Official Report: Minutes of Evidence
Committee for Health, meeting on Thursday, 22 October 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
Witnesses:Mr Seán Holland, Department of Health
Mr Mark Lee, Department of Health
Professor Charlotte McArdle, Department of Health
COVID-19 and its Impact on Care Homes: Chief Nursing Officer and Chief Social Work Officer
The Chairperson (Mr Gildernew): I declare an interest as a social worker in my previous career. Also, my wife is a nurse. We are well represented on the Committee today. I welcome, via video link, Mr Seán Holland, the Chief Social Work Officer (CSWO); Professor Charlotte McArdle, the Chief Nursing Officer (CNO); and Mr Mark Lee, who is the director of mental health, disability and older people in the Department. I invite you to brief the Committee.
We are not hearing any of you at this stage. We have you on the screen, Mark. Are you doing the initial briefing, or is it to be Seán or Charlotte? Can one of you please indicate? Do not forget to keep your phone on mute when you are not speaking and to take it off mute when you are ready to contribute. We are still not hearing any of you.
Professor Charlotte McArdle (Department of Health): Hello?
Professor McArdle: Can you hear me? Colm, I was going to make the opening remarks, but I am not sure whether my colleagues can hear me.
Mr Seán Holland (Department of Health): I can hear you clearly, Charlotte. What we planned, Chair, is that Charlotte will start, I will augment her comments and then we will take questions.
Professor McArdle: We will try to keep our introductory remarks short so as to allow as much time as possible for questions and discussion. The area of care homes illustrates more than anything else the tightrope that we have to walk to balance the quality of life with protecting life. We want, of course, to do everything that we can to look after the most vulnerable as safely as we can.
From the very beginning of the pandemic, Minister Swann has clearly articulated that supporting the care home sector is an absolute priority for him, the Department and the health and social care system. I begin by showing my appreciation of the tremendous work that care home staff have done and of the dedication and professionalism that they have shown during the pandemic. Care home staff have played an exceptional and essential role in looking after some of the most vulnerable people in our society. We fully recognise the resilience of the staff working in the care home sector right from the start of the pandemic and during what can only be described as an extremely challenging time. Care home nursing staff in particular have been under unprecedented pressure because of the COVID pandemic. That has been exacerbated by staff shortages owing to sickness and caring responsibilities. It is important to acknowledge the personal impact that COVID has had on staff. Although they carry out their duties in a very professional and skilled way, for many, doing so has been at personal cost to them in order to protect their safety and that of their family.
Society has recognised how important nurses and care assistants in the sector are and the difference that they have made to the lives of residents right across the sector, whether through caring for older people; looking after acute or chronic needs; managing pain; or looking after people with dementia, learning disabilities or mental health problems. I take this opportunity to remind everybody working in the care home sector that they are truly valued. They are valued by the public, their colleagues, the system and the people who receive care from them. Society as a whole values more than ever the contribution that the care staff have made during 2020. For some time now, there has been recognition that the complexity of care that is provided in care homes has increased greatly over the past few years, but it has really been brought to the fore by the pandemic, which has further highlighted the acuity of care and the frailty of people who reside in our care homes.
For that reason, we have committed to bringing forward, through co-design and co-production with the sector, a framework for enhancing clinical care across all areas of the care home sector. That will seek to examine, particularly in partnership with the staff, what would enhance nursing, medical and multidisciplinary support, clinical leadership and specialist skills. That will inform our ongoing response to the virus and help us rebuild care home provision for the longer term. Our aim is to support everyone to have the care that they need in their home, whether it is their family home or a care home.
I acknowledge the detrimental impact that COVID has had on residents and their loved ones. Care home residents rightly view the care home as their own home, where they should be able to maintain contact with their family and those who are important to them, as well as with their local communities. Probably more than in any other area, trying to find the balance between protecting life through reducing the transmission of the virus and ensuring a good quality of life has been extremely difficult. Our care home staff have worked hard to protect the residents while maintaining their quality of life. We want to continue to do everything that we can to keep those who are most vulnerable safe. We also know, however, that keeping older people and the most vulnerable people away from contact with their loved ones is hugely detrimental to not just their physical health but their mental health, emotional well-being and human rights. All of us understand the growing number of calls to relax the visiting restrictions. At the same time, others are calling for rings of steel to be put around care homes. Locking residents away from their family and those who are important to them is not sustainable or, indeed, at all tolerable, however.
We have to find creative ways in which to support the sector and to support people to have that contact with their family and friends and to use virtual visiting and other innovative ways of making contact. That is not enough, however, and needs to be supplemented with face-to-face visiting, particularly for older people, who may find the virtual method more difficult. The visiting policy recommends that that happen weekly, and more so at the end-of-life stage for those requiring palliative care.
In recognising that the risk of transmission will be increased with any rise in footfall in care homes, we are considering a risk-based, sustainable approach to support residents and loved ones to have meaningful connections, in particular where isolation is detrimental to a resident's physical or mental health.
I caught the tail end of the previous session with the Regulation and Quality Improvement Authority (RQIA). Many families have spoken of the detrimental effect on mental health and emotional well-being. We are therefore working with the care sector and families to introduce the concept of care partners. Care partners will have previously played a role in supporting and attending to their relative's physical or mental health needs. They will provide specific support and assistance to ensure that communication and any other health and social care needs are met. Care partners will help a resident avoid significant and continued distress. We are keen to implement that approach.
In conclusion, I express my sincere gratitude to the independent sector staff working at all levels. Key learning from the first surge of the pandemic is the requirement to work together and in partnership with the independent sector and to ensure that the independent sector is valued and seen as an equal partner in the delivery of health and social care.
I now pass over to Seán for him to make his opening remarks.
Mr Holland: I will not repeat the remarks that Charlotte has made about our gratitude to care home staff, but I certainly associate myself with them. I would highlight the work of care assistants in particular. I am sure that we will come to this at some point today, but you cannot help but be struck by the fact that they are often people working on minimum wage. They have turned up throughout the pandemic to do incredible work. The debt of gratitude will last long after this pandemic.
