Official Report: Minutes of Evidence

Committee for Health, meeting on Wednesday, 3 June 2020

Members present for all or part of the proceedings:

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


Mr Swann, Minister of Health
Professor Ian Young, Department of Health

COVID-19 Disease Response: Mr Robin Swann MLA, Minister of Health; and Professor Ian Young, Chief Scientific Adviser

The Chairperson (Mr Gildernew): I welcome the Minister of Health, Mr Robin Swann, and Professor Ian Young, the Chief Scientific Adviser, and invite them to brief the Committee.

Mr Swann (The Minister of Health): Thank you, Chair. I will keep my opening comments short today. Thank you for the opportunity to update you on the latest developments in my Department's ongoing response to COVID-19. This is my sixth attendance at the Committee since the start of March, and I have done three Ad Hoc Committee meetings as well, just to keep Assembly Members updated.

As you will be aware, deaths involving coronavirus in Northern Ireland have fallen for the fourth week in a row. Last Thursday, we reported no new deaths from COVID-19 for that day. That is what we are all working towards, and we need to play our part, as the restrictions lift, to limit the spread of the disease. While the downward trend is welcome news for us all, I must emphasise again that COVID-19 remains a real threat, and there is no room for complacency. I am always mindful that every death represents a loved one who is sadly missed by their family. We must never lose sight of that as we enter a new phase in the battle against coronavirus.

The Executive have announced a number of restrictions that could be lifted in the coming weeks, provided that the R number does not increase above 1, sot is vital that we continue to act responsibly in the days and months ahead. We must continue to adhere to the guidelines, making sure that we keep a safe distance away from others. Whilst it may seem trivial in light of the overall impact of the virus on the health service and the economy, continuing to wash our hands regularly is genuinely one of the most effective tools for us all in fighting the virus. People will never have washed their hands as much as they have done in the last few months, but I hope that, even after the pandemic has passed — it will pass — the new culture of increased hand hygiene will continue. Members will be aware of the progress that has been made across a number of areas since I last addressed you, not least the extensive operation of contact tracing. As per your request, Chair, I will not go into detail on that in my opening address but will instead focus on the ongoing work across the system to rebuild our services.

The impact of COVID-19 has been felt right across our health and social care services, with significant additional backlogs building up in areas such as screening and elective care. Whilst we continue to battle the virus, I have also been clear with my officials that I want to see the resumption of services as quickly as possible. All trusts have now submitted a draft phase 1 rebuild plan, but I was clear that, wherever possible, I wanted services immediately resumed, because now is not the time to be getting caught up in process. I am acutely aware that COVID is not the only illness, sadly, claiming the lives of people across Northern Ireland. It is important to recognise that there will not be a return to business as usual. COVID-19 will continue to impose significant constraints on the capacity to deliver services because of the need to adhere to social distancing and the need to use appropriate personal protective equipment (PPE).

The rebuilding of services will involve increasing service capacity as quickly as possible across all programmes of care within the prevailing COVID-19 conditions. However, the huge challenge we face as we move into the rebuilding phase is how to maintain the capacity to provide care for patients with COVID-19, while simultaneously increasing other urgent clinical services, important routine diagnostics and planned surgery. At the same time, we need to retain the ability to quickly repurpose and surge our capacity, if required, in the event of a second wave of COVID. My Department is developing a strategic framework for rebuilding Health and Social Care services, and I intend to publish that very shortly. The aim will be to maximise service activity within the context of managing the ongoing COVID-19 situation, which will prioritise services whilst embedding innovation and transformation, incorporating the Encompass programme, developing contingencies and planning for the future.

Chair, that is just a very brief opening statement, and I hope that it is helpful. We will both take questions.

The Chairperson (Mr Gildernew): Thank you, Robin. In your statement yesterday, you mentioned the rapid learning initiative. I welcome that, and I have said on many occasions that we do not have the luxury of time. We are in the middle of a live pandemic, and there is huge potential for additional spikes of this and further pandemics, so lessons learned have to be learned rapidly. Will you give more detail on what that entails and how that initiative operates?

Mr Swann: Certainly, Chair. While taking that point, we have said in the past in regard to inquiries that I have no doubt that there will be local, national and international inquiries into this, but now is the time for learning. I think that your point is right: it is where we learn and what we do now. I think it was Professor Sian Griffiths who said to the Committee, when she appeared here, that we should do the analysis post hoc and not have that blame culture. That is very much what the rapid learning initiative is about. It will be led by the Chief Nursing Officer. Its main aims will be the changes that have already been implemented in the Health and Social Care system, the impact of the interventions to date on COVID-19 transmission within care homes, and other safety and experience indicators determined to be significant.

The main objectives that the group will consider are the following key areas in care homes, the first being the experience of patients, residents, staff and the families of those who have people in care homes. The second will be symptom monitoring, intervention and care planning. The third is infection and prevention control. The fourth is actual physical distancing of residents, taking into consideration their conditions and isolation cohorting, visiting restrictions, staff turnover and footfall.

The group is to develop and monitor measurement processes that will assist in undertaking the current system; develop a learning system that will facilitate scale and spread; and seek to identify early evidence as it becomes available in real time in order to scale and spread those measures which demonstrate impact on controlling COVID-19 and on care home residents and staff. It is about getting those professionals in, seeing what has been done, and getting that learning back as soon as possible. It is being led by the Chief Nursing Officer. The main steering group will also have input from independent care home providers. Pauline Shepherd from Independent Health and Care Providers will be a member, and there will be a number of other professionals on it as well, including our Chief Pharmaceutical Officer. That is the bones of it. It has already started its work, so we hope to get that learning within weeks. It will be weeks rather than months, Chair.

The Chairperson (Mr Gildernew): That focuses quite a bit on what is happening in care homes right now, but will it look at what could have been done differently to prevent the —?

Mr Swann: It will also look at international practice, because it is about learning what we can do and need to do if there is a second surge and how we prevent COVID-19 from getting back into our care homes. It is quite an intensive piece of work that is being done over a very short time. That is the title — the rapid learning initiative — because it is about learning.

