Official Report: Minutes of Evidence

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


Witnesses:

Mr Swann, Minister of Health
Prof. Sir Michael McBride, Department of Health



COVID-19 Disease Response: Mr Robin Swann MLA, Minister of Health; and Dr Michael McBride, Chief Medical Officer

The Chairperson (Mr Gildernew): I welcome Mr Robin Swann, Minister of Health, and Dr Michael McBride, Chief Medical Officer (CMO). I invite you to brief the Committee, Robin. I ask you to be as brief as possible, as the members are up to speed on a lot of the general issues and we want to get a good question-and-answer session in today in light of the fact that your time has been limited.

Mr Swann (The Minister of Health): I appreciate that, Chair. I thank you for facilitating the change of date. The Executive was meeting on Mondays, Wednesdays and Fridays, and two weeks ago we moved to Mondays and Thursdays. I appreciate that you have facilitated this meeting on a Wednesday.

Chair, as ever, thank you for the opportunity to update you on the latest developments regarding my Department's ongoing response to COVID-19. I hope that today's update will paint a more optimistic picture than that which I provided the last time we met. A number of restrictions have now been eased, and we are seeing a steady fall in the death rate in Northern Ireland. Both are positive and welcome developments, but I cannot and will not forget those families who are suffering and will continue to suffer, as loved ones lose their battle with this horrendous disease.

Chair, this is Mental Health Awareness Week, and I want to take a few moments to acknowledge the pain and loss being felt by families right now, the pressure being felt by our Health and Social Care (HSC) workers and the daily worries and concerns facing local people who have adapted their lives to adhere to the restrictions currently in place. None of this was easy, none of this sits comfortably with our normal way of life, and none of us are alone in feeling this way. That is why, just a number of weeks ago, I announced my intention to put in place a mental health champion who will work to further the mental health agenda, to promote emotional health and well-being and, importantly, to promote recovery. I am pleased to say that the officials in my Department are working to progress this new role as I speak, whilst also working with colleagues in the Health and Social Care system and the independent sector to provide help and support during these difficult times. As you will know, yesterday I published the mental health action plan, along with a dedicated COVID-19 response plan which outlines the psychological well-being and mental health response to the current pandemic.

Together, Chair, we will get through this, and nowhere is that more clearly illustrated than in the collective impact we have made in recent weeks by socially distancing to save lives. Before the introduction of social distancing, almost three other people were infected by each COVID-19 patient in the community. As a result of the effort we have undertaken together at great cost to our lives and liberty, each COVID-19 patient in the community now infects less than one other individual, and that is reflected in our R value being 0·7 to 0·8. Thankfully, the death rate for COVID-19 in Northern Ireland is decreasing. While some people are becoming overnight statisticians and epidemiologists, with a tendency to make crude and often ghoulish comparisons on death rates, I encourage everyone to pay attention to the actual evidence and not to personal assessments presented as scientific fact. Chair, in reality the CMOs on both sides of our border have said that the spread of the virus and the numbers of those who have sadly passed away remain comparable. However, I will again make the point that we must not get too hung up on the language of statistics, because we must never forget that behind every single figure was a person who was loved and who is now missed.

Since we last met, Chair, some of the restrictions have eased. While some adjustments are being made to restrictions as part of the first step of the Executive's recovery plan, we must not let up on the efforts that are being made, nor undo the hard-fought progress that has been made in flattening the curve. I must commend all our citizens for the tremendous compliance and tolerance that they have displayed. We are making really strong progress in slowing the spread of this virus because of the sum total of responsible actions being taken by individuals in our community.

You will be aware that last week the Executive announced our five-step plan to aid recovery and renewal, taking into consideration the most up-to-date scientific and medical advice. We are progressing through step one of that pathway, which has seen the reopening of garden centres and recycling centres from Monday of this week, as well as the important step of allowing marriage ceremonies to take place for those who are terminally ill and want to fulfil their personal wish to marry their loved ones. In addition, the Executive have also agreed that groups of up to six people who do not share a household can now meet outdoors, as long as social distancing is followed. Churches will be able to open for private prayer. Outdoor activities, whether for work or leisure, can take place. Again, these are dependent on social distancing and good hygiene being maintained, particularly where surfaces may be touched by more than one person. As a result of the easing of these restrictions on outdoor activities, some sports, such as golf or tennis, can restart.

As I have said before, we need to take small steps as we move along the pathway to recovery. However, we will of course keep all these things under review. While some restrictions may have been eased, the advice on shielding remains current. Anyone advised to shield by their GP or hospital specialist should continue to do so until advised otherwise in order to protect themselves from infection. We are working at a national level to develop the future of the shielding programme. This work will carefully consider the need to protect people who are extremely vulnerable against the latest evidence of the risk posed by COVID-19. This is complex and detailed work, and we must ensure that we get it right. We are now starting the long journey back to something closer to normality, but be assured that we have not lost sight of those who have had to shield. As our plans develop, they will include updated advice and support for those who are shielding in their own homes.

I have been clear that I will constantly seek ways to help care home staff, and the vulnerable people they care for, stay safe and well in the face of this current pandemic. My Department and the wider health and social care service have taken a host of measures to support the care home sector at this difficult time. Guidance on responding to COVID-19 in community and residential settings was first issued in February and has been updated and revised in line with emerging evidence since then. It provides advice specifically for the care home sector on a range of issues, including personal protective equipment (PPE), infection prevention and control measures, visiting restrictions and testing. The most recent updated guidance was issued on 26 April.

We have continued to expand testing in care homes in line with scientific advice and guidance. As of yesterday, 4,950 residents have been tested; that is almost 40% of our entire care home population. In addition, 4,816 care home workers have been tested. Chair, as of 9.00 am this morning, there are 70 homes with confirmed outbreaks of COVID-19, with a further 34 suspected or possible outbreaks, and 35 care home outbreaks have concluded since the start of the pandemic. Whilst we are by no means through the storm, I am reassured that the situation in our care homes has greatly stabilised, especially when compared to the ongoing situation in care homes across the rest of the United Kingdom.

Last week, I announced the deployment of testing capacity by the Northern Ireland Ambulance Service and up to 40 nurses from the HSC system. At the beginning of this week, I announced a further expansion so that COVID-19 testing will now be made available to all care home residents and staff across Northern Ireland. HSC trusts have stepped in to provide thousands of hours of free staffing time to homes that need it. We have prioritised any professional staff returning to the HSC for deployment into the care home sector where their skills and experience match requirements. We have also reached agreement with local universities to bring forward the qualification date for social workers, allowing them to enter the workforce several weeks earlier than would have otherwise been the case. The Health and Social Care service has also supported care homes through the provision of PPE free of charge. By the end of the week just past, trusts had provided more than 1·5 million items of PPE to the independent sector care homes.

I will continue to review emerging evidence and best practice locally, nationally and internationally, and will actively consider any other measures that have the potential to protect care home residents and staff. Last Friday, building on that evidence, I issued guidance for care homes on a proposed new model of protection: Safe at Home. This model seeks to test the impact of staff living in or close to care homes on preventing the spread of infections.

Measures aimed at safeguarding the financial resilience of care home providers by guaranteeing a level of income have been in place since 17 March. This has since been supplemented with a support package of up to £6·5 million to address the additional costs that they have faced. However, I believe there remains scope to do more, and I intend to bring a paper to the Executive in the very near future that proposes, as an immediate priority, additional support for care home staff. While the allocation of £19·7 million of additional funding to Northern Ireland from Westminster will not automatically come to my Department, it will help to deliver this additional support.

I am keen to give way to your questions as soon as possible, Chair. However, if you will permit me, I will provide a short update on the work my Department is progressing on the test, trace, isolate and support strategy. That work is designed to break the chain of transmission of the virus by identifying people with COVID-19, tracing people who have been in close contact with them, and supporting those people to self-isolate so that, if they have the disease, they are less likely to transmit it to others. Our Chief Medical Officer has established a strategic oversight board for that work which will bring all the key elements together, namely testing, contact tracing, information and advice, and support. Support from the public will be absolutely critical to the success of the strategy, as we will be relying on citizens to report symptoms, to be tested and to follow self-isolation advice if recommended. However, let me assure you that participation will be voluntary and that people will have full control over what information they choose to disclose.

We have tested the processes for contact tracing and, as from Monday, we have been undertaking contact tracing for all confirmed positive cases of COVID-19. The service is built on a contact tracing pilot that was run by the Public Health Agency (PHA) and which began on 27 April 2020. The pilot programme had been operating on a five-day-week basis — the first of its type in the United Kingdom. Despite some slightly inaccurate reporting this morning, we have now firmly moved beyond the pilot phase. The service is now operating over a seven-day week, which will be a major commitment as we expect the service to be in place for the next year, at least. As an illustration, on Monday 18 May, we added 36 confirmed cases to the programme and successfully followed up on 35 of them. We already have sufficient numbers of trained contact tracers in place to trace all confirmed cases at present. A large number of volunteers have come forward to offer to assist with that work, and the Public Health Agency is finalising job descriptions for the service.

