Update 7 October 2020: Untenable pressure on local public health departments
Consultant in public health medicine with the HSE, Dr Anne Dee, has warned that regional public health departments are close to collapse. On the back of the CMO’s warning of surging numbers of COVID-19 cases, Dr Dee warns that the volume of work is too big and that outbreaks will be missed because there are not enough staff available to do sufficient contact tracing. As it is, public health staff are routinely working evenings and weekends to attempt to manage their workload.
Dr Dee said “We would normally have followed up all our cases and identified extra contacts and try to work out the sources of their infection. But none of that is possible there now because we are so overwhelmed. With the figures going up all the time, we are now even closer to collapse than we have ever been. Now we are having to prioritise, which is always bad in a pandemic.”
In response to these pressures, the government has announced a multi-million recruitment package for each of the country’s eight regional Departments of Public Health. On 30 September 2020, the Minister for Health Stephen Donnelly told the Oireachtas COVID-19 committee that he has sanctioned a doubling of our public health workforce capacity compared with pre-Covid levels and that 250 posts will be added to the service which currently has a national staff of 254 working on outbreak management, clinical queries, surveillance management, the operational management of surge capacity and complex contact tracing for COVID-19 while continuing to manage the risks associated with other communicable diseases and environmental hazards. Donnelly said to the committee that the HSE will begin a recruitment campaign for staff including public health doctors, nurses, scientists and support staff in mid-October. However, according to Dr Dee this effort will take too long and posts will not be filled until early next year while there is a critical need now.
Update 30 September 2020: New public health posts announced by health minister
The health minister Stephen Donnelly announced that new public health consultant posts will be created and the numbers of public health professionals working in health services will be doubled. Currently, Ireland has no public health doctors with a consultant status and the legislation necessary to create them was approved by the Cabinet on 30 September. The process will require consultation with the trade unions. In next week’s ahead, the Health Service Executive is expected to begin recruitment of 255 public health doctors, nurses, scientists and support staff.
This follows the commitment in the Winter Plan published last week to provide additional resourcing for the Department of Public Health, to address the capacity constraints created by COVID-19 including recruitment of new permanent staff. This is in line with recommendations made the 2018 Crowe Howarth report that public health specialist should have consultant status and the Sláintecare recommendations which specified building and supporting well-resourced and permanent public health teams is vital to its implementation.
https://data.oireachtas.ie/ie/oireachtas/debateRecord/special_committee_on_covid_19_response/2020-09-30/debate/[email protected]/main.pdf https://assets.gov.ie/9446/56efd96dac314a9692b785706b5a5ecb.pdf
Update 2 September 2020: Nurses’ union raise serious concerns over hospital over-crowding
The numbers of patients waiting on trolleys in Irish hospitals reached levels not seen since the very early days of the crisis. The Irish Nurses and Midwives Organisation (IMNO) said that overcrowding and COVID-19 make for a ‘toxic combination’ (https://www.inmo.ie/Home/Index/217/13612). A INMO spokesperson said ‘this is a deadly virus and our frontline members are rightly worried for their safety and that of their patients. Infection control is necessarily compromised in a hospital with patients in corridors and on trolleys, endangering staff and patients alike’.
In a May 2020 letter to the INMO, the HSE pledged “overcrowded health and social care facilities will no longer be tolerated”. The union is calling for direct government intervention to fulfil that pledge, including additional home care packages, higher staffed bed capacity, expansion of step-down, facility capacity.
Update 21 July 2020: Two thirds of nurses recovered from COVID still experiencing fatigue
Irish Nurses and Midwives Organisation (INMO) has surveyed 7,000 of their members about their experiences with Covid-19 (https://inmo.ie/Home/Index/217/13598). Of 545 respondents who said they had recovered from the virus, 497 (91%) stated they continued to experience symptoms, including mental health difficulties, headaches, breathing problems, anxiety, trouble concentrating or “brain fog”, dizziness/ light headedness, recurring fever, and palpitations (https://www.independent.ie/world-news/coronavirus/its-a-long-road-to-recovery-two-thirds-of-nurses-who-recovered-from-covid-19-still-experience-post-viral-fatigue-39384846.html). 81% of the total number respondents (including those who did not contract COVID-19) said that working in the health service during the pandemic substantially or somewhat impacted their mental health.