The Chairperson (Mr Gildernew): Thank you. My second question is for Ian. First, will you quickly give us your background in public health? You made it public that you were on long-term sick leave throughout, I think, March, so will you explain what your membership of the Scientific Group for Emergencies (SAGE) entailed and who represented us in that period when you were off?

Professor Ian Young (Department of Health): First of all, I am a clinician, specifically trained in laboratory medicine, with an interest in diagnostics, nutrition and the management of lipids — cholesterol etc, predominantly. I have been professor of medicine at Queen's University for around 20 years. For a significant proportion of that time, I was director of the centre for public health, which is one of the university's main research centres. I was appointed Chief Scientific Adviser to the Department of Health in 2015. That is a part-time role. My main responsibilities are for research and development; to provide general scientific input and advice, where required; and as head of profession for healthcare scientists, who are one of the components of the Health and Social Care workforce.

You are correct: I have publicly let it be known that I was off on long-term sick leave and returned to work towards the end of March. At that stage, I joined SAGE as a member representing Northern Ireland. From the first meeting of SAGE that I attended, I was there as a full participant with the ability to ask questions and participate fully in discussions, as are the other expert members. SAGE has released almost all of its minutes and papers, going back to the beginning of the current epidemic. That information is therefore publicly accessible via the SAGE website. It does not indicate that there were any Northern Ireland members in attendance as participants, but I believe that the SAGE papers will have been available.

The Chairperson (Mr Gildernew): Is it therefore the case that no one from here represented us on SAGE at the crucial time around 12 March and 13 March when the decision was taken to end contact tracing?

Professor Young: To the best of my knowledge — I have asked — no one from Northern Ireland was present at those SAGE meetings when those discussions took place.

The Chairperson (Mr Gildernew): What are your thoughts on that as Chief Scientific Adviser?

Professor Young: I would have preferred that Northern Ireland had been actively involved in discussions at all stages. The purpose of SAGE is to review the science and to provide advice based on the science. It is not to make policy decisions. I think that the decision to stop testing on the part of the UK Government was a policy decision rather than one that was based on scientific advice and took account of the realities of the situation at the time and the stage of the epidemic.

The Chairperson (Mr Gildernew): Is it your understanding that the scientific advice from SAGE was not to stop contact tracing?

Professor Young: I can only look back at the minutes of SAGE, as can others. From the beginning, the view of SAGE, and certainly my view, based on the science, was that testing is one very important component of our approach to the virus. We should conduct as much testing as possible, as frequently as possible. The challenge is that this is a virus for which there was no test six months ago. We are therefore moving from a position of zero possibility of testing through to a position where there is huge demand for tests and testing across the world. Even today, there is a global shortage of test materials and test kits —.

The Chairperson (Mr Gildernew): Sorry, Ian. My understanding from previous discussions is that, at the outset of this, we had a capacity here for testing and were testing 40 a day. That was limited, but it has been scaled up as time has gone on. My question is more around contact tracing and the decision to stop contact tracing or to stop building up the contact tracing resilience or structure that we had in place to do contact tracing.

Professor Young: Again, I have to emphasise that I was not at the SAGE meeting, nor did I participate in the discussion. My understanding of the SAGE minutes is that, at that time, it was felt that too many cases were occurring in the UK and there was not sufficient capacity to contact-trace in order to suppress the infections, so additional measures had to be taken. They came in the form of social distancing and what is generally referred to as the "lockdown", which have, indeed, been effective in suppressing the course of the epidemic.

The Chairperson (Mr Gildernew): But there would have been an awareness that there will be other stages to come where we will need contract tracing as an alternative. That should have indicated that we need to continue to build up our capacity.

Professor Young: Absolutely. Again, if you look through the minutes, you will see the SAGE advice. Since I have been attending SAGE meetings and participated in discussions, it has been absolutely clear that "Test, Trace and Protect" or whatever name you want to apply to a strategy is critical as we move forwards and attempt to release the lockdown and prevent further expansion of the epidemic.

The Chairperson (Mr Gildernew): Robin, were you not concerned that we did not have representation on SAGE at that point?

Mr Swann: At that point, Chair, we were getting feedback from SAGE through COBRA. We had, I suppose, part-time observer status on it when we needed it, but we were getting SAGE advice coming in through COBRA, which was attended by me, the First Minister and the deputy First Minister. The advice was coming to COBRA as a body general.

The Chairperson (Mr Gildernew): But we were not inputting our particular circumstances; that is the problem. It is not the advice coming out; it is the advice going in that I am more concerned about.

Mr Swann: At that point, Chair, I was under the impression that we had observer status and were sitting on some of those meetings and actually seeing what was going on. We were able to write in with questions, but we were not able to actually participate because Ian was not there as our full-time member.

The Chairperson (Mr Gildernew): I have asked for the questions that were being asked at that time to be provided.

Mr Swann: I do not know where we are on that, Chair.

The Chairperson (Mr Gildernew): I would like that expedited, please, Robin. It has gone on quite a while.

The final question from me before I go to members is in relation to the system that is in place now to take account of easements as they are made and the testing and tracing that will tell us, in time, to react. How does that contact-tracing system link to the decision-making process or the R number at present?

Professor Young: At the moment, anyone who has COVID symptoms should be getting a test. That is anybody with a new continuous cough, an elevated temperature or a change in the sense of taste or smell. Obviously, we are fully dependent on the cooperation of the general public to recognise the fact that they have those symptoms, to declare it and then to get tested. When somebody does that, they are advised to self-isolate along with the members of their household until the result of the test comes through, which typically should be within 48 hours. If the test result is negative — so, the individual has symptoms but not COVID, which will be the case for most people with symptoms — the individual and their household can go back about their normal business. If the test result is positive, the individual will receive the result and be contacted by the Test, Trace and Protect service to identify all of the contacts to whom they were exposed within the 48 hours prior to their developing symptoms. Those individuals, in turn, will be contacted and advised to self-isolate for a period of 14 days.

