Workforce Planning in the Health Sector (Resumed): Discussion with Fórsa

We are now in public session. This may be our last meeting regarding workforce planning. On behalf of the committee, I welcome the representatives from Fórsa: Mr. Éamonn Donnelly, head of the health and welfare division, and Mr. Chris Cully, Ms Catherine Keogh and Mr. Diarmaid Mac a Bhaird from the national health office.

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 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 advise witnesses that any opening statements made to the committee may be published on the committee website after the 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 now invite Mr. Donnelly to make his opening statement.

Mr. Éamonn Donnelly

Fórsa Trade Union warmly welcomes the opportunity to address the Oireachtas committee on the issue of workforce planning in the health sector. The Fórsa delegation today consists of myself, head of health and welfare division, and my staff colleagues at the Fórsa national health office: Mr. Chris Cully, Ms Catherine Keogh and Mr. Diarmaid Mac a Bhaird. Fórsa represents more than 30,000 workers in the public and voluntary health sector across a broad diversity of grades, groups and categories. A large portion of the Fórsa-represented workforce consists of health and social care professionals including physiotherapists, speech and language therapists, occupational therapists, dietitians, podiatrists, psychologists, social workers, social care workers, pharmacists, physicists, audiologists and orthoptists. This list is far from exhaustive. Fórsa also represents a very large cohort of clerical, administrative and management grades.

The concept of workforce planning is widely accepted as planning to place the right number of people with the right skills in the right place at the right time. In the area of healthcare, this should be designed with the sole ambition of providing improved patient outcomes which, in turn, deliver better care and improved quality of life. There are a number of contributing factors which militate against effective healthcare workforce planning and thus bring about a much-reduced capacity to achieve such improved patient outcomes.

To address taking a step back and reactive planning, the Irish health sector has been pieced together over 90 years as a composite of State and voluntary services. It has traditionally been dominated by the acute hospital sector. It is, at best, disjointed. The Irish health service is resourced with highly-competent workers who work honestly and diligently. However, such diligence is often compromised by a systems failure which consequently fails to deliver the required levels of improved patient outcomes. The social and political measurement of the performance of our health services is often based upon the number of patients waiting on hospital trolleys and the length of hospital waiting lists. This crude measurement leads to reactive and pressure-based planning. The cyclical nature of system failure and reactive planning will never bring about an integrated healthcare system which focuses on health promotion and improvement, community-based health intervention and appropriate acute hospital healthcare. Effective workforce planning requires taking a step back and planning to resource the type of health system envisaged in the Sláintecare model.

The current model whereby the annual funding allocation is distributed is not fit for purpose for an effective integrated healthcare system. Inevitably, as overspends arise, a cap-in-hand approach applies in whatever area of healthcare is attracting the most noise at a particular point in time. For example, if a particular controversy arises in mental health, unplanned supplementary resources are provided to ease political pressure. This approach can only lead to turf warfare in funding and, accordingly, we will never get to a point where preventive interventions realise their full value to society. If the fundamental principles of Sláintecare are to be achieved, multiannual budgeting will be a necessity.

The responsibility for recruitment of staff lies with national recruitment services, NRS. NRS is resourced with a cohort of highly-dedicated staff and is, quite simply, operating way beyond its capacity to generate timely staff recruitment. NRS is inhibited by rules surrounding the recruitment licence in addition to the sheer size of the task of recruiting staff on a national basis. Furthermore, the lack of a formal staff mobility policy ensures that there is a residue of workers seeking geographical relocation while at the same time residing on placement panels from which they are offered positions in areas outside of a geographical preference. A mobility policy would greatly ease the pressure on the system in this regard. The crude instrument of a recruitment freeze also introduces layer upon layer of derogation processes which take months to overcome, leaving vital posts remaining vacant or the utilisation of agency workers at a demonstrably higher cost to the State.

There exists a chronic situation with regard to vacant health and social care professional, HSCP, posts. The direct effect of this is felt by patients in need of interventions. The rate of churn of HSCPs is in excess of 7%, second only to hospital consultants. The Sláintecare model references the need for an additional 1,400 HSCPs. This figure does not even take into account the number of alarming and critical gaps in the current structure. As we seek to move to a model which places more emphasis on community-based health intervention which frees up acute hospital services to deliver what is needed in that area, HSCP recruitment cannot simply be an option. Without significant HSCP recruitment, the model simply will not get beyond the starting line. On an ongoing basis, the built-in excess whole-time equivalent planning which applies to cover maternity and parental leave in nursing should apply to HSCPs as 80% of HSCP staff are female. Additionally, there should be automatic progression from basic to senior grade therapist after five years' practice, subject to competency validation. This would be of great benefit to isolated rural areas as a therapist who has built up an intervention-patient relationship would not need to move from that rural area to attain career progression. There is also a clear need for a HSCP advocate in the Department of Health, which would operate in its own stream and not within a nursing reporting arrangement.

With regard to community healthcare organisation, CHO, primary care networks, Fórsa has given its support and co-operation to the establishment of nine learning sites, one per existing CHO, in the area of primary care. The establishment of the nine learning sites brings about significant change in the way HSCPs currently work. In order for the learning sites to succeed, they must be adequately staffed. If the Minister for Health’s proposal to create six integrated care organisations to replace the current configuration of nine CHOs and seven hospital groups comes about, it is likely that the network model trialled in the nine learning sites will continue. It is therefore imperative that, if the nine sites are deemed to be a success with adequate staffing, growth into more geographical networks are adequately staffed in the same way.

On clerical, administrative and managerial grades, there is an accepted lazy narrative in social and political circles that the health sector is awash with administrative staff and managers. This is neither true nor fair. In fact, the proportional number of administrative staff in the Irish health sector is lower than in many international comparators. Clerical staff are charged with tasks such as paying the wages of doctors and nurses and are often the first point of contact for members of the public. The acceptance of the narrative referenced above is demoralising for this group of workers, many of whom bore the biggest brunt of the cull in staff numbers during the financial crisis, at great personal cost.

Health sector managers are vilified for lack of performance and accountability whereas, in reality, the system is failing due to ad hoc planning. Fórsa is supportive of a performance system for senior managers as such a system would at least protect senior managers from a generic allegation which is made without any real basis. It would be hard to find, for example, many workers in the health system with as onerous a responsibility as that borne by heads of social care in the CHO structure. In fact, the dangerous level of risk borne by these workers has been independently verified. Recently there was an announcement in the national media, without any reference to this union, of the need to whittle down the number of managers in the system. This assumption is made without any meaningful analysis. In fact, this approach was tried before, resulting in a massive deficit of corporate and intellectual knowledge which, in turn, generated a subsequent re-establishment of previous numbers.

