Mental Health Services: Discussion (Resumed)

Chairman

I welcome to the meeting representatives from the Irish Hospital Consultants Association, IHCA; Dr. Roy Browne, consultant psychiatrist; Dr. Kieran Moore, consultant psychiatrist; Dr. Donal O’Hanlon, consultant psychiatrist; and Mr. Martin Varley, IHCA secretary general. I thank them for their attendance. The witnesses will be invited to make a brief opening statement, which will be followed by a questions-and-answers session.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members should also be aware that under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable. I remind witnesses and members to turn off their mobile phones or switch them to flight mode, as they interfere with the sound system and will adversely affect the television coverage and live streaming. Any submission or opening statements witnesses provide to the committee will be published on the committee website after this meeting.

I invite Dr. O'Hanlon to make his opening statement.

Dr. Donal O'Hanlon

I thank the Chair, Senator Freeman, and members for the opportunity to address them on the significant challenges facing the mental health services and specialist psychiatric care in particular. The IHCA represents 85% of all hospital consultants working in Ireland’s acute hospital and psychiatry services. This statement is a summary of the detailed submission provided to the committee in mid-January, which I assume members have received.

Ireland’s spend on treating mental illness is approximately half that of most northern European countries, at just 6.6% of the total health budget. We have yet to implement many of the recommendations of the Government’s 2006 mental health policy, A Vision for Change, with shortfalls across a spectrum of areas, including bed capacity, community care services and staffing. The IHCA shares the committee’s concerns that access is a vital factor to consider when examining each of the three high-level themes it has identified, namely, primary care, recruitment and funding. The association agrees that while primary care is well positioned to provide care to service users and patients with mild to moderate psychological problems, those with moderate to severe illness often require specialist psychiatric care provided by hospital-based consultant psychiatrists. Unfortunately, we do not have the resources or the number of consultant psychiatrists required to provide high quality, timely care and treatment to patients who need it.

The Hanly report in 2003 and the HSE national doctors training and planning unit in 2014 recommended that the number of approved consultant psychiatrist posts be significantly increased to 712 by 2016 and to 755 by 2024, respectively, to ensure that safe and effective psychiatry services can be provided on a timely basis.

Additional increases have been recommended, up to as many as 858 consultant psychiatrists by 2020, by the College of Psychiatrists of Ireland. This represents more than a doubling in current numbers. A further workforce concern is that of the existing 418 approved consultant psychiatrist posts, of which only 290 are permanent appointees.

Our psychiatry services in particular fall significantly short of the recommendations in A Vision for Change and in comparison with other European countries in terms of consultant workforce, bed capacity and funding.

Ireland has 6.1 consultant psychiatrists per 100,000 population, just half the EU average number of specialists and one third to one quarter the number in many EU countries. Ireland is ranked below such countries as Romania, Slovakia and Greece, and has 22% of the number of consultant psychiatrists in Finland for a comparable population.

The prolonged and deepening consultant recruitment and retention crisis is due to the failure of the State and employers to honour the 2008 consultant contract and the imposition of discriminatory terms and conditions on new entrant consultants. This has been exacerbated by the steep financial emergency measures in the public interest, FEMPI, cuts applied to consultant salaries and systemic funding shortfalls in the psychiatry services and mental health services during the past decade.

The Irish health service is uncompetitive in recruiting and retaining the number of high calibre consultant psychiatrists it requires. This sharp decline in competitiveness is evident from the fact that 31% of all approved consultant psychiatrist posts at the end of 2016 were either vacant or filled on a temporary basis. Nearly three quarters of temporary post holders, some 37 of the 51 staff had agency contracts, thus increasing the overall costs to the health service.

More recent figures released in October 2017 confirmed that of the 201 approved consultant posts, in all specialties known to be filled on a temporary basis, psychiatry accounted for a disproportionate number of posts, some 50 posts or a quarter of the total.

A quarter of consultant psychiatrist posts advertised in 2015 and 2016 had no applicants, with 30% having only one applicant for the vacancy. This recruitment crisis has also manifested itself in the appointment of 21 non-specialists to consultant psychiatrist posts across psychiatry specialist areas as follows: 15 non-specialists to general adult psychiatry; four to child and adolescent psychiatry; one to psychiatry of old age and one to learning disability psychiatry. This undermines the safety and quality of patient care and is in breach of the HSE’s recruitment rules and the Medical Practitioners Act 2007. These breaches have occurred across the country in Carlow-Kilkenny, Cavan-Monaghan, Clare, Donegal, Kildare-West Wicklow, Longford-Westmeath, Mayo, Midlands, Sligo-Leitrim and Tipperary south.

Ireland is not self-sufficient in the provision of specialist trainees, as we are not training enough to meet the requirements or replace current numbers, particularly given the difficulties in retention at non consultant hospital doctor and consultant levels.

Shortfalls in community team staffing levels are restricting the services' ability to deliver care to users and patients. The staffing deficits compared with levels recommended in A Vision for Change are up to 68% in intellectual disability services for adults; 47% in child and adolescent mental health services, CAMHS, 42% in psychiatry of old age services and 22% in general adult psychiatry teams.

Ireland has the third lowest number of inpatient psychiatric care beds in the EU, with 34.83 beds per 100,000 population. This is half the European average, and the bed capacity has declined sharply from 101 beds per 100,000 population in 2004. This has occurred at a time when Ireland’s population increased by more than 500,000 during the past 12 years, and while those aged 65 years and over increased by 35%. While A Vision for Change planned for a marked reduction in acute psychiatric hospital beds, the promised alternative services have not been provided in the community.

The number of adult psychiatry inpatient places available for acute admissions, 972 acute adult inpatient beds at the end of 2016 has been reduced to the point where there are frequently no beds available at night in many community healthcare organisations, CHOs.

Given that there are only four CAMHS inpatient services nationwide, located in Dublin, Galway and Cork, children often have to make 400 km round-trips from their homes in order to access treatment, thereby experiencing significant separation from their family, friends and school.

Furthermore, there is no co-ordinated national system to resolve crisis situations when they arise. This presents a significant patient care and safety issue.

The admission of children and adolescents to adult psychiatric units is a totally unacceptable but common practice, with 68 children admitted to 19 adult units in 2016. A third of those admissions to adult units were in one region – CHO 8, which encompasses Laois-Offaly, Longford-Westmeath and Louth-Meath. While this represented a 29% decrease on the number of such admissions in 2015, the admission of any child to an adult service is most unsatisfactory. The downward trend may be reversing again based on available data for the first five months of 2017, as 44 children were admitted to adult units compared with 36 for the same period in 2016.

The relatively low number of child and adolescent psychiatrists and shortage of required front-line resources have resulted in unacceptably high numbers of children on CAMHS waiting lists. In September 2017, 2,333 children were waiting for their first appointment, with 1,472 waiting more than three months to be seen, an increase of 42% compared with October 2016. The number of children waiting more than a year has also increased significantly from 170 in September 2016 to 317 in September 2017. This is all against the background of a 26% increase in CAMHS referrals between 2012 and 2017.

There were also only 29 teams for psychiatry of old age in place in 2017 compared with the recommended 39 teams recommended in ‘A Vision for Change’. The HSE projects that referrals to psychiatry of old age will increase by 17% between 2017 and 2020.

These deficits are not surprising, given that the 2018 mental health budget of €917.8 million is 10% below that allocated in 2009, which was€1,022 million. As previously mentioned, Ireland's spend on treating mental illness is approximately half that of most northern European countries, at just 6.6% of the total health budget. Designated, ring-fenced funding for specific clinical programmes in psychiatry is required to provide early intervention for first episode psychosis, the comprehensive treatment of eating disorders, and self-harm presentations in emergency departments. Resources are also required to support the overall management of the services by executive clinical directors.

Moreover, there are substantial regional disparities in the allocation of funding and resources, with community healthcare organisations, CHOs, of similar population size allocated significantly different budget allocations and staffing.

The above deficits are contributing to significant access problems in the acute psychiatric services, as demonstrated by the persistent and damaging long waiting times for treatment and the unavailability of specialist services promised in A Vision for Change.

The association welcomes the work of this committee on implementing a single, long-term vision for psychiatric care and the direction of mental health policy in Ireland. I thank the committee for inviting the association to its discussion today. We are available to address members' questions on the above and the contents of the association’s submission.

Chairman

I thank Dr. O’Hanlon. The presentation was extremely informative and a little depressing. The four members present will have seven minutes each to ask questions. I need to be strict on this because we have another group coming in an hour. I ask members to ask questions rather than make statements.

Seven minutes is a limit, not a target and, therefore, I will stick to that. I welcome the witnesses and I thank them for giving of their time. Their opening statement was depressing and negative. Despite that, almost €1 billion was spent over the past year on mental health services, with an additional €59 million to be spent in 2018 and a further €55 million in 2019, which is positive. Dr. O'Hanlon said only 6.6% of the health budget goes to mental health. How is that percentage calculated? Did he include the money spent on mental health by the Departments of Education and Skills, Children and Youth Affairs and Justice and Equality?

FEMPI has been a major problem in general and not just in mental health services, but the Minister for Health is working on that issue. Appointments have been made. For example, 120 psychologists are being appointed. The recruitment drive has been successful and it is expected that those positions will be filled and taken up shortly. It is, therefore, not all negative. Are salaries the biggest obstacle to recruiting psychiatrists? How much is a psychiatrist's salary? If I come out of college after seven years, what is the starting salary as a junior and what are the salaries as I work my way up to being a consultant? What are the different posts available? I would love him to compare those to his counterparts in the NHS. When I hear stories about psychiatrists, I find that the salaries that consultants earn are very high. Doctors of psychology probably spend seven or eight years in college. They work their way up to principal grade, of which there are few in this country. The salary is approximately €105,000. How does that compare to a psychiatrist's salary? What do the equivalents earn in the NHS?

Dr. O'Hanlon referred to inpatient accommodation. That is a difficulty for us but people are accommodated as inpatients and do well. When they return home, however, they do not do so well in their normal, day-to-day life and then they have to be readmitted. What is his opinion on psychiatrists being part of home care teams? A patient is supported to live at home in the conditions that caused the difficulty in the first place - the trials and tribulations of life. People get cocooned in an institution and they achieve a certain level of recovery but then they return to the place where it all started to go wrong for them. If more work was done by home care teams, including psychiatrists, perhaps fewer acute beds would be needed.

Telepsychiatry is used a great deal in the US whereby psychiatrists engage with clients on Skype. The clients visit a primary care centre with proper facilities and the psychiatrist has dealings with them through Skype. Will the witnesses comment on that? I would like direct, specific answers, particularly to the question about salaries. I am curious about the salaries and the different grades.

Chairman

Could the witnesses make the answers as precise as possible please?