Unlike GB, Northern Ireland already has an integrated system of health and social care. That has brought us benefit as we face the challenges of COVID, and it lies behind some of the positive points that Tony Stevens, one of the previous witnesses, highlighted. There already were close relationships between the independent sector and providers of adult social care in trusts, and those have been built on and strengthened further.
From March 2020, we have taken, and continue to take, a wide range of measures to help protect staff and residents in care homes. I will touch on those, starting with funding initiatives. I have to apologise, because I am conscious that, since we provided a draft copy of our opening remarks to the Committee, the Minister has announced a substantial package of additional funding to care homes, which I will now review.
A total of £27 million in new funding, subject to Executive agreement, was announced yesterday. That builds on previous funding packages, including the £6·5 million announced in April and the £11·7 million for enhanced sick pay, for enhanced cleaning and for equipment costs announced in June. Those are on top of the guarantee of income that was made at a very early stage to care homes and domiciliary care providers.
Of that funding, £9 million will be paid to care homes to reflect the costs of the rolling programme of testing for residents and staff; the costs of overseeing safe visiting and setting up the care partners arrangement that Charlotte mentioned; and the increased management time needed to oversee homes throughout this period.
The remaining funds will be available to homes to bid for to address issues such as continued enhanced sick pay arrangements; supporting enhanced cleaning levels; changes to the physical infrastructure to support social distancing and safe visiting arrangements; additional staffing costs for patients who are isolating or acutely unwell; and the block booking of bank or agency staff to help us reduce the movement of staff between homes.
We intend to continue to work closely with providers to help reduce bureaucracy and to ensure a streamlined approach to making claims. We are also ensuring that trusts have the resources that they need to process those claims in a timely way.
I will mention PPE and infection prevention and control (IPC). There is ongoing provision of PPE for care home providers. So far, over 42 million items of PPE have been provided to care homes at a value of over £14 million. That is not included in the figures that I previously referenced. Providers are not charged for access to that PPE.
In addition, we have made direct and remote training available through the Clinical Education Centre (CEC) and the Northern Ireland Social Care Council (NISCC). The training focuses on infection prevention and control and on PPE. In addition, there are Clinical Education Centre programmes aimed at staff who do not regularly look after respiratory patients and/or who have limited ward or community-based experience, alongside a number of clinical skills-type programmes to support staff dealing with respiratory patients. CEC programmes related specifically to COVID-19 are open, free of charge, to all sectors in Northern Ireland, as has been the case with the training provided remotely by the Northern Ireland Social Care Council.
On staffing support, trusts have stepped in to provide over 26,000 hours of staff time in care homes during the first stage of the pandemic. Although the continued provision and support from trusts to care homes forms part of our surge plans, we recognise that the staffing situation in trusts is more challenging than it was in the first wave, so we are considering what additional measures can be taken to address likely staffing pressures. We are in ongoing discussions with sector representatives on those measures.
There has been a significant increase in the supply of staff. Figures from the Northern Ireland Social Care Council demonstrate that, between September 2019 and September 2020, an additional 4,500 care workers were added to its register. Over 3,000 have been added since 23 March, when the council, along with the Department and others, worked to ensure that the ease of entry into the workforce was facilitated. We are now sitting at a point at which we have just under 50,000 staff registered with the council. The figure that I received just half an hour ago is that 4,997 staff are now currently on the register, and I welcome every single one of them. We know, however, that significant workforce pressures remain. That is particularly the case when it comes to accessing nursing staff. I envisage that that will be one of the major challenges that we will face going forward.
Colleagues have recently relaunched our workforce appeal, and we remain clear that trusts should consider how individuals identified through that mechanism can be placed in the independent sector, subject to all the appropriate risk assessments and considerations being in place.
A key part of maintaining sufficient staffing levels will involve ensuring that existing staff remain healthy and available for work. I therefore want to highlight the community pharmacy flu vaccination service, which is now available to Health and Social Care (HSC) workers at nearly 400 participating community pharmacies across Northern Ireland. Essentially, all Health and Social Care workers aged 16 years old and over are eligible for a free flu vaccine from participating pharmacies. That aims to provide an alternative route for care workers to access the vaccine, benefiting from the ease of access to community pharmacies across Northern Ireland, many of which are open in the evenings and at weekends.
As Charlotte mentioned, we are also acutely aware of the impact on staff of dealing with COVID. I reiterate her thanks to each and every one of them. As Tony Stevens referenced earlier, to help with that challenge, we have made health and social care trust psychological support helplines, which are staffed by psychologists and psychological therapists, available to staff in the independent sector. In addition, we were pleased to support an initiative to create "rainbow rooms" in care homes. Those provide a space where care home staff can take some time out from the pressures that they are experiencing in dealing with COVID.
I move on to testing. One of the key measures in place to help protect homes is the rolling programme of testing of care home residents and staff. The Committee will be aware that staff are being tested fortnightly and that residents are being tested every 28 days. That programme will continue to play a significant role in helping to minimise the risk of COVID-19 through early identification, which enables immediate steps to be taken to prevent the spread of infection, thereby ensuring the continued safety of residents and staff. Where necessary, trust teams have been stepping in to help support care homes to complete their testing of residents.
A significant proportion of outbreaks was, until very recently, asymptomatic. Outbreaks also tended to be limited, with a very small number of individuals in each home testing positive. We are now starting to see that change, however, as widespread community transmission begins to have an impact.
In addition, the Committee will be aware that it remains the case that individuals discharged from hospital to a care home should be tested for COVID-19, ideally 48 hours before discharge, and be subject to 14 days' isolation on arrival. Discharge is an area that we continue to consider and keep under review. We want to protect care homes from any risk of infection and to ensure that residents are not held in hospital, because we need to make it clear that, if they stay there longer than they need to, that also entails risks for them.
