Discharging patients from acute hospitals into community settings contributed to a surge in Covid-19 cases in nursing homes, the head of NHI tells Catherine Shanahan
Tadhg Daly’s father suffered a massive heart attack and died when his son was just six, forcing his mother into a bread-winning role.
The chief executive of Nursing Homes Ireland (NHI) attributes his strong work ethic to the example set by his mother Margaret, now 89.
“My mother was a huge influence on my life. She was a very hard worker and kept the show on the road after my father, Teddy, died in 1972, I was very young, just six years old, and I had two sisters, both of whom trained as nurses.
“One just retired, having worked in Cork University Hospital and the Mercy, the other is working in Melbourne, Australia. We are a very close family.
“My mother went back to work after my father died, as a commercial representative. She worked hard all of her life. She’s 89 this year, and still living at home,” he says.
The family home is Drimoleague in West Cork. Ballincollig is where Mr Daly, 54, now lives.
He went to school in Skibbereen and on to the ‘RTC’ (Cork Regional Technical College) in Bishopstown, Cork city, where he studied business and accounting. It’s where he got a taste for politics and advocacy.
“I spent a year as president of the students’ union in RTC and as student president, I would have been on the board of management of the college at the time. I was quite young, so it was interesting sitting around with the board,” he says.
The Union of Students of Ireland (USI) was the next port of call. He served as its full-time president for two years, during which time he was based in Dublin.
“Mary O’Rourke was minister for education at the time. It was an era of educational cuts and the unemployment rate was high, so we would have been quite active and it was a time of good engagement with the minister.
“It gave me a taste for dealing with public affairs and the whole political system,” Mr Daly says.
“Also as president of the USI, I would have been on the board of USIT, the student travel company, and that was a big commercial organisation at the time. J1 visas were on the go, so I got a lot of good experience as the student representative on the board.”
After his stint as USI president (1988 and ’89), he returned to RTC to finish his studies. It is where he met his wife Maura, whom he married in 1994, and with whom he has two daughters, Bronagh, 20, and Muireann, 15.
Studies completed, his next job was with the Irish Society for the Prevention of Cruelty to Children (ISPCC), from 1991 to 2005.
“I was working in fundraising and development, but again, advocacy would have been a huge part of my role, eg visiting schools, telling them about Childline and all that, so very happy memories of that time.”
In 2005, he joined the Irish Nursing Homes Organisation (INHO). At the time, there were four organisations representing the nursing home sector, but in 2008, they amalgamated into one — Nursing Homes Ireland (NHI), with Mr Daly as CEO.
Fifteen years later, NHI has almost 400 members out of 440 private and voluntary nursing homes across the country.
“It’s always been a busy role, but nothing compared to what it’s like now, with the pandemic. It’s night and day to be honest, seven days of the week, sometimes 12 or 15-hour days.
“Yes, it’s crazy, but I love what I do and I’m very proud of the role nursing homes play generally, but particularly in this current crisis.
“I probably met Simon Harris [health minister] twice a year in a normal year. I met him three times in the last 10 days,” he says.
Up to now, the most seismic changes in nursing home care related to regulation — the setting-up of health watchdog Hiqa, which inspects residential care centres and the introduction of Fair Deal, the nursing home support scheme, both of which commenced in 2009.
“There was no resistance to Hiqa — the nursing home sector was always pushing for higher standards,” Mr Daly says.
“But one of our biggest bugbears — and it’s still here today — is what I would say is probably the lack of respect for the sector and what we do.
“We have 25,000 beds, we are home-from-home for 25,000 people, with probably 32,000 directly employed whole-time equivalents, and the value of the sector and the role it plays is
misunderstood, to say the least.”
So where is that lack of respect coming from?
It’s evident in the way the acute sector gets priority, as per the current crisis, he says.
“There’s a sense that it’s about the health service, when it should be about health and social care.”
Mr Daly says this prioritisation of acute hospitals is reflected in the early decision to discharge large numbers of patients into the community, in anticipation of the potential chaos the virus could cause if hospitals became overwhelmed.
“When we look back, there will be learnings for all of us. But the fact that large numbers were discharged from the acute hospitals to prepare for surges — that in my mind has contributed to the surge of the virus in nursing homes,” says Mr Daly.
“Because a lot of those patients were discharged as residents of nursing homes and we would have raised that issue at the outset in terms of testing.
“We were saying they needed to be tested and they needed two clear swabs and I don’t believe that was done in every case.”
Check the metrics
Mr Daly acknowledges that there has been a significant number of clusters in nursing homes but says people may not realise that a home can have a “cluster” without the majority of its residents being affected.
“The HSE metric for a cluster is two residents or more [with Covid-19]. You could have a 50-bed nursing home with two positive residents. You can contain that with the right supports. And getting the right supports is the challenge.
“And the other thing people should be aware of is that while there have been deaths, there have also been residents who made a good recovery,” Mr Daly says.
He says private nursing homes are by and large better equipped to deal with Covid-19 than State residential homes because most have single ensuite rooms.
Mr Daly points out that while private and voluntary homes were obliged to meet Hiqa standards by 2015, HSE-run homes were given a six-year derogation in 2016 by the Government. At a health briefing yesterday, HSE chief Paul Reid said about two thirds of nursing home outbreaks were in the private sector.