Dr. Donal O'Hanlon

There are a lot of positive things going on. Many improvements are taking place in the standard of care but the problem is having the manpower to deliver them. Home care is a good example. Many areas cannot recruit home care teams, even though funding is available. There is, therefore, a problem with recruitment. All our services have lost people to other countries. Staff we have trained or employed for years have left and we are employing agency staff at twice the cost to replace them. The salaries appear generous but there is an international market. The Chairman asked what contribution salaries make to the decision to leave. I can only speculate on that, although research is being conducted into that. Salary is a big component, as is the lack of resources to do our job adequately. For example, to provide a fully staffed community mental health team, at least 12 AHPs and nurses are needed and many of our teams do not have that number. It is not uncommon for people to start in the system with three or four staff. There is also a difficulty in recruitment because there has been a breach of trust in the consultants' contract and it is difficult for consultants to feel respected by the system. Dr. Browne will address the salaries.

Dr. Roy Browne

The salary for consultant psychiatrist - no private practice, type A - as of last month, was €185,000. With regard to my experience in respect of recruitment and retention over the past two years, I have been involved as an external interviewer for much of the consultant recruitment over the past number of years. I was appointed 20 years ago and at that stage there were approximately 20 candidates for each post. I was on two interview boards recently, one before Christmas and one after. One candidate was interviewed for both posts and he got to choose which post he would take. After Christmas, we interviewed a candidate who was not suitably qualified for the post. We are now in a position where we have 50 posts unfilled. Comparisons can be made on salary between many disciplines in many sectors of the workforce in Ireland but we are in an international market, which is even more competitive in the English-speaking world, and we cannot recruit people back to Ireland currently. The problem worsened because in 2010 staff were offered the option to retain their pension entitlements if they left early and saved the State money by not having to pay them their full salary. A huge number of consultants left, some of whom have returned as temporary consultants but others have never been replaced.

We have a significant problem at that end.

I cannot answer the question about the figure of 6.6%. Perhaps Mr. Varley might address it.

Mr. Martin Varley

On the figure of 6.6%, it is €1 billion out of a total health budget of €15 billion. We have not included income or provisions in the Department of Justice and Equality which could obviously be taken into account separately.

What about the Departments of Education and Skills and Children and Youth Affairs?

Mr. Martin Varley

We have not included anything other than the health budget.

In that case, the figure is higher than 6.6%.

Mr. Martin Varley

Potentially, yes. We are only working from the health budget.

In terms of international competitiveness in recruitment, there are many factors at play. Obviously, the headline salary is one factor. We have made a submission to the Public Service Pay Commission comparing salaries with those on offer in the countries to which our doctors and consultants are going. On average, they are paying somewhere in the order of 50% to 100% more. In addition, cost of living comparisons with some of the destination countries show that living costs in Ireland are up to 10% higher. Taxation levels are also 10% higher on average. When one makes net comparisons, one sees that Ireland is not competitive. That explains why we have not been able to fill posts that have been advertised, not only in mental health services but also throughout all specialties. I know of posts that have been advertised four or five times across specialties such as pathology, surgery and so forth. That is the real difficulty. Being competitive comes into play. The other fact that comes into play is that relatively we have fewer consultants across all specialties on an international comparative basis. That means that the workload here tends to be heavier which often manifests in the number of patients in a clinic and I am not just speaking about psychiatry. Furthermore, the resources available on the front line are more stretched.

I am sorry, but can I just-----

Chairman

The Senator's question has been answered.

May I come back in to ask Dr. Browne a question? He made reference to a salary of €185,000 for a senior consultant.

Dr. Roy Browne

Correct.

Is that within the HSE?

Dr. Roy Browne

Yes.

That figure does not include income a consultant may earn from private practice. Is that correct?

Dr. Roy Browne

That is the salary for working entirely without private practice.

I am sorry, but I find that absolutely-----

Dr. Roy Browne

Let me explain the way the salary system is set up. Type A consultants do not engage in private practice; they work entirely for the HSE. Type B consultants work partially for the public service and partially in private practice. Type C consultants are an anomaly left over from the old contracts which cover those who had previously worked as private consultants. They have slightly increased private practice rights. What I have quoted is the salary for type A consultants.

The person who works solely for the HSE.

Dr. Roy Browne

Correct.

He or she earns a salary of €185,000. Dr. Browne says that while the salaries appear to be generous, they are not, but I argue that they are exceptionally generous. Expectations are very high-----

Chairman

The Senator has asked her questions. We will ask the delegates to send the answers in written format

I want to ask one more question.

Chairman

The Senator is over her time and now really pushing it.

I have one more quick question. They are very high salaries, yet we cannot get people to take the jobs. For what are they looking? For what salaries are psychiatrists looking to come back to work here? The delegates referred to the high cost of living and so forth. That also applies to nurses, psychologists and so forth who have to live here too. I want to know what psychiatrists want to come back to work here, if a salary of €185,000 is not enough. If politicians earned that salary, we would be called out and made accountable for it. A Senator earns a mere one third of that salary. I would love to receive an answer to my last question, please.

Chairman

I ask Dr. Moore to respond quickly. I will then hand over to Deputy Anne Rabbitte.

Dr. Kieran Moore

I thank the Chairman for giving me the opportunity to respond. It has been said there is a lot of positive stuff ongoing. I absolutely agree. In the context of the budget figure of 6.6%, the point we really want to get across is that there is a difference between mental illness and mental health. The patients we see are really suffering and unwell, as members of the committee well know.

Yes, we are aware of it.

Dr. Kieran Moore

I know that members are aware of it. We are also very interested in promoting mental health. In that context, the budget for education is very much about promoting mental health, which is really important. What we are trying to get across is that the patients who are sick are the most important part. While salaries and other elements are important, it is the patients who matter most. We are arguing that for a host of reasons, they are not receiving the care they need. While there is a lot of good stuff ongoing, there is a lot of bad stuff, too.

May I, please, receive an answer to my last question?

Chairman

I am sorry, but we must move on. I will come back to her if we have time.

I thank the delegates for their presentation. In their expert opinion, what is the impact on a child of being placed in an adult psychiatric unit? What is the impact from the point of view of recovery? The number of children being placed in adult psychiatric units seems to be increasing all of the time.

Dr. Donal O'Hanlon

They do not receive the same programming and are not shown the same understanding in the stage of life they are going through. People who are geared more towards dealing with adults are not aware of the transitions made in childhood. I will defer to Dr. Moore who is a child and adolescent psychiatrist on that question.

Dr. Kieran Moore

I thank Deputy Anne Rabbitte for asking what is a really important question. I am a paediatric or child and adolescent psychiatrist. One can look at the research in terms of the short and long-term effects, but the most important point is that it is unfair when a child is admitted to an adult unit. Despite the absolute best efforts of nurses, doctors and other staff in adult units, one ends up having a child in a room on his or her own, with nothing else ongoing in terms of the provision of treatment. There is no education and no access to the normal rights of a child. In paediatric hospitals parents are not just allowed but actively asked and encouraged to be with their children. That does not happen in psychiatry units, even those which have child and adolescent beds. It is devastating. I see children all of the time in adult psychiatry hospitals who I had to admit. One goes to talk to them and they are distressed because they do not understand the noises they are hearing from the people outside. There are people in them who are 70 or 80 years old and it is wrong.

To answer Deputy Anne Rabbitte's question and go back to what Senator Gabrielle McFadden spoke about, having inpatient units 200 or 300 km away does not make sense. We should be treating people, particularly children, at home. We should be linked with schools and the treatment teams in place. If we need a bed, we should have access to one in the local paediatric hospital for a number of nights, rather than having to wait for a bed a long distance away or put children in adult psychiatry hospitals which, in fairness, are already full with adult patients. My expert opinion is that, potentially and often, it is devastating for a child.

Chairman

Does Deputy Anne Rabbitte have further questions?

Yes, I do because that response is important. Dr. Moore has said children are in a room on their own. I come from Galway where the children in adult psychiatry units are not in a room on their own. They share rooms with adults. What is the impact on them?

Dr. Kieran Moore

It is devastating. We do not treat children with any other illness in the same way as we treat children with a mental illness. They are illnesses, as members know. We are talking about severe bipolar disorders, schizophrenia and so on. If a child has any other illness such as asthma or diabetes, we will not put him or her into an adult hospital with 70 or 80 year olds. By the way, I mean no disrespect to such patients. However, we seem to think it is okay to do it for children with a different type of illness.

Dr. Roy Browne

I am an adult psychiatrist and was clinical director of services in west Dublin for quite some time. The demand for acute psychiatric beds has become acute.

The patients in the acute psychiatric units are incredibly unwell and generally are treated as an inpatient for as brief a time as possible because somebody else who is worse is waiting to get that bed. In a situation where a young child is being exposed to behaviours, which at times can be very bizarre - nobody wishes to hear about this - because people are extremely unwell, one has to accept that must be very damaging for a child.

Chairman

I thank Dr. Browne for that. I advise Senator McFadden that I will make sure her last question is answered during the course of the meeting. Senator Devine has to leave and I call Deputy Buckley in her place.

I thank Dr. O'Hanlon for his presentation. I have a few questions. The opening statement indicated that in 2016 alone, 31% of all approved consultant psychiatrists posts were filled on a temporary basis. Can one of the witnesses define "temporary" in that context? Is it three months, six months or five years? The opening statement also refers to non-specialists being appointed to consultant psychiatrist posts. People who were not qualified were appointed to consultant positions on a temporary basis. Are they qualified for those positions?

On the issue of agency staff, almost 90% of temporary post holders had agency contracts. These post holders had temporary contracts and non-specialists were moved into consultant psychiatrist posts. It was stated that it costs more to hire agency staff. As Senator McFadden said, if a qualified consultant is paid €185,000 a year, are these temporary or agency staff being paid more than €185,000 a year?

Mr. Martin Varley

On the information the Deputy referred to in terms of 31% of the posts being on a temporary basis, that is because they cannot be filled on a permanent basis. Half of the approved posts which are not filled permanently are filled on a temporary basis, the other half are not filled at all. I am talking about the health service generally.

The issue of the duration of contracts can vary from months to years, sometimes repeated over several years. That gives rise to a situation where somebody who was appointed on a temporary basis may end up in a contract of indefinite duration, in other words, permanently in the post. A high percentage of the temporary appointees would be agency appointees with agency contracts. While we have submitted a freedom of information request to the HSE for information as to what they are paid, to date most of the replies I have received in recent months refused to provide me with information on the cost of an agency consultant or doctor. Therefore, I do not have that information. I know of evidence in acute hospitals generally rather than in the mental health sector where the payment for agency employees could be significantly above that of a long-serving permanent consultant.

Regarding consultants' salaries, I should add that the maximum is €185,000, as referred to by Dr. Browne. The starting point for newly appointed consultants is about €120,000. The starting point for a medical graduate joining a hospital as an intern is in the early to mid-€30,000s. When one compares their salaries with hospitals elsewhere, those hospitals elsewhere pay more. Unfortunately, those are the facts internationally, when one makes international comparisons. I am not sure if I covered all the Deputy's questions.

