Thursday, 13 May 2010
Nurses and Midwives Bill 2010: Second Stage (Resumed)
Part 4 includes provisions for the membership, committees and employees of Bord Altranais agus CnÃ¡imhseachais na hÃireann. The board will have 23 members, of which 11 will be nurses or midwives. Statutory provision is made for two committees relating to the fitness to practise functions of the board - the preliminary proceedings committee and the fitness to practise committee. Part5 deals with the accounts of the board. The board will continue to be funded by fees paid by nurses and midwives, but the Minister for Health and Children may provide financial assistance relating to its functions under Part 11. Part 6of the Bill provides for the registration of nurses and midwives. Only individuals who are registered by the board can practise as a nurse or midwife. Section 46 provides for three registers, the nurses and midwives register, the candidate register and the AMP/ANP posts register. A number of divisions are specified for these registers and the board may create additional divisions by rule. Section 49provides for the registration as an advanced nurse practitioner or advanced midwife practitioner which is linked to employment or offer of employment in the advanced practitioner post.
Part 7 relates to complaints regarding registered nurses and midwives. It details the grounds for complaint, which have been expanded to include a number of additional grounds including inappropriate behaviour. Part8 provides for the conduct of inquiry by the fitness to practise committee. The hearing will generally be held in public unless decided otherwise following a request. The powers and protection relating to witnesses and evidence are specified. It also provides for a situation where the nurse or midwife consents to a censure or remedial action. It provides for the report from the fitness to practise committee to the board and the steps to be taken by the board on receipt of the report.Part 9relates to the sanctions which can be imposed by the board following a finding against a nurse or midwife. The confirmation of the High Court is required for all sanctions imposed except for an advice, admonishment or censure in writing or where remedial measures have been agreed. Provision is made for the right to appeal to the High Court.
Part 10 provides for the roles of the board and the Health Service Executive with regard to nursing and midwifery education and training. The Health Service Executive will facilitate the education and training of nursing and midwifery students. The Health Service Executive will promote specialist nursing and midwifery education and training. It shall also undertake appropriate workforce planning in order to meet the needs of nursing and midwifery specialist staffing and training of the public health service. Part 11 places a duty on nurses and midwives to maintain their professional competence on an ongoing basis. The board can require a registered nurse or midwife to demonstrate their professional competence at any time and nurses and midwives are required to comply with any board direction relating to their professional competence.
Part 12 provides for the dissolution of the National Council for the Professional Development of Nursing and Midwifery. The employees, rights, liabilities and property of the national council will transfer to the board. Employees' conditions of service and pay will be no less beneficial than those which currently apply. Part 13 provides for a number of miscellaneous matters, including that a clinical supervising authority will perform the functions of clinical supervising authorities as specified by rules. It also provides for matters which are absolutely privileged in any action for defamation. Provision is made that the board may investigate unregistered persons suspected of practising nursing or midwifery or claiming to be registered in contravention of this legislation.The Scheduleoutlines the tenure of office of the board, proceedings relating to resignations or termination of membership and the filling of casual vacancies, the quorum required for meetings of the board, meetings, the role of the president and vice-president and the proceedings at meetings.
In conclusion, this Bill will put the governance of nursing and midwifery on a modern and robust footing, with the public interest and patient safety at its centre. It contains many elements that form the vision for nursing and midwifery that has emerged over many years of reflection on the professions and their role in the Irish health service. It will ensure protection of the public and support nurses and midwives in enhancing the high standards of education, training and competence of these professions, which will result in public confidence in their practice. I urge a thorough and considered examination of its provisions, with a view to its early enactment. I commend the Bill to the House.
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 â¬0.34 million in 2002 to â¬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 â¬3 million, of a competency assurance scheme. It is estimated there will be a recurring annual cost of â¬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 â¬34 for the set-up cost and an ongoing annual charge of â¬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 â¬5.80 per registered nurse-midwife.
In addition, there will be a further â¬1.90 increase for other costs. Therefore, the annual retention cost to a registered nurse or midwife is likely to increase by â¬25, from â¬85 to â¬110, with a once-off fee of â¬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 â¬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 â¬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?
That is an amazing exposÃ©. Deputy Charlie O'Connor is not from Tallaght.
The Bill contains positive elements while being deficient in other areas . It gives the Minister and her successors a great deal of power and control which could inhibit the workings of the board. These are markedly different from the powers left with the Medical Council. No explanation is given as to why this subtle but important difference in approach has been taken. This is a provision this side of the House will oppose strenuously. Any legislation which can give rise to political interference in a regulatory board is to be deplored and should not be allowed to spread to other boards or councils.
Equally, there is much greater control being retained by the relevant Ministers with regard to the creation and maintenance by the new board of competency schemes, education programmes and rules which are not so restricted in other legislation.
There lies the real problem with the Bill. There have been missed opportunities in allowing the nursing profession to respond to deficits and dangers in work practices. Equally, there is a strong sense of a heavy political hand in the running of the board. For the first time a Minister will have the right to appoint the president of the nursing board. These are dangerous developments.
The Labour Party broadly welcomes the introduction of this legislation. It has been a long time coming, recommended by the Commission on Nursing in 1998. The Bill has also been welcomed by nurses, midwives and their representative bodies. The Labour Party, accordingly, does not intend to oppose the Bill on Second Stage. However, it will raise some concerns and table amendments on Committee Stage which it hopes the Minister will consider seriously.
All parties want to ensure a proper regulatory system for the nursing and midwifery professions which would be in line with the Medical Practitioners Acts and the Health and Social Care Professions Act. As Deputy James Reilly said, there are some subtle differences between this legislation and these Acts. There is a heavy handed control aspect of it which we will seek to address. I tabled a question to the Minister answered on 11 May in respect of amendments to the Medical Practitioners Act and I call on the Minister to reply in respect of this issue. I was given to understand the Irish Medical Council sought amendments to that Act. In her reply, the Minister stated two minor technical amendments would be included in legislation later this year. The Minister went on to note that the Medical Council held certain concerns. Will the Minister address this issue? Understandably, the representatives of nurses are keen that if changes are being made to the Medical Practitioners Act later this year, we should ensure the Nurses and Midwives Bill is in line with that Act. Will the Minister clarify the changes to be made?
I refer to the issue raised by Deputy Reilly towards the end of his contribution, that is, the fact that there is no provision whereby nurses and midwives can advise health service providers, including the HSE, when they hold concerns about standards and the safety of patients in the workplace. Will the Minister consider empowering the board to provide for this on the basis of information coming from practising nurses and midwives? This is in the context of the current climate in which nurses and midwives are working with cutbacks and increasing number of patients for which individual nurses and midwives must care.
Yesterday, I spoke on the telephone to a man who informed me he was in the accident and emergency department of Beaumont Hospital along with a large number of others. He had to wait 15 hours for treatment and only four nurses were available to look after all the patients going through the department during what was a very busy night in that hospital. That is simply one example, but we all know of nurses who are literally rushed off their feet. There has been a great increase in the amount of paperwork and forms they must fill out and complete as well. A good deal of bureaucracy is attached to the work of a nurse now.
Many nurses have indicated to me that they are, fundamentally, a caring profession and would rather have time to listen to patients, to sit down beside them and to hear their concerns. However, it is proving more and more difficult for nurses to do so in the current climate. I raise the issue in the context of nurses being able to bring concerns to the attention of the providers of health services. In many cases, they are not listened to. I note the concerns in the context of the reconfiguration in my region whereby a small cohort of clinical leaders now make all the decisions. It appears other health professionals do not have a say, including general practitioners as well as nurses and public representatives who represent patients in the system. The general point is important in the context of this legislation, although I realise we are dealing specifically with the regulation and standards with regard to nursing and midwifery.
