Workforce Planning in the Irish Health Sector: Discussion (Resumed)

We will resume our review of workforce planning in the health sector. I welcome from the Irish Nurses and Midwives Organisation, Ms Phil Ní Sheaghdha, general secretary, Ms Eilish Fitzgerald, second vice president, Ms Niamh Adams, president, and I have left one person out.

Ms Martina Harkin-Kelly

It is me, Martina Harkin-Kelly, president. For the record, Ms Niamh Adams is the librarian and researcher.

My apologies.

Ms Martina Harkin-Kelly

That is all right. This woman will soon correct the Chairman.

I wish to draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable.

I also wish to advise that any opening statements made to this committee may be published on the committee's website after this meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I invite Ms Phil Ní Sheaghdha to make her opening statement.

Ms Phil Ní Sheaghdha

We very much thank the committee for this opportunity to present to it. We have submitted our written statement, which we have been advised is very lengthy. Therefore, we will endeavour to condense it in our presentation.

The issue of staffing in the health service is one on which we have been campaigning for more than a decade. It involved us taking strike action earlier this year. The issue still remains a major one for our members both in the hospital sector and in the community sector. The main issues particular to nursing and midwifery are that nursing and midwifery as professions have a worldwide shortage. We set out in the submission that the issues we face here are not unique to Ireland but, unfortunately, we have to work much harder to maintain our level of staffing and particularly to retain our graduates once they qualify. We qualify 1,850 graduates a year and we will manage this year to hold on to approximately 900, which is good. That is an improvement on previous years but, obviously, it is not good enough. We have set out the turnover rates in our submission and there is considerable detail on that, which I would like to go through with the committee, if that is okay. In the submission, we go through the global shortage and set out exactly what that means, which is that each country that requires nursing and midwifery is basically recruiting from the same pool. We are largely dependent on the non-EU workforce made up of nurses who come from the Philippines, India and Nigeria. They are the three top countries and are the countries on which the American countries, Canada and Australia also rely. The recruitment costs are quite expensive for obvious reasons.

We must send teams to interview and then ensure that when we recruit, we provide accommodation for a period of time. A stipend salary is also provided, estimated at a cost of €11,000 per person, prior to taking up a job in the health service. In the meantime, a recruitment pause was introduced in May, although the HSE continues to deny there is a pause. In fact, it is very evident, including in the front-line workforce, and presents a real problem. The circular issued by the HSE to service providers on 20 June states:

- No new posts [other than those approved and funded developments via the existing national control process] or replacement posts can proceed to offer stage or be put onto the payroll in any CHO, HG or [section] 38.

- No career break returnees or any other returns which are at the discretion of the employer can be allowed to take place during the period [this control] is in force. Also, no increases to weekly hours of staff who are not already working full time can be allowed to take place or approved during the period that [this control] is in force. Reductions to weekly hours can proceed.

This means that we have applications from nurses to return from a career break and that they are being denied and that they are sitting at home. Under the career break scheme, the employer has the right to postpone the return date by one year but must then lawfully take the employee back. Unfortunately, we are absolutely crippled by the recruitment pause. Our members report daily that they are working with completely inadequate numbers, that they cannot provide the required care and that conditions are unsafe. Their physical and mental health is being affected to an absolutely unprecedented and unacceptable level and no one can be recruited because of the introduction of the pause. It affects one third of the workforce and the turnover within the nursing and midwifery professions will be higher than in any other profession because of their numbers. Therefore, they will be affected by the pause to a greater extent and that is what we are witnessing.

We cannot open additional beds. We have had the overcrowding of hospitals reported this week at a figure of just over 100,000 people who are sick enough to be admitted to hospital and who require hospital care but for whom there are no beds. It is an absolute scandal. The figure is increasing week on week and we have been reporting it daily. We view that reporting as a very important part of our role. We do it in order to highlight that the health service is not working in the way it should be. It is now a dangerous place to which to be admitted. We have recently met groups that have reported to us that the admission of the elderly population, that is, those who are over 75 years of age, is at a higher rate than for those under 75. They have nowhere else to go in certain circumstances because community step-down services are not available. As there has been a decrease in palliative care services, people are being admitted to emergency departments and dying on trolleys. That is not the service in which our members want to work and provide care or for which they want to apologiese continuously.

When we talk about workforce planning, we say there are a number of solutions. In 2017 we presented all of these arguments to the Government and exhausted the machinery of the State through the WRC. We reached an agreement which required an annual service plan and a workforce plan to be developed and funded by November each year. The only year in which this was actually achieved was 2017. It was ignored in 2018. We met representatives of the HSE yesterday evening and it does not have a workforce plan for the professions of nursing and midwifery for 2019. That makes it two Novembers for which we do not have a workforce plan. What we have is a very serious restriction on the ability to recruit. The memo of instruction, dated 20 June 2019, from the financial officer of the HSE requires that for any post that becomes vacant for whatever reason, for example, if someone retires, resigns or takes a period of leave, the replacement to be sanctioned by the chief officer or the head of the hospital group. That is one person who must sign each form that eventually reaches that level. Can the committee imagine the delays in this process, considering the size of the workforce in the health service? There are approximately 70,000 staff in the acute hospital division and there is a turnover of staff. Obviously, this introduces significant delays. As late as Tuesday of this week, we were receiving reports from the directors of nursing in Cork University Hospital which is extremely overcrowded that they had been waiting for nearly three months for a response to the request that posts be advertised that had become vacant. We had to intervene again this week in the matter of unfilled public health nurse posts in east Galway. Services for the public are affected. For example, when patients receive chemotherapy at home, they require a public health nurse. The directors of public health nursing are saying such a service will have to cease because we cannot replace nurses.

These are very real issues for citizens who are dependent on the public health service. Until someone is in an overcrowded emergency department or ward, it is difficult to understand how serious the problem is and how serious the consequences are for those being cared for in areas that are overcrowded, with staff who are absolutely stressed and trying to provide a service that is safe. It is simply not possible to do so.

We are delighted to be here to highlight these issues, but we believe a number of very practical solutions can be introduced immediately. We ask the committee to make representations at the highest levels of government in that regard. We must immediately bring an end to the current recruitment pause, particularly in the nursing and midwifery professions. Once it ceases, there will be a ripple effect in recruitment for approximately six to eight months. That is how long it takes to recruit to the professions of nursing and midwifery. We also need to consider in the medium term increasing the number of undergraduate places. We need to train more nurses and midwives at undergraduate level in order to have a steady supply. As I said, we train approximately 1,850 across all disciplines. We could accommodate a greater number. We know, for example, that the Nursing and Midwifery Board of Ireland registered 1,750 non-EU nurses in the last calendar year. That is how many nurses are coming into the country to register to work in both the private and public sectors.

As part of the recent settlement of our dispute, we obtained agreement from the Government that it would fund the measurement tool to determine how many nurses and midwives were needed in hospitals in surgical and medical wards. We have never had such a tool and it is Government policy to fund it. It is called the framework for safe staffing and based on patient outcomes. It was measured by a team of researchers led by University College Cork over two years in six wards in three hospitals. What they concluded was that when the correct number of nurses were employed, the level of patient mortality and length of stay decreased, patient outcomes and retention of staff improved and the level of sick leave reduced, while there was a dramatic decrease in agency costs, all of which is good news and accepted by the Government. The Minister for Health launched the policy, but it was not funded. Therefore, as part of our strike settlement, we sought funding to be made available in this year's service plan for the nurse staffing framework. As late as yesterday evening, we sought confirmation that this part of our settlement would be honoured because it is a huge plank and everyone agrees that it is right to base staffing levels not on funding but on patient outcomes. Unfortunately, we have not yet received confirmation of the service plan, but we remind the HSE that the Labour Court recommendation that settled our dispute clearly sets out that funding has to be made available as part of this year's service plan, as well as the plans for 2020 and 2021, to fully roll out the framework over a three-year period.

