Jerry Buttimer (Cork South Central, Fine Gael)
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I remind committee members, delegates and those in the Visitors Gallery to switch off their mobile phones or leave them in flight mode because they interfere with the broadcasting of proceedings. I welcome those watching the meeting via UPC or on the Oireachtas website. Deputies Catherine Byrne, Peter Fitzpatrick, Eamonn Maloney and Robert Dowds have sent their apologies.

The purpose of the meeting is to discuss the HSE's new implementation plan under the Haddington Road agreement. As members know, the general secretary of the Irish Nurses and Midwives Organisation, INMO, Mr. Liam Doran, wrote to the joint committee requesting a meeting at the earliest possible date. I apologise to members for the early starting time and put everyone on notice that we must vacate the committee room by 1.30 p.m.

I invite Mr. Doran to make his opening statement.

Mr. Liam Doran:

On behalf of the Irish Nurses and Midwives Organisation, INMO, I formally thank all members of the joint committee for kindly agreeing to meet us. This will allow us to outline our very serious and substantial concerns arising from the latest proposals from the HSE under the Haddington Road agreement. I stress that none of our concerns arises from industrial relations issues; they all have their origins in the questions of safe care, safe practice and equality of patient outcomes.

As members of the committee will know, the Haddington Road agreement, to which I will refer as the HRA, runs for three years, commencing on 1 July 2013, and represents the second phase of efforts to reduce public expenditure in these difficult economic times. In particular, it provides for health service staff to work additional hours for the duration of the agreement, a review of rosters and skills mix to ensure optimal deployment of staff and other measures aimed at ensuring an efficient and effective but quality assured and safe public health service.

At the outset the INMO ask the committee membership to note that it is formally acknowledged by management that nurses and midwives and all other staff in the health service are fully compliant with their obligations under the HRA. At this time there are no serious disputes in any workplace or location with regard to the implementation of the various measures sought by local management under the agreement. Notwithstanding this level of compliance, on 13 May, HSE senior management at the health service oversight body - a body established to monitor implementation of the agreement - brought forward, without prior consultation or engagement, additional measures to save a further €80 million. This is in addition to the €212 million already saved under the agreement. All of these measures are targeted to impact on front-line staff, particularly those working on the 24-7 cycle, and were presented without any impact or risk assessment or safety audit.

In response to these measures which are detailed in a document entitled, Stage 3 Implementation Plan, the INMO immediately indicated its grave concern at the impact of the proposals on the ability of professional staff on the front line to deliver safe care to their patients and clients. The organisation has written to the Minister for Health, the two Ministers of State at the Department and the director of quality and safety in the HSE asking for immediate engagement on these issues, leading to a comprehensive review of what has been proposed.

In that regard I would ask the committee to note that we are due to meet with the director of quality and safety and the director of nursing-midwifery services, in the HSE, on next Monday, 23 June 2014 and a meeting has been arranged with the Minister for Health, Deputy James Reilly for Tuesday, 21 July 2014. However, in the interim, the HSE continues to work to implement these flawed measures and that is why we have asked for this urgent meeting with the joint committee.
In its latest implementation plan the HSE has stated it intends to initiate a number of further measures, all of which will impact upon front-line staff and services, in pursuance of a further €80 million worth of savings. We wish to reiterate that despite the fact that nurses, midwives and health service staff are fully compliant with the agreement, these proposals have been brought forward, in complete breach of the Haddington Road agreement, without any consultation, discussion or any level of engagement. In specific terms the INMO has grave concerns over the following measures: (i) the further reduction in frontline staff numbers; (ii) staff substitution; (iii) alteration to skill mix; (iv) replacement of public health nurses, PHNs and community RGNs with new graduate nurses under the graduate programme; and (v) reduction in nurse management grades in the care of the older person-disability services.
The HSE has indicated, both in the latest implementation plan and in its annual service plan for 2014, that it intends to reduce, by a further 3,400 posts, staffing within the health system. Under the latest implementation plan it is quite clear that no nursing or health care assistant post that falls vacant, in the front line, will be filled other than by graduate nurses or intern staff under two specific programmes within the HRA.
We would respectfully point out to the committee that this is an untenable manpower policy as it fails, completely, to recognise the need for specialist staff, in many critical areas in the frontline of the health system, the required mix of experienced and new staff and the need to ensure adequate and appropriate skill mix in all areas of the health system.
A blanket ban on recruitment, other than through two intern schemes, is fundamentally flawed, injurious to patient care and will certainly negatively impact upon patients'-clients’ welfare, and, ultimately, outcomes.
The recent proposals explicitly state that all qualified nurses, midwives and trained health care assistants should be replaced by interns, under the support staff internship programme, without any reference to patient acuity and dependency or, indeed, any input from the director of nursing or midwifery responsible for the service.
This measure, which was again brought forward without consultation, will severely compromise the statutory obligations of every director of nursing and midwifery both under their code of practice, as a registered, regulated nurse or midwife, and, under the various standards, laid down by the Health Information and Quality Authority, HIQA. It is not tenable to suggest that all vacancies that arise, in acute-continuing care disability services, can be filled by staff, notwithstanding their excellence and commitment, recruited under the support staff intern programme. To suggest that this can lead to best patient outcomes is, quite patently, false and nonsensical.
The latest plan explicitly states that the health service, in relation to care of the elderly and disability services, will move, without reference to any stated dependency tool, to a 40:60 skill mix, that is 40% registered nurse and 60% support staff regardless of patient-client acuity or dependency.
On this measure we would ask the committee to note the following: The Haddington Road agreement does not stipulate that there should be, as a maximum, a 40:60 skill mix ratio in any service. The agreement stipulates that “All staff will co-operate with measures to achieve the most cost effective skill mix and staffing ratios to meet service needs. An intensive engagement process will begin immediately to review existing skill mix and staffing ratios to ensure that these identified needs are met”.
The previous stated policy was a mix of 50:50. No consultation or engagement has taken place, with regard to this fundamental change in policy. Furthermore, as of today, the INMO has not been informed as to what dependency tool has been used, to arrive at this 40:60 policy, nor is there any commitment to engage in discussions on this pivotal issue. The implementation of this measure, in the front line, arising from this central diktat has the effect of removing, from directors and assistant directors of nursing and midwifery, all of the autonomy they need to ensure staffing levels and skill mix are appropriate to meet the full needs of the patient-client population.
Our experience and feedback to date, from directors and assistant directors who have been subject to review under this latest plan, has been that they have been told they must introduce the 40:60 skill mix without delay; this must be done through the replacement of all staff, who are absent for whatever reason, with interns under the intern support programme; failure to implement this measure will lead to the closure of that public facility and do they want responsibility for that to lie on their conscience; and failure to deliver the 40:60 skill mix will see them lose their authority to recruit agency staff.
This diktat, from central management in the HSE, also compromises the statutory and related obligations, of a director or assistant director, under the following standards and codes:the National Quality Standards for Residential Care for Older People in Ireland; the National Standards for Residential Services for Children and Adults;the National Standards for Safer Better Healthcare; and their obligations as a registered and regulated professional under the Code of Practice laid down by the Nursing and Midwifery Board of Ireland, NMBI.
The committee must note that it is not open, to a director or assistant director, to ignore his or her obligations under these standards. However arising from the latest HSE proposals he or she will be placed in an impossible situation which cannot be left outstanding. It is a simple fact, proven and reaffirmed by reports of adverse incidents in this country, similar reports in other jurisdictions and international research, that the local director or assistant director of nursing must have the authority, and autonomy, combined with accountability, to maintain safe services. This cannot be done if she or he is subject to such absolute direction from the centre.
The latest HSE proposal explicitly provides that all vacancies, arising from the departure of PHNs and community RGNs working in the community, must be filled by new graduate nurses employed under the graduate programme. This is again a fundamentally flawed measure which will gravely impact, upon already overstretched primary care services, for the following reasons: No one should expect a new graduate to have the experience or competence to work, as a lone worker, in the community immediately following registration. It is worth noting that during the four year undergraduate programme, there is one week only of community placement and sometimes that community placement can be in an environment such as sheltered employment and not necessarily on home visiting. Yet this plan states that all vacancies from October will be filled by newly graduated nurses. It is a well accepted standard that health professionals must have three years experience, post initial registration, before they can work alone in community services. It is also a requirement, under the HRA, that all graduates, recruited under the graduate programme, will have adequate mentorship and support and this is simply not possible if they are working in community locations; and it is also worth noting, but admittedly from a different perspective, that any graduate nurse, employed in this capacity would have to have their own transport. In view of the salary that applies to the graduate programmes, I think the members of the committee would have to acknowledge that the purchase and running of a car, to provide services for the HSE, is abject nonsense.
It is worth noting that the only mention of management grades, in the entire HSE implementation plan, is when it states it is intended to further reduce the number of nurse management posts in the care of the elderly and disability sectors. There is no mention, in the document, that other areas will have the number of management grades reduced or de-layered. In view of this we would ask the committee to note the following: all international experience and research indicates that when nurse management grades are reduced, with a resulting increase in the span or areas of responsibility for the remaining management grades, one reduces standards and compromises care. The same evidence suggests that properly empowered nurse and midwife managers, who also hold high levels of accountability, ensure best practices, best policies and best outcomes for patients.
The national standards which exist, particularly those brought forward by HIQA, explicitly require that a person in charge, PIC, be nominated, by the HSE or provider, who will hold responsibility for standards and environmental factors in that location. It is not possible to fulfil this stipulation, laid down by HIQA as a statutory body, if one does not have a designated person in charge, in the form of the director or assistant director in each work location. However, notwithstanding this reality, the latest HSE plan quite clearly stipulates that the person in charge will not be resident or located, in the individual workplace, but will still have overall accountability. This is simply an impossible task.
In the view of the INMO the latest HSE plan represents further attacks upon front-line services and, by extension, the quality of those services which will be available to patients or clients. All of the proposals, geared at saving a further €80 million, are specifically, and solely, targeted at the front line. No cost saving measure is identified, from any other area of the health system, with the result that only the 24/7 services are carrying the total burden.
It is also worth noting, and this is a particularly critical issue, that the HSE is saying, in its plan, it must further reduce its agency spend.