That there has been no whistleblower legislation is another issue. I understand the Government's approach is to introduce it in various bits and pieces of legislation. However, the Labour Party and I believe there should be overall whistleblower legislation, which would protect people in the service who raise certain issues. I have in mind nurses from Our Lady of Lourdes Hospital who were the first to raise concerns in respect of Dr. Michael Neary among other concerns with regard to that hospital. I refer also to the nurse who led and continued to lead the people who have concerns in respect of Mr. Michael Shine. Nurses are in a unique position to indicate where there are issue of concern that may directly affect the safety and well-being of patients. I believe strongly that relevant provisions should be in the Bill and I call on the Minister to consider this.
I refer to several other matters I wish to raise. I note the Minister stated more than 200 individuals, organisations and representative groups made submissions. Many voices have been included and there is a good deal of interest in the area. I welcome that midwifery is being recognised as a separate profession. This was sought and, as the Minister stated in her contribution, a direct entry midwifery undergraduate programme commenced in September 2006. It is a separate and distinct profession, which has the potential to be developed a good deal. AIMS, the Association for Improvement in the Maternity Services, recently called for more midwifery-led obstetric and maternity opportunities, which many women want. They prefer their babies to be delivered by midwives rather than obstetricians. That issue must be addressed as well. In her response in respect of maternity services and specifically the report of the Dublin maternity hospitals, the Minister indicated she is disposed to the idea but this matter must be addressed as well.
I refer to an issue raised by Deputy Reilly, that is, the fact that there is only provision for one midwife on the board, although there is provision for a separate midwifery committee. In the make-up of the board, there are nursing representatives from general, children's, psychiatric, intellectual disability and public health nursing and one midwife. Considering that fitness to practise issues will arise and form a considerable part of the work of the board, the presence of only one midwife makes it a very onerous job for that person to be able to deal with all the issues that affect midwives and I call on the Minister to examine this provision. Midwifery is acknowledged in the Title of the Bill as a separate profession but there is only provision for one midwife on the board, while there are representatives of a variety of areas of nursing on the board. It appears to be rather imbalanced and I call on the Minister to address this imbalance.
As Deputy Reilly noted, the Irish Nurses and Midwives Organisation has concerns about the membership of the board, its size and the fact that only eight members are elected while some 15 are appointed by the Minister. I realise this has happened with other legislation and that the Minister may reply that while she appoints the members of the board she has no role in choosing them because they represent various groups and organisations and so on. However, ultimately, it is the Minster who appoints these members and the president. It appears too politically ordered and everyone involved would prefer a greater sense of democracy and the presence of other voices in terms of the make-up of the board.
I refer to other matters which the Minister raised in her contribution. Deputy Reilly remarked on the matter of registration, fees and costs. It appears there is little clarity about how the money to run the board will be raised and where it will come from. If it is meant to be largely funded from fees paid by nurses and midwives I would have concerns, especially with regard to student nurses because they are included in the register. There is a list which contains the names and details of all individuals who are pursuing education and training. However, I am referring to students. I am unsure what fees they will be expected to pay and I call on the Minister to clarify this because, basically, students do not have the money to pay large fees for anything. There is also a concern in respect of students and whether they will be held responsible under the fitness to practise areas. Typically, a student is under the supervision of a qualified person at all times and this is the definition of a student experience. It is unclear how much responsibility students have if they make mistakes. If someone hauls them before the fitness to practise committee, to what extent is a student held responsible if he or she is on the register?
I also met with representatives of the Irish Nurses and Midwives Organisation who are concerned that people are to be added to the advanced practitioners register on the basis of post rather than qualifications. In other words, a nurse who does not have an advanced nurse practitioner's post, even though he or she may have previously worked in such a post and has the relevant qualifications, will not be included on the register. I understand the same does not apply in regard to registers of other professions.
In regard to the issue of fitness to practise, the Bill offers several ways in which complaints can be addressed. The preliminary proceedings committee will sift through complaints and decide which should be sent forward for investigation. This is a good proposal because it will mean, for example, that mediation can be proposed. We all like to avoid the confrontational approach if possible. I assume that part of the process will not be held in public. There is a recommendation that fitness to practise procedures be held in public but there is also provision for all or part of an inquiry to be conducted in private. It is important that complaints may be dealt with in private in certain circumstances. Public interest and patient safety are the primary concern, but where a person's good name is at stake, it may be appropriate to hold hearings in private.
Regarding education and training, it is important that the standards and so on are clearly set out. Unfortunately, many nurses currently in training are being trained for export because there are no jobs for them. Bright, well trained young nurses coming out of university have no option but to go abroad to work. It is striking that we are discussing education, post-registration training and so on, but the reality is there are no jobs. The proposal that premises where clinical training is provided should be inspected by the board is welcome. However, if a nurse is training in an overcrowded accident and emergency unit or an overcrowded ward, he or she will have legitimate concerns but those concerns are outside the control of the board. How may such concerns be addressed? I already raised the question of nurses and midwives being able to bring such issues to the attention of the Health Service Executive or the private health service provider.
The area of patient advocacy is important. Patients are often more likely to relate their concerns to nurses than to anybody else they encounter in hospital. There must be some mechanism whereby those concerns can be conveyed to the people running the hospital. There are all types of informal complaints procedures but much of the time the patient simply wants to bring the issue to somebody's attention so that it can be corrected for future patients. Patients do not necessarily wish to engage in an adversarial complaints system. A mechanism should be found to address many of these issues positively, and there is a role for the board in this regard.
Regarding the dissolution of the National Council for the Professional Development of Nursing and Midwifery, will the Minister clarify what additional staff will be needed and how this will operate in terms of funding. I understand the Minister for Finance is involved. Will staff from the Department of Health and Children be transferred? A recent newspaper article highlighted a report by the Department of Finance suggesting that some staff in the Department of Health and Children have nothing to do-----
-----while others are extremely overworked. Rather than putting the onus of extra costs on the nurses and midwives who are paying the fees, the Minister might review whether there are surplus staff within her Department. The Minister has successfully negotiated with the representatives of health service staff a level of flexibility that may not have existed previously. As such, there may be the possibility of transferring staff from her own Department.
I broadly welcome the Bill but there are genuine concerns on issues such as the size of the boards and that so many of the board members, including the president, are nominated by the Minister. There is also the issue of the muzzling of chief executive officers, as referred to by Deputy Reilly. This is an issue the Labour Party has raised in the context of many of the Bills that have come before us recently. There is no reason that the chief executive officer should not be allowed to express genuine concerns. The retirement yesterday of Mr. John Lonergan as governor of Mountjoy Prison reminded us of his considerable achievements. He pointed out inadequacies in the prison system many times over the years and was a powerful advocate for prisoners. As a result of his advocacy, some, though not all, of the changes he proposed were implemented. The chief executive officer of the nurses and midwives board and others should be able to express genuine concerns without that necessarily being seen as an undermining of the Minister for Health and Children, the Health Service Executive or anybody else. People are entitled to express their views.
The Bill increases to nine the definitions in respect of fitness to practise. Nurses' representatives have expressed concerns to me about the vagueness of the reference to "inappropriate behaviour". Could a nurse or midwife be hauled up for wearing a short skirt, for example? If fitness to practise hearings are held in public, a person brought up for "inappropriate behaviour", even if not found guilty, will receive considerable publicity. There must be clarity in regard to this definition.
There are issues regarding advanced nurse practitioners and student nurses, such as whether student nurses can be held responsible for mistakes and what fees they are expected to pay. Finally, there is the question of the Board's power to bring issues of concern to the attention of the HSE and other health service providers.
I have concerns in those areas. However, I welcome the fact that we are finally debating the legislation, and that it recognises the professions of nursing and midwivery. I hope the Minister will respond to the concerns expressed by Members of the Opposition when she replies to the debate.
I welcome the Bill. The nursing profession is, in general, very much in favour of it. Legislation that deals with nurses has been brought before the House before - I refer principally to the Nurses Act, 1985, which dealt with the operation of the Irish Nursing Board, An BÃ³rd Altranais.
