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It was the prelude to the first all-out national nurses’ strike in 1999. On screen was General Secretary of the Irish Nurses and Midwives Organisation (INMO) Mr Liam Doran.
“The mid-’90s were turbulent years, with ever-growing nurse and midwifery dissatisfaction and militancy,” read the text of the TV station-provided footage.
In the broadcast, Mr Doran spoke of a growing sense in the public sector “that people feel they are being short-changed”.
The clip was played at the INMO’s Annual Delegate Conference 2017, while marking Mr Doran’s imminent retirement. It was illuminating in many ways — it captured a profession at a crossroads and reflected the ‘militancy’ charge levelled at the INMO in intervening years. It also showed Mr Doran as an able media performer from the outset.
Speaking to the Medical Independent (MI), Mr Doran said he has never personally undertaken media training.
“The media part of it was something that I just seemed to be able to get on with,” he told MI during an interview covering doctor and nurse roles, pay and conditions and health service reform.
“I believe as a General Secretary of a union that represents 35 per cent of the health service staff, you have to speak up and speak out; and that, luckily enough, has come quite easy to me in that sense, but it is not training or programmed.”
Doctors’ views on the INMO have varied over the years. Some envy its strength and stability relative to their own union experiences; some view it as intransigent.
The IMO and INMO have co-operated at times, in that its members would share many concerns. However, inter-union rows have also occurred and these are likely to increase.
The territory of healthcare delivery is being rapidly redrawn, with ‘turf wars’ spanning wider frontiers. The nursing profession has gradually moved into spaces traditionally occupied by doctors. Yet both professions face global shortages and the related rise of ‘assistant’ roles — healthcare assistants, nurse associates (as piloted in the UK) and physician associates.
The report of the Oireachtas Committee on the Future of Healthcare, Sláintecare, stated “there is little use in workforce planning in silos in relation to doctors or nurses alone… Expansion and substitution of traditional and new cadres is important to deliver quality care for an expanded package”. Sláintecare also called for increases in doctor and nurse numbers, but the above extract seemed to suggest that other healthcare workers could move into doctor and nurse spaces.
Asked about this, Mr Doran said the health system cannot meet demand without moving away from the “medical model of care” that has “dominated” healthcare interventions. He said much of future demand would be driven by chronic diseases and involve primary care, making reference to the recent ESRI report on major demographic issues facing the Irish health service (by 2030, demand for acute hospital services will rise by 33 per cent and older persons’ services by 54 per cent).
“That can’t be done under a medical model of care, so we are all going to have to learn how to work better — that means expanding the role of the nurse, it also means expanding into primary care with physios, dieticians, occupational therapists and much more seven-over-seven arrangements,” said Mr Doran.
Last August, Minister of State at the Department of Health Jim Daly referred to health sector unions being the biggest barrier to reform, a contention Mr Doran has refuted. Nevertheless, the INMO chief appears to have unmovable positions on other types of grades, such as nurse associates; “subterfuge for substitution and replacement”, and physician associates, piloted in Beaumont Hospital, Dublin; “these things tend to come out of a failure to solve the core problem”.
The INMO is also seeking the conversion of non-training NCHD posts into advanced nurse practitioner (ANP) posts.
“I think at the last count, we have around 1,000-odd non-training places for NCHDs; how sustainable is that? In other words, you are an NCHD but the post you are in isn’t counting for your training… that isn’t viable so we have to grow our own cadre of advanced nurse practitioners to work in those kind of ED [emergency department] areas, in those endoscopy areas and so on. Because we are not attracting the doctors [into these types of posts], we won’t attract the doctors, they have a high turnover; when you have a high turnover the question of quality of care, continuity of care and so forth [arises].”
Currently, there are around 150 ANPs and just a handful of advanced midwife practitioners (AMPs).
In November, the Department of Health announced a new programme for ANPs, which will result in the delivery of 700 ANP posts by 2021. The ANP initiative is a key recommendation of the Department’s draft Policy on Graduate, Specialist and Advanced Nursing Practice.
According to Mr Doran, every ED should have six ANPs to manage the more routine injuries. “Only one hospital has six, in the ED at St James’s. Some have none still. None. That is an issue too about medical resistance to delegating and allowing it to happen.”
Are there specific examples of resistance to advanced nursing?
“Well, drug prescribing was resisted by medics for two years… It is 20 years next year since the Report of the Commission on Nursing recommended the establishment of advanced nurse practitioners. We currently have about 150 in the system — why is that? Resistance.”
From the IMO?