We have had an issue here all along with the retention and recruitment of staff. I cannot get my head around that problem. If we have people who are qualified to fill posts but we cannot employ them directly, yet we can sublet them to another company and pay them more to do the exact same job for which they are qualified, therefore, what is the problem? I cannot understand it. A photo and message was uploaded by a psychiatric nurse to Facebook, which shows how toxic the situation is. That message came from four psychiatric nurses during the weekend. It states:

This is a picture of 4 Psychiatric nurses who had to work to work because being psychiatric nurses we are bottom of the pile in regard to lifts by emergency personnel, because for some unfortunate reason people must think, people's mental health goes away when the snow comes! ...

Or maybe we are not seen as "real nurses".

As a newly qualified nurse I've learned so much already about the country and how we are valued.

But STILL, We put on our boots and WALK to work.

THESE ARE THE KIND OF NURSES YOU ARE LOSING TO OTHER COUNTRIES!!

That is a statement from psychiatric nurses. They went public with that message. We are paying agency staff more money and they probably have less responsibility than full-time staff. I can understand the gap in terms of pensions and so on but it comes back to the issue of the recruitment and retention of staff. We are wasting money on agency staff when we could be giving it to people who have spent their time here qualifying and want to work in the system because we recognise that it is not all about money. When staff feel they have no self-worth in the system, we cannot fix that problem. If we keep subletting these qualified personnel and privatising the service, we will have a dog chasing its tail for the rest of his life. We will be dead and buried and another committee will be in here asking the same questions.

How do we fix that problem? Are the unions responsible for this or does it come down to the contracts? Do the personnel have bad contracts? This issue is very frustrating. I was a member of the Oireachtas Committee on the Future of Healthcare, which deliberated for 12 months, and this same issue has come up again. We are wasting money left, right and centre. Is it €2 million a week that is spent on HSE agency staff?

Chairman

Before Dr. Moore or any of the witnesses answer the Deputy's question, I ask them also to include Senator McFadden's question, which basically related to the same issue. What are the psychiatrists looking for? If the salary is not high or good, what is it they are looking for, if it not only a good salary? I ask if they could also address the answer to that question in the context Senator McFadden's question.

Dr. Roy Browne

I will start by addressing that question. I cannot tell the Chairman what the psychiatrists are looking for, but I can tell her the reason we cannot get back most of those who we are trying to recruit. They are people we trained who left to work in America, Australia and New Zealand, the major territories that are taking our graduates. The National Health Service is not attracting as many of our graduates because it suffers many of the difficulties from which we suffer in the Irish health service. There is an enormous preponderance of managing performance in terms of vetting etc. These are very self-driven people, as are the nurses - to whom the Deputy referred - the psychologists and the social workers. These are people who are very much driven to look after their patients but find at times they are unable to have the necessary resources, for example, a room in which to see their patients or a secretary to type up reports. They type up the reports themselves and that is fine but it probably would have been more helpful if they had seen other patients and had been able to dictate those reports.

Chairman

Could Dr. Browne answer Deputy Buckley's question regarding the agency staff?

Dr. Roy Browne

In terms of locum, agency and temporary staff, with regard to the temporary posts, there is a churn in posts. People are leaving but the process of getting posts reapproved through the consultant appointment committee and funded through the CHO is very complex, therefore, that is a delay.

There is bureaucracy and red tape.

Dr. Roy Browne

There is an element of that in half of the posts. The other part is that when we get the permanent posts through, they go to the Public Appointments Service. I sit on the interview board with all of the various people. One person turns up and they are either suitable or not suitable. Therefore, there is also a problem with attracting them to come back to work in a system which they regard as toxic. It is something nobody likes saying about a system in which they work but, as time has passed, many of us feel it is a toxic system that at times tries to diminish the amount of work we can do. I was struck by the mixed messages from the HSE coming up to the snow event. Staff members were told that if they could not get into work, they would not be paid but then two days later, the message was that it would try to give staff a bedroom because it realised that it could not get any staff to come in and work. Four of my nursing colleagues spent three days in a hotel room coming back into work on shifts every night. Thank goodness they did so because otherwise we would have had probably one nurse looking after a group of 15 patients who were all extremely unwell.

Dr. Kieran Moore

May I add a comment-----

Chairman

A very brief one.

Dr. Kieran Moore

-----regarding the very valid point about agency staff?

To put it very simply, if a dog has a choice between being given a treat if it does a trick and being given one even if it does not, it will choose the latter. I do not mean to be disrespectful, but my analogy might make it simple. If a doctor comes to this country to be a consultant, he or she can either train to be a specialist, which takes three years and a lot of work and study on a lower salary, or go to an agency and work immediately as a consultant, although he or she has not been trained for it. After three or four years, he or she will have a contract of indefinite duration allowing him or her to be a consultant, even though he or she is not. In that sense, it is a no-brainer and I mean no disrespect to anyone. The solution is for the Legislature to examine the Medical Practitioners Act which does need to be examined.

Chairman

That was a very clear explanation.

I thank the delegation for the presentation. A number of weeks ago the secretary general of the Psychiatric Nurses Association of Ireland attended a meeting of the committee and painted a very dark picture of mental health services in the State. It was so dark that everybody was flabbergasted at the position on retention and the morale of psychiatric nurses. The report given today is not as damning, but obviously it contains an analysis of mental health services in the State.

I wish to refer to one point on which I want to obtain the delegates' professional opinion. Some of the questions have been answered. With regard to CAMHS beds, early intervention is key to most things medically. When there are waiting times that are completely unacceptable, medically and socially, what is the damage in the short and longer term to a child who is not being seen, with a view to receiving a key mental health intervention? It is completely unacceptable that there are waiting times for essential services. It is a societal issue. In the medical opinion of the delegates what does a delay do to the child and family?

Dr. Donal O'Hanlon

On a personal level, I agree that the waiting times are totally unacceptable. It is due to not having sufficient manpower in the service to provide an appointment. I ask Dr. Moore to answer because he is the expert on child psychiatry.

Dr. Kieran Moore

I thank the Deputy for the question, to which there are a number of elements. I shall answer it honestly. The simple answer is that it is absolutely devastating. The Deputy is correct in that regard. It is important when designing services that we try to examine the difference between mental health and mental illness. I say that because at any one time approximately 20% of children broadly have psychological difficulties which may extend from difficulties within the family and bullying at school to the other end. I am not saying one is different from the other, except where there is a very severe illness such as schizophrenia which is a long-term biological illness that, unfortunately, will require an input from the medical and other professions for the rest of the patient's life. It is about working out how we deliver the service. That is why we would very much welcome having psychologists in primary care services. In some parts of the country there is a waiting list of approximately four years, which is crazy.

To go back to our bit, it does not make sense that specialists end up seeing children who do not need to see them. Many of the children on the waiting list for the specialist service do not necessarily need a specialist service. However, they do need to see somebody, which is why we are very much promoting the idea that primary care psychology services and all of the other ancillary services should be resourced also. On our side, we really need help with the more specialist service.

To answer the Deputy's question, early intervention is key in anything about which we know. We know that 50% of mental illnesses which will require psychiatric intervention come on before the age of 14 years and 75% by 25. The earlier the intervention, the better, including in cases of autism and ADHD. Not only does it help the child, but it also helps society in order that people can work in the community and will not need to be in receipt of disability benefit for long periods. It is best to have intervention as early as possible. Expenditure is far lower than at the other end where one ends up treating people. Even with those with whom I deal, 17 and 18 year olds, it is almost too late. It is not too late, but it can be in some cases where people are already in trouble with the Garda or may not be able to work or go to school. It is not just about resources and early intervention, but they do have a huge influence.

To answer the questions on retention and recruitment, a large part is that people really enjoy working together when they are able to do so and when the resources required are in place. Colleagues of mine are frustrated across the spectrum. The psychological stress and burden in being overworked cause a lot of difficulties for people.

On the point about psychiatric nurses, there are really good, interested people who want to work and do work. However, the system does not work at times. Perhaps if we had more people and more support available, we could do better.

What happened to Linn Dara in Cherry Orchard is probably indicative of what is occurring in mental health services throughout the State. I am referring to the CAMHS unit that lost 11 beds. It is imperative that they be reopened.

Chairman

They have been.

We have finished one section of questioning. We shall now proceed to two more Deputies who will ask their questions. The delegates may then respond. I call Deputy Tom Neville who will be followed by Deputy Tony McLoughlin.

On recruitment, pay and retention, Mr. Varley has stated some other jurisdictions are paying 50% to 100% more and that the cost of living is lower. Is that correct?

Mr. Martin Varley

Yes.

Have those countries been tiered? What do Nos. 1, 2, 3, 4 and 5 represent? I hear all of the anecdotal evidence, but I would like to receive some statistics.

Mr. Martin Varley

We submitted the information to the Public Service Pay Commission a number of months ago. The average consultant's salary in Ireland is about €162,000. The average in the United States is €267,000 or €268,000 and €270,000 in Canada.

They are the salaries, but I would like to know what are the net figures. Is Mr. Varley referring to someone living in New York, Utah or Washington? Obviously, the standard of living is different in each location.

Mr. Martin Varley

It is an average figure across the country or regions. The cost of living differences are based on published accounting data. They are not our data. On data for comparative price levels, for Canada there is a figure of 94, with Ireland being at 100. The United Kingdom is at a figure of 92 and the United States, 87. These are monthly OECD comparative price levels. We are using independent data which have been appropriately adjusted having taken the cost of living, inflation and everything else into account.

What are the top five countries?

Mr. Martin Varley

We are talking about the North American countries, Australia and New Zealand. We looked only at the countries in which English is spoken. The others that come into play are the Gulf states which attract a lot of people, including teachers, nurses, doctors and consultants. The general problem, of which we should not lose sight, is that the WHO and everybody else have confirmed that there is a shortage of medical professional staff worldwide. The shortage is even affecting developed countries and, therefore, driving up the cost.

Mr. Varley alluded to the top five countries. Is the reason he gave the sole reason we cannot get what we are looking for? Is it just a question of the size of salary?

Dr. Roy Browne

I do not believe it is. We have been dealing with a degenerating health service in Ireland in the 15 to 20 years in which I have been working in it.

For what reason?

Dr. Roy Browne

For many reasons. There has been a reduction of money going into it over time. There has been an increase in population and in areas of deprivation. At times, there have been attempts to change the system. That has led to a system building on a system building on a system.

Has there not been the most money ploughed into the health services in the last year? Perhaps I am wrong?

Dr. Roy Browne

There has been plenty more in the last year. However, if we compare-----

The witness is talking about a-----

Dr. Roy Browne

Hang on a second. If we look at the extraction of beds-----

Chairman

I will have to stop here because there are other people who want to ask questions.

Dr. Roy Browne

-----over the past 20 years, we begin to get a picture suddenly of a health service that is deteriorating in fixed resources, which makes it increasingly hard to deliver the services. I can only give my experience.

Okay, that is fine.

Dr. Roy Browne

I worked for nearly 30 years in the health services. I started off in the Eastern Health Board, which then got divided into three, then four and then across the country into nine. The system is now getting regenerated in a smaller number of community health care organisations, CHOs, over time. They will eventually be linked back into hospitals. There has been a burgeoning bureaucracy and, often, a management structure that is not sure what it is managing. We are nearly back to where we were once upon a time where we had a health board for a local area and there were inputs from the carers, the politicians, the people who used the health service and the experts' managers.