This annual funding for the workforce strategy on which we had agreement in 2017 must form a normal part of business for the HSE annually. Otherwise, we will continue to be reliant on agencies and an ad hoc filling of posts and there will be an inability to open new beds to relieve the pressure on the acute hospital system. The working environment of our members in hospitals and the community, particularly in overcrowded hospitals, is such that their health and safety is being deliberately interfered with by the policy that has been introduced by their employer. That cannot continue. We are happy to answer any questions the committee may have.

I thank the delegates for their attendance. We have been down this road several times. I am well aware of the issues and recommendations. I support all of the recommendations. I hope to tease out through my questions where we are in practical terms. Every day, I deal with the issues raised by Ms Ní Sheaghdha. The two hospitals with which I deal most are University Hospital Limerick, UHL, and South Tipperary General Hospital. It is like a perfect storm or Bismarck's nightmare. They are two of the worst hospitals in Ireland for overcrowding.

Many people have contacted me regarding the recruitment freeze. I tabled multiple parliamentary questions on the matter and asked questions directly and indirectly of Ministers and the chief executive of the HSE . The answers I have received have all been rubbish. One gets a standard reply stating that there is no recruitment freeze but, rather, a process through which the HSE is managing its funds. That is rubbish. It is a recruitment freeze aligned with a lack of retention planning and other matters on top of administrative burdens that have been put in place to slow down recruitment. That is what is happening. Nobody can tell me otherwise. So many people have contacted me on this issue that I could probably take out my phone and get the details of 15 or 20 cases without having to check too hard. The issue of those returning after leave is incredible. I have had to contact hospital managers regarding cases where they stated they lacked nursing specialists in certain areas and I had people who were returning and wanted to go back to work. In some cases, I had to embarrass the managers or argue that the staff needed to be taken on to fill the vacancies the hospitals are publicly stating exist. In some cases, they were taken on. It is a significant issue. A modular unit in South Tipperary General Hospital will have to open in two tranches because the management cannot recruit sufficiently to staff it. If the hospital manages to stick to its plan, 20 beds will be opened in January and another 20 will be opened five or six months later.

I have carried out a comparative analysis of statistics for two hospitals that are of the same scale and model, namely, UHL and Beaumont Hospital. The Chair is well aware of my work on this issue. There are 1,294 nursing and midwifery staff in Beaumont and 1,016 in UHL. UHL has 349 health professionals compared with 527 in Beaumont and 228 support staff compared with 459 in Beaumont. This matter is of such seriousness that it goes beyond politics. I have never seen a situation like that in the hospital in Limerick this November. I have no idea what it will be like there in January and February. Several members of my family who have recently been in the hospital were left on trolleys for days or weekends. Very elderly people have been left on trolleys. Infection control is a significant issue there. Patients have been moved to Nenagh Hospital to avoid infection. That is not on.

The recruitment freeze must be lifted. We need to deal with this issue immediately. It has gone on for too long. We need to address the recruitment freeze, the administrative burden and the lack of planning and so on. I know the HSE and the Department of Health are watching these proceedings. I am begging Mr. Paul Reid to deal with this issue. I have written to him, spoken to him and questioned him. My pleas have fallen on deaf ears. I acknowledge he must try to meet his targets and do what he must do, but there must be other ways to reach those targets. People are suffering badly. The situation in Cork hospitals has escalated. It was not too bad in previous years but the situation has been aggravated by a lack of specialist nurses in certain areas, in addition to other issues.

I have significant understanding of the issues and sympathy for those involved,. My questions relate to details that could help us to formulate the necessary arguments. I agree with the remarks of Ms Ní Sheaghda. Does she have statistics regarding geographical areas and specific hospitals that have the biggest issues? She referred a slight increase in retention of graduates, which is to be welcomed. What is behind that increase? Is there a specific reason for it that we could push on a little more? Does she have more information on the lack of places in step-down care? Are there areas where particular issues have arisen? It is definitely a problem in my area. Has the INMO been consulted on the winter plan that is meant to be announced this week? I have no idea what magic the Minister will come up with, but it will need to be magic. If the INMO has been consulted on the plan, what is its opinion thereof? Ms Ní Shealghdha referred to a decrease in palliative care services, which is very disturbing and disheartening. Have specific areas been affected in that regard? I referred to the fact that beds in South Tipperary General Hospital cannot be opened because of a lack of nursing capacity. The new modular unit should open in the first week of January but that seems doubtful. I hope it will. Are there similar situations elsewhere? The workforce planning strategy was published in 2017. Who initiated it? Was it of benefit in the grand scheme of things? I presume it was. What has changed such that it has not been carried out in the past two years? Is Ms Ní Shealghdha aware of an example of its being of assistance? I presume it was of assistance. Why has it not been carried out since?

My hope is that the more we can focus on the areas, hospitals and policies that are not working and how they are affecting people, the more political traction we can get to deal with them. Given where we are headed early next year, we need to deal with them urgently. I am not being dramatic. The statistics back me up. This will be one of the worst periods in Irish healthcare. A hospital clinical lead told me that the trajectory of overcrowding is such that he or she expects catastrophic events this winter.

What they mean by that is that people are going to die unnecessarily. Would Ms Ní Sheaghdha agree with that statement?

Ms Phil Ní Sheaghdha

To answer the last question first, there is research that demonstrates that the period of time spent on a trolley causes the patient to have poorer health outcomes and unfortunately that means the patient is more than likely to have a very poor outcome. That clearly is not good enough.

We sought the workforce plan as part of a dispute on the numbers of nurses and midwives employed in Ireland. We have a maternity strategy that determines how many midwives we should have per birth. We should have one midwife for 29.5 births. That is the science and that is to ensure safe delivery of care to the mother and the baby. We are now 220 plus midwives short of that target in all of our maternity units. It is a national figure. We know this. The plan was put in place to recruit 90 in 2017 and the remainder in 2018. The latest figure we have is that we are even further behind the 2017 figure than when we started because we have an inability to retain and to recruit. This year when midwives graduated, we had to argue with employers to give them permanent jobs in Limerick, Galway and Letterkenny - throughout the country - despite the fact that the Minister for Health at our conference guaranteed that every graduating nurse would have a permanent contract. That did not happen. We recruited 900 because post strike, we concentrated on the low salary for the new graduates. We have improvements to that, we explained that to new graduates. We told them the salary is increasing; it is improving and the Minister for Health has guaranteed publicly that they would get a permanent job. That led us to a situation in September where we had to argue, in many instances site by site, for the retention of our graduates, which is beyond comprehension.

The workplace plan does make a significant difference because those posts are funded and therefore the arguments about whether we can put the advertisement on the HSE website or whether we can recruit disappear. The funding is there in advance, there is a set number and one's concentration is on filling the numbers set out in the workforce plan. We had a very modest 1, 270 odd as a target for 2017. The numbers who leave versus those who are recruited always leaves approximately 67%, onto which one must add. If 1,000 nurses are needed, one needs to recruit 1,670 to reach 1,000 because the turnover through resignation and retirements requires that. Very disappointingly, in the staff nurse grade according to the recent census, the numbers recruited since last December are down for that very reason. The HSE will say it is recruiting nurses but what it will not say is how many left during the same period. The margin is quite significant. Consequently, one cannot take one's foot off the pedal for recruitment and retention in nursing and midwifery. It is just too difficult to recruit without obstacles that an employer puts in. If that is coupled with a moratorium or a pause, one will be going backwards for several years. Unfortunately, we will be going backwards.

