Oireachtas Joint and Select Committees
Thursday, 24 January 2013
Joint Oireachtas Committee on Health and Children
Independent Study into Ward Staffing Levels: Discussion with INMO
I remind members, witnesses and those in the Visitors' Gallery to ensure that mobile telephones are switched off for the duration of this meeting as they interfere with the broadcasting equipment even in silent mode. Our discussion this morning is with the Irish Nurses and Midwives Organisation on the independent study into ward staffing levels in Irish hospitals. I welcome from the INMO Mr Liam Doran, General Secretary; Ms Claire Mahon, President; Ms Geraldine Talty, first vice-president; Mr James Geoghegan, second vice-president and Ms Elizabeth Adams, director of professional development. I thank the witnesses for taking time to attend the committee.
Before we commence, I remind witnesses of the position on privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if a witness is directed by the committee to cease giving evidence on a particular matter but continues to do so, he or she will be entitled thereafter only to a qualified privilege. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long standing parliamentary practice or ruling of the chair to the effect that they should not comment on, criticise or make charges against either a person outside the Houses, or an official, either by name or in such a way as to make him or her identifiable.
I thank the witnesses for bringing this important report to our attention. We look forward to this morning's debate. I apologise for missing the meeting with the witnesses yesterday. I had another engagement which I could not get out of. I thank them for holding the meeting.
Mr. Liam Doran:
On behalf of the Irish Nurses and Midwives Organisation - the INMO - I express our appreciation to the Chairman, Deputy Jerry Buttimer, and the members of the committee for agreeing to meet with us to discuss the many issues arising from our comparative survey of nurse staffing levels in medical, surgical, care of the elderly and admission and assessment units in hospitals in Ireland versus the UK. It is the sincerely held view of the INMO that the survey confirms that staffing levels in this country are at a critical and unsafe level. The survey was carried out independently by Dr. Keith Hurst, independent researcher and analyst and editor of the International Journal of Healthcare Quality Assurance and a most reputable expert in the area who has worked for the HSE and other major health employers. The INMO in approaching this exercise was acutely aware that there are many variables in health staffing including patient dependency and acuity, physical layout of wards and units, skill mix and grade mix and traditional roles of key grades. These variables make it difficult for any party to be absolutist as to what constitutes safe or unsafe staffing levels. Notwithstanding these caveats, we sit before the committee today clearly of the view that the survey confirms our worst fears that staffing levels have reached unacceptable levels which compromise patient care and the ability of registered nurses to ensure safe care through safe practice.
Apart from the demand from our own members, the INMO was influenced to undertake this staffing comparison by the Royal Commission report on standards of care in the Mid-Staffordshire Hospital Trust in the United Kingdom. The Royal Commission found that between 2005 and 2009 there were between 400 and 1,200 avoidable deaths due to poor care. In addition, the report found that nursing staff had submitted 1,722 incident reports on poor staffing levels which had not been acknowledged or responded to by the trust's senior management. It is of serious concern to the INMO that a similar environment now exists in Ireland with the same adherence to budgets, realisation of targets and contraction of frontline staff which led to negative findings in mid-Staffordshire. Our members tell us daily that their documented expressions of concern about patient care are being ignored by senior management due to a fixation with meeting budget targets and WTE ceilings.
The comparative survey was undertaken on a wholly independent basis by Dr. Keith Hurst and his team based in the United Kingdom. The survey involved a detailed sampling of wards in the four specialties of general medicine, surgery, elderly care and admissions and assessment. The number of wards sampled in each specialty is set out in the table in the opening statement document circulated to members. The difference in the number of wards sampled per speciality is explained by reference to the overall size of the respective health services. The methodology employed in the survey involved the collection of data from a cross-sample of medical, surgical, elderly care and admission and assessment units and, or, wards in hospitals of similar size and complexity; the analysis of this data with reference to the size of ward, grade and skill mix and patient acuity; the measurement in comparative terms of man hours per patient, staff per occupied bed, and the application of these measurements to a standard 25-bedded ward in both countries.
Appendix 1 to the copy of my opening statement as circulated to members provides a single-page summary of the findings of this survey which confirms that Irish wards, without exception, are larger in terms of bed numbers which, of itself, has significant nursing workload implications. The summary also states that the average 25-bedded Irish ward as compared to its UK counterpart has fewer staff as follows; six fewer surgical ward or unit staff; 3.5 fewer medical ward or unit staff; 13.5 fewer admission and assessment units staff; and 3.25 fewer elderly care ward staff. The average roster on these wards sees clinical areas operating with between one and two fewer staff members at all times over a 24-hour cycle as compared to UK counterparts. According to the feedback and responses from nurses in Ireland, the staffing deficit is negatively affecting patient care and increasing staff burnout, absenteeism and overall fatigue. We also set out in the appendix a tabulated breakdown of the staffing reality with reference to staff per occupied bed; total care hours available on a ward per week and the resulting ward complement on a 25 bedded ward. In addition, we have also detailed in a comparative sense the implications for a ward by reference to a sample daily roster of staffing on mornings, afternoons and night shifts.
It is necessary to remind the committee of a number of matters in order to contextualise the comparative survey. As a direct result of the public service recruitment moratorium, the number of nursing and midwifery posts in the public health service has fallen from 39,006 at the beginning of 2009 to 34,614 currently. This is a loss of 4,392 posts or 11.5%. The reduction in posts has taken place in an uncontrolled manner and has been particularly severe over the past 12 months due to the volume of retirements which took place in the weeks leading up to 28 February 2012. In the same period, the public health service has reduced the number of health service support staff, including ward clerks, health care assistants and ward support staff, from 18,517 to 17,142. This is a loss of 1,375 posts or 7.5%. The contraction in numbers within these grades has further depleted the number of ward-based staff which, in turn, increases workloads and negatively impacts upon the time available for patient contact, overall patient care and safe practice. During the same period - primarily under the clinical care programmes - the acuity and dependency of patients in these wards increased significantly. The reasons for that are as follows. There has been increased throughput as the number of day procedures has increased from 675,162 in 2009 to 804,274 in 2011. There has been a decrease in the average length of stay from 6.4 in 2009 to 5.8 at the end of 2012 and an increase in the occupancy rate from 89.3% in 2009 to 91.2% at the end of 2012.
