Workforce Planning in Acute and Community Care Settings: Discussion

I welcome our witnesses to the meeting this morning. They are all presenting remotely and will provide an update on the workforce planning in both acute and community care settings. I welcome from the Irish Nurses and Midwives Organisation, INMO, Ms Phil Ní Sheaghdha, general secretary, and Mr. Tony Fitzpatrick, director of industrial relations; from the Irish Medical Organisation, IMO, Ms Susan Clyne, CEO, and Dr. Matthew Sadlier, consultant committee; and from the Irish Hospital Consultants Association, IHCA, Professor Alan Irvine, president, and Mr. Martin Varley, secretary general. They are all very welcome to our meeting. The meeting will be in different sections for the different political groups, with rounds of ten minutes and seven minutes. We are hoping questions will be asked and answers given within that period. I know that will be difficult but unfortunately we must stick to the two-hour window.

Before we hear the witnesses' opening statements, I must point out that there is some uncertainty about whether parliamentary privilege will apply to witnesses giving evidence from a location outside the parliamentary precincts of Leinster House. Please note that the constitutional protection afforded to witnesses presenting in Leinster House may not extend to those presenting remotely. No clear guidance can be given on the extent to which evidence is covered by absolute privilege of a statutory nature. Therefore, if witnesses are directed by me to cease giving evidence in relation to a particular matter, they must respect that direction.

I now call Ms Ní Sheaghdha to make her opening comments on behalf of the INMO.

Ms Phil Ní Sheaghdha

I thank the Chairman for the invitation. The INMO is delighted to present to the committee today. I will briefly go through our opening statement, which members will already have received. It is broken down into three main parts. The first part relates to the additional beds that have been announced in the budget as well as the winter plan. We welcome these beds. However, we ask members of the committee to be conscious that each time they hear the word "bed" they must think the word "nurse" because without the nursing staff to staff the beds, unfortunately we are not going to make progress in expanding the much-needed capacity in the health service. In Limerick, for example, we are balloting our members because there is an acute shortage of nursing posts. We are attempting to open 90 additional beds but we are running with 125 vacancies before we start. The legacy of the moratorium still stands. We have to work very hard to recruit and we have to make sure pressure is not put on the system to open beds if there are not sufficient nurses to provide safe care.

At our conference last Friday week, the Minister for Health confirmed that the framework on nurse staffing, which is Government policy, will now be used to determine how many nurses and healthcare assistants are needed to provide care to patients in beds. This is important and welcome. It is a scientific method to determine how many nurses are needed. We understand this is funded for the incoming year. The settlement of our strike in 2019 stipulated that this funding would be made available for the three years following the dispute, with the staffing to be completed by the end of 2021. Multiannual funding is required. Funding for this year is welcome but it will only extend to model 4 hospitals. We have to be assured that when nurses are looking to their future in the public service, they understand there are commitments behind the correct staffing from a financial perspective. Otherwise they will leave and go elsewhere. That has been the practice.

We have set out the staffing levels at which we are running in our submission. The most recent census produced by the HSE tells us that in the staff nurse grade, which is the main grade of nurse working in the health service, there has been an increase of just under 300 whole-time equivalents since December last year. There have been significant reductions in our community services. We have 40 fewer public health nurses and five fewer midwives. Our midwifery workforce is very important because in order to implement the maternity strategy, we have to meet the ratio of one midwife per 29.5 births and we are far away from that. That means we are providing unsafe care in sections of the public health service because in some of our maternity units we are now at a rate of one midwife per 40 births, which has been proven internationally to be unsafe and dangerous. Nurse and midwife staffing is very important. The good news is that there is a scientific tool to determine staffing levels.

In our submission, we are advocating that in the medium and long term we should look at increasing our undergraduate places in order to ensure we are training sufficient numbers and have room. The good news is that 5,000 school leavers applied for nursing courses as their first preference in 2019 and we provided 1,700 places to them. There is room there to increase the number of undergraduate places. We need to do it fast and we need to be cleverer about retention because it is a big problem. We are still heavily reliant on overseas recruitment, particularly non-EU recruitment. We have put those figures in our submission. More than half the nurses who registered in Ireland in 2019 were from outside the EU, mainly from India and the Philippines. We are hugely reliant on recruitment from overseas and we have to make sure that continues in the current climate. It is continuing. It is slower, but it is continuing.

The children's hospital requires 300 additional nurses just to open and we are already short and are down below that 300. This means that when the children's hospital begins to operate its services, it will not be able to open all of its beds. It simply will not have the nursing numbers. We need to ensure we are training sufficient numbers at undergraduate level to make that timeframe. Unfortunately, we are two years behind on that already.

Right now, there is a crisis in the health service because of the high number of healthcare workers infected with Covid-19. Of those, we know that up to 34% are nurses. We have a high level of absence. Many of our members are reporting absences stretching into 16 and 17 weeks, particularly in areas where they have been directly caring for Covid patients. We need a fresh look at the occupational health policies of the HSE, particularly the policy that dictates that workers come back to work even if they have been close contacts of a Covid case. We believe that is wrong and is not aligned with the testing regime. There is no routine testing in our acute hospitals. We have surveyed our members and they want routine testing in acute hospitals. There is also the added difficulty of childcare. This committee has heard from us on this matter before. If there are any changes in Government policy on the closure of schools, we have to make sure that for the female-dominated workforce that is our nursing workforce, thought is put into how their childcare needs will be looked after in that circumstance.

We cannot have a repeat of what happened earlier in the pandemic, in March and April, when that was basically left to chance. We must ensure that, prior to any decisions regarding schools, provision is made for childcare for the 91% female workforce that is leading on providing care against this terrible virus in acute hospitals and communities.

I bring the attention of the committee to the fifth recommendation of the Special Committee on Covid-19 Response. It states that Covid-19 as an infection should be made an occupational illness. The INMO previously called for that to be done and the committee recommended that it should be catered for in the health and safety legislation. We need stronger input into the health and safety of the workforce that is meeting the virus head-on daily and nightly. The INMO has been and remains critical of the supports available to members of the workforce when they are infected, as well as of their protections at work. The quality and supply of personal protective equipment, PPE, has improved but, each week for the past two weeks, 50 nurses have been infected with Covid-19 while at work. That is a very high figure. I am happy to take questions from committee members.

Ms Susan Clyne

The Irish Medical Organisation, IMO, represents almost 7,000 medical professionals working across the acute primary care community and public health settings. Dr. Sadlier and I thank the committee for the invitation to speak on medical workforce planning, but we draw its attention to the fact that one year ago, we presented to the then health committee on this topic. It is a matter of extreme regret that little or nothing has changed since then. In fact, the situation has worsened despite numerous reports pointing to the chronic shortage of doctors.

Covid does not only expose the fragility of the health service in terms of its infrastructure and bed capacity. In addition, we are facing the enormous challenge of asking an understaffed and exhausted to deliver Covid and non-Covid care. It is evident that post Covid we will continue to have too few doctors to meet the health demands of an increasing population unless we act now.

The current picture is one of shortages across the system. There are 500 vacant consultant posts, leading to growing waiting lists - there are now more than 840,000 people on a waiting list. That leads to delayed diagnosis and treatment for patients which, in turn, leads to increased mortality. Ireland has the lowest number of specialists per head of population and not a single specialty has the required number working in it.

The HSE national doctors training and planning unit suggests that the HSE has a deficit of 1,600 hospital consultants. If one includes psychiatry, that deficit rises to approximately 2,000 consultants. Each year, slightly more than 700 doctors enter basic specialist training, while approximately 500 doctors enter higher specialist training. The HSE estimates that a minimum of 648 additional training posts are needed just to cover hospital-based specialties. That does not include general practitioner, GP, training places.

The healthcare system relies on a large number of doctors from non-EU or EEA countries who, up to now, have had no access to training posts. Although legislation has been passed to enable such access, all that is doing is increasing the number of doctors competing for a static number of training posts, which does not improve the manpower situation. A minimum of 600 GPs will retire in the coming years. The HSE estimates that we need an additional 1,260 GPs in the coming years to ensure we can meet the demands of patients. It is imperative that up to 350 GP training posts per year are funded to meet future needs.

Incredibly, there are only 60 public health medical specialists. The Crowe Horwath report which was accepted by the Government recommends increasing that number and ensuring they are supported by multidisciplinary teams. By comparison, New Zealand and Scotland, which have roughly the same population as Ireland, have 180 public health consultants. Worryingly, 50% of our public health medical specialists are due to retire in the next five years and there are insufficient trainees in the system to match those retirements, let alone to cope with any expansion of the workforce.

We have seen increasingly high rates of emigration by doctors in recent years and can state with some degree of certainty that that trend will continue. Doctors leave to enhance their skills and receive additional training but, unfortunately, they are not returning to Ireland. Doctors wish to work in a system that enables them to deliver care to patients and in which they are respected. For many, that now means going abroad.

