I thank Senators for raising this issue and for giving me an opportunity to make a comprehensive statement on medical and nursing staffing difficulties.
I have listened carefully to the contributions of Senator Henry and other Senators. Politicians and the general public must decide whether or not we accept regional statutory health authorities. The Government has been condemned this evening. Regional health authorities were established in 1970 with statutory powers to do certain things about which people are now complaining. The regional authorities are responsible for manpower and human resources. I do not condemn management at local or regional level but there is confusion on this question. Everyone wants the Government to take responsibility for matters, yet everyone loves the idea of regionalisation and trumpets the cause of regional authorities and the need for them. However, I am still asked parliamentary questions about why someone in Castlebar is waiting for an ENT procedure, for example. It is time we decided whether we want a regional approach to the health service or to have all power retained at the centre. We cannot have it both ways.
Senator Henry rightly asks where I get my information regarding the shortage of consultants and their recruitment. I do so by liaising with health boards. Structures of communication between the players in health boards are not satisfactory. Consultants tend to make statements to the medical press. I have often asked people who complain about situations if they have spoken to their health board on these matters.
I was in Mallow hospital last week to discuss a range of issues, particularly the expansion of the hospital. Many people still fear that hospitals will close as they did in the 1980s. It is no longer Government policy to close hospitals. Its policy is one of expansion. However, if a particular area of a hospital is changed, perhaps because of developments in Cork University Hospital, local people become defensive and fear that their hospital will close. There is a reluctance by major players in the health service to engage, even with the local or regional health authority. I stressed to those I met in Mallow that they must engage with their health board. They cannot demand that the Minister solves their problem because they do not wish to talk to their health board.
Progress has been made on the issue of medical examinations. The Medical Council is a statutory authority established by the Oireachtas to make recommendations to the Minister and to do certain work, yet the Minister is asked to intervene and tell the Medical Council what to do. The same applies to Comhairle na n-Ospidéal. Senator Henry has more experience of the comhairle than I. When people do not like what the comhairle tells them, in terms of where consultants should be appointed, they ask the Minister to intervene. There is a reluctance to accept that statutory bodies which have been established to do certain tasks must be allowed to do them.
The Medical Council was set up with great care and given clear functions with regard to the medical profession. Any Minister must be extremely careful not to undermine its statutory independence. I have had consultations with the board of the Medical Council on a number of issues and we have agreed to have ongoing consultations so that its professional development and training remit can be fulfilled while its impact on services in the short term is recognised. This problem deserves to be ironed out. Statutory health bodies have been established and given clear functions. We must acknowledge that.
Investment in health in the past three years amounts to £4.1 billion, although that figure means very little to patients or to people attending accident and emergency units. The hierarchical structure of hospitals has changed little in the past 100 years, despite much change in health and society generally. Hospitals retain the old hierarchical structure of consultant, registrar, house officer and intern. We must change and reconsider what we are doing. The medical manpower forum was not established by my predecessor to while away the time. Delays are regrettable but the forum will deal with issues which must be agreed by all sides and critical issues are outstanding. The medical manpower forum was established to investigate medical staffing in our hospitals and bring forward recommendations.
One of the reasonable expectations of a patient entering hospital is that he will be looked after by medical and nursing staff who possess the skills and experience necessary to undertake the task. The medical manpower forum was established to focus on addressing the imbalance in hospitals between career posts and training posts, the need to improve postgraduate medical training to keep more Irish medical graduates in the country and the need to provide the highest quality of medical care for those who require the services of hospitals.
At present there are approximately two junior doctors for every consultant employed. Non-consultant hospital doctors regard career prospects as poor and many emigrate. Young doctors tend to leave at the point where they have just acquired the skills and expertise and are ready to make a real contribution to Irish hospitals. Women doctors also leave the system and there is a need to examine the reasons why this is happening so that solutions can be found to facilitate the optimum use of their skills and develop training structures to accommodate their needs. I am not happy to preside over such a system and I intend to make major changes in the way hospitals are staffed. Other areas which require attention are the different needs of larger and smaller hospitals, combining other disciplines with medical staffing, general practitioners and nurses, and coping with the demographic changes which have occurred in Irish society.
The Medical Manpower Forum, in association with the various medical interests, will address longer-term contracts for non-consultant hospital doctors. I want to give greater certainty to young doctors as to where they will be working and what they will be required to do. A system of structured rotations that includes training in the larger teaching hospitals as well as smaller general hospitals will give young doctors a broad range of experience and make them fit to fill posts as consultants in the Irish health service. Other concerns include revised arrangements for medical training and the need to take the requirements of women into account. There is much to be done here and I am anxious to progress with agreed improvement and make greater provision in the system for the needs of women.
