Jo Tully argues that the upcoming industrial action by health service workers could overturn the legacy of the austerity years and mark the beginning of a fight-back against the deep crisis of our health service.
The trade unions including FORSA and the INMO are in the process of balloting its members for industrial action in the HSE up to and including strike action in the coming weeks.
While the HSE announced in July that it was lifting the recruitment embargo in place since May 2023, it appears to be – yet again – a game of ‘smoke and mirrors’.
The Trade Unions action is in response to the publication of the ‘Pay and Numbers Strategy’ which governs the levels of staffing available within the public health system in any given year. It was published in July, 6 months earlier than it normally would. It was published without any union consultation which itself breaches industrial relations protocols.
The strategy document classified all unfilled posts as of Dec 31st, 2023, as obsolete. This means that at the stroke of a pen thousands of HSE posts, including at least 2000 nursing posts, will disappear. Furthermore, the document sets a ceiling of 129,000 for HSE employees and puts in place structures which ensure that recruitment will be restricted. The proposed structures will strip out clinical involvement and will be controlled effectively by 8 designated officers in the HSE – bureaucrats – who are completely removed from any clinical involvement. Staffing levels will be dictated by budget requirements, not by clinical requirements, nor safety needs, nor by the demands of an expanding population.
Recruitment Freeze
This announcement has been made in the context of a recruitment freeze that was already put in place across the board in the HSE in May 2023 and which has affected all levels and staff grades. The May 2023 freeze resulted in serious gaps in staffing from nurses, radiographers, physiotherapists, to healthcare assistants etc. This new announcement of July 2024 copper fastens what was already frozen and imposes further restrictions on future recruitment.
In the autumn of 2023, the earlier May 2023 freeze was formally lifted for nurse recruitment – staffing levels being dangerously low – but the reality on the ground remained very difficult. The INMO insists that recruitment efforts have continued to be tied up in red tape resulting in unacceptable delays and the blocking of nurses returning from career breaks. They have also prevented nurses who have already interviewed from taking up promotional posts and made recruitment from overseas, on which we are dependent, next to impossible.
The restrictions of overseas recruitment are very worrying, given that last year more than one third of all those who applied to be registered with the Nursing and Midwifery Board of Ireland, formerly An Bord Altranais, were from outside the EU. Indeed, Ireland stands out in Europe for our dependence on overseas nurse recruitment. According to the NMBI Nurse Register, as many as half our nurses and midwives are international nurses and trained abroad. (State of The Register 2024, An Bord Altranais agus Cnaimhseachais na hEireann). And this was the situation prior to this latest announcement on recruitment restrictions. This is a living example of how our society needs these immigrant workers. Far from them somehow taking from the Irish they are providing vital care for them.
This 2024 restriction on recruitment comes on top of what had been an effective freeze across the board on recruitment since 2023. The unions credibly argue that it will seriously curtail recruitment into the future, leading to rapid further deteriorating staffing levels with knock-on consequences for patient care.
These recruitment restrictions, as noted by the Irish Independent in mid-November, block even agreed posts. In Tullamore Hospital a Healthcare Assistant who had been selected after interview for a permanent post was informed by management that these latest restrictions meant that her appointment would not go ahead.
It is simply unconscionable that, at a time of a budget surplus of €8 billion and a further windfall of €13 billion from the Apple case, recruitment restrictions are happening when the health service is so blatantly under-resourced and in chronic crisis.
Waiting Lists
These restrictions are being put in place as waiting lists continue to grow and staffing levels continue to be of major concern. Year after year, the numbers of patients waiting for beds in Irish hospitals increase – with the unnecessary morbidity and mortality consequences.
Back in Jan 2006, Mary Harney, then Minister of Health, declared the E/D crisis a ‘national emergency’ when numbers of admitted patients waiting for beds overnight reached above 500. In that month of January 2006, the number of patients waiting for beds reached a record 7069. According to INMO ‘Trolley Watch’ figures, the situation is now immeasurably worse: the number of patients waiting for beds in January, 2024, was 12,147, up by almost 42% on what has been deemed ‘national emergency‘ levels by Mary Harney.
Adding to the concern, the Irish Hospital Consultant Association (IHCA) in July 2024 highlighted the fact that now more than 911,500 people are on some form of hospital waiting lists, “the highest it has ever been”.
It should be noted that the waiting lists would be even worse without the National Treatment Purchases Fund (TNPF) which was set up by Mary Harney in 2004 in the face of unacceptable waiting lists. TNPF channels large numbers of public patients into private hospitals to ease the lack of public hospital beds and facilities. The scheme operates with public money, which bloats the profits of private hospitals, and serves only to mask the true nature of the public capacity crisis.