The Chairperson (Mr Gildernew): My question is aimed more at establishing what capacity we have in relation to the transmission rate. What is the transmission rate at present?

Professor Young: To answer the first part of that question: we have capacity in Test, Trace and Protect to contact trace everybody who has a positive test result. That is happening at the moment.

I am not totally sure what you mean by the "transmission" of the epidemic.

Professor Young: The R number. As indicated by the Executive last week, R was sitting at between 0·8 and 1·0. We have agreed that we will publish a value for R once per week. I believe that that will be on Thursday night or Friday of this week.

The Chairperson (Mr Gildernew): OK. On the present numbers of contact tracers, what increase in prevalence could we deal with? What increase in that number could we deal with in terms of having full contact tracing for all relevant contacts?

Professor Young: The modelling for the development of the contact-tracing service has allowed to contact trace for at least 300 cases a day, with up to 10 contacts per case. The service is planning, at the moment, and recruiting and training, so that it can flex in response to any future increase in cases. Obviously, we continue to model the likely transmission of the epidemic in future and would bring forward different recommendations, if we felt that that capacity was likely to be exceeded. For the moment, based on all the data that we have, that is the current planning assumption.

Mr Swann: Chair, I will give you the updates. On site, at this time, we have 102 contact tracers, and that number is made up of people who have been reassigned from multiple Departments where work was paused. They come from a number of backgrounds and include Public Health Agency (PHA) nurses, health improvement staff, trust nursing staff and environmental health officers. The recruitment campaign for contact tracers closes today, and that will be for the permanent staff who will be in post for a year, with an option for a second year, and the level 2 core contact tracers we will be looking for will be from a nursing or environmental health background. This is not just a call-centre approach. We are aware of other regions that have gone for that approach, whereas we want people who will be able to give advice and guidance, rather than just say, "You are a positive case; please go and get another test."

We have offered a contract already for two of the environmental health officers who are in post, and we have 20 retired nurses, who were ward sisters, lead nurses or assistant directors of nursing. They are starting their training next week, so that will add another layer. We have secured four doctors, who will work alongside the contact tracers, so they are able to give people medical advice. It will be led by a health protection consultant.

This is not just about contacting; it is about providing that next step, which is the support and guidance that people need. What we have experienced is that it is quite a daunting message for somebody to receive over the phone. We want to make sure that the people who are on the other end of the phone are able to do it in a way that is supportive and provides guidance. That is where we are at currently.

Recruitment for the full-time posts finishes today. We will go to the next stage. We have also put in a business case for a second premises. At present, we operate from the PHA headquarters in Linenhall Street.

The Chairperson (Mr Gildernew): How many have been recruited, or how many will be recruited?

Mr Swann: I do not have the figures. We have 102 who are on site or possibly can come in on site depending —

The Chairperson (Mr Gildernew): Clearly, the flex that Ian described will require more.

Mr Swann: — dial up or down, depending on the number of positive cases that come through.

The Chairperson (Mr Gildernew): We can come back to that, but I want to go to members now. I will give members equal time. We have about an hour for this session or a bit less. I ask members to be as brief and succinct as possible with their questions. That also goes for Ian and Robin with their answers.

If members feel that their question was misunderstood or a different question is answered or whatever, I will allow them to come in and say, "Listen, I am trying to establish this", just for the purposes of getting through as much business as we can.

Mr McGrath: I was gesticulating earlier because I am chairing a Committee meeting at 2.00 pm. I will need to leave sharpish to get the prep for that done.

I thank both of you for coming along today to give us the information. I definitely acknowledge, Minister, that you have appeared regularly in front of the Committee and the House. That is welcome, because it gives us the opportunity to have direct conversation with you and with various officers. There was mention of long-term sickness, and I am glad to see the Chief Scientific Adviser back as well.

Members of the BAME community have raised concerns with me. They feel that they are more susceptible to contracting coronavirus and that the outcomes for such patients can be less favourable than for others. Public Health England (PHE) announced yesterday that there is an increased chance of death of between 10% and 50%, when compared with others. Our trusts rely heavily on members of that community to provide front-line work. At this time, the trusts are unable to divert them from the front line, because, they say, there is no evidence to indicate that there is a problem.

Do we have an opportunity to undertake research to determine that and to help members of that background by diverting them into a role that, for example, is not in an ICU?

Mr Swann: Colin, Ian has nodded to indicate that he wants to answer this one, and I will not stand in his way. However, I will say briefly that the Public Health Agency carried out research on the prevalence of cases in Northern Ireland and published that last week. One of the indicators that I will bring out is the deprivation category. Across GB, a high prevalence was seen in the more deprived areas. In Northern Ireland, we see a prevalence in the least deprived areas. The more affluent areas of Northern Ireland have seen a small increase in positive cases when compared with other areas. In Northern Ireland, we see the reverse for positive cases. Ian will answer on BAME.

Professor Young: We are very aware of that issue and are seeking to do some research to identify the extent of any specific problem in Northern Ireland. Yesterday's PHE report was helpful in highlighting the increased risk, particularly among the Bangladeshi community, but also among other communities. Some of that risk appears to be related to an increased prevalence of what I think of as the more common risk factors. The risk factor that is often not really appreciated or talked about as much as it should be is overweight or obesity, which puts people at quite a significant risk of severe complications from the virus, if they become infected. Yes, we will look to do some further work. Our trusts are also aware of the issue.

Mr McGrath: In the short term, could a directive say that, if a staff member has concerns, they can work in another ward that does not deal with coronavirus? The staff member is not saying that they want to stay at home. If the person is working in the intensive care unit (ICU), has to wear PPE and is feeling very vulnerable, might that be something that can be done?

Mr Swann: Those HR requests to trusts are for someone who has underlying conditions or concerns, and they have always been addressed, especially during the past number of weeks.