For some years, the IMO and other organisations have been highlighting these issues. Successive Governments have commissioned and produced reports, all of which support the need to plan and resource medical manpower. What has been lacking is implementation, investment and resources. At a minimum, there is a need to resolve the disastrous two-tier pay system for consultants. It is inequitable and unfair and has been the biggest barrier to recruitment this country has ever seen. This politically motivated pay cut has had a very damaging and dangerous impact on the health services. Although we welcome the commitment to hire an additional 300 consultants in 2021, it does not even address the current 500 vacancies. There needs to be far more ambition in terms of recruitment targets to support the clinical programmes and models of care.

Public health specialists must be awarded consultant contracts. It is particularly galling in the context of Covid that the very doctors on whom we are relying to manage the pandemic are not recognised for their skills and expertise. We must significantly and rapidly increase the number of training posts across the specialties and ensure that training programmes lead to clear career pathways for trainees. Far more account must be taken of the needs of trainees and the changing demographic of those coming into medicine. In general practice, the transfer of care from acute settings to the community must be properly supported. It is very difficult to manage unplanned care and GPs are suffering from the same capacity issues as the hospital sector. In light of the demographics of the GP base, who are an older population, supports for GPs who wish to establish in general practice must be delivered.

I ask the committee to note that we have all the recommendations we need in terms of planning for our future needs but what we lack is investment and funding. This situation is bad for doctors but, more importantly, it is disastrous for patients and health outcomes. Dr. Sadlier and I are happy to take any questions.

Professor Alan Irvine

I thank the Chairman and members of the committee for the invitation to participate in this discussion. Ms Ní Sheaghda and Ms Clyne have eloquently pointed out that capacity is not just about beds, it is about people, including highly skilled professionals across all the medical and nursing disciplines that we need. It is clear that the health system lacks that capacity and has done for some time. The Irish Hospital Consultants Association, IHCA, represents 3,200 hospital consultants practising in acute hospital and mental health services, or approximately 95% of the total.

My remarks will mostly focus on the reasons consultant posts cannot be filled. Ms Clyne pointedly observed that these are not new reasons. They have been known and pointed out for many years. One of the greatest deficits is around listening. Some people will not listen, particularly to craft representatives. Too often, the offering from the employers' side is a one-size-fits-all, take it or leave it approach. If the employers' side were to listen carefully and implement what well-meaning and informed professionals from all of the groups represented here today were saying, we would not be in the current position.

As all present are aware, there is a severe shortage of hospital consultants. As Ms Clyne stated, there are 500 unfulfilled posts. Government reports itself have outlined an additional 2.000 posts are needed. The result of that shortage is very damaging for patients. Waiting lists for hospital care have ballooned in recent years, particularly since the 2012 decision. I entirely agree with Ms Clyne that that decision was politically motivated and exceptionally damaging. If the committee wishes to know why there are not enough consultants, it is as a result of policy decisions that were not evidence based or done in a collaborative way but, rather, imposed unilaterally. The decisions were foolish, absolutely counter-productive and costly. On every level, it was a gross error. What worries me is that the errors and political thinking that led to that decision persists and we will probably not fix the problem unless we change the culture and thinking around how we fill those vacancies.

The number of outpatients waiting more than 12 months is a record 250,000. There are 1 million people waiting for care in the public health service, including approximately 840,000 on lists and 190,000 waiting for diagnostics such as CTs and MRIs. More than 17,000 people are waiting more than a year for inpatient or day cases, compared with 131 awaiting such treatment in 2012 when the decisions to which I referred were made.

We have gone from 131 people waiting for over a year to 17,000. It directly ties in with a really ill-advised policy decision. One can see a clear cause and effect.

We have also had to recruit doctors who are not on the Medical Register. There are 117 of these in the HSE by the last count. That has been the result of adverse commentary in the High Court by Mr. Justice Peter Kelly and others.

What does it look like around the country? We see in Cork that approximately 35% of acute trauma cannot be listed in orthopaedics because the hospital does not have consultants to do it. In Cork and Kerry, there are the same number of ophthalmologists as there were in the late 1970s. We are all aware of the issues there with regard to people having cataract surgery. There are examples of this all around the country. The single most significant determining factor is the decisions made in 2012, which have not been corrected and continue to perpetuate these issues.

As Ms Clyne said, and we completely agree, we have the lowest number of consultants in nearly every discipline in Europe. That is a false dichotomy.

I want to specifically address our younger consultants, who are being discriminated against, as we have heard. They carried an extremely heavy burden of work in the past seven months and will have to do that in future. These are colleagues who we value greatly, and we, the health service and our people need more of them. We need to treat them properly and encourage them to work in the health service. That includes trainees in training schemes and higher specialist training, who want to be encouraged to come back. I echo Ms Clyne's point on that.

We are borrowing much money and expanding the health service at pace. We need the right people and we need to get them in rapidly and on terms they are happy to work on. We need to see clarity about how many consultant posts will be funded and how they will be filled in a short period. Some 16,000 additional staff are coming. The committee has heard from my colleagues about how difficult it might be to fill positions in their disciplines and we agree. It is the same for us.

To summarise, given the persistent shortfall of 500 posts, a clear conclusion is that the current offering is simply inadequate, in a broad sense. That applies to all of the pay and conditions, including the flexibility that is needed to bring people in. At this stage, most employers and organisations would conclude that maybe they need to engage with the people who are likely to fill these posts and improve their offering. We will start with a blank sheet now. I have been a consultant for 18 years. This has not been the way things have been done or how business has been conducted, and that is why we now have a health service that does not have adequate capacity for our people. We need to dramatically change the way that we recruit people. There needs to be much more listening, action and implementation, to echo Ms Clyne's comments.

There is no time to lose. Winter is coming. We need to build for this winter and every future winter. I will conclude my remarks there and, like the others, I would welcome and be happy to address questions.

I welcome the witnesses and thank them for their presentation. Professor Irvine said that the reduction in 2012 was politically motivated. Will he elaborate on that? There were other factors prevailing at that time and I would like to know what they were.

Will we take all the questions together, Chairman?

The Deputy is in the seat.

Okay. I have a question for Ms Ní Sheaghdha about the increase in beds and the nurses required for staffing. Is the funding made available in the course of the summer and budget 2021 sufficient to meet the challenges of recruitment etc.? Regarding the increase in the number of undergraduates, we are getting applicants from India and the Philippines. What is the ratio of students from Ireland compared with non-EU countries? We addressed retention of health staff at all levels in this committee in the last Dáil. It appears to be getting more difficult. If so, are prevailing conditions the cause of the problem? Is any part of it the fact that highly qualified medical staff have the world as their oyster on the world market at present and that we have to recruit against colleagues throughout the world?

Anybody and everybody can answer this last question. What are the witnesses' views on the extent to which the health services are meeting the challenges which have appeared on the horizon over the past six months? Do they think it can continue? Everybody criticises the services for their inadequacies and inability to deal with growing numbers. At the same time, if everybody throughout the country co-operated and carried out what we should with regard to correction of our interactions with other people and stopping the spread of the virus, I believe that it would make a significant impact on the workload and levels of stress caused in the health services. The witnesses can comment on that if they wish.

Professor Alan Irvine

There was one question for me, three for Ms Ní Sheaghdha and one more general question. I am happy to take the first one first. The question was why I said it was politically motivated. We know what position the country was in in 2012. We absolutely recognise the global financial crash and the implications that all of our people had to deal with. There were mechanisms such as the financial emergency measures in the public interest, FEMPI, cuts that applied to every group in the public service. In addition, in a vindictive and vicious way, one group was picked out, namely new consultants. They had an extra 30% taken from them on top of every other group, in addition to the FEMPI cuts, so I am here to speak for them. They felt that. That really hurt people as well as being a financial issue. They were told they were not valued. The mood around this was horrible. I remember it well. It was depressing. I am a pre-2012 consultant, so I do not have any financial issue with this personally, but I can see the damage that it has done to our health service and to colleagues. People are being told that they are less valuable than their senior colleagues. I believe that for all crafts, but in this case, I am talking specifically about our people. It is damaging and the mood around it, the opinion pieces launched and the ugly soundbites that we heard in the media all created an incredibly damaging lack of value for new consultants and for people in training posts, looking at new consultant posts. I tell anybody who wants to listen that that has been incredibly destructive, with op-eds, including one from Deputy Shortall in January 2012. It was very damaging to people and how they would be valued. These are the people who we are now asking to go the extra mile, put themselves on the front line and continue under these conditions. I will finish because I want to give Ms Ní Sheaghdha time to speak.

Ms Phil Ní Sheaghdha

In point 5 of our submission, we set out the statistics that we received from the Nursing and Midwifery Board of Ireland in 2019, which advised that 62% of newly-registered nurses and midwives trained outside Ireland. That is the figure as we know it. There are approximately 1,700 in training every year, which is the number of Irish graduates.

In addition, we also have nurses coming back to Ireland to register. However, of those who registered, 62% had trained outside Ireland. That will give the committee an idea of the numbers.