I move on to preparedness for the second stage that we are entering. As part of the preparations for the second surge, we established an adult social care governance surge planning group, which is co-chaired by Charlotte and me. Charlotte and her team, as has been mentioned, have led on a rapid learning initiative, which has since been used to refresh the regional care homes surge plan. We are taking a similar approach in other areas of social care. Actions in the regional surge plan have been assigned ownership, and the group that Charlotte and I chair will oversee the progress on implementing those actions, which include the 24 actions identified in the rapid learning initiative.
On monitoring, reporting and support, we continue to seek feedback and input from the care home sector to make sure that we understand the challenges that it faces. In particular, and, again, this was touched on in the previous session, valuable data continues to be collected through the RQIA-facilitated care home application. We are using that to provide a weekly report that assesses care homes, trusts and Northern Ireland as a whole against the agreed regional surge plan. Although we are in green surge status, it is clear that the small number of homes that are in red surge status, because of the number of residents who are COVID-positive or are in acute decline, is growing.
To provide advice and support, we have continued to update and refresh the guidance that we have provided to trusts, care homes and care home employees. We are working on further revisions, which include considering how we can make the guidance more usable for those on the front line. In addition, care homes have had expert support available to them from the RQIA, the Public Health Agency (PHA) and trust care home support teams. We are expecting to build on that support further to provide expert support to in-reach to care homes to help them ensure that their cleaning, their infection prevention and control and all the other measures that will impact on COVID-19 are as effective as they can be. Furthermore, Charlotte and her team have supported the development of leadership training on leading in a crisis for care home and trust staff.
In the Department, we continue to look at international best practice to see what more we could be doing. Although a recent international comparison has shown that Northern Ireland has fared better than other UK nations when it comes to the number of deaths in care homes, any unnecessary death is a tragedy, and we are determined to do all that we can to limit the impact of COVID-19 in care homes, while maintaining quality of life for residents.
There is a lot more that I could say as a prepared statement, but it is probably best that I stop there to allow questions and discussion.
The Chairperson (Mr Gildernew): Thank you, Seán and Charlotte, for your presentations. The value that we as a society now place on front-line health and social care workers across the piece from nurses to doctors to domiciliary care workers, porters and everyone else is something to come out of the pandemic that has hopefully moved the dial on how we provide health and social care and how we fund each part of it.
That is a conversation that, I think, we will return to on many occasions, because it is crucial. We will, however, remain focused on the care home inquiry that we are discussing today. I welcome many of the measures that you mentioned, such as access to training and leadership training. Those are practical and helpful steps.
The current rules on the discharge policy remain in place. There is a requirement for a test 48 hours before discharge, but there is no necessity to have received a negative test before discharge is gone ahead with. As part of the inquiry, we have heard evidence from the RCN that the need to isolate can put severe additional pressure on staffing levels in the care home sector and that some homes are not well built or well equipped to manage the isolation process. At this point, we do not know statistically what the impact of the discharge policy in the first surge was and what bearing it had on the severe situation that we saw in care homes. We are also seeing worrying statistics at present about the doubling of cases in care homes over the past short time. What is your assessment of how well the discharge and isolate system is working?
Mr Holland: I will start, and I am sure that Charlotte will want to join in. You are right that there is no need for a negative test result before someone is discharged to a care home. That reflects the fact that maintaining people in an acute environment is not the best thing for them when their needs can be met in a care home. To maintain in hospital people who are ready for discharge from acute medical care is detrimental to their physical and emotional well-being. It is therefore recognised that they can be discharged to care homes. That can result in pressure on staffing, which is one of the reasons that the previous funding package and the additional moneys that have been announced can be used to augment staffing numbers to reflect the additional nursing and care requirements for managing those residents.
You also said that some care homes are not well built or suitable to meet the criteria for isolation. In those circumstances, a care home should not admit the individual. That has been case. Care homes have declined to take discharges where they felt that they could not appropriately manage their care. We support that. Care homes should not be forced to accept people for whom they are not appropriately equipped or prepared to care. I will stop there in case Charlotte would like to add to that.
Professor McArdle: I will add a couple of comments. First, none of this is ideal. Nobody wants to have these arrangements in place, but we are having to make difficult decisions. We know that every day longer than is needed that older people stay in hospital has a detrimental effect on their muscle mass. Even a few days of a longer stay can make their rehabilitation more complex. Often, they do not get back to their previous level of independence. It is therefore important that people do not stay in hospital any longer than they need to be there.
The social care system does not work in isolation from the hospital system. They are an integrated system. The ability of one to respond to the other is important to making the whole system work well. There are currently 289 patients in medical beds in hospitals. As you said, Chair, community transmission is high, and we know that it will continue to grow rapidly, with the doubling time somewhere between 10 and 13 days at the moment. In some ways, although there is risk associated with going back to the care home, it is nevertheless something that the care home staff can manage. It is better for residents to go back to their own home. It also frees up space in the hospital setting for those who need acute care. We therefore need to look at this in the round. We need to look at both sides of the coin. For me, the discharge policy is working well and needs to continue. I absolutely accept that it is not perfect, but, in the circumstances that we all face, it is the best that we can do at this time.
The Chairperson (Mr Gildernew): We often talk about balance, and I think that we do understand, generally, that people should not be in a hospital setting for any longer than they need to be. In the context of balance, however, surely getting a test back in 24 or 48 hours is a period that can be worked with. Often, it may take only the 24 hours. Can testing not be prioritised so that results are returned quickly, in the light of the fact that you are aware that a person may be discharged into a vulnerable setting? Is that not something that can be done as a priority?
On your comments about isolation and homes not being under pressure, in late April, the permanent secretary sent out a letter in which he put in bold that a lack of a negative test should not be taken as a reason not to proceed with discharge. What was the urgency, given that there was capacity in the hospitals at that time? Why was that letter sent out, and did it place undue pressure on those responsible either for implementing the discharge or for taking discharged people at that time?
