Oireachtas Joint and Select Committees
Thursday, 16 July 2015
Joint Oireachtas Committee on Health and Children
Delays in the Registration of Nurses and Midwives: Discussion
Apologies have been received from Deputies Ciara Conway, Peter Fitzpatrick, Eamonn Maloney and Senator Imelda Henry. Deputy Dan Neville has had to leave the meeting. Regarding mobile telephones, I remind people that it would be appreciated if they were switched off or put in aeroplane mode.
Our first session is with the representatives of the Nursing and Midwifery Board of Ireland. I welcome Dr. Maura Pidgeon, the chief executive officer and Ms Ursula Byrne, who is the deputy chief executive and acting director of regulation of the Nursing and Midwifery Board of Ireland.
Our meeting arises from delays in the registration of nurses and midwives, which is having a knock-on effect in the delivery of essential health care services. A number of committee members have had meetings with different sectors of the health services regarding the issue. The committee has been monitoring the issue closely. I wish to apologise to the witnesses for the delay but the private business of the committee took longer than normal. I thank them for coming before us this morning at short notice to discuss the delay in registration of nurses and midwives.
I wish to advise witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not comment on, criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or any official by name or in such a way as to make him or her identifiable.
With that, I thank Dr. Pidgeon and Ms Byrne for coming before us and I invite Dr. Pidgeon to make her opening remarks.
Dr. Maura Pidgeon:
Good morning, I thank the Chairman and committee members for inviting my colleague and me to speak and for their interest in this matter.
I am accompanied by my colleague, Ms Ursula Byrne, who is acting deputy chief executive officer in the Nursing and Midwifery Board of Ireland. I will read an extract from my opening statement in order to keep within the time allocated.
We are acutely aware of the impact that delays in the registration of overseas nurses is having on the recruitment of nursing staff in the health services across all of the sectors. The extent of the problem is that there are currently 2,016 applications being processed, 70% of which cannot progress due to incomplete documentation having been received by the Nursing and Midwifery Board of Ireland from all of the applicants. All of the applicants who did not send complete documentation have been notified and are notified and updated on a regular basis. Some 35% or 698 applications have been in the system for more than 12 months.
Reflecting the lift in the economy, some 974 applications were received between January and June of this year, which compares to 302 applications received in the same period last year. Notable contributory factors to the delay include staffing levels and funding at NMBI, with revenue being significantly less than expected for 2015, due to a lower than expected annual retention fee for the year. This funding crisis has created uncertainty and insecurity among staff in the organisation with the subsequent increase in staff turnover for the first half of this year. Eleven staff have left between January and June 2015. This has added to the challenges of processing applications.
To get on the NMBI register, which is a legal requirement for anybody wishing to work as a nurse or a midwife in Ireland, the individual must demonstrate that he or she has met and achieved a level of competence in practice, educational preparation and would be prepared to work in accordance with the NMBI code of professional conduct and ethics. This standard applies to all applicants, regardless of whether they are students graduating from Irish nursing undergraduate programmes or from overseas. It is in the interest of patient safety that the process of registration must be rigorous and therefore cannot be compromised or undermined in any way.
There are two major streams to registration. Irish registration is about first-time registration for nurses and midwives following successful completion of their undergraduate programme and the annual renewal of registration of individual nurses and midwives. The annual renewal process allows for restoration of nurses and midwives to the register if an individual has been removed for non-payment of fees. If a nurse or midwife requires verification of their registration for the purposes of working overseas, a certificate of current professional status is issued. Issuing of these certificates does not mean that the individual has actually gone to work abroad.
Students of nursing and midwifery in Irish universities and institutes of technology on successfully completing their education programme must apply to get on the register by submitting an application for initial registration in the Register of Nurses and Midwives, which is signed by the head of the nursing department in their educational institution and the director of nursing of the partner hospital. This process takes place throughout September and October each year and the average time from receipt of application to confirmation of registration for students is seven days. The number of students graduating each year is 1,500 in total. Of that number, 860 are general nursing students, 290 psychiatric nursing students, 180 intellectually disability students, 100 children's general integrated students and 140 midwives. These are all registered within 15 working days. There is no delay in this part of the system.
For nurses and midwives who have trained outside of Ireland and wish to practice in Ireland, the registration process is best described in four steps. The first step involves the completion of a request for application and a payment. This is followed by the issue of a personalised application pack to the applicant containing a formal application form and a full suite of supporting documentation, setting out all of our requirements together with full instructions. The third step is the validation and verification of the application. This stage requires a thorough visual check and validation of all documentation provided by the applicant. The next step is that the application goes through an educational assessment for recognition of their qualifications and finally the application is assessed for determination of registration. The decision can be one of three outcomes, namely registration, refusal, or successful completion of a period of adaptation and assessment, during which the individual's competence to practise is assessed.
The period of adaptation and assessment can be undertaken in any health care facility that has been approved by the Nursing and Midwifery Board of Ireland, having met the standards for overseas adaptation. These standards are available on the website. On successful completion of this adaptation period, the applicant will have his or her registration confirmed by the board and his or her personal identity pin number is issued. All applications from EU member states are processed within 90 days, as set out in the EU Directive 2005/36/EC, providing all documents are in order.
In regard to the current situation, the number of applications in January to June this year is 974 compared to 302 for the same period last year. At the same time the budgeted revenue for the organisation was reduced by 33% as a consequence of lower than expected annual retention fee.
In addition, natural attrition of staff from the organisation was in the region of 23% of the organisation’s complement.
