Address by Mr Brian Lenihan TD, Minister of State at the Department of Health and Children, at the Irish Nurses Organisation Annual Delegate Conference
I am glad to be here with you today and would like to thank the Irish Nurses Organisation for this invitation to address your annual conference.
Commission on Nursing
Since your conference last year the death has taken place of Ms Justice Mella Carroll. Her passing was the cause of great sadness. Ms Justice Carroll was a successful barrister and the first female High Court judge. She will be forever remembered by the nursing and midwifery professions for her role as Chair of the Commission on Nursing in 1997-98. We would all agree that the Report of the Commission on Nursing has proved to be the most significant development in the history of the nursing and midwifery professions in Ireland, and is a testament to the commitment of Judge Mella Carroll and the high regard in which she held those who worked in the nursing and midwifery professions.
These are just some of the developments that resulted from the Government decision to implement the recommendations of the Commission:
- The successful transfer of general, psychiatric and intellectual disability nurse training to the third level sector;
- The building of thirteen new state of the art Schools of Nursing in third level colleges at a cost of €240m
- The establishment of the National Council for Professional Development of Nursing and Midwifery
- The development of a clinical career pathway for nurses and midwives – this has led to the approval of over 1,800 clinical specialist and advanced nurse practitioner posts
- The establishment of regional Nursing & Midwifery Planning and Development Units
These are just some of the developments that have flowed from the work of the Commission. This year will see further progress in the development and enhancement of the nursing and midwifery professions.
For some time now the Government has been conscious of the need to restructure and reform the health services and this need has been widely accepted. The last two years have seen dramatic change in the structure and governance arrangements for delivery of health services in Ireland. The reforms in the health sector are not being carried out in isolation – they have moved forward in parallel with the wider public service modernisation programme which was set out in the national partnership agreement, Sustaining Progress.
This process of health reform continues and it is essential that all stakeholders in the system support the process and provide a framework for the Health Service Executive to deliver on behalf of patients.
The Government for its part has put in place the legislation necessary to restructure the health service. The Health Service Executive has been established to replace the multi health board structure. National policies and standards are now being applied across the system. The reform process uniquely transferred the Health Vote to the HSE which now has full responsibility for operational matters within the health service. The Chief Executive Officer of the HSE is in fact the Accounting Officer responsible to the Dáil for the utilisation of the Vote. This was formerly the Secretary General of the Department of Health and Children. The Tanaiste was determined to ensure that the HSE would be directly provided with the funding and also be held accountable for the use of these public funds.
In short, the HSE’s job is to manage the health system with its own Board, a centralised management structure and its own Vote.
The Board is accountable to the Minister and the CEO is accountable to the Board while also being accounting officer to the Dáil for that Vote.
The Minister for Health (supported by the Department) is accountable to the Oireachtas for health policy, resource allocation and of course results. The Tánaiste approves the HSE’s service plan and capital plan which is prepared on an annual basis.
As I mentioned earlier it is absolutely critical that everyone supports this reform process to give it a chance to work. A partnership approach (incorporating of course, constructive criticism) is now required rather than a negative attitude. Everyone within the health system must share responsibility for the performance of the system and the quality and appropriateness of services provided to patients.
The Government is expanding the health service to meet growing demand. Recent years have seen a major increase in public funding (both revenue and capital), a substantial increase in staff numbers, and a significant increase in the number of patients treated, particularly in the acute sector.
Current funding has increased by 10.2% from €11.9 billion since 2005 and by 251% since 1997. Annual capital investment in the health services now stands at €578.5 million and the multi-annual five year capital programme is in excess of €3.2 billion. Public current and capital investment in health services has risen to over €12.75 billion in 2006. Ireland has now become one of the fastest growing OECD countries in terms of public spending per capita on health. By any standard this is a significant expenditure level.
