Mr. Liam Doran:

It is like this in the health system at the minute. We always try to be balanced. In fairness, local general management are being beaten all the time and they have an impossible problem to solve, because they may have posts to fill but they may have no money to fill them or they may have no money but they may have posts. One way or another they cannot answer the demand. They are avoiding the additional staff. This is the reason we commissioned the study in this area. There is a perception that most of the health service is made up of intensive care or coronary care area or the oncology services in the country and so on, but the vast bulk of health care is delivered in the ordinary areas such as a medical ward, a surgical ward or an elderly care unit. It is not necessarily the hi-tech intensive care or coronary care areas. It is precisely these areas that are being totally dissipated of the quality of staff they require and these areas have been shown up in the comparative study.

I try not to be too alarmist but the embargo has been an abject failure by downsizing our health system in an unmanaged way rather than allowing patient care to always determine that the right person is in the right place at the right time at the right grade to perform the right task on the patient. It has been uncontrolled and it continues to be uncontrolled. We have lost 11.5% of our workforce. I respectfully put it to colleagues present that an 11.5% loss of workforce, regardless of whether one factors in changes in work practices, increases in productivity, more flexible rosters and so on, must produce a give or compromise somewhere. That is the ordinary levels of care required by patients which are going undone by nurses and which is a source of concern to them.

I will not go there now but this is one of our pleas today. Our greatest fear at the moment is that there is no bottom line for our health care system and no one who will draw a line and say we will not go below it. It is because we do not have nurse-patient ratios. We have examined the idea of nurse-patient ratios long and hard. They are not the automatic solution to all of our difficulties, but they set a minimum whereby at least there is a commonality of standard whether I am in Donegal, Wexford, Dundalk or Bantry. We maintain this must be applied in Ireland. At present, what manager A says is safe may be deemed unsafe by manager Y for various reasons. There is simply no common standard. Many of our staffing levels are based on history, geography and whether one had influential people in situ over the years. We realise these are the realities. I put it to the committee that the comparative study has thrown up the deficits that exist. The deficits continue to worsen and to standardise the situation or put some foundation on it we maintain we must consider, debate and bring forward nurse-patient ratios to give a standard which would apply regardless of the hospital.

I will not go into the issue about graduates other than how it relates to the comparative study. We are not simply discussing the number of nurses. Within any grade there must be a skills mix as well. With respect to Deputy Fitzpatrick, if it were as simple as he has described we might all have an engagement but ultimately the employment of the graduate programme is only redirecting moneys currently given to agency employment towards graduate employment. There are no additional man hours.

When people refer to 35,000 and 36,000, I respectfully suggest that it is mere imagination. There are 36,000 people in the system already, albeit 34,500 in official whole time employment and up to 1,500 employed every day via agencies and so on. One cannot simply get rid of 1,200 experienced nurses and replace them with new graduate nurses, who will not have the mentorship and support envisaged in a graduate placement programme, and suggest nothing has been lost. There would be skills, expertise and experience lost by such a change. This is another thing wrong with the graduate programme apart from the 80% and so on. I genuinely and sincerely put it to Deputy Fitzpatrick that not one additional hour will accrue to any ward arising from the programme. They are displacing experienced staff and replacing them with new graduates. That is not a solution in a situation where short staffing already exists.

The committee should understand that we have not had our head in the sand on the issue of training. In 2007, we agreed with the HSE on job descriptions for health care assistants, based on a level 5 FETAC programme, a general job description and some specialist jobs descriptions for maternity, theatre and elderly care.

Nothing happened uniformly. The INMO does not have a difficulty with a 70:30 mix at ward level. We understand a ward cannot be staffed solely by nurses and that it would be wrong to do so. It would be a waste of time and not be a proper use of resources. Equally, there can be a ratio of 80:20 in some places and 60:40 somewhere else. There are no minimum educational criteria for support staff. If a nurse delegates to them, it is necessary to know that they are competent in certain basic areas such as in making daily observations, for example. We do not have a difficulty in engaging and embracing that dialogue, but there is no one on the opposite side of the table. We have agreed job descriptions and to the level 5 FETAC programme, but the system has not delivered the quantum of people required through that programme to put it back in situat health care assistant level to complement the nurse and take delegated duties from him or her. That is necessary and I plead with the committee in that regard.

I will deal with Senator Colm Burke's point, but when we engage with the health system, all we ever hear about is the extended role of the nurse, whether it be undertaking intravenous canulation, catheterisation, phlebotomy or first dose antibiotic therapy. We would embrace all of this. However, there has to be a safe cohort of people who have received vocational training and are ready to take up the slack. All we hear is that the nurse will do more, but there are no plans for the evolution of care from the health care assistant's role through vocational training. It is an excellent proposal and would be a brilliant addition for ward staff to have a 70% cohort of nurses or midwives and to grow towards reducing the reliance on the non-consultant hospital doctor. In particular, I suggest relying on non-training NCHD posts is not a cost-effective way of providing care in many of our smaller acute hospitals. We will participate, but it has to be in a continuum and planned. We are up for it, but all we get is talk about budgets, money, the lack of clarity and the nurse having to pick up the slack all the time. I will say unapologetically to the committee that this cannot continue. The nurse cannot be regarded as dispensable when it comes to filling posts but in the workplace regarded as the person who does everything that has not been done.

On the question of budgets, we are having a conversation in another place about what the Government is seeking. Like other public sector unions, we aim to put our best foot forward. However, with respect, I am a bit tired of hearing that, somehow or other, the public sector has got away scot-free in carrying the burden of recovery. We are talking about the new graduate programme and there was a cut of 24% before we even started. This does not include the numbers that were cut, the changes in rosters and work practices, as well as the expansion of the nurse's role. The new graduate, just like the nurse who has been qualified for ten or 20 years, is subject to the same regulations, correctly so. There is no difference between the person who has been a registered nurse for one day and the person who has been registered for ten years. All a patient wants to know is whether the person concerned is capable of performing procedures correctly to a high standard. The public has a right to have this measured by An Bord Altranais or the new nursing and midwifery board of Ireland. We have put our best foot forward on the issue of savings, although I know that is an argument for another place. After pursuing a degree course lasting four years, a nurse earns €26,700 - if the correct salary is paid - a salary that has already been cut by 24%. He or she will be asked to work all the hours God sends and required to be very flexible. In my view, the persons concerned have put their shoulders to the wheel and, correctly, will be measured to the same level of acuity, proficiency and perfection as every other nurse.

I have tried to cover all of the points raised. Have I left anything out?