Health Sector Pay Report: Public Service Pay Commission

I welcome to the meeting Mr. Peter McLoone, Mr. Kevin Duffy, Mr. Michael Kelly and Ms Joan Curry. On behalf of the committee I thank the witnesses for their attendance today. The format of the meeting is as follows. Witnesses will be invited to make a brief opening statement which will be followed by a question and answer session.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I also remind members and witnesses to turn off their mobile telephones or put them in airplane mode because they cause absolute havoc in here. I further wish to advise that any submissions or opening statements witnesses have provided for the committee will be published on the committee website after this meeting.

Mr. Kevin Duffy

I am joined here today by my commission colleagues Mr. Peter McLoone and Mr. Michael Kelly and by Ms Joan Curry, head of the secretariat to the commission. The commission is happy to take the opportunity to contextualise and discuss its recent report and to help the committee in its work in whatever way we can.

The commission was established to advise Government on public sector remuneration policy and in this regard its terms of reference are broad. In May 2017 the commission published its first report, providing input on how the unwinding of the financial emergency measures in the public interest, FEMPI, legislation should proceed. In this second phase of the commission's work we were obligated by our terms of reference to undertake an examination of whether, and to what extent, there are difficulties in recruiting and retaining staff in key areas of the public service which were identified in our first report. The broad frame in which we operate requires us to take into account current Government policy on public service pay, including the planned pay restoration provided for by the public service stability agreement, the general backdrop of fiscal sustainability and the many competing priorities for public investment. We were also aware of other developments in respect of the public service pay bill such as new entrants' pay and the settlement of the case taken by hospital consultants. Given the very specific terms of reference for this phase of our work, we adopted an evidence-based approach to all our considerations and we believe the conclusions we have drawn are well founded.

It is clear that the 2009 moratorium on recruitment and promotions in the public service had a significant effect on numbers in the public health service. The commission recognised the reductions during the period up to 2013, which across the nursing and midwifery grades was 9%, bringing the numbers to 33,676, and acknowledged that the level of demand for services did not reduce and has noticeably increased over the past decade with an increasing and ageing population. There is evidence that numbers have increased since 2013, although the number at the end of 2017, which stood at 36,777, was still not at pre-moratorium levels. Submissions to the commission confirm this increase is not simply a result of the lifting of the moratorium, but also required the development of a range of initiatives to attract and retain healthcare workers.

An early and very positive conclusion is that medicine and nursing and midwifery remain very attractive as career choices if we judge by the popularity of these courses among young people at university entry stage. Of this year's 57,000 school leavers, 9.6% have selected nursing as their first preference, with a further 5.6% choosing medical undergraduate education programmes. This means that this year, in common with many recent years, nursing and medical education programmes are oversubscribed. We continue to produce high-quality graduates in numbers which should meet our domestic needs; indeed, Ireland produces the highest number of medical graduates per capita in the OECD. We are also attracting significant numbers internationally. However, we are seeing some retention problems and Irish-trained graduates do not seem as inclined as previously to return after taking up international appointments.

We realised very quickly that Ireland is going through the same experience as many other health systems internationally. Healthcare skills are in short supply and all indications are that such shortages will continue. As a relatively small player in a highly competitive global market for health skills, we are facing a sizeable challenge in attracting and retaining competent practitioners. The commission acknowledges that numbers working in the public healthcare sector have increased since the lifting of the moratorium on recruitment. However, there is evidence of both recruitment and retention difficulties over recent years in the groups we examined. Much attention has already been given to resolving these difficulties, and the commission referenced and drew upon the findings of other relevant reports on the various aspects of these complex challenges in reaching our conclusions. We also noted that we are now beginning to see a positive impact from many of the measures already taken. Some examples include offering permanent contracts to nursing and midwifery graduates, increasing undergraduate places, improving access to training and providing flexible working hours.

A significant amount of work has already been done, often in a collaborative framework, but from our analysis there is no room for complacency. We are saying very clearly that recruitment and retention must continue to be prioritised and we point to a number of areas where policy and practice need further strengthening. In particular the commission reiterated its view, put forward in its initial report, that measures need to be put in place to address data gaps in collecting and analysing the transactional data necessary to monitor, manage and maintain an adequate and appropriate workforce.

Our work was informed by many sources, direct evidence provided by the parties and a review of international published work and domestic publications, including the Sláintecare report. It points to the need for integrated workforce planning as a major input to future service planning and delivery. This more rigorous approach should lead to a more reliable basis for planning workforce requirements and measuring more definitively where any possible recruitment or retention deficits may be. We found evidence of some small pockets of this discipline in practice, and very early indicators are positive. We invited submissions from employers and staff representatives. In the absence of consensus on the scale of the problem and, more particularly, on the likely solutions, we commissioned our own independent research. We looked at destinations and conditions of employment in the main host countries, and an opportunity was provided to staff for direct input via surveys and interviews. We acknowledge that the response rates were low and the results may reflect a group with views different from those of the generality of the cohorts surveyed. Therefore, while needing to be treated as indicative, the responses are nonetheless informative.

A consistent finding from all our research is that the decision to take up a particular post or to remain with a particular employer for a prolonged period is influenced by a multiplicity of factors.

These factors include the extent to which mentoring facilities are provided for new entrants, the degree of staff engagement within the employment, the relativities of remuneration, access to training and promotion opportunities available. Chapter 5 of our report deals with this in some depth and chapters 6, 7 and 8 include some of the key findings with regard to attitudes to recruitment and retention from the survey and interviews for each of the groups.

Based on our analysis, we have identified a number of measures for consideration in relation to each of the three groups we examined. These include strengthening human resources, HR, functions, a funded multi-annual workforce plan, an increase in certain allowances and a reduction in the service requirement necessary to reach the grade of senior staff nurse. We were also mindful of the commitment in A Programme for a Partnership Government to the full implementation of the MacCraith report to assist in the recruitment and retention of key medical staff and endorsed the recommendations contained in that report.

