Nurses & Midwives 2010

Speech by Dan Neville TD on the Nurses and Midwives Bill 2010 – Dail Eireann – 27th May 2010

Deputy Dan Neville

I welcome the opportunity to contribute to the debate on this Bill. While I have some concerns about the Nurses and Midwives Bill 2010, to which I will refer later in my discussion, in principle, I welcome it. The Bill serves to enhance the protection of the public in its dealings with nurses and midwives and to ensure the practice of nursing and midwifery with a level of integrity which, I believe, is already in place but to ensure it continues in future. The Bill is supposed to provide for a modern, efficient, transparent and accountable system for the regulation of the nurses and midwifery professions.

Deputy Arthur Morgan

Some chance of that.

Deputy Dan Neville

This is supposed to satisfy the public. The relevant professionals all of whom are nurses and midwives should be appropriately qualified and competent to practise in a safe manner on an ongoing basis. This is an important principle.

I refer to an issue I have raised for several years, that is, the need to ensure there is a system of regulation which is accountable for other types of professions. I refer in particular to the professions of counselling and psychotherapy. Serious issues arise in respect of dealing with people in very vulnerable conditions but there is no regulation whatsoever in this regard. I will deal with this matter at greater length later.

Let us compare the approach of the Bill to nursing and midwifery and the total absence of regulation in respect of 12 other areas, which were supposed to be regulated under the Health and Social Care Professionals Act 2005. Some 12 professions were regulated in that legislation including physiotherapists, welfare officers, and so on. Since 2005 nothing has been done and not one of these 12 professions have been regulated. I have campaigned to add the two areas to which I have referred, namely, psychotherapy and counselling but I am informed the other 12 professions must be regulated before would be is possible to add these two professions to the regulatory framework about which I am specifically concerned.

I have seen at first hand the damage that can be done by untrained people dealing with vulnerable cases. There is a course which takes place over eight weekends to train someone to deal with eating disorder difficulties. Eating disorders are among the more difficult areas of psychiatric difficulty. They involve psychiatric, emotional and physical conditions. A complex combination is involved. It is totally unacceptable for someone to be qualified to deal with this after eight weekends I refer to a situation whereby after 90 hours someone can obtain an advanced diploma in suicide treatment. Such people can deal with those who are suicidal and those bereaved as a result of suicide. These people are going into very delicate areas and this can cause difficulties. I have raised this matter with the Minister, who fully accepts the situation should be dealt with, but it will not be dealt with until the 12 other professions are dealt with in the 2005 legislation. However, none of these have been addressed yet. At this rate, none of us will be in the House by the time some regulation is in place in this area.

I refer to the controls in this Bill. Certain training elements are required for psychotherapy and counsellors.

Of the professions involved in that area, 22 have come together to recommend training to ensure competency, but that does not stop anyone putting a plaque on the wall and charging €80 an hour for counselling and psychotherapy.

The Bill repeals the Act of 1985 and puts in place a new framework in respect of nurses and midwives, the body to be known as Bord Altranais agus Cnáimhseachais na hÉireann, the Nursing and Midwifery Board of Ireland. It recognises midwifery as a separate and distinct profession and provides for the clinical supervision of midwives, who must have adequate indemnity insurance. I am sure the indemnity requirement already exists but it is important to regulate it. The Bill also ensures a non-nursing midwifery majority on the board and on the fitness to practise committee. There is considerable concern about the fact that there will be a non-nursing majority on the board, and I will deal with this aspect later.

The Bill will establish an improved investigation mechanism for complaints about nurses and midwives, including the establishment of an assessment committee prior to fitness to practise investigations, and the appointment of investigators to facilitate such preliminary investigations.

Surely the area of counselling and psychotherapy should be covered by the fitness to practise element of the Bill. I know of people who have been seriously damaged by unregulated counsellors and therapists. The principle should apply to the area I raised earlier. The Bill includes a prohibition on unregistered nurses and midwives engaging in the practice of nursing and midwifery. That is as it should be. We must ensure the proper training of nurses. The training of nurses has changed greatly over the years.

I am not convinced the new system is an advance on the old. My own wife was trained under the old system and my mother was trained as a psychiatric nurse in the 1940s. The practical training they received stood to their human approach to the patient in all aspects of nursing, whether in the community or in hospitals. The more academic approach loses much of that. I do not say the content of the modern academic training is questionable. It is acceptable. However, the marrying of academic study with experience on the wards during a period of training inculcated in nurses an understanding that there was more to nursing than passing a final examination and getting a qualification. There was a patient-nurse relationship aspect to nursing, which is lacking in the modern approach.

The Bill also deals with the registration of nurses and midwives, of candidates and of advanced nurse and midwife practitioners’ posts. There will be a new statutory framework for the maintenance of professional competence of registered nurses and midwives. The Bill also deals with the dissolution of the National Council for the Professional Development of Nursing and Midwifery and the transfer of its staff, assets and liabilities to the board. That is a practical aspect of the Bill.

The primary objective of the legislation is the protection of the public. Key aspects of this relate to fitness to practise, competency and a non-professional majority on the board. In this regard, I raise the following points. The Bill seeks to introduce what is regarded as a two-part fitness to practise structure, which would bring the Nurses and Midwives Bill in line with the Medical Practitioners Act 2007. This structure provides for the establishment of the preliminary proceedings committee to give initial consideration to complaints and an internal fitness to practise committee to conduct inquiries.

