2. Ensuring sufficient physical infrastructure and workforce capacity
ENSURING SUFFICIENT PHYSICAL INFRASTRUCTURE AND WORKFORCE CAPACITY is crucial for dealing with the COVID-19 outbreak, as there may be both a surge in demand and a decreased availability of health workers. The section considers the physical infrastructure available in a country and where there are shortages, it describes any measures being implemented or planned to address them. It also considers the health workforce, including what countries are doing to maintain or enhance capacity, the responsibilities and skill-mix of the workforce, and any initiatives to train or otherwise support health workers.
2.1 Physical infrastructure
Update 11 January 2020: Health system under pressure due to surge in COVID-19 cases
On 10 January 2021, there were 128 confirmed cases in hospital intensive care units, the highest recorded since April 2020. There were 1,575 cases in hospital with significant increases in both hospital and ICU admissions since late December. On 26 December, there were 22 people in ICUs and 268 people with CVOID-19 in hospital, therefore ICUS and hospitals have experienced a nearly six-fold increase in three weeks. Speaking on national radio on 10 January, HSE chief, Paul Reid said there were 37 adult and 11 child ICU beds available. Paul Reid also said using surge capacity was now inevitable and that a new deal done with private hospitals would facilitate this. This deal gives the HSE access to up to 600 beds which are currently in use for urgent non-COVID care.
There is evidence of pressure on hospitals dealing with growing numbers of Covid-19 patients. For example, there were reports on the night of 10 January of patients at Letterkenny University Hospital in Donegal being treated in ambulances outside the hospital due to lack of room in the emergency department. The hospital had few beds available, which resulted in delays in admission specifically for patients going to the dedicated Covid-19 zone.
Speaking on 8 January 2021, HSE Chief Operations Officer, Anne O’Connor, said that ‘hospitals were “coping” at present’. She said that hospitals were coping because they had scaled back on other work, but growth in the numbers of patients requiring ICU beds was inevitable and it could reach 300-400. All the hospitals have a crisis plan which activate to allow surge capacity. This includes postponing planned elective care and outpatient appointments.
The current situation is further hampered by high absentee rates by staff and COVID-19 outbreaks in healthcare settings. On 10 January 2021, there are 3,500 staff who are either sick or close contacts of people with COVID-19 who unavailable to work across acute and community services. This has led to the HSE having to close 600 beds in Irish hospitals due to a lack of staff. There have been 20 COVID outbreaks in public hospitals and 104 outbreaks in residential facilities in the last week adding additional pressure to a system already under pressure.
3 June 2020: Private hospitals contract to finish at end of June
On 30 May, the Government announced an end to the arrangement at the end of June. The cost of having private hospitals for public use the month of April was €97 million, with estimates that it will cost €300 million for three month they have been contracted for. At the Committee on 3 June 2020, Secretary General of the Department of Health Jim Breslin said that ’latest figures showed that 48% of private hospital bed capacity was being used and 56% of critical care beds’ (https://www.kildarestreet.com/committees/?id=2020-06-02a.249).
The original deal was done in a very short time frame, purely to have extra capacity in the system in case it was needed. Jim Breslin told the Committee that the pause in all non-essential health services recommended at the end of March by the National Public Health Emergency Team (NPHET) has led to up to 2,000 vacant beds at any one time, which was “unprecedented”. Non-COVID related care and routine scheduled care has restarted and “the HSE is continuing to increase its utilisation of the private hospitals for the remaining period of the current arrangement”.
In early March, testing was done in hospitals only and there was one lab analysing test results. Since then, there has been a significant investment in setting up testing facilities, expanding laboratory facilities (see Section 1.5: Testing).
Ireland was low on the numbers of acute hospital beds and very high levels of occupancy before the pandemic and worked rapidly to increase availability of beds, including announcing a partnership allowing public patients to access all private hospital beds from 1st April 2020. On 31/03/2020, an agreement was reached between the HSE and private hospitals so that their 2,000 beds, 8,000 staff including 500 consultants who work in private hospitals, are available to the public health system for the duration of the covid-19 crisis.
