Regional Independents submission to terms of reference to COVID evaluation
March 2024
Honesty
The over-arching primary objective of the inquiry should be to prepare for the next pandemic by drawing on the lessons of the last. With the General Election due within the next 12 months, it is imperative that Ireland’s COVID evaluation does not become a finger-pointing exercise, resulting in a less than constructive examination of the country’s pandemic performance. We must keep in mind that during the pandemic Government had to make tough decisions with limited scientific information; decisions which impacted the spread of the virus, the Irish economy and society. It's therefore imperative that the evaluation looks objectively at the outcomes of the decisions that were taken and learn from our mistakes to avoid repeating them. It is therefore vital that this evaluation is thorough, but it shouldn't be about assigning blame. The evaluation should give specific attention to policy decisions and their application regarding nursing homes, the vaccination rollout and mandatory hotel quarantining.
Evidence
We believe that it is important that the evaluation scrutinise the Government's claim of basing its decisions on “the science” and examine the source and quality of that science. While a similar approach was articulated by Governments globally, a 2022 study[1] analysing policy decisions taken during the pandemic showed that political biases influenced health decisions across Europe. This contradicts the stated policy position that decisions focused on evidence rather than political views. This needs to be explored in Irelands review and identify shortcomings in the evidence presented to Government; how the available evidence was utilised in decision-making process and how this can be improved in future. The COVID evaluation must take into consideration the economic and societal factors that influenced the decisions that were taken.
A key question for this evaluation is whether relying on the limited evidence available led to unfair decisions being taken impacting on specific cohorts of our population.
Frontline workers
It is important that the evaluation recognises best practice and in particular the vital role played by key frontline workers throughout the duration of the pandemic. Many of them placed themselves at risk; exposed their families to risks, by going to work every day to keep us safe and to care for those who were seriously ill.
Exiting the pandemic.
The severity and length of the lockdowns in Ireland need to be examined in an international context, particularly considering the guidance from the World Health Organisation that such a policy tool should be used sparingly and only for limited periods of time to build capacity to manage the pandemic.
In our Private Members Motion on mental health[2] during the pandemic the Regional Group sought to address after care issues by proposing the development of a trauma programme. Such a programme should now be developed, with learnings from the COVID pandemic, and be available to deploy as we come out of the next one pandemic or disaster.
The reality is that no matter how prepared we are for the next pandemic there will always be significant amount of trauma experienced, particularly as we outline below by particular sections of society. This needs to be considered as part of the COVID evaluation in terms of what should have been done as Ireland came out of the pandemic, and not solely focus on the period of the pandemic itself.
In that context the following aspects need to be incorporated into the Terms of Reference:
Mental Health
There is now emerging evidence that the COVID pandemic has resulted in increasing pressure on our mental health services and a deterioration in mental wellbeing particularly for younger and older people. While empirical evidence is only now emerging, one recent study analysing antipsychotic drug prescribing, has indicated that the prevalence has increased yearly from 2020-2022[3]. The negative effects of COVID on the nations mental health is compounded by the fact that the services in Ireland were already under severe pressure prior to the pandemic[4]. Not only do we need a detailed evaluation of the mental health impact of COVID to be included in this work programme, but the output must include recommendations on how to address the implications of this deterioration in mental wellbeing.
Children and older people
There is no doubt that the pandemic and the decisions taken in its management had a disproportionate impact on children and older people. It is important that this evaluation does not take too narrow a focus on these implications, not just at the time of restrictions themselves but into the longer-term implications of such restrictions on their health and wellbeing.
For example, research[5] in relation to children's experience of traumatic events indicates long-lasting effects on their psychological well-being. The impact of trauma and chronic stress traumatic events like this pandemic has affected students’ academic, emotional, and behavioural development.
Health service and delayed diagnoses
As a result of the pandemic there were both reduced and delayed presentations of non-COVID illnesses and the impact of these on the population health required further examination[6]. Just one example of this is a comparison for cancers diagnosed in 2020 based on historic trends which has suggested a reduction of 11 %[7] in diagnosis rates. However, a far more detailed analysis across our health service is needed over the full period of pandemic restrictions is required to properly evaluate in the impact of the COVID measures taken by Government. The failure to incorporate this into the Terms of Reference will undermine the validity of the overall evaluation.
Additional module
We firmly believe that the related issues of (i) changes to the rate of Social Welfare disability claims, its impact on the workforce and (ii) long COVID cannot be ignored within the terms of reference of this inquiry. This is a complex area as we set out below and we believe that it requires a separate module based on independently commissioned research.
(i) Disability
UK National Statistics (ONS) has revealed that the number of people inactive for health reasons was 2.8 million at the end of last year which was a rise of over 200,000 in the year and a jump of over 700,000 since the Covid pandemic[8].
