Engagement with Irish National Organisation of the Unemployed and Irish Nurses and Midwives Organisation

Apologies have been received from Senators Black, McDowell, Ó Donnghaile, Craughwell and O'Reilly. Senator Byrne is substituting for Senator O'Reilly and Senator Buttimer is substituting for Senator McDowell. It is the penultimate public session of this Brexit committee and I am delighted to start today with our engagement with the Irish National Organisation of the Unemployed, INOU, and the Irish Nurses and Midwives Organisation, INMO. I hope Mr. Doran is not too tired and did not have too late a night.

Mr. Liam Doran

It was 3 a.m.

That is not too bad. We are particularly grateful that he has come to speak with us this morning to share his experience and the opinion of his organisation and those with which he works regularly. Before calling on Mr. Doran to make his remarks, I will read the standard note on privilege. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Mr. Liam Doran

The Irish Nurses and Midwives Organisation, INMO, would like to begin this opening statement by thanking, most sincerely, the Chairman and members of the Seanad Special Committee on the Withdrawal of the United Kingdom from the European Union for the opportunity to meet today on this very important issue. The INMO is the largest representative organisation for nurses and midwives in this country, representing over 40,000 members working in all areas, both public and private, of health services here in the Republic of Ireland. The INMO has very strong, professional and binding relationships with the Royal College of Nursing and the Royal College of Midwives in the UK and we have worked closely with them on many issues of common concern over many years. The INMO and the Royal College of Midwives have held for the past 20 years an all-Ireland midwifery conference in October each year for the specific purpose of co-ordinating and enhancing midwifery services right across the island of Ireland. It is against this background of strong, vibrant links with our colleagues in the UK health system that the INMO has very serious and growing concerns about the impact the UK's withdrawal from the EU will have on all areas of our health services at cross-Border, national, regional and local level. The difficulty of the UK's exit from the European Union will not only affect health services north and south of the Border but also east-west between Ireland and the rest of the United Kingdom.

In the context of the withdrawal of the United Kingdom from the European Union, we bring a number of specific issues to the attention of the committee as follows. The island of Ireland currently has a total population of 6.5 million and in this context it is imperative - this has grown in recent years - that we increasingly provide health services on an all-island basis in order that we maximise efficient and effective use of resources and, in particular, develop and deliver specialist and tertiary level services in the most quality-assured manner. We must move to minimise duplication of services, not only in the interests of cost containment but also to enhance the outcome for patients, and this should be done, in any sensible way, by providing such specialist and tertiary level services on an all-island basis.

We already have a number of cross-Border initiatives for health care well established and these include the Co-Operation and Working Together, CAWT, partnership between health and social care services in Ireland and Northern Ireland. This has facilitated a number of collaborative projects, particularly in Border regions, which has brought great benefit and can yield further benefit in the broad area of health and social care to the populations in this region. This has also involved other cross-Border services, including GP out-of-hours services and shared expertise, such as that used in dermatological clinics. Specifically, we have radiation and oncology services and emergency cardiology services at Altnagelvin Area Hospital, which services the population regardless of the side of the Border on which they live. As for specialist children's services, such as paediatric cardiac surgery and congenital heart disease, Our Lady's Children's Hospital, Crumlin, in Dublin, has provided all-island services for many years.

The committee is also asked to note that the largest capital development in the history of the health service, the planned national children's hospital, is also being built in a manner designed to provide all-island services to children. Nothing should be done that will in any way harm, restrict or impede the access of children in all 32 counties from accessing this world-class service in the years ahead. It should also be noted that the recently published maternity strategy proposes the development of services to the mutual benefit of all mothers and children. This cannot be impeded by bureaucracy or imposed avoidable barriers to care and services.

The committee should also note that there are a number of other examples of cross-Border and east-west co-operation within the health system in such areas as the Health Service Executive purchasing care from Northern Ireland and Great Britain to address our waiting list difficulties and improve speed of access to services for patients, cross-Border health care for workers who cross the Border daily to and from work, and guaranteed access to public health care for all EU citizens travelling through member states, which, by definition, has provided access to health care for Irish people travelling to the UK and UK citizens coming to Ireland for many years.

The committee is also asked to note that from a more specific nursing-midwifery perspective, the following critical issues arise. Currently, we have mutual recognition and reciprocal arrangements for nurse and midwife registration for nurses and midwives who successfully complete programmes in Ireland and the UK. The removal of free movement of people, arising from a UK withdrawal from the EU, will see them depart from adhering to relevant EU directives pertaining to professional registration and this will have significant implications for health care manpower planning in both jurisdictions. The committee is asked to note that the number of applications for registration to the UK Nursing and Midwifery Council, its professional regulatory body, has dropped by over 90% in recent months. All this will do, in the context of Irish-registered nurses and midwives, is to increase still further the attempts by UK health authorities to fill their nursing and midwifery post shortage by aggressively recruiting here in Ireland. A simple example of this is the recurring practice of such great hospitals like Great Ormond Street Hospital for Children in London of coming to our graduates, particularly those who have just completed the joint general and children's nursing degree programme here, and recruiting them before they ever work here after registration. The pace and intensity of this recruitment drive by the UK will only increase as a result of Brexit as the numbers applying from within and outside the EU to work in the United Kingdom will fall due to concerns in a number of areas.

