Wednesday, 5 October 2022
Regulated Professions (Health and Social Care) (Amendment) Bill 2022: Second Stage (Resumed)
First, I welcome Wendy and all from Bluestack, Donegal. Well done to all. I wish you all well. When I am up visiting, I hope I get into your new café. I heard you have a beautiful new café. I hope you have a lovely day here in Leinster House. It is fabulous. Take care, and welcome.
The Rural Independent Group was in possession. There are four speakers who have 12 and a half minutes, if Deputy O'Donoghue would like to start.
I thank the Acting Chairman and welcome the people in the Gallery.
Public protection can only happen when correct standards and education are put in place. I understand the main purpose of this Bill is to apply statutory regulation to 18 health groups so as to protect the public.
The Bill will provide a structure for the assessment and approval of training courses, examinations and qualifications which will put in place a proper development of education and training for certain health professions. At present, only five professions are subject to statutory registration: doctors, nurses, pharmacists, opticians and dentists.
The new legislation will provide for statutory registration of 18 other health professional groups. This will strengthen the existing legislation regarding registration of certain professions such as doctors, nurses and pharmacists. In addition, new legislation will be introduced for the registration of health and social care professions, including physiotherapists, occupational therapists, social workers and child workers.
Ultimately, the public can be confident that the professional treating them is qualified and competent. When all the registration boards are in place, it will be responsible for the regulation of approximately 25,000 professionals.
I welcome anything that we can do for training for professionals in the health professions as long as it coincides with accountability, which it will, for all the health professionals. We have seen incidents within healthcare, from minor to major. The people who did not register those incidents were not made accountable. Legal funding was put in place to protect the people who did not report these incidents, as well as for the confidential agreements that were put in place to protect those people, but not to protect the people to whom the incidents happened. I welcome anything that will regulate and bring accountability to people in the health sector and all sectors as long as the protections are put in place for the betterment and the future.
On numerous occasions I have brought up heavy-heartedly the situation in University Hospital Limerick, UHL. For many years, it has been a problem. I had a meeting again during the week. The people I met told me that the next time, they want to meet me with their legal representatives. I will not be frightened by that. I am here to protect the people. I am here to protect the staff and the doctors, etc., in the hospital. We also need to make sure the management system is protected. I hope that the Bill goes some of the way towards doing that. I hope there will be accountability within the health sector that gives confidence to carers, workers, doctors and nurses and ensures they are not afraid of a management structure that is there to try to stop them from doing their job and improving the system.
Deputy Michael Collins and I are sharing time.
Obviously, the Government is committed to strengthening the existing legislation regarding the registration of certain professions such as doctors, nurses and pharmacists. In addition, new legislation is being introduced for the registration of health and social care professionals, including physiotherapists, occupational therapists, social workers and childcare workers. Of course, we all realise the importance of people working with the elderly or with children in all the different agencies of the State or elsewhere.
We have seen a horrendous case where children under the child and adolescent mental health service, CAMHS, were put in danger and in harm's way. Their parents took their children to HSE representatives who were supposed to nurture and bring on those children in the best way possible, but that did not happen. The exact opposite happened. Those children were harmed while under the care of a designated person appointed by the State. That would be every parent's nightmare. It happened on all of our watch.
I dealt with parents who came to me and said that they were worried about their child. The child was regressing - the child was under care but there was something wrong. We were all hammering away at it. I am so grateful to the whistleblowers and those involved in journalism and other avenues of life who helped to bring this to light.
I am grateful to the HSE. I previously named Mr. Michael Fitzgerald, who did excellent work in County Kerry in dealing with the situation there. I want the same care and consideration to be given to the parents and children from north Kerry. This situation has been at hand in south Kerry, but it is a big worry. It is a big problem but it highlights how something can go wrong.
I know in my heart and soul that nobody in the Government, in the Department of Health or in the HSE set out to harm a child, but it happened. That is frightening. We have to do everything we can to ensure it will not happen again.
The primary purpose of the statutory registration is to protect and guide members of the public so that they can be confident that the professional treating them is fully qualified and competent. Registration also provides the facility for legal action against the very small number of professionals who may harm patients or clients and bring their profession into disrepute through professional misconduct or serious illness.
The legislation for professionals already registered and for the health and social care professionals being registered for the first time will provide for consumer representation on the relevant statutory bodies. I suppose it is about building confidence. The CAMHS issue is one of the issues that would highlight why this legislation is necessary.
There is another thing that I could not let go while I have the attention of the Minister of State, Deputy Rabbitte. It comes under the broad umbrella of what we are discussing, which is the delivery of services.
I am sure the Minister of State is aware of the crisis we have with home help at the moment. I have my ordinary little filing system here. It might seem rough, held together as it is with a rubber band, but, between this book and my head, I do not do too badly. A great many people in my constituency have been allocated so many hours of home help in their homes, but that home help is not being delivered to them. The reason it is not is that we do not have the people to hand to provide the service. I am in no way coming in here and saying to the Minister of State that this is her fault; she knows I am not. What I am saying is that it is a problem that I have, that she has, that Deputy Michael Collins has and that everyone else has. It is horrendous to think we have older people and vulnerable people at home, in their houses, without this service. Their ordinary houses are their castles. If I were sick, God knows I would rather be in my own little bothán than in a hospital. Nursing homes and community hospitals are great, but what people want at the end of their time is to be in their own bed, alongside their own fire, if the Minister, Deputy Eamon Ryan, would leave them keep lighting it. They need care and services, and we are failing to provide those services. I just wanted to use this opportunity to bring that to the Minister of State's attention.
The Regulated Professions (Health and Social Care) (Amendment) Bill 2022 was published on 16 August on the Houses of the Oireachtas website. The Bill seeks to amend existing legislation in respect of registration-related issues which affect certain cohorts of registrants with the Medical Council and the health and social care professionals council, CORU.
