —

The Chairperson (Mr Gildernew): Gerry, can you just wrap it up? We can take only a question or two from each member.

Mr Carroll: I did not realise that, Chair. Sorry. There is a concern about maternity services. People feel that they can go into restaurants and bars, but they cannot take partners into maternity services for support. Will you comment on that?

Mr Swann: The visiting guidance across our whole health and social care sector was updated on 22 September on advice from the Chief Nursing Officer and her team. They have been moved to stage 4, which is more intense with more restrictive access.

On the specifics for maternity services, the revised guidance is applicable to women while they are inpatients in antenatal or postnatal wards or attending a maternity hospital for the following reasons: a 12-week scan; early pregnancy; an anomaly scan; attendance at a foetal medicine department; pregnancy loss and bereavement; and for the duration of labour and birth. That guidance has been updated and is on our website. I will send it across to the Committee so that it can be circulated because I know that a narrative started around what was and was not possible. The Chief Nursing Officer has done some messaging around clarifying exactly what is possible. When a woman goes into a side ward or a single ward for labour, the partner can be there for the duration and for a number of scans, but we will forward on that specific updated guidance.

In regard to additional attacks and violence in the learning disability sector, I am not aware of those, Gerry, but if you can provide us with information and specifics, we can follow up on that.

The Chief Medical Officer has led on the neurology recall. He met a number of charities recently.

Dr McBride: Yes, on 18 August.

Mr Swann: That was the last update. Michael, do you want to comment briefly?

Dr McBride: Yes. Gerry, you have raised the matter at many meetings in perhaps more normal times, and there is absolutely a commitment from the Department and the Minister to engage with the families as broadly as possible. We have had engagement with the neurology charities, and I and others met the charities on 18 August. Obviously, the charities do not represent all the individuals who have been caught up in the neurology recall. Again, I acknowledge the pain, hurt, concern and ongoing anxiety.

The difficulty with the neurology process is that, because of COVID, elements of the work that would be further progressed by now have not been progressed and have been paused. We recently recommenced that work. As I said, there is a commitment to engaging with the families affected. The challenge will be how we will do that with the current situation around community transmission of COVID, but there are means to do that using technology. We need to explore how we do that rather than allowing further time to elapse. That is not as satisfactory as doing it face to face. Perhaps there could be a combination of face-to-face meetings, such as we are doing today, plus others connecting remotely.

Mr Easton: Thank you for your presentation. To be clear about face masks: who is responsible for enforcing face masks being worn in businesses? Is it the business, the police or the council? I know the answer, but I need clarification.

What plans do you have to tackle the huge increase in coronavirus cases in Strabane and Londonderry? That needs to be dealt with quickly.

Mr Swann: The increase in the Strabane and Derry City Council area has been stark and dramatic. To be brutally frank, we were not expecting it. Further recommendations are going to the Executive this afternoon, specifically for that area. Chair, I have never broken the level of Executive discussion prior to a meeting, so I will not do that. However, I expect there to be further announcements later today on the back of our recommendations.

Our reading on the wearing of face masks in retail is that it is a law that has passed and is in regulation. The police have a responsibility, which I know that they have been reluctant to use to date. You may be aware that the Executive have set up a subgroup on compliance and enforcement of the regulations and the legislation that is already in place. It is being led by the junior Ministers and has representation from local councils, the PSNI and a number of statutory bodies in order to get that message through. It is one that we have never wanted to have to utilise, to be honest. When we see the level of non-compliance, we will have to go that way. We are also adding further regulations or recommendations on where face coverings should be worn, rather than just the current settings.

Dr McBride: I will go back to the Chair's comments at the outset. We do not need to wait to be told to do the right thing. As the Minister said, we cannot police or regulate this virus out of existence. I encourage everyone to wear a face covering in an indoor environment, and that includes settings where it is currently not regulated or mandated to do so. If you are sitting in a restaurant and not eating or drinking and you get up to move around or to use the toilet facilities, wear a face covering. If you are in a retail environment, you wear a face covering. If you are on public transport, you are mandated to wear a face covering, as you are in the retail sector. We all have our part to play. First and foremost, it is everyone's responsibility. Shops and the retail sector can decline entry to people and, indeed, some are doing so. Some of the big supermarket chains have taken action to do that recently. Where there are challenges and regular non-compliance, the police have a role. I am probably straying outside my responsibilities, but my view is that it is not, first and foremost, a responsibility for the police. The police have a role, but it is our responsibility, as citizens of Northern Ireland, to do the right thing to protect our family, friends and everybody else.