Delays are also being experienced in Irish registration in respect of issuing certificates following restoration to the register for non-payment of fees. The removal of nurses and midwives from the register for non-payment of fees and subsequent requests to be restored to the register is an annual event. This year the numbers requesting restoration increased from 159 in 2014 to 1,472, with approximately 300 requesting a waiver of the restoration fee. This volume of requests, against the backdrop of the resourcing issue outlined above, has given rise to delays in this process, which are currently being addressed. These delays have not prevented the individuals concerned from practising. Once an individual can produce evidence to his or her employer of completion of the restoration application and payment of fees, the registration is restored and the individual is able to practise, with the certificate being issued subsequently. We are introducing an internal mechanism to allow staff to track individual applications online, thus enabling a more efficient response to queries. Furthermore, the new restructured website will provide some online functionality, including the ability for individuals to track their own applications and payment options for applicants by the end of this year.
We have engaged in a collaborative process with key stakeholders so that we can further improve the process while maintaining the integrity of registration. Those involved in the process include representatives from the HSE, Nursing Homes Ireland, independent private hospitals, directors of nursing and midwifery, human resources experts, systems analysts and NMBI registration staff. Moreover, our revised spending plan has been approved by our board, and the Department of Health has recently authorised additional resources to assist us in respect of the overseas registration delay backlog. To clear the current backlog and ensure sustainability into the future as the demand on our organisation increases, we now require three additional full-time positions and funding for a web-based integrated case management system and register.
To sum up, while there are indeed delays in the registration of overseas nurses and midwives, these delays have come about as a result of a combination of exceptional and unforeseen circumstances, all of which have been or are in the process of being addressed urgently. We are making progress, but much remains to be done. In 2015 to date we have registered 253 nurse applicants from within the EU and 158 from non-EU countries, to a total of 411 nurses. In 2014 we registered 344 nurses from within the EU and 161 from non-EU countries. In the past 18 months, therefore, a total of 916 nurses registered with us. A total of 2,016 applications are currently in the system, of which 818 are from EU member states and 1,198 from non-EU countries. The number of applications received between January and June this year was 974, compared to 302 during the same period in 2014. The number of applications in process for more than 12 months is 698, and the number of applicants with incomplete documentation is 1,398. Of the 473 applicants who have received decisions, 330 were deemed to require adaptation, 43 have had their registrations refused, 55 were deemed to require further information following the initial assessment and 45 were recommended for registration. Progress is being made but it is not quick enough, and this gives rise to the need for additional resources. We welcome the support provided by the Department of Health and the HSE.
I welcome Dr. Pidgeon and Ms Byrne. There is no doubt in our minds about the importance of the work they do. We and our loved ones depend on the verification process to validate the capacity, professional training and expertise of nursing staff, who are often the people with whom we have the most significant engagement in our health delivery settings.
The correspondence we received from Dr. Pidgeon in advance of the meeting refers to a decision to fill nine vacancies on an interim basis. The issues relating to the protracted process and the delays in bringing people through the system have been evident for some time. In her opening statement, she presented a picture of a less than stable or happy work environment, with an exodus of 11 staff over the period in question. She also referred to uncertainty and insecurity among staff. That is unsettling for any organisation. Why were posts filled only in the relatively recent past and what exactly does "interim basis" mean in real terms? I would expect the positions to be on a full-time basis. The Nursing and Midwifery Board of Ireland appears to be late in responding to an identified need. While Dr. Pidgeon referred to a lower than expected annual retention fee, this has been a controversial issue in the past year or two. I ask her to elaborate on the purpose of the annual retention fee and any other funding the board might secure to carry out its work. If it is not solely dependent on the registration fee, perhaps she could help us to understand exactly where the funding difficulties arise.
There are 62,909 nurses and midwives on the active register. I expect that some nurses and midwives may for their own reasons maintain registration even though they are not active in the health delivery system. How does that relate to the numbers directly employed by the HSE or in private settings, including primary care and other practice roles?
Does Dr. Pidgeon have that information and statistics on the breakdown of nurses in the categories of general, psychiatric, intellectual disability, children and midwives? If she does not, would it be possible to forward it to us subsequently? I would welcome that.
The number of students graduating each year is 1,500. I expect that is the number coming through and graduating in this jurisdiction. Are the numbers coming through at full capacity? Does Dr. Pidgeon have information on the retention rate within our health system in recent years? Could she give us a sense of that? Has the retention percentage improved in recent years, particularly in the recent past with the lifting of the recruitment embargo, compared to previous years? What has the direct impact of that been?
Dr. Pidgeon referred to EU and overseas applicants. Is it the case that Irish trained nurses are grouped within the EU classification within the NMBI's role and responsibilities? I note the number of overseas applicants in the first six months has more than trebled compared to the same period in the previous year. How does that statistic reflect itself in terms of Irish-EU applicants? That figure does not appear to be given in the presentation but I could be wrong on that.
If the Chairman will allow me, I will conclude. I am interested in the comparable position between Irish and EU applicants and the number of overseas applicants.
I will close on this point. I can understand that time is required to properly evaluate and adjudge the bona fides of the suitably trained and qualified applicant getting through. Is there a verification process in place for the documentation presented by overseas applicants? In layperson's terms, is there any fear of somebody presenting fictitious, forged or wrongly acquired documentation, and can we have certainty as to the veracity of the information and documentation being presented in every case? Is verification by the issuing institution, in whatever setting globally, part of the work of the NMBI? I thank the witnesses for giving of their time to come here.
I thank our guests for the presentation and the briefing on this issue, which is one of concern to the committee and it is also a concern, on wider basis, in regard to the health services. The presentation appears, to some extent, to paint a picture of difficulties almost amounting to a crisis level within the organisation. The presentation states, "This has created uncertainty and insecurity amongst staff in the organisation with a subsequent increase in staff turnover for the first half of this year, with 11 staff having left in the first half of 2015". How many staff does the board have overall and what percentage of the overall staff would the 11 staff who left in the first half of 2015 constitute? That statement is quite broad and I wonder if there are particular reasons for that turnover of staff. There is a bigger workload within the organisation as we can note from the figures but it appears the staff numbers have decreased significantly. What is the background to that?
