Ms Phil Ní Sheaghdha:

We very much thank the committee for this opportunity to present to it. We have submitted our written statement, which we have been advised is very lengthy. Therefore, we will endeavour to condense it in our presentation.

The issue of staffing in the health service is one on which we have been campaigning for more than a decade. It involved us taking strike action earlier this year. The issue still remains a major one for our members both in the hospital sector and in the community sector. The main issues particular to nursing and midwifery are that nursing and midwifery as professions have a worldwide shortage. We set out in the submission that the issues we face here are not unique to Ireland but, unfortunately, we have to work much harder to maintain our level of staffing and particularly to retain our graduates once they qualify. We qualify 1,850 graduates a year and we will manage this year to hold on to approximately 900, which is good. That is an improvement on previous years but, obviously, it is not good enough. We have set out the turnover rates in our submission and there is considerable detail on that, which I would like to go through with the committee, if that is okay. In the submission, we go through the global shortage and set out exactly what that means, which is that each country that requires nursing and midwifery is basically recruiting from the same pool. We are largely dependent on the non-EU workforce made up of nurses who come from the Philippines, India and Nigeria. They are the three top countries and are the countries on which the American countries, Canada and Australia also rely. The recruitment costs are quite expensive for obvious reasons.

We must send teams to interview and then ensure that when we recruit, we provide accommodation for a period of time. A stipend salary is also provided, estimated at a cost of €11,000 per person, prior to taking up a job in the health service. In the meantime, a recruitment pause was introduced in May, although the HSE continues to deny there is a pause. In fact, it is very evident, including in the front-line workforce, and presents a real problem. The circular issued by the HSE to service providers on 20 June states:

- No new posts [other than those approved and funded developments via the existing national control process] or replacement posts can proceed to offer stage or be put onto the payroll in any CHO, HG or [section] 38.

- No career break returnees or any other returns which are at the discretion of the employer can be allowed to take place during the period [this control] is in force. Also, no increases to weekly hours of staff who are not already working full time can be allowed to take place or approved during the period that [this control] is in force. Reductions to weekly hours can proceed.

This means that we have applications from nurses to return from a career break and that they are being denied and that they are sitting at home. Under the career break scheme, the employer has the right to postpone the return date by one year but must then lawfully take the employee back. Unfortunately, we are absolutely crippled by the recruitment pause. Our members report daily that they are working with completely inadequate numbers, that they cannot provide the required care and that conditions are unsafe. Their physical and mental health is being affected to an absolutely unprecedented and unacceptable level and no one can be recruited because of the introduction of the pause. It affects one third of the workforce and the turnover within the nursing and midwifery professions will be higher than in any other profession because of their numbers. Therefore, they will be affected by the pause to a greater extent and that is what we are witnessing.

We cannot open additional beds. We have had the overcrowding of hospitals reported this week at a figure of just over 100,000 people who are sick enough to be admitted to hospital and who require hospital care but for whom there are no beds. It is an absolute scandal. The figure is increasing week on week and we have been reporting it daily. We view that reporting as a very important part of our role. We do it in order to highlight that the health service is not working in the way it should be. It is now a dangerous place to which to be admitted. We have recently met groups that have reported to us that the admission of the elderly population, that is, those who are over 75 years of age, is at a higher rate than for those under 75. They have nowhere else to go in certain circumstances because community step-down services are not available. As there has been a decrease in palliative care services, people are being admitted to emergency departments and dying on trolleys. That is not the service in which our members want to work and provide care or for which they want to apologiese continuously.

When we talk about workforce planning, we say there are a number of solutions. In 2017 we presented all of these arguments to the Government and exhausted the machinery of the State through the WRC. We reached an agreement which required an annual service plan and a workforce plan to be developed and funded by November each year. The only year in which this was actually achieved was 2017. It was ignored in 2018. We met representatives of the HSE yesterday evening and it does not have a workforce plan for the professions of nursing and midwifery for 2019. That makes it two Novembers for which we do not have a workforce plan. What we have is a very serious restriction on the ability to recruit. The memo of instruction, dated 20 June 2019, from the financial officer of the HSE requires that for any post that becomes vacant for whatever reason, for example, if someone retires, resigns or takes a period of leave, the replacement to be sanctioned by the chief officer or the head of the hospital group. That is one person who must sign each form that eventually reaches that level. Can the committee imagine the delays in this process, considering the size of the workforce in the health service? There are approximately 70,000 staff in the acute hospital division and there is a turnover of staff. Obviously, this introduces significant delays. As late as Tuesday of this week, we were receiving reports from the directors of nursing in Cork University Hospital which is extremely overcrowded that they had been waiting for nearly three months for a response to the request that posts be advertised that had become vacant. We had to intervene again this week in the matter of unfilled public health nurse posts in east Galway. Services for the public are affected. For example, when patients receive chemotherapy at home, they require a public health nurse. The directors of public health nursing are saying such a service will have to cease because we cannot replace nurses.

These are very real issues for citizens who are dependent on the public health service. Until someone is in an overcrowded emergency department or ward, it is difficult to understand how serious the problem is and how serious the consequences are for those being cared for in areas that are overcrowded, with staff who are absolutely stressed and trying to provide a service that is safe. It is simply not possible to do so.

We are delighted to be here to highlight these issues, but we believe a number of very practical solutions can be introduced immediately. We ask the committee to make representations at the highest levels of government in that regard. We must immediately bring an end to the current recruitment pause, particularly in the nursing and midwifery professions. Once it ceases, there will be a ripple effect in recruitment for approximately six to eight months. That is how long it takes to recruit to the professions of nursing and midwifery. We also need to consider in the medium term increasing the number of undergraduate places. We need to train more nurses and midwives at undergraduate level in order to have a steady supply. As I said, we train approximately 1,850 across all disciplines. We could accommodate a greater number. We know, for example, that the Nursing and Midwifery Board of Ireland registered 1,750 non-EU nurses in the last calendar year. That is how many nurses are coming into the country to register to work in both the private and public sectors.

As part of the recent settlement of our dispute, we obtained agreement from the Government that it would fund the measurement tool to determine how many nurses and midwives were needed in hospitals in surgical and medical wards. We have never had such a tool and it is Government policy to fund it. It is called the framework for safe staffing and based on patient outcomes. It was measured by a team of researchers led by University College Cork over two years in six wards in three hospitals. What they concluded was that when the correct number of nurses were employed, the level of patient mortality and length of stay decreased, patient outcomes and retention of staff improved and the level of sick leave reduced, while there was a dramatic decrease in agency costs, all of which is good news and accepted by the Government. The Minister for Health launched the policy, but it was not funded. Therefore, as part of our strike settlement, we sought funding to be made available in this year's service plan for the nurse staffing framework. As late as yesterday evening, we sought confirmation that this part of our settlement would be honoured because it is a huge plank and everyone agrees that it is right to base staffing levels not on funding but on patient outcomes. Unfortunately, we have not yet received confirmation of the service plan, but we remind the HSE that the Labour Court recommendation that settled our dispute clearly sets out that funding has to be made available as part of this year's service plan, as well as the plans for 2020 and 2021, to fully roll out the framework over a three-year period.

This annual funding for the workforce strategy on which we had agreement in 2017 must form a normal part of business for the HSE annually. Otherwise, we will continue to be reliant on agencies and an ad hoc filling of posts and there will be an inability to open new beds to relieve the pressure on the acute hospital system. The working environment of our members in hospitals and the community, particularly in overcrowded hospitals, is such that their health and safety is being deliberately interfered with by the policy that has been introduced by their employer. That cannot continue. We are happy to answer any questions the committee may have.