Ms Phil Ní Sheaghdha:

Go raibh maith agat, a Chathaoirligh.

I thank the committee for the opportunity to present our issues in respect of the trolley crisis. As we said in our letter in June when we requested this meeting, we have concerns regarding the count, which we have been conducting for decades, and the point that it reached in June of this year. That is why we sought this meeting. It is clear from our statistics, which are accepted as a measure of overcrowding in the public health service, that we will exceed the high number that we reached last year for those admitted for acute hospital care and for whom there were no beds. It was just under 100,000 patients last year.

In the time available, I will concentrate on three main issues we believe the Oireachtas can influence. We have provided a comprehensive background note on where we think the issue has come from. The reasons are not going to be any different to those suggested by my colleagues from the IMO and the IHCA. I am not, therefore, going to read them but will be happy to take questions. At paragraph 1.7 of our submission, we advise that the Sláintecare report, the Tallaght investigation by HIQA in 2012, the ESRI report of October 2017, the capacity report of 2018 and the Nevin Economic Research Institute's working paper on equality in Irish health care produced in May 2018 all inform our submission. They are all referenced. The overwhelming issue for us is capacity and staffing, followed by the issue of pay. Fundamentally, we believe the public hospitals system is in crisis and that bed capacity is not sufficient to meet demand. We confirm the daily effect of this on patients and the nursing staff and medical staff generally who work in these departments. It leads to early decisions to leave places of work and it has, unfortunately, subjected our members, in particular, to a high incidence of violence and aggression in the workplace which is completely unacceptable.

I will read the submission starting from page 4. Targeted protected additional funding is required that is linked with significant reform that supports the provision of services at the front line rather than the bureaucratic processes that exist within health. The problems that need to be addressed include the reconfiguration of divisions within the HSE so that all services are managed in an integrated service delivery model. The current mode of divisional budgeting and management of services works against efficiencies and cost savings across the service. There is a need to significantly increase bed capacity in the acute and step-down care areas, expand the number of community intervention teams and expand nursing services in long-stay facilities to relieve pressure on acute hospitals. The annual stand off between the HSE and Department of Health has commenced this year. We have all heard the projections of budget overruns. What that means for those who depend on public health services is that their services have been cut. In many instances, home care packages are no longer available in certain areas while services which are funding-dependent and demand-driven are no longer available to citizens, which is simply unacceptable. Patients have no alternative then but to attend emergency departments for services. Independent oversight of appropriate allocation is not available and must be introduced. This will require a managed accountability for subsequent spending. The model adopted for capital allocation protections should be mirrored to protect funding for specific services. Funding for front-line services must include funding for staffing plans and service developments. The INMO has publicly supported the Sláintecare report and now calls on the committee to recommend that Government must prioritise the required funding to execute and implement the transitional plan and ongoing annual budget increases. These must be protected and considered central to all Government policy to deliver the much-required reform.

The INMO has engaged with the HSE on staffing over the past two years. We have had disputes on staffing and an inability to staff new beds that have come on stream in care of the elderly and acute services. There is an acute shortage of nurses and midwives. I concentrate on nurses for this part of the submission because the maternity strategy is a different matter and does not affect emergency department posts. We identified nursing grade vacancies in 2016 which were very close to 350 in emergency departments alone. We reached an agreement with the HSE that to provide the best care to patients who were boarded in emergency departments and for whom ward capacity was not available 183 new nursing posts were required. Neither of those targets has been met and the posts remain unfilled. With the assistance of the WRC following a dispute, we agreed a funded workforce plan for 2017. The target for 2017 was to expand the nursing and midwifery workforce by 1,224 and that target was not reached. The number reached by December was just under 800 of the 1,224. That is not because recruitment is not taking place, it is because retention has become a bigger problem than recruitment. Currently, the average time to recruit a nurse is six months. We do not have agreement on a funded workforce plan for 2018 and we are in dispute with the HSE on the delay. We were supposed to have an agreement in November 2017 and as late as yesterday the HSE advised us that it will not have its final draft until later this week or possibly next week. It is now July. That means no matter how many nursing posts the HSE funds this year, they will not be standing beside patient beds before 2019. That reduces completely the ability to increase capacity.