There is the question of replacing those staff and the number of applicants is increasing but staff numbers are declining. Dr. Pidgeon might elaborate on what she means by interim staff. Are they temporary, part-time or long-term staff and how are they appointed? Is there a long recruitment process for these staff or what is the exact position regarding their appointment? How long are those appointments for or are they long-term appointments?
Dr. Pidgeon might elaborate on the financial position and the resources generally. What are the difficulties? What factors have brought about a situation where the level of funding is not adequate in terms of the number of applications with which the organisation is dealing?
On the issue of the number of nurses being trained, and this may not be relevant to the issue under discussion, does the NMBI have a role in the training of nurses? Does it have a role in making recommendations? In the area of gerontology and dealing with the elderly, it appears we will have a significant deficit in the number of nurses being trained. I am not sure if that comes within the remit of the NMBI or whether it has any input into that. Can Dr. Pidgeon see a time when the application and registration process will be manageable again within reasonable timeframes?
I thank Dr. Pidgeon for her comprehensive presentation. I wish to raise a few issues. I fully accept there are 62,000 nurses and midwives on the register and each one of them has to renew their registration every year.
Dr. Pidgeon gave a summary in regard to the people who are qualifying in Ireland and that they registered within 15 working days. That system seems to be very well set up. What is the staffing level dealing with the number of applications from people outside Ireland and from those who are non-EU citizens? Is there a gap between the time an application is received and when it is assessed to ascertain if inadequate documentation has been submitted or, on receipt of applications, are they assessed to determine if all the required documentation has been submitted, while not fully examining the application but merely identifying that if eight of nine items of documentation are required, they have been submitted?
I also wish to raise the issue of adaptation courses. I understand from Nursing Homes Ireland that more than 330 people have to take adaptation courses. Is there an adequate number of adaptation courses available and, if not, what mechanism is being put in place to ensure there will be an adequate number of them? I understand there is a long waiting list for them and that even if it is agreed and approved, people can practice in Ireland who must complete an adaptation course. What is the process for getting on to an adaptation course and what is the waiting period involved?
This question of the availability of adaptation courses is an important factor in addressing the broader issue. My understanding is that the HSE is not providing an adequate number of courses and Nursing Homes Ireland has had to enter into discussions with other organisations about putting courses in place. That needs to be clarified. We can complain all we like about delays in registration but if the adaptation courses are not in place, we are not really achieving anything.
Although it is not a matter for the delegates, I am aware of a case involving a medical doctor who, after graduating in Ireland, went to work in New Zealand. Within two weeks of applying for registration there, this person was eligible to practise. By contrast, when the individual returned to Ireland two years later, the registration process was still not completed eight weeks after the person had applied to the Medical Council. We seem to have a problem in terms of putting in place appropriate mechanisms for processing applications to register as health care professionals in this country. I fully acknowledge the difficulties that have arisen for the Nursing and Midwifery Board of Ireland as a result of the sudden increase in applications and the staffing issues it has to address. I am concerned, however, about what is being done in respect of the provision of adaptation courses. Even if we deal with the first problem, that issue will remain to be resolved.
Dr. Maura Pidgeon:
Deputy Ó Caoláin asked about interim staffing arrangements at the board. Essentially, we have a number of full-time staff working on a short-term basis - that is, for a period of six months. My comments regarding the workplace environment causing some uncertainty and unsettled feelings were in the context of the unexpected shortfall in revenue to the organisation, which meant I was not in a position to guarantee staff on short-term contracts security of tenure. Naturally, some of those staff left for secure and permanent employment elsewhere. Having said that, of the 11 staff who left, three were permanent staff who left for promotional grades and opportunities in other organisations. There was an element of natural attrition, in other words, and my comments about uncertainty and an unsettled feeling related to staff on short-term contracts.
The NMBI is a completely self-funding organisation and relies on members' annual retention fee and other registration fees for its functioning. We have had no other sources of revenue, except for two years ago when the Department contributed €1.6 million towards the implementation of the new legislation. We were then in position in which the revenue stream to the organisation was unexpectedly reduced.
Dr. Maura Pidgeon:
No. The contribution of the HSE towards the careers centre is a long-established provision for the recruitment of students into the university programmes. It had been significantly higher over the years but was reduced when nursing education went into the universities. It is specifically targeted at mature applicants.
Deputy Ó Caoláin referred to the increase in the annual retention fee. Following consultation between the board, the Department of Health and key stakeholders, and in the interests of the continued provision of services through nursing care in the health service, the decision was taken to reset the fee to its original level of €100. There are ongoing negotiations between those parties on how the board can be funded to meet its obligations under the legislation.
There was a question about the total number of nurses and midwives on the register. The figure of 62,000 relates to what we call the "live register". An additional 20,000 nurses, including those who are retired, people working overseas and so on, are listed on the inactive register. In regard to the breakdown of the employment status of the 62,000 nurses on the "live register", we have been in the process of collecting those data in recent months. Having more comprehensive figures will help to inform workforce planning for the organisation.
There are 1,500 nursing and midwifery students in training in the Irish education system. We do not have data on their retention within the workforce. At the time of completion of their programme, all new graduates apply to come onto the register, but we do not have information on where they go thereafter.
In regard to EU applications, those numbers are over and above the number of home-grown Irish students.
I will ask Ms Byrne to deal with the question of the verification of documentation.
Ms Ursula Byrne:
Deputy Ó Caoláin is right that in seeking to speed up the registration process, we must not lose sight of the importance of proper scrutiny of applications, in the interests of public safety and the reputation of nursing as a profession in Ireland. Every document that is received from an applicant or on behalf of an applicant is scrutinised with a view to ensuring the information we require is there and that the document does not raise any concerns as to its authenticity. That verification process involves examining not only the document itself but also the envelope in which it arrived. In some instances in which we have had concerns regarding the authenticity of documentation, they have arisen on the basis of the envelope in which the papers were submitted.
