Nurses' and Midwives' Pay and Recruitment: Motion [Private Members]

I move:

That Dáil Éireann, recognising the importance of nurses and midwives and valuing the contribution that the professions have made to the health service and to Irish society, and further recognising the recruitment and retention crisis that exists amongst the professions -

accepts that:

- nursing and midwifery make up approximately 33 per cent of the total public health service workforce;

- nursing and midwifery are predominantly female professions (greater than 91 per cent);

- nurses and midwives are on the front line and they carry the burden of trying to maintain a safe level of care within a reality of decreased services, decreasing staff, and increased demand;

- nurses and midwives educated in this State are among the highest educated and best trained healthcare/medical professionals in the world, with an esteemed national and international reputation;

- nurses and midwives in Ireland work longer hours per week compared with nurses in other countries, one and a half hours longer than nurses in Canada and the United Kingdom, and one hour longer than nurses in Australia;

- nursing and midwifery are high-risk occupations in terms of aggression and physical assault;

- between 1 January 2011 and 27 July 2016, the number of physical assaults on staff in statutory acute hospitals increased from 673 to 3,462 - of these 65 per cent (2,261) of the injured parties are recorded as nursing and midwifery staff (excluding psychiatric nurses), which this equates to an average figure of 34 physical assaults on nurses and midwives a month;

- the current age profile of nurses and midwives in the Health Service Executive, HSE, poses a serious challenge in terms of workforce planning, recruitment and retention, with 65 per cent of the HSE nursing and midwifery population over 40 years of age;

- in addition, there are almost 9,000 nurses and midwives over the age of 50 and many of these have an entitlement to retire at age 60;

- the 2016 turnover rate recorded in the health sector staff turnover estimate for staff nurses and midwives was 7.9 per cent;

- the report of the Irish RN4CAST Study 2009-2011: A Nursing Workforce Under Strain, identified burnout as a serious issue within the Irish health system with the majority of nurses working in medical and surgical units across the acute hospital sector reporting moderate to high levels of burnout and low levels of job satisfaction;

- a 2017 survey released by the Irish Nurses and Midwives Organisation showed that a staggering 78.1 per cent of student nurses considered emigrating when they qualified with 81.49 per cent of the total respondents placing pay, staffing levels, and working conditions as the major reason for considering leaving the health service;

- the female-dominated professions of nursing and midwifery are lowly paid in comparison with other professions with the same educational entry requirements;

- in recent years, owing to a deterioration in working conditions and pay issues, amongst others, the situation for nurses and midwives has dramatically changed and has become characterised by a high-stress working environment, poor staffing levels associated with unsatisfactory working conditions, and a poorly controlled working environment;

- nurses, midwives, and their unions have consistently reported working conditions, facilities, supports, training opportunities and pay as the causative factors for the decisions of nurses and midwives to leave the health service;

- the recruitment moratorium in the public sector was introduced in the health service two years before all other areas of the public sector;

- the blanket moratorium on recruitment has had a greater impact on nursing and midwifery than on most other grades and professions in the public health service;

- nursing and midwifery are high-risk professions, with low remuneration and inadequate staffing levels, where there has been little planning for retention and recruitment; and

- the recruitment moratorium and associated issues have created a recruitment and retention crisis within the nursing and midwifery professions;

further accepts that:

- in December 2007, there were 39,006 whole-time equivalent, WTE, nurses and midwives in the HSE, and at the end of December 2017, that stood at just 36,777 WTE nurses and midwives;

- this decrease in the numbers of nurses and midwives has coincided with a dramatic increase in hospital activity, with a reduction in acute beds and increased attendances at emergency departments;

- the February 2017 nursing and midwifery workforce plan agreed to grow the total number of nurses and midwives to 37,043 WTE qualified nursing and midwifery staff by December 2017;

- rather than the nursing and midwifery workforce increasing, it is struggling to retain current numbers, therefore, despite recruitment, the workforce growth has not met this target, and this has implications for the 2018 nursing and midwifery funded workforce plan;

- the national maternity strategy has determined the minimum level of growth for 2017 and 2018 is 200 WTE midwives;

- the WTE number of midwives in January 2017, was 1,461, but by January 2018, this had fallen to 1,409 leaving a requirement for an additional 252 WTE staff to reach the national maternity strategy’s determined level of growth;

- to deal with the shortage of nurses and midwives, the health service has an over-reliance on costly agency staff, with the bill for agency nursing running at €1.1 million per week;

- unions representing nurses and midwives, including the Irish Nurses and Midwives Organisation, INMO, Services Industrial Professional and Technical Union, SIPTU, and the Psychiatric Nurses Association, PNA, have been highlighting the issue of the recruitment and retention crisis amongst nurses and midwives for many years;

- nurses, midwives, and their unions have identified a number of key issues for existing and prospective staff - these include working conditions, facilities, supports, training opportunities and pay;

- pay inequality has contributed significantly to a nursing and midwifery recruitment and retention crisis that will continue to have severe repercussions for the health service unless it is urgently and adequately tackled;

- nursing is a globally recognised profession, there is a worldwide shortage of this human resource, therefore high levels of competitive recruitment practices are utilised by countries to attract nursing and midwifery personnel;

- the State is competing within the global market for nurses and midwives and failing to attract from other jurisdictions and failing to retain nurses and midwives trained here due to the issues of pay and poor working conditions; and

- the report of the Public Service Pay Commission identified problems in recruitment and retention, particularly in the health sector;

acknowledges that:

- it is vitally important that the State continues to attract sufficient students to the professions of nursing and midwifery and develops the ability to retain those within the public health system; and

- for the State to attract back nurses and midwives to the health service, the Government and the HSE need to address the key issues of working conditions, facilities, supports, training opportunities, and pay; and

calls on the Government to:

- introduce recruitment and retention measures based on realistic proposals which must prioritise pay;

- agree a roadmap with unions on how full pay equality will be achieved for nurses and midwives, with an implementation plan to deliver pay equality within a short timeframe across the nursing pay scales;

- thereafter, establish an independent commission on nursing, to look at all aspects of nursing, including future pay adjustments, working conditions, upskilling, and career progression, among other areas;

- work with unions to identify innovative and progressive mechanisms/initiatives to secure and retain staff; and

- target new graduates and other nursing staff by offering permanent contracts, attractive career structures and opportunities for other learning, education and skills development.

I wish to share time with Deputies McDonald, Adams, Funchion, Buckley and Quinlivan.

I am delighted to introduce this motion on nurses' and midwives' pay and the recruitment and retention crisis. I welcome representatives of nurses and midwives, as well as their unions, particularly the INMO, who are in the Visitors Gallery.

Tá na haltraí agus na cnáimhsigh tar éis go leor a dhéanamh ar son na seirbhíse sláinte ach anuas air sin déanann siad cuid mhór don tír ar fad. Is iadsan na daoine atá ar an líne tosaigh agus is orthu atá sé cúram sábhailte a chur ar fáil nuair nach bhfuil an maoiniú, an fhoireann nó an infreastruchtúr ann. Leis an rún seo inniu, tá bealach ann chun an scéal seo a chur ina cheart maidir le pá agus coinniólllacha oibre chun tacú lenár gcuid altraí agus cnáimhseach.

Nurses and midwives not only make a significant contribution to the health service, they continue to make a similar contribution to society. There are over 36,000 WTE nurses and midwives across the State. I doubt that there is a Deputy or a person in the State who does not know one personally or who is not related to a nurse or midwife. They are diligent, hardworking and caring professionals who are passionate about delivering the best health care possible. They are also workers. This is not a vocation for them.

The measure of nurses and midwives is that, in the midst of a crisis across the health service, anyone who raises a concern or a problem will always say that the nurses could not have done more. People will say that even though they were left on a trolley for 24 hours or they sat in pain in the emergency department, that the staff, especially the nurses, offered exceptional care in a calm and compassionate way. This is in stark contrast to the very conditions in which they work. Nurses and midwives are on the front line, carrying the burden of trying to maintain a safe level of care within a reality of reduced services, decreasing staff numbers and increased demand. They work longer hours per week compared with their counterparts in other countries - 1.5 hours longer than nurses in Canada and Britain and one hour longer than nurses in Australia - and for less pay. Added to this, nursing and midwifery are high-risk occupations in terms of aggression and physical assault with an average of 34 physical assaults on nurses and midwives every month.

In recent years, the situation for nurses has worsened as a result of the deterioration in working conditions and pay issues. Their jobs have become characterised by extremely high-stress working environments, poor staffing levels associated with unsatisfactory working conditions and a poorly controlled working environment. It is hard to describe the damage the recruitment moratorium, introduced in the health service two years before all other areas of the public sector, had on nursing and midwifery. It has had a near crippling impact. In December 2007, there were 39,006 WTE nurses and midwives in the HSE. At the end of December 2017, that number stood at just 36,777. That is the cold truth of it. Nursing and midwife numbers are down significantly at a time when both the need for and use of health services are increasing.

All the while, the work and dedication of nurses has been taken for granted. Successive Governments have failed to understand or address their situation or the reasonable requests they have made for better working conditions, better facilities, more supports, increased training opportunities and for the issue of pay to be addressed. If something is not done to increase nursing and midwifery numbers and address the issues which they and their unions have outlined as being a barrier to entry to the professions and a cause for exit, the crisis in the health service will only escalate. The professions of nursing and midwifery are at a crossroads. Not addressing the fundamental problems identified will have a calamitous impact on the health service.

The motion calls for the introduction of recruitment and retention measures based on realistic proposals and which prioritise pay. It also calls on the Government to work with unions to draw up a roadmap on how full pay equality will be achieved for nurses and midwives, with an implementation plan to deliver pay equality within a short timeframe. Nursing is not a vocation. Much and all as our nurses love their work, they do not do it just because they love it. They have mortgages to pay, car loans to be serviced and kids to be fed. It is time we addressed the real issues of recruitment and retention and which central to both is pay.

I wish to extend a warm welcome to those who join us for this debate this afternoon. I commend my colleague, Deputy O'Reilly, on her ongoing work and advocacy in respect of this issue and on bringing forward this motion.

In recent weeks, I have travelled across the State and met nurses and their representatives. At each meeting, the story has always been the same. Our nurses are under severe pressure and strain because of the stress-cauldron working conditions within our underfunded and under-resourced health services. The majority of nurses are worn down by the conditions and overcrowding they face in our accident and emergency departments, on our wards and in our clinics. It does not end there. The scandalously poor level of pay does not allow nurses to meet the scandalously high cost of living in the Ireland of 2018.

This is particularly true for new entrants starting on a salary of €28,000. They must work for 12 years before reaching the dizzy heights of the top rate of €44,000. It is fair to say the nursing profession is not alone at a crossroads but potentially will be driven to its knees. Working as a nurse in this State has become such an unattractive proposition for significant numbers of final year nursing students that they have already indicated their intention to leave Ireland and move elsewhere for better pay and conditions. This is not just young or newly-qualified nurses. There is now a trend among highly experienced nurses to leave the health service out of necessity in order to earn better pay abroad.

