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Hospital Staff

Dáil Éireann Debate, Wednesday - 15 February 2012

Wednesday, 15 February 2012

Questions (7)

Catherine Murphy

Question:

7Deputy Catherine Murphy asked the Minister for Health if, in view of the potential additional cost to the Health Service Executive because of the European Temporary Agency Directive, the arrangements that have been made to cover front line staffing by other means; his plans to introduce any initiatives whereby minimum numbers of front-line staff are kept constant; and if he will make a statement on the matter. [8292/12]

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Oral answers (7 contributions)

The HSE's national service plan 2012 commits to significantly reducing the volume of agency staff usage, with a target reduction of up to 50%. The plan also notes that the transposition into Irish law of the temporary agency workers directive will increase the unit cost of agency staffing. The service plan contains a commitment that overtime and agency staffing are not to be used to support service levels beyond those agreed in the plan or to substitute for staff losses.

I have no plans to specify minimum staffing numbers for front-line services. The impact of staff reductions, and particularly those occurring before the end of the present grace period, together with reduced financial resources, represents a significant challenge for the health system. The HSE's national service plan 2012, which I recently approved, sets out the actions to be taken to address this challenge. The executive is seeking to mitigate the impact of the retirements on front line services by: using the provisions of the public service agreement to bring about greater flexibilities in work practices and rosters, redeployment and other changes to achieve more efficient delivery of services; delivering greater productivity through the national clinical programmes to reduce average length of stay, improve day of admission surgery rates and increase the number of patients treated as day cases; and some limited and targeted recruitment in priority areas to help limit the impact of retirements on front line services.

The HSE service plan states that continuing the current number of temporary agency staff would result in an additional cost of €30 million, which is substantial. How will this happen? It is not that we would wish that there would be a level of service in each individual hospital but that we would make it happen. Essentially I do not see how that can be done without setting a floor below which we cannot fall. That is the kind of thing that gives some certainty. Whether in an acute hospital or a general hospital, the ratio of beds to staff is critical. For example, in the case of nurses if it falls below a certain threshold problems arise. I cannot understand why there is no deliberate policy to try to keep it at a basic level. I am not arguing with the Minister about efficiencies or roster changes. They will deliver something. However, there is a level below which the service should not fall because the service cannot be delivered below that. This is the central point that concerns me about how it should happen.

I thank the Deputy opposite for raising this and I accept her concerns. However, different areas require different skill mixes. There is some rather bad mismatching of some of our services at the moment. I was examining our situation vis-à-vis nursing ratios to health care assistants in some of our community nursing units. In some cases the ratio is not even 1:1 and there are more nurses than care staff. The Royal College of Nursing in the United Kingdom recommends a nurse to health care assistant ratio of 1:2.5 for long-term nursing care units. Many areas have different staffing ratios and one would need to examine each area individually to set the limit under which one would not be prepared to go. A one-size-fits-all approach throughout the system is not possible. There will be different ratios for emergency departments, cardiology, intensive care, paediatrics, ICU in paediatrics and so on. Different ratios apply in these cases. This is work we could do and it should be done. We will consider it.

There is a significant issue in respect of the skill mix in the country. There are varying ratios of medical and nursing staff in various emergency departments. Often it is suggested that one is not comparing like with like and that it is a question of comparing apples and oranges because of the complexity of injuries and disease that some departments deal with vis-à-vis others. However, the bottom line is that agency staff are remarkably expensive and, as someone who has worked in hospitals, I am aware that they present a problem in respect of continuity of care. I would far prefer to see and to make it our policy that where we recruit staff for replacement, they will be new, permanent staff. Issues have been raised with me in the past about whether many retirees will be coming back into the system. This is not our intention and it will be very much the exception rather than the rule.

I have listened to many of the Minister's replies recently. He has referred to dealing with this at an individual hospital level. However, the problem must be dealt with across the spectrum. I fully agree with Minister about a mismatch in services. This is obvious not only in front line services in hospitals but in other services such as speech and language therapy and occupational therapy services. There may be long waiting lists in one place and shorter waiting lists in another. One cannot simply move a person from Cork to Donegal if they have no wish to go but what if that is where the mismatch arises? I fully accept that there are different requirements whether for intensive care or accident and emergency departments. I fully accept the point made by the Minister in this regard. However, this is and should be measurable in terms of the historical information about the level of patient care in each department in a given hospital and the number of beds. I do not understand why a more targeted approach was not taken in respect of the redundancy package. It could have delivered a better outcome.

Deputy Murphy has raised an issue about the distribution of services at times. One need not go as far away as Donegal to find the issues. One need only consider the difference in the services for children with autism in Dublin, north and south, and the disparity in place. I have made it clear to those running the services that they must consult with the Minister of State, Deputy Lynch, and then come back with a plan that gives everyone a service rather than a Rolls Royce service for some and no service for others.

Another contention relates to safety. Dr. Philip Crowley is in charge of patient safety in the HSE. He is on the transitional programme as well to ensure any arrangements arrived at are safe. Our primary concern is to have a safe service and inherent in this is the idea that below a certain level is not safe and above it is safe. Any review must examine the case of each individual hospital and this is being done as part of the overall exercise, although not in the formal sense of figures being available for examination. However, I imagine if I seek them, I will get them.

The HSE has admitted that it has created a reliance on an unaffordable level of agency staff in recent years to maintain service provision. Some €200 million was spent last year on agency workers. The HSE has targeted a 50% reduction in the current year. Earlier this afternoon the Minister stated he would not lift the recruitment embargo, yet he has referred to a greater flexibility. We do not understand how this comes into play. The Minister has never spelt out how this greater flexibility offsets the intended and signalled cuts, the departure of some 4,200 staff from the health services by the end of this month which the Minister has acknowledged. Given a 50% cut in agency staff how will front line service provision be maintained? Will the Minister explain to the House and to the health spokespersons what his greater flexibility means and how it translates?

I will answer the last question first. It is straightforward. There is a moratorium on staff recruitment. Therefore, no new staff can be recruited. However, I have already informed the House that we are recruiting staff and this is where the flexibility lies. It will arise in areas where it is essential to replace staff to maintain a safe service. For example, Deputy Kelleher raised the issue of staff in Limerick. Some 16.5 whole time equivalent midwives are going but 15 new people are coming in. This is taking place in maternity hospitals because it is an area at risk and we have identified it as such. Emergency departments are another at-risk area. More new consultants are being hired in some areas.

There was a debate last night on stroke care in Ireland and it will continue tonight. Deputy Murphy was one of the sponsors of the motion. Many new staff are being employed in the stroke programmes to bring about a far better stroke service that will save lives and a considerable amount of money as well. The important thing is for us to save lives and reduce morbidity, a negative side effect. The policy of a moratorium has had unintended effects in terms of incentivising expensive operational options such as using agency staff and we will redress this.

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