Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Thursday, 27 May 2010

Vol. 710 No. 3

Nurses and Midwives Bill 2010: Second Stage (Resumed)

Question again proposed: "That the Bill be now read a Second Time."

I welcome the opportunity to complete my contribution on this Bill. As I stated on the last occasion, the nursing and midwifery professions have for quite some time been taken for granted. There have been significant changes in these careers over the past number of years and the educational requirements for nursing have changed drastically. As I stated on that occasion, the introduction of degree qualifications and the ongoing training and education while in the job have led to highly qualified and highly skilled professional staff, particularly in the specialist nursing areas. Today's nursing profession is a far cry from what it was a decade or 20 years ago.

The introduction of this legislation provides protection for those engaged in the profession but also for their clients. The Bill also further enhances the opportunities for recognition of qualifications, specifically by ensuring that the employers and management in hospitals are obliged to facilitate nurses and midwives in maintaining and improving their professional competence. That has been a considerable issue over the years. For a long time there was little scope for promotion in the nursing profession. That has changed drastically over the past number of years and this is to be welcomed.

In the past, usually the spotlight was put on the nursing profession only when a particularly nasty case of malpractice or abuse arose and ended up in the media. Given the highly personal nature of the business of nursing, nurses can often find themselves in situations where they are open to false accusations. While patients can suffer due to incompetence or a lack of commitment, the onus is always on the professional to ensure that there is an adequate service provided. The strengthening of the fitness to practice committee in this legislation and the hearing of inquiries in public in most cases will protect both the patients and the service providers, and a robust system of accountability is crucial to both sides of the equation here.

Turning to the main element, the Bill provides for repeal of the Nurses Act 1985 and for a new legislative framework in respect of nurses and midwives, and makes provision for enhanced protection of the public in its dealing with the nurses and midwives. Given the nature of these professions and the intimate and personal nature of them, that is very much to be welcomed.

The recognition of midwifery as a separate and distinct profession is also to be welcomed. Anybody who has been blessed to have gone through child birth can only admire midwives and their dedication to their profession. There is provision for clinical supervision of midwives, who must have adequate indemnity insurance. Insurance in the medical industry in general is a significant issue and is something that raises its head on a regular basis.

The provision of a non-nursing-midwifery majority on the board and on its fitness to practice committee will ensure that the highest standards are maintained and that those who are dealing on a daily basis with the issues that arise have an input and a say in how the profession goes on in future. The Bill also provides for a stronger governance and accountability structure for the board, which is important. In these days of extremely high requirements in corporate governance in general, it is correct that a strong structure is put in place from the start.

The Bill also provides for an improved investigation mechanism for complaints about nurses and midwives, including the establishment of an assessment committee prior to the fitness to practice investigations, and also the appointment of investigators to facilitate such preliminary investigations. Everybody is due a fair hearing and this piece of legislation will ensure that such is the case.

The Bill ensures the registration of nurses and midwives and also the registration of candidates for first-time registration with the board, and the re-registration of advance nurse and midwife practitioner posts. This also ensures very high standards.

As I stated at the outset of my contribution on the last occasion, this is a profession that for many years was taken for granted. It has evolved in recent times into a highly professional skilled job. I have often heard it said that nursing is not only a job but a vocation. I welcome the introduction of this legislation.

The Minister for Health and Children, Deputy Harney, in introducing the Nurses and Midwives Bill before this House two weeks ago, was at pains to point out that nursing and midwifery are the cornerstones of our health service and that Irish nurses and midwives have long enjoyed a fine reputation, both at home and overseas. She went on to state that this Bill is a key component in the construction of a system of governance and accountability for the health services which has the public interest and patient safety as the focal point. Those were fine words, indeed, noble sentiments, but unfortunately, straight from the manual of spin and doublespeak. I must ask how the Minister can reconcile these statements with the fact, according to the INMO, that we have lost 1,900 nursing and midwifery posts since the imposition of the public service moratorium, how she can reconcile these statements when none of the 1,600 2009 qualified graduates have been offered a post in the Irish health care system and how she can reconcile these statements when 1,064 hospital beds have been closed and are unavailable.

It is all very well to enact legislation on governance, but what type of chaotic skeletal health care system is the Minister trying to govern? No amount of window dressing will allow the Minister escape and dodge the fact that in her many years in charge of the health services in this country she has actively presided over the creeping introduction of a business-model based health system for the Irish people.

It has become clichéd but anybody who has been in our hospitals recently will have experienced Irish nurses and midwives under severe pressure trying to provide a most necessary service as they struggle to do the jobs of two or three. When their colleagues retire or go on maternity leave or sick leave, they are not replaced, all because of the public service embargo put in place by the Government. Increasingly, they are working in an environment where quality in the delivery of care is really secondary to the issue of finance, despite what the Minister might say.

From talking to nurses and staff working in our health services, morale has never been so low among staff, everywhere within the service and in every role. The public service recruitment embargo has undermined the value of their contribution to the health system in the country.

There is no doubt that science and technology and matters of governance and regulation are thriving in medicine. However, the Minister and Government should never think that because they have all the tools such as legislation, degree-led education and new corporate bodies, that this is the whole package; humanity and empathy for a patient's position are needed as much now as any time in the past. The Minister must take cognisance of the universal fact that the more prescriptive one becomes, the more one dilutes these characteristics. This is a balance she will need to continuously address.

When the Minister talks about governance and best practice with regard to nursing and midwifery, I suggest she considers the Mid-Western Regional Maternity Hospital which serves not just Limerick, but also Clare, north Tipperary and parts of north Cork. The hospital delivered 5,463 babies in 2009. One of the 5,463 babies born in 2009 in the hospital was my daughter Alma Maye Carey. My wife, Grace, gave birth to Alma on a bright summer's morning on 15 June last. Coincidently, five days later, a young fellow called Fionn Plunkett was born to very close friends of ours, Tadgh and Catriona Plunkett. Fionn's birth was followed by Saoirse Fitzpatrick who is the second grandchild of my constituency secretary, Kathleen Fitzpatrick. I will not leave out little James Buglar, the son of my personal assistant, Paul and his partner Shula. It could be said we kept the maternity hospital in over-drive for the month of June 2009 and there must have been something in the water in late 2008.

I pay tribute to the midwives, nurses, doctors and staff based in the maternity hospital in Limerick for their professionalism. My experience of childbirth and that of my wife was made so much easier by these wonderful hard working people. One of the consultants based in the hospital was in touch with all the Oireachtas Members from the mid-west early this year. He wrote:

The infrastructural situation at the hospital has become very depressing — it is now very close to something that could justifiably be described as a shambles. Shabbiness, over-crowding and a general inadequacy of facilities is the routine experience of patients from the moment they arrive in the car-park until they leave again and as they progress through almost every clinical area in the hospital. The term ‘public squalor' comes to mind. Were it not for the fact that we have a very good core of permanent staff who reside in the region, who are very committed to looking after their own community and who take great pride in their work, things could be very much worse.

These and other problems have been caused by a lack of strategic planning, poor governance structures and chronic under-funding. There is a plan to re-locate the hospital to the Dooradoyle site, but this is not being progressed because no political decision has been made. The disempowering and centralised nature of the current HSE structures means that there is no local decision making of any description. The maternity hospital has an annual budget of €18.5 million In comparison, the three Dublin maternity hospitals have budgets of between €62 million and €65 million per annum — they do about 8,500 deliveries each annually. In other words, the Dublin maternity hospitals have about 350% of the Limerick funding to deal with about 150% of our deliveries. They each have their own labs, management, financial and human resources set-ups, which is hardly an efficient use of national resources.