As for the geographical areas, we have a lot of information from various hospitals. There is no doubt but that the HSE sites are affected to a greater extent. The voluntary hospitals, the section 38 agencies - the Mater, Beaumont, St. James's - use a much more sensible approach. They try to recruit and retain and have a bit more autonomy in doing that. In respect of the statistics comparing Beaumont and UHL, Beaumont's argument has always been that it is a tertiary referral centre for neurosurgery in particular, which requires a higher staffing level in some of its intensive care units etc. It does a good job of trying to recruit and the committee will notice from the trolley figures that it has also done a good job in respect of trying to reduce the trolley count by ensuring, lobbying and getting additional capacity in the community in various units around north Dublin and that requires funding.

To be fair, it has more options.

Ms Phil Ní Sheaghdha

Well it does. To be fair to UHL it was – I suppose the only word I could use to describe it is-----

Ms Phil Ní Sheaghdha

It was the victim of a reconfiguration that did not increase its capacity.

Ms Phil Ní Sheaghdha

Certain services in Ennis and Nenagh were closed but UHL did not get additional beds. Nobody should be surprised that it is overcrowded. The problem is that the health of the people who work in that environment is now being affected. That simply is not good enough.

Ms Phil Ní Sheaghdha

I hope that answers the Deputy's questions.

We were advised that the winter plan would be launched on Thursday. We were not given any indication of what is in it, bar a very broad-----

The INMO was not consulted at all?

Ms Phil Ní Sheaghdha

We were not consulted. I co-chair the emergency department task force. We have had a lot of information about various sites and what they will do for winter but no consultation in respect of what is actually going to happen. We have sought-----

In previous years, has the INMO been consulted?

Ms Phil Ní Sheaghdha

It depends; some years we were. We seek always to have a dialogue with the employer in respect of a winter plan. It has happened-----

It is common sense.

Ms Phil Ní Sheaghdha

The big issue for us is that the winter plan focuses on providing additional home care packages and on the National Treatment Purchase Fund. The focus will be on buying services in the private sector. That is a small period when there will be relief and hopefully there will be relief in the acute hospitals but is by no means a long-term plan.

It is not sustained.

Ms Phil Ní Sheaghdha

We need to lift up the bonnet. It is very simple. If additional beds are required, as the Economic and Social Research Institute and the Sláintecare report tell us we need, staffing needs to be planned around those and getting to that point. We are not doing that. In fact, we are doing the opposite. We are closing the lid firmly on recruitment. It is simply counterproductive. The staff in our grades, nursing and midwifery particularly, are not hanging around. They are going to the UK, and particularly now, with the emphasis on Brexit, the UK has become extremely active in recruiting from the Republic of Ireland on the basis that it is not getting nurses who will travel to work from other European countries. We have a real problem. The Deputy said that he has written to Paul Reid, we have written to him also. We believe that the solution is very simple. One should look at the 2017 workforce plan and do what is supposed to be done in accordance with the agreement we have under the Workplace Relations Commission, that is, an agreed, funded, workforce plan for nursing and midwifery. If there is a need to pause, then one pauses but one makes sure those posts are filled because they are essential.

I thank the witnesses for coming before us and giving us their views. What has the HSE said about the recruitment pause? The Minister has said there is no pause. In Ms Ní Sheaghdha's opinion, what are the reasons for any slowdown or pause?

She mentioned that insufficient staff were available to staff wards and that there were beds available. She said many beds are available that cannot be used due to lack of adequate staffing. That is a simple question.

We had a meeting with the heads of services in our area in the past few days.

They seem to be optimistic about getting to grips with the situation in a much better manner than they had been able to do previously, for a variety of reasons. Can Ms Ní Sheaghdha tell us about the extent to which and the manner in which staffing levels are affected by career breaks? As she said, it has not been possible to allow people returning from career breaks to take up their permanent positions. To what extent has that affected the delivery of services? Where have such effects most often been recognised? Which region has been most affected in this fashion? On the question of recruitment and retention, can Ms Ní Sheaghdha give us an indication of the people who are most likely to be difficult to retain? Are they people who have been indigenously recruited or people who have been recruited through overseas recruitment? How does that affect the delivery of the service? Does Ms Ní Sheaghdha find that it is more difficult to retain those who have been recruited from overseas? Obviously, they may want to go back home. Where do they go? Has any of this been researched? Do they go to other overseas countries? I have some other questions that I would like to ask after Ms Ní Sheaghdha has answered the questions I have already asked.

Ms Phil Ní Sheaghdha

I have already given the reasons for the slowdown on the pause. There is a pause. The memo of 20 June 2019 sets out the particulars around it. No job can be offered and no recruit can be put on the payroll unless the correct process has been followed and the relevant form has been signed by the single national official who is in charge of this area. That is a fair bar when we are talking about over 70,000 people in a service.

Does that apply to nursing staff only?

Ms Phil Ní Sheaghdha

It applies to all staff. The point we are making is that a pause of this nature will have an effect on those grades that comprise a third of the workforce because the turnover happens more regularly. The budgeting is the reason. We are told that last year's overrun cannot recur this year. All recruitment is being stopped as a very crude instrument until the budget is brought down. I understand the relevant number at the moment is approximately 350. That is what the target has become. I will explain how the pause, which is affecting the front-line service, is manifesting itself. Some of the bed numbers that currently exist have been reduced. More importantly, we now have extra capacity on wards. We record that on a daily basis. As well as having additional trolleys in accident and emergency departments, there are additional trolleys on wards. I will mention an example of the reduced volume of workers that was given to us as late as last evening. Four nurses were supposed to be going on night duty, but instead there were just two. They should have had 28 beds, but instead they had 32 because of additional trolleys. It is simply not possible to provide any level of safe care in that environment. That is not an isolated incident.

Are beds vacant as a result of those glitches?

Ms Phil Ní Sheaghdha

No. Additional beds are being placed on wards because of the volume of dependent people. The staffing of those beds known as "surge beds" is a mixture of agency staff, which is very costly, and very poor staffing numbers. According to the last figure we had, just under 460 beds are closed throughout the country. We know from the Sláintecare and ESRI reports that we are down approximately 2,000 acute beds, based on the projected need and the fact that community services have not been developed to provide an alternative to acute hospitals. The Deputy asked what happens when people on career break are refused the right of return. Invariably, they will work as agency staff. In some instances, they will be employed through agencies. In other instances, they do not work as a nurse for a period of time or they go to the private sector. The point is that all of this is nonsensical.

Has this been measured and quantified within the system with a view to finding out roughly how many people go in each of the different directions?

Ms Phil Ní Sheaghdha

No. The point is that the memo of 20 June 2019 instructs that nobody who seeks to return from a career break should be sanctioned to return. The point is that if we are in the business of providing healthcare with safe levels of staffing, these instructions should exempt front-line staff. There should be an exemption for front-line staff.

That brings me to my next question. Was any priority given in terms of that pause-----

Ms Phil Ní Sheaghdha

Absolutely not.