In addition, the committee is asked to note, particularly in recent years, the offices of the chief nurse in Ireland, Northern Ireland, Wales, Scotland and England have worked increasingly together to collectively strengthen the nursing and midwifery input into health care in all five countries. This has the potential to yield greater benefits in the years ahead but this may all be minimised by the UK departure from the EU and the introduction of hard borders and all of its implications. There is a determined effort by nursing and midwifery to develop the infrastructure on an all-island basis by our all-island joint midwifery conference each year, and this will inevitably be compromised in some way arising from a UK departure from the EU and the issues that automatically arise.

In response to all of the foregoing which is universally negative for health services, the INMO believes there is an absolute requirement for proactive engagement on this issue and that is why we welcome the work of this committee. In that context, we believe it is imperative that the Irish Government, as part of the multifaceted discussions which are taking place with regard to Brexit, must focus on the following issues. Regulatory bodies in both jurisdictions must work closely together to find a way to provide to the political system methods by which the movement of nursing-midwifery and other health professionals can continue unimpeded following any departure. Standards of regulation and practice must be maintained at the highest standards in all health care qualifications and other areas, such as medicines, medical devices, food safety and public health. Whatever final shape the departure takes, arrangements must be put in place so that health care, in the island of Ireland and, indeed, from Ireland to the UK, has no borders and every patient can access, without delay or bureaucracy, the highest quality of specialist services his or her condition warrants. In that context, we must continue to develop the centres of excellence servicing all on this island in the critical areas of oncology, cardiac care, children's services, public health and primary care, including care of the elderly.

The challenges to ensuring access to quality health care in the most efficient and effective manner possible are significant as we face Brexit. We must recognise and plan to meet all of these critical issues over the next two years in the interests of all citizens.

On behalf of the INMO, I wish to conclude this statement by thanking the committee for taking the time to invite us and for allowing us to present our views. We are, of course, available for questions.

I thank Mr. Doran and appreciate his remarks. Before we go into questions, if it is okay, we will take both witnesses together. If Ms O'Brien from the INOU has caught her breath, I ask her to make her opening remarks. She should feel free to remain seated.

Ms Bríd O'Brien

I thank the committee for the invitation to speak this morning.

I will start by noting the changing context in which we operate. Thankfully, employment is rising and unemployment is falling. However, there remains a very considerable challenge to be addressed, even with these figures moving in the correct direction.

A striking aspect of the most recent figures, from the quarterly national household survey for the first quarter of this year, is the regional spread of unemployment. The unemployment rate ranges from 5% in the mid-east to 9.3% in the south east. It dropped across all the regions but that regional spread is quite striking, in particular when there is a target within the programme for Government to prioritise regional development and aim for an unemployment rate in each region that is within 1% of the overall national average. That, in itself, highlights some of the challenges the State faces, even with the employment and unemployment figures moving in the correct direction. This is an issue that Brexit will exacerbate.

It is important to note that these headline figures do not necessarily capture realities of the structural unemployment and labour market inequalities that face people living in disadvantaged areas, both urban and rural, and people facing discrimination because of their age, ethnicity or class, or because they have a disability or are parenting alone, or because of the implications of their long-term unemployment. A striking feature of research the CSO conducted a number of years ago on equality in Irish society was that the category with the second highest rate of discrimination discovered was the unemployed. That was captured because the CSO, in the quarterly national household survey, captures people's principal economic status. Those are issues that need to be named and addressed. They should be named and addressed anyway but with Brexit and its implications, they certainly need to be named now.

At national level, employment increased by 68,600 over the past year. It increased in seven of the eight regions; it dropped slightly in the Border region. Something we were struck by in the document the Government published in May, "Ireland and the negotiations on the UK's withdrawal from the European Union, The Government's Approach", is that it highlighted analysis undertaken by the Department of Finance that "the economic sectors most impacted by Brexit generally comprise indigenous enterprises that are small in scale, are significantly dependent on the UK as an export market, have deep links with the rest of the economy, have high levels of regional and rural employment (including around the border), and have relatively low profitability". These are challenges that already face us and, depending on the nature of the Brexit, could very much be exacerbated.

The document goes on to note, "Brexit poses significant challenges to the development of Irish owned industry and in particular to the regions which can be dependent on small, medium and large Irish businesses for job creation." It goes on to note that although reliance on the UK as an export market has declined over the past ten years, it "is and will remain the most important export market for the development of [Enterprise Ireland] client companies". Moreover, it is strategically important for first-time Irish exporters and for many small and medium-sized enterprises, and clearly for certain large companies here the primary export market of which is the UK.