In Dr. Browne's opinion, would that be a better type of model?

Dr. Roy Browne

I not do not know at this stage. I have been around in circles-----

Chairman

I will have to stop the witness there. There are three more members who want to ask questions. Can I hear from Deputies McLoughlin, Brassil and Browne and can the witness hear all the questions before answering please?

I thank the witnesses for their submissions and contributions. Are the HSE subsidies given to mental health professionals comparable with those given to other health professionals? Getting colleagues of the witnesses back into this country was mentioned. What is the most attractive element of working outside of Ireland and what is the least attractive element of working in Ireland for mental health professionals?

Dr. Moore mentioned that getting people at 17 years old may be too late. He is right. I represent the constituency of Sligo-Leitrim. There are many issues there and work is being done by child and adolescent mental health services, CAMHS. How can we intervene at an earlier age? There are problems at national school level as opposed to the witness meeting them when it is too late at 17. Perhaps Dr. Moore might comment on that?

I thank all the witnesses for their attendance. On the issue of recruitment, when a consultant retires, or is flagged for retirement, I have had the experience of ringing a hospital looking to speak to "consultant Murphy" and the answer has been that he retired and his replacement was not there yet. What processes are in place in that case? Does people flag their retirement two years, two months or two weeks in advance to give the opportunity for somebody to be put in place? Could the system be adjusted so that a consultant does not retire until there is a replacement there for him or her? It is a very difficult scenario. The person at the top of the ladder with regard to much of the decision-making is not there and therefore everything behind it begins to stack up. Then we have unfortunate consequences.

The same point applies across the board with doctors, nurses and all the way down. In the witnesses' experience, is the recruitment section of the HSE in need of an entire overall to try to go some way towards fixing this problem? The witnesses said there is a worldwide shortage. However, some countries fare better than others. As pointed out earlier by Deputy Neville, the money seems to have been put into the system. I would be interested in the witnesses' points of view on what could be done better? What could the committee recommend be done across the entire recruitment organisation of the HSE in order that we can go some way towards resolving this problem? I do not think it is going to come from politicians shouting about it. It is not going to come from the HSE trying to defend the indefensible. It is going to come from a broad-brush approach by saying this is how we should try to fix this problem. I would like the witnesses' comments on that.

I have two quick questions. Is it a common practice for non-specialist doctors to act as consultants? Is it a concern and is it acceptable or is it a blurring of professional lines? Is it safe and is the HSE attempting to normalise it and make it acceptable within the recruitment process? What are the consequences in the short term and the long term, both for the health care system and for patients?

Ireland has the longest targeted waiting time in Organisation for Economic Co-operation and Development, OECD, countries of 18 months. We are even failing to meet that. The Minister regularly blames the lack of staff. Is that purely a staffing issue, and therefore a recruitment issue, or are there other key difficulties that could be resolved but are leading us to have the single worst waiting times in OECD countries? There are eastern European countries where 25 years ago, we were looking at their health care systems and families were going over to those countries to rescue children from those systems. We remember the television programmes back in the day. They now have far superior health care systems in terms of waiting times and access than we do. In the respect we have not moved. They are my two questions.

I agree with Deputy Brassil. One of the key questions concerns the witnesses' recommendations with regard to recruitment and retention of staff. What should this committee recommend to the Government to try to get over that significant barrier and to make it more attractive? In a general sense, how many patients per day, week or month would a psychiatrist see across the different disciplines? Are there targets and, if so, are they met? How is that particular issue dealt with? Regarding college places, is there an issue with college courses and placements? Should a body of work be done in that respect? Are we turning out enough graduates to fill the gaps? Is sick leave also an issue that needs to be addressed within the system?

Chairman

I thank Deputy Carey. I ask the witnesses to try to answer as much as possible of those questions. What we will probably do is follow up with a letter if some of those questions cannot be answered now. Who would like to start?

Dr. Donal O'Hanlon

To start off, there are no subsidies for working in the mental health service as opposed to other branches of the HSE, to my knowledge. There are pretty standard working conditions. In respect of what makes a post attractive, I am in an odd position in that I spent 13 years in North America. Coming back, my working life changed because I was spending less time seeing patients directly and a lot of time looking for resources for patients.

One spends time looking for a bed for someone, trying to squeeze him or her into a clinic or trying to arrange someone on the team to plug a gap for an unfilled post in order that someone gets a home visit, etc. That is a difference. In general, when someone is recruited into our health service, many of the simple things to support him or her, such as a desk, a computer, an office in which to see patients or access to enough office suites to be able to work productively, may not be in place. It has been a long-standing problem in the system that these things are often not in place.

Salary is certainly a factor, but there is also the difficulty in understanding the management structures and the ethos. In other jurisdictions there were very clear governance structures that were very centred on patient care. There was very heavy medical influence on these as there were other professionals influencing them, but there was a clear voice.

I will try to deal with part of the question of recruitment. Overall, the HSE generally cannot recruit for a local competition. It needs special permission to do so. Therefore, often it will recruit from a national panel. For many other disciplines, if we wanted a nurse with particular expertise, we may not be able to organise a competition in one region to do so. We would have to pull off a national panel, which means someone may get a job in Dublin but may wish to work in Donegal. Therefore, that person may be there for six months and then a job may come up in his or her desired location and he or she moves. This is very understandable, but then one must start the whole process again. In general, my experience has been that it takes about six to 12 months to recruit someone. That seems to apply to all grades, and the stages-----

Chairman

Sorry, Dr. O'Hanlon. Someone's phone is definitely turned on. I ask whoever owns it even just to leave it on the floor.

Dr. Donal O'Hanlon

The process takes about a year and there are many stages to it. This applies to all health care staff, in my experience. For consultants it is different in that the first step is the consultant appointments committee, the preparation for which is time-consuming, taking about a month. Dr. Browne sits on that committee so he can probably speak a little more about the process thereafter.

Dr. Roy Browne

I think part of the question concerned what we do about pre-recruiting, so to speak, and being prepared to replace someone who is retiring. We know that most consultants contractually finish at 65. We know their dates of birth, so it is not beyond the wit of man to recognise when they will leave. Some may wish to go earlier. If so, they must give two months' notice, which is obviously a difficulty if one has only two months to recruit. The recruitment process is very independent of the HSE. It is carried out through the Public Appointments Service. It involves a very detailed description of the job in a particular layout, including the resources that are available to the applicant to do the job. This goes to the consultant appointments unit where it is then compared with the national programmes. The question is asked whether this consultant post needs to be refilled. Generally, it does. As Deputy Brassil said, if someone is doing a necessary job and then leaves, someone is needed to replace him or her. Once this process happens, which takes place over the space of about two or three months, it then goes to the recruitment process, which probably takes, through the Public Appointments Service, PAS, three or four months to advertise, shortlist and interview. Then we run into the difficulty that we are often bringing people back to Ireland from jobs abroad if they are finishing their training or something like that. They have a period of 180 days to meet specialist registration requirements, so then there is the difficulty of getting them a start date for work. Therefore, as Dr. O'Hanlon said, we are often talking about in excess of a year to progress this. This still misses the point that once we have gone to the PAS and the candidates have been interviewed and so on, I turn up on the interview panels and one or two people turn up to be interviewed, some of whom are not suitable for the job. Therefore, even as we go through the recruitment process, we run into difficulties at each step.

One thing I will say more generally about mental health services and recruitment is that, as Dr. O'Hanlon said, there are national panels. There are people who are offered jobs in Dublin who are living in Cork. They have two weeks to refuse the job and it goes to the next person on the panel. If there is a panel of 80 people, it can be seen that a year later, the last person, who is now in Donegal and wants to work in Cork, is being offered the post he or she wants. This is a huge difficulty.

Chairman

I will ask Mr. Varley to come in presently, but I wish to say that we have heard a lot of information about the problems of recruitment, and while I know the discussion has been recorded, what would the members think, and I am seeking the members' permission, if we asked someone from this panel to identify the exact problems of recruitment, including, as Dr. Moore said, the so-called treat part of the equation, and to come up with solutions to them in order that we could include them in our report? Is that agreed?

Chairman

Thank you. I call Mr. Varley.

I suggest we ask them to come up with suggestions. If they could come up with solutions, they would probably be-----

Chairman

I think we have solutions, but they are not being listened to, to be perfectly honest. I call Mr. Varley.

Mr. Martin Varley

A number of the most recent speakers raised questions about recruitment and resources, front-line resourcing in particular. This touches on the comments I wanted to make. We have two main problems from a service delivery point of view. First and foremost is a lack of front-line resources. I know we all hear we spend more on our health service than the other European countries. When we drill down into the figures, we do not see this level of resourcing presenting itself on the front line, so there is the question whether some of it is being lost, more so here than elsewhere, in administration, etc. The indicators for this are quite obvious, and we have already touched on them, namely, the number of beds, doctors etc. we have in the mental health services. The same applies to the acute hospitals. We have the lowest number of beds on a comparative EU basis across the acute hospitals and mental health services. We have the highest occupancy rate, at 95%. The recommended level is 85%. We are therefore occupying to a higher level. We have the longest waiting lists, as people have said, the reason being we have the lowest number of doctors and, on top of that, relatively speaking, an even lower number of consultants. Accessing the service, both mental health and acute hospitals, is coming back to the basic raw material.

How does one attract back consultants and doctors? The country made an absolutely fatal mistake ten years ago. It breached a contract blatantly such that the Minister of the day and the State offered contracts to 2,500 consultants, signed up to them and, within months, refused to honour them. I say it was blatant because I used to work in the Department of Finance in the early 1990s, after the depression at the time, and in the equivalent of the Department of Public Expenditure and Reform, DPER, we had a golden rule, which was one did not break contracts. Why? Once a contract with an employee or a group of employees is broken, they can no longer trust the person or body that broke the contract. We must remedy this breach in order that people can trust the State and, I stress, will honour the contracts they enter into.

The second thing we need to do, and it is an issue not just for the medical profession, but for teachers and nurses as well, is to end discrimination against newly employed professionals because equal work should have equal terms. These are very simple things, but unless we address them there will be problems.

Chairman

Will we address this letter to Mr. Varley?

Mr. Martin Varley

Yes, please. Absolutely.

Chairman

He knows exactly what we will be looking for. I ask him to include the details of the breaking of that contract as well.

Mr. Martin Varley

Absolutely.

Chairman

We will finish up now. I thank the witnesses. We have another group of witnesses ready and waiting to come in.

Sitting suspended at 3.10 p.m. and resumed at 3.15 p.m.

Chairman

From the College of Psychiatrists of Ireland, I welcome Dr. John Hillery, president, Ms Miriam Silke, chief executive, Dr. Miriam Kennedy, director of communication and public education, Dr. Roisín Plunkett, chair, trainee committee and trainee psychiatrist - higher specialist trainee.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members should also be aware that under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the House or an official, either by name or in such a way as to make him or her identifiable.