I read this letter into the record of the House in order to make the point again that all the legislation in the world with regard to governance and best practice cannot mask the fact that the Government, of which this Minister is a part, presides over many fundamental cutbacks which are affecting both patients and those working on the front line of public service, in this case our nurses and midwives.

There is a fine veneer for public consumption but little attention and in many cases deliberate attacking of the structures that would create a proper public health service. This is driven by a specific political ideology as presented by the Minister for many years, the Boston versus Berlin model. However, in the meantime, even the Boston model has now incurred changes with President Obama's reforms and yet in Ireland, under the stewardship of the Minister, we are happy to continue on down a road of health care provision that is in the process of being abandoned internationally.

The governing structure as proposed by the Minister in this legislation is at odds with the Minister's assertion of having the public interest and safety foremost in her mind. The current board consists of 29 members, 17 of whom are elected by nurses and 12 of whom are appointed by the Minister for Health and Children. The new board will have 23 members, 15 of whom are appointed by the Minister and eight elected by the professionals. The eight members of the new board are supposed to represent each discipline of nursing and midwifery. This, on the face of it, represents a slimmed down quango. However, I do not agree with the shift in balance between elected representation and ministerial appointment. The fact that the board, as envisaged by the Minister, is not allowed to comment on the environment within which nurses and midwives work does not indicate best practice for either nurse or patient, in my view. The fact that there does not appear to be any provision whereby the board has some advisory role to service-providers on staff shortages, physical environment, poor quality or unsafe conditions, is at odds with the Minister's stated intentions in relation to public interest and safety.

Our party spokesperson on health, Deputy James Reilly, asked the question last week about the subtle but important distinction as to the manner of how this new board is to be appointed and the independent powers at its discretion, in contrast to those that apply to a body such as the medical council. I have noticed a similar distinction in much new legislation over the past 12 months. The Minister for Finance and the Minister for the Environment, Heritage and Local Government, immediately spring to mind, now to be joined by the Minister for Health and Children, in that much more power and influence is being transferred to the Minister's office.

It is also interesting to note it seems quite likely that most costs associated with this new board will be met by nurses and midwives through increased registration fees. It brings to mind the establishment of the Teaching Council a number of years ago whereby the teachers of Ireland pay an annual subscription to this body with little discernible benefit accruing to them. In essence, the project has become a money-making exercise dressed up in the clothes of professionalism and advancement of standards.

I pay tribute to the superb work of the nurses working in Ennis General Hospital. Despite all the cutbacks and budgetary constraints as a result of the policy to centralise all acute services in the mid-west, the nursing staff at the hospital have remained at all times ultra-professional and dedicated to delivering the best possible service. The decision by the HSE 12 months ago, under the direction of the Minister for Health and Children, Deputy Mary Harney, has allowed the balance of health care provision swing towards the private sector.

There is much evidence that many Clare people who are lucky enough to have medical insurance are now opting for the Galway Clinic as their hospital of choice, even for acute services. This is an appalling indictment of the Government's failure to provide basic health care for its citizens.

The HSE's administrators have stripped Ennis General Hospital of services and moved us along the road to a commercially-based health care provision in Ireland, where what really counts is the size of one's wallet. Many Clare patients have been diverted to the Mid-West Regional Hospital in Limerick in recent months, where staffing embargoes and increased patient numbers are creating significant difficulties. I have witnessed at first hand the chaos in our so-called centres of excellence where people are stripped of all dignity and placed on trolleys and chairs for hours and days. No new facilities or extra patient space has been provided at Limerick Regional Hospital to deal with the additional workload despite all the promises made in this House. It is even difficult to park a car down there.

At Ennis General Hospital, I have been outraged at the ongoing situation with regard to CT scanning services. There has been a stream of conflicting information coming from the HSE concerning this much-needed facility. Last January, we were told that staff recruitment difficulties were resolved and that operations would be up and running without delay. Then we learned that services had been suspended again following the departure of a temporary radiologist. The latest news is that this vital service is now at last working again, seven months after closing. It is vital that this service is developed and opened up to outpatients.

Some weeks ago, I met with staff working in Ennis General Hospital to brief myself on the current situation in that facility. The under-investment continues apace, as does the agenda to close services and centralise. The endoscopy unit promised under the reconfiguration of services has still not been delivered, while the promised geriatric beds are not there either. The policy continues to be to cut whatever costs money and replace it with nothing.

I refer again to the roll-out of BreastCheck to County Clare. I first raised this matter here in May 2009 and since then I have raised it a further eight times. The latest statement from the HSE is that BreastCheck will be made available via a mobile unit in the grounds of Clare County Council in Ennis this September. These are more words, however, and there is a sense that we have heard all of this before. What we need now is action. The roll-out process should be fast-tracked and prioritised. The handling of this issue has been nothing short of a scandal. How can anyone have confidence in our health service when the administrators cannot roll out an essential programme such as BreastCheck on time and efficiently?

At this juncture, we need an overhaul of the country's health care system. Fine Gael has such a plan called FairCare, which will fix our broken health care system. Only then will we be able to adopt 21st century health care, where patients come first and not cost savings, and where everyone can have confidence in their health care system.

This week, fears were expressed that cardiac services in Ennis General hospital are under threat. The Minister for Health and Children should attend the House to make a statement on the long-term plans for cardiac services at that hospital. Yesterday, a very committed consultant, Mr. Terry Hennessy, who is based in Ennis, said he wants to see the services being upgraded there. Mr. Hennessy rubbished claims that cardiac services were under threat. Nonetheless, the Minister should make a statement to this House on the matter.

I welcome the main provisions of this Bill and look forward to the Minister, Deputy Harney, addressing the concerns I have raised.

Go raibh maith agat. The Deputy might convey our good wishes to all those little babies whose names have now been registered on the Dáil record. Well done. I now call the next speaker, Deputy Niall Blaney, who has 20 minutes in the slot.

Like Deputy Carey, I have availed of similar services in Donegal over the last four years. I had three children delivered in Letterkenny General Hospital. It is enlightening to hear from Deputy Carey that all of those with whom he is involved have had such good treatment in such restricted financial times. It is heartening as a Government Member to hear that. I am delighted to hear it.

I welcome the Bill, which recognises the professional standards of our nurses and midwives. I firmly believe that nurses and midwives are the unsung heroes of our health system. They are professionals that we all encounter at some stage of our lives.

It is significant that this Bill has been warmly welcomed by the Irish Nurses and Midwives Organisation. It is vital that the public are confident in the way we deliver and administer our health services, ensuring that patient safety is at the top of the agenda. Confidence in the system must be the cornerstone, both for the nursing and midwifery professions as well as for the general public.

This Bill follows on from regulatory changes introduced for other health professionals in recent years and, therefore, it is appropriate that nurses and midwives are recognised on an equal footing to other health care professionals.

It has been recognised that the regulatory framework needs to be modernised to include a greater emphasis on patient safety, governance, accountability, openness, fairness, efficiency in disciplinary procedures and assured standards. This Bill puts public safety and confidence at the heart of all that nurses and midwives do in a statutory manner, whilst also safeguarding the integrity of those professions.