With regard to the increase in the numbers of undergraduates, we make the point simply because we will have a greater focus on the need for education. We know the Minister with responsibility for higher education, in his new brief, is looking to expand opportunities for school leavers as Covid-19 will bring its own problems with employment. If there are 5,000 people putting nursing or midwifery first on the Central Applications Office form, they should be accommodated, encouraged and funded to undertake the course. There is a very real shortage and this is about supply and demand. There is a request from school-leavers and we should accommodate it, encourage and applaud them. We do not have to reinvent much but we must make a provision for them and ensure they can do it.

There are absolutely retention difficulties. As Professor Irvine mentioned, if we remember as far back as 2012, nurses who graduated not only got the 10% pay reduction that all public servants got but they also got a further 20% reduction in their graduating pay scale. In total they got a 30% pay cut and to a person they took that personally and emigrated. We are now looking overseas to that group and saying "Sure come home and we will treat you fine and better now". If they return, we give agency contracts rather than employment in the health service. There are many fixable problems that currently make no sense.

Our recruitment practice is bureaucratic. If I resign as a nurse today in hospital A, it will take a minimum of eight weeks for the director of nursing to get approval to go to advertisement and it would probably take approximately six months to fill the post. It is pure bureaucracy at work but such tasks must be delegated to the director of nursing. If there is a job and a person can continue to work, it should be up to that director to put that person on the payroll. It must be that simple or otherwise we will continually fight against ourselves in order to recruit.

In 2012 and 2013, all the austerity measures were introduced and on 1 October public servants got the last of those cuts to pay restored, aside from the hours aspect. Nurses in this country work a 39-hour week, a longer week than any other healthcare professional. As a result, 1.5 hours per week is owed to them each week by their employer, which they currently work for nothing. That is how they view it and it must be corrected in order to retain those staff. I hope that answers the Deputy's questions.

On the broader matter of what can be done, we cannot provide both of these services into this winter. We had over 100,000 people on trolleys last winter. If we face that again while trying to provide care for people with Covid-19, we will fail. It is simple enough. The people who work in the health services are doing their best, from doctors to nurses to porters to cleaners and everybody else. They are doing their best but they are human and exhausted. We did a very intensive survey last week and the main message is that people are exhausted. The citizens of this country understand the health service has limits but these are being reached and it will not be possible to provide both services.

As we have run out of time with the slot, perhaps Senator Conway could come in later.

I have one quick question for Ms Ní Sheaghdha.

The Senator will have to wait for the next slot.

I will not be here for that. I have a question on private healthcare. I listened with great interest to her interview the other day on RTÉ Radio 1 when she expressed concern about nursing pay scales and terms and conditions of nurses working in private hospitals. Will she elaborate on what, if anything, we can do to help rectify this? It seems to be extremely unjust.

Ms Phil Ní Sheaghdha

In its recommendations, the committee inquiring into Covid-19 matters, including its effect in nursing homes, made specific recommendations around collective bargaining rights and standards setting for wages and conditions for those who work outside of public service healthcare.

For example, we have nothing other than recommendations in respect of practice nurses working for GPs, as well as nurses working in private nursing homes, with an aspiration to public service rates of pay. They are contracted to work at rates between them and their employer. We are seeking collective bargaining rights for that group of workers across the private sector. If there is a rate of pay in a country, it should reflect the duties, and there should be equal pay for equal work.

In private nursing homes in particular we have a larger reliance on overseas nurses and there are difficulties in respect of where they live. In many, although not all, cases there are examples of cost of accommodation being deducted from a salary. Staffing levels are lower and it is more difficult to supervise work. In many cases the ratio of nurse to patient is extraordinarily high and therefore dangerous. These are very real issues.

The comment I made was in respect of an appeal not to "poach" private nursing home staff, although I may be misquoting. My simple point is that if the conditions exist where workers are happy in an environment, they will stay there. There would be no need to appeal to the State to block them from going for interviews in State-run facilities. If the conditions are right, people will stay where they are for work. Many of these people migrate not just to the public sector but to private acute hospitals, where the conditions of employment in the main are better.

I welcome all our witnesses. We now only have ten minutes each for questions. A previous health committee may have spent a bit more time putting questions but given our current context, we must try to master the art of brevity. I will try to make my questions as succinct as possible and I hope the answers will come in the same spirit.

How are nurses feeling now? I know they have been through a very tough time so will Ms Ní Sheaghdha give a flavour of how they feel at this point?

Ms Phil Ní Sheaghdha

As I said, we surveyed our members in the past month. They are very concerned about the infection rate among healthcare workers and, in particular, they are concerned about the infection rate in nursing as it reduces their rosters. The infection rate is unacceptably high and nurses believe additional measures must be put in place, mainly that the Health and Safety Authority must have jurisdiction. We were very happy to see that recommendation from the Covid-19 committee. We request that this committee would reinforce that recommendation and amend the regulation to allow Covid-19 to be classified as an occupational injury. It is central to the protection of workers in these environments.

Everybody knows Covid-19 is extraordinarily infectious but imagine working with personal protective equipment for lengthy shifts and not being able to get relief because staffing levels are so low. According to the WHO, fatigue is one of the main problems when it comes to additional exposure to the virus. In other words, a person is more vulnerable if he or she is fatigued.

Our members have said to us they are reflecting on their future careers and 70% have said they have thought about leaving, with 60% actively thinking about it. It is very serious. We want to encourage nurses to stay working in the health service and we do not want this experience to be such that it is really difficult to work in these circumstances right now. We do not want them to feel they have to change career. We want the employer and the Government to support them. We want to ensure whatever it takes is there so that when they are working in these dangerous and high-risk environments, they can be protected.

I thank Ms Ní Sheaghdha.

Ms Phil Ní Sheaghdha

I must specifically comment on unpaid student nurses, with 3,200 of them currently on clinical placement. They are being used as workers because rosters are just so short.

They are being used as workers because the rosters are so short. They are also being exposed to the virus and they have no comeback in respect of sick leave or protection. They are living in shared accommodation. It is absolutely exploitative and unacceptable. This committee should make a comment on that today.

I wish to make a number of comments on foot of that response. First, this committee certainly should support the recommendation from the Special Committee on Covid-19 Response that Covid should be an occupational illness. We must put the Minister on notice that it is one of the issues we want him to address in his opening statement when he appears before the committee after the recess. I fully concur on the issue of student nursing and the problems they face. It is unacceptable that many of them are not being paid or properly supported. That is something this committee must flag to the Minister when he next appears before it.

It is very important that we support the front-line staff. As this session is on workforce planning, I am struck by Ms Ní Sheaghdha's contribution. When the committee was in private session a number of weeks ago and considering our work plan, I raised the issue of increasing the number of undergraduate and trainee places across the board, and not just for nurses. I will come to Ms Clyne and Professor Irvine shortly regarding GPs, consultants and other specialties. That is an area on which the committee should focus. It is obviously aligned as well with the Department with responsibility for higher education. We must see more placements. Part of that has to be increasing the bursaries and supports. We must examine the total number of measures that would make that happen.

I have a final question for Ms Ní Sheaghdha. I only have five minutes left and I wish to question the other witnesses as well. She said her members are under major pressure. We all accept that. When does the peak arrive in the winter? That is what people will ask. We are heading into the winter season, and any winter is very challenging for the front line. When are we likely to see the peak? In a normal year, and we are not in a normal year, when would the peak be hit, and is she satisfied that when it is hit this year we have the capacity, resources and supports in place to ensure those on the front line can do the job they need to do?

Ms Phil Ní Sheaghdha

It depends on what one is measuring. What we measure normally is the hospital occupancy. The hospitals are occupied at a rate that is much higher than the 82% or 83% which is considered safe all year round. The peak does not happen like it used to, whereby there would be a reprieve during the summer. That does not happen. Our trolley count figures are increasing throughout the year but they get increasingly unmanageable in January and February, not so much in December although it is still very high. January and February are months that become extremely difficult in the hospital setting.

In the community, it is important to examine the public health nursing support and the reduction in numbers there. Those nurses tell us that the idea that they would have time to dedicate to geriatric surveillance, which was part and parcel of their role, is gone. They do not have a facility to have waiting lists for their service so each day they must determine what is the priority. They are not getting to massive areas because their numbers are insufficient. That is a very big problem at a time like this when people are cocooning and we are trying to support the elderly to stay at home. That is happening today.

I thank Ms Ní Sheaghdha. I wish to put questions to Ms Clyne and Professor Irvine. I attended Professor Irvine's national conference last week and found all the contributions to be very interesting, but the issue of pay parity has arisen time and again. This has been on the agenda for a long time. There are 500 vacant consultant posts and unless we deal with the pay issue, we will not be able to attract consultants. What I can understand from the Minister for Health is that he sees the public-only consultant contracts as the solution to this. That would mean those who are on the type B contracts being asked to sign up to the Sláintecare contracts. In Professor Irvine's view, does that solve the problem? If it does not, what else needs to be done?

