Policy responses for Ireland - HSRM

Ireland


Policy responses for Ireland

5. Governance

5.1 Governance

The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.

Update  14 May 2021 Vaccination roll-out is unaffected despite ‘major incident’ of cyber-attack on the Health Service Executive

On Friday 14 May 2021, the Health Service Executive (HSE) was subject to a sophisticated Conti ransomware attack. Speaking to RTÉ News on 15 May, Minister of State for Public Procurement and eGovernment, Ossian Smyth, described the event as ‘possibly the most significant attack on the Irish State’. The response, which is being led by the National Cyber Security Centre (NCSC) in collaboration with the HSE, required a shutdown of all IT systems as a protective measure. For the first week of the attack, nearly all of the IT systems including all clinical, diagnostic, patient records as well as administrative data including payroll were shut down. This resulted in restricted database access as well as significant disruption due to the cancellation of many out-patient appointments. In a letter to GPs, HSE Chief Clinical Officer Dr Colm Henry wrote that, without IT systems, clinical laboratory capacity to test and relay results ‘may be reduced to as little as 10% of normal’.

Speaking on radio on 21 May 2021, health minister Stephen Donnelly said that progress had been made up in getting some systems running in some voluntary hospitals including radiology, laboratory and patient administration systems. However radiology, oncology and laboratory services remain disrupted following last week’s cyberattack. Mr Donnelly emphasised that it was an ‘absolute priority’ for the HSE to get machines back up and running with teams working around the clock. The HSE has warned that it could take ‘many weeks’ to reinstate its computer systems.

Speaking to RTÉ, the HSE's Chief Operations Officer, Anne O'Connor, said that COVID-19 testing and vaccination services are among the organisation’s priorities as it deals with the fall-out of the incident. Although test results were temporarily disrupted, test appointments are now going ahead as scheduled. HSE Chief Executive, Paul Reid, told RTÉ that while the automated referral from GPs is not functioning, people can attend any of the HSE COVID-19 test sites. Anyone who has symptoms of COVID-19 is asked to self-isolate and contact their GP by phone.

The COVID-19 vaccination programme has not been affected by the attack. Mr Reid has advised the public to continue to register for a vaccine appointment through the online portal, saying that the system is safe to use. The vaccine portal for 45-49 year-olds opened as planned on 19 May 2021, starting with those aged 49. The HSE expects people in this cohort will be able to receive a first dose by the end of the month.

The last official figures published before the cyber-attack reported that there had been 1,922,913 doses of COVID-19 vaccine administered in Ireland. However, due to the current disruption of the HSE IT system, the updates to the GeoHive COVID-19 Hub have been paused until further notice. Backdated figures will be published ‘when possible’, a spokesperson for the Department of Health has said.

On 20 May, the HSE was granted a high court order restraining anyone from sharing, selling, publishing, processing or dealing with the data without consent of the HSE. In their affidavit to the high court, HSE chief Paul Reid said full recovery of the HSE’s IT systems would be likely to take several weeks and the overall impact of the disruption on the HSE and patient care here ‘cannot be overstated’.

Sources:

https://www.irishtimes.com/news/health/progress-in-restoring-hse-systems-but-disruption-continues-says-donnelly-1.4571338

https://www.irishtimes.com/news/crime-and-law/courts/high-court/hse-hack-clinical-diagnostic-and-payroll-data-all-potentially-compromised-1.4570810 

https://www.thejournal.ie/hse-cyber-attack-2-5438094-May2021/

https://www.rte.ie/news/health/2021/0517/1222037-hse-ransomware-attack/

https://www.irishtimes.com/news/health/cyberattack-a-despicable-crime-with-risk-of-stolen-patient-data-being-abused-government-says-1.4567243

https://www.rte.ie/news/2021/0515/1221732-vaccinations-continue-portal/

https://www.irishtimes.com/news/health/restoration-of-health-service-computer-systems-to-take-many-weeks-in-wake-of-cyberattack-1.4568751?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fhealth%2Frestoration-of-health-service-computer-systems-to-take-many-weeks-in-wake-of-cyberattack-1.4568751

https://www.independent.ie/videos/steady-progress-being-made-to-secure-hse-as-ceann-comhairle-condemns-despicable-crimes-of-hackers-40443878.html

https://www.rte.ie/news/coronavirus/2021/0519/1222479-coronavirus-ireland/

https://www.gov.ie/en/news/7e0924-latest-updates-on-covid-19-coronavirus/#the-latest-news-as-of-5pm-on-tuesday-18-may

Update 20 November 2020: Health Service Executive takes over running of nursing home

After 19 residents and staff in a nursing home in County Kerry tested positive for COVID-19 at the start of November, the Health Service Executive (HSE) has taken over its running due to serious infection control concerns. Residents who had tested positive for COVID-19 were not being isolated and cleaning was not being done with COVID-19 specific cleaning products. All staff members were in contact with all patients and there were no checks or restrictions on visitors to the nursing home. The HSE take over occurred when the Health Information and Quality Authority (HIQA) applied in court to have the nursing home’s registration cancelled.