The current Nurses Act was enacted in 1985 and we have come a long way since then in terms of health care provision. Our health system has developed further, bringing with it the nurses and midwives who have been ever willing to improve and progress their roles to meet the changing needs of patients. The Bill provides for the establishment of a new regulatory body, the Nursing and Midwifery Board of Ireland. The new board will have a lay majority among its board members. It will consist of 23 members in total, representing all interested parties, including nurses, midwives, educational bodies, members of the public and stakeholders. It is vital that nurses and midwives are assured that their views and concerns are represented on the board.

A major element of the board's work will be to administer complaints in conjunction with the fitness to practice committee. I welcome the fact that fitness to practice inquiries will be held in public in future, unless, on application, the particular circumstances of an individual case require it to be held in private. This provides for greater transparency for all of those involved. It is vital that a transparent complaints system is in place for all those who may need it. Nurses and midwives must have confidence in the complaints system, as must the public to ensure that best practice prevails.

Constant advances in medicine, surgery and obstetrics are immense, requiring similar advances in the ability and willingness of all those delivering such services. This Bill will provide for nurses and midwives to maintain their professional competence on an ongoing basis, which is vital both to the service and the confidence of our nurses and midwives. To ensure this happens, the board will establish a competency scheme to monitor the competence of all nurses and midwives in the State. Patient care and safety are key to providing their services, and regulation and governance must acknowledge that fact. This promotes the need for proper regulation and ongoing training among these professionals.

Nurses and midwives must be assured that their expertise, qualifications and experience are recognised. I welcome the definite focus on education and training in this regard. A positive feature of the Bill puts an obligation on employers to facilitate the maintenance of professional competence among nurses and midwives, in particular by providing learning opportunities in the workplace. We are all aware of the benefit of experience as an aid to education and training, particularly in practical settings such as a hospital.

This legislation will classify midwives as a separate and distinct profession also, which I believe is appropriate. The duties carried out by midwives in caring for women before, during and after childbirth require incredible professionalism and skill. We have an excellent service at Letterkenny General Hospital in my constituency in Donegal. I commend nursing staff there on their good work. In the past four years I have had an opportunity to experience the service at first hand as my three children were delivered in the hospital. The service was second to none. I also welcome the fact that the Bill provides for the establishment of a midwives committee to advise the board on all matters relating to midwifery practices.

I commend the Minister, Deputy Harney, and her Department on a worthwhile Bill. I understand she engaged in extensive public consultation, with input from all interested parties and stakeholders since 2007. The Bill will serve to improve the profession and give protection to both the professional and patients. Nurses and midwives usually encounter patients when they are in a delicate and vulnerable condition and the care provided by those professions leaves an indelible memory. We have all experienced the wonderful care provided by nurses and midwives. I commend the Minister on her Trojan efforts in bringing the Bill to the House and ensuring that all interested parties had a worthwhile input.

This is my first opportunity to wish the Minister for Community, Rural and Gaeltacht Affairs, Deputy Pat Carey, well in his new portfolio. I have known him for a long time and I am sure he will do a very good job in it. I wish him the best of luck. I am delighted he is a member of the Cabinet.

I welcome the opportunity to contribute to the debate. The Nurses and Midwives Bill 2010 repeals the Nurses Act 1985 and provides a modern statutory framework for the regulation of the nursing and midwifery professions. The primary objective of the Bill is the enhancement and protection of the public in its dealing with nurses and midwives. It will provide for a modern, efficient, transparent and accountable system for the regulation of the nursing and midwifery professions.

It is important to have the Bill before the House and to recognise the significant contribution nurses have made to society, especially to many people at a time of illness. We have heard stories also about midwives dealing with the births of children. People are dependent at such a vulnerable time. Many people in this country have trained as nurses. A total of 89,580 nurses are registered with the board. The profession has been dominated by women. Of the total number of nurses, 82,500 are ladies indicating that approximately 7,000 men have taken up the profession. They are the pillars of society in every country. It is unfortunate that one has to spend time in a hospital to appreciate the work of nurses.

It is a caring profession and many nurses are drawn to enter it because they want to make a real difference and to care for and help people. It is welcome that when young people decide to go into a profession so many take up one that is about helping other people. It is not only a worthwhile profession; it is a vocation that many young people choose. In England the young Irish girls who are being trained as nurses in hospitals such as Whipps Cross and many other well known places are spoken of highly in terms of being well trained and articulate. As a nation we must be proud of them. One cannot speak highly enough of nurses and their contribution to society. I have four sisters in the nursing profession and I have seen how dedicated they are to looking after other people. That is why I welcome the Bill.

In welcoming the Bill we must deal with the concerns and frustrations nurses encounter in their daily lives. At a time when it is more and more difficult to finance the needs in the health area, huge misspending of money in the Health Service Executive is evident. That is a strong statement to make but I do so because there were no cutbacks in management compared to the cutbacks nurses experience on the ground. Clonmel Hospital in my constituency is subject to the reconfiguration programme of the Minister for Health and Children and the Health Service Executive. Nurses in that hospital are worried and fearful as they go through the process of reconfiguration. They see at first hand the input each of them has made into the services in the county. The committee is reconfiguring the service, which will affect the service and take people's jobs and livelihoods away. The service is needed and nurses have to wait while management in the Health Service Executive consider leaving the county without it. It is understandable how 10,000 people congregated in the streets of Clonmel on a cold March day to march behind the nursing profession and the people of the county in order to maintain the wonderful service.

The existing maternity service has already been reconfigured, as part of it came from Cashel many years ago. The Health Service Executive is now considering taking the service out of the county. Are the Minister and the Health Service Executive serious about the proposed closure of one of the finest establishments in this country? I say that without fear of contradiction. I visit that hospital on a regular basis and I meet constituents who refer to sick relatives and how well treated they are in the hospital, yet an expert group is considering closing down the hospital service in the county. People are afraid that will happen but we do not know what will happen. We are waiting for a committee decision to hear whether it will take part of the services from Clonmel Hospital and put it into Kilkenny or take services from Kilkenny and put them into Waterford.

A big, new hospital is supposed to be built in Waterford. I heard the Minister for Justice, Equality and Law Reform, Deputy Dermot Ahern, say there is not a red cent to build a hospital in any part of the country. Why are we wasting time with officials looking at projects when there is no money to implement them? At the same time there is no money to pay nurses to fill positions in maternity hospitals and general hospitals. I read in the newspaper today that beds are being closed in Clonmel Hospital because there are no nurses or staff to look after people there. Who is in charge of what is happening in the health service in this country? Is it the Minister for Health and Children, the Health Service Executive, the Department of Health and Children or the Cabinet? I wonder who is in charge and is allowing this ridiculous situation continue. The reconfiguration should stop. We should stop wasting taxpayers' money.

I say that sincerely because according to a member of the Cabinet, there is no money to build a big hospital. Discussions on the amalgamation of services and the construction of bigger facilities are continuing nonetheless. Have I ever heard anything so ridiculous? Have I ever had to come to the House to explain something so silly to a Minister?