In the COVID-19 Action Plan published on 16 March the following actions were outlined regarding securing and sustaining continuity of access and supply to essential health products, equipment and vehicles:
• HSE continue to undertake ongoing procurement of essential health products and equipment
• Critically assess the short, medium and long-term requirement for, and availability of, medicines, medical devices, PPE and other essential health products and equipment
• Enhance availability of comprehensive real-time information about national stocks and map logistical requirements in relation to essential health products to enable equitable allocation to meet patient needs across all care settings
• Engage with pharmaceutical, med tech and other health product industries, suppliers, pharmacies and retailers to maintain responsible supply of essential health products
• Identify sources and deploy of additional vehicles from public / private sectors for National Ambulance Service
• Instigate nationally-mandated controls on the supply and distribution of all essential health products to ensure delivery of critical health services, if appropriate
In a press statement issued by NPHET on 07/02/2020, it stated ‘The HSE has been working with frontline staff in our health service over recent weeks in response to Coronavirus (2019-nCoV). 3,000 personal protection packs have issued to GPs and clinics around the country and will be received in the coming days. All acute hospitals have multi-disciplinary Coronavirus (2019-nCoV) preparedness committees to oversee implementation of the Health Protection Surveillance Centre algorithms and actions’. It also stated that all hospitals were preparing for increased demand, including ICUs and the ambulance service ‘is actively engaged in risk assessment and the co-ordinated response to case recognition and containment’.
A HSE media briefing on COVID-19 on 13/02/2020 stated that ‘an initial 4,800 Personal Protective Equipment (PPE) packs were distributed to GP Out of Hours Services, Public Health Departments and GP Practices. A further 1200 packs followed earlier this week’.
On 7 March, Dr Cillian de Gascun, Chair of the Expert Advisory Group, said: ‘There is a risk to patients of acquiring COVID-19 from an exposed health care worker. However, if a health facility cannot be staffed safely to provide critical services, then the following guidance to mitigate risk will assist:
• health care workers who have had close contact with a confirmed case of COVID-19 and have developed symptoms should be excluded from work
• health care workers who have had close contact with a confirmed case of COVID-19 and have NOT developed symptoms, AND are deemed to be essential workers, may work, provided they observe strict adherence to infection prevention and control precautions, and undergo twice daily active monitoring by occupational health, for 14 days after contact with a confirmed case of COVID19.
At the NPHET meeting of 10/03/2020, it was stated that ‘a paper in relation to guidance for healthcare workers was tabled at meeting 10 and further advice was received today from the Expert Advisory Group (EAG) outlining an approach to PPE for healthcare workers who are contacts of confirmed cases.’ This meeting also recommended that healthcare worker follow existing guidelines in relation to the wearing of masks.
During March and early April, there was growing concern from frontline health professionals about access to PPE. This includes HSE staff, GPs who are contracted by the HSE and staff in private nursing homes. On the HSE website on 3/04/2020, there was following statement ‘we want to reassure you that we are doing everything we can to protect our staff. The first delivery of personal protective equipment (PPE) arrived at Dublin Airport from China on Sunday 29 March. A series of deliveries is expected between Sunday and Wednesday. We are working on distributing the PPE across the system. HSE is seeking to manage prudently it’s PPE supplies in light of the global shortage of this essential equipment at a time of unprecedented demand’.
The HSE website gives guidance on using PPE stating ‘personal protective equipment is valuable as an additional protection for patients and staff. It should only be used where it is likely to be beneficial as outlined in the HSE Personal Protective Equipment (PPE) guidance. It should not be used in other settings where it does not provide any benefit. The unnecessary use of PPE will deplete stocks and increases the risk that essential PPE will not be available to help protect you, your colleagues and patients when needed’. The HSE Personal Protective Equipment (PPE) guidance will be monitored and may change as the coronavirus outbreak evolves. There is also guidance on PPE on the HPSC website.
Concerns in relation to the appropriateness and quality of the PPE delivery arose in the days after the first arrival from China. At a press briefing on 05/04/2020, the HSE acknowledged that between 20% of the equipment that arrived was not fit for use.
HSE Guidance does not recommend using surgical facemasks in situations other than being within one metre of a patient with droplet transmitted infection including coronavirus. Airborne precautions are only needed if an aerosol-generating procedure is being performed on a patient with suspected or confirmed coronavirus. There are two education modules on putting on and taking off PPE safely available on HSELand (the HSE online resource for staff). One is for staff in acute settings. The second is for staff in community settings.
Up to the arrival from China, there were reports of PPE shortages in Irish hospitals and nursing homes, including those working with Covid-19 patients. On 03/04/2020, the HSE said ‘Ireland, in common with every country globally, is facing significant challenges in sourcing PPE in an extremely competitive global market’. In an average year the HSE spends €15 million on PPE. HSE CEO, Paul Reid said on 29/03/2020, the HSE has an initial budget of €208 million for PPE to tackle Covid-19, of which €60 million plus has been spent to date.
