Workforce Planning in the Health Sector: Discussion (Resumed)

The committee will now resume its review of workforce planning in the health sector and receive an update from the SIPTU trade union. I welcome, from SIPTU, Mr. Paul Bell, divisional organiser; Ms Michelle Monahan, honorary vice president; Mr. Kevin Figgis, sector organiser; and Ms Marie Butler, sector organiser.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, 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, persons or entity by name or in such a way as to make him, her or it identifiable. I also advise the witnesses that any opening statements they make to this committee may be published on the committee 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 House or an official either by name or in such a way as to make him or her identifiable.

I call on Mr. Bell to make his opening statement.

Mr. Paul Bell

I confirm the appreciation of SIPTU for the invitation from the Chair and the committee to meet them today to discuss workforce planning for the health service. The SIPTU health division represents approximately 45,000 workers in the health service. Our membership is based across the public health system, private healthcare and section 39 employers. Our division is organised into several sectors which include support grades, nursing and midwifery, health and social care professionals, healthcare assistants and the National Ambulance Service. Our division represents members in all areas of the health service, including acute mental health, intellectual disability and care of the older person. In addition, SIPTU health division supports our members in all industrial relations aspects arising within the hospital groups and community health organisation areas. Our network of organisation and support includes national representatives, local officials and shop stewards, activists and members.

We are proud to represent these members.

In consideration of our presentation today, we note the following definitions of workforce planning which have been published previously. In 2017, the Department of Health said: "Workforce Planning is a core process of Human Resource Management which is shaped by the organisational strategy and ensures the right number of people with the right skills, in the right place, at the right time to deliver short- and long-term organisational objectives". The Department of Public Expenditure and Reform has said:

Without adequate skillsets where and when they are required, objectives cannot be achieved. Workforce Planning aims to draw together all of the various factors – including staffing, skills, learning and development, financial resources, succession planning – to develop a cohesive plan for the medium term.

In his 1996 book, Mr. Peter Reilly defined workforce planning as a "process in which an organisation attempts to estimate the demand for labour and evaluate the size, nature and sources of supply which will be required to meet that demand."

To summarise our submission with regard to the funding model, while our members note the principles of an effective workforce planning system, most do not recognise it within their workplace. The health service is overcome with consistent funding issues which are apparent from the end of one year to the end of the next. The current model of funding for our health service does not work and must change. If policies such as Sláintecare are to have any chance of succeeding, the model of funding approved for the health service must provide for the needs of the service and ensure it achieves the right number of people with the right skills, in the right place, at the right time to deliver short, medium and long-term organisational objectives.

In our opinion, the current model of funding for our health service is destined to fail each year. Concerning workforce planning, the current model requires line managers to prepare plans for the needs of the service in the following year. When this is completed, it is subject to various levels of scrutiny before being submitted to senior HSE management. While we do not have an issue with oversight and scrutiny, which we accept is required, our concern remains that, following the multi-layer overview by senior HSE management and officials of the Department of Health and Department of Public Expenditure and Reform, the final approved funding plan generally looks nothing like the original one submitted at department level. This results in a continuing battle playing out in each department where line managers are left struggling to provide for the ever-expanding needs of service.

In order to achieve the full aims of Sláintecare, support for staff to develop and expand their roles is essential. There is distinct evidence that SIPTU members embrace the development of their roles when supported through resources and funding. The examples of the development of the roles of paramedic and advanced paramedic from the previous title of ambulance driver in the national ambulance service and the development of the role of health care assistant are demonstrative of staff within the service embracing change and upskilling of their roles. Equally, within the area of health and social care professionals, radiographers have expanded their role to include cannulisation and the administering of contrast in computed tomography, or CT, scans and to undertake duties formerly assigned to dosimetrists. The committee will also be aware that nurses and midwives have expanded their roles to share duties previously assigned to medical staff to ensure the most appropriate staff member undertakes responsibility of a task at any given time or on any given day. These are just a few examples of changes which have been undertaken to provide a better, more efficient service to the patient or service user. We contend that these examples, of which there are more, demonstrate the willingness of staff to embrace greater responsibility, a pushing of boundaries and a new model for the provision of healthcare in Ireland. Unfortunately, our members argue a significant percentage of this responsibility is left on their shoulders only.

SIPTU members also contend that the focus of the HSE, the Department of Health and the Department of Public Expenditure and Reform with regard to health management is almost entirely on cost reduction from day one of each year. This results in departments not receiving approval to recruit identified safe staffing levels and those in employment not having guaranteed access to funding for postgraduate courses which are undeniably essential to the service provided. Our union argues there is something materially wrong in our model of healthcare when, for example, a department requires radiographers to upskill and undertake a postgraduate course in ultrasound but the members of staff are asked if they can provide the funding themselves.

On the system for approving recruitment within the HSE, the system of approval for the filling of vacancies or for submitting business cases for staff in new and existing posts is designed to frustrate and does not do what is needed, which is to fill vacancies. Line managers and staff within the system are left totally demoralised by the extensive effort and repeated procedures required to fill vacancies for essential posts. Even where replacement of a post is approved, it is common for recruitment to take well over a year to complete. During this time, staff are left carrying the demands of the service, all too often with insufficient staffing levels. This does not just affect the replacement of vacancies as it is the same procedure which also undermines the replacement of those on maternity leave and so on. In such circumstances, it is commonplace for the HSE to confirm a replacement for the person on maternity leave literally weeks before the staff member is due to return to the workplace. As a result, managers and staff have informed SIPTU that they use the system for the replacement of posts without any expectation that their application will be approved or, if it is approved, of when such approval will be received. The system of recruitment within the HSE is designed purposely to cause this frustration and is extremely damaging to our health service.

The current system of approval requires business cases to be submitted at multiple levels of the organisation. This results in a situation where staff, department level management and hospital and group management can all agree on the need for replacement staff in a given a post but national central management, which is not connected in any direct way, must provide final approval or no one will be recruited for the position. This is very narrow-minded and counterproductive for the HSE as it results in the loss of eligible qualified candidates for employment to the private sector and overseas opportunities. Evidence of the level of recruitment for our key grades over the past number of months and years is provided in the text of this presentation.

