Opening Statement
Minister for Health
Joint Oireachtas Committee on Health and Children
10 July, 2014
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Thank you Chairman, members of the Committee.
I am accompanied today by Minister White, Dr Siobhan O Halloran,
Chief Nursing Officer, Matthew Collins, Eligibility Unit and Fiona
Prendergast Finance Unit. Unfortunately Minister Lynch cannot be
here today and sends her apologies.
The Committee asked that I address issues raised by the Irish Nurses
and Midwives Organisation and the availability of epipens, arising
from hearings by the Committee.
The INMO raised issues regarding staffing in the health services. The
Committee will be acutely aware that public sector staffing and public
sector pay is subject to national pay agreements – Haddington Road –
and the moratorium on public sector appointments.
The health service is required to achieve savings of some €290
million in 2014 under Haddington Road. This is set out in the 2014
Service Plan. The HSE’s National Directors developed an
implementation plan to achieve the savings. It involves reviewing
rosters, skill mix and staffing of hospitals to ensure that the extra
hours provided for under Haddington Road are maximised so that we
can reduce spending on agency and overtime. This must be balanced
against the overriding need to ensure patient safety is maintained.
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The same imperatives apply to the number of staff employed in the
health service. There is a target to be reached as part of compliance
with employment control frameworks but this must be balanced
against the need to ensure patient safety is maintained.
That is why the HSE may recruit where it is necessary to do so in
order to ensure patient safety and quality care and to support service
delivery.
In terms of nursing, there are almost 34,600 nurses and midwives in
the health service, as well as almost 3,200 health care assistants –
including interns. While Haddington Road is about staff numbers, it
is also about things like the graduate nurse and midwife initiative and
the support staff intern scheme.
The Graduate Nurse/Midwife Initiative supports the retention of
graduate nurses and midwives within the Irish health system and
enables them to gain valuable work experience and development
opportunities post-graduation. Two-year contracts are being made
available under this initiative and nearly half of these have been filled.
I would take the opportunity to note that the HSE has a specific
sponsored Student Public Health Nurse Programme, graduates of
which fill public health nurse vacancies.
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The Support Staff Intern Scheme facilitates interns in achieving the
FETAC level 5 qualification, which are an invaluable asset in their
professional development. These interns will provide vital support to
healthcare professionals, including nurses, in the healthcare setting.
So, while overall nursing numbers may have fallen by 12% since
2007 (nearly 5,000), they still represent one third of the health
services workforce. Alongside this, the number of midwives has
increased by 46% (400), weekly working hours have increased, 450
nurses and midwives have started the graduate scheme and 330
healthcare assistants have started on the intern scheme. In this way
Haddington Road Agreement, has provided us with additional
resources and should be seen in the context of the overall reform
programme and the range of initiatives we’re pursuing to improve our
health services and enhance patient safety.
Collectively, these additional resources will enable the HSE reduce
expenditure on agency and my Department, with the Department of
Public Expenditure and Reform, is also looking at other ways to
achieve savings on agency, in light of developments with regard to
the Nurse Bank Initiative.
Given the challenges we face, we can’t conceive of our health
services as just a numbers game. That is why we are reforming how
we deliver health services. Hospital Groups are especially relevant
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here because the changes inherent in their establishment will enable
us to make optimum use of our high quality resources – including
nurses.
There is a wide range of challenges associated with determining
appropriate nurse staffing and skill mix levels in hospitals in Ireland.
Deciding on an optimal number of nurses is not an easy task. There is
a delicate balance to be struck to meet patient safety and economic
requirements. Achieving this requires relevant expertise to be applied
to the decision making process.
It is for this reason that we are establishing a taskforce to develop a
framework that will determine the staffing and skill mix requirements
for the nursing workforce in a range of major specialities. The focus
will be on the development of staffing and skill mix ranges which
take account of a number of influencing factors. In this regard I would
highlight that nursing is now a graduate profession and Ireland was
one of the first countries to embrace this – we’ve had the
undergraduate pre-registration programme since 2002. The benefits of
this highly trained workforce are just one of the factors that has to be
considered in looking at staffing levels.