In the NPHET meeting of 03/03/2020, it was stated that the Health Protection Regulatory Authority (HPRA) ‘updated the group and noted that work continues at national and European levels in relation to regulatory issues, supply of medicines, clinical trials and vaccination development. The group previously used for Brexit to co-ordinate potential medicines shortages was now been re-established. Queries to the HPRA from pharmacists on requests for additional supplies were noted and there was discussion of the importance of ensuring pharmacists, which are often a first point of contact, are up to date was noted so that they can provide advice and answer queries from patients’ It was decided that the Department of Health and HSE would include pharmacists in key stakeholder engagements on medicines supply and advice for patients.
At the NPHET meeting on 10/03/2020, it stated that ‘the HPRA updated the group and noted that work continues at the national level in relation to regulatory issues, supply of medicines, clinical trials. An increase in dispensing and the purchase of over the counter medicines was seen last week and a communication has issued to wholesalers with guidance’.
According to a statement from the health minister on 03/04/2020, ‘there have been no reports of Covid-19 impacting on the general supply of medicines to Ireland. However, international authorities, including the European Medicines Agency, remain vigilant to any potential risk. In Ireland, the Department of Health and the Health Products Regulatory Authority is working as part of this wider EU response to Covid-19. There are already additional stocks of medicines routinely built into the Irish medicine supply chain. Therefore, Ireland is unlikely to face general medicines supply issues now or in the near future as a result of any potential delays in the supply chain caused by Covid-19 related issues’.
Ireland has an existing Medicine Shortages Framework in place to help prevent shortages from occurring and to reduce the impact of shortages on patients and healthcare professionals whereby the HPRA co-ordinates the management of potential or actual shortages as they arise, in cooperation with a range of stakeholders. Significant work was done in this area as part of the preparation for Brexit strategy.
23 April 2020: More information has been released in the public domain on the arrangement between private hospitals and the State as part of COVID-19 response. Dáil (parliamentary) debates on 16 and 23 April discussed the arrangements between the State and private hospitals as part of the COVID-19 response. In early April, the Government agreed a deal to take over 19 private hospitals for a three-month period with potential to extend depending on the length of the Covid-19 crisis. The arrangement includes access to 2,000 beds, other facilities and most staff. A link to the deal available on the Oireachtas website is below. The Dáil debate included reference to the estimated monthly cost of the leasing of private hospitals of €115 million (https://www.kildarestreet.com/debates/?id=2020-04-16a.9&s=universal+healthcare#g217). The Taoiseach told the Dáil that agreement was on a not-for-profit basis and just covers the costs of the private hospitals.
However, this arrangement with private hospitals did not cover the 600 consultants who work exclusively in the private sector. These doctors were offered an A-type contract – under which only public patients can be seen and their salary ranges between €141,000 and €195,000 per year. On 23 April, the HSE said 150 consultants had signed up to the contract (https://www.businesspost.ie/health/private-hospitals-deal-hits-snag-as-consultants-seek-clarity-on-terms-85efe57f).
10 May 2020: At the weekly HSE briefing on 10 May, HSE chief Paul Reid said that testing, tracing and personal protection equipment, (PPE) could cost the HSE over a billion euro for the year. He also said that the costs of not investing in them would be much higher, that testing and tracing were key enablers to unlocking the country and that the ‘costs are at a scale that nobody could have foreseen months ago’. Nine million masks are needed in Ireland every week, with masks and gowns being the hardest PPE to secure. There were 60 flights carrying PPE arriving in Ireland last week. He added that the HSE will commission a report on how best to develop a sustainable model for testing and tracing in the future. It is expected that a contact tracing app will be rolled out by the end of May.
Info on the app here https://www.gov.ie/en/news/d2a00d-national-app-for-covid-19/
Government of Ireland. (03/04/20). Minister for Health signs regulations to assist with prescriptions during COVID-19. Press Release. https://www.gov.ie/en/press-release/d80ca9-minister-for-health-signs-regulations-to-assist-with-prescriptions-d/
Health Protection Surveillance Centre. PPE. https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/ppe/
Health Service Executive (HSE). Media briefings: https://www.hse.ie/eng/services/news/media/pressrel/
Health Service Executive (HSE). (06/04/20). PPE Stock update. https://healthservice.hse.ie/staff/news/news-items/prevent-the-spread-of-coronavirus-in-the-workplace.html
OECD. 2019. Health at a Glance: https://www.oecd.org/health/health-systems/Health-at-a-Glance-2019-Chartset.pdf
Press releases, Agendas and minutes of the meetings of the National Public Health Emergency Team: https://www.gov.ie/en/collection/691330-national-public-health-emergency-team-covid-19-coronavirus/
Private hospital deal: https://ptfs-oireachtas.s3.amazonaws.com/DriveH/AWData/Library3/Documents%20Laid/pdf/DOHdoclaid160420_160420_154056.pdf