Official Report: Minutes of Evidence
Committee for Health, meeting on Thursday, 11 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
Witnesses:Mr Alan Perry, GMB
Ms Rita Devlin, Royal College of Nursing
Mr John Patrick Clayton, UNISON
Ms Anne Speed, UNISON
Safe at Home Pilot Project: Trade Unions
The Chairperson (Mr Gildernew): I welcome Ms Anne Speed from UNISON, Mr Alan Perry from the GMB, Ms Rita Devlin from the Royal College of Nursing (RCN) and, in person and in the room, John Patrick Clayton from UNISON. I invite the members of the panel to brief the Committee.
Ms Anne Speed (UNISON): Thank you very much for the opportunity to brief you. We have been very aware of the very close attention that members of the Committee have given to this important sector of the workforce and of your particular concerns about what has been happening inside care homes. I understand that, as of yesterday, there have not been any applications to participate in the project. I checked that with the Department. At this stage, we are unsure whether any such project will ever get under way. For the record, it is important to elaborate and answer questions on what we felt were the problems with the project as it was presented to us. When we could not give agreement to it, the Department decided to write to the care home owners directly and invite them to apply. That was not really acceptable to us, but it was a fait accompli and there was not much that we could do about it.
I would like to ask Rita Devlin to come in and go through the broad points of our objections and concerns. Chair, if it is acceptable to you, at an appropriate time, I and other colleagues would like to make some general comments on the care home sector and raise some questions that we think need to be answered if we are to have a proper plan going forward to support the sector and look after the residents, the patients and the workforce. I suggest that Rita should address you now.
The Chairperson (Mr Gildernew): OK. We will hear from Rita and then ask you to make the remarks on the wider issues as briefly as possible. We will then move into a question-and-answer session. Go ahead, Rita, please.
Ms Rita Devlin (Royal College of Nursing): Thank you, Chair, and thank you, Anne. The Royal College of Nursing, UNISON and the GMB welcome the opportunity to clarify our position on the Safe at Home pilot. We would like to make it clear that we never refused to work with the Department of Health on it, but we had some very serious issues with what was proposed. The aim of the project was to implement a system whereby staff would live in care homes for a defined period to reduce the number of contacts and opportunities for infection. We were presented with the paper, and we gave our responses to that. Given that we had known for some time that the death rate among the older population was significantly higher with COVID-19, we were concerned that a more proactive approach had not been adopted at an earlier stage in the pandemic to reduce the risks to vulnerable patients. Since the onset, RCN, UNISON and GMB members working in nursing homes have received conflicting advice and guidance about personal protective equipment (PPE), and, given the recognised risk associated with these patients, it is regrettable that the arrangement for the supply of PPE to nursing homes was not considered a priority in the early COVID planning.
Introduced in the rationale for the proposal was a suggestion that COVID-19 could only be introduced by a new resident, a visitor or a staff member, and, for the staff working in the homes, we had serious concerns that this was introducing a blame culture at a time when staff already had huge anxieties and were dealing with unprecedented challenges. The guidance provided for nursing homes in relation to visitors was not updated between 17 March and 27 April on the Public Health Agency (PHA) website, despite numerous requests from the RCN, UNISON and GMB for clarity and direction. It must be noted that most homes used their own initiative and restricted visitors at the outset, and they attracted criticism for doing so.
The proposal described self-isolating for 48 hours prior to commencing living in these arrangements. There was not an understanding of the scientific basis for the 48 hours — we did not understand where that came from — and clarity was also required on where the self-isolation would take place and whether staff would be paid during self-isolation. We were concerned that it was unclear how the care homes had been identified for participation in the pilot. It was not clear to us how they had been chosen. We talked about testing being pivotal in the proposal and said that it should be in all nursing homes as we sought to protect patients and staff. Several of our members working in homes had already raised concerns that they had no access to testing or carrying out testing, and there was a concern about the accuracy of results.