The situation in our hospitals has been well rehearsed on the floor of the Dáil time out of number. We know it is often difficult to find cover for a nurse who is sick, even on a short-term basis. Under the Fine Gael Government, our nurses must choose between remaining at home with low pay and woeful working conditions or emigrating in search of something better. That is a damning indictment of the Government Front Bench and the position of the Minister for Health. Of course, the latter office was previously occupied by the Taoiseach.

The unfairness towards, and mistreatment of, nurses is a direct result of the Government's policies. We remember Deputy Enda Kenny promising time and again that Fine Gael would end the hospital trolley scandal. So committed was Fine Gael to this promise that it became the message of a now infamous billboard campaign, its infamy having come about because the promise was not kept. In the time Fine Gael has been in charge, that promise has been smashed to smithereens. The crisis went from bad to worse as the baton was handed from Deputy Enda Kenny to the former Ministers, Senator Reilly and Deputy Varadkar, and now to the current Minister, Deputy Harris, who is in the driving seat.

Nurses are at the front line of our services. I am sure the Minister understands that bad working conditions, overcrowding, low morale and poor levels of pay are interconnected, one follows the other as sure as night follows day. What is particularly infuriating in the case of nurses is that, in my view, this is being done as a strategy to hollow out the public health service and make it more attractive for privatisation. The lives of nurses, their careers and aspirations, the well-being of their families and their ability to plan for the future are all sacrificed on the altar of this bad health policy.

A stand-out theme from recent budgets has been the paltry level of investment of new money into the health services. We need a Government that will invest in the public health service to improve conditions and pay for nurses. Anything less than that is exploitation because not only do nurses get up early, they also go home very late but yet they are locked out of prosperity and opportunity. This must change. The Government has a duty to do right by those who treat our most vulnerable and our sick. The goodwill, talent and professionalism of nurses should never be taken for granted. Nurses deserve fair pay, good conditions and a fair future. As a first step to achieving this, I hope the Minister will not merely support this motion nominally but will grasp the initiatives outlined in it and make it happen.

I welcome the representatives of the Irish Nurses and Midwives Organisation who are in the Gallery for this debate.

I was in Our Lady of Lourdes Hospital, Drogheda, this week to visit a former Teachta Dála, Paddy Agnew from Louth, who has been waiting for more than a month on an appointment to the National Rehabilitation Hospital. The National Rehabilitation Hospital is seriously under-resourced. I have raised this with the Minister. Paddy spoke to me of the great work being done by the nurses and other health workers. I am sure he speaks for the vast majority of patients and that has also been my experience. I commend, acknowledge and thank nurses and other health nurses for their great service to society.

There is a crisis in our health service, we all recognise that. Nurses and midwives are in the front line of this crisis, trying to ensure that sick citizens are properly cared for in a safe environment. This crisis exists at all levels from emergency departments, elective surgery, waiting lists and the recruitment and retention of nurses and midwives.

Last month saw the highest ever number, more than 10,500 citizens, of patients on trolleys. Nursing and midwifery staff make up 33% of the public health workforce and the profession is predominantly female. I often wonder if they were male, would they be treated as badly. As Deputy O'Reilly noted, they work longer hours than nurses and midwives in other states like Britain and Canada and have much worse terms and conditions. It is no wonder that there is a high turnover rate among nursing staff or that almost 80% of student nurses are considering emigrating for better pay and working conditions.

The Government recently published its framework for safe nurse staffing and skill mix, which is based on international research and was piloted in three hospital sites, including Our Lady of Lourdes Hospital, Drogheda. However, it means nothing unless the necessary investment is made to provide for the recruitment and retention of nurses and midwives, including an agreement with the unions on full pay equality.

  It is time for real action, decisive action, to resolve the crisis in our health services. The Government should agree with the unions realistic proposals for recruitment and retention of nursing staff and midwives, a roadmap on how to achieve full pay equality and an independent commission on nursing. We need a plan to attract students to the nursing and midwifery profession in the face of global competition. This means addressing the key issues of working conditions, facilities, supports, training opportunities and pay. That what this motion sets out. I commend it and Deputy O'Reilly on tabling it.

I commend my colleague, Deputy O'Reilly, on her excellent ongoing work on this issue. Nurses and midwives play a very positive role in the health services. They are at the front line and often deal with very difficult situations. Nurses are sometimes expected to be almost social workers and counsellors in addition to their healthcare role, since people often open up more to nurses or to ask them questions because they feel more comfortable with them. They have to deal with all that, as well as delivering healthcare. There are many valid criticisms of our health service but when people actually access health services, one will often hear them speak of how the nurses were fantastic and did a great job, and how amazing it is that they are doing it under current conditions.

I have had many personal experiences with nurses and midwives in St. Luke's General Hospital in Carlow and Kilkenny. I want to note how excellent they were. I spent last Christmas in hospital with my son and cannot commend them enough on all their work and the support and care they showed, particularly to a child at Christmas. They were absolutely fantastic.

The work is demanding and often thankless and nurses deserve better working conditions and pay. As Deputy Adams noted, the workforce is over 90% female and I also wonder if that plays a role in their treatment. Action speaks louder than words. I call on the Minister to take action on this issue and give nurses and midwives the recognition, respect, working conditions and the pay they deserve.

At some stage in our lives, each one of us will have to rely on nurses and medical staff when we are sick and at our weakest and most vulnerable. The work these people do each day is incredible and providing them with good pay and conditions should not be up for debate. My constituents in Limerick regularly tell me stories of how impressive and hard working the nurses and health workers are in University Hospital Limerick. The staff members there are under huge pressure due to shortages of staff, beds and lack of investment but always try to make sure their patients get the best treatment.

They need Government help. This is not being provided by the Government of which the Minister is a member. Only last week, a woman of 85 years was left on a trolley in the brand new emergency department in University Hospital Limerick for four days, having been admitted with a suspected stroke. This is an horrific way to treat a woman of that age with a serious medical condition. It is left to the nurses to try to squeeze patients into corridors in a chronically overcrowded hospital and to apologise to the patients and their families, when the fault could not be further from their own.

I have often spoken of the dreadful overcrowding in University Hospital Limerick. It is the worst in the country. I have often called on the Minister for step in and address the chaos. Nothing has been done to alleviate the problems. Today, 54 people are lying on trolleys in University Hospital Limerick. The Minister has actually normalised the trolley crisis. Fianna Fáil and Fine Gael have consistently looked after bankers and big business when called on but front-line staff such as nurses, who are begging for adequate treatment, are ignored. It is a national disgrace. The HSE is struggling to attract back home Irish nurses who have emigrated, which is not surprising. There is a chasm to be bridged in making our system more attractive to work in compared with health systems abroad. I have no confidence that this Government will do that.

Fine Gael and the Independent members of the Government have failed to stem the problems of our health service. I reiterate what other speakers have said, namely, that Sinn Féin would not allow this scandal in our health service to continue.

I also wish to extend a welcome to everyone in the Gallery and commend Deputy O'Reilly on bringing forward this motion.

It is often said that nursing is a vocation, and of course it is, but primarily it is a job and a profession that requires a minimum of four years of work and study. Nurses are held up as paragons of virtue, and maybe that is also fair, but primarily they are workers and workers do not live on admiration. They live on their pay packets and on the goods, services and quality of life those pay packets provide. Nurses work very hard for their pay. They deserve our respect and that respect is best shown by a dedication to providing them with the best conditions in terms of their rights as workers and in terms of the system in which they have to work. Nurses have been let down badly by the present and previous Governments, which sought to exploit the image of nursing as a vocation and of nurses as paragons of virtue in order to cut corners. They have been let down by their pay, especially as trainees and newly registered nurses. They have been let down by the Government's tolerance of a healthcare system in disarray, which provides a chaotic, stressful and often unsafe environment for nurses. The priority for any employer should be the safety of its workers but nurses are expected to work long hours in the mess that is our health service, straining them mentally and physically and putting them at risk all too often.

Pay is not the problem but dealing with it is certainly a start. It is the first step in showing nurses that we value them as workers who play a vital role in our society. Members should not take my word for it, even though it is important. The numbers speak for themselves, as 500 vacancies exist right now in the mental health services. That is not to say there is a shortfall of 500 nurses but that there are 500 fewer nurses than provided for in the current standards, which fall short of the recommendations in A Vision For Change. This makes each nurse's job harder and makes the workplace less safe for that nurse and his or her clients. The reasons these vacancies exist are simple. After four years of hard graft as students, during which they are expected to work a considerable number of ward hours for no pay at all and no additional supports, why would anybody want to take a job here? They would work for less than €500 a week in a broken system in which things are only getting worse. The other options are much better for them. Abroad they can take on better pay and conditions and work in a healthcare system that treats them as workers of value, not saints to be abused. These are systems which are on the cutting edge of care, are public funded and are fit for purpose.

We need our nurses. It is clear they do not need us. It is time to act to address this imbalance. We are always told by the right that the high wages of chief executive officers in the public and private sectors are necessary to get the best people. Nurses are the best people and their pay must reflect that.

I too wish to begin by joining other speakers in welcoming the representatives from the INMO to the Gallery. They will be the most welcomed people ever to Leinster House. They are very welcome here today and I thank the president, vice-president, the officers and the general secretary for being here. It is important that they are here to hear the people's representatives debate what is a very important issue.

I acknowledge, accept and recognise Deputy O'Reilly's bona fides in respect of this issue. I do not intend to use the time available to me to answer some of the political charges, with which I fundamentally disagree, that have been levelled at me over the past 20 minutes or so. I intend to use the time available to me to outline where we are, what we have done and, more importantly, what we need to do in the future.

The Government will support the motion before Members this evening because it shares the analysis that we are facing a serious challenge in the nursing workforce and because we share the impetus to address it. The motion endeavours to address a number of very important issues facing nurses, midwives and, as a result, the health service in a logical and sequential way. All of us recognise the importance and the contribution of nurses and midwives. We recognise this as politicians and public representatives but also as citizens, as anyone who has had any contact with the Irish health service can see the dedication and professionalism of nurses and midwives are absolutely key to its day-to-day operation. There were a number of references to vocation and to how nursing is not a vocation. In case it was implicit that I might think it is, let me be clear that I do not. The professional, education and quality of Irish nurses is something of which I am very proud and seeing our nurses able to make an even bigger contribution to our health service, as they wish to, is also very important to me. I acknowledge that nurses and midwives often carry out their work in a high-stress working environment and in difficult situations, dealing with people at the most vulnerable moments in their lives.

We know that there are issues, and indeed there are some which are beyond the scope of the motion before us, which are priorities for me and for the Government. These include increasing bed capacity in the acute sector and the community sector. A number of representatives of Sinn Féin referenced trolley waits. Nobody referenced the fact that bed capacity was cut by colleagues in the Fianna Fáil Party long before the troika came to town. They decided there were too many beds in the health service. If one keeps cutting beds, how can one be surprised when more people turning up in our health service cannot access one? We are increasing bed capacity and that will improve, and must improve, the working environment for nurses and midwives. This is part of a massive capital investment programme in a health service that had been starved of capital investment. Even during Celtic tiger Ireland, when motorways, schools and many other important projects were built, hospital bed capacity was not increased. That bizarre policy is now being reversed. We are taking measures like these and others to address the issues but the Government also recognises there is also much more to do.