Turning specifically to mental health care, which is this committee's area of concern, the commission's report highlighted specialties within the mental health care area which were experiencing particular difficulties with recruitment and retention. We found that among nurses, the psychiatric staff nurse and the intellectual disability staff nurse grades recorded the most significant average annual declines of any nursing specialty between 2013 and 2017. We also concluded that while there is a general difficulty recruiting hospital consultants, with more significant problems in certain specialties and locations, psychiatry in particular was a specialty highlighted as experiencing recruitment challenges across a number of indicators.

The recommendations we have made should have equal relevance in mental health services as in other areas. The commission, however, stopped short of making sector or specialty-specific recommendations, due to the wide nature of its mandate. We hope our report will be helpful to the committee in its work and we will be pleased to clarify any aspects of my contribution or the commission's findings.

I thank Mr. Duffy. Deputy O'Loughlin has kindly agreed to allow me to make the first contribution because I have to leave at 2.30 p.m. My input will be more of a statement than a series of questions. While I understand Mr. Duffy's view that the report and its recommendations should be applied right across mental and physical health services, we are aware of the serious challenges and difficulties facing psychiatry. Will Mr. Duffy comment on that? Recently, while travelling on the greenway cycle path in County Waterford, I met seven retired psychiatric nurses, all of whom are younger than me. I asked if they were ever asked to return to the service given that we have such a shortage of psychiatric nurses. They said they were asked to return all the time but would never go back because it would involve working between ten and 12 hours a day in a difficult environment, often in buildings that are not conducive to having people stay in them. Is it part of Mr. Duffy's remit to examine the issue of working hours and the repeated use of the same staff, which has an major impact on their mental health?

Mr. Kevin Duffy

What the Chair says just confirms what we found, as set out in the report, namely, that a multiplicity of factors are causing difficulties. These relate to the physical environment in which people work and, in some part, to the conditions under which people work. In addition, some areas of the country are less attractive to people to work in than others. There is no single issue that one could focus on to solve the totality of that problem. A whole package of measures needs to be looked at, which is what we tried to do in the report. Our terms of reference were broad. We were asked to look at whether there were problems in recruitment and retention and to what extent they existed. We were also asked to look at what factors may have contributed to them. As the Chair and her colleagues will see from our report, we have identified a raft of factors. I will not take up the time of the committee by going into all of them.

Staff find it especially difficult to cope with the hours of work. Does Mr. McLoone wish to comment?

Mr. Peter McLoone

We recognised the need to address the question of flexible working hours. A recommendation in the report is that the HSE and employers generally should recognise that greater flexibility would improve the prospects for retaining and attracting back to the workforce those who, because of individual circumstances, are only available for work on a limited basis. We have made that recommendation.

Mr. Michael Kelly

The thinking on that issue came from a question we asked ourselves about agency staff. We asked why many nurses and midwives find agency positions more attractive than full-time positions. The answer at one level relates to pay and increments. Another part is that agency staff are not required to pay the pension contribution. The third part is about flexibility and the freedom to work under a more flexible regime. The report states that a nurse providing a contribution with flexible hours is far more valuable than a nurse not participating in the workforce. The modalities of addressing this are a matter for discussion between the parties. We could not get into that issue.

The solution may be to adopt an agency model in which staff have flexibility and better pay and do not have to reduce their income through pension payments, etc. That could be a solution-based approach.

I thank Mr. Duffy and the witnesses. They have done very valuable work on the report they have prepared for us. I have a few key observations and questions. It is interesting to note the comments on the number of this year's school leavers who have looked at careers in nursing and undergraduate medical programmes. Approximately 5,000 young people wanted to choose nursing.

These areas are oversubscribed. Approximately 2,500 opted for medical undergraduate programmes. We do not seem to have a problem attracting young people into the area. The State is spending lot of money on ensuring these young people have a very good third level education experience and come out very well qualified. The key issue is to ensure they have the opportunity and desire to stay in our country and enter into the services where they are so badly needed. There certainly is a lesson in this. Obviously the country is not doing enough to ensure these young people become part of the necessary and essential workforce to look after and care for people here.

The witnesses identified particular areas other than remuneration coming up as problems. The Psychiatric Nurses Association came before the committee and suggested subsidised accommodation should be offered to nurses to mitigate the high cost of living, particularly in the Dublin area. Is this something the witnesses could see as a possibility? With regard to geographic trends established on the non-retention of staff, the obvious links to the cost of living and availability of housing and remuneration not being the main issue, the witnesses spoke about mentoring, staff engagement, access to training and promotion as key areas that could be looked at. There certainly are areas we should look at. Do the witnesses have more guidance on these?

The area we are particularly concerned with is that of attracting professionals to mental health services. It is particularly disconcerting to see the decline in the number of psychiatric staff nurses. The area of intellectual disability, in which I have a particular interest, has been mentioned. Do these sectors need to look at increased incentives? We absolutely need to be able to increase the number of support nurses and staff in this area. Over the summer, my colleague, Deputy James Browne, highlighted the numbers. We are down 90% of the people we should have and this is at crisis point. Given our ageing population, what moneys have been set aside to deal with the increasing number of dementia diagnoses? This also leads to the mental health area. There are difficulties with dual diagnosis and people with intellectual disabilities can have mental health issues. There is an impact on all of them.

As the report indicates, the European Commission estimated a potential shortfall of approximately 1 million health workers in the EU by 2020. Irish healthcare staff are very much in demand abroad because it is recognised we have a very good training system. Many of our emigrants show little desire to return. Sláintecare emphasises the urgent need to plan our workforce better. Do the witnesses think we are making any progress in this regard? It is absolutely key.