The proposal did not indicate whether any consideration had been given to the mental and physical well-being of staff and how they would rest, exercise and relax. There had been no exploration around enhancing PPE or comparing how the spread of infection had been managed in hospitals as opposed to nursing homes, and there was no consideration of whether better access to PPE, testing or isolation — the model in hospitals — could be an influencing factor in patient outcomes.
The proposal indicated that Four Seasons Health Care had identified a number of homes. We did not know how they had been selected or whether any health and social care trust facilities had also been approached for inclusion in the pilot. Any plans to implement significant changes to models of care invariably benefit from full engagement with the trade unions and the professional organisations representing the staff to deliver new ways of working. We found it regrettable that the Department of Health chose not to engage with our organisations at an early stage of the development of the pilot and then presented us with an unrealistic timescale for commenting on the proposals. That is not within the spirit or the letter of partnership agreement.
Further to the submissions of concerns, the RCN was then asked to participate in a meeting with members of the nursing team at the Department, along with representatives of Four Seasons Health Care. The RCN agreed to take part in the meeting, and four members of the team, two of whom have extensive experience of the nursing home sector, participated. Although some of the concerns had been addressed, we remained concerned that a full risk assessment had not been completed in order to identify potential risks to patients, staff and residents. It was on that basis that the RCN, UNISON and GMB determined that they were unable to support the pilot in its current form. We also raised a number of concerns about the standard and appropriateness of the accommodation that was proposed to be offered to staff, not least the suggestion that they could stay in a mobile home in the car park of the care home. However, we were prepared to discuss staff being accommodated in nearby biosecure hotels, thereby reducing the risk to patients and residents and supporting the mental and physical health of staff involved in the pilot. It must be noted that, during the pandemic, hotel accommodation was offered to staff in the health and social care sector. It is unthinkable that staff working in care homes would be offered anything less than an equivalent standard of accommodation.
We were aware of the likelihood, because of the ethnic composition of the independent sector workforce, that a large number of black, Asian and minority ethnic (BAME) staff would be involved in the pilot. We were concerned about the potential risk to their health, given the emerging evidence that BAME staff are particularly susceptible to healthcare infections and death, as confirmed by the Public Health England report on 2 June 2020. It was not clear from the pilot submission what the associated learning would be. Indeed, it was agreed at the meeting that there would be neither a plan for rolling out, nor a capacity to roll out, the initiative beyond the pilot phase. Therefore, we were unable to identify what learning would be derived from the pilot that would justify the potential risks to patients, residents and staff. During the discussion, we identified ways in which risks to patients, residents and staff could be mitigated. These included increased numbers of cleaning staff to ensure constant cleaning of communal areas, handrails and bathrooms in areas where patients and residents were unable to adhere to social distancing or isolation. We requested that, where a patient had tested positive for COVID-19 and had isolated for 14 days, they be retested before discontinuing isolation. We asked for an increased number of staff to help patients to maintain social distancing and to keep them occupied and safe. We asked for better-quality and more readily available personal protective equipment to ensure appropriate and timely changing and disposal. We suggested that facilities be available for laundering staff uniforms within homes, and that scrubs be provided to enable regular uniform changing.
The RCN, UNISON and GMB hope that this summary of our position in relation to care home pilots has been helpful. As you know, we submitted these concerns to the Department, and we have provided already our submissions to you. Throughout the pandemic, we have highlighted the need and supported moves to address the impact of COVID-19 on nursing and residential care homes. This particular initiative, however, did not appear to offer any resolution to these issues, and bore the hallmarks of initiatives that were ill-conceived and not thought through. On that basis, the RCN, UNISON and GMB were unable to endorse the participation of our members.
The Chairperson (Mr Gildernew): Thank you, Rita. I will go back to the panel for the broader concerns or issues around care homes, and then into questions and answers with members.
Ms Speed: I will start on that, and I will call on John Patrick if he wants to add to this.