INMO general secretary Ms Phil Ní Sheaghdha and a nurse who has recovered from Covid-19 Ms Siobhán Murphy both testified before the Oireachtas Covid-19 committee on 21 July 2020 to speak about nurses’ personal experiences with Covid-19 recovery and the extra pressures of working during the Covid-19 pandemic (https://data.oireachtas.ie/ie/oireachtas/debateRecord/special_committee_on_covid-19_response/2020-07-21/debate/[email protected]/main.pdf). At this stage in the pandemic, 34% of those who have been infected with the virus in Ireland are healthcare workers. In that group 32% is made up of nurses and midwives, and 80% of those infections were acquired at work.
Ms Ní Sheaghdha also called on the government to empower the Health and Safety Authority, as the statutory agency holding responsibility for any other workplace accident, to investigate cases of virus outbreaks and to ensure the safety of nurses and midwives’ work environments (https://www.irishtimes.com/news/health/covid-19-vast-majority-of-nurses-who-contracted-virus-suffer-post-recovery-issues-1.4309649). She also called for staffing shortages in the healthcare system to be addressed and said that nearly 5,000 extra nurses and midwives are needed in the Irish health service to reach adequate staffing levels.
Update 23 June 2020: Inadequate childcare supports for nurses and midwives on the frontline during COVID-19
A survey conducted among members of the Irish Nurses and Midwives Organisation (INMO) details the childcare pressures faced by its members, including nurses and midwives working on the frontline of healthcare provision during pandemic (https://inmo.ie/Home/Index/217/13596). The survey found the inadequacy of childcare provision and support for health care workers during the COVID-19 pandemic (https://www.irishtimes.com/news/ireland/irish-news/nurses-using-annual-leave-to-cover-childcare-inmo-says-1.4286235).
1,826 INMO members with childcare needs participated in the survey, which found:
• 62% have taken annual leave to care for children,
• 22% are using paid childminders while at work,
• 10% are using grandparents to care for children,
• 69% did not have a partner available to provide childcare – often because they are a single parent, or their partner is another essential worker.
On 23 June 2020, the INMO representatives appeared at the Special Committee on COVID-19 Response in the parliament and called for the committee to recommend a range of measures to reduce childcare related hardship for its members, including:
• Reimbursement of any additional childcare costs incurred during COVID-19,
• Compensation for annual leave used to care for children,
• A scheme to pay healthcare workers for any childcare they source themselves,
• Priority access for nurses and midwives in access to preschools, crèches, and childminding,
• Reopening of schools to facilitate children of essential workers.
When all childcare providers closed their doors as part of the COVID-19 restrictions in March 2020, the government promised to provide childcare for frontline health workers. Various attempts to provide this care did not happen resulting in ongoing challenges for frontline workers during COVID-19.
At the NPHET meeting of 10/03/2020, the health workforce appeared as an agenda item.
On 17 March, the Government said it would recruit everyone available with appropriate qualifications for roles in the health service during the current crisis. That day it launched a new campaign called “Be on call for Ireland”, encouraging people at home and abroad to come and work in the public health service. By 5 April 2020, 70,000 people had signed up to ‘Be on call for Ireland’. Interviews for posts began the week of 24 March and by 29 March, an additional 260 nurses and 63 doctors had been hired, with 860 new recruits being processed in the last week of March/first week in April.
All student nurses are being hired as healthcare assistants and exams have been brought forward for final year medical students and other health care professionals to increase the workforce by early summer.
The COVID-19 Action plan includes the following items in relation to the health workforce:
• Facilitate recruitment and expansion of healthcare workforce
• Enable reassignment of military and other Governmental clinical personnel
• Enable reassignment of healthcare workers from private sector, and other external staffing supports, on needs basis
• Facilitate the re-recruitment of retired health sector workers
• Have contingency, Special Leave & Self Isolation plans in place
• Redeploy, reassign, second existing healthcare workers to frontline COVID-19 response, including increasing hours for part-time staff and overtime
• Continue to deliver measures to protect frontline staff from infection, including primary care professionals
• Examine the feasibility of providing essential healthcare workers with accommodation (e.g. onsite or hotel accommodation to avoid infection spread)
• Support service continuity through measures such as remote working, childcare, accommodation supports, transport
• Provide cross-training and deploy healthcare workers from other units and care areas where needed
• Deliver on ongoing basis training for healthcare workers to support COVID-19 response
• Mobilise Defence Forces to support the healthcare system and wider society needs
• Identify and deploy sources of essential staff from public / private sectors, conduct skills search to identify staff for redeployment
• Activate redeployment and reassignment, further expedite recruitment, mobilise returned retired healthcare workers, carers, health professional students, volunteers etc.