-----to the need to secure medical and nursing staff?

Ms Phil Ní Sheaghdha

No distinction was made between any grade of staff.

Okay. I also asked about recruitment from overseas. How does the retention of such staff compare with the retention of indigenously recruited staff?

Ms Phil Ní Sheaghdha

We do not measure based on where people have trained. We measure the number of staff nurses in the front-line grade, who normally work at the bedside. We know that since December 2018, the number of staff nurses working in the public health service has decreased by 395. We know the levers and we can measure that. The last statistics in that regard are from 2017. The number of overseas nurses working in Ireland is continuing at a pace. Approximately 1,700 are being registered. That includes the private sector. We get those statistics from the Nursing and Midwifery Board of Ireland, which has to register people who request to work here. We continue to be very dependent on our overseas colleagues to provide services. The Deputy also asked about where nurses are being recruited to. Nurses in general are being recruited to England first and to Australia second.

They are going from here-----

Ms Phil Ní Sheaghdha

Yes. It does not matter whether they trained in Ireland or they trained in a different jurisdiction and have experience of working in the Irish system. The Canadian health service looks to Ireland. When I attended a conference in Canada recently, I met a nurse who worked in the Mater hospital for six years. He is originally from the Philippines. He was recruited from Ireland to Canada along with six other people from his community with whom he had been recruited to Ireland in the first instance. Many recruitment agencies look at the Irish market with a view to recruiting nurses who were trained in Ireland and nurses who have experience in Ireland. It is seen as a good place to recruit from. When we introduce a pause, we make it more difficult to retain. It makes absolutely no sense.

We have come across that. We will take it up again. We will take it up with the HSE as well. I would like to ask Ms Ní Sheaghdha about the need for more undergraduate places. What is her view on the wisdom of increasing the number of undergraduate places here, bearing in mind the extent to which they tend to go abroad afterwards? It is generally accepted that it is not rewarding, from the point of view of the delivery of health services in this jurisdiction, for large numbers of medical and nursing graduates to go abroad, perhaps after staying at home for a year. A pattern must be identified as we look at what will happen if we end up handing over our graduates to the highest bidder after we have trained them. That is where we are going. We have dealt with this matter here. At a meeting here not so long ago, we were told by the HSE that we have to compete with Canada, Sydney, New York and the Middle East every time a post is advertised. In some of those jurisdictions, tax-free salaries of up to €120,000 are available. We cannot compete with that here.

In order to retain a reasonable staffing level and thereby provide a secure health service, how can we encourage graduates to remain here or encourage graduates from abroad to come here? Must we train staff from overseas in our training schools to try to provide the service expected and, in the course of doing so, improve the quality of life for staff at all levels in the health service? It is a convoluted way to ask the question. Ms Ní Sheaghdha has heard it before.

Ms Phil Ní Sheaghdha

The Deputy might have confused the issues. The point is that the graduates are not seeking to leave. Jobs are not made available to them to apply for because there is a recruitment pause-----

Hold on a second, that is not entirely true.

Ms Phil Ní Sheaghdha

The recruitment pause document states-----

Bear with me for a moment. I am not mixed up at all; I am quite clear on this. We have had representatives of the HSE here, asked the questions and got the answers. We keep asking the same questions and getting the same answers. How can we arrive at a situation whereby, by one means or another, be it recruitment at home or recruitment overseas, we can have an adequate level of staff, including nurses, medical staff and consultants, in our hospitals? I appreciate that Ms Ní Sheaghdha has no function regarding medical and consultant staff.

Ms Phil Ní Sheaghdha

The issue this year and last year was not that people are not interested in working when they graduate; it is that they were prevented from getting jobs because there was a recruitment pause or because jobs were not available to them to apply for. As I stated, we had to work very hard as a trade union to ensure graduates were offered posts this year. That was following a commitment from the Minister for Health that they all would be.

There are two fairly simple solutions. There is oversubscription in respect of school leavers applying to do nursing, which is good. Therefore, we know that students in school who are considering their career choices still consider nursing. Although the CSO figures indicate a drop, there is still oversubscription. The point is that if we provide more undergraduate places, they will be filled. We need to train more nurses and midwives but we also need to make sure that when they qualify, there will be jobs made available to them. That is simply done. We have put our proposal in this regard to the HSE in the past. When nurses and midwives are trained, they become employees in their fourth year. The get a contract of employment for 36 weeks. That contract needs to be extended to include the first year after qualification. It is simple. It cuts out all the bureaucracy of recruitment. The point is that the individuals are qualified and trained. Once they pass their exams, posts should be made available to them in order to consolidate their training. This would guarantee that they would stay. If they do not, they will have a reason other than one we are currently battling, which is that posts are not being offered to them.

In the context of existing places, there are 920 for general nursing, 140 for general and sick children, 420 for mental health, 210 for intellectual disability and 140 for midwifery. That amounts to 1,830. As stated in our submission, the conservative estimate from the workforce planners involved the development of the new children's hospital is that we will need 300 sick-children nurses over and above the current number. We are training 140 for general and sick children, which means some of them will remain in the general service after qualification. That is a four-year programme. Accounting for resignations, retirements, etc., we know this end that we will not have enough. Therefore, we need to increase the number significantly in order to staff the hospital.

We stated in our submission that much of the debate has been on the capital expenditure on the children's hospital. The workforce planning has not got an airing. It needs to because, although a very expensive hospital may be opened, it may not be possible to staff it. Therefore, some of the wards will remain closed. Those responsible for staffing must be cognisant of the fact that each of the rooms in the wards will be different. Being single rooms, a higher number of staff will be required. This is particularly the case for a children's hospital. That is a genuine issue. There are two ways of dealing with that. One is to recruit intensively now and do everything possible to retain every graduate within the discipline. That includes removing all obstacles of a procedural nature that are introduced by the employer, including a pause in recruitment. The second way involves increasing the number of undergraduate places to ensure supply will meet the need.

As with the new children's hospital, is there not a presumption that staff need to be employed when planning for the future, based on the identification of what is required and the predicted retirements and their likely impact? For as long as I can remember, no new institution that ever opened had an adequate supply of staff at the time even though the staffing requirement was well anticipated. This goes back as far as the opening of Beaumont Hospital, which was a long time ago. Beaumont was not open for about a year after it was built because of a lack of staff. At least that is what we were told at the time.

The aspect that irks me most is the pause. When it came, it affected all staff, even though this committee was raising time and again the need for medical and nursing staff to be prioritised. I refer to front-line staff. I do not expect Ms Ní Sheaghdha to answer this question but she can give me a hint if she wants to. Who made the decision? Was it the Minister, the HSE or somebody at mid-management level who believed it would be a good idea? Has anybody been identified as the culprit in failing to prioritise recruitment to ensure the required levels of nursing and medical staff?

Ms Phil Ní Sheaghdha

The authors of the memorandums set out why. It is Government policy to stay within budget. The HSE has issued the recruitment pause and all its properties by memo to the system. It is not a secret. Clearly, however, the HSE has to answer to the Departments of Health and Public Expenditure and Reform.

Is it recognised that all Departments have to stay within budget, for example?

Ms Phil Ní Sheaghdha

The summer economic statement set out clearly that there is extra scrutiny of health by the Department of Public Expenditure and Reform.

Because of overruns.