The combination of generally low pay for nurses and poor working conditions within understaffed services, including emergency departments, is a significant issue in the recruitment and retention of nurses in the Irish health service. It is clear to the INMO that the issue of nurses' pay needs to be urgently addressed to assist in solving the problem of staffing within emergency departments. A review of nurses pay is allowed within the provisions of the public service stability agreement. A report from the Public Service Pay Commission is imminent. The commission was tasked with examining the influence of pay on recruitment and retention issues which it identified as existing within the professions of nursing and midwifery and the medical profession in its first report. The commission is due to report at the end of July following its consideration of submissions and its own research. If low pay for nurses is not corrected, we will be unable to recruit and retain the nurses required to care for our citizens inside and outside the hospital system. That is a simple matter of fact. We will also be unable maintain present bed capacity, never mind the increased capacity we all agree is required to grow services for our ageing population. We have reached a pivotal tipping point in recruitment and retention of nursing staff and it will have detrimental effects if not addressed by Government. These effects will include the closure of beds and lengthening waiting lists. The framework on nurse staffing was published by the Department of Health and accepted by it as the determinant of nursing posts required to look after patients based on a scientific determinant, taking patient dependency and outcomes and skills mix into account. It must be fully funded and implemented to determine how many nurses are needed. Unfortunately, the initial draft of the funded workforce plan for 2018 contains no allocation of funding to implement the framework despite the commitment in the 2018 HSE service plan.

What are the effects of all of this on the front line and what happens to patients when they attend our emergency departments having absolutely no alternative? What happens to our nursing, medical and other staff who are trying to provide the best care they can? Our members have advised that the constant pressure of overcrowding, inadequate staffing levels, delayed care to patients and negative patient outcomes are leading them to personally suffer burn out and stress at an early stage in their careers. Nurses are also reporting to the INMO that they find themselves answering and apologising to the public before internal and external enquiries which they regularly must attend to explain inadequate services. They clearly outline their belief that the HSE does not support them appropriately when matters outside of their control cause patients to have poorer outcomes and where inadequate care is provided in unsuitable environments. Nursing staff feel a duty to raise concerns about patient care, as do their medical colleagues, as it is a fundamental professional responsibility of a registered nurse. It is unacceptable for professional nursing staff to feel that they are unsupported by their employers in dealing with the consequences of systematic failure in the health service.

A recent HSE report on assaults against staff in acute statutory hospitals indicates that 9,901 reported assaults were recorded between 2008 and 2018. To be clear, that report does not cover any of our voluntary hospitals, which represent a large portion of the employment census for nurses and midwives. More than 70% of those reported assaults were against nursing staff.

There is clear evidence that the numbers of verbal and physical assaults increase when long waiting times and inadequate and inappropriate staffing are features of healthcare provision. Unfortunately, we are finding that many of the assaults are career-ending for the people we represent. We believe this is a manifestation of poor planning and a lack of commitment to fund and implement agreed reform and national agreements. It cannot be ignored and simply frowned upon without the Oireachtas making an unambiguous commitment to front-line nursing staff that it will provide adequate and protected funding and for reform to correct the unacceptable experiences of one third of the entire workforce of the health service.

The reality of the emergency department nurses' daily and nightly experience is described as deep frustration and anger at the fact that they feel unable to care for their patients' fundamental needs in a way that they would wish to and that they are trained to do. The physical environment in which patients are crammed together within touching distance of each other and with little or no privacy and poor hygiene facilities is completely inadequate to maintain a patient's dignity and privacy. It is dehumanising and degrading and an experience we should not allow to continue for citizens. We already know from our figures from June this year that this problem is going to get worse before the end of the year and that it is going to be much worse than it was last year.

We believe the time for reviewing and analysing the emergency department overcrowding problem is over. Our members require immediate action as they cannot continue to tolerate this situation for themselves or their patients. We are heading into winter which is very likely to be worse than in 2017, unless appropriate action is taken, including proper planning and the provision of focused funding. Those in HSE management often rush to defend the work they are doing to solve the problem. The reality is it is getting worse and we need decisive action at the Cabinet table to implement and fund the measures that will actually work. The alternative is simply not tenable for citizens and certainly not for our members.

We again repeat our request which we set out at the start of the submission that a commitment be made to ensure protected, targeted and sustained investment to allow real reform; to ensure the bed capacity report will be implemented; primary and long-term care services will be developed, as set out in the Sláintecare report; and bed capacity in the acute hospital sector will be expanded. Workforce planning for nursing based on patient needs must be funded to ensure adequate front-line nursing staff. The recruitment and retention of nurses are dependent on the correction of the low pay rates for those in the nursing and midwifery grades who are the lowest paid professionals in the public health service. Globally, they fare very badly with those in the countries' that are also short of nurses but which are recruiting our graduates and, increasingly, our practised and experienced nursing workforce.

I thank members for their time. I will be happy to take questions on the issue.