We live in a world in which there is a global shortage of nurses and midwives and Irish nurses are much sought after internationally due to the quality of the education, training and experience they have received in universities and through their hospital experience. The recruitment moratorium that was put in place across the public service from 2007 by a previous Government has had a real impact on staffing levels. Some specialties, including midwives, have been particularly affected. Our current reliance on agency workers and overtime is not a tenable or sustainable solution.

Despite these challenges, I will put on the record of the House some progress we have made in increasing nursing numbers. Nursing numbers stood at 36,777 at the end of 2017 but I accept more needs to be done and that we are still not back to where we were before the recession. Nurses and midwives now amount to approximately one third of the health workforce. This arose as part of the nursing recruitment and retention agreement that was agreed with the INMO and SIPTU in 2017. Under this agreement, the HSE agreed to appoint and fund 1,224 additional nurses and midwives. The HSE filled 942 of these posts. A key contributor to this increase has been offering permanent posts to graduate nurses. Thankfully, we have moved away from the days when, as a country, we were unable to offer our graduates a permanent job. It was the reality here for a number of years that Irish nursing graduates were being told that they could have a temporary job in the health service or they could go abroad and a have a full-time permanent job. As Minister, I can now offer each nurse who graduates from an Irish university this year a full-time permanent post in the Irish health service. I reiterate that offer on the record of the Dáil today.

The recruitment and retention agreement set out a number of initiatives to increase the workforce in addition to the additional posts. These measures include converting agency staff into direct HSE employees, offering all graduating nurses and midwives full-time contracts and increasing the number of undergraduate places in 2017. We are now training more nurses than ever before in the history of the State. The challenge is to make sure we can keep them in the State when they graduate. International recruitment campaigns continue and we have an added incentive of a relocation package of up to €3,000 to nurses who return to Ireland from overseas. As well as working to attract new staff, the agreement has commitments aimed at retaining those nurses and midwives already employed in the health service. It provides for a new career break scheme. Nurses and midwives can also avail of improved educational opportunities and career pathways through important initiatives like the advanced nurse practitioner programme. In acknowledging that there is more to do, it is important to point to the importance of these initiatives.

The motion refers to the high level of student nurses considering emigrating when they qualify. I know we all wish this was no longer the case. However, I point out that even in an environment of intense global competition, the HSE has appointed 861 of the 1,055 nursing graduates, which is more than 80%. However, I accept that retention of nurses when we get them into the health service is the key issue. It is not good enough just to recruit them; we need to retain them. We are all aware that we need a plan for the future of our workforce. To that end, an additional 130 nursing undergraduate places were made available in the nursing degree programme. The HSE also introduced a pre-retirement initiative for nurses and midwives, with 37 employees taking up that offer. We have also rehired a number of retirees. These measures attempt to retain nurses who would have left the service to retire and ensures the knowledge transfer to new entrants.

I have talked about the Government's recognition that we need to do more and it is legitimate and justifiable that unions would raise the issue of pay in that context. We are all too aware of the impact of the budget cuts made during the financial crisis. The nursing and midwifery workforce suffered pay cuts, increment freezes and the moratorium on recruitment which I referenced earlier. As was the case with all public servants, people were asked to do more, with less, for less. However, the measures agreed in the public service stability agreement provide a statutory roadmap for the unwinding of the financial emergency measures in the public interest, FEMPI, legislation. This includes a series of salary increases that will see public servants, including nurses, receiving on average a 7% increase over the lifetime of the agreement.

The agreement commits to 90% pay restoration by 2020. In addition, a number of allowances have now been restored. Addressing pay, though, is a complex issue, and more work needs to be done on it. This is why I am pleased to see that the second phase of the work of the Public Service Pay Commission is under way. The commission is adopting a modular approach to reporting on its work, and its first module will include an examination of nurses and midwives. I look forward to its report and it being a roadmap for Government in how we deal with this issue. The Government took the decision that there should be a phase two of the pay commission in recognition of the recruitment and retention challenges we face in the health service. I know our unions and stakeholders, including the INMO, have an opportunity to feed into this process and to make their submissions and have them assessed.

Calls for pay parity for all new entrants are being addressed as part of another process under way being led by the Department of Public Expenditure and Reform. A data-gathering exercise has been carried out, and my colleague, the Minister for Public Expenditure and Reform, provided a report to the Oireachtas on these findings. This report makes clear the Government's commitment to working with the parties to address these issues, mindful of the cost involved. Further engagement, as colleagues know, is scheduled for this week.

As a result of the work being undertaken by the Public Service Pay Commission and the other numerous processes I have outlined, I do not agree that this is the appropriate moment to establish a new independent commission on nursing. I would rather see the pay commission conclude its work, and the outcome of that being implemented in terms of recommendations on recruitment and retention. I would also like to see further progress made in rolling out the framework for safe nurse staffing and skill mix in medical and surgical care settings, which I launched with the INMO and SIPTU in recent weeks. This is the first time in the history of our State that we have actually provided an evidence base as to how many nurses and other healthcare professionals are needed on each ward to manage patients safely and to have a good working environment. During the pilot stage of this framework, it demonstrated significant benefits for both patients and staff, and I welcome the support of nurses in the roll-out of this nationwide. We have seen in the pilot sites a sustained decrease of up to 95% in the use of agency staff. Therefore, it is clear we need to spend to save and that investing in evidence-based programmes such as the framework can make real progress in addressing the issues of retention and recruitment.

It is clear that the issues in the motion are complex and important. It is right and proper that they are raised on the floor of the Dáil and that as a country we try to grapple with how to address them now that we find ourselves in a better economic space. We have all accepted that nurses and midwives are a significant and important part of our health workforce, significant both in the number of staff they represent and in the sense of the services they provide, which we greatly value. In not opposing the motion, the Government accepts there is more to do but also acknowledges that a significant amount of work is under way. The work of the pay commission is extremely important, and I know that unions have made submissions to it. Let us await the findings of the pay commission to see the recommendations it makes, which will guide Government as we go forward. However, I assure the House and nurses and midwives that under this Government's policies we will see more nursing jobs, more colleagues working with them on the ward, more beds open, a plan for universal healthcare, as envisaged by Sláintecare, and the issue of pay continue to be addressed not just through the public service stability agreement, but also through the ongoing work of the pay commission.

Deputy Stephen Donnelly has 20 minutes. I believe he is sharing with Deputies James Browne, Mary Butler and Eamon Scanlon. Is that correct?

That is right.

The motion before the House speaks to the importance of nurses and midwives in Ireland and to the many challenges now faced by those professions. I wish to recognise the work of Deputy O'Reilly in developing and tabling the motion, which Fianna Fáil will support.

It is abundantly clear that all is not well for Ireland's healthcare professionals. This is true for our doctors and equally true for our nurses and midwives. I acknowledge the attendance in the Gallery of representatives of nurses and midwives. The importance and value of nurses and midwives is well recognised and cannot be overstated. They provide the majority of care in Ireland by a long distance. They make up a full third of everyone employed in healthcare in Ireland. For every hospital doctor and consultant, there are about four nurses and midwives, and for every GP in Ireland there are about ten nurses and midwives. Therefore, they carry the biggest load. They work every day to provide the very best in clinical and non-clinical care in our hospitals and throughout our communities. Ireland's nurses and midwives are highly educated, highly trained and highly skilled. They have an outstanding clinical reputation around the world and are duly sought after in an increasingly competitive global healthcare labour market.

However, we need them here in Ireland. This means we must make Ireland an attractive place for nurses and midwives to work, to develop professionally and to have their careers here. We cannot compete, nor should we, with the zero-tax offers of the Middle East and, sadly, we cannot compete with the Australian climate, but there are many things we can do. We can ensure equal pay for equal work. We can ensure a workplace where our healthcare professionals do not work in fear of being assaulted daily. We can ensure that on wards, in emergency departments and in primary care the nursing teams are of a sufficient size and skill mix to be able to do the job they know how to do. We can ensure there is access to high-quality training.

Right now, these things are not ensured in Ireland. As the motion sets out, assaults on staff in hospitals have skyrocketed. In 2011, there were 673 reports of assault. By 2016, just five years later, that figure had grown to 3,462, an absolutely extraordinary rise in the number of reported assaults. Three quarters of respondents to a recent INMO survey said current hospital conditions are resulting in poorer-quality training. Trolley counts are higher than they have ever been. Waiting lists are longer than they have ever been. Hospital bed occupancy is estimated to be at approximately 100%; some estimates put it at over 100%. Either way, it is much higher than accepted, safe international levels. All of this, of course, makes for a very stressful and difficult working environment for all our healthcare professionals, including, obviously, our nurses and midwives. We are seeing the results in demotivation, frustration, resignation and emigration. A recent survey of hospital nurses found that for every ten nurses leaving their jobs, seven are resigning. Therefore, it is not retirement or sickness; it is voluntary resignation from those jobs. I met INMO representatives just yesterday. They cited the following as some of the top reasons for these resignations: pay, including the difference in pay for new entrants; working conditions, including incorrect team sizes and skill mixes; and a deteriorating learning environment.

As to whether there is currently a shortage of nursing staff on average across the HSE, there are mixed views. The capacity review by the HSE benchmarks Ireland against some of the best healthcare systems in the world: Australia, New Zealand, Norway, Denmark, Finland and Sweden. It shows that Ireland has the youngest population. As such, we should need less healthcare than the other countries. We should need fewer hospital beds, doctors and nurses. The capacity review also shows that Ireland has more nurses per population than Australia, New Zealand and Sweden, although fewer per population by quite a bit than Norway, Denmark and Finland. The INMO has written on this and it disputes the benchmarking figure. It believes the figures for Ireland are overestimated relative to the other countries. On top of this - this is one for the Minister - for some bizarre reason, the capacity review does not include an analysis of the number of nurses and doctors we have, the shortage today or the number we need in the future. It includes an analysis for primary care, GPs, practice nurses, acute beds, ICU beds - all sorts of things - but it does not include an analysis for nurses or doctors in hospitals. There is, therefore, no official HSE or Government figure for the projected shortfall in the coming years, so we do not know that, and we need to know it quite soon.

There are things we do know. We know there are approximately 2,200 fewer nurses and midwives working in the system today than there were ten years ago. We know that in those ten years healthcare activity has increased a lot, so we know there are substantially fewer nurses and midwives dealing with a substantially greater workload. We know that in 2017, almost 80% of student nurses said they were considering emigrating after graduation. We know that in some hospitals and community care teams, understaffing exists and is making the job unbearable. We know that in the UK, a recent report estimated that the NHS will be short somewhere between 14,000 and 42,000 nurses and midwives.

The figure of 42,000 is more nurses and midwives than work in Ireland, so that is an estimate of how many the NHS could be short.

