Official Report: Minutes of Evidence
Committee for Health, meeting on Thursday, 4 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
Miss Órlaithí Flynn
Mr Colin McGrath
Mr Pat Sheehan
Witnesses:Mr Eddie Lynch, Commissioner for Older People for Northern Ireland
Ms Emer Boyle, Office of the Commissioner for Older People for Northern Ireland
Ms Evelyn Hoy, Office of the Commissioner for Older People for Northern Ireland
COVID-19: Briefing from the Commissioner for Older People for Northern Ireland
The Chairperson (Mr Gildernew): I welcome Mr Eddie Lynch, the Commissioner for Older People, Ms Evelyn Hoy, chief executive to the Commissioner for Older People, and Ms Emer Boyle, head of legal and policy advice.
I ask all members who are not speaking to keep their phone on mute, please. That helps with the reduction in feedback. When anyone speaks, please identify who you are, so that everyone on their phone and in the room will know who is speaking at any given time.
Commissioner, please go ahead and brief the Committee.
Mr Eddie Lynch (Commissioner for Older People for Northern Ireland): I thank the Committee for the invitation to provide evidence in these most worrying of times for older people. I also thank the Committee for its important work and the role that it has played during the pandemic in scrutinising the various authorities on a range of issues in the past number of months.
I am joined in my call today by my senior management team, as you know. Evelyn Hoy is the chief executive, and Emer Boyle is the head of legal and policy advice.
Representing older people across Northern Ireland from ages 60 to 100-plus in the context of the pandemic in recent months has not been straightforward. There are clearly groups across the wide age spectrum that have different levels of risk to coronavirus. During the pandemic, much of what is deemed to be the normal work of the company office has continued, supporting older people and their families, with our small team working mostly from their homes and attending meetings using phone or video conferencing technology. In my short address this morning, I will give my view on what has happened during the pandemic to date and my experience of trying to safeguard and promote the rights and interests of older people during this time. I also want to share some of my current concerns and concerns going forward in the short to medium term. Up to this point, my team and I have been dealing with a series of key issues during the pandemic. They include but are not limited to COVID-19 planning and preparation, personal protective equipment (PPE), reporting issues and testing issues. I will cover each one very briefly.
My team and I were involved at the early stages in giving advice to authorities on the need for care homes to receive appropriate support, as we saw the pandemic coming towards our shores. In those conversations, we outlined the needs of the sector with regard to staffing and extra support that they may need to cope with the oncoming pandemic.
PPE has been a huge issue. In the early stages of the pandemic, we worked very hard with the authorities and providers to secure appropriate and adequate PPE for care homes and domiciliary care workers, particularly in the early weeks.
Reporting has been a big issue. For many weeks, I argued for better reporting on the victims of the coronavirus. In the early stages, I was concerned that deaths in care homes were not being reported. Progress has been made in the information that is put into the public domain, which gives a much more accurate picture of the situation, but we still want to see further information being published. We have seen more information on infection rates and numbers of deaths by location, which is helpful, but I would like to see more data on survival rates as well over the coming weeks.
On the issue of testing, for some time, I was concerned that we had not rolled out the level of testing to help to protect our residents in care homes. I have called, for many weeks, for a rolling programme of universal testing. I am pleased now that the Minister has announced that, albeit many weeks into the pandemic.
I regret that I have to inform the Committee that, while progress has been made on each of the issues that I have mentioned, it took longer than I would have liked. It was an uphill battle to get support for the care home sector on a range of those issues.
There are two issues that I am focusing on at present: the ongoing roll-out of the testing programme that was announced by the Minister, and the potential impact on older people as society emerges from lockdown and eases the measures.
I welcome the recent announcement by the Minister that universal testing will now be rolled out across all care homes in Northern Ireland, so that all residents and staff can be tested. While that is not a guarantee of stopping COVID entering care homes, it should help to identify positive cases earlier and allow authorities to manage outbreaks more effectively. I still have a couple of concerns with regard to the testing. One is the length of time to test all care homes. At this stage, the Minister's commitment is for everyone to be tested by the end of June, and that is still some time away. The other is the regularity of testing. The Minister said that staff and residents would be tested every 14 days: I would like to have that on a more regular basis to increase the effectiveness of the testing regime.
On the issue of emerging from lockdown, it is important to highlight the fact that the majority of people aged over 70 have now been shielding for 11 to 12 weeks. That measure was completely necessary, as the grim statistics of the effect of coronavirus clearly show. However, we should not underestimate how big an ask that was for our older population. For many, it has clearly taken its toll. The lack of contact that older people have had with family, friends and wider society affects all of us, but the impact on older people can be particularly profound, given that many already experience loneliness.
