Official Report: Minutes of Evidence

Committee for Health, meeting on Thursday, 18 June 2020

Members present for all or part of the proceedings:

Mr Colm Gildernew (Chairperson)
Mrs Pam Cameron (Deputy Chairperson)
Ms Paula Bradshaw
Mr Gerry Carroll
Mr Alan Chambers
Mr Alex Easton
Miss Órlaithí Flynn
Mr Colin McGrath
Mr Pat Sheehan


Ms Pat Cullen, Royal College of Nursing
Ms Rita Devlin, Royal College of Nursing
Ms Fiona Devlin, Royal College of Nursing

COVID-19 Disease Response: Royal College of Nursing

The Chairperson (Mr Gildernew): I welcome via audio link Ms Fiona Devlin, chair of the Royal College of Nursing (RCN). Are you there, Fiona?

Ms Fiona Devlin (Royal College of Nursing): Good morning, Chair.

The Chairperson (Mr Gildernew): I also welcome Ms Pat Cullen, director of the Royal College of Nursing. Pat, are you there?

Ms Pat Cullen (Royal College of Nursing): Good morning, Chair.

The Chairperson (Mr Gildernew): I also welcome Ms Rita Devlin, head of professional development. Rita, are you there?

Ms Rita Devlin (Royal College of Nursing): I am. Good morning, Chair.

The Chairperson (Mr Gildernew): Good morning. I welcome you all very warmly to the Committee this morning, and I invite you to now make your presentation.

Ms Cullen: Thank you, Chair. First, I thank the Committee for the opportunity to brief members on the current issues in nursing on the COVID-19 response. The Royal College of Nursing has followed with interest the work of the Committee in recent weeks on the COVID-19 response and acknowledges its achievements in holding policymakers to account and in taking evidence from a broad range of stakeholders.

I hope that our briefing will be helpful to the Committee this morning in its contribution and deliberations. We will restrict our opening remarks as members will have received our briefing paper. I understand that, as time is of the essence, the Committee will wish to move to questions and discussions as soon as possible.

You will notice that the briefing paper is in two parts. The first part outlines the immediate issues on our agenda for COVID-19. The second details some of the more long-term issues that we believe need to be focused on in the context of the health and social care (HSC) recovery and the Minister's strategic framework for rebuilding services, which was published last week. The Royal College of Nursing has welcomed the Minister's frequent references to how there can be no return to business as usual and that the challenge is to build a health and social care system that more appropriately meets the needs of the people of Northern Ireland, rather than simply attempting to reconstruct the processes and ways of working that existed prior to the COVID-19 pandemic. That will not be achieved, however, without the direct engagement of organisations, such as ours, that represent the health and social care workforce, and health and social care recovery will not be achieved without renewed focus on the deep-rooted problems that existed prior to the pandemic, particularly in safe staffing. We also need to focus urgently on workforce planning for nursing. That process must embrace health and social care and the independent sector, particularly our nursing homes.

On 18 May, the Executive agreed to allocate £1·6 million to reimburse health and social care workers for the lost hours that were deducted from their salaries at the time that they stood on picket lines demanding safe staffing and equal pay. That followed a previous announcement that was made by the deputy First Minister in March. On 4 June, the Royal College of Nursing wrote to the Finance Minister asking for clarity on the reasons for delaying reimbursement to our members. The Finance Minister responded to the Royal College of Nursing, confirming that the money has now been made available to the Department of Health and that reimbursement should happen as a matter of urgency. We urge the Department of Health to make that a priority and to forward our members their money in their July salaries at the very latest. Our members are asking for that to happen.

The process of rebuilding health and social care services must demonstrate that specific lessons from the pandemic have been taken on board. The Minister, for example, indicated his aspiration to ensure that Northern Ireland becomes fully self-sufficient in the supply and availability of personal protective equipment (PPE). The Royal College of Nursing entirely supports that aim. Never again must the safety of patients, service users and health and social care staff be compromised as it was in the early stages of the pandemic. Innovations such as the removal of car parking charges and the provision of effective childcare support for health and social care staff must now become established practice.

The Royal College of Nursing will consult its membership before responding fully to the consultation on the strategic framework for rebuilding services. At this early stage, however, it is worth noting that the college shares the concerns that were expressed to the Committee last week by our trade union colleagues about the general lack of engagement with unions and the governance implications of the new management board that is being established. We would welcome the opportunity to explore those issues in greater detail with the Committee in due course.

If I could leave the Committee with one message from today's proceedings, it would be to highlight the urgent need to develop a timetable for the legislative requirements to ensure safe staffing in Northern Ireland, which is a commitment that is in the Minister's safe staffing framework and was endorsed by the Executive in January.

I hope that those are helpful opening remarks. I await your questions on points of discussion. Thank you, Chair.

The Chairperson (Mr Gildernew): Thank you very much, Pat. Before we go to questions, it would be appropriate for me, on behalf of the entire Committee, to thank your members for the work that they have done and the dedication and commitment that they have demonstrated over the past number of weeks and months, specifically on COVID-19 and in the run-up to that period, and for engaging on safe staffing on behalf of your members and the wider public. I want to share that very clearly with you and ask you to pass on to your members our best wishes and thanks for everything that is being done in that respect.

You mentioned safe staffing and the legislative requirement for it. Where is that process at? I understand that it was disrupted by COVID-19, but we are now looking at rebuilding certain things. Has that very important engagement restarted as it is one that needs to be taken forward at some pace in order not only to fill the gaps that existed before COVID-19 struck but, indeed, to manage any future spike in the pandemic or health emergencies? Obviously, staffing is a key issue.

Will you advise the Committee where that process sits at present?

Ms Cullen: Chair, that process is parked due to the response to the pandemic. However, we need those processes to be put back in place as a matter of urgency. We understand that the delay has been due to the reprioritisation and refocusing. However, now that we are in the business of rebuilding health and social care services, it is really important that the Department returns to these issues and that, as before the pandemic, they are at the top of the agenda. The safe staffing framework, and especially the underpinning legislation, is particularly important to us because our members stood on picket lines for that.