Professor McArdle: I think that the April letter was sent out in the middle of the first surge. Our hospitals were under increasing pressure, as were care homes, because of the difficult circumstances in them. I go back to the point about doing whatever is best for individuals, because, when they go back to the care home, they isolate anyway, regardless of the test result. I do not see the difference between April and now. Doing the right thing by people and getting them back to their care home environment is the important point to make here.
The Chairperson (Mr Gildernew): I will go back and check, but my memory is that, on 27 April, which is the date of the letter, it was clear that the surge, although it was bad and horrendous in many ways, was not as bad as had been anticipated and planned for. Moreover, there was hospital capacity at that time. I will check and come back to you.
I think that it was Seán who said that the discharge policy is being kept under review. What further steps may be or are required to be taken on the discharge policy, given what we have learnt and given that we are now in a second surge?
Mr Holland: Chair, before I address that point, I want to go back to the point about discharging patients from secondary care in April. Certainly, it was important that capacity for the acute healthcare sector be maintained, but that was not the reason behind an individual discharge. As Charlotte said very clearly, you look out for the best interests of the patient. Even if you have a bed in a hospital, that does not mean that it is the right place for individuals to be if they are fit for medical discharge. On the basis of the discharge, the advice to care homes is that, regardless of any test result, anyone being admitted should be considered as potentially having tested positive. That is why people are isolated for 14 days.
All aspects of how we are responding to this pandemic need to be kept under constant review. One of the things that has been said a number of times this morning, and on many other occasions, is that this is an emerging situation and that we are learning as we go on. If we therefore have evidence that there is a better way of responding to discharges, it is important that we learn, adapt and change as we move forward. That response will inevitably be integrated with developments that may happen in the testing regime. Yesterday, at the ministerial press briefing, the Chief Scientific Adviser, Professor Ian Young, referenced the fact that he anticipates that there will be developments in testing in the coming months, including new technological developments. When those are available, we will need to see whether that has any bearing not only on discharge policies but on a range of other policies. That is why we need to keep the discharge policy under continuous review.
The Chairperson (Mr Gildernew): The second area on which I want to ask a question is staffing levels. I heard your interview this morning, Charlotte. How are the restrictions on staff movement between homes operating, and to what extent have those restrictions had an impact on access to staff? I am particularly keen to know about their impact on access to agency staff, which you discussed this morning, Charlotte. What steps are being taken to address that issue?
Professor McArdle: Thanks, Chair. I think that this is very disconcerting because the video and the sound are not in sync, so when you stop talking, you are still speaking on the screen. It takes us a minute to come back, so my apologies for the delay.
On your question about staff moving between care homes, clearly that is not a good idea. We want to limit the movement of staff in care homes or between any facilities, whether it is between care homes or between hospitals and homes or any other facility. The Public Health Agency wrote to the agencies in July to ask them not to encourage that behaviour. The Minister announced clearly yesterday that funding is provided for care homes to allow them to employ temporary staff on what is called a block-booking basis, which is where the same member of staff can cover a number of shifts to prevent a number of different staff from coming into the home and sharing it across homes. So, it is not a good idea, and it is not one that we want to promote, but there will be occasions, particularly as we move through the winter, where it is a choice between a member of staff providing cover in a care home or leaving the care home with no cover. I know that, on a risk-assessed basis, if I were the care home manager, which of those options I would choose.
We have to make sure that we continue to abide by the COVID-secure rules around the appropriate use of PPE, good hand washing, social distancing, good respiratory hygiene and additional cleaning. Those are all measures that we know will protect residents, as best we can, from COVID. So, even if staff will have to move, on occasion, to provide cover over the winter period, as long as they adhere to the best procedures and practices, that is the most we can do.
It is going to be extremely challenging over the winter. As Seán, I think, said, in surge one, the trust's staff were able to provide quite a lot of additional hours, but we know that they will be faced with the same challenges in the winter, with staff having to self-isolate for 14 days as a result of the testing process, family members, sickness or childcare responsibilities. So, all of that
staff being unavailable for work causes an increased pressure right across the system, in both the health and the social care sides, so there is a balance to be struck about supporting the care homes. All that being said, Seán and I constantly take the opportunity on our regular calls to remind the trusts' chief executives that supporting the care homes is an absolute priority.
The Chairperson (Mr Gildernew): OK, thank you. Finally, on the staffing issue, we have heard from the unions that there has been a lack of engagement and a forum to share information, best practice or even concerns. There has been good evidence of engagement with the care home sector, and some good practical measures have been put in as a result of that. However, given that unions have expressed that concern, what can you tell us about working with unions and staff representatives, and what is being planned to address that issue?
Professor McArdle: Clearly we can do more; we can always do more engagement. However, in this context, I think that there are forums for the trade union side and colleagues to engage. They have been involved from the rapid learning initiative and the enhanced clinical framework for care homes. The Royal College of Nursing (RCN) and UNISON are involved in that. There are regular meetings between officials in the workforce policy directorate with the trade unions. Seán and I engage individually with trade unions from our professional backgrounds. While I accept that we could do more, there are definitely forums for them to engage, and they will definitely be part of the programme of work with regard to care partners and the enhanced clinical framework as we go forward.
Mr Holland: If I could add to that, Chair. I fully understand the view of trade unions that they would like more formal mechanisms for engagement, and I understand why that is the case. I also recognise the importance of engaging with unions. You referenced engagement with the sector, and I know that Pauline Shepherd gave evidence to you this morning and on other occasions. We engage with Pauline, and we recognise that she represents care home providers. That is a very valid and legitimate voice, and it is important that we listen to that voice, but it is one leg of a three-legged stool. It is important that, in addition to engaging with providers and hearing their voices, we hear the representative voice of staff who work in care homes. As you referenced in earlier remarks, we also need to hear the voice of residents and those who care for them and their families who love them. We need to hear all those views because they are not always aligned. The views and representatives of, for example, providers, will not necessarily be the same as the views of residents and their families or, indeed, staff.