“I am not going to blame [the IMO]. From doctors, from the medical profession. How do you justify staffing a service with NCHDs who are not getting training recognition for it… Surely you get a permanent workforce, grade them properly — advanced nurse practitioner — and have a constant [presence]. And I would ask anyone to show, where advanced nurse practitioners have been introduced, where it has been a negative.”
The IMO has registered very clear opposition to nurse-led services in the community via its Submission to the Department of Health on Draft Policies to Enhance Roles for Nurses and Midwives (May 2017). The IMO submission, while recognising “an opportunity to enhance” nurse roles in the community, said the draft Policy on the Development of a Community Nursing and Midwifery Response to an Integrated Model of Care “suggests an expanded role for nurses and midwives into roles that are traditionally within the remit of Specialists in general practice and their teams”. It said that while draft policy “suggests that clinics led by advanced nurse practitioners have been established in a number of jurisdictions, the development of non-physician-led healthcare services shows a profound lack of understanding by policy-makers and allied healthcare professionals alike of the key role played by general practice and community care in modern healthcare systems”.
In response, Mr Doran commented: “We had it today in front of the Oireachtas [Health] Committee — what does primary care mean? To the IMO and general practitioners, it would mean that they become ‘the chief’ of a very much expanded regime, if you like, but they want to maintain an independent contractor status. It is not compatible. If you have universal access to care in the community, all the team should be directly employed by the State… Primary care reform necessitates an end to the role of GP as gatekeeper for ‘everything that happens’,” argued Mr Doran.
“Changing demographics, the changing nature of health presentation and illness presentation is going to necessitate that anyway. Chronic disease management and care of the older person are going to be mainstays of demand, and obesity is the next epidemic coming our way. Are they going to be best managed by GPs, who are already over-run by the short, episodic-type consultations with patients? I don’t think so. Not fully utilising the skills of all other registered health professionals is pure folly, and protectionism.
“We are saying that all new contracts should be for directly-employed GPs, so that over 15 years you will phase out the current contract and replace it with a public-only contract, which has to have proper levels of pay and pension so we can attract the best and brightest into general practice in Ireland.”
To his knowledge, is the Department considering this?
“Well, we are about to find out… Look at it the other way, if you envisage Sláintecare as being a reality, which is universal GP care, universal primary care, how do you deliver it? You are telling me the way to deliver it is, a private sector person comes in and delivers universal care but everybody else will be directly employed? How does that work? Or are you saying ‘no, no, the GP should become a business and he or she would employ everybody else’.”
Mr Doran is of the view that GPs are reluctant to concede a situation where they have a public contract that also allows them to work privately. When MI suggested that many GPs do not consider the GMS contract as “good”, Mr Doran said: “Fine. What other contract do you get subsidised for employing practice nurses who can then generate private revenue for you? Why is that okay? The practice nurse will do flu vaccine but the GP will be paid for it, in addition to their GMS payment; do cervical smears, in addition to their GMS… is that a good sustainable model?”
Additionally, Mr Doran said change is needed in regards to out-of-hours GP services. He said patients are unlikely to ever see their own GP in out-of-hours settings and this results in unnecessary referrals to EDs.
“That is why the primary care team has got to work seven-over-seven; you have got to have access to my records — that is how you keep people out of hospital. The GP out-of-hours on-call is fully understandable for work-life balance but I gently suggest it is not necessarily the best model for continuity of care.”
Mr Doran also believes there needs to be a public-only “properly remunerated” consultant contract. He considers Ireland as “very short of consultants” and “too reliant” on NCHDs. He said the recent RTÉ Prime Time Investigates documentary showing some consultants breaching their private practice on- and off-site limits was a surprise to no-one.
On that issue, though, did senior nurses not also have a duty to raise a red flag where these cases were occurring?
“That is a fair point,” said Mr Doran. “I can remember in 1997/8, there was a grade of manager called ‘medical manpower manager’ appointed. What have they been doing for the last 20 years?…What have all these CEOs of all these hospitals been doing, what have the Group CEOs been doing for the last five years?
“Their job was oversight. I would accept that Directors of Nursing have a role to play in managing the whole hospital, not just their own [area]. But I would argue that senior management who drew up the contract with the consultants have the greater obligation to make sure it is being honoured in practice as well as in theory, and they went missing.”
Meanwhile, Mr Doran warned of trouble ahead if nurses’ claims for better pay and conditions are not realised. The INMO is arguing that nursing/midwifery pay scales are between 15-to-20 per cent lower than allied health professionals, who it says require identical entry qualifications and have a shorter working week.