I want to make a plea on behalf of my hospital, as Deputy Joe Carey did earlier on behalf of his hospital. Millions of euro have been invested in the service in south Tipperary. A High Court agreement is in place. If my figures are right, over €20 million has been spent across the hospitals in Clonmel and Cashel. Our Lady's Hospital in Cashel needs to be opened. The building works that have been ongoing for many years need to be finished. The nurses in that hospital should be allowed to get on with providing services. The same thing applies to Clonmel. The maternity and accident and emergency services in County Tipperary should be retained to reassure people in the county who are worried that their children may have accidents in the middle of the night.

There is a funny situation in County Tipperary. If the maternity unit in Clonmel is closed, no Tipperary child will be born in the county. If there is no hospital where children can be born in the premier county, which is one of the finest and largest counties in Ireland and has a population of 180,000, will we be able to stand over that? I challenge the Government Deputies who come in here week in, week out, to defend that.

I support much of what is in this Bill. We must start by looking after the nurses on the ground. The nurses in County Tipperary have been providing a wonderful service for many years. We need to give them a sense of freedom. As someone who listens to them every day, I know they feel they have been isolated by this Government. They are not represented on the committee that is supposed to be looking after their future. What is happening is wrong, unfair and unjust. The Government has to answer to the people of County Tipperary. I ask the Minister, Deputy Pat Carey to bring my message about Tipperary to the Cabinet.

I feel strongly about this huge issue. Regardless of which Government is in power, if it changes direction to do what is being considered in Clonmel I will not stand by it under any circumstances. Taxpayers' money has already been spent and reconfiguration has already taken place. I am putting up a sign telling the Government to keep its hands off the services in South Tipperary General Hospital. I mean it. I want to say it strongly. As someone who has family members working in the hospital, I know many of the people who have given a commitment to the hospital. At a time when we are talking about the wastage of money, it is wrong to allow this committee to continue to do what it is doing.

I am glad to have had an opportunity to say a few words on this Bill. I have made the case for the nurses of Clonmel. I welcome many aspects of the Nurses and Midwives Bill 2010, which will help to protect the community. We are all in this together. Everybody wants to ensure the people get a better service. They need to be protected. It is important that we are introducing regulations. That should be welcomed. I wanted to make a strong point on behalf of my constituents, including the nurses who are so committed to their jobs. We need to start by supporting them. If we make them feel they belong and ensure their work is honoured and recognised, we will have a better nursing profession. They will know that in the future, they can take out mortgages and send their children to college. If they are to have secure futures, their jobs are important.

I welcome the opportunity to speak about this Bill. A substantial amount of clarification and explanation is required. I hope to raise some questions. My colleague, Deputy Ó Caoláin, spoke in detail about this Bill recently. I suppose that gives me some latitude to look at the general position of the HSE and the provision of health care in this State. I remind Deputy Tom Hayes that the HSE is not responsible for the closure of hospitals throughout the State. The withdrawal of essential health services across this land is Government policy. The HSE is used as a mudguard to collect blame. The reality is that the HSE will do what it is told to do, by and large, by the Minister and in accordance with Government policy. I need to correct that misnomer at the outset.

Earlier this afternoon, I was told the hospitals in Wexford, Clonmel and Dundalk will be closed at the end of June, in effect, as no registrars or anaesthetists will be appointed to them. We already know that the appointment of junior doctors to Louth County Hospital for training purposes will cease on 30 June next. As a consequence, all acute medical services at the hospital will have to be transferred to Our Lady of Lourdes Hospital in Drogheda, which is already grossly overcrowded. This is a specific policy intention of the Government. There is a shortage of junior doctors at present because the Government made it much more difficult for junior doctors from outside the EU to get positions here. The Government has refused to recognise or accept the standard examination that is carried out in Britain. Applicants for junior doctor positions have to deal the significant delays and expenses associated with the similar — almost identical — test that applies in this State.

It is clear that the Government does not want additional junior doctors. It is much happier to close essential services and to corral health care into a number of bigger hospitals. Our Lady of Lourdes Hospital in Drogheda, which is such a hospital, is full to capacity. The hospital's accident and emergency unit, which was developed at a cost of €11.5 million, is waiting to be opened. It cannot open because sufficient staff are not available at present, largely as a result of the cap on recruitment. In some cases, people have to sit on chairs and trolleys in the existing accident and emergency unit for 36 or 40 hours because they cannot be moved into the new modern facility.

The difficulties that already exist in Drogheda will be substantially compounded by the arrival of significant numbers of acute patients from Louth County Hospital in Dundalk. The accident and emergency department, the intensive care unit and the male and female medical wards will be transferred from Dundalk to a hospital that is already grossly overcrowded. Is that good health care management by the Government and the Minister? I do not think it is. It is disgraceful.

The whole situation regarding anaesthetists, registrars and junior doctors needs to be dealt with by the Government as a matter of urgency. Unfortunately, I do not see any effort on the part of the Government to do so.

In fairness, it must be acknowledged the run-down of the health service in Louth County Hospital had started before the Government took up office. It commenced approximately 20 years ago. In 2001 the children's ward closed, follow by the maternity unit, the obstetrics and gynaecological ward and their services transferred to the Lourdes hospital in Drogheda.

Women and children first, a bit like the Titanic. The comparison is apt considering the Government, if it has its way, will sink the essential services for in excess of 100,000 people in the greater Dundalk catchment area. They will be crowded into the already overcrowded hospital in Drogheda.

The solution, it was claimed, was there would be a new modern, and state-of-the-art, midwife-led service provided at Louth County Hospital. Women throughout Britain were meant to be opting for this type of service. A similar service was located in Bristol which was supposed to be operating successfully. This was pure bunkum and lies. We were misled by those statements from the HSE, Health Service Executive, and local politicians both at council and Oireachtas level. The midwife-led unit never opened. The unit in Bristol that we were told was all-shining, terrific and modern we then learned had serious problems.

Women in the Dundalk area now have to decide to travel to the Drogheda maternity unit which has its own problems. Until recently, that unit's mid-wife complement was grossly understaffed. The international standard for midwives is 1:25 births. In Drogheda for a considerable time, it was operating at a complement of 1:48 births, almost double the international standard. I acknowledge it has begun to come down, an improvement of 1:35 births. It still, however, is a long way from meeting international standards to which women in the area entitled. Mothers-to-be in Dundalk have the other option of attending a private practice across the Border.

These choices are grossly unfair and come down to the nub of the Government's health policy. It is trying to privatise as much of the health service as it possibly can. It is trying to shut down public services and cajole patients into private health care. Its promotion of private health care has already been demonstrated by its huge tax incentives for private hospitals.

The Americanisation of the Irish health service is well under way. Up to 50% of the people of this State have opted for private health care because they have no other alternative as proper public health care services are not in place. This element of public health care provision, a responsibility of this and preceding Governments, is completely ignored. This is unacceptable.

If I were in charge of this Government, I would not allow the Minister for Health and Children, Deputy Mary Harney, to clean out a toilet in a hospital much less run an entire health service. She is neither competent in nor cares about dealing with the difficulties faced by the health service. The Government is happy, due to the politics of the situation, to allow her carry on being Minister to a service that is grossly underfunded and understaffed. The staff in Louth County Hospital no longer walk but run from bed to bed because of the pressures of understaffing. It is an indictment of this Government, the other Fianna Fáil-led ones over the past 13 years and their predecessors.