SIPTU contends that the recruitment procedure in the HSE must be overhauled immediately. National officials within the HSE and Department of Health reject the suggestion that there are instructions for a recruitment embargo, freeze or moratorium. While it would appear they are seeking to steer away from the stigma of these labels and their effects in the past, they are very much present in all their former aspects, albeit under the disguise of business cases and multi-layer approval bureaucracy.

In the context of the challenges of gaining approval for the filling of an accepted vacancy, money is spent on other expensive forms of employment, such as hiring agency staff, as an alternative. We trust the committee will be aware that the most recent estimate of the costs associated with agency expenditure in the health service for 2019 is in excess of €200 million. This includes a figure of over €60 million on healthcare assistants and €50 million on nurses and midwives. The data also suggest our health service has purchased in excess of 500,000 working hours this year to date through expensive agency arrangements rather than direct employment. SIPTU contends that the system of refusing approval for recruitment while utilising hundreds of millions of euro on expensive external employment options must be revised.

The reality is that many agency workers are employed in the same hospital or ward for years rather than the HSE deciding to recruit. Agency work may have a place in our health service for short-term, immediate or unexpected replacements. It cannot, however, be used as a replacement for direct employment for the filling of vital front-line health worker posts.

We need the right person in the right place at the right time. In this submission, we have highlighted some of the central principles required to successfully incorporate a concept of workforce planning within the health service. The modern-day health service utilises a multigrade, team-based approach. SIPTU believes the maintenance and development of this model will serve to benefit staff and patients alike. We are acutely conscious of the cauldron which is faced every day by staff providing services and, indeed, by those seeking to gain access to services from the outside.

SIPTU believes it is crucially important for all stakeholders to work to change the experience for staff and service users. We believe that a successful workforce planning model will be of assistance in supporting the change that is required to achieve this. There is no doubt that staff want to provide services in an environment that respects the dignity of all. SIPTU contends that the "right person, right place, right time" principle supports such an environment and presents an opportunity for staff to upskill or focus on duties and responsibilities which are in accordance with their qualification standards and their professional registration.

We note the recent framework for a safe skill mix between nursing, general staffing, specialist medical and surgical care settings in adult hospitals, as launched by the Minister in 2018. We contend that an examination of the appropriate skill mix and the safe staffing levels is crucial when services are being provided to patients and service users. It is noted that some grades are suffering from the effects of chronic understaffing and the restrictive labour market. This is due to pressures from the private sector and foreign employment opportunities. We believe there is merit in examining the possibility of seeking agreement on new methods of service provision. We think it would be appropriate for all stakeholders to be involved in this. There is a need to ensure the skills, duties and responsibilities of graduate-qualified staff who are at the pinnacle of their qualification or registration are maximised to provide support as part of a team-based skill mix approach. SIPTU believes such a model is challenging on several fronts, but will result in a changed environment for those who are providing services and for those who stand to benefit from it.

A significant focus on the development model of healthcare is recommended within the Sláintecare report. In that context, it is appropriate for our submission to be accompanied by a brief comment. SIPTU is actively aware of the challenges that are being experienced in communities where people are facing the realities of a two-tier health system as they seek to access services. When citizens face having to access healthcare, their last concern should relate to how much money they will need to afford private treatment. This model breeds inequality and forces an additional burden on the public system through longer waiting lists. Equally, we note that barriers to care in our community are being experienced in areas where they have never before been experienced. This can be attributed to the insufficient number of medical doctors in general practice in many towns and cities. Existing GPs are unable to cope with the level of demand.

While there will be many challenges in implementing the Sláintecare report, we support the principles underpinning it. As a union, we are seeking to bring an end to the bottleneck in accident and emergency departments. The never-ending and ever-expanding waiting lists must be dealt with. Community services must be developed. There is an urgent need for additional bed capacity. If the prescribed future for healthcare in our country is to succeed, lessons must be learned from the existing failed model of service delivery. Staff must be given opportunities to develop and upskill. The concept of multi-grade team-based working, which ensures that when duties are being allocated, they are assigned to the most appropriate person at the right time and in the right place, must be further enshrined. We must support our staff through career opportunities and education supports. This will ensure the public health service is the first choice for health workers in this country.

SIPTU would like to convey its deep concern regarding the slow pace of progress in securing the necessary funding to support the advancement of Sláintecare. In our opinion, a token level of funding is being afforded to this project as part of an effort to convey the optic that implementation is proceeding. We note that €20 million a year has been earmarked for the HSE and for Government Departments to date. This is insufficient to tackle the current challenges in funding the necessary actions to bring about real change. As I make this point, I note that funding of approximately €680 million per annum has been identified for Sláintecare.

We thank the committee for its time. Our submission includes a brief outline of the key sectors of our union within the public health service in reference to workforce planning. Before I conclude, I would like to mention an aspect of this issue that is not normally discussed. I refer to the arrangements put in place by some agencies when the health service identifies permanent posts. If a person who is registered with an agency goes to take such a post, the HSE must pay a fee that is demanded by the agency. We discovered recently how expensive this can be. In some cases, it is as if the employee is bonded to the agency in some way. This must be investigated by the HSE and perhaps by this committee.

Absolutely. I thank Mr. Bell for his comprehensive submission. Before I bring in members of the committee, I wish to ask a few questions. I ask Mr. Bell to give us some insight. We know that workforce planning is tricky in the short term. It is probably even tricker in the long term. I will mention two issues to illustrate that. In the long term, we have Sláintecare, and in the short term we have the winter initiative, winter plan or whatever word they are using to describe it this year. I ask Mr. Bell to give a brief indication of the involvement of the union in both cases. I do not need to remind him of the number of workers represented here this morning. Will Mr. Bell provide an indication of the level of involvement, consultation and engagement that SIPTU has had with regard to winter planning in the short term, and in the longer term with regard to Sláintecare?

Mr. Paul Bell

I suggest that the level of engagement with regard to winter planning was limited. Basically, we had a number of communications from the HSE advising us of what the plan was going to be. There was some local consultation but in some cases, we realised that the consultation was of limited quality.

What about the level of engagement, involvement and consultation with regard to Sláintecare?

Mr. Paul Bell

The engagement we have had so far with regard to Sláintecare has mainly been through the Irish Congress of Trade Unions, which has been trying to deal with the question of universal healthcare. We have made presentations on that matter at this forum. There has been zero engagement since that time.

