Mr. Liam Doran:

No. The figure was €84 million from April 2013 to April 2014.
In regard to maternity services, the Senator and other members of the committee are correct in that the public record shows that in 2006 every single midwife in Portlaoise hospital had raised concerns about the unit. They wrote to local Deputy who was Minister for Finance at the time. They also wrote to the head of the HSE at the time. Investigations were undertaken but nothing changed. The birth rate went up. The numbers did not decrease, per se, rather they were maintained, but the birth rate had increased. However, numbers were not increased to monitor it. We reached a situation in 2009, 2010 and 2011 where the numbers were very poor. The ratio was 1 midwife to 55 births at the beginning of this year and in March it had increased to 1 midwife to 70 births. These are the HSE's figures, not ours, lest anyone decides to question them. The norm in the United Kingdom, accepted in its Birthrate Plus programme, is one midwife to 29.5 births. In the North the current ratio is one midwife to 26 births. The current national average here is one midwife to 40 births. No hospital has a ratio of 1:29.5; the best is Holles Street and one other where the ratio is 1:32. The ratio in Portlaoise hospital is 1:55.

We are trying to address that with active recruitment. The problem is, and this is not meant to be an excuse to anyone, we have to grow our own midwifes. One cannot just snap one's fingers and have them appear. It takes four years to train a midwife or we have to get them back from abroad. There is not a surplus of midwives abroad who can come back. In the absence of a manpower plan, we are climbing a mountain to try to stabilise the situation with reference to an accepted tool, namely, the birth rate plus of one midwife to 29.5 patients.

The Deputy made a valid point in that our hearts are broken in regard to the nurse to population ratio. The OECD refers to a ratio of about 14.5 or 14.8, with reference to the total number of nurses on the live register maintained by An Bord Altranais as compared to the population. It is not with reference to the number of nurses working or employed. In its reports, the Department of Health has acknowledged this and says the more accurate number is about 10.2:1,000, which is slightly below average within the OECD because the others are maintained by the numbers who are not nursing. A fair point made by the Deputy is that we have only one qualification for nursing while some other countries which have ten would have a second-level nurse in the form of a licensed nurse or vocational nurse who would undertake a shorter course. We chose not to do that and I think we are right, with respect. We have excellence. This country is world class in how it trains and educates undergraduate nurses to graduate level. Ms Grace Murphy is going through a world class course but we do not fully utilise them. We help them to qualify and let them emigrate but we are about the norm in terms of the average. What we hope to do is begin the process of stabilising the nursing workforce with reference to international best practice and norms. With that mix of staff, one rate of qualification of nurse, a HCA, FETAC level 5, our hope was to bring them in and agree job description for surgical, medical wards to begin with and spanning it later. We genuinely thought that was the beginning of finding the floor.

We have a campaign about nursing hours per patient day similar to New South Wales, Australia. That would be our preferred model and we will bring that process to the table. That counts for nothing if, in the real world, staff are not replaced or, when they are replaced, they are replaced with interns on the support staff programme, which is what they are going to do here, regardless of its impact. The negative impact on patients is often a slow burner. It is not my cost base. I might discharge a patient in a shorter time, the patient might have a greater level of cross-infection but there are drugs, so that the cost base increases in ways which are hidden but my staffing cost goes down, so I am a good boy. That is the way the system is run much too frequently. We are not looking at quality patient outcomes, level of readmission and the cross-infection rate. The HIQA report on University of Limerick hospital group is sobering to anyone who has a belief in a public health system.