I know that the Minister, Deputy Stephen Donnelly, is not here but I thank him. I talked last week in my budget speech about getting neurologist nurses, especially in respect of Parkinson's disease. The Minister of State, Deputy Rabbitte, was very much involved in that also, and I acknowledge that 100% because this is a fight that has been going on for many years by those who suffer Parkinson's in particular and who had no nurse. I assure the Minister of State that it is money well spent. It will save money in the long run in respect of people who had no help and no one to talk to. Now, it is to be hoped that Parkinson's sufferers will have one-to-one, direct contact with specialist nurses. I thank Tony Wilkinson from west Cork. The Minister of State and the Minister, Deputy Stephen Donnelly, have probably met him on many occasions. He has been outside the gates of the Dáil with me over recent years and inside in the audiovisual room on several occasions fighting for the cause. He is after being nominated for the Cork volunteer of the year award. I think he has won it, rather than being nominated, so I congratulate him. He fully deserves that because, while he is a Parkinson's sufferer himself, he has given his time freely down through the years to others. He has been their nurse, even though he is not a professional nurse. He has been the person they go to, talk to and seek advice from.
While we are talking about professional healthcare workers who take care of us, I am still getting emails and phone calls from people who are supposed to receive the €1,000 recognition payment, which is a fair bit of a mess. The payment went to many of the workers directly employed by the HSE in hospitals but has not gone to those working in nursing homes and many more sectors. They have not got that €1,000. I heard the Minister for Health say a couple of weeks ago that this needs to be resolved but, sadly, it has not been. In some cases, in some hospitals, many improvements still need to be made. Maybe it is not fair to pick a case, but I got a call this morning from a friend or family member of a constituent, a young person, who is in Cork University Hospital, CUH, after major bowel surgery last week. Her treatment there, I am told, has been appalling. She has no call bell, they have forgotten to give her pain relief and they put her in a room with a Covid patient. She had breathing difficulties all weekend, and now there is a clot in her lung. Would you believe that her husband had to ring the hospital over the weekend to get a nurse to her room, and her bedclothes were not changed for three days? I would suggest that all is not well in the system. I think many staff in hospitals are massively overworked and under pressure. When you are sick, you are sick, and that is the only time you call on the system, and it fails.
While the Minister of State is here, I will ask her the same question I asked the Taoiseach more than once last week, when I did not get a very clear answer. I asked him for a cast-iron guarantee that the seven beds in the mental health unit in Bantry General Hospital would not be lost. The HSE has appealed the decision the Mental Health Commission made. That will go to some district court. At the same time, there will be some improvements, or so the HSE has told us, but the question is, when the improvements are finished, will there be 18 beds in the mental health unit in Bantry General Hospital? I am disappointed that the Taoiseach and the Minister of State, Deputy Butler, were in Bantry General Hospital and went to the medical side of the hospital, which is fabulous and top-class, but both of them walked past the mental health unit. They will say that we have to give people respect and their privacy, but we cannot afford to lose one bed there. I am looking for a cast-iron guarantee. I looked for it from the Taoiseach last week and did not get it.
We talk about pharmacists. One thing I know about pharmacists is that they are willing to do a lot more. We are told that the doctors are overstretched and that there are no more doctors coming into rural places, but the pharmacists are willing to do a lot more work and they have not been given it. I do not know why. I could keep going for another hour but I will conclude.
I welcome this legislation and the opportunity to speak on it. I thank the Library and Research Service for its detailed paper on the Bill and for the brief we got, which has been very helpful.
It has been said many times what the Bill involves. There are really six kernel points that have been set out for us. The Bill proposes to give effect to them. First, it makes amendments to the Health and Social Care Professionals Act 2005. For the benefit of people who might not have grasped what this is about, I will explain. I am going to go around in a circle in a moment as to why this is necessary and I will mention the report following the Dr. Neary scandal. Then I will come to the dentists, who have identified serious gaps in the regulation. The Minister of State may be aware of this in the context of Oranmore, County Galway, and what has been brought to our attention. It is important to point out what is good. There are six points. The Bill seeks to ensure that social care workers applying for registration are required to meet the same standards as other professions registered with CORU. That is very basic. It seeks to provide that the Minister for Health may prescribe or vary by order the qualifications required by designated professionals. That is very practical and we need that. Then there are amendments to the Medical Practitioners Act 2007, which I understand arose directly from the Neary scandal, among other changes the Government was trying to bring in. In that regard, the Bill seeks to provide that persons operating under the functions of the Medical Council will have appropriate immunity, which is absolutely necessary. Then the Bill seeks to provide that holders of UK medical degrees can access intern training posts in Ireland. That is absolutely vital. The Bill seeks to provide for the continued provision of a route to registration on the general division of the Medical Council register for certain cohorts of internationally trained doctors. I am not sure if I will get a chance to come back to that, but it is something I will keep a close eye on in respect of certain doctors and certain countries. Finally, the Bill seeks to provide for amendments to support the performance of triage, investigation and adjudication of complaints under the principal Act. Again, that is very important and something that is clearly missing when we come to the Dental Council of Ireland and what it identifies in its submission, which we all have. I welcome that and, as I said, I am grateful for the work that has gone into this.
I am not sure why there has been such a delay. It is now 2022. There was a health strategy in 2000 and then an Act in 2005. CORU was set up in 2007 and we are still struggling to bring openness, accountability and monitoring and to ensure competence and ensure there is a proper complaints procedure that is able to deal with complaints quickly and to the satisfaction of those making the complaints, once they are bona fide complaints. It has taken this long to do it, and I am not sure why.
Let me deal with the inquiry and the Medical Practitioners Act 2007 to give context to this. I know that the Minister of State is multitasking again, and I say "well done" to her on doing so in so many roles. I have before me some of the report of the inquiry that was set up and signed by Judge Harding Clark at the time. I think that was in January 2006.
The Medical Practitioners Act was enacted in 2007 and now we are seeking to amend that legislation to make the system better. Back in 1998 a very brave midwife broke ranks. Of course she was educated outside of the country, in Northern Ireland or England, and she drew attention to the high rates of Caesarean sections being performed in Our Lady of Lourdes Hospital. Finally, a non-statutory inquiry, with one member, was set up and we have the final report from Judge Harding Clark. I would advise every woman and man to read that report because it highlights how this happened and how it could happen again tomorrow if we do not learn from it, if our regulatory system is not fit for purpose - and we are trying to make it fit for purpose - and if there is not a duty to speak out. When I quote from the report, it will be clear why I say that. The process began in 1998 and continued up to the point at which the report was published on 25 January 2006. The inquiry was set up by order in 2004 and took less than two years to report.