There are several steps we go through to verify a document, depending on what it is. For example, we require proof of English language competence for non-EU applicants through the International English Language Testing System, IELTS, test, and that this proof comes from source. From the introduction of the IELTS mechanism in 2003 until very recently, that was done by way of IELTS posting us the results. Now, however, we are able to access the results online.
However, there are 15 different steps in the process of authenticating the document. If we identify a document about which we have doubts, we write to the applicant and say we have concerns about this document and ask them to provide an explanation or clarification of it. In a large number of such cases - it is not a huge volume - we never hear from the applicant again. A note is put on the file that we could not verify the authenticity of documents and the file and application are closed. The application does not progress.
Ms Ursula Byrne:
An application form is received directly from the applicant. Then there are a number of supporting documents which must be received directly from source, such as the transcript of their training, a reference from their current or most recent employer and proof of their valid registration in other jurisdictions and their good standing. As each of these documents come in we notify the applicant that we have received the document and we notify them of what is still outstanding. They get a letter, but we are now moving towards e-mail communication with applicants as far as possible to speed it up. We tell them we have received their application and that it appears to be complete or that they have not filled out a certain page or section. When we receive their verification from other regulatory authorities we acknowledge receipt of it and we identify whether there are problems. This is the primary area where, with additional resources, we wish to speed up the process of feedback to the applicant. As Dr. Pidgeon said, we are also developing a facility on our website, which we hope will be live by the end of the year, whereby the applicant will be able to log on using a unique identifier and monitor their application and the receipt of documents. That will cut down-----
Dr. Maura Pidgeon:
If I can add to that, this is one of the areas that is clearly a target for additional resources. It is simply the sheer volume of applications coming in and the ability to do even the initial identification of a shortage of documents. This is one of the areas that the working group, which includes our partners and colleagues from the employers and their agents, is drilling into in terms of working together to address this issue. In addition to targeting the backlog that has built up, another requirement is to work with employers if they wish to identify somebody and help applicants in the application process while they are overseas. It is complex. We have provided additional and more simplified information in that respect, but the issue is to work with them in identifying that before the forms even come in. They are two elements of trying to deal with the backlog over time.
I will respond to Deputy Healy's questions. To add to my response in respect of the staffing issues, it was 11 staff out of 51 that had left in the first six months of this year. The process of recruitment is in hand. There are internal mechanisms because there have been some promotional grades available, an opportunity for staff within the organisation, so it will be dealt with by the end of this month. We are working closely with the Department of Health and the HSE in respect of utilising the Public Appointments Service as well as HSE deployment in order to select and recruit staff into the organisation. That is in hand. Further meetings, even tomorrow, on the logistics of getting additional staff into the organisation are taking place.
Dr. Maura Pidgeon:
Yes, on the basis of the revised spending plan approved by the board at the last board meeting. We have to get approval from the Department of Health to replace permanent staff, so they have been approved, plus one. The Department of Health, acknowledging the difficulties within the organisation and the significant impact of delays, has provided for three additional posts.
Dr. Maura Pidgeon:
The process is in hand and we hope to have some of the additional staff in by the end of the month.
I have addressed the question regarding the resources. It is a self-funding organisation and, given the current circumstances with regard to the annual renewal fee, we are in discussions with the Department of Health about the ongoing funding of the organisation.
With respect to the number of students in training, that is determined at Department or Government policy level. The number of students is not determined by the regulatory body. However, the number of students has not decreased for several years and is still at 1,523.
Regarding a solution to the problems, several measures are being taken as we speak to address the criticality of the situation. One of them is the board's approved spending plan. The Department of Health has been very supportive with additional staff. We have also reviewed, and had been reviewing, our internal registration processes in regard to simplifying the process and providing greater clarity of instruction and guidance to applicants. That was in tandem with the development and restructuring of our website to have greater online capacity. That will come on stream by the end of the year. There will be a completely new website. It is not just about a fancy page. It is about the restructuring and the development of core applications to enable us to do our business online as a modern organisation.
Most importantly, as I mentioned earlier, we have listened to our colleagues in both the public and private sector in regard to the establishment of this working group. It has met and the sub-groups are working on two focused areas. One is to reduce the cycle time for overseas registration and the backlog. The second relates to the area of adaptation courses and the maximum utilisation of those courses. In addition, we are, and had been, using a call centre to deal with the volume of calls coming into the organisation and e-mail inquiries relating to registration and restoration. The Department is supportive of our expanding that facility to address customer need in terms of responding to calls.
On the other areas of work, I believe we will get the situation under manageable control.
There is an increase in demand. We are aware of a potential additional 1,500 vacancies to be filled throughout the sectors. With regard to coming here from overseas, the applicants will advise through the HSE, Nursing Homes Ireland and the Dublin academic teaching hospitals. We are putting systems in place and we have identified an internal manager to support the overseas project so we can clear the backlog and develop a robust and sustainable process to prevent further backlogs of this nature.
Dr. Maura Pidgeon:
It is quite difficult to identify a target date as to when it will be business as usual and we have a normal sustainable process. We will have additional staff by the end of the month. Our new website will be available in October which will provide online facilities. Over the course of the coming months we will work with our partners to have a more manageable process in place.
Dr. Maura Pidgeon:
Not until I have the staff to assess the situation. We hope that by the end of the month or by August we will have a clearer picture as to the progress being made and we can advise the committee when we have a definite picture.
Senator Burke asked about the adaptation programme. Adaptation courses are available and the working group is examining adaptation to maximise the utilisation of the courses and places available. The HSE has made a significant contribution to the provision of adaptation courses. At present there are 241 places, and an additional two adaptation courses will be made available in August through the HSE's structures which will provide for an additional 140 places. Adaptation courses can be provided in any health care facility approved by the board for students. Facilities must apply for approval and show compliance with the standards we have set.
Ms Ursula Byrne:
In addition to the adaptation programmes provided through the HSE system, a number of private health care facilities are going through the process of being approved as placement sites for adaptation courses. This is expected to be completed quite quickly and this will increase the number of places available, which is to be welcomed.
