Minister for Health statement at the Joint Oireachtas Committee on Health and Children

 Check against delivery

Opening Statement by the Minister for Health at the Joint Oireachtas Committee on Health and Children.  Thank you Chairman, members of the Committee.    I am accompanied today by Minister White, Dr Siobhan O Halloran, Chief Nursing Officer, Matthew Collins, Eligibility Unit and Fiona Prendergast Finance Unit. Unfortunately Minister Lynch cannot be here today and sends her apologies.

The Committee asked that I address issues raised by the Irish Nurses and Midwives Organisation and the availability of epipens, arising from hearings by the Committee.

The INMO raised issues regarding staffing in the health services. The Committee will be acutely aware that public sector staffing and public sector pay is subject to national pay agreements – Haddington Road – and the moratorium on public sector appointments.

The health service is required to achieve savings of some €290 million in 2014 under Haddington Road. This is set out in the 2014 Service Plan. The HSE’s National Directors developed an implementation plan to achieve the savings. It involves reviewing rosters, skill mix and staffing of hospitals to ensure that the extra hours provided for under Haddington Road are maximised so that we can reduce spending on agency and overtime. This must be balanced against the overriding need to ensure patient safety is maintained.

The same imperatives apply to the number of staff employed in the health service. There is a target to be reached as part of compliance with employment control frameworks but this must be balanced against the need to ensure patient safety is maintained.

That is why the HSE may recruit where it is necessary to do so in order to ensure patient safety and quality care and to support service delivery.

In terms of nursing, there are almost 34,600 nurses and midwives in the health service, as well as almost 3,200 health care assistants – including interns. While Haddington Road is about staff numbers, it is also about things like the graduate nurse and midwife initiative and the support staff intern scheme.

The Graduate Nurse/Midwife Initiative supports the retention of graduate nurses and midwives within the Irish health system and enables them to gain valuable work experience and development opportunities post-graduation. Two-year contracts are being made available under this initiative and nearly half of these have been filled.

I would take the opportunity to note that the HSE has a specific sponsored Student Public Health Nurse Programme, graduates of which fill public health nurse vacancies.

The Support Staff Intern Scheme facilitates interns in achieving the FETAC level 5 qualification, which are an invaluable asset in their professional development. These interns will provide vital support to healthcare professionals, including nurses, in the healthcare setting.

So, while overall nursing numbers may have fallen by 12% since 2007 (nearly 5,000), they still represent one third of the health services workforce. Alongside this, the number of midwives has increased by 46% (400), weekly working hours have increased, 450 nurses and midwives have started the graduate scheme and 330 healthcare assistants have started on the intern scheme. In this way Haddington Road Agreement, has provided us with additional resources and should be seen in the context of the overall reform programme and the range of initiatives we’re pursuing to improve our health services and enhance patient safety.

Collectively, these additional resources will enable the HSE reduce expenditure on agency and my Department, with the Department of Public Expenditure and Reform, is also looking at other ways to achieve savings on agency, in light of developments with regard to the Nurse Bank Initiative.

Given the challenges we face, we can’t conceive of our health services as just a numbers game. That is why we are reforming how we deliver health services. Hospital Groups are especially relevant here because the changes inherent in their establishment will enable us to make optimum use of our high quality resources – including nurses.

There is a wide range of challenges associated with determining appropriate nurse staffing and skill mix levels in hospitals in Ireland.

Deciding on an optimal number of nurses is not an easy task. There is a delicate balance to be struck to meet patient safety and economic requirements. Achieving this requires relevant expertise to be applied to the decision making process.

It is for this reason that we are establishing a taskforce to develop a framework that will determine the staffing and skill mix requirements for the nursing workforce in a range of major specialities. The focus will be on the development of staffing and skill mix ranges which take account of a number of influencing factors. In this regard I would highlight that nursing is now a graduate profession and Ireland was one of the first countries to embrace this – we’ve had the undergraduate pre-registration programme since 2002. The benefits of this highly trained workforce are just one of the factors that has to be considered in looking at staffing levels.