However, when considering this issue, we ask the committee to note the following: the HSE only incurs a high volume of agency spending because of the ban on recruitment into direct employment laid down by government policy; in order to overcome this policy while still living within their employment control numbers and maintaining a safe service, local managers are having to recruit agency staff to fill absolutely essential vacancies - they have no other option if they are to protect patients and provide the range of services that are being demanded by the community and by Government; and by definition, a sizeable proportion of this agency spend will, therefore, be on the front line, representing nursing, midwifery, medical or support staff costs. Therefore, it is fundamentally unfair and unjust to expect the grades in which this agency cost is incurred to carry the full burden of cutbacks and contraction whenever further money is to be saved. Front-line staff do not make Government policy regarding recruitment and therefore they should not be asked to shoulder in an unfair, onerous and unjust manner the consequence of an initially flawed policy which has to be ignored to some extent by local managers in order to maintain safe care.
In presenting our concerns to the committee, we are acutely aware that they can be portrayed as self-interest by a vested interest. In that regard, it is appropriate to remind the committee that a significant body of accepted research findings both nationally and internationally confirms the benefits to patients of safe and adequate nurse staffing levels in clinical areas. In that regard we attach to this submission a paper entitled Safe Staffing - The Evidence, which critiques the research done in this area in a concise and focused manner, and the RN4Cast survey, an overview of research evidence.
With regard to Ireland, the most recent research, which is underpinned by similar work in the European Union, is the RN4Cast report published inTheLancetearlier this year. This research found the following: every one-patient increase in patient-to-nurse ratios was associated with a 7% increase in deaths; and a 10% increase in bachelor degree nurses, which is the standard qualification in Ireland, is associated with a 7% decline in mortality. In commenting on the Irish results of this European-wide study, the renowned expert and academic in this area Professor Anne Scott, deputy president of Dublin City University, commented:

Our results suggest that the assumption that hospital nurse staffing can be reduced to save money without adversely affecting patient outcomes may be misguided, at best, and fatal at worst. This is crucial information for hospital managers given the significant reduction in nurse staffing in Irish hospitals since 2008 and particularly in light of the ongoing moratorium on staffing.

Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome Ms Claire Mahon, INMO president, Ms Geraldine Talty, second vice-president, and Ms Grace Murphy, who represents undergraduate student nurses. I also acknowledge the presence of Ms Helen Butler, Ms Karen Clarke, Mr. Darren Ó Cearúill, Ms Mary Walsh and Ms Phil Ní Sheaghdha in the public gallery.

The committee has no role in negotiations on behalf of any organisation or union, particularly in the context of the Haddington Road agreement. We also have no role in industrial relations matters involving Mr. Doran's organisations and the HSE. It is important that the INMO be allowed to appear before the committee to outline its views, and that is why we had this meeting. I am sure that, as part of our discussion on how we respond to Mr. Doran's presentation, we will form a view about what to do at a later date.

Billy Kelleher (Cork North Central, Fianna Fail)
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I apologise for being late. Like some nurses, we are a bit overworked in my party and short of resources and so on.

Mr. Liam Doran:

I hope the Deputy has a union.

Billy Kelleher (Cork North Central, Fianna Fail)
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We need a good union.

Jerry Buttimer (Cork South Central, Fine Gael)
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I hope the Deputy's party will be under-resourced for a long time.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome Mr. Doran's comments on the Haddington Road agreement. The agreement provides that all staff must work two additional hours per week. What is the best way to implement this change, not only in the context of the impact on INMO members but also with regard to the impact on patients, outcomes and productivity? If two additional hours were done every week in, say, 20-minute slots, as opposed to a system under which everyone works an additional day every now and again, better outcomes would probably be achieved in respect of health services and productivity, but it would have an impact on INMO members. What are Mr. Doran's views on how best to implement the additional hours? We have to accept that the Government is limited in the amount it can put into health services. As an Opposition Member, I would like more money to be allocated.