Professor Young: Fortunately, the incidence in our critical care units is very low at the moment. We have only six patients in critical care at present. Certainly, it is a message that we can pass on.

Mr McGrath: My final question is on contact tracing. I am conscious that we are on an island but have two health jurisdictions. If we are both developing apps, there is a concern that those apps may have difficulty working with each other. I do not want this to become a political issue about an orange or green app. The apps need to work with each other. In border communities, such as Letterkenny, Derry, Newry and Dundalk, where people are transiting back and forward, working and interacting with each other, and where families live on either side of the border, it is important that the apps can communicate with each other. I asked the First Minister about this two weeks ago, and the answer was, "Yes, we want those apps to speak to each other". Has definitive work been taking place between North and South agencies to make sure that the apps can communicate?

Mr Swann: Colin, it is not just North and South; it is also east and west. Our chief digital information officer, Dan West, chairs the UK/Ireland group on interoperability, which is about the two apps being able to talk together.

We are concentrating on contact tracing. We are concentrating on putting people at the end of the phone in offices rather than relying on the app, because we are aware of the concerns about the operation of the app. Bluetooth must be switched on, which drains the battery. There are things that make the app unattractive. The focus is on contact tracing and on people being on the phone. The app has been described by a UK Health Minister as the icing on the cake rather than something that we should get too caught up on. At this minute in time, our contact-tracing system is proving to be effective because of the number of positive cases.

Professor Young: The potential role of the app in contact tracing is often overstated. At best, it will be an adjunct. Even if 50% of the population used the app, which would be a considerable achievement, it would pick up only 25% of contacts automatically, so we will always have to rely on manual contact tracing as the core of our activity in this area.

Mr McGrath: If the app is using contact tracing as in ringing people and checking them out, is there an establishment for that to work North and South? If you have people based in Linenhall Street in Belfast but hear that they have been in contact with people who live in Letterkenny, will that be allowed to happen? Will Brexit have an impact, given that there will be difficulties in the sharing of information?

Mr Swann: No, because we can share information on medical grounds anyway. There has always been an established relationship between the National Public Health Emergency Team (NPHET) and the HSC. I think I have used this example before: the first case that we had in Northern Ireland was someone who landed at Dublin Airport and travelled up, so the two organisations have a long-established ability to talk to each other, especially on contact tracing.

Contact tracing is not new. We have always had a small group that in the past dealt with things like TB and food poisoning and STI outbreaks. There always was a small cohort doing that, and that conversation always went on North/South and east/west. We have the sharing of knowledge under a memorandum of understanding.

Mrs Cameron: That sharing of knowledge is important. I was made aware last week that anybody travelling to Northern Ireland from the Republic of Ireland was not required even to fill out the locator form that is available in the Republic of Ireland. Has that been addressed or changed? Is cooperation as full as possible to ensure that we know that people have travelled into Northern Ireland?

Mr Swann: That conversation is ongoing. It comes on to a further point later when we develop our own form asking people to self-isolate for 14 days. The conversation is going on North and South to make sure that the two systems are compatible and that we are giving the same advice to whoever lands, should somebody land in Belfast and travel to Dublin or somebody lands in Dublin and travels to Belfast. There is guidance specific to each jurisdiction, but the 14-day self-isolation will be a requirement for both. It is not mandatory yet.

Mrs Cameron: So, it is not resolved yet.

Mr Swann: It is not resolved yet, but it is being worked on at Executive Office level and in the Department of the Taoiseach.

Mrs Cameron: For clarity, if somebody is travelling from a part of the world that has a lot of COVID-19 cases, if they live in Northern Ireland they could come in through Dublin airport, for example, not have to fill in the form and travel into Northern Ireland, and we would not know that they had arrived or where they had been.

Mr Swann: That is correct, because we do not have that travel advice in the UK yet no matter where they are landing from. It is about sharing information. If anybody comes from an area like that, they follow the usual guidance, Pam: if they have symptoms or feel symptomatic, it is the self-isolation guidance that we give them.

Professor Young: I think that it is the same whether it is London, Dublin or wherever. At the moment, we do not require that.

Mr Easton: Minister, where are we in relation to shielding letters? They are up to a certain point. Will there be a reissuing of those letters? If so, will it be to the same people, and maybe include people with diabetes? I am starting to hear from people who got shielding letters whose employers are starting to ask them when they are coming back to work. Obviously, that is a bit of a worry because we are really not out of the pandemic yet.

In light of events at Ballyholme beach, Crawfordsburn, Helen's Bay, and other places, is there a fear that there could be a surge in COVID-19 cases in several weeks' time? Those actions are of great concern. I am sure that you would agree with me that they should not be happening.

Mr Swann: On your second question, Alex, there is a concern. The guidance is there: a two-metre distance, six feet apart, social distancing, all the rest of it. It is there for a reason no matter what age anyone is. As I said yesterday at the press conference, I understand the frustrations of young people having been locked up for so long, now having the opportunity to go out and meet in groups of six. The guidance says to meet in groups of six and be socially distanced; it is not to go out and have mad parties on beaches. That is where the threat comes in.

Young people may not lose their lives to this disease, but someone they love might. They can take it back to their homes and spread it through their families. The guidance is still please respect social distancing and please travel only when necessary. This is not an extended summer holiday. We are asking people to stay at home and stay off work. People have been furloughed for a reason, which is to allow us to combat COVID-19 and the spread of it throughout Northern Ireland.

In regard to shielding, we are aware that the first set of shielding letters comes to an end very soon. The Chief Medical Officer is leading a group that involves a number of stakeholders. The Public Health Agency issued a call last night for anybody who wanted to give an input as to what they thought the next shielding process should look like and what should be included in the letters. We have not determined how long the next shielding period will be for yet. That is being done at a Chief Medical Officer UK level.

There is also an assessment of the conditions of people who will be asked to shield and those who are most vulnerable and most susceptible to COVID-19. That will add to what we now know compared to when the first letters were issued. It is a reassessment of the conditions that were included in the first letter and the possibility of adding further ones. Those letters will issue in the next couple of weeks.