It is only natural that we should move on in the best interests of the public, and in the interests of integrity and nursing practice, to update legislation. We can all see how quickly changes are taking place in the health service.
Like the Minister, I do not believe that self-regulation is in the best interests of the public. The Bill states that we need to protect the public in its dealings with nurses and midwives, and to protect the integrity and practice of nursing and midwivery. Some nurses told me that they were talking about regulation, but were brought back down to earth when they saw that the first line of the Bill states that its purpose was to enhance the protection of the public in its dealings with nurses and midwives.
There has been good work on the Bill, particularly regarding the recognition of midwivery as a separate and distinct profession. The section of the Bill that provides for the clinical supervision of midwives is important. It makes the point that there must be adequate indemnity insurance. The Minister said it is considered necessary for mothers and babies that all midwives have adequate indemnity insurance in the event of a negligence case that could result in substantial claims.
We have to admit that there is a great deal of litigation in the health service these days. The Bill ensures that all midwives will require indemnity cover, and that those who are employed will be covered by their employer's insurance. Self-employed midwives who sign up a memorandum of understanding with HSE will be covered by the State's clinical indemnity scheme.
I have often raised with nurses the question of the number of unions involved in the profession. I was fortunate to be a member of the Health Board in the 1990s. People have criticised the Health Board; I am biased because I was a board member, as other Members of the House have been.
I was always impressed by the contribution of nurses at board meetings. There were representatives from the Psychiatric Nursing Association, SIPTU and the Irish Nurses and Midwives Organisation, formerly the INO - I am sure that is true of all health boards. They each emphasised different aspects in their contributions; SIPTU and the INO were the two biggest unions at that time.
We hear from experts in the field who say we should have just one union for nurses, one for teachers and one each for other professions. However, it is not as simple as that. The nursing unions have their own particular interests, and the needs of their members are different. That difference is acknowledged by the separate section in the Bill on midwivery as distinct from nurses in general.
The Minister visited Ballinasloe recently, and she met many members of the unions to discuss the developments at Portiuncula Hospital.
I am glad that when she was there - as Deputy Connaughton was too - she confirmed that the two consultant appointments to the region would be based on 27 hours in Ballinasloe and ten hours in Galway. That is welcome. I thank Mr. John Hennessy, who came to talk to us about developments at the hospital.
Ballinasloe town has a psychiatric hospital, and many of the nurses there are members of unions such as PNA and SIPTU. They are keen to link the work they are doing with the general hospital in Ballinasloe. There have been moves in recent years to build a more definite link between psychiatric medicine and acute hospitals.
We often discuss the need for flexibility in the nursing profession. Psychiatric nurses have shown they can achieve that flexibility. There were a huge number of patients in St. Brigid's Hospital years ago, but there are now only a few. It is a tribute to the nursing profession that they have left their place of work to go out and work in the community, with house parents, in many of the houses that were rented by the old Health Board and are now rented by HSE in towns throughout County Galway. It is a huge change for those psychiatric nurses to go from hospital to community surroundings.
Dental nursing is an area that has not received much attention. IMPACT has been involved in promoting the cause of dental nurses, who do excellent work and have to deal with anaesthetics. The public health nurses are working on the ground, and we must pay tribute to them. They deal with the elderly in particular, and with others who live in isolated areas.
If we are serious about keeping such people in their homes - as the Minister, and no doubt every Deputy in the House, wants to do - we need to recognise the importance of the people who work in public health. They provide a good and regular service to the elderly.
Nurses are held in high regard, particularly the public health nurses, who have to cover very big areas in some cases. They were there in the bad times when there was very little money in the Health Board. There are difficult times now, economically and financially, and they are still doing great work.
A lot of nurses now work in palliative care. Given the incidence of cancer - we have seen recent reports on the incidence of skin cancer, for example - there is a great need to develop services in that area. I remember, as I am sure Deputy Connaughton does, our battle to get funding for the Galway Hospice in Renmore, which went on for years. Those services have since been extended and developed in the community. There are nurses who visit people with cancer, and the hospice movement has strengthened. Those nurses are working in a difficult area, on which I commend them.
Deputy Jan O'Sullivan made a very interesting point about the training of nurses. She is right in suggesting many health professionals must leave the country after having been trained in order to find employment. This is not just true of nurses, but also of young doctors and other health professionals. Perhaps many young people feel they would gain experience working abroad. Many of them go to the more well-off countries but many others go to developing countries, particularly those in Africa, to do nursing.
We should spare a thought for those who are returning to Ireland to pursue nursing. Some have great difficulty not so much in finding jobs, but in trying to get their documentation together when they return. They are obviously put through a very thorough examination by An Bord Altranais, which is only right. However, even with modern technology, nurses find it hard to obtain documentation and references from the foreign hospitals in which they worked. They should ensure they have their work history and all their documents and references when they return to work in Ireland.
I am a little surprised that education and training are in Part 10 of the Bill because they are very important. There has been a considerable debate on the training of nurses. When a degree course became compulsory for nursing there were many objections because it was felt it would take longer to educate and train nurses. People felt nurses needed to be trained more quickly. The same argument was made in regard to teachers. The year after the teacher training course was extended from two years to three years, no teachers emerged from the teacher training colleges.
It is very important that nurses have a degree and extra training. One must remember that many young nurses wish to work outside the country and they need a degree to do so in European countries and internationally. It is only right that they have a degree. It is now accepted, despite the debates we had in the past, that nurses should have degrees and diplomas.
Let me refer to the membership of the board. The board, comprising 23 members, is quite big and represents nurses and midwives. Also represented are the educational bodies and stakeholders. As many Deputies suggested, there have been some questions asked about the representation of midwives on the board. Perhaps the Minister will re-examine this issue. The board will have the power to create committees to fulfil some of its functions. There is a reference to the preliminary proceedings committee, the fitness to practice committee, the midwives committee, the education and training committee and the health committee. I welcome the fact that the board is large and very representative. I also welcome the provision for sub-committees. This is not unusual as it occurred under the health board and in respect of An Bord Altranais.
I welcome the Bill, which has been very much welcomed by the nursing profession. There has been strong emphasis on midwifery, which is welcome, but we should not forget other types of nursing. Traditionally, we considered nursing a female professional but that is far from the case today. It is very welcome that so many young men are now entering the profession. I hope the Bill has a speedy passage through the House and that it will address the issues that arise regarding the registration of nurses and maintain the integrity of nursing and midwifery.
I welcome the Bill. If I were a midwife or nurse, which I am not, I would welcome it also. It puts midwives and nurses on a more professional footing. Deputy Michael Kitt mentioned the time it became obligatory for nurses to have a degree. I always supported that move. There was a great debate about it at the time not so much about the fact that there would not be as many nurses available in a given year, but about whether the bedside manner of a nurse would be more positive or negative on foot of her having a degree. This has nothing at all to do with bedside manner. The Bill puts the professions of nurse and midwife on a standing comparable to all the other professions. This point has been proven since the degree became obligatory.
I have not had an opportunity for many years to state how much I admire what nurses and midwives do. At the risk of turning back the wheel a little, it is no harm to remember that one of the remarkable features of Irish life, both urban and rural, was the presence of the midwife. The midwife represented one of the greatest connections between whatever health service existed and the birth of babies at home in very difficult circumstances. The Minister of State, Deputy Ãine Brady, will certainly have heard of the late Nurse Kilcommons of Mountbellew, who delivered more babies than any maternity wing in any hospital.
We all owe a great debt of gratitude to such people. They were very poorly paid and worked in atrocious conditions but saved a lot of lives. This is one reason there is a great degree of affection for all nurses and midwives. It is an interpersonal phenomenon for most people.