Given that I have the time, which is unusual, I am going to read out what the inquiry established. Judge Harding Clark writes:
It is a story set in a time of unquestioning submission to authority, whether religious or civil, when nurses and doctors were in abundant supply and permanent jobs were few and treasured.
The point being made is that precarious employment was a feature in the medical profession, so there was an extra burden on people not to speak out or they would lose their jobs. Indeed, one or two brave souls who did raise questions found that their contracts were not renewed. This happened not too long ago in Ireland. Judge Harding Clark, having described it as "a story ... of unquestioning submission to authority, whether religious or civil", continues:
It is the story of a relatively small but very busy hospital which operated by a separate and unique set of rules, and was accountable to a religious community rather than to objective medical standards.
That is what we are trying to do here. I will come back to that in the context of the Dental Council. The inquiry found that establishing the rate of Caesareans carried out, which was unacceptably high, was difficult because "key registers were missing" but that the "numbers are truly shocking". I will not take up time reading out the numbers but Judge Harding Clark described them as "truly shocking". The report goes on to say that "No one made a formal complaint and no one questioned openly", except the brave midwife who went along with her friend to the solicitor for the then Eastern Health Board. I want to compliment the man in charge at the Eastern Health Board at the time who took the whistleblower's disclosure very seriously and followed up on it. It was the former Eastern Health Board, from what I understand, although I never met the man and do not know him.
The report goes on to talk about Dr. Neary's fall from grace but I am not going to go into any of that at the moment. The report also refers to inadequate supervision as follows:
He came to work in a unit which lacked leadership, peer review, audit or critical capacity. It is the story of a doctor with a deep fault line, which was recognised early but never corrected. It is a story [in the Judge's view] of a committed doctor with a misplaced sense of confidence in his own ability. It is a story of deep misunderstanding and misapplication of clinical independence.
These are the actual findings and the consequences of same.
There was very little turnover of staff during that period. Job insecurity may have influenced a climate of silence. Consultants could, and did cause nurses to be transferred. Many witnesses recounted to us that a junior paediatrician encountered Dr. Neary’s displeasure causing her contract not to be renewed.
The report goes on to deal with statistics and so on, and finds that "No one seemed to know the actual numbers or suspect that anything was amiss or unusual". Of course, we had the usual internal review by three colleagues, who upheld everything that Dr. Neary did. They subsequently regretted that and Judge Harding Clark acknowledges that regret. However, they upheld everything he did and said there was nothing out of the ordinary. Through all of that, the person from the Eastern Health Board persisted, as did the whistleblower, even though it was very, very difficult.
I will finish with this point in the report: "Dr. Neary and Dr. O’Brien were reprimanded on a number of occasions for rudeness or abrupt manner". One of the recommendations was that they would learn how to say "hello" and shake hands with patients. That puts things in context. According to the judge, "Very few midwives volunteered to speak to us." She also found that notes had "mysteriously disappeared" which meant that a considerable number of former patients were "unable to have a review". I mention all of that, and there is more that I am not mentioning in the report, because it is really worth a read in the sense of explaining the blinding silence and the failure to recognise mistakes. The point is that no matter what legislation or regulations we bring in, they have to be matched by courage and more importantly, by the creation of an atmosphere that rewards people who come forward. That is the challenge for every institution and we are utterly failing.
In that context, I want to go to Galway, not to be parochial but because as the Minister of State knows, a serious problem has arisen there in relation to an orthodontist. This is currently the subject of an application to the High Court which I will not mention. In the meantime, the person is not able to practise, by their own admission. Over 200 families are affected, with people at various stages of orthodontic treatment left in the lurch. We have all been at meetings about this in Galway. My colleagues Deputy Grealish and Senator Kyne have both raised it in these Houses. Cross-party, we have listened to the concerns of the people on the ground who have been left without an orthodontist. Not alone is it terrible for the families who have paid money and lost it, and will now have to incur additional expense, but the difficulty is that the Dental Council has told us that the obligation is on that person, who clearly cannot practise. I am not commenting on a court case; it is accepted that the person cannot practise. How could the ethical obligation be on that person, be it a man or a woman, to sort out the problem when they are in trouble? There is a huge gap here. I will be using the word "gap" a lot in relation to dental services, which is not helpful and is a bad pun.
I will now turn to the Dental Council's submission regarding legislative change in dental regulation. We are being told that the legislation before us today is going to help with that. I see a reference to the 1985 Act for dentists but I see nothing since in relation to dentists. The executive summary of the submission points out that the council has an obligation to bring matters to the Minister's attention. The Dental Council is making this submission to the Minister under the relevant section of the Act. It is obliged to advise the Minister on all matters. The submission argues that there are two gaps in the 1985 Act that pose a significant risk to public safety. The first is the failure to oblige registrants to maintain their ongoing competence and the second is the failure to regulate dental practices. The submission holds that patient safety cannot be assured and patients have been harmed because of this failure to regulate. The council goes on to look in detail at how this happened. Indeed, it mentions Dr. Neary in the context of the Medical Practitioners Act 2007. Luckily and fortunately, we do not have the equivalent of a Dr. Neary in the dental profession, or at least not identified. However, I hope we do not need that to happen for us to take the appropriate action and update the 1985 Act, which we have utterly failed to deal with thus far.
While registrants, that is dentists going on the dental register, are ethically obliged to maintain an ongoing competence, this is not underpinned by legislation. The council goes on in its detailed report, which I have read, to highlight the fact that two thirds of dentists in Ireland are not Irish trained.
That is not a fact to comment on, except it makes it more complex to recognise the training and whether people are competent. There is no legal obligation in the Bill to keep up with competency.
The smile agus sláinte dental strategy is 22 years old . It is a bizarre name. There are gaps in my memory regarding it. I am highlighting this today. How could this be allowed to happen? What has happened since this was presented to the Minister in October 2021? Was there any possibility in the Bill to make provision for this? I find it very difficult to have somebody from the Dental Council telling us that the obligation is on the dentist who is in trouble and clearly cannot perform, for whatever reason, to take the appropriate action. That is a major gap in the system. What is to be done about that? Perhaps someone could give us an update on that.