Source:
https://www.irishtimes.com/news/ireland/irish-news/hse-takes-over-running-of-kerry-nursing-home-in-chaos-1.4414156

Update 19 November 2020: Republic of Ireland and Northern Ireland: Incongruent COVID-19 management

With an open border between the two parts of Ireland, COVID-19 management strategies in the Republic of Ireland and Northern Ireland impact especially in the border areas. Each jurisdiction has had a number of variations in their approach to handling the pandemic.

While the Republic is in its fifth week of a six-week national lockdown, Northern Ireland will come out of its current lock down for a one week on 20 November 2020 and will then impose a strict two-week ‘circuit breaker’ lockdown again starting on Friday 27 November. This means further difference, North and South, eg cafe and hairdressers will be open in North from 20 to 27 November whereas they remain closed in the South under level five which is in place until 3 December.

Source:
https://www.rte.ie/news/ulster/2020/1119/1179160-northern-ireland-restrictions/

Update: 5 October 2020: Expert advice divergence

Since the start of the COVID-19 pandemic, the Irish government has repeatedly stated that they are following the scientific evidence when setting policy on managing the response. As soon as COVID-19 came on the international radar, the Department of Health quickly established a National Public Health Emergency Team (NPHET) on 27 January 2020. NPHET is chaired by the Chief Medical Officer, Dr Tony Holohan and the group oversees and provides national direction, guidance, support and expert advice on the development and implementation of a strategy to contain COVID-19 in Ireland. Its membership is made up of high-level officials from the Department of Health and the Health Service Executive (HSE) as well as clinicians and academics in relevant disciplines.

NPHET provides regular and ongoing advice to the government based on up to date evidence and the profile (in terms of incidence, R0, outbreaks among vulnerable populations, pressure on health services and more) of the virus at the particular time. Based on this advice, the government makes policy decisions. Except for a some minor deviances since June, government has generally closely followed NPHET’s recommendations to date.

However, during the second week of October 2020, government decided to disregard NPHET’s advice in a significant way. At that time, counties Dublin and Donegal were at level 3 while the rest of the country were at level 2 in the 5-level framework for COVID-19 control measures. In a letter to the Minister for Health on Sunday 4 October 2020, Dr Tony Holohan wrote on behalf of NPHET recommending that Government move the whole country to level 5 for four weeks. Holohan wrote: ‘Disease modelling shows that, if current trends continue, 1,600-2,300 cases will be notified per day by 7 November. The modelling also shows 43 people with COVID-19 being admitted to hospital per day by that date. In light of the above, the NPHET believes that proactive and robust measure must now be taken such that very significant suppression of the disease with a reproduction number well below 1.0 is achieved.’

The recommendation to go to level 5 was leaked to the media by an unknown source and was reported widely on the night Sunday 4 October and caused much public and political upset. The next day, Monday 5 October, Dr Holohan and other NPHET team members met with the three leaders of the governing coalition, the Taoiseach Micheál Martin, Tánaiste Leo Varadkar and Green Party leader Eamon Ryan. Subsequently the Cabinet COVID-19 oversight committee met and later that day the full cabinet met. At this meeting, cabinet decided to move the whole country to Level 3 because of concerns that going to Level 5 would have serious negative consequences for society, for the economy, and for mental health. This decision is announced by the Taoiseach on the national broadcaster RTÉ’s 9pm news.

Later on the evening of 5 October, Tánaiste Leo Varadkar appeared on RTÉ and commented that NPHET’s advice had come out of the blue and had not been thought through. He also said that it had caused undue worry to hundreds of thousands of Irish people. It is the first instance of public and significant critique of the public health experts from a member of the Irish government.

