Joint Committee on Health debate -
Wednesday, 2 Oct 2024

The purpose of today's meeting is for the joint committee to consider staffing levels in the HSE, specifically on the back of a letter received from the Irish Nurses and Midwives Organisation. I am pleased to welcome from the Irish Nurses and Midwives Organisation Ms Phil Ní Sheaghdha, general secretary, Ms Caroline Gourley, president, and Mr. Neill Dunne, INMO member.

I am pleased to welcome from SIPTU Mr. Damian Ginley, sector organiser, health division, Ms Aideen Carberry, communications officer, Mr. John McCamley, sector organiser, and Ms Deborah Kelleher, radiation therapist.

I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity.

Therefore, if witnesses' statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that any such direction is complied with.

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

I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where they are not adhering to the constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members participating via MS Teams that, prior to making their contribution, they confirm that they are on the grounds of the Leinster House campus.

I ask members to keep to a seven minute slot because we have gone over time and there will not be enough time for a longer slot. If I can let members contribute again, I will do so.

I invite Ms Ní Sheaghdha to make her opening remarks on behalf of the INMO. She is welcome.

We are very happy to be here. I thank the members for agreeing to our request to address the Joint Committee on Health. We thought it was important when we heard the HSE and the Department of Health address the committee and set out the pay and numbers strategy and the story it paints.

The numbers the pay and numbers strategy are based on are incorrect. The situation is that any vacancy that was in place but not filled in December 2023 no longer exists. Those posts were made obsolete by the stroke of a pen last December. That has a huge effect on nursing and midwifery because it usually takes approximately six months to recruit a nurse. Members can imagine that if we carried vacancies for six months in 2023 and had vacant posts in December 2023 and the HSE decides that the posts cannot be filled in 2024 and that they will not be funded in 2024, that will have a massive effect on our services.

The recruitment as set out by the HSE in the numbers does not take into account the calibration of a whole-time equivalent post and its difference in 2022. In July 2022, nursing and midwifery hours were reduced from 39 hours per week to 37.5 hours per week. However, the number of whole-time equivalent posts remained the same. In other words, the hours loss was not recalibrated. We estimate that there are approximately 1,700 whole-time equivalent posts, when it is translated into hours. We referred that to the Workplace Relations Commission, WRC, as a dispute and had a conciliation hearing in May 2024. We then met the census division of the HSE, which confirmed that one whole-time equivalent post in July 2022 was calculated to be the same as one whole-time equivalent post calculated at the end June. In other words, no provision was made for the loss of nursing hours.

Members might recall that the loss was covered by a national pay agreement and that €150 million was made available by the State to replace the hours lost due to the reduction in working time. The pay and numbers strategy must take into account the recalibration and must be based on the actual number of whole-time equivalent posts. Since 2022, the total growth in net nursing is 547 whole-time equivalent posts. We know this. We have two directors of nursing, our president, Caroline Gourley, who is a director of nursing in care of the older person services and Neil Dunne, who is a director of public health nursing in Dublin, and they can give examples of how the real front-line shortage is affecting services. I have examples. We surveyed our members in recent months and it is clear to us that there is now a huge issue with waiting lists being introduced in, for example, cancer services and nursing-led services, such as children's services, that did not exist. As one might expect, all the services are affected when we are trying to develop community services. They simply will not happen.

The regional health areas have now been established and each of the CEOs has been advised of their budgets. They have not been advised that certain funds, for example, the funding for the framework on nursing and healthcare assistant safe staffing, which was indicated and agreed to be necessary for the maintenance of safe services in acute hospitals, is not protected. In other words, it may or may not happen, depending on the funding that is available. We are told that funding is interchangeable when we meet the regional health areas. In other words, they can decide what post to fill based on the financial allocation they have received and not on the agreements to maintain safe staffing. That is a huge problem because our members went on strike in 2019 to ensure they would have a mechanism to determine safe staffing and that rug has now simply been pulled out from under them.

The current situation is that this year the HSE will not protect any funding for agreements it has brokered on staffing. We also know that the recalibration of the whole-time equivalent hours has not happened. We have a real concern that by placing caps on recruitment, we will score the biggest own goal the country has ever scored, because research now indicates that in 2007 when the last moratorium was introduced, nursing and midwifery suffered the most. It took us until the middle of 2020 to recover the numbers we had in 2007 and that was done by going to all corners of the globe to recruit, because at that point many of our own graduates decided to leave because they were not offered posts due to the moratorium. We are in exactly the same position today. We are imposing caps and refusing to allow recruitment. It is the wrong move.

If the committee has any authority to influence that thinking, we argue that there must now be a system whereby the decision about recruitment is taken away from the financial control of the HSE and Department of Health and based on safety for patients. HIQA must be given the authority under the patient safety (licensing) Bill, which has not been enacted, but the heads of the Bill were published in 2018. We have a list of HIQA inspections I can share, but I am sure members of the committee know them well. All the inspections HIQA has done in the past five years in various acute hospitals point to the fact they are not staffed properly. However, there is nothing it can do about it. It can merely report on it. We want it to have the authority and we are asking the committee to ensure that section of the patient safety (licensing) Bill is enacted. It is imperative that patient safety is measured, not by the amount of money available but by the number of staff required and scientifically determined to provide safety.

From the good research conducted into nurse staffing and patient safety, we know that when the staffing numbers are correct, patient mortality improves, the length of stay reduces, readmission reduces and agency costs also reduce. It makes sense. Already this year we are spending more than €500,000 more on agency staff per month, which defeats the purpose of any moratorium. We estimate that by the end of the year, we will have spent just over €26 million more on nursing and midwifery alone than in 2023. It makes no sense. We should be recruiting and directly hiring. The premise on which the caps are imposed is very damaging to patients and retention. It will increase burnout. Already the number of assaults on front-line staff is increasing and that is always directly connected to the number of staff on duty. Furthermore, development of community services will stall. It will simply not happen.

If committee members want to ask us about any issues, I am happy to take any questions.

First, I would like to give apologies on behalf of John McCamley who cannot attend this morning. I am SIPTU’s sector organiser with national responsibility for support grades in the health division. I am accompanied by my colleague Aideen Carberry, who is the division’s communications officer; and our colleague Ms Deborah Kelleher, who is a radiation therapist. In the Gallery, we are joined by Sean Murray, Clara Cremin and Olivia Brereton, who are activists in our union.

On behalf of SIPTU’s health division, we welcome the invitation to meet the committee today. Our division represents over 41,000 members within both public and private settings. Our membership includes the widest scope of grades within the health service including health professionals, health care assistants, psychiatric nurses, support staff grades and the National Ambulance Service. Our union is a strong voice within the ICTU staff panel of health unions and the health service union representatives on the national joint council.

We have provided a detailed submission to the committee which seeks to highlight key issues for our members regarding staffing levels within the public health system. We have broken our submission into the following sections: a background to the recruitment embargo and subsequent suppression of posts; the need for safe staffing levels for all grades and departments within our public health service - currently figures and staffing levels are based on historical data; how insufficient staffing impacts the expansion of services within the public health service; a look at the HSE’s own employment census data; some case studies regarding staffing for SIPTU grades; and results and context to a recent survey conducted by SIPTU, demonstrating our members’ views on the recruitment embargo and subsequent suppression of posts.

Our union has chosen these topics for discussion within our submission. They broadly represent the views of our membership and the issues they face daily in relation to staffing concerns within the HSE. While our submission goes into details of our members' concerns, we wish to highlight a few keys observations for today’s hearing.

On the safe staffing framework, SIPTU contends that every department should have an established framework for safe staffing levels to meet the requirements expected of them. Currently most rosters are derived from historical information. It is our view that staffing levels should be measured to address the daily needs of the department and to ensure patient safety, but also to absorb the reality that the health service workforce has responsibilities outside of the workplace.

In relation to existing staffing levels, our members do not feel any relief coming from the increases identified in the national health sector budgets. Their concerns in relation to staffing levels are borne out in the HSE's own census figures, as outlined in a table we have supplied. In our view, the HSE’s own data demonstrate that despite talk of record levels of investment, many grades and services have not benefited from this investment and our members do not feel that investment on the ground. For example, in the last 18 months only an additional 19 whole-time equivalents have been recruited out of a total of 10,208 support staff. Despite growing demand for home care services, we are actually down 84 whole-time equivalent health care support assistants in the same period.

We note that National Ambulance Service management publicly stated in February 2023 that the service would need to more than double its staffing to deal with the unprecedented demands on the service. We note that according to the HSE’s own data, the number of whole-time equivalents employed by the NAS only increased by 140 from December 2022 to August 2024, an increase of just under 7%.

We have previously highlighted that our health services have a 30% shortage of radiation therapists and this is leading to increased delays in cancer treatments. This staffing crisis has led to at least four cancer treatment machines not being utilised. These machines could treat around 30 patients a day, meaning there may be as many as 120 cancer patients who are not being dealt with daily due to staffing deficits. The recommendations of the national radiation therapist review report need to be implemented in full and without delay to develop a safe staffing model for radiation therapy and address the staffing deficits. SIPTU is not disputing the increased numbers in employment within the HSE. However, we believe that some grades have benefited to a greater extent than other grades which also provide vital services to communities. An increase of just three radiation therapists has been approved in the last 18 months.