Fórsa once again thanks the committee for its attention and time. We will endeavour to answer any questions members may have either today or in further correspondence.

I thank Mr. Donnelly for his presentation and I thank the delegation for its time and for coming here today. These hearings on workforce planning were kicked off by the committee's serious concern about the lack of workforce planning for nurses and midwives, consultants, and many of the other healthcare professionals whom Fórsa represent. Mr. Donnelly has gone through some areas. I will ask him a broad question to begin with. For the sake of the workers Fórsa represents and the services they provide, we need to see proper multiannual workforce planning. We should know how many people we need at particular grades, with particular skill sets, and in different services in different parts of the country. We should be accounting for maternity leave, training, and mobility around the country. We should be treating our staff very well so that our retention rates would be high. The HSE should be a fantastic place to work because, first and foremost, that would provide the best outcomes for patients and, secondly but also extremely importantly, because everyone should a have decent workplace. That is the ideal. Some countries are good at it and some are not. Some parts of the public sector are good at it and some are not.

Some companies are good at it and some are not. With respect to the people Fórsa represents and the services they provide, can Mr. Donnelly broadly indicate how it is going? He has addressed some specific issues. Are there parts of the HSE or sections 38 and 39 organisations to which he could point and say that group is really good? He need not name particular groups but are there parts of the HSE or some of those organisations that are particularly bad, be it by geography or service?

Mr. Éamonn Donnelly

First, I could not state with any real confidence there is a stand-out part of the public service which excels at projected workforce planning. We cannot separate multi-annual workforce planning from multi-annual budgeting. If one was a systems person and thought there would be a reconfiguration of the health service and that the HSE would be very much streamlined downwards through a move to integrated care organisations that would have autonomy, and if one was workforce planning on an multi-annual basis, one would need workforce planning for that event. We are currently in a big state of flux. If everything was to stay the same, which we know it will not because it cannot, one might get away with the cap in hand approach year on year. However, if we were serious about, for example, relieving the pressure on acute hospital healthcare and were to allow acute hospitals to deliver acute healthcare and to have proper interventions in the community, we would need to have a multi-annual approach both from a budgetary point of view and a workforce planning point of view.

From a workforce planning perspective, Mr. Donnelly is not seeing that anywhere in the system.

Mr. Éamonn Donnelly

No. What we are seeing - this is not a criticism but an observation because we tend to work with what we have - is the machine can only plan one year at a time because we do not know what Sláintecare will bring about, and that is more of a inhibitor than a motivator.

Are there parts of it that are under particular pressure or that are particularly bad at workforce planning?

Mr. Éamonn Donnelly

I would say that primary care is not great. When we talk about the nine learning sites, an anecdotal comment often made to us by our health and social care professional members is that those in management will staff up the nine learning sites to adequate levels to make them work, with the inference being they will then leave everything else as it is and the staff will be under the usual pressure. If that is the anecdotal evidence, I would say primary care is probably under some pressure on workforce planning.

I was delighted Mr. Donnelly mentioned recruitment. I talk to various employers within the healthcare system around the country, be it a hospice or whatever the service provider is. I had a conversation with an employer in one provider that was considering moving from being a section 39 to a section 38 organisation and they were excited about that because of the cuts that had been applied to staff that had not been reversed for section 39 organisations. They thought they might get some breathing space if they were to become a section 38 organisation but they were warned about that by others organisations and told they should be careful because if they were to do that they would fall under the dreaded control of the national recruitment service which they were told was a nightmare as it can take a year and a half to hire anybody. First, it is a problem for the organisation in that it cannot get the people it needs when it needs them and, second, most people who have options, who are the type of people an organisation would want to hire, do not hang around for a year and a half. They will move on and in many cases they will move to Sydney, Boston or wherever it may be. I was delighted to hear Mr. Donnelly raise the issue of recruitment and he referenced the licence and alluded to capacity. What the hell is the going on with the recruitment service that it is taking 18 months to recruit people? Is it that it has a quarter of the staff its need? It is buried in red tape that is not suitable and should not be there? What is going on?

Mr. Éamonn Donnelly

There are a number of factors. First, the Deputy referenced the section 39 agencies. It is Fórsa's view that the funding model for section 39 agencies should be in line with our caring at what cost policy, a robust State funding model. There might be some advantages in an agency having autonomy but there are many disadvantages in having to go cap in hand to its funders every year to see if it can still provide a service.

The national recruitment service was created in Manorhamilton in Leitrim as part of a Government agenda to bring work to isolated rural areas; we are supportive of that. It is an urban town in a very rural country. Manorhamilton has a very good cohort of staff but the service is only operating at half capacity. It is Fórsa's view that clerical and administrative recruitment should be taken out of Manorhamilton and put into the community. Clerical and administrative workers have a generic skill set and are easier than other staff to move around. The service received 21,000 applications for the basic grade of clerical officer. Nobody in the Manorhamilton office will be able to handle that. If appointments were dedicated to, say, nursing, midwifery and health and social care professional recruitment, that would ease the pressure on Manorhamilton somewhat. In addition, when an invisible moratorium, which effectively is a moratorium, is introduced and one has to jump through layer upon layer of derogation, that makes the recruitment job for national recruitment service nigh on impossible. As the Deputy succinctly put it, people will not hang around for a nine-month derogation to pick up a post, particularly those who are coming out of college who have other options. The service in Manorhamilton has been hard done by. With respect to the recruitment licence, if there is a challenge to something we do we can focus on what is the material cause and effect of the challenge and sometimes we concentrate on what might be the result of a challenge rather than 99% of the business which involves running a competition and doing that without getting overly hung-up on every aspect of a recruitment licence.

The issues are staffing, red tape, embargoes-----

Mr. Éamonn Donnelly

Yes.

-----and multiple layers of derogation.

Mr. Éamonn Donnelly

The conditions are set down by the Public Appointments Service.

I wish to ask Mr. Donnelly an entirely different question concerning trust. I have worked in healthcare systems abroad and none of them is perfect but the ones that work best for patients have a reasonable level of trust between the employer and the workers. It is never perfect but there is a pride in being in the workforce and a general sense that the employer has the worker's back most of the time. One aspect that strikes me about the HSE, the Irish public health care system, is that it is opposite of that. There is a total lack of trust and a breakdown in the relationship between the employer - I do not mean individual local employers but the HSE, the ultimate paymaster - and front-line workers. It seems to be chronic or it may be that all the disgruntled people talk to me. We seem to be an outlier and it is for doctors, nurses, midwives, physiotherapists, primary care workers, health and social care professions. It seems to be across the system. Is there something we can do from the State’s perspective to rebuild trust so that the workers Fórsa represents feel valued, respected and listened to and can have a great sense of pride that they work for Ireland’s public healthcare system and, ultimately, can have a bit of trust that their organisation has their back?