In conclusion, I would like to add that the number of COVID-19 patients requiring critical care has maintained a gradual downward trend, allowing the decision to reduce the escalation level for critical care to "low surge". By way of illustration, that meant that, last week, I was able to announce that the Nightingale facility in the Belfast City Hospital tower block was being stood down. That is good news, because it will allow for the reintroduction of urgent surgery and a range of other key services on the site. I am acutely aware, however, of the severe impact that COVID-19 has had on the whole breadth of key services. Shortly, I will publish a strategic framework for rebuilding HSC services, but instead of waiting until that happens I have also made it clear to the trusts and the Department that, as soon as services can be turned back on, I expect them to be, and that is already happening.

As I said last week, before COVID-19 our waiting lists were awful, but now they will be frightening. It will require serious efforts and serious financial commitment to fix the damage that the virus has done, yet it will also be important to recognise that there will not be a return to business as usual, because COVID-19 will be with us for some time. There is no doubt that we have come a long way in a short time — the response by so many has been overwhelming — but we must be in no doubt that there is much more still to do.

I am happy to take members' questions.

The Chairperson (Mr Gildernew): Thank you for that, Minister. In the first instance, I acknowledge the developments that there have been. The expansion of testing into the care home sector for staff and residents is welcome, as is the further deployment of nurses and the commitment to proceed with investment in the reform of adult social care, including care pathways and training.

I want to focus on care homes. On 5 March, Sean Holland appeared at the Committee, and I asked him about the arrangements for care homes. He told us on that occasion that the Chief Medical Officer, Michael McBride, was leading the effort to contain the spread of COVID-19. On 23 April, in a meeting with the Health Committee, the Chief Medical Officer stated:

"The important elements are that our health and social care system is ready for any surge. That will be right across, from beds in hospitals, intensive care and, importantly, capacity in the community sector, in nursing homes and care homes, and making sure that there are resilient surge plans. We are working very diligently, right across the sector, to ensure that that is in place. You are absolutely right: now is the time to do that."

Considering that the COVID-19 crisis has developed in the way that it has developed in the care homes, do you still believe that everything was done to ensure that resilient surge plans were put in place in care homes?

Dr Michael McBride (Department of Health): Thank you for your question, Chairman. From the very outset, we made it clear that, as I said in my comments previously, a lot of preparation was going on across health and social care. It is fair to say that the focus — certainly, the media focus — was on the acute sector, particularly around ventilator capacity. Many of the questions that were received were about preparation in the acute sector. That was understandable, because we were seeing reports for other European countries where individuals were not able to access the level of care that would have secured a good outcome. To reassure you, all of that planning and preparation was under way within health and broader social care, the independent sector and the care home sector — both nursing and residential care homes, including domiciliary. That work was led and coordinated by respective organisations, including health and social care trusts, policy colleagues, Sean and his team, and myself and my team to ensure that we had an integrated response. With regard to whether we could have done more, or whether more could have been done, there will come a time for us to look back and examine all that we have done. There will, absolutely, be learning; there is no shadow of a doubt about that. We know more about this virus than we did weeks and, indeed, months ago. Undoubtedly, there will be learning and there will be things that we might have done differently. I am very happy to acknowledge that.

In terms of what we did do and the steps that we did take, I think that we took graduated steps at appropriate points in time. We issued our first guidance to the independent care home sector back on 27 February. We updated and revised that on 13 March, on 17 March, and again on 26 March. We repurposed the Regulation and Quality Improvement Authority (RQIA) on 23 March, from memory, to provide support to the care home sector, particularly around its needs in relation to PPE. We dedicated resources within the Public Health Agency, including our infection prevention and control teams, our nursing teams and our health protection teams, to provide support to the care home sector. As the Minister said in his opening comments, we provide significant expertise and nursing hours into the care home sector.

Our response, from the outset, has been comprehensive, supportive and detailed. There will always be an opportunity to look back and ask, "Could we have done more?", but as we look at how care homes right across these islands have been impacted, I think that the responses we took and the actions we put in place have actually put us in as —. The tragic consequence of this virus is that it preferentially attacks the frail, the elderly and those with underlying conditions. The impact on our care home sector could have been much worse had we not taken the steps that we took at the time that we took them.

The Chairperson (Mr Gildernew): It has also been significant. Was it a mistake, for example, to continue to discharge COVID-positive patients into a setting where it was hard to implement social distancing?

Dr McBride: At a point in time, we will have to look back and analyse the various factors and the decisions that we made. I do not think that any of us in the Chamber today, looking at what was emerging across Europe and the people who were dying because they could not access care, felt that it was anything other than appropriate to ensure that we had the capacity in our healthcare system to provide acute care, including hospital admission and intensive care admission, to those who were sickest. Let us not forget that those who are sickest are often the oldest. The virus preferentially attacks those who are older in our society, and those —.

The Chairperson (Mr Gildernew): But given — sorry to interrupt, Michael —.

Dr McBride: It is an important point —.

The Chairperson (Mr Gildernew): Given that we know that and given that we have known for a number of weeks that the surge has not been as bad as it might have been — due to some good work, and I acknowledge that — should we not have moved more quickly to stop discharging patients from hospitals, and should we not do it yet? I first called for this on 1 April. Should we not yet —.

Dr McBride: With respect, Chair, you have to remember that, at the time when we were making capacity to treat people in hospital, including older people admitted from care homes, we also had to ensure that we protected older people who were in hospital and fit to be discharged from becoming infected in hospital. We also have to bear it in mind that, at the time when we took the decision to discharge from hospital people who were fit to be discharged from hospital, we did not and still have not had significant outbreaks in our hospitals. So to suggest that we had outbreaks in our hospitals and therefore we were discharging significant numbers of people into care homes —.

The Chairperson (Mr Gildernew): I have not suggested that for a minute, Michael.

Dr McBride: I think that the inference from the question is —.

The Chairperson (Mr Gildernew): Well, I do not know where you are drawing that inference from. I am simply asking that, where people have tested positive for COVID-19 or are awaiting the result of a test, those patients not be discharged into a vulnerable setting until they have tested clear.

Dr McBride: What is hugely important is that everyone has access to the optimal care, irrespective of age, and that they are treated in the most appropriate care environment. At the time when we discharged individuals into the care home sector, we had not had significant levels of community transmission, and we still have not had, thank goodness, significant outbreaks in the hospital sector. It is important that we look at the evidence base to see how infections enter care homes — the vulnerability of individuals and the fact that there has to be footfall in and out of care homes because individuals there need very personal care with the activities of daily life that you and I take for granted, and, irrespective of how diligent we are in relation to PPE and infection prevention and control, this is a highly transmissible virus.

The Chairperson (Mr Gildernew): You referred to evidence, Michael. On what evidence are you basing your assertion last week that the virus was going into care homes via staff? What evidence is there that it was via staff rather than via admissions out of hospitals?

Dr McBride: Again, that is a misrepresentation of what I said. I made no such assertion. I said that it would require a piece of detailed analysis and work to understand the various routes of transmission into care homes. If you look at the actual detail of what I said, unfortunately, again, the headline over that was not what I said. What I am happy to provide for the Committee is the evidence base from other pandemics, given the fact that what we do know is that, in quite a number of outbreaks of infectious diseases, it is the movement of staff and others from the community — that is, visitors — that can introduce infections into any enclosed environment, whether that is care homes or other settings. Unfortunately, it is a matter of deep personal regret — let me put this on record — that media reporting of that indicated that the Chief Medical Officer was blaming healthcare workers. Nothing could be further from the truth. As I said in that same response to that question, the enemy here is the virus. The healthcare workers who are providing personal care in the care home sector are the heroes in this, going in, providing care, putting themselves, at times, in harm's way and looking after the very basic needs of those people.

The Chairperson (Mr Gildernew): I think that we all accept that, Michael. I was not calling into question the front-line staff. We appreciate that. I have a concern, and I understand that there will be a time to look back. However, this is a live, dynamic situation, and we do not have time. We need to learn, and implement the learning of, lessons in real time dynamically.

Mr Swann: In my opening statement, that is what I said in regard to how we look at international best practice and what is being done elsewhere. The Safe at Home project is one opportunity we saw from another independent care home provider here in Northern Ireland. We, as a Department, picked it up to try and roll it out across other care homes to try and reduce the number of people who are entering our care homes at this point in time. I visited a care home a couple of days ago that was still working through a live outbreak. The staff were appreciative of the support that they were getting, but they faced challenges by reducing the footfall, they felt, from the support of families to them as staff and to the residents. Both staff and families told me that they knew that it was tough, and they knew that it was a hard time to go through, but they realised that the steps that were being taken were for the right reason.