During the pandemic, most older people have had to rely heavily on family members, friends and neighbours to do their shopping and to keep in contact using phone or online media if possible. Unfortunately, we know that many older people do not have access to that technology, and that has left them increasingly vulnerable to loneliness and isolation.
Older people are not a homogenous group, and we have heard from many older people who are concerned about being advised to lock down for indefinite periods. I also hear from the families of older people in care homes. They are concerned about the impact that their lack of contact will have on their loved ones in the medium to longer term.
For older people who are advised to continue to shield, we need to look at how we will support their needs, including their physical and mental health needs. It would be wrong to base future advice on longer-term shielding on age alone. Advice and guidance must consider a range of factors that put people at risk.
I am very concerned that easing lockdown will heighten the risk to care homes, as it is likely that those measures will lead to an increase in community transmission of the virus. That would mean that nurses and social care workers may have a higher risk of being infected and bringing COVID-19 into home settings. That is why the testing, tracing and isolating system must be up and running before any further major easing of lockdown measures.
That is an overview of the key areas that I have been working on during the past few months. I am happy to discuss them further and to take questions.
The Chairperson (Mr Gildernew): Thank you, commissioner. I will ask the first couple of questions.
I noticed that, in your presentation, the issue of the policy on hospitals discharging people into care homes was not dealt with. Do you have any concerns about how the discharge of cases from hospitals was managed and any potential that that had to worsen the situation in care homes?
Mr Lynch: That has been a concern since the start of the pandemic.
We knew that, in the early stages, when the health system was preparing for the pandemic's arrival, it was clear that one of the aims was to free up space in hospital settings to increase capacity, in case hospitals became flooded with COVID-19 cases. Part of that was the discharge of older people back into care home settings. That was at a time when there was no testing.
I know of no evidence that those people had COVID-19 at that stage, but, during the pandemic, we have heard evidence of older people being transferred out of hospital settings without being tested and relocated in care home settings. There is no specific evidence to show that they may have had COVID-19 and contributed to its spread, but we know that that happened in many care homes, and families have brought their concerns to my office in relation to people being brought into homes without testing. Families are concerned that that might have contributed to outbreaks to or the spread of COVID-19. There is no concrete evidence that people with COVID-19 were brought into care homes, but, certainly, it was the case that older people were transferred out of hospital settings without being tested.
Mr Lynch: That issue has been on the agenda for some time. The Department moved on the matter some weeks ago, when it confirmed that people would be tested at least 48 hours before they were moved out of hospital settings into care homes. That is vital. We know from evidence elsewhere and from our own situation that the best way of protecting people in care home settings is to prevent the virus getting in in the first place. It is totally logical and absolutely necessary that anyone who may be exposed to COVID-19, as they would, naturally, be in a hospital setting, be tested and assurances given that they are COVID-19-free before being transferred into a care home.
The Chairperson (Mr Gildernew): You made reference to testing, and that is something that we were also very keen on. We welcomed the fact that additional testing was being done and that all care homes will be tested on a rolling basis. You mentioned your concerns that the two-week period may not be sufficient. What is your preference for a testing regime, Eddie?
Mr Lynch: I have had conversations with various organisations about this. I am not an expert on it, but I have spoken to other authorities. There does not seem to be an exact recommendation, but I have spoken to organisations in Scotland, for example, where specialists have suggested that the testing of staff and residents should happen every three days. Obviously, it is not an exact science. We all know that, with this virus, you can be negative one day and positive the next. In that sense, you could test people every day, although we have to be realistic about what is achievable. To me, 14 days between tests seems a very long time. I want to see us move towards a system where people are tested twice a week.
The Chairperson (Mr Gildernew): Thank you. Yesterday, we discussed with the Minister the issue of shielding letters and guidance on them. We welcome that more nuanced guidance will be provided, to take account of people's individual conditions and circumstances. We also raised the issue of carers for people who are shielding, who may themselves not be shielding and therefore do not have the protection that comes with that status, difficult as it is. Those people have a responsibility to the person they are caring for, who may be shielding, and may have additional pressures on them, especially if they are essential workers.
There is a range of issues on shielding letters. Are you involved in that discussion? Have you any views on how it should be done?
Mr Lynch: I am not directly involved in the conversation about guidance. However, I have said to the Department for Communities that they need to work with the Health Department on the matter, particularly for people who will have to shield in the longer term. I am concerned that many older people have contacted my office to say, "This has been a struggle. I have been happy to shield over the last few months, because I know the dangers. However, there is a big difference between doing it for 12 weeks and doing it for 12 months". Many people struggle with that. That poses a real challenge to us as a society
The other thing that we need to consider is that, until now, there has been a great response from the community in providing the support needed for people who are shielding. Great volunteering is being done by sports clubs, church groups and community organisations. However, as the lockdown eases and more people go back to work, the number of people who can provide that support will reduce. That can happen in families as well. We know that many families of older people stopped their domiciliary care packages simply because, as they were not working, they were able to care for their loved ones themselves. It is a concern of mine that families are being told that, when things get back to the new normal and people are back at work, they will have to reapply for packages. That is deeply concerning, because those families only stepped in and took that mantle up because they were able to. There is no evidence that older people suddenly do not need that support. That will be a concern when we ease out of lockdown.