I now turn to agency spend. In addition to the above concerns, agency spend is still increasing. The total agency spend in 2023 was €647 million. In 2024, for the first five months of the year, agency spend was up 10% to €288 million. Only a small number of posts within SIPTU-represented grades are identified to be secured via the agency conversion programme proposed by the HSE. The embargo prevented the recruitment of direct staff to offset the need for agency usage, even though it would be cheaper to do so. The increased use of agency staff and contractors to provide essential health services presents a risk to the State. In addition, announcements on additional home care hours are made without the HSE having available resources to provide them, which means they end up being provided by the private sector.

On health service demand, both the HSE and the Department of Health confirmed at the Joint Committee on Health on 18 September 2024 that there have been significant increases in demand for services. It is also recognised that there is significant demand on health services arising from population growth of over 11% since 2016. The HSE confirmed at last month's hearing that 2024 will see the highest level of activity ever within the public health system. To meet that demand, the Department of Health informed this committee that since 2021, emergency department presentations are up 29% and day cases are up 20%. The HSE is now delivering 4 million outpatient appointments, up 800,000 since 2021. Inroads are being made on waiting lists. Our members are behind those figures. They are working harder now than ever before and it is their view that any policy for the staffing of services within the HSE must take account of the expansion of services.

Previous attempts to introduce an extended working day failed because of the HSE and the Department of Health not investing in their staff. It is frankly irrelevant how many staff of another grade have been employed if they are required in an area such as diagnostics, catering, home care, portering or the NAS. To demonstrate the fact that the pay and numbers strategy may be undermining extended working days, we might look at diagnostic services. Within our 52 diagnostic departments, only 34 additional staff have been processed in the last 18 months. That is less than one per diagnostic centre across the country and in an overall headcount total of 1,527. It is important to note that a nine-to-five roster equates to a 40-hour week, whereas moving to an eight-to-eight, seven-day roster involves an 84-hour period. An extended working day requires more staff. It is not possible for staff who are already working in depleted areas and have not benefited from the increase in staffing numbers promoted by the HSE and the Department of Health to be expected to move to an 84-hour roster. Our members are already struggling to cover the nine-to-five regime with additional on-site, on-call or overtime requirements.

In summary, modern healthcare is a multidisciplinary effort. Many grades of staff interact with a patient during their treatment. Unfortunately, a lot of focus is spent on improving some areas of the service while little is spent on many others. It is for this reason that SIPTU contends that every department should have a safe staffing level determined to match the service demand required of them. Such a safe staffing level should incorporate issues such as the number of patients, acuity levels, speciality areas and hours or days of service, among other issues. The necessary staffing resources should then be made available to support the safe delivery of service. We have provided more detailed information on this in our submission. We look forward to the engagement with the committee today and are happy to answer any questions.

Cuirim fáilte roimh na hionadaithe ó SIPTU agus an INMO. First, on the statements, Mr. Ginley said that the "health service workforce has responsibilities outside of the workplace". Will he clarify what he means by that?

He noted that we are down 84 WTEs in home care support assistants. He said that additional announcements regarding home care hours are made without the HSE having available resources to provide them. Surely the hours are provided - that means they are funded. Is that not the case? The issue I have come across when dealing with this issue is the availability of staff.

On the 84 whole-time equivalents reduction, our healthcare support assistants were formerly known as home helps. Many colleagues would recognise that name rather than the current title.

They provide an important role in our community and in our home. Their function is to try to support the acute settings by assuring that service can be delivered in the community, as opposed to holding up beds in the public service. In that context, it is concerning that we have evidence from across the country on deficits in HCSAs directly employed by the HSE. For example, we are short more than 100 whole-time equivalents in the south. In the midlands, we are short of between 50 and 100.

An announcement was made about an additional 4 million home care hours. The challenge for us is that our members are already working their full-time contracted hours. They are already making themselves available for overtime and additional hours, but because there are not enough staff to provide those services, the additional hours are allocated to the private sector, which then picks and chooses what cases it wishes to take. We are calling for increased investment in the HCSA grade to enable the HSE to directly deliver the service.

Funding has been made available but the HSE is not able to deliver the service needed because of the lack of staff. Ultimately, the service is being provided by the private sector and there is an added concern there in relation to the terms and conditions of employment for workers in the sector, which are significantly less than those agreed with the HSE in the public service.

In case there is any doubt, I acknowledge from personal experience the hugely important role of home helps and HCSAs.

Ms Ní Sheaghdha said that, in effect, we have seen an increase of 500 in WTEs. To what period does she refer in that regard?

I am taking the period pre-July 2022, to date. Prior to that we had 39,000 whole-time equivalent nursing posts in December 2007. A moratorium was then introduced and approximately 7,000 posts were lost. We did not get back to the figure of 39,000 until mid-2020. The point I am trying to make is that the moratoriums do not just save money for the HSE, which is their stated intention for a short period, the long-term effect of a moratorium for professions like nursing and midwifery is that it can take nearly a decade to recover.

If I might just add in respect of home helps, when the HSE introduced the moratorium, it did not exempt home helps. It is forcing the privatisation of that service. What my colleague from SIPTU says is that the HSE will not provide additional headcount to allow recruitment for the 600,000 hours that were announced. There is something seriously wrong if a private provider with inferior conditions of employment can recruit and the HSE says it cannot get people.

It is the same for public health nurses. My colleague, Mr. Dunne, is a director of public health nursing. The service in the community is provided by public health nurses, community general nurses, and home helps. If we are missing any of those, we are not providing a whole service. Recruitment into public health nursing is down significantly over the past three years. Again, public health nurses were not exempt during the last moratorium.

We dispute that. The whole-time equivalent on the census tells us how many nurses and midwives there are, based on the whole-time equivalent calculator. It is 47,584, but some of that figure is made up, for example, of more than 918 who are student nurses in training, so they were not recruited. Some 417 nurses transferred in when the status of section 39 hospices changed to section 38, so they were also not recruited. Then the recalibration of the hours is about 1,700, so that is not recruitment. What we dispute is when the HSE says it has recruited, because it has not. It has recruited about 540 in that period.

The problem we have is that we raised this in the WRC prior to the pay and numbers strategy and the WRC offered the HSE five separate dates since and it has not been available. That is the reason we are forced to come into a public arena such as this and make the point that the pay and numbers strategy is affecting our ability to provide safe care because it is based on a number that is not correct for nursing and midwifery. We have a scientific tool – the framework on nurse staffing and skill mix – that determines how many nurses and healthcare assistants we should have to provide safe care in all surgical and medical areas and in emergency departments. We are not meeting the safety measurement in any of those locations.

We dispute it, but also the Department of Health has clarified in its most recent document from 2020 that the OECD numbers are based on nursing and midwifery, while in other countries they do not include midwifery. Also, in other countries, they only include bedside nurses, while in Ireland, traditionally, we include everybody working as a nurse, whether it is in education or research. It did not matter, as there was no differentiation. The Nursing and Midwifery Board of Ireland has now produced figures which can differentiate between bedside and other work, so the OECD figures for the future will probably be better. We estimate they are inflated and so does the Department of Health, which has contested the OECD figures.

I welcome all the witnesses. There is a lot of smoke and mirrors in relation to the pay and numbers strategy and the embargo that we just had for the best part of a year, including what we call it. We call it a recruitment embargo and the HSE wants to call it a temporary freeze. We have had all this messing for the best part of a year. What we can say for a fact is that there has been a hard break on recruitment, with very few exceptions. Very limited recruitment is happening at the moment because of the staff ceiling based on the pay and numbers strategy. It is 2,200 for this year. The hard break is there and it is having an impact.

The smoke and mirrors continues in what the HSE says about the additional headcount in place. Could Ms Ní Sheaghdha respond to the following question based on what she referred to in her previous reply? When the HSE talks about additional nursing posts, are they based on a 35-hour week or a 37.5-hour week? Are we essentially seeing a massaging of the figures from the HSE because it is using hours that are not relevant? Could she respond to that point first?

I thank the Deputy. The HSE's figures are based on a whole-time equivalent. It also gives a people number that makes up the whole-time equivalent. For example, at the moment, it says in August 2024 there are 47,584 whole-time equivalents in 37.5-hour nursing posts, with a headcount of 53,538. The point we make is that in 2022, when the hours changed, and specific funding was made available - €150 million was negotiated as part of the public service agreement, to backfill the hours – the HSE's whole-time equivalent calibration did not take that into account.

In other words, today you had a whole-time equivalent worth 39 hours, and tomorrow that same whole-time equivalent was worth 37.5. There are 1.5 hours for every single whole-time equivalent in the system that then had to be funded differently, in our view-----

I have that point, and it is a valid point.