This funding increase has led to major infrastructure improvements and the enhancement of services on a number of levels. Today, almost 120,000 people work full time or part time in our public health services. Of these almost 42,000 are nurses. Between 1997 and end of 2005, there was an increase of 9,637 nurses (or almost 38%) in wholetime equivalent terms. The increase in the numbers of individual nurses in the same period was over 12,800. Ireland now has one of the highest ratios of nurses per thousand of population in OECD countries. There are 12.2 practising nurses per thousand population in Ireland compared to 5.8 nurses in Belgium in 2003.
Value for Money
There is little need to emphasise to you that nursing is one of the most valuable resources utilised in delivering our healthcare service today. The challenge is to ensure that this resource is used to its maximum efficiency and optimal effectiveness for the benefit of patients. As we move forward with health reforms, being able to demonstrate achievement of improved value for money in our management of key resources is going to be become increasingly important.
As I mentioned, we have approximately 120,000 staff in the public health service. It is essential that we make the best use of the people we have by allowing them to work at the level to which they have been trained and for which they possess the necessary competencies. The appropriate skill mix is crucial to achieving an excellent affordable health service, which is rewarding for staff. For example as demand for health services grows, it will be necessary to increase the contribution of nurses to enable them to expand their role within their scope of practice.
Improved skill mix and the mainstreaming of the Health Care Assistant (HCA) role has been a key component of the modernisation agenda in Sustaining Progress. The Government has provided significant funding for the upskilling of support staff in recent years. I know that concerns were expressed that the upskilling of HCAs would lead to a reduction in nurses, that concern has proved unfounded, the number of nurses in the public health service has continued to increase as services have been expanded.
In addition to recent initiatives relating to support staff the Government has maintained a high level of investment in continuing education and training for post registration nurses. Specialist nurses play an increasing role in the delivery of services. Over 1,800 Clinical Nurse Specialist and Advanced Nurse Practitioner posts have been created during the last six years. The INO is a participant in the Expert Group on Nursing and Midwifery which is advising on pilot projects to examine the expansion of the role of the nurse and midwife in parallel with a reduction of hours for junior doctors required under the European Working Time Directive.
The goal of the health services is to deliver the best care we possibly can with the available resources, which are considerable. The HSE has emphasised that improved team working has to be at the heart of the reform programme. The delivery of care must be co-ordinated and driven by multi-disciplinary teams staffed by administrators, managers and clinical personnel working side by side. With the right teams the health services can deliver patient-centred care which is streamlined. Patients should not have to negotiate their way through the system – instead the system should respond to patients as an integrated service rather than individual bits of the system responding at different times.
Accident & Emergency
Despite what some people think, the health services are not just about hospitals and A & E departments. I’m sure that nurses working in the community, in disability, in care of the elderly and elsewhere would remind us of the critical importance of the services they work in. However A & E is a vital part of the health service and one which the public and health staff are justifiably concerned about. A & E is a service which must be delivered correctly for the patients’ sake. However it can be regarded as the shop window of the health service and it does influence the public perception of the service as a whole.
Put simply the delays being experienced by patients in some A & E units are totally unacceptable to the Government. I welcome the opportunity to speak about the work underway to improve patients’ experience at the accident and emergency departments where there are problems and undue delays. Indeed these problems are clearly articulated in your recent postcard campaign and I want to acknowledge your delivery of thousands of these cards last week.
The Government does recognise the very real problems that exist at certain accident and emergency departments. These are complex problems which require a range of actions to address them. The problems will be solved with a combination of reform, resources, management actions and improved efficiency, tailored to each individual hospital.
Last year, more than 1.2 million people attended accident and emergency departments nationally, an average of nearly 3,300 a day. The key fact is that the vast majority of patients attending A & E do not require admission to an acute hospital bed and are satisfactorily cared for and looked after in our A & E departments. However, there is a serious problem in some of our A & E departments for patients waiting admission to an inpatient bed.