Every day we look at the trolley counts and the numbers of people waiting in accident and emergency departments throughout the country.

We also look at the fact HIQA has brought forward reports which leave a lot to be desired in terms of patient safety in emergency departments throughout the country, the impact that is having on the provision of safe care and also the stress and pressure that INMO members are working under.

When I hear talk of comparatives, I am always a little confused because, in comparison to other countries, on one matrix, we have very good representation in terms of the nurse-to-patient ratio but, on another matrix, we have a very poor representation. Are we always identifying the same number of allied health professionals and nurses so we are comparing like with like? Could the witnesses suggest a country where we would be exactly comparing like with like in order to see how we perform in terms of the ratio of nurses to patients? Any assessment would show that the more nurses there are, the better the patient outcomes, as has been acknowledged in the detailed research on this issue.

On another area highlighted by Mr. Doran, when professionals say they have concerns about patient safety, they should be listened to. This is an area where I find that, very often, we do not listen. Consultants have said they are concerned about patient safety due to pressures in hospitals, including communicable diseases, overcrowding and many other associated problems. INMO members have known for quite some time that there is a major concern. Why is there not a more vocal outpouring from INMO members? I do not mean from Mr. Doran personally, because he is fairly good at that, in a positive way. However, is there some fear of reporting among INMO members? That is what I am trying to get at. INMO members are front-line staff on the wards of our hospitals throughout the country and they see issues they are concerned about. There is a reporting mechanism in place whereby they would fill out a form and relay that to management. Is there a fear or a concern that, if they do report, it could damage them in a professional capacity? Is there loose intimidation or a threat hanging over them that would explain why they are not coming forward in the numbers they should be, in view of what we know is happening in our health services? I would be interested to hear Mr. Doran's observations on that issue.

The Haddington Road agreement, industrial relations and what flows from that are for another ministry, the Department of Public Expenditure and Reform. However, the Department of Health also has a key role to play in this area and it cannot completely absolve itself from industrial relations. If the Department of Health does not provide enough funding through the Vote, it then falls to INMO members to make extra sacrifices to ensure the health services can continue. While many of us suggest more resources are needed, there seems to be an obsession with the Department of Health carrying an excessive cut that is over and above what would be deemed normal, even in extraordinary times, particularly given that an extraordinary figure of €4 billion has been taken out since 2007.

Has the INMO a view on the number of front-line staff versus administration and management? We cannot always just throw staff at a problem and there has to be a time when we prioritise the use of staff. When one considers the ratios in the HSE, there seems to be a lot of administration and management, yet the cuts seem to be falling on the front line all the time. I find it hard to understand why we consistently pare back the front-line services and staff before we look at the whole administration apparatus. We know it is a legacy issue from the amalgamation of the health boards and all of that, although my memory of the creation of the HSE was that the first question on everybody's lips, from all sides, was whether the Minister could assure people there would be no job losses. This is an area of concern. I would be grateful if Mr. Doran could address those issues.

Jerry Buttimer (Cork South Central, Fine Gael)
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Before I call on Deputy Ó Caoláin, I should acknowledge the presence of Oona Sugrue in the public gallery. I apologise for missing out her name earlier.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Cathaoirleach in welcoming the INMO delegation. As a committee, we recognised the urgency of hearing them on receipt of their request to come before the committee. I want to thank the Cathaoirleach and the secretariat of the committee for accommodating this at the earliest opportunity.

On that point, I note the INMO wrote to us on the same day it wrote to the Minister and the director general of the HSE. Has it received substantive replies from either the Minister or Mr. O'Brien? What is the status at this point in time of its request for a meeting with the Minister? The letter to Mr. O'Brien indicated a willingness, as always, to meet and engage. Will the witnesses advise where that might stand one full month later?

Without question, the members of this committee had a shared concern in regard to the situation Mr. Doran outlined. We regarded it as something that threatened grave consequences for patient care and safety, which would be one of the primary areas of concern in this committee. Having heard the INMO submission this morning, I have to say I am as alarmed as I was when I first read its communication. We are talking here about reductions in front-line staff numbers on top of all the reductions that have been imposed, particularly in the nursing sector, since 2008. We are looking at a situation of a reduction of the level of care for older people by trained nurses with substitution that has no basis in consideration, never mind agreement, it would be fair to say. This is totally unacceptable.

As a Dáil Deputy, I have no doubt the experience is replicated in the story of any of us here, Deputies or Senators. We are being exposed to the detail of very poor situations presenting, with not only poor outcomes but poor experiences, which are not a reflection on the professional commitment of those who are giving the service in a variety of hospital and other settings. However, it is indicative of the absolutely impossible situation that such a significantly reduced cohort of people are being expected to cope. That is the great difficulty and it will only be exacerbated by the measures the HSE has indicated, which will spell further misery for patients.

Mr. Doran said he would not accept it, which is good, because somebody needs to take a stand. We are at a very serious point. There are serious matters under address by risk advisers at various hospitals up and down the country, including in my own back yard, on a scale that might never have presented in the past but is presenting today. These cause great concern and worry in terms of public confidence. If the proposals are proceeded with, it will have a further negative impact on public confidence.

How do the INMO representatives see the practical outworking of the HSE proposals, if that is the right phrase to employ? For example, in hospital wards predominantly occupied by older people, how will this transpire?

What stance will the Irish Nurses and Midwives Organisation, INMO, take to ensure this plan does not develop? The representatives of the INMO are here today but what plan of campaign do they have? The seriousness of the situation must be impressed upon those involved and they must know the INMO will not countenance this.

I am interested in the response of the witnesses to the letters of 15 May. I hope to speak again at the end of this meeting but I wish to indicate that this meeting is only an opportunity for a hearing. I hope the joint committee acts appropriately at the conclusion of this meeting with the INMO. Depending on Mr. Doran's reply to my first set of questions, I think we should take appropriate unified action as a committee to urge the appropriate responses from the Minister and the director general of the HSE. I will better construct my proposition when I hear the detail of Mr. Doran's reply

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Deputy Ó Caoláin and, as I said at the end of my remarks, this committee will consider its response when it has heard all the evidence. I acknowledge there are no representatives of the HSE here today and due process demands we hear from all concerned parties. Today we will listen to the guests in attendance.

Jillian van Turnhout (Independent)
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I thank the Chairman and thank the witnesses for their submissions, which were very informative and comprehensive. The submissions answered many of my questions by outlining a problem and drawing attention to different areas. We are all concerned about reductions in front-line staff and staff substitutions. I was particularly concerned by the alterations that have been made to the skill mix, as was outlined. I read the note circulated by the witnesses and see that policy has changed from a 50:50 division to 40:60 and this refers to a maximum so the figures can be even lower. This especially applies to services for the elderly and disabled.

The Chairman has outlined the process of these discussions so I will also ask the following question of the HSE. Who set this policy and how is it determined? Having visited many different centres I know that the needs of patients vary as does the mix of patients. How is any figure set, be it a 50:50 division or a 40:60 division? It seems like an arbitrary process when some centres do not require a significant mix of skills sets and others may have many high-dependency patients that need a specialised skill mix.