I want to come back to the central point that has been made by all of the witnesses here, which is the suppressing of posts. I am looking at Ms Ní Sheaghdha's own opening statement. Some 2,000 nursing and midwifery posts have effectively been abolished. For listeners, people watching and those worried about what is happening in hospitals, what was the status of those 2,000 posts before they were abolished? Were they posts that were advertised and not filled, or where contracts were not signed? Were they to replace staff who had left? What was the status of those 2,000 posts at the point when they were abolished?

We estimate that the 2,000 figure is our figure, and that is from our surveys of directors of nursing right across the system. Those are posts they needed to maintain safety. What the HSE introduced in December 2023 was that any post that was not physically occupied was not carried forward. In other words, if you were on unpaid maternity leave, we are now finding nurses are ringing us to say they are being told-----

A mixture of both. In fairness, the funding for the safe staffing was awaited in some cases. I remind the Deputy that the Department of Health had confirmed that it would fully fund the numbers to ensure that the nursing and midwifery framework for safe staffing was fully rolled out in all acute hospitals.

It is hard to put a finite figure on it. With our colleagues in the INMO and other Congress unions, we have asked the HSE to provide clarity with regard to the status of the funded posts that have been suppressed as of December 2023. We can walk into any hospital or community centre and there are vacancies left, right and centre. By way of an example, I said earlier that within the support grades of the workforce of almost 10,200 whole-time equivalents, we have only seen 19 additional posts being secured in the last 18 months. Nineteen posts could be within one portering department in a big hospital in the Dublin region or in the south of the country. There are gaps everywhere, and we have had to go down the route of freedom of information requests to try to get some of this information to allow us to engage then with the HSE on how it addresses this.

I want to offer the remaining time I have to Ms Kelleher who is, we are told, a radiation therapist. Ms Kelleher might be able to give us a sense - Mr. Ginley spoke in his opening statement about equipment not being utilised and the shortage of radiation therapists - of what effect the embargo has had on her grade and on the service that her professionals and colleagues provide. I will give my remaining time to Ms Kelleher.

I thank the Deputy. As things currently stand, we have a 25% to 30% shortage of radiation therapists nationally, across the five public radiotherapy centres. That has resulted in closed cancer treatment machines, and they are closed as we sit here today. We have four closed currently. We have three CT scanners closed currently. That means that any new posts we would have gotten are now obsolete, so that is going to exacerbate the current situation. Cancer patients are not receiving radiotherapy treatment on those treatment machines because there are insufficient radiation therapists.

Through the Chair, I ask that if the unions are telling us they have sought data and they have not got it, maybe we can use our own offices here to request that information from the HSE regarding suppressed posts, unfilled posts and all of the information that the unions have not got. There has not been any engagement. What the witnesses are telling us is that unilateral decisions were made with regard to the embargo but, worse than that, the pay and numbers strategy, which is just based on finance as opposed to health need. I will leave it at that.

Good morning everyone. A lot of what Ms Ní Sheaghdha has said seems to be black and white, and it should be straightforward, where decisions were made and undertakings were given. With regard to the judgment or ruling from the WRC in May, what exactly did it say with regard to recalibrating the numbers, and did it instruct that this should be done within a certain timeline?

I thank the Deputy. The WRC process is conciliation, as the Deputy knows. We engaged and we sought numbers from the HSE. We then met its census people and they set out the manner in which they had engaged. We were then to reconvene. That is my point: five dates were offered, and the HSE was not available for any. In the meantime, we had the pay and numbers strategy introduced in July. In our view, the pay and numbers strategy is based on a false premise and that is causing the problems we now have in the services where we are short. We are short-staffed everywhere.

In last year's budget, €2.2 million was allocated to roll it out in all level 4 hospitals. What happens is the numbers are put in place and then you have your normal overrun, people who leave etc., and the backfill does not happen. You never maintain your safe staffing level. That is what directors of nursing are now saying to us. Many of the figures-----

There is an office in the HSE but again, it tells us that it does not have the facility to do anything other than ensure the first filling is based on the calculation as set out in the science.

The important point is - directors of nursing have been saying this to us - the data that are now being used are based on the 2021 activity. For example, we know that emergency departments have got much busier and we are still using data from 2021. We know that hospitals have got much busier. As my colleague from SIPTU has said, our population has grown and our dependence on the public health service for a large portion of that population has increased. In other words, we have a higher dependency on the public health service and we are basing the data need on 2021 activity in some locations. Plus, when we have turnover of staff, we have to make sure we have a mechanism that automatically brings us back to the level of safety. That is not happening.

In areas where the framework on our staffing never reached - that is, level 2 and 3 hospitals, as it was the big Dublin, Cork, Waterford, Galway and Limerick hospitals that were initially level 4-covered - they are categorically saying now, with regard to the backfill and turnover, the turnover in nursing and midwifery has increased. It has gone from 6%, which was the average, to just over 8.5%. If you are not backfilling, you are constantly working against a level that is going to ensure you are never going to have a safe level of care.

To be honest, I do not think there is. We keep asking the HSE about this. Directors of nursing tell us they were instructed, in regard to the 31 December figure, to the effect that posts that were vacant were no longer funded or considered vacant. That means from July of this year, the funding available determines the vacancy as opposed to the actual vacancies based on safety, the framework and the need of the population.

I thank Ms Ní Sheaghdha. On radiation therapists, it was said that there are four closed cancer treatment machines and three CT scanners are currently closed. This committee had a prolonged discussion with the HSE some weeks ago about the need to max out all of the expensive equipment and that it makes no sense to leave it idle. What is happening to those patients who are not receiving cancer treatment in the public service?

No, there is not an issue with clinical placements. Rather, there is an issue with receiving the funding for the clinical tutors. We sought six additional clinical tutor posts, for which we have been refused funding. Trinity cannot increase the number of students. This involves 20 additional students. We are training 30 radiation therapists in undergraduate programmes and 12 in postgraduate programmes. Cancer rates have grown exponentially in the past 20 years.

Apologies for being late. I tried to listen to the debate. It is lovely to have the witnesses here. The committee knows first hand of the consequences of the recruitment embargo. It is deeply disappointing to hear that although the embargo has been lifted, strict controls on recruitment are still in place. These constraints not only limit our capacity to expand services and meet the rising demands of healthcare; they also take a severe toll on the mental and physical well-being of front-line workers. That is the aspect about which I am concerned.

During our discussion on 18 September, there was considerable focus on time, including maximising the time we invest, average waiting times and timeframes for achieving targets. However, rarely do we do we address the time healthcare workers dedicate to caring for others, often at the expense of time spent with loved ones and, in particular, caring for themselves. It is not surprising that in the annual INMO survey, not one respondent rated staff morale as excellent. It says an awful lot that 70% felt their work impacts on their physical health and 41% said it negatively affects their psychological well-being. I ask the witnesses to expand a little on that. It is often the biggest issue. We forget about the impact of all of this on front-line workers.

What is the general sentiment among healthcare providers? Has working in the sector become less fulfilling? I presume it probably has. Bearing in mind that everyone is struggling with burnout, what supports are in place for those who need them? How heavily does this contribute to those who emigrate or take a career break? Are there any statistics on this? Perhaps that should be a factor in workplace planning, especially at a time when recruitment is so tightly restricted.

I recall being in hospital with my sister, who was very sick. The hospital was like a war zone. I remember looking at a nurse and trying to figure out what the story was. She looked as if she had PTSD. She was so traumatised, it was very hard for her to be present for herself or anybody else. It was 2 a.m. and the place was crazy. There were not many people on duty. I never forgot that, and I often wondered how that nurse coped and survived.

I thank the Senator. Not alone do our members treat the job they undertake as a job and a function, they are also very conscious of the public role they play in delivering an important service. It is very difficult to wake up in the morning and go into a workplace knowing that one will be met with a crisis response situation in the majority of cases.

The grades we represent have an added concern. They see a blunt instrument, which is what the embargo on recruitment is. At a macro level, it is a tool to cut costs, but porters and those delivering catering, cleaning and other services do not see the same blunt instrument when it comes to spending on agency staff or the use of contractors. People are being threatened in every manner in regard to their future role and function.

The HSE and the Government need to accept and decide once and all whether they are going to provide a public service. We referenced home care earlier. There is investment in that sector, but it is not going to the public servants working in that area. Rather, it is going to the private sector. That obviously includes profit. It is money that could be used to address the terms and conditions of employment of directly employed staff, invest in and build on services and support the roll-out of the community functions we are all on board with. The choice being taken at the moment is about how to contract or outsource and not increase headcount. That is the challenge for our members. When our members get up in the morning and go to work, they find it very difficult in light of all that. It is very challenging.

I will add to my colleague's comments. As part of our consultation with members on the impact of the pay and numbers strategy, SIPTU also conducted a survey among our members. What was very telling was that 86% of respondents said there was a somewhat or very negative impact, not only on staff but also on services.

As part of that engagement, we allowed people to come back to us with their comments on that. What was very telling was that people mainly seem to be concerned with services. They spoke about issues such as being late delivering meals to patients, an increase in waiting lists for patients and higher risks of infection due to certain areas not being covered from a household or cleaning perspective. Earlier, we asked the committee consider the fact that the delivery of healthcare is a multidisciplinary endeavour and that the workers SIPTU represents are as important as others in delivering vital services to the community.