I remind witnesses and members to turn off their mobile phones or switch them to flight mode, as they interfere with the sound system and will adversely affect the television coverage and live streaming. Any submission or opening statements witnesses provide to the committee will be published on the committee website after this meeting.

I invite Dr. John Hillery to make his opening statement.

Dr. John Hillery

Dr. Kennedy, Dr. Plunkett and I are in active clinical practice in public and private mental health services. The College of Psychiatrists of Ireland was formed in 2009 as the professional body for psychiatrists in the Republic of Ireland. It is the sole body recognised for the training of doctors to become specialists in psychiatry and for providing career-long competence for specialists in psychiatry, as regulated by the Medical Practitioners Act 2007 through the Medical Council. The college is not a regulatory, disciplinary or industrial relations body. It is a not-for-profit professional membership organisation and a registered charity.

The mission of the college is to promote excellence in the practice of psychiatry. The college fulfils its mission through education and training of psychiatrists; provision of continuous lifelong learning for psychiatrists; advocacy for resources to support best practice in the delivery of mental health services; promoting best practice in education, training and research in psychiatry; and public education on issues related to psychiatric illness, psychiatric services and mental health promotion. To fulfil our mission of promoting excellence in the practice of psychiatry, the college focuses on supporting, representing and leading member psychiatrists nationally and internationally; promoting excellence, best practice, recovery and collaboration in mental health care; setting standards for trainee psychiatrists; supporting the continuous professional development of our qualified members; working with key stakeholders, Government committees and agencies, as well as other organisations; promoting human rights and ethical conduct in psychiatry and mental health services; and working with service users, carers and their organisations.

The college also has several specialist groups called faculties, representing the main psychiatric specialties which exist in Ireland. These include academic psychiatry, addiction psychiatry, adult psychiatry, child and adolescent psychiatry, forensic psychiatry, learning disability psychiatry, liaison psychiatry, medical psychotherapy, old age psychiatry, and social and rehabilitation psychiatry. The college has several committees which take an active part in college projects including Refocus and the college advisory group.

Refocus is the recovery experience forum of carers and users of services and it originally formed in late 2011, with ten people with experience of the mental health services as patients, ten of their family members or carers and one psychiatrist. Members give their time to work with the college in improving training of psychiatrists and in identifying ways to improve the mental health services. The committee now comprises eight people with experience of the services - namely, service users - eight family members of service users and eight psychiatrists. The committee is jointly chaired by one psychiatrist and one non-psychiatrist. We also have an advisory board comprising persons of high standing in Irish society. It meets with the college officers to advise on how to progress the aims of the college and its members.

The subject at hand today is recruitment and retention of psychiatrists. Recruitment in psychiatry is controlled by the HSE and the main private psychiatric service suppliers. The HSE is the main employer of trainees and consultants in psychiatry, and the recruitment role is carried out by the HSE national doctors training and planning, NDTP, department. It incorporates medical education and training, consultant appointments and medical workforce planning and was established in September 2014. The role of the college is limited to the recruitment of trainees and the training of doctors to specialist level. The number of trainees that can be appointed to training schemes run by the college is set by the NDTP in consultation with the college, as a training body. Training is financed by the HSE through financial agreements with all relevant colleges in medicine and, in our case, with the College of Psychiatrists of Ireland, and through salaries to trainee doctors.

The structure of training is as follows. To train to be a specialist in psychiatry takes at least seven years after qualification as a doctor and internship, so we are talking about at least eight years after a five to six year undergraduate course. Training is divided into a one-year foundation year, followed by a further three years of basic specialist training, BST, and then higher specialist training, HST, of at least three years. BST is a general training in psychiatry whereby trainees rotate through various specialties and also complete exams and research. This follows on from the foundation year from which doctors must have graduated and then completed a year’s internship. HST is in specific speciality areas, broadly divided into adult or child and adolescent psychiatry but also involving subdivisions within each depending on the long-term career ambitions of the trainee. To enter HST, doctors must have successfully completed BST. Completion of HST leads to the granting of a certificate of specialist training that guarantees to the public that the doctor has achieved all the competencies set by the college as necessary to practice safely as a specialist in the area of psychiatry that he or she trained in. The college holds that a doctor should not be a consultant if they are not a specialist in the appropriate area of medical practice. Unfortunately, we are aware, as I am sure the committee is, that this is frequently not the case in the Irish mental health services.

The college holds interviews yearly and, depending on a number of factors, has a variable number of places to offer in training posts. These include the rules of the NDTP, the progression of trainees already in schemes through their training and the numbers leaving training. The latter is, hopefully, due to people completing training but can be due to other issues, such as lack of progression due to academic issues, change in career choices and decisions to work abroad. The training run by the college is flexible in order to maximise its attraction for young medical graduates who want to be trainees. By this I mean that the trainee can take time out and can map their route through training to its completion in consultation with college trainers, who are all practising consultant psychiatrists. This allows for high quality medical graduates to travel or to work in other areas of medicine and return to training in psychiatry in Ireland. It also gives employers an idea of the workforce that is available at any given time over a number of years. The college also allows for part-time training to facilitate doctors who have other issues in their lives that might have previously prevented them entering formal training, such as family or carer issues, which is common, and they can still take part in full specialist training, even though it may be extended due to the other activities they are involved in.

Regrettably, there are still difficulties filling training posts in psychiatry and there are also difficulties in getting specialists to fill consultant posts. This is an issue across medicine in Ireland, not just in psychiatry. There have been several reports in recent years that have examined the generic issues involved and proposed remedies. These include the MacCraith report and the recent report on consultant recruitment and retention published by the HSE. It is difficult to work out why many of the simple proposals in these documents have not been implemented, particularly as they were well enunciated prior to the reports being published. These include: developing a culture in our health services where trainees feel respected; planning for consultant retirements; remuneration; and simplifying and speeding up the process by which consultant posts are established, advertised and filled.

There are specific issues affecting recruitment in psychiatry that the college works to overcome. These include the so-called "hidden curriculum" in medical schools where psychiatry, and to a lesser extent, general practice are portrayed as not being worthwhile, having poor patient outcomes and not being branches of medicine. The college works on these erroneous perceptions through publications, participation in national recruitment days and our summer schools for students.

The committee may ask why the foundation of new medical schools and the evolution of old ones with increased places have not helped. Unfortunately, up to 50% of medical graduates have left the country following completion of their internships in recent years. Internationally, 4% to 5% of medical graduates choose psychiatry as a career. Unfortunately, in Ireland we have 4% of the 50%, which is insufficient. Even if an increase were achieved, it would not be enough for a consultant-delivered service. The college has been closely examining the factors that adversely affect recruitment and retention to psychiatry in Ireland. Most of the reasons are outside the college’s control. We know that a high percentage of new medical graduates intend to go overseas, drawn by a multitude of factors, including a search for adventure, peer pressure, perception of better working conditions in some accessible countries, perception of better career opportunities in some accessible countries and a perception of poor health service conditions and career opportunities in our own country.

The college interacts regularly with its trainees who identify poor resources in mental health services and reduction in remuneration compared with other countries as reasons for leaving Irish psychiatry. However, their experience of their training in psychiatry is overall a positive one. The Medical Council carries out an annual survey of trainees - Your Training Counts - which is independent of the training bodies. This survey provides an overall score of trainee satisfaction with training called the D-RECT score. For the past two years, the highest score for any of the 13 training bodies has been for psychiatry, with a particularly high score for supervision, assessment and feedback, that is, the direct links with a consultant superior who ensures the trainee gets education and supervision, which can only guarantee better services to service users. We work continuously with trainees and consultants, and with the recommendations in the aforementioned reports, to improve their overall satisfaction and experience further.

The college has circulated a detailed workforce planning document to the relevant stakeholders in Government and the health services, and we have also sent a copy to this committee. With consultant psychiatrist numbers of eight per 100,000, Ireland ranks behind all other northern European countries. In order to provide for a consultant delivered service in all areas of psychiatry in the future, the college believes there needs to be 800 consultant posts nationally. In fact, this number will be higher in the future, based on current and expected population changes, regulation and legislation changes and changes to the working practice of psychiatrists, such as job sharing and so on. This equates to a ratio of 16 per 100,000 people. This would allow for the increases in clinical demands and the multitude of non-clinical activities expected of specialist consultants, which include administration, training, examining and continuing professional development to maintain their own competency. It also allows for the other factors that currently impact on service delivery, such as leave, sick leave, maternity leave and parental leave. Currently, these are leading to the curtailing and even closure of services, especially in sub-specialist areas where a consultant leaves for one of these reasons, even for a short time. Of course, an increase in consultant numbers will require a concomitant increase in trainee numbers if the increased number of posts are to be filled. We have yet to get an opportunity to discuss this document in a detailed, practical fashion with those who are tasked with delivering clinical resources in the health service.

The college continues to point out that the percentage of the health budget allocated to mental health services falls far short of that recommended in the decade-old policy on mental health, A Vision for Change. The college believes that changes in population numbers and demographics mean the A Vision for Change figure of 8.4% is insufficient and that a figure of 12%, in line with other First World economies, should be the target. We have proposed that this increase should occur in a rolling way over several budgets. The rationale for this is that mental health problems account for 13% of the burden of disease across the world, according to the World Health Organization. The college has been lobbying for this for several years in successive budget submissions without success. Other organisations in the mental health area agree with us on this. We are happy to supply copies of our budget submissions to the committee, if required.

The poor budget allocations affect recruitment and retention. As stated already, highly trained clinicians wish to work in clinical environments that enable them to use and develop their skills. In psychiatry, this means appropriately staffed multidisciplinary teams with an appropriate range of available milieus, such as inpatient beds and day hospital and community services, and a range of treatment options, such as psychotherapies, vocational training and pharmacotherapies, available as needed. Terms and conditions are also an issue. Modern medical graduates are looking for a fair salary, an environment that encourages and facilitates challenge, career growth and progression and a good work-life balance. Once again, resources affect these to an extent that means other health services providers, either private providers in Ireland or providers in countries abroad, are more attractive.

There are legislative and administrative issues that affect recruitment and retention also. A change in the Medical Practitioners Act has excluded doctors from countries - such as, for example, India - that previously supplied candidates for training posts, many of whom stayed to take up consultant posts. Requests from training bodies, including ourselves and the Medical Council for a change in this have not been productive. I brought this issue up with the Minister for Health last week and he promised to review it.

Doctors from outside the EU have demands made on them as regards maintaining their legal status and that of their families in Ireland which seem more limiting than those of other countries in which they can work. That doctors on four-year training schemes with guaranteed jobs for those years still have to apply for work visas at the start of each six-month placement is a factor that must act as a deterrent to such high-quality doctors to work in Ireland. Difficulties faced by spouses in gaining work visas and by parents in gaining visitor visas of sufficient duration to allow them to have input into their children's and grandchildren's lives is also an issue.