The sophistication of modern maternity hospitals is something to behold. I acknowledge mistakes are made, and that we all make them, but statistics prove the life expectancy of babies has improved dramatically in recent years. While I do not want to make personal remarks on this matter, this was brought home to a member of my family last year. I happen to have a one year old granddaughter who is able to walk around although she started life not much more than a pound in weight. In the past, neither she nor her mother would have been likely to live. This is the only opportunity I will get in the House to state that the professionalism of the staff in the Coombe hospital and the hospital in Ballinasloe has caused great happiness in a particular house.
I can well imagine the reasons for this Bill. I wish to speak about some incidental aspects of it, as well as its major features. As it is a good Bill that appears to be accepted by all the stakeholders, one wonders why it should be spoiled to some degree by the insistence that the president of the council be nominated by the Minister. There will be 23 members on the board, 15 of whom will be appointed by the Minister and eight of whom will be elected by the professionals. I see nothing wrong with that. The idea is that the eight professional members of the new board are supposed to represent each discipline. I have spent a lifetime dealing with all sorts of boards. One can make all sorts of arguments about who is most entitled to be on a board. It seems at first glance that it could be argued that the midwives are not getting a great deal on this. Leaving all that aside, why is it necessary for the Minister to appoint the president of the council? I do not know the reason for that. It appears to me that this kind of thing should be autonomous. I do not know whether it will work out in that exact way. That is the perception around the country.
I want to refer to a number of other issues. It is natural that there is no place in this Bill for much of the day-to-day work of nurses or midwives. I do not hear or see anything in the Bill about a system to facilitate whistleblowers. When nurses, midwives and others in the health care profession see something going wrong, they may genuinely believe in their heart of hearts that something has to be done about it. I know efforts are being made to protect whistleblowers and thereby make whistleblowing more attractive. The Acting Chairman, Deputy O'Connor, knows as well as I do that the whole lot of it is a dangerous business. It is important to build mechanisms into every system - inside or outside nursing - so that action can be taken when a member of staff sees something going wrong. If something happens that is highly injurious to patients or the public, a mechanism must be available to allow the whistle to be blown without it rebounding on the whistleblower. It is a very lonely place to be. I have met a few highly principled people who believed they were doing right, but came out worse from the row. They might not have lost their jobs, but they were demoted and treated as pariahs in the workplace. The cases in question had nothing to do with nursing. It is against that background that one would hope that a whistleblowing mechanism can be worked into this Bill, or some other Bill.
Nurses and midwives have a huge degree of interaction with patients. I agree entirely with Deputy O'Sullivan's suggestion that most patients - I refer specifically to male patients - are more likely to reveal their innermost secrets to a nurse than to anyone else. I imagine that it is easier to talk to most nurses than to consultants. A consultant who is in a hurry in the morning might be good for one's health, but he might not be great for one's ego. We owe a great debt of gratitude to nurses and midwives of every discipline in our hospitals and elsewhere. I am familiar with the remarkable input of nursing staff and others in old people's homes, which is a major area at the moment. Such work calls for great compassion, expertise and professionalism. I am glad to see a great deal of that, for the most part, in nursing homes throughout the country. It is another feather in the cap of the nursing profession.
I am sure the new board will spend some time looking at the whole question of flexibility. This is one of the prime reasons this legislation will be seen in years to come as the bedrock or foundation of the nursing and midwifery profession. It will demonstrate that nobody, least of all those who work in this area, is an island. In the health sector, regardless of who one is or what one does, one depends on many other disciplines. There has traditionally been a fair amount of demarcation of what people should and should not do. I suggest that a more integrated approach is needed.
Deputy Michael Kitt spoke earlier about psychiatric nurses. They have surely shown a great ability to go with the flow. Many years ago, one would not see a psychiatric nurse outside the big walls of the mental institutions. Their work was not done anywhere else. They are now distributed throughout the country, including rural areas. I appreciate that this has nothing to do with the Bill before the House. I have to say the psychiatric nurses have covered themselves in glory in this regard. I refer to how well they have dovetailed with the social changes in this area. We now know that people with mental handicaps should never have been inside the big walls of the mental institutions at all.
The Minister of State, Deputy Ãine Brady, is familiar with my home village of Mountbellew. In this small village, there are four or five houses with five or six residents under the guidance of house parents. Every time I go there, I see the residents out and about. I have to say they are extremely well dressed and presented. They walk around the town and do their little bits of shopping. It must be heaven on earth, compared to the big institutions from which they came. I appreciate that they were looked after as well as possible in those times. It is a different thing altogether now.
One of the great pluses for society is that such developments have been welcomed by local communities with open arms. There was a time years ago when that would not have been the case. Local people were afraid that people with mental handicap might present some form of danger, but that has turned out to be absolutely false. The authorities that drove this change over the years were entirely right. It must be wonderful for the people in question to live as ordinary members of ordinary communities. Regardless of how bad the economy goes, I hope we will not have to stop this line of business. I hope the Minister of State agrees that this should not happen. How many minutes have I left, a Cheann Comhairle?
Another aspect of the Bill is the proposal to introduce a two-part fitness to practise structure which would bring the eventual Nurses and Midwives Act into line with the Medical Practitioners Act 2007. To be brought to the same level is a fundamental matter for all nurses. When the 2007 Act was being considered by the Oireachtas, many nurses asked me why legislation governing them was not proposed at the same time. I assume at the time it was believed this would follow quicker than it did. 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. Like most things in life, it is important to strike a balance. As is the case with TDs, civil servants, gardaÃ or any other group in the world, there is always a bad apple in the barrel and we all have to accept that. We are all human beings and that is the way we are. It is important, however, that a reasonable procedure be implemented. On the one hand, patients must have the absolute right to be properly, humanely, compassionately and professionally treated but, on the other, even if our Lord himself was present, it would be hard to please the odd patient. As Deputy O'Sullivan said, it would be bad policy if it transpired that a foolish, frivolous complaint with no standing whatsoever was made public and a medical professional dragged through the mire. I fully appreciate that such complaints stick, regardless of whether they are unfounded. However, if my understanding is correct, under the legislation an informal inquiry will take place first to sift through the detail of the complaint and, depending on its relevance, it can then proceed to the next level. I like this process and the Garda has a similar process. It will mean that frivolous complaints made to create trouble for everyone can be identified before they go too far.
I have stated repeatedly at meetings of the Oireachtas Joint Committee on Health and Children, of which I am a member, that the role of HIQA, the supervisory agency for nursing homes, is important. Its role under this legislation to ensure patients are properly looked after will be as important. Patients, irrespective of what stage in life they are at, be they young, giving birth to a baby or lying on the broad of their backs in their 90s in a nursing home, should expect to be cared for with dignity and decency and to be given a professional service, for which they pay directly or indirectly. It is against that background that I assume the Bill will fit that model, which I hope will be balanced. If there is wrong on any side, I also hope it will be rooted out.
At the end of the day, we are blessed in this country with the application and dedication of our nurses and midwives. I have seldom met a nurse or midwife who did not want to do the right thing, no matter what the circumstances were. Most of them will agree with that and, against that background, the legislation will enhance their role in society. They have nothing to fear. I understand there has been a great deal of briefing of, and discussion with, the various stakeholders and, with the exception of the few sections that I do not particularly like, I wish the legislation well.
I wish to share time with Deputy Aylward.
The Bill will result in the formation of a new nursing and midwifery board. The legislation recognises the role of nurses and midwives in the health care system and one of its important functions is to recognise the role of midwives and to classify them as a separate and distinct profession. It is only right that midwives be recognised in such a way. Their role in caring for women before, during and after child birth is distinct from other medical professionals. My own regional hospital in Mullingar is a fine institution in which there were more than 3,000 births last year. The midwives, nurses and doctors provide an excellent service in Mullingar and I pay tribute to them and to their dedication.
I am encouraged that the Irish Nurses and Midwives Organisation has warmly welcomed the publication of this Bill. The Bill incorporates recommendations on nursing made by the organisation to the commission and its officials feel it reflects the changing environment in which nurses and midwives practise. The organisation will examine the legislation and we will all welcome its feedback.
