James Reilly (Dublin North, Fine Gael)

The primary objective of the legislation is the protection of the public. Key aspects of this relate to the fitness to practise committee, competency and a non-professional majority on the board. On this basis, Fine Gael wishes to raise a number of points.

The Bill seeks to introduce what is regarded as a two-part fitness to practise structure, which would bring the Bill in line with the Medical Practitioners Act 2007. This structure provides for the establishment of a preliminary proceedings committee to give initial consideration to complaints and an internal fitness to practise committee to conduct inquiries. As pointed out in the Minister's regulatory impact assessment, the Commission on Patient Safety and Quality Assurance was established by the Minister, Deputy Harney, to develop clear and practical recommendations to ensure that quality and safety of care for patients is paramount within the health care system. This is something on which all sides of the House agree. Its report, "Building a Culture of Patient Safety", was published in August 2008.

On fitness to practice, Recommendation 6.18 of the report recommends that:

The Group will review current Fitness to Practise processes across the different professional regulatory bodies in order to develop plans to achieve greater separation between the investigation and adjudication functions performed by the professional regulatory bodies, and in order to devise means by which Fitness to Practise panels can be independently appointed and trained.

The Commission on Patient Safety and Quality Assurance advocates the separation of fitness to practise from the regulatory function. Under these proposals the board would be still responsible for the preliminary investigation and, if it is decided that there is a case to answer, the chief executive would present the facts of the case to a fitness to practise committee which would operate outside of the board.

According to the Minister's regulatory impact assessment, "There is a lot of merit in what is proposed by the Commission, however, the detail of how it would operate is not clear and it will be the work of the sub-group to examine and make proposals as to how this might be achieved." Perhaps the Minister could comment on why she has not accepted the recommendation of her own Commission on Patient Safety and Quality Assurance and why this proposal has not been developed. Given the passage of the Nurses and Midwives Bill through the Houses of the Oireachtas, is this not an ample opportunity for the implementation steering group to made recommendations in this regard? In summing up, perhaps the Minister, Deputy Harney will comment on that for us. It would be timely.

On the model of fitness to practise proposed in the Bill which is based on that model adopted in the Medical Council, it is our understanding that the Medical Council has sought amendments to the new legislation based on its experience through practice to date. Perhaps the Minister could confirm if this is the case and, if so, what amendment it has sought, as the Nurses and Midwives Bill will otherwise repeat the mistakes already made. I am sure the Minister would agree that we can use the experience of the Medical Council over the past three years to advise in some respects on the operation of this board.

The current board consists of 29 members, 17 of whom are elected by nurses and 12 of whom are appointed by the Minister for Health and Children. The new board will have 23 members - which is six fewer - 15 of whom will be appointed by the Minister and eight of whom will be elected by the professionals. The eight members of the new board to which I refer are supposed to represent each discipline of nursing and midwifery: two nurses, one from general nursing and one from children's nursing, of whom at least one is in clinical practise; two nurses, one from psychiatric nursing and one from intellectual disability nursing, of whom at least one is in clinical practise; one midwife and one public health nurse, of whom at least one is in clinical practise; one nurse/midwife engaged in education; and one older persons' nurse.

My party has met with the Irish Nurses and Midwives Organisation which has voiced serious concerns about the proposed structure of the board and the adequacy of the representation of nurses and midwives on the board. They claim that there is "no way" the work of midwives can be adequately represented or safeguarded with only one midwife on the board. The situation is the same for the other strands of nursing.

The board, at 23, must be compared with a 25 member board for the Medical Council. These numbers beg questions. I accept that the Minister cannot have a board of 50 as it would be far too unwieldy. Nonetheless, the Minister has a 25 member board looking after 7,000 medical practitioners and she will have a 23 member board looking after perhaps 35,000 nurses - certainly more than 25,000 practising general nurses. The board seems a little light. The Allied Health Professional Council, which has a membership of 21, looks after 5,500 to 6,000 allied health professionals.

The proposed membership does not provide adequate recognition of the differing numbers within each area of nursing and midwifery, for example, there is one general nurse engaged in clinical practice who will represent more than 25,000 practising general nurses while one public health nurse will represent 1,700 public health nurses. Perhaps the Minister could comment on these points and whether they adequately reflect and represent the discipline. Without being confrontational about it, perhaps she could explain the logic behind it and how the decision was made to come up with these ratios.