Bed occupancy of over 80% is internationally recognised as overcrowding. The continuing closure of beds, acute and non-acute means that we now have 2,469 beds closed throughout the country. The source for that information is our own bed count, not an external source. In addition to these specific measurable increases in productivity, we have also seen the introduction of specific targets at hospital level, including no patient waiting longer than nine months for admission and a maximum of six hours' waiting time, from presentation to either admission or discharge, in emergency departments. Both of these increases, while welcome, have further increased the pressure upon surgical, medical, admission and assessment units.
In recent years, successive Ministers, the Department of Health and the HSE have consistently and repeatedly stated that Ireland is "rich" in the number of nurses we have per 1,000 of the population when compared with fellow OECD countries. This is wholly incorrect, seriously misleading and not borne out by any serious examination of the real manpower figures.
In 2002 the Department of Health and Children undertook the first large-scale study for workforce planning which provided a comprehensive approach to the issue of nursing and midwifery workforce planning inclusive of 118 recommendations. This report identified and corrected one of the most significant misconceptions in relation to our nursing and midwifery resource, which suggested that Ireland had one of the highest ratios of practising nurses per 1,000 of the population at 16.5. The Department’s own text states that this figure was significantly inflated and the actual figure was 10.8 per 1,000 of the population and 8.04 in the public health service. This correction, however, is consistently ignored by the Department of Health when making public comment.
Furthermore, in the context of the impact of the recruitment embargo, summarised earlier, and the current population of Ireland, the INMO believes a more relevant measure is that of employed nurses in the public and private health service which is as follows. The number of nursing and midwifery posts in the HSE is 34,614. The number of nurses and midwives in the private sector is approximately 10,000 which, minus the number of midwives in public and private hospitals, leaves 2,200, giving a total of 42,414 nurses employed for a population of 4.6 million. Therefore, the ratio of nurses per 1,000 of the population is 9.22. This falls within the average ratio found by the OECD and fails to take into account the following: the unique demography of the Irish population, that is, the percentage over 65 and percentage under five which places pressure on the hospital system; the reduced level of acute beds per 1,000, resulting in high acuity, dependency and overall turnover; and a very high bed occupancy rate which, internationally, would be accepted as ongoing overcrowding.
It should also be noted that, in Ireland, the undergraduate nurse or midwife, when undertaking a rostered placement, is counted as 0.5 of a whole-time post. This confirms their inclusion as an integral part of the qualified nursing workforce despite the fact that they are not registered nurses and midwives. In comparison, the UK excludes all reference to undergraduate nurses and midwives undertaking clinical placements when they calculate their nursing and midwifery numbers.
This Registered Nurse Forecasting, RN4CAST, study funded by the European Union also found that the Irish nurse per 1,000 population falls within the average OECD ratio. The RN4CAST studied features of hospital environments which impact on nurse recruitment, retention and patient outcomes in approximately 500 general acute care hospitals in 12 European countries, as listed in the document submitted to the committee. The study found that workforce planning in the Irish health service and for nursing in particular has been limited due to poor information on public health workers and inadequate availability of information on the supply and demand of health care workers in the private and voluntary sectors. The RN4CAST found that the determination of staffing levels on Irish wards with 30 participating hospitals was reported to be largely historical for 24, not based on a formal system for 25, variable across wards in 23, reviewed regularly in almost half the hospitals - 14, not determined by reference to benchmarks in 17, not set to match existing benchmarks in 20, not set to exceed existing benchmarks in 28, not matched to patient acuity or dependency in 21, somewhat based on informal review of patient acuity in 18, and not planned on a shift-by-shift basis using patient acuity or dependency in 23. The need for a comprehensive approach to strategic workforce planning for the health service is becoming more evident. There are no set or recommended nurse to patient ratios in Ireland and workload assessment tools, staffing systems and workforce planning techniques are varied and lack integration. The World Health Organization states that "the formulation of national human resources for health (HRH) policies and strategies requires evidence-based planning to rationalise decisions".
In every economic downturn, and particularly where cost containment is required in health, nursing and midwifery staff are often seen as a target for cost saving rather than being an essential part of the solution. The current emphasis is on crisis management as opposed to a planned strategy of how best to use existing valuable resources like nursing and midwifery. Over decades research studies across the world, as detailed in appendix 2 of our submission, have established a direct association between lower nurse staffing and higher mortality; adverse events and poor care; less effective and efficient care; and higher fatigue and burnout. Lower staffing associated with higher patient mortality has been identified in numerous countries, including the USA, England, Switzerland, Belgium, China and Taiwan. Poor nurse staffing practices are associated with increased incidence of a range of poor patient outcomes, including increased rates of pneumonia, rates of urinary tract and surgical site infection and pressure ulcers. Lower nurse staffing is associated with longer lengths of stay, as well as increased rates of readmission to hospital after discharge. Both readmission and longer lengths of stay increase health care costs.
Internationally, it has been demonstrated that poor staffing levels increase the risk of burnout among nurses. This in turn increases the risk of poorer patient care. This has also been supported by the RN4CAST research across the 30 participating Irish hospitals which found 77.6% of staff reporting that there was insufficient staff to get all the required work done, 74.9% reporting there were inadequate numbers of registered nurses to provide quality care, and 42% of nurses surveyed reporting high levels of emotional exhaustion.