Later in the week, Tony Holohan at the press briefing on 7 October said that he had been in touch with Minister for Health Stephen Donnelly on Saturday 3 October and Sunday 4 October expressing his grave concern, questioning Varadkar’s assertion that NPHET’s recommendations on 4 October came out of the blue. The public rift and the ongoing telling of the story in the media is the first instance of Government and NPHET not presenting a united front in their approach to the management of COVID-19 and it remains to be seen what the effect of it will be in terms of ensuring that the response remains based on the scientific evidence. 

Figures presented at the press briefing on 7 October show some indication that level 3 measures in Dublin and Donegal are slowing the increase in the spread of the disease.

Sources:

https://assets.gov.ie/89950/7a01b63b-8fff-483c-b967-298ffdadbda8.pdf

https://assets.gov.ie/68995/3c6b8b0449074db9801b0d92d1f8c1e8.pdf

https://www.irishtimes.com/news/politics/timeline-nphet-level-5-recommendation-who-knew-what-and-when-1.4375677

Update 15 September 2020: Resilience and Recovery Plan for Living with COVID-19 launched by Government

On 15 September Taoiseach Micheál Martin, Tánaiste Leo Varadkar and Minister for Health Stephen Donnelly launched the Irish government’s medium-term plan for managing COVID-19 through the coming winter and into spring 2021. In recognition that the virus is likely to be with us for some time to come, the plan offers a framework focused on protecting the health of the population while living alongside the virus with as little interruption to people’s lives and economic activity as is possible.

The framework has five phases with the lower levels imposing fewer restrictions at times of low incidence and community transmission of the disease, with isolated outbreaks. The higher levels detail measures which will be put in place to deal with higher incidences of the disease.

Levels 1-5 will be assigned on a county-by-county basis and influence the numbers of people who can participate in activities including household visitors indoors and outside, weddings, indoor events, sports fixtures, bars and restaurants, ‘wet’ bars (bars that do not serve food), religious services, funerals, and domestic and international travel.

Assignment of current level either locally or nationally will be done by government on advice from the National Public Health Emergency Team (NPHET). The level will be determined based on a number of indicators on an ongoing basis. These include:
  • the 14 and 7 day incidence per head of population
  • the rolling 5-day average of cases by county
  • the number and location of clusters of cases
  • the level of cases in nursing homes and other residential healthcare settings
  • the number of admissions to hospital and ICU, hospital critical care occupancy
  • the number of deaths.
Increased restrictions will be put in place for three weeks at a time after which they are expected to have taken some effect and to allow for easing to a lower level.

There are seven sections in the report.
  1. Governance and Communication
  2. Staying Safe
  3. Being Prepared and Responsive
  4. Resuming Public Service Delivery
  5. Developing Economic Resilience
  6. Growing Our Resilience
  7. Remembering the Loss

In the first section of the latest COVID-19 plan, a new governance structure for the high-level management of COVID-19 in Ireland is detailed. Where the National Public Health Emergency Team (NPHET) until now has been reporting directly to the government, they will now report to a new COVID-19 oversight group. The oversight group will meet weekly and report to a cabinet committee on COVID-19 chaired by the Taoiseach and will “provide advice to Government on the strategic economic and social policy responses to the management of the disease and to consider the NPHET advices”. The plan also envisages that this group will oversee and direct implementation of policy responses.

The new plan was launched a week after the acting Chief Medical Officer Dr Ronan Glynn expressed grave concern at the rising number of cases in Dublin and recommended that the guidelines should be changed immediately from allowing six people from up to three households to gather in a home or garden to allowing only two households to interact.

In a letter on Friday 11 Sept 2020 to the Minister for Health, Glynn stated that there is likely ‘a substantial disease reservoir in Dublin that, if left unchecked, has the potential to transmit widely and quickly’, and warned that there is a growing risk of disease at this volume spreading to residential care settings and among vulnerable populations potentially putting strain on the hospital system and leading to higher mortality. Government waited till the following Tuesday to request that Dublin residents take extra precautions and not leave the capital with mixed messages from different politicians fuelling confusion.

Sources:

https://www.gov.ie/en/publication/resilience-and-recovery-plan-for-living-with-covid-19-your-questions-answered/

https://www.gov.ie/en/publication/e5175-resilience-and-recovery-2020-2021-plan-for-living-with-covid-19/

https://assets.gov.ie/87202/11f276b2-4c70-47c4-999e-ff48c12f71fa.pdf

Update 11 September: Five level grading system recommended for clarity on local restrictions based on the level of Covid-19 transmission

On the 10 September, the Cabinet’s sub-committee on Covid-19 met to discuss the medium-term COVID-19 strategy for the next six months, which is due to be published on 15 September. The committee is reported to be recommending a grading system for the country with up to five levels of COVID-19 restrictions to be applied regionally depending on the grade for each county or area (https://www.rte.ie/news/coronavirus/2020/0910/1164479-covid-government-plans/). Grade one is expected to be “normal” while five being most serious and requiring most severe restrictions, and a possible lockdown. Each grade would include a clearly outlined restrictions, for example, on social gatherings, events, business remaining open and travel. The criteria for determining grades for each area would be 14-day incidence rate of COVID-19 cases per 100,000, the number of COVID-19 related hospital admissions and ICU admissions.

