Mr. Liam Doran:

A public health nurse has the registered general nurse, RGN, qualification, probably five years' experience and a higher diploma in public health nursing, which is a full-time course including a work placement. The community RGN would have five years' experience in public health nursing. All that is being cast aside by this throwaway comment in the document. The impact of it beggars belief at a time when we want to try to shorten patients' length of stay and maintain independent living, which requires more experienced people in the community who will assess not just the physical presentation but the psychological and environmental factors. We want more PHNs to do this, not graduate nurses entering the system.

Senator van Turnhout asked who sets the policy on the skill mix. I would like to know. Under the Croke Park agreement, the Department of Health and the HSE produced a document that said it should be 50:50 in care of the elderly. Suddenly, on 13 May, it became 40:60. Because we were not involved in any discussions, and are unaware of any nursing or midwifery involvement in them, I cannot answer the question. I agree that in any proper approach to this the skill mix cannot be set in stone. I could have a house with very mobile people who are independent in daily activities, and the mix could be 30:70, while in another house it could be 70:30 if they are all very acutely ill. We want to work with the HSE to achieve a situation whereby the nursing workforce in care of the elderly facilities perform a much wider, expanded range of duties, such IV fluid balance, blood transfusion and first-dose antibiotics. They all need to be done to minimise the unnecessary transfer of elderly people into acute environments where they will be disoriented. We will work towards that, but it cannot be done looking down the barrel of a cutbacks gun which says the ratio must be 40:60 and we are lucky to get it. We do not know who sets the policies.

Much is said about management grades in the health system. We want to be very clear. There is not an oversupply of front-line clerical administration posts in our health system. We need the front-line staff - administrators, ward clerks, reception staff in emergency departments, medical records people - because if they are not there, nurses have to pick up the slack, further taking them away from the bedside. The middle and upper management layers of the health system have become very maze-like and complicated for the senior nurse-manager to navigate through to get to the people who might free up the purse strings and address the clinical issues. Directors of nursing would be driven to dementia trying to weave their way through the matrices at the higher level of the system. The front-line grade 3 and 4 staff do pivotal work at ward level, such as medical record administration and emergency department and outpatients administration, and if one does not fill those posts, nurses have to pick up the slack, which is a poor use of a nursing resource. Last week, HIQA criticised the management of Wexford General Hospital for postponing infection control and hand hygiene training because a nurse went on maternity leave and could not be replaced.

There is no quick fix. We have travelled a terrible journey in the past five years, but what they propose for the next 12 months will take us to a place to which, with the greatest respect to everybody, the INMO cannot go quietly. We must highlight it and challenge the system. Today is an excellent opportunity for us to do that. We are not quoting industrial relations and we will never get into that because this is about care, patient outcomes and the empowerment of the nurse, who has accountability for money and everything else, to do the right thing in the right place at the right time. This plan completely turns it upside-down.