Mr. Kevin Duffy

The Deputy has made a number of very important points and we have addressed some of them in our report. I ask the committee to look at our report and see the emphasis we have placed on a number of issues. The reality is we are confronted with an absence of reliable data on what vacancies there are and where they are. This is a problem. We have suggested a solution, which is that we need adequate workforce planning. This is not there at present. These factors are of huge importance and are central to the recommendations we have made. At present, there is very little in the way of planning to deal with an expansion in the demand for services, to deal with retirements or to deal with the fact, which has always been a reality, that a certain number of people recruited will leave. Depending on how we count the figures, and whether people retiring are counted as people leaving, between 5% and 7% will leave. Some people will say this is not huge in terms of the overall numbers, and certainly it would not be regarded as huge compared with what we see in private sector employment, but it represents a significant loss to the health services and to the investment made from public funds in training these people. The more we can reduce this number the better. We have suggested certain incentives in the nature of allowances and increased opportunities for promotion as a way of encouraging people to stay who might otherwise leave for a variety of reasons.

I must ask Mr. Duffy to move on because we are running out of time.

Mr. Kevin Duffy

My colleagues might like to augment what I have said because a number of other points were made.

Mr. Michael Kelly

I understand completely the anxiety with regard to improving our chances of recruiting more psychiatric nurses, psychiatrists and other staff to the mental health service. As Mr. Duffy has mentioned, the decision to stay with a particular employer is multifactored, as is the decision to leave. When we look at the impact of the moratorium, at one level it reduced numbers but for the people who remained it left a more difficult work situation. When we look at the responses of people, some out of the workforce, some still in it and some people working abroad, with regard to their perspectives on working in the Irish healthcare system, the one thing that comes through consistently is the personal and professional pressures overcrowding and understaffing put on individual practitioners. Part of the solution to this is to try to get the service right. Much work, including the work of the committee, is being done on this. There is a catch-22 here because if we do not have the people it is difficult to do it. The various pieces of this must happen in tandem.

Deputy O'Loughlin asked about subsidised housing. That would be intuitively attractive in certain geographic areas with a particular shortage but no matter what way we disguise it, it would be part of a remuneration package. There is nothing wrong with looking at it but it needs to be looked at as part of the wider spectrum of issues that need to be resolved. Hitting at one issue in isolation will not solve the underlying problem.

As Deputy Buckley will take the Chair in approximately ten minutes I invite him to ask his questions now.

I welcome the witnesses and thank them for their presentation. I have some very brief questions. I am frustrated about the recruitment and retention issue.

Mr. Duffy mentioned positions for nursing being oversubscribed, but there is a swallow hole of emptiness when it comes to looking for specific staff in areas of the mental health sector. I cannot understand it. If one needs a pound of sugar tomorrow, one goes to the shop for a pound of sugar. If one needs two pounds the day after, one buys the two pounds of sugar. We are dealing with forward planning. If we know there is going to be a shortage in coming years, and Mr. Duffy referred to retirements and the fact that a certain number will leave, why are we not training more staff? Why are we not giving them better opportunities?

Mr. Duffy mentioned demographics as well, which set off a light in my head. Why can we not plan? I have been following this matter for the last 14 or 15 years, including in my short time as a Member of the House, and in that time everybody who has appeared before committees has spoken about the problems. Nobody speaks about the solutions. We know the demographics in certain areas and we know which teams are fully staffed within the CAMHS and which are not. Why can we not pick a specific area and state that the plan for the next two years is to fully staff that area and provide the resources to do that? If one moves out of Dublin rents are far cheaper. We should be forward planning for that. There is a model in the hospital in Southampton where the staff who work there have cheap accommodation on campus. There are solutions but nobody comes up with them.

Mr. Duffy referred to the examination in detail of recruitment and retention, yet there appears to be a lack of evidence or very little detail. If there is very little detail how can we get an evidence base? Can the commission provide details of the health service employers' engagements that took place and what grades it examined? Is it possible to get that? I was struck by the line that the PSPC will not take the place of direct negotiations between the Government and employee representatives. The witness referred to the FEMPI. If the commission is not engaging with it what is the purpose of the commission's report on that?

The witness spoke about recruitment and retention. It is frightening that part of another report that was attached to the documents today regarding CAMHS and the 57 units that were investigated shows that 79% of the units that were inspected were non-compliant. Some 69% were non-compliant and deemed to be high or critical risk to residents, not to mind staff, and 51% of the regulated services were non-compliant on an ongoing basis. That is one area that is toxic. If we are expecting somebody to put his or her hand into the boiling pot without cooling the water we are in trouble. This is not a personal attack on the commission but just shows the system. The presentation is all about the problems and no solutions. We need solutions. Will the day ever come when somebody will grab the bull by the horns? My area of Cork is a disaster when it comes to CAMHS. It has a huge population so we should staff the service and move on to the next county and then the next county.

Mr. Kevin Duffy

The thrust of our report is to suggest solutions to problems that we have identified. I commend the report to the Deputy.

Regarding the matter the Deputy referred to at the end of his comments, I am not aware of that report. The quality of accommodation in such places is not a matter that came within the ambit of our terms of reference.

Third, it is a fact that there are more applicants for places than can be accommodated. The number of points required to get into nursing or medicine indicates this. There are proposals in the report for additional training places. Obviously, a large number of people want to be nurses and doctors but they cannot because they cannot get into the training places. We believe there is a need for more training places. I accept the point made by the Deputy. It is a good one. The purpose of manpower planning is to identify the number of people who may leave, retire or who may simply decide they do not like that career and go off somewhere else. Proper manpower planning will anticipate that. That might well mean that if 1,000 nurses are required now we should be training more than that number to accommodate vacancies that will inevitably arise down the road. That issue of manpower planning is central to the recommendations and the solutions we tried to identify.