It is important to look back at the employment and unemployment figures over the past five and ten years because, even though these figures are currently moving in the right direction, having that backward view highlights the remaining challenges. In terms of employment, we now have more than 2 million people employed, as compared with five years ago when the number employed was 1.8 million, but that is still lower than ten years ago, when it was 2.1 million. Likewise, unemployment has dropped dramatically when compared with five years ago when more than 321,000 people were unemployed but it is still 50% higher than it was ten years ago. Looking at long-term unemployment, thankfully, that has also dropped in comparison with five years ago, but it is two and a half times the level of ten years ago.

A figure we find useful to look at is what the Central Statistics Office calls the potential supply of labour. It helps to capture those who do not answer "Yes" to the two questions to which one must answer "Yes" to be captured as officially unemployed, which are, "Were you looking for work in the past four weeks?" and "Are you available to take up work in the next two weeks?" If, for whatever reason, one has lost heart and stopped looking, or if one has care or transport issues and believes it will take more than two weeks to sort them out, one might answer "No" to one or other of those questions. The most recent rate of potential labour supply - we use the third definition here because it is the one that is consistent over the past ten years - is 9.5%. It captures those who answered "No" to one or other of those questions or those who are working part-time but do not wish to - those who are underemployed. It is a figure that captures the employment challenge that remains and continues to face Ireland.

In my submission, I cite a number of quotes in the paper from the ESRI capturing the impact of what Brexit could do to the Irish economy, in particular, to sectors that are particularly important to Irish indigenous industry and those seeking work. At the end of the first quote, the ESRI highlights, "Approximately 30 per cent of all employment is in sectors that are heavily related to UK exports – particularly SMEs in the agri-food and tourism sectors – and are likely to feel the brunt of any negative shocks to trade." The ESRI also notes, earlier in the quote, "The negative shock to foreign demand is expected to flow through the economy by means of lower exports, which has implications for the labour market and employment."

In the scoping paper published a year and a half ago, the ESRI captured the reality for many that when work is not available here, the first port of call when seeking work is the UK. Both the nature of the Brexit that emerges and the nature of the border that emerges have significant implications in that regard.

I welcome that the Government, in its May document, notes the commitment by both the Irish and British Governments to maintain the common travel area, as well as the support from the European Union around these issues.

There is still a long way to go in negotiations before we find the reality on the far side.

At some of our recent regional forums to discuss the impact of Brexit, people noted the importance of being able to commute between Ireland and the UK. That includes those who live and work on either side of the Border on this island. People also noted that those who live in rural and urban areas commute to Britain on a Monday-to-Friday basis to work and highlighted the difficulties Brexit could cause in this regard. People also noted, from a personal and family perspective, how individuals access health and education services and the implications of Brexit for that. Many people living in the Border area feel that the Border is no different between their counties and the other counties in Ulster than the borders between Dublin and Meath or Cork and Kerry. There is a potential impact on people trying to go about their daily business.

Our most recent conference called on the Government to plan for the employment and unemployment impacts of Brexit and, in particular, to identify the emerging and possible job losses, the potential alternative enterprises and jobs, and the education and training supports that are required to ensure unemployed people can gain access to these jobs, which must be decent and sustainable. We feel the latter is particularly important if people are to be able to move from welfare into work and be able to establish their own economic independence with its accompanying social benefits.

In May, the EU published the country-specific recommendations. The second part of the second recommendation calls on Ireland to "Enhance social infrastructure, including social housing and quality child care; deliver an integrated package of activation policies to increase employment prospects of low-skilled people and to address low work intensity of households". These are the very people we would be concerned about. They often come from families and communities where there is experience of structural unemployment or inequalities in the labour market. They are often people whose only access to the labour market arises from activation programmes or precarious employment. We would be concerned that Brexit could exacerbate that dynamic for people and leave many in a continuing precarious position.

At present, Ireland's national employment service focuses primarily on people who are in receipt of a jobseeker's payment, be that benefit, allowance or the transition payment. The service is overseen by the Department of Social Protection and contains the following elements: Intreo, with a strong focus on the shorter-term unemployed; the local employment service, with a strong focus on longer-term unemployed and referrals from Intreo; Intreo also refers people who are unemployed to jobs clubs and the social inclusion community activation programme; and JobPath with a strong focus on longer-term unemployed who receive referrals from the Department of Social Protection.

The main policy underpinning these services is Pathways to Work 2016-2020, which was published before the decision in the UK referendum to withdraw from the European Union. It refers to changing from activation in a time of recession to activation for a time of recovery. Its two main objectives are: to continue and consolidate the progress made to date with an initial focus on working with unemployed people, particularly those who are long-term unemployed; and to extend the approach of labour market activation to others who, although not classified as unemployed jobseekers, have the potential and the desire to play an active role in the labour market. Brexit will throw up challenges to those two objectives. In order to achieve the latter and to ensure good outcomes for the long-term unemployed, it will also be important to ensure that active inclusion in principle and practice is an integral part of how this policy is implemented.

The latter part of those objectives feeds back into the European Commission's country-specific recommendation and the need to ensure that this recovery strives to be truly inclusive. However, to do this demands a level of integration across relevant Departments and their agencies that is not in evidence at the required level of consistency that is essential if we are to see the country-specific recommendations and that objective met as they ought to be.

