Wayne O’Connor
Hiqa chief Phelim Quinn believes that how nursing homes are run is a factor in Covid-19’s spread through the sector, reports
ON the morning Ireland finally got a sense of the havoc Covid-19 is reaping in nursing homes, Hiqa boss Phelim Quinn was sitting at home in Belfast contemplating how powerless we are in the face of this virus.
The sun beamed brightly through a window behind him, but last Thursday was a dark day. “It is a dreadful tragedy that is unfolding. It saddens us. We are an organisation that has had a relationship with this sector over the last 12 years and it is unprecedented. Nobody could have anticipated the sort of numbers we are seeing at the minute.”
The day brought news of multiple deaths in care settings his agency has a mandate to monitor and inspect. There were eight deaths in one home, yet there is still no sense of how bad this crisis is going to get. Quinn couldn’t say then if things were about to get better or worse, but more than 400 people in nursing homes had Covid-19 last week, he added.
The numbers have got worse since. More than 300 Covid-19 deaths in Ireland are linked to residential centres, including nursing homes.
Quinn has some first-hand knowledge of the impact of the virus. His brother, a GP in south Armagh, contracted it three weeks ago and the Hiqa chief executive said he understands the difficulties it poses. For nursing homes, this has been even more acute.
Quinn concedes support for the sector was slow arriving, and efforts will have to “flex up” in the coming weeks. This will also involve assessing homes free of outbreaks to make sure they remain clear.
About one third of nursing homes are infected. Like many, Quinn blames a shortage of personal protective equipment (PPE) and staffing issues brought on by the spread of infection. These have all been the subject of 28 complaints to the watchdog about nursing homes from concerned residents, families and staff, but surely other issues are at play too?
How some nursing homes are run is a factor, and Quinn admits regulations do not go far enough to ensure residential settings can cope with a pandemic of this scale.
“The ability to make and provide a good contingency plan is dependent on the quality of good governance and leadership within the organisation and I think some of these nursing homes function well within normal times. They may not necessarily have the ability to manage or flex up at a time of such crisis. This includes having access to banks of staff or agency staff, making sure they have adequate supplies in because contingency does relate to things like staffing, PPE, oxygen, infection prevention control and training of staff.
“The standards of regulation would never have stretched to the sort of circumstances we are finding ourselves in now. Infection control is certainly something we would look at. Outbreak control or outbreak management is something we would look at, but the speed and volume of infection in this instance far outstripped what would be required as part of the regulations and standards.”
So if the regulations do not sufficiently control a crisis like this one, is he satisfied with the role Hiqa has played since Ireland recorded its first case of Covid-19? Hiqa inspects nursing homes and other care providers, as well as developing standards they must abide by.
“I think from very early on we recognised the potential for this was there. However, that does not deal with the individual tragedies that are occurring in these circumstances. I think Hiqa has been central to ensure there has been a clear spotlight on the sector and how it is managing and coping with this.”
A lack of oxygen has played a role in this crisis, and Quinn admits this impacted patient care, with some residents in nursing homes having to wait longer than would be expected to receive it.
Hiqa has routinely criticised HSE-run public nursing homes. Quinn holds serious concerns about the old-fashioned “dormitory-style accommodation” at some centres where five to six people share rooms. Concerns have been raised in the past about shared bathrooms in some of these facilities and a shortage of handbasins for staff and residents.
“Certainly we would have highlighted them as risky services because of the configuration of the dormitories and bedrooms,” he said.
“Obviously if an infection such as Covid-19 got into one of those facilities we would see rapid spread… but the vast majority of services we have taken issue with are services provided by the HSE and they have performed pretty well in this crisis.”
There have been five complaints to Hiqa about such homes. Most of the concern surrounds private sector homes, which have been the subject of 23 complaints. Many private nursing homes struggled to contain the virus despite most offering private en-suite bedrooms and strict infection control policies.
Quinn believes the pandemic highlighted an urgent need to review how Ireland cares for elderly people. This includes modernising public-sector homes and, most critically, reforming how care is mainly provided by private companies whose only interaction with the State is often a financial transaction to supply a service. Critics often claim this model encourages bargain-hunting and negatively impacts how care is delivered.
“I think the model of care means these services in the main, about 80pc, are provided by private providers. Some of them are very small in nature with a limited number of beds. Some are much larger but, I suppose, they don’t have a relationship with the HSE.
“In other countries they would have a system such as care management, which is localised commissioning. It is system whereby a public health service provider would recognise from a very early stage the increased frailty or social care needs of an individual and put in place a tailored package of care, whether that be home care, right through to long-term residential care. That is where I would like to see us go.”
It is hard to say if the virus would have been challenged better if such a model already existed here. Countries in Scandinavia with greater individualised care packages for elderly people have also been hit badly by Covid-19. Quinn said now is not the time to prioritise reform but it must form part of how we will reflect on how Ireland waged war with Covid-19, and lost crucial battles along the way.
He called for a “rapid review” of long-term residential care after we emerge from Covid-19’s stranglehold.
“It is critical that there is a review of the relationship between that sector and the HSE as the main commissioner of care and services. The HSE, on behalf of the State, is providing significant amounts of care into that sector on an ongoing basis and there needs to be more accountability from a clinical and social care governance perspective.”
This will have come too late for hundreds in the country’s nursing homes.
‘We would have highlighted them as risky services because of the configuration of bedrooms’