In 2023, SIPTU undertook a survey of radiation therapists’ opinions. The results of that survey were that 60% of radiation therapists did not see themselves working in the profession in the next five years. That is a very telling and worrying concern, considering that, in 2003, there was preliminary evidence of issues within the profession. There were issues with attrition rates and vacancy rates were high. We were not training enough radiation therapists in 2003. Here we are today in 2024 with machines closed and with a 30% shortage of radiation therapists. It has come to pass. There is a dire need for serious action.

In the survey Ms Kelleher referenced, while the intention to leave is increasing, we are also noticing nurses and midwives retiring well ahead of their retirement date. They are actually retiring early. That means they do not see their future in the health service because they cannot work in that situation. As an example, I will give the committee a comment from one of our members who works in one of the busy Dublin charity hospitals. The hospital had 8,500 births but is only staffed for 5,500 births. It is impossible to keep going to work and feel protected. Assaults on nurses and midwives have increased from 3,465 in 2023 to well over 4,000 in the first half of this year alone. That is not a service. An employer can say it has an employee assist programme, which was one of the questions asked, but that is after you are assaulted. Employees can then have a phone call with a counsellor. We want preventative measures, not post-event measures. Intention to leave was way too high among public health nurses and community general nurses we surveyed recently. It is a combination of poor staffing levels and the focus not being on safety.

It is important to state we do not want a free-for-all in respect of recruitment. We want recruitment to meet already measured safety levels. That is not happening. That is the distinction. In places like California and south Australia, where there is a nurse to patient ratio of 1:4, retention is really good. When places are staffed properly, nurses and midwives are drawn to those areas. They want to work in those locations and they stay working in those locations.

To follow up on what was said about radiation services, the last time we had a group from the HSE and the Department before the committee, I raised the issue of a child with scoliosis who was in Crumlin hospital. The child was there a number of weeks in Crumlin hospital with the parents sharing the room with two other children because they could not get an MRI. Thankfully, the child has got that MRI. There were other difficulties in that case as well. An anaesthetist was needed because of the pain the child was going through. That puts things in context.

Ms Kelleher mentioned machines being down. When I was getting radiation, in a lot of cases, there was a machine on standby because of breakages and everything else. Will she tell the committee where those machines are not operating at the moment? We heard for years there were two machines in, for example, Tullamore hospital, with one of them not being used. A few years ago, the Minister, when was asked before on the issue of scoliosis in relation to Crumlin hospital, said he was going to get an additional machine to help with the backlog. Will Ms Kelleher give us a sense as to where those machines are down?

Not having the staff for the machines is the big crisis. We hear all the time about the amount of money that is being spent on the health service, but it is almost like we are spending more money to stand still. There is huge money, but also huge gaps in this regard. Our population, as the witness said in her own contribution, has grown. Thankfully, we have a young population. We also have an older population who, we know from the statistics, are staying longer in hospital. The reality is we are faced with those challenges, which are positive ones for society, given that people are living longer. We have to back that up, however. We say all the time that these are the people who built the economy and we need to look after them. That is the general consensus of everyone. We do not, however, have the staff to do it. When we throw out all these figures, people do not really understand them. If a nurse is missing on a particular ward, who fills that gap? That is the big challenge.

Ms Ní Sheaghdha mentioned the number of assaults. If someone is waiting for a long time, the tension that arises, particularly in an emergency department, is understandable, and I am not excusing such behaviour. We do not have the services within the community because we know for a fact the community services, or many of the key members of them, are missing, so people cannot get those services. We are told the best place for people to be is in their own home, but people cannot get the services in their home. A number of steps must be taken. While trying to fix this is not rocket science, the impression at home is that this is impossible. There has been reference to the Department of Health as "Angola" and the question has arisen of who would want to work in it. A lot of staff want to work in it. They see the wastage and the challenges. The biggest frustration when talking to members of the witnesses’ union is that they see that this can be fixed with not a huge amount of money or anything else. If there is a moratorium on jobs, those jobs are obsolete. It then takes six months to fill them, which creates a gap and means you are falling behind. I can understand the frustration of people wanting to get out of the service to go abroad and get into a service which works and provides a better quality of life. The message we need to be sending, as a committee, is that these people are doing really positive work and we want them to continue.

Will the witness give us a sense as to where the worst challenges are with regard to radiation services? Is there a specific geographic area in question? Are the challenges in the Dublin area or throughout the country?

The challenges are equal between the west, south and east of the country. The vacancy rates are standardised throughout the country. The machine closures are standard as well, with one closure in each corner of the country. We have recently just completed a national review of radiation therapy services, which has 16 recommendations. Many of those recommendations are very easy and cost-effective to implement. It is just about getting those accepted by the Department of Health and implemented in a timely manner. They would make big differences in terms of staffing, attrition rates and reopening services.

We also need to get those clinical tutor posts in. We need to start at the basics. Getting students into college places is essential to get the services up and running. That is a quick fix. We have only 12 radiation therapists being trained in UCC annually in a postgraduate programme. That is a two-year programme. There are only 30 places in Trinity College Dublin. It is easy to boost those numbers quickly and cost-effectively. We have amazing infrastructure in the country for radiation oncology services and phenomenal services in all parts of the country. Leaving them sitting there idle is the biggest curse to the country when we have such high rates of cancer. One in two of us will be affected by cancer in our lifetime. They are stark figures. First and foremost, opening up places to students and looking after our radiation therapist students would be a good start. Unfortunately, we were not successful within the health and social care professions group. We did not get any additional places this year. We seem to have been omitted from that pot this year and I do not really understand why when we have clearly stated that lifesaving cancer services are closed. Implementing the recommendations of the review would be a good start.

There are now chemotherapy lists for nursing-led chemotherapy services. We never had waiting lists for chemotherapy before. For example, a service which is very important for patients going through chemotherapy, that is, the scalp cooling service, is not being provided in certain locations because there are no clinical nurse specialists employed due to the cap on recruitment.

With regard to paediatric services and palliative care, it is so wrong that there should be a wait.

Mr. Dunne will give a flavour in general terms of what it means to work short in community services in Dublin.

Public health nursing is geographically based, meaning that when there is a vacancy, there is a community without a nurse. You will often see that. There has been advocacy at TD level regarding communities with no public health nurse. Public health nurse recruitment is once per year through the student public health nursing programme and it did not reach its potential this year. The circumstances are even more worrying for next year. Currently, there are only 21 registered public health nurse vacancies within the system. That is extremely concerning. We have spaces to train 140 per year. When there is no nurse in an area like south inner-city Dublin, nurses must cross-cover, and that is when burnout arises. It means no patient- or family-centred relationship. We do not get to work upstream in circumstances where we need to work on the preventive side. Early contact with families and children on referrals is really important to later outcomes. Therefore, trying to protect the clinical workforce is so important, and that is obviously the job of the committee today. There is a particular challenge within community nursing or public health nursing services.

We do not have safe staffing. We do not have the science behind it yet. While it will arise at some stage in the next couple of years, we do not have a scientific measure. The model is based on an historic model, from 1966, for public health nursing and community nursing.

We want to deliver Sláintecare, so it is important that we have a strong foundation of generalist community nurses within Sláintecare working with specialist nurses. However, we do not have that balance, and we do not have a model of care for public health nursing either. I could go on, but that gives a flavour of some of the challenges within public health nursing.

UCC places came on stream about three years ago, with 12 postgraduate places. Originally, in 1996, there were 12 radiation therapists trained nationally. Now, in 2024, there are 30. That is not a massive increase considering the increase in the cancer incidence. While there are 12 places in UCC, they cannot be filled because they are not partly funded. It is my understanding that while the HSE has an agreement with the diagnostic services to partly fund some places, there is no such reciprocation regarding radiation therapy.

With regard to the census figures, that means that from January 2023 to July 2024, there has been an increase of two whole-time equivalents on the ground. That is the impact. It is similar in our diagnostics departments. One Dublin hospital has been down five staff since December last as a result of the suppression of posts. That department has informed us it was down a further three staff since January, which means it is now down eight staff. In the 18 months from January 2023 to July 2024, we have had an increase of 34 staff within the 52 diagnostic centres. That is the scale of the challenge facing us. The resultant impact is that work ultimately ends up privatised or sent to the private sector. Private providers deliver some of the services that should be offered within the public system. Any case deemed complex ultimately comes back to the public system anyhow.

We need practice tutors to support students on placement. We originally applied for six practice tutors nationally, which would be one in each public department. We had hoped that what we proposed would be effective from September of this year but we did not get the approval. A great deal of work was done in the background to try to get it through but we were not successful this year. We did not get an explanation as to why. Trinity was not able to increase its number of places that would have been effective from this year, nor was UCC, so we must wait until 2025.