The Chairperson (Mr Gildernew): I will turn to members for their questions. I will go first to the Deputy Chair, Pam Cameron, and then to members on the phone in the order in which they came in. After that, I will come back to Gerry and Alan in the room.
Mrs Cameron: Thank you, Eddie, and your team. I wish you all the best, Eddie, in your second term in office. I want to thank you and your team for all that you do to champion the needs of older people at this critical time.
You mentioned your desire to see testing happening very frequently. I completely understand the need for that. Has your office been dealing with complaints, and are you getting complaints from residents or the families of residents who are concerned about the testing process? We know that it is quite intrusive and unpleasant. Is there reluctance, or is it a struggle to have tests done? Do you see that being a problem, even if testing is made more available and more frequent?
Mr Lynch: Thank you for your comments, Pam. We have not received many complaints from families opposing testing. You made a good point about the process: it can be quite intrusive and unpleasant. We have heard some evidence that testing in care homes is taking longer than was originally thought. That is simply because you are dealing with older people with different conditions or people with dementia who do not know what is happening and may resist it. It is a delicate issue, and there are practical problems with it. However, the overwhelming majority of families who have contacted me and the team over the past number of months have been more concerned about the lack of testing and have been in favour of it being ramped up. The Minister's announcement of the move to a rolling programme of testing has been broadly welcomed.
I will ask my colleague, Emer Boyle, who has been dealing with some of the cases that have come through, whether she has anything to add to that.
Ms Emer Boyle (Office of the Commissioner for Older People for Northern Ireland): Thank you, commissioner. I will confirm that, while we have had many contacts from families with relatives in care homes, none has raised concerns about the intrusiveness of the testing process.
It has been as the commissioner outlined. Any concerns about intrusiveness have come from officials and people explaining the difficulties with administering the process.
The Chairperson (Mr Gildernew): Emer, on a technical point, there is a lot of distortion on your voice. Are you using headphones? If not, maybe you should try to use them if you have access to them; or maybe there is something else on in the room. Your voice was loud enough, but it was distorted. I suggest that you try something different the next time you speak.
Mrs Cameron: Thank you for your answers. Eddie, has the number of complaints that you have received increased? If so, by how many? Are you concerned that complaints might not be able to get through because of the lack of communication, the lack of technology in care settings or, perhaps, due to the stress or pressures of work in care settings? Will you provide us with an update on the complaints or reports that you have received, and the details, and whether they have changed recently? Is the nature of the complaints similar to that which you normally receive?
Mr Lynch: The majority of complaints have related to the pandemic, but, previously, a wider range of issues came up. The vast majority of complaints that we have received in contact with families have been about care homes, although there are also issues with domiciliary care.
The other side of it is that we have had a few calls from people saying, "I'm in my 70s and in fairly good health. I do not want to be locked down in the longer term. I feel that I can manage the risk. I want to have choice in the longer term". We have also heard from the older age group. People well into their 80s say that they understand the risks involved but do not want to face what is possibly the last year or two of their life locked down and not seeing their family. That is what we are grappling with. Older people are not one group; they are very much different people. Like any other age group, they have their opinions and views.
It is important to stress that all the evidence continues to show that the people most at risk from coronavirus are those in the older age category. The statistics are stark: 80% of deaths in Northern Ireland are in the 75+ age group. Conversations that I have had with medical experts — virologists and epidemiologists — have been about the fact that age is a key factor and that older people are more at risk. We want to ease out of the lockdown and get back to some sort of normality, but it is important that the messaging remain strong that the virus is still here, that it is as deadly as ever and that particular groups are susceptible to it.
We have to follow the instructions, but it is a complicated picture for older people. There are those with underlying health conditions who are very much at risk if they get it, but many older people want to be given the flexibility to get back to some aspects of their life.
Mrs Cameron: Thank you for that, Eddie. I am glad that you recognise the complexity of the situation and respect the different needs and wants of those individuals. Are you supportive of the introduction of safe measures to allow some form of visiting into care homes where it has been requested?