In January, US Senator Bernie Sanders held a committee hearing on Long Covid at which Dr Ziyad Al-Aly said "Long Covid has wide and deep ramifications on the labour market and the economy. Some estimates suggest that the toll of Long Covid on the U.S. economy is $3.7 trillion- on par with the 2008 recession... The burden of disease and disability in long COVID is on par with heart disease and cancer.... Even if people managed to emerge unscathed after the first infection, they can get long COVID after reinfection, and this isn't well known."
Looking at high level data here in Ireland based on an Oireachtas Parliamentary Budget Office (PBO) analysis the 2022 data from the Department of Social Protection[9]. The general trends do not indicate a similar trend in Ireland, but the PBO did advise that a more detailed analysis would be required to investigate if a trend similar to that in the UK can be identified.
However, comparing Table F3 from the 2022 report with the same table from the 2019 report[10], specifically looking at Disability Allowance recipients by gender and age cohort, with the caveat of being at a high-level analysis it did show that:
▪ The under 30 y/o cohort has grown since 2019 for both males and females both in terms of recipient numbers but also as a % of all recipients.
▪ Broadly speaking, recipient % in the cohorts 30-54 y/o have declined.
▪ This seems to show increases are concentrated at opposing ends of the age spectrum of Disability Allowance recipients.
▪ Research would be required to uncover what is driving these changes – and whether long-COVID has impacted upon changes in cohort sizes and priority.
The bottom two charts show this somewhat u-shaped pattern, with:
▪ Recipient numbers increasing pretty much across the board, but
▪ Rising cohort priority (the % that cohort makes up of the total) at each end of the age-spectrum (here it is calculated as 2022 cohort % of total – 2019 cohort % of total).
◦ For example, males under 30 made up 23.3% of DA recipients in 2022, up from 21.7% in 2019 – illustrated below as a 1.6% increase in cohort priority.
(ii) Long COVID
Last July Denis Naughten TD commissioned research on the prevalence of long COVID in Ireland (pending the HSE analysis which has yet to be published) indicating that over 5% of Irish adults are actively living with symptoms of long COVID[11]. The data is based on a national survey conducted by the polling company Ireland Thinks. Based on figures pertaining to the Irish adult population; the polling data shows that more than 192,000 people across the country could be impacted by long COVID.
The result of the Ireland Thinks survey found that:
§ 1% of adults in Ireland are living with self-reported symptoms of long COVID.
§ 76% of those with symptoms of long COVID report that their ability to perform daily activities has been reduced as a result.
§ The most frequently reported symptom was fatigue (68%) followed by shortness of breath (50%) and sleep problems (42%).
§ Memory problems are more commonly experienced by 18–34-year-olds (51%) compared to those aged 65+ (10%).
A similar study commissioned by Deputy Naughten in November 2022[12], found that 6% of adults in Ireland were reporting symptoms of long COVID; hence the more recent study shows a marginal reduction in the active community prevalence. The significance of this reduction is unclear, but it is expected data from an official HSE commissioned survey on long COVID later this year should provide a greater insight into these emerging trends.
This series of surveys is the first of its kind to be conducted in Ireland and offers a stark perspective on the community prevalence of long COVID, which does not currently have a defined treatment pathway. These exploratory surveys have shed some light on the prevalence of long COVID by Irish adults self-reporting symptoms and is similar to the methodology used in the UK[13].
Therefore, considering the emerging data on disability claims and long COVID we believe that a separate module should be focused on these intertwined issues.
Long COVID Impact on labour market
The EU Commission has just published a Report on long COVID[14] which provides estimates of prevalence of Long Covid in the EU alongside estimates of the impact of Long Covid on people’s ability to work – e.g. Looking at what percentage of people have reduced work capacity, the degree of that work capacity (reduced hours, or withdrawal from the labour market), and the duration of this reduced capacity.
It uses these to estimate the impact of Long Covid on the EU labour market. The authors allow that this is a “complex exercise” which is limited by high remaining uncertainty on long COVID incidence/prevalence, duration, severity, and the variety of impacts on individuals. They also note that in research terms it is quite soon to be trying to make such calculations (a section is dedicated to the limitations / applicability of the findings).
For wider reference, the report also presents data estimating the impact of Long Covid on the US labour market (see pg.10).
A graph of pg. 13 presents data on the number of people ‘inactive’ in labour market terms in the EU – this is the same type of figure used in the Guardian article you sent with your enquiry. It shows an overall increase over time (since 2005), but more marked since 2019.
Key findings identified by the authors are:
· This tentative approach yields an estimated prevalence of long COVID cases of around 1.7% of the EU population in 2021 and 2.9% in 2022, resulting in a negative impact on labour supply of 0.2-0.3% in 2021 and 0.3-0.5% in 2022.
· In person-equivalents, this means long COVID would have reduced labour supply by 364,000–663,000 in 2021 and by 621,000-1,112,000 in 2022, combining the effect of lower productivity, higher sick leaves, lower hours, and increased unemployment or inactivity.