It will also be critical to ensure that activation programmes act as a real stepping stone - as described on the Department's website - for unemployed people and others of working age into a decent job, including self-employment, or further education and training opportunities if required. I have included a table for the members' information to show how participation on programmes has changed over the past five and ten years. The number availing of the back-to-work enterprise allowance is considerably higher than ten years ago and down slightly on where it was five years ago. Tús did not exist ten years ago and now has more than 7,000 people participating. The JobBridge internship measure was introduced in response to the crisis and has since been closed, with the figures dropping quite dramatically. Participation on community employment, which is an important support for many communities trying to manage disadvantage and economic and social exclusion, has stayed at approximately 2,000. Gateway was slow to get off the ground and had a short burst of activity and now the numbers are falling dramatically. They reached a high of 2,500 approximately two years ago. The numbers on full-time training, which was under the remit of FÁS and is now under the remit of education training boards, have continued to fall, which is of concern to us because in the past they were interventions with good employment outcomes. The identified skills gap between the experience unemployed people have and the experience and skills required for the jobs available is an issue of concern for us. At present, in the region of 67,000 people are on activation programmes. For many, these are a critical first step into the wider labour market. However, a great deal of work needs to be done to ensure that people can then progress to better employment in the wider labour market.

To address the impact and implications of Brexit, it is critical that an integrated, interdepartmental and inter-agency approach is developed to ensure that the maximum possible number of unemployed people gain access to employment and to work with those in danger of losing their jobs. This will require a mapping exercise that identifies the emerging and potential job losses, and that looks at the alternatives and supports required to ensure people are able to access this work.

A recent report from the expert group on future skills needs on the food and drink sector highlights the importance of good inter-policy and agency co-operation. The report noted:

The Food and Drink sector has expanded significantly over the period and increased exports by more than 50 per cent; employment in Enterprise Ireland, IDA Ireland and Udaras supported firms has increased by almost 6,600 (+13%) since 2009 to reach 54,000 in 2016. This recovery in employment and expansion of output has been in the context of significant change in the food and drink sector generally with an increased focus on sustainability and traceability of origin and increased integration of ICTs, regulatory requirements and of science-based product innovation and a diversification of markets for Irish exports. The impact of Brexit will further accelerate the impact of a number of these drivers of growth, in particular in relation to market diversification. The sector relies on skills supply from both the domestic education and training system and also from a continued flow from outside the country. This is particularly the case at operative and production occupation levels.

The critical one for us is the reliance on the skills supply from both the domestic education and training system.

To ensure that unemployed people and others of working age who are more distant from the labour market are properly supported to address the challenges of Brexit, a systematic approach is critical. As one affiliate noted, it is likely that the individuals benefiting less from the economic upturn will also be impacted disproportionately by any negative fallout from Brexit. As a result of the fact that such individuals tend to live in specific communities, those communities should receive specific supports to assist them in dealing with the impact of Brexit.

That systematic approach must include: early engagement with companies that make job announcements with a view to gathering information on the nature of the positions to be filled; clarification of the skills, experience and competencies required to successfully do the jobs; and details of the recruitment process to be used for filling these positions. This, in turn, should inform the work of the local employment services and education and training provision to unemployed people and others of working age to avail of those opportunities. A quote from the Action Plan for Education captures the importance of people being able to access good education and training services and supports, both the impact on them personally and also on their personal goals in life, which for people who are unemployed means gaining access to a good job.

At our annual delegate conference there was a call on the Government to resource the provision of good career and employment guidance to support unemployed people to make informed choices and access appropriate education and training, leading to good-quality employment in terms of job security and salary levels, and in particular to ensure this is available to individuals and communities most disadvantaged in the labour market.

The onset of Brexit demands well-resourced action on this front. The provision of person-centred services that focus on supporting unemployed people to assess their learning needs and the necessary opportunities to improve their employment prospects must be an integral part of such action. This involves providing good-quality information and guidance, improving integration and transition between employment services and education and training supports, working proactively to get the referrals and the matching piece correct - this is absolutely critical - and ensuring all programmes are open to unemployed people. The appropriate resources must be provided to ensure that people who have yet to see the benefits of an improving economy start to experience this positively in their own lives.

I thank Ms O'Brien for her detailed and engaging statement. I ask Senators to put questions to the witnesses.

I welcome Mr. Doran and Ms O'Brien and thank them for their presentations. Mr. Doran mentioned that many nurses from both sides of the Border went to England for training, including specialised training. I will mention one area that is of concern in this context. Many qualifications are recognised at present. If nurses train here, their qualifications are recognised in the UK, including Northern Ireland. The reverse is also the case. There is a fear that such qualifications will not be recognised in future. Will Irish students be treated like non-European students if they go to the UK for training? Will they have to take additional courses when they come back here? Such issues are of concern to people who are currently in training. Many nurses went for specialised training in advance of the recent opening of a new accident and emergency department in Limerick. They were unable to receive some of that training in Ireland and had to travel overseas. Such questions would cause me to fear what will happen in the future, for example, when people seek to intensify their training. Something has to be worked out if this is to be kept to the fore.

