Speeches

Address by Micheál Martin T.D. Minister for Health and Children at the Annual Conference of the Irish Nurses Organisation

Introduction

I am delighted to be here with you today and would like to thank the INO for the invitation to address your annual conference.

I note that, yesterday your conference had an emergency motion on health cuts and I would like to address some of the issues raised. I know that you are concerned regarding the recent statements in relation to 250 beds being closed in the Dublin region. I would like to inform you that as of yesterday there were 81 beds closed, and when you take into consideration the 520 extra beds put into the system since this time last year it leaves us with an net increase of 439 beds a fact not widely acknowledged. As you are aware the bed capacity review that I initiated last year the first phase of which will provide a total of 709 beds (Costing€118M). The Government remains committed to providing in total an additional 3,000 beds over the lifetime of the Health Strategy.

I want to assure you that no Minister for Health and Children wants to see bed closures. In relation to recent reports of bed closures in the main Dublin hospitals, officials from my Department, the ERHA and the hospitals concerned are having ongoing discussions, and no final decisions have been taken. Any action initiated, be it industrial action or otherwise, would be premature. Also, I have made arrangements to meet Mr David Begg, General Secretary of ICTU next week, to discuss the overall situation .

I want to place on record some of the achievements of the health service. In 2002 alone there were 960,000 inpatient discharges this was a 23% increase in the number of inpatients treated since 1997.

Since 1997, we have witnessed unprecedented levels of investment in the health service. This investment has covered additional infrastructure, the introduction of new services and improvement of existing services, and substantial improvements in pay and staffing levels. There has been an increase of nearly 30,000 people working in the health service 6,000 of which are nurses. The average salary increases for nursing staff alone since 1997 has been between 30% and 50%.

This investment has been matched with increases in the quantity and quality of healthcare outcomes, and we need to guard against undermining the achievements of all who work in the health service. It is important to remind ourselves, that every day, thousands of people have satisfactory experiences of the health service, and successful outcomes.

While there has been a substantial amount of adverse comment about the health service, no one can deny that the system is providing more and better services than ever before.

The past year has seen a significant number of developments and challenges in the health service. The Audit of Structures has been completed and the Commission on Financial Management and Control has finalised its work. A new Social Partnership Agreement – Sustaining Progress has been agreed. The work of the National Task Force on Medical Staffing has progressed, with invaluable input from the nursing profession.

The ambitious reform agenda upon which we are about to embark, will consolidate the achievements of recent years, and lay a firm foundation for the challenges that lie ahead.

Sustaining Progress

I was heartened by the acceptance by INO members, by a margin of two to one, of the new Social Partnership Agreement – Sustaining Progress. The importance of these agreements cannot be over-estimated. They provide a framework for stability and growth within which our economy and society can develop, while at the same time providing for an equitable sharing out of the benefits of that development.

The framework for developing these agreements, which is based on partnership and inclusivity, is a practical acknowledgement of the interdependencies that exist in a modern society.

The private and public sectors cannot operate in isolation from one another – the decisions and activities of each have implications for the other, and for the wider community. In a small open economy such as Ireland, we are especially susceptible to the vagaries of the international marketplace. In a period of slowing economic growth and international uncertainty, we have to be sensitive to the prevailing economic factors.

This is the context within which Sustaining Progress was framed. The agreement is divided into two parts. Part 1 deals with the policy framework for sustaining progress, and includes broad guidelines for macroeconomic policy that will help to build, maintain and share economic development and prosperity, while at the same time deliver a fair and inclusive society.

Part 2 deals with pay and the workplace. In addition to the pay aspects, the document sets out a comprehensive modernisation agenda for the health services. The new agreement provides a significant opportunity to improve and develop our health services in the context of much sought after industrial relations stability. For patients and the public at large, it aims to create an environment where change can be introduced without recourse to the threat of industrial action, and the consequent uncertainty about the continuity of health service to the public.

As you all know, the past year has been a particularly active one on the industrial relations front, both nationally and locally.

The threat or commencement of industrial action has a destabilising effect on the industrial relations procedures, distracts the attention of both management and unions in the quest for solutions, and causes great anxiety among the users of the health service and the general public. It also leads to a poor public perception.