While the public health officials have access to such data, it has not been available to the public. Currently, public data on Covid-19 trends is published by the Department of Health and the HSE’s Health Protection Surveillance Centre (HPSC) (see: https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/surveillance/covid-1914-dayepidemiologyreports/ ). These do not include more local detail on infection trends, for example, by electoral area which could enable citizens to make informed decisions based on the virus circulating in their area. The regional breakdown of infections was published by the HSE early in the pandemic. While the National Public Health Emergency Team (NPHET) has access to much more detailed up-to-date data, its release to the public as part of HPSC reports has been considered as “not feasible” given its heavy workload (https://www.irishtimes.com/news/health/public-covid-19-data-not-giving-clear-picture-of-current-trends-1.4350798).

Update 27 August 2020: EU Commissioner Phil Hogan resigns after breaching public health guidance

Irish EU Commissioner Phil Hogan resigned his position on 26 August. The resignation comes as the fallout from an event organised by the parliamentary golf society on 19 August which had 81 people in attendance, in breach of public health advice. It has since emerged that Hogan also breached the 14-day quarantine rule after returning to Ireland from Brussels and that he travelled to and from county Kildare several times while that county that was under restricted movements with just essential travel for work and care allowed (https://ec.europa.eu/commission/commissioners/2019-2024/hogan/announcements/memorandum-president-von-der-leyenstatement-commissioner-phil-hogan-recent-visit-ireland_en).

Prior to the resignation, the leaders of each of the three parties making up the coalition government issued a statement acknowledging that Hogan had made clear breaches of public health guidance (https://merrionstreet.ie/en/News-Room/News/The_Taoiseach_Tanaiste_and_Minister_Ryan_acknowledge_Commissioner_Phil_Hogan%E2%80%99s_recent_account_of_his_movements_when_he_travelled_to_Ireland_.html). Minister Eamon Ryan TD, head of the Green Party, also said on the radio on the morning 26 August that government had lost confidence in Hogan.

Update 26 August 2020: Oireachtas COVID-19 committee meeting

On 26 August the Oireachtas (parliamentary) COVID-19 committee met and heard from representatives from the Health Service Executive (HSE), the National Public Health Emergency Team (NPHET), and from Minister for Health Stephen Donnelly TD (https://www.oireachtas.ie/en/debates/debate/special_committee_on_covid-19_response/2020-08-26/). The focus of the discussion from each of the witnesses was the current increase in COVID-19 cases.

HSE CEO Paul Reid warned of the likelihood that Ireland will be living with the virus for the foreseeable future and that it is likely there will be ‘significant peaks, and, we hope, significant troughs very soon and those changes may not always be national’. The strategy therefore is about managing the peaks through public health measures, testing and tracing.

Niamh O’Beirne, the HSE’s lead on testing strategy said that the median turnaround time for a test to be completed is now 2.2 days, and the average is 2.4 days. She also said that the HSE is examining different tests for children, including saliva tests, to make it less unpleasant.

With schools reopening, the committee heard from Chief Clinical Officer, Dr Colm Henry that while there will inevitably be cases in schools, the current evidence shows that child-to-child transmission in schools is uncommon. He also said that in households, the risk of a child being a primary source of transmission is believed to be low.

Minister for Health Stephen Donnelly told the committee that Ireland is at a tipping point and may have to go into lock down again if a second wave emerges. Currently targeted measures such as the recent restrictions in counties Kildare, Laois and Offaly have been successful in quelling outbreaks. He said if public health advice is followed the virus can be suppressed and schools and businesses can remain open. However, if that is not the case and a second wave does emerge, the Minister said, ‘the Government will have to consider the blunt instrument which we know works, that is, a lockdown. We are doing everything we can to avoid that’.