The HSE is setting targets for each hospital to drive continuous improvement in waiting times. Consistent with international standards, its ultimate objective is to ensure no patient will wait any longer than six hours to be admitted after the clinical decision to admit has been made. Our challenge is to support these hospitals to ensure they maintain this standard and bring all hospitals up to the same level of performance.
The HSE is taking the following approach on a hospital by hospital basis. It is developing specific time-based targets in relation to accident and emergency and delayed discharges, it is putting in place financial and other incentives linked to performance which is a new development in accident and emergency in our health services and it is developing targeted initiatives aimed at delivering immediate and sustained impact in attendances, delayed discharges, and efficiency.
The measures being taken by the HSE include linking financial incentives to improvements, instructing hospital network managers to treat A & E as the top operational priority, improvements in discharge processes, the trebling of the number of homecare packages for the elderly, the greater use of public and private nursing home beds, improved access to and utilisation of diagnostic services, greater availability of hospital consultants at all times, and the redirection of hospital care to improved community based services.
Acute Hospital Beds
Despite what some might say, the provision of additional acute hospital beds is not the simple solution to our A & E difficulties. The fact is we must consider those issues which I have already outlined. The other fact is that in recent years we actually have provided more hospital beds.
There are about 13,255 beds in public acute hospitals and 1,800 in private hospitals, apart from psychiatric hospitals. Since 1997, the number of public acute hospital beds has increased by 1,528, up from 11,727. Most of the increase – over 900 – comprised inpatient beds.
Our five year capital investment programme includes provision for 450 more acute beds. We are also encouraging the private sector to invest to create new public beds by moving 1,000 of the existing private beds out of public hospitals.
The Tánaiste’s ten-point action plan for accident and emergency is regularly mentioned and I feel it would be useful here to outline some of the measures taken under the plan.
New A & E departments were provided in 2005/2006 in St Vincent’s hospital and Connolly hospital in Dublin and at Cork University Hospital. The A & E department at St James’s hospital was significantly upgraded. These units incorporate new minor injury clinics to increase efficiency of treatment for patients. Funding was also provided for the expansion of minor injuries services at St. John’s Hospital in Limerick, and the provision of a minor injuries unit at Waterford Regional Hospital.
The planning for the provision of Acute Medical Assessment Units, (AMAUs), in Beaumont Hospital and St Vincent’s hospital is under way. In Beaumont Hospital, planning is under way for the development of a 29-bed AMAU, to be ready for commissioning by the end of the year. In St. Vincent’s hospital the unit is partially developed. The aim is to have 20 beds fully operational by the end of next month.
Intermediate care beds were provided to allow the discharge of 560 patients from acute hospitals in 2005. Some 280 patients have been discharged to intermediate care beds so far this year.
Additional home care packages facilitated the discharge of 409 patients from acute hospitals in 2005. Some 184 patients have been discharged to date in 2006.
The HSE hopes to have an out-of-hours general practitioner service for north Dublin in place by the summer.
Additional palliative care services have been developed at Our Lady’s Hospice, Harold’s Cross, and have been in operation since October last. Six palliative care beds have commissioned at the Blackrock Hospice.
The elements required to address accident and emergency department problems are in place: the analysis, the resources, the reform programme, the management, the targets, and the incentives. Implementation at local level in each hospital and in the community services in its locality is the key to success. There is no other way. The Government and the Health Service Executive will continue to give this top priority. I am confident the actions will result in the sustained improvements that patients and their families deserve. But we must all work together on this to bring these improvements on stream as speedily as possible.
The future challenge of nursing and midwifery education relates to expanding boundaries to meet the needs of the population. Education is one of the most powerful developmental engines at our disposal, so clearly both at local and national level nurse and midwifery education must be a priority for all. The Commission on Nursing emphasised education as an integral component of professional development and therefore central to the provision of continuing high quality nursing care.