Basically, social care has been the poor relation in the health service, and we now have to throw down a challenge to the Department. This sector needs much greater regulation. We would prefer public provision. We live with the reality of procured services and outsourcing, so regulation is absolutely essential for not just the practise of care but the regulation of the organisations that provide it. If you can have regulation of public utilities like water and electricity, surely you can look at social care in the same way. It is of crucial importance that that happens. There should be regulation as well on the margin of profit. We should stop the profiteering that is happening, and it is happening within some of the providers in Northern Ireland. Their names have been in the public arena. There should also be regulation of the market for procurement. Are these fit organisations to be providing such care? These issues have to be absolutely central to any strategy, going forward, together with the right of workers to organise and bargain collectively and the need to raise not only care standards but the standards of employment for the workers.
Mr John Patrick Clayton (UNISON): I will be brief because I know that members want to get to their questions. It is worth reflecting on the fact that, back in 2017, the report 'Power to People' made numerous proposals for the reform of adult social care more generally, including for home care and nursing homes, and structures were set up on the back of that. A reform board was set up, and I have taken part in that on behalf of UNISON over the last number of years. More recently, we saw the Minister, which was welcome. He acknowledged our members' concerns about concerns of the lack of proper sick pay, low pay and poor terms and conditions across the sector. Anne referred to the lack of recognition of trade unions and the lack of collective bargaining within the sector.
If, moving forward, we are to have a much more stable workforce, those issues have to be addressed. That is also very important with regard to COVID-19. We should be mindful of the potential for a second surge. As the Committee will be aware, COVID-19 is not going anywhere in the short to medium term. The reform of social care cannot be postponed. It needs to be progressed. The Minister indicated that he will bring forward proposals on that.
Going back to our earlier session, I think that there needs to be engagement on those proposals. The project board that was doing some work was stood down as a result of the pandemic. From a trade union perspective, we have a number of proposals that we want to be implemented in any reform process. Anne referred to having a much more transparent and ethical commissioning and procurement process when a decision is made to outsource services. Clearly, our ambition is that we see this as a public service and move it back into the public sector.
The Chairperson (Mr Gildernew): Thank you. It is true that we have taken a great deal of interest in the entire area of protection. From a very early stage of the pandemic, we expressed concerns about the provisions that were being made for care homes. We acknowledge the good work that you mentioned, John Patrick, in dealing with some of these issues. Some were dealt with belatedly, but that work was welcome nonetheless.
I will move on to testing, PPE and discharge policies. I was astonished to find out that, around the end of April, trusts were being instructed to go ahead with discharge to care homes, even people who were COVID-19 positive, while there was capacity in the hospitals. That is a grave concern. It is one of the key issues that we need to learn from with regard to any additional surges or spikes so that we can do much better.
Listening to Rita setting out the issues with the Safe at Home pilot acts almost as a case study of how not to do something. The idea that you do not consult those with specific expertise because of a lack of time is, in my eyes, counter-intuitive, because you lose time through having to pick up on the issues. Had unions been involved at an earlier stage, you could have raised the issues on which you are uniquely experienced in representing your members. In general, getting a wider base of discussion, expertise and input is always a good idea.
Before we go to members' questions, I remind everyone that we are looking at being here until no later than12.45 pm. I ask members and the panel to bear that in mind.
A concern raised on many occasions is about BAME people, who are uniquely vulnerable to the impacts of this disease. Is there any progress to report on a policy or strategy to protect workers who may be uniquely vulnerable? Has that been progressed to any great degree?
Ms Speed: Yesterday, we got a document from the Regulation and Quality Improvement Authority (RQIA) — actually, we did not get it; we got a copy of a document that was sent to independent providers — and it makes links to general advice. However, we do not believe that it is based on any real analysis or data. Rita might want to comment more on that. It came up in a discussion that we had yesterday.