Mr Lynch: That is being talked about. I am aware of care home providers reporting that they see the impact of the lack of social contact between residents and their families and see the deterioration of some people as a result. It is a serious issue that we need to consider. However, doing it safely is a fine balancing act. I have had many calls, on a weekly basis, with organisations and colleagues across the UK, including the Welsh commissioner. We are looking at the issue in a lot of detail. We are very aware that families do not want to go without contact with their loved ones in the long term. We know that the average stay in a care home is not that long; it is about 18 months. If we start to say that this could be a longer-term thing over another year or so, that has huge implications for families seeing their loved ones.
We need to look at the issue, and I am looking at it closely. If there is a way of doing it safely, we should definitely explore it. We have heard of examples elsewhere of care homes organising drive-through visits. There is still a limit to the contact that they can have, but it gives families more of an opportunity to see their loved ones in care homes. There are difficulties as well, though. The other thing that we have to recognise is that families themselves have different views. It is about striking a balance between putting a ring of steel around care homes and recognising the social and emotional needs of residents and their families.
Mr Sheehan: I welcome Eddie, Evelyn and Emer. Thanks for your presentation. Eddie, I want to talk to you about care homes more generally. We cannot divorce the COVID-19 pandemic from the problems that already existed in care homes. I know how familiar you are with the scandal in Dunmurry Manor and other homes, particularly those run by Runwood. Of course, Clifton House has been in the media more recently. We heard, in the 'Spotlight' programme the other night that, according to Regulation and Quality Improvement Authority (RQIA) inspections, 26% of care homes in the North had already been having infection control issues. The virus has brought into sharp relief the deficit in some, although not all, care homes. Some care homes have been particularly badly managed. I have been a bit long-winded in getting to the question: what would you like to see coming out of all this for the management and regulation of care homes?
Mr Lynch: Thanks, Pat. You are right in what you say about what happened in Dunmurry Manor. Unfortunately, some of the stories that have come out of Clifton Nursing Home in the past couple of weeks have been depressingly familiar for myself and my team, because they mirror a lot of the issues uncovered in Dunmurry Manor.
The simple answer to your question is that what I would like to see happen is the implementation of the recommendations of my 'Home Truths' report, which has been out for almost two years now. Some of the issues emerging in Clifton House are very similar to the problems in Dunmurry Manor. One of the most disturbing aspects of my investigation was the number of chances that care homes had to fix what were serious failures of care and the time that it took care homes to do that. Recently, we have heard that Clifton struggled with infection control measures over a significant period. The issues that are being highlighted and any other issues that have been highlighted since the 'Home Truths' report on Dunmurry Manor came out are not new.
They are problems in the system that need to be changed. For me, it remains totally unacceptable that we have to wait such a long time to see improvements, and it is completely unacceptable for the residents. That is their home. It is where they live, and failures of care impact daily on every resident. It is just not good enough to have months go by before the management in homes fix that problem. If some good is to come out of what has happened in recent months, it highlights once again the need for changes to how we regulate and inspect our homes and how we take a tougher stance and insist that homes make the improvements much more quickly to protect those who live in them.
Mr Sheehan: Thanks for that, Eddie. I have a final short question. Many experts say that, from here on, we will see new viruses appearing regularly, so it stands to reason that we should be prepared for that eventuality. I have been banging the drum about South Korea and its record of having no deaths in a care home setting, which goes to prove that, if you are prepared and are in a state of readiness for whatever comes at you, you can deal with it. Do you think that there was too much focus on the acute care setting here at the outset and that care homes were basically left by the wayside to look after themselves?
Mr Lynch: You are right about the future threat. We are still very much in phase one. There could be other waves coming down the line. Whilst dealing with a pandemic like this was new for many authorities and we had not, as a society, dealt with this before, the lessons that clearly have been learnt have to be put into place so that, if there is a second or third wave, we will be much better at protecting what we know to be some of the most vulnerable locations and residents from the virus. You are quite right.
Homes have had to deal with things like infection control regularly anyway, even before now, with outbreaks of flu, norovirus and MRSA. We have to learn from the mistakes and get things in place more quickly. At the start, there was no doubt that the focus was on the acute settings in our health system. There were deep concerns about it being overrun and flooded and not being able to cope. In the midst of that, our organisation and others were advising government about the vulnerability of the care home settings and that more action needed to be taken at an earlier stage.
It has been frustrating for me to see how many of the homes were slow to get the PPE that they needed. The testing regime, I believe, should and could have been rolled out earlier. We saw from other countries and had the advantage of seeing the terrible things that were happening across Europe in Italy, Spain and other countries as the virus came our way, and we knew that people in care homes were very much at risk if the virus got in there, just by the nature of them.