Are there things that we can learn? Are there things that we are changing and adapting as we go through this pandemic that has been here in Northern Ireland for the past number of weeks? Yes, there are. We are responding, and I think that we are responding quickly. Members in this Chamber will know that, in the past, when we tried to change something in the health service, it took months, if not years. We have responded in a matter of weeks. Will we look back and learn? We are already looking at what is being done elsewhere, and we are already learning. That is why the four nations Health Minister calls are useful, and that is why the calls with Minister Harris, the Tánaiste, the First Minister, the deputy First Minister and the Secretary of State are useful as well, because we can share that information. I think that it is important that we use this stage to learn and adapt. There will be a time for inquiries and for evidence gatherings, but let us do it when we have fought through the battle. One of the things that we should not allow —.

The Chairperson (Mr Gildernew): Let us also agree that we do not have the luxury of time.

Mr Swann: That is why I say that we have to adapt and learn from best practice now. I think that we are, when we look at the international best practice and we start to make those changes. Nothing that we are doing is so set in stone that it is not adaptable to change. That is the point that I want to make. With regard to inquiries and asking questions, could we have done something different knowing what we know now? With the speed with which this virus has progressed through Northern Ireland, through the health system and across the world, we are talking about weeks. Nobody knew in January what we know now about the virus and how it behaves, because this was a new virus that was attacking and tackling us. I hope that that is useful, Chair.

The Chairperson (Mr Gildernew): There are things about all viruses and pandemics and rules that apply across them. Those play books have been written and, despite the fact that there are novel things about coronavirus — we all accept that — there are certain things around testing, tracing, isolating and stopping social interaction and all of that. I am going to move on, because I want to give members an opportunity —.

Mr Swann: Sorry, Chair; can I just come back? With regard to all pandemics — you mentioned testing — we have never managed a pandemic like COVID-19 where testing was so important or was utilised to the extent that it has been. When we tried to deal with SARS, avian flu, swine flu and all the rest of it, we were not doing the same testing programmes that we are now; we never went into the isolation and the lockdown phases that we are now. This virus is like nothing else that we have combated. It is so virulent, and it is so deadly as well. That is one of the things that we need to be cognisant of.

Dr McBride: Again, it is important to emphasise that the only pandemics that we have dealt with in decades have been flu pandemics. Think back to 2009-2010: we did not test extensively for H1N1. We had community surveillance in place. This virus is different. The same rules do not apply. This is a highly transmissible virus, more infectious than the flu virus. We often forget that, outside of China, no one knew about this virus until the end of December. We did not have a test in the United Kingdom. Indeed, we were one of the first countries to have tests until —.

The Chairperson (Mr Gildernew): That was one of the big advantages that we had at the start: we had testing, but the tracing was stopped.

Dr McBride: I am sure that we will come on to that, as we have every time that we have come before the Committee, and I am sure that we will come onto it this time as well, because it is an important issue, and obviously I am happy to take questions on it. To say that this is like any other virus — I think that, as the Minister has said, this is different from any other pandemic that we have had this century.

The Chairperson (Mr Gildernew): I am not saying that. I acknowledge that there are novel elements to this, so I am not saying that it is like any pandemic. What I am saying is that there are certain things in pandemics — truisms that exist.

Dr McBride: I accept that.

The Chairperson (Mr Gildernew): OK, I will move on to members. Alex first, please.

Mr Easton: I suppose I need to declare that my sister is a nurse and she has got COVID-19, so she is off sick at the moment. That is just to keep myself right.

Thank you for your presentation. I believe that you are doing the best job that you can, Minister and Chief Medical Officer, and I want to acknowledge that to you. I believe — I may be wrong — that there are two wards closed in the Ulster Hospital and a whole floor in the Lagan Valley Hospital. What is the extent of the closures of wards due to a lack of staff because they have been infected with COVID-19? Will you give us an update on how many staff have actually contracted COVID-19?

Mr Swann: Thanks, Alex. First of all, pass on our best wishes to your sister and wish her a speedy recovery, and thank her for the work that she is doing. The most recent figures that I have — these are figures that I carry to every briefing now, no matter where I go — show that 284 staff were absent due to a positive COVID-19 test across the National Health Service. That is the equivalent of 0·4% of the staff population. Some 1,792 — 2·5% — are self-isolating. They may be self-isolating due to a family member or due to having received a shielding letter. Therefore, something in the region of 2·9% of our entire staff are currently off, either because of a positive COVID-19 test or because they are self-isolating. For comparison, 4·8% of our staff population are off due to medical reasons. In the comparison of the two, it is a good place to be, but it is not a good place to be for people like your sister, because we know that they have been there doing the work, and we want to get them back to full health and back to the front line as soon as possible.

Mr Easton: My next question is on nursing homes, and it is something that I do not understand. In nursing homes, the majority of people who seem to be getting infected in the nursing homes are elderly, which I do understand, but while some of them are, no doubt, being admitted to hospital, a lot of those who die are dying in the nursing homes. I do not understand why they have not been admitted to hospital. Is there any reason or explanation for not admitting them to hospital?

Also, you mentioned that 4,950 residents and 4,816 staff have been tested, which is good. Do we have any number for how many of those have tested positive?

Mr Swann: I have that figure somewhere, but the Chief Medical Officer will have it to hand. Just under 11% of staff in care homes who have been tested have tested positive, and about 17% of residents. They are not insignificant numbers, but, to put them into perspective, since our testing programme has started in those homes where there are infections or suspected infections — we are testing that cohort first — we were expecting those numbers to be higher. As we move into the other 300-odd homes that currently have no COVID-19 infections, that percentage will start to come down. It is important that, at the start, we focus our testing capacity on those homes with positive COVID-19 results or suspected outbreaks. The Chief Medical Officer will speak about the best place of treatment.

Dr McBride: Across the United Kingdom, there are some 400,000 individuals in care homes. There are significantly more beds in the care home sector than there are in the acute sector. The vast majority of those individuals are over 80 years of age, and there is a preponderance of females, because women live longer than us males. Many of those individuals have very complex needs and significant underlying health problems — two or more, often three or more. Many of them, not all, will have dementia, and many of them, but again not all, may be in the last months or year of life. However, we must not forget that most people, irrespective of age, recover from COVID-19; I think that that gets lost sometimes. The loss of life is tragic, and behind every one of those numbers that we see is the personal loss of a grandparent or other relative, but most people, irrespective of age, will recover from this. Obviously, that becomes less likely as you get over 70, and over 80 in particular.

In the care home, it is appropriate that a discussion takes place between the family and relatives of the individual and the staff to discuss the most appropriate care for that individual. We need to bear in mind that the care home is the individual's home, and we also need to consider what the right care is. The relatives, the general practitioner and others in the home will discuss that. That is obviously a very sensitive matter and an issue that you would expect to arise. In looking at the holistic needs of an individual, whatever is the most appropriate care for that individual will be the care that that individual receives. If it is felt most appropriate for that individual to be transferred into the hospital environment for acute care, then that is the care that they will receive. The Minister announced last week, I believe it was, that we have also been bringing hospital care, as it were, into the care homes. The Minister directed it, and we have worked with hospital trusts, the acute care at home teams, the enhanced care at home teams, general practice and respiratory nurse specialists, doing virtual ward rounds and telephone consultations so that we provide the appropriate support for those staff working in the care home sector.

As the Minister said in his previous statement, one of the learning points from this, as if we ever needed to learn it, is that the care home sector is not what it used to be. The level of acuity of individuals, as the Minister said —. Nursing homes effectively are now providing care that used to be provided in the old "care of the elderly" wards some years ago. Nursing homes are now providing that care, and residential homes are essentially providing the level of care that nursing homes used to provide. So the answer is that whatever is the most appropriate care for an individual will be the care that they receive, whether that is to maintain their treatment and support in a care home or whether it is a transfer to a hospital environment.

Mr Swann: Just to come in on that best practice thing, we developed the virtual ward round visits for care homes that the Chief Medical Officer announced earlier, and, not to blow our own trumpet, three days later Matt Hancock announced a similar system for the NHS in England. So there is sharing of practice; it is not all about ownership or keeping those ideas to ourselves. Once we develop and we see them working, we share them.

The Chairperson (Mr Gildernew): I am all for that. We can be the exemplar. There is no reason why we need to follow people, so I am all for that.

Just to be clear, I have advised members that everyone has approximately five minutes, so, where one of you can answer a question, that will be fine. We will try and keep within that five-minute period, but thank you.

Mr Swann: I think we come as a double act now. [Laughter.]

Mr McGrath: Thank you for the work that has been done to date. I acknowledge the remarks that were made earlier.

Minister, since the week beginning 3 April, there have been 766 excess deaths in Northern Ireland when compared with the average number of deaths for the five-week period previously. There is a suggestion that 568 of those are related to COVID-19, and that leaves us about 200 above and beyond what we would normally have. Beyond the obvious, what concerns you most about that figure of 200 additional deaths where we do not know what the cause was?

