Ms Martina Harkin-Kelly:

I thank the Chairman. On behalf of the Irish Nurses and Midwives Organisation, INMO, and the 40,000 members we represent, I wish to begin by thanking the committee for affording us this opportunity to meet and engage with them on the hugely important work of this committee and the potential it offers - supported by the political system - to reform our inequitable health system. The INMO wishes to state that the work of this committee must be the first step in a radical, comprehensive, transformational and sustained process of change.  This must lead to a seamless, universal, single-tier health service, with access based solely on health need rather than ability to pay. In putting forward this view we accept that moving from our current inequitable two-tier system will require, at a minimum, up to 15 years.  This change will also require political consensus stretching far beyond the normal electoral cycle and will necessitate future Governments and Opposition parties accepting the process of change complete with the funding and resource requirements necessary to deliver that change.

The INMO also supports the view that a single-tier service it must be funded to the tune of a minimum of 10% of gross domestic product, GDP and 12% to 14% during the transitional period. In addition we must have a separate funding system and stream, spanning five to seven years, providing for the necessary capital investment to improve existing health infrastructure and develop new community based health facilities. In delivering a quality-assured, accountable and responsive service, it will also be necessary that we have a simplified and lean organisational structure.  Funding and real accountability must be devolved to front-line managers - primarily nurses, midwives and health professional managers - who can respond to changing demands, needs and demographics in a much more flexible way than is possible in the context of the current bureaucratic and layered management structure.

I will now turn to the current realities. Our written submission has detailed the very bleak journey Ireland's public health service has endured in recent years. More than €4 billion has been cut from health funding, which is an unprecedented contraction of expenditure in any OECD country. There has been a loss of over 2,000 beds. Public supports for vulnerable people have been undermined such as the privatisation of services for older persons services, the curtailment of mental health services curtailed, the silent but hugely damaging cuts in disability services and the very severe contraction, despite commitments to primary care, to public health and community nursing, home care, home help and related services.

The injurious, unmanaged and unmeasured contraction in staffing levels has resulted in a loss of more than 5,000 nursing and midwifery posts, 13.5% of the workforce. The system is still working with some 4,000 less nurses and midwives than it had in 2009, compromising patient care on a daily basis. We have a loss of 3,500 general support and care staff and a reduction of 1,200 in the number of clerical and administrative staff. It is acknowledged that during this period there were some increases, including in respect of the number of medical personnel by more than 1,500. There was also a small increase of 800 in the number of allied health professionals. The impact of this unmanaged contraction, driven solely by budget considerations regardless of its outcome upon patient care or the ability of the health service to meet demand, has been completely underestimated by the political system and this is evident in record levels of admitted patients on trolleys in overcrowded emergency departments and wards. Record numbers of patients are on hospital waiting lists and waiting lists for services in the community.

This committee must be acutely aware that this contraction resulted in the forced emigration of young, recently-graduated health professionals in the nursing, midwifery and other allied health fields.  In considering any real transformation for our health service the first challenge will be to attract back these health professionals while we also educate additional numbers and ensure they remain in Ireland upon qualification. The committee must recognise that the morale among nursing and midwifery staff has never been lower.  They feel totally disrespected by their employer and their professional judgement is, on a daily basis, set aside or ignored by senior management whose continuing focus is solely on budgets and numbers and not on the needs of patients and service users. It is against this reality that the required transformation must begin with the replacement of lost staff, together with the recruitment of additional staff, which will require sustained investment. If we do not have nurses and midwives, and other front-line staff, we do not have a health service that is fit-for-purpose.

Consider the transformation and what is required. In calling for this major organisational transformational programme the INMO recognises that it must be in tandem with how and who delivers care, and where that care or support is provided in the context of devolved funding and accountability arrangements. The fundamental principle of our new and changed health system must be a guarantee to any service user that they will receive integrated care whether they need it in the home, in a primary care setting, an acute hospital or a long-term care environment. There can be no silos with regard to budgets or who delivers care. Such silos are currently real and growing barriers to meeting the needs of patients and service users.

It is against this background that the INMO makes the following points to the committee on organisational reform. In the context of 11 years of organisational reform, with no improvement, the INMO, as part of this transitional programme, believes that certain measures must be put in place including: simplified organisational structures from the Department of Health; regional health authorities; and individual local units and areas. There is no cohesion or accountability within current structures, which include the Department of Health, the centralised HSE, seven hospital groups, nine community health organisations, 17 mental health areas and numerous section 38 and section 39 service providers. This lack of cohesion will always result in a lack of transparency and accountability with front-line staff not having the necessary autonomy, with responsibility to shape service delivery to meet patient or client need.