Our members are clearly saying to us that they wish to see the promises set out in the Minister's framework document, which brought about the suspension of strike action by nurses and nursing assistants, now given the required attention. We want that to happen now. In particular, as I said, there is a need to accelerate safe staffing legislation. I can honestly say to the Committee that nurses will not relax until they get the legislation to ensure the safe staffing that they were promised. That was the change that they required. That is what kept them on the picket lines. That is what they were calling for and willing to lose pay for. We truly hope that they will not be let down.

We all know that when laws change, behaviours change. Legislation will mean that the people responsible for financing our health services will have to think twice before looking for cuts and cost savings from our front line in the future, and the people who have seen us through the most difficult of times will not be placed in that position again. That is what we ask for on behalf of our members.

The Chairperson (Mr Gildernew): Thank you. I am aware that there has been an announcement on strike pay. From what you are saying, it has been confirmed that the money has been allocated to the Department of Health from the Department of Finance. What is your understanding of why that has not been paid already?

Ms Cullen: Initially, we were left with the understanding that the delays were in the Finance Department, which is why our members instructed me to write to the Finance Minister on 4 June asking why, after an announcement had been made, further barriers, as they perceive it, were put in place that prevented Minister Swann from paying their reimbursement. The Minister of Finance, as I said in my opening remarks, wrote back to the Royal College of Nursing advising that the money had been released to the Department of Health. His letter stated very clearly that it was a matter of urgency that the money be paid to those who stood on picket lines to ensure that the health service was in a place to provide services to the people of Northern Ireland during a very difficult period. This morning, we ask the Department of Health to, please, do the right thing now and pay those lost hours back to some of the lowest-paid workers in Northern Ireland. That needs to be a matter of urgency, and we ask that, at the latest, the money should be in their July pay packet.

The Chairperson (Mr Gildernew): Thank you. My final question before moving to members' questions is about the engagement process. We have established the principle that when designing and rolling out services, it makes sense to engage as many of the relevant and experienced stakeholders as you can. Related to that is the rapid learning initiative arising from the COVID crisis in care homes and the dreadful situation that has emerged in that sector. We are aware of issues with the management board, and we discussed that with a range of unions last week. As a Committee, we encourage broader engagement with unions. It is of qualitative benefit to all concerned, in that they bring their perspective, experience and unique insight.

On rapid learning, I fail to understand how you can learn quickly if you do not speak immediately to the people who experienced what happened. Are you engaged in the rapid learning initiative? How do you assess the progress in learning lessons, given that we need to be ready to implement change in order to do things better should there be additional spikes and surges?

Ms Cullen: Chair, I will hand over to Rita Devlin, the associate director for professional nursing practice, to answer that.

Ms R Devlin: Chair, the RCN is involved in the rapid learning initiative. One member of staff has been seconded to the Department of Health to work with the Chief Nursing Officer and the deputy Chief Nursing Officer on the initiative. Another very senior member of staff, who has vast experience in the nursing home sector, is leading on one of the work streams. It is our understanding that the aim of the initiative is to get a clear understanding of the measures that have been most, and least, effective in minimising the impact of COVID. There is a wide range of stakeholders involved in the initiative, and they are looking at the experiences of residents, families and staff. They are looking at how symptoms were monitored, interventions in care planning, infection prevention and control measures, and the impact of restricted visiting and reduced footfall. They hope, as far as I am aware, to have produced something in the next few weeks so that, as you say, lessons can be learned for the future.

The Chairperson (Mr Gildernew): There was an announcement yesterday of a new framework for the development of care in the nursing home sector. Are you aware of and engaged in that?

Ms R Devlin: The first we heard of that was when the press statement came out yesterday. Of course, the RCN would welcome that initiative. Nursing in the nursing home and care home sector is a highly skilled role. It is important that our highly skilled nurses and healthcare assistants have access to the multidisciplinary team and are able to access whatever they need to give the best care for their patients. As I said, we did not know anything about the framework until the press release yesterday. However, we hope that the Department of Health, under the principles of co-production and co-design that it continuously espouses, will work with all the trade unions to ensure that the best possible framework can be developed, delivered and implemented.

The Chairperson (Mr Gildernew): Thank you. I am surprised that the press release was the first that the RCN, which represents a profession that will be central to the framework, had heard of it. The earlier that people are involved, the more they benefit from it. It is a bit of a concern that you heard about that through the media.

Mrs Cameron: Thank you, panel, for your attendance this morning. We recognise the selfless contribution that your profession makes in everyday life and during this pandemic.

The employment survey from 2019 for Northern Ireland makes for disturbing reading. It states that 73% of nursing staff in Northern Ireland work additional hours at least once a week, and 48% of them are not paid for those hours. Some 85% of nursing staff said that, during the preceding 12 months, they had worked when they should have reported sick. I declare an interest in having a relative who is a nurse. I have raised this concern a few times, including with the Minister: whilst such dedication is admirable, nurses, particularly throughout the pandemic, are not receiving the right rate of pay through their pay band.

What negotiations are ongoing with the Department to resolve that issue and ensure that those nurses, who are absolutely on the front line — especially in the face of the pandemic, which, we know, is not over yet — and who will probably be geared up in full PPE again in the near future, actually get the right pay and what they deserve for the job that they do?

Ms Cullen: First, I thank the member for her very kind remarks about our profession. It is really important for nurses to hear that from people at the highest level of government. We want to thank you for that.

The survey results are the same results that we get year-on-year-on-year. It is really disheartening for the college to read them. However, at the end of the day, they are unsurprising. That is the first thing that I want to say. Those are the very messages that the Royal College of Nursing, as a trade union and professional organisation, has been giving to the Executive, the highest level of government, and the Department of Health for many years, urging them to take a close look at the pressures on the nursing workforce.