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. The new degree programme commenced in September 2002 and the Government is providing €110m revenue funding per annum to train our future nurses. This is in addition to the €240m capital funding which I referred to earlier. We look forward to the historic graduation of the first students from this programme this June. The National Recruitment and Retention Group is working with health service providers and Directors of Nursing to ensure that our new graduates are employed and obtain meaningful experience. We expect that the majority of these graduates will go on to have rewarding and fulfilling careers in the public health service.
The next phase in the nursing and midwifery education revolution will commence later this year. Last November the Tánaiste announced plans for the introduction of two new direct entry undergraduate midwifery and children’s nursing degree programmes with the first intake of students this autumn. The midwifery degree programme will be of 4 years duration, and the integrated children’s/general nursing degree programme will be of 4 ½ years duration.
The new programmes will be provided in a total of 7 third level institutions across the country at a cost of €3.8m in 2006 rising to almost €17m in 2011, when the programmes will have a full complement of students. The undergraduate midwifery programme will offer 140 new places per annum and the integrated children’s/general programme will offer 100 places per annum. These places will be in addition to the 1,640 places currently in the system each year for general, psychiatric and intellectual disability nursing.
The new programmes will reduce the time it currently takes to qualify as a midwife or a childrens nurse and will put the education of midwives and children’s nurses on a par with that of other nurses. These programmes are designed to increase the supply of midwives and children’s nurses in response to existing and anticipated future workforce needs within a changing health service. Midwives and children’s nurses are critical in the delivery of services to women and children.
These new programmes will provide an exciting and attractive career option for school leavers as well as for mature students wishing to make a career change and their introduction reflects the Government’s ongoing commitment to nursing and midwifery education generally. I am glad to report that nursing has, once again, performed exceptionally well in this years CAO applications campaign. At a time when overall applications to the CAO have fallen, 8,600 applications have been made for 1,880 places on nursing and midwifery courses with the two new degree courses proving particularly attractive with 11 applications for every one place on the midwifery course and 12 applications for each place on the integrated childrens and general nursing course. These figures are concrete evidence that school-leavers and mature students alike continue to view nursing as an attractive and worthwhile career. I would like to congratulate the Nursing Careers Centre in An Bord Altranais and members of the profession who have promoted nursing as a career over the last number of years.
As science, technology and the demands of the public for sophisticated healthcare become increasingly complex it is essential that the empirical underpinnings of Nursing and Midwifery practice be continually built upon and strengthened. Nursing and Midwifery had struggled with increasing urgency to create and maintain a culture of research based practice.
The Research Strategy for Nursing and Midwifery in Ireland (2003) has provided the framework to allow nursing and midwifery research to thrive and the development of a cadre of Nurse and Midwife researchers. A key recommendation was the appointment of a Research Development Officer as a shared post between the Health Research Board and the National Council for the Development of Nursing and Midwifery which has now been filled. It also recommended a study to identify the Research Priorities for Nursing and Midwifery in Ireland which is due too be published in June of this year.
Last year the Tánaiste launched the Review of Nurses and Midwives in the Prescribing and Administration of Medicinal Products which was jointly conducted by An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery.
This report recommended that prescriptive authority should be extended to nurses and midwives subject to regulations and that the relevant legislation should be amended to enable this. The international evidence is strong that nurse prescribing is effective, safe and improves the service to patients. The US has had nurse prescribing for thirty years and the UK has been developing policy and practice in this area since 1987 with legislative change and the first pilots starting in 1994.
The changes recommended in the report are all about safe and convenient access to medication for patients. Nurse prescribing will promote the more effective utilisation of the nursing resource, both in terms of nurses’/midwives’ time and their skills and will facilitate the optimum utilisation of the medical resource; doctors will be able to focus on more complex cases without being diverted by routine tasks. In other words, it will assist the development of a service based on the right person delivering the right care in the right setting.
The Government introduced the necessary amendments to the Irish Medicines Board (Miscellaneous) Provisions Act before Christmas to enable the Minister for Health & Children to make regulations to allow for prescribing for certain nurses and midwives. My Department will shortly launch a consultation process on the implementation of nurse/midwife prescribing. This consultation process will be completed before any regulations are drawn up and I hope you will take the opportunity to engage in this consultation process.