A great deal of resources has been committed by the taxpayer to the establishment of a comprehensive industrial relations infrastructure which, if used as intended and to the fullest extent possible, will result in mutually satisfactory outcomes.

The new partnership agreement – Sustaining Progress – provides for a strengthening of these procedures. Among the additional measures being taken is the setting up of a strategic, problem-solving group comprised of sectoral representatives from unions and management, which will meet on a quarterly basis to monitor and oversee developments in the industrial relations environment. Your General Secretary, Liam Doran, has been nominated to represent the union side on this high-level group.

The National Joint Council will be the primary forum for the management of industrial relations in the health service. The role of the NJC will be widened, and appropriate resources will be provided to support this new role. It is expected that the NJC will be fully utilised by all parties prior to any industrial action being considered.

Partnership has a key role in helping to deliver better industrial relations. The mainstreaming of partnership will help realise its full potential in driving and managing the change and modernisation process. This will ensure that a broad range of issues amenable to resolution through partnership will not be allowed to develop into industrial relations difficulties.

Audit of Structures

One of the main conclusions in the Health Strategy was that while the system has served us well in many respects, some significant concerns remain. These include the need for:-

  • stronger co-ordination and integration of functions and services;
  • greater consistency in access to, and delivery of services throughout the country;
  • greater clarity around levels of decision-making in the full range of organisations, and
  • the need for “whole system” effectiveness.

A number of reform initiatives have been undertaken, including the Audit of Structures and Functions in the Health Service. The Audit was commissioned to ensure: –

  • Clear lines of accountability and communication within the system;
  • No overlap or duplication between organisations, and
  • A proper alignment of the structure as a whole to the vision and objectives outlined in the Health Strategy.

The study found that there are a number of barriers to achieving the improvements sought in the Health Strategy. It also identified the need for strengthened frameworks for governance and accountability, as well as the need to develop and enhance supporting processes to secure improved planning, integration, delivery and evaluation of services. It also found that there was too much fragmentation and multiplicity of agencies.

While the consultants who carried out this audit have identified a number of shortcomings, it is important to be clear that the findings relate to structural issues, and do not in any way detract from the expertise, skill and dedication of the workforce.

The Government is committed to taking early and decisive action on the reform agenda, and I will be making proposals to Government for the implementation of an integrated package of re-structuring measures in the near future.

I am confident that there are gains to be made from a radical re-structuring of the health system. The proposals now being advanced are a considerable challenge. I will not understate the enormity of the task ahead – there are no “quick fixes” for the kinds of changes we envisage undertaking. I would also say that the full potential of the system can only be realised if we continue to invest as we reform.

National Task Force on Medical Staffing

I established the National Task Force on Medical Staffing in February 2002, to prepare an implementation plan for reducing the working hours of NCHDs, and achieving a consultant-provided service in line with a number of previous reports.

The terms of reference of the Task Force are primarily concerned with medical staff. However, it is important to examine the role of other key health professionals such as nurses, health and social care professionals and other personnel who form a key part of the delivery of health care.

In this context, a group chaired by Mary McCarthy, Chief Nursing Officer of the Department of Health and Children, is considering the implications of the work of the Task Force for the development of nursing. The emphasis is on identifying ways in which the role of nurses and midwives can be enhanced, in the context of the developments in nursing and midwifery generally. This work commenced in December 2002 and is continuing.

The INO is represented on this group by Mary Fogarty.

Effective Untilisation of the Professional Skills of Nurses& Midwives

The Commission on Nursing recommended that the Department of Health and Children, health service providers and nursing organisations examine opportunities for increased use of care assistants and other non-nursing staff.

My Department established a Working Group representative of nursing unions and health service employers to address these issues in 2000. The Working Group´s conclusions are based on the premise that the nursing function must remain the preserve of nurses. The recommendations of the Effective Utilisation Working Group were adopted by the Review Group on Health Service Care Staff, which was established under recommendation 4.55 of the Commission on Nursing.

Following this, a pilot programme for the formal training of Health Care Assistants was undertaken last year, in conjunction with the Further Education and Training Awards Council.