I spoke to some nurses I know prior to this meeting and they all raised the issue of the moratorium on recruitment and the difficulty it has created. As a consequence, there has been significant spending on agency nurses. We all know this is an issue so I wonder why the moratorium continues. Is it the case that if the moratorium was lifted flexibility to adapt the skill mix would be lost? I think this issue should be faced.

Another matter regularly raised is the increased administrative burden imposed on nursing staff by the Health Information and Quality Authority, HIQA, and others. Everyone stresses that the changes are welcome but repetitive form-filling takes nurses away from patients and this has increased in recent years. Professional staff are being taken away to do repetitive administrative work when other areas could be examined in terms of savings. I would welcome the views of the witnesses on this because it is a view I have heard.

The study presented by the witnesses on safe staffing raises issues such as length of stay and poor care and these issues must be examined as they are interrelated.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Senator van Turnhout and I will now call Mr. Doran.

Mr. Liam Doran:

I will answer questions in the order in which they were asked.

Jerry Buttimer (Cork South Central, Fine Gael)
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If members wish to intervene they should do so but we must leave this committee room by 1.30 p.m. Perhaps Mr. Doran could keep his answers short as he was given latitude with the opening statements.

Mr. Liam Doran:

The latitude of the Chairman knows no bounds. A delicate line must be walked and we come before the committee today with no industrial relations perspective on this issue. We will deal with industrial relations and the ins and outs of the Haddington Road agreement in time but this is not an industrial relations matter for the INMO and it will not be solved through traditional industrial relations methods on disputes. This is about the quality of care people receive at 6 a.m., 2 p.m. and 11 p.m. Will the right person bein situ to look after the needs of those people? We will not turn this into an industrial relations dispute because we must turn the ship around through professional persuasion and so on.
All nurses and midwives are obliged to work 1.5 extra hours under this agreement and they are doing so in a manner that was agreed by local management. The new rosters are in place since 1 July 2013 and they have been implemented in a mixture of ways but local management has been involved and everyone is working the extra man hours.
On the issue of HIQA and trolley count, trolley count is a form of measurement that is issued by us every day and is accepted by the HSE and the Department of Health. I believe the system has been anaesthetised so that it is difficult now to understand the plight of individual people. Some 5,900 people were on trolleys in the first four months of this year and this is down 15% on last year, which is good. It is down 24% on the figure from two years ago and that is even better. However, this year's figure is up 27% on that pertaining to 2007, when trolley overcrowding was called a national emergency. I make this point only to show that everything is relative. We made these points with regard to the emergency department, ED, in Limerick every year from 2005 to 2012, inclusive. We welcome the latest HIQA report but why did it take so long to address an area that is patently unsafe for patients and staff and is replicated in other emergency departments around the country?

Jerry Buttimer (Cork South Central, Fine Gael)
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If that was the case five years ago and Mr. Doran's remarks are correct then this issue is not just a matter of resources.

Mr. Liam Doran:

Not if "resources" refers only to staff. There are major issues relating to areas such as bed capacity, step-down facilities and primary care. The problem in Limerick was exacerbated by the reform programme that remodelled facilities in Ennis and Nenagh without educating the public on how to use them. Due to this members of the public are still filtered to Limerick although their minor injuries and so on could be dealt with in Ennis or Nenagh. The preparatory work was not done. The reconfiguration was done in haste and patients are repenting, though not at their leisure.

A good point was made on nurse staffing and the irony of the situation in which we find ourselves. I will raise a compare and contrast scenario for the committee. On the Friday of our recent annual conference the Secretary General of the Department of Health attended on behalf of the Minister for Health because he was ill. He announced that the Department is to establish a workforce on nurse staffing. This is to be the first step in the collective agreement to stabilise the nursing workforce and is to be in tandem with the military workforce forum that was established after the Portlaoise tragedies to stabilise the military workforce.

We had that announcement on a Friday about nurse staffing, and we had the midwifery workforce up and running. The following Tuesday, the HSE produced this plan to replace nurses with interns and community nurses with new graduates, or else to downsize nurse management structures and care of the elderly. The organisation is therefore fully entitled to make the point to the committee - and the newly appointed chief nursing officer has stressed it, too - that we had the potential to arrive at a stabilised nursing workforce underpinned by best evidence and correct utilisation of the nurse-patient ratios. We had a 12-month timeframe in which to do it and were all committed to it, and then, four days later, the HSE announced its plan, which had no engagement, uses no known dependency tools and rips up everything that currently exists. That is what we find frustrating.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is it safe assume that there was joined-up thinking between the Secretary General at the Department and the HSE? Would the Department have read and known that this was done?

Mr. Liam Doran:

Yes. I was not at a meeting between the Department and the HSE about the workforce and nurse staffing, but I can suggest with fair confidence that it was aware that the announcement was going to be made. That was completely contradicted and turned upside down three days later by the statement. It is very hard to cite two countries where the skills mix and professional matrix for registered nurses at degree level are comparable. For example, what qualifications are required? Is there a second licensed nurse? Is there a qualified HCA? What level of qualification is needed? It is very hard to compare like with like, but we were trying to grasp that nettle in a proper way over the next 12 months. This plan rips it asunder. We wanted the stability of being able to do that in 12 months, but the HSE came along and announced all the cuts in the here and now. It renders questionable how valuable that exercise will be. We will participate fully. Midwifery is in very bad order in terms of numbers and we need that to be addressed. We will always turn up and participate, but it breaks one's heart to turn up and participate over here and the HSE is initiating draconian cuts without engagement over there.

Jerry Buttimer (Cork South Central, Fine Gael)
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Has that process commenced? Has there been communication with the INMO on it?

Mr. Liam Doran:

Yes, it is about to commence.

There is a fear of reporting. Registered nurses and midwives are reticent about coming forward and voicing their concerns. They are beaten up by the workloads they carry. We encourage our people to put in disclaimer forms where they believe that the system is such that they cannot provide the full range of services required by the patient if there are delays, for instance, in medication rounds, after-care procedure or post-operative mobilisation. If they are being compromised by shortages of staff, one has to document them. It does not happen as much as it should and that is because there is a sense among nurses that they will be put upon if they highlight such concerns.

The contradiction in all this, and it was mentioned by another member of the committee, is that documentation, which is the heart scald of nurses and midwives at the moment, is being received all the time, but the problem is that, when something goes wrong, the system looks only for the written word. If it is not written down, it did not happen. That is the bottom line of measurement of patient interaction. Everything that one now has to do might be subject to subsequent investigation. Therefore it has to be written down. HIQA insists on a strict regimen of forms and, because nurses are in the front line and are there 24/7, they are the profession that has to do it. However, no account of that is taken by those who would staff up the system to ensure that it was all done in a timely way.

Ms Claire Mahon:

Nurses' decision-making is often overruled by others and, on occasion, that can be by non-qualified clinical personnel. If one looks at our community settings, one sees that public health nurses in particular have a large amount of documentation to complete on a visit to get services for an elderly person. Often their assessment can be overruled by a non-clinical person purely on a financial basis. We do also have nurses in the hospital setting who will have their judgment questioned and have clinical risk issues sent back to them with a request to downgrade them.