It is, and the only obstacle at the moment is the cap. Thankfully, there are more school-leaver applicants than places available, which is a good sign. The WHO has advised Ireland that it needs to recruit ethically. In other words, it has to grow its domestic supply of healthcare workers to avoid poaching – this is the term used – from countries that need their own workforces but that are poorer and whose healthcare workers consequently migrate. We are now heavily dependent on non-EU workers, particularly in nursing. Our population of Indian nurses has grown significantly. The WHO has given us a target for recalibration by 2030. We have to ensure we train domestically so as not to rob countries that need their own healthcare workforces of those workforces. This means that, by the period 2030 to 2035, we should, if following what the WHO has stipulated, be training over 7,000. We are training about 2,100 at the moment.

Every time a nurse works as a public health nurse or in the community, she has to do postgraduate education for a year. Going to college takes these nurses off the front line for a period. They work as students while training and, again, that requires supervision and clinical mentors. All the posts just do not have any level of protection in the current system with its moratorium.

Based on what Sláintecare has projected, we need an additional 700 public health nurses and an additional 2,000 registered nurses working in the community just to have needed services expanded into the community. We do not have a chance of achieving this with a postgraduate course that produces about 140 public health nurses every year. The training happens only once a year, meaning that if you do not fill your places, you do not get a second chance. Community general nurses advise that postgraduate education has not been provided for them, specifically in respect of the community. It is an ask that dates back over a decade. Many of the nurses tell us they must sometimes cover two roles when health nurses are not available. Clearly, there are not enough public health nurses employed.

Overall, the HSE is too reliant on nurses in training. We met student nurses again last week. Senator Black asked what makes nurses want to stay. It is heartening to see students with enthusiasm for the career they have chosen but they tell us they are being absolutely exploited. They are on no pay, working in clinical placements and given responsibilities they should not be given. It is not even that they are low paid because, from first year through to third year, they get no pay at all. When they are in fourth year, for 36 weeks they get 80% of the pay at the first point of the qualified nurse salary. We saw during the Covid pandemic that the exploitation of unpaid labour, particularly of those in the student nurse grade, was just extraordinary, and that is still going on.

We have a situation where we want people to stay where they train. It is really important to consolidate your training and stay working where you did the bulk of their training. It is good, the evidence is there, and we all know that, but our system, our overwork and the exploitative nature of short-staffing means they make decisions not to stay. That is fixable. That is easily fixable.

I am listening to many other sessions here that it is very hard not to come to the conclusion that there is a very deliberate policy of privatisation at play. I do not know where that is coming from, whether it is at a political level or at a senior level within the Department of Health or the Department of Public Expenditure, NDP Delivery and Reform. The level of outsourcing at the moment is shocking. The point has been made already that it results in poorer terms of employment. It also results in considerable profits being taken out of the health service, money that should be used for the provision of front-line services. That has to be ideological. There is no doubt that in recent times there has been an acceleration in that. It absolutely flies in the face of the principles underpinning an effective public health service and what was agreed on a cross-party basis in relation to Sláintecare.

Today we were told about nurses, home care assistants and radiation therapists where the push is very much towards outsourcing. That has to be arrested at some level. There has to be a responsibility at Government level for that huge push. We used to talk about creeping privatisation. It is more like galloping privatisation in the health service now. It is very concerning.

In respect of the older person services, the long-term care, we know now that 82% to 83% is delivered through the private sector. Ms Gourley works as a director of nursing in long-term care in the public sector. Beds are closing in the private sector and those patients are then coming back to the public sector. The service has to be provided when people are in long-term care. Obviously, that has to happen then. It was not today nor yesterday, as members know, when Sláintecare did its review. In this year's budget, I was reading yesterday, the allocation is to maintain the HIQA standard, which means actually to reduce beds in the public sector. Single and double occupancy rooms - changing away from the old buildings we had - have actually reduced significantly. However, 82% of long-term care is now provided through the private sector.

Eighty-two percent of residential care is long term. It is not patient centred nor patient focused in the community. They do not get to choose where they go. The residents themselves are put wherever a bed is available. With privatisation nationally in the country, when nursing homes close, which they can do due to HIQA, we then have to source beds within the public area for those patients. It is very difficult. As Ms Ní Sheaghdha already alluded to, HSE accommodation is all multiple occupancy. People do not want to share anymore. Covid-19 had a huge impact on whether people shared rooms. They now want single rooms. The majority of beds within the public sector need refurbishment. They need to be changed. To meet the service need, we need about 10,000 long-term beds in the public service. Therefore, it has all been outsourced.

It is where privatisation becomes a deliberate policy, if the public service is not funded. Interestingly, during Covid-19, the current Taoiseach, as Minister for Health then, and the previous Taoiseach, Leo Varadkar, both said we needed to move to a new model of care for older people. They said the big commercial 200-bed nursing homes that are so sterile needed to change. Nothing has been done about that.

Even the model for Sláintecare, to have the person in his or her own home, is not occurring. It is not patient-centred. Referring to Senator Black's comments about staff, the staff want person-centred care but they have to choose in the community who gets priority. I can guarantee that, because of the age profile and the demographics, it is not the older person in their own home that gets priority. We do not have the home supports and the staff do not like making that choice. They are not providing the service our residents and the people require, nor are they providing the ultimate service they themselves want to provide. Staff are leaving, but they are also going home at night-time worrying that somebody does not have a situation. They could have somebody with dementia at home. I had a case recently where a woman fell. She was the main carer for her husband who had dementia and her son who had special needs. She lay on the floor for two days because she would not go anywhere because nobody could mind her husband and her child. We eventually got a place for them and sorted out care for them. That is the ultimate of what is happening in the community. The staff are not able to take it on anymore. They are leaving in their droves, as Ms Ní Sheaghdha said.

On that point about outsourcing, unless a department has a public service level agreement, obviously those patients are being outsourced to the private sector, but some centres do not have service level agreements and a significant number of patients who have a cancer diagnosis are waiting for radiotherapy and the machine is closed.

We have been advised that just over 450 posts can be created by conversion of agency posts. However, when you think about that, those people are already working in the system, That is not going to increase the workforce. It is just going to change how they are paid. The agency spend in 2023 was in or around €7.5 million per month for the 12 months. Up to August 2024 the figure, which we have from the HSE, was €63.8 million. Again, we believe that €6 million more will be spent on agency posts over the course of this year than in 2023. Conversion of agencies is a mechanism to say we will increase the nursing workforce by 450 posts by converting agency, but actually those people are already working.

I will pick up on some of the points from earlier in the meeting. This discussion is a great one to have directly after the meeting we had last week, which touched on some of the issues regarding staff ceilings, which is the new phrase used in place of the word "moratoriums". There was some discussion about radiation therapists and radiotherapy more generally. I have some questions on the area of cancer care.

First, I want to pick up on the discussion regarding agency staff and the 450 posts that are expected to convert. We were given varying numbers by the HSE. I asked the HSE witnesses for numbers. I do not know whether the witnesses before us have that information. I am trying to get a sense of how many agency staff across the services are suitable for the conversion process. How much of a dent in that process was made by the additional posts, whether the number is 350, 400 or whatever the HSE might be telling us it is?

I apologise. My question on agency staff was not in respect of radiation therapy. I am asking about the situation across the health service. I totally understand that many agency staff are covering a maternity or sick leave and are not appropriate for the conversion scheme. At the same time, there are services that are being held up by agency staff who really should be HSE staff.

I mentioned earlier the requests for data we submitted to the HSE, along with our colleagues, on behalf of the group of unions, for precise details in this regard. Within every grade of the health service, there is agency usage to some extent. We are finding more and more that as well as the staff coming into work every day who are directly employed, are on the roster and carry out their shifts, etc., equally, there are staff who are employed by agencies coming in and doing the exact same work. They are there long term. At this stage, across all grades, we are talking thousands of agency staff who should be directly employed by the health service and should be able to avail of the pensions, terms and conditions, sick pay and so on that come with that direct employment, as well as the security of employment, which is a key factor as well. From the figures identified by the HSE, I understand that in the region of 900 posts are being earmarked for conversion. As our colleague Ms Ní Sheaghdha alluded to, almost half of those posts may be in nursing. However, that is not making any impact on the gaps and challenges in the system. It is just putting a new badge on somebody who is already needed on the line and on the roster.

Going back to cancer care, we have discussed radiotherapy. There are significant delays at the moment, or at least concerning reports of such delays, in chemotherapy services. What is the witnesses' impression in that regard? Is the situation affected by staff ceilings or the previous moratorium, particularly in terms of capacity in day wards? I presume day wards require significant administrative work to usher people in and out, book appointments and so on. I am interested in the witnesses' thoughts on this matter.

Yes. There are not enough nurses or enough physical space. Invariably, in some of those locations, the nursing posts that become vacant are not replaced. That leads to delays, which is not acceptable in anybody's book.

