Official Report: Minutes of Evidence

Committee for Health, meeting on Thursday, 2 April 2020

Members present for all or part of the proceedings:

Mr Colm Gildernew (Chairperson)
Mrs Pam Cameron (Deputy Chairperson)
Ms Paula Bradshaw
Mr Gerry Carroll
Mr Alan Chambers
Mr Alex Easton
Miss Órlaithí Flynn
Mr Colin McGrath
Mr Pat Sheehan


Dr Cathy Jack, Belfast Health and Social Care Trust

COVID-19 Disease Response: Belfast Health and Social Care Trust

The Acting Chairperson (Mr Sheehan): I think that we have the chief executive of the Belfast Trust, Cathy Jack, on the line. Are you there, Cathy?

Dr Cathy Jack (Belfast Health and Social Care Trust): Yes, Chair.

The Acting Chairperson (Mr Sheehan): Cathy, you are very welcome to the Committee. I am Pat Sheehan. I am acting as Chair today. The Chair and the Deputy Chair are unable to attend Parliament Buildings. There are a number of Committee members here in the Senate Chamber in Parliament Buildings. Another few — three, I think — are joining us remotely.

I welcome you to the Committee. I commend you and all your staff in the Belfast Trust. I know that it is the job of health and social care (HSC) workers to take care of patients and save lives. That is what happens day and daily. The situation that we are in at the minute is different, insofar as your staff are not only saving lives but putting their own life at risk by going into work each day. I am sure that everyone at the Committee meeting will concur with me when I commend all your staff and wish them well. I hope that they stay healthy and safe in the weeks and months ahead.

Cathy, I do not know whether you want to give a short presentation or just take questions. How much time do you have to give us?

Dr Jack: Chair, I have to join another call at around one o'clock. I thank you and your colleagues around the table for your support at this extraordinary time.

You are absolutely correct: the selflessness of the staff, particularly those on the front line, who are putting themselves at risk — when the world steps back, they step forward — is second to none, and our staff have been outstanding. That is what I wanted to say. I am very happy to take your questions, and I am sure that you have a number of them. You will know that this is an emerging and fast-evolving situation, so if I cannot give you the absolute information that you require today, I will take the question away and commit to coming back to you within 24 hours.

The Acting Chairperson (Mr Sheehan): Thanks for that. I will ask the Chair and the Deputy Chair to come in first. I will come in later, seeing as I hogged so much of the previous business. Colm Gildernew, do you want to come in?

Mr Gildernew: Yes. Absolutely. Good morning, Cathy.

Dr Jack: Good morning, Colm.

Mr Gildernew: I endorse Pat's comments about the work that everyone is doing. I know that you and the trust have been working on a number of things over the past while, so I thank you for that.

My question is on personal protective equipment (PPE). There are conflicting signals about the amount of PPE that is available and that is getting distributed across and within the trusts. Can you give us an idea of how you are fixed at the minute with equipment? Are there difficulties in getting it distributed in your trust area?

Dr Jack: PPE is many things. We have sufficient surgical masks — that is, the fluid masks — aprons and gloves etc. The biggest challenge at the moment is acquiring a special type of respiratory mask, which is the FFP3. That is a challenge worldwide, and it is no different in Northern Ireland. We have a number of stocks of that mask, but every single different type of mask needs to be fit-tested to individuals.

We have had over 6,000 staff fit-tested on a specific type of mask, called the 1895. That mask is required whenever aerosols are generated, so in intubations, in suctions and in the highly complex care that you would see in an intensive care unit or, indeed, a respiratory-positive COVID-19 ward. Stocks of it are currently limited. We were getting in a shipment of 60,000 and had expected our share, which was to be over 10,000. That did not happen. We got just over 1,000 at the beginning of the week.

We have another mask, called the 8833. We have 8,000 in stock and have an assurance from the Department and the Business Services Organisation (BSO) that we will get 30,000 more, but, at the moment, only 666 staff have been fit-tested for that mask. They are in our high-risk areas, and we are able to fit-test 240 staff a day. We are therefore making sure that we match our requirements so that our staff are protected, but PPE, and in particular the availability of FFP3 masks, is a real challenge for us. We are doing everything that we can to protect our staff and to make sure that they are fit-tested and have the right equipment at the right time.

The Acting Chairperson (Mr Sheehan): Colm Gildernew must have dropped off the line.

Mr Gildernew: Sorry, Pat. I lost you for a second. Cathy, thank you for that. I will allow other members to come in.

Dr Jack: I will just add that those are the stock levels in our central store in Belfast. Once we release the stock to the ward areas, we no longer count it. We count it as it is being used in reality. Those are the stock levels in our central store, but we have 30,000 more of the 8833 mask coming today.

Mr Gildernew: Cathy, has the Department indicated when the supply of FFP3 masks, in the numbers required, will be coming to you?

Dr Jack: I understand that the 60,000 masks were in transit but that the delivery was turned back. The Department now expects the supply next week.