Mr Swann: I think that that is the bit that concerns me most, Colin: that we do not know what caused it. We look to the Northern Ireland Statistics and Research Agency (NISRA) to get those excess death figures. We are fortunate in Northern Ireland that we have NISRA, which can undertake that sort of analysis. It does that clinical analysis very well. It is that piece of work where we have to look over that five-week period that you talk about, from 3 April to 1 May, where those additional deaths occurred, and ask what the underlying condition is. That piece of work is ongoing. We also take notice that in the last one, for the week ending 8 May, the number of excess deaths came down to, I think, 62.

Dr McBride: Yes.

Mr Swann: So we are starting to see a tapering down of the differential between the excess deaths and the average number of expected deaths as well. While we were at peak COVID-19 we saw additional excess deaths as well, so, as the number of COVID-19 deaths comes down, that peak is closing as well.

Mr McGrath: Does that not suggest that those people died of coronavirus, if their numbers are coming down at the same rate that the coronavirus number is coming down? That would mean that the number of people who have died from coronavirus is much higher, because that excess death figure is 25% bigger. Also, say, for example, that 10% of those, which would be 20 people, were in nursing homes and care homes, then there are people whom we have not diagnosed as having coronavirus that were actually there, and, as each person transmits it on, it has been passing out and out. I know that this comes full circle to the question that we just needed to ramp up the whole concept of testing much, much sooner, because it would have shown that those people had the virus. Is that not an obvious correlation?

Mr Swann: I hate to say that anything is an obvious correlation when it comes to NISRA reporting, because NISRA is the expert in what it does, and it has been a vital tool. One of the things that we have seen when we get the weekly NISRA update on a Friday is that it does the full analysis piece of every death certificate — so where COVID-19 has been suspected, not just a test. That starts to close that differential of only COVID-19 deaths that have tested positive as well. A further piece of work needs to be done on those excess deaths to see exactly the reasons and the locations.

Mr McGrath: As my colleague Daniel McCrossan raised with you last week, there are people who have had coronavirus listed as the reason for death even though they had not had a positive test. They are included in the figures of people who have had coronavirus, so these are people above and beyond that again. I am a bit concerned, as I have been right from the start, about how we record who has the virus. At my very first Health Committee meeting, I asked you a question about that and got a forthright answer that there was nothing to be worried about. Now, six weeks down the line, I feel that there are some things there that we should be concerned about.

Mr Swann: Since Daniel raised the issue about COVID-19 being on a death certificate where the family felt 100% that it was not there, another MLA has raised a similar case with me. I promised Daniel that we would look into how that can be challenged on a death certificate, if there is a purpose to it or if it can actually be done.

Ms Bradshaw: I dealt with the case of a constituent yesterday; it was cancer in that instance. In the Chamber last week, you said that you would issue the guidance to Members.

Mr Swann: On how it could be challenged, yes.

Dr McBride: If I may, Chair, those are all valid points. As the Minister has said — I know that we are paraphrasing — I worry about every death, but you are absolutely right that there is an issue about trying to understand what the statistics are telling us. Setting aside the fact that those are individual deaths and losses, what are the statistics telling us?

One of the things that we were very concerned about — the Minister made the message repeatedly — was that many people were staying away from healthcare because of two things. First, there is no doubt, having talked to family and friends, that there are people who otherwise would have attended with an underlying health condition or an acute new symptom, but were concerned that attending a hospital would put them at risk of contracting COVID-19. They should have gone to hospital but they chose not to, and that may be a factor. We saw significant reductions in attendances at our emergency departments. Also, there is no doubt that people were concerned about putting too much burden on the health service. People stayed at home who should have come, and that is a real concern for me.

We have issued guidance on two occasions now to the medical profession about the completion of death certificates where there is either a confirmed positive case or a suspected case. We have made it very clear: if it is suspected at all, put it on the death certificate. I am as confident as I can be that we accurately record those that are COVID-related. However, as the Minister said, it will be many months — maybe longer — before we look back and see, of the excess deaths that have occurred in this period, which ones were directly as a result of COVID-19 and confirmed; which were suspected; which were indirectly as a consequence of that; and, perhaps, which were deaths where, tragically, people's lives have been shortened. Many might have died within a year anyway, but their life expectancy was shortened.

Mr McGrath: May I ask you, just finally —?

The Chairperson (Mr Gildernew): I have to move on now. Be very quick, Colin.

Mr McGrath: Chief Medical Officer, you should know that. Northern Ireland is not a big place. If 200 people have died here in the last five weeks, you should be able to tell me exactly what they have died of and what the occurrence was. To me, it seems strange that we have a medical service that does not know why people are dying. You said that there was a piece of work there; can you tell me what that piece of work is? People will want to know that, if 100 people die in the next six weeks, we will be able to work out why.

Mr Swann: Colin, I do not think that that is accurate. We will ask NISRA to do a piece of work because it is the official record-keeper, for want of a better word. It is a piece of analysis that has to be done on the additional death certificates that are presented to NISRA. The death certificate has a main cause of death and then underlying factors as well.

It is a bigger piece of work than simply counting, because of the sensitivity involved. This is not a tick-box counting exercise.

Dr McBride: The General Register Office (GRO), the Registrar General and NISRA provide us with the information. The analysis is carried out by experts in statistics, who look at all of this and produce quarterly and annual reports — they are producing weekly reports at present — that inform us, as Departments right across government, about policy priorities, including that very important analysis that you have just indicated. That is not work that I undertake as Chief Medical Officer, but I do take that statistical analysis and use it to provide advice to the Minister on areas in which we may need to prioritise resource or develop policy. That detailed analysis is carried out by NISRA, under the auspices of the General Register Office in the Department of Finance.

Mrs Cameron: Thank you for being here today, Minister and Chief Medical Officer. We appreciate your expertise, particularly yours, Michael.

On the back of the discussion on the non-COVID-19 deaths and the recording of deaths, do you see the addition of the symptoms of loss of —

Dr McBride: Anosmia.

Mrs Cameron: — taste and smell having an impact on the number of deaths that are recorded as being attributable to COVID-19?

I also want to ask whether the addition of those symptoms will have an impact on people who are shielding. Is there an intention to extend the time for which people should shield, and will they receive further direct communication on shielding advice?

Mr Swann: I will pick up on the shielding question, and the Chief Medical Officer can answer the other.

Some 80,000 people were written to and advised to shield because of medical conditions rather than because they are aged over 70. We are currently reviewing that and providing advice to the Executive. If we are to continue with our current shielding policy, which advises people with underlying medical conditions to stay at home and shield from the virus, we also have to be able to provide them with support, should that be support through the provision of food boxes from the Department for Communities or through direct pharmacy deliveries. That is also being reviewed. Although I have not had direct scientific advice, I anticipate that we will be extending the shielding period. We have not finalised for how long yet. The virus is still out there, and the 80,000-plus people who received a shielding letter are still the most vulnerable and most susceptible to the ravages of the virus. As we come out of lockdown through the different steps, our advice and guidance will be updated and supplied to them.

It is also important to clarify the situation for those who are over 70. If they are not in receipt of a shielding letter, they should be following the general guidance and advice anyway. Shielding is just a recommendation for that cohort of people, so, when it comes to going outdoors and meeting in groups of six, with social distancing, there is nothing precluding the over-70s from doing so, because shielding is not part of the regulations but part of the advice and guidance.

Dr McBride: Briefly, I do not believe that the addition of anosmia — the loss of smell and taste — will have any impact on deaths recorded as being COVID-19-related or on shielding at all. Anosmia has always been recognised as a symptom, but there has been growing international evidence for it and in the UK to the extent that we have now decided that it should be considered a trigger symptom. It has always been listed as one, and there are lots of typical and non-specific symptoms, but we now feel that there is sufficient evidence to show that loss of smell and taste can be an early symptom, even sometimes appearing before the onset of a cough or fever. It has been added so that we catch as many people as we can. I use the word "catch" just to emphasise the point. At the early stage, when people start to develop symptoms, I advise them to isolate and for their household to isolate. I advise them to get a test so that, particularly as community transmission falls and we move into the phase of test, trace, isolate and support, we can ensure that we keep the R value as low as we possibly can and thus break chains of infection.

We will keep symptoms continually under review, as I mentioned to the Chair earlier. Our knowledge is growing all the time, and it may well be the case that, as we move into the autumn and winter, there will be more symptoms that are not really related to COVID-19 but that could be confused with COVID-19. Some of the symptoms are atypical, so we may need to make further modifications and changes.

We will keep shielding under review. We absolutely recognise the impact that it is having on individuals. Before the 12-week period is up, we will provide advice to Ministers on the next steps.