I thank the Minister of State and welcome the Bill. It is important that social care workers applying for registration are required to meet the same safe standard as all other CORU professions. I welcome that work is being done by the Social Care Workers Registration Board to ensure that the registration of social care workers will open on 30 November 2023. I wish this had happened in 2022, as promised. I have concerns about the hundreds of social care students who do not know whether their degrees will be accredited. This is because new entrants to such courses of study must have an approved qualification to work in the sector from November 2023. The registration process will begin a two-year transition period for existing practitioners to apply to register with CORU, while grandparenting will apply.
I welcome that on 30 November 2025 the title "social care worker" will become legally protected in Ireland. As part of the work to open the register and set the title in law, it has become clear that the registration route provided for existing social care workers who do not hold the necessary qualifications differs from other professions and this is problematic and unsafe. I ask the House to support a Bill that fixes this problem.
I have been contacted by social care students who are studying in Carlow and were conducting their placements when the Covid-19 crisis began. Their placements were immediately suspended, yet CORU stated that students had to complete their placement hours to be recognised as qualified social care workers. The question was then asked as to how teachers, nurses and doctors can be awarded degrees while social care students are not. The Bill will fix this type of inequality, which is important.
The Bill will also help with our staffing challenges in the medical sector. We have long had a tradition of doctors moving between Ireland and the UK to train, especially when it can often be cheaper to study abroad. Due to the departure of the UK from the EU, holders of UK medical degrees are prevented from accessing medical intern training posts in Ireland. We have to make sure that medical degrees completed wholly or mainly in the UK meet the requirements for registration as qualified interns in Ireland. Such students need to be registered in the proper way. It is vital that holders of UK medical degrees can access intern training posts in Ireland. This urgent issue needs to be addressed.
A degree must meet the criteria set by the Medical Council for recognition, and it is important that those who study in the UK meet the requirements for recognition for intern qualifications. We must also maintain a route to registration on the general division of the Medical Council register for certain cohorts of internationally trained doctors, and the Bill will also address that.
I welcome this important Bill. Previous speakers have mentioned GPs. In Carlow, we are crying out for GPs, dentists and social care workers. Previous speakers spoke about home help. We need more home help. It is important that this happens as soon as possible.
I welcome the Bill and thank the Minister of State and her Department for the work done in progressing it. It is important that regulation and legislation be kept up-to-date at all times. This is the third or fourth Bill we have dealt with regarding registration. The CORU figures for 2017 to 2021, which include social workers, medical scientists and physiotherapists, are interesting. The number registered has increased from 12,574 in 2017 to more than 22,866 in 2021. There has been a significant change in the number of physiotherapists registered. The figure for 2017 was 1,782 and it is now 5,323. It is welcome news that this rate of registration is taking place. It is about making sure that there are checks and balances in every area of the healthcare sector, whether that is social care workers, people working in the community, GPs, general doctors in hospitals or nursing staff. It is important that there are checks, balances and regulation in place.
One major change that has occurred over the past 25 years in Ireland is the reliance on overseas medical personnel across the board, including nursing staff, doctors and care assistants. We are running into problems in some areas such as nursing homes, which are finding it difficult to get nurses and care assistants. It is fine bringing people in, but it also need to be ensured they have the correct training and qualifications and expertise required.
The number of doctors registered in Ireland has increased from 18,000 in 2013 to in excess of 24,000 today, an increase of 33% in less than ten years. That is welcome, but it is important that we use them to best effect. We need to ask whether work is being done by general doctors that other professionals could do instead. That is one of the structures we need to examine in our hospitals. I worry in particular about whether doctors who are qualified for less than three years are doing jobs that could easily be done by experienced and trained nurses. We have a significant advantage in this country in that we have expertise in the nursing profession and we do not appear to have given nurses a greater role in the management of patients. Doctors could then do other work and this would make the system more efficient.
When people come in from overseas, it is important that we make it as easy as possible for them to register while, at the same time, making sure that they have reached a certain standard. I heard of a case where a junior doctor was taken on and had given the impression that they had worked in a hospital in the UK. After a week or two, people became concerned and found the doctor had only worked as an observer in a hospital in the UK. That can easily happen, but the issue did not arise in the interview process. That is why we need personnel to be monitored carefully. They are managing people's care and the wrong decision can make a huge difference to how that care is provided and managed.
Another important issue has occurred with training. While we are very much tied into the UK system in respect of medical training and a number of countries are very much involved in medical training together, there is a different type of training throughout Europe, even in EU member states, and it is different again outside Europe. Doctors in many jurisdictions are not required to do basic stuff that doctors here are required to do and even though they are registered, these doctors may have difficulties in dealing with the challenges when they work in a hospital here. It is important that we make sure the regulation and registration is properly put in place and that there is supervision thereafter to make sure that, at all times, the best possible care is being given to our people in our hospitals.
I know the Minister of State is making a plan on the issue of Irish people who qualify here but we are losing quite a number of Irish people who are qualifying in various areas of nursing or as care assistants or doctors and we need to do much more to keep them here, rather than relying on getting people from abroad. When we bring people from abroad, especially from countries outside the EU, we are taking from their medical services. We need to do much more about keeping our trained staff here.
I have raised on a number of occasions at meetings of the Joint Committee on Health the need to do exit surveys. We are not doing enough exit surveys of our staff. Why are they leaving? What is the reason? Is it that the training they are getting is not what they want? Do they feel there is no opportunity for further promotion? How do we deal with that?
I was recently talking to a nurse who had left a hospital in Ireland to work in London. She started off at level 5 within the nursing profession in London and she can climb to level 7. There is a clear pathway for her to do so. The other issue she raised with me was the ratio of senior nurses to nurses qualified less than four years. No matter what day of the week one is working in the hospital, there is a set ratio of people who are qualified for quite a long time and those who are recently qualified. She found that did not happen in Ireland. It varied from day to day. One might have one senior person to 15 or 16 juniors one day and five senior people to ten newly-qualified people the next.