Ms O'Brien spoke about skills and training. As a member of the Joint Committee on Education and Skills, I am aware that additional money has been put in place for training and skills. I suppose third level education is not for everybody. It is important that extra funding is provided so that more courses, skills and apprenticeships can be offered. I share Ms O'Brien's view that not enough people are on these courses at the moment. There is not enough choice. I am aware that consideration is being given to expanding the range of courses on offer. I do not know whether the INOU made a submission to the Department of Education and Skills when it was looking for suggestions of areas where there are shortages. If not, I encourage it to contact the Department. This issue has been highlighted in Ms O'Brien's report. A great deal of community employment has been created under the community employment schemes. I am hearing that some community centres are finding it very hard to get people who qualify for such work now because they are working part-time. Does Ms O'Brien think the qualification criteria for these schemes need to be changed?

Mr. Doran referred to the recent decrease in the number of people applying for registration to the UK Nursing and Midwifery Council. How can that be linked to the potential for Brexit that is coming down the line? My colleagues on this committee hear me saying every day of the week that although we are all hoping for the best, we have to plan for the worst. The worst-case scenario is that Brexit will go pear-shaped and we will end up with a hard Border and a hard Brexit. What contingency plans are in place for such circumstances? What work is being done by the organisations represented by the witnesses with that in mind? Is any work being done? Are we just hoping for the best here? What is the position of the organisations on the outcome that none of us wants or desires? Have they drawn up plans that can be enacted in such a scenario?

I thank the Chairman for giving me this opportunity to speak and for the work he has been doing along with his colleagues on this committee. I would like to begin by referring to something that does not relate to Brexit. I congratulate and pay tribute to Mr. Doran regarding his tenure as general secretary of the INMO and for his stewardship of that organisation over the years. I had the privilege of getting to know him during my term as Chairman of the Joint Committee on Health and Children. Even though we come from different hurling counties - Cork and Kilkenny - I have to say he has always acted with professionalism and courtesy as an official representing his members and as a person. On a personal level and on behalf of everyone on this side of the Oireachtas, I thank Mr. Doran and his family and wish him well. At a time when people were under severe pressure, Mr. Doran never lost sight of his task and continued to do his job in a personal and convivial manner. I thank him for that.

I was interested in what Mr. Doran had to say. This is an important session because there has been very little discussion on these issues. It is important that there is a focus on health today because Brexit will have a profound impact in this area.

Mr. Doran referred to the aggressive manner in which the UK is coming in and taking some of our qualified nurses and other health care professionals. The issue of access to treatment arises in this context. We must be absolutely resolute that there can be no physical return to a hard Border in the area of health care. We must continue to support those who need to access treatment in hospitals on this island, including Altnagelvin Area Hospital and Our Lady's Children's Hospital in Crumlin, and those who need to go elsewhere under the treatment abroad scheme or the cross-border health care directive. The figures show that a staggering number of people cross the Border or the Irish Sea for health care purposes. I ask Mr. Doran to comment on whether it is possible, in the interests of the quality of that interaction, for us to retain some of best personnel here rather than having to export them. I would like to hear his views on the role of remuneration in ensuring we can continue to retain staff in our health system in a post-Brexit scenario. How does Mr. Doran envisage that the cross-border health care directive and the treatment abroad scheme will have an impact from a patient perspective? He raised an issue with regard to the quality of registration. How can we ensure there is a value system that is upheld in the same way that currently happens with the EU?

It is also important to look at the impact of Brexit from a European point of view. The Chairman and others have argued strongly in favour of the European Medicines Agency moving from the UK to Dublin. I was hoping it would go to Cork. The Chairman has been making the case for Dublin. I know the Minister of State, Deputy Corcoran Kennedy, recently attended a meeting on this matter in Brussels. It is important for us to lend our support in any way we can to the relocation of the European Medicines Agency in Ireland. How does Mr. Doran envisage that EU regulations and directives on medical devices, the quality of drugs and the monitoring of standards will have an impact? What can we do in this regard by using our negotiating power within the EU? I was struck by Mr. Doran's remarks about the national maternity strategy and the need not to be impeded by bureaucracy. I would be interested to hear his view on my fear that in a post-Brexit scenario, we will put on hold many things that are of importance for the evolution of a modern professional health care system.

My final question relates to the possible strategies that have been proposed by the INMO. How does Mr. Doran envisage that the regulatory bodies involved in the regulation of practice will move from an all-Ireland perspective? There is no power structure in Stormont at the moment. Voting is under way. I wish all the candidates well in today's elections in the North. There is no assembly and no Executive. How can the various organisations that are working with the Good Friday Agreement, including the Oireachtas and the assembly, ensure there will continue to be an all-island approach regardless of what happens?

I welcome Mr. Doran and Ms O'Brien. For newly qualified nurses and people who want to train, the UK seems to be a great lure as many of our nurses go there. Mr. Doran has described the aggressive recruitment drives that go on while by the same token, we need more nurses here. Mr. Doran is regularly on the radio speaking about that issue. Might the Brexit dynamic give newly qualified nurses who are considering leaving here pause for thought and make them consider staying in this country? We can look at it in terms of both a hard and soft Brexit. Could there be a new dynamic whereby we would see more graduates staying?