Update 21 August 2020: Senior minister resigns after breaching public health guidance

On 21 August, Dara Calleary stepped down as the Minister for Agriculture when a newspaper story revealed that he had attended an event organised by the parliamentary golf society on 19 August which had over 80 people in attendance. As a member of cabinet, Dara Calleary was part of a unanimous government decision with effect of 18 August that no more than six people should gather indoors. Speaking after the resignation, Taoiseach Micheál Martin said Mr Calleary’s attendance at the event was ‘a catastrophic error of judgement on his part’ (https://www.irishtimes.com/news/politics/dara-calleary-taoiseach-was-angry-and-disappointed-with-me-1.4335705). The future of Ireland’s EU Commissioner, Phil Hogan and a senior judge, Seamus Wolfe, who also attended the event was being called into question, as they are being asked to ‘consider their position’.

The controversy puts the government in a difficult position as it came at the end of a long week with increasing concerns about the incoherence of messaging and contradictions between words and actions in relation to COVID-19 measures and the stability of the government.

Update 14 July 2020: Publication of the Interim Report from the COVID-19 Nursing Homes Expert Panel

The COVID-19 Nursing Homes Expert Panel Interim report was published on the 14 July 2020. Following a recommendation of the National Public Health Emergency Team on 14 May 2020, an Expert Panel on Nursing Homes was established to examine the complex issues surrounding the management of COVID-19 among this particularly vulnerable cohort.

The purpose of the Panel is to examine the national and international responses to the COVID-19 crisis, and to examine the emerging best practice. COVID-19 is a new disease, which can present atypically in the frail elderly, and new evidence and best practice in its management are constantly emerging. The Panel has under taken a range of actions, these are
  1. Stakeholder engagement and consultation – this includes a
   a. Public Consultation/Open call for Submissions;
   b. Request for Written Submissions – In addition to the open call for submissions that Expert Panel wrote to over 30 identified organisations and individuals inviting them to make a written a submission for the consideration of the Panel. The Panel, facilitated by the Health Information and Quality Authority (HIQA), also wrote to all (584) designated centres for older people (nursing homes) inviting their input through the written submission process;
   c. Meetings with organisations - As well as the open call and the invitations to organisations for written submissions, the Panel has established an intensive programme of engagement with key national stakeholders through a programme of virtual meetings;
   d. Direct engagements with Nursing Homes including residents. This includes meet with a small number of nursing homes. The Panel is particularly keen to engage with and hear from those who: have been managing the response to COVID-19 on the nursing homes frontline; have been providing care in nursing homes throughout the pandemic; and, most importantly, nursing home residents with lived experience of the impact of the pandemic for them. The voices, experience and learnings from these vital stakeholders will provide a key input to the Panel’s deliberations.

Update 3 July 2020: Continuity of COVID-19 governance as new Irish cabinet committee reviews progress on Ireland’s Covid-19 response and new leadership in the Department of Health

The new Irish Taoiseach Micheál Martin chaired the first meeting of the new Government’s Cabinet Committee on Ireland’s Covid-19 response on 3 July 2020. The Cabinet Committee was re-established by the new Government on the same basis as the outgoing Government to ensure continuity with the Government’s response to the global pandemic. Ministers received briefings from senior officials from relevant Government Departments, including the acting Chief Medical Officer, Dr Ronan Glynn (https://merrionstreet.ie/en/News-Room/News/Cabinet_Committee_Reviews_Progress_on_Ireland%E2%80%99s_Covid-19_Response.html).

The main item on the agenda for the Cabinet Committee was international travel. Recommendations were referred for discussion and decision by the Government at the cabinet meeting on Monday 6 July 2020.

In the last two weeks, there is new leadership in the Department of Health, with a new health minister Stephen Donnelly, a new acting Secretary General Colm O’Reardon and new acting Chief Medical Officer, Dr Ronan Glynn.

Update 18 June 2020: A significant change in the model of care for older people needed

On 18 June 2020, the chief executive of the Health Service Executive (HSE) Paul Reid appeared before the Special Committee on Covid-19 Response in the Irish parliament to discuss the situation in the nursing home sector and the measures in place to ensure the safety of their residents (https://www.oireachtas.ie/en/debates/debate/special_committee_on_covid-19_response/2020-06-18/4/). 

Speaking in his opening statement, Paul Reid argued that “very significant changes in relation to the models of care” are necessary to provide services for Ireland’s older population (https://www.irishtimes.com/news/health/coronavirus/elderly-care-will-require-significant-changes-to-manage-covid-19-1.4281816). This will require a “concerted effort across policy makers, regulators, providers and clinical experts to achieve a safe and sustainable model of care into the future”.