Mr. Éamonn Donnelly

I am not sure the problem is as easily analysed as saying there is a complete breakdown of trust. I was at a meeting yesterday when I met a person who said when it comes down to it the HSE is a great employer.

Mr. Éamonn Donnelly

I do not hear that often, to be honest, but there was that sense. One can never have trust, particularly between a front-line workforce and a corporate employer, if the way we do things is that every time there is a controversy or a scandal we try to generate a blame culture and react to that then by putting in place resources.

The senior manager who may want to consult everybody in the world is told to go out and deliver something to alleviate this controversy or scandal. People then come to us to tell us what is happening to them. There is no shared vision. In my 20 years as a union official Sláintecare is the first attempt to get on the same page about a healthcare system. In order to generate the trust Deputy Donnelly talks about, we will need to work on a vision and get away from this turf warfare of one person being more important than someone else. The patient is the important aspect in all this.

I do not think it is a lost cause. We will struggle so long as we continue to react to scandals and controversy, as the dominant dynamo.

I do not think any of us thinks it is a lost cause; otherwise we would not be here. We are all hopeless optimists.

Ms Catherine Keogh

On the issue of trust and wanting to be positive, a key thing for our health and social care professionals is to be listened to and valued for the work they do. There is a great pilot in Connolly Hospital where advanced practitioner physiotherapists are seeing people on the orthopaedic surgeon waiting list. This values the work the physiotherapist does and cuts waiting lists, and, if we are simplistic about it, at a lower cost to the Exchequer, which is good. Our health and social care professionals will say they do not have an advocate in the Department of Health. In talking about trust and respect, that is one key thing we seek.

We have talked about Sláintecare and we need to look at the citizen at the centre of this. Obesity is a problem, but we do not have enough dieticians in the community to deal with this early. Every bit should be joined up. We represent home help co-ordinators, who are considered managers in the HSE census figures of managers. They are grade 6 on a clerical-administrative scale; that is just the pay relationship. One home help co-ordinator might manage 106 home help care assistants going into 600 homes. There is great value, but if these grades had a strong advocate in the Department of Health - we have been pushing to reinstate this - it would go a long way to rebuilding the trust the Deputy mentioned.

I will ask my final question and then slip in one more at the same time before the Chairman notices.

On the health and social care professions, we have a long waiting list across the board. It is really chronic with many children and adults suffering. We need to hire more people, hold on to the people we have and get the most out of them in doing the job they want and know how to do. What would the witnesses ask the committee to do or ask the Government to do that would make it easier to hold on to these people? Is it flexibility, maternity care or something else? What would be the top things we could ask the HSE to do to make their lives better?

I will slip in the following question before the Chairman notices. This morning's newspapers have reported the Secretary General at the Department of Public Expenditure and Reform speaking about the lack of ability to sanction civil servants for low performance. It is a real problem in the Civil Service. Do his comments also apply to the healthcare system?

Mr. Éamonn Donnelly

There is a fairly complex answer to those questions. I will try my best. Before I came back to the health sector in the trade union movement, I was actually in the Civil Service. They spend a disproportionate amount of time trying to analyse performance. Do I believe there should be performance accountability in the Civil Service? Absolutely, yes. We are on record as the only trade union to offer ourselves up for that. Every St. Stephen's Day I hear on the radio that there are 672 people on trolleys and straightaway the hospital manager is blamed. How can a hospital manager in that capacity stop 672 people being on trolleys when it is a systems failure? I would rather for that hospital manager to be protected by a performance management and accountability system; it would make more sense. That should apply to workers.

It is quite simple with health and social care professionals. At the turn of this century in 2000 there was no career structure whatsoever because a physiotherapist was a physiotherapist and an occupational therapist was an occupational therapist. Speech and language therapy barely existed. When people had strokes they were almost losses to society. The world has changed and we have the skills available. As a result of our co-operation with the new community health structures, we are in the process of reviewing the career pathway for health and social care professionals.

We should not underestimate how important it would be to see automatic progression from basic rate to senior grade therapist because it touches on some of the things the Deputy has mentioned. It must be validated that the therapist is competent so it is linked to performance. I will use the example of Leitrim and Longford again. Someone there may have developed a four or five-year relationship or connection with patients. All of a sudden in order to access a senior grade he or she probably has to go to Sligo to follow where the population is to get on a panel and so on.

We are trying to convince our health and social care professionals, apart from the value to the patient of clinical specialisms, advanced practitioning, that maybe at some stage in their career they might need to say, "I'm going to actually use my expertise and put down my tools. I'm actually going to populate posts that are responsible for service planning and delivery. All this stuff you talk about in terms of how you view a service, I'm going to bring my clinical expertise to this." We then need the creation of directorates for the various professions. If we had a vision set out like that, remaining on as a health and social care professional in this country would be a more attractive option. Many of our people look the British National Health Service, NHS. It is not quite like nurses and doctors where potential hospital consultants go to Australia; our people tend to go to Britain. We could stem that tide very quickly if we had a pathway mapped for them.

I welcome the witnesses and thank them for their submission. I agree on the need for managers to direct; we need a command system. I feel that the command system has failed but I cannot put my finger on the reason for that. For instance, if people are on trolleys in a hospital I immediately ask why they are there. Is the hospital the appropriate place for them in the first instance? Should there have been an interruption? There is no sense in being vague about it and saying that primary care rests with the primary care area and they can get an equal or better service at home. Unfortunately, it does not work that way.

To what extent is the healthcare system capable of dealing with the daily influx of patients into our hospitals? We, as policymakers, were told for years that we did not need more hospital beds. We need fewer hospital beds because the patients would be dealt with on a turnaround of two or three hours. It did not happen. It is not happening, nor is it likely to happen.

We now need somebody or some system to decide to intervene as soon as the patient arrives at the hospital in an ambulance and not to leave the ambulance outside the door with the engine running for three, four, five or ten hours as the case may be, and with five or six ambulances all lined up at the same time. This is a total waste of resources. It is a risk to the patient and it is unacceptable. How can we intervene to stop that? I believe we need to find out where the logjam in the system lies. What is stopping the first patient who arrives in the hospital that morning from being processed instantly?

I know people will say that they have been triaged and they are now waiting for a bed. This is also a total contradiction to what we were told years ago when we were told there was no need for beds and yet strangely we now need 3,000 beds.

I do not know if we have the information readily available to us but we would need it at this level. We would need to know what is going on in the various hospitals throughout the country, what is holding up the queue in the morning time, and what is forcing patients to be accommodated in corridors, in waiting areas and in generally unsupervised situations in the hospitals. It is unfair to the patient, dangerous from a patient's point of view, unfair to the system and unfair to the staff.