It is not that I want to labour the point, but, I suppose, as a new director coming into the college, the most challenging time of my 35-year nursing career was to lead my very own colleagues onto the picket lines. I never, honestly, thought that I would see the day when nurses would be pushed and forced to do that. It certainly was never in our DNA to do it. They found it really difficult. It will take a long time for nurses to get over that. However, the figures that the member has just relayed at this time demonstrate why they felt the need to do it. Our health service was, as the permanent secretary said, staring over a precipice and was in crisis. As director of the Royal College of Nursing, I honestly believe, and I know that our Northern Ireland board does too, that it was our nurses and other healthcare workers who brought the health service back from the precipice and left it in a position where it was able to actually respond to a pandemic and to the people of Northern Ireland when they needed it the most.

What we are asking, now, in the next round of pay negotiations, which have just commenced, is for Ministers — those who are at the highest level of government — to pay nurses and other healthcare workers their value, the value that you put on them, and the value that was put on them by the public when they came out every Thursday evening and clapped for our members. Our members are telling us very loudly and clearly that, whilst those thank yous were really important, please, do not reward them with acknowledgements such as badges. That is not what they are looking for. They are saying that it is investment that counts.

Investment is needed to sustain the health service. With that, nurses need decent pay awards, because only when you pay people decently and in line with their value and the value that you put on them will you be able to fill the vacancies that exist in the health service and also attract nurses who have left these shores to work elsewhere because they believe that they are paid more decently in other places and are given the time, space, investment and resources to care for their patients in the way in which they are highly educated and expert. All those issues need to be brought to the fore once again, when we have settled down, as we have now, having gone through the first phase of the pandemic.

We really want to see those issues being picked up. Pay discussions and negotiations have recommenced at this time. We will keep a very close eye on that. However, we cannot, in another year's time, hear nurses saying that they have had enough and cannot take it any more. The stories that we are hearing now in the college are not dissimilar to the ones that we heard prior to the pandemic, which is that nurses still feel demoralised. They feel that they cannot continue to work at the pace at which they are working. They feel that they cannot continue to work the unpaid hours, which the member referred to, and work the additional hours. However, they will always be willing to do it — that is what the nurses in Northern Ireland do best — but, surely to God, we have to start to look at the value that we put on those people.

Rita, as the lead negotiator, do you want to add anything to the discussion?

Ms R Devlin: Yes. Thank you. The banding issue has been raised and is apparently being looked at a regional level. One of the areas is where nurses in intensive care who were working at band 5 had stepped up and were working at band 6 level because they were supervising non-intensive-care nurses. If you look at the results of the report by the task force that was chaired by Sir Richard Barnett, you will see that one of his recommendations was that we had rapid acceleration. We did


rapid accelerated pay progression from band 5 to band 6. Very interestingly, that is one of the recommendations that Minister Swann has not accepted. That was very disappointing to the Royal College of Nursing because, as you realise, we have the highest percentage of nurses at band 5; much higher than any of the other professions. If you look at the table of nurses' pay bands, you will see that there is a far lower percentage of nurses at bands 8a, 8b and 8c than of staff in the other professions or, indeed, admin, clerical or estates roles. That is a very difficult issue for us. We want to see that addressed with pay progression and career frameworks.

The Chairperson (Mr Gildernew): I declare an interest in relation to my previous career as a social worker and the fact that I am on a career break from one of the trusts, my membership of NIPSA, and the fact that my wife is a nurse.

Ms Bradshaw: Thank you, panel, for coming this morning. It is great to have you here. I just wanted to pick up on childcare, which you mentioned in your opening remarks. Recently, I asked the Department of Health about the free childcare that was provided to key workers on an interim basis between April and May. It advised that that was provided by the Belfast Health and Social Care Trust. I think that, in your opening remarks, you intimated that that is something that the Department should look at going forward. Can you comment on how that could work in practice?

The second issue relates to the welfare of the student nurses whose passage into the front-line workforce was expedited by COVID-19 and how they are being looked after, because, one minute, they were in a classroom and, the next minute, they were dealing with very traumatic situations on the wards. Can you tell me about the welfare of newly graduated nurses?

Ms Cullen: Again, I thank the member for her kind remarks. It is really important for nurses to hear them. The college represents the majority of nurses in Northern Ireland. There are very few nurses who are off duty this morning who are not tuned in to the Health Committee. Those acknowledgements are really important for nurses to hear.

First, I will pick up the member's question about childcare. Then, I will pass over to Rita, who will deal with the issue of students, who are also our members.

The first thing that I want to say is that a number of initiatives that were put in place to support not just nurses and nursing assistants but the wider health and social care workforce over the period of the pandemic are very welcome. I want to pay tribute to the trusts, which have worked very hard to support staff during a challenging time. Really innovative solutions were put in place to make sure that staff on the front line were able to continue to work during the pandemic. Unnecessary red tape was certainly removed. Governance bureaucracy was set aside in order to make sure that decisions were made in a timely manner, not just to support front-line workers but to support patients. Our members are asking us that there be a review of the bureaucratic governance processes that are barriers to them carrying out their clinical work. Nurses fully understand the need for good governance; we absolutely support that. It must not drive and dominate their clinical practice, but it must be there to support it, and we would ask for that.

Childcare is one of the key issues that is raised with us daily. Over the last number of days, in particular, increasing numbers of nurses have come to us to ask for our support to work with them to achieve career breaks or reduced hours or to resign from services. The reason for that is that they are very concerned about what will happen in September, when children return to school on a phased basis. As you will know, and as Rita referred to, in Northern Ireland, we have the highest percentage of nurses at band 5 in the UK. Those nurses receive the least that you can pay a registered nurse.

The way in which our schools will supposedly operate from September, with nurses having to work shift patterns and to manage homeschooling on top of that, while not knowing whether their children will be in school for two or three days a week, is putting enormous pressure on nurses. Quite frankly, they are telling us that they cannot afford to continue to work, because they have to try to get additional childminding put in place for the shift patterns that they are working when their children are not at school from September, and those childminding services will, inevitably and rightly, be looking for additional payments if they will be involved in homeschooling our members' children. That is an untenable position for our members to have been placed in, and there is heightened anxiety among members about how they will manage that.