Mr Gildernew: Do you know why the delivery was turned back?

Dr Jack: No, I do not. I am not party to that. BSO told us.

Mr Gildernew: OK. That is obviously very concerning and something that we will need to follow up on. Thank you for that, Cathy.

Mrs Cameron: Cathy, thank you very much for being able to speak to the Health Committee. We absolutely understand the pivotal and front-line role that you and the trusts are playing in managing the response to COVID-19. You are absolutely right: the selflessness of staff has been outstanding, and I commend each and every one of you for that.

How is the trust ensuring that charitable contributions of PPE from businesses and individuals are being harnessed in the most effective way in order to meet demand?

My second question to you is about visiting. Are members of the public abiding by the ban on visiting? With whom is the trust working to ensure that the ban is enforced? Is the Wi-Fi system in hospital settings capable of sustaining virtual visiting through video calling?

Dr Jack: Thank you for those questions. The first one was about charitable donations of PPE. We have a key contact through our director of nursing, and that is to where all charitable donations should be channelled. Such donations can be anything from perishable food through to gowns, masks and scrubs. We are overwhelmed by the generosity of local people, small businesses etc in supporting us at this time. We have a key contact whom we are promoting on social media and in our daily COVID-19 updates to all our staff so that we can manage the situation safely and make sure that donations are equally distributed to the areas of need. As I said, we have a key contact, and we can share who that is with you, if that would be helpful.

Mrs Cameron: That would be very helpful, Cathy, because we would like to do our bit in any way that we can to share that information. I know that the public are very keen to help out in any way that they can, so that would be appreciated.

Dr Jack: I will share that with you after the call.

The second question was about visiting. The ban on visiting has gone live. As you know, it is one parent whose child is in hospital, one birthing partner or one family member, if a relative is receiving palliative care, and visiting is restricted to one hour at a time. That is to reduce the viral load on individuals who are visiting, to promote social distancing and to protect our staff.

We have worked very closely with families in the Mater Hospital, and we have purchased a number of iPads that families can use through our Wi-Fi system to link to their loved one at a distance. Therefore, although only one member of the family can visit for no more an hour, other members of the family can call in. We have just cleared the purchase, through charitable funds, of another number of iPads, as we move into the City Hospital tower and other areas.

I have to tell you that the nursing staff in the Mater have been exceptional. That initiative has been driven by the front-line staff, because they are committed to compassionate care, so I am being guided by them. We also can link to chaplains in the same way.

With patients on a palliative care pathway or who pass away without someone at their bedside, the nurse caring for them will write a personal card to their family within the next week to discuss how they passed away, their symptoms and anything that they said in their final moments. That is not the way in which we would wish to deliver the care, but it is a new world, so we are doing all that we can to connect through our Wi-Fi and our iPads. We are not having a problem with our Wi-Fi at the moment in getting video calls through.

Mrs Cameron: Cathy, that is really good to hear. Your comments really drive home how serious an issue this is and what incredibly difficult circumstances we are in. We can only sit back in awe of what you guys are doing to try to look after each and every one of us, and the fact that you are doing so with such sensitivity at this time is greatly appreciated. I want to finish by thanking you once again. I would appreciate it if you would pass on my thanks to your colleagues at this time.

Dr Jack: I will indeed. Thank you very much.

Mr Carroll: Thanks, Cathy, for your presentation. I want to add to the concerns raised about PPE. I am still hearing reports of staff not having the appropriate or enough PPE.

You may or may not be aware, but the Chartered Society of Physiotherapy (CSP) emailed me, and I assume other members, to say that staff who are delivering urgent respiratory care have highlighted the fact that they do not have enough equipment and said that some of them have been threatened with disciplinary action. I am not sure whether you are aware of that, but is it of concern to you, Cathy, that staff do not have enough equipment and that, when they are raising that as an issue, some of them are being issued with the threat of action possibly being taken against them?

My other question is about ventilators and ICU beds. Are you confident that we have enough ventilators and ICU beds at the minute to deal with a worst-case-scenario number of people with COVID-19? I think that 18% of the population have respiratory problems, so are you confident that we have enough ventilators and ICU beds to deal with people who contract COVID-19?

Dr Jack: Gerry, thank you for that. There are two questions and some of them have different parts. I got the CSP letter, through


last night. I have asked for that to be looked at. Clearly, as you know, I take this very seriously, and the most important thing that I and my organisation do is ensure that staff are protected appropriately when they put their own health at risk on the front line. We need to make sure that they have the most appropriate PPE, and I will do everything that I can to make sure that staff have that at all times.

I am really shocked that anyone would threaten physiotherapists with disciplinary action if they do not want to go in because they do not feel that they have the appropriate PPE. That is not an organisation that I recognise and, if it does happen in Belfast, you can contact me later because I would be very keen to deal with that immediately and stop any recurrence of that.