Ms Phil Ní Sheaghdha

When the Minister, Deputy Donohoe, set out the summer economic statement, there was a specific reference to scrutiny in the Department of Health. From our perspective, the most important point we are trying to make at this committee is that there is a ready-made solution. There is a pre-existing agreement indicating there is a need for a workforce plan that is funded to cater for the numbers of nursing and midwifery staff required to provide a public health service that is safe. We are aware, although we do not like reporting it, that people are now afraid of going to public hospitals. They are afraid of the waiting time and they are afraid that they will not be seen on time. That is very unfortunate. It should not be happening in 2019.

I thank Ms Ní Sheaghdha.

I apologise sincerely for being late. We are trying to keep St. Joseph's Shankill dementia care centre open so we had a big rally outside the gates. I needed to be there.

I acknowledge the work of the INMO's members. The current system is extraordinarily difficult. Almost every interaction I have had with public hospitals and some of the community-based services - the nursing services - points to extraordinarily dedicated nurses and midwives working in what are becoming impossible conditions. The circumstances were very difficult and demanding, leading to demoralisation and burnout, but I am now seeing conditions that are inhumane. Ms NÍ Sheaghdha used the word "inhumane" recently. I acknowledge the work the nurses and midwives are doing to keep the system going in what are inhumane conditions.

I read through the INMO opening statement last night with a mixture of despair and frustration that the INMO needed to come here asking for something as basic as a workforce plan. There are something like 30,000 nurses and midwives in the system and we have thousands of doctors in the system, and the idea that there is not a plan for training, recruitment, retention and promotion of nurses and midwives in our hospital system beggars belief. As the INMO lays out, there was a Government commitment to do so. Is it the case the HSE does not have a workplace plan for nurses and midwives for 2018, 2919 or 2020? Is that essentially what the INMO is saying?

Ms Phil Ní Sheaghdha

In 2017, we negotiated through the Workplace Relations Commission a funded workforce plan for nursing and midwifery and the numbers were set out within each of the categories. That was to be repeated in November 2018 and November 2019, and it has not been. A workforce plan is grand in theory but it has to be funded, so the key is that we get a funded workforce plan. The funded workforce plan for 2017 was fairly modest, considering our turnaround. We know how many nurses we need to recruit in order to just replace those who retire and resign. The workforce plan was designed in that year with the assistance of the WRC to ensure we at least broke even at the end of the year. However, as I reported earlier to the committee, we know now that we are further behind in 2019 than we were in 2017. For example, the maternity strategy required an increase of just over 240 midwives to maintain a safe level of care, given 1:29 births is the threshold. Dr. Peter Boylan was on radio this weekend describing what it means for situations in maternity hospitals and general hospitals when there are two midwives looking after a very large volume of very seriously ill patients, and the consequences of that.

Thank you. I apologise to the Chair if I am covering ground that has already been covered. Given it is obvious a workforce plan is needed, given we are looking at one-year, five-year and ten-year thinking and investment in training, in graduate courses and in recruitment and retention, and given there is a commitment in place for that, and it is plain as day that we need it, what is the INMO's view as to why these commitments have not been honoured by Government? It is something the Government committed to and something we obviously need. What is the INMO's sense as to why the Government has reneged on these promises?

Ms Phil Ní Sheaghdha

The obvious issue this year is that the Government has instructed the Department of Health to stay within its budget and then the HSE and the health services have determined that, in order to do that, they will hit the lowest hanging fruit, which is the workforce. We can overrun in our capital spend but we cut back on the workforce because that is the only easy method of reducing the annual cost.

We are still running our health services on an annual budget. We have challenged both the political system and the HSE itself on this. The Sláintecare report clearly states we cannot plan on a yearly basis when we have a service like ours, which has a growing elderly population and an increased cost of pharmacology. We are very proud to work in a health service that develops and is developing new, innovative ways of looking after and improving population health. Unfortunately, we cannot do that and then cut the workforce.

While the committee has probably already discussed this at length, we had senior management of the HSE at the committee recently and I put the recruitment pause directly to them. I said I am being contacted by nurses who are telephoning hospitals around the country, and I named various hospitals, and they are being told there is a recruitment ban in place. I put it directly to HSE management and they said unambiguously there is no recruitment ban in place. They then caveated that by saying that, of course, if they do not have X, Y and Z in place, they may not be allowed to hire anybody. It is certainly my contention, but is it the INMO's contention that there is essentially a recruitment pause or ban in place at the moment for nurses and midwives?

Ms Phil Ní Sheaghdha

Again, I opened our presentation today by reading from the memo that has been issued by the Health Service Executive and I will read it again. It states that the mandated interim controls provide that no new posts, other than those approved and funded developments via the existing national control process, or replacement posts can proceed to offer stage or be put onto the payroll in any community health care organisation, hospital group or section 38. That is a pause. In fact, it is a moratorium - that is exactly what it is.

Yes, that is exactly what it is. I thank Ms Ní Sheaghdha for that. Some really good progress was made by the INMO over the last two years in terms of getting agreed safe staffing levels. When I go into the acute hospitals, what the doctors and nurse managers say is that they do not have the nurses on the ward. I was in a hospital recently and one nurse seemed to be doing all the work in two wards. I looked and I thought that she looked very young, so I went and had a chat with her. Of course, she is young; she is a student and not a qualified nurse. The INMO made good progress in terms of the research and then, I thought, agreement with Government to get to safe staffing levels. Certainly, I know my own anecdotal experience of our healthcare system and while it may be I am wandering into the least staffed wards around, I bet I am not. Has there been any progress on getting to safe staffing levels for nurses and midwives?

Ms Phil Ní Sheaghdha

The Deputy is correct. The progress we made, which is Government policy and which we were very supportive of, was the policy framework on safe staffing on surgical and medical wards for nurses and healthcare assistants. This is a measurement tool that determines how many are needed. When this framework was piloted in Beaumont, Loughlinstown and Our Lady of Lourdes in Drogheda, it proved to do a number of things. The main one was that it cut the spend on agency staff significantly - from 100 to 30 was one of the examples given. It improved the patient experience significantly, reduced the length of stay in an acute hospital, which is the most expensive part of our healthcare provision, improved retention of staff and improved and reduced burnout and sick leave. It ticks all of the boxes from a patient perspective and from an economic perspective because it saves money.

The agreement, as part of our strike settlement, was that that would be funded in 2019 outside of the service plan to the tune of €5 million and that, in the service plan for this year, which covers 2020 and 2021, there would be sufficient funding available to roll it out across all of the remaining hospitals. We met the HSE last evening and we asked what is the progress, where is the service plan and how much is being assigned to the framework. Clearly, if, in a strike settlement which covers from May to the end of the year, one is allocating €5 million, one will need to allocate a minimum of €10 million for a full year. They were unable to tell us. It is still, they tell us, a dialogue between the HSE, the Department of Health and the Department of Public Expenditure and Reform. We are very clear this is part of the strike settlement and it has to be funded and implemented. Otherwise, it is a breach of the agreement.

If I understand what Ms Ní Sheaghdha is saying correctly, no commitment is in place for that, as things stand.

Ms Phil Ní Sheaghdha

"The service plan is under discussion" is the official response from the HSE. The commitment we have is that the Labour Court has recommended that it is funded and we have a letter from the Department of Public Expenditure and Reform confirming that it accepts the Labour Court recommendation.

Funding has to be found to roll out safe staffing levels for nursing and midwifery on surgical and medical wards.

Has any progress been made to date or is this something we are hoping happens in the future, in terms of actual staffing levels and ratios?