Professor Young: Obviously, those who have been shielding have made a considerable sacrifice and have suffered significantly as a result. So, there is a desire to give more nuanced advice to support people to make decisions. The risk to an individual who is shielding if they contract the virus remains as severe as it has ever been, but as the level of virus transmission is much lower in the community, their risk of being exposed to it is less than it was in the past. That is what may allow the more nuanced advice currently being discussed.

The Chairperson (Mr Gildernew): An issue that has arisen that needs to be considered is when someone is shielding, and their carer, while not shielding, is an essential worker and is working in circumstances that are very unsafe. There appears to be a lack of understanding in some settings, so carers need to be considered and the impact that their caring role has on the shielded person. That needs to be considered.

Mr Swann: That is a fair point, Chair.

Ms Bradshaw: Thank you for coming along this morning, Minister. Two weeks ago, when you last came to the Health Committee, I raised the issue of families who have children with disabilities living at home who are at the end of their tether. They are looking for some flexibility on their direct care payments and on the use of that money and the updated guidance. My phone has flared up over the last 12 hours since the debate last night in the Assembly, and rightly so. People are very insulted, because they are struggling during the pandemic. We cannot say that we support families who are providing support to children with disabilities if we are not going to follow through at a time like this. Where is that information? When will those families get the support that they need?

Mr Swann: I have not had a direct update on that, Paula. I thought that you would have received guidance since our last meeting. I will get back and check on the guidance on direct payments. I know that it is being looked at in the Department, but I have not had an answer as to where the changing payment structure is. However, I will get it to you.

Ms Bradshaw: Please do, Minister.

Mr Swann: I understand.

Ms Bradshaw: My second question is for Professor Young. How do we take account, as we go through the tracing phase, of people who do not have symptoms? Alex Easton just mentioned all the children congregating and going home together. There is also the issue of groups of six. How do we take account of people who are vectors as opposed to those showing symptoms?

Professor Young: The fact that a significant proportion of people with COVID are asymptomatic or have very little in the way of symptoms is one of the main challenges in our future control of the epidemic. If you were to give me a magic wand and infinite testing, I would test everybody in the population every day, and that would provide us with a mechanism to bring this under control. We cannot do that. Certainly, we are considering the possibility of more widespread testing in higher-risk settings. Research will be under way in England. They have decided to open their schools, as we are aware, in June. A programme of work will be undertaken to look at what surveillance and testing might be possible in the context of schools to pick up the asymptomatic infection, particularly among children. We will have an opportunity, I hope, to learn from that experience before our schools open towards the end of August.

The best guess at the moment is that around one third of individuals will be asymptomatic. Our hope is that focusing on the symptomatic individuals — identifying and isolating all of them and their contacts — will be of sufficient impact to negate the positive spread that comes from asymptomatic individuals. That is why we need people who are contacts to self-isolate for 14 days. People might think that they feel fine, that there is nothing wrong with them and ask why they are being asked to isolate for 14 days. It is exactly because they may be an asymptomatic person with the virus and, if they do not self-isolate, there is the risk that they will spread it.

Ms Bradshaw: Will we be able to move to getting test results back with 24 hours? People would comply a bit more if they could get the answer quite quickly.

Professor Young: Yes, it is absolutely a goal to have test results back within 24 hours. There is a testing group pushing very hard for that. For the service to work, we need 80% of contacts to be told to self-isolate and to do that within 48 hours of the first test on the case. For that to work properly, we need to get test results back within 24 hours.

Mr Swann: Paula, my apologies. We wrote to the Committee this morning, and that letter has an answer to your question about direct payment. It is there.

Ms Bradshaw: It is in an inbox somewhere.

Mr Swann: It was sent to the Committee just this morning, so the Committee will have that for you. There is guidance there. The Department has been working with trusts and service users to develop that guidance, and there is a paragraph there for you.

Mr Carroll: I have two questions, one on care homes and one on contact tracing. Minister, you announced an extra £11·2 million for care homes yesterday, including money for sick pay for staff. That will provide some relief for staff who have been underpaid and undervalued for so many years. However, there is a concern about regulation, especially given the revelations in the 'Spotlight' programme last night, particularly around Clifton and Runwood. In 2018, the Regulation and Quality Improvement Authority (RQIA) found that Runwood had no washing powder or washing-up liquid, yet senior executives were paid £17 million when they left the company. Everyone accepts that people working in care homes should get paid a fair wage. The concern is that giving public money to private care homes that make large profits is unfair and unsustainable. How do we ensure that these companies pay their staff sick pay and that they are not just protecting their profits throughout this pandemic?

Mr Swann: Gerry, on the specific point about us being able to pay sick pay at up to 80% of value, that is because we were aware that some providers were relying on basic statutory sick pay. Staff, many on zero-hours contracts, were put in the position of having to come into work or not getting paid. That is what this allocation of over £3 million is specifically for. It is targeted at and must go to people who are off because they are COVID-positive or are self-isolating. It is part of how that money will be allocated and spent. That is the main thing.

I will turn to your question about a group of homes. Unfortunately, where we sit at the moment is that each home is a stand-alone entity. I have no power, and there is no power in the Department, to look at how the overall management structure of a group of homes is working. We can look only at individual homes and not the group itself. I have asked officials to look at how we can change that so that, if there are concerns about a provider rather than a specific home, we could start to take actions and address concerns about that entire group.

Mr Carroll: There are concerns, Minister, especially about Clifton Nursing Home. Concerns about infection prevention were raised in 2013, which was, of course, before your time, but there is a systemic problem, and people feel that there is a lack of focus on care homes.

On the subject of contact tracing, Minister, you spoke previously about the need for a single app to be used across the islands. That was your preference. Everybody accepts that we need contact tracing to happen and that we need to have a system in place. However, a number of concerns have been raised by human rights organisations — Amnesty International, in particular — about the UK having a single, central state database. My understanding is that other states have decentralised databases. There are concerns about surveillance and data breaches. In particular, do you know how long it will be before the collected data is deleted?