The most important element of this Bill is that it not only regulates and protects nurses and midwives but also expectant mothers and families. It will provide a new regulatory framework, through the nursing and midwifery board, which can give everyone confidence in the system and the service that is provided and received. Nurses and midwives will have full confidence that their expertise, qualifications and experience are recognised. The legislation prioritises confidence in the profession. It will give the public protection and serve to increase the integrity of the profession, which it rightly deserves.
The new board will register nurses and midwives, regulate nursing and midwifery education, recognise qualifications, set standards of practice, give ethical guidance, maintain professional competence and handle complaints. I am pleased membership of the board will include many nurses and mid-wives. Of its 23 members, 11 will be nurses or midwives with eight being elected. I am also happy there will be a broad representation of competencies with nurses drawn from the disciplines of psychiatry, intellectual disability, public health and geriatric care. I am hopeful nurses and midwives will be confident that their views and concerns will be adequately represented on the board, which will regulate the profession.
The goal of the board is "protection of the public in its dealings with nurses and midwives and the integrity of the practice of nursing and midwifery through the promotion of high standards of professional education, training and practice and professional conduct among nurses and midwives". It is essential that midwives have the appropriate qualifications and competencies to practise and the new board will provide the guarantees that everyone involved in the profession needs. It does not serve midwifery as a profession well if people who are unregulated or unqualified set themselves up as midwives. It is a recipe for disaster, not only for the pregnant woman, but also for the profession as a whole, which could be damaged by unregulated, unqualified people not performing as a midwife should. I am happy that the Bill allows for strict penalties for those who practice unregistered. I am confident large fines and the threat of imprisonment will prove to be an adequate deterrent.
The Bill will allow for the establishment of three registers. The nurses and midwives register will include the names and qualifications of registered nurses and midwives and will include divisions on nurses, midwives, advanced nurse practitioners and advanced midwife practitioners. A candidate register will include the names and details of all candidates who are in education and training that will lead to first-time registration with the nursing and midwifery board. The third register will be the advanced midwife practitioner-advanced nurse practitioner register. The Bill will allow for the setting up of other registers if needed by the board. I welcome this flexibility. Those registers will ensure that both health professionals and the public have guarantees of transparency on the nursing and midwifery professions and everyone can be assured of the relevant qualifications and experience. The registers will be published but personal information will be protected from disclosure.
Extra protection will be provided for expectant mothers and their families. The prohibition on unregistered nurses and midwives practising will be complemented by an improved investigation mechanism for complaints. A preliminary proceeding committee will be established as part of the Nursing and Midwifery Board of Ireland to give initial consideration to complaints against nurses and midwives. At least one third of the committee will not be nurses or midwives. Grounds for complaint will include professional misconduct, poor professional performance, inappropriate behaviour or the failure to comply with an undertaking or to take any action specified in a consent given in a response to a request.
The board can appoint persons including members of staff to assist with investigations undertaken by the preliminary proceeding committee. It can also suspend the registration of a nurse or midwife where it is considered necessary to protect the public. The Bill ensures that all parties involved in a complaint will be kept fully informed of the progress of any complaints. The board can impose measures against the nurse or midwife including advice or admonishment, a fine, conditions to registration, suspension or cancellation of registration or the prohibition on applying for the restoration of registration for a specified time. All of these measures can serve to increase public confidence in nursing and midwifery. No one likes to consider the worst happening at such a joyful time as the birth of a child, but having a transparent method of dealing with complaints can only improve public confidence in the profession. I also welcome the fact that all parties will be kept informed during the process. That is important as any cause for complaint would be a source of considerable stress and distress not only for the patient, but also for the practitioner.
The Bill also ensures that midwives will have adequate indemnity insurance as it is considered vital that mothers and children are protected in the event of a negligence case. Those midwives who are employed will be able to avail of their employers insurance but those who are self-employed will have to sign up to the State's clinical indemnity scheme. It is important that the role of midwives is recognised and that they are supported in their work. Part of that support is education and training and I am pleased that the Bill has a strong focus on this area. As per the Bill, the HSE will facilitate, in so far as it is possible, the education and training of midwifery candidates. The HSE will also promote and co-ordinate the development in co-operation with the new board of nursing and midwifery training bodies. The HSE will also undertake planning to meet the needs of nursing and midwifery for the public health service and will advise the Minister for Health and Children on the need to develop specialist nursing and midwifery education and training. That is vital if practising professionals are to keep up to date with the latest research and international practice.
I am hopeful that nurses and midwives will look at this Bill and consider the implications. I am confident that it will serve to improve the profession giving protections to both the practising professionals and their clients. Childbirth is a wonderful time for any family and nurses and midwives play a huge role. It is only right that their role and professionalism should be clearly recognised and that they should be supported in their work. The formation of the Nursing and Midwifery Board of Ireland is an excellent development and I am confident that it will be a great success.
I thank my colleague, Deputy Kelly, for sharing time. I am pleased to have the opportunity to speak in support of and to praise the Bill before us today on Second Stage. At the outset, I extend my congratulations to the Minister, Deputy Mary Harney, for bringing the Bill to fruition and for producing a pragmatic and comprehensive piece of draft legislation.
The Bill has been in gestation for some time and I welcome it without hesitation. I am also conscious that the Bill was not formulated until the Minister and her Department had engaged in an extensive public consultation process since 2007, not least with the various interested parties and the obvious stakeholders who will be affected by its provisions. I understand the response and the input made to that particular exercise was considered, thorough and enlightened. Now that this essential and valuable process has been completed and the various concerns and proposals have been heard clearly by the Minister, we have before us a Bill which reflects the views and the aspirations of the public and the noble professions of both nursing and midwifery.
The existing legislation which governs these professions at present is barely adequate and is clearly well and truly out of date. It is 25 years old and, in many respects, it has become archaic and outdated. It no longer meets the exacting requirements of the modern and dynamic professions it addresses, both of which have evolved radically since 1985. I welcome the Bill as timely and one that addresses the needs of the public and the two professions in question.
First, I salute the nursing profession and the profession of midwifery and all those individuals who work so hard and tirelessly for all of us. Many of us would not be here today, literally, were it not for the care and skill nurses and midwives profess. Irish nurses and midwives are recognised the world over for their finely-honed skills and unique dedication as expert care-givers. Any of us who have had the privilege of being treated by nurses know that they truly excel in their professionalism, sincerity and kindness. We are most fortunate to have such a fine, genuine and committed workforce which is generous with its compassion and its humanity. I thank all the nurses and midwives who work so selflessly and tirelessly everywhere around the country. They are a magnificent group.
At the end of 2009, there were more than 89,500 nurses and midwives registered with An Bord Altranais. A total of 43,264 of those individuals were working in the public health service and approximately 9,000 nurses and midwives were employed in the private sector. Like any other profession on whose services the public relies, nursing and midwifery needs to be properly regulated in a robust and transparent manner. The halcyon days of self-regulation are over. We have entered a new and welcome era where the public demands a framework of regulation that ensures the safety, quality and efficacy of the service being delivered stands up to rigorous, ongoing scrutiny and the highest possible standards.
The central feature of the Bill is the protection of the public interest. That imperative is clearly enshrined in the Bill. Every aspect of the Bill is predicated on the public interest and the provision of a top-quality health service to each and every individual. Public confidence in, and respect for, the professions of nursing and midwifery are paramount. The quality and efficient delivery of an effective health service is probably one of the single most important objectives which the Government can achieve. I am pleased to say the Bill represents yet another significant milestone in achieving that aim.
The health service is critical to all our needs and the calibre of all those involved in the delivery of that service is second to none. However, the technical nature of the professions engaged in that service is complex, sophisticated and is one which is changing and developing constantly. Advances in medical, surgical and obstetric practice are immense and it is necessary to ensure that all staff who work in the health service are well versed and well trained in the execution of the service. Optimum performance and optimum results are what the service is about and that is, rightly, what the public, as the customer, expects.