Mr Sheehan: It is clear from the statistics from the South that deprived areas are most affected by COVID transmission — for example, Tallaght, Ballymun and so on — while places such as Killiney and Blackrock have the least infection. What measures are you putting in place to ensure that the areas that are disproportionately affected will get the greatest support?

Mr Swann: We see the same evidence in Northern Ireland. You will know that from what we see in Belfast and the postcode restrictions. It is about making sure that testing is accessible and having conversations with our GP colleagues in those areas so that they can supply the necessary support. We are also working with your party colleague, the Minister for Communities, to make sure that the additional support packages that were available during the initial phase of lockdown are still there to support communities as and when they need them.

It is about having equal accessibility to health services no matter what your postcode or where you live. We are working with the Department of Education to make sure that any health messaging is being utilised and that children are taking it home to parents to make sure that we are getting the message through.

We are aware of ethnic minority populations in those areas. The PHA is engaging with ethnic minority organisations to translate our guidance into a number of languages. I met the Polish consul yesterday to utilise his offices. We can put out as much messaging as we want, even through this forum, TV channels and newspapers, but a large section of the community and the ethnic community is not utilising those channels. It is imperative that we use every means of access and everything that is available to us to get our health message through.

Mr Sheehan: In terms of accessibility to the health service, we had a debate during the week about children with hearing difficulties having access to tests. We had the news yesterday that 30,000 women have missed out on breast screening since the pandemic started. You know about this case — you have communicated with the family — of the young woman with endometriosis who is in excruciating pain but cannot get surgery. A lot of people are saying that we now have a COVID service rather than a health service, and, unless you have an immediate life-threatening condition, it is very difficult to get treatment. When can we expect a resumption of normal services?

Mr Swann: Pat, I do not have an answer on when normal services will resume. To do that, we would have to say that COVID has gone away and that we are not putting the necessary resources in place to support patients with COVID. We are dealing with surge plans and our three-monthly rebuild plans to open up as many services in as many locations as possible and to ensure that it is safe to do so.

In January, our challenge was to run a transformation service beside a health service. We are now trying to run a transformation service beside a health service beside a COVID service. I will not deny that that is the main part of the work that we are doing as a health service. I am still working with a reduced number of staff. We are recruiting, but it takes time for those people to come to the front line. We are working with a tired workforce. They were tired in January and when they were going through the first phase, and they are tired now, but they are still there. They are dedicated and want to deliver as many services as we can safely deliver. I go back to the Chair's comments, and that is why we are looking at different approaches: orthopaedics, elective day-care surgeries and cancer rebuild services. It may mean that people have to travel to access a certain specialty, but we have to do it to deliver the service.

Mr Sheehan: May I make a quick comment?

The Chairperson (Mr Gildernew): Very quick.

Mr Sheehan: A lot of people do not understand why the services are not available. In some cases, they hear that surgeons are willing to operate now, tomorrow or whenever. Other services have been suspended and people do not understand why, other than hearing about the broad brushstroke that people are needed on the front line. If it was explained better as to why services have been suspended, people might be more understanding.

Mr Swann: That is a fair point, Pat. It goes back to your point about a surgeon being available, but the waiting room may not be available and the nurses and cleaners are all somewhere else. It is the strength and the weakness of our service that it relies on everybody who is a part of it. It does not just fall to one individual.

Dr McBride: Very briefly on that point, Pat, if it would be helpful. We must primarily provide a service that is safe for those who need access to it, notwithstanding the fact that people need access and that there is an immediacy and a challenge around the delays that people are experiencing. It has to be safe not only for the individual patient who needs the treatment or screening test but for the healthcare professional. Take, for example, screening services: there are 28 work streams under the rebuild programme board, and rebuilding screening services is one of them. Throughput in screening services reduced by 50% because, as the Minister said, of the number of people whom you can see in a particular clinic and the time that needs to elapse between when individuals are seen and the donning and doffing of PPE by staff. We have taken a risk stratified approach for screening, and we look at people at highest risk so that we can prioritise them. We will not have business as usual for many, many months — I think that Paula asked that question at a previous Committee meeting — and until such times as we have better control of the virus.