Mr. Éamonn Donnelly

There are many observations in that. First, about managers, I want to be clear that managers form less than 1.5% of the entire health workforce. The percentage is low by comparison with international comparators. I was talking about the poor individual soul who is charged with the entire responsibility of running a hospital such as Portlaoise who, as soon as there is a logjam, should be held to account, and that would will never work.

Deputy Durkan is absolutely right. Bed capacity was always an issue. I do not know how it was decided that bed capacity should be reduced. The question is who is in the beds. I have personal experience of my own mother being in one for four months - when, quite clearly, what she needed was a step-down facility with a hoist to deal with her incapacity to get herself up in the morning - in a big hospital in Drogheda where there were trolleys all over the place. Definitely bed capacity is one issue.

The number of people who land in accident and emergency is a problem. I would say it is at best probably more than it should be. I refer to the lack of primary care interventions and the referral system as well. I do not know, if one is ever to get Sláintecare off the ground, whether we will ever tackle the general practitioner, GP, model but the entire referral system creates logjams in the hospital system because we have grown up over 90 years with a hospital-centric healthcare system and everything lands there. Until we get away from that, one will have this. One can increase the number of beds. If one increases the number of beds by 3,000 one will have probably 1,500 fewer trolleys but one will not solve the problem.

The next issue is the staffing levels and the configuration of the staff. I came across a situation recently where there was only one doctor available in a hospital. I do not know who decided that. I do not know how that came about but it should not happen. If that is the way it is, there is a reason for it, we need to know what is the reason for it and we need to do something about it. It is not a complex issue. It is a simple issue.

If there were 80 patients waiting in a hospital area on Monday of last week, the presumption is that there would be a similar number next week and the week after unless something is done about it. This is the problem. We spend our time talking about this and going over and over it which is detrimental to those working in the service but we do not seem to identify the cause of the problem, and the cause of the problem has to be addressed.

From my own observation, we went through a hiatus in this country over the past ten years. We went from a situation where almost 0.5 million people left the country and services were closed down due to very serious financial issues - there was no way around that and we were told what we had to do and we got to do it - to one where those people have come back with more. If one tours around the various industrial hotspots of this city and the country in general and looks at the volume of heavy traffic on the roads in the morning about which we complain, the answer to the question as to where are all the heavy trucks coming from and what are they doing is that they are doing their business. They are producing for home consumption or for export, whatever the case may be. It naturally follows that the health service must compete and cater for a much bigger market than it did 11 or 12 years ago. If we do not do that and we do not identify the most immediate issues upfront, we are missing out and we will talk about it forever.

I should say that I am a strong advocate of community care. I was a member of a health board in the past. I believe it was a better system because the inspiration for the response came from the ground up where the GPs were involved, where the pharmacists were involved, where the nurses where involved and where the psychiatric system was involved. Everybody was involved in a consultative capacity at the coalface. That is all gone and it is now centralised. The theory is that centralisation is a more effective and efficient method for delivering services. It is not.

This is the last point I want to make on that. I refer to recruitment and attraction to the system. I see no reason we cannot have temporary appointments instead of agency staff. The temporary appointment - while waiting for the permanent appointment to be approved - could fill the space, provide the service and deliver the service to the public which is what we are supposed to do. We are not an employment agency. We are deliverers of service. We require employers to deliver the service. Unless it becomes policy to utilise the temporary appointment, we are at nothing. I am not asking Mr. Donnelly to make a political statement on this. That is my view on it and I would like to hear the counter view.

Mr. Éamonn Donnelly

I will share the Deputy's view on that. While I am a part-time distant commentator on healthcare because of my field in terms of the categories of workers I represent, I can tell the Deputy there is no reason in the world one could not have temporary workers instead of agency workers. First, it is cheaper. Second, they do not accrue permanent employment rights for four years. If one cannot get it right in four years, one is struggling.

I agree that a centralised system has not worked out. We would be great advocates of the six regional authorities with a scaled-down HSE so long as those authorities do not become hospital dominated. If they become hospital dominated, what will happen is one will have the same problem in six different areas. It must be integrated. It has to be.

The committee will hear a bit of honesty here. I do not know how many doctors in the system coming through university are not getting jobs but it would seem that the supply system is not great either.

Ms Chris Cully

I want to contribute on the issue of temporary staff and our experience of the usage of agency staff. We believe that such staff should be temporary direct employees of the health service. Part of the reason there are quite a number of staff being employed from agencies is because of the slow process of approving posts for filling and the moratorium that is not a moratorium but is really a moratorium. We have experience of seeking for a post to be filled, for example, for a maternity cover, and it taking nine months to get approval. If one has a front-line situation where one needs to have the post filled, if it will take nine months what one will do in the meantime is take in an agency person. That is what the people on the ground are experiencing. They are trying to fill the holes because of slow systems that they are a victim of when they are trying to run a front-line service.

I will allow Deputy Durkan just one more question and we will move to his colleague.

The Chairman will be glad to know I have only one more question anyway. I am aware the Chairman is anxious. I am also anxious, I can assure him, to get parity with everybody in this business.

The point I want to make is this. There is a proportionality issue as well. If we employ 10,000 new staff over a period of time, there must be a proportional number of those proposed for the coalface as well as the administration level. What the proportions are varies from one discipline to another but it is important to recognise that there is no use employing 10,000 administrators and no medical staff.

On the slowness of the appointments, I both accept and do not accept it. On this one, I am for and against. I honestly believe that it is simple to figure out, first, whether the person applying for a temporary post is qualified for the post. Second, while the rest of the appointment process is laboriously being entered into, they can be at work notwithstanding the fact that they may or may not be still a candidate for the position.

They may have changed their mind and gone elsewhere. The longer a person is kept waiting, the more expensive the system becomes. We need to address that as a matter of urgency. To conclude, there is no sense in having 100,000 administrators if their numbers are out of proportion to those at the coalface. It is not going to work. It cannot work. We can have all the people in the world telling us what should be done and when, but there must be operatives with the required expertise at the coalface, putting their fingers on the various sensitive areas to identify how the flow can be best assisted. I am not sure that we have done that. We have not done that for a long time. We need those people to move the queue along. The critics will say that I am another politician trying to jump the queue. I do not want to jump the queue at all. I want the queue to move along, for God's sake. How long must we wait before we all realise that?