The University of Ulster has been commissioned to conduct an evaluation of the programme. It is anticipated that the recommendations derived from the evaluation will influence the extension of the programme on a national basis. The evaluation will be completed within a matter of weeks, and I intend rolling out the training programme in September.

Primary Care – A New Direction

Last year, I spoke about the Primary Care Strategy, and I would like to bring you up to date with developments in the past year.

Primary Care: A New Direction acknowledges the central role of primary care in the future development of our health services, and proposes an inter-disciplinary, team-based approach, which will be introduced on a phased basis using existing infrastructure and encouraging the use of public-private partnerships.

Primary Care: A New Direction will enable primary care to develop the capacity to meet the challenges with which it is faced, such as ageing of the population; earlier hospital discharge; care in appropriate settings; as well as the opportunities afforded through modern information and communications technology.

Last October, my Department gave the go-ahead for the establishment of ten implementation projects and funding totalling €8.4m has been provided in 2002 and 2003 for this purpose.

The projects involve putting in place, at ten locations around the country, a primary care team which will include GPs, nurses and midwives, healthcare assistants, home helps, an occupational therapist, physiotherapist, a social worker and administrative personnel.

As the ten projects are rolled out, more than 80,000 people will benefit from having direct access to an improved range of primary care services; and, as the new model is developed, a wider network of other primary care professionals will also provide services as the needs of the populations in the catchment areas dictate.

It will provide opportunities for nurses and midwives to play a wider role in the delivery of primary care, and will have significant implications for professional development and expansion of scope of practice. These developments will be underpinned by the Nursing and Midwifery in the Community Strategy, which is due to be completed in 2003.

The intention is to have the implementation projects commence operations in the middle of this year and be fully functional by December.

Nursing Degree

By far the most profound development in nursing in Ireland has been the transfer of nursing education to the higher education sector, and the introduction of the new 4-year degree leading to registration in general, psychiatric and mental handicap nursing. This was one of the key recommendations of the Commission on Nursing, and it is most gratifying to be able to stand here today and report to you that the entire process has been accomplished without any major difficulties. The new degree programme commenced in September 2002 in thirteen higher education institutes across the country, with a record number of places available.

As you know, the Government has committed substantial capital and revenue funding to the degree programme. A new, purpose-built capital infrastructure is being put in place in the thirteen higher education institutes at a total cost of some €230m over the next three years.

The Government´s commitment does not end there. By the time the programme has a full complement of students in the autumn of 2005, the annual non-capital cost of running the programme will be in excess of €90.0m per year. These are very substantial sums in anyone´s book, and reflect the Government´s commitment to the development of nursing and the wider health service.

It is important to point out that the Government´s investment in nursing education did not begin with the degree. Since 1998, we have steadily increased the number of training places available. In that year, 968 places were available across the three divisions at pre-registration level. By 2002, just four years later, this figure had risen to an all-time record of 1,640, an increase of almost 70%.

 

This is the first year that nursing has been part of the mainstream applications process administered by the Central Applications Office, and has had to compete in the education marketplace alongside all other third-level courses processed through the CAO.

I am glad to report that nursing has performed very well in this year´s applications campaign. Overall, there are 7,200 first preference applications for nursing, of which almost 1,600 are from mature code applicants. These are excellent indications, and I am confident that all places will be filled this year.

These figures are concrete evidence that school-leavers and mature students alike view nursing as an attractive and worthwhile career choice.

I would also like to congratulate the Nursing Careers Centre of An Bord Altranais for the success of their advertising and promotional campaign this year. The newspaper and radio ads were very effective, and they have succeeded in raising the profile of nursing as a career to a very high level.

The transition to a new nursing degree was a complex and difficult process, and congratulations are due to the members of a number of organisations. These are: –

  • The Local Joint Working Groups who made things happen on the ground;
  • The hospitals and institutes of higher education;
  • Regional and national agencies, including health boards and government departments;
  • The nursing unions;
  • The National Implementation Committee, and
  • An Bord Altranais.

This has been a tremendous achievement, and I would like to convey my personal thanks to all involved.

Increased Maintenance Grant

While much of the focus has been on the new nursing degree programme, we must not lose sight of the fact that we still have students completing the three-year nursing diploma.

