With a public inquiry into the UK’s response to Covid-19 expected to start soon, questions are being asked about how Ireland will review its handling of the pandemic. David Lynch reports
How do you review a country’s response to a pandemic when it is still ongoing? Two years into the Covid-19 crisis and this question is beginning to be posed in countries across the globe.
Covid remains a public health emergency of international concern as defined by the World Health Organisation (WHO), and most medical and scientific experts nationally and internationally agree that the pandemic is certainly not over.
This has not stopped a significant increase in political discussion regarding the need to review countries’ responses to the challenge posed by the virus.
In Canada, there have been recent calls for a public inquiry into the matter, while since the beginning of the year a growing number of Australian politicians have been seeking a royal commission or other type of inquiry regarding Covid-19.
In the UK, the situation is more concrete. A public inquiry into its response to the pandemic is due to begin in spring and a chairperson has been named and appointed. The Guardian has already predicted the UK inquiry is “likely to be one of the most complex undertaken in legal history”.
These developments and debates find echoes here in Ireland, certainly in political circles. Last month, Sinn Féin President Mary Lou McDonald told RTÉ radio that the country’s response to Covid-19 should be the subject of a public inquiry.
The Sinn Féin President said her party wanted “a time-bound” public inquiry “and it has to look at all of the areas”.
“An area of particular concern is the experience in nursing homes in the first wave of this public health emergency, but there are other issues that need to be investigated, some of them very serious let-downs and flaws within the management of this public health emergency.” Deputy McDonald also noted that aspects of the State’s response had been carried out “efficiently and effectively”.
According to news reports, the idea of a proposed expert panel to review the country’s response has been discussed by Government. Last month, Taoiseach Micheál Martin told RTÉ radio that it was intended to have a public review of the country’s pandemic response, but he preferred to call it an “evaluation”. He also raised concerns about a review during a period when the pandemic was not yet over.
In late 2020 the Oireachtas special committee on Covid-19 response published a report (see panel), but no major review has taken place. To date, no detail on what type of review the Government proposes, or when it is expected to take place, has been announced.
Last month, the Minister for Health Stephen Donnelly announced the formation of the new public health reform expert advisory group. He pointed out that the group will be looking at aspects of the public health response to the pandemic. Minister Donnelly said that “while Ireland continues to respond to the ongoing challenges of the Covid-19 pandemic, it is important to learn lessons both from the Irish and international public health response to Covid-19”.
However, this group will not be conducting a full review, this newspaper has been told.
The group “will not be looking at the entire response of the health service to the pandemic”, a Department of Health spokesperson told the Medical Independent (MI).
The Department said the group’s “focus will be more specific”, initially looking at what can be learned from the public health components of the response to the Covid-19 pandemic “with a view towards strengthening health protection generally and future public health pandemic preparedness specifically”.
Chaired by Prof Hugh Brady, President-designate of Imperial College London, the group will produce a final report, which is expected to be submitted to Minister Donnelly by mid-2022. The spokesperson added that the group will “also identify lessons from international best practice regarding reform and strengthening of other core public health functions, including the promotion of health and wellbeing, population health research and health intelligence, and health service improvement”.
Then what of a full review? Questions remain about what form it should take, and whether it is too early for such an exercise, as high numbers of Covid-19 cases continue to be reported and the course of future variants is unclear.
It may not serve the greater good if it has largely political goals, is a box-ticking exercise, or aims to put blame on organisations or individuals
The work of specialists in public medicine during the pandemic has been fundamental to the health service response since early 2020. Therefore, they have a particular interest in any future review process.
The Irish Society of Specialists in Public Health Medicine (ISSPHM) was formally
launched towards the end of last year. As reported earlier this month in MI, the Society’s first position paper, titled For better pandemic control now and into the future, made four recommendations to apply the “lessons learned from our collective experiences with Covid-19”.
One of the recommendations was for a review specifically on “the governance structures for public health”, incorporating all health protection functions from surveillance to case and outbreak management, source identification, and contact tracing, as well as health improvement, health service improvement, and health intelligence.