Jerry Buttimer (Cork South Central, Fine Gael)
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Can Ms Mahon give members an example of who would question that?

Ms Claire Mahon:

Unfortunately sometimes it may be by their nurse managers, sometimes by risk managers and sometimes by general managers. Every nurse is obliged to use her own clinical judgment in every situation and this must be taken as one situation in isolation. They can feel very intimidated at times when they complete risk forms.

Mr. Liam Doran:

One of the greatest difficulties we are facing at the moment when we talk about documentation is the HIQA inspections where a person in charge is designated. That person is always the senior nurse in the house. There are many reports where the person in charge is named in a manner which seems to say he or she is an unfit person to be the person in charge. However, that same person in charge will have a paper trail as long as one's arm pointing out that environmental factors and staffing numbers short-change patients and investment is required. That does not come from the area, general or sectoral managers - it is the nurse who is named in an external report. The registered provider, the HSE, is a corporate entity and the only person who is identified as having failed is the person in charge, who is the registered nurse. Nurses have had their autonomy taken away slowly in recent years but this document completely robs them of it because they must move to 40:60, they must substitute with the intern programme etc. That is patently wrong. They cannot do both things; they cannot live with the HSE instruction and at the same time deliver safe care through the exercise of their professional judgment. We might not agree with every director of nursing's professional judgment - we might say it should be even better - but they call it and each registered nurse under that director is entitled to express concerns, fears or whatever. That is the code of practice laid down by the statutory body and that is completely disregarded by the HSE which does not seem to understand that a registered, regulated professional has obligations to his or her employer but also to his or her professional body to maintain best practice for patients.

This point is important to put on record. We wrote to the HSE; we received a letter last Friday from the director general who has indicated total satisfaction with the proposals, that they were subject to scrutiny, he was happy with the scrutiny and that patient care is central to all of the HSE's decision making and the plan stands. He also said if we had difficulties they could be processed through the Haddington Road structure. Obviously that was a disappointing letter. We met yesterday under the Haddington Road process. I raised the subject of the letter and again the HSE advised that this is being driven by various sectoral, divisional directors and that it was satisfied that patient care was not being compromised by the proposals etc. That is where that matter lies.

As I outlined in our document, we are due to meet the Minister on 21 July on the back of our letter and we are to meet the director of quality and safety with the HSE next Monday because we are anxious to find out what involvement that directorate had with the drawing up of these divisional plans. We know that nursing and midwifery in the HSE had no involvement in that, which again poses a question about scrutiny, how they were quality assured and safety assessed. We will continue to examine that.

On the development of the campaign, the INMO has an absolute view that what is required to stabilise our health system in a quality assured way that maximises patient outcome is to stabilise the front-line workforce. There is absolutely no floor at the moment below which management feels, because of financial constraints, it should not go. I state that clearly. There are no norms; what is acceptable at one level is unacceptable at another. We are striving to reach a position that we have norms and that regardless of whether one is in Letterkenny, Cavan, Kilkenny or Bantry the same broad skills mix and staffing levels apply.

It is the only way we can do this and it must be informed by international evidence and fair comparison. That is what we thought the workforce would do, but while we are trying to do that, this is cutting at the front line.

We have already met the Irish Patients' Association and will meet other patient groups, disability groups, support groups and the National Federation of Voluntary Bodies. We are trying to mobilise and get collective about it. I am not being smart, and I do not mean to be injurious to anybody. Last week, Stephen McMahon of the Irish Patients' Association said publicly that the report on University Hospital Limerick and the patient journey being experienced there requires the same prioritisation by the Government as the medical card issue. The problems with our health system do not begin and end with the urgent need to address the medical card issue but begin with capacity, bed numbers, access, primary care and staffing. We will mobilise on this campaign, trying to highlight the deficits that already exist that would be further exacerbated by the proposed changes.

The changes on the community side are inexplicable. The Department suggests that from 1 October we will have earlier discharge from hospital, maintenance of independent living at home and maximisation of the independence of the individual, but then says all public health nurse, PHN, and community registered general nurse, CRGN, vacancies should be filled by new graduates who have had one week of experience during their four-year undergraduate programme. They will become a significant minority in the public health and community nursing work force. That is not right. It is not a question of INMO's opinion. It is fundamentally flawed, and whoever drew it up knows nothing about community nursing services.

Jerry Buttimer (Cork South Central, Fine Gael)
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Up to now, what experience did a nurse need before taking up such a post?

Mr. Liam Doran:

A public health nurse has the registered general nurse, RGN, qualification, probably five years' experience and a higher diploma in public health nursing, which is a full-time course including a work placement. The community RGN would have five years' experience in public health nursing. All that is being cast aside by this throwaway comment in the document. The impact of it beggars belief at a time when we want to try to shorten patients' length of stay and maintain independent living, which requires more experienced people in the community who will assess not just the physical presentation but the psychological and environmental factors. We want more PHNs to do this, not graduate nurses entering the system.

Senator van Turnhout asked who sets the policy on the skill mix. I would like to know. Under the Croke Park agreement, the Department of Health and the HSE produced a document that said it should be 50:50 in care of the elderly. Suddenly, on 13 May, it became 40:60. Because we were not involved in any discussions, and are unaware of any nursing or midwifery involvement in them, I cannot answer the question. I agree that in any proper approach to this the skill mix cannot be set in stone. I could have a house with very mobile people who are independent in daily activities, and the mix could be 30:70, while in another house it could be 70:30 if they are all very acutely ill. We want to work with the HSE to achieve a situation whereby the nursing workforce in care of the elderly facilities perform a much wider, expanded range of duties, such IV fluid balance, blood transfusion and first-dose antibiotics. They all need to be done to minimise the unnecessary transfer of elderly people into acute environments where they will be disoriented. We will work towards that, but it cannot be done looking down the barrel of a cutbacks gun which says the ratio must be 40:60 and we are lucky to get it. We do not know who sets the policies.

Much is said about management grades in the health system. We want to be very clear. There is not an oversupply of front-line clerical administration posts in our health system. We need the front-line staff - administrators, ward clerks, reception staff in emergency departments, medical records people - because if they are not there, nurses have to pick up the slack, further taking them away from the bedside. The middle and upper management layers of the health system have become very maze-like and complicated for the senior nurse-manager to navigate through to get to the people who might free up the purse strings and address the clinical issues. Directors of nursing would be driven to dementia trying to weave their way through the matrices at the higher level of the system. The front-line grade 3 and 4 staff do pivotal work at ward level, such as medical record administration and emergency department and outpatients administration, and if one does not fill those posts, nurses have to pick up the slack, which is a poor use of a nursing resource. Last week, HIQA criticised the management of Wexford General Hospital for postponing infection control and hand hygiene training because a nurse went on maternity leave and could not be replaced.

There is no quick fix. We have travelled a terrible journey in the past five years, but what they propose for the next 12 months will take us to a place to which, with the greatest respect to everybody, the INMO cannot go quietly. We must highlight it and challenge the system. Today is an excellent opportunity for us to do that. We are not quoting industrial relations and we will never get into that because this is about care, patient outcomes and the empowerment of the nurse, who has accountability for money and everything else, to do the right thing in the right place at the right time. This plan completely turns it upside-down.