One of the challenges with PPE guidance is that Public Health England (PHE) and the Public Health Agency (PHA) here have given the national guidance but some of the Royal Colleges have given slightly different guidance. The four Chief Medical Officers (CMO) in the different jurisdictions are meeting to try to rationalise that into a single, cohesive guidance, because this is clearly very upsetting and very confusing and is very difficult for organisations to manage. We have been tasked to manage the PPE guidance in line with PHE and PHA advice, but this is evolving and emerging. I also understand that more guidance is due out in the next 24 or 48 hours, which may change the guidance around some of the aerosol-generating treatments.

Physiotherapists are members of staff on the front line with aerosol-generating treatments, so I absolutely hear what you say and I need to look into that to make sure that my staff are fully protected. They should be protected at all times. That is my commitment you.

Mr Carroll: I will contact you if I am given any more information. Do you think that staff are equipped appropriately enough with PPE at the minute?

Dr Jack: I think that we have enough at the moment. My big challenge will be in three or four weeks You will have seen that the surge plan is projecting a 20-week surge. The supply chains are opening up. The Department is working on — we have asked for it — having a central store of perhaps 30,000 masks so that, at any time, our staff know that we have enough masks in our back pocket to keep them safe. That would build a reassurance in the system and that is why I was delighted when we got clearance that 30,000 masks would be coming to Belfast today. If we go into the regional Nightingale hospital, the only thing that I can do is make sure that I have enough oxygen, that my staff are protected and that I can support them in delivering the care that they want to provide.

Mr Carroll: What about the ventilators?

Dr Jack: In the reasonable worst-case scenario, I have sufficient ventilators in Belfast to deal with that. You will know that, in the regional surge planning — the modelling that came out yesterday — there was different modelling. If you look at the reasonable worst-case scenario, with the new ventilators that are coming — I understand that those have been confirmed — they should have enough capacity for the 118. However, in the modelling, you will also see that, in the worst-case scenario, if social distancing does not work, approximately 1,000 people would need to be ventilated. We do not have that number of ventilators in the system at the moment.

I have enough ventilators at the moment. I also have enough ventilators for the reasonable worst-case scenario modelling, but if we had the absolute worst case, we would not have enough. I know that ventilators are coming to Belfast because of the Nightingale model that we are being asked to provide for the region. That is 230 ventilated beds on the City Hospital site. At the moment, Belfast does not have that, but I have assurances that those ventilators are coming to us to provide the care that we need to provide.

Mr Carroll: Thanks for your answers, Cathy. Your last point was very concerning, but I appreciate your answers. Thank you.

Ms Flynn: Can I come in?

Ms Flynn: I want to indicate that I would like to come in at some point when there is space.

The Acting Chairperson (Mr Sheehan): OK. No problem. I will put your name on the list. I have Alan, Paula, Órlaithí and Colin on the list of members who want to ask a question. Alan.

Mr Chambers: Thanks, Chair. Cathy, I would certainly like to be fully associated with the remarks of the Chair in offering the support and good wishes of the Committee to you and your staff.

A few weeks ago, the Mater Hospital was announced as the Belfast centre for patients who had contracted the virus. Has the entire hospital been set aside for that function or just a specialised part of it? Last night, a statement was issued that the City Hospital was now going to receive those patients as well. Does that indicate that the Mater Hospital has reached capacity for dealing with infected patients, or is there still some spare capacity there? The statement also said that existing patients in the City Hospital were being moved to other locations. Can you assure us that moving such patients will not compromise their well-being? Thank you.

Dr Jack: OK. Thanks for your good wishes, Alan. I think that we need to be very clear about the local plans in Belfast, the regional ask and the regional requirement.

Can I just go back to the ventilators? Locally, in Belfast, we have enough ventilators for the modelling, but, as we are asked to take on a regional role for a regional intensive care facility in the Nightingale, that is where the 230 ventilators come in and that is where I am saying that that will be a step up. We do not have those 230 ventilators on-site today, but I have an assurance that they are coming. I just want to be clear on that in case my clumsy way of speaking did not get those messages out there.

The Mater is the local hospital for Belfast. It is not yet at capacity. We have over 70 patients with COVID-19. You are correct that that hospital has, in its entirety, been given over to the management of patients with COVID-19 symptoms, and our flows into the emergency department through ambulances mirror that. What was announced last night was the regional requirement for a 230-bed intensive care unit that will not just be for the people of Belfast but for those in Belfast and beyond and will supply the regional requirement for intensive care. The reason for that is that you can, by consolidating the really skilled expertise, safely manage greater numbers in one location. The same discussion was had about a potential field hospital. However, because the City Hospital has good infrastructure and the oxygen supplies, the decision was taken regionally that it would be a better fit for us in Northern Ireland at this time. They are different pieces of work; it is local plans versus regional plans. We have emptied the City Hospital tower block from levels 1 to 9 and we have emptied some wards in the Royal because we are consolidating regional services. Our very first phase in the surge plan was managing the small number of cases in our infectious diseases unit in the Royal Victoria Hospital in ward 7A. Our second phase was planning for the Mater as a COVID-19 hospital. This is now our third phase, and it reflects the regional requirements.