Phase I of the taskforce project will focus on developing a staffing and skill mix framework related to general and specialist adult hospital medical and surgical care settings.

The taskforce will be chaired by Dr Siobhan O’Halloran, the Chief Nursing Officer, and will comprise a range of experts. The use of staffing ranges, as opposed to staffing ratios, will retain flexibility in the system while ensuring the safety of patients.

The INMO is represented on the Taskforce, the first meeting of which will take place on the 23 July.

On epipens, let me first take this opportunity to extend my deepest sympathy to Ms. Sloan and her family on the loss of their daughter, Emma, who suffered an anaphylactic reaction last December.

I know that this tragedy prompted the Committee to hear evidence from a number of contributors in relation to the provision of adrenaline auto-injectors in Ireland – and I know Ms Sloan was one of those who appeared.

The Pharmaceutical Society of Ireland, whose primary function is to regulate the pharmacy profession in Ireland, is currently undertaking a statutory investigative process related to events on the night Emma died. In these circumstances, therefore, it would not be appropriate for me to comment further on the specific case.

Let me say first of all that my Department is currently examining the feasibility, taking account of policy and patient safety considerations, of amending Prescription Regulations, to facilitate wider availability of adrenaline pens in emergency situations. My Department plans to conduct a consultation process which will serve to inform a policy decision on the matter.

If I may discuss the issue more broadly, the incidence of allergy, including nut allergy in developed countries has risen steadily in recent years. While the reasons for this increase are not fully understood, the effects of a nut allergy can be severe. Avoidance is key, along with a combination of proper diagnosis, attention to food labelling and the available of emergency medication.

Adrenaline auto-injectors, as injectable medicines, are supplied as prescription only medicines. Under Irish law designated health professionals, that is to say registered medical practitioners, dentists and nurse prescribers may prescribe adrenaline auto-injectors. Strict controls are placed on who may supply medicines to patients, for example, registered pharmacists. Regulations control those health professionals that may administer prescription medicines to patients in certain circumstances (for example registered pre-hospital emergency care personnel, registered opticians and others). The Regulations also provide that a pharmacist can supply a prescription medicine in emergency circumstances without a prescription.

Proposals to widen access to adrenaline auto-injectors range from making them available without a prescription to making them available in every school and restaurant in the country.

However there are complex considerations to be considered to ensure that patient safety is fully protected. These include for example, the identification of the category of persons designated to administer the auto-injector. This would involve a register in order to clearly identify the individuals who have an entitlement to supply or administer the adrenaline auto-injector.

In order to quality for inclusion on the Register an individual would have to complete a certified training programme which would cover such things as identification of an anaphylactic reaction, the administration of the medicine and the follow up care after the injection has been administered. It would also involve setting up a clinical practice guideline or protocol which would cover such aspects as the supply of the auto-injector, the certification of the establishment where the auto-injectors are located, their storage, persons responsible for storage and record keeping.

There are also patient safety considerations. These include the misdiagnosis of anaphylaxis and the potential adverse implications of incorrect or inappropriate administration of adrenaline. There is potential for harm if administered to a patient with certain underlying conditions who is not suffering from an anaphylactic reaction. These include administration to patients with a history of/or underlying cardiac arrhythmias, cardiovascular disease including angina and hypertension where incorrect administration could result in an exacerbation of these conditions or a significantly worse healthcare outcome.

Availability of auto-injectors is another issue. The Health Products Regulatory Agency (HPRA), formerly the IMB, continues to work to ensure that there is availability from multiple sources. In view of the potential for supply problems, however, it is essential that adrenaline auto-injectors are utilised in the best possible manner.

The shelf life of AAIs is relatively short ranging from 18 to 24 months. It is important that the products are not used after the shelf-life has expired as after this time the efficacy for the product can be reduced.

To conclude, I support making medicines more accessible to patients where it is safe and appropriate to do so and my Department is examining this particular issue as a priority