Mr. Edward Mathews:

Absolutely, it is not being sufficiently recognised. It must be recognised. That is one element of it. The other element is the tortuous process that has grown organically for the development of advanced practice roles. We must move to the model that has been implemented in other jurisdictions, which is a credentialing framework using the nursing and midwifery register. This recognises the skills and competencies that are available in the graduate workforce, recognises and supports the ongoing education of people and experiential learning, credentials that, that is, annotates it to their register, and allows them to progress to the advanced practice role. It must be within the HSE service plan or that of whoever or whatever will manage the health service into the future, in our recommendation the health authorities with the Department of Health having the policy lead, to embed advanced practice roles within the delivery of care across the models of care to ensure that people get the right professional at the right time delivering the right care. It involves the credentialing framework and the willingness of the system to deliver that.

In tandem with that, I will respond to Deputy Madigan's point which is a concern relating to, perhaps, a medical negligence issue and the advanced practice role. Quite simply, the issue does not arise. The standard of care that must be delivered is based on the level at which the practitioner is operating. When people reach an advanced practice role, international research and all of the safety literature show that those advanced practitioners are competent and capable to deliver and manage care, both complicated and uncomplicated, across a range of headings and to be competent and capable to discharge people and cross refer between services and professionals and between advanced nurses and physicians, to ensure the delivery of the care that is required.

On chronic disease management and the role of practice nurses, as I said, there is an absolute necessity to have nurses embedded at specialist and advanced practice level to ensure the proper delivery of chronic disease management, which is the issue of our time, particularly in the context of the possible doubling or more of the elderly population and changing demographics as we move forward. Practice nurses should not be privately employed. They should be employed by the public health system. If we are to have an integrated delivery of care, we must have a managed and delivered service within which people are working as part of a team rather than employed by somebody else and siloed off in a separate location. These people must have access to the supports and systemic advancement opportunities which come within the public health service that we are envisaging, such that a practice nurse working at a particular level automatically progresses to a specialist or advance practice role, be that in chronic obstructive pulmonary disease, cardiac epilepsy and so on, in respect of which there are good models throughout the service. Currently, there is no standardisation within the service to allow that type of progression.