Mr. Éamonn Donnelly

I would like to respond to that if I may. At no stage are we suggesting that there should be a disproportionate number of administrators. We find that narrative quite demoralising. The proportion of administrators in the entire health service is about 10%. That is comparatively low. We are not suggesting that there should be any more. We are suggesting that we should be valued for what we do. If a patient presents himself or herself to cardiology, somebody has to hand the consultant the chart and make sure that chart is accurate and reflects the proper medical histology. Is that or is that not a part of the coalface? It is classified as administration. Ms Keogh already referenced home help co-ordinators. The net produce of one home help co-ordinator affects 600 homes. They are counted as administrators. The people who pay the wages of doctors and nurses are administrators. We are not suggesting that there should be a disproportionate number. We are not looking for more administrators. We are simply saying that we find this simple narrative tiresome. An assumption is made, without any analysis, that the administrative cohort of 10% is somehow disproportionate and is inhibiting the health system from doing what it should be doing. Deputy Durkan is dead right to say that purpose is putting front-line workers at the coalface.

I thank the witnesses for their presentation and the work they are doing. It is a difficult area. There are so many different areas in the health service, including doctors, nurses, care assistants, cleaners, porters and administrators. It is complex. One problem I see with the health service is that everyone is fighting their own battle. There is a huge problem. There is no team effort. I have come across a few cases where nurses were not given support when there was an adverse outcome. I was really disappointed when somebody recently came before the committee and spoke about the lack of support offered when there is an adverse outcome. That applies to administrative people, nursing staff and doctors. That puts people on the defensive for the rest of their lives. Their attitude is shaped by the experience of not getting support when they needed it. I am really worried about that in the health service. That has happened time and time again to people I know who work in the health service. We need to work on that.

This is not a criticism; it is just an observation. Since December 2014 the number of staff in the HSE has increased to 135,000. It has increased by 16,000 full-time staff. Meanwhile there is a perception out there that an embargo is in place and no new staff are being taken on. It is unfortunate that this impression has taken hold among the public as if nothing has been done. Actually 16,000 additional full-time staff have been taken on. That is a huge increase in staff numbers. However, during that five-year period there does not appear to have been a plan outlining which crucial areas needed more employees. It appears to have been a case of who shouted the loudest. That is my worry.

I will come back to the issue of administrative staff. This is not a criticism, because I know a lot of staff were laid off. The actual number of administrative and management staff has gone from 15,030 in December 2014 to 18,600 in March 2019, the last time for which I have figures. That is a 24% increase. I have no problem with that. My problem is that this was disproportionate. There was an overall increase of 17% in the number of HSE staff but administration and management increased by 24%. I have a problem with the fact that the number of public health nurses only increased by 3.7%. It appears that no-one was fighting their corner. Public health nurses play a very important part.

This is not a criticism of administration and management. However, it appears there was no plan which took account of numbers and of needs for the next 12 months or two years and determined how to use the budget. That is one of my concerns. I do not know the witnesses' views on that. It does not appear to have been a priority. The public perception is that there are fewer doctors and nurses but that is not the case. In fact there are more doctors. Comparing the current figures to those of 2009 shows that we have gone from 7,000 doctors in the HSE to 9,000. That includes consultants, the number of which has risen from 2,100 to more than 3,100. The number of junior doctors has also increased by more than 1,000. The number of care assistants has increased, which is a huge advantage because they provide a very good service. That number has increased by 2,000. I am still concerned. No-one is saying at the start of the year that we need an extra 500 care assistants. The increase seems to have happened in bits and pieces around the country. From their own dealings on this issue, what are the witnesses' observations? Some 16,000 additional staff is a huge number to take on without any overall corporate plan. Certainly if a private enterprise decided to take on 16,000 people there would be a clear two-year, three-year, four-year or five-year plan. That does not appear to have been in place. We need to set clear targets when planning. Let us talk about the targets first and then talk about how to resource them. We seem to be deciding to hire people on the basis of the money we have for a certain year. We need to do that far better than we have done. I do not know what the witnesses' observations on that are.

Mr. Éamonn Donnelly

I have several observations. Members may have read in The Sunday Business Post the week before last about the director general's announcement of a targeted redundancy for managers. That throws everything into the mix. As an advocate of workforce planning I say that if that is what is required, that is what we will deal with. However, there must be some analysis of whether this is the right fit before we make sweeping statements. This is what I keep saying.

If members wish to consider this after our session I would draw their attention to the HSE staff census in 2009, when we were really bankrupt. The reason there has been a 23% or 24% increase in the number of managers is that those roles faced the biggest cull at that time. The proportionate increase is from a much lower base. Moreover, a redundancy package was part of that cull. That one crude instrument removed a pile of corporate knowledge. Then people wondered where the knowledge had gone. The result was that people were rehired on a consultancy basis into positions that had been deemed fit for redundancy. This caused a bigger spend. That is not right. I am all for embracing the problem. If people think we are awash with managers, let us analyse it and have an adult conversation about it. We cannot proceed on the mere statement that the number has increased by 24%. There is a deeper-rooted history to that.

Secondly, if the Senator is talking about increasing the workforce I agree with him. The fact of the matter, however, is that we have a bigger population. It is getting older.

That is why we need more planning.

Mr. Éamonn Donnelly

People are a bit sick now but they are not as sick as they used to be in the 1970s when people died in their 60s but nobody knew the cause. People are now presenting with conditions that require more care so obviously one will have to consider an increase in staff numbers, and in the care industry with which I agree. Again, if one increased the HSE's staff headcount one might be in a different position. If one had a regionally accountable health service that delivered services at the heart of the community it would relieve the pressure on acute hospital care. Such a health service might be a better fit with multiannual budgeting and workforce planning, which is where we started the conversation.

Ms Chris Cully

The description of what comes under the heading of "administrative" is misleading. When one considers the numbers, administrative is not strictly administrative and is just the way people's jobs are described in the statistics. For example, assessment officers assess children for disability, under the Disability Act, but the officers are categorised as administrative staff. One cannot say numbers have increased by 20% or whatever because there are people who do very serious and important jobs, such as assessment officers, but are paid on an administrative pay scale and, therefore, fit into the administrative scheme of things. There are other categories of staff just like that.

At no stage in the past five years have we seen a plan that outlined at the start of a year that "X" number of people were needed in a particular area by the end of the year. Local authorities present a five-year plan that outlines what they want to develop but that is not done in the health service. We have Sláintecare but we still need an overall plan. Mr. Donnelly made a valid point about many people ending up in accident and emergency units who should not be there at all. We need to consider how to deal with the issue. There are super clinics in other countries that offer a range of services. The minor injuries unit in St. Mary's Health Campus in Cork works very effectively and takes approximately 8,500 people out of the accident and emergency departments in the Mercy University Hospital and Cork University Hospital. Maybe we should consider a similar scene for around the country. Well over 75% of the people who present at accident and emergency units do not require a hospital stay. Yes, they require some care and treatment but they do not need a hospital bed. We need to work out how to move those people away from accident and emergency units into a proper care provision without clogging up the hospital system.