As the Committee will know, with our vacancy rate, never mind the additional staff that we need, we cannot afford to lose one hour of one nurse's time from the health service. If the level of people who are coming to us looking for support to take career breaks, reduce their hours or leave the service continues at the current rate, we will be in an absolute crisis. There is a real need to address the issues around childcare and schooling and to support our members, who are the absolute front-line workers. We must have those arrangements in place. Our members are coming to us now to plan for September because they have to give the trusts three months' notice if they want to reduce their hours, take a career break or, indeed, leave. Therefore, those plans need to be put in place right now to support members to continue in the roles that we need them to be in.

I will now ask Rita to answer the member's question about students.

Ms R Devlin: Thank you for your question, member. First, I would like to pay tribute to our students, who have stepped up during the pandemic. They have been absolutely fantastic. They have done a great job and have worked really hard to ensure that patients and the public of Northern Ireland get the best care possible. I would also like to pay tribute to the universities, which have turned their worlds upside down to make sure that the students could come out and function properly.

As you will know, the Royal College of Nursing has many students in its membership. It also has student ambassadors, and there is a student lead in the college in Northern Ireland. She has worked very closely with our students and has had weekly conversations with them, during which they were able to identify their issues or concerns. We were then able to bring those to the appropriate people in the universities, the Department of Health or the Public Health Agency (PHA). We have been able to act as a conduit for those students.

To date, we feel that the students have managed very well, and we hope that any issues that were brought to us have, in the main, been dealt with to the satisfaction of the students. We are aware that there is one group of students — first-year students — who have not yet been able to go on clinical placements because of COVID. Usually, they would have been out and have been introduced to the health service. That is a worry for us, and we are having conversations with the universities regularly to try to make sure that we can support them, they can support us and we can all support the students.

Ms Bradshaw: Thank you very much.

The Chairperson (Mr Gildernew): Thank you, panel, for your answers. I will now move to the phones. The first person is Colin, and I will then go to Órlaithí, Alex and Pat. Colin, are you with us?

Mr McGrath: Yes, thank you, Chair, and I thank the panel for their presentation. I echo the remarks that have already been made about the dedication and work of nurses during the pandemic. I also extend my thanks to their families. I know a number of nurses whose families have had to make changes to their regimes and other things. The families will appreciate the shout-out.

I want to ask about nurses, from within their membership, who work in the care home sector. During the pandemic, did they see, at the front line, the differences between how services were being delivered in the hospital and the care home sectors? Did the representatives and nurses from the care home sector feel as if they were being left behind, which is something that was being reported to us?

Ms Cullen: I thank the member for his kind remarks. It is disappointing to say this, but, yes, that is the feedback from our members in the care home sector; they genuinely felt left behind. For various reasons, the emphasis appeared to be on the acute hospital sector at first. It took sometime for our care home sector to be prioritised in the same way. We now know, and it was mentioned in the press statement released by the Department of Health yesterday, that the care home sector is caring for the most acutely ill patients. Those patients, a few years ago, would have been cared for in acute medical wards in our main hospitals. Our care home nurses and social care staff are caring for those people now in the care home sector. It was not right or proper that they had to push as hard as they did to get personal protective equipment and the equipment that they were due.

Anyone who watched the news yesterday evening and saw the nurse from the Somme Nursing Home being interviewed would have seen the pain that was etched on her face with regard to how she felt about the pressure that she was under to try to provide care and treatment for her patients. I want to pay tribute to her for her testament yesterday.

They did feel left behind, and that should not have been the case. The Royal College of Nursing has significant membership from our independent care home sector, and we work very hard, through our independent network. Our independent care home network is made up of expert nurses and nurse managers from all our care home settings across Northern Ireland. There is a body of knowledge and expertise amongst those people that we need to utilise, and it will be very useful to the work that was announced yesterday by Minister Swann to be taken forward by the Chief Nursing Officer. We urge the Department of Health to draw on the Royal College of Nursing independent care network. It comprises of the people whom I have referred to. They will keep the Department right. They will extend their expertise and ensure that the right thing is done for patients. Should we find ourselves in another phase of the pandemic, it is really important that the care home sector is not left behind, as it was during the first phase.

Mr McGrath: Absolutely.

Ms Flynn: I will just repeat the remarks from my colleagues on the Health Committee in thanking your profession for all the work that it has done.

My first question is about the big issue of safe staffing and workforce planning. We know that there has been a lot of delay, particularly with COVID-19. The focus now needs to be on resuming those conversations and that work. Has the Department given the RCN any indication that it is looking at this process again to develop a legislative framework?

Pat mentioned that, in the early stages of the pandemic, unfortunately, the safety of patients and staff was, in some cases, comprised. Is the panel confident that that would not be the case again if we were to face a second wave?

Ms Cullen: I thank the member for her kind words. I keep repeating that it is important to our members, who hold on to every little bit of support that they can get.

The first thing about safe staffing is the importance of legislation. I do not want to labour the point too much, but I feel that I have to on behalf of our members. The need for safe staffing legislation, as set out in the ministerial framework from Minister Swann, was the light at the end of the tunnel for our nurses. It is what took them off the picket lines and suspended the strike action. That is very important to say. We have not ceased our industrial action; it has been suspended. That is because our members' trust has been eroded over a number of years. Our members need to build up that trust again with the Department of Health and the Executive to enable them to bring the industrial action to an absolute end. We are not there yet. As they keep reminding me when they are holding me to account — they pay my salary — it will take seven days for them to re-engage in industrial action if they believe that the people of Northern Ireland are going to be let down again. What they mean by that is that they need to see the legislation being put in place in the same way that it has been in Scotland and Wales. We are very envious of those countries, but we are delighted that their patients and populations have safe staffing legislation in place.