We have moved some low-risk fracture patients out of the Royal Victoria Hospital. We have moved hepatobiliary services out of the Mater. We have moved our large complex gynaecology surgery and our large complex colorectal and upper GI all over to the Royal into those vascular wards, and the low-risk fractures have been moved to Musgrave Park. These are unprecedented times. We are working to secure the flows of patients receiving cancer treatment in the Northern Ireland Cancer Centre and Bridgewater so that there is no transference. If we need to totally distance services, there may be some shift in some flows in cancer treatment out to the independent sector. We are working as a region to make sure that our key services continue for those who are most in need. As a region, we need to protect the regional specialist services like neurosurgery and vascular and cardiothoracic services. We need to protect our trauma flows into the Royal — the surgery that can only happen there — and yet we need to be ready and prepared for those patients and the increasing number of COVID-positive patients who will need acute medical beds and large numbers of intensive care unit beds.

Mr Chambers: Thanks, Cathy. Stay safe.

Ms Bradshaw: Thank you, Dr Jack. I want to raise a couple of issues. I am not sure that you will necessarily have an answer to the first one, but I want to make sure that you are fully aware. As MLAs, we are receiving correspondence from petrified staff members, who may be single parents, who have children at home who are very vulnerable and have additional needs. They are so scared to go into work in case they carry the infection home to their loved ones. When they raise these issues with their line managers, they are offered, in some instances, three days of unpaid carer's leave and that is putting them in a really difficult position. Do you have any comment on how they could possibly be accommodated?

I appreciate your update on cancer treatments, but there is still a bit of confusion and a lack of information about the breast-screening programmes and whether people should attend. I looked on the trust's website and I think that there are maybe some information gaps there. If the patients and the website could be kept updated, that would be appreciated.

I am not sure whether you were listening, but I asked the Minister how many extracorporeal membrane oxygenation (ECMO) systems he has ordered. He confirmed that he has none here in Northern Ireland but that he had a pathway to use the Northern Ireland air ambulance service to ferry people about. Are you concerned that, when ventilation fails — obviously, there is a time factor here — patients may die if these ECMO systems are not here in Northern Ireland?

Dr Jack: Paula, please call me Cathy. You asked about the carers. Like any organisation, we have a number of staff who are single parents and we are actively working with them to try to support them. We have a number of childcare schemes. We have up to about 130 places and that is about to expand to 250 so that our key workers can come into work and do the job that they want to do but also be protected.

We also have a number of staff who have vulnerable children at home and who do not necessarily want to go back home. We have secured accommodation for them in some of our local hotels so that they can sleep safely and can get a warm meal and a good breakfast. Our local schools have been tremendous; we have showers available through schools such as St Malachy's, Methodist College and St Mary's. Those are our big sites. Belfast City Council is exploring the option of using leisure centres for our community workers, and we are also looking at a number of pods so that our staff feel that they can go home safely at night. We are now running our summer schemes within the trust, not only linking with the schools, and we are making sure that, when they come to work, all our staff have free car parking and can get meals in our canteen and any hot drinks that they need, because the whole success of this will rest on how we care for our staff who care for the patients in need. My number-one priority is caring for the staff so that they can care for others who need it.

You raised the issue of screening programmes. That is an issue for the PHA. As you know, those are regional programmes that are managed through the Public Health Agency, not in the trust. We are continuing to run our assessment programmes if the screening programme flags an issue, but the question about the screening programmes really needs to be directed to the Public Health Agency.

Lastly, you raised a very specific issue about ECMO. That is a very specialist service that needs highly trained and skilled individuals who also need to be regularly undertaking it. Clearly, these have not been ordered, but we have always, even during the swine flu epidemic, been able to access those very specialist centres in the UK. National ethical guidance is being developed to ensure that there is fairness and equity in the use of those scarce resources.

Ms Flynn: Thanks very much, Cathy. As a Belfast MLA, I want to thank you for all the work that you have been doing. I know that Carál Ní Chuilín has had a brilliant working relationship with you over the past couple of weeks and you have been really responsive to any issues that we have brought to your attention. As locally elected reps, we really appreciate it.

Dr Jack: That appreciation goes two ways, because you hear different things than I might hear. If that is happening, I am very receptive to hearing the voices and trying to address any issues of concern. As you know, if there are issues with the supply chain, I will tell you.

Ms Flynn: Cathy, that is brilliant. It is great for us to hear. We really appreciate it.

