I reiterate the fact that the purpose of the Bill is to enhance the protection of the public in its dealings with nurses and midwives and to ensure the integrity of the practice of nursing and midwifery. This legislation will provide for a modern, efficient, transparent and accountable system for the regulation of the nursing and midwifery professions, which will satisfy the public and these professions that all nurses and midwives are appropriately qualified and competent to practice in a safe manner on an ongoing basis.
The principal features of the Bill are the enhanced protection of the public in its dealings with nurses and midwives, the repeal of the Nurses Act 1985 and for a new legislative framework in respect of nurses and midwives. The regulatory body, Bord Altranais agus Cnáimhseachais na hÉireann — the Nursing and Midwifery Board of Ireland, will have a stronger governance and accountability structure. It provides for a non-nursing-midwifery majority on the board and on the fitness to practise committees. It recognises midwifery as a separate and distinct profession and provides that midwives attending a woman in childbirth must have adequate clinical indemnity insurance. It provides for improved investigation mechanisms for complaints about nurses and midwives, including the creation of an assessment committee prior to fitness-to-practice investigations, and the appointment of investigators to facilitate such preliminary investigations. Fitness-to-practice inquiries will generally be held in public. The legislation provides for the registration of nurses and midwives, the establishment of a register of those training to be a nurse or midwife and the prohibition of unregistered nurses and midwives engaging in the practices of nursing and midwifery.
The Bill provides for the approval of programmes of education and further education necessary for the purpose of registration, the specification of standards of practice for registered nurses and midwives, and guidance on all matters related to professional conduct and ethics. It further provides for a new statutory framework for the maintenance of professional competence of registered nurses and midwives, including an obligation on employers to facilitate the maintenance of professional competence and midwives, in particular by providing learning opportunities in the workplace. It also provides for the dissolution of the National Council for the Professional Development of Nursing and Midwifery.
I will outline in more detail the various Parts of the Bill. Part 1 contains preliminary and general information and provides the Title of the legislation. It sets out the definitions of words and terms used throughout the Bill and that midwifery is recognised as a separate profession from nursing. It provides the Minister with the power to make regulations under the legislation. It provides for the repeal of the Nurses Act 1985 and that any expenses incurred by the Minister in the administration of the Act can be paid out of moneys provided by the Oireachtas to the extent approved by my colleague, the Minister for Finance.
Part 2 contains provisions related to the board. The board will continue but will be renamed Bord Altranais agus Cnáimheaschais na hÉireann, or, the Nursing and Midwifery Board of Ireland. This not only reiterates the recognition of midwifery as a separate profession but helps to herald the new era in nursing and midwifery regulation.
I will outline some of the more important sections in this Part of the Bill, commencing with sections 8, 9, 13 and 15. Section 8 sets out that the objective of the board is protection of the public in its dealings with nurses and midwives and the integrity of the practice of nursing and midwifery through the promotion of high standards of processional education, training and practice and professional conduct among nurses and midwives. I cannot stress enough that the protection of the public will be central to the regulation of nurses and midwives.
Section 9 outlines the functions of the board. These include the registration of nurses, midwives and candidates for these professions, the regulation of education and training and recognition of qualifications of nurses and midwives, including qualifications awarded in other countries. Other functions will be the setting of standards of practice and ethical guidance for nurses and midwives, the maintenance of their professional competence, the establishment of a code of professional conduct for registered nurses and midwives, the specification of criteria for the creation by employers of specialist posts, the handling of complaints and inquiries relating to the conduct of nurses and midwives and advising the public on all matters of general interest relating to the functions of the board and to nurses, midwives and their practice.
The board will also advise the Minister on all matters relating to the functions conferred on it by this legislation. It must have regard to the functions of other bodies and the policies and objectives of the Government to the extent that they relate to the board's functions. The Minister for Health will have the power to confer additional functions on the board.