• Expedite and streamline ongoing recruitment
• Ensure psychological /social supports are in place for healthcare workers
• Measure absenteeism and engage agency staff to fill any staffing shortages identified
• Ensure a plan is in place and implement, as required, measures to support private and public sector workers
• involved in the provision of essential services (e.g. remote working, childcare, care of dependent, transport)
• Activate the redeployment of general health, civil and public service, if required
• Clarification of arrangements for Public Service Special Leave and DEASP COVID-related illness benefit supports in place
• Deploy additional sources of staff as required
• Introduce prioritised transport protocols to facilitate critical care staff
• Prepare and plan for the potential redeployment of general health, civil and public service staff to support COVID-19 response.
So far, there are high numbers of healthcare workers testing positive for COVID-19. Figures for 04/04/2020 show that 27% of those tested are healthcare workers. An HSE briefing on 05/40/2020 said that many of these workers were contracting it in the community not in the workplace. In relation to PPE, there is a strong emphasis on training how best to use PPE in order to keep them protected.
There are a range of supports in place to support the mental health of health workers. The HSE has a section on mental health for the population as a whole as well as a specific section for healthcare workers (see: https://healthservice.hse.ie/staff/news/coronavirus/staff-minding-your-mental-health-during-the-coronavirus-outbreak.html and https://www2.hse.ie/wellbeing/mental-health/covid-19/minding-your-mental-health-during-the-coronavirus-outbreak.html). Additionally, there is a specific webpage on the RCPI in relation to physician wellbeing with a range of advice, tips, resources and video links. (https://www.rcpi.ie/physician-wellbeing/covid-19-health-and-wellbeing-support/). The Psychiatric Nurses Association also has a page of links including a free phone number to support psychiatric nurses (https://www.pna.ie/index.php/member-information/1147-healthcare-worker-covid-19-leaflets-and-information).
On 22 April 2020, the Health Protection Surveillance Centre issued guidance with immediate effect on the use of surgical masks in healthcare settings within two metres of a patient, regardless of the COVID-19 status of the patient. The HPSC advice on the use of surgical masks two objectives:
• To reduce the risk of droplet transmission of infection to the wearer.
• To reduce the risk of droplet transmission of infection to others.
The advice specifies that it is in addition to and not as a replacement for other measures to reduce the risk of transmission of infection. Other measures are hand hygiene and maintaining a distance of 2m between people whenever possible. The Irish Nurses and Midwives Organisation welcomed a change in national policy, which now mandates facemasks in all settings for any healthcare workers who provide care within 2m of a patient. The INMO says this will mean nearly all frontline healthcare workers will wear facemasks. Until now, many parts of the health service did not require or permit staff in all areas to wear facemasks. The new guidance from the HPSC is here: https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/ppe/useofsurgicalmasksinhealthcaresetting/
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).
On 21 April 2020, in a letter from CMO Tony Holohan to the health minister outlined measures for assisting healthcare workers with childcare needs (https://www.gov.ie/en/collection/691330-national-public-health-emergency-team-covid-19-coronavirus/#minutes-from-meetings-in-april). It stated that ‘paid leave will be provided for some partners of healthcare workers to assist with childcare issues in the home’. The proposal has two aspects. The first is to provide paid leave to the partners of healthcare workers. This only applies to partners who work in the public sector and allows them to stay at home and provide childcare. The second component is to use child minders to go into people’s homes. But given concerns in relation to spreading the virus, this measure will be considered by 5 May. Upon announcement of the measures, the Taoiseach admitted that it is an inadequate response for those who are lone parents or whose partners do not work in public sector. As reported in the Irish Times, the new childcare proposals were strongly criticised by nurses’ representatives who claimed they were “worse than irrelevant” (https://www.irishtimes.com/news/health/coronavirus-paid-leave-for-some-partners-of-healthcare-workers-to-assist-with-childcare-1.4235059). The Irish Nurses and Midwives Organisation (INMO) said the proposals would “do nothing for the vast majority of nurses and midwives”.
On 28 April 2020, healthcare workers who cannot find childcare are to be allowed to stay home to mind their children and be paid (https://www.rte.ie/news/coronavirus/2020/0428/1135445-childcare/). This followed measures introduced the week before which were widely criticised by unions representing healthcare workers.