I will bring it back to Paula's point about the anxiety that is naturally creeping in among staff about going to work and possibly contracting the virus and bringing it back to their families. In the first session with Minister Swann, we said that one of the big elephants in the room at the minute is the impact that the lack of testing could be having on our health and social care staff. I want to ask you about the uncertainty around staff getting tested and the psychological impact of them going home to their families while also trying to carry out their life-saving duties in work. Do you have any idea of the impact that this is having on your staff in the Belfast Trust area? Do you have a figure for how many are currently off sick? Obviously, a proportion of those people could be in work doing their duties if they were being tested. Do you have any concerns that your staff in the Belfast Trust are not getting the maximum amount of testing that they need in order to allow them to be in work and to give them reassurance and security that they are safe to go home to their family? That is the first question about the testing.

The second issue that I raised with the Minister was the broader issue of the mental health of the workforce. Robin Swann said earlier that work is under way and that support will be there for staff who need it. I am interested to hear your views on that and on whether there is anything that we can do to help, working with the Minister, to make sure that we get those provisions in place to help staff over the next couple of weeks and months.

Finally, if you do not mind, a query was brought to my attention by district nurses working in some of the community centres. They asked whether, once they have been in contact with a patient who has tested positive for COVID-19, they are — it is as simple as this — expected to travel home in their own car and in a uniform that may be contaminated. There could be a scenario where children are getting into that same car later on that afternoon, that evening or the next day. You mentioned briefly the shower facilities within trust premises. Are you content that district nurses and other staff who are working with COVID-19 patients have access to shower facilities so that they are not contaminating the whole building? Are there measures in place to ensure that, if they are working with a patient, they can get a shower or get their uniform washed? There are some wee concerns about practical things like that. I know that I gave you a lot there, Cathy. Thank you.

Dr Jack: Not at all. If I heard you right, there are three elements: testing, mental health and how the district nurses can protect their families.

As regards testing, at the moment — these are yesterday's figures — I have 1,200 staff who are self-isolating because a family member is symptomatic, and I have 791 staff who are self-isolating because they are symptomatic. That is just under 2,000 staff, which is nearly 10% of my workforce. Clearly, if someone is symptomatic with a high fever, you would not want them at work anyway. If they have COVID-19, you certainly would not want them at work. If they do not have COVID-19, they may have something else that is infectious. So, we are really looking at how we can test the 1,200 who feel well but have a family member or a close contact who is displaying symptoms.

The big challenge is that, whilst our laboratory staff have worked outstandingly and stepped forward, and whilst the number of tests that we can do in the lab has increased from 40 up to nearly 900 or 1,000 a day, we have an issue with the reagents and the Roche supply chain. Whilst we have machines that can do the tests, they rely on reagents that come from outside Northern Ireland to undertake those tests. At the moment, with the amount of reagents that we are getting, our limit is 300 tests a day. I know that the Department is looking at that. It is looking at the universities and at the Agriculture Department. It has a regional group looking at whether we can do different tests to upscale that to the level that we need and whether we can open up the supply chain of the reagents — the sort of liquid that we need to run the tests — to get back to the capacity that we currently have in our lab. I would like to see the majority of those 1,200 staff, if they do not have COVID-19, coming back to work. That means that we would be testing family members and close contacts.

On the second issue about mental health, we have a clinical psychology service. Sarah Meekin is running a team within the organisation to look at how we support staff right across our organisation in managing their mental health at this time. I told you about some of the issues that our nursing primary care support staff are having to grapple with in the Mater. I have asked them about their personal experiences in the palliative phase that people move into. Is it a good death? Do patients struggle? How are they managing their own mental health? They have a safety huddle every morning when they come in; they talk about, "Here are our stores. These are our challenges today. Is everybody OK?". They have a touch-out. At the end of a shift, they take time out to check in with their mental health. We have a B Well app. Our occupational health team is looking at how we can support staff. I know that there is a regional piece of work that is looking at the mental health of our workforce. We have had a number of retired psychology staff and psychiatric staff coming back with offers of help so that they can help to support staff. We already have Schwartz rounds and Balint groups. That is about how staff feel when they come into work. How do they feel at the moment about the situation that they find themselves in? It is an opportunity for staff, in a safe space, to talk about their feelings. We are linking them through the Microsoft Teams platform, where people can be socially distanced, yet have a safe space to talk about the challenges that they face in a completely different world from the one that we normally work in. This is all extremely difficult.

Lastly, on your issue about district nursing, I absolutely hear that. We are looking at guidance about how to clean cars. We want staff to come in their own clothes and be able to change into scrubs, work in scrubs, with appropriate PPE. When they have finished their job, they will shower, put their scrubs in the laundry — knowing that there will be sufficient to pick up the next day — change into their normal clothes, clean their car and then go safely home. I cannot stress this enough: my job and the job of all the management in Belfast Trust is to support staff to do the job that they need to do and to protect them while doing it.

Ms Flynn: Brilliant, Cathy. Thank you very much.

Dr Jack: We are looking at using leisure centres and pods for showers, as well as anything else that we need to do. If they do not feel safe going home, we will link with local hoteliers to get them a nice warm bed, clean sheets, a good meal and a good breakfast to be able to go back in the morning to face the challenge of the day ahead.