Mr Swann: We are looking at using our own app, Gerry. Our chief digital information officer is looking to establish a Northern Ireland app because of the concerns about how NHSX might be shared. We are still working with NHSX, as are the Scottish and the Welsh, to see whether those concerns can be worked out and dealt with accordingly. While that work is ongoing, we are also looking at how we might develop our own app in Northern Ireland. It will use the same platform as the Irish app, so that connectivity will be a lot easier [Inaudible.]

Ian, do you want to add to that or are you happy enough?

Professor Young: No, I think that that is correct.

Mrs Cameron: Thank you for your time here today. I appreciate the work that all of you are doing. On the back of Alex's query, I wanted to ask about shielding letters. First, I have had many requests from people who have had shielding letters with different dates on them. I presume that that does not really matter because the situation has not changed, but can you clarify that? Secondly, I would like to hear what advice you have for people who are being asked to return to work soon, given that they are still waiting for that additional information on shielding. What do they do? How do they broach that with their employer? That is very worrying.

Mr Swann: It is one of the reasons why we want to get the letters right and out as soon as we can so that the guidance can be included. If a person is in receipt of a shielding letter at the moment, the guidance that they have been given is that they should still be shielding.

Professor Young: I agree with that completely. If somebody is currently in receipt of a shielding letter, they need to shield. I hope that any employer would support that. Of course, when updated letters are issued, it is possible that there will be more nuance to them and an attempt to identify categories of people at the highest risk versus somewhat less risk. Then, there would need to be a discussion between the individual, in the context of the new letter, and their employer about what is possible. I hope and expect that any employer would be sympathetic and would look at making all reasonable adjustments to help someone to return to work and adhere to the conditions of their shielding.

Mr Swann: On your question about dates, Pam, the only reason I can think of is that a centralised batch of letters was sent to GPs from HSC. GPs were given instructions, but with some leniency on timing, to issue letters to individuals or specific cohorts in their practice. That might explain the slight difference in dates. When we issue the updated letter, that same process will probably be in place.

Mrs Cameron: When that further shielding advice is issued, it will be very welcome. Will employers receive guidance on how to deal with employees who have shielding letters?

Mr Swann: It will be the same as before. It will be a general message about how to support those who are shielding.

Mrs Cameron: Professor Young, I welcome what you said about the nuanced approach. The threat from COVID-19 is still as big as it was to people who are being told to shield, but, as you say, if the instances are kept very low and we keep our distance from each other, the risk will reduce, which is very welcome.

The reason why I went back to the need for shielding information is that people with shielding letters have serious medical conditions and are very much at risk, yet employers are asking them to come back to work soon in what are, I imagine, quite high-risk areas such as supermarkets. Do you have any specific comments on the type of workplace or type of work that those who are shielding need to avoid?

Professor Young: For those who are shielding, it is difficult to give general advice. It depends on the risk for the individual. In the category of people who have been told to shield, some are at an extremely high risk and, effectively, they might need to continue to shield. There will be others who are at high risk, but the risk is lower. The advice to them will be closer to the advice that we currently give to the vulnerable groups — the over-70s and those with underlying conditions who are not shielding — which is that it is particularly important for them to adhere to the social distancing and other recommendations that we put in place.

In general, I hope that it is possible for vulnerable individuals, depending on their level of vulnerability, to avoid being in occupational roles that involve risk of high-frequency contact at relatively close proximity to others. That certainly might apply to some but not all retail settings. We need solutions to be worked out by sympathetic employers, with the interest of their employees in mind, and, hopefully, agreed between them.

Mrs Cameron: That is useful. Thank you.

My second question is about the recording of death of those who had an underlying health condition and lost their life to COVID-19. Is an underlying health condition recorded in a COVID-19 death? Should it be? Why are some of the death certificates that ascribe COVID-19 as the cause being questioned? Are the levels of complaint in that regard higher than you would normally expect them to be?

Professor Young: I am not involved in looking at death certificates or in the death certification process; that is dealt with elsewhere in the Department. All doctors have been given direction on how to report and record deaths. They should be following that direction for COVID-19 and other conditions.

If a doctor feels that an underlying condition has contributed to a patient's death, that should be recorded as part of the death certification process. There is an element of judgement involved on the part of individual practitioners, so there may be some variation in that.

In addition, for many of the deaths, we have a much more detailed capturing of all underlying health conditions as part of national surveillance. That is what gives us the strongest information about which underlying conditions are particularly predisposed to severe COVID-19.

Mr Swann: You talked about the concerns about death certificates. I signed a letter to all Members stating that, should a family have a concern about COVID-19 being recorded on the death certificate and they do not believe that it should be there, there is a process to query that. That letter has been issued.

Mrs Cameron: Thank you. On the back of your answer, Professor, I am thinking about, for instance, the Diabetes UK letter. The more data that we have to enable us to drill down into what the vulnerabilities in people might be, the better. Would it not make more sense for some kind of direction to go out stating that as much detail as possible should be recorded on death certificates so that, going forward, we have the information to decipher, examine and investigate?

Professor Young: There is limited space on a death certificate, and we need much more detailed information than it is possible to include. That is why we rely on other sources of information to capture that. These are approved national studies whereby we collect data on tens of thousands — even hundreds of thousands — of COVID patients with underlying conditions and their clinical course. Much of that information is available through the public domain. It is published in scientific papers, so it is not necessarily the most accessible, but it enables us to get comprehensive information about underlying risk factors.

Mrs Cameron: Is there a greater risk with a diagnosis of diabetes?

Professor Young: Yes, there is an increased risk of severity of COVID for patients with diabetes. Diabetes is a broad label, and there are people with — I do not like to say "mild" diabetes — but diabetes that can be controlled by diet alone and does not require medication or insulin. The extra risk is probably relatively modest compared with people who have much more complex or unstable diabetes, where the risk is likely to be greater. Even within diabetes, there is a considerable gradation of risk in the context of overall risk.

