Ms Phil Ní Sheaghdha:

Good morning, Chairman, and many thanks for facilitating the remote link in. I thank the Chairman and members for accepting our request to appear before them and organising this meeting this morning. We set out in our written submission the issues that, unfortunately, remain a feature of the acute hospital overcrowding, which is not only occurring in emergency departments but throughout the hospitals. We now have wards that are overcrowded, which is not a new feature and that continues to be the case. As the committee heard, the issues facing nurses, doctors and other workers in acute hospitals are now such that they were described at a meeting we held with our members last evening as akin to whistleblowing. They are asking this Oireachtas committee to make significant changes that are necessary in order to ensure we do not face this problem year in, year out. As the previous speaker said, Covid-19 did not cause this problem but it most certainly has made it worse. We now have one single workforce dealing with two different types of care delivery and, obviously, with the donning and doffing of personal protective equipment, PPE, gear, it makes the arranging of care much more laborious and the delivery of care takes longer.

Obviously, our infrastructure does not lend itself to single rooms, which means that we are constantly moving patients from location to location to ensure they can be isolated. In any event, we have an overcrowded system and a tolerance of overcrowding that needs to be tackled. In our submission, we have set out actions we believe the Government needs to take immediately to ensure the process of changing this broken system is begun. We say this with a view to the welfare of patients who are attending. Our president, Ms Karen McGowan, who is in the room with the committee today, is a working advanced nurse practitioner in one of the large acute hospitals and can give the committee first-hand evidence of patients not being treated and of conditions in our acute hospitals becoming inhumane, including having to advise patients of their treatments and give them very bad news in very public locations. They are not afforded the dignity of privacy or of having a bed in which to have a decent night's sleep. Instead, they are left in very busy environments. They do not always stay there just for 12 hours or 24 hours. In many instances, they are going for treatment and then returning to the trolley. The trolley is their permanent base in the acute hospital. As the previous speaker set out, there is ample evidence that tells us that this, in itself, can cause a person's health to deteriorate. That is not a situation that any of the people who provide the care have control over but it is certainly not an environment in which they can continue to work.

It is also detrimental to retention, which is now a real problem. We are still battling the legacy of the recruitment moratorium for nurses and dealing with a system, particularly in the HSE, that is extremely bureaucratic when it comes to recruitment. On top of that, our system is causing those who work in it to suffer burnout much earlier than they should or to make the decision to leave because they simply cannot deal with a broken system any longer. One of the areas that has been looked at over recent years, since 2016, as a result of two nurses' strikes is a measurement tool to determine how many nurses are needed in these departments. That is now Government policy in surgical and medical wards. It is termed the framework on nurse staffing. It was meant to be fully implemented by the end of 2021 with funding available in each October's budget. Unfortunately, that has not happened to the level it should have. This framework now only applies in 12 hospitals throughout the country. When we have a model that measures and determines the skills mix and number and mix of nurses and healthcare assistants needed, that should be funded because the evidence is absolutely clear that, when the framework is in place, patient outcomes are better, the cost to the State is reduced because the dependency on agency staff is reduced and retention is improved, which is extremely important right now. That is one of our big asks.

We have appeared before this committee on numerous occasions to discuss Sláintecare and the very good work that was done across all parties to determine what changes are needed in the public health system. We strongly believe that fiddling around at the edges and tinkering with changes will not work. We need the fundamental change that was set out in Sláintecare. We need the Oireachtas to take ownership of that and we need to see evidence of real reconfiguration and integration of services at every level. The days of one manager saying that his or her budget is affected and that the money, therefore, cannot be spent between acute and primary care must end. We must have real integration. This would allow the patient's journey to be paramount and would make moving someone from a hospital to a community setting much easier. Those services must be funded and put in place. That is not happening at a helpful level and pace. It is too slow and the Oireachtas must insist that this change be overseen by the highest and most senior office in the country, that of the Taoiseach, as was envisaged in the Sláintecare report when it was originally produced.

The bottom line for nurses who are working in acute hospitals, both on overcrowded wards and in emergency departments, is that they fundamentally believe that patients are affected negatively when admitted if they are left waiting on trolleys for prolonged periods. We have surveyed our members in five of the most overcrowded hospitals over recent months and, to a person, they are now saying that there are negative effects for patients, including missed care, and that they unfortunately do not believe these areas are safe places to provide care. This is known. This is not news. They are now saying that, when they raise this from the front line, somebody must start to listen and take the necessary decisions to bring about change.

That change is already designed in Sláintecare. A version of Sláintecare or Sláintecare with a different focus is not what they want. They want the report implemented as it was set out. The fundamental changes that are required, particularly with regard to improving the services that are available outside of the acute hospital, must be made and they must be made this year. We must see more diagnostics and step-down beds in the community. We must see more chronic disease management led, in the main, by clinical nurse specialists and advanced nurse practitioners, as it is now. That requires investment. We must see the real change that is the integration of care so that we do not have separate budgets for community services and acute hospital services. That mitigates against integration at every level. When HSE management appears before the committee later, members need to ask where the evidence of change is because it is not visible to the people who are dependent on our public hospitals. What they see is longer waiting times for outpatient treatments and others treatments and some not receiving treatment in the emergency departments because they get so frustrated that they leave.

In summary, no more than we did with our presentation in 2018 on this subject, we are saying that the evidence of overcrowding remaining a great problem is very obvious. We have set out the percentage differences in trolley count figures across hospital wards and emergency departments between 2020 and 2021 on page 4 of our submission. Members can see that the increase was significant. That is a continuous problem. There is also the significant issue of hospital wards now catering for additional patients with reduced numbers of staff because wards are, in the main, staffed for the bed numbers that are allocated and funded but they are dealing with additional beds constantly, as are the emergency departments, where there are patients for whom there are no nurses allocated because the areas should not be used and are, therefore, not staffed. In our submission, we have set out what this means for the staff working in those areas. We have seen higher incidences of violence and aggression and, unfortunately, the majority of those incidents are recorded against nurses working on the front line.

We have also set out in our submission that there is a role for the Health and Safety Authority, HSA, and Health Information and Quality Authority, HIQA. We were disappointed with their response when we asked them to investigate these units. We believe that these statutory agencies have responsibilities and we ask this committee to examine the responses from the HSA and HIQA to date. If strengthening of the legislation that underpins their responsibilities is required, this committee must make recommendations to that effect.

Having an agency that is responsible for the statutory safety of staff at work must mean the same thing in hospitals as on building sites, and it does not. Currently, you can work in an emergency department or hospital ward, be subject to a career-ending assault, and there is no change to your workplace. That is not acceptable.

We are happy to take any questions but we ask the committee to see our request as a cry for help. As one of our members said at the meeting last night, when the front line is screaming for assistance, somebody must listen. That is the request to the committee. Gabhaim buíochas leis an gcoiste.