Institutional structural reform is needed to allocate clear responsibility for ensuring the quality of training in Irish hospitals. There is a need to place more fully trained doctors in our hospitals. This is especially true of night cover and at weekends.
The Medical Manpower Forum seeks to propose policies that maintain and improve patient care while providing a satisfactory working environment and career structure for all hospital doctors. While the forum is expected to advocate an increase in the number of doctors and consultants, major changes are recommended to the structure of training for NCHDs as follows: each hospital should have a training strategy and there should be development of training partnerships with UK and US hospitals, with accreditation of training placements abroad, with training structures and opportunities made available in modular form, both full-time and part-time, forming part of an overall professional development structure that also meets the needs of nurses and other grades of hospital staff. The report will address the need for improved medical education.
Other changes recommended include advocating the development of new training structures which allocate protected time to research, an important issue, the provision of career opportunities for Irish medical graduates with a research orientation, a five year national research strategy, the development of links with private funders and the exploration of roles for senior medical researchers. The Medical Manpower Forum has much to offer NCHDs and we want to publish its first report shortly.
Senator Henry raised the point about the meetings of the forum. Over the past few months, there has been a series of bilateral meetings with individual organisations that constitute the forum to try to make progress on some of the thorny issues that are still unresolved. We think there has to be change. Other interests will have different perspectives on those issues but we will have to continue to negotiate to arrive at a conclusion. We must also resolve the situation with the junior doctors which is currently with the LRC. This House is not currently the correct forum to resolve those issues. The matter is with the Lab our Relations Commission and both parties should work in that context to resolve the outstanding issues.
I take a deep personal interest in the non-consultant hospital doctors' issues. We have already agreed an interim agreement on overtime rates. I have taken a personal interest in the entire industrial relations framework in the health arena because I am conscious that we had 12 major disputes in the past four years. We must move on now to a new era. The LRC will engage in an audit of the health situation in terms of industrial relations. The national partnership group for health under the Programme for Prosperity and Fairness will be meeting to develop protocols and so on.
I am developing the concept of involving all the health partners in a strategic approach to health over the next ten years so that we could collectively develop a strategic plan for the next decade together. All the players should have a sense of ownership in that plan. It is the direction I want take away from the sort of "pot-shotting" going on between management, partners or the different players and to move on to a different plane and put industrial relations on to a new framework.
Some junior hospital doctors work long hours which had the effect of making many NCHDs more inclined to seek positions in other countries or, indeed, in other professions. For this reason, I welcome the new proposed EU Working Time Directive. Initially, NCHDs as doctors in training were, as the Senators know, one of a number of groups excluded from the original EU Working Time Directive adopted in 1993.
I am glad to note that agreement has now been reached on a formula which provides for a nine year transition period to apply the directive to junior doctors. I took the initiative to move from the 13 years down to nine years and I would like it noted that this is an indication of my goodwill towards resolving the situation in which junior doctors find themselves. We must work together to find the right logistics and mechanics to enable us to achieve that timeframe which will be a challenge in itself. We are committed to reducing doctors' working hours to an average of 48 per week as quickly as we can in accordance with European legislation. If we can do this quickly, I will be glad to do it. I am confident that, with the full co-operation of the profession, we can achieve that objective in the nine years ahead.
As part of our preparations for this eventuality we are conducting a major study of NCHD working hours on a joint basis with the Irish Medical Organisation. The study is being undertaken at eight hospitals by PA Management Consultants. The report of the study will be available by the end of this month.
As I have outlined, I had consultations with the Medical Council already, which has decided today that candidates who achieve an overall pass mark in the PLAB – Professional Linguistic Assessment Board – examination conducted by the General Medical Council in the United Kingdom will be exempted from the requirement to take the Irish equivalent assessment. Part 1 of the PLAB can often be taken in the applicant's country of origin. This should make it easier for some non-EU doctors to consider working here.
Some health boards have been actively trying to recruit junior hospital doctors from countries such as Germany where currently there is a surplus of non-consultant hospital doctors. I am also aware that health boards are attending medical employment fairs to encourage junior hospital doctors to work in Ireland. We have been proactively talking to health boards and telling them to enter the market, start recruiting potential junior doctors and meet their manpower shortages and requirements.