In respect of the agency staff, the HSE tells us every month how much it spends on those staff. Across all categories in 2024, we are talking about more than €30 million a month. That is the point we are making. When a staff ceiling or cap is imposed, the expenditure on agency staff goes up. Changing the title will not increase the workforce. It is simply a case of describing the expenditure differently. We would prefer if there was not a ceiling. We want to reach safety-measured staffing levels without being as reliant on agency staff. We know this works because when we did a pilot study in 2020 on the framework on nurse staffing, agency expenditure reduced significantly once sufficient numbers were hired to meet requirements. Where we had a requirement for one nurse for four patients or one nurse for six patients and that number was funded and employed, agency expenditure dropped significantly. This information is available through the Department of Health. It is part of the framework for nurse staffing and skills mix.

There was a 10% increase.

I return to chemotherapy delays and the issue with clinical nurse specialists. Regarding the recruitment of oncology nurses and the revision of the use of space, I presume there is specifically a requirement for the recruitment of oncology nurses. Will Ms Ní Sheaghdha outline some of the barriers arising in that regard?

There are no exemptions at present. Up to July, when the pay and numbers strategy was introduced, we had negotiated with the HSE that some exemptions to the moratorium would be in place for safety-critical posts. For example, midwives, ICU nurse positions, some cancer services posts and some emergency department and theatre nurse positions were exempt. However, that changed when the pay and numbers strategy was introduced. What has happened is that the six regions have each been allocated a sum of money and they must determine what posts they will fill based on the money that is available. Some have advised us that the total across all grades would be in and around 260 posts for one region. However, we know that, in that location alone, there are about 400 vacancies in nursing and midwifery. It does not make any sense not to look at what is required to provide the required patient safety levels. We have measured that requirement and the Government has accepted our measurement. In fact, the Government and the Department of Health initiated that study. They know what is required. When that does not translate to protections for those posts, it is a futile exercise.

I am almost out of time but, if the Cathaoirleach will allow, I have a final question. Has the HSE provided the INMO with any monitoring or governance structure specifically to monitor any regional disparity that arises as the six authorities start to make decisions on staffing, for example, that might not align with each other?

The regions went live on 30 September. We are meeting with the regional authorities individually. We have a national joint council of health sector unions and we will be asking it to report nationally on the disparity between the regions. The children's hospital is aligned to one of the regions but has huge issues.

We have raised concerns in this regard. Prior to the roll-out of the new structures in the past couple of days, there was a national oversight forum in which we could raise issues centrally. We have discussions with the HSE centrally through the national joint council, as Ms Ní Sheaghdha mentioned. Under the new structures, while the national joint council will still be there, there are concerns in regard to how the national position will be implemented. Basically, there are six entities across the country, each with its own control, responsibility and authority. We have sought individual engagements, as mentioned, but there is a concern as to whether the six entities will be rowing in the same direction.

I thank the witnesses for their statements. My first question is on the recruitment embargo. Obviously, this embargo lasted for a year and had a detrimental effect on the health service. Would I be right in saying that the pay and numbers strategy is almost a continuation of the embargo but just with a different name? If that is the case, and it seems to be the case where there is a recruitment embargo in a different form, is this heading towards industrial action on the part of the witnesses' unions?

From a SIPTU perspective, we have carried out a consultation process with our membership, and the feedback is that where there are significant deficits being identified in either a grade or an individual location, that is, a hospital, our members will be pursuing courses of action in that context. The one frustration we touched on earlier is that across all grades and parts of health, there is a growing frustration among the workforce with regard to the blunt instrument of the embargo and pay and numbers strategy, and the impact that is having on workers in their local hospital, ward or community setting. That frustration is growing.

It is a policy adopted by the HSE that, going forward, each of the six regional health areas controlled by a regional executive officer, REO, will have a sum of money to provide services within that region. They are not allowed to breach that sum of money or that ceiling. We have identified that, at the starting point, we are already in deficit because with regard to the figures from December 2023, which are being utilised as the starting point going forward, there are gaps all over the place.

The REO in each area has a sum of money they are not allowed to spend in excess of, so decisions will be taken with regard to filling posts within their areas based on the greatest need but you will end up in a situation where you are potentially robbing Peter to pay Paul. If I make an argument for one grade and there are resources put in to fix that, the money to pay for those resources will come from another grade. That is where it is flawed from the start. We are starting from a base that is unsustainable. There are deficits across the service at the moment and the HSE is asking workers to operate, going forward in this new world of pay and numbers, with that deficit. It is going to create challenge and crisis everywhere.

We have said from the start that it is a flawed approach. Staffing should not be determined by numbers or money solely. Yes, there are budgets and we understand that but you have to be able to provide a safe staffing framework for all grades that will determine the numbers needed in each grade and category to provide a safe service for the patients who need and demand that service. The approach being adopted is not going to achieve that.

If I might add to that, the important point is we have agreements. We have patient safety-critical agreements that specify the number of nurses who must be employed to provide safe care. The framework on nurse staffing is Government policy. It does not exist as far as the new world is concerned because it is not protected. For those agreements to be honoured, they must be protected, that is, funding has to be red-circled to make sure we maintain the numbers required to provide safe care. If we do not, then the employer is in breach of agreements with their workforce. It is as simple as that.

For example, we recently did a review of ED staffing, and there are 419 whole-time equivalent vacancies - that is confirmed - across our EDs. We are going into the winter. Today, I think we counted just under 600 patients on trolleys. This is what we are facing. This is what the workforce is now facing.

Senator Black asked what would encourage people to stay. What would encourage nurses and midwives to stay is safe staffing levels across every aspect of the service, that is, acute, maternity, children's, community, long-term care and ID services. When you go to work and you have correct numbers on your roster that are safe, that is a different scenario entirely. We know this to be true because there is evidence from where that exists. In California, New South Wales and other states in Australia, they have introduced staffing ratios and they are mandated by legislation to ensure they can never not do it, and then their retention is much improved.

We are saying it is now time to enact the patient safety licensing legislation. It has to happen because the patients are not being well served by the current focus on, "You are over your budget; therefore, cut your staff". That leads to poor, catastrophic and fatal outcomes and it is not what our members want to work in. That is not the service they want to work in.

Obviously, the pay and numbers strategy is going down like a lead balloon with the unions.

I have a final question and it is probably to Ms Ní Sheaghdha. On the public health nurses, this is a very acute issue in CHO 7. I am going to focus in on CHO 7, Clondalkin and Lucan, where there are no public health nurses whatsoever. I asked a parliamentary question recently, and the HSE tried to recruit students into the public health nursing sector and it recruited zero. Why is that? Why is there such a shortage of public health nurses in a community health setting where, you would think, this would be the gold standard with regard to front-line staff?

Again, and Mr. Dunne can answer on this as well, the numbers of public health nurses who are trained every year range between 129 and 140. It needs to be far greater than that but Dublin, and retaining public health nurses working in specific areas of Dublin, is becoming really difficult. It is because the workload, as Mr. Dunne said, the nursing measurement, is based on a 1966 circular. To be eligible for public health nursing services, you have to have a medical card or have that status bestowed on you by the Minister. In reality, that figure has gone far beyond what the measurement of public health nurses was based on so it is not possible to provide any service. Then, when you are working in an area like that where you are constantly working short and constantly working beyond your hours, it is not possible to retain people.

Yes, the expectation of the public in respect of what you can provide is very stressful for staff on the ground, where families are, rightly so, looking for service and we are just not able to provide it, and obviously with management levels. There is also the demand from acute hospitals with regard to discharge. We are just not able to provide. For diabetics, urology patients and the people who need the care, people who are going to be with us for the rest of their lives and our work lives very often, we just cannot provide that service with the current challenges in recruitment. Public health nurses do take a long time to recruit, as the Deputy can understand, with the student public health nurse programme being a once-a-year programme. There are recommendations to look at that with regard to other pathways into public health nursing, and that is through 39 recommendations, which we could talk about at another stage, around microcredentialling community-registered general nurses.

The problem also is that there is a huge clinical nursing demand in the community, particularly with Sláintecare and the move to the left, and we have not looked at the workforce required for that. Where your public health nurse, who is a generalist nurse, is constantly pulled into clinical nursing, wound care and the chronic thing, they are not then getting to the children or the child developmental assessments because there is that generalist role. What is needed is the community RGN to be able to step up to that. There is no science yet. We do not have safe staffing within that, like in the acute hospitals. We need to increase our community RGN workforce to allow public health nurses to do what they were trained to do.

With the Department of Health and the dedicated child-health workforce in the next few years, there will probably be a recommendation that public health nursing retain that child-health focus because we know that early intervention creates much better outcomes in life. That is the challenge we have - the general public, the acute hospitals and the need for new clinical grades in the community to support public health nursing, if possible.

I welcome our guests. Recruitment and retention has been an issue in recent years for nursing and all other staff. What are the main features of the difficulties that are being created there? Is it lower pay or lack of accommodation or is there some other reason that we should know about? It is absolutely essential that we have adequate staffing at all levels throughout the health service but that they stay within budget at the same time. I note that permission was given for extra recruitment of 6,000 staff in 2023 but actually 8,000 staff were recruited. That cannot work because it is way above budget at that stage. What are the areas in which we have the most acute shortages? Why do we have those shortages? Why are we having difficulty in recruitment and retention?

