Ms Phil Ní Sheaghdha:

Conditions will only be improved if we retain our nurses. The biggest problem we have is that when our members go to work there are not enough of them to provide the service. This makes their conditions very difficult to work in and increases the incidence of burnout. This has been studied internationally and in Ireland as part of the RN4CAST. There is absolutely no doubt that staffing levels are inadequate to meet demand.

If I could combine that answer with my answer to Senator Burke's question on the issue of prioritising areas, it is fairly simple in our view. The comparison and staffing determinant for nursing is not based on the number of doctors but on patient outcomes. That is the model the Department of Health has accepted and agreed to implement. The problem is that the Department is not funding the implementation. We know from the study conducted over the past four years in four of our large acute hospitals, including Beaumont, Our Lady of Lourdes and Loughlinstown hospitals, that the outcomes for patients are significantly improved when a staffing ratio of 80 nurses to 20 healthcare assistants is put in place. The difference it makes to the mortality rate of patients is incredible. The agency spend and value for money are improved significantly because retention is improved. All of this is known to the HSE and Department of Health. The only barrier is that it is not being funded for implementation, which is a big problem.

When the number of consultant posts is increased and hospitals get busier, more nurses are needed to staff the additional workloads. In the funded workforce plan the HSE does not determine the staffing increase that will be needed for increasing services.

We have major problems in community care. We have already reached an agreement with the HSE, which is two years old, on expanding the role of the nurse in long-term care, step-down units and primary care. There is absolutely no reason in this day and age that patients should be transported from care for the elderly facilities to acute emergency departments to get services such as hydration or antibiotic therapy, which can be provided by nursing staff in those facilities. They are trained and qualified to do it. The problem is the process and procedure have not been built to allow them to do it.

In respect of other services, the community intervention team, CIT, model has proven to be extraordinarily successful in keeping patients out of hospital. It needs to be funded and expanded. The management of chronic disease is something nurses do in every jurisdiction. In Ireland, there is a long-held view that the management of chronic disease can be delivered outside of acute hospitals. We believe nurses are very well placed to provide that service. They are qualified to do it. They are expert in many of the diseases and chronic conditions that cause patients to be admitted to hospital, particularly respiratory conditions, diabetes and cardiovascular disease.

The role and function of the nurse is an area we are happy to talk about and examine. We have reached agreements already which confirm that we will expand our practice. However, we are baffled as to the reason that is not being taken on and utilised as a cost saving and value for money initiative but it requires additional numbers, and that is the problem. We cannot get the numbers until we get the pay right.

On the VHI step-down initiatives, I would answer that question by saying community intervention teams are the way to go.

On Deputy Murphy O'Mahony's questions on funding local hospitals, she is absolutely correct that there are services that should not be centred in facilities such as Cork University Hospital. St. Finbarr's Hospital, which is one of the main facilities that takes patients from Cork University Hospital, advised us recently that it was cutting nursing staff numbers. We had to refer the matter to the Workplace Relations Commission, WRC, and go into dispute with the Health Service Executive, HSE. Those are nursing led services. They are extremely important to keep patients out of the acute hospital and allow discharge to the acute hospital. They also allow general practitioners to admit directly to community hospitals such as Bantry hospital and other locations. Cutting staff in those areas is a short-term funding measure that makes no sense.

Regarding endoscopy, it is on the record that there is cross-party support for the Sláintecare report in respect of the availability of diagnostics outside the acute hospitals sector, which again is a matter that needs to be speeded up.

I think I have answered Deputy Durkan's questions on pay parity and who we are competing with. We have two problems with the recruitment and retention of nurses. One is that we are heavily dependent now on recruitment from non-European Union countries and have been for some time. Nursing was one of the grades subjected to the moratorium, while other medical grades were excluded. We are, therefore, still catching up from the posts that were not filled from 2007, which was when the moratorium was implemented in health. We are down 2,000 posts from that point, even though our hospital activity, as my colleagues in the Irish Medical Organisation, IMO, have pointed out, is way over 100 in most hospitals in terms of bed occupancy, etc.

We are recruiting from non-EU countries, from which other countries are also recruiting. When nurses acquire experience in a western environment like ours, the American and the Canadian markets come here to recruit them from us.