That applies to doctors and consultants as well. Consultants have difficulty giving the time that trainees require in certain hospitals. I heard of one junior doctor who had a very good consultant working with her who made sure she had an opportunity to come to theatre and be involved in the whole process from the ward right through to theatre. The next hospital the junior doctor went on to, she found that she was told to go for this and that but got very little training. It is important that there should be a structure for training that is implemented and there are checks and balances.
However, I very much welcome this Bill. It is very important that the proper regulation should be in place but we also have to deal with the delay in registration because that is a complaint I get. Sometimes people get very frustrated with the time period to get the registration through from start to finish. We need to do something. It may be the case that the various bodies require additional staff. I heard of general doctors going to New Zealand and within two weeks, they were registered with the medical council there, whereas when they came back home they found it took 12 weeks. That is going back a few years ago. I am not sure what the up-to-date position is. We need to follow up on these issues and make sure there are no glitches in the system. I thank the Minister of State for bringing forward the legislation and I look forward to working with her on it.
While the Bill is largely technical in nature, it is very much welcome. Many students leave Ireland annually to go to Britain to study their chosen medical degree. It is only right and fitting that the Bill removes the road blocks before people who hold a British medical degree to availing of medical intern posts here. This is the right direction in which we need to move to attract more doctors into the HSE.
Our health service faces continuing pressure brought on by inadequate staffing. While the Bill is a step in the right direction, much stronger measures are needed. We are losing Irish doctors at an unbelievable rate. Some 402 of them obtained Australian visas in the first five months of this year alone. That is nearly doubt the figure for the whole of 2019.
While this may be a shocking statistic to many, it is hardly surprising to those working in healthcare. A recent survey of non-consultant hospital doctors carried out by the Irish Medical Organisation, IMO, clearly showed why so many are leaving. A staggering 96.8% of those doctors have experienced mental health conditions relating to or made worse by their work and working conditions. Some 80% had concerns for their own mental health and 78% were at risk of burning out.
While the Bill falls short in its failure to provide regulation of the home care sector, the sector is in desperate need of professional regulation. This call is not only being made by workers and unions, but by HIQA. One family I know has serious issues retaining home care staff. I raised this previously. The individual needs two carers at a time and uses a care company that appears to be very well run and fair to staff and pays well. Of course, the company is picking up the slack from the HSE and carrying out the work on its behalf. The HSE will call the company and ask whether it has a carer to go out to this family and the carer goes out to look after the individual. However, there is a difficulty for the family and the care company whom I met the week before last. The company said that while it was doing everything it can by paying staff well, giving them all the necessary training and working with them through the various training required, it is losing them to HSE roles and nursing homes. The company has staff for six or seven months before they leave. One carer would not show up and another carer cannot do everything by himself or herself.
I know that people are saying it is the sector and staff are not being paid well enough. Maybe that is the case but there are companies that are paying well enough and they should not be penalised for being good employers. It has a considerable impact on them because they are getting dragged in by the people who are not paying the proper rates or being good employers.
I know it is complex but families should not be subjected to this. The alternative is State care, which is significantly more expensive. I know the Minister of State knows and realises this. She has not come down from some strange planet. She works with people in this area and has heard it more than I have. However, we very much need to ensure there is some level of fair play for care companies. Staff should get visas. People leave for the HSE to get visas. If that could be applied to home care, maybe it would make a difference.
Amending the regulation of health and social care professionals by the Medical Council and CORU is the subject of the measures in the Bill. The amendments to the Health and Social Care Professionals Act 2005, Medical Practitioners Act 2007 and Regulated Professions (Health and Social Care) (Amendment) Act 2020 are very welcome.
The Bill will restore the ability of holders of British medical degrees to take up intern training posts in this State. This is essential for attracting sorely needed internationally-trained doctors into the HSE and protecting all-Ireland movement of students and professionals, especially in the health and social care sectors. A report published by the education committee on third-level student cross-Border enrolment in Ireland exposed the low levels that exist. It showed how partition continues to have a huge effect on where students go. Brexit posed, and continues to pose, a threat to the low level of students we see going North or coming South to study.
During my research for that report, the RCSI and others raised the issue of the effect Brexit had had on the mutual recognition of qualifications on this island and between Ireland and Britain. Prospective students must have full confidence that their qualifications will be recognised in the other jurisdictions. It is also essential for the functioning of a variety of sectors. It is incumbent on all stakeholders to work together to minimise the Border’s ability to separate us and limit the education options for students and employment opportunities for graduates. This Bill is a step towards addressing those concerns but more needs to be done. Guarding against any hardening of the Border centred on maintaining an absence of physical infrastructure and frictionless trade and this justifiably became an important political issue at national and international level. However, the public discourse did not always show the degree to which the Border is present and exists as a very real barrier in many aspects of people’s lives in its current form.
I echo the comments made by my colleague, Deputy Cullinane, on the regulation of home care workers. Home care workers continue to operate in an unregulated manner. Workers in the sector know that this has a negative effect on employment standards and pay. People in receipt of home care hours and their families also deserve to know that the sector is properly regulated. Many of these people are vulnerable and should have these standard safeguards. HIQA has repeatedly made these calls but they seem to be falling on deaf ears. The absence of formal recognition for home care is directly connected to the shortage of home care workers. I am constantly dealing with difficult cases where people are awarded home care hours but are forced to survive without the service because the workers simply are not there. The Minister of State is well aware of that as many of those cases land on her desk. The Government’s hands-off approach and the HSE's outsourcing of home care to private providers has failed. Do Deputies recall when we had a good home help and home care service across communities? Everybody was happy and people got an hour and knew they were worth an hour. Then the HSE started chopping it down to half an hour and less than that. It has been an absolute failure. Proper regulation as well as secure, well-paid employment conditions are long overdue.
Many Deputies, including the Cathaoirleach Gníomhach, have talked about the difficulties relating to the GP shortage but that has not happened by accident. We have not had proper workforce planning or the number of places we need in the third-level sector to make it easier for people. I meet people all the time who desperately wanted to do medicine but could not. I meet nurses all the time who did a post-leaving certificate course but only 3% of them go on to do nursing because we do not have the places for them. Joined-up thinking is needed in this regard. Our not doing that is putting people in jeopardy and is a terrible indictment of us.