We know that Brexit is being blamed, quite rightly, for a record number of nurses and midwives from other EU countries leaving the NHS, which is something that maybe should have been considered beforehand. Applications for nursing degrees in the UK from people from other EU countries is down by a quarter. We also know the NHS is actively targeting experienced and graduate nurses and midwives in Ireland, and that it has an awful lot of resources at its disposal to attract them into the UK. The question is, what can we do about all of this if we accept that we have a serious problem on our hands, that the current position for our nurses and midwives is not sustainable, that their working conditions and unequal pay are not acceptable and that inadequate access to continuous professional development is not acceptable? We can make sure that pay equality is achieved quickly. The report on pay equalisation was a key demand made by Fianna Fáil in the confidence and supply arrangement. The report has been published and there is an onus on the Government as a matter of urgency to set out a roadmap for how equal pay will be delivered and rectified for new entrants. We need the complete unwinding of FEMPI on a fiscally sustainable basis and we need it to start before 2020. My understanding of the current Government proposal is that consideration will begin in 2020. Fianna Fáil's view is that it needs to begin before then. The Government needs to ensure that nurses and midwives receive ongoing training. The Government needs to take immediate steps to ensure the rise in assaults is not just stopped but immediately reversed. It is utterly unacceptable and entirely preventable. We should ask no one in this country to go into work in fear of being assaulted. Longer-term measures will help, including reducing stress on the hospital system thereby reducing the frustration of patients, but there are short-term measures that can and should be taken. We need to ensure that the staff ratio and skill mix are correct. The framework for safe nurse staffing and skill mix is an indicator of where we need to go. The pilot study is interesting. It has seen improvements in the retention of nurses, the reduction of agency staff and positive outcomes for patients. The lessons learned in this pilot must be rolled out on a wider basis.

The Minister has laid out steps that have been taken and it would be unfair to say nothing has happened because things have happened, but when I talk to nurses, midwives and other healthcare professionals, they say that they see an awful lot of reports and hear a lot of warm words but, to date, they have seen very little action, and it is action we would like to see as soon as possible on behalf of the nurses and midwives.

I thank Sinn Féin for tabling the motion on nursing pay and recruitment and I am glad to support it. Our nurses work to an incredibly high standard. I know this because my sister is a public health nurse. They remain committed to the task at hand amid intense pressure as our hospitals and care centres struggle to cope with a lack of resources.

The HSE has a clear shortage of doctors and nurses working in our hospitals and in our communities. Research from the ESRI shows how we will witness increased demand for healthcare services over the next decade. To meet this rise in demand, the Government must address the need to recruit and retain key healthcare staff and, in particular, nurses.

As my party's Front Bench spokesperson on mental health, I have seen first-hand the amount of pressure that psychiatric nurses endure on a daily basis. Within mental health services, nurses' conditions of work are so poor that no pay would convince many of them to stay on. Wholly unsatisfactory working conditions make it difficult for nurses to meet the overwhelming demands on mental health services. Safeguards against assaults on staff within psychiatric facilities at times appear non-existent. Often the patients who carry out assaults mean no harm, as they are not in control of their own actions during these assaults. However, nurses in the mental health services clearly face increased risks from such assaults in their line of duty. There is no question but that the shortage of staff is a key contributor to this. Accordingly, special measures are needed to ensure they can carry out their work in a safe manner. Last week, The Irish Times reported on how staff members at one psychiatric unit were recently threatened by a former patient with a butcher's knife. The situation was so severe that staff locked themselves and patients into rooms. The Psychiatric Nurses Association, PNA, believes that staff shortages and the lack of development of alternative services, as highlighted in A Vision for Change, may be linked to the growing number of assaults on healthcare staff. For example, according to a PNA survey, there is a significant shortage of staff in Waterford's mental health service.

The dearth of resources places an extraordinary burden on these nurses who meet families with children in dire straits. The impact on the nurses' own mental health must be horrendous. We saw some of this impact only last week at a meeting of the Joint Committee on the Future of Mental Health Care, when some excellent staff came before us to explain their experiences and the stress they are under. Waiting times are chronic and children are not being assessed for mental health services in a timely fashion and sometimes not at all. At the end of January this year, 1,635 children had been waiting more than 12 months for a primary care psychology appointment. It is almost impossible for nurses to triage in such desperate situations when there is such a backlog of patients awaiting treatment.

The increasing number of patients presenting means that patients do not get enough time for medical attention from a nurse. Conditions will not improve unless the Government takes action and tackles the dysfunctionality of our healthcare system. We spend the fourth highest amount per capita on healthcare yet we have the worst healthcare system in Europe in terms of waiting times. The HSE must take measures in order that our nurses want to stay in Ireland and not leave to go to the NHS, a situation that almost certainly will become more acute in the event of a hard Brexit. We are losing too many graduates to the UK and who could blame them? When they leave here, they leave behind salary packages that are lower, and abroad they find they have accommodation packages, good conditions and upskilling opportunities but, more importantly, they feel appreciated. The Government needs to comprehensively resolve once and for all recruitment and retention and show that nurses are deeply appreciated in this country.

Fianna Fáil recognises and greatly values the contribution the nursing and midwife professions make to our healthcare, often in the most difficult and trying of circumstances, especially in the acute sector. We welcome the tabling of this motion and are supportive of the aims and objectives stated within it. I thank Sinn Féin for tabling it.

As the ESRI projections and the capacity review make clear, there will be significant increases in demand for healthcare over the next decade. It is estimated that by 2030 there will be approximately 1 million people in Ireland aged over 65 and by 2040, 440,000 of these will be aged 80 or more. The demands on the health services will be more acute than ever. Everyone hopes that as they grow older they will be supported to stay in their homes for as long as possible but, as we all know, this is not always possible. The levels of population aging will be associated with higher levels of disability and long-term ill-health and now is the time for planning and investment.

With an ageing population, the acute hospital system, which is already overstretched to breaking point, will be unable to operate effectively unless there is more of a shift towards primary and community services as a principal means of meeting patients' needs. Therefore, the need to recruit and retain key staff, such as nurses, is absolutely imperative. Nurses and midwives are skilled, committed professionals who have a career, dependants, responsibilities and costs. They go over and above in terms of hours worked and they are very committed to their patients and their profession.

Fianna Fáil believes that the Government must set out a clear pathway for the delivery of full pay equality for new nurses. Since 2011, those who enter the nursing profession are on a much reduced pay scale compared with those who began working prior to 2011. This has led to serious financial difficulty for many young nurses, given the rocketing cost of rent and housing. It is deeply unfair that new nurses are paid significantly less than their established colleagues. These nurses are already working under intense pressure given the lack of resources in hospitals. This is then leading to nurses leaving to work abroad with better terms and conditions and a better quality of life available to them. We must stop this brain drain. We are losing our brightest, smartest and most qualified nurses to other countries and are experiencing many problems as a result The least that they deserve is to receive equal pay for equal work.

The report on pay equalisation in the public sector was a key demand made by Fianna Fáil in our discussions on the confidence and supply arrangement. This report has been published and there is now an onus on the Government to set out in detail how it will go about delivering pay equality for new nurses. It will help with the retention of nurses in the years ahead and will encourage more young people to enter what is, in many ways, a caring vocation.

I am glad to have the opportunity to speak on this issue and I thank Deputy O'Reilly for bringing forward the motion. At some stage, each of us has had reason to attend hospital, be it for ourselves or our families. One can see that nurses are working in very stressful situations but they carry out their work professionally. There is no question about that and they should be rewarded accordingly. The number of assaults that take place, particularly late at night and in the early morning, in accident and emergency facilities is absolutely outrageous. The job is stressful enough without having to worry about who is coming in the door or who could assault you. It is very wrong. More security should be made available in accident and emergency departments, particularly at weekends, because that is where the problem lies.

The current shortage of nurses in mental health and general nursing services will only get worse and services will only deteriorate further unless the Public Service Pay Commission delivers for nurses. The reality is that on current nursing salaries, the HSE cannot compete with health employers in UK, Canada , Australia and elsewhere when it comes to the recruitment of nurses and nurse graduates. We just cannot compete. The culture of emigration among our nurse graduates will not be broken while salaries, allowances and support for professional development remain significantly better in other countries than they are for nurses in the Irish health system. The incentive for Irish nurses to take up better-paid and more attractive posts abroad is growing, not decreasing. There are currently 25,000 nursing vacancies in the UK's NHS, with experts predicting a significant further push to recruit Irish nursing graduates post Brexit. Unless there are improvements in nurses' pay which close the gap between salaries here and those available to nurses emigrating to the UK, the Irish health service will lose another generation of nursing graduates. The absolute necessity for the Public Service Pay Commission to comprehensively address nurses' pay is obvious when we consider the yawning gap in pay and conditions between Ireland and the UK. In the UK, the professional qualifications of a nurse are recognised, with the first point on the nurse's pay scale being above the maximum of the health care assistant scale. UK nursing packages include €8,000 relocation costs, educational opportunities, low-cost accommodation and a 37.5-hour week. In the UK, the nurse is recruited at the same level as therapy grades, for example, physiotherapist, occupational therapist or podiatrist. In Ireland, the nurse is treated as a lesser professional than the therapy grades.

In its report, the Public Sector Pay Commission said that some of the submissions it received recognised that increasing pay will not address the issue of recruitment and retention, particularly in the health sector, and that, when compared with employment in the private sector or in other countries, a range of other relevant factors - such as a pressurised work environment and the provision of continued professional development - which impact on whether nurses remain in Ireland must be addressed as soon as possible.

I thank Deputy O'Reilly for bringing forward this motion, which relates to a matter about which she has spoken a number of times. The Labour Party will support the motion. I also welcome the representatives of the unions.

The Minister of State knows me quite well. I am a fairly direct speaker. I was asked recently - colleagues should not laugh - to give career advice to a couple of young people.


I knew that was coming. Two of them are considering becoming nurses. A number of members of my family are in the nursing profession. I had to be honest with the two young people in question. I think being a nurse is a noble profession. There is no doubt that it is a vocation. It is something about which one must think long and hard. However, I also had to tell them the truth because I had to be honest. It is a very difficult profession. It is a profession that is not just difficult because of what it involves but because of the environment that has been created in this country for people in the profession. I would advise people to think long and hard about going into nursing. I would still advise them to go into it but they would have to understand what they are getting into because it is not the same career that it was even as recently as 20 years ago. It is completely different. As a body politic, we are going to have address this issue pretty quickly. At a time when we have a trolley crisis and when we consider the conditions in which many nurses work, the situation in many maternity wards, accident and emergency departments, particularly at weekends, and psychiatric wards, the future of many different services, the uncertainty surrounding certain services and what is expected of nurses, we must understand that this is a very difficult profession and we must address the problems relating to it.