I have great pleasure in announcing a 7% increase in the annual maintenance grant payable to nursing diploma students from 1 June 2003. The grant is being increased from €4,533 to €4,850 per annum. This increase will cost an estimated €418,000 in 2003 and €344,000 in 2004.

Recruitment and Retention

Our ability to recruit and retain skilled and experienced nurses is a vital component of the Health Strategy. You will be aware of the financial supports for nurses and midwives undertaking post-registration courses introduced as part of my overall recruitment and retention strategy, including: –

  • Payment of fees for part-time degrees;
  • Payment of fees for courses in specialised areas of clinical practice;
  • Payment of fees and salary to nurses undertaking “back-to-nursing” courses.

At a strategic level, the Study of the Nursing and Midwifery Resource was published last autumn and this will help form the basis for the nursing and midwifery input to the implementation of Integrated Workforce Planning, as provided for under the Health Strategy.

I would like to illustrate the improvements that have taken place in nursing numbers generally over the past few years. In 1998, there were 26,611 whole-time-equivalent nurses employed in the public health system. By the end of 2002, provisional returns indicate that this figure reached 33,449. This is an increase of over 6,800 during the period, or almost 26%.

It is clear from these figures that the recruitment and retention measures I introduced are proving to be very effective.

Clinical Nurse Specialists and Advanced Nurse Practitioners

The Commission on Nursing identified the need for order and a coherent approach to the progression of specialisation, and for the development of a clinical career pathway for nursing and midwifery. The Commission recommended the development of clinical or midwife specialist and advanced nurse or midwife practitioner posts to rectify the situation.

To date, the National Council for Nursing and Midwifery has approved 1,421 clinical nurse and midwife specialist posts.

It is important to acknowledge that this level of clinical progression is new to Ireland, and I would commend everyone involved for the great strides that have been made in just over three years. Of necessity, the Council has concentrated its early efforts on the development of clinical nurse specialist posts, but it is encouraging to see that advanced nurse practitioner posts are beginning to be seen in our hospitals.

Five such posts have been established, four in emergency and one in sexual health. Other posts are currently in course of development in emergency, oncology, haematology, breast care, rheumatology, diabetes and critical care.

I would also like to refer to the Proposed Framework for the Development of Clinical Specialism and Advanced Practice in Mental Handicap Nursing, which was circulated earlier in the year. The conclusions of the report are based on the premise that nursing must expand to meet the diverse and changing needs of people with intellectual disability, and marks a genuine step forward for mental handicap nursing.

I would encourage Directors of Nursing and service providers to maximise the potential of CNS and ANP posts, as part of the drive to optimise the utilisation of the skills of the healthcare professions generally.

Research Strategy

Last January I had the pleasure of launching the Research Strategy for Nursing and Midwifery in Ireland. This is a very important step forward in providing a cohesive and organised approach to nursing research.

I believe that an active research community involving nurses and midwives, in all healthcare settings and third level institutions, is critical to the continued improvement of the quality of our health services. I also know that an active research community is critical to the development of the nursing and midwifery professions.

A Nursing and Midwifery Research Committee has been established to oversee the implementation of the strategy.

The committee, which is chaired by Mary McCarthy, the Department´s Chief Nursing Officer, had its first meeting in March, and is working to develop a project plan for the implementation of the recommendations of the strategy.

The Irish Nurses´ Organisation is ably represented on this committee by your Director of Professional Development, Ms Annette Kennedy.

New Nurses Bill

We in the Department are currently working on a new Nurses Bill that will amend the Nurses Act, 1985 to address the recommendations of the Commission on Nursing.

As you know, the Commission made wide-ranging recommendations to amend the Nurses Act. Some of the professional issues to be addressed include: –

  • That the general concern of An Bord Altranais should be “protection of the public”;
  • The provision by the Board of professional guidance and support to nurses and midwives, and
  • Revised fitness to practice procedures.

Another important issue to be considered is the extension of limited prescribing rights to nurses and midwives.

I hope to bring proposals for the new Nurses Bill to Government later in the year.

The Health Strategy – Implications for Nurses

Contrary to popular opinion the Heath Strategy is alive and well I am pleased to report that 91 of the 121 actions set out in the Action Plan are currently being implemented. It is after all, a seven to ten year strategy which is only 18 months old.