Section 13 sets out the board's power to make rules for the purpose of the better operation of any provision of this legislation or at the request of the Minister. The board will make rules for the operation of committees; registration; receipt of evidence by the preliminary proceedings and fitness-to-practice committees; the establishment, membership, functions and procedures of sub-committees; the setting of standards and criteria for nursing and midwifery education and training; requirements for indemnity insurance for midwives and any professional competence scheme. To provide for greater accountability, draft rules will be subject to a period of public consultation and rules will be subject to the approval of the Minister for Health. In addition, the Minister for Finance must approve any rules relating to a professional competence scheme. Rules will be laid before each of the Houses of the Oireachtas.
Section 15 allows the board to enter into co-operation agreements with prescribed bodies to avoid duplication of activities and to allow for appropriate consultation and joint studies. It also provides for information to be shared. Section 16 allows the board to pass on information regarding the commission of an indictable offence, while section 17 prohibits the disclosure of confidential information unless it authorised by the board.
Part 3 sets out the board's obligations in regard to the preparation of a statement of strategy for its term of office and the preparation of annual business plans and annual reports. Part 4 sets out provisions for membership, committees and employees of the board. The key sections of this Part are sections 22 and 24.
Section 22 provides that the board shall have 23 members representing nursing and midwifery, educational bodies and stakeholders. Eleven members shall be nurses or midwives, of whom eight shall be elected. There will also be nurse representatives from general nursing, children's nursing, psychiatric nursing, intellectual disability nursing, public health nursing and nurses engaged in the care of older persons. In addition, there will be a midwife or nurse employed in the public health sector and engaged in the education of nurses or midwives. At least three of the elected members must be engaged in clinical practice. In addition, a director of nursing or midwifery and one nurse and one midwife from the third level education sector will be appointed as board members. The non-nursing or midwifery members of the board will be appointed from a variety of areas. The Medical Council, Health and Social Care Professionals Council and Health Information and Quality Authority will each nominate a member, the Health Service Executive will nominate two members and a member will be appointed from the voluntary sector. The Minister for Education and Skills will also nominate a member from a third level establishment. A further five members of the board who are not nurses or midwives and who have such qualifications, expertise, interests or experience that, in the opinion of the Minister, would enable them to make a contribution to the performance of the board's functions will be appointed.
The president and vice president will be elected by the board from among its members. The president of the first board does not have to be a nurse or midwife. However, subsequent board presidents will have to be nurses or midwives. The vice-president will always be a nurse or midwife.
The board's power to establish committees to fulfil any of its functions is set out in section 24. These committees will be established under board rules. Five committees will be established on a statutory basis. The preliminary proceedings and the fitness to practise committees will be established, respectively, to investigate complaints and to inquire into complaints made under the board's disciplinary procedures under Parts 7, 8 and 9. At least one third of the members of each of these committees will be board members and the majority of members will not be nurses or midwives.
The midwives committee will advise the board on matters relating to midwifery practice. Following further consideration during this Bill's passage through the Dáil, the minimum membership of this committee has been increased. The midwives committee will comprise at least eight members, including two registered midwife practitioners, two other midwives, of whom one may be a self-employed community midwife, a medical practitioner in obstetrics or gynaecology, a registered nurse board member and two persons who are representative of the public interest and who are not nurses or midwives.
I have received a number of representations in regard to the functions of this committee. In particular, an amendment has been sought to provide that decisions made by the midwives committee would be binding on the board. However, it is not possible for a committee of a board to make binding decisions on the board. This would be contrary to good governance because the board is accountable and responsible for decisions.
Two other committees will be established on a statutory basis. The education and training committee will perform functions in relation to the education and training of nurses and midwives and the health committee will support nurses and midwives with relevant medical disabilities or who have given consent to medical treatment under fitness to practise procedures. The Part also includes provisions for the appointment and terms and conditions of the chief executive officer, CEO, and employees of the board.
Part 5 contains provisions relating to the accounts and finances of the board, including provision that the board's accounts will be subject to audit by the Comptroller and Auditor General.
Part 6 sets out the requirements for the registration of nurses and midwives. Unregistered nurses and midwives will not be allowed to practise, except where rendering first aid. The board can issue a permit to a nurse or midwife who is registered in another country in circumstances where they are entering Ireland for a short period for humanitarian purposes for a period of no more than 30 days. The Bill sets out the penalties and offences for contravening these provisions. I intend to speak in more detail about the midwifery provisions of this legislation later, including the necessity for midwives who attend a woman in childbirth to have adequate clinical indemnity insurance.