We must address the standard of pay when we compare it with that in other countries. Many people who enter the profession want to stay in Ireland. However, a survey of those going to college and becoming nurses has shown that a large quantity of them have said that they will leave. They will do so because they know what they are facing into, not because they want to leave. They will leave, go abroad and work and earn an awful lot more in Australia, Dubai, Great Britain and other locations because they know the conditions in which they will work. It is not all about money. It is about the working environment and the place where they will end up. They can see it with their own eyes. They must go out and train. They know what is ahead of them. I see it every day. My local hospital is University Hospital Limerick. The conditions in which some of the nurses, many of whom live near me, have to work are, quite frankly, scandalous. They are scandalous because of decision-making that has happened over the greater part of 20 years. Some of the nurses end up sick and getting injured. To leave them in those circumstances is unacceptable.

We must also do something about security in hospitals fairly quickly, particular when it comes to protecting those who enter this profession because this is becoming more of an issue every week. We see many cases of nurses being assaulted. When it comes to a policy from Government, and we did this through Sláintecare, of trying to make it more viable to enter this profession, if people working in the profession are not even protected to the level they should be, it is a fairly desperate situation.

I also want to raise a few issues that could help the situation. The over-reliance on agency staff is becoming crazy. There is no continuity of care and no certainty as regards the volume of people who will be entering the wards from day to day or into various different areas because of this over-reliance based on a failed policy over a period.

Something that would significantly help many in the nursing profession - I have been a strong supporter of this and have spoken on it in here and at meetings of the Joint Committee on Health on numerous occasions - is fast-forwarding the roll-out of various different components of the national ehealth strategy in view of the conditions in which many nurses work, the paper trail, the administrative burden and the fact that they are unable to take lunch and are staying on at work. Relations of mine who are employed at Tralee General Hospital often stay on an hour later in the evening because they have to complete administrative work. That is not acceptable. They are working an extra hour for nothing. It is a vocation. If the procedures had been put in place to ensure that we can have an ehealth strategy and all the various components of that rolled out, there would no need for the administrative burden imposed on nurses and midwives.

I am disappointed the Minister of State with responsibility for older people had to leave. I am disappointed the Minister, Deputy Harris, is not present.

In my remaining few minutes I wish to raise an issue relating to nurses in the rehabilitation unit in St. Patrick's Hospital in Cashel. This is happening right now; I have just spoken to them. It appears a 21-bed unit is about to close, which will have catastrophic implications for the elderly patients in the hospital. There are two reasons for this. The consultant geriatrician needs to be reappointed immediately. The medical officer, whose position has been temporarily filled by locums, also needs to be reappointed. If that does not happen, this unit will have to close on Friday. This has happened only in the past 24 hours because somebody in the HSE did not realise the funding that was coming from South Tipperary General Hospital for the geriatrician post would no longer be in place and assumed that somebody else would solve it, but it has not been solved. This is what the nurses in St. Patrick's have told me in the past hour. They do not know where they will be working on Saturday. If this unit is closed, will they remain in some other unit in St. Patrick's? A number of the patients are over 90 and one is over 100.

What will happen to the patients there who will either have to go home or be transferred to one of the most overcrowded hospitals in Ireland, South Tipperary General Hospital?

Tipperary is served by University Hospital Limerick on one side and South Tipperary General Hospital on the other - the two most overcrowded hospitals in Ireland. We are talking about moving patients, some of them over 100 years of age-----

The Deputy is moving into somebody else's time.

-----into that hospital.

Staff do not know where they will be based on Saturday.

This is an emergency. I would appreciate if the Minister addressed it.

There is approximately an hour left and people who go over time are eating into other Deputies' time.

I will be sharing my time with Deputy Bríd Smith.

The Minister needs to increase significantly and quickly the pay of our nurses and midwives because otherwise the problems in the health service that relate to the recruitment and retention of nurses, which is already at a very serious level, will get even worse. The Government backed a campaign to get nurses to come back home, the "Bring Them Home" campaign. It spent €100,000 on a website to advertise the campaign. How many came back? It was fewer than 50.

Last year more than 50% of all the graduates left the country. Campaigns that do not get to the heart of the matter and do not deal with the issue of pay and conditions will not work. We will not be able to open new wings and increase the number of beds. How will we staff the children's hospital?

What needs to be done on pay? First, two-tier pay needs to be ended immediately. There have been pay cuts of 10% - more than €3,000 per annum. The pay cuts are only part of the story. What is the position with the allowances that have been cut? Nurses and midwives have seen the following allowances - most of which are pensionable - cut in recent years: midwifery qualification; registered general nurse in the community allowance; nurse co-ordinator allowance; specialist co-ordinator allowance for nurse tutors; nurses assigned to occupational therapy and so on. We read in the newspapers that the pay element will be addressed. What about the allowance element that also must be addressed? It should be done in one go in 2019 and not spun out over a number of years. It should include the reversal of the allowance cuts. Moneys that were taken from nurses should be returned and backdated.

It is not just about two-tier pay. In addition to the two-tier pay, there is a 12% pay gap between nurses on the one hand and other allied professionals on the other hand. It would take a nurse more than 15 years to reach the same pay scale and pay awards as an occupational therapist. In the Nordic countries a nurse's starting pay is €38,000. In Ireland the equivalent figure is €28,000. It is a global market. How can the Irish health service compete in a global market when there are gaps on that scale?

The Government needs to ensure the ending of the two-tier pay rate and return the pay and allowances taken from the nurses. They need to bridge that 12% pay gap. We need decent pay and justice for our nurses and midwives now.

We support the motion as others have done. I will start by stating the obvious that we have a crisis in our health system in all sectors, including in accident and emergency departments, the care of the elderly and other vulnerable sections of society, and in mental health services.

There are two basic reasons for that crisis. The first is ideology of the current and past governments that deliberately set up a two-tier health service, systematically encouraging the privatisation of vital healthcare. We have poor public healthcare and poor public hospitals to ensure we have a blooming private healthcare sector that can maximise profits. We shower them with tax breaks and incentives and increasingly use the private sector to deal with public patients. We have invested a great deal of effort and money in ensuring that private health care is the cover that most ordinary people desire as a necessity because they see the public healthcare system in such a crisis. The queues across all our key services, the waiting times for treatments, scans and therapy including speech and language services for children, the home care hours, help for the elderly in the home and the trolley crisis are not a series of unfortunate events but the predictable result of a policy of privatisation, designed to force people into the private sector.

The other reason for the crisis is the one addressed in this motion - the attempt by this and the previous governments to blame the recession on public sector workers and to use the recession as an excuse to put the boot into them all, particularly the nurses, midwives and other healthcare workers. We cannot have a decent healthcare service while putting the workers who provide that service into intolerable situations of cuts, closed wards and worsening conditions in which they have to work.

Nurses are also required to work an extra shift every month for free in crowded and understaffed hospital and emergency wards. We worsen their pay and conditions and we create a two-tier pay structure that discriminates against newly qualified staff doing exactly the same work. The recent Public Services Stability Agreement did not address these issues. Pay restoration is still not a reality and workers are earning less than they were before the recession. There is no real solution for workers when rents and housing costs are rising. They are being forced out of the country as clearly illustrated by the letter we all received from the Psychiatric Nurses Association today.

It seems to be difficult for any Government to acknowledge that the inequality in pay and the brutal conditions under which nurses and midwives are forced to work, contribute to the health crisis. It is extraordinary that we find it so difficult to acknowledge that the pay of nurses and midwives needs to be increased when we can increase our own pay and the pay of bankers overnight. Thanks be to God there are more of them than us, but the visuals of that inequality are stark.

Those Deputies who have supported the FEMPI legislation and nodded and winked when it has been renewed every year bear a responsibility for the continuation of that legislation and its contribution to the crisis in our health service because it abuses nurses and midwives. FEMPI has to go.

It was an extraordinarily blunt instrument and has outlived its purpose. With that pay equality and a complete change in the way we treat our health service workers must be ushered in. We lost the whole child and adolescent mental health service, CAMHS, unit for six months of last year in Cherry Orchard Hospital, as the Minister of State well knows, because of a failure to retain psychiatric nurses. That will happen again and again. This crisis is in some ways only beginning because of the shortage of nurses. If we begin by paying them properly and giving them the respect they deserve we might begin to address the crisis.

I welcome and will support this Private Members' motion on nursing recruitment and retention put forward by Deputy O'Reilly of Sinn Féin. Trying to run a modern fit-for-purpose health service, faced with increasing demand and changing demographics, on minimum funding and a short-term strategy does not work. That is what previous governments have done. The problem of retaining qualified nursing nurses and midwives is yet another example of the need for a new approach to providing healthcare as outlined in the Sláintecare ten year strategy report, alongside a commitment to financially increase funding in the service.

The "Bring them home" campaign was a complete failure. Launched in July 2015, it targeted 500 nurses and midwives employed in the UK. Only 91 were enticed to return to work in the Irish public health service and of them 40 left prior to fulfilling a year's service. The central issue here is pay and conditions. Comparison with other countries, particularly the countries our qualified highly trained nurses emigrate to such as Australia, the USA, Canada and the UK, shows Irish nurses work longer hours for less pay. To attract graduates and entice them home that has to be reversed to fewer hours and more pay.

There are now 2,500 fewer nurses in comparison with 2007 which, along with the general crisis in the health service, has created a very stressful working environment which adds to the problem of retaining staff. Under the national maternity strategy, the appointment of an additional 96 midwife posts in 2017 was a failure too. The total number of midwives in January was 1,461 and by August that had fallen to 1,408. Instead of the workforce growing by 96 it decreased by 52.

Figures show a high level of burnout. The Nurse Forecasting Study in Europe, RN4CAST, was a cross-sectional observational study of ten European countries. Ireland was second highest in the list of countries where nurses describe burnout as their primary reason for leaving. The figure for assaults is staggering. It went up from 673 on 1 January 2011 to 3,462 on 27 July 2016.

The Irish Nurses and Midwives Organisation, INMO, quite correctly sees the key problem as pay inequality. Over 90% of nursing staff are female. That is no accident. Historically, women associated with caring have been less valued than others in "real" jobs. Despite having a high level of qualification, nurses and midwives are paid less than other healthcare professionals with the same level of qualification requirements. A graduate garda starts on an annual salary of €31,000 but nursing graduates after four years' training start at €28,900.

In addition there is, as in the teaching professions, a lower pay level for new entrants into nursing since 2011. We have a two-tier health service with the two-tier payscale for new entrants. In 2016, in the staff nurse grade 2,573 started and 2,271 of them have left, 71% having resigned not retired. There is a huge crisis in our health service which must be linked to the implementation of the Sláintecare report which must be implemented urgently so nurses and midwives feel they have some structure to work within.

I thank Sinn Féin for the opportunity to discuss this very timely and necessary motion. If we do not address its content the crisis in our health service will accelerate. We all know the important role nurses play in our society. I am not going to reiterate those points and patronise those people because they do not want a pat on the head. They need a reversal of the policies of austerity, which have been to no-one's benefit since 2012. It was a bit ironic listening to the former Labour Party Minister who was part of that process telling us now how it was all so wrong.

