James Reilly (Dublin North, Fine Gael) | Oireachtas source

All I can say in response is that anticipation is half the pleasure. I thank the members of the committee. I am accompanied today by the Minister of State, Deputy Alex White, and the Chairman has already gone through our team. They are Dr. Siobhán O'Halloran, chief nursing officer; Mr. Matthew Collins from the eligibility unit; and Ms Fiona Prendergast of the finance unit. As the Chairman noted, unfortunately, the Minister of State, Deputy Kathleen Lynch cannot be with us and sends her apologies. We all wish her well. We are also accompanied by seven members of the HSE, including Dr. Tony O'Connell, the new director of hospitals; Mr. Stephen Mulvany, chief financial officer; Mr. John Hennessy; Dr. Anne O'Connor; and Dr. Áine O'Carroll.

The committee has asked that I address issues raised by the Irish Nurses and Midwives Organisation, INMO, and the availability of epipens, arising from hearings by the committee. The INMO raised issues regarding staffing in the health services. The committee will be acutely aware that public sector staffing and public sector pay is subject to national pay agreements, specifically the Haddington Road agreement, and the moratorium on public sector appointments. The health service is required to achieve savings of some €290 million in 2014 under the Haddington Road process, and this is set out in the 2014 service plan. The HSE’s national directors developed an implementation plan to achieve the savings involving the review of rosters, skill mix and staffing of hospitals to ensure the extra hours provided for under the agreement are maximised so we can reduce spending on agency work and overtime. This must be balanced against the overriding need to ensure patient safety is maintained. The committee is aware that patient safety is the biggest priority in the national service plan for 2014.

The same imperatives apply to the number of staff employed in the health service. There is a target to be reached as part of compliance with employment control frameworks but this must be balanced against the need to ensure patient safety. That is why the HSE may recruit where it is necessary to do so in order to ensure patient safety and quality care and to support service delivery. In other words, the moratorium is not a blanket approach but it is being used in a way that where staff are no longer necessary in an area, we can replace them with staff in other areas. We are allowing for a change in the model of care and getting the skill mix right. As we move to a more community-based model, particularly with mental health, we can in this way get more community nursing and other therapists in the community. Similarly, when the Minister of State, Deputy White, addresses the committee, I have no doubt he will point out that the move from a hospital-centred model to a community-centred model means we need many more staff in the areas of speech and language, occupational therapy and physiotherapy, and this is accommodated for with additional money made available for primary care. The Minister of State can deal with that in more detail.

There are almost 34,600 nurses and midwives in the health service, as well as almost 3,200 health care assistants, including interns. Whereas the Haddington Road process concerns staff numbers, it also deals with issues like the graduate nurse and midwife initiative and the support staff intern scheme. The graduate nurse and midwife initiative supports the retention of graduate nurses and midwives within the health system and enables them to gain valuable work experience and development opportunities after graduation. Two-year contracts are being made available under this initiative and nearly half of these have been filled. I take the opportunity to note that the HSE has a specific sponsored student public health nurse programme, graduates of which fill public health nurse vacancies. The support staff intern scheme facilitates interns in achieving the FETAC level 5 qualification, which is an invaluable asset in their professional development. These interns will provide vital support to health care professionals, including nurses, in the health care setting.

Whereas overall nursing numbers may have fallen by 12%, or nearly 5,000, since 2007, they still represent one third of the health services work force. Alongside this, the number of midwives has increased by 46% or 400, weekly working hours have increased, 450 nurses and midwives have started the graduate scheme and 330 health care assistants have started the intern scheme. In this way the Haddington Road agreement has provided additional resources and should be seen in the context of the overall reform programme and the range of initiatives we are pursuing to improve our health services and enhance patient safety.

Collectively, these additional resources will enable the HSE to reduce expenditure on agency staff and my Department, with the Department of Public Expenditure and Reform, is also looking at other ways to achieve savings on agency expenses in light of developments with regard to the nurse bank initiative. Given the challenges we face, we cannot conceive of our health services as just a numbers game. That is why we are reforming how we deliver health services. Hospital groups are especially relevant because the changes inherent in their establishment will enable us to make optimum use of our high quality resources, including nurses.

There is a wide range of challenges associated with determining appropriate nurse staffing and skill mix levels in hospitals in Ireland. Deciding on an optimal number of nurses is not an easy task, and there is a delicate balance to be struck to meet patient safety and economic requirements.

Achieving this requires relevant expertise to be applied to the decision-making process.