We have asked the Department of Health repeatedly for that work to be resumed, for that to be made an absolute priority and for the ministerial framework that was endorsed by the Executive, having been set out by Minister Swann — we cannot thank him enough for that — to be given the priority needed. As we say, when legislation is in place, it changes behaviours. We never want to return to a place when, if cost cuttings are being looked for, they go to the front line. That must stop. We must never be in that place again.

The second part of the member's question was about the compromising of safety in the early stages of the pandemic. That was the most difficult time for any nurse, because they felt under pressure due to a lack of PPE. Those discussions have been well rehearsed and are a matter of record, should there be an inquiry. We have had many correspondences with the highest level of government, with the Executive and the deputy First Minister and the First Minister, and we also wrote to the Health and Safety Executive on a number of occasions to raise concerns on behalf of our members and, ultimately, their patients.

Do we believe that we are in a place to respond differently and safely to a second wave of the pandemic? We are getting there. There is certainly a willingness among the trusts to make sure that they do the very best for our nurses and patients, but a one-off stockpiling of PPE will not do that. We now have time and have to learn the lessons from what happened before. We need to become self-sufficient and stop relying on other countries to bail us out or look for PPE. We have time and energy to put our stockpile in place. We have seen how the public in Northern Ireland stepped up to support our health and social care workforce. The likes of O'Neills and other businesses pulled out all the stops to make sure that PPE was available at very short notice. That should not stop; it should continue. We should make sure that we have the stockpile in place that makes us self-sufficient and gives our nurses and other healthcare workers the confidence that, should we hit another wave of the pandemic, they can safely and effectively care for their patients, because that is what they want to do.

Ms Flynn: Thanks very much, Pat.

Mr Easton: First, thank you for your presentation. I declare an interest, as my sister is a nurse. I reiterate my thanks to all nurses for the sacrifices that they have made on our behalf across Northern Ireland. Thank you very much for that.

I have a few questions. First, you mentioned car parking charges, which is something that I have never agreed with. I do not believe that people should be charged for a car parking space when they come to work. Have there been any discussions with the Department of Health to have the charges removed?

My second question is about nursing vacancies. There have been considerable


to the number of nurses that you have. Is there a reason for that? From an Assembly question that I asked, I know that the vacancy rate is quite high. I accept that it may be because nurses are not getting childcare support, among other reasons. Can you explain whether there is something going wrong in the trust that is delaying the filling of nursing vacancies?

Finally, there has been a delay in getting the money back to nurses from the strike. How long has that money been with the Department of Health, if you have that information?

Ms Cullen: I thank the member very much for his kind remarks; he is clearly from good stock if his sister is a nurse. Again, thank you for all the support that you have shown to our members and the workforce.

On car parking charges, the first thing that I want to do is pay tribute to Nichola Mallon, the Minister for Infrastructure. She really stepped up and sent out a very clear message to our nurses, particularly our district nurses who were struggling to respond to patients in their own homes during the pandemic. They were expected to wear very high levels of PPE when arriving at patients' houses. In urban areas, they were finding it challenging to park close to a patient's home, carry excessive amounts of equipment, and, then, try to change into PPE to make sure that everyone was safe. The Minister resolved a number of those issues by eliminating car parking charges and ensuring that nurses and other health care workers could do their work in an easy and accessible fashion for patients. It was very much welcomed by our nurses.

Car parking charges in hospitals have been an issue for our nurses since their introduction. The position of the Royal College of Nursing is that the charges should never have been introduced. We have files of correspondence asking for car parking charges to be eliminated, but we have not been successful. Car parking charges are borne by the people we referred to earlier, the band 5 nurses, who are paid the lowest wage that you can pay a registered nurse. They are paying out excessive amounts every month to get to work on time. We have stories about nurses who start duty at 7.20 am, who have to queue for an hour before they are due to go on duty to try to get a car parking space. From evidence collected by the college, in the dark winter months, nurses have been subjected to many attacks when they have been going to their cars that they have parked in side streets because they cannot afford the car parking charges.

These are real issues for our members, and we believe that we owe it to them to relax car parking charges so they can get to their work on time and can care for their patients in the way that they want to. That is not much to ask.

We have talked to the Department of Health on many occasions and listened to what it had to say. Any help that the Committee can give us to try to push that agenda forward would be most welcome.

The vacancy level in the health and social care workforce remains at over 10%. We believe that it is much higher in the independent sector. Those are the Department's figures. Unfortunately, we do not collect workforce data for the independent sector. We ask that that be done as a matter of urgency. Many issues contribute to the vacancy rate. Of course, the one area that had a significant impact was the fact that, from 2012, nurses were not afforded the appropriate pay awards. If you track back to 2012, when Northern Ireland broke away from the Agenda for Change pay awards that were due to nurses in other countries, you can see the deterioration in the number of nurses who remained in the service. Northern Ireland was drained of nurses. Other countries were very happy to get them because they were so expert, highly trained and skilled. Our nurses left. They did not leave just because they were not being properly paid but because the message that that sent to them was that they were not valued, and they did not feel that they were respected.

As a consequence of nurses leaving the workforce or not wishing to take jobs here, we found that the nurses who were left behind were under enormous pressure. Earlier, Pam mentioned the workforce survey, which bears that out: we have ended up with 73% of the nursing workforce having to do additional hours and 48% of them working unpaid hours. That pattern has existed for a number of years, and it has placed enormous pressure on nurses. Workforce morale is poor. It is unfortunate that I have to say that. As Rita said earlier, the opportunity for career progression has been reduced significantly in Northern Ireland. In many ways, it has been painted as a perfect storm. We knew that when the entire picture was put together, we would end up where we are now: with a workforce that is demoralised, under pressure, low-paid and finding it difficult to get back on its feet. Those are some of the reasons that the college is aware of as having contributed to vacancies.