There was clearly a slowness in moving to protect that has led to an increase in infections. We are where we are now, and we have to make sure that we do everything in our power at this stage to provide that ring of steel and that level of support in the testing and tracing. More can still be done. There could be more roll-out of testing. There is nothing inevitable about this. As you said, other countries learned from the past and have taken different approaches, so there is no inevitability about victims in care homes from coronavirus. We have to learn the lessons of what has happened in previous weeks and months and apply that now.
Mr McGrath: Yes, indeed, Chair. Thank you to the panel for the presentation. My questions and comments follow on from what Pat said. Given where we are with the pandemic, there are two things to say. We can reflect, see what has happened and say, "What can we change for the future?". I just want to probe a little bit further. You talked about what was happening in Italy and Spain. It was obvious that there was a major issue in care homes in those countries, and we had weeks and weeks of a heads-up, as it were, that that was coming down the line. If you saw that, what action did you take to go in and say to Ministers and Departments that the issue was coming down the line and that, as the Commissioner for Older People, you gave real weight to what was happening in other places and that they needed to do something?
We would generally accept that the eye was taken off older people's homes and the focus was on acute care. There was, at least, a six-week or seven-week lag between the effort that was put into the acute sector and that in the care homes. When you add that to what was happening in Italy and Spain, we had probably about eight to 10 weeks of a heads-up. Can you detail to us the representations that you made? Were you finding that doors were closed or that nobody was listening to you and you were banging your head against a brick wall trying to raise issues around what was happening in the care home sector?
Mr Lynch: Thanks, Colin. In the early stages, the situation was clear to us. We were in daily contact with the providers on the ground, and we were seeking reports about what was happening. Many providers came directly to my office to raise their concerns. That was our intelligence, I suppose, and, in those early stages, I and the members of my team were in daily contact with officials in the Department, raising the concerns on the ground.
The big one at the start, in the first number of weeks, was PPE. We were back and forward many times, stressing the need for PPE to be released into care home settings. Many providers reported to me that, while they were requesting PPE, it was not forthcoming or was slow to get to them. We have heard that many of those providers believed that, as a result of that, the focus was very much on maintaining some supplies for the acute settings. I had been getting assurances. In the early stages, I spoke to very senior officials in the Department of Health, and they were given assurances that the trusts were to provide homes with that equipment where requests were being made.
In the early stages, some homes were being told that it was their responsibility to seek PPE and get the equipment in. However, it became clear that it was unrealistic to ask that of the homes. As the virus spread globally, it was clear that there was a global shortage of PPE. Providers were telling me that they did not have a chance of getting the orders because they were competing with countries that were placing orders and making requests. They struggled in the early days and expressed real concerns, as I did, to officials about why that was taking so long to get out. That has been well documented. Many providers have publicly said that they felt left behind and that they did not get the guidance and the equipment that they needed. They felt that they were playing catch-up from very early on.
The Department had a series of meetings in early March that COPNI attended along with other groups and organisations such as Age NI, the independent healthcare providers and Volunteer Now. It was clear at those meetings that concerns about the care home industry were being raised with officials and that they should not be forgotten about or seen as secondary to acute services, given the high risks for people who lived in care home settings. That really was the situation in the early stages. Clearly, there were many weeks when PPE was slow to get out to care homes. While that issue seems broadly, now, to have been resolved for a number of weeks, it really could have been identified earlier and rolled out more fully.
Going forward, though, we need to ensure that we are not complacent about supplies of PPE and that all providers get their stocks replenished when they need them. We also need to see that, when care is being provided in the community, domiciliary care workers are included.
Mr McGrath: I do not mean to be rude by kicking in, but, because time is short, we have been told that, if we do not feel that the answer is going in the direction that we want, we are to come in as quickly as we can. That is all very factual and is very much the information that we were provided with as well. What I am asking is this: as the Commissioner for Older People, did you feel that you were being listened to by the Department when you made representations? Likewise, we, as the Committee for Health, heard that there were problems with PPE and testing. We heard all the same issues from the same lobby groups, and, then, we made those representations collectively to the Minister and others. We can, then, determine whether we feel that we got a proper hearing. As the Commissioner for Older People, do you feel that, when people were coming to you and raising concerns and you were going to the Department with those concerns, it was taking them on board, listening to what you were saying, and acting on that?
Mr Lynch: There was no issue with getting access to the Department and officials. I was able to raise concerns, and I had many phone calls. However, with regard to the Department's actions, I have to be honest and say that much of the advice given by me and my team was not taken on board to the level that I would have liked, and it certainly was not taken on board as quickly as I would have liked. There were many times when I sought answers from the Department and the response was very slow. On certain things, the response was quick, but, on other areas where I gave advice or asked questions, the response from the Department was slow.
Ms Flynn: Yes. Thanks very much, Eddie and the panel. I would like to ask two questions. Pam touched on the first issue. Eddie, has your office done any sort of audit of the number of COVID-related complaints or cases that have been brought to your attention since the beginning of the pandemic? How many of those complaints have been resolved? More importantly, how many are pending? That is my first question.