The health service is perhaps the only service with which everyone has interface at some time in their lives. At such a time, people are brittle and vulnerable. We must recognise that patient care and safety are the fundamental elements in the health service and anything we do in terms of regulation and internal governance must acknowledge that fact and seek to promote and uphold those basic principles. That is why we must guarantee that the professions with which they relate are regulated properly, that the necessary qualifications are in place, that clinical and technical training is provided on a regular, ongoing basis, and that there is a fair, adequate and transparent complaints procedure is available if the need arises. That is what inspires public confidence in this vital system. It is important to have secure safeguards, for the protection of the patient, the nurse and the midwife. All other professions within the medical arena are now very well-regulated and there is no reason why nurses and midwives should not be subject to similar-safeguards and strictures. This Bill is consistent with the stringent regulatory regime which we have adopted for other-professionals in the health sector including the medical practitioners, the health and social care professionals and the pharmacists and I believe: it creates a welcome level of uniformity in the regulation of all healthcare professionals.
For the first time a separate distinction is made between the nursing profession and that of the midwife. This is a welcome departure and recognises that the training and the discipline of midwifery are specific and quite different in many practical aspects to that of nursing. I believe that the Nurses and Midwives Bill will greatly improve the existing situation and enhance the statutory framework within which these professions are governed and regulated. We have seen very substantial progress in nursing and midwife practice since 1985 and there has been an enormous leap forward in the area of training and development. Of course, there is ever-increasing emphasis on the issue of accountability and the rights of the patient. There is a clear need for nurses and midwives to keep abreast of all the new developments and naturally, patients must be kept fully informed. As we are all aware the expectations of the public have increased very significantly in the past 25 years, and rightly so. Both the Government and the various stakeholders were acutely aware that the time had come to modernise the framework of regulation in which nurses and midwives operate. We have to structure and adapt our framework to ensure it is fit for purpose, contemporary and that it properly accommodates those essential features such as the safety of the patient, the absolute assurance of standards, sound governance, accountability, openness, and of course, justice and fairness when it comes to matters of complaint and procedures for discipline. An appropriate balance has to be struck between self-regulation and public accountability which will reflect the changes in attitude over that past 25 years and I believe that this Bill takes into account those changes and it adjusts the legislative framework accordingly.
The Bill will undoubtedly enhance the protection of the public in all its interactions with nurses and midwives. The creation of a competency assurance scheme emphasises the clear and definite focus of this legislation. This will ensure that the integrity of those in professional practice is maintained, high standards of professional conduct are observed and that all nurses and midwives have the relevant qualifications and are competent to carry out their work in a safe and effective manner - and that they can demonstrate that profession competence. The Bill will ensure that the necessary education and professional training and development facilities are provided, and that nurses and midwives will be able to avail of additional training and up-skilling throughout the course of their careers in the health service by providing suitable education opportunities in the workplace.
I welcome the establishment of the new nursing and midwifery board, which will have as its core and overriding objective the protection of the public interest at all times. I also welcome the fact that the representation on the board will include a majority, not from the nursing and midwifery professions, but from other areas within the health service, from education and from the public. A similar composition will apply to the fitness to practise committee and the new preliminary proceedings committee. I am pleased to note that the Bill will introduce a new, streamlined and more flexible fitness to practise procedure that will include a measure to screen complaints and which can refer complaints to the fitness to practise committee or to other procedures if the complaints are not appropriate for the board's fitness to practise procedures. The fitness to practise committee will certainly have teeth: it will have similar powers to those of a High Court judge and, for example, it may compel witnesses to attend and be examined under oath,and the production of documents.
I note that in future, fitness to practise enquiries will be held in public unless, on application, the particular circumstances of individual cases dictate that they be held in private. At present, all these hearings are held in private behind closed doors so they are lacking in transparency and do not lend themselves to the same degree of confidence that a public inquiry does. I believe that this departure will be positive and will be embraced both by the public and by those who may find themselves involved in such proceedings.
I gather the Bill has been broadly welcomed by the nurses and the midwives alike. In view of increased public awareness and consciousness in all matters to do with health and the overarching need to ensure that the highest possible standard of service is delivered and maintained, I am confident that it will achieve its stated aims. It will serve to augment widespread confidence and respect among all its many stakeholders and it will create an appropriate and enlightened response to the challenging needs of our times
I am happy to support this Bill without any reservation.
At the outset, I should like to acknowledge the presence in the Visitors Gallery of a group of students from LIT in Limerick, led by their teacher, Ms Martina Neylon. They are all very welcome.
I welcome the opportunity to contribute to the debate this afternoon because for far too long nurses and midwives have been playing second fiddle to other health care professionals. At the end of last year, as Deputy Aylward has said, there were 89,545 registered with An Bord Altranais and it is a profession that was predominately embraced by women. In fact 82,545 of the nurses registered in the country last year were female, and women outnumbered men who chose to study nursing by a ratio of 10:1. Be the end of last year there more than 7,000 registered male nurses in the country. That is one for the Minister of State, and she might acknowledge that we are getting there.
Nurses from all over the world are among the pillars of our society, as previous speakers have indicated. It is only right that their profession should receive the recognition it deserves. Dag HammarskjÃ¶ld once said, "Constant attention by a good nurse may be just as important as a major operation by a surgeon". How true it is. Anyone who has had to spend any length of time in a hospital appreciates the work of a nurse. It is a caring profession and many nurses are drawn to it because they want to make a real difference and want to care and help people.
The role of a nurse in our society for long periods was very much under valued; possibly because it was a profession which was significantly dominated by women. It is now finally being recognised as a profession and I welcome that. Nurses in our hospitals are working under very difficult circumstances; budgetary constraints and the policy of reconfiguration without having the additional resources in place when services are being transferred, which has caused real problems. Take the mid-west region for example and my constituency of Clare. When the Minister and the HSE made the decision to transfer services from Ennis General Hospital in favour of the Mid West Regional Hospital in Limerick, it is the patients and the nurses who have to endure the pain, because the cart was put before the horse. The additional resources were not put in place in Limerick to cope with the influx of additional patients from both Nenagh and Limerick. The situation at the emergency department in Limerick can best be described as chaotic at times and this overcrowding led to an industrial dispute at the Hospital late last year nurses were forced on to the streets to highlight the situation.
I have received numerous complaints about the situation in Limerick from Clare patients. One family was very upset during the year when their mother who has a heart complaint was left sitting on a trolley for over 24 hours before she got a bed. Is it any wonder then that nurses who have to work in these conditions feel undervalued?
It is the same story at Ennis General Hospital where the restrictions on budgets, the transfer of services; the embargo on recruitment has left nurses enormously concerned for their future. Morale is low as nurses are very much undervalued in a system which is geared more towards saving euro, when it should be geared to providing and developing the services it provides to its patients.
There are major opportunities for nurses to develop at Ennis General Hospital if the infrastructure and services are delivered to the hospital. Ennis hospital was led to believe that it would be the right arm of Limerick Regional Hospital when reconfiguration came in, but sadly it is being left behind. Nurses at Ennis General Hospital in fact have been shortchanged by the promises made by the HSE and the Minister when the reconfiguration was mooted. The CT scanner at the hospital was no sooner in operation that the plug was pulled. I understand that a permanent radiologist has been appointment, but this position could again be under threat, since the consultant might be based at Limerick instead of Ennis. I ask the HSE to clarify that situation. The fact that the Hospital is only providing a limited CT service, does not encourage GPs to send on their patients to Ennis and as a result private patients are attending elsewhere to have their scans done.
As a result, private patients are going to other hospitals where the scans can be done. If nurses are to have confidence that they can develop their careers in hospitals such as Ennis, it is essential that services are developed in this hospital, where there is a clear demand for them, and that funding be made available for and invested in developing those services.
