 My name is Barry Kalfer and I'm the Director of Research here at the IIA in Dublin. I want to welcome you all to this event on Frontline to the Pickett Line, Striking Nurses and the NHS Crisis. We're delighted to be joined today by Professor Nicola Ranger, who's the Director of Nursing of the Royal College of Nursing in the UK. She's taken the time to be with us to discuss this important topic. We really appreciate it. I think life is always busy as a nurse, but life at the moment as a nursing leader in the UK must be extremely busy. We're also really thrilled to be joined by someone who you'll know, Phil Nehay, the General Secretary of the Irish Nurses and Midwives Organization. We're also delighted we'll be able to chair this event. I'm shortly going to introduce Phil and hand over to her to introduce Nicola. After Phil's introductory remarks, Nicola will speak for about 20 minutes. This will be followed by a conversation between Phil Nehay and Nicola Ranger, which I'm really looking forward to. This will provide a chance to learn about the situation in the UK, but also how this compares to the situation in Ireland and indeed across the EU. No better people to do this than our two speakers. Depending on how we go then, I might come back on the mic towards the end to put some questions to the speakers if any come in throughout the session. So my final role to introduce Phil. Phil is a trained intensive care nurse and General Secretary of the Irish Nurses and Midwives Organization, the INMO. Phil has worked as an ICU nurse in Ireland, Australia, the UK, and at Memorial Sloan Kettering in New York following training in Dublin and London. Phil began work for the INMO in 1998, later completing an MA in industrial relations and a higher diploma in employment law. Phil was Director of Industrial Relations in 2008 until 2018 when he was appointed General Secretary. As General Secretary, Phil has overall responsibility for the organization, leading on the INMO's advocacy on national nursing policy and through various public sector pay agreements. In 2019, Phil led the organization's first strike in two decades, winning pay increases and staffing improvements for nurses and midwives. Phil is one of the Vice Presidents of the Irish Congress of Trade Union's Federation and Co-Chair of Ireland's Emergency Department Task Force. She is currently also an Executive Council Member of the European Federation of Nurses and a Representative of the European Federation of Public Services Union. Phil, Nicola, thanks a million for being with us both. Phil, I hand over to you to introduce Nicola. Thank you very much, Barry, and delighted to join this webinar today and also to be sharing a platform with Nicola. So just by way of introduction, Professor Nicola Ranger joined the RCN in December 22. She was previously Chief Nurse and Executive Director of Midwifery at the King's College, the NHS Foundation Trust in London. Before that, she held Chief Nurses Posts of both Brighton and Sussex University Hospitals, NHS Trust, and Firmly Health NHS Foundation Trust. She's also held a number of senior nursing roles at University College London, Hospitals, NHS Foundation Trust, and Surrey and Sussex. Earlier in her career, she worked at America's George Washington University Hospital in Washington and at Mount Sinai Medical Center in New York. And most interesting of all, which is not in the official bio, is she trained as an intensive care nurse with me in 1991 in Kingston Hospital, where we had some very good times and great memories. So it's great to be reconnecting with you. We still call you Nikki, but I now have to call you Professor Nicola. So really looking forward to your presentation. Thank you so much. Thank you so much, Phil. It's great to be here. And I'm absolutely delighted that I will be able to be here. I'm incredibly sorry for anyone who is slightly disappointed because you were expecting Pat Cungin. And I'm a poor substitute, too, is our general secretary at the Royal College of Nursing and brilliantly led our nurses to the first ever strike action in England following her success in Northern Ireland. So, you know, I'm sorry for some of you that are obviously a bit disappointed about not seeing Pat, but hopefully we'll still be able to explain to you what we have been doing. I'm just going to ask if someone can just share the presentation, if that's all right. I can share the slides there for you. Thank you very much. That's absolutely brilliant. So I think we will know that nursing has had recently a lot of discussion, a lot of a lot of challenge in the press. And I think people are really thinking about nursing and its impact because we're hearing a lot about global shortages of nursing. Next slide, please. I just want to briefly explain the Royal College of Nursing. It is the largest professional body and trade union in the world. We have a membership of over half a million members. And actually, as was said, we have a very significant, we've had a very significant impact in our college, particularly recently over that, our first industrial action in the Royal College's history in the UK. And what I hope you'll get today is a bit of a sense as to why nurses are striking. This isn't something that's happened overnight. I think it's led over a decade or more of real concern for patients and patient care. What has been absolutely clear is that when we've listened to the real strike action, can you still see me? Yes. Okay, for some reason, I can't see you guys. There's an issue there. I think, Mark, you just shared the wrong bit of your screen. We can see your teams. Okay, that's probably what I'm saying. That's absolutely fine. I just want to make sure that you can still see me. That's absolutely fine. When our nurses have been striking though, what has been absolutely clear is that they haven't just been striking for themselves. They're paying conditions. What they really have been talking about is not having enough staff to look after patients and clients wherever they are. And one of the number one issues for our members has been safe staffing. And we absolutely clear, as I've said, that this has not happened. This has happened over a long period of time. So it's absolutely key that we get this right. It is about safe staffing. It's about pay. It's about well-being of staff. And what has also happened in the UK in 2016 is that student financing was taken away in the form that it previously was. And nurses now have to pay