Mr Chambers: Minister, last week, we had a presentation from a professor from Hong Kong, who told us about the good COVID outcomes that it had had because of lessons learned from the devastating SARS outbreak. Hong Kong created 1,400 isolation rooms in its hospitals, there was no shortage of PPE and there was intense ongoing infection control training. We all acknowledge that the NHS was not in a good place in the early part of this year, but how much additional pressure did the inadequate backup stocks of PPE and the availability of ventilators in the early stages of the outbreak create for your Department? How would you describe what your Department and the staff throughout the NHS at all levels have achieved in dealing with the infection?

Mr Swann: I will go back to the Chair's point, and there was a worldwide clamour for ventilators. We never got to the point at which we were looking for a ventilator because we had enough, but we are still buying more to make sure that they are there.

Our challenges with PPE have been well documented. We had a four-week supply, which was the normal level, and we went through that in a matter of weeks. We have now moved to a 12-week supply, which is the pandemic level. That is the level that we are maintaining. We had challenges with PPE and got to a position at which we were able to deliver it in a better way for our care home sector, our GPs and our hospitals. With regard to isolation rooms, I would love to have inherited an estate like the one in Hong Kong. Hong Kong probably has that estate because it has learned over time, and, coming out of this pandemic, we will look at our estate — where it is, what it is being utilised for and what work needs to be done on it.

Ms Flynn: Following on from Alan's point, I do not know whether you picked up on this, but, in the presentation last week, we learned that Hong Kong is using one model of testing kit. We are using different models, so I do not know whether the Department is looking into that.

Two quite significant issues have arisen in Committee in the past couple of weeks about legal advice. The first one was raised by the Chief Pharmaceutical Officer, who was asked a few questions on the Internal Market Bill and whether she could guarantee that there would not be medicine shortages in the North. She took that issue away and was awaiting legal advice. Do you have any update on that?

We also had a briefing from a departmental official last week on data sharing between the North and the South. There have been some difficulties with that process, and there was a meeting with the legal team last week on it. Are there any updates on those two pieces of legal advice?

Mr Swann: Those are detailed questions, Órlaithí [Laughter.]

I have written to FM and DFM on where we are on the Internal Market Bill as an Executive; it is not solely a Department of Health issue and has been raised through the EU committee of the Executive. That letter asks them to look for a 12-month derogation on what we have so that we do not hit those problems. The letter has just been sent, and I have had no answer or feedback. Chair, I will make sure that the Committee is copied into any reply that I receive.

You asked about data sharing between the North and the South. There was a meeting last week because we had received input from the Attorney General in the Republic of Ireland. He said that he did not think that it was legally possible at that point and that he would look at what work needed to be done to change that. The North/South Ministerial Council meets tomorrow in health format, so it will be me, Stephen Donnelly and the two CMOs. We expect an update at that meeting on what we need to do to progress the matter.

We have a good working relationship. It is about legalities rather than about the will of the Health Department or the Health Service Executive (HSE) in the Republic of Ireland. I do not think that there is any reluctance to do it; it is just about the practicalities and legalities. We are working on that. Michael, do you have any comment?

Dr McBride: There are differing legal interpretations of the ability to do that. The Attorney General in the Republic of Ireland appears to be clear that, unless it is for a particular purpose, in that the information is obtained in the Republic of Ireland for utilisation there, the current situation is that they are not able to share it outside the jurisdiction. Our advice is that there are exceptions to that, so both legal teams are discussing it to get that issue resolved. It is a technical legal matter that is well beyond my competence, I am glad to say, but it needs to be sorted.

Ms Flynn: I have a very quick second question.

The Chairperson (Mr Gildernew): No, Órlaithí, sorry. I have to move on. I have only enough time for other members. You had two questions. Go ahead, Paula.