Section 25 of the Bill allows for the payment of allowances to members of the board or committees. Perhaps the Minister could clarify the numbers of people who will be eligible for such allowances and whether there is a cap on such costs? What will be the maximum amount each member can claim?

Section 46 establishes what is referred to as a "candidate register". According to the explanatory memorandum, the candidate register will include the name and details of all candidates who are pursuing education and training leading to first-time registration with the board. It will consist of at least two divisions - the nurse candidate division and the midwife candidate division. Essentially, this means that undergraduates will have to register with the new board and pay a fee for the privilege. Will the Minister explain the reasoning for this new register and its purpose or benefit to the board other than, as many construe, it being a money-making exercise? Candidates are not independent professionals, but are supervised at all times. It is not clear why they must register and the additional cost to the individuals is a concern.

Section 46 establishes what is referred to as an advanced nurse practitioner/advanced midwives practitioner, ANP/AMP, post register. This register will contain the names and details of advanced nurse practitioner posts and advanced midwife practitioner posts, and any other information required by rules. It will consist of at least two divisions - the advanced nurse practitioner posts division and the advanced midwife practitioner posts division.

This register applies only where there is a post. If an advanced nurse practitioner wanted to move to Letterkenny, where there is no ANP post, he or she is not registered. Perhaps the Minister could explain the purpose of this register? Is it, as some suggest, to prevent people from developing services where the HSE and Minister do not want them, that is, subject to there being a post? If one is off the register for a number of years, can he or she get back on to it? No such stipulation exists for any other registered professional and his or her registration. This register will by default, perhaps not by design, prohibit the development of the profession. This is a serious concern, which, to give the Minister the benefit of the doubt, may be unintended. It certainly needs to be re-examined because it could have a very negative effect, and will not give the signal to the nursing profession that we are interested in promoting and encouraging advanced nurse practitioners. We all know that with the current manpower crisis across the health services, particularly in medical manpower, there is an increased role for advanced nurse practitioners and there are many areas where they could provide invaluable input. I hope the Minister will come back to us on that in her response or address it on Committee Stage. The membership of five proposed for the statutory midwifery committee is regarded by many as hopelessly inadequate. This will not ensure that the many areas of midwifery are represented, even through nomination, in the workings of the midwifery committee.

The issue of the independence of the board is a significant concern to the profession, to those outside the profession and to Members on this side of the House. The current legislation as interpreted by the board does not allow the board to comment on the environment within which nurses practise.

Section 9 sets the functions of the board. This section does not include a provision whereby the board has some advisory role to service-providers on staff shortages, physical environment, poor quality or unsafe conditions. I know the Minister would agree it would be very important if a practising nurse regarded conditions to be a danger to patients, he or she would be duty bound to report this. There is very little room in the Bill for this to happen. The board should have some role in this area so that it could direct nursing staff where to express those concerns. We all know that industrial relations can be fraught and that legislation in these areas can be used to advantage by people from time to time.

However, this would need to be accommodated because the safety of patients must be paramount. If professional staff express concerns about the conditions in which patients are being treated, it behoves us to ensure the public is aware of this and that the situation can be addressed. The days of trying to keep things in the dark and trying to muzzle professionals, so that we do not hear what we should hear and know about, is dangerous.

Every action the board takes must be directed by the Minister, with the agreement of the Minister. The independence of the board will be severely undermined in this case considering the number of individual board members appointed by the Minister. The Minister now wants the right to nominate the president of the board. This does not happen on any other registration board of which I am aware, such as the medical and dental councils who elect their own presidents. This is an extraordinary development.

The Minister will need to explain the thinking behind this proposal. It leaves the Minister wide open to the accusation of political interference, not something the Minister would wish to be accused of. Fine Gael will oppose this provision. While we have no objection to the ideology or the logic of having a lay majority on the board, this board is supposed to be independent and not open to be used for political purposes. When so much power is vested in and rests with the Minister, there has to be an extraordinary danger of this happening. The Minister may say that this is not her intention and I hope it would not be. However, if legislation to govern such an important professional body is to be enacted, we must ensure that this legislation will stand the test of time and will not be open to abuse by less democratic individuals than the Minister. This is a very serious flaw in the Bill.