Ms Flynn: Thank you, Cathy.

The Acting Chairperson (Mr Sheehan): Thank you, Órlaithí. I want to bring in Colin McGrath now. Colin, do you want to take this seat?

Mr McGrath: Can we just check? Cathy, can you hear me from here?

Dr Jack: Yes, I can hear a little bit. Excuse me if I ask you to repeat anything, but I can hear you.

Mr McGrath: That's OK. I have come a bit closer to a microphone that works.

Dr Jack: That is much better.

Mr McGrath: I appreciate that you have answered lots of questions at this stage. It must be difficult to be under such intense pressure to give detailed answers, so thank you very much for the responses to date.

I want to ask you for your view on testing. We seem to have decided only this week that we should be increasing testing, although we are probably a good six weeks into this pandemic in the North. Do you feel that we have missed something by doing the not testing to this stage and now suddenly deciding that we should do it?

This is a separate question. What are your connections with the private sector on the ground? Obviously, private care homes, private residential homes and private nursing homes are clambering to get the same stock that you, in the National Health Service, are trying to get to as well. Do you have any way of checking whether there is scarcity on the ground? If a private residential care home was not able to get the right level of stock, would it be able to contact you to get some stock?

This is my final question. I understand that figures released today show that, so far, there has been a 20% rise in domestic violence. That is obviously shocking. The trust probably works in partnership with a number of domestic violence organisations, so I was just wondering whether it is a key responsibility for somebody to ensure that the provision of appropriate services that need to be on the ground is not prevented as a result of the coronavirus outbreak, and that every service that is required for those who may be suffering from domestic violence is handed out to them. Thank you.

Dr Jack: OK, Colin, I think that there are three key areas that you want me to cover. First, we continue to do our best on testing with the resources that we have. I acknowledge absolutely that we need to test the patients who come in to be under our care so that we can make sure that we manage them optimally and protect our staff at all times. The key workers who need to be tested are those who are delivering essential services, such as our health and social care staff, including members from the independent sector. We are working on extending that in the region and in our other agencies. I am not responsible for regional procurement, but we link in with our sister organisations through silver command to raise that point. I know that that work is ongoing at a regional level and is linking with any private providers, universities and other Departments and agencies in government to try to get the resources that we require to extend the testing.

The second point that you raised was about private residential care in the independent sector. We have a number of clients in those institutions. We have a clear designated distribution point and a named member of our staff who is responsible for distributing PPE to those organisations. Whilst I acknowledge that those organisations are normally responsible for sourcing their own PPE, it is very clear that, if they do not have available sources, they can come to local trusts to be provided with it. To date, Belfast has always matched that. We have provided it and have very good working relationships with our local nursing and residential facilities and even local hospices. We have provided them with the PPE that has been required, and we will continue to do so. That is part of our central distribution point. We have done that, we will continue to do that and we have stock for it, so I can give you some reassurance on that.

On domestic violence, I have to check, but we have not seen an increasing number of cases as I sit here today. That has not been flagged to me as something that is coming through our local EDs. We have clear schemes for our staff if they have any issues, but we would, of course, not stand down any of our work with sister organisations across Belfast that deal with domestic abuse and mental health and physical well-being in the home. We continue to do that, and, while we may not be the lead organisation for it, we certainly have our staff on the ground linking with those that we need to link with to ensure that we can provide whatever help we can.

Mr McGrath: Thank you very much.

The Acting Chairperson (Mr Sheehan): Cathy, this is Pat Sheehan, the Acting Chair. I want to ask you a couple of questions about the virology lab and the processes in testing. I also want to ask you about the mortuary services.

First, on the virology lab and the testing that takes place there, I understand that that is the only place where testing for COVID-19 is happening. Is that right?

Dr Jack: No, that is no longer the case. Initially, it was, Pat, but COVID-19 testing is now available in the Northern Trust, and I think that there is also some available in the Southern Trust. If it is not available there, it is due to come online in the near future. So, two other trusts are now testing.

The Acting Chairperson (Mr Sheehan): OK. Will you walk me through the process? My understanding is that there is a testing kit and that swabs are taken from someone who is suspected of having an infection. What happens after that?

Dr Jack: OK. I visited the virology lab, I think about a fortnight ago, to look at their systems and processes and to meet the staff. I am not a virology expert, so forgive me if I get this wrong. They have separated their sampling collection points. As you know, swabs are taken from an individual's throat and nose. They are then triple-bagged or triple-boxed to make sure that they are marked separately and very secure, and there is a separate reception centre for the COVID-positive, or suspected COVID-positive, specimens. The first thing that happens when specimens arrive in the centre is that they are inactivated so that the staff in the lab are not put at risk when they process them. My understanding is that the process is based on RNA and replicating it up at scale. There are a number of steps in the process. Staff inactivate it, clean it, multiply it and can then show whether the test is positive. A small number of tests need to be checked again if the result is borderline.