The same question is addressed to Ms Clyne. I also have a question for Ms Clyne regarding GPs. We need more training positions to come through, but also better supports and pathways for GPs to practise when they come through. The age demographic of GPs is obviously not good. It is a major challenge. Perhaps Ms Clyne will respond on the issue of GPs and ensuring there is a better pathway when they come from training to practise, and both witnesses will respond to the question of how we get more doctors and consultants into the system. Aside from the pay issue, there are other issues relating to caseload, workload, access to theatre space, equipment and so forth. Perhaps Professor Irvine will address those issues first, followed by Ms Clyne.

Professor Alan Irvine

I will be very brief because Ms Clyne has not had a chance to speak and she has two questions to answer while I have just one. On the question of the public-only contract, one of the reasons we are in this position is that we have a vision that is created centrally by employers that will "solve the problem". It does not take cognisance of what the people who actually know what will solve the problem will say. If this is another unilateral offer, it will not work. Unilateral offers rarely do. The public-only contracts will work for some disciplines and some people, depending on the conditions. We have not seen those. We are not in a negotiating space yet, nor is the IMO. We are not involved in that yet. We will negotiate things as we are allowed, but if there is a prefixed ideal from one side of where that should end, it probably will not solve the problems.

There are reasons that people want to retain freedom to work outside the public system, and they are not all financial. Many of them are due to work satisfaction, having access to a list and perhaps being able to do a procedure one cannot do. We are going to see procedures squeezed out of the public hospitals because of capacity issues. We are already seeing the cancellation of routine work. If one is a physician or a surgeon who does procedures, one wants to be able to keep the skills set in which one has invested heavily over the years in training, and perhaps one cannot express that in the public system. Controlling every aspect of these senior professionals' lives, over and beyond what they discharge wholly in their public contracts, does not necessarily make good sense. It will not fill all the gaps in the system. We need a flexible approach, but we mainly need people to listen genuinely and not come with a prefixed idea.

Ms Susan Clyne

I support what Professor Irvine said. It is important to know that the Minister has committed several times, both in opposition and as Minister, to fixing the 30% pay cut. The public health contract that has yet to be negotiated by either the IMO or the IHCA will not solve this issue. In fact, it will drive more people away. It must be remembered that there is currently a public-only contract on offer, and there has been since 2008, yet we have been unable to attract consultants on that contract. The vast majority of consultants who have been contracted since 2008 have been on a type B contract.

If all private practice goes out of public hospitals, the public hospital system will be down by between €500 million and €600 million per year. The Department and policy makers must work with us, not against us, in trying to solve this problem. However, the 30% must be fixed. As in the point made by Ms Ní Sheaghdha, recruiting doctors is a long-term process. It can take from 20 months to two years to get a consultant into post. We have identified the problems, and there are ways to fix them. We have to start fixing them now.

With regard to GPs, there is a problem in general practice. That has been highlighted for a number of years. It is easy to predict how many GPs are going to retire and how many GPs we need to train. If we fix those two issues, the gap is how we help younger GPs to establish. Establishing a practice is not like walking into a State facility, where all one's costs are paid. It is a business, and it is very costly. There has been little predictability in GP income over the last number of years. That is changing with the IMO agreement with the State, but there is little predictability about being able to say for sure what one's financial position will be given that the State controls a percentage of one's income without making any payment towards a percentage of one's costs.

I am sorry, Ms Clyne, but we have run out of time for this.

Ms Susan Clyne

There are huge problems and there are ways to solve this if we talk to each other.

I thank the witnesses for their contributions. Some of the questions I wished to ask have been asked, so I will not repeat them. There are some specific questions. My party is due to have a parliamentary party meeting tonight.

I will raise points made specifically with regard to student nurses with the Taoiseach and Minister and see why that is the case given the circumstances in which the country finds itself.

I have some specific questions regarding the fact that there is no routine testing in hospitals. What is the testing regime in hospitals? I will direct that question to Ms Ní Sheaghdha.

Ms Phil Ní Sheaghdha

The current situation is that unless there is a close contact in an acute hospital, and I am speaking specifically about the acute sector, there is no routine testing. For example, in the private sector and care of the older person services that are public services, there is routine testing of all staff every fortnight. We and our members believe that the same regime should be in place in an acute hospital because we have a lot more information about asymptomatic presentation.

Ms Ní Sheaghdha told us that 34% of healthcare workers who tested positive were nurses. What is the percentage of consultants who have tested positive? That question is for Professor Irvine.

Professor Alan Irvine

I do not have the answer to that question at hand. That would not be data that we routinely collect. The answer to that is that I do not know.

Regarding childcare needs, if there was a change in the circumstances around the opening of schools, in an ideal world, what structure would work for nurses? If Ms Ní Sheaghdha could wave a magic wand regarding childcare for nurses in the event of schools closing, what would that structure be?

Ms Phil Ní Sheaghdha

We know that when female workers, and it is female workers in the main, have difficulty in securing childcare, that is something that is less than a priority in the normal course of events. However, if one works shift and has childcare provisions, one relies on formal childcare and schools. One sometimes relies on parents and elderly people, who are now cocooning.

I know and I get that. I was just asking that if Ms Ní Sheaghdha could put a structure in place, what structure would she put in place?

Ms Phil Ní Sheaghdha

If all of that is removed, the healthcare worker will be unable to go to work. The point is that if the State is saying people have to come to work and do their jobs but the State will not provide them with a facility to mind their children, we will say to our members to stay at home and mind their children until there is provision to allow-----

Ms Phil Ní Sheaghdha

We have just had to refer this matter as a grievance to the Workplace Relations Commission, WRC, and argue that annual leave that was forfeit by nurses should not have happened.

Can Ms Ní Sheaghdha hear me?

Ms Phil Ní Sheaghdha

We have just had to argue that in our industrial relations procedures.

I do not think she can hear me. I am on her side. I know all of that. I am asking what the State could put in place if schools and childcare facilities had to close. Rather than the narrative of what is needed, what, ideally, would be put in place?

Ms Phil Ní Sheaghdha

Safe childcare must be provided to facilitate those nurses attending work, particularly those who are essential workers. Some countries have kept schools open to make that facility available for healthcare workers. London did that. There are many examples. We make the decision in respect of schools as if it will not have any effect on the next service, which is the health service, but it does.

Professor Alan Irvine

We have many young mothers and fathers in the consultants' body as well. It is a point well made by Ms Ní Sheaghdha but I have colleagues who come in and do ward rounds at 5 a.m. so they can go back and share the childcare with their partners. It affects female workers in every discipline, including medicine, and consultants.

Dr. Matthew Sadlier

Not only do we have that with consultants and nurses, we also have it in the junior doctor population, members of which are often sent on a rotation to a different part of the country away from their partners. They must arrange childcare within very short periods of time because they are moving around the country on six-month rotations as part of training schemes. This was identified in the MacCraith report as something needs to be looked at if we are to retain junior doctors and trainees in the country.

There is one suggestion there, which is that in the, we hope unlikely, event that schools or childcare facilities had to close, schools would remain open for the provision of childcare to front-line healthcare workers, as is the case in other countries. That is an interesting one to see.

My final question relates to Covid as an occupational illness. What way is Covid treated now? Ms Ní Sheaghdha has been the most articulate one but perhaps the question could be shared around.

Ms Phil Ní Sheaghdha

If I contract Covid-19 at work, my employer is required to notify that to public health because it is a public health concern. It is not required to report it to the Health and Safety Authority as an occupational problem - an occupationally acquired illness. If I go into work this evening, work in a ward, am injured in the course of my duty and am absent for three days, there is a statutory responsibility on my employer to notify the Health and Safety Authority if that is a physical assault. The consequences of getting infected with Covid-19 are such that the long-term effects about which we are now learning are catastrophic in many cases. The employer is the health service. If it was a meat factory, it would be exactly the same. An employer is not going to investigate its own practice sufficiently objectively to determine whether it had any part in that infection. Therefore, that is the purpose of an independent investigative process, which in this country is the responsibility of the Health and Safety Authority. In the event that someone dies from Covid-19, it is not a reportable death to the Health and Safety Authority if the person is a healthcare worker who acquired that infection at work. This is wrong. An occupational illness or injury should have that status if it is caused by an infection, assault or anything in which one's employment was the main factor.

I have another question.

Ms Phil Ní Sheaghdha

As I said, we welcome the fact that the Special Committee on Covid-19 Response recognised those arguments.

Does it apply to MRSA or mmsA?

Ms Phil Ní Sheaghdha

It does not apply to MRSA but there are occupational health schemes in place to protect the worker and to provide, for example, leave with all of the person's remuneration and sick leave entitlement protected for MRSA. That does not apply in the context of long-term Covid-19 at the moment.

Ms Susan Clyne

In terms of the number of doctors who have been affected, of the total number of infected cases in healthcare, doctors account for about 5%. The real problem is that there is no resilience in the workforce, so when someone goes out sick, there is nobody to take on. For both doctors and nurses, therefore, it means that the people who are left are working twice or three times as hard with more shifts and longer hours. We see that, for our non-consultant hospital doctors, working 24-hour shifts is becoming much more prevalent in the system. They are working over and above their safe working hours in terms of the European working time directive, so there is no resilience in the health service workforce across all the grades.