Forward planning seems to have disappeared and, by way of explanation, I will outline one of my big criticisms of the current recruitment of consultants. In the past the old health boards were aware that a consultant would retire in a particular year and 12 months before that a recruitment process would be put in place. Now we seem to wait until the person retires, then a locum is selected to cover for the consultant and only then the recruitment process is undertaken. Do witnesses know from their own experiences any way that process can be changed? Nurses are recruited in similar fashion. No one thinks outside the box when it comes to the recruitment and retention of staff in a whole range of areas.

Mr. Éamonn Donnelly

Frankly, with the way things are at the moment, if we lose a therapist it could take nine months to replace him or her. Let us say it is a head of discipline or a therapy manager who manages a service. He or she could be replaced on a temporary basis but somewhere along that line, and probably most likely at a basic grade level so it is at the level of direct intervention with a patient, one will lose the person.

The Senator made interesting comments about consultants. If one is about Sláintecare then it is not just about knowing a consultant is retiring and replacing him or her. One must also tackle the public-private mix in hospitals. There are all sorts of other associated arguments that we are familiar with.

I will outline my own view, and I am probably making the fatal mistake of thinking on my feet. One needs to know what one is planning for. If we are planning for all of the things that appear in Sláintecare I would say there a number of historical and cultural inhibitors that would stop us from getting all of that journey. It would not be too wild to imagine a system of six integrated care organisations or redefined health boards that do not have a political layer. We could start planning for that. I do not think that is too big an ask because it is necessary whether Sláintecare, in its entirety, happens.

I will outline one of the things that we must plan for. There are 637,000 people over 65 years of year now and in ten years time the number will have increased to 1 million people.

Mr. Éamonn Donnelly

Yes.

Ten years will pass very quickly so we need to start planning now. The number of people who are over 85 years will also quadruple in a decade so additional services must be put in place. We certainly need to start planning for that situation. It is not just a matter of writing this in black and white; it is about implementing a plan year by year between now and 2030, which is a serious challenge. The demographic is not going to change and it will put huge demands on the health service.

Ms Catherine Keogh

I wish to declare that I have clogged up an accident and emergency unit on two occasions. I broke my arm in Athlone and ended up in Roscommon County Hospital on a Friday afternoon where I received a brilliant service. I was in denial about having a broken arm but it turns out that I am no good at self-diagnosis after an X-ray proved that it was broken. I was working in Athlone that day so I returned to work after a plaster of Paris was applied to my arm and before I left the hospital I was given a note to go to Beaumont Hospital as I live in Dublin. When I went to Beaumont Hospital I had to queue again but this time in its accident and emergency department. Therefore, I visited two accident and emergency units with one broken arm. Before I left the county hospital I was given a CD that contained copies of my X-ray. When I presented my CD to the staff in Beaumont Hospital a couple of days later they could not read the CD so they had to cut my plaster and perform another X-ray. My arm was X-rayed, a diagnosis made and plaster of Paris reapplied but I needlessly clogged up the unit in Beaumont Hospital for four or five hours.

Earlier my colleague, Ms Cully, referred to the definition of administrative grades. In terms of administrative grades, planning, joined-up thinking and integrated services, my experience of having a broken arm showed there is no proper IT system. Within those admininstrative management figures are IT people. Again, the IT personnel are highly qualified and perform a highly responsible job. We agree with the Senator that planning is needed but throwing numbers into the system will not suffice and we stress that a targeted approach is needed.

Ms Catherine Keogh

Yes, there should be an increase in admininstration. However, there must be an IT system that ensures when a patient moves from one hospital to another that he or she does not need, as in my case, to have to endure the reapplication of a plaster of Paris. I am a hardy middle-aged woman but it would be unacceptable if an elderly person had to wait in an accident and emergency unit for a second time and, being practical, it is not economically sensible. Fórsa strongly advocates local and regional thinking. That is why Fórsa got so heavily involved with the learning sites because we advocate bringing things back to the local level and empowering decision-makers. We were not being facetious when we said there needs to be more targeted administration.

Ms Catherine Keogh

I shall say one more thing on behalf of our administrative cohort because we have said a lot on behalf of our health and social care professionals. There needs to be adequate administrative numbers because nurses need to nurse, doctors need to diagnose, physiotherapists need to be doing what I said they are doing in Connolly Hospital and take people off the lists of surgeons, occupational therapists or OTs need to get people back to their homes, and dieticians need to help people learn how to eat again after suffering a stroke.

A strong original administration team, including secretarial support, is needed as well. We have no shame in saying that this is a vital component of the health service.

Mr. Éamonn Donnelly

If there is a hang-up about increasing administrative staff, such staff can be redirected. The administrative cohort of staff, unlike any other cohort of staff, has a generic skill set. Such staff are moveable.

Perhaps Sláintecare, which has been mentioned on a number of occasions, should be reconsidered as a forward planning report along the lines of A Vision for Change. One of Sláintecare's main recommendations was that there should be a move away from a hospital-centric model to a model that is centred on community and social care and where people are looked after in the community. It is hoped that this will prevent unnecessary attendances in hospital, which should be kept for complex and acute care. The witnesses represent physiotherapists, speech and language therapists, occupational therapists, dieticians, podiatrists, psychologists and social workers, all of whom are key members of community care teams. Unfortunately, many of our community care teams are missing many of these important specialists. This inhibits the delivery of care in the community. Is there a lack of such specialists applying for jobs? Is the moratorium inhibiting the recruitment of people? Is the complex nature of recruitment the problem? Many teams are deficient.

Mr. Éamonn Donnelly

If we keep going as we are, the first part of the Chairman's analysis will prove to be correct. In other words, we will not have enough people trying to come through the system because it will not be attractive anymore. At the moment, the problem is more one of hiring and planning than one of availability. The people are there, but they will not always be there if this problem is not captured. We may have to look at graduate training models and stuff like that.

I would like to speak about the learning side of primary care. There are nine areas at the moment. If it works, it will be fit for conversion into six. It is envisaged that all of these people will work in a co-ordinated way on the teams in question. That would be a massive benefit for patients. That is why we are so invested in it.

Is there a difficulty in retaining staff who are in place, particularly in section 39 organisations? Staff who are trained up and skilled often move to the private sector or into permanent jobs in the HSE. Is this a difficulty that has been encountered?

Mr. Éamonn Donnelly

It is a difficulty. If someone who is working in an agency that does not have a pension scheme receives an offer of a public service job that does have a pension, he or she is likely to take it up. Most people, particularly those with families, would make such a move. It is a problem. The whole section 39 model is wrong. It cannot continue to function as it is at present.

I ask Mr. Donnelly to expand on that. When representatives of section 39 organisations have been at meetings of this committee, they have said that their big problems are funding and staff retention.