If the Government is not concerned about the individual cost to nurses it should be concerned about the impact this is having on our health service because the motion correctly points out the correlation between the decrease in staffing levels and the increase in workload, which is a huge strain on the service, on those working in it and on all of us who need to access a hospital. The commission on nurses pay is due to publish recommendations in June and has to be cognisant of the strain that the nursing profession has been under since 2012 and has to take steps to reverse this damage. The recruitment embargo and the decision to reduce the starting salaries of graduate nurses and midwives has undoubtedly had a massive negative effect on recruitment and retention and the continued failure to address this means that the profession has become less attractive. It is an incredibly big request to expect somebody to be a nurse, a very demanding job, against the backdrop of an average industrial wage of €37,000 with the starting salary of €28,600. A person could not rent a room or get their children into childcare in this city on wages at that level. The INMO this year highlighted the aggressive recruitment of Irish nurses by UK hospitals and the Health Service Executive, HSE, is not competing on pay and conditions. The education of these individuals is funded by the Irish taxpayer and that is handed over to hospitals in the UK. It is probably just as well that they have to look after many of our women who we send over there for treatment but that is a different story.

While Irish nurses consider leaving for better wages elsewhere we are left with two serious consequences: the inflow of nursing staff from other countries and the outsourcing of work to agency staff at a higher cost. The inflow of nurses from other countries, generally developing countries, has had an impact on those countries of origin in that they lose the skills to this country, where we have a highly trained workforce and should not have a shortage of medical staff. This is appalling. It is a practice that is shunned by the International Labour Organization because it creates a brain drain in some of the poorest countries in the world, which most need the profession.

We also have the truly wasteful policy of outsourcing and what the new buzzword calls "self-employment" at a higher cost to the HSE. This is an overall pattern. One in five in the education sector are now on temporary contracts and this is being replicated in the health sector. According to this mythical "self-employed" category, one in ten workers in health and social work are self-employed. These are professional occupations which are being pushed into the category of insecure work. If we do not address it now it will have an impact on the health service even greater than it has already had, not to mind the enormous cost to those individuals who take on that work.

I thank Deputy Louise O'Reilly for tabling this motion because it goes to the centre of the issues facing our health service, recruitment and retention of specialised staff. We are educating our nursing graduates not only for export but also for the private sector and other careers. Many are leaving the profession after qualification because there is little or no management support when they qualify. There is also an excessive workload and responsibility. Many nurses leave the profession for fear of litigation and because of understaffing in the departments in which they were educated, where they know what the future is. I know people who have qualified as midwives who now work in the hospitality sector and they are extremely happy to have moved career because they were under immense pressure due to understaffing.

There are other issues in respect of a poor career pathway and poor career progression for our nurses. Speciality nurses who come back from abroad to work in Ireland are told they cannot work in the area in which they have expertise but must go into whatever ward they are put on. That is extremely demoralising for them and they pass word back to their colleagues, who will not return to Ireland if these are the conditions in which they have to work. Poor working conditions are a huge issue for recruitment and retention.

The cost of living, particularly in Dublin, is also out of proportion to a nurse's income. That is also having a negative impact on recruitment and retention. Then there is the two-tier pay scale, which was referred to earlier. Many nurses do not feel they are valued members of the health service and, because they do not feel they are valued, they do not have a commitment to the service. For those nurses who are leaving the service, there is no exit survey to ask why they are leaving. Many nurses go to the private sector or to agencies, give up altogether or emigrate. This is the reality of nursing today in Ireland.

I am delighted to speak on this motion. We all got an email recently from a nurse which gave us the devastating news that some student nurses have as little as €6 a week left to buy food. That is appalling. Indeed, fourth-year student nurse, Tara Nic Chormaic, who is 28, has stated that the hell of the hospitals has left the class of 2018 burnt out and disillusioned. In addition, the massively disproportionate ratio in the recruitment of administrative and management staff compared with nurses, at a rate of three to one, came to light recently. It is bedlam and disorganised dysfunction in the HSE. Young nurses go into their career with a desire to help and to care for people and it is not right for them to be treated like this, that is, put into the hell of the hospitals.

The Minister of State, Deputy Finian McGrath is not listening. Where is the Minister for Health? He is probably out canvassing down the street with Colm O'Gorman or something to repeal the eighth amendment. He should look after the hospitals. South Tipperary and Limerick regional hospitals are two of the worst in the country for overcrowding. The pressure the front-line nurses there are under, as well as all the other doctors and front-line staff, is just devastating. We would be brought up for war crimes, as I said before, if it was in a war situation, with the mistreatment and abuse that the patients, elderly and young, are being put through.

I saw Deputy Kelly with his crocodile tears. He was part of the Government that destroyed their income and welfare and he wants to turn on the tap now. I would nearly want to give him a handkerchief to stop him from crying, with such tears for the nurses. He did not care about them and walked over them.

I seek assurances from the Minister of State, as I have stated already today, that the patients in the assessment unit in St. Patrick's Hospital, Cashel will be looked after. I met one of them last week who came into her 101st year last Sunday and now they are being left in a limbo situation. The HSE says nothing is happening there. It is a fact that they cannot get a doctor. We had an excellent doctor there for years, Dr. Willie Ryan, and we need to get a doctor there to have certainty for that fabulous unit in Tipperary.

I am grateful to Sinn Féin for the opportunity to speak on this motion. Like many of our public sector staff, nurses and healthcare professionals have been badly hit in recent years. It is no surprise that many of our nurses are leaving Ireland to seek work abroad or are changing their career paths, given the working conditions and pay scales they experience. Despite the so-called economic recovery with which the Government claims to have been involved, nursing staff are certainly a cohort of our dedicated emergency staff that has not seen any of the recovery in terms of their salary. The FEMPI cuts that were forced on public sector staff have not yet been restored and are causing huge strain on our already struggling health system.

Another point I wish to raise is one that was raised on Facebook recently by a young student nurse. The brave student went viral after her heartfelt open letter to the Minister, Deputy Harris, was shared all around the country. She explained her struggle of living on less than €7 per week. She talked about nurses and new graduates forced to sleep in their cars due to the unaffordable rent across Ireland, while questioning why student nurses are working a 39 hour unpaid placement each week. Although officially student nurses are not counted as staff members on the wards, they are thoroughly relied upon to keep the health system going. It is no wonder that we are finding it difficult to recruit nurses if these are the conditions they are facing. I am pleading with the Minister of State and his Government to look at this issue. They must reverse FEMPI cuts for healthcare and all public sector workers, including newly-qualified teachers, who also face a two-tier pay scale.

I am glad of the opportunity to talk on this important matter. Nurses are under severe pressure in University Hospital Kerry, Killarney Community Hospital, Kenmare and Dingle hospitals and Bantry General Hospital, to which many people from our side of the country go. I remember only too well the intensive care unit of Tralee general hospital as my father was there for many weeks. The night shift used to come on at 8 p.m. and they were to be there until 8 a.m. the following morning. If one was missing, they still carried on. They had to carry on because there was no one to make up the numbers and they had to do the work regardless. The amount of paperwork and work that they do, as well as the load they carry is entirely unfair. When we hear that the HSE is hiring management vis-à-vis front-line staff at the rate of three to one, it is totally unfair. It is the height of blackguarding. The Minister of State is one of five Ministers with responsibility for health in total. Why do they not do something about it?

I raised the case during the Order of Business the other day of a girl who wanted to come back to get a higher degree in nursing. She gave 23 and a half years in this country before she went. She was away for three and a half years and now she will have to pay double for her course because she was out of the country for more than three of the last five years. She will not qualify for a SUSI grant either. How can the Government expect people to come home when these kinds of regulations are put upon them? This girl had given 24 and a half years of her life in Ireland. She was born here and is one of our own, bred and reared. The rules and regulations are militating against them and that is why they are not coming back. They do not have the right conditions. They are overloaded. They are driven down through the ground with work.

The Government is not listening to us. We have five Ministers for health and a Government that is not listening to the people when we are calling for more front-line staff. What are they doing? Employing more managers. Too many chiefs and not enough Indians. That is the truth.

The Deputy is wasting other people's time. Glaoim ar na Teachtaí Shortall agus Ó hÉallaithe. Tá siad ag roinnt ocht nóiméad.

Ceithre nóiméad an duine. I commend Deputy O'Reilly on bringing this important motion before the House. It is very prescient. There are two interrelated issues that must be considered when we examine nurses' pay. The first is that of basic fairness, the unwinding of FEMPI measures and setting appropriate levels of pay for front-line workers in the health service. The second issue is that of poor pay and conditions, which are contributing to overall strain in our health service.

From the outset, it is important to state that as qualified professionals, nurses and midwives are the lowest paid professional grade in all of the Civil Service. The starting pay for a qualified staff nurse who has undertaken and completed a degree and clinical placement is €30,802 per annum. This compares, for example, with respiratory technicians who start on €37,000, or radiographers who start at almost €36,000. Both the Irish Nurses and Midwives Organisation, INMO, and the Psychiatric Nurses Association of Ireland, PNA, have called on the Public Service Pay Commission to address this pay scale as a matter of urgency. The pay scale must be understood in tandem with the unequal conditions for new entrants into the profession introduced under FEMPI.

While the process of unwinding the FEMPI cuts will continue as part of the public service stability agreement, PSSA, up to 2020, it is undoubtedly still the case that many nurses continue to vote with their feet and travel abroad to work. It is a scandal that we export highly educated professionals to Australia, the Middle East and North America when their skills are so much in demand in this country. According to an INMO study, the purchasing power parity, PPP, of nurses in public sector hospitals in Ireland compares badly relative to other countries. Crucially, PPP for nurses in Ireland is below Australia, Canada and New Zealand, the destinations to which Irish nurses are most likely to emigrate.

In addition, the PNA tells us that UK nursing packages include items such as an €8,000 relocation support grant, subsidised accommodation and a shorter working week. Unless these disparities are addressed, nurses will continue to seek work elsewhere.

The second issue is the inability of the HSE effectively to retain nursing staff and the impact this is having on the delivery of care right across the health service. Pay aside, nursing and midwifery are stressful and sometimes dangerous occupations. The number and frequency of physical assaults on nursing staff have increased in recent years, along with reported cases of burnout. When we look at the figures, we can see a shocking level of understaffing in our hospitals which is undoubtedly contributing to the high turnover of staff and the eroding levels of job satisfaction. It is a vicious cycle. If we take psychiatric nursing as a case study of understaffing, the figures are shocking. PNA branches across the country tell us that up to 500 nursing vacancies exist in mental health services alone. If A Vision For Change is to be fully implemented, a minimum of 1,963 new nursing posts will need to be filled. In August 2017, HSE showed that only 93 psychiatric nurses were recruited in the previous 12 months. It is no surprise that many are going abroad to develop nursing careers in countries with functioning health systems where they are treated with respect and valued. The staff turnover rate in 2016 was almost 8%. Unless we address these issues, the haemorrhaging of staff will continue. The proper remuneration of nursing staff is crucial in order to ensure the recruitment and retention of these highly-trained professionals and for the proper functioning of our health service. We cannot continue to ignore this fact.