Regina Doherty (Meath East, Fine Gael)
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I thank the witnesses for attending. I have 12 questions, and while they may seem antagonistic, I do not mean them to be. It is a great pity we do not have the other people here so that we could put opposing questions to them. With respect, it is an IR issue, because all the concerns the witnesses raised existed when they sat down to take out the first €213 million that some mad loony agreed to take out of health under Haddington Road last October. While the issues may be exacerbated when we seek to take out the extra €80 million, they are not new.

Due to my ignorance, I have many questions on the research. Compared to other EU or OECD countries, Ireland has one of the largest proportions of nurses per 1,000 people. I have great respect for Professor Anne Scott, who is a neighbour in my village. She stated that to increase the patient-to-nurse ratio in the field of service would increase mortality by 7%, but, although we have done that in the last number of years, through no fault of the witnesses', our mortality rate has not gone through the roof. It is not very much different from other countries which have fewer nurses per 1,000 patients than we have. It all boils down to the skills mix. Mr. Doran said he would love to know where the plan is because he does not have the evidence. Somebody, somewhere must have the evidence of best practice in skills mix.

We spend much more than everybody else but still complain about it. Pick a country that spends a relatively decent amount of money on its health service, gives a good service and has a good skill mix, and put it in a matrix to compare it to ours. Please tell me somebody, somewhere, has done that. When the witnesses meet at the beginning of the year they should all have the same sheet of paper that says the best practice is, say, 10:1, the INMO wants it to be 11:1 and the HSE wants it to be 9:1, and they can argue over it and meet in the middle. I am hearing that there is no such piece of paper, and, therefore, the discussions about where to pare off the €80 million are done with no statistics, analysis or evidence of best practice from an international or OECD perspective. If that is the case, how do the parties negotiate with no starting point?

As a patient, if I did not understand the difference between a nurse in a white uniform and a nurse in a green uniform I probably would experience no difference in care because of the superb quality of care given by undergraduates, trainees or nurses with 20 years' experience.

Is the skills mix we are trying to achieve to secure the best value for money such that we would not need to have a ratio of ten patients to one nurse, that we could have, say, a ratio of 12 patients to every nurse as long as the nurse had a trainee nurse working with him or her under supervision? I do not fully understand it, but is that the process Mr. Doran would have been trying to achieve in the negotiations that would have taken place in next 12 months which obviously have now been thwarted by the letter he received? If at the end of that 12 months negotiating process the same outcome was put before him that they are trying to achieve today, would he be happy with it? On what is he basing his organisation's best practice data? Are they on the basis of what his organisation's members are telling him, or are there other best practice analyses from Australia or elsewhere? I ask him to point me in the right direction. I cannot even find reports on the web because the OECD material is very confusing in that it appears one country can get away with having five nurses per 1,000 population, whereas we have a ratio of 14.5 nurses. Mr. Doran might help me in understanding it.

Colm Burke (Fine Gael)
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My apologies for being late. Unfortunately, I had a prior engagement which was arranged more than two months ago and I could not get out of it. I apologise for missing Mr. Doran's presentation. Following on from his replies to earlier questions, on the management structure in the HSE, we have seen it happen in the private sector during the past two to three years where, for example, one organisation reduced its seven grade management structure to three. Does Mr. Doran consider it is time to examine this in the HSE and are there certain grades that are not needed? One of the concerns I have about the management structure - I spoke to the Minister and the Taoiseach about this recently - is that many jobs are now being filled on a temporary basis. Staff are in temporary positions for two to three years and then suddenly find they are permanent. Once there is a vacancy, they are moving up the line without going through an interview process. That is the information I have received and it is an issue about which I am extremely concerned. My first question is does Mr. Doran believe we need to consider reducing the number of layers in the management structure?

The second issue I wish to raise is the cost of agency staff. I have consistently raised this issue during the past three years, particularly when it was focused on junior doctors, and we have now moved on to consultants and nursing staff. We have an overall figure, but does Mr. Doran have a breakdown of the cost of agency nursing staff? I may be incorrect, but I understand agency staff costs in January alone were €10 million. Does Mr. Doran have an idea of what the total cost of agency staff will be in 2014?

The third issue I wish to raise is that of maternity hospitals. It is one about which I am very concerned, as are the delegates. I understand nursing staff in Portlaoise hospital had been filing their concerns consistently, not for a number of months but for a number of years, and no action has been taken. I have compared the position in Portlaoise hospital to that in a school. A toal of 1,000 babies a year were being delivered in Portlaoise hospital and that number increased to 2,000, but the hospital had fewer rather than more staff to deal with the increase. If we compare this to the position in a school in which the enrolment has increased from 1,000 to 2,000 pupils, all hell would break lose if it were to be left with the same number of teachers to deal with the increased number of pupils, but we seem to have accepted this position in the case of hospitals, especially maternity care services. We have a further report this morning on Cavan hospital on access to a theatre. We have a number of problems in maternity hospitals, especially the 11 smaller units around the country as regards the provision of adequate support, especially nursing staff.

To return to Portlaoise hospital, why was someone not forced to take action once nursing staff had filed genuine complaints and concerns? Where does the buck stop? Who did not take action when it was clearly indicated that it was urgently required? I understand a large number of genuine complaints were filed by nursing staff in the hospital and also in other units where no action has been taken. Where does the buck stop? If it is not with the hospital manager, where along the line does it stop? What is Mr. Doran's organisation trying to do and how can we assist him to make sure we will not have a repeat?

Sandra McLellan (Cork East, Sinn Fein)
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I will brief. I thank the delegates for their presentation. Mr. Doran identified in great detail a huge mismatch in skills and experience resulting perhaps in lives being put a risk from what we have read in the reports. These measures were being implemented without consultation. I find this unbelievable because measures should not be implemented without consultation.

I note research was conducted EU-wide. Is further research required on nursing staff profiles in the State and what would the benefits of such research be?

I wish to raise an issue on which Senator Colm Burke touched. How much is being spent on agency and nursing staff? How does this reflect the amount the HSE wants to save?

Jerry Buttimer (Cork South Central, Fine Gael)
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We have quarter of an hour remaining.

Mr. Liam Doran:

I might leave the question on the nurse-population ratio until Deputy-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes, Deputy Regina Doherty will be back.

Mr. Liam Doran:

It is a critical issue and I want to explain the position to the committee.

The amount of €84 million is the last figure we were given for the agency spend on nursing staff. As an aside, one of the pressures on the HSE this year is that the medical agency spend has increased by more than 100% because of EWTD compliance. That is a further drain on resources and the burden is having to be carried by others. I point out to the Senator and colleagues that we tried to make this point in our initial submission. Our heart is broken by the fact that the agency spend has been targeted by the HSE for a reduction, but then it targets the grades that its argues are incurring the spend. They are only incurring it because local management has decided that while it cannot fill a post directly, it has to fill it to maintain patient care. It is a decision made by local management, not by nurses on a ward, but now they are having to pay the price, as it were, because a budget has to be tackled. It is a flawed policy.