Mr. Éamonn Donnelly

I can see the case that they make for their autonomy to provide services away from a model that we have all been complaining about this morning. I am not saying that they are wrong when they make that case. I do not know whether the Chairman has seen our Caring at Cost document, which we intend to relaunch. The document makes it clear that the funding model is wrong because of what it does not allow. If we decide to allow providers to provide on behalf of the State, we must consolidate their position within the funding model.

In Mr. Donnelly's experience, are staff hired as important members of these teams? Are they given protected time for education and career progression? We often hear complaints that people who want to develop their skills and experience are not given the time or opportunity to do so.

Mr. Éamonn Donnelly

Continuing professional development in the health and social care area is nothing short of atrocious by comparison with other professions. That is an honest answer to a straight question.

Does Mr. Donnelly think that leads to people moving on to different areas of the health system where they would be more valued?

Mr. Éamonn Donnelly

They would certainly feel more valued. It certainly grinds people down when they see that they cannot do continuing professional development because there are three vacancies here and two vacancies there. In any event, there is no real hard and fast policy for continuing professional development in the profession. That is just not sustainable.

Ms Chris Cully

Many health and social care professionals are regulated by CORU and are required to engage in continuing professional development. They do that completely at their own cost. Other professions within the health service, which are not represented by this union, have better access to supports from their employer. They are given time off and financial support to engage in continuing professional development.

We hear from health professionals that, in many cases, pay is not the principal reason for deciding to move to Australia, New Zealand, Canada or the UK. They want to be valued, to have a work-life balance, to have proper career progression and to be valued within the health service. It is not purely about pay. Is that taken into account when recruitment takes place? I know that this question has been answered, more or less. I hear many people saying that they got a job, but they were not valued or taken into account when decisions on planning were being made. Front-line staff are rarely consulted on how services should be planned.

Ms Chris Cully

That goes back to a point we made earlier in our submission. Health and social care professionals would feel more valued if they were involved in the planning and delivery of health services. They have a lot to contribute. They feel they are not listened to when services are being developed. That is a key thing. They should be at the centre of service planning and delivery at all levels of the Department of Health and the HSE, etc.

Mr. Éamonn Donnelly

We do not lose 93%. We lose 7%, which is high. The proximity of the UK system is a particular attraction for health and social care professionals. It is a community-based model. That is where the UK system excels.

Ms Catherine Keogh

The proof is in the pudding. With the exception of the hospital consultant grade, our grades have the highest rate of turnover. This can be attributed to the fact that the community-based model in the UK places a much stronger emphasis on multidisciplinary and interdisciplinary working. The staff in the UK feel more valued. If we could introduce a proper system of mobility that would allow people to make progress in their careers in the geographical locations that suit them, we would see better career progression. If this was accompanied by continuing professional development and the presence of an advocate in the Department of Health, staff would buy into the greater experience rather than focusing on the pay element.

I will ask one more question before I bring in Deputy Neville. Do the witnesses feel that their opinions are valued when it comes to workforce planning? Are they consulted on this issue?

Ms Chris Cully

No.

Mr. Éamonn Donnelly

No, because there is no joined-up workforce planning. There was a time when we would ask for a workforce planning sheet and be denied access to it. That is about the level we are at. When we look at the pressures on the health system, it is clear that a multi-annual budgeting and workforce planning arrangement is needed. People in the union movement do not need to be workforce planners. That is not our function. The function of the people who plan the service is to act as workforce planners. When the union is asked to give a commentary on some of the pressures on the health system, it needs to say that multi-annual workforce planning, based on where we want the health service to be four or five years from now, is a must.

I thank Mr. Donnelly and call Deputy Neville.

I thank the Chairman for allowing me to contribute. I will ask one or two questions in respect of the recruitment of mental health services staff. I may have spoken to our guests at a meeting of the Joint Committee on Children and Youth Affairs. Has there been any change in the recruitment process relating to mental health services in the past 12 to 18 months in the context of timelines, etc.? Has there been any change regarding the flexibility of panels?

On Tusla, when he appeared before the Joint Committee on Children and Youth Affairs, Bernard Gloster referred to trying to appoint people to permanent posts. Is any of that starting to happen in the mental health services area, particularly in circumstances where agency staff are employed? Have there been any contract buy-outs or any attempts to convert temporary posts to permanent ones? Where a person in the private sector is a contractor for six months or more, he or she is brought in as a permanent employee. In the opinion of the witnesses, have there been any improvements in that regard?

Mr. Éamonn Donnelly

Before I bring in any of my colleagues who would have expertise on panels, I must state that, as a general rule, the recruitment process relating to mental health services has not changed.

Mr. Éamonn Donnelly

I referenced this earlier. When one reaches to a point of pressure-----

I saw that in Mr. Donnelly's report.

Mr. Éamonn Donnelly

-----there is sometimes response to that which allows us to jump over the particular derogations. On Tusla-----

May I stop Mr. Donnelly there? When there is a point of pressure, what exactly does Tusla do in order to circumvent it? If one takes a case study and there is a point of pressure in a particular area - a recruitment pressure point - what is done to alleviate matters or speed up the process?

Mr. Éamonn Donnelly

A business case is made for a derogation. There is a recruitment freeze at present. Every national director has frozen recruitment. If there is a point of pressure, one has to apply for a derogation in order to get somebody in. If there is a particular controversy, reaction to that tends to be that the derogation is granted quickly, whereas it can normally take nine months.

Let us tease this out further. If the derogation is granted, is the process robust enough to ensure that someone is recruited?

Mr. Éamonn Donnelly

It will take a few months.

Will that be three, six, nine or 12 months? I am taking budgets into account when asking this question.

Mr. Éamonn Donnelly

It depends on whether one is recruiting one, two, three or 20 people. If one has to create a panel, that is where the experts beside me come in. I will ask Ms Cully or Ms Keogh to explain.

Ms Chris Cully

It depends on the category of staff. If we focus on health and social care professionals, particularly those in the therapy grades, the panel system for recruitment is mind-boggling.

Ms Chris Cully

For example, in the context of the physiotherapist senior grade, let us say that a panel was created in 2016. One would be aware that, because of the Commission for Public Service Appointments, CPSA, rules, one could only keep that panel in existence for a year, with the possibility to extend it to a maximum of three years. I ask the Deputy to bear with me, the picture will become clear. Some 100 people might have been placed on the 2016 panel and then supplementary panels might have been set up in 2017 and 2018, despite the fact that there were still people on the initial panel. I refer back to points made before the Deputy arrived, namely, that people are using the recruitment process as a means of mobility within the system. Let us say, for example, that I am a senior physiotherapist but I still apply for placement on the panel. I get onto the panel but am offered another. If it is not in the location I want to move to, I will sit there on the panel and keep turning down job opportunities. It is an administrative nightmare for the people we represent-----

It is too restrictive.