I thank all our guests. I will concentrate on the issue of public health. Probably before last March, very few people knew there was such a thing as public health. From the point of view of prioritisation and resourcing in the health service, public health was exceptionally under-resourced. If we have learned anything from the past seven or eight months, it must be that we must concentrate on public health, resource it properly and expand the capacity, because as it stands, it is very inadequate. Regarding the point about which we were talking earlier with regard to the collapse of the tracing system, that is a result of inadequate resourcing of public health.

I have a question for Ms Ní Sheaghdha about those public health leaders at community level - public health nurses.

Public health nurses are often a very undervalued group of healthcare workers. They are the people who have the expertise in child health, care of older people, vaccination programmes, chronic illness management in the community and so on. Traditionally, it has been very underresourced. There have been a lot of vacancies. How adequate is the capacity of public health nursing now?

I have a similar question relating to doctors for Ms Clyne. She said that not only is the provision of public health specialists wholly inadequate relative to other countries but also that public health specialists, unlike their peers, do not have the opportunity to be consultants as there is no such grade in this country. The Government indicated that it would address both of those points. What is the status of that? Ms Clyne said that 180 consultants were needed. What is happening about creating the consultant posts and expanding them to the level required?

I have a question for Professor Irvine if there is time. I would not disagree that serious mistakes were made in cutting consultant pay by 30%. It was a real slap in the face to new recruits and has done much damage. If he has time, will he tell us the other factors that discourage people from staying to practise in this country such as culture, career prospects and working conditions, which various surveys have told us discourage people from staying here after training? What action, if any, is being taken on those issues, which I think are probably equally important as pay, which is undoubtedly a major factor?

Ms Susan Clyne

I will speak on the public health consultant issue. The Deputy is correct about public health doctors. People were very unaware of public health and all of a sudden the whole nation has become public health experts. In 2003, around the time of SARS, public health specialists had to resort to industrial action. We have 60, and it is a mainly female workforce, who are not consultants yet are expected to lead teams to deliver the care. Recently we had a meeting with our public health members. They unanimously decided that if the Department and the HSE did not progress this matter they would have no option but to take industrial action. The Department and the HSE have both confirmed that they would address it, and the Minister confirmed that to the Covid committee. However, we have not yet had an invitation to the Department for any serious talks. These people are absolutely on their knees with exhaustion. Most work seven hours a day, have little or no cover, and have very few support staff. Both the winter plan and the budget anticipate that support staff will be hired in but there is no definitive commitment to award consultant contracts to the 60 people who are already there and at least increase the numbers to 85 immediately, increasing it to a similar level as Scotland or New Zealand over time. These public health doctors, no more than other consultants, are like gold dust - every health system wants them. Our people are being recruited into the UK, particularly Wales and Scotland, where they are told they can work for the NHS but do so from Dublin. They will not have to leave Ireland while they work for another jurisdiction. It is so galling for them. They are managing all the outbreaks in every residential centre, in schools, in work places and they have to train up the contact tracing teams. We have seen the problems that have arisen with contact tracing over the weekend. There are just too few of these positions and way too much is being asked of them. There is absolutely zero respect being shown to them. Politicians, and many others, are busy thanking public health doctors, congratulating them on all their efforts, yet they are having no meaningful engagement with them to sort out this contractual issue which has been very long standing. Furthermore, there are not enough trainees. Career prospects for this specialty are so poor that there are not enough trainees in the system to match the numbers retiring out of the system.

Ms Phil Ní Sheaghdha

I thank Deputy Shortall for her question on public health nursing. The capacity report recommended that we increase the number of public health nurses by 700. We are going backwards. We have 40 fewer public health nurses now compared with December 2019. We need to increase the training places and we need to greatly improve the circumstances of employment. Community general nurses are supporting public health nurses in the community. As I said, they do not have a facility for waiting lists but they tell us. For example, they have responsibility from a new mother coming home with a baby, where they will make the first visit and undertake domiciliary care for a few weeks where they go into the home and provide the care. They do the same for those who require palliative care, who have chronic disease and require management in the home, and they also run immunisation clinics and so on. They have a very wide job description.

We are not training them in sufficient numbers. Something we could do quickly would be to expand the training places. There are 13 institutes of education in Ireland that provide undergraduate training but only four areas that provide public health nurse training. Because it is a postgraduate qualification, people are established where they work. There should be encouragement for people to go to their nearest educational institution and where they would be provided with postgraduate public health nursing education in all the 13 institutes of education, as well as undergraduate training. That is something that is sensible and could be done quickly.

We should also encourage those who wish to access public health training. We need to give them a break so that for those who have worked in the community and are familiar with how the community works, the time required on the public health nursing higher diploma would be reduced. These are two small things that we think would assist immediately in increasing the numbers working in those categories.

Ms Clyne and others might also want to comment on structures. We are being told that the HSE is restructuring the community. Various committees are looking at how the community will be structures from the perspective of management and governance. It is interesting that nursing is not being consulted largely in that. Public health nurses and nurses who work in the community have made a massive contribution and will continue to do so. We need to seriously look at how we align the managerial function and the community with the clinical responsibility and advice. We saw it during the pandemic when we saw public health nurses coming to the fore -----

We are way over time.

Ms Phil Ní Sheaghdha

----setting up testing centres and so on. That has to be part of the management structure into the future.

There is no time for Professor Irvine to respond but he might give Deputy Shortall a written reply, if that is acceptable.

Professor Alan Irvine

Okay.

I wish to ask Ms Ní Sheaghdha about advanced nurse practitioners. There was brief reference to it in her opening statement but not a great deal. My question has three parts. What is the status of the 2% target of advanced nurse practitioners? We were just talking about public health nursing and how we can optimise that through postgraduate qualifications, bursaries and more local access to those types of courses. Are those things a factor in reaching that 2% target? How is the creation of nurse practitioner posts impacted by the Covid crisis?

Ms Phil Ní Sheaghdha

We have a target of 700 advanced nurse practitioners.

We are about halfway with that, at just over 300 at the moment. Funding for advanced nurse practitioner training has been committed to us as part of our strike settlement. In response to an earlier question from Deputy Durkan which I did not answer, we are waiting to see how much that budget allocation will be because we have not been advised about the allocation of that money as yet. We have been given information regarding the allocation of funds for the winter plan, but not concerning funds from the budget in respect of specific nursing posts.

We are looking to the Department of Health to ensure that the target of 700 is met and met on time. In addition, we have a requirement for clinical nurse specialists. They train in Ireland, and up to about five years ago there was a body to register and accommodate training. That has now been removed, and clinical nurse specialists find it very difficult to get employment, as clinical nurse specialists, when they move from place to place, despite having the qualifications. A tidy up needs to be done, therefore, but there is also a need to look at the roles and expertise of advanced nurse practitioners.

We know that where and when they work, for example, their statistics regarding hospital avoidance are quite extraordinary. It is the same in respect of our community intervention teams. We are very glad to see that there is some focus on community intervention teams for hospital avoidance in the winter plan and we must ensure that translates into additional clinical nurse specialists and advanced nurse practitioners in the community, and not just focusing on hospital settings.

I thank Ms Ní Sheaghdha. Advanced nurse practitioners in a community setting, particularly in the context of long-term chronic illness, have excellent outcomes and are important.

I will return to some of the discussions regarding consultant contracts, if I have enough time. One of the earlier speakers referred to the type B, public-only contracts. I was glad to hear that because I had gone looking for a mention of it in the submissions, but not found it. I thought that as a new Deputy I might have been missing something. In December 2019, the band for that contract was outlined by the then Minister and the then Taoiseach in the Dáil as being between €180,000 and €222,000, rising to €252,000. Specialists agreeing to take up a public-only contract will make that one of the highest rates in the OECD area.

This would not be a new contract insofar as Sláintecare included this kind of a contract idea in the 2017 report, and it was also mentioned in 2019 in the de Buitléir report. I was surprised, therefore, that it was not mentioned in the submissions. If we are looking at having one of the highest salary rates in the OECD for a public-only contract, and that is not acceptable to consultants, what does that mean for the future of Sláintecare?

Dr. Matthew Sadlier

I will make some points on this question. The category B contract is the one which allows for a certain limited amount of private practice. I think what Deputy Hourigan is referring to is the category A contract, which has no private practice provision and is a public practice only contract. Heretofore, that has largely been concentrated in several specialties. It applies to about 20% of consultants, but those are largely concentrated in emergency departments and psychiatry. The salary scales referred to by the Deputy are for people employed pre-2012, and not those after that date. If somebody took up a category A contract now, for example, that person would not be on that salary scale.

What would the salary scale be now?

Dr. Matthew Sadlier

It would be 40% lower, while the salary of a colleague appointed before 2012 is on that salary.

Is it €210,000?

Dr. Matthew Sadlier

No, it is less than €210,000. It is a scale with nine points, so if somebody were to be appointed on that today, he or she would not reach the top of that scale until 2029, and that top rate is less than €200,000. I think it is in the region of €190,000.