I refer Members to sections 40(1), 46 and 50. Section 40(1) of the Bill provides that no person shall, for reward, attend a woman in childbirth unless the person is a registered midwife who maintains adequate clinical indemnity insurance in accordance with the rules. The provision continues on to list others who can attend a woman in childbirth. This includes a registered medical practitioner, a person undergoing training to be a registered medical practitioner or a registered midwife who gives such attention as part of a course of professional training or a person undergoing training in obstetrics who gives such attention as part of a course of professional training.
This provision is included as there is a need to ensure that midwives have adequate insurance lest a case of negligence is taken, as court cases relating to a birth where negligence is proven often result in very high damages being awarded. It would add further to the distress of the parents if a case of negligence was proven and the midwife involved was not insured. However, I will address this matter further later.
Another important section is section 46 which provides for the establishment of two registers. The nurses and midwives register will include the names and qualifications of registered nurses and midwives and will consist of at least two divisions — the nurses division and the midwives division. The board can create other divisions in the register. The candidate register will include the names and details of all those pursuing education and training leading to first time registration with the board. It, too, will contain a nurses division and a midwives division. The Bill provides that the registration of a nurse or midwife can be annotated to include additional qualifications. Both registers will be published. However, I assure Members of the House that personal information will be protected from disclosure. Conditions can be attached to a nurse's or midwife's registration as a result of a fitness to practise inquiry or a declared medical disability.
Section 50 sets out that a nurse or midwife can apply to have his or her name removed from the register unless they are the subject of a complaint under the board's fitness to practise procedures. The board may remove a nurse or midwife from the register if they are suffering from an illness or terminal illness which would render their practice unsafe and where they are unable to self-remove from the register. This Part also includes the board's and the nurse's or midwife's responsibilities relating to the maintenance of registers.
Parts 7, 8 and 9 set out the provisions with regard to the board's fitness to practise functions. Part 7 provides for the function of the preliminary proceedings committee, which will given initial consideration to complaints. It is section 55 in this Part of the Bill which provides that complaints can be made relating to professional misconduct, poor professional performance, non-compliance with a code of professional conduct, relevant medical disabilities, failure to comply with a relevant condition, failure to comply with an undertaking or to take any action specified in a consent given in response to a request under section 65 — where a registered nurse or midwife consents to a censure or remedial action, an irregularity relating to the custody, prescription or supply of a controlled drug or a conviction for an indictable offence in the State or in another jurisdiction. Part 7 also contains provisions for the appointment by the board of investigators to assist the preliminary proceedings committee, the ability of the board to make an ex parte application to the High Court for an order to suspend the registration of a nurse or midwife should this be deemed necessary for the protection of the public, the referral of complaints to another body, should this be more appropriate to the functions of another body, or to mediate. Section 60 sets out that the board may prepare guidelines for the resolution of complaints by mediation or other informal means. Both the complainant and the nurse or midwife must agree to participate in mediation. Complaints cannot be resolved through the giving or receiving of financial compensation. I am sure Members will agree there may be cases in which the use of mediation would be the most appropriate method of complaint resolution. This legislation will provide for its use but only as and when it is appropriate to so do. Each complaint to the preliminary proceedings committee will be examined case by case.
Part 8 sets out the role and duties of the fitness to practise committee and how hearings should be conducted. Provisions are included to ensure all parties involved in a complaint are kept informed regarding that complaint. For the purposes of an inquiry, the fitness to practise committee will have the rights and privileges vested in the High Court. In general, hearings of this committee will be held in public in a measure to improve openness and transparency. However, if an application is made by the nurse or midwife or witness, part or all of the inquiry may be held in private. I should mention section 65, which provides that the fitness to practise committee, with the consent of the board, may at any time during an inquiry request the nurse or midwife to give consent in respect of a board censure, undergo medical treatment or give an undertaking to take a course of action the committee deems the appropriate with regard to the resolution of the complaint. Where a required undertaking or consent is given, then the inquiry is considered complete. If a nurse or midwife refuses to give such an undertaking or complaint, the committee can proceed with the inquiry.