Ms Phil Ní Sheaghdha

In respect of how it is rolled out, it requires an IT system which gathers all of the statistics which can then prove the savings and the improvement. That is being rolled out and nine co-ordinator positions have been advertised across the country. Nine co-ordinators at nursing grade will oversee that. The uplift at the pilot sites at Beaumont, Loughlinstown and Our Lady of Lourdes in Drogheda to meet the safe level of staffing has been maintained in the large wards and areas. However, in some instances it has not been maintained because of the normal recruitment issues. When the emphasis on the pilot was reduced, shall we say, funding then had to be found within the hospitals' budget. This requires national funding. It is national policy, agreed by Government and it was launched by the Minister for Health as a policy that will ensure good patient outcomes, safe levels of care and an economic way of staffing wards.

Has the ratio moved in the right direction?

Ms Phil Ní Sheaghdha

No, it has not.

Is it true to say that nothing has happened?

Ms Phil Ní Sheaghdha

It has not commenced because the funding has not been made available. The service plan which is currently under negotiation will have to provide funding to ensure it happens.

By definition we are still running our healthcare system at unsafe staffing levels. Is that correct?

Ms Phil Ní Sheaghdha

Yes.

There is a hiring moratorium in place which we are being told is not in place. We are running on unsafe staffing levels and those levels have not changed. Bits and pieces are being put in place but we are not hiring nurses and midwives-----

Ms Phil Ní Sheaghdha

The levels have deteriorated. We know from the statistics that, for example, in December 2018 we had 395 more staff nurses than we have now.

So we are going backwards in terms of staffing.

Ms Phil Ní Sheaghdha

We are going backwards.

We are going backwards on midwifery-----

Ms Phil Ní Sheaghdha

There are 37 fewer public health nurses employed than there were in December 2018 yet we are supposed to be trying to ensure that primary care services are improved to take the pressure off the acute sector.

In spite of all the promises, we are going backwards.

Ms Phil Ní Sheaghdha

The recruitment moratorium and the lack of funding to back up and implement agreements that have been reached is affecting the safety of the service we are trying to provide. Even if the moratorium is lifted tomorrow, the fact that it has been in place since last May will have a knock-on effect.

I spoke with a midwife in Wicklow recently. She loves her job and loves being a midwife. She has undertaken all sorts of extra study, training and education, including completing a master's degree in midwifery. She works in one of the Dublin hospitals. She said that her job has gotten so difficult, the cost of living has gone up so much, congestion has gotten so bad and the conditions in which she is trying to treat mums and their babies are such that, with a very heavy heart, she is currently looking for a job in the local supermarket. I talk to nurses on the wards and I keep hearing stories of nurses being burnt out. This is particularly true in certain areas like emergency medicine. We know there is pressure on the entire system but are there particular pressure points where it is becoming more difficult, where INMO members are under even more pressure than is the norm? Are there pressure points in particular areas like emergency medicine, paediatrics, oncology or in certain parts of the country where, as a matter of urgency, we need to act immediately?

Ms Phil Ní Sheaghdha

I wish it were as simple as that. Unfortunately, the pressure exists throughout the system. The statistics that we have show us that there is an increase in resignations at nurse manager grades. Nurse managers are now finding it extremely difficult to manage in a system into which they have no financial input and over which they have no control in terms of who is recruited, how recruitment takes place or even whether recruitment can take place, despite the clinical need. The lack of autonomy of nursing managers is causing an increase in resignations, as evidenced by the statistics. That is hugely problematic.

When Ms Ní Sheaghdha says a lack of autonomy, is she talking about the inability of nurse managers to do their job?

Ms Phil Ní Sheaghdha

Absolutely, yes.

Why is that? Is it creeping centralisation? What has happened to cause that?

Ms Phil Ní Sheaghdha

The framework on safe staffing that we discussed earlier recommended that nurse managers would be supernumerary to the roster, that is, they would have the right to manage their staff and to do all that goes with managing a ward. Unfortunately, because of the staffing levels, that is not always possible. In fact, it is the norm for nurse managers to take a patient caseload as well as carry out their management functions and that is simply not possible. That causes burnout. Nurse managers tell us that in some cases nurses, some of whom are not even trained, are taking charge of areas. Employment controls are in place and there are not enough staff working. This means that nurse managers go on duty to find that instead of the six nurses required, there are only three. Patient volumes have increased because the emergency department is overcrowded and there are additional trolleys on the ward. What do the nurse managers do? It is impossible. If the nurse manager makes a mistake or if there is an omission of care, he or she will be referred to the registration body to determine fitness to practise. That is the strain under which nurse managers are working. It is inhumane. That is the only word that describes it adequately. The employer's health and safety obligations are being completely ignored in these circumstances. The employer is obliged to provide a safe place of work for nurses and midwives. They go to work with the aim of doing a good day's work but they are being prevented from providing safe care because of the moratorium. The system does not discriminate positively towards front-line staff, which it should do.

I thank the witnesses for coming in today. I could also say thanks to the members of the INMO but everyone says that. There is never a bad word said about nurses. I do not know how many times people in my clinics in Swords, Balbriggan and elsewhere say that they do not know how nurses put up with it or how they do what they do. However, it is getting beyond the point of being reasonable at this stage. I was thinking earlier of the last moratorium on recruitment, of which Ms Ní Sheaghdha would have been aware. She and I would have worked together at that time. Again, it was the same story from Government in terms of denial. As Yogi Bear says, it is like déjà vu all over again.

It is right that we focus on patients, 603 of whom are on trolleys today, according to the INMO. We have already hit the 100,000 mark this year, which is an absolute shame on this Government, its policies and those who support it. I am interested in the impact on front-line staff. If one goes back to 2007, one of the issues that we would have raised at the time was the potential long-term impact of the moratorium. Has there been any recovery from the 2007 moratorium? I do not recall a massive uplift in recruitment in the interim that would have buffered us against this new moratorium. It is not just this year's moratorium but also the historic impact of the previous moratorium that we are dealing with now. If my memory serves me, the Government imposed a moratorium on the health service first and then on every other sector about two years later.

Ms Phil Ní Sheaghdha

In 2008.

As I said, it was a different Government at the time but the same line was used, namely that there was no moratorium, just a pause.

In truth, I and other Deputies see it. We know that in some instances, albeit erroneously, they have committed to writing that there is a moratorium, yet they come in here and deny it. Was there a recovery? Are we working off a higher base than we would have been? Was there a significant uplift in recruitment that would buffer us against this, or are we still falling from one to another?

Ms Phil Ní Sheaghdha

In our submission, it can be seen that the census figure for December 2007 was 39,000. The census figure for August 2019 was 37,998. Of that figure, 882 were students in training. That leaves us with about 37,116 qualified nurses, so we have not recovered. That is the point we are making. Introducing a pause to nursing and midwifery has a longer-term effect and it is very much an expensive game to be in considering the global shortage.

I wish we had a time machine because I would like to go back and remind everyone of exactly what we were saying at the time, which is that this would have long-term implications. It is clear that there have been implications and we are living with them. Regarding the impact of this on staff, my understanding is that there are a number of implications where there has been a failure to recruit and the staffing levels are low. One is the cost of agency staff. We know that this is only going in one direction. Ms Ní Sheaghdha might outline the figures if she has them. If not, she can send them on to us. The second implication is around the issue of the workplace becoming a dangerous place for workers. There is a direct relationship between the levels of staffing and the levels of assault, so if Ms Ní Sheaghdha has some information that, I would appreciate hearing it. I would like not just to find out the figures, because I know that there is an issue with healthcare professionals. I know from my previous work that there is significant under-reporting of assaults. We know that is happening. Will Ms Ní Sheaghdha outline the numbers and types of assaults and their impact on the workplace, not just in terms of time lost but in terms of morale and the work environment for nurses and midwives who are up against it and indeed all healthcare workers? Would that it were exclusive to one particular grade group or category of workers, but we see a lot of shortages among front-line staff. Will Ms Ní Sheaghdha outline the impact this has on the workforce?