A number of research studies have also shown that increasing the number of staff with lesser qualifications will not bring about the same care improvements as increasing the number of registered nurses. Similarly, poorer care outcomes have been associated with lower proportions of registered nurses in the staffing profile. The RN4CAST survey found in relation to grade mix of staff on the last shift that Ireland had a 72:28 ratio of nurses to support staff and the UK ratio is 70:30. This further rebuffs the perception that Ireland is "rich" in nurses.
In this comparative survey and associated research, the INMO has sought to outline, through the use of wholly independent sources, the very serious staff shortages and deficits which now exist in critical areas of our hospitals throughout the country. The comparative study itself has confirmed our worst fears as it has identified in surgical, medical, care of the elderly and admission and assessment units that our staffing levels are significantly below those of the United Kingdom. These staffing deficits are undoubtedly at this stage compromising both the quality and quantity of care available to patients and the ability of registered nurses to provide safe care through safe practice.
This situation continues to worsen due to the current application of the public service recruitment moratorium and the policy, imposed by Government, of further contraction of staffing in our health service, which this year alone demands a further 2,500 net loss of posts. We respectfully suggest to the committee that this cannot continue and this unmanaged approach to staffing on the front line must cease.
Arising from this study, and the compilation of related research, it is also possible to state the following. Ireland does not have an oversupply of nurses compared with the OECD, and the actual number of nurses employed falls within the average range. At a ratio of 72:28 of registered nurse to support staff, our grade mix is very similar to that which applies in the United Kingdom where it is 70:30.
However, this fails to take into account that all of the support staff, included in this ratio in the United Kingdom, have undertaken standard vocational-type further education. Staffing levels, in our wards, continue to vary, considerably and would appear to be based on historical factors rather than any qualitative estimation of need or measure of patient acuity or dependency. This cannot continue and needs to be addressed as part of the ongoing reform and reorganisation of our health service.
Associated academically-proofed and wholly independent research continues to record the growing fears of registered nurses that patient care is being compromised on a regular basis arising from this low staffing level and that burnout and fatigue resulting in absenteeism are now significant problems for nurses. All measures brought forward to address this critical staffing shortage must ensure that adequate numbers of registered nurses remain in the clinical area, as international research shows patient outcomes are improved and enhanced when the required level of registered-nurse presence is maintained.
It is the view of the INMO that the health service must fundamentally alter how it determines and maintains adequate staffing levels on wards, which ensure the best outcome for patients and safe practice for registered nurses. In this context and having studied many other jurisdictions, it is our view that the best and ultimately most cost-effective way of doing this is to introduce mandatory nurse-patient ratios. It is therefore our request that once the committee has studied, examined and analysed this comparative study and related international research, it would initiate discussions with all the relevant stakeholders on bringing forward the required regulation which would introduce mandatory nurse-patient ratios. This would ensure consistent care standards and patient outcomes throughout our health system regardless of geography or any other factor. We believe this reform is of greater relevance and importance than the constant attention being given to the reform and reorganisation of management structures while hospital wards and units are left understaffed and overworked.
I thank the Chairman and members of the committee for affording us the opportunity of this meeting this morning. I thank them for their kind attention and we will now try to answer any questions or queries they have.
In fairness, Mr. Doran went to the trouble of giving a very in-depth presentation for which I thank him. I take the opportunity to pay tribute to nursing and midwifery staff in hospitals and in the community for the Trojan work they do. We appreciate they are valued members of our public service. On a personal level, I thank Mr. Micheál Dineen and Ms Patsy Doyle for their hospitality and their ongoing communication with me in Cork. They are two fine people who do great work for the INMO, for which I thank them.
I join the Chairman in welcoming the INMO delegation this morning. I commend Mr. Doran on his presentation and on taking the initiative to commission and publish this report. It is a very valuable aid to the members of the committee in our respective roles here in the Houses of the Oireachtas in addressing the very obvious staffing deficiencies in our hospital network. It confirms from international research the adverse impacts, as Mr. Doran has documented, of understaffing in our hospitals, including increased mortality as outlined in a number of the reports. This impact is firstly and most importantly on the patient. However, we are also very conscious that it has a significant impact no front-line staff - not only nurses but also hospital doctors. We are very conscious that is stretching them to the limit in their workload. It is not an overstatement to say that the overwhelming number of them are coping only through heroic efforts.
The report focuses on international research. Can the INMO delegation give us a picture of the current impact of understaffing in our hospitals? Can they give us some insight into the realities of their members' experiences because of the current inadequate staffing levels? While the contribution is huge, I ask for elaboration. We know of the short-term impact, but if the recruitment embargo is to remain in situ what are the medium to long-term consequences of the current hospital understaffing? Will the recently announced intention of the Minister to relegate newly qualified nurses to some spurious trainee status-----
I believe I have been very careful in how phrased this. I would be very conscious that if proceeded with, this will compound current and projected difficulties. I invite the INMO delegation to reflect on that.
Yesterday on the "Liveline" radio programme a succession of nurses and junior hospital doctors outlined the reality under which they were working. They described excessive and unsafe hours. Later yesterday evening I discussed with some of my colleagues what they had heard. Some of the situations described suggest that the reality presenting in some hospitals is beyond the law and that what is required of nurses and junior hospital doctors is unlawful. Has the INMO considered taking appropriate action to address this in a challenge to what is legally permissible and legally safe at the very extremities? Clearly there are extremes within the accepted range, but some of what was described yesterday goes beyond that. Might that not be another form of address of what is an intolerable situation for nurses, doctors and patients?
On that point, Senator Colm Burke has commissioned a report on the role of NCHDs and as part of the committee's work programme for this year we are considering their working hours and conditions.