That is a nice round figure in any event. We discussed the moratorium with representatives of the Irish Nurses and Midwives Organisation when they were here last week. I suppose there is a bit of a misnomer with that. People think the moratorium is a new thing that was imposed recently. Does Mr. Bell estimate that a full recovery was made from the moratorium that was imposed in 2007? Did the health service get back to full staffing levels before the new moratorium kicked in? I have no hesitation in saying, as I did at the time, that the impact of the 2007 moratorium is still being felt across the health service today. Does Mr. Bell share that view?

Mr. Paul Bell

I share that view quite strongly. We do not believe we have recovered from previous staff moratoriums. I will defer to my colleagues here who have more direct experience in this area. In the past, the HSE would have said that it needed to enforce a recruitment embargo or moratorium - it does not matter which language we use to describe it - but that is no longer the practice. In many cases, people have applied for posts on foot of competitions that were advertised and have been deemed to be successful, only to be advised subsequently that there is no starting date for them. Such cases can drag on for a number of months or a year. In some cases, the successful candidate has moved elsewhere by the time the post comes to be filled. In such circumstances, a very skilled person will have been lost.

That is something we are hearing right across the board.

Mr. Paul Bell

It is happening right across the spectrum of healthcare. The agency spend, which is increasing all the time, is feeding into that.

That brings me on to my next question, which relates to the increase in the number of hours being provided by agency staff. It is estimated that up to 500,000 working hours are being worked by such staff. Will Mr. Bell give us an indication of the level of increase in recent years? More crucially, is he aware of a value for money audit of the purchase of such labour, as opposed to directly employed labour, being conducted by the HSE?

Mr. Paul Bell

I am not aware of any such audit. We are raising this issue at the forums we share with other unions, including the national joint council and the health service oversight body, which deals with the public service stability agreement. We believe the current level of spending is out of control. No attempt is being made to erect any barriers to it. There is no recognition of the fact that some of the policies being implemented, such as the embargo or pause on recruitment, are feeding directly into this.

There is no recognition that some of the policies being implemented, such as the embargo on recruitment, or the recruitment pause, are directly feeding into this. We see that other parts of the health service suffer even greater consequences. In community care, for instance, the hours for our most vulnerable citizens who require homecare were cut back. It seems to be easy enough to say there are no further hours available and expenditure will not be increased. This is kicking in right across the service. In some of the areas, most of the damage being done in the delivery of the health service is invisible to the eye unless someone is demanding a service for the care of the elderly or a service related to an intellectual disability or mental health issue.

Reference was made to staff being lost to the private sector. I presume they are following the NTPF money into the private sector.

Mr. Paul Bell

Yes.

If there were a shift involving proper, sustained investment in the public service as opposed to the private sector, would the staff come back? Is there capacity to attract them back? Some of them have gone abroad and maybe we have to draw a line in that regard. More, however, have gone to the private sector here. In the event that we made the requisite investment, would we get them back?

Mr. Paul Bell

Let us explore how some of these successful people arrived in the private sector. The recruitment process of private sector employers is very direct and aggressive. They know the market exists. There are various incentives to attract staff. The recruitment process itself is very fast and focused. We want public health service employment to be seen as the employment of choice. Various strategies would have to be agreed to attract the staff back. There are very good reasons people would like to work in the public health service, and there are various opportunities within the public health service.

Competing with those who attract staff abroad is a bit more complicated because sometimes various professionals and health workers see that the development of their career and skill set can be achieved abroad. However, the problem that arises is partly related to the fact that there may be precarious work. In other words, staff may end up doing agency work or may not be able to get a full-time contract. That is not just in one particular sector of the health service; it is spread right across.

I thank all the witnesses for attending this morning for what I have to say was one of the most comprehensive and well thought-through briefings I have heard. They have gone through the issues grade by grade and outlined the current position and the various effects of Government policy or the lack of progress. I thank them for that.

After my questions, I will have to leave, unfortunately. Normally, I stay for the whole meeting but Fianna Fáil is introducing a motion in a few hours in the Dáil on emergency department care. I have to do some work on that so I apologise for my having to leave after my questions.

On emergency department care, the witnesses have covered many areas. One of the main pressure points in the health system is the collapse in decent waiting times for patients going through emergency departments. We have seen figures that have never been seen in this country before - figures that are really not seen in any other European country that I can think of. One issue is that we do not have safe staffing levels in our emergency departments. Another is that we are not taking care of our own staff, be they consultants, nurses, radiographers or any of the other wonderful people the witnesses represent.

Specifically on emergency care, how are SIPTU's members feeling? Are there issues that are particularly egregious? If the witnesses were in charge, what would be the first steps they would take to try to make things better?

Mr. Paul Bell

Mr. Figgis deals with the nursing profession.

Mr. Kevin Figgis

I thank the Deputy for the question. I am responsible for nursing and midwifery staff but also the health and social care profession, including radiographers and radiation therapists. A number of these would have a role within this.

We described the emergency departments as the bottleneck of the health service. There is a bottleneck because there is so much on one side and such a little gap on the other. Filtering is also an issue. Clearly, the staff working in this area are working under major pressure. They are doing so all the time. Part of the difficulty is with getting the necessary resources and services to assist. It is really about being able to look after patients to "get them moved on" within the system, such that they are either being admitted or discharged. We all hear about the long delays faced by patients in being seen and in waiting for a bed. Many of these factors feed into one another.

We mentioned the difficulty in regard to general practitioner access. In this regard, we have mentioned the difficulty concerning diagnostics. Many people talk about accessing diagnostics. They do not talk about anything else in this regard other than the need to access diagnostics, as if it were just a matter of a button that just has not been pressed and as if it were easy to do so. The reality is that the services are under major pressure. We have given examples in our paper showing that the reality is that most diagnostics departments have not had a review of their staffing levels, possibly for decades. When people talk about the fact that the departments are fully staffed, they should note that they were possibly fully staffed when they were last examined, in the 1990s, but that does not mean they are fully staffed now. In addition, staff are trying to use equipment that is well beyond its sell-by date. Moreover, funding cannot be obtained for staffing. I recently dealt with a case in which people wanted to know why certain equipment was not being used. The equipment was funded but there was no funding for somebody to use it.