for their degree. Their bursary is £400 a month in England, which is nowhere near the running cost. The student finances has been a real, real key issue. And all of these unaffordable things with the cost of living crisis has really, really had an impact on the profession. And what isn't always understood is that nursing is a safety critical profession. And you'll also know we are, I think, questions do need to be asked is that we are a 90% female profession and whether or not the full responsibility that nurses has is fully understood. And I have heard politicians say to me, well, it's a second salary. There's still a bit of a view that it's just sort of pin money for people and not really recognising how essential nurses are for patient safety. So safe staffing, all of these things have had a big impact on that. Next slide, please. So the scale of the problem, I think when we look at objectively, particularly in the NHS in England and the UK, there has been significant erosion of care. So if you look at A&E waiting times, they've got considerably worse over the last decade. If you look at elective waiting times, they have got considerably worse. And all of this has had an impact on how people feel particularly about the NHS and the vacancies in England. 40,000 vacancies, over 2000 in Northern Ireland. And actually, this has had a tremendous impact on the care that nurses can offer, offer patients. And as a result, I think people are really questioning whether it's a profession that they want to come into. And applications, sadly, this year have fallen by a further 12%. So we have got a significant nursing crisis in the UK. Next slide, please. Have I lost the slides of you? You can still see them. And you want to go to the next one, I think, Nicola, don't you? Yes, please. Yeah. So we can see it all comes back to patient safety markets. The next one. Yeah, I think we have to, unfortunately, settle for this, you Nicola, if that's all right. I'm not sure who I would. Okay. I'm just trying to get this slides in order. Are you back at the scale of the problem is where I'm at? There we go. Perfect. Thank you very much. So applications have fallen by 12%. The next slide, please. So sadly, as a result, I'm sorry, I don't know if I should take over. We are massively reliant on international recruitment. I'm absolutely, I'm afraid, quite embarrassing, ashamed to say that in the UK now, one in six of our nurses is internationally educated. Now that isn't to say that we don't welcome our international nurses. We absolutely do. They're vital parts of our workforce. And we've always had and welcomed international nurses into the into the NHS. We've had nurses from Ireland, from the West Indies, Europe, all over, but actually, particularly recently, since the COVID pandemic, the number of nurses that we now are reliant on internationally is not a sustainable model. One in six is internationally educated. And actually, since Brexit, we've had far more nurses joining from outside the EU. I do just want to pause here as well, just to say that the other key factor that has made a big difference, and we're really seeing that, is I've talked about the fact that care has slightly eroded and got worse, particularly in the UK over the past 10 years. But on top of that, with all of that, those vacancies, with all of the challenges that we've had, we then did have COVID. And I don't think we should underestimate the effect that that has had. On a personal level, I, as Phil said, I've been a chief nurse in hospitals. But I was the chief nurse at Kings before I came to this post. We had, at its peak, 780 patients in the hospital with COVID, 140 of them ventilated. So our nurses were absolutely pushed to the to the nth degree, some more challenge or death than they've ever seen and really pushed them to the limit. So I think that we shouldn't underestimate that with waiting lists, poor care, that sometimes we're residing over vacancies, and then COVID, it is no wonder that nurses are feeling incredibly challenged. And since then, I think we can we can really see that things are very, very difficult. Next slide, please. But what is happening is because we're so reliant on our international nurses, we are undoubtedly, I think, in the UK, destabilising other countries. I recently attended the International Council of Nurses, where over 130 countries, nursing associations were represented. And it was heartbreaking to listen to the impact of our international recruitment is having on other countries. And actually, the World Health Organization identified 55 countries that are on that workforce safeguard, sometimes called red list countries. And actually, I am ashamed to say that in the UK, 22% of our international recruits now are from those red list countries. And just the next slide, we'll just give you a little bit of a breakdown that in more detail. So India and the Philippines are the two countries where most of our international educated nurses are coming from that are joining our register. And you can see the other countries, Nigeria, Ghana, Zimbabwe. And actually, this is undoubtedly having an impact. And I think many of us have probably I've often thought countries like the Philippines, this has almost been part of their their way of working as a country was to actually have a slightly higher supply of nurses with the with the thought of people migrating. But I heard a brilliant lecture that when I was at the ICN from a lecture from the Philippines, that was absolutely clear, the impact this is now having on the on the Philippines. And they're getting to the stage where they can't fully look after their own population. And as a result, are starting to think about potentially ensuring that their nurses have to stay for three years before they migrate. So I found it astounding to listen to countries like like the Philippines, really beginning to question that. With regard to Europe, I mean, it's for me on a personal level, it's been heartbreaking to see since Brexit, how many of our European colleagues have gone back to their country of origin, because they bought so much to the NHS. So I think we have got a significant, significant challenge. And actually, now, our workforce that has gone up by nearly 10% of those that trained outside Europe. So we are really, really having an impact. Next slide, please. So what is the RCN doing? Honestly, I think there is never a time for us to be more active than we are at the moment. I think listening