Paul Reid outlined a comprehensive response of his organisation to covid-19 outbreak in the nursing homes including: setting up Area Crisis Management Teams and Covid Response Teams to implement and manage pandemic response locally, providing additional staffing, setting up a national PPE distribution system and issuing regular public health guidance and expertise. All of the above have been provided to public, private and voluntary providers. He also emphasised the unprecedented level of collaboration between the HSE, the Department of Health, an independent regulator Health Information and Quality Authority (HIQA) and Nursing Homes Ireland representing private and voluntary providers.

The chief executive argued that in order to prepare for further outbreaks, both covid-19 and of other infectious diseases, the overall governance for Private Nursing Homes needs to be reviewed and the support structures for nursing home sector, i.e. Covid Response Teams, need to be developed further. There is also a need for improved funding model for long term residential care in Ireland and for considering alternatives to such care.

The number of deaths in nursing homes in Ireland was assessed at the “upper end” compared to other countries by WHO’s envoy Dr David Navarro speaking in the Irish parliament on 11 June the previous week (https://www.irishtimes.com/news/health/irish-nursing-home-deaths-due-to-covid-19-at-upper-end-compared-to-other-countries-1.4276462). However, he acknowledged that “Ireland has probably got the widest circle of inclusion” when it came to counting cases which partly accounted for its relatively high rates of deaths in nursing homes.

In Ireland there is a National Public Health Emergency Team (NPHET) which is chaired by the Chief Medical Officer, Dr Tony Holohan, in the Department of Health. It started meeting in late January in response to the spread of coronavirus in China. The NPHET works closely with the HSE National Crisis Management Team which leads and manages the HSE’s response.

The governance structure of the Irish government’s response to COVID-19 response is detailed on page 8 of the COVID-19 Action Plan. 

An Ethical Framework for Decision-Making in a Pandemic was published on 29th March 2020. It was developed by a multidisciplinary group and published by the Department of Health. Seven ethical principles to apply in decision-making during a pandemic are listed and described. The weight given to different principles may vary at different stages of the pandemic. The principles are minimising harm, proportionality, solidarity, fairness, duty to provide care, reciprocity and privacy.

Ethical principles apply to the decisions that are made, whereas procedural values relate to the manner in which those decisions are made. This high-level framework is intended for policymakers and healthcare planners and providers in acute and community settings. It is also designed to assist clinicians in implementing the ethical principles outlined below in their clinical practice. It is not designed to guide individual clinical decisions but to assist healthcare workers in thinking through the difficult decisions that will need to be made.

A meeting of the NPHET on 27th January set the terms of reference for a coronavirus specific NPHET. This confirmed the role of NPHET as ‘the mechanism for overseeing the health sector response to significant health-based emergencies. It facilitates the sharing of information between the Department and its agencies and provides a forum for agreement as to strategic approaches to such emergencies’. Issues discussed included the international epidemiology of the disease, the preparedness of the public health system, the levels of Personal Protective Equipment and potential communication channels including issuing of posters to schools and health facilities.

A Stakeholder Forum chaired by the Department of the Taoiseach was established in late February. This is an authoritative platform to disseminate important public health information and support public health measures; as well as to inform Government on emerging downstream social and economic impacts of Covid-19 in Ireland. The Stakeholder Forum comprises bodies from a wide variety of sectors (business, education, health, childcare and social services, sport, tourism etc.) with membership currently at 120 organisations. This Stakeholder Forum met on three occasions in early March.

In addition, a Coronavirus Expert Advisory Group was established, which first met on 04/02/2020. This is a sub-group of the National Public Health Emergency Team. The Expert Advisory Group, chaired by Dr Cillian de Gascun, Laboratory Director at the National Virus Reference Laboratory (NVRL) is a multidisciplinary group with experts from all relevant specialities. The role of the Expert Advisory Group is ‘to monitor and review national and international research and developments in relation to Coronavirus and provide expert advice to the National Public Health Emergency Team, the Health Service Executive and others, as appropriate.’

At the NPHET meeting of 03/03/2020, ‘the establishment of several subgroups to support the work of NPHET was discussed. The subgroups will be chaired by DOH and provide oversight to the co-ordinated response. They will require cross agency membership. Four initial subgroups have been identified as:
  • Vulnerable Group
  • Acute Hospitals Preparedness
  • Medicines and Medical Devices
  • Healthcare Workers and Staff.