Ms Bradshaw: Thank you, Chair. I want to come back to the issue of companionship in maternity services. I will get a wee message up on my screen. I got this from a constituent last week:

as you know, that is in the Ulster Hospital —

I have a constituent who had to drop one child off to say goodbye to the mother. He then drove to McDonald's and pretended that this — their mother passing away — was not happening, because they could let only one of the children say goodbye to her. I could read out 100 emails about the really horrendous situations that people are in because they are not able to be with loved ones at these critical times.

We are storing up a mental health pandemic due to the trauma that people are enduring because they are not able to see their loved ones at times of birth, traumatic antenatal appointments or at the end of life. This virus will be with us for some time. What are you doing around home births, palliative care at home or other ways in which people can be with their loved ones when they need to be? The situations that people are being put in are inhumane.

Mr Swann: I would say, Paula, that the virus is inhumane, because it kills people. The guidance on hospital visiting was not a decision that my Department took easily, and it was not easily recommended by the Chief Nursing Officer and her team. They went through all those different scenarios. Our Chief Nursing Officer, her midwifery team and the team that draws up the guidance and recommendations were at those bedsides and in those wards before the pandemic, and they have experienced this. We have not brought in these recommendations on hospital visiting for ease. They are to make sure that we can provide as safe a service as possible to the people who are utilising it and for the people who work in it.

Unfortunately, we have already seen, in the past number of weeks, outbreaks in hospital settings. We do not want to see an outbreak of COVID-19 on an antenatal ward or a maternity ward. These decisions are hard to make because we know the effects that they have. In regard to the decisions being proportionate to provide safety in a workplace setting and for family members as well, it is what we are there for, what is recommended and what we have brought forward, and I stand over that. You have received emails and messages, and I can assure you that I have received them, too. They are heartbreaking and hard to read, but, when I get advice and guidance from my medical team that says that this is proportionate, I accept that advice because they are the experts.

Ms Bradshaw: Are you looking at any alternatives such as people being able to put on PPE, home births and palliative care at home?

Mr Swann: It is about the utilisation of PPE in those scenarios. In palliative and end-of-life care, there is a support mechanism, and there is a specific section in the hospital guidance, as there is on maternity services.

You asked about providing palliative support at home. It was Palliative Care Week last week. There are organisations, which are part of our Department and the health service, that deliver that for people who want it. Not everybody wants that. We cannot support that without additional resource, which we do not currently have.

A number of midwives are there to support home births but in very specific circumstances

Michael, do you want to come in?

Dr McBride: Yes.

The Chairperson (Mr Gildernew): Very briefly, Michael, as I have another member who wants to come in.

Dr McBride: Those are valid points. It is about achieving a balance. We have a responsibility to recognise the point that you make, which is that visiting is hugely important. That is why we have maintained visiting. There are exemptions for palliative and end-of-life care in the guidance, which I refer you to. We have also maintained visiting in care homes because we know the real harm that comes to older people, particularly those with dementia, who are deprived of direct, face-to-face contact. We have put precautions in place. Throughout the pandemic, arrangements have been in place for women in labour, and arrangements have been in place whereby partners can accompany them at staging scans or foetal abnormality scans.

The enemy here is the virus. What we try to do in all of this is to balance the risk of visitors, not just to the individual patient who is in a ward or unit but to the other patients. It is a difficult juggling act, but it is one that we cannot duck. I apologise for the distress caused, but we are trying to do the right thing to keep everybody safe.

Mr McGrath: As I am at the end of the list and much has been asked, I have one or two comments rather than specific questions.

I am a living embodiment of the COVID app working. I got the alert on Monday during the Executive Office statement. I immediately left the Building and came home. I have been in isolation since and will be until the 14 days pass. Later that evening, I had questions and things that were going through my head. I found it difficult to find the information. I tried ringing the helplines, and they rang out. I searched the internet and eventually found some of the information that I was looking for.

I previously asked one Department for a simple flow chart to enable businesses to find out what they should do when a member of their staff has COVID. That was published this week, and the business sector has said that it finds it incredibly helpful. It is clear and concise. It is one page, which they look at and know what to do. Does a simple graphic like that exist for someone who thinks that they have COVID so that they know whether they have symptoms, whether they are being told to isolate and what they should do? Many people are visual; they could look at an image, trace it through and know exactly what they have to do.