The philosophy of formatting medical training in Ireland is that there should be the exact numbers taken into training as are required at consultant level. This is not a philosophy set by us. It does not allow for losses due to dropouts, emigration or career changes to psychiatric practice or need that increases the requirement for trained specialists. The ideas of the NDTP and of the college as to the numbers who should be allowed into psychiatric training do not always coincide, with the college looking for higher numbers at both BST and HST than we are eventually allowed. Since its formation, HSE-NDTP had approved 60 new entrants to BST in psychiatry each year. With improved interest in our programme, the college requested an increase of 10% this year. HSE-NDTP approved a 5% increase to 63. The pity of this is we have good applicants but we cannot take them in.

The equity of financial support for training across and between medical disciplines is not transparent and there is a feeling that psychiatry gets less than other medical specialties - this is in the grant with the service level agreement, SLA, between our training bodies and the HSE. We make continuing efforts to clarify this but so far have not been successful. This has led to a perception among specialists and trainees that the playing field is not level and that psychiatry is not seen as important by the national leadership.

The following are some solutions. The college wants mental health services in Ireland that are based on a philosophy of recovery and that ensure access to assessment and intervention with an appropriate menu of interventions available to people with mental illness based on need, not geography or ability to pay. This requires financial and cultural change. The recommendations as to how this could occur are in the documents referred to and in submissions by the college to Government over the years.

There are some changes that we see as being easy to make. First, barriers to training posts in psychiatry could be lifted. The college has poured significant resources into promoting psychiatry as a speciality and then when this is successful, we are told that there is a limit to the number of trainee doctors we can appoint. This is despite the fact that there remain significant vacancies in trainee posts throughout the country. Second, a quality mental health service needs a highly-qualified and experienced team of medical professionals to deliver high-quality services. The service cannot continue to rely on depleted multidisciplinary teams, MDTs, with no trainee doctors and sometimes no consultant due to absence, such as retirement or sick leave.

We need the primacy of teaching, training and research to be reinstated within the profession of psychiatry to ensure MDTs maintain and attract highly-qualified professionals. The President of Ireland, as patron of the College of Psychiatrists of Ireland has been quoted as saying:

... the promotion and undertaking of research must always be a central aim rather than an optional extra in mental health. Developing new ways of preventing, diagnosing and treatment of mental illness must continue even while acknowledging the need to be more efficient and using resources more effectively.

In addition, the recruitment process for consultants needs to be fit for purpose. For example, recruitment for a vacant post should start months before a consultant is due to retire instead of after he or she has retired. I have been through this process in the past year whereby it was only after my colleague retired that I was sent the documents for the post that was to replace her post which then had to go through the various stages to get ratified before we could even look at advertising for someone to replace her. It has not happen yet, two years later.

On legislation relating to registration and immigration, amending the Medical Practitioners Act to allow recognition of the internship year in other countries would allow more doctors to come and train here. In our simplistic way as non-legislators, we feel this could be done rapidly.

The disparity of salary at consultant level has an impact on those who carry out altruistic work for their profession, such as training and examining. New consultants, who are on a lower salary than colleagues, are less likely to participate in doing this sort of important professional work, which ultimately affects the standard of training and education in the services.

We are happy to answer any questions.

I thank Dr. Hillery for the presentation and the delegation for attending. It is great to see three women present, especially given the week that is in it.

I have a few questions. On public service and psychiatry and consultant psychiatrists, we learned in the earlier session that a senior consultant would earn approximately €185,000. The public would not understand and I suppose would not empathise with one who says that that level of salary is not attracting what we need. We went into the different reasons such as, for example, that perhaps it is more than just salary, but we all are recovering from the idea that €185,000 will not attract psychiatrists to a post.

I am not sure if we got the detailed breakdown from the CHOs or from the HSE of the amounts and contract duration of the temporary and agency consultants who are being employed, some of whom do not have the speciality of the post in which they are employed. I would be interested in that because it seems to be nearly double €185,000. It seems we are shooting ourselves in the foot by employing many different bits and pieces here and there. Agency staff, while dedicated, do not feel like a whole part of the team because they can be gone on a whim and perhaps their dedication to the area is not as robust as that of permanent staff. However, I would like to see those figures. They are significant in the budget about which we give out.

Dr. Hillery spoke of material change to allow doctors from other countries - he referred to India in particular - to come here and amendment of the Medical Practitioners Act. That is something practical that we can take on. It is like where eventually Bord Altranais agus Cnáimhseachais na hÉireann listened and changed. It took the unions several years but Bord Altranais agus Cnáimhseachais na hÉireann announced recently significant material change to its operation and recruitment. Bord Altranais agus Cnáimhseachais na hÉireann is taking in post-experience as opposed to training experience and training modules and it will allow many other nurses to apply. Perhaps we could work on the Medical Practitioners Act. Given that it takes a year, according to the previous group here before the College of Psychiatrists of Ireland, and two years, according to Dr. Hillery, to get a post through all the red tape and all the various committee stamps, sealed, signed and delivered and then eventually advertised, at which point maybe only one or two turn up for interview, it is such practical steps that we are here to look at, listen to and act on and we have got so many so far for the interim report that will issue towards the end of this month or next month.

Given that there is a new unit being built beside Portrane, I will focus briefly on forensic psychiatry. We have not done this previously, as there has been concentration on child and adolescent mental health. The level of incarceration in this country was significant in the 1940s, 1950s and 1960s, more so than in Russia. At one stage, we had 22,000 patients incarcerated behind asylum walls. That seems to have shifted now to the prisons and there is a significant number of prisoners with severe and enduring mental illnesses who are being incarcerated. On the forensic psychiatry part of it, will we be able to provide enough beds in the new unit? Would Dr. Hillery know that or can we find out? I refer to those waiting lists of 30 to 40 persons throughout the country who are either in prison or in other approved centres who cannot get into the forensic unit. Will the new unit accommodate all that is needed, given the increase in criminalising those with mental health difficulties? Its seems as though the pendulum has swung from incarceration in asylums to prisons. I do not want to overstate it but we need some correction on that.

The committee has discussed IT systems at length.

I know we cannot get IT. The public cannot get email addresses when they are looking for information on their children or to set up meetings with CAMHS. We seem to frown upon IT systems that will modernise things and make matters easier if we go with the flow and have a fit-for-purpose IT system and apps for the public and ourselves.

My final point relates to capacity. It is all about capacity. In part, recruitment and retention are about not being able to deal with the chaos because of the capacity issues that people find overwhelming. While they want adventure abroad, they also choose a caseload that can be managed where they feel they can do something worthwhile for their patients or those whose care they are entrusted to improve.

Chairman

Would anyone like to respond to that?

Dr. John Hillery

I will deal with the first issue. I think a salary of €185,000 is very attractive. I do not think anyone would disagree with that. The trouble is new entrants are paid considerably less and there are differentials across the health services that make it unattractive. It involves the differences in salary between two people working in the same department, which is a change that came in a few years ago.

Would Dr. Hillery say they are divisive?

Dr. John Hillery

I would say they are divisive if someone is working in job where the person beside them gets €50,000 or €60,000 more than they do. All the trainees I talk to - Dr. Plunkett will address this in a moment - want a fair salary but many of them feel that the new entry-level salary is not fair, particularly compared with what was there before and what they see in places such as Australia or Canada, to which they can go and where they see the quality of life the Senator has just referred to - with better supplied teams, more guaranteed hours and guaranteed progression - as being better. I would agree that €185,000 is a very attractive salary but the new entrants are not eligible for that. That is an issue and has not been discussed at length. Salary is not the main deciding factor for trainees. I might come back to the agency issue but Dr. Plunkett might comment on matters from the trainees' point of view.

Dr. Roisín Plunkett

I would love to. I really appreciate Senator Devine bringing that issue up. As Dr. Hillery mentioned, it is not salary that attracts people to or puts them off work. What attracts people to or puts them off work is whether they can work effectively and be trained by somebody who is a specialist in the area and who is dedicated to developing this service and post. As the Senator mentioned, a locum - despite being a professional and being dedicated to his or her professional practice- is not in a position to develop the service or make long-term changes because there is uncertainty around how long he or she will be there. Within the service in which I work, I am aware that possibly the majority of consultant posts in Connolly Hospital are locum cover or temporary consultant cover. Not knowing who will be working alongside you or supervising you on call from day to day is a really fraught place to be as a trainee. A trainee coming through will consider how the profession will develop if this is the landscape where people are not in jobs for 20 years and do not have that security and that base. That point is really well made and I appreciate the Senator bringing it up.

Chairman

Does Dr. Hillery wish to add to that?

Dr. John Hillery

The agency issue is particularly close to our hearts because it has a few effects. First of all, there is the risk to the public because of non-specialists. Dr. Plunkett's point is really valid. The public is going into a service that has no continuity and that has "leaders" who are not in leadership roles because they are temporary. I had an excellent higher specialist trainee a few years ago. In line with the Medical Practitioners Act, I went to offer a second opinion at a Dublin hospital. I was not happy with the notes I had seen so I went back and asked the trainee about it. She told me that the consultant in question was her senior house officer before she came to work for me but the person got the membership and then applied for a consultant post rather than applied for training because the money for the temporary consultant post was good. So it has two effects. It is taking certain people away from training because they see that this is better paid but it also means that the trainees, who are experienced, qualified and write papers - my trainee at the time was finishing her MD - are answerable to somebody with fewer qualifications and experience. This cannot be good for the public. Part of the reason for the agencies seems to be a historical issue that goes back to when I was a junior doctor, which is a few years ago now. When someone is due to retire, we know when they will do so. People usually retire on their 65th birthday. It is after this that everything kicks into place so there is a mad rush to look for someone to fill the post. Sometimes they ask the person who has been doing it to stay on. Many of us do not want to do that anymore so they look for someone else. A process then arises for the creation of a consultant post that, as I have outlined, can take a few years while in the mean time, roles are filled by locums and the higher trainees who we have trained are looking around and saying that no post has been advertised for which they have been trained but there is one in Australia, the UK or somewhere else or in the private sector and they may as well try that. We just do not seem to be able to get that act together. It has been going on for as long as I remember and it is very damaging. The most significant point is that it puts the public at risk.

Chairman

I am sure we will get back to Dr. Hillery about that in a moment.

The point just made by Dr. Hillery was made by the group that was in before him. It is incumbent on this committee to come up with a very strong recommendation about the recruitment process and how to go about it. I welcome anybody who comes in with solutions listed in his or her final paragraph. I think Dr. Hillery suggested that recruitment for a vacant post should start months before a consultant retires. I would suggest a minimum of 12 months to give the system some opportunity to recruit-----

Dr. John Hillery

If I may interrupt, with most large employers, if someone at a high level was retiring, the employer would bring in someone who would replace the individual who was due to retire and shadow them. The HSE is the largest employer in the country and we are most highly paid members of that organisation. No private business would function in that way - letting posts lapse. I apologise for interrupting the Deputy.

It seem so obvious that it is quite amazing that we operate the system this way. It really is time to change it. The witnesses went through the training process. If I am correct, we are looking at about 13 years from someone's first day in college, which is an inordinate amount of time. Is there any jurisdiction where psychiatry is a stand-alone qualification where somebody decides at an early stage in his or her career that this is what he or she wants to do, is trained as such, comes out with his or her primary degree and possibly trains for a period of ten years after first starting? Does that occur anywhere else and, if so, is it something at which we could look?