The difficulty faced by the nurses, doctors and support staff working in an emergency department is that they need to be able to work with and integrate with the other grades of staff in order to make the decisions ultimately necessary to determine the pathway for the patient. The problem in the emergency departments is that these difficulties extend well beyond their corridors, although it is clear that safe staffing is an issue. It is a national disgrace considering the pictures of people sitting on chairs and the like.

May I ask about diagnostics specifically? I am one of those who keep saying we need to open the diagnostics suites for longer. One of the points I make is that in many of our hospitals, an MRI machine might be open from 9 a.m. to 5 p.m. from Monday to Friday. I had arguments with hospital managers over an elderly man who was strapped to a backboard and in urgent need of an MRI. The conversation was to the effect that since they believed he could not be admitted before 5 p.m. and that it was Friday, he should be kept strapped to the board until Monday morning, when an effort was to be made to admit him. In this case, the diagnostics suite stayed open. One of the points made to me as somebody who argues diagnostics suites need to be open for longer is that, in Australia, the patient receives a letter saying he will get his MRI at 2 a.m. on Saturday night. It is said to me that the unions would never allow that here. I am told such a system is all well and good and that I am awfully naive because the unions would stop me dead in my tracks. I do not believe that. The witnesses represent the unions. What is their response to people who say that?

Mr. Kevin Figgis

I will respond briefly and then hand over to my colleague, Ms Michelle Monaghan. Since she is a radiographer by profession, she will be able to deal with the question to some degree.

Specifically on the unions, in 2012 we actually agreed the extension of the working day for radiographers according to an 8 a.m. to 8 p.m. model. It was agreed that it would be brought in from Monday to Friday in the first instance. Basically, the day was extended by one third. Does the Deputy know how many staff were deployed in order to achieve that? Zero. What happened was that medical staff, or clinical staff, were arriving in the diagnostics department asking why a particular room that was open the day before was not open. The response was that the staff who were in the department the preceding day between 9 a.m. and 5 p.m. would be in at 12 noon because they were now working from noon until 8 p.m.

People will talk about these great ideas but great ideas need funding and that is why we are discussing this issue. There is not an education fund for radiographers. We have examples of radiographers throughout the country who, through credit union loans, have funded their own postgraduate education.

Ms Michele Monahan

Between 2010 and 2016, the number of CT scans increased by 90%. That figure is taken from the national dose survey report so it is an accurate figure. The increase in the number of CT scanners in the same time----

What was the timeframe again?

Ms Michele Monahan

It was in the period from 2010 to 2016, which was when the last population dose survey was taken. There was an increase of 90% in the number of CT scans and a 12% increase in the number of CT scanners. We have 19 CT scanners per 1 million population. That includes the private sector. The equivalent figures for Korea, Iceland, Denmark and Spain are 38, 44, 40 and 18, respectively. The figure for Spain does not include private centres. As a person who has to deal daily with people seeking access to diagnostics, I would happily do anything I can. However, as Deputy O'Reilly noted, whatever staff one had on the floor on 31 December 2007 was taken as the new whole-time equivalent. If the unit had five more staff earlier in the year than on that day, its whole-time equivalent was reduced by five. That has not been restored. Every year, on 31 December, that is the new norm. The unit loses its position numbers and can have fewer staff this year than it had in the current or previous years. The volume of diagnostics increases by 10% by putting more and more pressure on the system and the scanners. The majority of CT scanners in use here were installed in 2009. Their sell-by date was 2017 and we have no hope of replacing them.

What was the names of the report Ms Monahan referenced. It might be useful for us to have it.

Ms Michele Monahan

It is the medical exposure radiation unit, MERU, data of the population dose survey report. MERU was what we had before the current legislation.

I thank Ms Monahan for that.

Ms Monahan said that at the end of the year, one could end up with fewer staff for the next year. How would that arise?

Ms Michele Monahan

We were not able to recruit people into vacant positions because it takes so long to recruit. Recruitment goes through layer after layer and it takes at least a year to interview and appoint someone, especially if recruiting through HBS Recruit, the national recruitment division.

If a member of staff leaves, it takes at least a year to get a replacement.

Ms Michele Monahan

If a member of staff leaves, the local manager submits the necessary forms, which go to the next layer. If the hospital approves it, it then goes to the group for approval. There are delays of weeks in that process. The local manager hopes that somebody will advertise the position. Then there is the interview process followed by a delay of three to four months before anybody acts on it. If recruiting through the national service, it takes at least a year from submitting the application to having somebody on the ground.

In the meantime presumably, some of our bright, young experienced radiographers will note the process involved, say they need a job in the next two months and if they are told the recruitment process will take between nine and 18 months, they will go somewhere else to take up a job

Ms Michele Monahan

They are doing that. The voluntary hospitals are allowed to recruit themselves and they get the choice. The HSE hospitals are at a major disadvantage in this process.

What happens when a staff member goes on maternity leave? If a radiographer goes on maternity leave for six or 12 months, is an agency person quickly brought in to cover that position?

Ms Michele Monahan

No. The agencies cannot find radiographers at this time, which means we do not get anybody to provide cover. As stated in the submission, we may be given a name a few weeks before the person is due back from maternity leave. This means we will have bolstered and covered that work and moved people around. The Deputy asked how staff feel. Staff in every grade dealing with emergency care are overwhelmed. We do not have enough resources in terms of equipment, people or time. We see the patients coming in. We deal with those sick patients and do our best to provide diagnostics. The Deputy will note the increase in the volume. We are overwhelmed because we are not being supported with the provision of equipment or people at any level.

Mr. Paul Bell

I will ask my colleague, Ms Marie Butler, to comment on Deputy Donnelly's question regarding what is happening in accident and emergency departments. We have issues in community care where patients are going to hospital who should be cared for in the community.

On the ambulance service, members may not know that when an ambulance is dispatched to a location the ambulance crew must take that patient to an emergency department. We have highly skilled advanced paramedics and emergency medical technicians. By "highly skilled", I mean they can issue up to 44 different types of medication at the scene but they have no power to discharge. The ambulance crew must bring the patient to the accident and emergency department unless that patient discharges himself or herself. That issue has been overcome in the Scottish ambulance service which has two distinct services. One is a hear-and-treat service where the people in the control room involved in planning services for the ambulance dispatch can determine if the patient needs to go to his or her GP or pharmacy and does not require the use of an emergency vehicle. The other scenario is where an ambulance crew arrives in a community or an incident has occurred. Much of the care of the elderly could be considered from the perspective of how ambulance personnel treat those people. They cannot recommend anything other than taking the person to hospital unless that person decides not to travel and in such cases, he or she must sign off on that. My colleague, Ms Marie Butler, will explain how some people in the community care area are ending up in emergency departments unnecessarily.