The final part of the member's question related to payment for hours lost due to strike action. On 18 May, the Minister of Finance said that he had made the money available. It is not the college's responsibility to track when the money leaves one Department and arrives in another. We take, and have every right to believe, a Minister at his word. On 18 May, there was significant buoyancy amongst our members, who believed that the Minister of Finance, on the back of what the deputy First Minister had said, had made that money available. It had been costed at £1·6 million, not just for nurses but for the entire health and social care workforce. When it arrived in another Department is not our business. We expected that it would be in our members' June pay. When that was not forthcoming, our members asked me to write to the Minister of Finance because we were led to believe that he had asked for additional evidence, paperwork or whatever; we do not know. Our members said, "Let us ask the Finance Minister why there is a delay now", and that is what we did on 4 June. I hope that that has answered the member's queries.

Mr Easton: Yes. Thank you.

Mr Sheehan: I thank the members of the panel for their presentation. Nurses have been absolute heroes during this pandemic. Not only are they there, day and night, caring for patients but, during this crisis, they have been putting their lives at risk. That is highly commendable. In that context, it is all the more disappointing that legislation for safe staffing levels has not been brought forward more quickly. I take account of the situation that we are in, but the Committee should press the Minister on that. It is also disappointing that nurses' representatives are not central to the strategic framework for rebuilding services. I would like to hear your comments on that.

My second question is about the care sector. The latest NISRA statistics show that over 50% of deaths occurred in care homes or were of people who had been transferred from care homes to hospital and died there. Despite international experience that care homes were disproportionately affected, not a lot was done to protect them. Does the panel think that enough is being done to prepare for a second wave? The RCN has been particularly critical of the Safe at Home initiative. I would like some comments on that.

Ms Cullen: Thank you very much for your kind remarks that each and every nurse will really appreciate.

It goes without saying that we are disappointed with our engagement with the strategic framework and the management board. We are disappointed that, as a Royal College with not just trade union responsibilities but equal responsibility for the professional engagement of nurses, we are not involved. We provide significant education on behalf of nurses, we set standards and we direct and influence policy. As a Royal College, our responsibilities are two-fold. We are really disappointed, because we have so much to offer, on behalf of our members, to the management board and to the work that it will carry out.

We are very clear that there needs to be more comprehensive engagement and involvement with the trade unions — that means all trade unions, including our UNISON colleagues etc — and with us as a professional organisation. It is regrettable that the level of engagement on behalf of nurses and, ultimately, their patients, is perceived as being — as our members see it — unnecessary and non-essential. That is how our members read the decisions that are being made at the minute. The college asks that the Department of Health and the Minister reignite and reconstitute that group so that there can be a more diverse representation of voices on the board. There is nothing to fear from trade union involvement. It means that our members will be represented, fully engaged and — in the words of the Department of Health — working "in the spirit of co-production" and co-design. The way in which the board is set up means that it represents one interest, which makes it incomplete, as far as we are concerned.

I am sure that the Royal College of Nursing is not everyone's friend. It believes that it has a responsibility to speak truth to power. It is much more healthy and beneficial, for all concerned, that the voice of the front-line nurse is heard at the table and is not, as some members referred to earlier, an afterthought. Without the full engagement of nurses, there is no transformation. We all know that, and we must learn from past mistakes. Having the same people at the same table, without the voice of our members being fully represented, will lead to the same results as before. That is not where we want to be for the people of Northern Ireland. Poll after poll, all of which are a matter of record, tells us that nursing is the most trusted profession and that nurses get things done, so why not have their representatives fully engaged and involved? That is a must, and it needs to be dealt with right now, before we move into a process from which nurses feel distant and in which they feel that they are not fully respected in all the decision-making.

I will not rehearse what we said earlier about legislation. Safe staffing legislation is essential. The last thing that we want is nurses having to take to picket lines again to fight for legislation that ensures that they can safely provide for their patients. It needs to happen now, and there is no reason why the delay need continue. Across the island of Ireland, nurses have taken industrial action on safe staffing. I know from my engagement with our sister organisation in the Republic of Ireland, the Irish Nurses and Midwives Organisation (INMO), that it has already started those discussions on what will happen post-pandemic. So, there is no reason why those discussions should not happen urgently between the Department of Health and us.

I will ask Rita to pick up on the issues with the Safe at Home model.

Ms R Devlin: Thank you. This was a proposal from the Department of Health to look at a live-in model for nursing homes. The RCN has a timeline of questions and concerns that it had raised on behalf of members through the RCN independent network. We have been raising these issues since 17 March. Given that we have known for some time that the death rate amongst the older population was significantly higher, the RCN was concerned that a more proactive approach had not been adopted earlier in the COVID-19 pandemic to try to reduce the risk to vulnerable patients in nursing homes.

On 29 April, we received a proposal for the Safe at Home model. The pilot was aimed at trying to reduce the spread of COVID in nursing homes. We were concerned because, since the onset of the pandemic, RCN members in nursing homes had received conflicting advice and guidance about PPE — what to wear and when to wear it. Until 27 April, the guidance on visiting in nursing homes had not been updated since 17 March, despite numerous requests from the RCN for clarity and direction. Indeed, our nurse managers had to take the initiative and close their homes to visiting, and they got a lot of criticism from families for doing that.

The Safe at Home proposal talked about staff self-isolating for 48 hours prior to commencing living-in arrangements. The scientific evidence for that was not available, and it was the first time that we had heard that two days' isolation would be sufficient. Several of our members working in nursing homes had raised issues about patients being discharged from hospital to homes without any testing prior to admission. Indeed, some homes tried to refuse patients and were told that they had to accept them. The proposal had not given any consideration to the mental and physical well-being of the staff who would be engaged in the live-in model. There was no facility for staff to rest or relax in their downtime. The RCN asked whether the Department of Health, before looking at the Safe at Home live-in model, had thought about exploring, for example, enhancing PPE, enhancing cleaning regimes in homes or comparing the spread of infection and how it was managed in hospitals as opposed to nursing homes.

One of our major concerns was that the first proposal for the Safe at Home model identified that staff might have to sleep in daybeds in the day room, which we find absolutely unacceptable. In a follow-up meeting, it was said that the workforce could sleep in motorhomes in the car park. Again, this was not acceptable to us, given that hospital staff were offered accommodation in hotels. For all these reasons, the RCN, UNISON and the GMB could not support the Safe at Home model. However, we did suggest how things could be improved in care homes.