Notwithstanding the point about formal forums, we have been engaging extensively with individual trade unions. I have held meetings with Charlotte and individually, and she has done the same, with the key unions. We have very close engagement with the RCN, NIPSA and UNISON, which are particularly significant in the care home sector. I do not think that we could approach this without that kind of engagement. Decisions as to how that might be formalised or structured in the future are for others to make, but I do not consider it being realistic or desirable to go forward without making sure that the voices of the workforce are heard.
Ms Flynn: Thanks, Seán and Charlotte. Seán, you mentioned that we heard from Pauline earlier, and it was referred to in one of your answers that we have heard twice now about the pressure that the trusts are coming under with having to carry out repeat testing. There was mention of ongoing discussions around that. How soon do you think that can be resolved? The pressure is on at the minute, so the sooner that can be resolved, the better.
To go back to the inquiry, what control does the Department have over the care home testing programme? What is its role? Does the Department decide which homes get tested? We heard earlier about some inconsistencies across the five trust areas. Charlotte mentioned that you tie in regularly with the CEOs. Perhaps that consistency issue can be fed back into that group.
Finally, we have had a couple of conversations around pillar 1 and pillar 2 testing models. Has any consideration been given at a departmental level around expanding the capacity for pillar 1 tests to include social care staff?
Mr Holland: I will start with the support for testing that we are providing to care homes, and I am sure that Charlotte will want to come in on some of the details about the testing regime. The intention is that the money that was announced yesterday will be available to ease the burden on care homes for participating in the testing programme. We recognise that rotas have to be organised, a degree of management time is required and individual care workers have to be available to be tested. That is why that package includes financial support for easing that burden.
As part of the arrangements, we do not think that care homes should have to claim retrospectively for that element. We are calculating what we think is a reasonable amount of care home time to be required to support the testing regime, and we will pay on that basis. That will facilitate the flow of money and support to care homes without increasing the administrative burden on them.
The Department has an overview in relation to testing. The Chief Medical Officer has a group that specifically considers care homes and testing and ensures that the policy is developed in line with emerging scientific evidence. Charlotte will want to add to this answer.
Professor McArdle: Thanks, Seán. Órlaithí, to build on Seán's answer, the CMO has a testing group. I understand that we are now on protocol 7, because it has been amended throughout the pandemic to take account of learning and the rapidly changing position. It is my understanding that all care homes are part of the testing programme, and it is a rolling programme to test staff every two weeks and residents every 28 days.
There are differences between pillar 1 and pillar 2 testing. Pillar 1 is managed locally through the health and social care laboratories and the Northern Ireland Scientific Advisory Consortium. The results from Pillar 1 are usually available in 24 hours, and that is specifically for homes that are having an outbreak. Pillar 2 is the national programme, which is managed by the Department of Health in London, and it is for the surveillance programme of regular testing.
Pauline raised some issues about the speed of test returns. Most of the care homes use the pillar 2 programme, and between 27 September and 10 October, there were 22,000 results communicated within 72 hours. That works out at about 85% of tests. The remaining test results were communicated in between 72 and 96 hours. So, of 22,000 results, a significant number were returned within 72 hours, and for 85% of test results to be returned within 72 hours is a really good performance. I understand that there are still concerns about some tests, but there are specific reasons why the results are outside the 72 hours. Does that fully answer your question?
Ms Flynn: Yes, that is useful, Charlotte. Obviously, an integrated testing system for healthcare has been raised at the Committee. Has the Department ever considered including the social care workforce in the pillar 1?There are concerns about the testing delays. The 72-hour turnaround time for 85% of tests is positive, but it still has knock-on impacts for people working in the sector, and the 24-hour test result could make a difference.
Professor McArdle: This is management information, and it does change form month to month, but within the 85% of 72-hour test results, 50% of the tests are returned within 48 hours. Actually, a significant number of tests are returned within 48 hours. We are trying to keep the pillar 1 tests for outbreak situations so that results can be returned rapidly and manage the difficulties it causes as quickly as possible. Moving 22,000 more tests to pillar 1 will delay pillar 1 test results, and they will not be able to meet the 24-hour turnaround time. It is a balance, and I think of pillar 2 as a surveillance programme that picks up asymptomatic staff much earlier than we did before we started this testing regime. We are catching the virus early. As Seán has already said, that is starting to change now, as the transmission is so high. Still, over 70% of those are asymptomatic staff cases.
Ms Flynn: Thank you, Charlotte. Seán made the point that we heard some of the details at last week's Committee meeting. We heard that the Chief Scientific Adviser and the Department are starting to look at other testing models, such as more rapid testing and saliva testing. Hopefully, other quicker test models will start to open up down the line. Thank you, I appreciate your response.
Ms Bradshaw: Thank you very much for your presentation. I forgot, at the start, to declare an interest. I have a family member who works in a care home. I know how hard those staff work, so my question is no reflection on them.
Some of the evidence that we have taken from the relatives is that, when they get to see their loved ones, they see a decline in their condition, usually with a long-term condition like dementia. Whose responsibility is it to assess the decline in these conditions so that interventions could be brought in?
Continuing with the theme around care partners, Pauline Shepherd indicated that she had received an invitation from you, Charlotte, to work with them in trying to expedite the guidance and regional framework. I would appreciate some timelines for that. A lot of relatives are very keen to do whatever they have to do to get into the care homes and provide that support.
Professor McArdle: Seán, I will start with the care partners, if that is OK.