Deputy Séamus Healy:
I welcome the delegation from the INMO and thank them for their in-depth presentation. I wish to put on record my appreciation and thanks to nursing staff throughout the country and particularly in south Tipperary, where I have worked closely with nursing staff over a 20-year period. The presentation referred to crisis management in our hospitals and health service. Last night and this morning one of the hospitals I managed for more than 20 years has 26 patients on trolleys in the emergency department, in corridors and offices off the emergency department, and indeed in the atrium of the hospital. At the same time that hospital has had approximately 30 beds closed. I am speaking about South Tipperary General Hospital. That is clear evidence that there is now effectively crisis management in our hospitals.
There is no doubt that in recent years the face of nursing and the provision of services in hospitals has changed. That has put huge pressure on staff generally and on nursing staff in particular. That so many beds are closed and that we have lost so many nursing staff - almost 4,500 nursing staff have gone in recent years - is causing enormous difficulties and more nursing positions are ear-marked for reduction in the coming year. This, coupled with the move to more day-case treatments and reductions in the length of stay for patients has changed the face of nursing and placed enormous additional pressure on nursing staff throughout the hospital system.
In the context of this independent report, which contains international comparisons, it seems there are now no regulations or guidelines for staffing levels on wards in Irish hospitals. Has there been any engagement by the HSE or by the Department of Health with the INMO, or with staff generally, regarding the setting of agreed standards and ratios for hospital wards? How does the INMO believe the existing recruitment moratorium and the continuing reductions in staff will affect the current situation? I imagine it will create an even more difficult situation. I will not ask about the graduate scheme, Chairman, but how does the INMO feel the availability of opportunities for nursing abroad will impact on the availability of nurses here?
I should put on record that it is not that we are not going to discuss the graduate scheme but rather that the request came in last November from Mr. Doran that the committee would discuss this particular report. We were very happy to facilitate that request. I do not want people to think we are shying away from any discussion but the specific request was that we discuss this report. To be fair to the committee members, we agreed that this topic would be the sole item on our agenda today. It is an important report and that is why we facilitated this discussion in early January.
I thank Mr. Doran for his very detailed presentation. As someone who has several family members working in both the medical and nursing professions, I am very much aware of the difficulties that exist in our hospital system. I am approaching this from the budgetary point of view and in 2011 and 2012, the total budget for health care exceeded the total amount of money collected in income tax. This year, as I understand it, the budget for health care will be approximately 90% of the total income tax take. Over the last number of years, despite the downward trend in terms of tax yields and the budgetary constraints under which the Government is operating, increments continue to be paid in the public sector whereas in the private sector, salaries have decreased by as much as 40%. If one takes the legal profession, for example, on average, young solicitors have experienced a drop in salary of up to 40%. In terms of the way forward in the health sector, we are not going to be in a position to increase the budget, certainly in the next three to four years. In fact, we will be very lucky to hold the budget at its current level. In that context, how can savings be made in some areas so that we can actually maintain, if not increase, the levels of front line nursing staff in the system? I agree that there are enormous demands being made of those in the front line. The INMO's own report gives a very comprehensive overview of changes in the level of day-care, where the number of procedures has increased from 675,000 to over 804,000. The number of outpatient appointments has increased also from 2 million per annum to more than 3.5 million. There have been huge changes which have placed huge demands on staff. Nevertheless, we still have a budgetary problem and I would like to hear suggestions from the INMO on how the budget could be more carefully managed so that we can maintain, if not increase the number of nursing staff in the system.
I thank Mr. Doran and members of the INMO for their presentation this morning. The most frustrating aspect of the health service, for those on the front line and for members of this committee examining the system is that we see the HSE managing the cents while, at the same time, haemorrhaging thousands of euros in the way in which it operates the system on a day-to-day basis. The report before us today clearly undermines the general impression that there are too many nurses in the system. We have seen how the large numbers of nurses who retired last spring has impacted on the numbers of agency staff being used, which is unsustainable. I wish to ask the witnesses about the vacant posts within the system. On foot of the retirements last year, the HSE gave approval to managers, on a case-by-case basis, to sanction individual posts-----
It is relevant in the context of staffing numbers in the hospital system. These were key posts that were part of overall staffing numbers. The presentation today was very much about decision making, about who makes staffing decisions and about the fact that it should be nurses who make them. Approval was given to fill a number of key nursing posts deemed to be critical to the day-to-day operation of hospitals. That was shelved last August when the new moratorium was introduced. The Department has given the impression that the new graduate scheme will fill those vacancies. Is that the case? Will that scheme fill those critical posts or how will it address that issue? The problem now is that in many hospitals, including one in my own area, patients are being transferred to private nursing homes because of staffing difficulties.
On the issue of the registered nursing forecasting system funded by the EU, a very telling point in the study was that there is a very poor level of information on public health workers and that the information that is available is inadequate. Is it not the case that the inadequate compilation of information is allowing individual hospitals to cook the books, so to speak, regarding what is happening on the ground? I have given evidence here, backed up by the HSE, that a particular hospital was actually managing the trolleys in order to undermine the trolley count. In light of that, does the INMO believe more investment is needed in the collation of information so that we know exactly what is happening. We should not have to rely on the INMO to fund independent research in order to get this data.
In the context of the registered nursing forecast findings, the point was made that the ratio in Ireland relative to the UK is roughly the same, with a difference of about 2%. However, that 2% equates to approximately 1,000 front line nurses. The INMO has made the point that there has been a lot of vocational training provided to support staff, who number about 30%, in the UK. Is the INMO making the case today that as well as dealing with the challenges that we have regarding recruitment, there is room to improve efficiency by having properly trained support staff who could release nurses back onto the front line, as has been done in the UK?
Despite the moratorium on recruitment in the HSE, some 720 nurses have been employed in the past two years and 186 of those have been in the mental health area. The salary in the United Kingdom for nurses starts at £25,000. New graduates are being offered posts at up to €25,000. The most important thing at the moment is the health of the patient. The HSE employes 35,000 nurses. It would be a fantastic opportunity for these nurses to take up these posts. I recognise that it is 80% of the salary of a normal nurse.