Ms Marie Butler

Deputy Donnelly's original question was what would we do immediately. I would immediately recommend that healthcare assistants be utilised in the emergency departments. Many patients come into hospital and they may only need to be looked after. They may need to be brought to the toilet and their personal needs taken care of. Often they are left sitting on a chair because there is nobody to do that work. While those engaged in diagnostics, clinical work and assessments are under great pressure, much could be done to enhance the patient's experience at that level. That is an under-utilised resource. Healthcare assistants are qualified support grades. They do not get enough recognition for the work they do or could do to alleviate the patients' suffering at that early stage of their journey. Many elderly people end up in accident and emergency departments for no medical reason when they could be taken care of in their own home but, again, there are no resources available.

There are many reports on the gaps in professional services. However, I do not believe we would find a report that would set out the work health support grades do in the community. The nearest we have is the healthcare assistant report which is an independent review of healthcare assistants and the types of work they provide. If we wanted to find what support grades do externally in community care, we would not find an independent report that deals with that. That is a gap. The Sláintecare report refers to moving into the community but healthcare assistants and healthcare support assistants, which were previously known as home helps, are only mentioned twice. That indicates that there is a great deal of emphasis on diagnostics, clinical work and assessments, and rightly so, but there is a major resource that is not being tapped into. I believe the reason is that people do not know what these support staff do. In the absence of independent reports, it is difficult to know what they do.

That is a great point. We must look at that. For example, in several hospitals, the number of men, women and children on trolleys waiting for a bed is broadly equal to the number of delayed discharges in the same hospitals.

Ms Marie Butler

Yes.

Such matters never stay still but hospital by hospital, there could be 20 people on trolleys waiting for 20 beds, and 20 people in beds who have been discharged but cannot leave the hospital because they will not get two hours of home care.

Ms Marie Butler

Many healthcare assistants sit with people who need one-to-one care, whereas such people should be in a properly provided mental health facility where they can be properly cared for. Community healthcare assistants are under-utilised. There are community healthcare assistants in mental health services and intellectual disability services. They are all over the place but nobody knows what they do. We should consider that in tandem with other issues such as diagnostics and assessments, given that, naturally, people want to get well. The patient experience could be greatly enhanced if the support grade was given a bit more recognition. We strongly recommend that the recently published healthcare assistant report be given full support by the Department of Health and the HSE-----

The committee keeps hearing about HR practices within the HSE, and not much is good. Staff have hidden pregnancies for fear of not getting promotions or of something happening to them, while junior doctors have had their training records falsified by hospitals because they work hours well in excess of European directives and are supposed to receive training. There have been burn outs in all the grades that SIPTU represents. "Overwhelmed" is the word Ms Monahan used and that I will use later, and that we have heard more and more frequently. Healthcare is busy. It has always been, and will always be, a busy, high-pressure environment - such is its nature - but it cannot be overwhelming for staff or patients. SIPTU represents workers throughout the country in many organisations, some with healthy HR practices and others with unhealthy HR practices. In respect of how it treats its staff and of its HR practices, how does the HSE compare with good and bad employers in Ireland, about which SIPTU has an awful lot of knowledge?

Mr. Paul Bell

It would be easy for trade union officials to say everything wrong with staffing issues or practices is the fault of HR managers. In voluntary section 38 hospitals, the management is close to the staff. It is not a large geographic spread. I refer to hospitals such as St. Vincent's University Hospital, with which the Deputy will be familiar. Sometimes issues can be resolved more quickly or staff matters can be attended to on the basis that it is closer to the staff member. While we do not want to generalise because it would be unfair, given that we view the HSE as a national organisation, it should deal with issues concerning staff consistently across the board, whether it is a grievance, a policy on dignity and respect at work or whatever it is.

Sometimes, however, we have found that our union gets into difficult positions where some HR managers decide there will be a regional variation of a national policy. That makes us engage on issues where we have agreed the policy at national level, how the staff members should be cared for and the employer's rights, but in cases of grievance resolution, for example, one may find that one set of hospitals in the north east will comply with policy set down nationally by the HSE corporate employee system, whereas in Cork it may not be interpreted that way. We then have to jump through hoops to try to have the matter resolved. That leads to bad industrial relations and tensions in the system, which does not need more tensions. It leads to difficulties.

I am trying to answer a slightly different question. Are SIPTU's members treated well by their employer?

Mr. Paul Bell

That is a very general question.

Mr. Paul Bell

Based on our members' terms and conditions, in some cases people will say we are treated well. Nevertheless, there are people in professions who would say they have been left behind, as can be seen in the movement of people into the private sector or abroad. Nationally, it is a difficult organisation because of the pressure on it. Most of the difficulties encountered are due to the sheer pressure people are under in their workplace.

Mr. Kevin Figgis

One of the major changes from an industrial relations point of view has been visual, namely, the refusal of more senior level staff, either within the HSE, the Departments or whatever, to allow people at local level to make changes. To be fair to people within HR roles and so on, there has been a demonstrative change in their ability to negotiate, sit down and discuss problems. The tools they are given to problem solve are minimal. Aside from localised discussions that may take place, it is evident in the types of cases that go to conciliation within the Workplace Relations Commission, WRC, and so on. This is no disrespect to people who work and provide a valuable service at the WRC, but it is clear that the managers attending hearings are not given the remit within which to solve the problem, while those who have the remit ensure they do not attend.

In my experience, HR departments might as well be issued with water tenders because their job is to put out fires caused by understaffing. Some of the most sophisticated arrangements are in place in that employment, such as on the national joint council and others. The problems are wide. It is not in the gift of anyone within the HR department, with the best will in the world, to resolve such issues.