We set an initial date of 2 November for implementation of care partners. I am aware of quite a bit of concern from the sector about the implementation of care partners. I am completely committed to it and think that it is, absolutely, the right thing to do. If it is the right thing to do, then we need to find ways to make it happen safely. Pauline is working with us and we are engaging with families. I have asked the Patient and Client Council (PCC) to bring forward arrangements to continue to engage with families. She has had an initial meeting with some families, and there is a meeting planned for tomorrow with the PCC, with more families. The purpose of the meeting tomorrow is to consider how we can continuously engage with families and get more people involved. The families' perspective is as important as that of the care providers. I have had ongoing dialogue with Pauline around some of the issues that they are raising. The Minister's announcement yesterday supports us to move forward, both with visiting and with care partners, because there will be additional resource to support the care homes in delivering that safely.
We are still working towards 2 November, but I do not expect full implementation on 2 November. Some care homes have gone ahead and already implemented care partners. I am really keen to find out how they have done that, what works well and whether we can transport that learning to other care homes. That will be part of the network that we have set up recently with the care home sector. The first meeting was held this week, and we proposed a layered approach, whereby it will give access to individuals working at care home level as care managers. If we work together and share the learning, I am convinced that we can do this safely and that it is the right thing to do, accepting that there are a number of concerns and that we need to work with the sector to iron those out.
With regard to care, it is the care home manager and the registered nursing staff's responsibility to assess continuously the care that they are providing and any deterioration in condition and to call in the appropriate supports that are needed, either the GP or the care manager or whatever support is needed. That is one of the reasons why we are developing an enhanced clinical care framework. We recognise that that is rapidly changing in the care home sector, and the acuity of the people whom we look after is much higher than it was. The care home staff need the support of a full wraparound team, by way of medical cover and also enhanced clinical support from nursing and allied health professionals, to support them to deliver the best care that they can.
Seán, I am sure you will want to add to that.
Mr Holland: Yes, I will just add a few points. The experience of relatives visiting and noting a decline is very distressing, but it is also, probably, inevitable. A condition like dementia, even with the best care possible, unfortunately, is a progressive condition. If you have had limited access to your relative, when you finally visit and get to see them, that decline becomes visibly more marked. It is deeply upsetting for people, but there is a degree of inevitability about it. The important thing is, as Charlotte said, that the clinical team, both within the care home and support from trusts, work together to try to respond appropriately to whatever decline there may be.
With regard to care partners, I have heard some of the concerns that have been raised by Pauline and others, and I understand and respect it. However, like Charlotte, I really believe that this is the right thing to do. This is not just about COVID. It is important to be clear about that. Some people have mistakenly thought that this is a way of getting more hands on deck to ease staffing pressures. The care partners are not intended to substitute, in any way, paid staff work; that is not the intention. The intention is to properly recognise the knowledge and expertise that a loved one has about their individual relative and to make sure that that is respected and utilised. Going back to your discussion in the earlier session about the need to make relatives feel more empowered in dealing with care homes, I hope that the care partnership scheme, as it moves forward, will be a way of empowering relatives by recognising them as a valid and vital voice, in partnership with others, in meeting the key needs of individuals.
The final point that I would make about it is not something that we have discussed particularly openly, but it is also relevant to some of your earlier discussion. Unfortunately, we know that, occasionally, care is not as it should be. The RQIA certainly plays an important role in trying to address that, and you had an extensive exchange on this with Dr Stevens earlier. However, one of the most important things in making sure that a care home is as good as it can be is making sure that the care is as transparent as it can be. Making sure that relatives have access to care homes and have eyes on the ground to see how well their loved one is being cared for is a huge protective factor in that. We should not underestimate that.
Mr Sheehan: I want to raise the issue of international best practice. I said in the earlier session that it is disappointing that we benchmark with the other countries across the water. We say that we have done better than they have, but I do not think that that is any great recommendation. I do not think, either, that our performance being better than the performance under Boris Johnson in England, for example, would be any great consolation to someone who had a loved one die in a care setting here.
We know that other countries have performed much better. There have been far fewer deaths in care home settings and much lower rates of transmission in places like South Korea, Vietnam, Taiwan and Hong Kong. What discussions have taken place between the Department and the health services in countries that have previous experience of epidemics, such as SARS, MERS and swine flu, to garner learning from them about best practices for here?
Mr Holland: First, I agree with you wholeheartedly that any discussion about numbers and relative performance is of absolutely no consolation whatsoever if you have lost your loved one. That is one of the reasons why we have been reluctant to talk too much about international comparisons. This is not a competition. It is not about league tables and saying we are above someone else or below someone else. If you have lost your loved one to COVID in a care home, that does not matter a jot to you.
However, it is important that we have some awareness of where we sit internationally. I take your point about the comparison with other countries. You referenced England a number of times. It is important to note that there is an International Long-term Care Policy Network (ILPN), which is hosted by the London School of Economics. It looks at the situations in care homes around the world and has been collating information. I shared with the Committee Chair a copy of a recent report by that network that looked at different performances. That report indicates that, in terms of excess deaths, which is probably the most comparable measure that you can find, Northern Ireland actually performed significantly differently to not just England but Scotland and Wales. That is an organisation that looks at international comparisons, not just comparisons between the UK countries, and it noted Northern Ireland as being in a different position from the other three UK countries in terms of its excess deaths, taking into account overall international performance. As I say, it is no consolation whatsoever to individuals. However, when we say that Northern Ireland performed better than other countries in terms of excess deaths, the International Long-term Care Policy Network would not include Northern Ireland in the same category up to this date.
That takes us to what makes the difference in other countries. Certainly, we have been using that policy network to try to benchmark measures that other countries have taken, to see whether anyone is doing something that we are not doing, and we have been adjusting our position accordingly, where we see another country doing something that we feel has merit to it. We have been updating the benchmarking process against the IPLN reports. Currently, we hope to have a report on that available in the coming days.
It is not always easy to compare different countries. There are measures that some countries have taken that would not be acceptable here. For example, I am aware of a country that has, in effect, locked down its care homes. Staff have to live in hotels, and they are not allowed access to their own families over an extended period. I will be honest; there was a point when we looked at that. We explored the possibility of doing that. After an awful lot of soul-searching, consideration and consultation with trade unions and providers, we realised that that kind of complete lockdown was not available to us. There is no doubt that such a lockdown makes the likelihood of care home deaths less, but it has to be something that we can do in the context of our society, and that is just not possible. We cannot completely lockdown a care home.