Wexford, Nenagh, Louth, Sligo, Monaghan and Navan hospitals, essential health care services to their localities, will be closed down by Government policy. Those first affected by these closures will be women, children and older people. They will now be required to travel ever longer distances to access health care. This is an indictment of the Government's scandalous and unacceptable health policy.

Bring on the next general election because I hope the people of this State will give the Government the electoral result it deserves. Never mind the banking crisis, what is going on in the health service is just as big a scandal. It is a scandal in the provision of fundamental public services to our society. This Government does not care about society; it does not have a social conscience. All it wants to do is bail out its greedy and corrupt banker and speculator friends.

By this I am not referring to those working in the banks serving members of the public at the front desk. They are the hard-working but underpaid, doing a decent job. I am referring to the senior executives in the banking services that are corrupt.

I am also referring to those the senior people in the HSE, those from a professional medical background, who know what exactly they are doing in their administration and closing down of the services. Of course, they will be all right because if they ever decide to go back into medicine, there will be a position for them in privatised hospitals. These very hospitals were incentivised to the tune of 100% by the taxpayer for construction and kit-out costs with a 15% allowance for the first six years and 10% for year seven.

This specific Government policy does not care about people who cannot afford private health care. This is a Government that does not care about the sick. It only cares about the golden circle, evidence of which we see in this Chamber every day when debating these matters.

When the National Treatment Purchase Fund was introduced some years ago, its purpose we were told was to shorten the lengthy waiting lists for people who needed essential care. While I support this scheme because it facilitates, say, pensioners' hip replacements in the private health sector if they have had to wait over three months, it must be seen that the Government never sought to make proper provision for hip replacements in the first instance. It has become the standard to funnel these public patients into the private health system at huge costs to the taxpayer when public provision should have been made in the first instance.

The fact people are willing to pay exorbitantly for private health insurance suggests to me they would be willing to pay a specific additional percentage in taxation that would be ring-fenced for the proper provision of health care. Is that happening? No, because the Government wants to Americanise the whole Irish health care system, which is a scandal.

I have referred to the Louth County Hospital and Our Lady of Lourdes Hospital, Drogheda both of which are within my constituency but let us consider Monaghan General Hospital for one moment. It does not have the same catchment area as Dundalk, but does that mean the people of Monaghan are less entitled to health care service? The hospital has been in place for more than 50 years and has served the people of that area well. Why is it being closed now? We are informed it is because of re-configuration. That represents only a buzz-word to me, learned from public relations people who, in turn, sourced such terms from the beginning of the buzz-word era with the Americans and the Vietnam war. This might appear to be a lengthy connection but it is a fact. Re-configuration was a buzz-word introduced to try to bluff people who might believe that such people know what they are talking about when they use such words. However, they are simply referring to cutting back a service, in this case for the people of Monaghan and its catchment area. The local hospital has served the people of Monaghan very well for more than 70 years but it is now closed or virtually closed. There is no acute medicine in place and no accident and emergency department. Patients from that area are being sent to the Cavan General Hospital at the moment. The people in the Cavan area might believe that is a great thing and it means their health service is being maintained and functioning but only in the short term. It is only a matter of time until Cavan General Hospital patients will have to travel the additional journey to the already overcrowded Our Lady of Lourdes Hospital, Drogheda. This hospital in turn will be still further overcrowded by the patients from Dundalk, never mind the people from Cavan coming down.

It is worth noting that for the people of Blacklion, Cavan, in the west of that constituency, there is a 100 plus mile journey to their nearest hospital. This is the result of what is happening in the north east and the people of Cavan need to know as much in advance of the next general election. Soon, they will be expected to travel. Let us remember we are discussing people who are ill, who are about to be admitted to hospital, who are sick and who need attention. The last thing one should do with someone who is unwell is to send them on a 100 plus mile journey to the nearest hospital for acute medical care, but that is exactly what Government policy is forcing the people of Cavan and Monaghan to do.

I refer to the Louth County Hospital, which is about to close for all intents and purposes. It will not close completely. The doors will be open and it will deal with some endoscopies, minor procedures and cuts and bruises but it will deal with nothing serious. We were promised a minor injuries unit in the Louth County Hospital but I will not hold my breath for that to happen because I do not believe it. However, if it does take place, no service will be adequate to replace what has been in place for 50 years now, that is, a proper, functioning accident and emergency service.

The people in Meath, especially in the Navan area, need to know that the services of Our Lady's Hospital, Navan are already being run down and it will be closed as well. There is a slow burn in place and those working there have already been put on notice that re-configuration will take place. The people who use that hospital will have to travel a substantial distance for health care.

I intend to use my last two minutes to say it is a shame, not only on this Government and its Ministers, but on every Member who votes in favour of the Government. It is scandalous that, time after time, certain backbenchers get up and walk through the lobbies and vote for this policy which is grinding down our health service. The Minister for Health and Children is somewhat like an absentee landlord. She shows up here once in a blue moon but has shown no diligence, interest or enthusiasm for the position she holds. She should go. In fact, she should be sacked and put out the door for neglect of the service. Similarly, the Government should be told to go as well. I look forward to an early general election to give the people an opportunity to give an answer to this Government once and for all and to say to it "No more". It should turn this policy around to give a proper health care service to everyone in the State not only to the millionaires who can afford it, but to the ordinary people wherever they come from. People should have reasonable access to a proper health service no matter what the size of their bank account.

I welcome the opportunity to contribute to the debate on this Bill. While I have some concerns about the Nurses and Midwives Bill 2010, to which I will refer later in my discussion, in principle, I welcome it. The Bill serves to enhance the protection of the public in its dealings with nurses and midwives and to ensure the practice of nursing and midwifery with a level of integrity which, I believe, is already in place but to ensure it continues in future. The Bill is supposed to provide for a modern, efficient, transparent and accountable system for the regulation of the nurses and midwifery professions.

Some chance of that.

This is supposed to satisfy the public. The relevant professionals, all of whom are nurses and midwives, should be appropriately qualified and competent to practise in a safe manner on an ongoing basis. This is an important principle.

I refer to an issue I have raised for several years, that is, the need to ensure there is a system of regulation which is accountable for other types of professions. I refer in particular to the professions of counselling and psychotherapy. Serious issues arise in respect of dealing with people in very vulnerable conditions but there is no regulation whatsoever in this regard. I will deal with this matter at greater length later.

Let us compare the approach of the Bill to nursing and midwifery and the total absence of regulation in respect of 12 other areas, which were supposed to be regulated under the Health and Social Care Professionals Act 2005. Some 12 professions were regulated in that legislation including physiotherapists, welfare officers, and so on. Since 2005 nothing has been done and not one of these 12 professions have been regulated. I have campaigned to add the two areas to which I have referred, namely, psychotherapy and counselling, but I am informed the other 12 professions must be regulated before it would be possible to add these two professions to the regulatory framework about which I am specifically concerned.

I have seen at first hand the damage that can be done by untrained people dealing with vulnerable cases. There is a course which takes place over eight weekends to train someone to deal with eating disorder difficulties. Eating disorders are among the more difficult areas of psychiatric difficulty. They involve psychiatric, emotional and physical conditions. A complex combination is involved. It is totally unacceptable for someone to be qualified to deal with this after eight weekends. I refer to a situation whereby after 90 hours someone can obtain an advanced diploma in suicide treatment. Such people can deal with those who are suicidal and those bereaved as a result of suicide. These people are going into very delicate areas and this can cause difficulties. I have raised this matter with the Minister, who fully accepts the situation should be dealt with, but it will not be dealt with until the 12 other professions are dealt with in the 2005 legislation. However, none of these have been addressed yet. At this rate, none of us will be in the House by the time some regulation is in place in this area.