Mr. Paul Bell

I will speak from my experience this year. We have discussed how people are treated when working for the HSE or voluntary hospitals. Following on from the point the Vice Chairman raised, there is a new player on the field. When the HSE tried to resolve issues nationally with its employees, there was a continual intervention by the Department of Public Expenditure and Reform. Some of the issues we now face, such as staff recruitment, the pressure of people getting posts, including promotional posts, and so on, it feeds back to the Department of Public Expenditure and Reform, which demands the final say because it is an expenditure issue. We found ourselves in a national dispute this year, as members will recall, whereby we had an agreement to deal with people's pay and conditions through an independent process. The obstruction was not the HSE per se or the Department of Health; rather, we found ourselves in a confrontation with the Department of Public Expenditure and Reform. With respect, the people responsible for the health service are the Department of Health and the HSE. We found ourselves to be in a continuously difficult position in that regard, and other groups have had a similar experience.

I acknowledge the work SIPTU's workers do. It is becoming harder and they are overwhelmed. They have been put in an impossible position.

We all know they still go to work every single day, keep the lights on, treat the parents, run the machines and make sure that men, women and children are getting the best possible service the union's members can provide. It is becoming increasingly difficult for them to do it. They are doing an incredible job. I acknowledge that and I ask Mr. Bell to convey my thanks for all the work that they are doing.

Mr. Paul Bell

I thank the Deputy. I appreciate that.

I thank the witnesses for coming before us and for their presentations and the information they made available. I have been around the health services for a long time and the system does not seem to change because the issues that have been raised were raised 20 years and they have not changed since then. That is the case in particular with part-time staff, agency staff, short term, part time, whole time and the various descriptions of staff within the service that seem to impact negatively at all times on the delivery of the service.

In recent days, I also heard reference to the fact that Ireland is one of the wealthiest countries in the world. I reminisced on the days of the Celtic tiger when we were high on the list of the wealthiest countries. Of course, it is not true. Our wealth is based on salaries and house property values, which are unsustainable and can fluctuate from day to day. We know that because it happened previously. The problem is that we are not recovering to the point from where we fell in 2007 as fast as we need to, but we are getting there as fast as we can. That is the conundrum.

When the moratorium on recruitment was introduced, was any provision made to prioritise front-line services or was it just the case that recruitment generally would be opened up? Could Mr. Bell indicate what happened? It appears there was an over-abundance of administrative staff as opposed to front-line staff. All staff are important because they all have a part to play in the delivery of services. Was nothing done in the health service to prioritise front-line staff? In a bakery, for example, the baker has to work. Was anything done to ring-fence the need for front-line staff when recruitment opened up?

Mr. Paul Bell

I will take the Deputy back a couple of steps. The health service has been subject to two massive shocks in a 40-year period due to recession followed by cuts in public expenditure. In the meantime, the demand for the service continued to grow. We are talking about the changing demographic in the country whereby there is a big requirement for care-of-the-elderly services. There is a concentration on trying to put that type of service into the community, which is right, but it has to be funded. We all talk about funding on the basis that healthcare, whether we like it, is labour intensive and every service is connected.

In response to Deputy Donnelly's question on whether priority has been given to front-line services, he should remember that the HSE, and the Departments of Health and Public Expenditure and Reform, for their part, have never formally confirmed that there is a recruitment embargo or a moratorium. That has never been said.

Mr. Paul Bell

That is a deliberate tactic because one cannot then confront it. What we see is certain areas of funding being exhausted, for instance, in community care. My colleague, Ms Marie Butler, referred to that. We also see greater pressures on the ambulance service because it is involved in providing services, not necessarily at the beginning of the process.

Yes, but they are on the front line.

Mr. Paul Bell

Yes, but it is commonly asked whether priority has been given to administration as opposed to front-line staff. I have always said, and will continue to say, that nobody is employed in the HSE, in any of the voluntary hospitals or in section 39 organisations that is not required. The problem in some cases is that there are not enough of them or that they are not given the leadership they need to develop into providing the very best care they can provide. In response to Deputy Durkan, I think we are going to continue to experience these pressures unless we get serious about what the political system, including Oireachtas Members, has agreed on the way forward, namely, Sláintecare. We have tried to look at all the challenges that are coming against us.

I refer to something that is in the background but is also adding to the stress on the health service in terms of expenditure, which is the continuing expenditure on the children's hospital. That is taking resources and we do not know where it will end. I listened to a programme on RTÉ radio recently where it was stated that nobody could confirm whether the hospital would cost €2 billion or €2.5 billion. We are concerned about how we can develop the health service if that drag is on the budget. There is also capital expenditure, which means we need to develop new hospitals and new facilities, including primary care centres.

I understand what Mr. Bell is saying but to go back to the various drags on the system, they are different. One is capital expenditure and there is a different means of funding that, as those of us who are involved in the health service know, which does not affect the current expenditure at all. I accept that it affects overall borrowing but not current expenditure. I have strong views on that issue. I have long been a member of this committee and I was a member of the committee that devised Sláintecare. I have been on all sorts of committees in recent years. I was around when an bord snip nua became involved. I was very conscious of the recommendations of an bord snip nua, which dug much deeper than was applied eventually, unfortunately so. The point is that we were forced to live within our means, and our means were very limited and they were on a downward trajectory at that particular time.

I do not expect Mr. Bell to have the answers to my questions but he does have a pivotal role in dealing with the issues at ground level and on the front line, whereby he may have a different assessment of what is required. Regarding the cost of the children's hospital, I have looked everywhere and I have found no solid assessment of an estimate based on anything other than a guess. The overrun, as it may well be considered in some quarters, is not an overrun. It was a failure to assess accurately the costs in the first place, based on sound economic advice. That is not my problem. My problem is to try to do something in the aftermath or to make some contribution to it.

In terms of value for money, my belief has always been that the permanent filling of posts is better with less reliance on agencies, but it never seems to change. Even when we had money during the Celtic tiger boom, there was no shift or change at all in that regard. That ties in with what the witnesses said. One could find oneself with fewer staff at the end of the year, depending on where one was when the chopper came down. We accept all of that. The next part is how we proceed from here. Sláintecare will be expensive and there is a lot of other attendant expenditure as well. What I cannot understand is why it is not possible within the health service to identify precisely, within reason, the budgetary projections. That has not happened for some years. It has not happened for a long time, even though my colleagues might tell me that it is a recent phenomenon. That is not true. It has not happened. I am concerned whether a means can be found whereby all those responsible, including the witnesses, the committee, or whoever is responsible, can identify the projected expenditure or if we need to opt for a flexi-budget that has a contingency built into it because it is a demand-led service and we can expect the demand to increase in one area or more or whatever the case may be and how and if we can provide for that. We must keep in mind also that taxpayers must pay for all this and the extent to which they are able to shoulder the burden.