On 6 May, Minister of Children Katherine Zappone announced a new childcare scheme with effect of 18 May which will be overseen by the Department of Children providing state funded childcare in the homes of 5,000 essential healthcare workers (https://www.gov.ie/en/publication/240258-up-to-date-information-on-covid-19/). Registered childcare services are being invited to take part in the scheme to provide 45 hours of childcare a week. Participation in the scheme is voluntary. However, on 13 May 2020: it was announced that the scheme had been abandoned due to the low take up of the scheme. Only six providers signed up the scheme due to a range of reasons including at the lack of availability of insurance cover, concerns over transmission of the virus and lack of protection for workers going into other people’s homes. The minister with responsibility for the scheme, Katherine Zappone noted that ‘her department remains strongly focused on developing solutions to the significant challenges of a phased reopening of early learning and childcare facilities for 29 June in line with the government’s Roadmap for Reopening Society and Business’ (https://www.gov.ie/en/news/701e2e-statement-on-cancellation-of-temporary-childcare-scheme-for-essentia/).
22 May 2020: Senior health officials have been questioned during the last week over the use of private hospitals and the extent that privately practicing consultants have signed up to the public only work contract for the duration of the COVID-19 pandemic.
Speaking at the parliamentary committee meeting on COVID-19, the HSE chief Paul Reid, and Department of Health Secretary General Jim Breslin said that the HSE is carrying out a review as to whether it should extend its contract with private hospitals for a further month from the end of June. Given the cost of €115 million cost, the HSE will consult with the Minister for Public Expenditure Paschal Donohoe on the issue and it has to inform the private hospitals of its decision by the end of May.
The Government’s deal with private hospitals covers the costs of the use of the facilities, the treatment of patients and staffing costs up to a salary of €200,000. However, it does not cover the cost of 600 private consultants who work in these hospitals (https://www.irishtimes.com/news/ireland/irish-news/private-consultants-resign-from-contract-to-treat-only-public-patients-1.4259143). These consultants were offered a temporary locum contract to treat only public patients with a salary ranging from €141,000 to €195,000. Many private consultants are stating their concern that the proposals negatively impact the continuity of care for their private patients and threaten the feasibility of their practices as the contract does not cover the cost of their private rooms and staff.
Jim Breslin, secretary general in the health department told the committee that ‘more than 280 consultants have signed up to the contract offered’. Concerns have been cited in relation to the under use and occupancy of private hospitals. Mr Breslin pointed out that non-essential care ‘was not taking place in either public or private hospitals up until the start of this month’ but that this is now being ramped up. He said he wanted to put on record that in private hospitals ‘6,646 inpatient discharges have taken place. There have been 21,350 day cases, which might include chemotherapy, 26,386 diagnostic procedures, and 15,862 outpatient procedures. Mr Breslin explained to the committee that ‘many things that were happening in public hospitals have now moved lock, stock, and barrel into private hospitals. We want to keep it away from an area that might have COVID and run it in the private hospital, and run it in a facility that is purpose-built for that. The private hospital facility makes an important contribution to how we meet healthcare needs at this stage. What we will have to review is the extent to which we continue with that’ (https://www.kildarestreet.com/committees/?id=2020-05-19a.39).
17 June 2020: COVID-19 infection in healthcare workers
Figures for COVID-19 infection in healthcare staff have identified a total of 8,018 cases in Irish healthcare workers and for those where the source of infection is known, 88% contracted the virus at work (https://www.inmo.ie/Home/Index/217/13594). In 32% of the cases the sources of infection is unknown and those are not included in the breakdown of infection sources below:
• 88% got the virus in a healthcare setting as staff
• 4% from contact with a confirmed case
• 3% from travel
• 3% from community transmission
• 1% from a healthcare setting as patients.
Healthcare workers make up a third of all COVID-19 positive cases in Ireland. Nurses are the single largest group among infected healthcare workers and represent one in ten cases in Ireland (https://www.irishexaminer.com/breakingnews/ireland/seven-healthcare-workers-have-died-from-covid-19-1004880.html).
As of 30 May 2020, seven healthcare workers have died from the virus, 1,515 (19%) have recovered, and 4,823 are still ill (60%). 20% of cases have a currently unknown status.
To combat the high rate of infection among healthcare workers, the Irish Nurses and Midwives Organisation is calling for three policy changes:
• Amend regulations to class COVID-19 as a personal injury under health and safety legislation.
• Facilitate healthcare workers who come into unprotected close contact with COVID-19 to self-isolate for 14 days, without exemptions.
• All healthcare workers – not just those in nursing homes or clusters – be provided with regular COVID-19 testing.
Government of Ireland. COVID-19 Action plan for Ireland: https://www.gov.ie/en/publication/47b727-government-publishes-national-action-plan-on-covid-19/
Health Service Executive (HSE). Be on call for Ireland. https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/oncall/
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