Part 9 sets out the duties of the board and the chief executive officer were complaints have been referred to the fitness to practise committee to inquire into. While the role of this committee will be to inquire into complaints, it is the board, as the regulatory body for nurses and midwives, that will decide on the appropriate measure to be imposed against a nurse or midwife. A key section within this Part is section 69, which sets out these measures, namely, an advice or admonishment or a censure in writing, a censure in writing and a fine not exceeding €2,000, the attachment of conditions to registration, the transfer of a nurse or midwife's registration to another division of the register, suspension of registration, cancellation of registration and prohibition from applying for restoration for a specified period. The imposition of sanctions is subject to High Court approval, except a decision regarding an advice, admonishment or censure in writing, and is subject to the right to appeal. The board is obliged to inform the Minister and the employer regarding the imposition of sanctions and to notify a registration body in another jurisdiction where it is appropriate to so do. Further to this, if the board deems it necessary in the public interest, the public can be informed of sanctions against a nurse or midwife and the board can publish all or some of an inquiry transcript.
Part 10 sets out the duties of the Health Service Executive, HSE, and the board with regard to education and training. The HSE will, in so far as is possible, facilitate the education and training of candidates for registration and will promote and co-ordinate the development of specialist education and training. It will co-operate with the board and training bodies in respect of workforce planning. The board will set and publish standards of education and training and will have the power to approve programmes and bodies for the delivery of these and to recognise qualifications awarded in other jurisdictions and will be responsible for the provision of career information on nursing and midwifery.
Part 11 contains provisions for the maintenance of professional competence by all midwives. It states explicitly that it is the duty of each nurse and midwife to maintain their professional competence, in particular through the provision of workplace learning opportunities. The board will establish a professional competence scheme or schemes to monitor the competence of all registered nurses and midwives in the State.
The demonstration of professional competence by nurses and midwives is a method of enhancing protection of the public. Many nurses and midwives already actively pursue the maintenance, if not the further development, of their own individual practise and many employers facilitate this. However, by placing the maintenance of professional competence on a statutory basis, all nurses and midwives will be obliged to maintain their competence. Where a nurse or midwife fails to demonstrate their competence at the request of the board, they will be subject to a number of actions which can include a requirement for training to ensure their practise is brought up to an adequate standard, or in more severe cases, the referral of the nurse or midwife to the board's fitness to practise procedures.
The National Council for the Professional Development of Nursing and Midwifery is dissolved under Part 12 of this legislation. The council was established in 1999 to further develop nursing and midwifery and has done excellent work. However, I consider that some of the work of the council is more appropriate to the board as the regulatory body for the professions of nursing and midwifery. Those functions that are not appropriate to the role of the regulatory body will be undertaken by the Health Service Executive under the provisions of the Health Act 2004. Furthermore, the dissolution of the council is in line with the rationalisation of State agencies.
I ask that my thanks to the National Council for the Professional Development of Nursing and Midwifery, its employees, its CEO, Dr. Yvonne O'Shea and its chair, Dr. Laraine Joyce, are read into the record of this House. This Part also provides for the transfer of the council's employees, assets and liabilities from the council to the board.
Part 13 sets out a number of miscellaneous provisions, including the provision that the board may investigate unregistered persons suspected of practising nursing or midwifery or claiming to be registered in contravention of this legislation and that summary offences under this legislation may be prosecuted by the board. The Schedule outlines the matters relating to the board and its members including its tenure, the split term of office for board members, resignations or determinations of membership, quorums for meetings, structure of meetings and the role of the president and vice president of the board.
I have just given an outline of the structure and contents of the Bill. I will now say a few words in regard to specific issues that have come to the forefront in the development of the Bill. Midwifery is now a separate and distinct profession, with its own direct entry career path via the undergraduate midwifery education programme, which commenced in 2006. The Title of this legislation, the Nurses and Midwives Bill, supports this distinction. The Bill also recognises that midwifery is a separate professional area to nursing.