SIPTU is in a unique position to be able to identify the things that happen at ground level and the outcomes relating to which might be better determined if we took a different approach.

Mr. Paul Bell

Before I defer to my colleague, Mr. Figgis, I will answer one question. Deputy Durkan talked about the budgetary provision or the Estimate. Perhaps we should ask ourselves while we are in this forum, who makes the final call on the budget? I think I know the answer to that. When health service managers put forward their requirement, it is based on what they anticipate to be the patient and service user need. The cost of those objectives are then presented, and this is about maintaining the normal service. The HSE, when agreeing the Estimate, has a lot of interaction, I suggest, with the Departments of Finance and Public Expenditure and Reform about what will be spent. One then finds that the actual estimate of what the HSE believes it requires to operate a full complement of public health services, whether we like it or not, is cut back. In every single year in which I have operated in this service, which amounts to 21 years, I have witnessed a situation in which either the budget was not sufficient or we had supplementary budgets, even though we were told some time ago we could no longer have supplementary budgets for health. The budget, or the Estimate, is therefore doomed to fail right from the start because it does not address the actual needs that will present or that are projected to present. It should be remembered that this is not an exact science; as Deputy Durkan said, it is a demand-driven service. We are not saying we should just see what falls out at the end of the year. We understand that there must be a budget, that managers must manage their budgets and that our members who perform those services have a role to play. If, however, we do not face up to what the actual budget requirements are and how they are arrived at, we will end up in the same position all the time.

When it comes to recruiting and retaining staff, we are wasting a lot of money. I ask the committee to consider the agency costs that have arisen, which are one example, and the amount of money being spent on contracts. I do not wish to be confrontational, but I take slight issue with the idea that the cost of the children's hospital does not impact the health service. It does because we cannot invest in capital projects that are required in the health service. We saw the recent concerns of the citizens of Waterford about their mortuary. That is just one example. We have other services in respect of which our members are fighting off private sector interests. In the Mater Hospital here in Dublin, for example, a new sterilisation department is required for the preparation of surgical instruments. The Department of Health says it has no money to replace the existing facility, that it would much prefer a private sector organisation to be brought in and that perhaps that the latter could build the facility and run the service. Ultimately, however, with respect to everyone here, it is still the taxpayer who will pay for that, and that is before we stray into the other areas of diagnostics and what happened with CervicalCheck.

We will not agree on the children's hospital. I believe it is an absolute necessity. It should have been built 20 years ago-----

Mr. Paul Bell

Absolutely.

-----or 40 years ago. It was not, however, and therein lies the kernel of the problem. The Waterford mortuary should have been dealt with 12 or 14 years ago, when there was no children's hospital competing with it. That is my point.

With respect, there is probably a limit to how much value we will get out of that because I do not think there will be-----

Everybody else got a lot of value out of the reverse side of the coin. I am entitled to my side of it.

I do not intend to dispute that at all. Has Deputy Durkan further questions?

No. Mr. Figgis wishes to respond.

Mr. Kevin Figgis

I will make one or two brief points in response to the two questions Deputy Durkan asked together. He asked whether there is a co-ordinated or integrated approach to the filling of vacancies, employment, etc. The last time there was a co-ordinated and integrated approach was when the opposite was being done, that is, when there were incentivised schemes such as those relating to early retirement, voluntary redundancy, etc. However, there was no correlation at all regarding the effects this would have on the service. It was really just a case of getting as many out as possible. It was the classic sledgehammer approach. What we have not seen since then is a rebuilding of the health service.

We recently carried out, by joint agreement with the HSE, an independent review of the radiology department in University Hospital Kerry, which has had its own challenges. I refer to this purely as an example. We implemented a review and agreed terms of reference. We also appointed independent people to come down, and it was to be chaired independently as well. They prepared their report based on the existing safe staff guidelines published by the professional body. That report stated that that department had 60% of the staffing it should have had. The HSE and the hospital group in the summer of last year accepted that report and all its recommendations. I met with them about ten days ago under the auspices of the WRC because it was impossible to get any progress made. Their current plan is such that they have no approval to go any further and that the department will remain 30% down on recommended staffing levels. They have no plan whatsoever to fill the vacancies they accept are there. Everything is overheating because there is such a small staff complement. In this example, 60% of staff every day of the week are trying to deal with what 100% of staff should be doing. That is just one example among, I would imagine, most departments in most locations throughout the country.

The difficulty we have in the model of recruitment is, as we have said in our paper, that it is about frustrating matters. There are not only so many layers that people must go through but also the layers even outside of the health service in that these things ultimately go to the Department of Health or the Department of Public Expenditure and Reform. As we said, line managers are asked what they need to provide for the safe level of service in their departments and to meet the demands made of them. They come up with those plans, they base them on safe staffing guidelines and, by the time they go through the rigmarole of the bureaucracy, they either get back something that looks nothing like what they asked for or just do not get back anything at all. At a meeting I was at two weeks ago a person said to me, "I am at the stage now where I just keep submitting every two weeks. I do not change anything; I just keep submitting the plan." One wonders to whom such people are submitting their plans. Clearly, they are just landing on someone's doorstep and they just do not open that post.

The Vice Chairman will be glad to know that I am nearing a conclusion. To what extent has overall staffing throughout the health services increased in the past year or two years, given that during an bord snip nua's regime it went down dramatically? There have been many staff increases. This goes back to my question as to which area the staff increases have gone to. It is fine to say these are crucial posts. All of them are. If I was in one of the posts, I would say mine was a crucial post. The question, though, is whether staffing levels have gone up by 2%, 3%, 10%. To what extent have staffing levels gone up in general throughout the public health sector? I know there have been increases. Have they gone in the direction which is likely to affect most fundamentally the delivery of services to the public?

Mr. Paul Bell

We have outlined this in our written submission. The whole-time equivalent figure for HSE and publicly funded employment, for all grades, as of September 2019, was 119,126. That represents an increase from December 2018 of 1,269. The Deputy will remember that we are still trying to recover from the gap left by the number of workers who left the service under various inducements over ten years ago and who have since retired. He will also notice that there has come to be an even deeper reliance on agency provision.