In February, a Cross Government Coordination Communications Group was established, chaired by Department of Health, which met for the first time the week of 18/2/20202. There is also a Government Task Force on Emergency Planning and a dedicated Cabinet Committee was established, which meets regularly and is supported by a Senior Officials Group (SOG).

On 16 March, the Cabinet Committee on COVID-19 approved a National Action Plan. The plan was prepared following involvements from all departments and key agencies. Its main aims are to:
  • minimise the risk of people becoming unwell
  • minimise the health, wellbeing and social impact for people who may be at greater risk
  • reduce the economic and social disruption associated with the COVID-19 outbreak

The plan includes information on:
  • what we know about the COVID-19 virus
  • what the public can do to reduce the threat
  • the public health led approach being taken
  • supports for businesses and those who have lost their jobs
  • supports for vulnerable people in society
  • measures to ensure continuity of essential services
  • measures to protect vital supply chains

The plan outlines how the Health Service Executive (HSE) is implementing a wide range of measures that are unprecedented in their scale and speed in order to face the enormous challenges that COVID-19 will pose in the coming weeks. The plan will continue to evolve as the situation evolves.

Implementation is overseen by the Cabinet Committee, which is supported by a Senior Officials Group, and continues to act on the advice of the Chief Medical Officer and the National Public Health Emergency Team: https://www.emergencyplanning.ie/en  

The NPHET met on 23 and 24 March to review Ireland’s response to COVID-19 preparedness. The following recommendations were made by the National Public Health Emergency Team and adopted by Government:
  • Ireland has adopted the World Health Organisation case definition for COVID-19; A patient with fever and at least one sign of respiratory disease e.g. cough, shortness of breath
  • individuals should work from home unless attendance at the workplace is absolutely essential
  • non-essential retail outlets are to close to members of the public. Essential retail outlets are to implement strict physical distancing measures
  • all sporting events are cancelled, including those behind closed doors
  • all playgrounds and holiday or caravan parks are closed
  • all organised social indoor or outdoor events of any size are not to take place
  • all cafes and restaurants are to operate on a take-away or delivery basis. Strict physical distancing measures apply to queuing for this service
  • people should not use public transport unless it is absolutely necessary.

On 28 April, the Department of Health published details on the governance structure of the National Public Health Emergency Team after concerns expressed by opposition politicians in relation to transparency. The document confirms that the NPHET gives expert advice and guidance to the Government on the overall response to Covid-19 (https://www.gov.ie/en/publication/de1c30-national-public-health-emergency-team-nphet-for-covid-19-governance-/). It’s meetings take place in private and there have been no minutes published since March. CMO Dr Tony Holohan said this was purely a workload issue.

The document says the group was established on 27 January to provide national direction, guidance, support and expert advice on the development and implementation of a strategy to contain Covid-19. It says that after each of its meetings its recommendations are communicated by letter to the Minister for Health and the Health Service Executive's Chief Executive. These recommendations are to assist the Government in informing its decisions in responding to the public health emergency. The document said that NPHET is "committed to transparency" in how it does its work. It added that actions and recommendations from its meetings were communicated publicly and were announced through daily press releases and media briefings.

The group is made up of a series of subgroups covering acute hospitals, medicines, vulnerable people, workforce, health legislation, ethics, modelling, behavioural change, and guidance and evidence.

On 5 May 2020, A meeting of the Dáil’s (lower house) Business Committee agreed in the absence of government formation and the establishment of Oireachtas committees, that a temporary COVID-19 Committee would be established to increase parliamentary oversight and accountability. The Committee which will have 19 members (four from each of the three biggest parties and one for each other party/group). It will meet in the Dáil chamber in order to comply with social distancing requirements.

The Committee also agreed the resumption of written Parliamentary Questions with effect from the week of 11 May.  Questions to the Minister for Health will be limited to three per member in view of the exceptional workload of the Department at the moment (https://www.oireachtas.ie/en/press-centre/press-releases/20200505-dail-business-committee-agrees-establishment-of-special-covid-19-committee-and-resumption-of-most-written-parliamentary-questions/).

19 May 2020: First hearing of COVID-19 Dáil (parliamentary committee)

The Secretary General of the Department of Health and the Chief Medical Officer, Dr Tony Holohan appeared before the first session of Ireland’s Dáil (parliamentary committee) on COVID-19.
Speaking in his opening statement at the committee, Jim Breslin said ‘decisions are being made in real time. The threat from the virus will be a reality for the foreseeable future and we must all protect the space for inquiry and learning’ (https://www.kildarestreet.com/committees/?id=2020-05-19a.39).