Ms Devlin: The RQIA sent an email to home managers and providers referring them to what is on the Public Health England (PHE) website on BAME and talked about ensuring that they are risk-assessed. However, it must be noted that small independent nursing homes, etc, do not have access to the same facilities as trusts for risk assessment, identifying risk and being able to do things like provide higher levels of PPE or redeploy members to a different part of the organisation to reduce risk. It is concerning that a one-size-fits-all approach to BAME has been taken in our nursing-home sector. That is something that we have not been involved in, but we are very clear that we need to be involved in it, because the same facilities are not available to staff in small care homes.
Mrs Cameron: I thank the panel for their attendance. At the outset, I declare an interest in that I have a family member working in the care sector.
First and foremost, did the unions carry out a staff audit to gauge the appetite for taking part in the Safe at Home pilot initiative? Do you have any evidence of staff members who have gone ahead and voluntarily decided to move into care homes? If so, are they receiving support?
Secondly, you raised the issue of how care homes were selected for the pilot. What was the issue that you had that you needed information about how particular homes were selected for the pilot?
Ms Speed: I will make an initial comment, and then ask Alan to respond to the member's question. We did not conduct an audit of staff who are members of our respective organisations without having a concrete proposition to put to them. I am not aware of any staff who have participated in a similar project as an individual care-home initiative. Remember what we said earlier that some of those doors are closed or those staff may not be our members.
Mr Alan Perry (GMB): Thanks, Anne, and thanks to the member for the question. In relation to doing an audit, it was pretty clear from the outset that it was actually our members who made the trades unions aware that this pilot was in the domain. They were asking serious questions about being forced — that is their word — to participate in a pilot that would involve them staying in a home for seven days. That happened on the Monday, we had a conference call with Four Seasons on the Tuesday to get a wee bit more of an insight, and, that week, we responded to the Department with our submission. Given that timeline and the restrictions that were in place where we could not enter into the homes, it would have been impossible for us to carry out an audit at that time. I am not aware of any members in the two Four Seasons homes that have been earmarked who were willing to take part in it. I think that, if they were to take part, they would want more clarification and information about what the role involved.
Ms Devlin: One of the RCN's networks is an independent sector network. The nursing-home managers work with us every week. We asked them their opinion on it, and they agreed with our concerns.
Ms Flynn: First, one of the witnesses said that the Department of Health chose not to engage early enough on the proposals, so when did the unions first become aware of the pilot?
Secondly, and more broadly, has the Minister or the Department shared any proposals with you about future reform of social care in general? We know that the 'Power to People' report was shelved because of Brexit, so do you think that the Department has a different approach to social-care reform now?
Ms Speed: We received a copy of a very detailed proposal from the Chief Nursing Officer and the head of social care at the Department. We were presented with a finalised proposal that we could comment on, so we were not involved in the co-design or co-production. We presented our finalised comments, which were a critique, as outlined by Rita, and endorsed by the three organisations. On foot of that, the Department, first of all, went silent and then decided to withdraw the proposals to the two care homes and the one employer — Four Seasons — and to write to all care homes.
Mr Perry: As I said previously, we found out from a number of frantic phone calls from our members who said that the home manager was indicating and compilation a rota system in one of the homes that was going to start the pilot the following week. I think that was on a Monday, and the pilot was due to begin, allegedly, on the following Monday, so we found out from our members on the ground prior to any discussions with the employer or the Department.
Mr Clayton: To answer the second part of the question about overall reform, as I mentioned before, structures were set up after 'Power to the People' was published in early 2018. There were a number of meetings of various workstreams to look at proposals, and numerous papers were prepared by the Department prior to Minister Swann coming into post. It would be fair to say, as far as I am aware, that there has never been a final set of proposals that we have seen about how the recommendations in 'Power to People', particularly around the workforce, will be taken forward.