That demonstrates that those staff are required but they are not in direct employment. For value for money, if we were talking in those terms, a continual fixation with agency work is driving the budget in the wrong direction. There is a commission that must be paid for those staff. There are also the VAT implications. VAT, at 23%, must be paid. Of course, agency staff, like other workers in the health service, are entitled to be treated equally with their full-time colleagues.

I thank Mr. Bell. I have one or two questions of my own. There has been a suggestion that there are HR practices that, if overhauled, would improve working conditions. My view would be that without the requisite staff, one can overhaul and restructure all one likes. There seems to be, from my memory anyway, fairly sophisticated HR practices in terms of communication, committees and meeting points. Has Mr. Bell a view on that?

Mr. Paul Bell

Sorry?

I refer to the overhaul in HR practices. Would that be necessary?

Mr. Paul Bell

I have an interest, as the Vice Chairman would have had in her previous role. We are now talking about a restructuring within a restructuring. Dare I say it, it is almost like we are returning to the health board system and there are these regional units, the community healthcare organisations, CHOs. My colleague put this correctly. It is the autonomy of those who are managing.

They just do not have it.

Mr. Paul Bell

What rights do we have? There are certain issues with which we end up in difficulty, and we all ask how we got to this space in the end. With position and rank come responsibilities. In some cases, it is difficult to get to a position where one is clear on who the decision-maker is. That has become frustrating over the past while. I note the media commentary over recent weeks on where the director general of the Health Service Executive sees restructuring developing, but we have not had a full dialogue with that particular person at this stage.

I have one final question and it relates to the scope of practice for healthcare assistants. It is fascinating that the matter is still being discussed since there is a willingness on behalf of the trade unions to expand the scope of practice. In its submission, SIPTU states: "To this end we suggest that the Review of the roles and responsibilities of HCA is given full endorsement and that the support and the resources it needs are provided, so that this role can be developed along a cohesive and professional pathway." That is motherhood and apple pie. That sounds great. Will Mr. Bell give us an insight into why that is not happening? It seems, on paper, like a good idea. When one of the first reviews of it was done, perhaps 12 or 14 years ago, it was probably a fairly good idea. SIPTU is calling here for it to be "given full endorsement". Will Mr. Bell outline who is not endorsing it in the first instance?

Mr. Paul Bell

I will hand this part over to my colleague, Ms Marie Butler. There has been, I am glad to say, some progress made in recent times, led by my colleague, Ms Butler. The Chairman will see that in many areas of the health service there is basically no understanding of how the healthcare assistant role has developed, and we are still trying to develop it. The ongoing review has been dealing with the acute hospital setting. My colleague, Ms Butler, will outline what exactly has been going on there.

Ms Marie Butler

In December 2018, or back a bit further to 2016, we asked the Department of Health to conduct an independent study into where healthcare assistants were at the time. That independent review eventually launched in December 2018 and the HSE fully endorsed the recommendations. One of the issues with the healthcare assistants is that the role has developed differently in different areas. In some areas healthcare assistants are doing observations and quite intricate patient care while not in other areas. They all must have Quality and Qualifications Ireland, QQI, level 5 now. There are a number of areas where they are developing quite well. Certainly, in some of the acute hospitals they are developing quite well. It is much slower in maternity and in mental health. It is much slower even in care of the elderly and in other areas. However, the independent review clearly shows how and where they could be developed further. There is no real objection to it, other than an unwillingness to get going on it.

Okay. Basically, everyone thinks it is a good idea but nobody is actually doing it.

Ms Marie Butler

Yes. One of the recommendations in the review is that there would be a permanent national forum set up for all matters relating to healthcare assistants so that there would be a one-stop shop for everything to do with healthcare assistants, from which would permeate all that needs to happen to make this grade of worker work within the community settings, the acute settings or wherever. It has been agreed by the HSE to set that up, but that is where it sits. It has not been resourced. They have not put the people in. That needs to be done. The idea of the permanent forum is that it would look at the healthcare assistant role in all of the different services and develop it from there as a support to the professional grades. It is not in competition with the professional grades. We are not looking to be nurses, doctors or anything else. They just want to do their role professionally in a way that they can and to develop to the roles that they can do.

In the report, there are approximately 16,500 people in support grades who could be considered healthcare assistants. That does not include the 6,000 home helps or, as they are called now, healthcare support assistants. As I stated, that is the only report that I am aware of independently conducted into a support grade, and yet Sláintecare is moving everything that moves into the community and there is no report being done on how support grades operate currently in the community, let alone how they are supposed to operate in the future. While we accept fully the importance of medical care, diagnostics, etc., the only impediment to the healthcare system being rolled out is it is not happening.

It is not happening.

Mr. Paul Bell

If I may add to my colleague's remarks, whether we like this or not, ten years in the health service are a short period. By 2030, according to the World Health Organization, we will be short 15 million health workers globally. People think that refers to the developing world or non-developed world, whatever term one uses. The biggest stresses will be in the provision of health service in the community. If we accept that, and my colleague, Ms Marie Butler, has outlined it clearly, the healthcare assistant has to have a place in assisting in the delivery of health service while not being in competition with any other professional group. The greater the expectation for community care, the more healthcare assistants there must be. It means the ambulance service must provide a different service from what it and its professionals provide.

We believe there must be a concerted effort to make sure that healthcare assistants and their equivalents in community care are properly regulated so that it is understood that when people are providing health services in vulnerable people's homes, there is governance, even from a regulatory body. That is important on the basis of where healthcare is going, and especially in line with Sláintecare.

I thank Mr. Bell. On behalf of the committee, I thank the witnesses for attending. On behalf of the committee, I thank the members that they are representing here today for the work that they do 24 hours a day, seven days a week, and for the commitment that they give to the public health service.

As there is no other business, this meeting of the joint committee is now adjourned until 2.30 p.m. tomorrow, Thursday, 21 November, when we will meet to discuss the proposed closure of the Irish Wheelchair Association's Cuisle accessible holiday resort and respite care centre, Donamon, County Roscommon.

The joint committee adjourned at 1.10 p.m. until 2.30 p.m. on Thursday, 21 November 2019.