The last time the Minister, Deputy Varadkar, was before the committee I raised this issue and I am delighted to see a quick response. I was told when visiting nursing homes in Dun Laoghaire that some of them may have to close beds because they do not have nurses. HIQA instructed one nursing home to stop taking in residents until it is able to fill its nursing vacancies. I am particularly worried about nursing homes. I understand that public health is of huge importance. What is the status of the applicants who have been in the process for longer than 12 months?
I am delighted to hear there will be an online facility. It is how one applies for many careers. One must fill in the form on screen to progress. It is something the witnesses should examine.
A number of care staff working in nursing homes are qualified nurses who do not have registration. They have been waiting for 12 or 18 months and feel totally frustrated. They are nurses but they are not recognised here as such. I have been told they make an application but there is no response until they are told the application is being reviewed six months later. It is a very untimely process. I absolutely understand the staffing issues but if we must close down nursing homes and hospitals are backed up with acute beds being kept by patients we have a serious problem. This is why we want the witnesses to sort it out or tell us how to sort it out.
I thank the delegates for their presentation. I pay tribute to the midwives, nurses and other staff in the maternity hospitals across the country. They do a wonderful job and sometimes do not receive half the recognition they deserve. What further information is required to be submitted by the 55 applicants? Is there a deadline before people have to return the relevant information? How will it be processed? How long will the entire process take?
Regarding the recommendations for registrationin the final stage, for how long more will applicants have to wait to have their forms processed? Incomplete documents were submitted by overseas applicants in 70% of cases. There were 1,398 applicants with incomplete documentation. One would regard people applying for a job in this area as being very professional and as having considerable education. One wonders why it is not simple to provide the right documents or information. Is it a simple process of ticking a box or is it more complicated? It seems the form is complicated. How many live applications is the board dealing with at present? I am not too sure.
The board said it had 55 staff and is down 11 but that it hopes to recruit 11 more. Is the board seeking another three staff in addition?
I welcome the witnesses and acknowledge the important work done by the board. This is obviously a much more challenging time than in the days when six or seven Irish nursing schools provided all the graduates that were needed. Circumstances are now very different.
Having had extensive representations made to me by individual nurses and their representatives at the time of the proposed increase in the retention fee, I learned they have a number of concerns that need to be addressed. There was a sense that increasing the fee by 80% over two fee cycles in two years seemed hard to justify. The nurses asked repeatedly what extra they were getting for the 80% increase in the retention fee over the cycle. It is important that the delegates and members know that a consistent refrain I heard from many nurses - I am not saying I agree with their perspective - was that the board appeared to have two functions, the first of which was to take nurses' money and the second of which was to discipline them. This was certainly a widespread opinion among registrants.
Nurses felt they had suffered disproportionately the effects of personal circumstances cutbacks during the recession. Like everyone else, they were subject to the universal social charge. Since they were mostly public servants, they sometimes had very substantial decreases in pay. Many of them had depended on what had been non-discretionary overtime, which disappeared. More important, many of them felt they were working much harder. They were working harder because there were fewer replacement posts being filled and people were being allowed to retire. The increased attention paid to the capping of staff numbers within publicly funded institutions meant retiring colleagues were not being replaced. These were all concerns of the nurses. Many of them asked where the board was when these issues were arising. They wanted to know what position of public advocacy it was taking.
I have a few specific questions. The board tells us it is understaffed, which I accept. We are well used to hearing that a body run by the public service is likely to be either understaffed or "malstaffed". By how many is the board understaffed? What is the budgetary shortfall required to refill the positions? I am not trying to be provocative but feel this is an opportunity to bring points to the attention of the board that were brought to my attention. Nursing members had concerns about how the board's money was spent. They wanted to learn how much was being spent on public relations, travel and other items. I am sure all these expenses were legitimate but the nurses questioned whether there were opportunities for cost savings. At the time, they were wondering whether the cost savings could have been passed on with smaller retention fees. Could the cost savings be passed on by hiring extra staff to do what is required?
Many Irish graduate nurses train in medical schools with which the board is very familiar. The board knows all about these schools and the individuals concerned, who have been with the board for many years. Re-registration of somebody with this background should be very simple by comparison with the registration of somebody who may have come from a medical school on a different continent, bearing in mind the interrogation of credentials. A foreign nursing school may be a very fine one, but the board may not be familiar with it. Is there any degree of cross-subsidisation of the current expenses? Are the relatively simple registration requirements of Irish and EU-trained nurses being used to subsidise the appropriate interrogation of the credentials of nurses coming from schools that are less well known?
I have raised the question of fees on several occasions when it looked like we were facing a shutdown in the health service on this issue. Many nurses said they would not pay the increased fee. I am thankful that there was an outbreak of compromise and common sense. The then Minister gently reproached me and said I misunderstood the function of the board. I was told there was one function only, namely, to protect the public. I kind of get that. There is a need to protect the public but if one is entirely protecting the public, the public should pay for it. If one is protecting the public and also defending the standards of the profession and individuals in the profession, then it is appropriate that those in the profession should pay some component of the fee.
We have in Ireland a tendency to follow the tombstone principle, which is the principle enunciated in the world of air safety. Rather than trying to prevent crashes, most of the great air safety organisations wait until a crash has occurred and then investigate what happened. In air traffic circles, prevention would involve advocacy of telemetry and real-time monitoring of cockpit management, etc. I get the sense we do in our health service what is being done in the world of air safety. We have a very unsafe health service. We have a health service which, in all the critical front-line areas, is grotesquely understaffed. Staff are overworked and expected to do jobs they are sometimes not trained to do at all. In these circumstances, there is a higher frequency of adverse outcomes, lawsuits and general quality queries than in other equivalently sophisticated health systems. I have made the point to HIQA, and now make the point to the board, that it is important that those concerned prospectively rap the knuckles of the people who hire the nurses and make decisions. It is important that they tell them there are problems they need to fix and that they should not be depending on the board to come in as the police force afterwards to investigate people who, sometimes in difficult circumstances, produce outcomes that are not as good as they should be.