I refer to the controls in this Bill. Certain training elements are required for psychotherapy and counsellors. Of the professions involved in that area, 22 have come together to recommend training to ensure competency, but that does not stop anyone putting a plaque on the wall and charging €80 an hour for counselling and psychotherapy.

The Bill repeals the Act of 1985 and puts in place a new framework in respect of nurses and midwives, the body to be known as Bord Altranais agus Cnáimhseachais na hÉireann, the Nursing and Midwifery Board of Ireland. It recognises midwifery as a separate and distinct profession and provides for the clinical supervision of midwives, who must have adequate indemnity insurance. I am sure the indemnity requirement already exists but it is important to regulate it. The Bill also ensures a non-nursing midwifery majority on the board and on the fitness to practise committee. There is considerable concern about the fact that there will be a non-nursing majority on the board, and I will deal with this aspect later.

The Bill will establish an improved investigation mechanism for complaints about nurses and midwives, including the establishment of an assessment committee prior to fitness to practise investigations, and the appointment of investigators to facilitate such preliminary investigations.

Surely the area of counselling and psychotherapy should be covered by the fitness to practise element of the Bill. I know of people who have been seriously damaged by unregulated counsellors and therapists. The principle should apply to the area I raised earlier. The Bill includes a prohibition on unregistered nurses and midwives engaging in the practice of nursing and midwifery. That is as it should be. We must ensure the proper training of nurses. The training of nurses has changed greatly over the years.

I am not convinced the new system is an advance on the old. My own wife was trained under the old system and my mother was trained as a psychiatric nurse in the 1940s. The practical training they received stood to their human approach to the patient in all aspects of nursing, whether in the community or in hospitals. The more academic approach loses much of that. I do not say the content of the modern academic training is questionable. It is acceptable. However, the marrying of academic study with experience on the wards during a period of training inculcated in nurses an understanding that there was more to nursing than passing a final examination and getting a qualification. There was a patient-nurse relationship aspect to nursing, which is lacking in the modern approach.

The Bill also deals with the registration of nurses and midwives, of candidates and of advanced nurse and midwife practitioners' posts. There will be a new statutory framework for the maintenance of professional competence of registered nurses and midwives. The Bill also deals with the dissolution of the National Council for the Professional Development of Nursing and Midwifery and the transfer of its staff, assets and liabilities to the board. That is a practical aspect of the Bill.

The primary objective of the legislation is the protection of the public. Key aspects of this relate to fitness to practise, competency and a non-professional majority on the board. In this regard, I raise the following points. The Bill seeks to introduce what is regarded as a two-part fitness to practise structure, which would bring the Nurses and Midwives Bill in line with the Medical Practitioners Act 2007. This structure provides for the establishment of the preliminary proceedings committee to give initial consideration to complaints and an internal fitness to practise committee to conduct inquiries.

The Commission on Patient Safety and Quality Assurance was established by the Minister to develop clear and practical recommendations to ensure that the quality and safety of patient care is paramount within the health care system. The Commission on Patient Safety and Quality Assurance advocates the separation of fitness to practise from the regulatory function. Under these proposals, the board will still be responsible for the preliminary investigation and if it is decided that there is a case to answer, the chief executive will present the facts of the case to the fitness to practise committee, which would operate outside the board. According to the regulatory impact assessment, "There is a lot of merit in what is proposed by the commission. However, the detail of how it would operate is not clear and it will be the work of the sub-group to examine and make proposals as to how this might be achieved". The Minister, in concluding the debate, might comment on why she has not accepted the recommendations of her own commission on patient safety and quality assurance and why the proposal I refer to has not been developed in the Bill, but left to a sub-group, who will examine it and make proposals as to how the situation might be dealt with. While the Bill is going through the Houses, there is an opportunity for the implementation strategy group to make recommendations in this regard.

The proposed fitness to practise model is based on the model adopted by the Medical Council. It is my understand that the Medical Council has sought amendments to the new legislation, based upon its experience through its practice as a medical council. Can the Minister confirm if this is the case? If it is, what amendments has the Medical Council sought, as the Nurses and Midwives Bill will, otherwise, repeat mistakes already made? There is an indication that the medical council is concerned that the difficulties it identified will be repeated. The difficulties have already been experienced in the Health and Social Care Professionals Bill, before even one of the 12 professions has been regulated. The Minister has written to me on this matter and informed me that she must bring forward a Bill to correct difficulties experienced in that Bill. It was passed in 2005 but nothing has been affected by it yet.

The current board consists of 29 members, 17 of whom are elected by nurses and 12 appointed by the Minister for Health and Children. The new board will have 23 members, 15 of whom will be appointed by the Minister and eight elected by the professionals. There is concern at this arrangement.

The eight members of the new board elected by professionals are to include two nurses, one from general nursing and one from children's nursing, of whom at least one must be in clinical practice; two nurses, one from psychiatric nursing and one from intellectual disability nursing, of whom at least one must be in clinical practice; one midwife and one public health nurse, of whom at least one must be in clinical practice; one nurse or midwife engaged in education; and one older persons' nurse.

My party met the Irish Nurses and Midwives Organisation, which has voiced serious concerns about the proposed structure of the board and the adequacy of the representation of nurses and midwives thereon. It claims there is no way the work of midwives can be adequately represented or safeguarded with only one midwife on a board of 23. The same applies to the other strands of nursing. The board of 23 must be compared with a 25-member board for the Medical Council, which looks after 7,000 medical practitioners. The Allied Health Professional Council, which has a board of 21, looks after 5,500 to 6,000 allied health professionals.

The proposed membership does not provide adequate recognition of differing numbers within each area of nursing and midwifery. For example, there is one general nurse engaged in clinical practice who will represent more than 25,000 practising general nurses while one public health nurse will represent 1,700 public health nurses. Perhaps the Minister of State will outline the rationale that applied when this decision was made and whether she believes the approach she is taking adequately represents and reflects the discipline of nursing.

Section 25 allows for the payment of allowances to members of the board or committees. Perhaps the Minister could clarify the numbers of people who will be eligible for such allowances.

Section 46 establishes what is referred to as a "candidate register". This means undergraduates will have to register with the new board and pay a fee for the privilege. Will the Minister of State explain the purpose of this new register and its benefit to the board other than its being a crude money-making exercise? Candidates are not independent professionals but are supervised at all times. It is not clear why they must register in the way proposed.

Section 46 establishes what is referred to as an advanced nurse practitioner/advanced midwife practitioner, ANP-AMP, post register. This post register will contain the names and details of advanced nurse practitioners' posts and advanced midwife practitioners' posts, and any other information required by rules. This register applies only where there is a post. If an advanced nurse practitioner wanted to move to a different hospital with no such post, he or she would not be not registered.