Mr. Liam Doran:
As a Kilkenny man who has been resident in Louth for the past 30 years and who is happily married there, I will give Deputy Fitzpatrick the benefit of the doubt, apart from stating that I fundamentally and absolutely disagree with his critique with regard to the graduate programme, but I will return to that in a moment.
Mr. Liam Doran:
I will try to cover the ground as best I can and perhaps my colleagues will fill in the gaps on the issues raised. We could come here and be alarmist and suggest that it is horrendous and people are being compromised and deaths are being caused and so on, but we have steadfastly stayed away from that. One of the first questions asked was about the impact of the staffing levels upon the real world of health care every hour of every day. The Irish Nurses and Midwives Organisation, INMO, has advised all members to submit what we call disclaimer forms to their management whenever they find their ability to provide safe care is compromised. These are being submitted on a daily basis, sometimes two and three times per day, in most hospitals throughout the country as we speak, because the registered nurses in situ maintain they cannot provide the care. In our submission we said our fear is that this is a sign or symptom of the mid- Staffordshire situation, which was ignored repeatedly. The views of front-line staff were ignored and the end product was an adverse care environment.
I have one question about front-line staff being ignored. Is it fair or correct to say that the HSE officials do not engage with front-line staff or they only engage with the umbrella organisation?
Mr. Liam Doran:
Let us set aside the INMO. They do not engage with directors of nursing at management level now. It is not a question of staff nurse or ward sister level. I am referring to the arguments of directors of nursing about the need to replenish staffing levels and to have the right skills and grade mix. These people are being ignored. The INMO will do its job but I am more concerned about when a head nurse in hospital X believes there is a need for an additional supply of the right skills and staff and that is denied them by people further up the ladder.
Mr. Liam Doran:
It is like this in the health system at the minute. We always try to be balanced. In fairness, local general management are being beaten all the time and they have an impossible problem to solve, because they may have posts to fill but they may have no money to fill them or they may have no money but they may have posts. One way or another they cannot answer the demand. They are avoiding the additional staff. This is the reason we commissioned the study in this area. There is a perception that most of the health service is made up of intensive care or coronary care area or the oncology services in the country and so on, but the vast bulk of health care is delivered in the ordinary areas such as a medical ward, a surgical ward or an elderly care unit. It is not necessarily the hi-tech intensive care or coronary care areas. It is precisely these areas that are being totally dissipated of the quality of staff they require and these areas have been shown up in the comparative study.
I try not to be too alarmist but the embargo has been an abject failure by downsizing our health system in an unmanaged way rather than allowing patient care to always determine that the right person is in the right place at the right time at the right grade to perform the right task on the patient. It has been uncontrolled and it continues to be uncontrolled. We have lost 11.5% of our workforce. I respectfully put it to colleagues present that an 11.5% loss of workforce, regardless of whether one factors in changes in work practices, increases in productivity, more flexible rosters and so on, must produce a give or compromise somewhere. That is the ordinary levels of care required by patients which are going undone by nurses and which is a source of concern to them.
I will not go there now but this is one of our pleas today. Our greatest fear at the moment is that there is no bottom line for our health care system and no one who will draw a line and say we will not go below it. It is because we do not have nurse-patient ratios. We have examined the idea of nurse-patient ratios long and hard. They are not the automatic solution to all of our difficulties, but they set a minimum whereby at least there is a commonality of standard whether I am in Donegal, Wexford, Dundalk or Bantry. We maintain this must be applied in Ireland. At present, what manager A says is safe may be deemed unsafe by manager Y for various reasons. There is simply no common standard. Many of our staffing levels are based on history, geography and whether one had influential people in situ over the years. We realise these are the realities. I put it to the committee that the comparative study has thrown up the deficits that exist. The deficits continue to worsen and to standardise the situation or put some foundation on it we maintain we must consider, debate and bring forward nurse-patient ratios to give a standard which would apply regardless of the hospital.
I will not go into the issue about graduates other than how it relates to the comparative study. We are not simply discussing the number of nurses. Within any grade there must be a skills mix as well. With respect to Deputy Fitzpatrick, if it were as simple as he has described we might all have an engagement but ultimately the employment of the graduate programme is only redirecting moneys currently given to agency employment towards graduate employment. There are no additional man hours.
When people refer to 35,000 and 36,000, I respectfully suggest that it is mere imagination. There are 36,000 people in the system already, albeit 34,500 in official whole time employment and up to 1,500 employed every day via agencies and so on. One cannot simply get rid of 1,200 experienced nurses and replace them with new graduate nurses, who will not have the mentorship and support envisaged in a graduate placement programme, and suggest nothing has been lost. There would be skills, expertise and experience lost by such a change. This is another thing wrong with the graduate programme apart from the 80% and so on. I genuinely and sincerely put it to Deputy Fitzpatrick that not one additional hour will accrue to any ward arising from the programme. They are displacing experienced staff and replacing them with new graduates. That is not a solution in a situation where short staffing already exists.
The committee should understand that we have not had our head in the sand on the issue of training. In 2007, we agreed with the HSE on job descriptions for health care assistants, based on a level 5 FETAC programme, a general job description and some specialist jobs descriptions for maternity, theatre and elderly care.
Nothing happened uniformly. The INMO does not have a difficulty with a 70:30 mix at ward level. We understand a ward cannot be staffed solely by nurses and that it would be wrong to do so. It would be a waste of time and not be a proper use of resources. Equally, there can be a ratio of 80:20 in some places and 60:40 somewhere else. There are no minimum educational criteria for support staff. If a nurse delegates to them, it is necessary to know that they are competent in certain basic areas such as in making daily observations, for example. We do not have a difficulty in engaging and embracing that dialogue, but there is no one on the opposite side of the table. We have agreed job descriptions and to the level 5 FETAC programme, but the system has not delivered the quantum of people required through that programme to put it back in situat health care assistant level to complement the nurse and take delegated duties from him or her. That is necessary and I plead with the committee in that regard.