It is for this reason that we are establishing a task force to develop a framework that will determine the staffing and skill mix requirements for the nursing workforce in a range of major specialties. The focus will be on the development of staffing and skill mix ranges which take account of a number of influencing factors. In this regard, I wish to highlight that nursing is now a graduate profession and Ireland was one of the first countries to embrace this. We have had the undergraduate pre-registration programme since 2002. The benefits of this highly trained workforce are just one of the factors that must be considered in looking at staffing levels.

Phase 1 of the task force project will focus on developing a staffing and skill mix framework related to general and specialist adult hospital medical and surgical care settings. The task force will be chaired by Dr. Siobhán O'Halloran, the chief nursing officer, and will comprise a range of experts. The use of staffing ranges, as opposed to staffing ratios, will retain flexibility in the system while ensuring the safety of patients. The Irish Nurses and Midwives Organisation is represented on the task force, the first meeting of which will take place on 23 July.

With regard to epipens, let me first take this opportunity to extend my deepest sympathy to Ms Sloan and her family on the loss of their daughter, Emma, who suffered an anaphylactic reaction last December. I know that this tragedy prompted the committee to hear evidence from a number of contributors regarding the provision of adrenaline auto-injectors in Ireland, and Ms Sloan was one of those who appeared. The Pharmaceutical Society of Ireland, whose primary function is to regulate the pharmacy profession in Ireland, is undertaking a statutory investigative process related to events on the night Emma died. In these circumstances, therefore, it would not be appropriate for me to comment further on the specific case.

My Department is examining the feasibility, taking account of policy and patient safety considerations, of amending prescription regulations to facilitate wider availability of adrenaline pens in emergency situations. The Department plans to conduct a consultation process which will serve to inform a policy decision on the matter.

If I may discuss the issue more broadly, the incidence of allergy, including nut allergy, in developed countries has risen steadily in recent years. While the reasons for this increase are not fully understood, the effects of a nut allergy can be severe. Avoidance is key, along with a combination of proper diagnosis, attention to food labelling and the availability of emergency medication. Adrenaline auto-injectors, as injectable medicines, are supplied as prescription-only medicines. Under Irish law, designated health professionals, that is, registered medical practitioners, dentists and nurse prescribers, may prescribe adrenaline auto-injectors. Strict controls are placed on who may supply medicines to patients, for example, registered pharmacists. Regulations control the health professionals who may administer prescription medicines to patients in certain circumstances, for example, registered pre-hospital emergency care personnel, registered opticians and others. The regulations also provide that a pharmacist can supply a prescription medicine in emergency circumstances without a prescription. That is a key point.

Proposals to widen access to adrenaline auto-injectors range from making them available without a prescription to making them available in every school and restaurant in the country. However, there are complex considerations to be considered to ensure patient safety is fully protected. These include, for example, the identification of the category of persons designated to administer the auto-injector. This would involve a register to identify clearly the individuals who have an entitlement to supply or administer the adrenaline auto-injector. To qualify for inclusion on the register, an individual would have to complete a certified training programme which would cover such things as identification of an anaphylactic reaction, the administration of the medicine and the follow-up care after the injection has been administered. It would also involve setting up a clinical practice guideline or protocol which would cover such aspects as the supply of the auto-injector, the certification of the establishment where the auto-injectors are located, their storage, persons responsible for storage and record keeping.

There are also serious patient safety considerations. These include the possibility of a misdiagnosis of anaphylaxis and the potential adverse implications of incorrect or inappropriate administration of adrenaline. There is potential for harm if administered to a patient with certain underlying conditions who is not suffering from an anaphylactic reaction. These include administration to patients with a history of or who have underlying cardiac arrhythmias and cardiovascular disease, including angina and hypertension, where incorrect administration could result in an exacerbation of these conditions or a significantly worse health care outcome.

Availability of auto-injectors is another issue. The Health Products Regulatory Agency, HPRA, formerly the Irish Medicines Board, continues to work to ensure there is availability from multiple sources. In view of the potential for supply problems, however, it is essential that adrenaline auto-injectors are utilised in the best possible manner. The shelf life of these products is relatively short, ranging from 18 to 24 months. It is important that the products are not used after the shelf life has expired as after this time the efficacy for the product can be reduced. I support making medicines more accessible to patients where it is safe and appropriate to do so, and my Department is examining this particular issue as a priority.

I realise members have many questions. I am joined today by a range of people from both the Health Service Executive and the Department who will be more than happy to help the committee in any way they can.