Perhaps the Minister of State will explain the purpose of this register? Is it to prevent people from developing services where the HSE and Minister do not want them? If one is off the register for a number of years, can one get back onto it? Many nurses, who are predominantly female, decide to leave nursing for a period to rear a family and then return to nursing. Many of my family friends have done so. No stipulation exists in the Bill for any other registered professional and his or her registration. The proposed register will, by default but perhaps not by design, prohibit the development of the profession.

The membership of five proposed for the statutory midwifery committee is hopelessly inadequate and will not ensure that the many areas of midwifery are represented, even through nomination, in the workings of the midwifery committee. The current legislation, as interpreted by the board, does not allow it to comment on the environment within which nurses practise.

Section 9 sets out the functions of the board. This section does not give the board a role to advise service providers regarding staff shortages, physical environment, poor quality or unsafe conditions. Every action the board takes must be carried out with the agreement of the Minister. Therefore, it is not acting independently in the interest of the public. It acts on the instructions of the Minister. As Members have stated, ministerial instructions do not, at all times, represent the best interest of the public. The Minister nominates the president, who does not have to be a nurse.

The chief executive officer of the new board will not be permitted to make any statements that differ, contradict or oppose ministerial and Government policy. A similar restriction does not apply to the chief executive officer of the Medical Council or the chief executive officer of the Allied Health Professional Council. Why is the chief executive officer of the proposed board being gagged? Surely it is in the interest of transparency that the chief executive officer be in a position to ensure the public interest is protected where he or she is extremely concerned about a certain development and is not being responded to by the system, Minister or the dysfunctional HSE.

The regulatory body should be allowed to seek to meet the service provider, advise it regarding a given matter and ask if anything can be done. Provision in this regard should be included in the Bill. Perhaps the Minister of State will comment on why the board does not have authority to do as I propose.

Like other speakers, I am glad to have an opportunity to speak on this Bill. It is important and it has a regulatory function. It introduces new requirements in certain areas and replaces others. We should always welcome improvements but we are not so certain that all the provisions in this Bill are improvements. As we have come to recognise, very often the legislation we pass worsens a problem in need of remedy. I am not so certain that problems will not arise on foot of this Bill.

The explanatory memorandum states:

The purpose of the Bill is to enhance the protection of the public in its dealings with nurses and midwives and to ensure the integrity of the practice of nursing and midwifery. It will provide for a modern, efficient, transparent and accountable system for the regulation of the nursing and midwifery professions, which will satisfy the public and these professions that all nurses and midwives are appropriately qualified and competent to practice in a safe manner on an ongoing basis.

Would it not be great if this applied to the entire health service? I am sure the Ceann Comhairle agrees with me, although he cannot get up and applaud. It would be very reassuring to the public if it did apply to the health service as a whole.

The Bill allows for the protection of and provision of information to the public. It is to ensure the highest standards will apply and that there will be a right of reply and access. This is only proper but I hope the rest of the system does not strangle the intentions of the Bill and create something we did not intend to create in the first place.

The Bill, according to the explanatory memorandum, makes provision for "a regulatory body to be known as Bord Altranais or the Nursing and Midwifery Board of Ireland and an explicit statement that it performs its functions in the public interest". That is laudable and I fully support the concept. Another element of the Bill, according to the explanatory memorandum is, "The recognition of midwifery as a separate and distinct profession. Provides for clinical supervision of midwives who must have adequate indemnity insurance." I agree with that. It is important that midwifery be recognised as a separate and distinct profession and that the highest possible standards prevail.

In doing so, we must not create another tier of management and bureaucracy that could impede the way the profession operates or the service the patient expects. That could happen in a number of ways. The necessity for indemnity is increasing and obvious demands occur on a regular basis. We have witnessed numerous instances of this and I am not sure the supervisory structure is in accordance with what might be in the best interest of either the profession or the patient. How often have we heard of court cases in which it was suggested that procedures were not followed or interventions and decisions were not taken when they should have been? While the purpose of the legislation is to streamline procedures and to make sure everything works in a co-ordinated fashion, I can envisage scenarios in the future where a decision was not made because the person in charge is not fully in control or does not have the latitude required to take the decision or has thrust upon him or her additional responsibilities, which could, in turn, jeopardise their judgment and career or somebody's health.

The provision of a stronger governance and accountability structure for the board is also laudable and I fully support that. However, based on our experiences in recent years, when boards of all shapes and sizes have been formed in the health and financial sectors, the reverse has been the case. Everybody ducks and dives and runs for cover while getting away from responsibility. They do not come up with reports or answer as they should, they are not transparent or accountable and they do everything in their power to ensure their own base is covered and to hell with everybody else. This is a serious issue and many Members, including myself, have raised this previously.

The legislation concerns a vital element of the health service where a decision taken or not taken, a question answered or not answered or a person accepting or unwilling to accept responsibility in the chain of command can have widespread implications for everybody involved, including the lives of patients. While I fully support the concept of accountability and governance, I have my doubts, like many Members who have commented on this subject, about whether it will come to pass on the basis of long years of experience. I spent a number of years on a health board, as did the Ceann Comhairle. My only knowledge of this area is based on my experience on the health board and in dealing with constituents. However, as elected representatives, we need to keep this interaction in mind at all times.

We are due to take Question Time at 3.30 p.m. It appears there will be no more contributors on Second Stage and, therefore, I would like to give the Minister of State the opportunity to conclude the debate before Question Time. Will the Deputy facilitate this?

In the spirit of co-operation that exists in the House, in anticipation of an improved service from the HSE in replying to parliamentary questions that have remained unanswered for some months and given the Minister of State is a constituency colleague, I am willing to make many sacrifices, including forfeiting the final five minutes of my slot.

Tosach maith leath na hoibre.

I thank the Deputy.

I refer to the prohibition on unregistered nurses and midwives engaging in the practice of nursing and midwifery. I thought that was a given. If I were representing a person who needed services or I received a query from a constituent in this regard, I would like to think that was the case. Will the Minister of State clarify the instances in which the prohibition was required? That would be helpful.

The approval of programmes of education and further education necessary for the purposes of registration is an excellent provision and a similar provision applies in other areas. It is important in the medical profession in general that there be ongoing training to ensure awareness among medical professionals about modern practices and developments, to make sure the highest standards of safety apply and to ensure full information is available to those working in the sector at all times. It is of major importance and I strongly support the provision as well as that relating to advanced nurse and midwife practitioner positions.

Responsibility and decisions are important and sensitive issues in this area. I pay tribute to the nurses and midwives who over the years have given tremendous service throughout the State, well beyond the call of duty in most cases. They have rarely received the recognition they deserve over the past 70 years, particularly in remote parts of the country where they had to travel long distances in inclement conditions while in receipt of low pay. Ongoing education, upgrading of skills, awareness of new and emerging practices and the continued insistence that health and safety requirements are maintained must be ensured for the benefit of all.