Mrs Cameron: This is a quick one, Chair. I have raised the issue of speech and language therapists before, but I have just received a bit of information that speech and language therapists in Wales have now been given been access to full code-red PPE, when required, by the trusts' infection control group, on the back of an evidence paper from the Royal College of Speech and Language Therapists (RCSLT). Speech and language therapists here are looking for the Department to make a local adjustment to the guidelines to reflect the same in Northern Ireland. Are you any closer to doing that? We are well into this pandemic, and speech and language therapists are doing incredible work on the front line and are very much at risk. To look after both patients and staff, it is vital that they receive full code-red PPE.

The Chairperson (Mr Gildernew): I am glad that it was not a long one, Pam.

Mr Swann: I gave the member the commitment last Thursday in the Chamber that we are looking to update the guidance, especially for treating people with dysphagia.

Dr McBride: Dysphasia.

Mr Swann: Dysphasia. Close. It is to do with the swallow and cough. It is more the cough that is the concern of speech and language therapists. The guidance is currently being reviewed and will be updated.

Dr McBride: Very quickly, regarding the guidance that is in place, it is important that staff feel safe. Evidence is one thing, but it is about whether staff feel safe, irrespective of what the evidence says. We need to recognise that. Indeed, current guidance on the use of PPE does recognise that. It may be that, as community transmission hopefully continues to fall, staff feel more confident in certain situations in which they may not feel confident at present. It is a combination of evidence and practicalities. Staff need to feel safe when they are providing care for patients.

Mrs Cameron: May I just ask quickly again when the decision will be made?

Dr McBride: I assume that it will probably be made in the next number of days, or within a week or so. I am not trying to duck the question. I will be on a call with my CMO colleagues this evening, during which further conversations on this and a range of related issues will take place. It is not the only example, but you are absolutely correct. We need to have a unified position rather than send mixed messages to various professional groups.

Mrs Cameron: I will come back to you in days.

Mr Carroll: Thanks for the presentation. I refer you to the case of Ann McConnell, who is a constituent of mine. There could, unfortunately, be a pattern of behaviour here with other families, but her father was admitted on 16 March to a care home, where he sadly died on 11 April. A number of concerns were raised about infection prevention in that care home in 2017, 2018, 2019 and this year, 2020. He was sent in without the family being given any explanation of the concerns raised. I am concerned at the possibility that there could be a pattern of behaviour there. It could point towards systemic failings that have led to potentially hundreds of deaths in care homes. There is a concern, and it is not just shared by me and people whom I have talked to but people further afield, that there could be a connection between complaints raised and deaths. There have been deaths in Ringdufferin nursing home, where infection prevention concerns were raised, and deaths in Glenabbey Manor care home, Parkview care home, Owen Mor care centre and Our Lady's care home, and those are only the ones of which I am aware. As I said, I am very concerned that there could be a pattern of behaviour there. It is worth saying that my concern is not about the staff, many of whom are agency workers, but about a system of for-profit care, and that is very worrying indeed.

If you are not aware, CMO and Minister, I will bring it to your attention that, several weeks ago, I and other Committee members asked the RQIA what specific plans were in place for care homes and residential homes, and we were referred to winter preparation plans. This is not a flu or anything like it, as people are aware.

The CMO mentioned that this is a novel virus, and that is the case. I am concerned, as are many people, that there is a pattern of behaviour, and if not of neglect, certainly of overlooking, ignoring or not following up on concerns raised about care homes. On 20 March, Michael, you directed the RQIA to stop inspections in care homes. My understanding is that, from 20 March to 30 April, there was only one on-site, physical inspection at a nursing or residential home. Can you confirm whether that was the case? If it is, that very low figure is very worrying indeed.

To conclude, all of that is concerning in and of itself, but it is especially concerning because we are being told that the R value cannot be calculated in or added from care homes. We are told that the lockdown will be eased. There are suggestions, not from hurlers from the ditch but from experts, that the death rate could be higher. Can the CMO and the Minister respond on those points?

Mr Swann: To start with, Gerry, I have been very clear in the Chamber about where the care home sector in Northern Ireland should be better funded and how it should be supported centrally. That is an indication of where I am coming from. It is my personal political view about the way in which the sector should move. This is about the direction in which we have allowed the sector to move. I think that you are right: the sector is not under the direction of the workers or even that of the people who manage homes.

A bigger piece of work needs to be done. We put in place a support package of £6·5 million to support care home workers. Another piece of work is being done on domiciliary care workers who have tested positive with COVID-19 and have had to go off work on statutory sick pay. We need to support those people. Therefore, greater work needs to be done on how we support the care home sector and the domiciliary care sector. It has been the Cinderella service. We have always accepted that care workers are part of Northern Ireland's healthcare system and Northern Ireland plc and that they are doing something that not an awful lot of people want to do. Now that the Executive, the Assembly and the people of Northern Ireland realise the service that those workers provide, it is time for us to bring them into the light and give them the support that they need to do the job that they want to do.

Since I have been in post, I have visited care homes and talked to domiciliary care workers. One thing that I have seen is that, for them, their job is as much a vocation as any other in the health service. They love what they do and love the people whom they look after. They are a second family to many of those people. There is a duty and responsibility on me as Minister and on all of us to ensure that we get that support into care homes and get the domiciliary care package right. It is unfortunate that it has taken a pandemic to bring that to the forefront, but now is the time to get it right. Similarly, we need to get it right with the RQIA.

Dr McBride: Gerry, thanks for your question. Working with the Chief Social Work Officer, Seán Holland, and the Chief Nursing Officer, Charlotte McArdle, we use a range of intelligence and evidence — international evidence and evidence that we have developed locally — about care homes that may be at greater risk. We use a range of sources of information. That is really important, because we need to use that information to target testing, interventions and support in care homes. I want to reassure you that we are doing that.

To go back to the point that I made earlier about footfall in care homes, we made a decision to scale back the frequency of inspections in care homes, not to stop inspections in care homes. As you indicated, there have been inspections in care homes, where those were required to happen, and there were concerns. I do not have the exact numbers for you. What we also did, which, I believe, the care home sector has found beneficial, is that we took an early decision to repurpose RQIA staff, remembering that they are experienced nursing staff and social workers, to provide support to the care home sector, working in conjunction, as I mentioned, with the Public Health Agency, infection prevention and control nurses in the PHA and health protection teams. The Public Health Agency and the RQIA have played a vital role in that. The RQIA is in daily contact with care homes. We have —.

Mr Carroll: I think that they are; nobody is suggesting that that is not the case. The problem, however, is that there is a pattern of complaints and a feeling that there is no action. Is there a connection between the complaints raised and deaths in care homes?

Dr McBride: I do not know the answer to that. We are a looking at a range of intelligence that might steer us towards that. We also need to bear in mind that many homes will have concerns raised by the regulator and that many of those issues are addressed. The importance of inspection is that it drives improvement. It is about driving improvement, supporting residents, and allowing care homes to improve.

I genuinely believe that the support that we have provided through RQIA into the care-home sector has been extremely beneficial to it. We have also developed, with RQIA, a checklist aide-memoire for Health and Social Care staff who, by virtue of their role and responsibilities, have to visit care homes to ensure that there is a mechanism by which they can raise their concerns, should they become aware of anything that causes concern, . They can be the eyes and ears, because —.

Mr Carroll: That is true. Quickly, Chair —

The Chairperson (Mr Gildernew): Very quickly, because we do need to move on.

Mr Carroll: — my figures show that there was only one inspection between the 20 March and the 30 April. Will you confirm whether that is the case?

Dr McBride: I do not have those figures. However, if it would be helpful, Gerry, I would be happy to get them from RQIA.

Mr Swann: In your first comment, Gerry, in regard to your constituent, if you want to get us all

[Inaudible]

—.

Mr Carroll: OK, thanks.

Ms Bradshaw: Thank you, gentlemen, for attending this morning. My substantive question relates to parents who have children at home with disabilities and who are receiving direct payments. Apparently, new guidance on flexibility comes out for social workers next week. Will there be provision in it for when the carer no longer comes into the home so that they can use some of the money to pay family members? That is because they are providing 24/7 care for very complex needs, and that is very draining. They would like to know whether that will be possible. It is possible in England but not here. Will they be able to use some of the money to purchase sensory equipment? Since the children are not at school, they are not getting that, and parents would like clarity.

As you know, trusts are requested to provide PPE. There was a zoom call with a lot of those parents on Monday of this week, with some of them waiting for up to five weeks to get PPE from their health trust. Trusts have agreed to supply it, but parents are not getting it, so carers are still coming into homes. That is not good enough.

Some of the children are moving between the home and care settings; think of something like

[Inaudible]

, as an example. How are those children being factored into the testing programme? Are they tested as they leave the care home to go back to the family home? Families want that information. If you answer those questions, I will move on to smaller ones.

Mr Swann: In answer to your substantive question about payment support, I do not know, as we have not updated that. However, we can look at what England is doing. We have to liaise with the Department for Communities as well. Are those people staying overnight or are they there for a day?