That takes us to probably the most significant feature in relation to deaths in care homes. Some of the countries that you mentioned, that managed very low numbers of deaths in care homes, have also managed much lower levels of community transmission. The reality is that the two are linked. If you have really significant levels of community transmission, you will have an increased level of deaths in care homes. If you are in a position where you have been able to perform better in community transmission for reasons of geography, like New Zealand, or because you have the experience and were quicker off the mark, like those countries in the Far East which had experience of MERS and SARS, that will feed through. It is also one of the reasons why we have been reluctant to make too much of the fact that Northern Ireland, in the first phase, performed particularly well. While, undoubtedly, some of that performance was down to the outstanding work that health and social care staff did, some of it was
probably the biggest factor was the level of community transmission. We are not guaranteed that that benefit will continue. If we see high levels of community transmission as we go forward, that position is by no means guaranteed.
Mr Sheehan: I accept a lot of what you say, Seán. I do not accept that some countries have introduced measures that just would not be acceptable here. At the outset of this pandemic, many people told us that a lockdown, similar to what had been happening in China, would not be acceptable here, but when the conditions demanded it, it was accepted.
I accept the point that rates of community transmission are completely intertwined with rates of transmission in care settings. That is why we need to look at international best practice. Have there been any direct discussions with any countries where there are low rates of transmission, both in care settings and in society in general? I am asking about the Department. Has it had any direct contact with any of those health services?
Mr Holland: We have not had direct discussions with other countries. We have relied on the international network which gathers evidence from the different countries and identifies the steps they are taking. Then we benchmarked against those.
In relation to the point, Pat, about measures that other countries could introduce that we could not, you are right. We can introduce some measures that other countries do. We need to learn from them, and we have been doing that. However, there have been instances where we have looked at things and found that we could not introduce them. We shared information previously with the Committee about an initiative that we called "Safe At Home". The idea was to pilot a complete lockdown in care homes.
We were enthusiastic about testing that. We secured financial resources to test it, but, when we engaged with staff and providers, we found that we could not progress it for very understandable reasons.
It is not a straightforward picture, Pat. There are measures in other countries that we need to look at and learn from, and we have been doing that. There are some things that we can do, but I do not think that we can put guards around care homes, as some countries have done.
The Chairperson (Mr Gildernew): OK. Thank you. This is just a comment. Seán, you indicated earlier that health and social care and community transmission are interlinked. I am conscious that we are focusing on care homes, but the impact of not having, in the first place, a proper test and trace system in place needs to be acknowledged, as well as the impact of stopping tracing, given the figures that there were in England at the time and the impact, in recent times, of the contact tracing system becoming overwhelmed as a result of an underestimation of the demand. All that had an impact on the care home sector as well as the community. That is of relevance as well.
I go to Colin and then Gerry.
Mr McGrath: Thank you very much, Chair. Thank you to the panel for its presentation. I have two quick questions. First, in this morning's presentation, reference was made to an inconsistency in the guidelines for the use of PPE in care homes across the various trusts. Would it be better to examine that to ensure that there is consistency of approach across care homes in the North?
Secondly, to follow up on the visiting issue, we need to do everything that we can to ensure that visiting can take place, not least given the human right of residents in care homes to a family life. I understand that there was not great uptake in accessing the original funding for care homes to try to deliver additional capital projects in care homes. If there is new funding, is there any way of trying to encourage people to pick up on that and deliver it, so that we can try to encourage as much visiting in homes as possible in a safe manner?
Mr Holland: I will be very quick. All care homes and all trusts operate under the same regional guidance on PPE. If people are aware of inconsistencies in how that is being applied, both Charlotte and I would be very happy to hear about those inconsistencies, and we will troubleshoot to make sure that the guidelines are being applied appropriately.
I have sometimes heard public commentators make statements in public forums about certain issues, and we have proactively contacted them to say, "Please, give us the information so that we can follow up". Sometimes it has turned out that what they have described has not actually been the situation that we have found when we have explored it.
There should be consistency in the application of the guidelines. Certainly, if any provider, representative, family member or member of staff experiences a lack of consistency, we will respond to that.
I will ask Mark to come in on the uptake of funding, if that is OK, because he has been doing an awful lot of work on the funding support — the original £6·5 million, then the £11·7 million and the funding announcement yesterday. He has been looking at the deployment of those funds. I will hand over to Mark, and then, I am sure, Charlotte will want to come in again on the visiting point.
Mr Mark Lee (Department of Health): I will say quickly that we were ambitious in the amounts that we made available. That is an important piece of context. The uptake of the money that was available for equipment including iPads and such things to support visiting was probably stronger than it was for the couple of other legs that we provided funding for.
We have listened to some of the feedback. I think that you heard from Pauline earlier about the need for physical changes in buildings as well, and we are looking to support that as we go again and make more money available. We were ambitious in the first place. There was reasonable take-up. We are listening and learning from the feedback and are thinking about the eligibility criteria as we look to do more.
Professor McArdle: Chair, I will finish on Colin's point about visiting. We got feedback that uptake of the funds available was poor. That was because people felt that they did not need virtual visiting equipment such as iPads etc, because they already had that. In some cases, it was not a popular choice, particularly for older people. I encourage care homes to be as creative as they can be in relation to the visiting policy. Now that we have a network, Colin, across the independent sector and a much closer working relationship through the enhanced clinical care group, that will be the forum through which I will continue to support care homes to utilise the visiting money. A percentage of that is going directly to care homes, as Seán said. It is there for them to use, and the rest of it can be drawn down on evidence that they are using it effectively to support visiting. Another issue will be about enhanced cleaning and providing a visitor champion in the homes, who will work with the families and the residents to make sure that that is all carried out safely.