The Commission on Patient Safety and Quality Assurance was established by the Minister to develop clear and practical recommendations to ensure that the quality and safety of patient care is paramount within the health care system. The Commission on Patient Safety and Quality Assurance advocates the separation of fitness to practise from the regulatory function. Under these proposals, the board will still be responsible for the preliminary investigation and if it is decided that there is a case to answer, the chief executive will present the facts of the case to the fitness to practise committee, which would operate outside the board. According to the regulatory impact assessment, “There is a lot of merit in what is proposed by the commission. However, the detail of how it would operate is not clear and it will be the work of the sub-group to examine and make proposals as to how this might be achieved”. The Minister, in concluding the debate, might comment on why she has not accepted the recommendations of her own commission on patient safety and quality assurance and why the proposal I refer to has not been developed in the Bill, but left to a sub-group, who will examine it and make proposals as to how the situation might be dealt with. While the Bill is going through the Houses, there is an opportunity for the implementation strategy group to make recommendations in this regard.

The proposed fitness to practise model is based on the model adopted by the Medical Council. It is my understand that the Medical Council has sought amendments to the new legislation, based upon its experience through its practice as a medical council. Can the Minister confirm if this is the case? If it is, what amendments has the Medical Council sought, as the Nurses and Midwives Bill will, otherwise, repeat mistakes already made? There is an indication that the medical council is concerned that the difficulties it identified will be repeated. The difficulties have already been experienced in the Health and Social Care Professionals Bill, before even one of the 12 professions has been regulated. The Minister has written to me on this matter and informed me that she must bring forward a Bill to correct difficulties experienced in that Bill. It was passed in 2005 but nothing has been affected by it yet.

The current board consists of 29 members, 17 of whom are elected by nurses and 12 appointed by the Minister for Health and Children. The new board will have 23 members, 15 of whom will be appointed by the Minister and eight elected by the professionals. There is concern at this arrangement.

he eight members of the new board elected by professionals are to include two nurses, one from general nursing and one from children’s nursing, of whom at least one must be in clinical practice; two nurses, one from psychiatric nursing and one from intellectual disability nursing, of whom at least one must be in clinical practice; one midwife and one public health nurse, of whom at least one must be in clinical practice; one nurse or midwife engaged in education; and one older persons’ nurse.

My party met the Irish Nurses and Midwives Organisation, which has voiced serious concerns about the proposed structure of the board and the adequacy of the representation of nurses and midwives thereon. It claims there is no way the work of midwives can be adequately represented or safeguarded with only one midwife on a board of 23. The same applies to the other strands of nursing. The board of 23 must be compared with a 25-member board for the Medical Council, which looks after 7,000 medical practitioners. The Allied Health Professional Council, which has a board of 21, looks after 5,500 to 6,000 allied health professionals.

The proposed membership does not provide adequate recognition of differing numbers within each area of nursing and midwifery. For example, there is one general nurse engaged in clinical practice who will represent more than 25,000 practising general nurses while one public health nurse will represent 1,700 public health nurses. Perhaps the Minister of State will outline the rationale that applied when this decision was made and whether she believes the approach she is taking adequately represents and reflects the discipline of nursing.

Section 25 allows for the payment of allowances to members of the board or committees. Perhaps the Minister could clarify the numbers of people who will be eligible for such allowances.

Section 46 establishes what is referred to as a “candidate register”. This means undergraduates will have to register with the new board and pay a fee for the privilege. Will the Minister of State explain the purpose of this new register and its benefit to the board other than its being a crude money-making exercise? Candidates are not independent professionals but are supervised at all times. It is not clear why they must register in the way proposed.

Section 46 establishes what is referred to as an advanced nurse practitioner/advanced midwife practitioner, ANP-AMP, post register. This post register will contain the names and details of advanced nurse practitioners’ posts and advanced midwife practitioners’ posts, and any other information required by rules. This register applies only where there is a post. If an advanced nurse practitioner wanted to move to a different hospital with no such post, he or she would not be not registered.

Perhaps the Minister of State will explain the purpose of this register? Is it to prevent people from developing services where the HSE and Minister do not want them? If one is off the register for a number of years, can one get back onto it? Many nurses, who are predominantly female, decide to leave nursing for a period to rear a family and then return to nursing. Many of my family friends have done so. No stipulation exists in the Bill for any other registered professional and his or her registration. The proposed register will, by default but perhaps not by design, prohibit the development of the profession.

The membership of five proposed for the statutory midwifery committee is hopelessly inadequate and will not ensure that the many areas of midwifery are represented, even through nomination, in the workings of the midwifery committee. The current legislation, as interpreted by the board, does not allow it to comment on the environment within which nurses practise.

Section 9 sets out the functions of the board. This section does not give the board a role to advise service providers regarding staff shortages, physical environment, poor quality or unsafe conditions. Every action the board takes must be carried out with the agreement of the Minister. Therefore, it is not acting independently in the interest of the public. It acts on the instructions of the Minister. As Members have stated, ministerial instructions do not, at all times, represent the best interest of the public. The Minister nominates the president, who does not have to be a nurse.

The chief executive officer of the new board will not be permitted to make any statements that differ, contradict or oppose ministerial and Government policy. A similar restriction does not apply to the chief executive officer of the Medical Council or the chief executive officer of the Allied Health Professional Council. Why is the chief executive officer of the proposed board being gagged? Surely it is in the interest of transparency that the chief executive officer be in a position to ensure the public interest is protected where he or she is extremely concerned about a certain development and is not being responded to by the system, Minister or the dysfunctional HSE.

The regulatory body should be allowed to seek to meet the service provider, advise it regarding a given matter and ask if anything can be done. Provision in this regard should be included in the Bill. Perhaps the Minister of State will comment on why the board does not have authority to do as I propose.