On nursing, at the end of 1998, a total of 26,695 wholetime equivalent nursing staff were employed which represents over 31,000 individuals due to the very significant numbers who have opted to work in job sharing or part-time arrangements. In addition, significant resources have been invested to facilitate general practitioners in employing practice nurses in their surgeries. There are now several hundred nurses working in this area.
While the number of qualified nursing staff in employment is now at an all time high, the transition from the traditional apprenticeship model of nurse education to the diploma based programme has impacted on the availability of nurses. This is because the service contribution of students trained under the traditional model has been replaced by a skill mix of registered nurses and non-nursing personnel. While this has enhanced the quality of nursing care through the creation of additional nursing posts in hospitals, it has had the effect of absorbing the pool of surplus nurses that existed when student nurses were part of the rostered workforce.
The House may recall that in 1993-4 when the first diploma based programme was being planned, there was increasing resistance from the nursing profession to maintaining a high student intake at a time when nurses on registration were finding it difficult to find employment. This issue was highlighted by An Bord Altranais in 1994 in a report which referred to a general contraction in nurse employment both at home and abroad. In 1990, the Department commissioned a study of nursing personnel which was presented to the Department in 1995. That took a long time to complete. That report recommended a gradual reduction in the number of student nurses up to the year 2000. We can see how dramatically the situation has changed. Ironically, there is now a general shortage of nurses not only in Ireland but in the United States, Britain and most other European countries.
Against this background, it is encouraging there has been a net inflow of nurses to Ireland in recent years. Data maintained by An Bord Altranais show that, in 1996, the inflow was 939 nurses while the outflow was 1,079 nurses. By 1998, the number coming in had increased to 1,400 while the number leaving had decreased to 850. The inflow figure for 1999 is 3,181 which represents a dramatic increase over 1998. This trend proves that Ireland continues to be competitive when it comes to recruiting nurses from abroad.
As the House will be aware, agreement has been reached between the relevant Departments, to refer to Senator Jackman's point, on a procedure for fast tracking immigration clearances and work permits for non-European Union nurses. The indications are that there is not a nationwide problem regarding the availability of nurses and the difficulties largely relate to the greater Dublin area. While some nurses have always moved from Dublin to other parts of the country, investment in hospitals and the development of regional specialities in recent years have increased demand for nurses outside the Dublin area.
Nurse recruitment is carried out on an ongoing basis in most hospitals and the level of vacancies fluctuates accordingly. At any given time, significant numbers of nurses would be in the process of being appointed by employers or moving from one employment to another.
Hospitals are taking a number of recruitment initiatives. We have been in touch with hospitals and again in touch with health boards telling them to go to the international fairs and start recruiting and make sure we can bring in as many nurses as we can. For example, Beaumont Hospital's most recent initiatives to attract nurses included large stand-alone advertisements in national and international papers and nursing magazines highlighting what the organisation can offer, participation in the recent national recruitment skills fair in the RDS and interviewing foreign nurses. The hospital continues its advertising programme in Northern Ireland, England and Canada as well as its in-house recruitment and retention initiatives.
The Mater Hospital anticipates that approximately 70 nurses from the Philippines will be employed in the near future. However, it will be necessary for them to attend a six week orientation course prior to commencing employment. The first such course commenced last week.
Tallaght Hospital is engaged in an international recruitment drive. It has made 92 job offers to date with the first recruits expected in early July. Its overseas recruitment will continue throughout this year. St. Vincent's Hospital, Elm Park, is involved in a number of initiatives, including contracting ex-members of staff and offering more flexible working hours. It also continues to work with nursing recruitment agencies to fill vacancies.
St. James's Hospital is also employing a range of initiatives to fill positions. As well as advertising in the national press, it interviews and appoints successful candidates who forward their CVs without any invitation. A nursing recruit ment agency is also being utilised to locate specialised nursing staff worldwide, particularly in South Africa, for the critical care and operating theatre areas. The hospital is promoting flexible working hours and creating a family-friendly environment. A proposal to develop an on-site crèche is being prepared. I visited the hospital recently to open a new cardiac facility and it was interesting that it had made great progress in terms of recruiting nurses. The lesson is that different initiatives are being taken by hospitals and agencies but some are more proactive than others and are, therefore, making greater progress in terms of manpower issues.
The major Dublin hospitals have also undertaken a recruitment and retention research project. An action plan for implementation of the report's recommendations is under consideration by chief executive officers and directors of nursing. A range of initiatives has also been taken, or is being progressed, at national level with a view to stabilising the situation and improving it, where possible. These initiatives include new arrangements which have been introduced to give better starting pay to nurses taking up employment by giving full recognition for previous experience at home and abroad. A significantly improved regime of allowances in respect of nurses working in specialised areas, such as operating theatres and intensive care units, has also been introduced.