I apologise for not being present at the start. I will have to blame traffic. However, I read the witnesses' document. Just to point out, "An Bord Altranais agus Cnáimhseachais na hÉireann" is spelled wrongly at the top, but that is a minor point.
Like Senator Crown, I had serious concerns at the start of the year about the registration retention fee and how that issue was handled. I have had greater concerns since about the way the organisation is being run. The statute requires that it be run independently. At the time when we in the Seanad were raising the issue of the extortionate increase in the fee, the Minister for Health was telling us he had no role whatsoever in it. However, the witnesses have told the committee that the organisation changed the policy in consultation with the Department of Health. Under what statutory provision was that done?
I am also interested in the Lansdowne Road agreement. The Nursing and Midwifery Board of Ireland seems to be a party to it, as nurses have been given the commitment that there will be no increase in fees until 2019.
Was the board a party to the Lansdowne Road agreement? Was political pressure put on it? The corollary of my second question is whether the Department is forcing the board down a particular route to reduce its income stream, resulting in it not being able to carry out its functions while being unable to replace that income. The Department seems to be forcing it on various issues, including that of fees, contrary to its statutory independence and reducing its income without replacing that income.
I will only take a minute. I thank the witnesses for their presentation. I will go straight into my few questions. It was mentioned that the board received €1.6 million to help implement the legislation. I note that the witnesses stated the legislation also provided for a mandatory competence assurance scheme, which has not been commenced yet. We are nearly three years on. Why has it not been commenced and when is it likely to happen?
I noted that, according to the document, it takes approximately one week to register 1,500 new nurses. It also mentioned a backlog in the re-registration of the approximately 1,400 people who left the list. Given that 1,500 can be registered from scratch in seven days, surely it should only take a couple of days to re-register the 1,400 and issue their certificates. I am sure it is only a few clicks of a button, although perhaps not. Will the witnesses go through this issue?
I do not know whether my next point is relevant to the board, but I will make it anyway. There are 1,500 graduates, but it sounds as if we need more and that, if we had more, we would not have issues with applications from EU and non-EU countries and the constant problems with paperwork.
Dr. Maura Pidgeon:
That is no problem. Perhaps I will respond first to Senator Crown's questions as we await the return of other members. I thank the Senator for his questions. The rationale for the increase in the annual retention fee has been well documented. The fee was increased in two consecutive years due to the low cost base on which the organisation had been operating for some time. In 2013, the board proposed to increase the fee to €140 in 2014. Given the circumstances, however, it decided to leave the fee at €100, with a view to increasing it in 2014 for the 2015 annual retention process. The reason for the fee increase was simply the cost of implementing in full the new legislation and the subsequent need to modernise the organisation. This involved the development and replacement of old information and communications technology, not to a highly sophisticated level but to a level that would allow a modern organisation to conduct its business. The fee was primarily due to the cost of implementing the new legislation, which amounted to more than €8 million in a four-year period.
The cost as a result of the new legislation was in excess of €8 million over that period of time. The issue of how the organisation and regulatory body is viewed by those we register is of concern. We are mindful of it and one of our objectives, as we work our way through the implementation of the new legislation and conduct our business, is to create greater awareness of what it is to be regulated and how regulation can support individual nurses in the advancement of their practice on a daily basis.
The sole of objective of the regulatory body is to protect and safeguard the public from people referring to themselves as nurses who may not have met the competencies or who have impaired standards. We do that through the setting of standards for education, continual professional guidance and the code of professional conduct. In that respect, the public interest is addressed through the setting of standards for nurses and midwives.
In respect of value for money and the costs of running the organisation, the nursing board, under the new legislation, comes under the remit of the Comptroller and Auditor General. The board's accounts have been audited by it for 2012 and 2013 and the process has not made any adverse findings to include in the report of the accounts of the public services that were laid before the Houses of the Oireachtas. The accounts for 2014 have recently been completed and no matters of substance emerged during the course of this audit.
With respect to the costs of replacing staff who have left the organisation, the overall cost would be in the region of €500,000. These costs had been budgeted for in the business case for the original fee of €150.
With regard to travel, as the Senator would be aware, international work is a routine and normal part of the work of the regulator, in particular regulators of health professionals which is very much a global activity. The recognition and appreciation of the developments of nursing and midwifery in Ireland is recognised across the world and in order to sustain that development and apply evidence-based practice to our regulation, it is important the board continue that international work. The international work and participation in international forums and networks is no different to that of my predecessors over the years. I am contractually obliged to carry out this work. As I said in regard to auditing, all of the travel costs have been audited and are in compliance with Department policy.
With respect to the tombstone approach, there are three elements and I appreciate that nurses and midwives do not always see the middle element of regulation. First is registration and second is maintaining nurses' competence while on the register. We have continued to do that during the past four years through the launch of a new code of professional conduct and ethical practice. We recently approved a new scope of professional practice for nurses and midwives which will enable and facilitate greater latitude in the work nurses and midwives can do. We have revised the practice standards for midwives. Our revision to the undergraduate standards and requirements for the education of nurses and midwives will go to the board for approval in the autumn.
We are, in conjunction with the HSE, revising our guidelines for the management of medications. A multidisciplinary forum is revising the policy and standards on nurse prescribing. We address the professional development of nurses and midwives. On registration and renewal, I will defer to Ms Byrne who can provide some of the detail on that and can explain why it is more complex.
Ms Ursula Byrne:
In terms of the comparison in timelines between Irish trained registrants and those who trained abroad, when Irish trained registrants start their education programme, they go on our candidate register. We already have them on our database and have assessed their identification document. Once they complete their programme and are signed off as being suitable to register by the head of the college and the director of nursing in the primary hospital where they had their placements, that process is very quick.