In your briefing note, you mentioned concerns around older people who are shielding. Does your office have any practical suggestions on how the Department could better support the mental health needs of those older people? Can you give the Committee a sense of how we can support any practical suggestions that would help our older people in these worrying times?
Mr Lynch: Thanks, Órlaithí. Perhaps, I will go to one of my colleagues about the details of the number of cases. I am not sure that we have an exact number, but they will give you a sense of the cases that are coming through to the office.
I will answer the question on shielding first. We have been doing a number of things. Obviously, the calls that we get from older people and their families are a rich seam of information for us on how older people and their families feel about the situation. Many people have contacted the office and given their views, which is really helpful. The other thing that we established early on was the "Check in and chat" service with Age NI. We enhanced the service that Age NI provides. Many of our staff also volunteer with that service.
That was not just about providing support and advice to older people; really, it was about identifying those who are shielding and who might be lonely and not have contacts or family members. At the minute, we have a group of volunteers who make weekly, sometimes twice-weekly, calls to older people, just to chat through how they are getting on. That is very useful as well. It feeds into our work and into the advice that I give government about how older people feel about the future. That has clearly shown us that there are deep concerns about the longer term. We talk about the "new normal". There is a danger that, while most of us will get back to some aspects of normality, we will forget those who are most at risk and have to shield in the longer term.
There is a big piece of work to be done on how we provide support and services. We might need to start being more innovative in the type of support that we provide. We might need to look at the social care model. I welcome the Minister's announcement that he is to reform social care, because it is my view and the view of many that the system has been broken for many years and needs to be revised. I call on the Minister to make sure that the reform process is as open and transparent as possible and involves all stakeholders. We have to look at how we provide support for some of the most vulnerable, and we have to get that right.
I hope, Órlaithí, that that gives you some answer to that question. I will pass on to Evelyn Hoy, the chief executive, who might tell us a bit about the casework.
Ms Evelyn Hoy (Office of the Commissioner for Older People for Northern Ireland): Thank you very much, Chair and Commissioner. Órlaithí, you asked whether we did an audit of the cases related to COVID. I can clarify that we always log each call or enquiry according to category. We cannot get into the detail of any of those, but we would be happy to provide the Committee with exact figures.
We have had a significant increase in enquiries, and one of the increases that we are noticing, apart from the number, is the complexity of some cases. It began with people complaining about being locked out and being unable to visit older relatives in nursing homes. It has gone on to all manner of issues about not knowing what is going on in nursing homes, not being told when there are COVID outbreaks and concerns about people coming out of hospital and going into care homes. Then, there are the usual concerns that arise from what is happening to relatives in care homes. We have had some enquiries regarding the community as well. We are happy to come back to the Committee with exact figures on those.
Ms Bradshaw: Thank you, panel. That was very interesting. Many MLAs have asked questions that I was going to ask. I want to drill down into the situation of people who have carers coming in. These are people who do not have shielding letters, but they are vulnerable. I am interested in how they access primary care at the moment. Many are not going to their GP or to emergency departments. Have you any thoughts on how we can encourage them and reach into their homes? They are less involved in social media, so how should we encourage them to come forward when they have non-COVID-related illness?
Mr Lynch: Thanks, Paula. It is a good question. There is a real fear factor amongst older people. Naturally, we will be concerned as we start easing lockdown. Some will probably rush out the door and get back to life, but many will be concerned about coming forward. We have already heard many of the medical family express concern about the drop in the number of people reporting to accident and emergency departments and in the reporting of the normal illnesses and diseases that we deal with in society.
I am due to have a session with GPs in the next couple of weeks to discuss the pandemic, and that is one of the issues that I am interested in discussing. Much of this is about communication. It is about making people, particularly those who are afraid to cross the door and go back out, aware of the precautions that they should take. A message has to go out. The age sector also has a role to play in making sure that older people who experience other health issues act on them. We know about the major dangers of delaying with certain illnesses. It is a good question, and it is one in which I am interested in getting more involved. Good delivery systems have been set up during the pandemic, such as the response by pharmacies to the increase in demand for home deliveries. As a society, we need to communicate to people that they must come forward with concerns about their health — physical or mental.
Ms Bradshaw: I want to follow on from that. I am concerned that, if one of the elderly residents has a shielding letter, their partner, husband or wife is still providing an intensive level of care during the lockdown. How can we provide better respite? We know that a lot of reconfiguration has taken place and that the usual systems are not there. What can we do in a practical sense for carers at this time?