Standardised overtime working arrangements have been introduced following agreement with the nursing unions. Some 11 hospitals throughout Ireland provided back to nursing courses in 1999 for those wishing to return to the workforce. A total of 304 places were available. The expansion of these courses is aimed at maximising the available nursing workforce. During 1999/2000 16 new post-registration programmes have been developed. This year there will be 660 places on such courses in specialised areas of clinical practice. Some 11 of the 16 new programmes will be located outside Dublin in response to an identified need.
An anti-bullying document prepared by the HSEA and agreed with the nursing unions was published in December 1999 and has been widely promoted within the service. The promotion structure within nursing, including the introduction of a clinical career pathway, is being significantly improved on foot of the recommendations of the Commission on Nursing. Up to 1,250 clinical nurse midwife specialist positions are to be introduced for nurses who have recognised expertise in particular areas. These posts attract clinical nurse manager 2 salary. Nurses are also benefiting from an agreement to upgrade 1,100 staff nurse posts to clinical nurse manager grade 1, which is being implemented.
A study of the nursing and midwifery resource by the nursing policy division of the Department of Health and Children commenced in 1998 with the primary purpose of forecasting future nursing and midwifery resource needs. Following this, a national study on turnover in nursing and midwifery has been commissioned by the Department through the Health Research Board and awarded to the Department of Nursing Studies, University College Cork. Employers have stepped up recruitment from abroad with significant success in Scandinavia and the Philippines, in addition to ongoing recruitment within Ireland.
Swift progress is being made on the implementation of the agenda for change mapped out by the Commission on Nursing. It is all systems go from the Department's perspective in this regard. It was interesting that when all the nursing union leaders spoke at their respective conferences they heaped considerable praise on the nursing division of my Department. They were satisfied with the bona fides of that division in terms of its drive and commitment to implement the commission's recommendations. They had problems with regional authorities in terms of implementation on the ground. We have spoken to health authorities in respect of the absolute importance of fulfilling the agreement that was reached as a consequence of the industrial dispute and we have maintained close dialogue with these authorities to make sure that outstanding payments are made to nurses as fast as is feasible. Many health boards have difficulties in terms of payroll systems, etc., in implementing this complex agreement but we are sparing no effort to implement the recommendations of the Commission on Nursing.
I will continue to oversee their implementation. I have met all the unions in the nursing profession on a number of occasions, including the PMA. We had a good discussion with that union recently and I am glad that collectively we deferred the industrial dispute which had been planned. Channels of communication were opened that could lead to a better industrial relations climate. That is my objective and it is something that I am keen to develop with the HSEA and the Department.
The Commission on Nursing recommended that the Department, health service providers and nursing organisations should examine the development of appropriate systems to determine nursing staffing levels. The need to address skill mix issues was also highlighted in the commission's report. Both of these recommendations are included in the priority action plan agreed with the Nursing Alliance as part of the settlement of the nurses' strike.
We are also keen to attract young people into the nursing profession. The number of training places increased by 153 between 1998 and 1999. This was the first increase in places since the diploma programme was introduced in 1994. Some 3,100 student nurses are in training. The 2000 intake will be 1,500, an increase of 300 on 1999. This increased figure was agreed with the Nursing Alliance as part of the settlement of the nurses' strike. A further 20 places are available on a new direct entry midwifery programme which is being introduced on a pilot basis. There was a record intake of psychiatric nurses last year. We have turned the corner in terms of attracting young people into psychiatric nursing and have opened new schools in this field. Two more will open in Ardee and Monaghan. We have developed good relationships with the institutes of technology in certain locations and they will serve as host schools.
In 1999, following a local and national recruitment campaign costing £400,000, which was funded by the Department, the number of applicants increased by more than 40% on 1998. This resulted in the largest number of direct entrants to nursing for several years. A total of 1,215 training places were filled in 1999, including record intakes of students to psychiatric and mental handicap nurse training. Further funding totalling £400,000 was made available to the various schools of nursing nationwide late last year to enable them undertake local marketing campaigns aimed at promoting nursing as a career. This year there were more than three applicants for every available training place. This is most encouraging bearing in mind that the total number of training places has been increased by 25% over last year to 1,500 and the reduction in the volume of applicants for public service positions generally.