Colm Burke (Fine Gael)
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Will the spend in 2014 be €84 million?

Mr. Liam Doran:

No. The figure was €84 million from April 2013 to April 2014.
In regard to maternity services, the Senator and other members of the committee are correct in that the public record shows that in 2006 every single midwife in Portlaoise hospital had raised concerns about the unit. They wrote to local Deputy who was Minister for Finance at the time. They also wrote to the head of the HSE at the time. Investigations were undertaken but nothing changed. The birth rate went up. The numbers did not decrease, per se, rather they were maintained, but the birth rate had increased. However, numbers were not increased to monitor it. We reached a situation in 2009, 2010 and 2011 where the numbers were very poor. The ratio was 1 midwife to 55 births at the beginning of this year and in March it had increased to 1 midwife to 70 births. These are the HSE's figures, not ours, lest anyone decides to question them. The norm in the United Kingdom, accepted in its Birthrate Plus programme, is one midwife to 29.5 births. In the North the current ratio is one midwife to 26 births. The current national average here is one midwife to 40 births. No hospital has a ratio of 1:29.5; the best is Holles Street and one other where the ratio is 1:32. The ratio in Portlaoise hospital is 1:55.

We are trying to address that with active recruitment. The problem is, and this is not meant to be an excuse to anyone, we have to grow our own midwifes. One cannot just snap one's fingers and have them appear. It takes four years to train a midwife or we have to get them back from abroad. There is not a surplus of midwives abroad who can come back. In the absence of a manpower plan, we are climbing a mountain to try to stabilise the situation with reference to an accepted tool, namely, the birth rate plus of one midwife to 29.5 patients.

The Deputy made a valid point in that our hearts are broken in regard to the nurse to population ratio. The OECD refers to a ratio of about 14.5 or 14.8, with reference to the total number of nurses on the live register maintained by An Bord Altranais as compared to the population. It is not with reference to the number of nurses working or employed. In its reports, the Department of Health has acknowledged this and says the more accurate number is about 10.2:1,000, which is slightly below average within the OECD because the others are maintained by the numbers who are not nursing. A fair point made by the Deputy is that we have only one qualification for nursing while some other countries which have ten would have a second-level nurse in the form of a licensed nurse or vocational nurse who would undertake a shorter course. We chose not to do that and I think we are right, with respect. We have excellence. This country is world class in how it trains and educates undergraduate nurses to graduate level. Ms Grace Murphy is going through a world class course but we do not fully utilise them. We help them to qualify and let them emigrate but we are about the norm in terms of the average. What we hope to do is begin the process of stabilising the nursing workforce with reference to international best practice and norms. With that mix of staff, one rate of qualification of nurse, a HCA, FETAC level 5, our hope was to bring them in and agree job description for surgical, medical wards to begin with and spanning it later. We genuinely thought that was the beginning of finding the floor.

We have a campaign about nursing hours per patient day similar to New South Wales, Australia. That would be our preferred model and we will bring that process to the table. That counts for nothing if, in the real world, staff are not replaced or, when they are replaced, they are replaced with interns on the support staff programme, which is what they are going to do here, regardless of its impact. The negative impact on patients is often a slow burner. It is not my cost base. I might discharge a patient in a shorter time, the patient might have a greater level of cross-infection but there are drugs, so that the cost base increases in ways which are hidden but my staffing cost goes down, so I am a good boy. That is the way the system is run much too frequently. We are not looking at quality patient outcomes, level of readmission and the cross-infection rate. The HIQA report on University of Limerick hospital group is sobering to anyone who has a belief in a public health system.

Regina Doherty (Meath East, Fine Gael)
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If the merit in that process is seen by all, and Mr. Doran definitely sees it, and obviously so did the HSE, otherwise it would not have started it-----

Mr. Liam Doran:

With respect it was the Department.

Regina Doherty (Meath East, Fine Gael)
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Sorry, what of the sledge hammer? Has it decided not to bother doing that for the next year but will deal with it with the sledge hammer?

Mr. Liam Doran:

With respect-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I want to call Ms Geraldine Talty and Ms Claire Mahon who have indicated.

Mr. Liam Doran:

The short answer to that question, with respect - we are not oblivious to the world - is that the HSE has been told to save €292 million under the Haddington Road agreement this year and this is the easiest way of finding it because its front-line staff, has the highest turnover of staff, it has a female workforce. This is the easy option without any consideration being given to patient impact. What we are desperately striving for and we would be right would be to call a truce to the cut in the health system, let us properly staff it, using international best practice and then we can grow and plan our manpower. We would welcome that but what we have at present is freefall.

Jerry Buttimer (Cork South Central, Fine Gael)
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I call Ms Claire Mahon and then Ms Geraldine Talty. I invite Ms Talty to proceed.

Ms Geraldine Talty:

I thank the Chairman. There are many questions about skill mix, staffing numbers, registered nurses, health care assistants, costs, agency spend and so on. As a registered nurse and as a ward sister or ward manager, what I see is that the HSE is cutting incorrect priorities such as targets, money and cost savings. That the HSE puts those priorities before the needs of patients is detrimental for the public. I am a taxpayer and as such I am entitled to a good public health service. We must place quality of patient care and safety before any other aim.
Deputy Billy Kelleher asked a question about fear. There are nurses who go to work every day in fear and go on night duty in fear that they will not be able to provide adequate safe care for patients because there are not enough of them. It is unfair to patients and it is unfair to all of us. The irony of all this is that the HSE is trying to save €180 million but yet it is wasting money on providing services with agency nurses and other agency professionals when it will not allow us hire nurses directly. It is absolutely insane. This plan will cost money and lives. It will cost nurses their registration because we are being forced into making mistakes. A 2013 report from Mid-Staffordshire stated that good people can fail to meet the needs of patients when their working conditions do not provide them with the conditions for success. This is the problem we have at present. The HSE, my employer, is forcing me to make a mistake at work and forcing me to provide poor care for patients because there are not enough nurses because it is putting targets and costs before patient safety and patient care. That is detrimental.
On the issue of registered nurses and health care assistants, another irony is that the better the nurse and the better qualified the nurse is, the less likelihood there is of the patient or the client noticing what has actually happened. If I am a really good registered nurse and walk into a ward I can see in ten seconds what is wrong with a patient, what are the problems and a deterioration in the patient's condition. That is what Ms Grace Murphy is learning but she cannot tell that at the moment and any health care assistant will never be able to do that. That is the difference and that is how it will cost us money.

Jerry Buttimer (Cork South Central, Fine Gael)
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I call Ms Claire Mahon.