In relation to carrying out non-COVID work, Mr Breslin said ‘we can now do non-COVID work, we are ramping up and planning how we do that, it will take longer… it will cost more and there is a good chance we will end up doing less over this period. The way to try and buffer that is through the innovation that we have introduced through the use of technology, telehealth and so on but we will be in a very challenged healthcare environment for the foreseeable future’ 
Many issues which came up repeatedly at the committee were nursing homes, private hospitals, transparency and direct provision centres.

21 May 2020:  Expert panel on nursing homes announced

Speaking in the Dail (parliament) on 21 May, health minister Simon Harris announced the establishment of a nursing-home expert panel (https://www.rte.ie/news/post/103413313/). The four-member panel will be chaired by a public health expert and also include a geriatrician, senior nurse and public interest representative.

Minister Harris told the Dáil there had been ‘particular focus on the challenges in the nursing home sector and it remains an absolute priority for me. He added that it is a “crucial aspect of good planning” in navigating the coronavirus landscape to “ensure the best possible safeguards are in place to protect the many people who call nursing homes their home”.

Figures reported on 6 May found that over half of all covid death have been in nursing homes. there have been 857 COVID-19-related deaths in community residential settings (62.3% of all COVID-19-related deaths), 740 of which were in nursing homes (53.8% of all COVID-19-related deaths)
(https://www.gov.ie/en/publication/20f2e0-updates-on-covid-19-coronavirus-since-january-2020/).

On 26 May 2020, representatives from the private nursing home sector, the HSE and the independent regulator HIQA appeared before the Oireachtas COVID-19 Committee where its focus was on nursing homes (https://data.oireachtas.ie/ie/oireachtas/debateRecord/special_committee_on_covid-19_response/2020-05-26/debate/[email protected]/main.pdf). HIQA warned the Department of Health of more than 200 ‘high risk nursing homes before there was a surge in outbreaks at care facilities as a result of Covid-19.

Light touch regulation, the privatisation of the nursing home sector and fragmented care between public and private providers were all raised as issues at the committee. The HSE spoke about the ‘unprecedented level of support’ it has provided to nursing homes, while politicians criticised NPHET for not mentioning nursing homes until the 11th meeting of NPHET. The Chief Medical Officer defended NPHET on 28 May saying a specific sub group on vulnerable groups dealt with nursing homes. The minutes of the sub groups are not available and said that previous NPHET meetings dealt with the issue but may have used the term long-term residential care rather than nursing home care specifically.

In the Irish Times on 28 May 2020, figures from an unpublished report from the HSE were published revealing a breakdown of 1,030 deaths in 167 facilities caring for older people across the country, including community hospitals, long-stay units, residential institutions and nursing homes. They identify ten nursing homes where 240 deaths occurred, many of which were not previously in the public domain (https://www.irishtimes.com/news/ireland/irish-news/the-human-cost-of-covid-19-ireland-s-care-homes-with-the-most-deaths-revealed-1.4264170?mode=print&ot=example.AjaxPageLayout.ot).

The Department of Health published a NPHET paper on Overview of the Health System Response to date Long-term residential healthcare settings. Hundreds of pages of correspondence between Nursing Homes Ireland the Department of Health were published on the Department of Health website in response to questions at the Oireachtas Special Committee on COVID-19 Response on 25 May 2020 (https://www.gov.ie/en/publication/656cf-department-correspondence-with-nursing-homes-ireland-january-may-2020/). The records outline the engagement between the department and Nursing Homes Ireland during the COVID-19 pandemic. Engagements remain ongoing.

27 May 2020: An up to date list of the Membership of NPHET was given to the Dail. This includes 31 multidisciplinary and multi-sectoral members on the NPHET (https://www.kildarestreet.com/wrans/?id=2020-05-20a.1810&s=universal+healthcare#g1812.r).

Key sources:

Government of Ireland. Statement from the National Public Health Emergency Team – First meeting of the Expert Advisory Group takes place. Press release: https://www.gov.ie/en/press-release/eca0a9-statement-from-the-national-public-health-emergency-team-first-meeti/ 

Government of Ireland. COVID-19 Action plan for Ireland: https://www.gov.ie/en/publication/47b727-government-publishes-national-action-plan-on-covid-19/

Government of Ireland. Ethical Framework for Decision-making in a Pandemic: https://www.gov.ie/en/publication/a02c5a-what-is-happening/#ethical-framework-for-decision-making-in-a-pandemic

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/