I will deal with Senator Colm Burke's point, but when we engage with the health system, all we ever hear about is the extended role of the nurse, whether it be undertaking intravenous canulation, catheterisation, phlebotomy or first dose antibiotic therapy. We would embrace all of this. However, there has to be a safe cohort of people who have received vocational training and are ready to take up the slack. All we hear is that the nurse will do more, but there are no plans for the evolution of care from the health care assistant's role through vocational training. It is an excellent proposal and would be a brilliant addition for ward staff to have a 70% cohort of nurses or midwives and to grow towards reducing the reliance on the non-consultant hospital doctor. In particular, I suggest relying on non-training NCHD posts is not a cost-effective way of providing care in many of our smaller acute hospitals. We will participate, but it has to be in a continuum and planned. We are up for it, but all we get is talk about budgets, money, the lack of clarity and the nurse having to pick up the slack all the time. I will say unapologetically to the committee that this cannot continue. The nurse cannot be regarded as dispensable when it comes to filling posts but in the workplace regarded as the person who does everything that has not been done.
On the question of budgets, we are having a conversation in another place about what the Government is seeking. Like other public sector unions, we aim to put our best foot forward. However, with respect, I am a bit tired of hearing that, somehow or other, the public sector has got away scot-free in carrying the burden of recovery. We are talking about the new graduate programme and there was a cut of 24% before we even started. This does not include the numbers that were cut, the changes in rosters and work practices, as well as the expansion of the nurse's role. The new graduate, just like the nurse who has been qualified for ten or 20 years, is subject to the same regulations, correctly so. There is no difference between the person who has been a registered nurse for one day and the person who has been registered for ten years. All a patient wants to know is whether the person concerned is capable of performing procedures correctly to a high standard. The public has a right to have this measured by An Bord Altranais or the new nursing and midwifery board of Ireland. We have put our best foot forward on the issue of savings, although I know that is an argument for another place. After pursuing a degree course lasting four years, a nurse earns €26,700 - if the correct salary is paid - a salary that has already been cut by 24%. He or she will be asked to work all the hours God sends and required to be very flexible. In my view, the persons concerned have put their shoulders to the wheel and, correctly, will be measured to the same level of acuity, proficiency and perfection as every other nurse.
I have tried to cover all of the points raised. Have I left anything out?
I accept Mr. Doran's point about the cuts in salaries across the public sector. There have been cuts of 40% to 45%. I compared the public sector with the private sector and increments continued to be paid after the cuts were implemented, with which I have no problem. However, there is a contracting budget. In fairness to the health service, nurses, junior doctors and consultants have made significant compromises in an attempt to maintain the same level of service. The best example is the maternity care service in which the number of deliveries has risen from 55,000 to 75,000 a year, without a great increase in staffing levels. We also have one of the lowest perinatal mortality rates in Europe. The service continues to be provided, which is not in question. However, how can we move forward, taking into account all of the difficulties encountered? I asked the HSE to supply the number of junior doctors with contracts of six months, 12 months and two years, but it was unable to supply the information. The system has been in place for 25 years and we have done nothing to change it.
Mr. Liam Doran:
The only law is the European working time directive in terms of how it is applied to NCHDs, non-consultant hospital doctors. It is an absolute disgrace that this country has still failed to comply with the directive in the case of NCHDs, years after the derogation was worn out. We are now liable to penalties. It is all down to a failure to grasp the nettle in terms of numbers, rosters and the roles involved.
Mr. Liam Doran:
The number of hours worked by NCHDs outside the average figure of 48 hours continues to grow. There are two reasons for this. I do not want to be misunderstood when I say this, but the numbers of NCHDs and medical staff have been maintained throughout the embargo period, which is wholly proper. However, the numbers of nurses and support staff have dropped. This has meant that the pressure has fallen more on NCHDs in the out-of-hours periods. I refer to the abject failure to redefine in a planned way the roles of nurse and health care assistant. If these roles were redefined, there would not be a need to call a doctor at 4 a.m. to perform a relatively simple task which the nurse should be empowered to do. The ward should be staffed appropriately to carry out such tasks. The problem on the other side is that there are no laws in place with regard to what should be the workload of staff. I do not wish to be alarmist, but as a citizen of Ireland, I genuinely and honestly say to the committee that I am fearful of where the health service is going in terms of its ability to look after me when I get sick, as the staff are being stretched. They do not have the time they need to perform procedures properly. They are documenting this, but it has been ignored or forced to be ignored by managers who do not have the money or the posts-----
Ms Claire Mahon:
Frequently the director of nursing will bring forward a business case to general management, but there is no guarantee that it will be acted on or that anything will be done. They may even redeploy someone from another area of the hospital temporarily, which will leave that area short.
Ms Claire Mahon:
Not necessarily. The INMO has been running a safe practice campaign around the country for the past 18 months at its own expense and which is free to members. The campaign is focusing on clinical risk and completion of clinical risk forms.
It is about the nurse protecting herself. Somebody commented that it is not about the staff but that the link between the nurse and patient outcomes is integral. One does not have good patient outcomes if one does not have the quality of staff. According to feedback we receive, although people fill in the clinical risk forms, staffing shortages are frequently not used as an excuse for something that has happened. The productive ward series, which is being brought out within our hospital level, aims to maximise the amount of time the nurse can have with the patient instead of carrying out other duties. Even through the small amount of data from the productive ward series, it is possible to correlate increases in falls with drops in staffing numbers. One frequently finds the same number of staff on duty in hospitals during the day as during the night, although the day workload is excessive. This is due to staff shortages. Patient outcomes and the burnout level among nurses are affected. Somebody spoke about the length of shifts. Nurses frequently tell us that once they have had their lunch break at 2 p.m., they work until 9 p.m. and may not get a cup of tea because there may be three nurses on duty dealing with 30 patients and a turnover of patients. That all leads to an increase in infection and we know we have a significant issue with infection across our hospitals. It also leads to an increase in falls and pneumonia. The significant factor is the mental exhaustion experienced by the nurses. They do report these issues but they do not see anything happening on the ground because people put their hands in the air and say they cannot do anything about it because of the budget. Nurses are faced with such decisions on a daily basis. They are facing the public on the front line and taking the criticisms but are powerless to do anything to make this better apart from refusing to take additional patients into their wards. It is coming to the stage where that will probably happen. We are there to protect the nurse but are also there to protect the patient.