Ms Claire Mahon:

Just briefly, the RN forecast was mentioned. It is clear from page 4 of the document provided to the committee that there is a wealth of international information which proves the benefits of higher ratio of nurse to patient. I would like to relate this to the patient at the bedside. We all have to think of how we want to be cared for. Do we want to be cared for by somebody who is overworked, stressed, over-burdened, anxious, upset and distressed or by professionals who know what they are doing and are working in a diverse skill mix? We do that every day of the week but in a trained skill mix that has the knowledge and is regulated when it comes to our nursing graduates and qualified nursing staff. To put an ill-qualified nurse in a situation where she feels unsafe does harm to patients, not just to the nurse. We are being forced to do that. We all have to think seriously about the social dynamic of how we want to be cared for across all our care environments because currently they are not safe. We have said this previously. We appeared before the committee in November 2012 and presented a staffing survey, carried out by an independent person, Dr. Keith Hurst, from the UK, which showed we had on average six fewer staff per shift in Irish hospitals wards than in the UK. We have been saying this for a long time. None of us wants to look back in ten or 15 years to see reports like Mid-Staffordshire being fired at us, to say that we did nothing. That is why we are here.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am conscious that Ms Grace Murphy is here and had not spoken. She is free to contribute.

Ms Grace Murphy:

I thank the chairman for the opportunity to contribute. I am glad to have been given the opportunity to have four years of training. It is top class training and much emphasis is put on making sure we are competent when we come out of interns as graduate nurses. Much emphasis is put on competence yet we are released into a health care environment where we are not allowed use that clinical judgment to work in a safe environment. I would like to know there is a future beyond those four years of training where I can work in a safe hospital with reliable colleagues who are no so burned out and stressed that we cannot do the job for which we have been trained.

I would like a future and to take these four years of study and continue to work in the hospital where I have trained rather than to have to emigrate to the NHS or beyond.

Colm Burke (Fine Gael)
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I had a question.

Mr. Liam Doran:

Yes. It was on layering of management and the grades of the management structure. It is our view that the management structure is multi-layered now, although not at the front line where the grade 3 and 4 managers are essential. When one goes away from that into other areas, there are many layers of management. The expressions-of-interest method of filling posts is bedevilling the health system at the moment. In fairness and with respect, however, that is another by-product of the embargo. It is trying to circumvent the embargo by asking for expressions of interest. Expressions of interest may not deliver the best person for the job, which is a further weight upon the health service. We all want to be led by leaders and those who challenge us every day. We do not have an automatic right to be right, but my problem is that I do not know where we are going. Surviving the budget is the only thing that matters at the moment in the health system. There is no manpower plan.

Before I say "Thank you" to the committee, I acknowledge that Deputy Pearse Doherty started by saying it was an IR issue involving €230 million, but I say with total sincerity that the Haddington Road agreement does not talk about a 40:60 skill mix, substitution of support interns for qualified nurses or putting Ms Grace Murphy into the community when she qualifies. This plan mentions those things, however. We did not sign up for this, which is a horse of a different colour. That is why we are against it.

We say genuinely to the committee that we have asked it to examine a few options at the end of our submission. We do not believe this is an IR issue, but that we are now cutting bone in the health system. It is not just a case of vested interests wanting to protect themselves. We will develop the role of the nurse, but we must have enough of us to do so. We want primary care and all of those things, but this plan is the last way to go about it. It must be reviewed.

On behalf of the INMO, I thank the committee very much.

Jerry Buttimer (Cork South Central, Fine Gael)
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There is one further question.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Is 21 July 2014 the date of the meeting with the Minister?

Mr. Liam Doran:

Yes.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It is quite a ways away. It is after the summer recess here and we will not get a report from the INMO until we resume after the summer period. It is unfortunate that it has taken this long.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is beyond our remit, as the Deputy knows. He could be Minister.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It is, of course. We encouraged this committee to accommodate the INMO's request, as it has successfully, and we were able to win the Chairman around.

Jerry Buttimer (Cork South Central, Fine Gael)
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I did not have to be won around anywhere.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I am only teasing. I go back to the point I made earlier, the response Mr. O'Brien has given and this defence of the situation. I do not need to hear the HSE explain its perspective for me to recognise and understand that what is now to happen is not in my interest as a prospective patient. That is the bottom line. On that basis, we should encourage rather than wait for our diary to accommodate other opportunities. We should express concern, which is a mild way to do it, at what we now know to be in the offing. I propose that we write to both the Minister and Mr. O'Brien accordingly.

Ms Geraldine Talty:

One of the major flaws in this whole plan is the fact that the HSE and the Department seem to see registered nurses as a cost. That is not what we are at all. The fact is that we are a brilliant asset. That we are treated as a cost is hugely detrimental for patients and the public.

Mr. Liam Doran:

On GDP and spending on health, we refute the suggestion that we are overspending. The comment from Brussels last week must be challenged by the Department. We do not overspend as a proportion of GDP. The last OECD figure was 8.9% and there was a 9.6% figure. Germany spends 11.2%. The very people who are telling us to cut back are spending more than we are. We do not overspend.

Politically, I say the following. I acknowledge the committee's position, but I refer to the wider political population. I sit in front of the committee today to say there is no political support for a world-class public health service. It is viewed by too many politicians as a waste of taxpayers' money and as inefficient and ineffective. There are 102,000 people working in the health system, 99.9% of whom went to work this morning to do a good job. They do a good job in impossible circumstances and they need support, not condemnation.

Jerry Buttimer (Cork South Central, Fine Gael)
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On that point, it would not be fair to say the members of the committee were of that view in the context of health. We recognise that health is a public service and that the people who work in it deserve tremendous credit, not just for their professional commitment but also for the work they do outside that and the care they give to patients and each other. It is a bit unfair to say that politicians as a general matter view health that way. The Ministers have said and all of us recognise that health is not an ATM and that one cannot keep putting the card in and taking money out.

Mr. Doran spoke about the floor. Our meeting today has provided the INMO with a platform to raise and articulate issues. From our perspective as a committee, it is important to express back to the Department and the HSE the views we have heard today. It is important as part of our quarterly meeting with the HSE to invite it to comment on the INMO presentation today. We will ask its representatives to do so. We will present to the HSE a copy of the INMO presentation and a transcript of the meeting with a view to asking it to reply as part of its engagement with us at the quarterly meeting in July.

Ms Claire Mahon:

Is that before the meeting?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes. It is also before the meeting. It is important to do it. It is also important that we ask the HSE to engage meaningfully with the INMO, notwithstanding that the committee does not have a role in industrial relations. It behoves all of us to ensure that those who work as and represent front-line staff in particular are engaged with properly by the HSE, which is the responsible body. It is not acceptable to announce X one day and to then do Y. It is important that we recognise that there are two sides to every story. As Chairman I must take into consideration both views.

Today's meeting has been very important. It is important to acknowledge the tremendous professional commitment of INMO members to all citizens, including patients and visitors. As someone who had a relation in hospital recently, I note that the level of care on the front line was superb. That must be recognised. I say that as someone who spent days in an intensive care and emergency department.

We will discuss future options at our meeting of Tuesday, 24 June 2014. The joint committee will adjourn until Tuesday, as we meet as a select committee on Thursday morning to deal with the Health (General Practitioner Service) Bill 2014. On 24 June, we will deal with the issue of EpiPens. That is the work programme.

Ms Claire Mahon:

I thank the committee for the opportunity to be here today. None of us wants to be at the end of any further inquiries.