As I mentioned earlier, the Minister has made some very welcome statements recognising concerns about low pay, terms and conditions, and sick pay, specifically in the context of COVID-19. What we do not have sight of yet is specific proposals about how he intends to deal with that and about how the system will reform itself to deal with that. That is the kind of engagement that we need to be having. We have proposed a bargaining forum to go through some of those issues, for example, the procurement of services, because our concern has been that when services have been procured from the independent sector for domiciliary care, it seems to have very much been done on a cost basis, at the expense of quality and of terms and conditions for the workforce, so those issues need to be dealt with. The need for specificity about what is intended is really important, and I do not think that we got to that stage of the reform project that the Department had initiated, which was then halted in its work because of COVID-19.
Mrs Cameron: What was the specific issue for the unions in which care homes were being selected for the proposed pilot?
Ms Speed: I will ask Rita to come in on that. I do not think that we objected to a particular home. It was the conduct of the project itself.
Ms Devlin: We did not object to any particular home; we objected to the fact that we had not been informed. We did not understand, and they were not able to be clear about, the criteria that they had used to pick the two homes. For example, we wanted to know about layout. They were talking about accommodating staff in the home. We wanted to know what criteria they had used to identify that the home would be appropriate to house staff overnight. That was why we had difficulty. It was not that there was any specific home, home owner or organisation that we objected to.
Mr Carroll: Thanks again, panel. In regard to care homes, I think, Anne, that you said that there is a concern about profiteering in the private sector. I share those concerns, very much so.
There is concern among the people I speak to about safety concerns being raised and either no inspections happening or inspections happening and there is no punishment for private care homes. I imagine that if concerns were raised about union members, those people would probably be disciplined or fined. Is there is a concern that there is one law for how workers in care homes are treated and another for how the operators and owners of care homes operate, especially the larger ones?
Ms Speed: The delivery of bad service and bad care has to be challenged, and there have to be penalties where that occurs. There is a problem with compliance and monitoring, and, if you like, with the policing of the sector. That is something that lawmakers and policy leads in the Department have to address. You used the word punishment. Well, there are penalties that can be applied: the withdrawal of a contract, fines, etc. That would be part of a future discussion, but, most certainly, there are employers who think that there is one law for them and another for their workforce, who are subjected to grievance and disciplinary procedures, and often in a very difficult and intimidating environment.
If a sector of employers opened up themselves to scrutiny by allowing collective bargaining, the good standards and the good practices that we know exist among a number of employers would become visible, and perhaps they would influence their peer group to improve. Collective bargaining and trade union organisation always gives exposure to those issues. It is a right, as far as we are concerned, and a means by which workers can be protected, bad practices rooted out, and bad employers challenged.
The Chairperson (Mr Gildernew): Thank you. OK, members, that draws our session to a close. Sorry, go ahead Paula, I did not realise that you were looking to come in.
Ms Bradshaw: Apologies. I had a couple of questions, but I will go to the primary one. It may be for you, John Patrick, to respond to because you were talking about the future of care homes.
During the pandemic we have seen the vulnerability of our wonderful hospices because of the lockdown and the inability to fundraise. As we know, they have to provide 50% of the cost of palliative care beds. What role do you see care homes playing in the future of acute palliative care, since there is such a shortage in the system?
Mr Clayton: That is an important question. In a way, probably, the reform project on social care will have to take account of the fact that the COVID-19 pandemic is now there and other aspects of care, be it the work of carers, palliative care or community and voluntary providers, will undoubtedly have been drastically affected by it.
The concern that we have had throughout this has largely been to do with the fact that you already had a workforce across the board that was generally undervalued, underpaid and largely overworked and there were poor standards across the sector. That led to an awful lot of churn in the workforce. I cannot necessarily speak specifically of the palliative sector, but, generally, across social care, there was the churn that is referred to, with people moving between different providers based on their ability to earn a little more money, often very small additional amounts of money, through working for different providers. Particularly post-COVID, there will be an imperative because of COVID to standardise things across the sector and to have much better pay and terms and conditions across the sector so that we do not have a workforce that is moving frequently between different employers. The sick pay element also fits into that. That was always a concern among our members, and we talked about the impact on BAME workers. We had a cohort of workers who could themselves in financial hardship if they self-isolated, because they received only statutory sick pay. Longer term, if we are to deal with COVID properly in social care, we cannot put workers in that position.