In terms of individuals who were taken off the register for not paying their fees and their restoration to the register, once we receive their application for restoration forms, which they can download from the website and send to us by email, and we have received payment of the restoration fee their restoration is complete within three working days. The issuing of a certificate of registration takes a bit longer than it would have done in previous years because of the volume this year, but they are legally entitled to be back in the workplace after three working days because their employer will be able to see on the online register that their registration has been restored.
A number of committee members asked about incomplete documentation. This does not just involve issues with the application form which the applicant nurse submits to us. It also involves issues to do with the supporting documentation which they must get from other sources. Somebody who is Irish trained will find the Nursing and Midwifery Board of Ireland is somewhat of a one stop shop in that we provide verification that the person is registered, is in good standing with us and that his or her education programme met certain requirements. Somebody coming into the country may need to go to three different institutions to get that information and send it into us. He or she does not get all of the information from one place, depending on what country he or she comes from.
Deputy Mitchell O'Connor mentioned people who are already working in this country. Ironically, that may work against them because if they are in their home country and there is a delay in getting documentation from third parties, they can visit the offices of that third party and speed up the process. There are great difficulties in some countries which are outside of our control, in terms of applicants getting documents. There are also some countries where the documents come to us in a format that raises persistent queries about the content of the documents. This is an area where we work with recruiters so that if they are going to a particular country to recruit we can advise them as to the particular issues in that country. If the documentation is incomplete, we try to speed up the process of informing the applicant of exactly what is missing or needs to be clarified.
There was a question about what might be the issue after the assessment process.
This is information that primarily relates to the content of the transcript of training that the person sends in to us. It is only when that has undergone detailed scrutiny that questions arise, usually in respect of particular countries where there are issues, where it is not possible to make a decision until certain queries have been raised about the content of the person's education programme.
The other issue raised about education programmes relates particularly to the numbers undertaking their education programmes in Ireland. The number of places on courses is a matter for the Department of Health. It would, however, always consult with us on this matter. Programmes must also meet our requirements and standards so that we can be satisfied that at the end of the programme the student has had the requisite education and clinical experience. One of the key issues in respect of the number of students on programmes is that there must be sufficient staff in the clinical sites to support the supervised clinical practice and assessment of students. If in the morning there was to be a vast increase in the number of students, the clinical sites would not be able to support that. These are the same clinical sites that support overseas applicants undertaking adaptation placements. It is a question of getting that balance correct.
Dr. Maura Pidgeon:
In response to Deputy Mitchell O’Connor, we do fully appreciate and acknowledge the difficulties that have been experienced from the perspective of nursing homes and private and public hospitals. That is why we have been listening and have engaged in open information sessions and workshops to deal with the timeframes around the cycle and the adaptation programmes. The restructuring of our website will provide for some online capacity in the initial stages this year. The procurement of an information management system for registration will allow for infinitely more online capacity and the development of a smoother system for registration of all calibres.
In response to Senator Byrne, we fully endorse his acknowledgement of the work of midwifery. There has been a huge emphasis on the work of midwives across Ireland, and in May we revised the practice standards for midwives. The standards for education and training of midwives will soon go before the board. One of the key elements of the change in the legislation is the acknowledgement of midwifery as a profession independent of nursing. It is important and appreciated that Senator Byrne appreciates the work of the midwives.
I apologise for not picking up on the typo.
Dr. Maura Pidgeon:
More important, I hope I have provided some rationale for the need for the annual retention fee to have gone up at that time. In respect of the Senator’s point about the concerns about the running of the organisation, I hope it is clear that the organisation has been going through an enormous period of change and during that period there will be considerable stresses within the organisation at different times. The exceptional circumstances that the organisation has had to cope with over the past six months have not helped that situation. Given the circumstances, I have to acknowledge the enormous work and commitment of the staff in the organisation in registering the number of nurses we have now.
As a State agency, we are self-funded. Independent regulation is a cornerstone of the Nurses and Midwives Act 2011, as it is for all the health professions. Needless to say, within that structure there are reporting and oversight mechanisms in the parent Department, and there would always be consultation and discussion about issues pertaining to the organisation, funding and policy direction. That is what I meant by the board and its-----
Dr. Maura Pidgeon:
In response to Deputy McLellan, we received the €1.6 million from the Department at the end of 2012 and the beginning of 2013 towards the implementation of the legislation, but one element was the absorption of the former National Council for Nurses and Midwives. Under the new legislation, we brought the staff, or some of them, from that organisation into the board.
The mandatory competence assurance scheme is part of the Nurses and Midwives Act 2011. It has not yet been commenced. The development work is quite substantial and costly. We have had to defer a large part of the development. We can develop the model, but the roll-out and management - the business model - have had to be deferred, given the funding arrangements.
With regard to the question about having more graduates, as I said in response to a previous question, that is a matter for the Department of Health in respect of number of students.
I mentioned the figure of 698. Can Dr. Pidgeon respond to that point, please?
I have received communications stating that health care assistants, whom I mentioned earlier, are frustrated at the length of time it takes to register.
They are leaving the country and going to the UK, where they can be registered within a matter of weeks. Is the documentation they use in the UK not accepted in Ireland? Why can they be registered quickly there when it takes so long to do it here? We have 1,398 people with incomplete documentation.
On the Lansdowne Road process, the Minister for Public Expenditure and Reform announced that the Nursing and Midwifery Board of Ireland would not be increasing its retention fee until 2019. What was the role of the board in that? What on earth is role of the Minister for Public Expenditure and Reform in that organisation? Is the board being told not to collect money? We have been told that under statute it can and must collect money to fund the organisation. It has, however, been told politically not to do so by the Government, which is not giving any extra funding to make up the difference. The result is that the witnesses have been dragged in to this committee to hear a load of complaints from all of us about how they are running the organisation. I am not trying to defend the fee increase, by the way. Is there political interference going on to suit a Government agenda which is having a negative impact on the organisation?