Suggestions included more money for proper cleaning regimes; more help for patients who are unable to isolate owing to cognitive impairment; more help for home managers to get the resources that they require; and a level of commitment to supporting the homes with whatever they need. Those are our views on how we can improve the care of patients in nursing homes. We are still of that mind. Moving forward, we need to look at all the issues to ensure that care homes are as safe as they possibly can be for our elderly and most vulnerable population.

We would like to think that the new initiative that the Minister has announced, and on which the Chief Nursing Officer will lead, will address those issues as part of the overall picture of support for nursing homes.

The Chairperson (Mr Gildernew): Thank you. I am conscious that the panel is at the end of the allocated time for the briefing. Are you OK to stay with us for another few minutes to take other members' questions?

Ms Cullen: Yes, we are. Absolutely.

The Chairperson (Mr Gildernew): Thank you. I appreciate that.

Mr Carroll: Thank you, panel. It was a pleasure to stand on the picket lines with you just a few months ago, but, what with everything that has happened, that seems a long time ago.

I have two questions. You have mentioned safe staffing and the lack of legislation. The Department's numbers show that we are at least 2,000 nurses short. Have you had any assurances from the Department that that number of vacancies will be tackled or filled?

It is very concerning that there is a bit of toing and froing going on between Departments over strike pay. We will be briefed on the June monitoring round later on, and the view might be taken that giving one set of workers strike pay may influence another set of workers to take action. If that is the case, that will be very worrying, because it will not deal with the issue of strike pay for the RCN. It may also pit one set of workers against another. My main question is about staff shortages, however. Thanks.

Ms Cullen: I thank the member for his questions. Although the vacancy rate has reduced slightly, and I do mean "slightly", our rate remains the highest across the countries of the UK. We cannot afford to continue with the vacancy rate that we have. One of the reasons that nurses stood on picket lines was to seek an increase in the number of student nurse places in Northern Ireland. That was one of our asks in our industrial action dispute with employers and the Department of Health. We feel that more student nurses are necessary for a number of reasons.

We need to become much more self-sufficient in some areas, including that of PPE. We need to stop relying on other countries to support us and bail us out, for want of a better phrase. We also need to become much more aware of ethical recruitment right across countries. We know that there are 5·9 million vacancies in the nursing workforce throughout the world. Most of those vacancies sit within Asian countries: countries that really need to hold on to their resources. Although nurses who have come to Northern Ireland from overseas are very much part of our workforce and our nursing family and make a significant contribution to our workforce, there are other ways for them to join our workforce. We should have some reciprocation. We should ensure that we do not drain other countries of their resources without paying something back. That is really important to us. One way in which we can do that is to have exchange mechanisms in place with other countries so that we can learn from the highly skilled nurses that come from overseas to here and so that our nurses have an equal opportunity to go to other countries throughout the world to provide care and treatment for people. That is the first thing that I want to say.

The second is that we are delighted that nurses who stood on the picket lines were able to secure an additional 300 nurses, as well as student nurse places for the next three years, equating to 900 students who will join our workforce. We all know that that will take time, but we have to start somewhere. Our nurses were very clear that we needed to start somewhere, and we thank Mr Swann for making sure that that was put into the ministerial framework document. I saw such optimism among our nursing workforce when the Minister signed that off. We will see that happening for us, which will address our vacancy rate. In the interim, we need to have ways of retaining the nurses whom we already have in our structures. As I said earlier, we cannot afford even to lose an hour of a nurse's time, never mind lose one nurse.

We need to pick up on childcare issues. We have to make sure that nurses are supported to be able to come to their work. We are a 96% female workforce. With due respect to everyone, we tend to pick up the majority of the childminding responsibilities and arrangements. Of our workforce, 56% are either a single parent or the main breadwinner in the family, so they have other caring responsibilities. You can therefore see that we need to put arrangements in place and wrap ourselves around those nurses to make sure that they have proper childminding facilities in order to come to work.

They must also be paid appropriately, however. We must not be embarrassed, as nurses were in the past, to ask for a decent pay rise. If we do not have proper career structures in place that pay nurses appropriately, and if we do not move away from the idea that we can keep every nurse as a band 5 nurse and pay them the lowest wage that we can possibly pay them, we are going to get what we always get, which is nurses who will vote with their feet and go elsewhere. Let us therefore pay them the value that we have put on them during the pandemic. If we do that, we will not go wrong, and people will see our vacancy rate being addressed in the ways in which it should be addressed.

You asked about strike pay. We are very aware that whatever we do in Health and Social Care can set precedents elsewhere. We understand that, but our nurses stood on picket lines. Anyone who was out on them, as you were, Mr Carroll, which we appreciate, will know that the days were not the warmest when we stood from six o'clock in the morning until 10 o'clock at night. A lot of those nurses stood on picket lines after they came off duty or off night duty. Nurses on annual leave came to stand on picket lines. We have rehearsed those points, and they are well documented.

Leaving aside the fact that it may set a precedent, let us not reduce everybody to the lowest common denominator in Northern Ireland. I strongly believe that nurses are entitled to have their pay reimbursed for fighting for the health service. If other professional groups have done the same to make sure that we have the public services in place to respond to the needs of our population, it is right and appropriate that they be reimbursed. That is what we are here for as public servants: to make sure that the front-line workers, should they be in education or heath and social care, or in any other part of the public service, such as the Police Service or elsewhere, are paid right and properly and reimbursed appropriately. As a trade unionist, I fully support that happening.

Mr Chambers: I fully associate myself with all the words of admiration and appreciation expressed by Committee members. Some months ago, I was very pleased and proud to stand on the picket lines along with the nurses in support of strike action, and I hope that you never have to do that again.