Generally, there needs to be fundamental reform in the workforce, and it needs to be much more substantively valued. There is now a recognition of that at ministerial level. We need to be sighted on and informed about what that means in practice and substance, and that will go to areas like palliative care, where, as you say, people are in a unique position in that they have to fundraise in part for their activities. That probably goes to the broader conversation, which is also relevant to social care, about how we deliver those services and how they are funded. I know that that is an issue for health more generally, but COVID-19 has shown us, if we did not know it already, how important good social care is across the board.
A concern that we had from the very early days after 'Power to People' was published was that there seemed to be a planning assumption that there would not be more money for social care. I do not know if that is necessarily a safe assumption to make going forward, because there will need to be more resource to enable things like better pay and better terms and conditions and, most importantly, to make sure that the public get a very good standard of care. When we talk about rebuilding HSC services, I think that that was potentially something in the Minister's document that possibly warranted a little bit more attention. There has been a focus on the acute side, which is understandable, but, going forward, we have to think very carefully about how social care is handled, because that could be, as we have seen over the last number of weeks, where COVID, in particular, may surge again.
Ms Devlin: Chair, could I add one thing?
Ms Devlin: It is to make a plea that, in any discussions that we have on social care, nursing homes and care homes etc, we identify that workforce issues are impacting severely on care homes. Care homes find it very difficult to recruit and retain registered nurses, for example, because the terms and conditions in the health service are much more favourable. There are issues and concerns about the healthcare support workers and the amount of money that they are paid compared with those who work in supermarkets etc. We need to be very clear that without a proper, well-trained workforce and a strategy to ensure that we can look at recruitment and retention in this area, we will fail in our attempts to improve the delivery of care for older people.
The workforce is key. We need the right people with the right skills in the right places at the right time, and any model that looks at workforce planning must include the independent sector.
Mr Chambers: Thank you. I just want to echo what my two colleagues said. One thing that stood out for me through this all is the phrase "front line". That has been mentioned on numerous news channels and meetings that we have all attended and watched. The fact that we have had care staff on that front line over the past 12 or 13 weeks, the majority of whom, if not all, have been on the national minimum wage, speaks volumes for the work that they do. Overall, there needs to be a complete review of the independent care sector as a whole.
One aspect that needs to be touched on is the training for those people. The people who work in these homes carry out an assessment online. In my view, that is not the way for somebody to get adequate training to carry out their role. There are numerous things that we need to look at, and it is important that we all have a part to play and that we are all playing it together.
The Chairperson (Mr Gildernew): Thank you, panel, for presenting to us and briefing us on these issues. We have all developed a much more acute understanding of the nature of essential workers, many of whom you represent, and those workers who have been so hard-pressed during this period. On behalf of the Committee, I take the opportunity, through you, to thank the front-line workers, all the staff you represent and yourselves for the important work that you are doing and have been doing on this. The Committee sought to engage with you at a much earlier stage, and we on the Committee recognise the vital role that you play in the entire health and social care system.
There is now a heightened awareness of the vital need for good public health and social care in pandemic preparedness. Gaps have been exposed, and lessons can and should be learned. Throughout our time on the Committee, we certainly hope to engage with you on how we value, support and develop that workforce.
I wish you all the best and thank you once again for your time today. We wish you well in the time ahead. Go raibh maith agaibh, agus slán go fóill.
Ms Speed: Thank you, Chair. On behalf of all our participants, I thank the Committee for the goodwill that you have shown in allowing a number of us to participate. We are a very big movement — there are 60,000 workers in the health and social care workforce — and you gave us an opportunity to speak. We are very conscious of the scrutiny work that you are doing. We follow you very closely, and we wish you well in your future deliberations. Thank you very much.