Mr Lynch: That has always been an issue for me, even before the pandemic. Often, we do not value the daily work that carers do or the huge role that they play in the health system. They can do that only if they are supported and if they look after their own health and are supported to do that. You are right: the role of carers has probably intensified during the pandemic. That has to be part of the strategy. We have to think about the needs of the people who have to shield, but we also have to think about the people who play a central role in supporting them. There is a big challenge for us.
There are major issues not only in mental health but in physical health. People have not been able to leave the house and exercise, so there is a big challenge ahead. Departments need to look at the support that we provide to people in that situation and ensure that we do everything possible. That will involve us doing things differently. We need to look at this to see what other measures can be put in place.
One thing that has been positive in the pandemic is that there are many examples of older people who had never been interested in going online and have, maybe, been forced to do so by their families during the lockdown. They have benefited from that. We have heard positive stories of people tuning in every evening at dinner time to communicate with their family. They are WhatsApping and Skyping. That is a positive thing. The Minister's announcement earlier this week of investment in technology in care homes to increase contact with family members is a step forward.
I do not underestimate the challenges that we face. Carers are definitely one of the groups that have to be in the priority category. They will probably be relied on more than ever, and we need to look after their welfare.
Mr Carroll: Thanks, Eddie and team, for your presentation and work. Since your report on Dunmurry Manor in June 2018, the RQIA has taken enforcement action against three Runwood care homes. Is there a case for your office to investigate Runwood as a service provider? Is there a case that Runwood should not receive public money, at least until serious changes are implemented? Commissioner, in 2018, you said that the staff in Dunmurry Manor were afraid to speak out. Why is that still the case in 2020? Do you believe that we will still be talking about Runwood homes in 2021 and 2022?
Mr Lynch: Thanks, Gerry, for those questions. You raise some good points. I am extremely disappointed that, two years on from 'Home Truths', we are talking about similar issues in a care home. That has been the case for many years. In many previous reports, we identified some of the failures and weaknesses in the system.
On Runwood, the Minister announced this week that he was planning to review aspects of the regulation and inspection system, which is welcome. He said that he wanted to look specifically at where there were failings across a number of homes under one ownership. It is important that we do that. Whilst there is more of an individual approach to homes at the minute, there have been a number of homes under Runwood where concerns have been raised, including the shutting down of Ashbrooke, Dunmurry Manor and others, and there is now the issue at Clifton.
Any changes to the system as a whole are important. One thing that I found in the investigation of Dunmurry Manor and the wider work in care homes was the importance of leadership and management in a care home, and that has to go right to the top. If you get that in place, you usually find that the care is better throughout the home. That should be welcomed.
On public money, one of my recommendations in 'Home Truths' was that, when organisations fail to meet the minimum standards, there should be tougher financial penalties and quicker action to get them to turn around much more quickly the care and treatment of people in their homes.
Your final question was about complaints. We saw that people in Dunmurry Manor wanted to raise concerns but the culture was not one that welcomed complaints, quite the opposite. My office finds that one of the most valuable sources of information about what happens on the ground in care homes or other care settings are the people who work there. The many whistle-blowers who have come forward to various authorities, particularly my office, over the past number of years have been useful. If we are to see proper change in homes, good homes should welcome concerns, whether from staff or family members, and address them quickly. You find that the homes that have struggled do not have in place a complaints culture that allows people to raise concerns.
Those are some of the fundamental recommendations in my 'Home Truths' report. Some of the stuff that we have heard in recent days about Clifton again highlights the need for change. One of the things that I will focus on, certainly with the Minister of Health, is trying to push forward those recommendations as soon as possible.
Mr Carroll: There is a concern that some care homes do not accept trade unions, which would be a better avenue for people to relay concerns.
We have heard a lot about this being a novel virus, which it is. My concern is that some of the issues in care homes — neglect, discarding and not investigating complaints and putting in place fines and measures — were not addressed before the virus emerged.
Mr Chambers: Before asking my question, I want to pick up on a few points and a couple of your answers. You said that people can be tested one day and be negative; the next day, they can test positive. That would happen because of inadequate infection control in the environment in which they were living.
Are you satisfied that the infection control provided by care home providers at the moment is adequate?
You talked about acute services being ramped up in the early days of the pandemic, perhaps at the expense of those in the care home sector. Do you accept that the ramping up of acute services was done for the benefit of all of society, which includes older people? Indeed, in the event of there having been a major surge, older people would have made up the biggest section of patients who required acute services.