Ms Bradshaw: The parents are in receipt of direct payments. The health carers who used to come in are no longer doing so because they are shielding, so the family unit is providing all the care for children with complex needs.

Mr Swann: On the testing, is it a residential facility?

Ms Bradshaw: It is not quite respite care. The children may be there for a week and come back home or go away at the weekend and then come back. They are moving between home and care settings.

Mr Swann: It is not something that has come to our attention. However, we will look at it now that you have raised it.

Dr McBride: I could give you a generic answer, but I think that you are looking for a specific one, so it is probably best that we come back to you.

Ms Bradshaw: Will you try to chase up the issue of PPE with the trusts?

Mr Swann: We will. If you have specifics, Paula, let us know, because there should be an easier flow —

Ms Bradshaw: Five weeks.

Mr Swann: — for what we have established, or what we understand to have been established.

Ms Bradshaw: Six weeks ago, on behalf of whistle-blowers, I raised concerns about PPE in the Nightingale with the head of the Belfast Health Trust. Six weeks later — the day after Nightingale closed — I got a response. It was insulting not only to me but to those nurses who came to me with concerns.

I am concerned therefore that, despite the secure email that you set up through which nurses could report issues with PPE, we have not seen any evidence of enquiries coming though and how they are being handled. Have you been assured that that system has been working and that the nurses and medics who raised concerns are being properly communicated with?

Mr Swann: In regard to your first point, was that the Belfast Trust —?

Ms Bradshaw: Going back to the initial point, the systems are in place. However, whether they are working is another matter.

Mr Swann: Your first point was solely about the Belfast Trust.

Ms Bradshaw: This is about the Belfast Trust.

Mr Swann: One of the reasons that we set up the anonymous email account was so that it could be anonymous. I spoke to the Chief Nursing Officer, whose office is looking after it, about numbers, very high-level cases or descriptions of what the concerns are. She has assured me that they are being addressed, and that is where I have left that responsibility, because the Chief Nursing Officer, I can assure you, has the interests of nurses at heart.

Ms Bradshaw: No, I am not —.

Mr Swann: However, I can follow the matter up. We set up the email account in the Department so that anyone could raise an anonymous concern. It has worked to date. The number of contacts that we received through it is lower — much lower — than I was expecting. However, I am assured that there are answers and responses and that if anything needs to be followed up with a trust or a care provider the Chief Nursing Officer and one of her team is following up on it.

Ms Bradshaw: OK, finally and very quickly, Chair, the mental-health action plan that came out yesterday is very welcome. I did not see, in the COVID-19 response, anything about gambling addiction. I am very concerned that there are many vulnerable people at home being bombarded through virtual sites and TV ads. That is emerging as an issue in mental health in terms of addiction and mental-health problems.

Mr Swann: It is not just a COVID-19 problem; it has been in society for quite some while. I think that the Department for Communities, if I am correct, was looking at updating legislation in regard to —

Ms Bradshaw: About the therapies.

Mr Swann: — gambling addictions. Of course, we do not have anything in Northern Ireland specifically for gambling addiction. However, DFC was working on policy development. I will check to see where DFC is with it. We will look at it as a specific—.

Ms Bradshaw: Will you look at it in the spirit of the mental-health services as opposed to the regs?

Mr Swann: We made it clear, in developing it, that it is a living document. One of the advantages of moving from the action plan to a long-term, 10-year strategy is that we have time to add to it. We have had a lot of user input and co-production when we were developing it.

Ms Bradshaw: Thank you.

Mr Sheehan: Robin, I want to ask about contact tracing. However, before I do, there has been some suggestion that your treatment at the Committee has been less than polite, that it has been rude and even that there might have been a bit of bullying. I know that you are well up for this, that you are well able for the powder-puff treatment that you get in here and that there is absolutely no problem. I just wanted to put that on the record. One of our difficulties is that we have such a short time to ask questions, and sometimes we have to interrupt. If that appears rude, I apologise. It is not meant to be rude; it is just to get at the issues involved.

One of the unique things about the pandemic — there are many — is that it affects nearly everybody. Alex mentioned that his sister was diagnosed with it. Other members are in the same boat. Others have elderly relatives, parents, grandparents who are shielding and they are concerned about them, and so on. The kids are off school.

As we sit here, a long-time friend of mine is being buried in Milltown cemetery. Gerry Higgins was the man. He was a few years older than me. I played Gaelic football with him in the same club. He also played for the county, and he played Irish League football for Distillery as well. He was a superb athlete, a great family man, and a loyal friend. We are all affected. I do not want to find, in five years' time, that, "Jesus, Gerry Higgins could still have been alive if such-and-such a step had been taken".

I want to know the answers now; all of us are eager for answers. There is nothing personal in this, Robin. I play the ball, not the man. I want you to know that.

Going back to contact tracing, our responsibility as Committee members is to scrutinise any policies or legislation that you bring forward and to hold you to account for them. Our job is to hold you to account. I am sure that you understand that, and, if the tables were reversed, you would be doing the same with us, especially in the context of this terrible disease. One of the problems is that the information that we have been getting has had gaps in it, has been vague and, sometimes, totally inaccurate. On the 16 April, the CEO of the PHA told us that 500 people had been recruited and were being trained for contact tracing. When she reappeared three weeks later and was interrogated on that claim, she said that she had spoken out of turn. However, we had assumed that 500 people were in the process of being trained.

By the way, I welcome the start of contact tracing. It is a good move. Some people believe that it should never have been stopped, but that is a discussion for another day. Moreover, some of the information is vague. Michael, I cannot remember whether you were here or whether you spoke with us on the phone on 23 April, I think it was, but you said that there were offers of 400 people to do contact tracing. I am still not sure what that meant. There is the issue of when contact tracing stopped and on what basis it was stopped. You told us, Michael, that it was done on the best scientific analysis and sound public-health principles, and that may well be true, but I do not know, because I cannot see the evidence and you were not prepared to give it to us. I am not prepared to accept, "Trust me, I am a doctor". It is not good enough, and that is not us holding you, Robin, and your officials to account. When did contact tracing stop, and, when it did stop, how many were involved in it? Can you tell me that?

Mr Swann: I will start by saying that I am no shrinking violet. I think that you know that. I led the Ulster Unionist Party for two years, so, trust me, there is nothing that can be thrown at me in this room that I have not had elsewhere. [Laughter.]

Part of the frustration with the exchanges that we have had in the Committee has been when we are not in the room. You mentioned it yourself. We are trying to have these exchanges. I think that it was one day that you were in the Chair and Michael was not there and it was only me who was dealing with it. I was frustrated because I was taking part in the meeting by phone and could not see people's faces. I could not see where the question was coming from or where the answer was landing. We were talking blind.

On the matter of when contact tracing stopped on 3 March —.

Dr McBride: Twelfth of March.

Mr Swann: That is the exact date. We were at a stage where the PHA was doing this with a very restricted pool of people, so when we moved to complete lockdown and isolation, it had been proved scientifically — whatever way it was presented — that it was no longer practical to do contact tracing because everybody was staying in the house.

Mr Sheehan: I do not want to interrupt you, but I understand that argument; it has been made previously. Whether I accept it or not is another matter, but I do not really want to go into that at this stage. How many people were involved in contact tracing at that time?

Mr Swann: I do not have that figure. I know that there were PHA —. When I went down —.

Mr Sheehan: Do you have a rough figure?

Mr Swann: Put it this way, Pat, they were in a room no bigger than a quarter the size of this Chamber.

Mr Sheehan: So, 10 or 20. I will explain why I am asking.

Mr Swann: I could say 10, but it could be 20, Pat. Can I get you the exact figure and come back to you?

Mr Sheehan: I am not trying to pin you down to an exact figure, but I am trying to say to you that that was nearly two and a half months ago. We now have 58 people who are trained to carry out contact tracing. On the 12 March, a certain number of people were involved in it. Subtract that from 58, and, in two and a half months, we have trained up whatever it is.

Michael, you said that you reckoned that we would need between 300 and 600 people to be involved in contact tracing. I want to come to the issue of a phone app later. If the phone app is not suitable here, we will need more personnel on the ground to carry out contact tracing. It has taken us two and a half months to train — let us just say for argument's sake — 40 people, and there are another 24 being trained. I do not know whether you read the document on contact tracing from the European Centre for Disease Prevention and Control. It says that it should take between four and 20 hours to train a person to carry out contact tracing. The Scottish Government put out a public advertisement asking for people to come forward to do contact tracing. I do not think that we have done anything similar; have we? Who is doing the recruiting for this?