Mr Sheehan: Thanks for your presentations and for answering the questions. I want to take you back to the decision on 12 March, Ian. You said that it was a policy decision; it was not a SAGE decision. At that time, transmission rates were fairly high in London and the south-east of England in particular. Some people would argue that the policy decision was right, because the system was being overwhelmed by the numbers. That was not the case here. On 12 March, there were only 47 positive cases of COVID-19 in the North. While the policy decision was taken across the water and there are clear reasons for arguing that it was the right decision, that was not the case here. Why did we make a similar decision? The decision was ours; we have a devolved health system. What exactly happened? I want to understand the process.

Professor Young: Unfortunately, as I indicated, I was off sick at the time, so I was not party to the discussions. Given that I was not there, I do not think that I can answer that question. I am not sure whether the Minister can answer it.

Mr Swann: Pat, the fact is that we went into lockdown at the same time. It was a capacity issue. The last time that I was here, you asked about the number of contact tracers. We had about 12; that was our full capacity. As we hit the spike, we did not have the capacity for contact tracing. You are right about the 47 cases, but, very shortly after that, the number started to increase.

Professor Young: I can maybe add to that. Although you identified the number of cases that were diagnosed at the time, the truth is that there would have been substantially more cases than that because testing capacity was more limited.

Mr Sheehan: My difficulty with that, Robin, is that I have asked this question on a number of occasions: was testing and tracing stopped because of a lack of capacity? On two occasions, I was told that the answer was that it was not related to capacity. The issue is out there, and I will not press you on it.

The point that I am trying to make is this: whatever is decided across the water is fair enough; that is up to them. I am on the record as saying that I think that, from the outset, the decision-making of Messrs Johnson, Cummings, Raab and Hancock has been shambolic. Maybe "messers" is a good description for them, because it has been an absolute disaster, as far as I can see. In fairness to you, you are eminently much more plausible in dealing with this. One thing that I am sure of is that you certainly have much more integrity than any of those people in dealing with COVID-19. I want to be clear: when there are two completely different contexts, you need different decision-making processes.

I want to move on to care homes and the 'Spotlight' programme of last night. It showed footage of the Chief Medical Officer from 25 March in which he said that, in care homes where carers and residents were asymptomatic, there was absolutely no need for personal protective equipment. Given what we know now about how badly care homes have been affected in the pandemic, do you think that the Chief Medical Officer would give the same advice today?

Mr Swann: Again, Pat, that would be a call for him. It is about how we judge the pandemic as we look back on it. I have talked before about judging the pandemic with the benefit of hindsight. Would we do things differently? Yes. Would we give different advice? Yes. Ian, do you want to add anything?

Professor Young: If you asked for scientific advice now, it would absolutely be that they should wear PPE in care homes, regardless of the presence or absence of symptoms. That is based on our scientific understanding of the transmission of the virus.

Mr Sheehan: Thanks for that. I have a final, short question, again on care homes. You mentioned that you do not have the power to do an overarching investigation of providers. Robin, I think that you will have to look carefully at that issue. Two of the care homes most in the news over the past number of years — Dunmurry Manor and Ashbrook — are owned and run by Runwood. Coincidentally, both have had their names changed since all the bad publicity about them. In my view, rebranding and renaming to try, in some way, to confuse people about the history of those places is very cynical. I ask you to look at that and the renaming of care homes that have performed badly.

Mr Swann: Pat, maybe a bit deeper than that, we are undertaking a review of the regulatory policy and considering the principles behind regulation. That includes fundamental questions such as why we need regulation, what type of regulation is appropriate, and who it should apply to. As I said in my answer to Gerry, rather than looking at one home, should we look at the entirety of a provider's homes?

The development of a new regulatory framework is being taken forward in two phases, which will offer an opportunity to examine the remit and role of the RQIA, in line with the revised policy. I intend to issue a proposed policy document setting out the principles of regulation for consultation later this year. It is about taking the step that you have asked for. We have started that work, because we realise that that is what we need to do.

The Chairperson (Mr Gildernew): Thank you. Quickly, Gerry.

Mr Carroll: On that point, Minister, you said that the RQIA has the power to review and inspect homes. The problem is that they are inspecting and raising issues, but private care homes still get public money, time after time. Issues are being flagged, but the contracts are ongoing, public money continues to be paid, and people are pulling their hair out as to why that is happening.

Mr Swann: Gerry, the public money that I am putting into care homes is to support residents and staff. That is the focus, and we were very specific about that. That money is being targeted at supporting staff who need statutory sick pay, and money has also been allocated for additional cleaning so that we can get the homes that have had outbreaks through the other side and clear again. The money goes to support staff and residents; it is definitely not going into operators' pockets.

The Chairperson (Mr Gildernew): I am going to Órlaithí on the phone. Órlaithí, are you there?

Ms Flynn: Yes, thank you, Chair. When Pat Sheehan was asking his first question, my phone went silent. It cuts out every now and then, so I could not hear what Pat asked, but I assume that was along the same lines as the question that I was going to ask about how the scientific evidence of the North was represented at the SAGE meeting in mid-March and about the statistics of our levels of transmission and our capacity to deal with contact tracing. However, from the responses that I heard from the Chief Scientific Adviser and the Minister, I assume that that is what Pat had already addressed.

Ms Flynn: I will move on to a few other questions. This one is for the Minister, please. Robin, as it has been brought to our attention, do you intend to bring forward plans for the rehabilitation of patients who are recovering from COVID-19? I know that some appointments have already been made in Scotland and Wales, where they have appointed a rehabilitation lead, and I think that they have taken their lead from the Chief Allied Health Professions Officer. I am not sure whether the Department has thought about that or whether you are planning something similar.