· The lower bound of this range is close to a recent estimate put forward for the US (Abraham & Rendell, 2023). These figures imply that long COVID could have caused an output loss of 0.1–0.2% in 2021 and 0.2–0.3% in 2022.
· Available labour market data suggest a mixed picture when it comes to the impact of long COVID. Overall, the possible role of long COVID in the rising trend in sick leave, disability and activity-limiting health factors, warrants careful monitoring going forward, due to its potential impact on labour supply and labour productivity, and on public finances through increased social benefits, pensions, health care and long-term care expenditure.
Future
Finally, we must as a society build on the learnings from this evaluation. As the Health Information and Quality Authority has indicated, in its evaluation of public health system and the lessons learnt from the COVID-19 pandemic[15], is important that policy moves away from a “business as usual” approach with a broader focus on public health in a post-COVID era if health inequalities are to be addressed.
We believe and to achieve this the Terms of Reference should consider broader considerations for the future and incorporate such things as the development of a trauma programme as outlined earlier and on improving pandemic resilience, which may for example, consider the holding of strategic stocks of PPE in Ireland, that could be rolled over every few years.
This aspect of the Terms of Reference should also consider the WHO Pandemic Treaty which has set out as its main goal to foster an all of government and all of society approach to future pandemics. However, its provisions have been open to controversy and should be scrutinised in detail as part of this process.
[1] Toshkov, D., Carroll, B. & Yesilkagit, K. (2022) Government capacity, societal trust or party preferences: what accounts for the variety of national policy responses to the COVID-19 pandemic in Europe?, Journal of European Public Policy, 29:7, 1009-1028, DOI: 10.1080/13501763.2021.1928270
[2] Mental Health Policy: Motion [Private Members] – Dáil Éireann (33rd Dáil) – Wednesday, 9 Dec 2020 – Houses of the Oireachtas
[3] Vaughan, M.; Lucey, S.; Sahm, L.J. Prevalence and Cost of Antipsychotic Prescribing, within the Context of Psycholeptic Prescribing, in the Irish Setting. Healthcare 2024, 12, 338. https://doi.org/10.3390/healthcare12030338
[4] https://www.irishtimes.com/life-and-style/health-family/ireland-s-mental-health-pandemic-from-crisis-to-emergency-1.4464399
[5] Trauma effects worldwide:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7250671/
https://www.psychiatry.org/patients-families/coping-after-disaster-trauma
[6] Marron L, Burke S, Kavanagh P. Changes in the utilisation of acute hospital care in Ireland during the first wave of the COVID-19 pandemic in 2020. HRB Open Res. 2022 Oct 12;4:67. doi: 10.12688/hrbopenres.13307.3. PMID: 36204710; PMCID: PMC9513415.
[7] O'Reilly S, Kathryn Carroll H, Murray D, Burke L, McCarthy T, O'Connor R, Kilty C, Lynch S, Feighan J, Cloherty M, Fitzpatrick P, Falvey K, Murphy V, Jane O'Leary M, Gregg S, Young L, McAuliffe E, Hegarty J, Gavin A, Lawler M, Kavanagh P, Spillane S, McWade T, Heffron M, Ryan K, Kelly PJ, Murphy A, Corrigan M, Redmond HP, Redmond P, Walsh PM, Tierney P, Zhang M, Bennett K, Mullooly M. Impact of the COVID-19 pandemic on cancer care in Ireland - Perspectives from a COVID-19 and Cancer Working Group. J Cancer Policy. 2023 Jun;36:100414. doi: 10.1016/j.jcpo.2023.100414. Epub 2023 Feb 24. PMID: 36841473; PMCID: PMC9951610.
[8] The Guardian 14th Feb 2024: https://amp.theguardian.com/politics/2024/feb/13/uk-labour-market-long-term-sickness-economy-workers
[9] Statistical Information On Social Welfare Services: Annual Report 2022
[10] Statistical Information On Social Welfare Services Annual Report 2019: https://www.gov.ie/pdf/?file=https://assets.gov.ie/86167/66194a05-82f8-480f-8be0-4350e1218a62.pdf#page=null
[11] Ireland Thinks survey results July 2023: https://denisnaughten.ie/wp-content/uploads/2023/09/Poll-July-LongCovid-v2.pptx
[12] Ireland Thinks survey Nov. 2022: https://denisnaughten.ie/2022/12/11/first-national-poll-on-long-covid/
[13] https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1december2022
[14] European Commission (2024) Long COVID: A Tentative Assessment of Its Impact on Labour Market Participation & Potential Economic Effects in the EU. Available here:
[15] Lessons learnt from the COVID-19 pandemic in selected countries to inform strengthening of public health systems: a qualitative study: https://www.sciencedirect.com/science/article/pii/S003335062300392X