On a related matter, I raise with the Minister of State the care students from the Dublin Business School, DBS, who were left in abeyance because they could not get the CORU approval earlier this year. Many of those students are still in limbo. I have written to the Minister to ask him what the options are for them. I am aware there are options for a limited number of them but approximately 80 are impacted. They are all social care workers who need to be in the system. This block should not be put in their way. Schools such as DBS need to step up to the mark to ensure these courses are accredited before they sell them to students. After all, the schools make a lot of money from them. I would appreciate it if the Minister of State could give us an update on that as well. I thank her for the Bill and welcome it.
It is encouraging to see some movement on what appears to be the seemingly insurmountable problems inherent in our health system when it comes to the provision of doctors. This Bill seeks to remove the obstacles for people who hold a British medical degree from availing of medical intern posts here and to ensure a route to registration on the general division for international doctors. While it a positive avenue to go down, it does not take from the fact that Irish doctors are leaving this country at a rate of knots. This has become such a problem that our health system is increasingly difficult to access.
The rate at which doctors are leaving is summed up in figures that show 402 work visas were issued by Australia to Irish doctors in the first five months of 2022. Given that the figure was 272 three years ago, it is apparent that far from being addressed adequately, the Government is overseeing a rapidly worsening situation that is leaving communities and regions with a severe shortage of doctors. That is where the problem is being experienced and while the provisions of the Bill are welcome, they do not address the fundamental problem of our doctors are leaving. The Government, through various policy failures across the sectors, has created a situation that leaves talented graduates with little choice but to seek better conditions and opportunities abroad.
In my constituency of Tipperary, we have a minor injuries unit in Cashel where the availability of a doctor has been in the lap of the gods for much of this year. Earlier this year we had a situation where I would get word that the unit was to close temporarily. No information was given to local representatives and when I inquired about it, the issue stemmed from the inability to replace the doctor. Despite assurances the matter would be resolved and that Deputies would be regularly informed of any changes that might occur in the future, the unit’s hours of operation continued to be ad hoc and dependent on the availability of the replacement doctor. This kind of uncertainty is unacceptable, as is the lack of communication on the matter. However, it ultimately comes to down to the fact that under the Government and its predecessors, the health service is an unattractive prospect for the professionals we need, including doctors and nurses. Any measures that seek to boost the workforce are, therefore, welcome but the Government also needs to act to retain health professionals that have qualified here, and who would ideally stay here among family and friends, were they to be appreciated by the State and if the housing and services they needed were available and accessible.
A further example of where the Government needs to get its act together can be seen in what is not in this Bill. It does not provide for regulation of the home care sector. We have heard HIQA calling for regulation of home care services and that is something the unions and those working in the sector have called for as well. What about properly recognising the work home care workers do and the contribution they make to keeping people in their homes in their own communities?Surely if they were properly paid and given good conditions and pensions, which they are not currently, this would be seen as an attractive career and we could keep people out of hospital and long-term residential care. I appreciate getting the time to speak on this matter and hope the Government will take on board the points made by the Opposition.
Like my colleagues, I welcome this Bill from the point of view of its dealing with a particular problem we have with people who work in the health and social care sector and have certain British qualifications that should be recognised. However, as Deputy Browne said, we have issues with a large number of health workers from nurses and doctors through to people who work as physiotherapists, speech and language therapists in acute hospitals and emergency departments and right though to disability services. As was said earlier, the workforce planning might not have been done. We do not have the places there. We have huge gaps that are creating a great impact on families out there. This also affects us as Members as we must deal with people who sometimes find themselves in difficult circumstances. We have no choice but to deal with this situation because we cannot leave it to continue as is. We are foisting far too much difficulty and pain onto people. The Minister of State will be aware from the disability sector of the necessity for constant, consistent interventions that must happen as early as possible. There are particular issues with the children's disability network teams and so on. Significant work must be done to put in place a system that can deliver for our people.
I join other speakers in mentioning that we have a major issue with home care provision. While accepting that funding has been in place for a long time, we just do not have the people in place to provide the care that people need. All of us in this Chamber are well aware of families who have come to us just to seek enough help to allow their loved ones to stay in their home which is something we should all be facilitating.
I have had many discussions with the Minister of State, Deputy Butler, about the task force. I had understood that draft proposals were to go to Cabinet and should have been dealt with in the budget. Does the Minister of State think that this will provide us with some of the proposals? I know there were many things, including tax breaks, to facilitate certain people to work in the health sector and, in particular, to make themselves available for weekend work. We all know there were issues regarding expenses. There were multiple issues. There were issues with visas for people coming from abroad.
I agree with Deputy Martin Browne that we need to do absolutely everything we can to keep those who have been trained to the highest level in the State. We should support them as much as we can to keep them working in the system. We know we have major issues with the number of doctors, etc. We have the ongoing issue of Navan hospital and the concern over closing an accident and emergency department which would put pressure on hospitals such as Our Lady of Lourdes Hospital in Drogheda, which is already under serious pressure. It has led to many people with a medical background stating that this is just not a solution at this point in time.
We need to do the due diligence on all the positions we need filled in our health service. We then need to ensure we have the throughput to get people working in those settings. As much as we welcome this legislation, it is but a small step on a much longer journey. If we start to deal with individual gaps in the system, there are multiple gaps in the system we could all mention.
I ask the Minister, Deputy Stephen Donnelly, to update me on diabetic services, particularly in Louth County Hospital. There are issues with the required education programmes and ensuring that we have the facility to provide people with insulin pumps, etc., to allow them to live their lives fully and play their part. There are too many gaps at this time.
There is a wider issue which I have raised previously. It was raised with me by a locum working in pharmacies throughout the Louth area. I think it was in Drogheda where a lady who was on the drug payment scheme was late picking up something for a very serious illness she had. She had been taking her medication every second day to save money. She had previously been on a medical card but it had been refused. This locum made the point that he had seen a number of people who had lost their medical cards. In some cases, they had not realised they had lost their medical cards until they had gone into pharmacies. This lady did not have the €80 she needed to pay for her medication. In the middle of a cost-of-living crisis we need to address this very specific problem. I understand the locum paid the cost himself because he felt he had not gone into the job to refuse to provide someone with medication.