Mr Swann: We are looking at that opportunity, because this is a new virus and we have to make sure that the people who come through it are supported. Órlaithí, it is not just the physical and respiratory fall-out from the condition; there is also the mental-health impact for those who have been through the trauma of COVID-19. It is highly stressful, not just for them but for their families as well. It is about making sure that when we look at how we support patients who have come through COVID-19, that there is greater mental, rather than solely physical, support.

Ms Flynn: Thank you, Minister, and thank you for making the reference to the mental-health element, because the genuine parity of esteem is that for any time we talk about physical health, we know that there is also a mental-health element to it, so I appreciate that.

My last question is this: given the new process, is there the capacity to contact-trace all suspected cases, or will it just be those who have come into contact with someone who has had a positive lab result?

Mr Swann: At this minute in time, it is from a positive lab result.

Professor Young: As I said earlier, everybody who has symptoms needs to get a test. A weblink is available through the PHA website; the number is 119. However, we need everybody with symptoms to get tested.

Mr Chambers: The comment that I will make will obviously be no consolation to the families who have lost a loved one to this dreadful virus, and they will continue to be in our thoughts. It is easy to look back and find fault, and I am sure that useful lessons will have been learned. However, there has been a public recognition of the fact that our health authorities have got a lot of things right in this process, and people are grateful for that.

As a matter of due diligence, I am sure that you are all working towards the possibility of having to deal with a further outbreak. Is another outbreak inevitable? Could such an outbreak be an out-of-control surge? That is the sort of thing that we feared might have happened, or thought was a possibility, in March at the start.

I have a quick question. I see that a lot of employers are checking the temperatures of their staff going into work every morning. I do not question the wisdom of it, but is it a useful filter?

Mr Swann: I will pick up your first point about getting things right. If we put things in context, we sit here at the start of June, but at the start of January our nurses and healthcare professionals were on strike in Northern Ireland. What our health service has come through, stepped up to and delivered, over the past five months, is unbelievable. The professionalism and dedication of everyone across the sector is something that we should all be proud of, and amazed, that they have got us to the stage we are at.

As regards the inevitability of a second surge, Professor Young will talk about the science, but, from a personal point of view, I hope that it is not inevitable. That is why we still ask people to take the basic steps: stay two metres away from others, wash hands, practise good respiratory hygiene, and follow the guidance. If, in the next two or three months, we can achieve as much as we did in the past two or three months, we will have done well. We have reduced the number of deaths, positive cases and ICU admissions. If we can keep that train going, Northern Ireland will be in a very good place. Ian, do want to say something?

Professor Young: There is certainly potential for another outbreak. That will remain the case until we have substantial levels of immunity in the population. Probably at least 70 or 80% population immunity is required. At the moment, the best estimates of population immunity in Northern Ireland are that it is around 5%. We will have accurate figures on that, I hope, later this month.

Either we need a vaccine that works, or we will continue to have potential for another outbreak. I hope that, given all the measures in place and the way we now monitor things, it would not be an outbreak of such severity as would overwhelm the system. However, anything remains possible. The risk, while it exists, will be greater in the autumn and winter months, given the pattern of similar respiratory viruses.

With regard to temperature monitoring, it is something that we have looked at through our strategic intelligence group in the Department. Having reviewed the evidence, it suggests that, through checking temperatures, you may pick up around one quarter of people who are infectious but at the price of identifying a lot of people who are not infectious and telling them to go home and isolate. It is a matter of judgement whether you think it worthwhile.

It is also open to manipulation. You could put a cold facecloth over your face before your temperature is checked or take a couple of paracetamol, although I hope that people would not do such things. Checking temperatures might have some value, but it is likely to be pretty limited, and, generally, I do not think that it is scientifically useful at the moment.

Mr Chambers: I think that the message is that the public still has a huge role to play in trying to prevent another outbreak of the virus.

Professor Young: Yes, by adhering to the restrictions and taking the basic precautions: handwashing, respiratory hygiene and social distancing. Moreover, I would like to see a lot more people wearing masks; when I visit my local supermarket, I am almost the only person wearing a mask. I would like to see more people wearing cloth face coverings in enclosed locations. Above all, if you have symptoms, you must get tested.

The Chairperson (Mr Gildernew): Thank you for all those answers. Before we wrap up, one thing occurs to me. Robin, I am glad to hear you refer to Sian Griffiths, and I certainly hope that you had the benefit of hearing that panel. My question is: what is the one thing that you would do differently now? What is the one thing that you have learnt?

Professor Young: He would not have taken the health portfolio [Laughter.]

Mr Swann: On 11 January, I would have taken Agriculture [Laughter.]

I do not know that I could pick one thing, to be honest with you.

With the benefit of hindsight, there are avenues that we would go down differently. I cannot pick one thing off the top of my head, to be perfectly honest with you.

Professor Young: I am the same. It is impossible to pick one thing.

Just to assure you, we take scientific evidence from SAGE, but we also look very carefully at the reports from the Independent SAGE, as well as at international practice and at papers and publications from elsewhere. For scientific advice on policy, we are not relying just on the output from SAGE.

The Chairperson (Mr Gildernew): That is welcome, and we all should do that. Science works best when it is open to challenge and to a range of information. For clarity, I do not think that the Independent SAGE even existed at the time. It was then just a group of people who had experience relevant to what we are all dealing with.

I thank you both for your time today. I note that all the easement measures in your document reference the fact that they are dependent on good social distancing. On behalf of the Committee and, I know, on behalf of you, I reiterate to members of the public please to abide by social distancing and to work from home if they can. We are not out of the woods yet, and the easements depend on our adhering to the guidance that comes from you. I ask people to continue to do that.

Mr Swann: I appreciate that message, Chair, and I appreciate the support of the Committee. It is about asking people to take those small steps with us. In Northern Ireland, we are not in the place that we could have been, thankfully. That is down to our health service, but it is also down to the people of Northern Ireland working with us.

Thank you very much again. I think that we are pencilled in next for 23 June, Chair.

Mr Swann: We will see you soon.

The Chairperson (Mr Gildernew): Thank you, Minister, and thank you, Professor Ian Young.

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