The main reason right now that we cannot recruit is because there is a cap. The HSE imposed a cap on recruitment. The two directors of nursing who are here with me today do not have permission to recruit. They must go through at least four layers above them to get permission to put the advertisement in. If the Deputy is asking what is the main issue, I would say simply it is the cap and not giving the front-line clinicians who know where the gaps and vacancies are permission to recruit. That has become a bureaucratic nightmare. It takes about six months to get through that process. For example, if I know that ten of my staff will retire and they notify me a month in advance, I cannot advertise until I get permission but I cannot start asking for permission until they are actually gone. It is designed to delay recruitment.

We made the point earlier that the population growth in Ireland has significantly increased the demand for our health service but our staffing numbers are not meeting the demand. It is not that they have recruited more staff than they should have recruited but, rather, the demand required that number to be recruited-----

Yes, and I said earlier that we are not looking for a free for all. We are looking for the Government and the HSE to uphold agreements they have with us that say they will recruit to the level that is determined safe for patients - that is called the framework for safe nurse staffing and skill mix – but they are not doing that.

How do we compare with staffing levels in adjoining jurisdictions, for instance the UK, France or Germany? We are in the European Union. We are always extolled to comply with regulations that prevail in the European Union. How do we compare with our next-door neighbours when it comes to the payment of staff and salaries in general?

The UK is not in the European Union but we know that Brexit significantly affected its ability to recruit. We know it has had a lot more difficulties recruiting. The European Union does not set standards for staffing. It sets standards for education. In other words, there is an EU directive on the standards one must meet in order to practise as a nurse or midwife from the education perspective. What we do know is that countries or areas, such as New South Wales and California, which apply ratios based on patient safety and patient outcomes have much better retention. Nurses want to work in those locations and they go there to work. The Deputy is right – pay does affect this, of course, as does housing. There is absolutely no doubt about the influence of the high cost of rent. Staff nurses tell us that over 70% of their wages is spent on rent in some locations. That is a factor. In our prebudget submission, we sought for tax relief to be made available to those who have to rent close to where they work. It is not an option for nurses or midwives to work from home. They have to go in and attend. Many of our hospitals are in big urban areas and rents in those areas are expensive.

We cannot compete with the sunshine countries in terms of climate but we should be able to compete generally in terms of salaries for staff. It is suggested, for instance, that there are 12.8 practising nurses per 1,000 head of population, which is one of the highest ratios in the European Union. I do not know whether that is true or false. Is it correct?

I addressed this earlier but I can address it again, with the permission of the Chair. The OECD numbers in respect of the nurse ratio have been contested by the Government and the Department of Health because, traditionally, midwifery figures were included, but other countries do not include midwifery. In addition, other countries only count bedside nurses, whereas we count the whole spectrum of nursing. That will improve because the Nursing and Midwifery Board of Ireland has now taken responsibility for determining the numbers. Until now, it was done under the quarterly household survey and it was not specific. Those figures have been contested and they are not correct.

That is debatable because it depends on who you talk to. We get criticism on that, too, and we have to try to answer the criticisms.

When staff levels were increased - recruitment of 6,000 was approved and it went to 8,000 – what were the most sensitive areas to which those staff could be detailed? Were there areas that were more sensitive than others? Were there posts that need not necessarily have been filled at that stage? What is the situation there? We keep hearing criticism on the extent of the health budget and how it has raced ahead of all other services. We know that it is demand-led and that the population is increasing but we also have to have some ability to respond to the criticisms that are levelled at us.

On expenditure, our submission highlighted concerns regarding moneys going to the use of agency contractors, etc. Significant amounts of taxpayers' money are being spent on external consultancy expenditure, for example. Millions of euro are being spent on the provision of services via contractors and there was huge expenditure, of €647 million in 2023, on agency spend. Funds are being made available in the health service but they could be better used in some cases to provide more direct employment rather than funding private providers to provide healthcare.

Our challenge is that we cannot pick and choose when it comes to the delivery of health. For the person on the receiving end, that is their number one priority. It is very hard to say we should put funding into one area rather than another. We have called for what is in place but is not being honoured in respect of our INMO colleagues, namely, a staff safety framework which would allow services to be delivered based on the safe provision of staffing. Those figures are based on individuals, the acuity of the care required, the number of patients, the type of service and so on. That would allow someone the comfort whereby their work environment is one that is deemed safe by those measures. That contrasts with the current model for many grades, which is based on expenditure and money being allocated to an area and spent accordingly. That is what our submission today calls for. I will give an example. We called out some of this earlier. Support staff grades include the cleaners who keep the hospitals clean, porters who transport patients, catering staff who feed the patients and so on.

There are over 10,189 whole-time equivalents within support grades. For the last 18 months, that figure has gone up 19 across the country. Our members do not see the additional expenditure that has been allocated to health impacting them in their job on the ward, in a kitchen, in a porters' department and so on.

It is immediately obvious to some people within the service. There are some who claim within the service that is the way they see it. I agree with the assessment in respect of HSE staff but they have traditionally been over-employed in the health services. That is going back 20 years. There was always the reliance on agency staff and they became greater than the cause. Then those numbers grew and grew. For one reason or another, the ratio of agency staff to permanent staff has always grown but it has always been a problem within the health services. That is a fact. I have been there.

In fairness, in the last moratorium, which was introduced in the health service in 2007, we saw an exponential growth in agency staffing, directly as a result of the suppression of recruitment. It does the opposite of what is intended. When you put a moratorium in place, you will increase your agency costs because people still turn up at the hospital and they have to be cared for. They still require services in the community. It is not an option. The problem I think everybody needs to focus on is that we have a growing population. Our needs in the health service are increasing. We only have to look at the Government's own figures and projections. They ask for projections but when they get projections, they put a cap on recruitment. It is simply not sustainable.

If I might just give the figures I am quoting, the capacity review of 2018 to 2031 says there will be a 40% increase in demand for practice nursing, a 46% increase in demand for public health nurse appointments, a 39% increase in the need for residential long-term care, 70% for in-home care, a 16% increase in ED attendance - in fact, it is higher than that - a 37% increase in acute medical admission units and 24% increases in inpatient non-electives. We are not staffed to meet that projected requirement. Today there are almost 600 people sitting on trolleys in our hospitals because we do not have the capacity.

If the Cathaoirleach will indulge me for a second, I want to assure Deputy Durkan that the spending review 2022, a Government of Ireland publication, sets out the OECD numbers and states - I will quote this as the Deputy asked about other European countries - "For Austria and Greece, the data include only nurses working in hospitals. Midwives and nursing aides (who are not recognised as nurses) are normally excluded." Midwives are included in the figures for Ireland and Spain. The point is that we are not comparing apples with apples. We are comparing two different things. That will now be corrected by the nursing and midwifery board.

I will not take that length of time. I thank Ms Ní Sheaghdha and Mr. Ginley for coming in. Answering Senator Kyne earlier, they referred to the difference between the number of whole-time equivalents that have been hired and what the HSE is saying, and said that some services are being brought in and are being included in the numbers. Have they tried to engage with the HSE to get agreement on the numbers? It would seem quite mischievous on its part, presenting to us that recruitment is at a certain level when in reality it is not at that level. Have they engaged with the Minister on that? We need to get accurate information, as they can appreciate.

We referred the matter to the Workplace Relations Commission, as I said earlier. We had a conciliation conference in May of this year where we asked specific questions. I am just referencing nursing figures. The HSE confirmed that 417 whole-time equivalents were increased in the HSE census due to the transfer of the four hospices from section 39 to section 38. They were not recruited, it was just a change of status of the employment. Likewise, they confirmed that the fourth-year intern student nurses are included in the nursing figures. Again, they are not recruited. We asked for other information, which we now have because they have supplied it to us. We are to reconvene at the WRC. However, in respect of the last five dates that have been offered to the HSE to reconvene, it has not been available.

In respect of Deputy Durkan's point, on the expenditure, we had quite an in-depth conversation about home supports earlier this morning. In the Dublin region in its entirety, home support is provided by way of section 39 organisations. That is still an expenditure incurred by the HSE to provide those hours, but they are not direct employees and we are currently in dispute with that sector in respect of terms and conditions of employment. The expenditure is there to deliver services but they may not be delivered directly by direct employees, for example, by way of the section 39 arrangement or agencies.

There is an acceptance that there has been an increase in expenditure and that there has been an increase in posts. However, our submission endeavours to get members to interrogate some of the figures provided by the HSE and perhaps see that not every area has benefited to the same level. For example, the National Ambulance Service stated that it needed to double its workforce as of February 2023. What we have seen in the HSE's own data is that it has had a reduction in staff since December of last year, wholly brought about by the pay and numbers strategy.

Thank you. Ms Carberry's information is very useful but it is eating into my time, unfortunately. The information is important and it has to be acknowledged. If she could provide it all in a note to the committee, it would be appreciated.

As Ms Ní Sheaghdha knows, I come from the mid-west and I would like to give her an opportunity on the public record this morning to outline her latest view on the situation in University Hospital Limerick from her nurses' and midwives' perspective, given the ongoing situation.