The endoscopy unit at the hospital is not yet in place, and there are no dedicated geriatric beds, although these were promised. Funding is also required to ensure the surgical department has adequate facilities available to encourage greater utilisation by consultants. Ennis General Hospital is well capable of delivering a top-class service with high patient safety focus. However, proper investment is required if reconfiguration is to be achieved in a timely fashion.
Clare people feel that when it comes to health services, they are at the bottom of the pile. When the mammography unit at Ennis General Hospital was decommissioned in 2007, Clare patients were promised they would be accommodated at the centre of excellence which was being set up in Limerick. In March 2008, Limerick Regional Hospital advised that it was only accepting symptomatic cases. In April 2009, the National Cancer Screening Service took the unusual step of issuing a press release indicating that the roll-out of the service to Clare would face further delays because of the Government's ban on recruitment. The Government assured us this was not the case and that the roll-out would go ahead as scheduled in June.
This week, however, further controversy erupted in an Adjournment debate taken by the Minister of State, Deputy Ãine Brady, earlier this week. In reply to a Clare Deputy, the Minister of State claimed that when BreastCheck was seeking an appropriate site for a mobile unit, Clare County Council had delayed the project. The county council denies this. Perhaps the Minister will clarify this at some stage in her contribution, as it is an important issue for the women of Clare. We do not want to hear one authority or body blaming another. Who was delaying the project? The service will be up and running by next October, but a war of words is not in the best interests of the women of Clare, who are still waiting for this essential service. The roll-out must go ahead as scheduled without any further delays.
This country, like many others, has moved away from hospital-based schools or colleges of nursing to courses based in third level institutions. Ireland is probably unique in that all nursing courses are at degree level and professional registration is only available through a degree-level qualification. The fact that nursing programmes are now based in our third level colleges has helped engender a greater respect for those entering nursing as a career. Sadly, however, like many other young people, qualified nurses are leaving the country in droves. Fresh from graduation, Irish nurses are being swept off their feet with offers of employment in the UK. While researching my contribution this afternoon I found that every one of the new recruits at the Royal Berkshire Hospital last December was Irish and that the management of UK hospitals are delighted with the influx of Irish graduates. They say that Irish nurses are well trained and flexible; they speak English, naturally; and they are highly educated university graduates. In addition, Whipps Cross hospital in East London recruited 132 nurses from Ireland last year. These statistics speak volumes.
According to the INO, none of the 1,600 nurses who qualified in this country last year was offered a post in the Irish health system, and some 1,900 nursing and midwifery posts have already been lost as a result of the moratorium on staffing. Nurses have been leaving the country for many generations by choice, but now they are leaving because there are no jobs for them here. In 1945 and 1946, more than 7,000 Irish women applied to train as nurses in the UK, and by 1971, one in eight nurses working for the NHS was Irish. It appears we are heading backwards and educating another generation of nurses for emigration. That is a great pity, given the focus on the nursing profession in Ireland.
This drive across the Irish Sea is not helped by the embargo on public service recruitment in this country. We must consider seriously what is happening in our health services. If good health care professionals who are highly qualified continue to be driven out of this country, what kind of health service will we be left with?
The Nurses and Midwives Bill 2010 promises that programmes of education and further education will be provided to nurses for the purpose of registration. In its submission to the Minister for Health and Children on the proposed heads of the Bill, the Irish Association of Directors of Nursing and Midwifery warned that "funding must be provided and ring-fenced for continuing professional development". It also warned that "Resources, time, finance and opportunity [for] education and training must be protected by the Act." While welcoming the fact that legislation is being introduced which will underpin the role of nurses and midwives, it warned that the necessary infrastructure for nurse and midwife undergraduate and postgraduate education which is in place must be maintained.
The report from the Commission on Nursing published in 1998 also warned that there is a need for a long-term financial commitment for staff development programmes. However, given the fact that most nurses are now under major pressure as a result of the recruitment ban, when will nurses be able to attend these development courses, and will they be penalised if they are unable to attend because of the pressure of their work? This is something that must be considered. Will the majority of development courses involve on-the-job training? This is an important point which needs to be clarified by the Minister.
With regard to the registration system which will now apply, I understand it will be funded by fees collected from registered nurses and midwives. Currently, nurses pay an initial fee of â¬145 when they first register and an annual retention fee of â¬85. It is estimated that it will cost â¬3 million euros to set up this new board. The transfer of certain regulatory functions from the National Council for the Professional Development of Nursing and Midwifery will result in a â¬25 increase in the annual retention fee, and a once-off fee of â¬34 will also need to be paid for the establishment of a competency scheme. Some argue that the registration fee is lower than the fee charged by the Medical Council, which is â¬490; however, the high fee charged by the Medical Council is accounted for by the fact that there are far fewer medical practitioners registered here.
Perhaps the Minister could also explain why the mental health, intellectual disability, children's and public heath nursing sectors are not being put on a statutory basis. Furthermore, clarification is required with regard to nurses and midwives who are pursuing education and training which will ultimately lead to first-time registration with the new board. Why do undergraduates need to register with this new board and pay a fee? I would like to hear the reasoning behind this from the Minister.
Will the Minister also clarify the position with regard to nurses and midwifes who have taken time out from their career for one reason or another and who are not registered for that period? What conditions will these nurses and midwifes be required to fulfil when they return to the profession and will these involve additional costs? What is the situation regarding the registration of international nurses who come to work here, particularly international students who take up clinical placements in our hospitals? Are these students to be treated the same way as our undergraduates, for example, or will there be a separate section to cater for rostered international students?
On the issue of the funding and setting up of the new structure, I never cease to be amazed by the number of jobs created on boards by the Government to dole out to its political friends. We have seen many such examples over the years. The new board proposed here will comprise 23 members, both elected and appointed members. Unlike the composition of the previous boards, the majority of members will not be nurses or midwives. Instead, only eight members of the board will represent that sector and only one midwife will sit on it. This is completely inadequate, particularly given the fact that in 2008, for example, we saw the highest number of births recorded in Ireland since 1896, with a total of over 75,000 births recorded. There is no way that the work of midwives will be adequately represented by just having one member on the board. I urge the Minister to clarify this situation.
Section 25 allows for payment of allowances to members of the board or committee. Who will receive these allowances? Are they for the political appointees and what is the maximum amount each member will be able to claim? What criteria are being applied by the Minister for those non-nursing representatives who will sit on the board? In respect of appointments to boards, it is surely time that proposals for appointees to State boards should come before the relevant DÃ¡il Committee to be scrutinised. Perhaps the Minister should clarify what qualifying criteria will be applied in respect of these appointments and whether she supports the notion of appointees coming before the DÃ¡il health committee.
There is huge potential for development in the area of care of the elderly and nurses have an important role to play in this regard. Ennis General Hospital was promised dedicated geriatric beds following reconfiguration, but once again the Minister and the HSE failed to live up to their promises to the people of County Clare. The Commission on Nursing recommended that the Department of Health and Children should examine "as a matter of urgency the conditions and staffing levels in care of the elderly services". The report was published in 1998, but as we all know from the calls we get daily in our offices, home help hours have been cut. We were promised that we would have a more integrated approach to primary care and that home care packages would be available and adapted to meet the patients' needs. However, the experience is very much the opposite and people cannot access the help they need. Every day I receive pleas for help from older people and their families.
The Bill also provides for the resolution of complaints through mediation and other formal means. It establishes a competency scheme to monitor the competence of all nurses and midwives, deals with fitness to practice and proposes the dissolution of the National Council for the Professional Development of Nursing and Midwifery and the transfer of its staff, assets and liabilities to the board. While I welcome the recognition the Bill gives to nurses and midwifes, it is very important that adequate consideration is given to all these issues and that they are debated fully here in the House.
