Nurses Retention Fee: Further hospital crisis imminent if NMBI don’t respond appropriately

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Speaking in the Seanad during my commencement debate on “the urgent need for the Minister for Health to outline the contingency plan to prevent an effective shutdown of hospitals in the event of mass un-registering of nurses by the Nursing and Midwifery Board of Ireland (NMBI) on March 2nd.”

Watch video of debate here:

An Cathaoirleach: I welcome the Minister for Health, Deputy Varadkar, to the House.

Senator John Crown: I am sorry if .I have delayed the Minister. As he knows, we have a professional relationship as peers in this House, but in my day job I work for him. I was a little bit tied up this morning, delaying my getting here.

What are the contingency plans of the Department and the HSE in the event of the apocalyptic scenario of the great majority of the nurses in the country finding themselves unregistered in approximately six weeks’ time coming to pass? Without boring the Minister with details with which he is familiar and that he has responsibly been trying to deal with, the nurses feel aggrieved that their registration board has recently asked them for a 50% increase in their registration fees, amounting to an 80% increase in the registration fee over two fee cycles. The nurses feel aggrieved because they correctly believe that they have suffered disproportionately among their peers the ravages of the recession, both in economic, take-home pay terms and in quality of work terms. They have been asked and risen to the task bravely of stepping up and taking on an increased burden in what the Minister honestly admitted recently was a health service that had been subjected to a cycle of cuts that under his stewardship has now thankfully come to an end.

However, the reality is that, during that time, nurses saw their salaries decrease, their workload increase, a failure to replace nurses due to embargoes and the same tax and USC increases and water and housing charges that everyone faced. Their hard question is on what they have been getting in return for the increased registration fee. The representations that I have received from many nurses were to the effect that they have not felt that the board has given them good value for the fee. I will not go into details or personalise the matter, but the board has had quite a few expenses that the nurses find difficult to understand, for example, public relations costs and travel costs, which I am sure were undertaken for entirely legitimate business by the board. The nurses’ sense is that the austerity has not been well spread.

Under instruction from their organisation and with a high degree of loyalty to same, they have indicated that they will not pay the increased fee, but will instead pay last year’s fee, which would have the effect of finding the overwhelming number of nurses unregistered by their board by some date in early April. I hope that this will not come to pass, but I would be grateful to know whether there has been contingency planning. I thank the Minister for attending.

Minister for Health (Deputy Leo Varadkar): The Senator did not hold me up, as I have just come from the Dáil. I am the full-time parliamentary spokesperson for the HSE on Wednesday, so I will return to the Dáil and the Seanad at least once more today.

Senator John Crown: I thank the Minister.

Deputy Leo Varadkar: I thank the Senator for raising this matter. As he may be aware, the Nursing and Midwifery Board of Ireland, NMBI, voted on 17 September 2014 to increase the annual retention fee of each registered nurse or midwife to €150 from €100. The annual retention fee in 2013 was €88. The registration fee is set by the NMBI, which is a self-funding organisation. I recognise that the board must meet its obligations within the financial resources available to it. At the same time, this demands that obligations are met on the most economic basis possible and all planned expenditure can be demonstrated as necessary.

It was made clear on the enactment of the Nurses and Midwives Act 2011 that the board would continue to be self-funding and needed to plan and cost how it would fulfil its legal obligations. Following detailed negotiations with the executive and board members in 2013, it was agreed in October 2013 that an initial one-off sum of €1.6 million would be granted by the Department to the board to cover its 2013-14 costs, but that the board would have to increase its income in 2015 to undertake its commitments under the legislation.

The staff associations have undertaken a campaign of non-payment in respect of the new annual retention fee of €150 and have advised their members to pay the 2014 fee of €100 instead. Any nurse who does not pay the appropriate fee may be removed from the register. If a nurse or midwife is removed from the register, he or she will not be permitted to practise from the date of deregistration. However, the commencement of any deregistration process is an administrative matter and at the discretion of the NMBI. The NMBI has advised that it is committed to making its best endeavours to resolve the impasse with the staff associations.

I met the president, vice president and chief executive of the NMBI on 29 January to discuss the dispute. I again requested that the board re-engage in discussions with the staff associations as a matter of urgency. I expressed my concern regarding the implications for the health service and patient safety should the current impasse over the annual retention fee continue. I have asked the board to arrive at an outcome that secures its minimum financial operating requirements and avoids a scenario whereby nurses may be removed from the register for non-payment of fees, with potential consequences for service availability and continuity of care.