I refer in particular to the provision that all midwives attending a woman in childbirth must have adequate clinical indemnity insurance. I am aware that concerns have been raised about the intention of this provision. I consider this provision necessary for the protection of the public. I consider it essential that all midwives possess adequate clinical indemnity when attending a woman in childbirth and that it is necessary that the penalties for any contravention of this are robust enough to deter any contravention. Midwives must have adequate insurance to ensure, in the tragic event of a catastrophic incident during a birth, where negligence is proven against a midwife and a court action results in damages being awarded, that these can be paid. It would add further to the distress of parents if the midwife involved was not insured. Damages in these cases are often very high.
It is only in regard to attending a woman in childbirth, that is, a woman's labour and delivery of the baby, that a midwife needs indemnity. A midwife is not required to have indemnity for other areas of her or his work. A midwife does not require indemnity, for example, to run prenatal classes or breast-feeding classes or any other services which do not involve attending at the delivery of a baby. In many cases, as midwives are employees of hospitals or other maternity providers that practise, their practices will be covered under the employer's liability cover.
However, there are a number of self-employed community midwives in the State. To facilitate them obtaining indemnity, an arrangement has been put in place to allow them to access the State's clinical indemnity scheme via the HSE. A self-employed community midwife who signs a memorandum of understanding, MOU, with the HSE and abides by its terms is covered by the scheme. The MOU is constructed on the basis of appropriate forms of governance, clinical supervision, clinical care pathways, performance management and audit frameworks being in place. The MOU outlines conditions and factors which indicate increased risk. There is a need to ensure that where the State provides clinical indemnity, a midwife adheres to the standards set out by the HSE. A national steering committee on home births has been established by the HSE and it is reviewing the implications of the MOU for the provision of a safe, evidence-based home births service for low risk women.
The committee is also drafting policy guidelines for cases that do not meet the inclusion criteria set out in the MOU. The committee comprises representatives of a wide range of stakeholders, including self-employed community midwives. The inclusive nature of the committee facilitates discussions on key areas of concern and will inform future guidelines and developments. A review of the MOU is progressing. I stress that access to the clinical indemnity scheme via the signing of the MOU is designed to facilitate self-employed community midwives to obtain indemnity for their continued practise as self-employed individuals. There is nothing in the legislation to prevent such a midwife from obtaining indemnity cover from a private insurance provider, should he or she wish. However, some midwives seek unlimited indemnity from the State. The State cannot indemnify midwives for high risk cases and it cannot be expected to provide unlimited indemnity without a governance structure. All insurance policies are replete with terms and conditions.
The Bill provides that midwives must have adequate indemnity cover in regard to their attendance of a woman in childbirth. This is a recognition that, while childbirth is a normal life event, it can have serious consequences if something goes wrong. It is not possible to legislate against catastrophic occurrences. However, the public can be protected, in so far as it is possible, through continuing professional development, lifelong learning and the maintenance of professional competence. After all, the primary intention of this Bill and the primary objective of the board is the protection of the public.
I support choice for women but the option of home births must be provided in a safe manner. Home births can be a safe option for low risk, healthy women. Low risk means no history of medical or surgical problems that might affect pregnancy and no present or previous pregnancy complications.
A second issue raised by Opposition colleagues in the passage of the legislation was the belief that decisions of the midwives committee would have a binding effect on the board but this is not possible. The board is the regulatory body for nurses and midwives. The decisions of a committee cannot be binding on a board. The committee structure of the board is designed to provide that people who are not board members can be members of a committee. This is to ensure board committees have a membership with adequate knowledge to fulfil the functions delegated to it by the board. However, the board has responsibility for the regulation of nursing and midwifery. I have ensured there is an obligation on the board to consider the advice of the midwives committee.
The legislation places the protection of the public at its core. This is reflected throughout its provisions and in the new governance structures for the board which focus on openness, transparency and accountability. It modernises the regulatory structure and places it firmly within the domain of protection of the public.
I thank the House and commend the Bill to it.