Mr Swann: Again, this was a good conversation that we had with Conor Murphy about the Department of Finance. While we are in these restrictions, a number of civil servants are not being deployed or utilised in their current roles because those parts and functions of government are not working, so we are working with Conor. We have had 800 volunteers come forward to support the staff who we have trained and tested. We have a small number trained and up and running now, Pat. We have over 60 at this time and more cohorts in training. As I said to you in the Chamber on Thursday, we are looking at a central location, so they will not all be down in Linenhall Street in Belfast. If one centre gets infected, we do not want the whole lot going down. The number of tracers is proportionate to the number of cases. We activated those 36 cases at the start of the week, and the 60 tracers that we have are more than enough to work through that system. As we go further out of lockdown, we will need to have a pool of people whom we can call in. It is not about having a bank of people just sitting there waiting on somebody to get a positive test. It will be a very fluid workforce, for want of a better description.

Mr Sheehan: I understand that. As restrictions are eased, we can expect a rise in the number of cases and that there may be clusters that need to be dealt with.

Mr Swann: That is why the training work is being done at this time. That is why the second location is about to be signed off as a facility to be used. It is all falling into place. We went live at the start of this week. You mentioned Scotland. We had the four nations call yesterday evening. Scotland has put out an advert for these people; we have started them working. That is where we are in the progress of that.

Mr Sheehan: Who is actually recruiting the contact tracers, Robin?

Mr Swann: The PHA.

Mr Sheehan: Is it the PHA itself or the Business Services Organisation (BSO)?

Mr Swann: Well, the BSO sign off.

Dr McBride: Yes. Obviously, BSO is involved in providing support. There is an overarching oversight board, which I chair. There is a group within the PHA that is looking at all elements of this and which has BSO support from the HR perspective.

I will put this in context. You are absolutely right that we need to be able to dial this up and dial it down as the need requires. The key in it is maximum flexibility. It absolutely and crucially depends on the number of cases, which is relatively small at the minute. However, it also depends on the number of contacts. As we step back some of the current restrictions — social distancing etc — the number of contacts per index case will increase and, therefore, the number of people that we need to do contact tracing increases. We have graduated to do that.

On the estimates of 300 to 600 that I gave you last time, Pat, I reassure you that we have been modelling by looking at numbers of anticipated cases. We have planned on a reasonable worst-case scenario by looking at R, the number of cases that we might expect to see per day, and the number of contacts for each of those individuals. What we know at the moment is that the average number of contacts per case is about three. Whenever we moved in Northern Ireland on 12 March, it was about 10. We are building in a degree of tolerance. We are planning at the upper end so that we have sufficient staff in place to do the appropriate contact tracing. There are three tiers to it, and I am very happy that we share the detail.

Mr Swann: Yes, we will share that.

Dr McBride: There are three tiers to it. There is the expert public health for the really complex cases, and we are adding more public health consultants to do that. There is tier 2, which is the contact tracers. As the Minister said, 58 are trained. It takes up to a day to train a contact tracer and then they shadow for a day. Twenty-four more are being trained this week. Tier 3 is the call handlers, and, obviously, as you know, we have arrangements in place to call down contracts to do that. We have the scripts written for all of that. I reassure you: very, very detailed planning is under way.

Finally, thank you for your comments. This virus has cost lives. It has messed with our lives, but it actually has messed with all our heads. There is no doubt about that. The way that we have been working has been highly unusual, not being able to get into a room and have a conversation. The last time that we had a conversation, it was your voice on the box. It has been deeply difficult when you are not in a room and making eye contact with people. As I said, if at times I have responded in a way that was not conducive to answering succinctly a question, I have reflection to do there as well.

Mr Swann: Pat raised the app. Our focus at this time is on contact tracers. We want people on phones. There are issues with difficulties in the app and uncertainties in the app, and there are the questions of who owns the data and of where the data does not lie. At this time, we have recommendations to the Executive. If the NHS acts, the UK app will go live here, because we are part of it. We are part of the UK, so we will have access to it whether we want it or not.

Mr Sheehan: Can I just say —?

Mr Swann: It is up to anybody to download it; it is not compulsory. So, at this time, we are looking at making sure that we have progress on work done for a Northern Ireland version that probably looks so that it can interact with the Republic of Ireland one.

Mr Sheehan: If it does not, Robin, it is not going to cut the mustard.

Mr Swann: We know that, Pat, and that is why we are putting our focus on our recommendation to the Executive. Our focus has to be on contact tracers rather than relying on the app.

The Chairperson (Mr Gildernew): An app would never replace that pen and paper.

Mr Swann: Again, it goes back to our original point. It is the personal interaction. It is about being able to talk to somebody on the phone rather than your thing.

The Chairperson (Mr Gildernew): That provides advice and all. Some of that speaks to the whole issue that, if we do not have regular contact with you, these questions are piling up. Time gets short and all of that, so we need to manage that a little better in moving forward.

Mr Chambers: I am going to quote, Minister, from comments that were made by a political spokesperson quite recently. I will maybe not quote verbatim, but pretty closely. I think that you will get a flavour of the points that they were making. They said:

"I think they were too focused on the hospitals. They were afraid of the number of patients who would be admitted to the Nightingale. In a lot of the focus, they talked about not overwhelming the health service, but they really weren't talking about not overwhelming our social care service at the same time. So, I think that their focus has been much more on: how many ventilators have we got, how are our wards reconfigured in our hospitals? And they haven't been thinking about the most vulnerable people, very susceptible to infections in these clusterings of care homes. So, I think they have been completely wrong in their focus from the start of this pandemic."

How do you react to those comments?

Mr Swann: I do not know who and where they have come from at what point in time, Alan. I would not reflect that as being accurate in the Department. Since the first case that we got, our focus has been on how we save life across the entire health sector. In regard to the focus on ventilators, I suppose that, when anyone looked across to where Italy was and where Spain was, the media and public focus was on ventilators. That was not where we were focused. The Department got on and did whatever it had to do behind the scenes. As the public face, we dealt with the media enquiries on how we challenged the virus as it came at us. Where the virus was positioned in the media was not always where it was in the medical profession or in how we were treating it across the health service. The media focus was often in a different place from the work that we were doing, but it did not distract us and it would not distract us.

Mr Chambers: Personally, I disassociate myself from that criticism, because I think that the Department was doing its absolute best to prepare for a big surge and a lot of deaths. I think that you did all the right things at the time.

For the testing that you are now going to do in nursing homes to be truly effective, what frequency of testing do you see as having to be carried out in these homes? It cannot be a one-off. Will it be a rolling programme? How often are you going to do it? Are you confident that you will get the cooperation of the patients and the staff for a rolling programme; to go in every fortnight and conduct a test that we all appreciate is not a particularly pleasant test? How frequently do you think you will be going into care homes, subjecting patients and residents to this test?

Mr Swann: I will let Michael pick up on the point about frequency. On your point about the people who are tested, we cannot force somebody to take a test, as I think I said to you in the Chamber last Thursday. That will be the challenge, and I think that it is also the challenge for elderly people who are in homes that are COVID-free and who maybe are reliant on a third party to act on their behalf. We are talking about an invasive test. We cannot force it upon anyone. I advise as many people as possible in care home settings to avail themselves of the testing because it allows us to give that reassurance to them, to their families and to the staff.

Dr McBride: Your point about frequency is a very good one. It is the right question, to which I do not have an answer at this time, although we are very actively considering that with all the best international and other science available to us. Our aim at the minute is to bring the existing infections and outbreaks in care homes to an end, and, in those care homes where there is none, it is to ensure that, as the Minister mentioned earlier, we prevent infections. To go back to Gerry's point: it is that we use intelligence to ensure that we prevent outbreaks in those care homes where there have been none and that we actually learn what the difference has been between the care homes that have had and those that have not. Obviously, there is important learning there. There is no doubt that, as infection in the community falls, the risk to care homes lessens. There is absolutely no doubt that those who are working in the sector are doing everything that they can to minimise the risk to those whom they care for, and they are to be commended for that.

The frequency of the test is not yet determined. Obviously, we cannot test staff every day, and I think that the Minister mentioned a rolling programme. That has to be guided by the science on how frequently we would repeat tests. The other thing that we might need to combine that with is symptom checkers of staff and looking at what combination of symptoms would advise us. There may be different thresholds for testing people in the community as opposed to testing in care home or in hospital sectors, so that, if you have certain symptoms, you have a test but the evidence might suggest that you would be safe to work with certain safeguards or, if you have another group of symptoms, you should stay at home until such time as you have a test. Once we get through this phase, the challenge will be to ensure that we keep our care homes free of COVID, and testing of staff will have a key part to play in that. I do not yet have the answer to how frequent the tests will be, but we need the answer to that, and we will look at all the evidence.

Mr Chambers: I have a brief, final comment, Chair.

Mr Chambers: With the recent relaxations of the restrictions, a lot of people are saying to me and, I am sure, to the rest of the Committee, "Why can I go and fish or shop at a garden centre or go to a recycling centre but cannot go and visit my grandchildren?". Can you confirm that the message is still, very firmly, "Stay at home"?