Since meeting the board’s representatives, I have been informed that it has engaged in discussions with the nursing unions with a view to holding further talks, possibly facilitated by a third party, on the means by which the board and staff associations might come to an agreement on the fee structure for the future. The NMBI has indicated that it will consider amending the fee at a meeting scheduled for 3 March. Furthermore, it has indicated that it will withhold issuing reminder notices to registrants until after the review takes place at that board meeting.

As of 12 February, 25,980 nurses had paid the full €150 fee.

An additional 8,000 have paid the €100 fee and some 30,000 have paid nothing so far. The 1,245 graduates of 2014 who registered with the NMBI and paid prior to December 2014 have registration certificates which are valid until the end of this year. I will continue to monitor the situation closely over the coming weeks and I again encourage all parties to take the necessary steps to reach a resolution to this issue. It should not be insurmountable. In the event of any nurses being de-registered for non-payment of the fee I am confident the HSE will take appropriate action to ensure that patient safety and continuity are maintained. It appears that a process is under way involving a third party so it will not be the case that anyone will be de-registered in six weeks time. A process has to be gone through before any nurse is de-registered and that process has been suspended during the current talks.

Senator John Crown: I am very grateful to the Minister for his thoughtful response. Nurses believe right now that their only two interactions with the board are to be given their money and to be disciplined by them. They are not aware of any great service being rendered to the profession, in particular in the area of continuous professional development and they feel the board has not stepped up to the mark in that area. I am hopeful that the current potential crisis can be overcome but in the long term some serious thought should be given by the board to the whole portfolio of their activities relating to developing the nursing profession.

I am reassured that in the event of a large number of nurses being de-registered steps will be taken to ensure patient safety. There only seem to be three ways that can happen. The first is to somehow give the nurses who have been de-registered some administrative leeway to allow them to continue to work. Second, it can be achieved by hiring other registered nurses to strikebreak, though I am aware that is not necessarily the right word. Perhaps I should say “overcome the industrial dispute”. Third, we can cancel procedures and decrease the workload per nurse. I understand there is a negotiating position but can the Minister give us a hint as to which way the specifics of the measures to ensure patient safety will lean?

Deputy Leo Varadkar: The Senator knows this but it is important to put on the record that the main service the nursing and midwifery board provides is to the public and to patients. It is not there to service the interests of nurses and midwives per se, nor is it a trade union or staff association. It exists to protect patients and ensure fitness to practise. It hears complaints, such as those against the nurses shown up in the “Prime Time Investigates” documentary on Áras Attracta. It does, of course, provide services to nurses, such as the documents they may need to travel and work overseas, and it is intended to bring in competency assurance as well but the main reason it is there is to protect the public and patients. It is not a nursing advocacy organisation. It is also generally well established that professionals should bear the cost of their own regulation. The fee nurses pay is higher than that paid by therapists but medical and surgical interns, many of whom earn less than nurses, pay more, at €310. Pharmaceutical assistants, who also earn less than nurses, pay over €200. The fee nurses are being asked to pay is very much in the middle range. Nonetheless, there has been a big increase and it has almost doubled in two years. It is legitimate for nurses to ask why this increase has taken place, how the money is being spent and whether it will keep going up. The nurses have reasonable concerns in this matter and I hope all the questions can be answered to their satisfaction and to that of the board through the current process. The HSE does have options and it is probably best for me not to speculate on which of the three or four options, or which combination of them, is intended but contingency planning is under way. Having said that, it is my expectation and hope that this is resolved as everybody wants it to be resolved without patients being endangered in any way.

Senator John Crown: I agree with the Minister and I do understand the role of the nursing board but the best way to ensure safety is prospectively, not retrospectively. In Ireland we have too often followed the black box philosophy. We put structures in place to investigate health care disasters after they occur. If I may paraphrase an expression usually used in another context, it is the politics of the last health care atrocity. We need structures which prospectively prevent such disasters occurring. I believe the nursing board does have an advocacy role for standards in the profession and is not there just to inspect them after something happens. The money would be much better spent if the board used its efforts to ensure continuous professional education is developed.

Deputy Leo Varadkar: I agree that the board also has a role in advocacy and it is not only concerned with fitness to practise One of the aspects of the legislation I am about to commence deals with exactly that subject, namely, competence assurance. There is, however, a cost associated with that and the cost will have to be met.

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