However, on the prospect of a wider review of the State’s response to the Covid-19 crisis, the Society has some words of advice.
“It may not serve the greater good if it has largely political goals, is a box-ticking exercise, or aims to put blame on organisations or individuals,” an ISSPHM spokesperson told MI.
“It needs to be about learning lessons and identifying issues and to clearly state recommendations to address those issues as soon as possible.”
In regard to the structure of any such review, the ISSPHM spokesperson said that “a senior official” needs to be identified “who will be held accountable for the implementation of the recommendations, with deadlines”.
“This official needs to have the power to ensure that adequate resources are mobilised to implement all recommendations.”
Pointing to the ISSPHM’s recent position paper, the spokesperson said it “outlines the main strengths and weaknesses of our response” and highlights “key and urgent recommendations on how to improve our pandemic responsiveness going forward”.
“It is therefore important not to have further reviews that take a long time to implement, finalise, and act on, and that may delay the urgent implementation of these recommendations.”
In general, the spokesperson said there “is much to learn” from the collective experience of managing the Covid-19 pandemic.
“It was our collective failure to apply many of the lessons from past public health emergencies that left us so vulnerable, with resultant loss of lives and livelihoods.”
Healthcare professionals’ input
Hospital doctors have been dealing with the clinical impact of Covid-19 in emergency departments, wards, and ICUs, and also with the resulting hit on elective care.
The IHCA told MI it believed that a review of the health services response to the pandemic was “critical”, but the Association noted that its terms of reference would also need to examine the circumstances of the health service at the onset of the crisis.
A spokesperson said the input of all healthcare professionals would be important to prevent any such review from being “yet another administrative exercise”.
While the pandemic “has been unprecedented in many ways… the reality is our health services were under pressure long before Covid-19”, they added. The health services were “not resourced effectively to withstand such a shockwave”, particularly hospitals.
“So a review of Ireland’s response to the pandemic, especially in terms of how hospital services were impacted, is critical to understanding how we can mitigate and future-proof against this reoccurring again as much as possible,” the spokesperson said.
“A key learning must be to ensure greater capacity in our health service by hiring the required number of consultants and investing the necessary beds and other facilities needed to provide and maintain continuity of care in future.” The spokesperson pointed to the impact on patients two years into the pandemic: “We now have some 880,000 people on a list waiting to see a consultant or receive treatment. We cannot allow this situation to continue.”
In regard to the nature of any upcoming review, the IHCA said that it should “include consultation with and input from” all healthcare professionals, “particularly hospital consultants who have been at the helm of clinical leadership on the frontline throughout the pandemic.”
“Without a clear and lived perspective from those on-the-ground delivering the service, such a review risks being yet another administrative exercise that does not translate into practical and workable solutions to address some of the core issues in our health service,” the spokesperson warned.
This newspaper also contacted the IMO and a number of postgraduate colleges on what those organisations would like to see within any future review. Responses were awaited at press time.
The HSE informed MI that a “critical after-action review” of its response to the pandemic would be “important”. However, considering the continued impact of Covid-19 on services, such a “structured” review would be “premature at this point”, according to its spokesperson.
The Executive said it “continually reviews” all aspects of its services to respond and “adapt to changing pressures from day-to-day” and these ongoing reviews take place through the HSE governance pathways.
The spokesperson told MI that “although wider society has moved towards normalisation the HSE is still under intense pressure managing day-to-day Covid-19-related pressures as well as other demands”.
“With this in mind, the HSE has not at this point planned an after-action review of its response to the pandemic. The value of this, however, is well understood.”
The spokesperson said that “in the meantime” the HSE had “undertaken reviews in areas such as testing and tracing, public health, and other Covid-19 measures”.
The Executive is “considering which elements of change introduced in response to the pandemic” may need to be “retained long-term” to improve services.