I welcome any Bill that will help to strengthen and make our health service better. I understand the need to regulate and ensure that the patient receives the best treatment at all times because we are all fine until we get sick. When people present with some problem, they need to be treated properly. In that vein I must mention the child and adolescent mental health services, CAMHS, in Kerry. The problem of teenagers and young adults being overmedicated appeared in south Kerry some months ago and now it is manifesting in north Kerry. My concern now is that this may be widespread throughout the country. Is it the policy of the HSE to just drug people up in order to calm them down or whatever? If that is so, I do not think it was right to do that. In south Kerry, a junior doctor was blamed, but now it is in north Kerry.
People have problems at the accident and emergency department in University Hospital Kerry in Tralee with the queues and all that is going on there. What has been allowed to happen and allowed not to happen in that hospital is totally unsavoury. We in the hinterland of Kerry, all the way down into Cahersiveen and Valentia Island, and even people from parts of north-west Cork and west Limerick, depend on the hospital so much. People who become sick are waiting for hours or even days. Elderly people, some 90 years of age, have sometimes been on a trolley for a day, a day and a half or two days. Recently a 92-year-old woman spent two and a half days on a trolley.
Other speakers have mentioned this issue. It is the natural desire of elderly people to stay in their homes for as long as they can. They feel they are being sent to the departure lounge if they have to go into a nursing home for the end of their days. They are really worried that the end is near. If they had home help, they could stay in their homes much longer. The problem is that people get an allocation for the extra time they need, but then no one turns up.
-----of this Chamber to raise something that is not happening and to raise an issue that has let people down. I have a proposal to make on it. I realise as much as anyone else that the staff are not there and the HSE cannot get them.
Thousands of Ukrainian people have arrived on our shores. Could the English-speaking people from this country be trained up? I believe they have cars and everything. Could they be trained up to become part of the home help force even in Kerry? Just the English-speaking ones, I realise it would not work going into a house to elderly people if they did not understand the people.
We have a shortage of consultants. As a result, procedures are not happening and people are languishing and suffering adverse effects due to different consultants not being available. One man can only do so much, whatever his area is. Likewise we have a shortage of GPs in every aspect of Kerry, including south Kerry; every area of it. I am only wondering what we can do as elected Members here to ensure that we have an adequate number of GPs. God almighty, if some sick and elderly person at home rings a GP's office today, Wednesday, they will be very lucky to be seen next Monday. The Minister of State knows that hours and time are important to people when they are sick.
We are training as many nurses as any other country but they are not staying. Why? Are we not paying them properly? We hear they are going to Dubai and Australia. I happen on to an awful lot of what was long ago called an American wake, when someone was leaving our shores to go abroad for employment. I am happening across a lot of these now. They are going to Australia, Dubai and everywhere. Can we not do something to entice them or reward them sufficiently that they do not have to think about that again? For a long time we did have enough professionals. We are here today discussing regulating professionals but the sad fact is that we do not have enough in all the areas I mentioned.
Carers, those who are caring for family members, are not really being appreciated at home. They do not get sufficient time off or whatever. It is a tough struggle for some of them who find themselves minding a wife, a husband or some sick child, God help us, as a result of accidents and different things.
I have requested this before. It happens farmers a lot that they have an accident or get sick and find themselves in hospital. Then there is a panic that they do not have a medical card. They apply for a medical card but it takes a number of weeks to process, and we all recognise that. I am asking that from the day the person makes the application, if they qualify for the medical card later, that the medical card is dated to the day the application was sent in. Between that time and the date they get the medical card, there is a bill accruing that they cannot afford. It seems very logical to me. We can do it with other applications in social welfare and different things, so that the date the application goes in is the date the person becomes eligible. Why not with the medical card? I appreciate the Leas-Cheann Comhairle allowing me to raise these very important things.
Perhaps the mistake was made at the beginning, that all of us Deputies may refer to what is in the Bill or what could be put into it. That is the extent of the range. Maybe we will do it at the beginning in future.
On behalf of my colleague, the Minister, Deputy Stephen Donnelly, I thank those who contributed to the Second Stage debate today and two weeks ago with the Minister of State, Deputy Butler. The fundamental objective of this Bill is to improve patient safety. The overwhelming support of Deputies for the Bill's provisions reflects the importance of patient safety and reflects our shared goal of constantly working to improve our health and social care services. I understand that the issues which were raised with the Minister of State, Deputy Butler, have already been brought to the attention of the officials of the Minister, Deputy Stephen Donnelly. I will be happy to update the Minister on further issues speakers have raised with me today. The officials are taking notes of everything, even including Deputy Ó Murchú on the issue of the medical card which he raised before on the floor of the Dáil. Deputies raised a very wide range of important matters and I hope to address the majority of these in the time available to me before I make some concluding remarks.
I understand there was much discussion of the issue of regulation of the homecare sector. This is clearly a matter of concern to many Deputies. I am pleased to advise that the Department of Health is currently developing a regulatory framework for the licensing of homecare support providers to deliver services for adults aged 18 years and over. This will comprise primary legislation for the licensing of providers, secondary legislation consisting of regulations to set minimum requirements and the HIQA national standards. A public consultation on the draft regulation was concluded in early August and this will inform further development, together with ongoing engagement with key stakeholders including HIQA, the HSE, private and voluntary providers and service users' representative groups. I can also report that my colleague, the Minister of State, Deputy Butler, has established a cross-departmental strategic workforce group to examine current challenges associated with the recruitment and retention of home support workers and front-line carers in nursing homes. Arising from the completion of an evidence-based review and targeted consultations, a report for the consideration of the Minister of State, Deputy Butler, is currently being prepared. This will set out key recommendations.