In the context of transforming models of care, this overhaul must result in nursing and midwifery and medical staff being empowered, with accountability to deliver care at the most effective level. The INMO would put forward the following framework in this regard. The single-tier service would see all new appointments to consultant and general practitioner posts involve a public-only contract including an obligation to work rosters on a five as opposed to a seven-day basis. Existing consultant and general practitioner post-holders who do not wish to change their contracts must be allowed to retain them. All new appointments should be replaced with public only contracts. This will require an increase in the number of consultants to our public health service.  This can be partly funded by a reduction in the number of non-consultant hospital doctor, NCHD, posts, reducing our current over-reliance on medical staff undergoing continuing training or education in the clinical area. There should be very significant expansion of the role of the nurse and midwife in all clinical areas requiring a significant increase in the number of nurses and midwives in the hospital and community who are empowered to prescribe within agreed protocols. There should also be an expansion of nurse and midwife led services involving advanced nurse and midwife practitioners as follows: the empowerment of nurses and midwives to order diagnostic tests such as X-rays and bloods, whether they work in hospitals or community settings; the mainstreaming of an expanded role with regard to first dose antibiotics; intravenous cannulation for fluid balance; out-of-hours phlebotomy; nurse-led discharge; and other appropriate roles within all care settings. The role of the health care assistant, including their job descriptions and training pathways, must be standardised, nationalised and become the minimum required for entry to this grade. This is an essential part of front-line reform which should lead to best practice skill mix ratios such as 80:20 for registered nurses and health care assistants in acute medical and surgical wards and 50:50 for registered nurses and health care assistants in care of the elderly facilities, as confirmed by international research by RN4CAST.

I will now turn to devolved funding. The INMO is also calling for reform leading to a practice where funding is devolved to units, wards and community level. Currently, front-line managers have no input into what funding is required and can work the whole year without ever knowing what funding was given to their area or unit, which leaves them in an impossible position.

In simplifying organisational structures, the INMO is also calling for new accountability rules which would ensure the director of nursing or midwifery is involved, at all stages, in the formulation of the annual budget for that location and area. Once the budget has been finalised for that area or location, it would then be devolved to the front-line manager, that is, the clinical nurse manager or the head of physiotherapy, who assumes responsibility and accountability for the budget but with complete autonomy as to what services can be delivered safely within that budget. Directors of nursing and midwifery and senior hospital area managers, as appropriate, would be empowered to seek amended funding levels to reflect changes in service demand, acuity and dependency.

The greatest damage done to the health service in recent years has been the totally unmanaged contraction of staff numbers. This, in turn, is a major reason for the broken spirit and morale of front-line staff, particularly nurses and midwives, at this time. As we embark on this transformational programme we must introduce an evidence-based approach to staffing our health service at levels which optimise the well-being of patients.

This process is already under way through the work of the task force on nurse staffing and skill mix in adult medical and surgical wards. The further roll-out of this approach to staffing is fundamental to the transformational programme and the next area planned is emergency department nurse staffing. This work must be accelerated, and we use evidence-based mechanisms, as determined by the front-line manager, that is, the CNM2, to determine appropriate staffing and skill mix requirements.

It is self-evident, and very regrettable, that to date the HSE, the Department of Health or the Government have not done enough to address the loss of our best and brightest young professionals. Therefore, the public service pay commission must be accelerated and FEMPI unwound, together with the early renegotiation of the Lansdowne Road agreement, in order to garner trust within staff to deliver this radical transformation. In addition, it is the belief of the INMO that the crisis with regard to nursing and midwifery recruitment and retention requires unique measures to be brought forward immediately to reduce current excessive workloads and improve patient care. No matter what model of health care is used, the reality is that all health systems are labour intensive and must be staffed by committed, dedicated and flexible people. This must be recognised with the health service being an employer of choice offering excellent pay and conditions.

As we state in our written submission, the latest OECD figures confirm that in 2013 the Government's allocation to public health spending was 72% of GDP. The OECD figures also indicate that when this public expenditure is combined with private health expenditure the overall health spend in this country is approximately 10% of GDP. However, the manner and nature of this expenditure, which clearly reinforces the two-tiered structure, only serves to guarantee faster access to diagnostics and treatment for those who can afford private insurance or direct out-of-pocket expenses. This is inherently unfair and inequitable.

Therefore, in calling for a public health spend of no less than 10% of GDP, and 12% to 14% during transitional years, we recognise that this must be done with total transparency so that it secures and maintains the confidence of all citizens and taxpayers. We also call for the phased abolition of all tax reliefs pertaining to private health insurance, the ending of any contracting for services to provide direct care and the phased ending of subventions to private nursing homes, while recognising this will take an extended period due to existing contracts and bed stocks and the need to develop new publicly-funded direct facilities.

In recognising the challenge that meeting future health costs will bring, we draw the attention of the committee to recent papers produced by the Nevin Economic Research Institute, which remind us that by 2046 the number of persons over 65 years of age will have increased from 606,000 to 1.8 million. In addition, we face the growing epidemics of obesity and alcohol abuse which will also increase demand on our health service. Against this stark reality, the political system must fully understand the implications of these demographic and lifestyle changes. All taxpayers must also understand that we cannot reduce general taxation levels and provide the same type and extent of health service the population will need.

Our call today to the committee is to begin the revolution necessary to deliver a single tiered health system within 15 years, which will serve all the people of this country equally and in a world-class manner. In calling for this, we also recognise that health service structures and how all health service staff work must also be subject to transformation. No vested interest should be allowed to halt the pace of progress necessary to prepare for the growing demand that will be made on our health system.

To deliver this change will require the health service, including its funding and structures, to be removed completely from the traditional electoral cycle and budgetary practices. We ask members to make these recommendations, safe in the knowledge that all future generations of Irish citizens will live in a more equal society with regard to health care, which is an investment in the future and will realise healthier communities and a stronger economy.