Dr. John Hillery

Not that I am aware of. I know that some European countries have a separate medical school for general practice but I do not know of one for psychiatry. My colleagues might be able to add something.

Dr. Roisín Plunkett

Will I answer the question now or wait until the Deputy is finished?

Is it something we could look at and lead on?

Dr. John Hillery

One of the issues we might have with that is that we feel psychiatrists need the broadest base of training in medicine because many presentations with mental health problems may be presentations with physical health problems so we need to be fully aware of those. We have shortened the undergraduate medical school curriculum, which should help to shorten things.

Chairman

Could we hear the rest of Deputy Brassil questions? All the witnesses can answer them as a group after that.

At the end of the seven years, is the person a qualified consultant or just a qualified psychiatric doctor who must then go on to become a consultant? Does it take another few years before a person reach the ultimate position?

Chairman

The Deputy can come back in later if he wishes to add to that.

No, I think that is it. The final paragraph is very welcome and is something we should definitely take on board because what we are looking for here is a method by which we can make recommendations that, hopefully, will be taken on board and implemented.

Dr. John Hillery

I will clarify the consultant issue and then hand over to my colleagues regarding the first question on training. "Consultant" is an honorary term and an advertising term. We just talk about specialists. We feel all consultants should be trained as specialists in the areas in which they are consultants.

Not all consultants are specialists, but they should be. Consultant is a job that is advertised by the HSE or by a private provider. Private providers tend to insist on people being on the specialist register, but it is not necessarily so with temporary posts, especially. When the permanent posts were advertised by the HSE they are always for the specialist register but at the end of seven years, we certify people as specialists and we consider that they are competent to be specialists in that area and they are competent to be consultants.

That goes back to the earlier point that somebody who is doing the training may be answerable to somebody who is not a specialist but is a consultant because he or she applied for the job and got it.

Dr. John Hillery

That is it, yes.

Dr. Miriam Kennedy

There are some places where there is a quicker route. As was said, for undergraduates, it can be four or five years. In other jurisdictions, one can be a psychiatrist in four to six years. Our point there is twofold. Once people qualify as interns they are working within the system and they contribute quite significantly in terms of our higher specialist training, doing research or doing projects, service management, etc. We would make a strong case for the benefit of being a medic, a doctor, first because a person's mind, body and brain are all the one.

Also, our training programme over the last five years in psychiatry has brought in psychological services. Many people will need psychological treatments or they will need their team to be trained like nurses, in solution-focused and other types of psychotherapist, which ultimately benefits our patients. That is incredibly important because not everybody will need a psychologist. Perhaps a complex presentation will need a psychologist. There are very many mental illnesses where psychological interventions are needed and that is where we have training in that now in social.

We would not be for shortening it because it shows a commitment in that regard, even though there are models and there was some concern in another jurisdiction, where everything was problem solving, four years, etc., and then through in three years, that there were gaps and the gaps were related to the medical knowledge of the presentations.

Chairman

I am also on the list to speak but I am sure the next two members will not mind if I jump in here. I have a couple of questions. We have often spoken about how psychiatry is a specialised service, so who is providing that service at primary care level? That is the first question. The witnesses have proposed many simple proposals to the HSE, I presume, and have come up with some very simple answers. Why will the HSE not take up these simple proposals from the people who know what they are talking about? That is the second question. I only need brief answers to these questions. Why is it that some applicants cannot be taken on? What is preventing some applicants being taken on? How many graduate every year from the College of Psychiatrists of Ireland? The witnesses said only 50% of them stay in Ireland but I would like to have the exact number.

I refer to recruitment. We heard from previous witnesses that there is a panel of people. The witnesses mentioned the HSE but the previous witnesses did not mention it. They mentioned some other panel that is responsible for the recruitment. It is done at national level. Someone may want to go to Donegal but they are here hanging around in Dublin before they get there. What is the problem there? Why is it like that and what can be done about that?

I thank Deputies Carey and Buckley for giving me the time to ask those questions. I would be grateful if those questions were answered.

Dr. Roisín Plunkett

A couple of the questions require short answers and one of them requires a slight clarification. I refer to the question about how many people graduate from the College of Psychiatrists of Ireland and linking it to 50% of those people leaving the country. Those are fundamentally different colleges we are talking about. Some 50% of medical graduates leave the country after graduating from university. The College of Psychiatrists of Ireland is a specialist training body like the Royal College of Surgeons in Ireland or the Irish College of General Practitioners, so once one has qualified as a doctor and has done one's intern year, one is a registered medical practitioner. One can then go into a specialism, either directly or after some years practising. Dr. Kennedy might be best placed to answer how many people actually graduate. One has to do one's basic specialist training, BST, and the examination in order to proceed on to higher specialist training, HST, and then through.

Chairman

Dr. Kennedy, would you know the number?

Dr. Miriam Kennedy

We do not have it now but we can get it for you.

Chairman

We will probably put those questions in a letter and ask you to respond to that. Dr. Hillery, were you going to answer a question?

Dr. John Hillery

The Chair asked why our proposals are not taken up. On the issue of doctors from countries such as India, it is a matter for the Department of Health and the Oireachtas to change the Medical Practitioners Act. We had been told it was dependent on a large Bill to put through certain factors to do with the Medical Practitioners Act and that we had to wait for that, but we have been told that for a few years now. Then two weeks ago, all of us on the medical register got an email saying the Medical Practitioners Act had been amended to say that we had to have indemnity for our practices. That made me wonder. There was already an ethical guide that we had to follow. I do not know why it needed to be put in law, but we need a provision in law so that we can take more doctors in. Many members will know doctors from India and other countries who are consultants or general practitioners, and many in psychiatry. Their successors can no longer come here to be trainees. Funnily, they can be on the general register, so they can come here and practise without any supervision or any education but they cannot become consultants and they cannot enter our training schemes. The delay is with the Department of Health which is saying it wants bring a larger Bill to the Oireachtas. However, we would say if it can bring one forward on insurance, surely it can do so on this issue. I put that to the Minister last week.

Chairman

I promise we will follow up on that as the committee.

Dr. John Hillery

The proposals about recruitment go back to when I was a boy. They are there, especially in that recent report commissioned by the HSE which talks about things like preparing for retirement and having job descriptions in place. It is actually simple stuff that would happen in any company, but it has not being happening in the HSE. I cannot tell the members why. It was also happening in the old health boards. It is very frustrating.

Chairman

I refer to that last question on psychiatry being a specialised service. This committee is very focused on primary care. Who is delivering mental health services in primary care that is specialised?

Dr. John Hillery

We would say that psychiatry is the same as cardiology and respiratory medicine. One goes to see a specialist when one has specialist needs. At a primary care level, one goes to see one's general practitioner who should have access to other inputs at a primary care level that are appropriate to one's needs. That especially includes talking therapies. The general practitioner, GP, can prescribe medications if he or she thinks it is appropriate. There is a national counselling service which is supported by the State but I hear from my GP colleagues, and the committee has probably heard from the Irish College of General Practitioners, ICGP, that this was very good when done at a pilot level in the north east but has not become as accessible when rolled out across the country. That is an issue. I am not sure if that answers the question. Primary care should be the same for people who have diabetes and respiratory problems. If one is at a certain level, one gets inputs from primary care but it needs access to the different inputs it would like to give people.

Chairman

The problem is that we have these terrible waiting lists. Many children and adults probably do not need psychiatrists, so there should be something at primary care level that filters all of this.

Dr. John Hillery

I think I made this point at a committee last year in regard to children's mental health. There are people on waiting lists who should be dealt with by school psychologists. They probably have some form of reading problem or mathematical problem. They may have an intellectual disability of a mild level. They may have a variant of autism. What they need is an assessment and then to get the proper supports and that is not psychiatry.

Unfortunately, two things happen. They go on waiting lists to see psychiatry in order to get these assessments but they are left on the waiting lists. They are also increasing the length of the waiting lists but the other problem is that if a child who has an intellectual disability or educational support needs is put in a mainstream class and an assessment is not done, the child will eventually develop mental health problems, as any of us would if we were in an inappropriate place without the supports. Then the child will need to be seen by a psychiatrist but that should not be happening. That is at educational and other levels.

I thank the witnesses for the presentation. I will go through it as fast as I can. The presentation mentions the college requesting a 10% increase on the entrance for the BST in psychiatry and the HSE said it will only be a 5% increase. Why is that? That is the first question. There is a shortage of everything here but it is saying to keep that shortage. I will explain why I am looking at that.

That is the first one.

I very much welcome that the page on solutions in the submission refers to ensuring "access to assessment and intervention with an appropriate menu of interventions available to people with mental illness based on need, not geography or ability to pay". That is also contained in the Sláintecare report that we hope to drive on also. It might be a little thing but it is progressive.

The submission also stated:

barriers to training posts in psychiatry could be lifted. The college has poured significant resources into promoting psychiatry as a speciality... we are told that there is a limit to the number of trainee doctors we can appoint. This is despite the fact that there remain significant vacancies...

Who advised the College of Psychiatrists of Ireland of that and why is it the case? I cannot understand it. The multidisciplinary teams always seem to need to be specialist or consultant-led. Can we not think outside the box? In the Portuguese model nurses are allowed to prescribe medicine because they got an opportunity for promotion up through the grades.

The one thing that really grieves me is the lack of common sense on recruitment when it comes to retirements etc. Who makes the rules meaning that we have to wait for the individual to retire? Do the witnesses feel they are being held back on that section?

The specialist groups of faculties include medical psychotherapy. Interestingly I got an email today from an individual who is trying to get an internship and wants to work in CAMHS, work with adults and work as part of a psychiatric care team. However, the reply from the HSE is that it is not recognised at the moment. Therefore the individual cannot even get a chance to progress. They are more or less forced to go to England or somewhere else to get that training. I cannot understand why that is. If it is part of the curriculum and part of what we have to do, it runs contrary to everything to have people who want to work in the system but are being told they will not be able to qualify in this country. I think that is absolutely ludicrous.

Chairman

Who would like to answer those points?

Dr. John Hillery

I am from Munster; I can follow someone from Cork.

The limits are set by National Doctors Training and Planning, NDTP. The Deputy talked about the IHCA making appointments; that is done within the HSE by a committee and the NDTP is part of that system. In my six years in the college, we have regularly had constructive arguments with the NDTP about the number. Perhaps they were not so constructive, as I have said. When the Taoiseach was Minister for Health, he helped us out one year in asking the HSE to extend the number of trainees we could have. It is a constant issue for us. Why is that so? I could say that I do not think psychiatry is taken as seriously as some other specialties in medicine but I have no evidence for that. It is just the feedback we feel we get. We will keep campaigning on that. As the Deputy will know from the document we put together, we need many more trainees.