The chief executive officer of the new board will not be permitted to make any statements which differ, contradict or oppose ministerial and Government policy. This is an extraordinary situation. A political imperative can now supersede the safety of patients, if the council wishes to express a true and real concern through the chief executive officer. No such restriction applies to the chief executive officer of the medical council or the chief executive officers of the allied health professionals. They are not being mugged in the way the Bill clearly sets out that the board will be muzzled.

The regulatory authority should be allowed to seek to meet the service-provider, to advise it of this and to ask if anything can be done. Such a provision included in section 9. I ask the Minister to comment on why the board does not have the authority to do this.

Figures provided by An Bord Altranais show an overall rise in the cost of fitness to practise between 2002 and 2009 of 357%, from a cost of €0.34 million in 2002 to €1.214 million in 2009. The number of applications for a fitness to practise inquiry increased from 27 to 67 in the same years. In 2002, seven inquiries were held. This had increased to 19 inquiries commenced in 2009. Will the Minster provide information on the legal costs for this period of years? Information made available to Fine Gael indicates that An Bord Altranais ran a deficit last year and that legal costs increased by some 100% during this time. I ask the Minister to confirm if this is correct. If so, this would be a cause for concern. These escalating costs need to be addressed. There needs to be a strategy to deal with this situation.

The competency scheme is a most welcome development. The Bill as published provides for the introduction of a professional competency scheme for registered nurses and midwives. This is a very positive development which is welcomed on all sides and by the profession. However, there are some concerns about the set-up costs, which the board has estimated at €3 million, of a competency assurance scheme. It is estimated there will be a recurring annual cost of €1.5 million for the administration of the scheme. If the full cost were to be passed on to nurses and midwives, this would amount to €34 for the set-up cost and an ongoing annual charge of €17 per registered nurse-midwife, based on current numbers of registered nurses and midwives. The cost of the additional regulatory functions transferred from the National Council for the Professional Development of Nursing and Midwifery is estimated at €5.80 per registered nurse-midwife.

In addition, there will be a further €1.90 increase for other costs. Therefore, the annual retention cost to a registered nurse or midwife is likely to increase by €25, from €85 to €110, with a once-off fee of €34 for the establishment of a competency scheme, if this is not funded by the Exchequer. If the fitness to practise cases increase, this may lead to an additional increase in fees. This is a concern. The board has stated that the introduction of a formalised system of competence assurance may lead to an initial increase in the level of cases being referred to fitness to practise inquiries. The board estimates €1 million for legal costs arising out of referrals to the fitness to practise committee

The Bill allows for the Minister, with the consent of the Minister for Finance, to provide Exchequer funding to the board. This may arise in respect of the introduction of competence assurance and a contribution to related set-up costs. Will the Minister clarify how much will be paid for by the Exchequer and how much by the board? Given current economic circumstances, will the Minister agree it is unlikely these costs will be met by the Exchequer? Will she agree the costs will more likely be met by the profession through increased registration fees?

The legislation dissolves the National Council for the Professional Development of Nursing and Midwifery. The board will be assigned additional functions which relate to the work undertaken by the national council. The staff, property, rights and liabilities of the national council will transfer to the board. The national council is fully funded by the Exchequer. Although no increase in funding is envisaged, the funding of the staff that will transfer to the board and the assumption of additional responsibilities may in the future be funded by the board via fees. The cost of staff transferring to the board is estimated at €500,000. Will the Minister clarify the arrangements?

Any professional competency scheme proposed by the board must have the approval of both the Minister for Health and Children and the Minister for Finance. This stipulation does not exist for medical practitioners or allied health professionals. The cost of the introduction of such a scheme and its maintenance appears to be left with the board. Will it impose significant additional costs on the nursing profession? Such costs are not borne by the boards for medical practitioners or allied health professionals. Will the Minister be directing these boards to cover the costs of their competency schemes?

The legislation provides for a significant role for the Health Service Executive, HSE, which is not replicated in other similar legislation. It suggests the HSE can very much influence and control the new board and its workings which suggests a restrictive form of independence for nurses and midwives. Any objective person would be concerned at any undue influence in this area by the HSE. It is a body that has had little public confidence since its inception.

Nurses and midwives hoped for a role on the board that would allow them to provide advice and guidance to their employers to ensure best nursing and midwifery practices thus minimising misadventure and negative incidents. The legislation is silent on this whole area. An opportunity has been missed to allow for an orderly and structured communication from the work on the ground to the board.

How much time do I have, Acting Chairman?

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