to our membership, many people, majority of nurses, still absolutely love their profession. But it's the environment that they're currently having to work in. I think it's an absolute disgrace that we are so dependent on our international workforce. And actually, we still have no clear domestic plan. So we have a long term workforce plan, but actually, none of that is going to happen without investment. There is no quick, easy way out of this without investment, whether it's people supporting people through a direct university grant, whether it's an apprenticeship, whatever route it is, there is no way that we're going to get out of this with having a strong domestic plan, which sadly is still lacking. We absolutely need to support nurses that are coming here, leaving their families coming over. Our immigration system is not set up to fully support them. So we absolutely need to be strong in this place. And I'm afraid we have still got the political challenge that I'm not sure that people fully understand the role of nurses and how essential they are of being the lifeblood of any organization. Next slide please. Fair pay. As I talked earlier, we've absolutely got to be strong with regard to fair pay and doing all that we can with regard to correcting that. You'll know that we recently had strike action and actually did we fully achieve everything our nurses needed? Absolutely not. And even though on our second ballot, we didn't have enough to get with our, we have to have a paper ballot in England and we had to have a threshold of 50% in order to take legal strike action and ours was at 43%. So didn't quite get over that threshold for a second round of strike action. But with the volume of staff and nurses we had over 100,000 nurses in England still voted for strike action. So is this over? Absolutely not. Have we got nurses that are still frustrated and unhappy? We absolutely have. So is there a lot that we need to do? Yes, there is. And now with nurses not striking, they are surrounded at the moment in England with their consultant colleagues and their junior doctors taking strike action. So for nurses it's a double whammy in the fact that they're now supporting their colleagues and I've never seen such unrest in the health service as there is at the moment in my entire career. So it's absolutely key that RCN has a strong voice particularly coming up to the election. Next slide please. What's really, really tragic is also when our recent survey another 57% said that they are actually then thinking of leaving their profession and we lost 25,000 nurses off the NMC register last year. We have got a problem that we absolutely need to solve and I'm afraid with terrible situations like Lucy Letbey of course is an absolute tragedy for everybody. I think what is the real fear is that more and more scrutiny, more and more compliance, people are feeling that they work with a great deal of scrutiny on their profession in the actions they take. And I think with our pay you hear nurses often say actually I could earn more working at Amazon with far less scrutiny and I think we've really got to think about we have to value our profession and really think about what it is that will keep them in our profession. So I think pay conditions is absolutely key and as I mentioned earlier you know all of this really matters when we're a predominantly female profession. I do worry sometimes that sometimes falling behind in pay parity you do question whether that has any bearing on all of this. We're going to introduce nursing associates which is a two-year registrant and is not a fully recognised RN. I think that's if I'm honest I think there's a real risk in England where it was introduced that some politicians will see the opportunity to have a less experienced nurse that's cheaper and we've got to really safeguard our profession with regard to that that that registrant being introduced. So there's a lot of work being able to really make sure that that doesn't happen. I think recently as well we have felt that we had to go back as a college and really define what nursing is which is which is something that we are have put out literally this week. The reason is because I think many people don't always recognise that you need both a heart and a brain to be a nurse actually and it is an absolutely safety critical profession. It isn't just about caring of course care matters but we absolutely essential to keep people safe and really putting that front and centre is also one of the things that we really need to nurture and make absolutely clear that we are very very skilled in what we do. I think it's tragic that many people don't see what a brilliant career nursing can offer as Phil you know the introduction to Phil and the introduction to myself we've had the honour of being able to travel influence and have a great career and I'm proud of being a nurse still proud of being a nurse and it sounds a bit corny but you get the opportunity to look after people at the most vulnerable times in their lives and actually doing that brilliantly is absolutely key to everybody wherever they live and it's absolutely key for the public that we safeguard the profession so that we can look after people in a skilled and brilliant way. Next slide please. I think what also hit me when I went to the ICN when I've talked about what we're doing to other countries in the UK we do have the National Health Service which actually is free at the point of access and actually the establishment of that was an absolutely brilliant thing and decades ago I would say was the envy of the world and certainly when I listened to other countries the infrastructure is there in the UK but what is really tragic there is no universal healthcare coverage there is no NHS without the workforce and without nurses who are the backbone and the largest work largest professional group in that workforce there is no NHS and I'm not sure that's fully recognised and what's tragic to me at the moment is I am seeing the dismantling of the NHS happening right before our eyes because we have not looked after and valued the workforce and actually centre to that we absolutely have not looked after and valued nurses and I'm absolutely determined that as Pat as our leader that the RCN plays our part in fully explaining that because if we don't act now we will rue the day that we didn't stop and halt and think what can we do to get things better for nurses and most importantly to look after patients.