I am very interested to hear from the Minister with regard to the consultation process she undertook before she brought the Bill before the House. Perhaps she will outline some of the issues which were raised. I am pleased to have had this opportunity to speak on the Bill and look forward to the Minister's response.
I welcome the opportunity to make a brief contribution to this important and interesting debate. It is good to be here in the Chamber when things are so quiet, after the emotions and excitement of this morning. I will try my best not to cause any disruption. I have listened to the previous speakers and heard numerous references to Galway, Clare and other places. I presume, therefore, I will be allowed mention Tallaght.
I welcome the attendance of the Minister of State, Deputy Ãine Brady, and wish her continued success with her work. She knows I am a fan of her work and I am trying to persuade her to come to Tallaght to visit some of the elderly services. The Minister, Deputy Harney, will visit Tallaght shortly. She is no stranger to Tallaght and will open a new facility in Whitestown. I will take advantage of the Minister of State's presence here today and invite her to visit me in Tallaght some day.
Deputy Paul Connaughton made some interesting observations, including one I hope gets some headlines. He said that male patients in our hospitals trust nurses. Sometimes I try to bring my personal experience to our debate. Thank God, I have enjoyed very good health throughout my life, but I have had a few experiences with hospitals. I had my tonsils removed years ago in Mercers Hospital and, as some Members know, I had a heart attack in 1999. Funnily enough, it happened at a Francis Black concert. I was treated in Tallaght Hospital, was there for some weeks and then had surgery in the Mater Hospital. When I look back on that period, I can say that I saw at first hand the dedication and tremendous work done by male and female nurses in our hospitals. I recovered and my experience does not seem to have done me any harm. I also spent some time in the cardiac rehabilitation programme in Tallaght Hospital. Keep it quiet, but I might not be a DÃ¡il Deputy today except for those experiences, which helped me through a difficult time. I have nothing but admiration for the nurses and staff of our hospitals, particularly in Tallaght.
I grew up in Crumlin and have four sisters. I remember a lady appearing at our house one day. She was a midwife. I did not know her, but I remember her visit. Like many of my generation, I forget things that happened yesterday, but I remember the particular day this lady came to our house. I heard she was a midwife, but did not have a clue what a midwife was. However, I remember her as a caring, friendly person. She went up to my mother, whom I understood to be sick, and a short time later my sister Pam was born. That was the only home birth my mother had, but whenever I look back at that day I am aware the midwife made an impression on me. It is good to remember that in this debate. I heard other people today mention the dedication of midwives and the manner in which they look after people, and there is always an issue around whether people should go to hospital or stay at home for the birth of a child. It is for that reason that I mention my experience.
In the context of nurses and midwives, I could not mention Tallaght without mentioning that I, like other colleagues, strongly support the campaign for the provision of maternity services in Tallaght Hospital. This is important. The Coombe and other hospitals have provided a great service for my part of Dublin, but it is time that Tallaght, the third largest population centre in the country, had its own dedicated maternity unit. I am glad that is now being progressed. I urge the Minister to keep pressure on the administration in the Coombe Hospital, as well as in Tallaght Hospital, to provide that. There is also a plan for a major children's hospital in Eccles Street, which has been a controversial issue for Dublin and especially for Tallaght where there is already a fine children's hospital. There is also a children's hospital in Crumlin.
It is important in the context of the future development of children's services that there should be progress on the maternity services which it is accepted should be moved to Tallaght. It is fair to make that point in this debate. I seek the assistance of the Minister of State, Deputy Ãine Brady, and the departmental officials in that regard. I realise I am not allowed to name officials so I will not do so; I have no wish to get anybody into trouble. However, at least one of the officials has had a great deal of contact with us in Tallaght and has given dedicated service to Tallaght hospital. I am happy to acknowledge that, without naming him.
It is important to acknowledge it.
My colleagues have spoken about the importance of public health nurses. Again, I can only talk about my experience. I had a little mishap with a hernia two years ago, which is always a very sore condition. However, I was able to go home from Tallaght hospital quite quickly but I could not have done so, and many other people cannot do so, without the service provided by the public health nurses, in my case in Brookfield in Tallaght. They were able to keep me out of hospital. That happens daily in every community throughout the country. Those who provide services for the elderly would also want us to acknowledge the work of public health nurses in that regard.
As a Fianna FÃ¡il Deputy, who is today speaking from the Labour Party benches in the House, I have no difficulty pointing out that I have the same concerns as those Members. I am happy to be on that party's benches.
It is important that we continue to stress to the Government the need to fund the home help service, in so far as resources will allow. I am on the board of Tallaght Welfare Society, now trustus, in Tallaght so I am aware of the huge challenges facing that service. All Members can make the same point. We speak about keeping people out of hospital or getting them out of hospital as quickly as possible and creating a situation in which they do not end up in nursing home care, although I have no problem with nursing homes where they are necessary. We should try to keep people in their own homes in so far as possible and a dedicated home help service is essential in that regard. I have had much experience in recent years with the provision of such services. We must continue to fund them in a meaningful way.
I also wish to comment briefly about the composition of the board provided for in the Bill. I note that the non-nursing and non-midwifery members of the board will be appointed from a variety of areas. The Medical Council, the Health and Social Care Professionals Council and the Health Information and Quality Authority will each nominate a member and the Health Service Executive will nominate two members. A member will be appointed from the voluntary sector, the Minister for Education and Skills will nominate a member from a third level establishment and five members of the board, who are not in a nurse or midwife role and who have such qualifications, expertise, interest or experience that in the opinion of the Minister would enable them to make a contribution to the performance of the board's functions, will be appointed.
One hears differing views about the composition of boards. Deputy Pat Breen spoke about the appointment of nominees. The time will come - I do not know how soon that will be - when his party will have the opportunity to make such appointments.
Sometimes there are unfair comments about ministerial appointments to boards. People have a contribution to make. I have been appointed to a number of boards over the years. My first appointment was to the board of St. James's Hospital. I was then appointed to the Tallaght hospital planning board for a number of years. I was removed from a number of boards, although not the hospital boards, by Fianna FÃ¡il Ministers and was re-appointed to the Tallaght hospital board by a Fine Gael Minister, Deputy Howlin.
I am happy where I am.
I wish to make a very serious point about the HSE without engaging in the usual HSE bashing, although I am capable of doing that. Under this legislation the HSE will nominate two people to the board, which is fair enough. However, that conflicts with what it is doing in my local hospital. I was a member of the AMNCH board when the hospital was established in 1998. When I became a county councillor, I resigned as a member of the health board and was replaced by another county councillor. When the HSE was established it decided, for its own reasons, not to take up its appointment to the hospital board. It still refuses to fill it. In recent correspondence, the HSE has told me it will not take up the appointment. If the HSE is saying it will take its place or places in the case of some boards and will participate, why does it not do so in the case of Tallaght hospital, at a time when there have been difficulties and issues surrounding accountability at the hospital and where letters went unanswered and X-rays were not dealt with? That is a big issue for my community and for the local doctors in Tallaght and the surrounding region. It should be borne in mind that the Tallaght hospital catchment stretches through parts of Kildare and Wicklow and down to Carnew. This is an important issue. What is the thinking on the part of the HSE? It cannot have things both ways. I hope somebody will examine this and report back to me on whether it is good enough for the HSE to take up its positions on certain boards but then decide, for its own political reasons, not to take them up on others. I am a little confused by this.
I am glad that colleagues on the Opposition benches welcome the thrust of this legislation, with some reservations. I am a strong supporter of the Bill and I hope it will be passed expeditiously and implemented as soon as possible. The purpose of the Bill is to enhance the protection of the public in its dealings with nurses and midwives and to ensure the integrity of the practise of nursing and midwifery. The Bill will provide a modern, efficient, transparent and accountable system for the regulation of the nursing and midwifery professions which will satisfy the public. That is important. It will ensure that all nurses and midwives are appropriately qualified and competent to practise in a safe manner on an ongoing basis.