I welcome the representatives of nurses and midwives to the Public Gallery. I compliment Deputy O'Reilly on bringing forward this motion and I confirm my support for it.

We all know there is a recruitment and retention crisis in the health service. We also know that nurses and midwives do invaluable work in our hospitals and health services right across the country and are absolutely dedicated to their profession. They are working above and beyond the call of duty on an ongoing basis. The pressure they work under is unremitting; it is not just now and again. They work in a highly pressurised environment, which results from things such as the moratorium introduced in 2007, the reduction in nursing numbers, pay reductions and, of course, the two-tier pay system. While all of that was happening, our hospitals experienced increased activity levels. My local hospital, South Tipperary General Hospital, is working at approximately 125% capacity, when the accepted maximum level would be approximately 85%. There were 750 patients on trolleys at South Tipperary General Hospital in 2011, compared with over 7,000 in 2017. That is an indication of the pressurised work environment in which people are working. Physical assaults on nurses have increased to a rate of approximately 34 per month. That situation resulted in a reduction in nursing staff by approximately 3,000 between 2000 and 2017.

The national maternity strategy, which requires an additional 200 midwives in 2017-2018, is completely off track. In January 2017, there were 1,461 midwives. By January of this year we had lost 52, leaving a total of 1,409. There is already a deficit. Psychiatric services face the same situation. There are approximately 500 vacancies in that area. In St. Loman's in Tallaght, there are 52 vacancies, which represents 20% of the staffing requirement. There are 64 vacancies in Portrane, which, again, is 20% of the staffing requirement. In Waterford, Louth, Meath, south Tipperary and other places, the situation is repeated. On top of that, A Vision For Change requires 1,400 addition staff in that area.

We are operating in a global market. Nurses are very scarce and we are competing with other countries that are offering much better pay and conditions. It is absolutely key that pay and conditions of employment are improved and that pay inequality is addressed by this Government as a matter of urgency.

I commend Teachta O'Reilly on tabling this motion, which deals with the retention and recruitment of nurses specifically but it could apply to many healthcare professionals working in our acute health services. The Minister of State knows that, along with the housing crisis, the issue of the retention and recruitment of nurses has been with us for a very long time. When the Minister of State and his colleagues in the Independent Alliance sat in opposition, they raised these as issues concern. Like the housing crisis, this has not happened by accident. It happened by design because successive Governments led by Fianna Fáil and Fine Gael prioritised private medicine over public health services, did not prioritise our public service and allowed a situation to arise whereby far too many of our nurses are not staying in the country because of the pressures in our public health service. Nurses are not getting the due recognition and pay they deserve. To add insult to injury, a previous Government decided to create a two-tier pay structure, which has still not been resolved, whereby many new entrants to the system are not on the same pay scales as their colleagues.

I remarked to Deputy Ó Caoláin earlier that anyone born in Ireland since the foundation of the State has lived under Governments led by either Fianna Fáil or Fine Gael. That is the reality. As long as we have Fianna Fáil or Fine Gael-led Governments, we are not going to have a resolution of these issues. While Fianna Fáil and Fine Gael are in government and are being propped up by people such as the Minister of State, we can use Private Members' motions as a mechanism to apply pressure and to ensure we get resolution on these issues. My party has put forward practical, realistic, deliverable solutions that will ensure that we can retain and recruit as many nurses as possible.

This issue has an impact on services. In Dungarvan Community Hospital, beds were closed last year because of a lack of nurses. Along with other Members, I am trying to get additional cardiology services in Waterford, but we are told that the hospital cannot recruit the staff. This problem applies across the board; it is not just a nursing issue. The Government needs to get its act together, do something about this issue, and stop prioritising private medicine over and above our public health services.

It is very clear that there is a crisis in our health service. Everyone is aware of that. The crisis in the health service is reflected in the issue of retaining our nursing staff. Everything is connected. There is a crisis in housing; people cannot afford houses. Nurses cannot afford to pay rent in this city or in many other parts of the country. There is a crisis in childcare, which means that young nurses with families cannot get childcare, particularly given the long rotas they have to work. There is also an issue with pay and conditions in a stressed work environment. These things all feed into the overall problem. The Government must step in and take bold action to try and resolve these issues.

All previous speakers have stated that pay is one of the first issues we have to tackle. That is true but we also have to tackle the issue of professional development and training. Many of the nurses who qualify in this country go abroad because there are greater opportunities to develop and access training in different countries.

We also have to look at the whole issue of creating a better working environment within the hospital system. The shortages of staff, not just of nurses but of consultants and others, as well as a trolley crisis, all lead into a working environment which people find stressed and pressurised and they do not want to enter it. The Government has to take real action in regard to all of these issues. It is interesting because recruitment and retention is something that very clearly has a big effect on the professions and the health service but, as I said, it also impacts on all the other things around it, such as the housing a crisis. If a nurse is lucky enough to get a position in the city of Dublin, for example, he or she cannot afford to rent a house to stay here. All of those things have an impact.

My third-oldest child, Clare, has said since she was in primary school that she wants to be a nurse. She is doing her junior certificate in the coming weeks and she still has that ambition. I encourage that because it is a magnificent profession and nurses can go anywhere in the world and get work. They can also contribute so much to their community, to society and to everyone around them. We all want to see more people trained and working in the caring professions, yet the State treats them so badly. What does that reflect? It is not a reflection of the people, rather it is a reflection of an establishment which does not seem to care. That has to change.

I appeal to the Minister of State, Deputy Finian McGrath, in particular, given, as my colleague said, that he is propping up the Fine Gael Government. It is time to give them a bit of a kicking and tell them they need to step up to the mark in this regard. That is what he needs to do. I know he has always promoted the issue of quality health care and the position he now holds is all about that. However, at the end of the day, he is propping up the Government that is allowing this situation to continue and he needs to reflect on that point.

I commend Deputy Louise O'Reilly on drafting what is a very detailed motion which sums up many of the issues that exist in the sector. I met in recent weeks with the chief executive of Cork University Hospital and representatives of the INMO. There are many things they do not agree on but there was clear agreement on the issues that exist around the recruitment and retention of nurses, which are related to both pay and conditions and which, to a large extent, are connected. The pressures that nurses and midwives are under at the moment in our hospitals, particularly the major hospitals, is enormous. Any time I speak to people in that profession, I find their frustrations are enormous and the pressure and stress they are under is obvious. This takes away greatly from their ability to enjoy and appreciate their profession. The statistics are incredible. A 2017 survey showed that 78% of student nurses were considering emigration and 81% of those listed pay, staffing levels and working conditions as the main reasons.

The pressures people are under are very clear. This should be dealt with not only in the interest of nurses, but in the interests of everyone. The two great social and strategic challenges facing this country are the housing crisis and the crisis in our hospitals. To deal with the crisis in health care in the hospitals, we need more beds. To get more beds, we need to have more nurses and midwives. How do we deal with the crisis of recruitment and retention? Everything has been tried except pay, and we have to address that point. The level at which they are paid is very much a reflection of the value we place on people in the caring professions, particularly in nursing and midwifery. Deputy Martin Kenny makes the strong point that the cost of living crisis is enormous for the population as a whole but particularly for people in that profession. For anyone who is trying to rent in Dublin or near Cork University Hospital, it is impossible to find any kind of decent accommodation. Many means have been tried in order to retain and recruit but the one thing that has not been tried is pay. We need to get rid of the two-tier pay system, treat our nurses with respect and pay them accordingly.

I commend Deputy Louise O'Reilly on putting forward this important motion. It is an ongoing issue that needs to be addressed. We need action and commitment from the Minister for Health because this has gone on too long.

The depletion of nursing and midwifery staff from our health services and the gradual erosion of their working conditions has reached catastrophic levels. It is undeniable that if these issues of pay, retention and recruitment are not addressed as a matter of urgency, the crisis will impact severely on medical outcomes for patients. Irish nurses who leave this country arrive abroad with an internationally recognised quality standard which is much sought after but it is not appreciated here, while those who remain here at home, and who work tirelessly and with dedication in our hospitals, are treated with contempt by the State.

Irish nurses and midwives work longer hours and are at greater risk to their personal safety than any of their European colleagues. They are contracted for 78 hours, or two full weeks, per year more than their UK or Canadian counterparts. On top of this, an average of 34 non-psychiatric nurses and midwives are subjected to workplace assaults every single month. That is unacceptable and needs to be addressed.

I urgently call on the Government to introduce measures which will ensure the retention of existing staff and secure the recruitment of new entrants. We know nurses are under severe pressure given overcrowding has become a prevalent feature of our health service. We know accident and emergency departments are overcrowded every single weekend. In my constituency, the Midland Regional Hospital in Tullamore is one of the hospitals where staff are under tremendous strain. That is unacceptable and it leads to the cancellation of elective surgery for elderly patients. This is having a knock-on effect. The way we are treating our nurses affects all of society and we need to address this. It will only be addressed by treating our nurses fairly and by pay equality and permanent contracts across the grades of the professions on the pay scale, and by the introduction of new workplace safety measures to reduce the incidence of assault.

I thank Deputy Louise O'Reilly, the other Sinn Féin Members and all other Members for their contributions to the important debate on nursing pay and recruitment that has been raised in this Private Members' motion. Similar to the Minister, Deputy Harris, I too appreciate the dedication and strength of character demonstrated by the nurses and midwives, and I value the contribution they make to the health service on a daily basis. I particularly commend those nurses who work in the disability sector. I accept the argument that all nurses deserve a decent pay rate and proper working conditions. That is one of the reasons I went into government, that is, to try do something about it. It is one of the reasons we included in the programme for Government the new accident and emergency hospital at Beaumont, the new cystic fibrosis unit at Beaumont and the recently opened new kidney unit. These are all practical issues that show clearly I am not propping up any Government and that I went into government to act on these issues.

To prove our sincerity, the Government will not oppose the motion, which is an important statement I am making on behalf of my colleagues in the Independent Alliance. It is clear from the contributions in the House that there are issues to be resolved but, similarly, we know measures are being taken which are clearly focused on addressing these issues. There are a number of points in the motion with which I strongly agree. We agree the nursing profession accounts for a significant and important part of the public health service and is predominantly female. We agree the average age of the nursing and midwifery workforce is 44 years and plans are required regarding this ageing workforce. We all agree the financial crisis has had a damaging impact on the delivery of service. At the same time, I will not take lectures from people who were involved in the devastation of our health service in the recent past. The recruitment moratorium occurred at a time when hospital activity and patient activity were increasing and they continue to increase. We also acknowledge that many nurses and midwives operate in a high-stress working environment and sometimes in difficult situations with vulnerable people.

Regarding the issues relating to recruitment and retention of nurses, a concerted effort is already being made by the HSE to increase the number of nurses and midwives as part of the nursing recruitment and retention agreement. The overall number of nurses and midwives at the end of 2016 was 35,835. At the end of 2017, it stood at 36,777. This is an increase of 942, including student nurses.

While we do not have the number of nurses we had in 2007, we must be realistic. There are challenges in recruiting and retaining some specialist staff, midwives in particular. There are ongoing efforts to address this issue. We have committed in the national maternity strategy to increase the number of midwives, and we remain committed to doing this.