What is the appeal of the UK at the moment and what is actually on offer to newly qualified nurses there compared with here? How do the salaries compare? From speaking to some young nurses, it seems the conditions of work and the chances of progression in their careers might be key. Can the witnesses give us a flavour of that? We are told the HSE is recruiting here but it seems difficult to fill a number of these types of posts. I would welcome Mr. Doran's comments on that issue.

On the issue of training and education, in the past number of years it has struck me there is a cohort that has difficulty in getting into the labour force. One might be talking about people in their 50s up to retirement age who have perhaps lost a job. That particularly arose during the downturn and the mass of unemployment that was created from that. These people find it hard to get work and upskilling or reskilling is an obvious way to change that. Women who took career breaks to look after their children find that because they are not entitled to a social welfare payment, they do not qualify for particular courses that might help them find work. While there may be an abundance of options in Dublin to upskill and reskill, where I am from much of the upskilling and reskilling on a basic level is being delivered by the Department of Social Protection. I understand it is means tested and that it applies only to people on social welfare, but there are people in difficult situations who want to work and contribute but cannot get work or upskill. They feel forgotten about. It might be a woman who raised her children or a man who had worked the best part of his life in a now obsolete profession and who is not wanted anywhere. It is quite a wallop to a person when this happens, especially when there is no alternative offered by the State. I am not talking about people who are massively wealthy and for whom this is not an issue. I refer to those who are pretty much getting by and just do not meet the technicality of qualifying. I would appreciate Ms O'Brien's comments on that issue.

Ms Bríd O'Brien

To respond to Senator Mulherin's questions first, in the past, particularly before the recent crisis hit, people were able to undertake FÁS training programmes even if they were not in receipt of a payment. That was one of the early changes made when the crisis hit. Since the Department of Social Protection absorbed FÁS's employment services, access to services now is very much related to a payment. Many people, such as women who did not have an entitlement in their own right because of their partner's income or who perhaps were not claiming in their own right, often tried to access return-to-work courses or the FÁS courses, which were the only options. Their availability depended on where people lived and what access was available in those areas. It is an issue we have called on the Department to look at seriously. It absorbed the national employment service and really should be providing an employment service to everybody of working age, regardless of the payment.

It is an issue many men started to experience during this crisis. If their partner was working, once they got to the end of their social insurance payment they then did not qualify for the means-tested payment and so found themselves entitled to no supports of any nature. When we raised this with the Department at senior level, we were told that people can drop into the local Intreo office for supports. However, the reality is that the local Intreo office's work is assessed by looking at whether the live register is being reduced and if people are getting back into work. Its work is being assessed in a way that does not lend itself to an inclusive service for everybody of working age. That certainly needs to be addressed. Depending on the nature of Brexit, we may have limited space to address that because we may start to see more unemployed people. It would be wonderful if the worst-case scenario did not arise. The issue must be addressed because services should be available to everybody of working age, particularly those who wish to try to get back into the labour market and secure employment.

On the questions Senator Byrne raised, some additional programmes have been rolled out, for example the Springboard programme, which was very welcome. Springboard was one of the programmes which facilitated people who perhaps had a certain level of education training, because many of the pre-crisis supports were designed on the assumption that those who were unemployed were in receipt of other working age payments and perhaps did not have a certain level of education. They were designed to try and bring people up to certain levels. When the crisis hit we then had people with significant experience and in some cases high-level qualifications looking for help. Springboard and the ICT conversion courses helped to address that gap, because that was a big gap in provision.

When we look at some of the expenditure over time, there is definitely less provision in certain areas and a concern that people have - particularly those who are working with people whose literacy levels are not good - is that in some of the training schemes involving community employment, there an presumption that people are already at level five of the national framework of qualifications. In some cases people are doing well if they are at level 3. We have to design the system to meet the needs of the individual rather than designing programmes in a very tight way and then trying to squash the individuals into them.

The Department of Social Protection's strategic objective is about building services around the individual. Within the further education training strategy, the national skills strategy and the Action Plan for Education, there is a strong emphasis on creating supports and services that allow the individual to flourish. However, because of the way those systems meet, people still find themselves not able to exercise informed choice or being referred to things that may not be suitable for them. We feel it is in the system's own interest to take that initial time to really talk things through with people, work with them, find out what stage they are at, what they need to do, what is available to them and what needs to be done to get them there. Taking that time at the beginning to work that out and map out that journey would make a huge difference to the individual and would also mean that we are using resources more effectively.

Community employment plays a variety of roles that sometimes pull against each other. It is often the only access point to the labour market for people who are particularly distant and who may be experiencing discrimination because of their age, their ethnicity, where they are from, their parental status or because they have a disability. Sometimes the individuals who need that opportunity and what the sponsoring organisation needs in terms of existing skills and talent do not always fit. That can be a challenge.