In relation to the Health Strategy generally, it is important to realise that you, as nurses, are the largest individual professional grouping within the health service. You are also the most frequent channel of communication between the patient and service provision. You are, therefore, uniquely placed to ensure that the service takes on a more people-centred approach to service delivery. Your pivotal role between the patient and the service also provides you with an opportunity to be a force for positive change in the way services are delivered.

A&E Services

A&E services is one of the areas that has received much attention in recent times, and I would like to report to you on the main developments since the last time we got together.

The implementation of the LRC proposals has been substantially progressed. Admission and discharge policies have been agreed and implemented. A bed management review has been undertaken and its findings are due to be discussed at the next meeting of the A&E Forum. While this report found that there are issues to be dealt with both within the hospital system and at the interfaces with hospitals – pre-admission and post-discharge – the study found, and I quote:-

“. . .considerable evidence of good bed management practice around the country.”

A security review has been completed and funding provided for enhanced security measures.

Phase 1 of a staffing review has been completed and Phase 2 is underway. The management of A&E departments has been strengthened by upgradings and the assignment of additional staff.

To date, €9.75m has been provided to A&E departments to fund these measures.

The LRC continues to facilitate progress reviews. I was glad to note that, following the last review all sides acknowledged that significant progress has been made.

National Patient Perception of the Quality of Healthcare Survey

Last March, the National Patient Perception survey was published by the Irish Society for Quality & Safety in Healthcare. The results of this survey are very encouraging for all involved in the delivery of a quality healthcare system.

This independent study examined key areas of in-patient care including admission procedures; communication with staff; medical procedures and operations; and nursing staff assistance.

Key findings in relation to nursing are:-

  • 85% of patients reported that sufficient nurses were on duty always or most of the time;
  • 86% of patients considered that nursing care at night was as good as nursing care during the day, and
  • Over 90% of patients received the help they needed from nurses in a timely manner.

Overall, 86% were satisfied or very satisfied with A&E services, and almost 93% were satisfied or very satisfied with the overall quality of care they received during their stay in hospital.

The survey also highlights a number of areas identified by patients where improvements might be made but, interestingly, these areas were not linked to any question of resources. For example, communication was identified as an important dimension of quality, and respondents would welcome more written and verbal information in relation to their hospital stay, as well as post-discharge advice.

While no one would claim that the health system is perfect, this independent survey demonstrates that the service is infinitely better than many commentators would have us believe.

The very high levels of satisfaction reported are proof of the dedication and professionalism of all who work in the health service. You, as nurses, have particular cause to be proud of your pivotal contribution to this achievement.

Nurse2Nurse Website

I would like to congratulate the INO on the continued development of the Nurse2Nurse website. The website provides a valuable source of nursing information on a wide range of topics and allows nurses and midwives to communicate with each other, and also to search for information. I am told that the interest in the site is overwhelming and growing daily, with over 10,000 members registered.

I consider that this is a very worthwhile initiative and I was pleased to be in a position to provide some €138,000 over the past few of years to support this development. I am glad today to be able to allocate a further €50,000 to the INO for this project.

Changing of the Guard

This year we mark the departure of Teresa Cody from Nursing Policy. Teresa has been transferred to Community Health Division. I am sure you will agree with me when I say that her contribution to the development of nursing in Ireland is rivalled by few.

Teresa was instrumental in the establishment of the National Council for the Professional Development of Nursing and Midwifery, and was a member of the Council until recently. She also played a key role in assisting in the resolution of various contentious issues as they arose.

I am sure you will agree with me that Teresa was always willing and available to assist your Organisation with any difficulties that arose. I wish Teresa all the very best in her new role, and I am sure you will join me in expressing appreciation for her outstanding contribution to nursing.

Teresa´s replacement is Eugene Lennon who joins us from the Department of Finance. I welcome Eugene to the Department and wish him well in his new role.

Conclusion

I will now conclude by thanking your President, Claire Spillane and your General Secretary, Liam Doran for their kind invitation to address your conference. I hope you have a successful conference, and that you all enjoy this opportunity to discuss and debate issues of mutual interest with colleagues.