Unfortunately, the overcrowding situation is not improving. We believe that the number of beds has to be increased, for obvious reasons, and the staffing has to match. We have a lot of vacancies in University Hospital Limerick and we have insufficient nurses working in the hospital to provide the care. As we have already put on the public record in respect of the tragic events that happened - again we offer our sympathies to the family and the loved ones who have to now deal with the outcomes - we would simply state that the staffing caps are going to cause more heartbreak and it is preventable. We have to make the correlation that has been scientifically made, that where you have the correct numbers of staff, you will have safer services for patients.

I have absolute sympathy for Ms Ní Sheaghdha's colleagues working there. It is horrendous.

She was talking earlier about a safe level of staffing. That has to be the worst example in the country.

The bottom line is that where we have gone to the trouble of having a scientific, researched tool that tells us what the safe number we must have is and it has not been implemented, we ask this committee to support our call to introduce legislation that would make it a requirement to implement the measure that has been scientifically proven. Legislation was on Committee Stage in 2018, namely, the patient safety licensing legislation, and that needs to be enacted. HIQA needs to have the power to do more than just report on unsafe staffing levels. It needs to be able to do something about it. This legislation will give it that authority and enforcement power, and we need that.

I thank the witnesses for their presentation. They mentioned that they have notified their organisations' members about a ballot. Will that comprise just these two unions or will other unions be involved in that? I am just wondering about the structure of the ballot and whether it will be a co-ordinated event among a few unions.

Fórsa, which represents administrative and clerical staff, is not represented at this meeting. We hear a lot about there being too much of this, that and the other grade and all the rubbish that people like to throw around as though it would somehow miraculously resolve the healthcare system if we just fired a few administrative staff or something like that, which we know would not work. We hear about the impact of not having enough nurses, ambulance drivers and so on, but will the witnesses speak to the impact on nurses or other medical staff when those administrative and clerical staff are not supported, are insufficient in number or are also up against pay deals and so on? What impact is there on patients and their safety when that piece of the jigsaw is missing?

I wrote to the Cathaoirleach looking for this engagement on foot of the HSE's presentation, but I absolutely think the committee should and must invite the Fórsa trade union to appear and present the case for the grades it represents. We work, in the health service and largely in the community, as teams comprising speech and language therapists, occupational therapists, social workers, public health nurses, community general nurses and home help workers. We do not represent the other grades but it is important the committee hears from them because they face exactly the same issues. The cap applies to everyone, not just the grades that are represented at this meeting, and if they were here, I am sure they would set out the facts and be delighted to appear.

That is welcome. In respect of the industrial action, all unions have their own constitutions setting out their rules, and the INMO has taken a decision that too many of our agreements with the employer have been broken and that our members are now working in circumstances that are causing significant health and safety risks to themselves. Fórsa has also got sanction from its national executive for the same decision, while other unions are at different stages. The national health sector trade unions will protest as one throughout the health service leading up to the ballots.

It is our intention to ask the public to help us here because what is happening in the health service is wrong. The current moratorium and cap on recruitment is going to lead to further poor and catastrophic outcomes for patients. We do not accept that. We do not accept it on behalf of all workers in the health service and we hope that, by coming here today and setting it out for this committee, the public will know we are on their side. This is not a pay claim. It is a desperate attempt to illustrate the folly of the current approach to the pay and numbers strategy, which is putting patient safety secondary and way down the list of priorities over and above balancing books into which we have no input regarding what is needed as representatives of those who work in the health service.

As Ms Ní Sheaghdha alluded to, lest there be any doubt, the staff panel of trade unions is working collectively on this matter. We meet each week as a group of trade unions because we share a common challenge in this context. It is not about one union over another union. We all see the impact of the lack of a given grade. We work with all parts of a multidisciplinary team and we need to have all the parts of that fully staffed to ensure the service we deliver will be safe and efficient for the patients who require it. We are working together and, as Ms Ní Sheaghdha outlined, protests are due to commence this week in an escalation of our campaign in response to the blunt instrument of the pay and numbers strategy adopted by the HSE, and that will escalate as time goes on.

It was helpful that Ms Ní Sheaghdha and Mr. Ginley highlighted that team element because it is frustrating when people do not understand that a plethora of people work in patient care, including clerical, administrative and all the medical staff. It was helpful to hear that on the record. When people throw out these willy-nilly comments suggesting that if we could just get rid of a certain part of the team, that would somehow resolve the health funding crisis, it is good to hear the unions say they are all part of a team that needs to work together as a whole to ensure patient care and safety.

I appreciate the Chair letting me in. I listened to as much of the meeting as possible from my office, and it has been a very concerning discussion. The introduction of the pay and numbers strategy is an underhanded move, and the witnesses gave a good description of how it will impact on services. A regional executive officer, REO, was appointed for my region, the mid-west, which suggested the reforms of Sláintecare were being implemented and was a positive indication, but we have since learned that a ceiling will further restrict that role and prevent us from ensuring safe staffing levels.

In respect of UHL, the witnesses might speak to the low morale the nurses are experiencing because of the pressures they are facing. The hospital has had huge increases in the number of admissions, especially among those over the age of 75, and there is strong population growth in that region in particular. In the context of management reform, there has been an indication that national implementation of the reform policy is coming down the line. Have the unions received any information on that? How are things for the nurses in this interim period when disciplinary action is being taken? Is that affecting their workplace?

On the vacancies in UHL, in August I asked how many vacancies there were in nursing positions and was told there were 240.46 whole-time equivalent vacancies. Is that the number the witnesses have? They spoke about the amount of public expenditure that is going on contractors, external consultants and agency staff instead of direct employment in those positions. That comes across as a bit of a waste. Will the witnesses specifically talk about agency staff in UHL and the cost of them, if they have that number? If not, will they speak about national numbers?

I thank the Deputy for the questions. The staffing numbers are what the Deputy set out. The biggest issue is the vacancies that arise not being filled and the bureaucratic process involved. We set it out earlier. It takes six months at a minimum. We now have a situation where directors of nursing, for example, cannot immediately advertise and fill a post. They have to go through a bureaucratic process, which slows everything down.

The big issue right now is that there is real pressure on maternity and paediatric services in UHL. We had a briefing session before the budget where one of our members from the paediatric service said it is impossible to provide sufficient, safe care given the number of vacancies. There is a vacancy rate of 30% in paediatric services. It is simply too high. Posts are suppressed. Posts required for dementia care, for example, are not being advertised. These are significant and important posts.

From our survey and from speaking with nurses, we know morale is poor. Unfortunately, that is not confined to UHL. It is right across the service now. People feel desperate that there is no end in sight. We had a really bad winter in 2019, when overcrowding hit levels it had never hit before. We then went straight into the Covid-19 pandemic, and now that we are out the other side, we are being hit again with the recruitment embargo. No one can be faulted for saying, "What is the point? I am doing my best." We are working very hard in very difficult circumstances with assault numbers increasing and we are still being told we have to do more with less. It not safe. That is the message we want to send from our members, nurses and midwives working in hospitals and in the community. They are saying that this is not a safe policy. It is not designed to ensure patient safety is front and centre. It just is not. Where we have agreement to recruit numbers to provide a safe level of care, it is not being honoured.

On low morale and UHL, as Ms Ní Sheaghdha said, it is spreading across the country. Within the region, we are seeing its impact in Croom and Ennis with the challenges the staff are facing arising from the significant challenges in UHL. There are vacancies in the region of approximately 70 support staff grades. I understand there is a similar figure, if not a higher one, for healthcare assistants. That is all adding to and creating the challenge our members face every day.

On the reform policy and threats related to non-adherence to it, our movement is made up of respect, people being consulted, engagement in advance of any change and respecting workers to be part of that change. We have called on the HSE, with the roll-out of the new structures, to make sure it adheres to the agreed information and consultation processes and the collective agreements in place which provide for opportunities to evolve and change in a manner that is consistent with a transparent process that involves workers' input, consultation, engagement and, where issues arise, mechanisms to address them through the State machinery we are all well used to. It is important, while there is pressure on the health service, that we do not lose sight of the agreements that are in place and of their importance in ensuring we move forward in a collective manner.

I was struck when Mr. Dunne was talking about the importance of the district nurse. I dealt with a case of an elderly couple a number of years ago. The man was upstairs in their house as he could not leave the room. His wife could not get up the stairs. Their son, who was their carer, was in a chaotic addiction and it was only due to the role of the district nurse that the support services kicked in. It is an example of the important day-to-day work district nurses follow through on every day. If we do not have those services or supports - whether it involves elderly people, young people or young mothers who have just had a child, all of which supports need to kick in - there will be a gap in services and it is the same in acute services.

We tried today to focus on the nursing aspects of this whole area. If we have time and if there is enough space in the work programme, we certainly hope to return to this issue again. I thank the witnesses on behalf of the committee for coming in and giving their valuable insight into the challenges facing their members. I thank the INMO and SIPTU for assisting the committee in its consideration of staffing levels in the HSE, especially in the area of nursing. Again, I thank the witnesses. This morning was very useful.