Mr Carroll: Thanks, panel. I have two quick points. Maybe Seán should answer the first one. Do you have any concern about care home providers that have had complaints made about them, prior to and during COVID, still being in charge of the care of a lot of our elderly population and potentially getting PPE support and other financial support measures?
Previously, Seán, you were indicating support or, maybe, were making positive indications towards publicly run care homes under an NHS-type model. Given the situation with Four Seasons, which a few weeks ago said that it wanted to sell 42 of its care homes, have you made any recommendations or given any views to the Minister about the Department or trusts maybe taking a role in the provision of those care homes?
Mr Holland: Gerry, on financial support to care homes, I will make a point that does not quite address the question that you asked, and I will then address your specific question. Certainly, if a care home is not particularly well run, it will be at greater risk of an outbreak. However, it is also really important to emphasise that some excellently run care homes with really outstanding facilities and which are examples of best practice have had outbreaks and have had deaths. So, it is wrong to assume that, if a care home has had an outbreak, it is a bad care home. That is not the truth. It is not borne out by analysis or facts.
Mr Carroll: With respect, Seán, that was not my question. I said that there have been examples of complaints in care homes prior to and during COVID, and concerns have been raised and investigations made into some of those. I would appreciate it if you would respond to my question.
Mr Holland: I accept that, Gerry. I think that I was trying to make a point that probably relates to the earlier panel hearing. Please forgive me for that.
On the point about whether I have concerns about where concerns have been raised about care homes and where they are now accessing financial support, that is one of the reasons why you have this tension between wanting to get financial support to care homes quickly so that it can be deployed but at the same making sure that there is good governance and probity. People talk about bureaucracy in negative terms. The reality is that some bureaucracy is necessary to try to make sure that, where a care home provider is not behaving appropriately, the support is being used as it should be.
On the balance of provision between public and private provision, I have to be careful. This, ultimately, is a political decision, and I am a civil servant, not a politician. However, I do not think that, when the policy was set, which is now many, many years ago, where we talked about a mixed economy of care, it was envisaged that the mix would be 99% private and only 1% in the statutory sector as that relates to nursing homes. It is slightly different but not much different in relation to residential units. I think that there is a recognition that a mixed economy of care probably requires a greater footprint from statutory providers in this sector. I make that as a general point, because I talk to colleagues in England, Scotland and Wales, and they are all reflecting that point as well. It is starting to be reflected in practice. Certainly, trusts here are expressing an interest in taking on some more direct provision in the sector, and I know that local authorities, certainly in Scotland and Wales, are increasingly looking at their own direct provision in considering whether or not they have got the balance right. What this has highlighted for us is that trusts or local authorities — whoever is providing the service — probably need to have greater experience of directly running care homes if they are going to be able to properly support the independent sector under this kind of stress. That is my professional view, but we need policy decisions on that.
The first thing that I will say about Four Seasons is that we anticipate that a change of ownership should be achieved without any disruption to the continuity of care of residents in those homes. The standards of care that will be expected are the same, regardless of who the provider is. There is an issue not with Four Seasons specifically but with the model, whereby some large care home provider groups became incredibly complex financial arrangements with offshore shell companies and it became really difficult to work out who owned a care home. I am not sure that that is the best model going forward, but I am probably overstepping the mark with that.
The Chairperson (Mr Gildernew): OK, thank you. We are really tight for time now. I will check in with Pam Cameron, who has rejoined the meeting, and then I will check in with Alan. There is time for only two quick questions.
Mrs Cameron: I apologise for missing Charlotte and Seán's presentations; I was away having a nasty test.
I am sorry if my question has already been asked, but I wonder whether anyone can clarify how the Nightingale 2 at Whiteabbey Hospital will be used. Will it be available as a step-down facility for discharge before a test result or on a positive? Will there be provision for residents leaving care homes who have to attend A&E for falls, for example?
Professor McArdle: Nightingale 2 will be available for step-down accommodation for all patients and residents coming out of secondary care for enhanced rehabilitation with a maximum length of stay of 14 days. The clinical pathways are still being worked up and developed, but we anticipate that the same discharge arrangements would be in place. That is one of the issues that we addressed earlier. The current discharge protocol is that patients will be tested 48 hours prior to discharge and that, where possible, they should have that result in place. However, where it is not in place, it should not impede the discharge. Where a patient is transferred to another area of care, isolation will be maintained for 14 days. Those arrangements will be continued in the Whiteabbey Nightingale and that has been planned for in the capital works that are being done at the moment and in the clinical pathways that are being developed.
Mrs Cameron: OK. Does that include visits to A&E where you are not admitted?
Professor McArdle: A visit to A&E means that you should go directly back to the care home.
Mrs Cameron: OK. That was my concern. A constituent contacted me about a parent who had taken a fall and had to go to A&E, where she had a test and got a positive result when she was back in the home.
Professor McArdle: I will be happy to follow that up outside the meeting. The independent network is available now, so we can deal with some of those issues directly in that way.
The Chairperson (Mr Gildernew): Just to concur with Pam, I am aware of cases where people have been discharged back in and then were informed of a positive test. I am aware of at least one case where there is now an outbreak in the unit where that person was. That is an issue.
Do you have a question, Alan? A short one, please.
Mr Chambers: I have no questions, but I want to show my appreciation for a very informative presentation from the team. Thank you.
The Chairperson (Mr Gildernew): I concur with Alan in that respect. On behalf of the Committee, I thank Charlotte, Mark and Seán for attending and for giving us your briefings and responding to some of the issues.
We will, obviously, continue to factor in all the responses and different perspectives on all that to our care home inquiry.
Thank you very much. We send our best wishes to everyone whom you represent out there on the front line in what is, once again, a very worrying time. We wish you all the best in the time ahead.
Mr Holland: Chair, thank you very much for that. We wish all MLAs who find themselves self-isolating and waiting for test results, like everyone else, the very best. It is a difficult time for everyone; MLAs are not exempt from that.