I missed that number, I am sorry. Is it a salary somewhere in the region of €190,000?

Dr. Matthew Sadlier

The salary of €190,000 is at point nine of that scale for someone appointed post-2012. The Deputy is referring to what has been suggested multiple times as the Sláintecare contract salary scales. That has not happened, however, for anybody appointed post-2012 and we are still offering the contract today.

This is not so much about the quantum of money. I was appointed in December 2012, so I just got in at the very start of this process. My point concerns people working in a job side-by-side with other people who have identical responsibilities, hours and levels of stress and pressure but who are earning 40% more. As Ms Ní Sheaghdha pointed out earlier regarding the similar nursing situation, this cut was on top of the 10% cut. In reality, therefore, the vast majority of people on the new salary scale are being paid 40%, not 30%, less than their colleagues.

With respect, is Dr. Sadlier saying that the public-only contracts will not be acceptable?

Dr. Matthew Sadlier

Deputy Hourigan is using the future tense, but I am talking about the current situation. There is a little bit of confusion here regarding what has been suggested and the reality.

I am using the future tense because we are trying to implement the Sláintecare process, so I am trying to understand what this disconnect means for that process because the future of healthcare in Ireland is in the public system.

Dr. Matthew Sadlier

Yes, but we have not yet seen a Sláintecare contract. There have been multiple suggestions, but nobody has offered a contract. The reality now is that a person employed in the morning on a public-only contract will have a salary scale with nine points. The top of that salary scale is roughly €190,000, perhaps €193,000, but I cannot remember exactly, but that will be 40% less than colleagues appointed before 2012. I think Professor Irvine might want to comment as well on this issue.

I ask Professor Irvine to be brief.

Professor Alan Irvine

I do not think we should get too distracted by soundbite headlines regarding large sums of money being released. When Sláintecare was devised, the IHCA, which represents 3,200 members, was not invited to present to the committee. It will be interesting, therefore, as we roll out Sláintecare and I think we will need better engagement with people who represent future colleagues to fill these vacancies. These contracts must be flexible, multifaceted and locally delivered. There will not be a single silver bullet contract that will fill every vacancy in every discipline that we need filled in our health service.

I have two sets of questions. I thank everybody for their contributions. My first question is for Ms Clyne and it concerns non-EU doctors. They now make up 53% of all doctors and more than one third of doctors in the health service are trained abroad. Those doctors are highly trained and highly motivated, but there seems to be a glass ceiling for them regarding career paths and achieving better prospects in the Irish health system. Will the proposed change in the legislation under way in the Oireachtas, and which will be implemented in June 2021, make a difference to that set of doctors? I ask that because the submission from the IMO referred to the major shortage of consultants in the Irish health system. At the same time, however, we also have this cohort of highly educated and highly motivated doctors who seem to be discriminated against. Will Ms Clyne please comment on that aspect?

Ms Susan Clyne

I will make the general comment that it is unethical for Ireland to be recruiting so many doctors from countries that need those doctors to look after their own populations. A better system is one where doctors move around countries to get enhanced training but then return to their home country to practise, in the majority of cases. The WHO and the WMA, therefore, will state that this is an unethical practice anyway and that we are depriving other healthcare systems of much-needed health professionals.

That group of doctors who come here, however, do not really want to stay here because they have not been able to access the training posts. While the recent legislation, therefore, is helpful in that it gives them some access, they are merely competing with a greater number of doctors now for the same number of training posts.

That move is not going to help with our medical manpower shortage in any way. It will not make a jot of difference or fill one additional post. Non-EEA and non-EU doctors have been treated very poorly. They mainly emigrate from Ireland quite quickly because they are treated badly. To see them as an answer to the consultant shortage would not be a correct interpretation of the situation.

Consider what we could have done since the Covid-19 pandemic, apart from all the normal planning based on previous reports. In July of this year, several specialist registrars, SpRs, had finished their training and were ready to take consultant posts. We asked the HSE to offer each and every one of them a temporary consultant contract. This was denied. We now have a situation where highly qualified and trained SpRs are working as registrars or are doing locum work. It is an absolute disgrace. We do not value any of our doctors, whether they are Irish-trained or non-EEA doctors. We are very appreciative of all the work these doctors have done to prop up our health services, but it is wholly wrong and completely unethical to allow such an over-reliance on non-EEA doctors.

I would like Ms Ní Sheaghdha to comment on student nurses. They are working as de facto care assistants. Due to the Covid-19 pandemic they are not allowed to take second jobs, which presents a huge financial burden. How does Ms Ní Sheaghdha feel about the exploitation of student nurses in the health system at this time?

My second question concerns infection rates among healthcare workers. Ms Ní Sheaghdha said 50 nurses are having to stop work each week. If that continues the Irish health system will be in serious trouble. What provision can be made to prevent a tipping point from being reached?

Ms Phil Ní Sheaghdha

I thank Deputy Kenny for those questions. We have commented on student nurses already in this hearing, but it is important to state that we strongly believe that they are being exploited. There is a shortage of nursing and midwifery grades. Student nurses are now rostered for the clinical placement part of their training. They are being used to fill gaps without pay. It is as simple as that. We strongly believe that payment is the very least they can expect. We do not advocate unpaid work for anybody in our health service. In the middle of a pandemic, when every other student in the country is being told to stay at home and take classes online, student nurses are being told to come in to work in these wards. Not only are they not paid for that period, but that work costs them money. Just like any other students, they usually have part-time jobs to supplement their incomes. Once employers hear that an applicant is a student nurse working in an acute hospital they do not want him or her. That is a secondary problem student nurses now face.

We do not want the situation in nursing to reach the point where these students have to leave. They simply cannot afford to pay for accommodation in cities like Dublin or Cork, where most of the training places are located. They work 12-hour shifts in many instances, with work expanding beyond the normal shift pattern. I can find no other word but "exploitation". We met representatives of the Department of Health last Friday and outlined these concerns. We have appealed to the Minister and we have appealed to the public to support the student nurses in their campaign to get proper remuneration for what can only be described as work.

The HSE figures indicate that 50 nurses are becoming infected each week. That requires a period of absence of 14 days at a minimum. Many nurses are telling us that the post-Covid-19 infection period can extend to 16, 17 or 18 days or even longer. That creates a huge gap in the roster. We must have proper occupational health facilities in place. I am not talking about a free counselling helpline or a text message asking nurses if they are okay. We are allowing health service staff who have been in close contact with patients to return to work if they are asymptomatic. We know too much about this virus to risk that. Not having a routine testing regime to accompany that policy creates a risk for others who come in contact with that person. We have to test in acute hospitals and ensure that we identify asymptomatic cases. We must provide greater protections, in the form of testing, for those who work in our acute hospitals.

I apologise for being late. I was listening to the hearing from my office before taking my seat. Ms Susan Clyne's submission states that "[f]or young GPs seeking to establish themselves in a new community, the initial investment costs in premises, equipment, IT systems, insurance etc ... are particularly prohibitive". How do the primary care centres that have been built in different areas fit into that picture? Do they alter the situation?

I have previously spoken to this committee about Westdoc Limited and the underfunding that is evident in certain areas. I am not referring to the most rural areas, but to those in close proximity to Galway city, such as Moycullen and Oughterard. How offputting is the inability of Westdoc Limited and comparable groups throughout the country to recruit and retain GPs?

Ms Susan Clyne

Whether they go to a primary care centre or a centre of another kind will make no difference to younger GPs trying to establish themselves. They will still have to pay the rent and all the associated overheads. That does not really help matters. If the HSE is going to invest in primary care centres I urge it to act in consultation with GPs in the area. There is little point in building a brand spanking new primary care centre if ten GPs have already built centres in the area. That would simply be a waste of resources.

Whatever about current GPs and older GPs, who are used to being on a 24-7 contract, young GPs will simply not accept that general medical services, GMS, contract. Nobody is going to accept a contract under which they have to be available all day, every day. To a large extent, GPs fund out-of-hours services from their own resources. Out-of-hours services face problems throughout the country. They are getting busier and busier, particularly in these times. We need to separate the issue of funding for out-of-hours services. That should not be the responsibility of GPs. Responsibilities are much heavier in more rural areas, which disincentivises younger GPs from establishing themselves there. We need to look at ways to help GPs establish themselves financially over a period of time. They need some income certainty in that period of time. We also need to help existing GPs who are going to retire to take on these younger GPs and transfer practices with reasonable financial models. We need to grapple with the out-of-hours system. It is absolutely ridiculous that GPs are expected to pay for locums to work red-eye shifts. Most GPs work until 8 p.m. or 10 p.m. on the out-of-hours rota. The red-eye shift from 8 p.m. to 8 a.m. is effectively funded by GPs themselves. A 24-7 contract is not sustainable.

I thank Ms Clyne.

My next question is for Professor Irvine. The year 2012 was a different world, and whatever justification was there at the time, and there were plenty of justifications, I do agree that it is time to look again at that. I will certainly advocate on behalf of the Irish Hospital Consultants Association. Professor Irvine has comparatives to the pre-2012 salaries for Australia, Canada and the US. How does the public-private model fit in there around consultants working in the private sector as well, or is that excluded under those jurisdictions?