The Department of Health is currently pursuing an ambitious programme of legislative reform in relation to the regulation of healthcare professionals. The proposed Nurses Bill 2006 is intended to modernise the regulatory framework for nurses and midwives. It will update and amend the Nurses Act, 1985 in order to reflect and respond to the significant changes which the health services and nursing and midwifery professions have undergone since 1985.
The Nurses Bill, together with the Health and Social Care Professionals Act, Act, 2005 and the Medical Practitioners Bill, will strengthen, modernise and expand the statutory registration of healthcare professionals.
It is the Tanaiste’s firm intention to put in place a comprehensive legislative framework that will help to ensure the highest level of competency amongst nurses and midwives. The primary objective of these measures will be the protection of the public.
The Tánaiste intends to publish the Draft Heads of the Nurses Bill in the coming weeks. Once published a consultation process will be initiated and I would expect that your Organisation will contribute to this process.
The current national agreement, Sustaining Progress, will conclude at the end of June. The agreement has delivered substantial pay increases to nurses (over 13%) in addition to the benchmarking increases of between 8% and 16%. In return for these pay increases nurses and the other parties to the agreement committed to co-operation with flexibility and modernisation. From the point of view of the public a key result of this agreement has been industrial stability within the health services. While there have been disagreements along the way, the partnership approach has worked well and has delivered for nurses and employers alike. It is vital that we work together and where necessary change outdated work practices and reconfigure services, for the benefit of our patients. We hope that ongoing discussions on a successor to Sustaining Progress, which the INO is involved in, will reach a successful conclusion over the next few weeks and provide the basis for a continuing stable industrial relations environment. In January the Minister for Finance established the second Public Service Benchmarking Body, as provided for under Sustaining Progress. Other public service unions are co-operating with the Benchmarking process. I would ask that the INO reconsider its position, and to participate in the agreed process. This would allow it to make the case for increases in pay for nurses and midwives within the benchmarking framework.
Nurses and midwives face the challenge along with all of us, of embracing new methods of care delivery which will provide a quality service that is truly patient-centred. As the structures of the health service develop, the manner in which healthcare is delivered will continue to evolve. The Health Reform programme has promoted a culture within the health services that emphasises the value of continuous learning and improvement of skills and experience. There is growing evidence of the need to link continuing professional development with organisational goals.
The advent of nursing and midwifery specialisation and the attendant opportunity for nurses and midwives to expand the scope of practice, the implications of nurse prescribing, and the training and wider deployment of health care assistants present a unique challenge for nurses and midwives to re-define their roles and, in the process, to re-define healthcare delivery. I would like to acknowledge and thank nurses and midwives for the contribution they make to the delivery of services across many different healthcare settings. While we are still striving for a world class health service, nobody can deny that the current standards of our nurses and midwives are second to none.
I would in particular like to commend the nursing and midwifery professions for facilitating the integration into our health service of a significant number of overseas nurses in recent years. I’d like to welcome and thank these nurses for their admirable contribution to provision of services in many aspects of the health system in different locations around the country.
It is fair to say that the health service is synonymous with nursing particularly in the acute sector. There is universal appreciation of the contribution nurses and midwives make to patients and I would like to convey thanks to the profession not only for its key input into the development and maintenance of services but also to those individual nurses who day and night look after and care for the most vulnerable in our society. It is all too easy when one is describing structures and systems to bypass the trojan service being provided by individual nurses and midwives to individual patients in a service as complex and as large as our health service. The Tánaiste recently publicly acknowledged the midwife who had the professionalism, courage and integrity to draw attention to the situation that arose in the Lourdes Hospital, Drogheda. Individual professionalism and integrity must never be forgotten or lost in a service as crucial as nursing.
Thank you for your attention and for your kind invitation to address this important conference.