Ms Chris Cully

-----in the NRS. We are trying to resolve that with Tusla by streamlining it to make it better. We are in discussions with Tusla on that at present.

I apologise for interrupting but I am conscious of time. Where do those discussions stand? Is there any light at the end of the tunnel as to changing the model?

Mr. Éamonn Donnelly

We offered the suggestion of a mobility policy which would solve the problem to which Ms Cully is referring.

What kind of reaction has Fórsa received?

Ms Chris Cully

There has been a positive reaction. We are midstream in our discussions on that.

Mr. Éamonn Donnelly

We are right on it.

Ms Chris Cully

We met recently, last week or the week before, and we will meet again before the Christmas to see if we can move matters on. It is an administrative nightmare for the NRS, which is operating way above capacity. It is not about the people working in the NRS, it is that the system is not conducive to producing good turnover and linking that to the moratorium. It is just a nightmare. Ms Keogh has statistics if anyone wants them or is enthusiastic about such data.

Ms Catherine Keogh

I will provide an example that might better illustrate things. The senior posts are those in respect of which one finds this happening in the most. These are done as a national panel. Let us say that I am a senior occupational therapist, OT, and I want to become a senior OT as a basic grade. I see a national panel and I apply for it. Equally, I am already a senior OT but want to move to a different area geographically and the only way I can do so is by applying for the national panel. In 2016, in the case of 20-odd positions - we can share this information with the committee because the HSE has shared it with us - a great amount of work was done by the NRS to qualify 425 active candidates for an OT panel which ran for three years. There are still 400 people on that panel because most of those who were offered jobs did not want them because they were not in the right geographical areas. We were given figures at the Workplace Relations Commission, WRC, which indicate that 50% to 60% of any panel at any time is made up of already established HSE staff. From an administrative and resource point of view, a great amount of work goes into qualifying all of these people, when they do not really want to be on the relevant panel. They want to be on transfer panels, which is understandable. They are young, they qualify from college, they take their first jobs and they may want to move back home due to family commitments and all that goes with such commitments. Following two extensions, the 2016 panel with the 425 qualified candidates on it expired on 10 October last. Those 425 people are still looking to be moved around the country and they have nowhere to go. They will start being reinterviewed next year in order to be placed on another panel. A supplementary panel with 224 people on it now takes over. The NRS will start working its way down through that, offering jobs to people because there is no geographical alignment.

It is offering jobs to people who are going to turn them down.

Ms Catherine Keogh

Yes, because is no-----

They are not qualified on the basis of geography.

Ms Catherine Keogh

They are qualified based on the fact that they can do the job.

When I say that they have not-----

Ms Catherine Keogh

There is no way - this is what we have been pushing for - other than to bring it back to a geographical level so that one can-----

The recruiters are not qualifying the candidates.

Ms Catherine Keogh

To be fair, the recruiters are qualifying the candidates for roles, posts and competencies.

They are not qualifying them, however, on the basis of geography.

Ms Catherine Keogh

The Health Business Services has to offer these posts as they arise on the basis of expressions of interest. It will ask the 400 on the panel if they would like to express an interest in a post in Donegal. If one is in Cork and on that panel, one will say "No thanks". One will then wait for the next offer and so on.

Mr. Éamonn Donnelly

To put it simply, what would solve most of that problem would be a mobility policy that would allow people to express two geographical preferences and if they are offered posts on the basis of those two preferences and take up neither, well then they have made their choice.

Ms Chris Cully

Three strikes and you are out.

Mr. Éamonn Donnelly

We have been advocating this since 2016. Due to the madness of the current situation, however, we are finally at a stage where somebody is saying that it has to happen.

Ms Chris Cully

We negotiated a mobility policy within Tusla - this recruitment issue is not about Tusla, but I represent members of Tusla and deal with it regularly - and it is working fine.

One model can transfer across.

Ms Chris Cully

These are two separate employers. That is a matter for the HSE.

It make common sense.

Ms Chris Cully

The model could be used if we could get an engagement on it. We are getting close to that through our WRC process.

What does Fórsa want us to do to make that happen or to increase its speed?

Mr. Éamonn Donnelly

That is a hard question. When we are asked those type of questions, we normally look for a little political assistance in respect of funding. There is no funding-----

Let us park the issue of funding. We are talking about the nuts and bolts here. There are other debates in respect of funding whereby it is claimed that money is being put away, is not being spent, etc.

Mr. Éamonn Donnelly

We do not need funding for this.

We are talking about the nuts and bolts of the recruitment model. In the opinion of Fórsa, what can we do to push what it is looking for in the context of the recruitment process?

Mr. Éamonn Donnelly

If the committee made a very overt recommendation that mobility should be introduced in order to free up blockages in the panel system relating to appointments, that would certainly accelerate the conclusion of the process. It would make a huge difference.

Does Fórsa represent people working in the private sector?

Mr. Éamonn Donnelly

Yes, section 39 agencies.

What about people working in private hospitals?

Mr. Éamonn Donnelly

Yes. It is not a significant cohort but we have them.

Is there a different recruitment model in the private system?

Mr. Éamonn Donnelly

Yes, they recruit their own.

So there are no panels, there are no-----

Mr. Éamonn Donnelly

They recruit in the same way as Tesco or Bank of Ireland does.

If they need a physiotherapist, they go out and get one.

Mr. Éamonn Donnelly

Yes.

There are no panels waiting-----

Mr. Éamonn Donnelly

They pay the same rates and they generally apply the same conditions but they recruit in their own way.

If a physiotherapist who has been on a panel for three years decides to take up a job in a private hospital, she can get a job in the morning given that she has the qualifications, etc. The private system operates in a completely different way from the public system in its recruitment processes. Does the public system's bureaucracy create barriers?

Mr. Éamonn Donnelly

Of course. Because of the size of it, that is just the order of things. There is a bit of that. A private employer has its own ability to do things but let us not get confused. We are for the publicisation of the health services.

Ms Chris Cully

In any organisation, but particularly one the size of the HSE, there must be checks and balances about processes, so the same processes, checks and balances must apply to recruitment. It is just on a larger scale compared with any of the private sector health providers.

Mr. Éamonn Donnelly

We should not underestimate how much pride our health and social care professionals take as practitioners in working for the public health service.

I thank the witnesses for appearing before us this morning and for their evidence, which was very direct and forthright and will feed into our report on workforce planning.

Ms Chris Cully

If the committee would like a copy of our Caring at Cost document, we can send it over.

We will circulate it.

The joint committee adjourned at 10.45 a.m. sine die.