Again, some issues have arisen because, unfortunately, when Jobs Ireland was rolled out it had a few blips, and it still has. That has definitely created logistical issues in filling schemes such as community employment. Schemes that have been successful in being filled have very much gone back to developing personal relationship with key parts of the system in order to get referrals. There is a challenge there. The system has moved in this very directive fashion of people being directed into things rather than being allowed to opt into things. For an employment programme that can be an opening opportunity for people, the fact that the system is so different to how people secure employment otherwise is not advisable. Apart from someone who is headhunted and is at the top of the labour market, most of the rest of us go out looking for a job and have to roll our sleeves up and all that. I think it is a false relationship that is not necessarily helpful to the person trying to move on to bigger and better things. I believe that needs to be addressed.

In terms of planning for the worst and hoping for the best, the inference of Senator Paul Daly's question was that somehow we would be able to pull it all around on our own. If we could do that, our affiliates would be delighted with life, not to mention our individual members. What we are doing and will continue to do is to engage with Government across a whole range of policy makers and implementers on what we feel needs to happen to try to lessen the impact of Brexit. If the worst-case scenario arises, the implications for employment and unemployment are unpleasant. For younger people who are trying to secure their first job and for older people who may have realised that because of their age they were not going to get work in Ireland and went elsewhere to find work, there are huge challenges. We really need to try to ensure that the Border is as invisible as possible and the common travel area is maintained. However, there is a long road to go to make sure that happens.

Mr. Liam Doran

I will begin by thanking Senator Buttimer for his kind comments. I am not going until the end of the year. I am worried now that something is happening around me. For light relief, Ms O'Brien mentioned borders. As far as I can remember, Cork has had a big border around it for years that people have never managed to get through.

I will divide my answer into two parts. One part is generic and the other part is about specifics. Let me be quite clear: from our perspective, there are no upsides whatsoever for health care, health services or health users from Brexit. Whether it is a soft or a hard Brexit, there are no positives. As health care evolves, its essential requirement, particularly in specialist and tertiary services, is critical mass. One of the best things that Ireland did in the many years of humps and hollows was the development of centres of excellence in oncology services. We have world-class oncology services, though they are in need of review and so on. One of the reasons for that is that we have critical mass. We bit the bullet and said that if we are going to have the best possible patient outcomes, we have to have a service that has the diagnostics, the capital infrastructure, the human infrastructure and the best clinicians, nurses and specialists that will give us the best chance.

We have 4.6 million people in Ireland and 1.9 million people in the North. Whether it is the brilliant work in Crumlin on an all-Ireland basis in cardiac and congenital heart disease, oncology or respiratory heart disease, we need to work together every day of every week to ensure that all of our specialist services are subject to critical mass. That does not only mean North and South. It also means east and west. We cannot think that we can be stellar over here while 100 miles away in Cardiff there is also a stellar facility costing a fortune. We must bridge those things. Brexit drives a coach and horses through that. There are no winners. In particular, the patients will lose because neither country, North or South of the Border, will invest in health.

I will be more specific in terms of the questions about travel and professionals moving and so on. I have to be quite blunt. Britain has always relied upon immigration to staff many parts of its health system, full stop. That has been generated simply by the history of the Commonwealth, as well as the EU and so on. The response of the population at large to Brexit in terms of health care has been a 90% drop off in registrations from outside the EU into the UK health system within months of the vote. Britain normally gets 1,500 registrations a month. That went down to 150. In terms of scale, we have to remember that Britain employs 500,000 nurses. We employ 35,850 nurses. Britain is 54 miles away by sea.

What Britain has done quite clearly is reduce the bursary for nurse education. It is training fewer nurses and people are coming into the country. Whatever they do with Brexit, hard or soft, the UK authorities will have a common travel area for Irish nurses because it is a tap. Irish nurses are degree-level, English-speaking people who land running. Britain will incentivise their recruitment.

Senator Mulherin asked whether they would not pause for thought. The journey our nurses travel is quite simple. It is not to the EU but to the UK they go to within the EU. Outside of the UK, they go to Australia and North America with some transitory passage to the Middle East. The impact of Britain leaving the EU will not have any consequence for the nurse who wants to travel and work in the UK if they cannot get work here or because of shorter hours, better staffing levels or better career opportunities elsewhere. The door to that will remain open wide. I genuinely and sincerely suggest to the committee that it will actually be embellished, because Britain will need that flow even more because the flow from outside the EU to the UK is going to dry up.

When we graduate 1,500 nurses a year, that is the entire pool we have, whereas 1,500 nurses is a drop in the ocean to Britain. It will take every last one. We could use the example of Great Ormond Street, which is a brilliant and world-class facility. It went into Cork a few weeks ago and took every last one of the graduating nurses. We have a four and a half year degree programme in general and children's nursing. It is a brilliant programme. It is brilliant for the graduate because he or she can walk anywhere and be taken into employment. Great Ormond Street took the entire class. The nurses have not even registered yet. We trained them and the UK took them. Do not get me wrong, being hired by Great Ormond Street is like being asked to play for Real Madrid on a free transfer if one is a soccer player or for Kilkenny if one is a hurling player.