Mr Swann: We are moving into step 1. We have not moved through it yet, Alan. I say to people and to the Committee members that we need to maintain that message. As an Executive, we have taken that first small step. Let us not start running, because, once we start running, if the virus gets in front of us, we might not catch it this time.

The Chairperson (Mr Gildernew): I will go to Órlaithí on the phone for a question and then give Paula a quick right of response.

Ms Bradshaw: Can I have my right of response now?

Ms Bradshaw: Obviously you are talking about me. I stand over that. The Chief Medical Officer said today that the priority was the acute end. I stand over those comments. If you have an issue, you should have come to me directly as opposed to raising it at the Health Committee. I stand over those comments.

The Chairperson (Mr Gildernew): Through the Chair, Members.

Mr Chambers: I think that I have every right to raise it wherever I wish — wherever I wish.

Ms Bradshaw: The figures show where the concentration of deaths has been.

Mr Chambers: Wherever I wish.

The Chairperson (Mr Gildernew): Members! Through the Chair, Paula.

Ms Bradshaw: The Chief Medical Officer said that this is new. The international evidence that you just mentioned shows that pandemics have always focused on institutional amplification settings. We cleared our schools; we got prisoners out; we stopped people going to pubs; we stopped the clustering. Yet the surge plan put people into care-home settings. It was on that basis that I made those comments, and I stand over them 100%.

Mr Chambers: I make my comments in this forum, not on the radio or in the media.

Ms Bradshaw: I am entitled to go on the radio.

The Chairperson (Mr Gildernew): OK. I am going to our member on the phone, who has been very patient. I also appreciate the fact that both Michael and the Minister have remained and taken further questions beyond the time arranged. Are you on the phone, Órlaithí?

Ms Flynn: Yes, Chair. Thank you. I thought that you had forgotten about me for a wee minute.

The Chairperson (Mr Gildernew): Not for a second, Órlaithí.

Ms Flynn: I know that we are over time, so I will be really brief. I have two questions for the Minister and Michael. First, I am delighted at yesterday's announcement of the in-term mental-health plan. I know that there has been brilliant feedback from the perinatal mental-health sector already, Robin. Do you know when we can expect a decision to be made on the perinatal mental-health service model?

My second question is about the COVID-19 recovery. I heard yesterday, at the all-party group on suicide prevention, which I chaired, that the silver cell grouping that has been established to look at the COVID-19 responses in relation to mental health still has to agree terms of reference. There was some confusion about whether there would be representation from the community and voluntary sector on the silver cell group. Following on from that, concerns have been brought to my attention by grass-roots community groups that feel that they have not been involved at that level. They also worry that they were not involved with the co-producing of the mental-health action plan. Robin, you said earlier that that is an ongoing piece of work. I would be thankful for any clarity on both those issues.

Mr Swann: When we first presented to the Committee on where we were with COVID-19, your question was on mental health. I gave you a commitment at that stage that it would not be forgotten. The work has been done on the action plan, and we are moving into the strategy. It was developed by co-production, but there will be a further chance for engagement as we move to the next step. As regards the silver cell, that is an internal management discussion for the delivery group in the Department. It would not be normal for third-sector or voluntary and community groups to be involved in it. They will feed into it with how they interact with and manage it.

The perinatal delivery plan is still subject to funding. The proposals will go in to make sure of delivery. As I said, we had full Executive support for taking this forward as part of New Decade, New Approach. The commitment is in the delivery. I am trying to find the document for the planned timescale, but I just cannot put my finger to it. Hold on. Sorry, just as I say that, I find it.

"Consideration of business case for perinatal mental health services – April 2020. Agreement on new service model for specialist perinatal mental health services by September 2020."

If you have the plan there, Órlaithí, it is on page 21.

Ms Flynn: Thank you, Minister.

Dr McBride: Órlaithí, in relation to the Protect Life 2 implementation group, we need to continue on with important policy matters. I am chairing a group in the next couple of weeks either by Zoom, a Microsoft platform or some such mechanism, and if there are issues that any of the community groups want to raise at that meeting, or if you want to forward me any information in advance of it, I will be very happy to consider those approaches and interventions.

Ms Flynn: Thank you, Michael.

The Chairperson (Mr Gildernew): Thank you, and thank you, members. There is an issue that I want to raise on behalf of the Committee while I have you both here. You have already, in your exchange with Pat, explained things. Robin, you said that you have been around a long time and have been involved in a lot of Committees. On a number of occasions, the Committee has asked for information that has been slow in coming. On 6 April, we asked for an internal stock check, which had been the subject of a media report the day before and which your Department had responded to. We should have received that document on or about the 21 April. On the 14 May, there was a response dated the 7 May, and we were told that BSO would get it for us, despite the fact that BSO had been with us on the 30 April.

We asked for a strategy on testing on the 6 April. We received a new strategy but not the previous one. We asked for it again, and, again, it was to be received on the 11 April and we then received an answer but no documents.

Mr Swann: Chair, may I —?

The Chairperson (Mr Gildernew): Just let me finish —.

Mr Swann: If you have a list of those, forward them to me. I am not aware of —.

The Chairperson (Mr Gildernew): On the 14 April at the Committee, I asked you about the questions that you had asked at the Scientific Advisory Group for Emergencies (SAGE); I asked it again in the Assembly. We were sent a link to the SAGE website that contains absolutely no answers about the questions that you asked. All that information is still outstanding. We need to scrutinise things in real time. We are in a fast-moving context, so if documents do not come to us until three weeks later, time, of course, has moved on. That is why we need them in a timely fashion. It is only fair that if we are working with you, and if we are to have a positive impact, we need to get information quickly.

Mr Swann: I have sat in your place on the Public Accounts Committee and the Employment and Learning Committee, and I know that issues like that were always raised through the Committee Clerk with the departmental Assembly liaison officer (DALO). If those have not been actioned or forwarded through that system, I will follow them up now. If the Clerk follows through to the DALO, we will pick up on those four pieces.

The Chairperson (Mr Gildernew): OK. I have just one more quick question. You mentioned that, as the Nightingale facility is run down, there will be a gradual return to services. When will we know what services are returning? Where will those services be based? What will the criteria for those decisions be? What level of co-production will there be with workers and unions across the sector, and when will that be happening?

Mr Swann: The Department and the trusts are already communicating. As I said in my statement, we have told the trusts that if they can go ahead of the Department in a collective response to re-engage some of those services, they should do so. We need to deliver on our waiting lists. It is not about the co-production of services; the services that have been stood down or scaled back have to be re-engaged as quickly as possible.

The Chairperson (Mr Gildernew): I will let you go after this question about the stay-at-home scheme. You are aware that we have very many care-home settings and that there are a lot of people in precarious work and in agency work. It is crucial that staff and unions are engaged in the work on the stay-at-home scheme and that it is done in a way that is truly voluntary. There should be no element of coercion, where people who are in precarious work feel that the stay-at-home scheme is putting them under pressure. Can we have that assurance?

Mr Swann: Is that the Safe at Home scheme?

Mr Swann: We were heavily engaged with our trades unions colleagues in that. We were not able to deliver it in the timescale that we had, because they raised concerns that we and the home owners were not able to address. That is why we went to a public call. We had been working with a specific provider who has a heavily unionised workforce, and we could not get agreement on the homes that we were looking at. That is why we put the call out to any home that wants to engage in it. Of course, it is up to staff to engage with us voluntarily. It is us supporting the homes to deliver the service; it is not something that we are commissioning. There is a pot of money there to deliver it. Again, it is another step that, we hope, can get us further down the road.

The Chairperson (Mr Gildernew): OK. Thank you for your appearance today. We hope to have you back soon.

Mr Sheehan: Would you indulge me for one second? I want to volunteer a piece of information. It is not a question, and I am not expecting an answer, if that is OK with the Minister.

Mr Swann: Certainly, Pat.

Mr Sheehan: It is about research carried out by Public Health England into genome tracking, centred on six care homes in London. The research showed that the virus was being carried unwittingly into the care home by temporary workers, who were in to replace other care workers who were self-isolating. There is a similar situation here with agency workers moving from care home to care home. I wonder whether you will take note of that.

Mr Swann: Part of the advice that we have already given to care home providers is to minimise that as much as possible, because it is something that we are cognisant of. We can do further reinforcement work on that, as well. Chair, I think that we are back in June.

The Chairperson (Mr Gildernew): Well, in a couple of weeks.

Mr Swann: Well, that is June. [Laughter.]

The Chairperson (Mr Gildernew): It is is important that these meetings be regular. We appreciate your time, your answers and your presentation. We wish you both well in the time ahead and in the important work that you continue to do. We reiterate the message that is central to all of us: stay at home, maintain social distancing and wash your hands. They are the very basic things to support the entire effort. Thank you.

Mr Swann: Thank you.

Dr McBride: Thank you.

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