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.

We also feel it necessary to remind the committee of other reports in Ireland, particularly recent reports from HIQA such as those into accident and emergency department overcrowding at University College Hospital Limerick and hygiene in Wexford General Hospital. Both reports highlight staffing levels as a factor in the potential lowering of standards in the care delivered to patients.
The INMO contends that general management, when attacking the front line to make savings, are simply repeating the mistakes of the past both in this country and in other jurisdictions. It makes no sense, either economically or in terms of health outcomes, to have poor staffing levels, an inappropriate skill mix and inadequate front-line management structures when one is seeking optimum levels of patient care. The current HSE plan, therefore, represents a tried, tested and failed model of financial containment in our health system and must be reviewed.
It would be remiss of us in presenting our views if we did not remind all members of the committee of the journey that has been travelled by the health system over the past six years. In summary, the following facts are now known: the reduction of more than 20% in health expenditure over the past five years is unprecedented in the context of OECD countries; there has been an overall reduction of 9% in staffing levels in the health system since 2009; however, in the same period, there has been a 13.5% reduction in nursing and midwifery staffing, which confirms the disproportionate impact upon the front line arising from the recruitment embargo; in the same period, there has been an 11% decrease in support staff numbers, again hitting the front line; and the continued insistence by Government that the health service must lose a further 5,000 staff, leading to a total of 95,600 by the end of 2015, represents an impossible request and only serves to apply further pressure upon an overworked and overstretched public service. We welcome the recent reported statements from both the Minister for Health and the Minister of State at the Department of Health, Deputy Alex White, that the health system has carried an undue burden of cuts and cannot sustain any further cutbacks while maintaining services and meeting demand. We ask the committee to consider all of these facts when analysing the impact of the latest HSE plan upon front-line services and, ultimately, patient or client care.
In presenting its views, the INMO is not oblivious to the financial challenges that continue to face this country and, by definition, the provision of public services. However, we cannot accept that the latest measures are appropriate when one takes into account the pressure on front-line services, the workloads that are being carried by nurses and midwives every day, the flexibility being shown by all grades of staff on the front line and the complete implementation of staff-side obligations under the Haddington Road agreement.
Against this background we have called for, and are still calling for, the following: that the HSE agree to suspend the implementation of all current measures contained in its most recent plan that have an impact on front-line staff; that the committee ask the HSE to explain the rationale behind its recent proposals, and, in particular, why it is seeking to implement skill mix substitution and other arrangements not covered by the Haddington Road agreement, which go against the findings of national and international research; that the committee ask the HSE why it has not engaged with staff representative organisations, in a time-limited manner if necessary, to consider such issues as skill mix and staffing levels; that the committee seek confirmation from the HSE that it does, and will, respect the professional judgement of every registered nurse or midwife and accept that it cannot implement measures it believes will negatively impact upon patient or client care; that the committee ask the HSE what weight is being given to the expanding body of research, both national and international, which confirms the positive impact on patient outcomes of an adequate nurse staffing workforce; that the committee ask the Minister for Health and the two Ministers of State how they reconcile the latest HSE plan with their stated concerns that the health service cannot carry any further cutbacks or contraction; and that the committee consider recommending the adoption of the standards recently introduced in the UK with regard to public information on staffing levels in wards and minimum nursing numbers in care settings.
In conclusion, we sincerely thank the Chairman and all members of the committee for attending and listening to our presentation. We will gladly take questions from the committee.