Mr. Liam Doran

Therefore, we are up against it totally both in terms of patient care and the efficient and effective use of resources. I am not saying that health is all about nursing and midwifery. It is a part of it. For my area of nursing and midwifery, Brexit is only bad. Britain will increase their incentives and thereby increase migration. We lost 7,500 nurses to the UK in the last six years based upon the certificates of verification. The reality is that movement will increase.

The issue that arises is the reciprocity of qualification. The EU did many things, but one thing it did was standardise via EU directives nursing and midwifery education. In fairness, medicine and other professions have it as well. There is no way Britain will lower its standard but we do not yet know whether it is going to respect the EU directives. It will want the 4,600 clinical hours and so on. Britain will always want that. It will want to offer pathways to train and pathways in which it can build up specialist programmes, because it can offer specialist programmes that we can never match. Without being smart for one moment, if I graduate in Cork and I am taken over to a great London hospital, Great Ormond Street, Manchester Royal Infirmary or any of those, I will be offered an incentive payment to go, accommodation for a period of time and professional development.

Providing I do nothing wrong, within 12 months I will access a specialist programme such as intensive care, coronary care, emergency department nursing, theatre nursing, ophthalmic or burns. When I have that and if I get tired of the UK, Australia and North America call me because they are English-speaking countries. We do not go to mainland Europe by and large. Australia and North America will want me to be experienced so when I graduate I might stay here for six or nine months. A total of 80% of last year's graduates have got certificates of verification to leave already. They have to pay for that and cannot do so unless they have money coming and unless they are going to use it. They are leaving.

The Senator says they will come back. I was educated in Richmond, Surrey, in England. I got home once a year. How many members have gone to London for a day? It is a different world. They can go to live over there, travel over on a Monday and back on a Friday but they will not come home. When they get the specialist qualification and go to Australia or North America, they can command very good money because there is a worldwide shortage of nurses and midwives. Britain has always been a place to which we migrate. Its attractiveness and aggressive recruitment will increase because it is not growing its own. It will rely more and more on Ireland and drain what is already a drained pool. The reciprocity of qualifications will be maintained because Britain will not worry too much about French or German nurses; it wants Irish or Commonwealth nurses. There is no upside.

I am not saying that because of the pounds, shillings and pence, but because it is true. We are absolutely banjaxed when it comes to nurse and midwife supply, recruitment and retention, and that has to be addressed. What the UK is doing in parallel with Brexit will exacerbate our problem. There will be no one pausing for thought. It will not change the flow because it will aggressively offer money and incentives to newly qualified people who will then consolidate their skills, go to Australia or North America and there is no evidence that they come back in great numbers. The Bring Them Home campaign run by the HSE, which aimed to get 500 nurses, officially brought back 92 and, of those, 40 have gone away again.

Forgetting that for the moment, for the patient there is a lot of good cross-Border work, with co-operation in centres of excellence. Hard or soft, what are our strategies? We have to find a way politically to ensure that health care has no borders and that we have critical centres of excellence in specialist services. In doing that we save money, the economy thrives, and we provide optimum patient care on the island of Ireland. The east-west relationship should not be forgotten. I do not know whether the UK is willing to have that. I understand from the Royal College of Nursing and the Royal College of Midwives that they think the authorities are willing to have that kind of arrangement but politically it must be an imperative in the talks.

Was Brexit-proofing part of the public sector pay negotiations? Given Mr. Doran's analysis of the incentivisation programme in the UK and that the Bring Them Home campaign here has been an unmitigated failure, is there anything we can do to ensure we can retain more graduates? I accept that some will go abroad no matter what happens. How can we ensure that our graduates whether nurses, physiotherapists or doctors, stay here?

Mr. Liam Doran

I will be very blunt. At 3 o'clock this morning I left pay talks which took two and a half weeks. Nothing came back. I am a union guy but I say this without blinking. Nothing came back from the management side in those two and a half weeks.

Does Mr. Doran mean the HSE?

Mr. Liam Doran

No, the Department of Public Expenditure and Reform.

Was there nothing about Brexit in those talks?

Mr. Liam Doran

No, there was nothing at all. The Department showed no awareness of, interest in or willingness to address the reality. There is a general section about recruitment and retention which is generic. There is no recognition in the Department of the extent of the crisis and no willingness to recognise it. We are still in talks on the margins and have not quite completed our part yet. To answer Senator Buttimer, there was no recognition of the reality facing the health system in respect of attracting and retaining our own people, doctors, radiographers, physiotherapists and so on. There was nothing done to give primacy, urgency or immediacy to the measures necessary to arrest the haemorrhage we have suffered for the past few years before everyone's eyes. Parts of Government appear absolutely oblivious to it. I did not come here to say that. Our frustration is absolutely beyond measure. This is not a union cry. It should be that the employer comes to us asking what does it need to do. That did not happen.

I thank the witnesses for their contributions and for the work they are doing on this issue and the wider issues.

Sitting suspended at 11.17 a.m. and resumed at 11.19 a.m.