I welcome both the witnesses today and hope they have never felt that they were "dragged" before the committee. I am delighted they have come before us to clarify some points.
Going back to the first response Dr. Pidgeon gave on the nine recently recruited staff, she said the contracts were for six months and used the phrase "full-time". Those are not permanent posts. There is no security. One of the issues that contributed to the departure of 11 people over the first six months of the year was insecurity and the general sense of things within the organisation. Surely the anchorage that is needed is job certainty and security. Does Dr. Pidgeon hope to be able to make these temporary positions, as they clearly are, into permanent posts? Is that something she envisages in the short term? I would be of the view that the numbers currently presenting are likely to maintain themselves for some considerable time. Surely this is a requirement in order to deal with the work levels that are presenting for the NMBI now and into the future.
The witnesses have addressed most of my questions. My only remaining one is about public relations costs. What public relations contract does the Nursing and Midwifery Board of Ireland, NMBI, have and how much does it pay for it?
Dr. Maura Pidgeon:
In regard to Deputy Mary Mitchell O'Connor's question about those working as care assistants and awaiting registration and the 698 people in the system, I will ask Ms Ursula Byrne to provide the Deputy with detail on that. The processing can be quite complicated and Ms Byrne is best placed to provide clarity.
Ms Ursula Byrne:
On the 698 who are in the system longer than 12 months, it is our policy that if we have not received all the required documents by the end of a calendar year, we close the file. However, closing files requires resources and we took a decision to prioritise trying to progress those files that are still active and ongoing, rather than diverting resources to closing others. When our staffing numbers are back to the required levels, we will review whether those files can be progressed or closed. It is not in anybody's interests to have applications through the system.
For those who are working as care staff in Ireland and have applied, the fact that they are physically in this country does not change the dynamic of their applications, except that they may find it more difficult to get their supporting documents. We are trying to increase the level of feedback to applicants on where their applications are in the system and how they are progressing. We have very long-standing, ongoing communication with our colleagues in the UK. The UK system, which was recently revamped, is on a par with our own in terms of the documents required and level of complexity of the process. I would question whether people are able to get registered in the UK within a matter of weeks. There are no short cuts in the UK and their process is as rigorous as ours.
Ms Ursula Byrne:
The HSE has indicated to us in the last two days that it is putting on more courses in the coming months. As I mentioned earlier, a number of private hospitals have applied to be approved as sites for adaptation programmes and their applications are currently under assessment. We expect decisions to be reached and issued very shortly. It will then be up to those private facilities to decide on the number of programmes they run and how many participants they take. It should increase the capacity.
Ms Ursula Byrne:
The HSE has indicated that it is increasing the number of courses it is running. If these private facilities which have applied for approval receive it, as we would hope and expect to be the case, they can make decisions themselves on how often they take a group and how many people they take within each group. They have the facility to provide more places around the country.
Dr. Maura Pidgeon:
That is okay. On the Lansdowne Road agreement, that was part of the national arrangements. The Nursing and Midwifery Board of Ireland is not party to the discussions on those national proposals currently out for consultation, no more than the Medical Council would be, as members will understand.
In respect of the relationships between the board and the Department----
Who took the decision, then? It is the board's decision to increase the fee, yet that decision seems to have been taken by the Minister for Public Expenditure and Reform and the Minister for Health in these negotiations. What else were they telling the board to do?
Dr. Maura Pidgeon:
My understanding of the Lansdowne Road arrangement is that there is a cap on what the nurse or midwife will pay for the next three years. The matter of the ongoing funding of the organisation - in addition to the revenue from the €100 fee - is being discussed on an ongoing basis with the Department of Health.
Dr. Maura Pidgeon:
I can answer that question. The communications contract also includes the web restructuring. It incorporated a member of staff because we do not have a full-time communications person, which we needed for a period of four months, and an annual retainer. The amounts budgeted for have been in the region of €300,000 for last year. That is the public relations spend. It is now considerably reduced because we do not have the staff member there and the web project will be coming to a conclusion at the end of October.
In regard to-----
I have to leave for the vote. I am not putting Dr. Pidgeon on the spot because she may not have all this information at her fingertips, but is it the same company? Web design and public relations are very different skillsets. Is the same company doing both for €300,000?
Dr. Pidgeon may not know this off the top of her head, but how much of that is for the web part and how much for public relations? I am very interested. It is not just the Nursing and Midwifery Board of Ireland, I ask everybody this. I have a bee in my bonnet about public bodies spending money on public relations.
Dr. Maura Pidgeon:
Yes, I just wanted to deal with the question about the staff. The staff that we are replacing are temporary staff on a short-term contract for a period of six months. The reasons for that are, first, that we have to finalise the funding of the organisation - creating permanent positions in the absence of firm funding arrangements into the future would not be very prudent. The second reason for the short-term contracts is that we wish to address the current crisis in terms of the backlog and fixing and enhancing our processes. On that basis, we will evaluate the progress being made because with enhanced systems and with more online capacity as we get towards the end of the year, there may not be the need for the same numbers of staff. It will be evaluated over that period of time.
Regarding the difficulty in expediting applications, some of the complaints we received were that communication about incomplete applications does not happen for weeks or months. I am not sure whether that is the reality, but those are the complaints we are getting.
Dr. Maura Pidgeon:
That is the situation, as we said earlier. In the last few months, there have been delays in getting to the first stage of reviewing applications as they come in. That is purely a resource and volume issue. That is where the target would be in regard to the additional resources required. It would be to focus in on that number in order to get the information out to the applicant.
I apologise to Dr. Pidgeon for the inordinate delays in the votes this morning and thank her and Ms Byrne for their co-operation and patience and for their testimony this morning. I know they have another meeting to go to. On behalf of all the committee members, I apologise for that.