My issue, Eddie, is testing in care homes and nursing homes. I understand why people feel that it is the right thing to do, but I feel that there is the perfect situation and there is the reality. It is easy to say that teams should be put into the homes. You are calling for testing in homes to be done twice a week. I do not know whether you have been present when a test has been carried out: I have not. I have only had the benefit of seeing the test carried out on TV, but it appears to be a particularly invasive and unpleasant experience. The swab has to be put far enough down the throat to cause the patient to gag, and it has to remain there for a period to get an adequate result. The same swab is then placed up the patient's nose. It is an invasive and unpleasant experience. I know that there are patients in nursing homes who will be able to give their consent, but I wonder whether, if they have it done once, will they be as amenable to having it done two or three days later or having it done twice a week for an indefinite period? That concerns me a little.
My other concern is about dementia patients. They are patients in a nursing home setting, and it might be difficult to get them to take medication, food and drink. How do we manage that? You can imagine the terror of a dementia patient being approached by a stranger in full PPE. How do we overcome that? Those people will not sit quietly and allow the test to be done. For testing in care homes to be effective, everybody in the home needs to be subjected to it. I know that, as Commissioner for Older People, you speak on behalf of older people and you are calling and campaigning for testing twice a week. Maybe no one is complaining about it now, but, once this becomes widespread, you might start to get complaints from next of kin and, indeed, from patients. Who will speak on behalf of the older people or their next of kin who decide that they do not want the test carried out? Who will give them a voice?
Mr Lynch: Thanks, Alan, for those very fair questions. Clearly, infection control has been the main focus of the RQIA. When the pandemic started, the RQIA was repurposed, and one of its key roles was to provide advice to all the care homes on how they handled infection control, given how important that is in controlling the virus.
Unfortunately, we have heard about the problems in Clifton Nursing Home. That has clearly been identified as one of the key areas that need a close eye kept on it.
I will turn to your comments about the focus on acute services and about those services being ramped up. You are right: at the start of the pandemic, we were all very aware of the threat that was coming to our shores. We saw what was happening in other countries and how even good health systems struggled to cope with the tsunami of cases coming their way. It was right for the authorities to make sure that our health system was geared up as much as possible; indeed, messages were going out to society about the steps that we could take to ease pressure on the system. Nevertheless, I do not believe that it was a case of one or the other. We have to view our social care settings as part of the overall health system. Whilst it was quite right to get our acute health settings as best prepared as possible, it was equally clear that there was a real threat to older people in care home settings. It was not a case of one or the other. It was clearly outlined to the Department that here was a very vulnerable group of people — the stats showed it — and that more protection needed to be put in place at an earlier stage.
Your points about testing in homes are well made, as it is clear that the testing process can be invasive. However, it is also important to point out that there is a bit of a balancing act here. Yes, it is not something that any of us would want to do regularly, but there is a balance of rights. The right to life and the protection of life trumps everything else. Many invasive procedures are common in the medical care of older people, whatever setting they are in. Done properly, they can be done compassionately. Care home staff are professionally trained to deal with the challenges that they face, as some of them are not new. Many people who work in care homes face challenges in dealing with people with challenging behaviours who may not understand why they are getting the health support that they receive.
You made the point that consent is vital. It is important to listen not just to residents but to their families. Obviously, we have to be compassionate and conduct testing in a way that people can be comfortable with. It is not about forcing testing on anyone. Where concerns are raised, they need to be listened to. We need to get the consent of families for testing. The vast majority of those who have contacted my office in recent times have felt that testing needed to be ramped up. Their primary concern was about trying to do everything possible to reduce the spread of the virus in the homes, because they have seen at first hand the devastation that it can bring. Your points are all very well made and are issues that we need to consider, but it is not about forcing things on people; it is about doing it with consent.
The Chairperson (Mr Gildernew): Thank you, Eddie. I have one final quick question. We learned yesterday from the Minister that a rapid learning initiative is being put in place, and we welcome that in light of the necessity to learn lessons very quickly and implement them rapidly so that they can safeguard, as far as possible, against further surges or spikes. Are you or do you expect to be involved in that initiative?
Mr Lynch: I have not been contacted about that yet, but I welcome it. Any step that takes forward learning from the pandemic is to be welcomed. I would be happy to communicate with the Department to give my views and those of my team to any such initiative. There is learning to be had, and steps still to be taken more generally in respect of care homes. We all have a role to play in making sure that we provide the best possible care for our loved ones, some of whom are the most vulnerable in society
The Chairperson (Mr Gildernew): Thank you all for your presentation and answers. I, too, wish you all the best for your second term, Eddie. I look forward to working with you just as closely as I have done during your first period. You have done important work, some of which remains outstanding, as you said about the recommendations in the 'Home Truths' report. The reform of adult social care is crucial work that we all need and, I think, want to be involved in.
Thank you, Eddie, Evelyn and Emer. On behalf of the Committee, all the best for your work in the time ahead. We look forward to meeting you again soon.
Mr Lynch: Thanks very much, Chair and Committee members.