I know that efforts to recruit the remaining nurses and midwives will continue into 2018. The agreement also set out other key measures, including the appointment of all nursing graduates; a career break scheme; 130 additional undergraduate places in 2017; reinstatement of some nursing allowances; and offering nurses and midwives improved educational opportunities and career pathways. Thankfully, we have moved away from the days when we were unable to offer our graduates a permanent job. I am pleased to say that all graduating nurses in 2017 were offered permanent contracts within a hospital group or community healthcare organisation, CHO, subject to their attaining registration. Once again, the HSE has issued an instruction that all graduate nurses are to be offered permanent contracts to work in the Irish public health service in 2018.

We all acknowledge that there is a global shortage of nurses and midwives, and that nurses educated and trained here in Ireland are sought after worldwide. There is evidence to suggest that the number of nurses seeking to work overseas has declined in the past 12 months. We are hopeful that Brexit will have a positive impact on our efforts to retain Irish-trained nurses and potentially attract nurses from overseas who would have previously considered the UK as their destination of choice.

Pay is a significant concern for nurses and midwives. We accept that argument. We have already begun to see the unwinding of measures taken under the Financial Emergency Measures in the Public Interest Act 2010, FEMPI, through the public service stability agreement, PSSA. This includes a series of salary increases that will see all public servants, including nurses, receiving an average increase of 7% over the lifetime of the agreement. A number of allowances have been restored to nursing staff. Pay parity for new entrant nurses and midwives is also being addressed as part of another process being led by the Department of Public Expenditure and Reform.

A comprehensive data-gathering exercise has been carried out. My colleague, the Minister for Finance and Public Expenditure and Reform, Deputy Paschal Donohoe, provided a report to the Oireachtas on the findings. This report makes clear the Government's commitment to working with the parties to address these issues, mindful of the significant cost involved. Further engagement is scheduled for the coming weeks.

As was said previously, addressing pay is a complex issue as it extends beyond the nursing grades. An evidence-based approach that can stand up to scrutiny needs to be taken in order to reach a solution. Phase two of the work of the Public Service Pay commission is now under way. The commission is adopting a modular approach to reporting on its work. Its first module will include an examination of nurses and midwives. The Government looks forward to its report in June.

Irish-trained nurses and midwives are among the most highly educated and well-trained in the world. There are training and development opportunities available to nurses and midwives. The recruitment and retention agreement committed to providing 120 advanced nurse practitioner places. This has been a huge success for both nurses and the health service. The agreement also provided an opportunity for nurses to attend leadership academy programmes. Nursing education is an ongoing process. Mandatory training and other courses are available through centres of nursing and midwifery education. Last year, these centres provided training to 28,027 nursing staff.

The work environment that nurses work in on a day-to-day basis has also received attention here today. The safety of all staff who work in the health service is of paramount importance. I can assure the Deputies that all hospitals have 24-7 security cover. The majority have security based either within the emergency department or close to it. An external expert was commissioned to undertake a review of security arrangements in HSE emergency departments, and the findings were sent directly to each hospital to progress implementation of the actions emerging from these reviews.

The issue of physical assault on staff from patients or service users is a complex one, as those being cared for may not always have the capacity to be responsible for the actions they carry out. Safety in the workplace is paramount to the HSE. A national incident management system is in place which records the number of assaults on staff. This has recorded 3,610 physical assaults. In response to a recent priority oral parliamentary question, the Minister for Health, Deputy Simon Harris, indicated that the HSE anticipates that the number of recorded incidents will rise as the new system becomes further embedded and better data becomes available. Much is being done by the HSE to address this complex issue and to ensure the safety of its staff in a balanced and cohesive way. I acknowledge that working in this type of environment can take its toll on a person and lead to job dissatisfaction and in some cases burnout. In these instances, I would urge any affected employee, be they a nurse, doctor, health care assistant or porter, to seek assistance from their employer and to use the supports that are in place in the HSE.

Nurses and midwives are a valued member of the health workforce. We acknowledge that there are recruitment and retention challenges. However, the measures that are already in place are having a positive effect. Work continues to recruit nurses and midwives. Pay for nurses is being addressed through the pay commission and the unwinding of FEMPI. Salary scales for new entrants will also be considered under the PSSA. We await the outcome of these processes. As the Minister outlined in his opening speech, an independent nursing commission is not required. The Department's Office of the Chief Nursing Officer is doing valuable work in developing the values and future role of nurses and midwives. As we work towards implementing Sláintecare and all it will bring, nurses and midwives will be an integral part to the health service of the future.

Nurses are the bedrock of our health system. They are the front line and the essential building blocks of our response to the care and treatment needs of our citizens. It is my belief that this State has treated our nurses appallingly over the past ten years. We have watched our hospitals crumble at the seams while simultaneously waving goodbye to our nurses at airports and ports all around Ireland as they went off to practise their skills in other countries. Ireland has provided them with world-renowned education and training, but not with pay parity or an appropriately delineated career pathway.

Given the short time available, I will cut to the chase and speak about the Minister of State's specific area of responsibility, disability rights. In order to deliver on the commitments of the recently ratified United Nations Convention on the Rights of Persons with Disabilities, investment and care in services is needed, as the Minister of State well knows. Recruitment of additional nurses to fulfil our obligations to our disabled brothers and sisters will go some way to achieving this, and retention is equally important. I appeal to the Minister of State and his Government colleagues to invest in our young nurses. Invest in these caring young people, respect these highly educated front-line public employees and thereby serve the nursing needs of our citizens and communities.

I support this motion, and I extend my thanks to the nurses and the midwives across this State who are working so hard to keep our health service afloat, despite being under such enormous pressure. If it was not for the dedication of these front-line staff, we would be in a much worse situation. However, words of thanks and appreciation for these staff are simply not enough. Many feel they have been taken for granted, because they have. They are working long hours, they are under-resourced and they are under immense pressure. They are stressed almost to breaking point, but amid all of this, they are always professional and caring.

Their work needs to be appreciated through decent pay and conditions, without which the health service will be left to fester and worsen.

Once they have completed nursing courses at universities and colleges and have been awarded degrees, many nurses do not see a future for themselves in Ireland and head off to the United Kingdom and elsewhere. Nursing is a profession with poor pay and conditions, particularly when one considers the level of training and education needed for the job. We must retain qualified staff in the public health system and attract new graduates by demonstrating to them that they can progress their careers here. We need pay equality for nurses.

I acknowledge the presence in the Public Gallery of the general secretary and president of the Irish Nurses and Midwives Organisation. They are very welcome. Mar atá ráite ag mo chomhgleacaithe, is ceist ríthábhachtach í an cheist atá os comhair an Tí. Without repeating the valuable contributions of my colleagues, it is important to convey to the House the importance and gravity of this motion. I commend Deputy Louise O'Reilly, the sponsor of the motion, who has shown herself to have a deep understanding of and a clear commitment and consistent dedication to the issue of nursing pay, recruitment and retention and the effects they have on the health service.

The question, "Who would want to be a nurse?" is often asked, perhaps in jest, when nursing is being discussed. Such is the challenge in the workplace and facing the nursing workforce. This rhetorical question has even be used as the title for a research paper examining the impact such workplace stressors have on recruiting and retaining nursing talent in the health system. It is a remark that recognises the undeniable truth that those working in the nursing profession are among the most dedicated, hardworking and caring people to be found anywhere.

In ainneoin é seo, thig linn comparáid a dhéanamh idir ár gcuid ospidéal agus an limistéar cubhaidh de bharr an t-anord atá iontu. Bíonn altraí ag streachailt achan lá chun aire a thabhairt do na hothair. Tá brú mór millteanach orthu agus iad ag obair i rannóga éigeandála agus bardaí ospidéil nach bhfuil acmhainní ar fáil acu.

Given their resolve and dedication, it is hardly surprising that Irish nurses and midwives are in high demand globally. With such attractive remuneration and significantly improved working conditions on offer elsewhere, how can we compete in attracting and retaining nursing talent? The evidence shows that we are not competing. Government enforced recruitment embargoes and wage cuts, coupled with underinvestment, have decimated front-line health services and driven nurses to flee our hospitals in their droves. Agus tá na himpleachtaí dár seirbhísí sláinte le sonrú gan amhras. Tá an córas uilig ag titim as a chéile.

My colleague referred to the impact in his constituency. In County Donegal alone, staffing shortages have been solely to blame for the closure of 41 beds in the community setting since 2015, with all the knock-on consequences this has for services, patients and staff working elsewhere in the health service. It is against this backdrop that I back the motion and call on other Deputies to do so. By supporting this motion, we will show to nurses and midwives that the State values them as individuals and professionals whose invaluable work and selfless contribution to the health service we cannot forego.

I will respond to some of the points made by the Minister of State, specifically his comments on the level of assaults on nursing staff. Every Deputy who contributed in the past two hours noted how valuable nursing and midwives are in the health system. It is a little insulting to these professionals to attribute an increase in the number of assaults on improvements in the recording system. Short staffing and unsafe working conditions are the causes of the increase in assaults. It has nothing to do with the way in which assaults are recorded. Nurses and midwives are not assaulted by a recording system but in their workplaces and the way in which assaults are calculated is immaterial to staff. I have met many nurses who have been a victim of an assault. They want to know that their employer is on their side rather than telling them how marvellous he or she is because the way in which assaults are recorded has been fixed. That is of no value or use to nurses and midwives.

The motion will pass because it has the support of the majority of Deputies and the Government has indicated it will not oppose it. The Minister for Health stated we should await the findings of the Public Service Pay Commission. I spoke many times about capacity and I was consistently told I should await the findings of the bed capacity review. The review found that a minimum of 2,500 beds will be needed in the system. These much needed additional beds cannot be opened unless we have sufficient staff in place. It is not good enough to argue we should wait for the Public Service Pay Commission to report or for another review to conclude. Graduate nurses and midwives will not wait and have already indicated they intend to leave the country.

With respect, the offer of a full-time job and permanent contract will remain deeply unattractive to nurses and midwives unless we tackle the issues of pay and working conditions. We will not be able to increase the number of beds in the system by 2,500 or recruit and retain the vital nursing staff we need unless pay is at the centre of the recruitment process. The Minister stated he would not oppose the motion. I would prefer him, as I am sure would our guests in the Public Gallery and the nurses and midwives outside the Chamber, to indicate the Government would support the motion and place pay at the centre of any recruitment and retention strategy. Without doing this, the offer of full-time employment is an offer of a job in a intolerable and unsafe workplace, which is unacceptable and not what we want for nurse graduates.

The Government hopes Brexit will save it. I doubt that will occur because many nurses move to the United States, Dubai, Australia and other far-flung destinations and they will not return. We must put pay at the centre of any recruitment and retention strategy because all the fine words uttered in this Chamber will not recruit a single nurse or midwife.

Gabhaim buíochas le gach Teachta a ghlac páirt sa díospóireacht seo agus a chlóigh leis an am.

Motion put and agreed to.