Ms Phil Ní Sheaghdha

Again, the Deputy is correct. The correlation between assaults and staffing levels is well documented in nursing and midwifery across European and international studies that have proved that when staffing levels are reduced, unfortunately, assault numbers go up. HSE assault figures are recorded by hospital group. Traditionally, they would have only been recorded for the HSE hospitals with the voluntary hospitals being left outside of that, so we do not have a full figure but we know that 60% of all assaults are perpetrated against nursing, are recorded as being perpetrated against nursing and midwifery staff, and are on the increase. The issues are that assaults are not confined to what we would have traditionally viewed as areas of concern such as psychiatry and emergency departments. We see an increased incidence in locations such as children's hospitals and care of the elderly. Again, there is no excuse. It is a requirement of the employer to provide a safe place of work. In particular, with regard to emergency departments, we have an agreement dating back nearly six years where security personnel must be employed. Our members report to us that there are incidences when that is not the case, which is unacceptable. Assaults constitute a problem that is increasing.

In addition, we have significant cross-infection in hospitals with which staff must cope. Staff are becoming unwell themselves because of the incorrect overcrowding and all that goes with that when there is a contagious condition. These are the well-documented consequences that are well known to the employer and the Health and Safety Authority. The employer is obliged to notify the Health and Safety Authority when somebody is absent for three days as a result of an assault at work, so all those figures are available and known. No more than anything else, the pause does not stipulate that the grades of nursing and midwifery be treated in a manner that is any different from any other grade employed in the health service.

I have raised the presence of security guards with the Minister on a number of occasions. To be fair, his response is that they prioritise the health and safety of staff. Is it common for a security guard not to be physically present? The response I sometimes get is that there will be a security presence in the hospital but it will not necessarily be in the emergency department. Does the agreement referred to by Ms Ní Sheaghdha specifically refer to a presence in the emergency department?

Ms Phil Ní Sheaghdha

It does.

Ms Phil Ní Sheaghdha

In many instances, security personnel are there but not for a 24-hour period.

That correlates with the information I have. Regarding the winter plan, and I know this was raised previously, will Ms Ní Sheaghdha outline best practice because we love that? It involves best international practice and looking at somewhere where they are getting it right, where they are getting their winter initiative and planning correct and are bang on the money. I assume they would publish their plans much earlier than we do. My understanding is that it is expected next week. I apologise if this question was asked previously but will Ms Ní Sheaghdha outline the level of negotiation that has taken place and the funded element of that if there is one for workplace planning?

Ms Phil Ní Sheaghdha

The NHS publishes its winter plan much earlier. We have requested that the winter plan be published towards the end of August. The response we get from the HSE is that it is planning all year for the winter. I am not being flippant about it but we know that the overcrowding figures have increased significantly this year during the summer. They are moving towards 100,000 and it is early November, so we know that whatever plan is there is obviously not working. We are advised that the winter plan will be published this Thursday, which is tomorrow. We expect that there will be some announcement in respect of the additional provision of home care packages and services through the National Treatment Purchase Fund. If there are announcements around additional beds at this point in the year, it will be impossible to staff those beds because the pause will remain in place and the pause has caused people who graduated in Ireland to make decisions around where they work. We managed to increase the number of graduates who were employed, but not all of them were offered jobs and they do not hang around. This is the point we made earlier. Likewise, when a service is working short-term continuously, people do have choices and there is a really active recruitment campaign from the UK and the private hospitals in Ireland. If the announcement indicates that additional beds, which we know are needed in community settings and in long-term and step-down care, will be made available, our fear is that it will be impossible to open them because the staffing crisis is such that we do not have staff to recruit to staff those beds.

Is that what happened last year?

Ms Phil Ní Sheaghdha

It was exactly the same last year. The beds in the modular build in South Tipperary General Hospital have been announced for nearly four years running but still have not opened. Some beds were opened but many of those beds were staffed by agency staff.

It is déjà vu.

On the engagement of graduates, in her presentation Ms Ní Sheaghdha said there would need to be a 50% uplift in the numbers we were training to shore up the deficit. Are efforts being made with the colleges to that end? It would be an awful shame if any effort to increase numbers was only to the benefit of the private sector, as well as hospitals in Britain, America, Australia and everywhere else our graduates have gone. Is this work ongoing with the colleges to build capacity? Some of the colleges are full to capacity. Is that plan in place?

Ms Phil Ní Sheaghdha

We have had no engagement with the HSE on its involvement with the third level institutions. I understand negotiations are ongoing with one private educational provider, but we are not privy to them. We know that if jobs are available, people like to consolidate their training in the country where they have been trained. There is the obstacle of making the job available, plus we know, thankfully, that school-leavers still consider careers in nursing and midwifery to be attractive. The numbers applying for courses still exceed the numbers of places available. Therefore, if the number of places is increased, there will be applicants. The trick is, as we have said on a number of occasions, to make a contract of employment available in the fourth year when they become employees that will expand the initial period post-qualification. That seems to be entirely sensible to us. It would give us a ready and guaranteed stream of graduates every year. The numbers of college places and the clinical placements have increased slightly since 2017 in specific disciplines. There is a need to increase numbers, particularly, as we said, in children's nursing, intellectual disability and mental health services, as well as the general sphere. The overall intake can and must be increased.

I am not convinced that they will be increased to the levels required. I note the discussions with the private educator, but I am not convinced that it will shore up the gap in any meaningful way.

I thank the representatives of the INMO for coming as I know that they are busy, but it is very useful for us to get the picture from the front line. I thank INMO members for the work they do day in and day out. We need to be able to get to grips with this problem and this is an opportunity to highlight the issues. We need to start to hear about the Government's plans to deal with it as we are caught in a very expensive spiral.

I have a number of questions. Sláintecare makes a proposal which is accepted for a regionalisation of the HSE into six regions based on hospital groups. Will that make recruitment and retention easier? Will it reduce the number of steps required to recruit somebody in the organisations?

On limiting recruitment, a moratorium or a pause, does the INMO believe the Department of Health and the HSE understand it is a counter-intuitive move? Limiting recruitment will have knock-on effects. There will be an increase in the levels of unmet need and waiting lists and poorer outcomes for patients. Patients do not tend to go away. If they are not receiving a service in one location, they will seek it in another, unfortunately, in emergency departments.

Is there still a pay differential for nurses? If so, what effect does it have on recruitment? Does the INMO believe nurses are valued within the system or are they seen as a resource, rather than employees? Are they encouraged to advance their careers by increasing their professional education to gain extra qualifications which can be fed back into the system? I understand there is very little financial support in that regard, as well as limited opportunities to take leave to attend education courses.

Ms Ní Sheaghdha spoke about the recruitment of overseas nurses. Did I understand her correctly that it costs up to €11,000 to recruit an overseas nurse? Surely that is-----

Ms Phil Ní Sheaghdha

That is the figure the voluntary hospitals have submitted to us. We have included it in our submission to the Public Service Pay Commission.