Ms Geraldine Talty:
I will address the question about risk forms and the filling out of incident forms when one finds one's self without adequate numbers of staff to provide safe care. The difficulty is that in many hospitals, when one fills out the risk or incident form, which is for a near miss, sets out that A, B and C are going to happen if one is not provided with another nurse, health care assistant or member of staff and sends it to the risk manager, business managers and other people, while the director of nursing may endeavour to get more staff in view of all the international evidence about staffing numbers, one must go through hoops, roundabouts and unbelievable paperwork to get somebody who is not a nurse to make a decision on behalf of the nursing profession about whether the risk form is adequate or not. Many people are filling out forms - some of us are better at filling them out than others - but those of us who fill out a lot of them do so because we see the difficulty at ward level. The people making the decisions about staffing numbers are not nurses, which is why we need to have directors of nursing making decisions about nursing, staffing levels and patient safety.
We cannot get away from the fact that everybody and anybody will tell one that it is nurses who are the glue holding the health service together at present and in the past. The Minister agreed with us on that and said that the people who keep the health service going are the nursing staff. To answer Senator Burke's query, the difficulty lies with the budget. When we qualify and train, all we are ever taught, and all that is engendered in my bloodstream as a registered nurse, is patient safety and putting the patient and quality first. Unfortunately, the people in charge at the moment put the budget first. One cannot put the budget first if one is trying to put patient safety first. To answer the question about how we might save money, all the evidence in Ireland, from the RN4CAST and internationally for years and years is that when nursing numbers are cut, as they have been in Ireland, with a view to saving money because of budgetary constraints, the patient impact is so great that there is definitely an increase in the number of patients who fall and get pneumonia and urinary tract infections. After a fall, a patient may not be able to go back to live in his or her own home. It can cost a fortune in respect of having fractured femurs fixed and requirements to go to the operating theatre. There is also the question of the general impact on them and their re-entry into society, because the majority of people who fall are over 70. The difficulty is that antibiotics must be used for pneumonia and urinary tract infections. There is also an increase in the number of pressure ulcers if there is a reduced nursing staff.
If one increases the number of nursing staff to the levels we are asking for, guided by international best practice, one will save a fortune. Things are extremely unsafe at the moment due to the numbers with which we are working. We are working with one hand tied behind our back, which is impossible in nursing because it is very labour-intensive. We are not being recognised for the job we do on a daily basis. The consequences for patients are detrimental. It is definitely dangerous; I cannot use another word. What we and the patients are being put through every day is dangerous and not right. We are responsible and accountable, unlike other people who are not in the nursing profession and who are making decisions about those incident forms. These people cannot be struck off the register of nurses tomorrow morning because they made a mistake. Yet we are being prevented as registered nurses and midwives from doing our job, which is to ensure patient safety, care and quality. A fall-----
Mr. James Geoghegan:
I thank the Chairman and committee for inviting us here today. I am a staff nurse on a medical ward. Since I qualified ten years ago, I have seen a gross deterioration, particularly in respect of staffing levels. I had a quick look at my ward yesterday as I was working. This time 12 months ago, we had a whole-time equivalent, WTE, of 23.5 for a 31-bed ward. We were told 12 months ago by our managers that this would be reduced to 22.5 and would affect all wards. Yesterday, our WTE was 19.8. This obviously has a compromising effect on our patients in respect of giving timely care and observing them. We have definitely seen an increase in falls in all the wards.
In response to Deputy Fitzpatrick's question, I will not bring up the graduate nurse and midwife programme, but I have worked in Australia with a different staff-patient ratio, and I did not encounter one fall in the five months I worked there. We see falls on a weekly basis in our hospital. I would certainly tell graduates to go to the sunny climes of Australia or to Canada.
When I was training, I had a nurse preceptor, a person who embodies nursing. When I see her coming to me in tears telling me that this is not nursing, that what she is doing is firefighting and that she goes to the chapel in the morning before she goes to work to pray that nobody dies on her shift, it is a sad state of affairs. We are feeling overwhelmed. I sent two risk forms down yesterday morning. One of my colleagues had to go down to the emergency department so I rang my assistant director of nursing to inform her that we were now short and looking for assistance. She had no nurse to give us and we were told to get on with it. We send our risk forms but feel we face a culture in which it is thought we should not be saying these things and in which one is marked out as a troublemaker if one does highlight these things. We are trying to show that a risk exists. I read the report on the Mid Staffordshire NHS Foundation Trust and my fear is that we are slipping slowly into this. We will look back in five or six years' time and ask why nobody said "Stop". Staff nurses are trying to say it through the risk forms and our disclaimers but feel we are on the floor and are not being heard.
Mr. Liam Doran:
My colleagues can enunciate it in the real world rather than through the words I am trying to articulate, but I would like to make three points to the committee. I do not want to get political about savings, but if we are really talking about the Irish public health system and all the changes facing it, notwithstanding the agreement announced before Christmas, our drug costs are still unsustainable vis-à-vis those elsewhere.
There may well be an overseas employment dimension to this. We need these companies and they are very good employers. However, the health service cannot be made to suffer because we are obliged to pay overinflated prices as a result of the quid pro quo. In the context of the debate on funding within our health system, I sincerely and respectfully suggest that this is not factored in to a sufficient degree to explain what we actually spend on direct staffing costs, patient care, etc.