Reference is made to the specification of standards of practice for registered nurses and midwives and guidance on all matters related to professional conduct and ethics. While there has been much debate about conduct and ethics generally, nurses and midwives have rarely been mentioned but they deserve to be mentioned. People depend on the professional opinion of the person with whom they are dealing and they need to have absolute confidence in that person. If he or she is adequately qualified and deserves to be registered, the public can have every confidence in the services, which is important. Unfortunately, there have been a number of cases in other branches of the health services where the reverse was the case. I am not aware of any such breach in the midwifery area but the degree to which there was a breakdown in the relationship between the patient and the practitioner at senior level is, to say the least, appalling. I do not wish to go into the details of the original cases, of which the Ceann Comhairle is also aware. When members of the public put themselves in the hands of the medical professional, at whatever level, they are vulnerable and are entirely dependent on the judgment, ethics and conduct of the person in whose hands they have placed themselves. I must say — it has often been spoken of in this House — there were many breaches in which that confidence was seriously eroded at very senior levels, which is regrettable. I hope the provision is not necessary in this instance. I know, from my own knowledge, it generally was not in any event. However, there will be variations in the degree to which individuals apply themselves to the task and devote themselves to their vocation. Nevertheless, it behoves us all to recognise that whenever we put in place in the health services a person or persons who have particular responsibilities and obligations and who, for one reason or another do not observe these or recognise the pivotal role they play, this can have a major and negative impact, not only on an individual patient but in terms of the erosion of public confidence in what is a vital service. I cannot overemphasise this.

It is interesting to note the obligation on employers to facilitate the maintenance of the professional competence of nurses and midwives, in particular by providing learning opportunities in the workplace. It is important that a work situation should not exist whereby it becomes impossible for the nurse or midwife to avail of an opportunity for ongoing improvement and training. The argument may be advanced that it is understood that such an opportunity would exist in any event but it may be given in the spirit but not in the letter of the provision. A situation could arise whereby the pressure of work would be so great that it would be impossible to avail of such opportunities for ongoing training.

It is stated that fitness to practise inquiries will generally be held in public but a decision may be made by the board to hold some or all of the inquiry in private depending on the circumstances. That is fair enough although I am not much in favour of inquiries being held in private. If an issue needs to be dealt with that may have a public interest dimension or that may have an impact on services of which the public may have to avail, where at all possible such hearings should be held in public. Much can be learned from that process. I had wished to comment on a few other matters but in the spirit of co-operation, I will conclude at this point.

I thank Deputy Durkan. I am glad to note that there seems to be a broad welcome for the Bill and agreement that we should update and enhance the regulatory and governance framework for nurses and midwives. I will briefly address some of the significant issues raised:

First, I assure the House that the board will have a minimum of two midwife members. One of these will be elected by the professions and one will be appointed from the third-level education sector. In addition, there is a potential for a further two board members to be midwives. The elected member who is engaged in the education of nurses and midwives could be a midwife and a director of nursing or midwifery member could also be a midwife. I am committed to a non-nursing midwifery majority on the board and I am sure my colleagues agree with this. It is also vital that the composition of Bord Altranais agus Cnáimhseachais reflects the wide ranges of skills both of nurses and midwives and of other stakeholders including the Medical Council, HIQA, the HSE and the education sector. At the same time, the board must reflect the principles of good governance which I believe are better served through a reduction in the size of board memberships.

A number of the speakers addressed the issue of the proposed reduced membership of the board and the ratio of nurse-midwife board members to the number of nurses or midwives on each division of the register. Board size is not related to a ratio of the number of members from the professions. What is required is a board membership which will provide for good governance.

As the Minister, Deputy Mary Harney, stated in the House when she proposed this Bill, a reduction in the size of the board will not impact negatively on the performance of its functions, many of which will be carried out by committees. Non-board members can be members of a committee and this will allow for committees to include individuals with relevant expertise and experience to undertake the functions assigned to them. Some Deputies expressed concern that the Minister for Health and Children can appoint the president of the board and that it is not essential that the president be a nurse or midwife. I would like to clarify and emphasise that this only applies in the case of the person to be the first president of the board.

There is no intention to compromise the independence of the board. Rather, the intention here is to allow the Minister to select a member of the board who is considered to have the necessary knowledge and experience to lead the new board in its first years. I would emphasise that the Bill provides that all subsequent board presidents must be elected by the board from its nurse or midwife membership. This is provided for in the Schedule, paragraph 13.

I have already addressed the issue of the midwife membership of the board. I should now like to deal with the composition of the midwives' committee where Deputies are concerned about the size of the committee and its ability to adequately represent all areas of midwifery practice. This committee will consist of a minimum of five members,and it will be open to the board to select its members. There is no maximum membership laid down. At least three members will be registered midwives — one of whom must be one of the midwife members of the board. As committee members do not have to be board members, there will be flexibility to ensure that committees such as the midwives' committee, as well as the preliminary proceedings committee and the fitness to practise committee have adequate knowledge and experience to perform their functions.

Some Deputies asked for clarification on the registration of advanced practice posts. Advanced practitioner posts are developed in response to patient needs and healthcare service requirements and have been shown to be very effective in certain situations. Before the creation of a post the HSE or a service provider must determine the service need and put in place appropriate structures and procedures for the post to be registered. The competencies and skills required for the advanced midwife practitioner or advanced nurse practitioner differ, depending on the specific requirements of each advanced practise post.

To guarantee the required structures and governance, skills and competencies, registration as an advanced nurse practitioner or an advanced midwife practitioner is dependent on employment or an offer of employment in a registered advanced practice post. This ensures that the public is protected by guaranteeing that advanced nurse practitioners and advanced midwife practitioners are only those who meet the standards and requirements for advanced practice and have the skills and competencies necessary for the post they are working in, and that the required structures and governance procedures are in place to enable them to carry out their duties in that post.

The Bill will not limit the development of the professions or the expansion of advanced practise unnecessarily. It will, however, ensure that service need for advanced practice is clearly defined. Any service provider, including the HSE, can identify the service need and can apply to have an advanced practise post registered, and it will be so registered if it meets the standards and criteria set by the board.

Deputies Reilly and Neville made reference to the recommendation contained in the report of the Commission on Patient Safety and Quality Assurance in relation to fitness to practise provisions and asked why we did not opt for the separation of fitness to practise from the regulatory function. This was, in fact, answered in the regulatory impact analysis as follows:

. . .the detail of how it would operate is not clear and it will be the work of the sub-group to examine and make proposals as to how this might be achieved.

As it may be some time before the implementation steering group is in a position to make recommendations it is proposed that the Nurses and Midwives Bill should proceed in line with the Medical Practitioners Act 2007 and can be amended if necessary in the future like for all other regulated health professions.

As the Minister has regularly stated, this legislation is aligned with the Medical Practitioners Act 2007 and has been examined in detail and adjusted where necessary. The Minister has taken into consideration the experiences of other regulatory bodies and the legislation pertaining to them.

Deputies have raised the issue of possible amendments to the Medical Practitioners Act and the impact these would have on the legislation currently before the Houses. I assure the Deputies that proposed amendments to the Medical Practitioners Act were examined with regard to the Nurses and Midwives Bill to ensure that the relevant issues were addressed.

Several Deputies suggested that the board should be assigned a role as a conduit for the concerns of nurses and midwives regarding the health services. The board is a regulatory body for nurses and midwives; however, it can refer matters to other bodies, such as the HSE's complaints procedure, HIQA, or other regulatory bodies. As the Deputies are aware, HIQA is responsible for setting standards in the public health services and for monitoring compliance with those standards.

These issues and others will be discussed in greater detail during the forthcoming Committee Stage and in the passage of the Bill through its remaining Stages in the Oireachtas. I welcome this debate. The views articulated reflect the widespread interest in this Bill, in the modern and robust regulation of nursing and midwifery, and in ensuring full public confidence in these professions.

Question put and agreed to.