Mr. Peter McLoone

This is just another report on top of many others .At some stage committees such as this must look at our report and if our recommendations are endorsed there is a stronger chance they will be acted on. The one thing this service does not lack is reports that are full of analysis. It is a question of how one pulls this together and says the commission has got certain aspects of this right. If these things are endorsed and acted on we will not be talking about the same issues again this time next year.

It has been absolute repetition on our part. There are 12,000 reports, incidentally, and many do exactly what you are doing. We are also looking at the retention and recruitment issues. Thank you for that and thank you for attending. Deputy Buckley will take over the Chair and I thank members for letting me leave.

Deputy Pat Buckley took the Chair.

I apologise for being late. I was attending another engagement. One of the narratives we have seen in the committee is the retention of staff in the health service. It is a crisis. Some of my questions have already been answered. On the issue of retaining staff, obviously it is not just about pay but also about working conditions. I worked in the health service previously and I know how stressful the job and environment can be. Sometimes one is dealing with life and death and very stressful situations. It is a difficult job and the burnout rate is quite high. I have friends who are psychiatric nurses and general nurses. They find the job extremely rewarding. They do not do it for the money but to give something back. They love the job but they find it extremely stressful, be it on the wards or elsewhere. That comes with the job but it is probably amplified now more than ever because of conditions in the health service, cutbacks and so forth.

I have a question about other jurisdictions. I am sure other jurisdictions probably have a similar situation with retention of staff. We know that nurses are going to Australia but I am sure Australia has a situation where it cannot retain nurses. Is that the case? In other jurisdictions, particularly Britain, there are incentives for keeping staff, such as rental accommodation where rent is very reasonable in a costly rental market.

Is that possible when there is a housing crisis in Ireland? I do not know if it is possible. Can there be an incentive for retaining staff, particularly staff who have emigrated and want to come back? Such people might look at their balance sheet and decide that it is not worth their while to return because of the cost of living. Could the Government provide for those people, especially around accommodation?

I will probably ask the following questions of everyone appearing before the committee. How bad is the situation now? How bad might it get? Can it get much worse? How good was the situation previously, and how did we arrive at the situation where staff are haemorrhaging from the health service? There are many reasons for this, but I believe the main reason is the pay on offer. How has this situation arisen and how bad could it get? Non-retention of staff - as was the case when I worked in the area - lack of co-ordination, lack of clarity and a lack of familiarity with patients can have a major detrimental effect on service users and the health service in general. My questioning approach has been a bit scattergun, but I would like to hear the witnesses discuss the retention of staff. Could the situation get worse?

Mr. Kevin Duffy

The Deputy asked where this problem came from. To put it in context, I would suggest it has its roots in the moratorium on recruitment and promotion in the public service generally. Numbers went from almost 40,000 to around 33,000. There was a huge loss there. People retired or left their positions and were not replaced.

Is the witness referring to 2011?

Mr. Kevin Duffy

No, I am referring to 2009.

Mr. Peter McLoone

During the period from 2008 to 2013, there was a very sharp decline in the numbers employed.

Mr. Kevin Duffy

The decline was across the public service and was a consequence of the economic state the country was in. That was a huge factor, and we are still trying to catch up. That is the reality. The moratorium has been lifted, but that does not mean that people will fall out of the sky to fill the vacant positions. It is going to take some time. The indication we have received in the course of our work is that things are improving. Those findings are set out in the report. Perhaps they are not improving at the pace everyone would want, but they are improving nonetheless. I hope that the situation cannot get worse, but it is true that no one anticipated the factors that caused the problems in the first place. At the minute there are many measures in place which are designed to make sure that the numbers match the needs.

The Deputy is correct to point out that the stressful nature of the job is an almost self-perpetuating cause of decline because people are working under pressure. This came across in surveys and submissions we received. Where a person gets sick and is out of work, this puts more pressure on his or her colleagues. That is a feature of probably every health service. The report makes it clear, and all of the available evidence confirms, that difficulties in recruitment and retention of staff are a feature of practically every health service, no matter the location. To some extent, Ireland is competing internationally to get people to come here. Some people are leaving Ireland and being attracted to other countries that have difficulties. This is an international phenomenon and not by any means confined to Ireland. Our remit is to look at the situation in Ireland and to suggest solutions for the Irish health sector.

Mr. Peter McLoone

Mobility is a feature of nursing and medicine now that was not as important when I was a nurse many years ago. When we looked at the period from the lifting of the embargo on recruitment, it was noticeable that it was underpinned by quite a number of initiatives that were taken by the HSE and employers generally to try to attract nurses to come and work in their services. We are depending on the domestic market and are also taking people from abroad. Australia, Canada and the United States are coming to Ireland to attempt to attract medical and nursing staff away from the Irish health services to work in their jurisdictions. This is why we strongly recommended the idea of a workforce plan that is funded. Such a plan has not been in place before. We have evidence that an initiative was taken in 2017 with general nurses and midwives involving an oversight group which achieved approximately 80% of the target it set itself. Our view is that something similar should be developed nationally and funded for three years so that there is certainty about it, but it should also apply to intellectual disability, mental health and other areas and should not focus exclusively on general nursing or midwifery. That is not to say that general nursing and midwifery are unimportant, but the plan should address all needs and all areas of the health sector.

We should not hold our breath and wait to see if the situation gets worse. We should recognise that plans have to be put in place now to ensure that not alone will the trend of recruitment and retention improve but that we have plans in place to ensure that the needs of citizens will be met in the future. If the ambitions of Sláintecare are to be achieved, it seems to us that these measures should be taken now.

The embargo during the austerity years has caused a legacy issue, the effects of which are felt still. The Irish health service not only lost thousands of beds but also thousands of staff. It is playing catch-up. It is similar to the housing crisis. This is probably not a State secret, but are the witnesses saying that the Irish health service is lacking 6,000 to 8,000 front-line nursing staff? The embargo has been lifted and more people are becoming nurses, but there is still a lack of front-line staff in the Irish health service.