Is the issue with safe staffing simply the result of a lack of qualified nurses locally coming through the system? Is the interest in entering nursing as a career matched by the number of available additional training slots that you mentioned? Are those all taken up? Is there a huge dropout rate or is it a small number of trainees who drop out during their course? Is there a practice in trusts of moving some senior and very experienced nurses with long service into full-time administration duties that remove them from front-line nursing duties? Is it a concern that so many trained nurses gravitate towards signing up with employment agencies rather than working for the NHS directly? On safe staffing in private nursing homes, do you have a sense that owners are cutting the availability of trained nurses to the bone simply to protect their bottom line?

Ms Cullen: Thanks to the member for his very kind words. They are very much appreciated.

We are really pleased that we have absolutely no shortage in Northern Ireland of young people applying for training places in nursing. That is a testament to our universities. The level of education and training at Northern Ireland's two main universities is second to none and the envy of many countries throughout the world. That is why our nurses are so sought after. Ulster University and Queen's University have much to be proud of, and we are absolutely delighted to have them. There is no shortage at all. At the most recent count, around 16 students were applying for each nursing place. That is not confirmed, but, from some of the discussions that we have had with the universities, that seems to be the figure. There are no issues there.

You referred to attrition rates and dropout rates. We constantly ask the Department of Health, which commissions preregistration education for our students and is responsible for that along with our universities, for data on attrition rates to be made available. There is anecdotal evidence of a significant attrition rate, but that is not properly evidenced. I therefore cannot honestly say that we have that data at this time, but it is a really important point to bring up. We need to keep an eye on students commencing nursing and then moving into other programmes or leaving etc.

There are some issues that we would like to see addressed. We know that nursing is not a degree that can be completely university-based. It relies heavily on practice placements. We are restricted in our practice placements because of the number of students that we have coming through the system now. We need some work to be done to ensure that those student nurses have a quality experience. We are working with the Department of Health and our universities to ensure that that happens. We are using the students who are part of our membership to do so.

I take your point on senior nurses. Historically, if you wanted to progress in nursing, the only way in which to do that was to move from clinical practice into managerial positions. A change is certainly happening. The Chief Nursing Officer has worked very hard to put in place career frameworks for nurses. We really support the work that she has taken forward and her leadership. We need to see a continued enhancement of clinical career structures for nurses so that they can progress in their career but remain in contact with patients, which is what they want to do, and not feel forced to achieve career progression by moving into purely management positions.

Nurses have been telling us that the reason that they have decided either to work as full-time bank nurses or take up full-time positions with employment agencies is not because they want to — by moving to a full-time agency contract, they deprive themselves of a decent pension and all the other benefits that come with having stable, contracted hours of work — but so that they can add some control to their life. The vacancy rate in nursing that we have had historically, and that we continue to have, as well as the pressures that our member mentioned earlier from the survey, pressures that remain very much to the fore for nurses, has meant that the only way in which our nurses felt that they could have any control over the hours that they worked, over where they would be placed when they arrived on a ward or in a community or over being able to go home and sleep in their own bed at night, was to give up their permanent post and register with an agency. They could then have some degree of choice and control over their working life and not have to work an additional 75% unpaid hours etc.

That situation needs to be corrected. We are on the right path now with Minister Swann's framework document, the additional students and the legislation that we are being promised. We are only at the start of that path, however. We need to continue on it and make those things part of the working life of a nurse. Nurses need to have in place proper career structures and proper contracted hours for which they are paid. They must also have confidence that the legislation will be taken forward as soon as possible.

The member's final question was on the level of trained nurses in the private nursing home sector. We are aware that, in many respects, the number of registered nurses in the nursing home sector is pared to the bone. I hope that the Minister, as part of his review of nursing homes, will look at their commissioning arrangements. That honestly needs to be looked at. Although we hear that many nursing homes make profits, there is no doubt, from what we hear and from having worked on a commissioning board, that there are many other, smaller consortiums that, financially, just about make it and nothing more. There needs to be a root-and-branch review of the financial arrangements that are in place for our nursing home sector, and it needs to happen as part of the Minister's review. Those financial arrangements need to be prioritised to ensure that the right staff are in place and that those nurses are paid appropriately and given some incentive to work in what are very highly complex environments, with patients with some of the highest acuity throughout our system. That needs to happen as a matter of urgency. Nursing homes are very challenging places in which to work.

There is another thing that we have been not so good at in the health service. Our nursing homes go on recruitment drives, particularly overseas recruitment drives that bring in workers from other countries. They spend a significant amount of time training them and providing them with in-depth induction. As soon as that has happened, however, there is a recruitment drive in our health and social care services, and those people are then drained from the nursing home sector. That is no way in which to run our health and social care services. There should not be competition between the two. We rely on each other. We should be working as one, not competing against each other. All those areas need to be taken into consideration in the review that the Minister has announced.

Mr Chambers: Thank you.

The Chairperson (Mr Gildernew): Thank you for that very extensive session, panel. Thank you for your presentation and answers. I, too, recall being on the picket lines with you, and indeed my wife, on those rainy mornings. What struck me at the time was the harmony across our society over what you were struggling for. There was cohesion among all the unions and sectors but also engagement with and buy-in from the public. That is relevant to two aspects of what we have discussed this morning. First, strike pay is recognition of the unique issue, the length of time that parity had been disrupted and the safe-staffing element of your action on behalf of the public. Secondly, it is relevant to engagement on how we rebuild services after COVID-19, and how we learn the lessons from it.

We have heard a lot of talk about the front line recently. I reiterate that, if I were seeking to learn rapidly what was done well and should be built on and what was done wrong, the first people whom I would want to speak to would be the people who are on the front line. They will know what went wrong and what went right with PPE, staffing and all of that.

Thank you very much for your presentations this morning. On behalf of the Committee, I wish you and your members all the very best in the time ahead. The health service is difficult to work in in any case, but you are dealing with a pandemic full on. Thank you for that, panel. All the best to Fiona, Pat and Rita. Go raibh maith agat agus slán.

Ms Cullen: Thank you, Chair. Thank you, members.

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