“I will never accept that a nurse in a modern health service is worth less, 15, 20 per cent less, than all other health professionals. I mean, I would make the point, I am not being smart — is a registered nurse worth 15-to-20 per cent worse than a play therapist, which is currently the case? I don’t believe it is. Or a physiotherapist? I don’t believe it is…
“We work two hours longer than those people; why? Why should a nurse in a very physical work environment work two hours longer than an OT or a physio, who are also working very hard? I don’t think it is fair.”
The Public Service Pay Commission will issue a report on recruitment and retention by quarter two, 2018. If it fails to recommend “the necessary improvements in pay”, the INMO will ballot for industrial action, indicated Mr Doran, who could not “pre-empt” what type of action that could be.
He said there are 3,100 less nurses and midwives in the system than 10 years ago and the quantum of work has increased by around 20 per cent. The focus on decreased length of stay and day-case procedures is very “nurse-intensive”, something he said is “completely disregarded and misunderstood by the system”.
“So, when you say, ‘what is wrong with Ireland as a place for Irish nurses to work in’, it is too hard. Simple as. Poor staffing, poor pay, long hours, and until we solve that conundrum’ we won’t grow our health service…
“Nursing and midwifery, since our staffing agreement last March, is subject to a section 10 order under the Health Act 2004. What the Minister did there was, he stipulated there should be a 1,224 increase in the nursing workforce by the year’s end — it is fully funded. The last report indicated we had grown the workforce by 13 [whole-time equivalent net increase from December 2016-August 2017]. Now, the HSE is saying the last quarter will show a spike because the graduates will take up [posts], but their last estimation is 600 to 650 graduates of the 1,500 who graduated are taking up the permanent jobs…
“We are training a good number of nurses in this country — actually, this year 1,800 started just in September. What we have to do is create a situation where, when they graduate in four years’ time, the vast majority of those, 90 plus per cent, of those people stay. And we are a long way short of creating that environment at the moment.”
Mr Doran said that over 9,000 nurses left Ireland from 2009 to 2013, with a high percentage going to the UK. In that sense, there is a population that can be enticed to return with better pay, he argued. But health service management believe this is all “union rhetoric,” he added. “They just don’t get it.”
“Management in Ireland have never valued the contribution of nurses to the healthcare system — never. Management in Ireland view them as ‘blue-collar workers’, not a ‘white-collar professional’, if you want to put it in descriptive terms. They never have. If they did, they would have woken up and smelled the coffee years ago. But what they don’t realise is that the demographic clock is ticking… ”
Successive ministers for health have gotten it wrong, maintained Mr Doran. “All of them — they have listened to the bureaucrats, been swayed by the bureaucrats. Gone with the latest groovy idea.”
The only people held accountable in the health service are the regulated healthcare professionals, he said.
On health service management reform, Mr Doran would like to see four regional health authorities. He wants a de-layered system, with clinical directors and directors of nursing empowered to make decisions and control budgets.
The salaries of union bosses came under renewed attention during the recession. The INMO has always refused to publicly state the salary of its General Secretary.
“You can take the simple view — the INMO is a private sector employer. I have a contact of employment with my employer, that is totally private,” said Mr Doran. “My salary is paid for by members and every year in the annual report we publish the grade — the media was a bit slow, to be honest with you, to work out my salary because we have put for years that I get paid the same as the Director of HR in the HSE [approximately €147,000]… So we put the grade… not names, but everybody knows me in that sense.”
However, Mr Doran believes that public disclosure of salary is not warranted when the salary is not paid by the public purse. He said INMO members are fully entitled to know the salary, ask about the issue and debate it.
Mr Doran recalled driving out of the INMO offices some years ago and being snapped by a tabloid photographer who had been hiding behind a wall. The next morning the photo appeared alongside an article, with the tone “no wonder Doran won’t take a pay cut in his new car”.
It was a nice car, but no Rolls Royce or Ferrari, Mr Doran pointed out.
“Hiding behind a wall and taking a picture of my new car was fairly sad, I thought. But it was part of the Ireland of then.”
Ms Phil Ni Sheaghdha will take up the post of INMO General Secretary from January 2018. Like Mr Doran, she is a former Director of Industrial Relations at the INMO, and very much in her predecessor’s mould.
In fact, she is also a former nurse, like Mr Doran.
While some may vehemently disagree with Mr Doran’s views and position on certain areas, they may also concede that he has always displayed passion in his advocacy for nurses and defended the profession strongly. Would it have been this way if he hadn’t been a nurse himself?
“I would like to think so but I suppose human nature is what it is,” he said.
“I can visualise what it was like, even though nursing is very different to what it was then, but at the same time I would like to think I have some sense of connection with what a nurse does and the fact that I think they have been appallingly treated, particularly in the last decade since the recession hit.”