COVID-19 Moral and Ethical Advisory Group Wales: 3rd December 2020

Heather Payne (Chair), Aled Roberts, Alison Mawhinney, Helena Herklots, Kevin Francis, Alison Parken, Rhian Davies, Viv Harpwood, Carol Wardman, Kathy Riddick, Idris Baker, Valerie Billingham, Chantel Patel, Liz Davies, Baroness Finlay, Aled Edwards, Ben Thomas

1. Welcome, Apologies & Introductions  

The Chair made introductions, welcomed Paula Hope from Swansea Bay Mental Health & Learning Disability and noted apologies.  

2. Previous minutes 

The Chair asked group members to provide any comments/amendments regarding the note of the last meeting to the Secretariat.   

Actions 

Welsh Government policies relating to the use of the Rockwood clinical frailty score. CQC have now challenged the blanket decision to impose ‘do not attempt resuscitation’ orders.  Fair to report that unadulterated use of the Rockwood clinical frailty score did not happen in Wales or England. Feedback from our group was used to challenge the admission into intensive care approach.   
 
NICE guidelines dated March 2020 was shared with the group.  Discussions in the four countries Moral Ethical Advisory Group that advises the four CMOs lead to the statement “any patient aged under 65 or any age with stable long term disabilities, do not use the clinical frailty score”.  As a product of the discussions held at this group our Welsh guidance became consistent with the NICE guidance.   
 
We have been asked as a group to review the latest version of the extreme surge guidance for Wales by 11th December 20.  Document is currently classed as official sensitive but we are waiting for permission to share within our group, we will need to meet again next week to identify any issues.  Individual contact welcomed from those able to access the document through health board routes.   
 
We will need to consider our discussions around moral injury to NHS and care staff who are being put into intolerable positions and having to make decisions which conflict with their own values and sense of self-worth.    
 
Discussions are needed with health boards to determine what monitoring arrangements are in place and how can they ensure that decision making is consistent and transparent at clinical level. 

3. National Network Clinical Ethic Committees  

Members were asked to comment on the draft Terms of Reference provided together with a link for the UK Clinical Ethics Network draft Terms of Reference.  Working document to take forward to CMO and CNO to respond to feedback at the self-reflection and review and discussion with CEC committees.  We do need a Wales Wide Network in order to support and advice across Wales to make sure we maximise the value of this broad group we have.  We are a fantastic resource but we can sit on top of CEC’s and also support the trusts who do not have a CEC. 

Comments: 

• More thought into fair and open recruitment process.
• Nature of referral to ethic groups slightly different to those at a local level.
• Breadth of expertise and perspective on committee is more useful than formal representative than different identifiable professional or other groups.
• Emphasis needs to be on strategic, we need gateways rather than gatekeepers.  We need to find the balance from Moral and Ethical issues that can’t be solved locally. 
• Do we just need a network of the Clinical Ethical Committees outside CMEAG structure? 

The Chair asked members to send all comments to the Secretariat.   

4. How have the principles in the CMEAG ethical Framework been used in decisions during the pandemic? 

Idris presented a paper providing a background and reflection of decision making.  The fact was highlighted that having an ethical framework hasn’t meant that all the difficult problems have gone away.  A range of four examples were discussed to illustrate some of the different ways that the framework have or have not influenced decision making.  The conclusion drawn from these four examples is that we know in some cases the right principles found their way into the decisions, maybe before our framework was produced.   
 
The Chair opened up a discussion. 

• An evaluation could be carried out by way of questionnaire sent to clinicians across health boards in Wales.   
• Concerns around how the health boards have interpreted the principles.  Can we identify the consistency of use and implementation across the health boards? 
• Concerns about our transparency to public around ethical decision making.  Do we have any thoughts about how we can add transparency, creditability and protection to those who make these decisions?   

The Chair asked members to send all comments to the Secretariat.   

5. Testing individuals with Learning disabilities - update

Paula described the ongoing issues over testing individuals with learning disabilities and the barrier it has created in accessing respite.   
 
The Chair opened up a discussion. 

• Additional skills needed in understanding deficit.  Conversation needed with HEIW to ensure that training is available to promote understanding.  
• Education and Training Framework developed by University of South Wales.
• Mandatory Tier 1 Level 1 for all NHS and front line public services staff.  HEIW conversation initiated – how do we maintain it?     
• Positive personal experience with track and trace regarding degree of understanding but not testing centre.  Found process difficult, how would someone with learning difficulties cope?  Using private contractors causing an issue. 

6. Draft ethics of JCVI Covid Vaccine – update 

Concerns over anti-vaccine groups, will be challenging to go around the ethics of encouragement and persuasion in the absence of being able to make compulsory.   

7. Rural Health brief update

Aled is discussing issues with North West contacts, will attempt to bring a paper to the next meeting.   

8. AOB 

None  
 
Next meeting in one week.