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Phase I of the taskforce project will focus on developing a staffing
and skill mix framework related to general and specialist adult
hospital medical and surgical care settings.
The taskforce will be chaired by Dr Siobhan O’Halloran, the Chief
Nursing Officer, and will comprise a range of experts. The use of
staffing ranges, as opposed to staffing ratios, will retain flexibility in
the system while ensuring the safety of patients.
The INMO is represented on the Taskforce, the first meeting of which
will take place on the 23 July.
On epipens, let me first take this opportunity to extend my deepest
sympathy to Ms. Sloan and her family on the loss of their daughter,
Emma, who suffered an anaphylactic reaction last December.
I know that this tragedy prompted the Committee to hear evidence
from a number of contributors in relation to the provision of
adrenaline auto-injectors in Ireland – and I know Ms Sloan was one of
those who appeared.
The Pharmaceutical Society of Ireland, whose primary function is to
regulate the pharmacy profession in Ireland, is currently undertaking a
statutory investigative process related to events on the night Emma
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died. In these circumstances, therefore, it would not be appropriate
for me to comment further on the specific case.
Let me say first of all that my Department is currently examining the
feasibility, taking account of policy and patient safety considerations,
of amending Prescription Regulations, to facilitate wider availability
of adrenaline pens in emergency situations. My Department plans to
conduct a consultation process which will serve to inform a policy
decision on the matter.
If I may discuss the issue more broadly, the incidence of allergy,
including nut allergy in developed countries has risen steadily in
recent years. While the reasons for this increase are not fully
understood, the effects of a nut allergy can be severe. Avoidance is
key, along with a combination of proper diagnosis, attention to food
labelling and the available of emergency medication.
Adrenaline auto-injectors, as injectable medicines, are supplied as
prescription only medicines. Under Irish law designated health
professionals, that is to say registered medical practitioners, dentists
and nurse prescribers may prescribe adrenaline auto-injectors. Strict
controls are placed on who may supply medicines to patients, for
example, registered pharmacists. Regulations control those health
professionals that may administer prescription medicines to patients
in certain circumstances (for example registered pre-hospital
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emergency care personnel, registered opticians and others). The
Regulations also provide that a pharmacist can supply a prescription
medicine in emergency circumstances without a prescription.
Proposals to widen access to adrenaline auto-injectors range from
making them available without a prescription to making them
available in every school and restaurant in the country.
However there are complex considerations to be considered to ensure
that patient safety is fully protected. These include for example, the
identification of the category of persons designated to administer the
auto-injector. This would involve a register in order to clearly identify
the individuals who have an entitlement to supply or administer the
adrenaline auto-injector.
In order to quality for inclusion on the Register an individual would
have to complete a certified training programme which would cover
such things as identification of an anaphylactic reaction, the
administration of the medicine and the follow up care after the
injection has been administered. It would also involve setting up a
clinical practice guideline or protocol which would cover such aspects
as the supply of the auto-injector, the certification of the
establishment where the auto-injectors are located, their storage,
persons responsible for storage and record keeping.
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There are also patient safety considerations. These include the
misdiagnosis of anaphylaxis and the potential adverse implications of
incorrect or inappropriate administration of adrenaline. There is
potential for harm if administered to a patient with certain underlying
conditions who is not suffering from an anaphylactic reaction. These
include administration to patients with a history of/or underlying
cardiac arrhythmias, cardiovascular disease including angina and
hypertension where incorrect administration could result in an
exacerbation of these conditions or a significantly worse healthcare
outcome.
Availability of auto-injectors is another issue. The Health Products
Regulatory Agency (HPRA), formerly the IMB, continues to work to
ensure that there is availability from multiple sources. In view of the
potential for supply problems, however, it is essential that adrenaline
auto-injectors are utilised in the best possible manner.
The shelf life of AAIs is relatively short ranging from 18 to 24
months. It is important that the products are not used after the shelflife has expired as after this time the efficacy for the product can be
reduced.
To conclude, I support making medicines more accessible to patients
where it is safe and appropriate to do so and my Department is
examining this particular issue as a priority.
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