Professor Alan Irvine

In Australia, for example, it is quite common for people to predominantly work in the independent sector and do two or three days per week in the public sector. That is the dominant model in Australia. I am less familiar with the model in Canada but the remuneration, terms and conditions, and supports are different. There is also availability of operating lists, of outpatient suites and of the whole multi-professional support. Doctors are not islands, they work in highly skilled teams. Nurses and other healthcare professionals are essential and have enough support around those also. There are lots of differences around the anglophone countries. North America and Australia are the really only relevant comparators. That is where we tend to lead people. One would need to break it down by region. Certainly, the model in Australia is a very mixed, blended model. The remunerations in the United States of America are just off the scale and we are not going to replicate those necessarily in Ireland. We do, however, have to find our own way to bring people in and that means listening. As I said earlier, we have to listen to people rather than just present them with the take it or leave it option. That has failed and is failing, and it will always continue to fail if we take that approach.

I will whizz through seeing as my time is being cut short. Deputy Kenny raised the issue of non-EEA doctors in the system, and that they cannot access consultant posts. If one was to take out the effective embargo on the number of people who can be hired, is there capacity in the system with those doctors to try to make fairly decent headway into the shortage outlined? Reference was made to the issue going back as far as education and that we are just not educating enough people in certain areas. What kinds of numbers do those non-EEA educated doctors make up, if there was no block on how many could be recruited? Would that make any decent headway into the shortage in numbers?

With regard to the recruitment plans for the high-level wholetime staff equivalents for the winter plan, under the heading of nursing midwives, managerial and administration I see that the HSE has proposed employing only 101 more nurses. Surely this has to be questioned. The overall recruitment goals, and not just for nursing, possibly need to be questioned. Based on the presentation the committee has had this morning these numbers seem wholly unrealistic. What do the witnesses say to this? What impact will this have on healthcare provision overall?

Student nurses are doing unpaid work, which I believe is absolutely and utterly unseen. Student nurses are contacting me every single day, including a nurse working on a Covid ward who is not being paid. It is absolutely and utterly disgraceful that nurses on Covid wards are not being paid. I wrote to the former Minister for Health, Deputy Simon Harris, and the Minister for Health, Stephen Donnelly, on this matter. I have heard diddly squat about it. I am aware that the Union of Students in Ireland have lobbied on this and they too have heard diddly squat on it. Ms Phil Ní Sheaghdha has said that the Irish Nurses and Midwives Organisation has engaged with the Department. Does Ms Ní Sheaghdha believe that anything is actually going to happen or are we all going to continue to clap for these student nurses and hope for the best? What sort of engagement has the INMO actually had and is there any genuine intention to deal with this issue?

Dr. Matthew Sadlier

I will deal with the non-EU and non-EEA doctor issue. It is a very complicated issue because one can divide doctors from that category into non-consultant hospital doctors and consultants from those areas. When we focus on the non-consultant hospital doctors the problem is that they are not able to access the formal training. The IMO brought up this issue as far back as 2008, and it has taken 12 years give or take for the State to solve this problem. They can work in posts in Ireland and can work beside somebody who is in a training position. They are getting the same experience and often getting the same education and the same level of competence as that person, but because of a legal technicality they have not been able to have that experience and education recognised and thus have not been able to achieve the certification to say: "I am a fully trained specialist". That is their difficulty. Ultimately, this leads to those doctors having a problem in getting a consultant post because in order to get a consultant post one has to be a fully trained specialist.

On the issue of whether there are enough doctors in the system to fill vacancies in the consultant posts, if we were to increase the number of consultants to get to where we should be at, which is increasing the number of consultants by about 2,000, the answer is "No". This is because these doctors, unfortunately, have not been able to get the certifications to be able to take on these posts. As Susan said earlier, there is also a massive ethical problem with countries in the western developed world continually relying on importing healthcare staff, specifically doctors who are being trained in the developing world where we know there are huge heath needs. The solution here is that we need to have more training places overall; allow those training places to be open competition for doctors, irrespective of what country they trained in; and, increase the numbers of doctors we train in the State so that for every doctor who takes an Irish training post there would be an Irish doctor taking a training post in another country.

The history of medicine has always relied on doctors travelling to different countries either for training posts or for long-term posts for that cross-pollination of ideas and academics.

I thank Dr. Sadlier. Perhaps Ms Ní Sheaghdha could come in now as we only have a few seconds left.

Ms Phil Ní Sheaghdha

On the issue of student nurses the INMO met with the Department of Health last Friday. We put a proposal to them and the Department has confirmed they will revert to us this week. We await their reply on that. Our proposal is very simple. At our conference last Friday week the Minister confirmed that a review will be conducted of the undergraduate payment scheme in general. That was promised by the former Minister, Deputy Harris in 2019. The Minister, Deputy Donnelly, has confirmed that the review will be completed within the next month. In the immediate term, we have sought payment. It is work, but unfortunately the students find themselves in very busy wards in very busy workplaces where staff are reduced and the qualified staff members are reducing. The students are being used to fill gaps, as I said earlier. It is the view of the INMO that these student nurses need the protection of a contract and they need to have the protections of all other workers in those environments in the event that they get sick, which I hope they do not.

Ms Ní Sheaghdha might come back to the committee on the report the INMO will get from the Minister, Deputy Donnelly, on the student nurses.

I thank the witnesses very much for all their contributions. My first question is for Ms Clyne. Ms Clyne has said that GPs need a lot of help establishing themselves. Obviously it is a huge question, but generally what is Ms Clyne's view on GPs being employed directly by the State? I am aware that a lot of young GPs do not want to pay rent, rates and staff. I know it is a very wide question.

My second question is to Professor Irvine on the many people not attending their physicians at this stage because of Covid, and waiting until afterwards with any ailments they may have. In light of the huge waiting lists outlined in his submission, how worried are his members?

My third question is to Ms Ní Sheaghdha, and follows on from Deputy John Lahart's suggestion on childcare. Ms Ní Sheaghdha said that in London designated schools and crèches are being kept open to facilitate front-line workers in the event that crèches and schools are closed. Is that a particular request of the INMO? Deputy Lahart suggested that we could bring this to the parliamentary party meeting tonight, and directly to the Taoiseach and the Minister. Perhaps I could have Ms Ní Sheaghdha's view on that also.

Ms Susan Clyne

I will address the question on GPs. The independent contractor model works very well in general practice and can really deliver for patients.

At the moment, however, the self-employed contractor model is very expensive for younger GPs to get into. It is not correct to say that GPs are not currently employed. GPs all over the country are employing other GPs, they just get no support to do so.

I am saying they are not employed by the State.

Ms Susan Clyne

As regards being employed by the State, we have seen how well a two-tier system has worked in the consultant area. We could not immediately introduce a two-tier system in primary care. Where would the State employ GPs? Is it going to run centres to which the GP would go to work? That is not the current model.

I am asking why the Irish Medical Organisation would not consider changing the model. What is its view in that regard?

Ms Susan Clyne

Our view is that the independent contractor model works and that GPs need to be supported. The State needs to support new GPs in establishing practices. In the UK and other jurisdictions, the State assists with the costs of establishment and the ongoing costs of running a practice. It must be remembered that only 50% of the population are covered by a medical card or GP visit card. General practice is a mix of public and private and, therefore, the independent contractor model is what works best. It delivers well and has huge satisfaction ratings. The younger GPs, however, are not being supported. The surveys will show that many young GPs do not want to take on the responsibilities of running a business immediately on completing their training. As they progress through their careers, they become more inclined to do so and are happier to do so. At the point at which they have just completed training, they need to be able to go into an established practice to get a feel for how things are and to be supported in that practice. When and if they decide to set up their own practice, they need a pathway to assist them with establishment costs.

Can I suggest-----

Professor Alan Irvine

I thank the Senator for her question on patients with symptoms not presenting. It is really important and is a cause for concern for our members. Many members are saying they are not seeing the volume of people presenting with colorectal or other cancers that would normally be expected based on year-on-year averages. That is definitely the feedback we are getting. It is an important message to get out. There is no question but that we are in the second wave of the pandemic but it is not April. The health service is better prepared. People who have urgent symptoms will be seen and assessed and should present to their GPs, possibly remotely if that is the safest way to proceed. They should also subsequently attend their appointments if they have new symptoms. We want those people to come because we simply do not know how long this phase is going to last. Nobody does. It is not predictable. People with urgent symptoms need to come and have them investigated and treated. Time-sensitive cancer care remains in operation, as does time-sensitive care for heart disease. We want these people to present. The hospital environment has been made safe and accommodating. People are much better at dealing with this than we were in April. We had to learn a lot in April. Services effectively shut for non-Covid work. There was a huge burden on us. Those services are not going to shut again. We cannot afford to let them. People should and must present. It would be welcome to see them.

Perhaps Ms Ní Sheaghdha could tic-tac directly with Deputy Lahart and Senator Ardagh with regard to the childcare elements of their questions.