The regulation of counsellors and psychotherapists with CORU was also raised by several speakers. The work of the counsellors' and psychotherapists' registration board is significantly more challenging than for other CORU professions. This is due mainly to the many different educational pathways into the profession and the variety of specialties and titles used. The initial stages of regulating a profession can be very complex as there is an obligation to balance the right of existing practitioners to practice their profession while ensuring that those who are placed on the register are safe to practice. Much progress has been made by the board, including the verification and assessment of historical qualifications as well as international research into regulatory norms in other jurisdictions. The drafting of separate and distinct standards of proficiency for counsellors and psychotherapists has also begun. However, a substantial body of work remains to be undertaken before that register is opened. I want to assure the House that CORU fully appreciates the importance and urgency of this work.
Another CORU matter which I will respond to and which was raised by a number of speakers is the issue affecting students of social care work attending Dublin Business School. All Deputies will know the register for social care workers is to open in November 2023. The social care workers' registration board has engaged extensively with colleges over a number of years on the standards required for educational programmes to ensure that the graduates are trained to an appropriate level to deliver their service safely to the public. In July 2022, Dublin Business School withdrew its application for approval by CORU of its social care work programme. This effectively means that graduates of the Dublin Business School programmes will not be automatically eligible for registration with CORU. The Minister is aware that this is deeply distressing for the students affected. I want to assure Deputies that the concerns of students are very much understood. The issue is being carefully considered by officials from both the Department of Health and the Department of Further and Higher Education, Research, Innovation and Science with significant support being provided by CORU.
Medical workforce planning is another area on which several speakers raised concerns. The Department of Health is currently developing a health and social care workforce planning strategy and workforce planning project model based on international best practice. A key outcome of this project, which is being technically supported by the European Commission, is to equip the Department with the necessary tools, processes and technical capacity to produce rolling action plans on workforce planning. These will help to implement targeted policy measures for health and social care workforce reform. Extensive work has been completed to date, with the project team currently focused on the document of the strategy and the action plans. It is expected that the project will be completed in 2023.
I will now respond to some specific workforce planning issues raised by various Deputies. On the issue of intern places for medical graduates, following an increase in intern places over several years, we no longer have a shortage of these places. An additional 120 permanent intern places have been created, which represents a 16% increase compared with pre-Covid levels. I confirm that for the 2022-23 interim year, an additional 90 graduates were appointed to intern posts and a supplementary reserve list was created to fill the remaining posts. Resolving the historic shortfall in placements is a significant development and will help to support our efforts to retain doctors who have trained to remain in Ireland.
The issue of access to specialist training posts was also raised. Deputies will be interested to know that the Department has recently embarked on a broad programme of legislative reform, which includes addressing certain registration and access issues identified by the Medical Council. Included in this is the removal of a legislative barrier that prevented certain doctors who trained outside of the EEA from applying for specialist training in Ireland. This barrier was removed in November 2020. In addition, earlier this year, significant changes to working arrangements and immigration permission for most non-EEA doctors were announced. These changes reduced the administrative burden for effective doctors and make Ireland a more attractive place for these professions to relocate to.
It is important to recognise the strength of global competition for healthcare talent. The steps we have taken are welcome and positive developments that recognise that the Irish health service is supported by highly skilled and caring doctors from across the world. We will continue to work with doctors and other health professionals who wish to live and work in Ireland.
The final workforce issue I will address is non-consultant hospital doctors, NCHDs. As several Deputies highlighted, the NCHDs raised a very legitimate concern about their experiences working in Ireland and we know there is significant room for improvement. There is an urgent need to review the issues they have highlighted if we are to increase retention and continue to attract new doctors to join our medical workforce. The Minister for Health is fully committed to addressing the issues affecting the NCHDs. To this end, in the past few weeks, he established a national task force on the NCHD workforce. This task force will develop policy initiatives that will result in improved on-site facilities, structures and training supports for all NCHDs working in Irish hospitals.
I regret that I do not have time to directly address all of the issues raised by colleagues across the House. However, I hope Deputies will have found this information somewhat helpful.
Turning now to the specifics of the Bill, I will briefly recap its main provisions. First, it will amend the Medical Practitioners Act to ensure the holders of UK medical degrees can access intern training posts in Ireland. Citizens of both jurisdictions have long benefited from the freedom to work and study in each other’s country – a freedom that is enshrined in the common travel area agreement. This amendment will ensure that, once again, holders of UK medical degrees can benefit from those rights and apply for intern placements here.
The next issue addressed by the Bill is the continued provision of a route to registration on the general division of the Medical Council’s register for certain cohorts of internationally trained doctors. The amendments essentially correct a small number of errors in the Regulated Professions (Health and Social Care) (Amendment) Act 2020, which were detected prior to commencement.
The Bill makes a number of amendments to the Health and Social Care Professionals Act, the legislation under which CORU operates. First, it will allow the Minister to prescribe and vary by order transitional period qualifications listed in Schedule 3 of the Act. This Schedule was drafted in 2005 and needs to be amended to reflect passage-of-time changes.
The Bill also makes changes to the Act’s transitional period registration route for social care workers to provide that applicants meet the same standards as other CORU professions. As Deputies will appreciate, social care workers are in contact with some of the most vulnerable members of society. It is vital that CORU is satisfied that these workers have the skills and experience to deliver safe and high-quality care.
Two amendments will deliver these changes. First, existing practitioners will be required to attain their work experience in the State. For social care workers, this can currently be in any jurisdiction. Second, applicants will be required to undergo an assessment of professional competence, rather than have their competence attested to by way of the employer reference, which is the current requirement. The existing provisions are considered to pose an unacceptable risk to patient safety and these amendments mitigate that risk and align the registration process for social care workers with other CORU professions.
The remaining significant provision in the Bill is related to the Medical Practitioners Act. The Bill proposes to make a number of amendments to support the Medical Council in its triage investigation and adjudication of complaints function. This will support changes introduced under the 2020 Regulated Professions (Health and Social Care) (Amendment) Act and will lead to a more efficient examination of complaints.
Finally, the Bill will introduce immunity for certain persons operating under the provision of the Medical Practitioners Act. Deputies will appreciate that where a serious complaint is being investigated, experts and others appointed to assist must be free to participate without fear of litigation.
On behalf of the Minister, Deputy Stephen Donnelly, I thank all the Deputies for their input in recent days.
I regret that the topics the Leas-Cheann Comhairle raised are not addressed in my response. However, my colleagues indicated they will convey them to the Minister.