The annual maintenance grant for nursing students, which is not subject to a means test, has been increased to £3,325 with effect from 1 April 2000. The grant is almost double the maximum grant for which other third level students may qualify. In addition, allowances for external clinical placements, books and uniforms have also been increased. These initiatives represent a significant effort on our part to improve the situation. In the longer term it is hoped that the substantial increase in the number of student places will provide enough registered nurses to fill all vacancies.
I refer to the important fees initiative which I announced recently at a cost of £15 million over a number of years. From 1 January 2001 nurses working in the public health service who want to undertake nursing and certain other undergraduate degree courses on a part-time basis will have their fees paid in full by their employing agencies. Fees will be paid in return for a commitment on the part of the nurses to continue to work in the public health service for up to two years after the completion of their courses. This fees initiative will continue until at least 2005, at an estimated additional annual cost of £3 million. It is intended both to marry people's needs by giving them opportunities and to monitor the supply side of nursing.
The initiative is designed for the benefit of nurses who do not already have a degree and includes fees for access courses and nursing degrees undertaken through distance education. It will apply to nurses employed in our public health service in either a permanent or temporary capacity. An important objective of the initiative is to provide an assurance to graduates of the three year nursing diploma programmes that they will have an opportunity to undertake a part-time degree course and have their fees paid.
This should act as a real incentive to newly qualified nurses to enter the workforce following registration and to remain there, thus alleviating the current shortage of nursing personnel. The thrust of this fees initiative is to encourage graduates from the nursing diploma programmes to enter the workforce immediately and for employers to retain them. I am glad to say this initiative has been warmly received by the nursing unions who regard it as the most equitable approach to the provision of financial support to nurses and midwives wishing to undertake post-registration education programmes, irrespective of their model of pre-registration training.
I wish to conclude by again referring to the issue of funding. The health budget this year is in excess of £4 billion and the increased investment in funding under this Government is unprecedented. A major opportunity is opening up to bring about fundamental and lasting improvement in services. It will take a sustained effort but the challenge is to deliver a service that has the confidence of the entire community, where standards are uniformly excellent and where it is acknowledged that decisions, including decisions about resource allocation, are made wisely and on the basis of objective evidence concerning needs.
Since taking office, the Government has made available an extra £1,500 million to health, which represents a 56% increase in the day to day resources going into the health service. This level of increased investment will be sustained and if I have anything to do with it, it will be improved over the years.
An indication of the priority attached to health by the Government can be seen in the fact that previous Governments made available just over £400 million in extra funding. That said, we recognise that in moving forward, not only do we have to spend additional moneys but we must get value for money and we must reform procedures within hospitals and the health service generally. Money alone will not solve this issue. Many good points were made in the House this evening on management issues and the reorganisation of what is happening in the health service, in particular, in hospitals. I am keenly aware of that.
Over the next seven years, a spending programme of approximately £2 billion will be undertaken within the provisions of the national development plan. There is no doubt that will have a dramatic effect on improving facilities. It will impact on the quality of services in hospitals, including accident and emergency departments. My Department is currently engaged in a review of bed capacity under the Programme for Prosperity and Fairness to assess bed needs in the health service over the next few years. I understand the change in figures that has taken place over the past ten years and where we stand in the OECD statistical table. We are examining that area in a critical fashion and hope to have feedback on that matter by the end of July when we will feed that information into the Estimates process.
The only difficulty we will have in spending the £2 billion is whether or not the system will be able to deliver the range of projects covered under the NDP. That is the big issue now. Whereas people are lobbying for various units, this presents a huge challenge to the health service because such moneys have not been invested in capital projects before. It involves getting design teams organised, presenting briefs and achieving all that work in the 2001-07 period. The timeframe in which to spend the money is very tight. I am also conscious of building inflation and other difficulties that are coming down the tracks, which will present real challenges. In addition, people are seeking more than the £2 billion that will be available.
The only question that one can realistically pose in terms of extra capital allocation, if I get it, is whether or not we would actually be able to spend it. Would the system be able to deliver the projects in the timeframe we have set? That is one of the major challenges facing us. My Department will have an overseeing role in spending the money and we will work with the health boards in providing extra resources to enable them to get these projects done on time.
This represents an historic opportunity if we can deal with the organisational issues. I acknowledge the points that Senators have made and I recognise that we have much work to do and more progress to make. However, if we can marry organisational change with the increased investment we will witness an improvement to the quality of health care. I thank Senators for having raised this issue and for allowing me to address the House.