“The HSE considers that a critical after-action review of its response to the pandemic will be important to inform planning for future emergencies. While defining the ‘end’ of the pandemic is difficult at this time, it’s clear from a clinical and operational perspective that Covid-19-related demands for the HSE remain intense at present and are in the context of high overall demand for our services.”
The Department of Health told this newspaper that the Government “has always said that reviews of the response to the pandemic are very important”.
“There has been a clear national commitment to continue to learn from the pandemic as the national and international understanding of the virus evolves, and where necessary to ensure that the public health-led approach evolves, as evidence and learning materialises,” the Department spokesperson told MI.
The spokesperson added that, during the pandemic, Government established the nursing home expert panel, which has examined and advises on the Covid-19 response on an ongoing basis .
“We have to make sure that with any future pandemic, people work flexibly and fast. As the WHO’s Dr Mike Ryan said, ‘speed trumps perfection’.”
Committees… reviews… reports
Although no major, wide-scale review of Ireland’s handling of the pandemic has taken place, a number of committees, reports, and reviews have looked at aspects of the response of the health service over the last two years.
On 19 August 2020, the Covid-19 nursing homes expert panel report was published. The report contains a range of recommendations in line with lessons learned to date and international best practice “aimed to safeguard the residents in nursing homes over the next 12-to-18 months and into the longer term”.
In October 2020 the Oireachtas special committee on Covid-19 response published a report that found a public inquiry should “be established to investigate and report on all circumstances relating to each individual death from Covid-19 in nursing homes”.
As recently as earlier this month, Fine Gael TD Fergus O’Dowd urged the Government to establish a full inquiry into the care of older people in nursing homes during the pandemic.
In response to Deputy O’Dowd’s call, Minister of State for Mental Health and Older People Mary Butler said: “It must be recognised that the pandemic has not concluded and at this time a priority focus of Government remains on the ongoing management of the Covid-19 response….”
In terms of any future reviews, she said the “Government is continuing to look at options which may be available to the State in relation to listening to the voices of those who have lost a loved one”.
“I have had ongoing engagement including a number of meetings with family members to listen to and consider their experiences and have communicated and shared their views with relevant agencies.”
As well as an inquiry into nursing homes, the cross-party Oireachtas special committee on Covid-19 response also called for a review of the impact of privatisation in Ireland’s nursing home sector. The committee’s report further highlighted the need for investigation into the meat processing industry, following a series of Covid outbreaks in those settings in 2020.
During September and October last year, an “intra-action review” under the World Health Organisation (WHO) International Health Regulations 2005 monitoring and evaluation framework was conducted into Ireland’s health service. As yet no report from this review has been published on the WHO website.
The new public health reform expert advisory group has been charged with looking at public health components of the response to the pandemic, with a report expected to be made available to the Minister for Health later this year.
In late 2020, the Minister also established the regional health areas advisory group in part to replace the former Sláintecare implementation advisory council.
The “core term of reference” of this advisory group “is to provide guidance, support, and advice on the design of a regional health area implementation plan to Department of Health and HSE officials charged with delivering this reform”, a Department spokesperson told the Medical Independent.
However, the spokesperson also noted that the “Covid-19 response will be considered as part of this”.
- 136 out of 485 consultant psychiatry posts are unfilled or are filled on a temporary locum basis, the IMO recently told the Oireachtas sub-committee on mental health.
- 33.5 inpatient psychiatric beds per 100,000 population are in place, which is less than half the EU average of 68 inpatient psychiatric beds per 100,000 population, according to the IMO.
- 1 -in-five (19 per cent) directors of nursing in Irish residential care homes are actively planning to leave their posts, according to a new study from Trinity College Dublin.
- 28 per cent have considered leaving after the stress of the pandemic.
- 893,000 people are on some form of National Treatment Purchase Fund waiting list, including almost 98,000 children.
- 380 patients in hospitals were awaiting a hospital bed on the morning of 10 February, according to a HSE statement on the impact of ‘winter pressures’ on the health service.