Obviously, the shortage of nurses is feeding into the lack of supply of theatre services. Are theatres closed because hospitals cannot recruit sufficient numbers of theatre nurses? It feeds down through the system, with a backlog of surgical cases backing down into emergency departments. What is happening in emergency departments is just a symptom of what is happening in the health service. Because of what is happening elsewhere in the health service, community services and the supply of beds and recruitment, people end up in emergency departments unnecessarily and inappropriately in some cases. Their progress through the emergency department is then limited because of the lack of bed capacity and recruitment. I ask Ms Ní Sheaghdha to comment on these issues.

Ms Phil Ní Sheaghdha

I will deal with the final point first. Theatre time is not being utilised largely because hospitals are admitting a large number of medical patients to beds through the emergency department. The majority of patients admitted through emergency departments are medical patients. Therefore, the post-operative beds are simply not available. One will often hear stories from patients who are taken directly from the emergency department to theatre and then to the recovery room in some instances for two or three nights because no ward bed is available for them. That is impacting on patients booked in for elective procedures. If no bed is identified, obviously they cannot be asked to come. Many patients talk about elective operations being cancelled repeatedly because of the lack of availability of beds.

Theatre nurses are highly trained and skilled and in short supply. While we have managed to keep numbers sufficiently above the threshold, the requirement to provide an on-call service impacts significantly on them. As well as working a 39-hour week, they also need to provide an on-call service which in many instances takes them out of the service. We need to staff theatres inclusive of the on-call commitment. Basing it on a 39-hour week is not helping to determine the correct number because every single night of the week an on-call team needs to be available and in some instances two, depending on the specialty involved. In some hospitals where maternity services are also a feature, if there is an emergency, the hospital might only have one on-call team to deal with an emergency and it might have an emergency obstetrics case. It has become a significant risk in some hospitals, particularly those outside the maternity specialism. Some hospitals cater for general admissions, maternity services and paediatrics all under the one roof and have one theatre on-call team, which is not safe.

With regard to the pay differential, the settlement of the dispute, which was delayed but has now started to be implemented, will see a big difference in salary at staff nurse grade. The second part of this is the expert group on the management grades. We are disappointed in the length of time it has taken the Department of Health to revert to us on the terms of reference and the parties to conduct it. The Labour Court has instructed that it has to be concluded by next May in order to feed into the next round of public service pay talks. Despite numerous requests, we have not received the terms of reference. We have submitted our draft terms of reference and the parties to conduct the expert review. We are awaiting this from the Department and it is well overdue.

With regard to-----

Ms Phil Ní Sheaghdha

The counterproductive element of the pause?

Ms Phil Ní Sheaghdha

The Chairman is absolutely correct. Placing difficulties in the way of recruitment would be viewed by other countries as nonsensical. They will probably take advantage because if we are hampered in recruiting, it will be to their gain, particularly that of the UK, our close neighbour. Britain is short of nurses and has reduced payments and bursaries for undergraduates, which saw a drop-off in its training places. It has a huge interest in recruitment from the Republic of Ireland.

What is the position with regard to nurses being supported in their work and professional career?

Ms Phil Ní Sheaghdha

Education is piecemeal. The Chairman is correct that it is not supported. We have best practice that states advanced nurse practitioners should make up 2% of the overall workforce. This would require us to have 700 advanced nurse practitioners, of which we have approximately 247. These nurses can provide services that have proved to reduce waiting times in emergency departments and the need to admit. When advanced nurse practitioners work in emergency departments they reduce the length of time patients wait and can assist in getting the patient home as opposed to being admitted. Likewise, in all other services where they work, and international studies demonstrate this, they improve the patient's journey considerably and they provide a very safe service. Unfortunately, in this country we have had a real problem in getting the Government to fund places for advanced nurse practitioners to the point that we are still well below the recommended 700 mark for these grades.

We have met the leads on Sláintecare who accept that advanced nurse practitioners add to the efficient use of bed time. They also accept that advanced nurse practitioners can and should be extended more broadly into community services. There is an idea that management of chronic disease in the community should not be led by advanced nurse practitioners but everybody knows they have a great deal to add. The same applies with regard to clinical nurse specialists. However, this requires investment in educating nurses and midwives to these levels. That would give us a service that actually has a chance of delivering primary care in the community in a very safe manner and in remote areas where advanced nurse practitioners could lead services. We can have nursing-led services in these areas. The plan needs to be approved, the availability of education needs to be fast-tracked and we need to look at models of healthcare delivery that are not solely based on the medical model. Advanced nurse practice and clinical nurse specialism are well established but they need to be funded.

When a nurse is recruited is it built into the contract that there is protected time for further education?

Ms Phil Ní Sheaghdha

No. It is only protected in areas that are mandatory. Mandatory training is protected but outside of that it is not. People apply for training and it may be sanctioned.

Does Ms Ní Sheaghdha believe the development of regional integrated care organisations will make a difference in responsiveness, whereby when a nurse is required an application would be made to the regional authority and a response would be received faster than through the centralised system we have at present?

Ms Phil Ní Sheaghdha

We hope this will be the outcome because otherwise there is no point. We hope the legislation will bring about the regional authorities being devolved so the financial authority, recruitment and retention is decentralised. The centralisation of these, particularly with the pause at central national level, makes absolutely no sense. The regional authorities should have and must have the right to recruit and manage their budgets based on their geographical patch.

Community intervention teams have been a great addition to the delivery of services in primary care. They keep people out of hospital and allow people to come out of hospital quickly. My experience of community intervention teams is that they are now being restricted. There is a recruitment difficulty and their work has become so expansive that they find it very difficult to supply the service because more and more work comes from hospitals.

Ms Phil Ní Sheaghdha

The community intervention teams are a great addition to community services. They provide a 365 day a year service on a 24-hour basis. They provide care in the home after discharge and sometimes pre-admission. The problem we have always had is in expanding this very good service to areas outside the restricted areas in which they work at present. There are not that many community intervention teams but where they exist their statistics demonstrate they make a major contribution to hospital avoidance. By default, a person can stay in his or her own home and be provided with the care required. In some instances where people attend an emergency department, there is a facility to have care provided through a community intervention team in the home. It makes perfect sense. It is the right model. Again, these teams are staffed by staff nurses and clinical nurse managers and are covered in the recruitment pause.

With regard to morale over the past three and a half years, has Ms Ní Sheaghdha found morale is increasing, decreasing or staying the same? What is the situation with regard to burnout of nurses? Those who are left still standing in the system tend to bear the brunt of the extra work. They will burn out quicker and their morale must be affected.

Ms Phil Ní Sheaghdha

Without offering platitudes to our members, the level of service and the mindset they bring to their daily work must be commended. They are extraordinary. Anybody who interacts with a nurse or midwife at work would readily say that they are extraordinary. They are very tightly scrutinised by professional bodies, HIQA, and their employers in an environment in which it is becoming impossible to guarantee safe care. They do extraordinary work every day.

Morale is very low and there is absolutely no doubt that burnout levels are increasing. The concern we have as a trade union representing nurses and midwives is that, despite the fact that all of the statistics and reports indicate this, the health and safety of the workers in the mix of a financial imperative for overspend in the health service is ignored and neglected. This is not in accordance with any health and safety provision in our legislation.

On behalf of the committee, I thank the witnesses for coming in to contribute to our workforce planning meetings. We have had four or five such meetings to date and we might have one more.

The joint committee adjourned at 1.40 p.m. until 9 a.m. on Wednesday, 20 November 2019.