Mr. Peter McLoone

It was evident to us that, during the period of the moratorium, the demand for services did not diminish. In fact, demand increased. The Sláintecare report referenced the issue of the ageing population. Recent years provide all the evidence required to show that demand for services has increased, which has created the stress the Deputy referred to when he spoke about his experience. It is hard to quantify the need from our perspective, and this is why we put such emphasis on the need for workforce planning. It would allow us to define the services required and to engage with the resources required, be they nursing, medical, ancillary or support staff, or other skills.

It is clear that we are just over 2,000 short of the number of nurses that were in place in 2010. There were 39,000 in 2010, and we currently have just over 37,000, despite all of the initiatives that have been taken.

We have a way to go to get back to where we were, but I am sure if we got back to that figure, there would still be an argument that it was not sufficient to meet our current and future needs.

Mr. Michael Kelly

We should not lose sight of the fact that the concern about this is shared, for example, by health employers within the HSE, the Department of Health and the Department of Public Expenditure and Reform. A number of things are happening around sorting out the new entrants salary scale. A process is under way to look at the more recent entrants and see what needs to be done. Another thing is offering permanent contracts to new graduates. A key need is to recruit everyone coming out of training into the Irish healthcare system and, one hopes, retain them. We were trying to envisage the additional pieces that could be put in place to reinforce that if we succeeded in attracting these young graduates in the first instance and in retaining them. We put forward a number of additional steps that are designed to reinforce the good things that are happening. We hope that if they are acted upon, the combined impact will be to make the Irish healthcare system a more attractive and enjoyable place in which for professionals to work.

This will be a bit of over and back. I hope the witnesses do not mind if my questions are a bit out of kilter. I apologise for being slightly late. On the findings, in the terms of reference for phase 2, a final report is to be given to the Minister by the end of 2018. Are the witnesses working on a final report or is it their recommendation that one should be done?

Mr. Kevin Duffy

No. We have dealt with the health sector in the report that the committee now has. There are other areas we have to look at. The final report will deal with other areas. This is an interim report to deal with the health sector.

Will the final report be ready by the end of this year?

Mr. Kevin Duffy

That is the target.

Do the witnesses think they will make that target?

Mr. Kevin Duffy

We hope. We cannot predict. The interim report was supposed to have been available at the end of June, I think, but because of difficulties in getting data and various other factors-----

What kind of difficulties emerged in getting data? What stumbling blocks were there?

Mr. Kevin Duffy

Some of it simply is not available.

Will Mr. Duffy give me an example of what may not be available?

Mr. Kevin Duffy

For example, there is no database of the positions that need to be filled.

I am a bit perplexed that there is not. There is no specific database of positions to be filled, broken down either by CHO or by subspecialty.

Mr. Michael Kelly

There are good pockets of information but, across the system, we would love to find a good matrix of demand and supply. For example, when we look at retention, we would like to find a good, documented understanding of the reasons people leave and some analysis of it so that we can begin to work on the measures. There are pockets of good information around all of that but we did not find a comprehensive data set.

With the greatest respect, as the witnesses are just telling us what they are finding and this is not a slur on them, there is a centralised human resources, HR, service across the HSE. Does it not have that data?

Mr. Kevin Duffy

It is important to say that was a problem we identified. One of our recommendations is that it be rectified. That information should be readily available, not to us, obviously, as we have done our work, but it should be available to managers in the system.

We have been presented with figures of staff shortages that are broken down by community healthcare organisation, CHO. When the witnesses asked for those figures, that was manager-driven to get those specific figures. Were the witnesses able to get them?

Mr. Kevin Duffy

We got figures from various sources. Mr. Kelly was saying that it is not possible to tap into a definitive database and identify the number of positions that need to be filled. That does not exist.

Is the report going to streamline where the quick wins may be and where the medium-term and long-term wins are? I think the committee heard that there are 26 or 28 steps to hiring a psychiatric nurse, which is very cumbersome. Will the report be highlighting the quick wins?

Mr. Kevin Duffy

We have finished our report. The committee has it. That is the report. As I am sure the Deputy has seen in the report, we do highlight that problem and suggest ways of dealing with it.

We are trying to tease out where there are quick wins. The likes of the IT systems need to be changed, and that is going to take longer, but those 28 steps could be cut pretty quickly. That is the basis of the question.

On recruitment and retention, other jurisdictions are in competition. We know it is a global marketplace now, the price of flights is cheaper, it is easier to get to places, and all that has a knock-on effect. What are the top barriers outside of pay that are stopping people from coming back? Let us put pay aside. I know from my own background in recruitment that pay is a very important factor, but it may not be what stops people from coming back. We cannot compete with Australia because Australia has natural resources and can pay people more out of those natural resources than it sells. It is the same with the Middle East. We are trying to find the other, softer sides outside of pay where we might be able to compete. We discussed car insurance before and there is the price of rent and all those things. Has the Public Service Pay Commission identified what might be the top barrier? I am trying to ascertain quick wins in how we market to our graduates and to our emigrants.

Mr. Kevin Duffy

There are a variety of factors and trying to rank them is difficult. Issues that were readily identifiable included career opportunities and progression. We have made recommendations on that. For very many people, bearing in mind that the vast bulk of nurses are women, flexibility of working hours can be an issue. That was touched on earlier by the Acting Chairman. Initiatives should be taken to try to make it more attractive for people to come back. Training opportunities would be welcome, because most people who work in the health sector want to develop their skills and abilities. That in turn helps in terms of career progression. In-service training is important. There are a raft of initiatives that are being taken and that need to be developed further. The ones that came across most in our deliberations were those I have mentioned. There are other factors that also have to be looked at but it is generally a question of trying to make it more attractive.