Mr Swann: Colin, no, I do not think that there is a simple graphic, but there will be shortly. It is about having a graphic or flow chart with easy steps. I know that it is on the app, where it is easy to access and follow through. The app takes you through steps and stages, but not everybody is seeking and utilising that guidance or advice through the app. We will follow up on that.

Mr McGrath: The text messages that are sent out were mentioned. I appreciate that, because of the sheer numbers — two weeks ago, there were maybe 30 cases a day; there are nearly 300 now — staff will be under a lot of pressure. There has been a bit of spike in my area, and, as a result, lots of people are getting messages and updates. However, I know one person who has been waiting for the best part of 48 hours now and has not had any contact from the contact tracers. The text messages are good, but there needs to be a dedicated person at the end of a dedicated phone line so that, if you get that message, you can ring them and get some information.

Finally, I echo what Paula and others said. I have been contacted about end-of-life visiting by people for whom it has been a very traumatic experience. They are not able to say goodbye. If there are other ways to help people in that scenario, those would be really appreciated.

The Chairperson (Mr Gildernew): OK. I appreciate that this morning's session has been very tight. Hopefully, we will be able to get into some more detail. While you are here, I want to reflect our ongoing concerns about the level of information that we are getting on statutory rules (SRs) and our ability to scrutinise the restrictions and regulations. I flag that up as a concern.

I have a quick final point, Minister. What is your analysis of what is driving the current surge? What are the key issues behind it? What key things should people do?

Mr Swann: If you have specifics on information for the SRs, will you give them to us, please? It is part of the complication that has developed. They all relate to health, so they all come through the Health Department and through you, as a scrutiny Committee, but some decisions are without [Inaudible.]

The Chairperson (Mr Gildernew): We have raised issues with your officials, so they should be aware of the information —

Mr Swann: We will follow up on that.

The Chairperson (Mr Gildernew): — that we are looking for. That is in the system. The problem is that we do not have it.

Mr Swann: Community transmission is driving the current surge. There are small numbers — five and fewer — of social clusters in the Derry City and Strabane District Council area. We can garner information only from the information that people give to our tracing team. If people are not forthcoming, we cannot capture it. That is why the contact tracers go through their specific list of questions and ask about a person's activities, what they have done and where they have been. As far as we can see, it is community transmission. As I said previously, we cannot point to any one business, industry or locality and say, "It's that"; if we could, it would be easy to control. We saw it at one point in BT43, where we had an outbreak that was associated with a meat factory and the community around it. In that case, we knew where to target our focus. We also saw it in the early days in Limavady, I think, around a karaoke party. Everybody told us that that is where they had been, and we were able to expand from that. From what we are seeing, there are small amounts of community transmission.

Dr McBride: More broadly, the seasons are not with us. We are into autumn and winter, and we know that coronaviruses and respiratory viruses spread more readily because of our behaviour. During autumn and winter, we spend more time indoors and less time outdoors. That will be a challenge in the months ahead.

The Executive, rightly, decided to make significant relaxations from May. Associated with that, as Pam mentioned, quite a number of the population — not all — relaxed their adherence to the simple message of watching their distance, washing their hands and wearing face coverings. We need more people to download the StopCOVID NI app, and we need more people to self-isolate when advised to do so, as Colin is doing. If people need to get a test, they should get a test and complete their period of self-isolation. All of us will have to hunker down hard for the next six months, until we get to the spring. It will be a very challenging period, as you said, Chair.

The Chairperson (Mr Gildernew): Colin, on behalf of the Committee, I wish you and your family well at this worrying time. It is good to hear of a positive example of the system working, because it is vital that it holds up.

Thank you, Chief Medical Officer and Minister, for attending this morning. We look forward to seeing you again.

Mr Swann: Thank you, Chair. Again, I thank you and the Committee for your continuing support of our messaging. While we have the siren voices who seem to want to challenge for the sake of challenge, one thing that has been steadfast is the Committee's support for our health service. You challenge what we do, but you support the message that we need to get through to the public of Northern Ireland. Thank you for the work that you continue to do.

The Chairperson (Mr Gildernew): Thank you. Ádh mór. All the best.