Against the Government’s Own Policy
This latest announcement is also in direct contravention of the government’s own health policy on safe staffing levels and highlights the complete disjuncture between funding and policy. In May this year, to great fanfare and before the HSE’s July announcement of these new recruitment restrictions, the government announced plans to deliver 4,367 acute beds to its badly needed bed capacity by 2031. It is impossible to do this without a massive across the board recruitment drive, and thus at odds with the recently announced recruitment restrictions.
Secondly, the recruitment restrictions go flagrantly against the government’s own 2022 policy on ‘ The Framework for Safe Staffing’. This staffing framework is internationally recognised as critical for patient safety and quality of care. Insufficient and inadequate nurse/patient ratios lead to care being compromised and lead to adverse incidents, inferior clinical outcomes, even death.
We have seen too many tragic and well publicised outcomes here in Ireland – the death of 16-year-old Aoife Johnson in University Hospital Limerick is a shocking case in point.
The Clark Report, the official inquiry into Aoife Johnson’s death, concluded that her death “was almost certainly avoidable” and that the E/D was “grossly overcrowded”. (Irish Examiner, Sat 20 Sept 2024). The Report found that staffing levels on the night in question in the E/D were way below what best practice would mandate – there were only 3 nurses on duty in the E/D that night, to care for 70 patients at the beginning of the shift. At the end of the shift the patient count had risen even higher, reaching 85, and cared for by those same 3 nurses. (World of Irish Nursing, Vol 32, Number 7, Oct 2024)
The Framework for Safe Staffing lays down ratios of 4 to 6 patients per nurse, with higher nurse patient ratio needs in critical areas such as ICU and E/D. The framework was finally accepted by government in 2022, after years of INMO campaigning on the grossly inadequate staffing levels in Irish hospitals.
While the policy on safe staffing has been successfully trialled, it is not mandated and therefore not enforceable. Phil Ní Shéaghdha, General Secretary of the INMO insists that “on any ward or ED today, tonight or tomorrow the scientifically based staffing ratios will not be in place. Senior management in the HSE knows this and the Department of Health knows this, yet they introduced the recruitment moratorium with rigid caps on staffing”.
Investment without adequate staffing
It is true that that investment in the Health Service, in both bed capacity and staffing has increased since 2020 and the politicians will sing sweet songs about this – but it was only in 2020, after a cut of 11% or 5000 nursing posts, that our nurse numbers only got back to their 2007 pre-austerity levels.
Secondly, and shamefully hidden amid all the talk about increasing investment in Health, the most recent figures from the state’s own statistics show that the national bed capacity, which was shrunk by approximately 2000 beds during the austerity years, has still not recovered to their 2007 levels. In 2007,the bed capacity was 12,123. In 2022, the bed capacity was just 11,581, a shortfall of 552 on the pre austerity levels. The Dec 2022 figures are the most recent figures as there is no available data from 2023/2024.
It is of course crucial to keep in mind that investment in our Health Service before austerity was at a very low base to begin with: our bed capacity was below half that of the European average in 2007 and our nurse numbers way below any acceptable internationally accepted levels. Also, to make matters even more pressing, our population has grown by almost 1 million since 2007.
As inadequate and under resourced as the health service was before the financial crisis of 2008, the austerity years that followed has left a legacy which is still being felt today. Only in Greece was Health Service spending more severely curtailed.
Hold our trade union leaders to account
The Trade Unions are right to ballot their members for industrial action to prevent further attacks on our already crippled health services.
However, workers must never forget that pressure must be applied and maintained on the trade union leadership itself, by in-house meetings etc, to ensure that the trade union leaders do not surrender to government pressure, as they did during the austerity years. They cannot be allowed to accept in any shape or form any recruitment restrictions. They must be prevented from accepting any further degradation of conditions for both staff and patients in our health service.
After the financial crisis the government managed to introduce austerity only because the trade union leadership cooperated and colluded with government to do so via the austerity deals which were negotiated and facilitated by the trade union leadership- for example, the Croke Park Agreement of 2010, the Haddington Road Agreement of 2013, the Lansdowne Road Agreement of 2015.
If the trade union leaders had not surrendered another path out of the crisis could have been forged. The banks and property developers might not have been bailed out at the expense of public services and the pay and conditions of their workers. The rich could have been forced to pay their fair share of tax to support the provision of a functioning public health service.
Housing and the cost of living generally need to be made a pressing trade union issue. When workers – both Irish and immigrant workers – cannot make a living in this country which enables them to have a house and have a decent standard of living, they emigrate to places where they can.
It is about time the Trade Unions used their collective power to bring about a fairer society. Might this industrial action on the part of workers in our health service mark the beginning of the much-needed fightback, a step from which other workers will take heart? Only widespread solidarity with the important struggle of our health workers can ensure that it will.