Leaving aside altogether people who leave and whom we are trying to get back again, the Irish health service is dependent, as are other health services, on people who are trained in other countries and on getting them here. There are a number of elements that delay this process, although they are clearly necessary, such as the need to verify people's qualifications.

In some instances people's identity needs to be verified. Garda vetting needs to be done. I return to the point that Deputy Kenny made earlier about the effects of the embargo, which did not just affect the numbers recruited directly in healthcare provision. Rather, it affected the totality of the public service, including the administration services in the health service. There are shortages in the personnel department, where it is often difficult to have the numbers of people to have several competitions, to verify candidates' qualifications and to do the various checks that need to be done. They are all problems.

I agree, but has management level in the HSE not grown?

Mr. Kevin Duffy

We did not measure the management level but it is self-evident that in many areas there has not been a return to the pre-moratorium levels of staffing. Whatever about stripping down the front-line staff during the moratorium, ancillary services were really hit. The answer to the question is there are still difficulties there. If external recruitment is to be intensified, obviously staff are needed to organise competitions and deal with all of what we might call the infrastructural things that need to be put in place, in order that if a candidate is identified he or she can be put in a ward to do a job. They are not insurmountable difficulties, but they are difficulties nonetheless.

I thank the witnesses for their presentations. I will continue from where Deputy Neville finished. He was exactly in my vein as I was going to ask about ICT and data. First and foremost, how long did it take the data to be compiled, and could they be taken from one direct point?

Mr. Kevin Duffy

No.

How many sources or points did the commission have to go to in order to get the data?

Ms Joan Curry

Approximately 40.

There is one HSE and one human resource, HR, department that govern it all but we had to go to 40 different sources to see where the gaps were in recruitment and filling up positions.

Ms Joan Curry

Yes.

That is shocking. The witnesses spoke about the embargo being possibly one of the worst things that had happened. The worst thing that I am seeing today, however, is that we do not have a central base for knowing exactly where the gaps in the system are. We should not be focusing on the embargo, but rather on the management skill sets to identify where we need people to work in the various places around the country.

Mr. Kelly mentioned something in which I believe passionately. I would like to know about the commission's essential workforce and increased incentives. As staff qualify, we should entice those young persons in, immediately make permanent those who make the cut and allow them their two or three-year break to travel the world, if that is what they so wish, before returning to their permanent job. Has that idea been teased out, or recommended as an incentive?

Mr. Michael Kelly

We did not have to make that recommendation because the idea of a permanent contract is already in place, having recently been implemented by the HSE. It means every graduate coming in is offered a permanent contract at the point of qualification.

How many are being recruited directly from the nursing schools? I know that in Limerick there was a high uptake among all the nursing staff who were approached. I wonder in all the various nursing schools where is it being managed and how did the commission find the data in its report?

Mr. Michael Kelly

I do not have the exact data on that, but with regard to things that can be done my point is that permanent contracts are already in place. I will not dwell on the revised payscales that were introduced in 2012 because I have already mentioned them, but there is work afoot on that.

Mr. Duffy has responded to the question about what sort of things would help to make a career in the Irish health system more attractive. All the evidence we receive suggests it is about professional development opportunities, career development and so on. When one sees the growth in the number of specialist posts in nursing, advanced nurse practitioners and so forth, it is all part of that construct. There is much work already going on, but the more that is done to look at the new areas in which nursing practice can be expanded, and to action it, the better.

That is the word - "action". We were discussing the current professional recruiting of nurses, which was a part of what was announced in the past 18 months. When this review was being done how many of the nursing schools were approached, and how much of it was actioned?

I am conscious of time. If Mr. Kelly could park his answer, we will get to the remainder of the speakers.

We focused a lot on the negative effect of the embargo, which I take on board. This was a positive action introduced in the past 18 months, and I would like to know if it was measured as part of the commission. We are going back to 40 different sources.

The Deputy will get an answer, but I would like to give everyone else a fair turn. We will return to the matter in the last ten minutes. I call Deputy Crowe.

The witnesses are all welcome. I am frustrated as they are, having listened to the members today talking about the lack of data and the fact the commission had to go out and create its own evidence, which seems bizarre and reflects on the service. It did not make it any easier for the commission to try to carry out the work it was being asked to do by the Government. There were a lack of availability of essential data, low-response rates and a lack of consensus between employers and employees. Therefore, the commission had to gather evidence externally, which caused difficulty, but how can it arrive at the conclusion in that case that some areas are facing recruitment and retention difficulties while others are not if it does have those data?

The Minister for Public Expenditure and Reform says it is not a pay review but rather a pay-related response for some areas but not for others, where allowances recommended for some areas but not for others. If one does not have the full picture, one gets the impression that this needs to be done. As the representatives said, there appears to be a lack of evidence that recruitment and retention issues were examined in detail. In the couple of minutes remaining, will the witnesses provide details of the health service employer engagements that took place and what grades were examined in detail?

Given the issue of pay inequality across the public sector, including in healthcare, is there a case for restructuring the payscales to make entrance more attractive, while avoiding inflating wage levels? Junior doctors and entry-level consultants seem to be paid far less while also working harder. Is this unsustainable and does it perpetuate the idea that there are unattractive arrangements at that level, thus turning people off? What kind of cost-of-living measures are needed to address that? Deputy Kenny referred to the London rate. Should there be a Dublin rate? There was a meeting over the summer with child and adolescent mental health services, CAMHS, in Ballyfermot, where people were saying that part of the problem was where people could stay or where they could live.

They are living two or three hours away from Dublin. That is not sustainable. In other jurisdictions the accommodation comes with the job. That may be something to consider. How does the reliance on agency staff affect retention and recruitment because that is part of the difficulty?