While it is not directly related to this matter, we are of the view that there is another important point which must be made. We are always appealing for a nursing perspective to be brought to the areas of decision making, leadership and so on. The chief nursing officer post in the Department of Health has been vacant since 28 February last year. That is almost 11 months.
Mr. Liam Doran:
It was 28 February of last year. Nurses and midwives comprise 35% of the total health service workforce. In that context, we must work to find the most efficient and effective way of delivering quality care to patients. We cannot be aloof and stand apart, we must be part of the solution. However, leadership is required in that regard. In my view, not having a chief nursing officer in the Department for almost a year-----
Mr. Liam Doran:
Yes. There is also a chief dental officer and so forth. We have no problem with the chief medical and chief dental officers. They are both excellent individuals. I am merely making the point on behalf of my organisation that even though nurses and midwives comprise 35% of the health service workforce, there is no chief nursing officer.
Mr. Liam Doran:
No, there has never been a deputy position. There was previously a nursing unit that was very well staffed and in which my colleague, Ms Adams, was employed. However, there is now no nursing and midwifery unit in the Department and, as already stated, the post is vacant. In addition, there are no support posts. That renders still poorer the analysis, critiquing and determination of policy. In my view, there is no way the Department would have developed the flawed graduate programme if a chief nursing officer had been present to outline the reality of what is likely to happen as opposed to focusing on the budgetary arithmetic involved.
Mr. Liam Doran:
Okay. We can come before the committee and articulate, as stridently as possible, the staffing deficits we believe exist, the compromising of care, the excessive workloads, the bizarre manifestation of embargoes and how what happens is unmanaged and unplanned. A man who runs a major airline would not let everyone go on a given date and still suggest that the airline could continue to operate the following day.
Mr. Liam Doran:
He might but the regulations would come into play. We genuinely suggest that we must engage with the committee and other stakeholders. Some type of uniformity must be achieved in respect of the skill mix and grade mix issues and also the nurse-patient ratio in order that there might be a bottom line. There must be a spectrum whereby patients can expect from nurses the same standard of care, and broadly the same conditions, whether they are in hospital in Dundalk, Sligo, Wexford or wherever. At present, we do not have this. We need those ratios and the relevant discussion in respect of them must take place. This committee is in a powerful position in the context of stimulating that discussion. We understand that we must engage in it. Others will also have an interest in it. We have arrived at the conclusion that without the ratios I referred to, we will never have a standard safe environment right across the spectrum of ordinary specialties. I do not refer here to high-end specialties, I am referring to ordinary surgical or medical wards, care-of-the-elderly facilities, etc. The latter are the settings in which the majority of care is delivered and in which that care is being most compromised at present.
I do not wish to engage in a major debate at this point but are the nurse-patient and other ratios being discussed in the context of the new negotiations on a successor to the Croke Park agreement?
Ms Clare Mahon:
I wish to focus on the level of burnout among nurses. If one considers the age profile of the people who left last February, one can see that we have lost a good ten years' worth of experience out of the workforce. The majority of the individuals who left were in their early to mid-50s. We have, therefore, lost a massive number of senior and experienced staff. We do not have staff coming along behind these people to gain experience. At ward level, there is a very poor skills mix. I am not referring here to nurses and health care assistants in this regard, but to the level of experience among the nurses working on wards. This has a major impact on patient outcomes. It must be recognised that nurses are going home each day both exhausted and worried and that this is a real problem. After all, nurses operate at the coalface and they witness the problems that exist. Mr. Geoghegan indicated his belief that we are heading towards a scenario similar to that which obtained at Mid-Staffordshire hospital. I am of the view that, were the truth known, we have already arrived at that scenario. The reality in this regard is not being acknowledged.
I thank our guests, Mr. Doran, Ms Mahon, Ms Talty, Mr. Geoghegan, and Adams for their attendance, for their engagement with the committee and for their excellent, thought-provoking and challenging presentation. I also thank them for commissioning the study. There is no doubt that we are living in challenging times and it is important that the committee should understand and recognise the pressure and demands being placed on nurses, midwives and public health nurses. We must also recognise the significant change that those our guests represent have brought about in the delivery of health services. At a time when there has been a great deal of, in many cases, unfair criticism of public servants, nurses and those in the other health care professions have delivered major changes. It is important that the committee should reflect no just on our guests' presentation, but also on the testimony they have provided during these proceedings. I refer, in particular, to their request in respect of the nurse-patient ratio. We will certainly reflect on the comments that have been made and on our guests' presentation.
I again thank our guests for giving of their time to come before us. I wish to place on record our appreciation of the work done throughout the country each day by the people they represent. The nature of the relationship between politics and trade unionism at times does not allow us to recognise the humanity and professionalism displayed by and the humanitarian work and caring done by nurses each day in our hospitals. Anyone who engages on any level with the health service will agree that the INMO's members are a credit to it and to the hospitals in which they work.
I wish to again place on record my thanks to Mr. Michael Dineen and Ms Patsy Doyle in Cork for the great work they do. As our guests will be aware, I work very closely with Mr. Dineen and Ms Doyle. We do not agree on everything but we do engage in respect of the relevant matters.
Mr. Liam Doran:
No, all I wish to say is that we do not want a situation to develop whereby in six months we will be asking where have all the flowers gone. We want to retain these graduates. Every profession needs young people to come along and challenge those who have gone before them. I thank the Chairman and members for their time and attention. We would be happy to engage further with them at any time. As already stated, the major issue we must confront is the ratios.
I remind members that next Thursday's meeting will be in private session. We will be dealing with the issue of our three-day hearings. The select committee will also meet to deal with the Public Health (Tobacco)(Amendment) Bill 2013. The time at which the select committee will meet will be made known to members during the week.