I thank all the witnesses for their submissions. While I was aware of the pressure on our health workers, I have learned a great deal today about just how bad that pressure is and about how indebted we are to our front-line workers. Thanks are important but they are just not enough. If gratitude is to be given meaning it should lead to an overdue reassessment of who we value most in society and how we treat them. It should not take a pandemic to expose how poorly paid, insecure and badly treated many healthcare workers are. Society cannot function without them.

I have one question in addition to making that point. In Ms Ní Sheaghdha's submission, I read that research has shown that front-line hospital staff and other key workers have a higher chance of experiencing mental health difficulties during the pandemic. We know the Covid-19 pandemic has created stressful working environments for many people. I want to again highlight the disgraceful treatment of student nurses who are exposed the dangers of Covid-19 without any payment at all. This must be corrected.

I also have a question for Ms Ní Sheaghdha. It relates to the impact of the pandemic on the mental health of healthcare professionals, particularly nurses. What supports are needed to address this problem? I thank all of the groups represented for their fantastic work in looking after the most vulnerable in our society.

Ms Phil Ní Sheaghdha

We surveyed our members very recently. I do not believe they are out of kilter with healthcare workers throughout the world. The response rate was very high at nearly 3,000 and nearly 82% of the respondents said that Covid-19 has had a negative impact on their mental health. That is not surprising. It is consistent with the findings of other nursing unions across the globe with which we tic-tac all of the time.

The World Health Organization, WHO, says that exposure time must be reduced. In other words, if I work on a Covid ward, I need to be relieved from work on such a ward and from constantly wearing personal protection equipment, PPE, and to be assured of sufficient rest time to recover before coming back in to face it again. That is not happening because we are very short-staffed. We know of instances of nurses across all age groups from students to those who are very close to retirement who must wear PPE constantly for periods of six hours before getting a break for hydration. One of the simplest things to do is to ensure that nurses finishing a tour of duty have a set period of time, paid for by the employer, to provide relief and to ensure they can look after their own physical and mental health. This is a very difficult environment. One gets very warm when wearing PPE. It is very restrictive.

Nurses, doctors, speech and language therapists and all other healthcare workers are doing their best to be innovative with regard to communicating with clients. It is amazing what healthcare workers have done in trying to communicate and get messages across to patients who are intellectually disabled right across the sector, from acute hospitals to community settings and long-term care. One of the things coming across is exposure to lonely patients. I refer to patients in the community, particularly the elderly in nursing homes, who no longer receive visitors. The healthcare workers are now doubling up as their main mental and moral support. That is fine if a centre has enough staff to provide the required time but staff are feeling guilty because they do not have enough time to spend with these patients. Of course, there is mental anguish. We hope not to see a staffing crisis that is even worse than it was going into the pandemic. We can do things to prevent that.

Dr. Matthew Sadlier

May I jump in on this? As I have said, I work as a psychiatrist within the public hospital system. The pandemic has exposed significant gaps in our mental health services. The percentage of our total budget we spend on psychiatry is one of the lowest in the world. I echo what Ms Ní Sheaghdha has said. By profession, I am an old-age psychiatrist. My day job involves me going in and out of nursing homes and visiting people at home. Isolation and loneliness has been a very significant issue during this pandemic, especially for the elderly. I welcome the introduction of the concept of the support bubble within the level 5 restrictions. It was a very good late addition and may help to offset some of the problems we saw during the first wave of the pandemic.

We need better integration of community psychiatry and acute hospital mental health care. The division of psychiatry out into the community comes with the side-effect of reducing the supports available to the general hospital system in places. This needs to be seriously thought about. Liaison psychiatry, the special type of psychiatry in hospitals, needs to be better resourced because not only does it provide care to patients within the hospital, but having a good and well-resourced liaison psychiatry department within a hospital provides a resource for the staff of the hospital. It is able to look at matters such as psychological first aid, a programme we ran in the Mater hospital in Dublin, and other such initiatives to support staff. If the staff's mental wellness can be supported, we can prevent mental health problems developing.

If we can stop it becoming a mental health problem then we can prevent it becoming a mental illness problem. There is a gradated system from wellness to illness that happens in all parts of the body but specifically with regard to mental health, we have look at the integration of community and acute hospital care.

I am sorry but we are away over time. We are going to establish a sub-committee on mental health so maybe we will be able to return to this issue at some stage in the future.

Dr. Matthew Sadlier

That would be very useful.

We are over time but before we finish I will allow Deputies Burke and Crowe to pose a short question each. If they have several questions, however, we will have to ask the witnesses to respond in writing.

I will be very brief. What changes do the witnesses want to see with regard to specialist registrars and their training, as well as junior doctors? I would appreciate a written reply on the changes they would make in order to assist people who are in that category. There also seems to be a lack of understanding around consultant contracts. A lot of people do not understand that a lot of consultants under contract are on a one-in-three or one-in-four rota. That means that they work all day, every day, five days a week and are on call every third or fourth night as well as being on call every third or every fourth weekend. There are even consultants on one-in-two rotas. There is a lack of understanding among the public about that.

The other issue that we need to understand is that under the current category B and category C contracts consultants, who number about 2,000, have about 2 million appointments per year outside of their work for the HSE or within the public system. If there are 3.5 million outpatient appointments annually, this means that if we bring everything into the public sector, we will have to see a huge expansion very quickly.

Another issue I want to raise is the challenges facing GP trainees. As I understand it, there are currently around 5,000 GP vacancies in the UK. The IMO referred to the fact that the training of doctors needs to be modernised. Could we get a written submission on what modernisation is being referred to here? I ask them to include a response on the number of additional GP training places we need. I was speaking to a GP last night who told me that one in eight GPs is over 65.

I ask the witnesses to provide written replies to those questions. Deputy Crowe is next.

My first question is for Ms Ní Sheaghdha. She referred to inadequate staffing in her presentation. Does that break down on a regional basis? I am specifically interested in the mid-west region. I am a Deputy for Clare and over the past two or three years, the trolley crisis has been at its worst in my region. I would welcome a brief response on that.

I have a question for Ms Clyne on international recruitment. I have recently been helping an individual who I do not want identify, except to say that he would be a key individual to recruit into the Irish system, but have come up against a barrier which has not been mentioned today, namely problems with securing a visa from the Department of Justice and Equality so that his family can accompany him here. He has a young family and will not come here until they can come too so because of an administrative delay, patients are losing out. My point is that there are barriers other than those already referred to by the witnesses.

Finally, the Hanly report identified the need for 3,600 consultants by 2013 but now the estimated requirement is approximately 4,500. One can make an analogy with premiership soccer. There was a time when a decent soccer player would play for any club and be proud to do so but now players only want to play for the London clubs and northern English football has suffered as a result. There is something quite similar happening with consultants in Ireland. They do not want to come west of the Shannon. Endocrinologists, neurologists and all of the other specialists needed west of the Shannon in places like Ennis and University Hospital Limerick are not coming. I ask Professor Irvine to elaborate on the other barriers that exist beyond the issue of pay which he well articulated earlier. I think there are unwritten and unmentioned barriers, many of which relate to the unattractiveness of leaving Ireland's cities.

I will give the witnesses a minute each to reply because we are really under time pressure.

Professor Alan Irvine

I will take the question on recruiting to the west of Ireland. We would argue that we need to decentralise the recruitment process. It is overly centralised at the minute and our view is that the people in Clare, Limerick and Galway know best how to recruit people into their system and should be given the flexibility to do so, including with regard to contracts. It should not be a centralised, one-size-fits-all model because that definitely gets in the way of people moving to those locations.

Ms Phil Ní Sheaghdha

As I said earlier, there are 125 nursing vacancies in University Hospital Limerick. The hospital is trying to open 90 additional beds but it has to fill the existing vacancies before it can start staffing those beds.

There is a great university in the mid-west as well as institutes of technology in Tralee and Castlebar. They should be running postgraduate courses for nurses in public health nursing, intensive care nursing and so on. More postgraduate courses for nurses should be provided locally so that nurses do not have to move back to the big cities to further their education.

I agree with Professor Irvine that the recruitment process is overly bureaucratic and overly centralised. It needs to be at the level of the hospital and community directors in order to speed it up.

Ms Susan Clyne

There are many barriers to recruitment across the country, in the cities as well as west of the Shannon but unless the Department and the HSE sits down with us, listens to us and resolves these problems, they will get worse. That is just a simple fact. It is not always about money. Doctors and all other healthcare workers want to be able to work in a system that allows them to do the job for which they were trained. It is time to sit down with us and work through these issues. We raise them at this committee and similar fora all of the time but nothing happens. The culture and attitude of the Department and the HSE to the medical profession has to drastically change.

I thank all of the witnesses for their helpful engagement this morning and apologise for cutting them off. We are trying to operate under a crazy system. I wish them well. If there are specific issues that were not addressed during the meeting or questions upon which they would like to elaborate further, I urge them to write to the committee.

The joint committee adjourned at 1.38 p.m. until 11.30 a.m. on Wednesday, 4 November 2020.