Even today, when the Taoiseach was asked about the number of nurses in the system he said that compared with other jurisdictions we have more nurses per bed. Nurses do not only deal with patients in bed. There is a range of issues for which they are needed. There is almost a denial that there is a crisis in the service. This was debated in the House last night. Did the witnesses pick that up in their inquiries?

I thank the witnesses for their presentation and information. They referred to the positive impact of a changed approach by the HSE to recruiting graduates directly, offering contracts and having the proper training. How far did they go back in their inquiries? Did they ask how many graduates are opting to enter the health service? What is the percentage now? What quantifiable change did they identify in the report? If we are to be serious about holding on to people, we need to make the job attractive from the start for those graduates who have gone through our educational system which is highly regarded throughout the world. Recruiters from other countries come here. We could solve the problem if we championed that and made it attractive for graduates to come out of college and work within our health service.

The report refers to having more undergraduate courses. Has that happened? Are more courses available and, if so, to what extent? Are they available throughout the country or only in specific parts of the country? It would be interesting to know how many graduates are joining the health service directly from college compared with previously. The State has come through the dark period of the economic crisis and is doing better now. Emigrants are also returning.

I am sorry I missed a good bit of the discussion but it cannot be helped.

It is apt that members of the public service pay commission on the health sector are before us today when the Psychiatric Nurses Association, PNA, and the Irish Nurses and Midwives Organisation, INMO, are meeting to discuss the commission's report. The commission ignored recruitment and retention in their report but not in their presentation today. Maybe they intend to deal with that now. Many members have asked about the future of mental health services and staffing, in particular nursing staff. There are more than 2,000 vacancies, of which more than 700 are in the mental health sector. These include 88 vacancies in the St. Ita's campus, 76 in St. James's Hospital, 56 in Dublin north city, 62 in Galway and 46 in Louth-Meath. Did the commission factor in the implementation and future development of A Vision for Change because only 30% of it has been implemented so far? We need more than 700 nurses just to stand still, not to speak of the implementation of the outstanding 70% of recommendations.

Did the commission factor in the potential retirement of 1,752 nurses immediately and over the next few years? That number is, shockingly, 34.2% of mental health nurses in the country. The current position is unsustainable but those figures paint a depressing picture of the future. We have discussed what caused the current problem, for example, the yellow pack grade offered to nurses some time ago, which we defeated. The former chief executive officer of the HSE, Tony O'Brien, shortly after the haemorrhage started, acknowledged that we forced them out. We shot ourselves in the foot with the moratorium. Everybody should have known that health would have been affected because the moratorium resulted in the loss of almost 10,000 nursing posts. We have seen that the mental health care needs of our population and, significantly, of the children born in that lost decade, have been compounded, as has their suffering and the demand for care.

A total of €300,000 per week is spent on overtime. Overtime costs €2 million annually for nurses in mental health care alone. That is not sustainable.

The number of vacancies in mental health nursing has increased by 200 since last year. Nurses say that shortages would be best addressed by an across the board pay rise for their grade, yet the commission proposes a €20 million increase in allowances aimed at a small area. Nurses are demanding an across the board pay increase. A survey published today and funded by the Health Research Board showed that 36 of 51 Irish medics and staff who were interviewed in Australia indicated they had no plans to return due to the broken health system and the misery they experienced working in the health service here. The focus is on salary as well. There was a presentation to the committee before the summer which showed that pay here, given all the other external factors, does not match pay elsewhere. It is shocking that 34% of mental health nurses will retire in the next five years.

When will the working week of 37.5 hours, which nurses secured following various industrial disputes, be reinstated? In some cases, nurses are still working one extra day free per month. Did the commission address this issue in its report? The Chairman commented on the long hours nurses are working.

I welcome the increase in the number of nurse graduates. Unfortunately, there are no mentors in the hospital with the experience to mentor them and young nurses who are not yet competent are running wards of 35 people. We have to address the haemorrhage of experienced nurses because they are not returning.

I welcome Deputy Louise O'Reilly. Deputy O'Reilly will be brief.

I have one question. I welcome the witnesses, some of whom I know very well. I will have to leave early as the Topical Issue matter I have submitted will be taken in the Dáil. Are the witnesses aware that the INMO has recommended to its members just now that the commission report be rejected? The witnesses may not have heard because they have been at this meeting.

The Minister for Finance stated in advance that this was not a pay review and could not be a pay review. In light of the fact that a very large group of workers in the public service have received a recommendation to reject this report, but obviously the members have not balloted yet, will the witnesses explain the influence the Minister had over the conclusions, as he seemed to think it was not about pay? A significant group of public sector workers say it is very definitely about pay. There are references in the report to allowances, and clearly that is about pay, because no one divides their wages into the elements of pay and allowances.

I am very conscious that we have only four minutes, so the witness will not have an opportunity to answer all the questions.

Mr. Kevin Duffy

I will be quick and snappy. I will start by responding to Deputy O'Reilly, whom it is great to see.

In response to her question on whether we knew in advance of the decision of the members of the Irish Nurses and Midwives Organisation, INMO, obviously we did not. We were aware of the fact that they were meeting. I am not going to comment on that as that is its decision and its prerogative.

The commission is independent, but it is not at large in the sense that it can do what it likes. It is circumscribed by its terms of reference. These did not enable the Public Service Pay Commission in this module to act as if it were a pay review body. It is also important to remember that the genesis of this phase of our work can be found in the public service stability agreement, which is a collective agreement. That is the job we were to do. It was not a general review but we made suggestions. There has been a great deal of comment about the pay commission having rejected the nurses' pay claim. The commission did nothing of the sort. It did not reject the pay claim in its merits. The members of the commission did not believe that we were in a position to consider it, but we did say that it should be considered. That nuance has been lost, unfortunately. These are the two main points made by Deputy O'Reilly. If there is any aspect I have missed, I have no doubt she will come back to me.

I thank Mr. Duffy.