We now have three different machines doing that, which means that we have some resilience in the system. That is why we have our own machine, which delivers 150 every day, but the other machine depends on a Roche supply of kit that comes from elsewhere. When you put the sample in, you have to put it in the fluid medium where you grow the inactive RNA so that you can test it on the machine. It is that medium that we are struggling to get through the supply chain.

The whole process takes about four and a half hours from the time that the sample arrives in the lab to its being verified by a consultant virologist. These are all formally accredited tests, so we know that, when we give a positive, we can stand over that result.

I hope that that makes sense. If not, it is probably because of my clumsy way of describing it. If you would like a briefing, I am sure that our consultant Conall McCaughey, who is superb on this, would be happy to talk you through the detailed process. That was just my layman's view of what happens in the lab.

The Acting Chairperson (Mr Sheehan): I understand that, Cathy, and thanks for that.

I suppose that, as Colin said when he was asking his question, there is some surprise that the level of testing has not increased substantially over the past number of weeks, given the warnings that we were getting from China as far back as early January. I understand that there appears to be a problem with the reagent, or the medium, that is used to test the samples, although I noticed that a journalist tweeted the other night that he had spoken to representatives of chemical industries in England who told him that the only reason why there was a shortage was that the reagent had not been ordered or asked for. I suppose that is by the by, but we now understand that that has created a pinch point in the system. Are there any other areas where there are difficulties or obstacles? Are there enough testing kits and so on? Have enough staff been trained? Is the virology laboratory big enough to cater for the demand if there were sufficient testing kits, reagents and so on?

Dr Jack: As you know, capacity in the lab to do the tests has increased considerably, and we are up to 1,000 tests a day. Just for your information, we did 514 on 31 March — that is yesterday's data — and a total of 86 were positive. That shows you the level that we are working at. Our rate-limiting capacity in the lab is not the manpower or the equipment but the supplies of the reagent, which come from Roche.

The second thing that you asked about was the testing kits, which are the swabs. We have a sufficient number of those. We have two pods: one outside the Royal Victoria Hospital and one just off the Crumlin Road.

We take up to 120 a day for testing, and we open that up for our staff to be tested, because the patients are being tested as they come in to our ED, or for staff from other hospitals and the Northern Ireland Ambulance Service etc who are coming through. We have the ability to test 120.

I saw this on the news yesterday, and I know that there is work looking at increasing testing using different sites across Belfast so that we can increase the level of testing. I also know that the Northern Ireland Blood Transfusion Service is looking at how it can come online to double the testing capacity, and then, from the regional calls and silver command, I know that the universities are looking at that and at how we have worked. They are looking at how we can train some of their staff. DAERA is also involved. I know that a lot of work is going on in that area to scale up further, but the rate-limiting step for us today is, as you said, Pat, the reagent.

The Acting Chairperson (Mr Sheehan): Thanks for that. My understanding is that there is a very small number of staff in the mortuary services in the Belfast Trust and, specifically, in the Royal. What restrictions have been put in place when someone dies as a result of this coronavirus? What processes are in place to handle the remains after death?

Dr Jack: Guidance was released just yesterday on the care of the deceased and on how we can make sure that there is no onward transmission after death. This is something that individuals are not sure of, so there is detailed instruction on how we secure the body in a secure bag and how that bag is then secured and zipped. You are right: we have limited capacity in the RVH mortuary at the moment. We are meeting the demand. I know that phase 1 and phase 2 have been about preparing for ill patients, and work is ongoing at a regional level for phase 2 to use the regional forensic coroner's service and then on to the work — [Interruption.]

The Acting Chairperson (Mr Sheehan): Sorry, Cathy. Are you still there?

Dr Jack: Yes.

I heard the Justice Minister talking about the decision on the field mortuaries. There are three waves in this, but, as I sit here today, the RVH mortuary is able to meet the current demands. Very detailed instructions have gone out to our hospital staff and local undertakers on the care of the deceased. As you know, it is really difficult for everybody — really difficult.

The Acting Chairperson (Mr Sheehan): I take from what you are saying that the relatives will not be able to view the deceased — their own relatives — after death.

Dr Jack: Not once the body has been placed in the bag and then the external bag as well. Several bags are used to make sure that there can be no onward transmission. That is one of the many heartbreaking things that we face now. It is just not the way Northern Ireland works. It is just not what we do here.

The Acting Chairperson (Mr Sheehan): That is all the questions that I have.

Mr Gildernew: Can I get in there if Cathy has another minute?

Dr Jack: Yes, Colm.

Mr Gildernew: I want to flag up one issue that is not directly related to you, and then I have a question.

The Committee will be discussing later correspondence that we are engaged in with the Department about other vulnerable groups, in particular those with motor neurone disease. I want to flag up that there may be particularly vulnerable groups here that have not yet been identified, and that may increase the pressure on services, particularly in the Belfast Trust. So, I wanted to flag that up to you.