Mr Daly says despite the challenges faced by nursing homes, where the biggest concerns raised by members relate to staffing, testing, and shortage of personal protective equipment, the HSE has been slow to react.
For instance it was only last week, (April 15) that the HSE sent out a memo advising that nursing homes should be prioritised for new staff hires.
The memo, from Anne Marie Hoey, HSE national director of human resources says: “I would advise you… to consider as a priority, not removing successful applicants from areas that are under particular pressure, most notably in the private nursing home sector.”
Mr Daly says the memo only went out “six weeks into the crisis”.
He is also unhappy at the level of PPE available to members, and references another HSE memo sent to Midlands community services on April 15.
“The PPE provided should only be used for confirmed positive/suspect client cases and not for normal use within the services,” it said.
Mr Daly said rationing PPE “goes against what we are trying to do” in terms of trying to prevent further clusters, especially as many patients are asymptomatic.
Equally, he has concerns about delays in getting the results of tests in for staff and residents in nursing homes. While acute hospitals were getting results in one to two days, “in some cases, we are looking at over the incubation period of 14 days”.
“I don’t want to be overly critical, but in effect there’s lots of commitments being made and I don’t doubt the willingness to work with us on this one, but members are frustrated by, I suppose, what they see as the lack of prioritisation of the nursing home sector at the outset, and now they are saying to me that what’s being promised isn’t always delivered on.”
Annoyance at chief medical officer
One of the most frustrating moments in the Covid-19 nursing home saga was the lack of support they initially received at Government level when they introduced visitor restrictions in the first week of March.
On January 30, NHI issued guidance to its members, alerting them to Covid-19. In late February, it wrote to the Department of Health just as the first case was confirmed in Ireland.
“It was essentially ‘guys we need to be ready here’. At that stage, I had shared an international paper that I had come across and said we should look at dedicated advice for the community care/nursing home sector, given the vulnerability of the population.”
With the department still focused on the acute sector, NHI consulted members and took the decision to restrict visits.
Mr Daly announced the decision on RTÉ radio on Friday, March 6.
“The reason we did it on a Friday is we were conscious of the fact that we were coming into a weekend where you would potentially have large numbers of people visiting nursing homes, and looking back, it was always the right decision.
“The level of community transmission was probably much higher in January and February than we will ever know, so I think it was very important that we moved when we did.
“It was a max of one visitor per resident, although it was reported as a ‘ban’, with exceptions around end-of-life care,” he says. “Our members took the decision with a heavy heart because we all understand the need for socialisation.”
A few days later, Tony Holohan, chief medical officer, described the restrictions as “unnecessary”.
How did Mr Daly feel?
“I don’t want to get into a public spat with the National Public Health Emergency Team (NPHET) or Tony Holohan, but we had a huge amount of calls from the general public, asking ‘What have you done?’
“I’m on the record as saying we were surprised by his comments. The members fully supported the decision, which for me was important, but also reflected that we had our finger on the pulse.”
Did Mr Daly tell the department prior to announcing the restrictions?
“I had a conversation with one of the officials in the department on the Friday morning. We felt it was important to inform them of our intention.
“Nobody picked up the phone and said anything to us. It was the following week when Dr Holohan said at a press conference that we had basically moved too early. He also used the word
‘unilateral’ in relation to our decision.”
Was Mr Daly annoyed by that comment?
“Very annoyed. I wasn’t one bit happy. But there was no percentage to be honest in getting involved in a public spat about it, as far as I was concerned. We were fully confident that our decision was the right one then and it’s the right decision now.
“Some people might say we should have done it sooner, but I think the timing was right.”
Mr Daly continues to chase up other concerns: The 5,000 nursing-home residents who are not part of the Fair Deal scheme and who therefore do not qualify for aid under a special financial support package for nursing homes originally announced on April 4 by Government, with details sent out last Friday night.
Mr Daly had spoken with Mr Harris earlier on Friday and says he was given a commitment that there would be further engagement with NHI before details of the scheme were released.
He is unhappy that this commitment was not adhered to.
He is also unhappy that no-one from NHI was invited to be part of a subgroup set up by NPHET, focusing on vulnerable persons during the crisis.
Future of nursing homes
Does Mr Daly worry that the battering nursing homes have taken in the crisis will make people reluctant to see family members go into residential care in the years ahead?
“I wouldn’t think so, no,” he says.
“The feedback we are getting is very positive. I think we have to be realistic here: Nursing homes have a huge role to play and it is the most highly regulated sector in the health service. The acutes are not registered or regulated; our sector is.”
What is the biggest thing he has learned from this crisis? “The lack of preparedness for community care.”
Does that go back to the lack of respect for the sector that he mentioned at the outset?
“I think they are related [lack of respect and lack of preparedness] but they are not the same thing. I think the acutes have a huge role to play but the parity of esteem isn’t there for community care.
“The preparedness for community wasn’t at a level it should have been and I am not saying we [NHI] got everything right by any stretch of the imagination, but sparing our own blushes, we got a hell of a lot of it right.”