Mr. Kevin Duffy

Deputy Rabbitte raised questions on the numbers of undergraduate places. Time does not allow me to read the numbers but they are set out in a report in table 6.1 and page 61.

In terms of monitoring numbers and getting people in, one of the initiatives that was taken, independently of anything that the commission recommended, was to set up an oversight group as a consequence of an agreement reached between the nursing unions and the Department of Health. Good work was done in trying to identify where vacancies were and the numbers of people who should be recruited to try to fill them. One of our recommendations was that the oversight group should continue.

Deputy Rabbitte asked how the commission came up with the figures in the absence of data. As my colleague, Ms Curry, told the committee we had to look at 40 sources. It was not that we did not get information, but it was difficult to get it. Deputy Neville asked the reason for the delay. It was the difficulty in having to go to a multiplicity of sources to get the information.

On the points just made by Senator Devine, none of the figures that she gave to the committee were before our commission. No one spoke to us about the figures she had. I am not so sure where those figures come from. We acknowledge in the report the difficulties in the mental health area, and we suggested initiatives that could be taken at least to ameliorate those difficulties.

Deputy Crowe raised a number of issues on recruitment, data, the living measures, employment engagements, the London rate and so on.

Mr. Kevin Duffy

Deputy Crowe made the point that the Public Sector Pay Commission was not set up as an alternative to the established mechanisms for determining pay and conditions of employment for health service workers. That, happily, is a system of collective bargaining. We are not going to usurp the well-established mechanisms between trade unions and employers. We are not an industrial relations body. We were not given that task, and I do not think that people in the trade unions or on the employers side would thank us if we were to usurp their function and try to do their job for them. Many of those things are matters that would be dealt with in the normal course day to day within established collective bargaining mechanisms. We are not going to usurp that.

No one asked the commission to usurp that role. Mr. Duffy referred to recruitment and in particular to pay and that low pay does have an impact of people staying in the service. The commission can, therefore, make recommendations in respect of it.

Mr. Kevin Duffy

What we have said in the report, and again this is an important point, is that pay in and of itself is not the only issue. We did not say that it was not an issue, but that in and of itself it is not the only issue. Again, that has been misinterpreted by people who have commented on our report. We did make some recommendations on pay and we stated, as I told Deputy O'Reilly, that there is sense of grievance among nurses about their pay levels vis-à-vis that of others, but it is not confined to nurses, and the members of the commission said that this needs to be looked at as a separate exercise.

I take the Deputy's point. We are working towards a holistic approach, but we had to work within the parameters of our terms of reference, and we could not go beyond those.

There are many issues, and I have no doubt that, in the fullness of time, they will be dealt with. We have made the recommendations that we felt we could make and were justified in the report.

Deputy Brassil wishes to address a question to Mr. McLoone.

I apologise for being late as I was at other meeting, so if my question has been asked, I will revert to the Chair for the answer. On the issue of retaining graduate staff and attracting graduates to return, is pay the primary issue or are work standards, workplace and workforce planning bigger issues?

What is Mr. Duffy's advice to the committee on this particularly difficult issue?

Mr. Kevin Duffy

I understand what Deputy Brassil is saying. The report deals with the totality of the difficulties that we believe exist. As I pointed out to Deputy Crowe, in the report we state that pay is not the totality of the problem. There are other difficulties which must be addressed. The report contains international comparisons on rates of pay, but I do not have enough time to get into the detail of that. Our conclusion was that even if everyone was given a significant increase in pay tomorrow morning, all of the other problems would still need to be addressed. Of course, we could not do that because our terms of reference did not allow it. A holistic approach must be adopted. There are structural difficulties which must be addressed in terms of workforce planning, providing access to data and information on where vacancies arise and trying to make the job more attractive for people who we might want to encourage to come back into the system. We have tried to set out a holistic approach to a multiplicity of issues in our report.

I thank Mr. Duffy. Is Deputy Brassil satisfied with that response?

I ask Mr. McLoone and Mr. Kelly to address the final point raised by Deputy Crowe.

Mr. Peter McLoone

Debate on the issue is complicated by the presence of pay problems. However, recognising the committee's terms of reference regarding recruitment and retention in the mental health area, the report contains several important recommendations that it is hoped will be of assistance to the committee in its further report. I cannot overemphasise the importance of developing a workforce plan. I have worked in the health services for approximately 40 years as a practising nurse and a full-time trade union official. The health services have stumbled from year to year for so long that it is time to recognise that new and different measures which focus on are our workforce needs are required. In a global competitive market, we need to engage with that challenge. Such actions must be taken in the coming months or this will end up being another report that is put on a shelf and the discussion and analysis of the problem will continue as they have for years but no steps will be taken to taken to solve it.

Mr. Michael Kelly

Deputy Neville earlier asked about obvious things that could be done which would not necessarily take a great deal of time and which are reasonably well-defined. I will mention three such measures. Mr. McLoone discussed the funded workforce plan, which is fairly basic and bedrock. Another measure would be to follow up on the MacCraith report in respect of non-consultant hospital doctors. There is a well-defined agenda in terms of four specific things that have been identified and on which action must be taken. While I do not want to go into the detail now, I am not saying they are simple, but they are well defined. The position of psychiatrists has not been mentioned during our discussion, but the current gap for new or recently recruited consultants is identified in the report and must be addressed in some way because it sends a very loud message back to non-consultant hospital doctors training here or abroad. If we do not get that right, it will send a significant message to those doctors. It will not easy be easy to address but we must do so.

I thank the delegates for attending. These matters are not easily dealt with - they never are - but we will take everything on board. A significant amount of useful information has been garnered today which will help the committee in its work. I do not envy the witnesses the tasks they must tackle.

The joint committee adjourned at 3.25 p.m. until 1.30 p.m. on Wednesday, 10 October 2018.