There has been documentation lately that says that the trust will be interpreting flexibly — this is to do with nursing homes and residential settings and discharges from hospital into those homes — the requirements on reviews and assessments, including the regulatory standards. First, what discussions have you had with the Regulation and Quality Improvement Authority (RQIA) and the trusts about those standards? Secondly, what support are you giving to the care home sector to ensure that it has proper guidance on how to treat and look after people who are discharged in order to protect them and the people who do not have COVID-19? In practical terms, what are you doing to support that sector to provide oxygen, medicines, including anticipatory medicines, and PPE, which we are all aware there is a wide of range of concerns about?

Dr Jack: OK, Colm. On your first question about the vulnerable groups, including those with motor neurone disease, I know from the electoral register and GPs that vulnerable individuals are being identified. The PHA and the region are identifying through a heat map vulnerable individuals across different localities. I have seen some of the basic maps, and we hope that, once the information has been cleared with the CMO, we will get right down to a level of detail that will help us to safely manage those who are most at risk in the Belfast locality. There has been a huge amount of work in that area. If we can get access to that information, it would really help our community teams and the volunteers who are coming on board now to ensure that, in a time of social isolation, we are a connected community right across the city.

On your second question about the trust, the nursing homes and the residential homes, there has been a change in RQIA. RQIA wrote out about its role in the regulation of nursing and residential homes and how it is freeing up its staff to go in and support nursing homes at this time. As you know, we have a named contact for our nursing homes who advises on the appropriate use of PPE, makes sure that PPE is there and looks at the other requirements. I do not know specifically about the provision of oxygen because that is usually done through community pharmacists, but I will pick that up, Colm, and take it back.

We are also looking at how we use our acute-care-at-home team to support our GP colleagues and better manage those individuals who live in a nursing home — that is part of their normal home — and how, if they get ill, we can support them in that environment to a much better degree than perhaps we have done historically. There is a lot of work going on in that area.

The heat map shows all our nursing homes and residential homes as well as the number of individuals in those homes so that we can see where the risks are. In the sitrep of our community services that I get, I get the number of positive cases and the number of suspected cases. Any staffing issues or challenges are also flagged up in our daily sitrep. I do not just have a hospital sitrep for Belfast; I have a community sitrep for adults and a children's community sitrep that is coming online, so I can see the entirety of the services that we are responsible for. Patients and clients in nursing homes are still our responsibility, and I will do all that I can to make sure that they are well looked after and that the staff looking after them, whether they are in the independent sector or in statutory homes, are also provided for and looked after.

Mr Gildernew: Could I ask you a hypothetical question? I know that this is not a hypothetical situation by any means, but if you could focus on one thing and one thing only to help you do your job in tackling this disease, what would it be?

Dr Jack: For me, it would be about ensuring that I have the confidence of the staff and that I support them to do the job that they need to do. That is about making sure that the staff's anxiety about PPE has been addressed and that we have in our stockpile a bank so that they know they will be safe at all times, and it is about making sure that I can provide the small comforts. As in Maslow's triangle of human need, I want to make sure that they feel psychologically safe as they come in to do the work. That is where I would focus. You asked me for one thing, but I am going to ask for a second, if I can, which would be that we could test the families and the key workers to ensure that we have enough staff at work, if they can be at work, as we face into the surge. We are looking into unknown and uncharted waters. Thirdly, I would connect our staff right across, continue to tell them how fabulous they all are and make sure that the small comforts are being addressed. That is my wish list of three things.

Mr Gildernew: Thank you very much, Cathy. It is incumbent on all of us who are involved in this to deliver on those three requests and ensure that those tools are put into your hands and those of front-line healthcare staff, who are out there doing all that they can and who will be severely challenged in the time ahead.

I want to end by reiterating my thanks to you and your staff for the way that you have engaged with reps across the board. That has been hugely helpful, and I know that you acknowledged that. I wish you and your entire staff all the best over the weeks and, possibly, months to come. Thank you, Cathy.

Dr Jack: Thank you. Public support has been overwhelming, and every single one of us is touched and humbled by it. In this time of social isolation, I have seen communities come together like never before, and the partnership working across all the sectors and with the MLAs and so forth is exactly what we need to get through this. I will give your thanks back to you, to the Health Committee, to everybody in the room and to all your partners and contacts. You are doing a fabulous job, too. Thank you. Keep coming with queries, because that is very helpful to us all. We will take them away, get back to you as soon as we can and address them, because it is only by working together that we can get through this.

The Acting Chairperson (Mr Sheehan): Thank you very much for that, Cathy. Thanks for your time. Needless to say, you have the best wishes of all of us on the Committee in the days, weeks and months ahead. I reiterate the commendation that I gave to all your staff; not just staff the Belfast Trust but staff in all the trusts and all those who are on the front line putting themselves at risk. Thank you, and thanks to everyone else.

Dr Jack: Take care, keep safe and thanks again.

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