Mr. Liam Doran:

One of the greatest difficulties we are facing at the moment when we talk about documentation is the HIQA inspections where a person in charge is designated. That person is always the senior nurse in the house. There are many reports where the person in charge is named in a manner which seems to say he or she is an unfit person to be the person in charge. However, that same person in charge will have a paper trail as long as one's arm pointing out that environmental factors and staffing numbers short-change patients and investment is required. That does not come from the area, general or sectoral managers - it is the nurse who is named in an external report. The registered provider, the HSE, is a corporate entity and the only person who is identified as having failed is the person in charge, who is the registered nurse. Nurses have had their autonomy taken away slowly in recent years but this document completely robs them of it because they must move to 40:60, they must substitute with the intern programme etc. That is patently wrong. They cannot do both things; they cannot live with the HSE instruction and at the same time deliver safe care through the exercise of their professional judgment. We might not agree with every director of nursing's professional judgment - we might say it should be even better - but they call it and each registered nurse under that director is entitled to express concerns, fears or whatever. That is the code of practice laid down by the statutory body and that is completely disregarded by the HSE which does not seem to understand that a registered, regulated professional has obligations to his or her employer but also to his or her professional body to maintain best practice for patients.

This point is important to put on record. We wrote to the HSE; we received a letter last Friday from the director general who has indicated total satisfaction with the proposals, that they were subject to scrutiny, he was happy with the scrutiny and that patient care is central to all of the HSE's decision making and the plan stands. He also said if we had difficulties they could be processed through the Haddington Road structure. Obviously that was a disappointing letter. We met yesterday under the Haddington Road process. I raised the subject of the letter and again the HSE advised that this is being driven by various sectoral, divisional directors and that it was satisfied that patient care was not being compromised by the proposals etc. That is where that matter lies.

As I outlined in our document, we are due to meet the Minister on 21 July on the back of our letter and we are to meet the director of quality and safety with the HSE next Monday because we are anxious to find out what involvement that directorate had with the drawing up of these divisional plans. We know that nursing and midwifery in the HSE had no involvement in that, which again poses a question about scrutiny, how they were quality assured and safety assessed. We will continue to examine that.

On the development of the campaign, the INMO has an absolute view that what is required to stabilise our health system in a quality assured way that maximises patient outcome is to stabilise the front-line workforce. There is absolutely no floor at the moment below which management feels, because of financial constraints, it should not go. I state that clearly. There are no norms; what is acceptable at one level is unacceptable at another. We are striving to reach a position that we have norms and that regardless of whether one is in Letterkenny, Cavan, Kilkenny or Bantry the same broad skills mix and staffing levels apply.

It is the only way we can do this and it must be informed by international evidence and fair comparison. That is what we thought the workforce would do, but while we are trying to do that, this is cutting at the front line.

We have already met the Irish Patients' Association and will meet other patient groups, disability groups, support groups and the National Federation of Voluntary Bodies. We are trying to mobilise and get collective about it. I am not being smart, and I do not mean to be injurious to anybody. Last week, Stephen McMahon of the Irish Patients' Association said publicly that the report on University Hospital Limerick and the patient journey being experienced there requires the same prioritisation by the Government as the medical card issue. The problems with our health system do not begin and end with the urgent need to address the medical card issue but begin with capacity, bed numbers, access, primary care and staffing. We will mobilise on this campaign, trying to highlight the deficits that already exist that would be further exacerbated by the proposed changes.

The changes on the community side are inexplicable. The Department suggests that from 1 October we will have earlier discharge from hospital, maintenance of independent living at home and maximisation of the independence of the individual, but then says all public health nurse, PHN, and community registered general nurse, CRGN, vacancies should be filled by new graduates who have had one week of experience during their four-year undergraduate programme. They will become a significant minority in the public health and community nursing work force. That is not right. It is not a question of INMO's opinion. It is fundamentally flawed, and whoever drew it up knows nothing about community nursing services.