The block with regard to the Medical Practitioners Act was snuck in as part of an amendment to the Act a few years ago and it needs to be taken out again in order that we can get more people from abroad who want to train here and allow them to train. Obviously somebody in a training post, rather than in a non-training post is better supervised and is a better doctor for the public. The international evidence is that departments containing trainees produce better outcomes for patients. That is why we need the Department of Health to propose a change in the Oireachtas to free that up. The limits are set by the NDTP and we keep battling away. Any support members of the committee can give would be very welcome.

Dr. Roisín Plunkett

I might answer Deputy Buckley's question about the team always needing to be consultant led. It is really important that it would be, in the same way that an oncology service needs an oncologist at its head. That is not to say that there is not an opportunity to develop nursing roles further. Specialist nurses form a very useful part of an overall team. It ties in to what the Chairman was talking about earlier. The development of primary care mental health services would be welcome. It would lead to more access to other helpful supports at primary care level for people with mental health difficulties who have not met the threshold for mental illness. When a person meets the threshold for mental illness it is important that they have access to a specialist psychiatry service in secondary care, which is consultant led and multidisciplinary. It only needs to be for a brief period of care while they are acutely mentally ill and then they can go back to good supportive primary care mental health services in the same way that people with other illnesses go from primary care to secondary care and back. That is the vision we have.

Dr. Miriam Kennedy

I agree with Dr. Plunkett. We have surveyed our members in the past year about their role and what they are doing. We say, "rebranding the shrink is to think outside the square." Many of our consultants want to work in teams with that flexibility. We are happy to get nurses trained up with some medication prescribing or some psychological therapies. We want the leadership there. Sometimes our members feel a little disconnected from management in how that change can be effected. Modern consultants want to work within teams and bring our experience to bear in that way.

The Deputy spoke about the psychological therapies. While we want primary care to do that, I also find in my practice that someone is referred to me who perhaps should have been referred much earlier. It can be a real shock to see people with that kind of illness. We have the ability to work with primary care to provide assessments. There is not an inopportune assessment actually, but we need to be able to have a quick discharge back to the relevant care. Psychologically there are therapies that are very helpful, as the Deputy will know from previous discussions, which have an evidence basis. Some others are just a waste of time; a good friend could do the same thing. A community pulling together after a trauma is much more powerful than a specific psychotherapy in the early stages of trauma.

It is about the evidence-based treatments that we have between primary care and us. It is not always that talking therapies will do the job because they will have side effects if they are not recognising what is needed or indeed if another resource like a community or a housing resource is what the person needs for his or her distress.

The college would be very open to agreeing that the consultant does not have to do everything. We do not want to be photocopying, as well as providing psychotherapy, but we want to be able to assess, liaise and lead, based on the evidence.

Dr. John Hillery

The Deputy asked why the recruitment is taking so long. There is another HSE committee, the CAAC. I do not know what it stands for but it is the consultant appointment committee. It is an important committee. It needs to look at whether a job is needed and what the job description should include. It goes across medicine and is not just in psychiatry. As I illustrated with an example earlier, when my colleague retired I was asked by one of my senior colleagues to draw up the job description with him. However, that was two months after she had retired. I fully support having committees that oversee things to ensure we are not wasting money or appointing the wrong type of consultant. However, surely that could happen a few years down the line, as Deputy Brassil suggested earlier. It is not about saying that we have too many committees; we probably do not have that many. However, there are hold-ups in the system that we should eliminate by starting earlier or else seeing if they can be freed up in some other way.

Chairman

Before I call Deputy Carey, do members agree it would be useful for us to invite representatives of the NDTP and CAAC to appear before the committee, given their responsibility for the recruitment or lack of recruitment? Agreed.

I thank the group for a clear, informative and constructive engagement with the committee. In particular I welcome my fellow Clare man, Dr. Hillery. Many of the issues I wanted to raise have been raised and answered.

Perhaps we could get more information about the individuals within the system, an issue raised by the Chairman. Could we get a breakdown of the figures in terms of positions available? If those positions were filled would there still be a shortfall? Reference was made in the presentation to leave, such as sick leave, maternity leave, paternity leave and so forth. Can the witness quantify what type of impact that is having? There was also a reference to modern medical graduates looking for a fair salary. Dr. Plunkett said it is not just a salary but that other factors come into play. Can the witnesses give a figure for what they would quantify as a fair salary?

I note the issues raised regarding the Medical Practitioners Act. That must be addressed. The committee should examine that and advocate for change in that area. Points were also made about the recruitment process. It must be fit for purpose and it certainly is not at present. It must be done in advance to plan for matters such as retirements. I agree with Deputy Brassil's point that it should be done 12 months in advance.

I commend the witnesses on the positive and constructive proposals they made in the presentation and on their engagement with the committee.

Dr. John Hillery

My chief executive has said she will supply what figures we can to the committee or else point the committee in the right direction for those we cannot provide. The impact of leave has been such as to close down services. Last summer I was contacted by a very specialist service in the south of the country. There was one consultant who was taking parental leave so she was told by the HSE that the service would close because there was no leadership for the multidisciplinary team. There should be more than one consultant in order that one of them can be off for whatever reason. The impact can be that bad or else it can slow things down and increase the bottleneck in the waiting list. Whatever one's training, all the colleagues I have worked with, be they nurses, social workers or psychologists, want the cover of a consultant because of the various approaches taken by the courts in Ireland. As responsibilities are usually pointed towards the consultant, there must be a consultant involved from the point of view of carrying the responsibility. Even if the person is only off for a week or two it can slow down movement through the waiting list.

It is hard for me to say what is a fair salary given that I am at the other end of my career. I do not know if I should ask Dr. Plunkett to respond or whether she will be slaughtered by her colleagues.

Dr. Roisín Plunkett

It might be useful to explain. A consultant contract was introduced in 2008, which had a very attractive salary. That was the carrot, as it were, for the fact that there was a stick with many other less attractive changes, such as the retirement age moving from 55 years to 65 years and limitations to the types of practice people could do. That contract was a huge change and the promised salary was higher. When Senator James Reilly was Minister for Health he unilaterally cut the new entrant consultant salary by 38%, which was, in fact, less of a reduction of cost for the HSE than there would have been by reducing everybody's salary within the HSE by 1%. Obviously, it was a move that was easy to make because, in theory, one is going from large figures to slightly smaller, but still large, figures. However, it was not a very wise decision. When one comes to the end of long training and goes into a job with a huge amount of responsibility one would expect a salary to be commensurate with that of a highly trained business person or a highly trained doctor in another service. The salary having been cut so drastically, understandably in the midst of huge economic hardship at the time, has never been properly redressed. The MacCraith recruitment and retention process has come out of trying to mend some of the difficulties with recruitment and retention. Acknowledging that it is not just about money is very important but, at the same time, if one is in a job where somebody else is earning 38% more that is difficult to swallow. It is same as the position for the new entrant police or firefighters. It is just not fair.

Dr. Miriam Kennedy

We are not in industrial relations, IR, but there has been feedback from colleagues and people who have emigrated. They have said that when it went to the new €105,000 and €111,000 rate, which people said is grade eight or principal officer, they actually left the country. They were very keen on research and service development but said it was from the point of view of mortgages, loans, moving their family around and the worry. Somebody else mentioned a salary of €185,000. I have many colleagues who have said that somewhere between the two is good, as long as it is equal across the board. It is the disparity for some of our colleagues. We used to have a session for research time or supervision time and we used to be able to get cover to keep up our CPD and to go to two-day or four-day conferences during the year. We are not covered for that now. There are all of those shifts within the system. It is always hard to say but certainly in the case of psychiatry, where most people are in public jobs, even those who are in private practice, we do not have the same drive from the salary point of view, although I might be shot by colleagues for saying that. If it is a good commensurate salary that is fine. There is not a huge amount of private practice, nor is that the driver. Our feedback from people, when asked why they stayed in it, is that the driver seems to be that people say it still floats their boat even though it is difficult. We care.

I will respond to Senator Devine because she mentioned something very important, which is trans-institutionalisation. Having worked in forensic psychiatry as well, not all the beds will be filled by the new ones. It probably comes back to what makes us psychiatrists. I have never met a psychiatrist who does not love a person with schizophrenia. It is just that one understands what it is to be different and to experience the way they experience life and the difficulty. There is real trans-institutionalisation. What would float our boat is to be able to have step-down, rehabilitation and so forth within the system, and to bring them back. It is not just the medium secure but also people who have been devastated by the effects of illness early in their lives. The college is hugely committed to the issue of what we can do to make those links and provide those services. Forensic psychiatry will not be the total thing. It is also to do with not just homelessness but picking them up earlier. I have worked at a time when there were changes in contract and changes in the public service where suddenly everything was centralised and I could not replace two community psychiatric nurses, CPNs. I was told that the 40 young men with schizophrenia could come to outpatients. I said: "They will be sick in six months. If they cannot get up and get their breakfast, what does it matter to have an appointment there?". That joined-up thinking is awfully important. We are very passionate about the quality of life. What makes us exhausted is if one does not feel one is involved in that type of improvement or one is leaving people out on the street.

Chairman

I thank Dr. Kennedy. That was very insightful.

I thank the witnesses for their informative contributions. My first question relates to doctors practising as consultants who are not specialists in the areas. How common is that? Is it acceptable? Is it becoming normalised in the HSE or is there an attempt to normalise it? How safe is it? Is it potentially dangerous? Is anybody effectively overseeing or accounting for any of these non-specialists practising as consultants?

My other question relates to another restructuring of the HSE. It appears the implementation of the restructuring will mean there will be nobody at the top table with the term "mental health" in their title. There will no longer be a director of mental health. How concerned are the witnesses about that? We already know mental health is the Cinderella of the HSE but with nobody at the top table any more, will accountability and representation be lost? On a deeper level, is there a concern that the restructuring relating to the finance side, and I am finding it difficult to get a handle on that at present, will mean accountability for the spend on mental health will be lost? One of the ways we hold the Government to account is the ability to compare year on year on year and I am concerned that this restructuring will mean we will no longer be able to do that because there is a blurring of the financial side of it.

Dr. John Hillery

We are equally concerned about those changes in the HSE. The committee will remember that in A Vision for Change it was envisioned that there would be a czar for mental health, similar to the approach taken in cancer services which has been very successful. Cancer services have improved exponentially since this approach was taken, but the same never happened in the mental health service. However, we did get a national director within the HSE, but we are not sure what will happen now. We have a very good national director, with whom we have a good relationship, but she is to be given a broader remit. We do not know what will happen, particularly given the focus on psychiatry. The people Dr. Kennedy has just mentioned are often left out. I refer to people with a chronic and enduring mental illness. We see them as valuable members of society who are able to recover, but they are often left out of the discussions. That is a worry for us and we are not sure how things will turn out. We would appreciate public representatives addressing this issue, too, because the czar for psychiatry and mental health was never appointed. At least, we were given a designated lead and the term was used. Having it used in a high position in the HSE was really important because perceptions are very important and it has been fruitful.

We also have concerns about accountability and what will happen to the finances. Mental health services not seen like cardiology or neurology services. It is not the case that a certain amount of funding is allocated to psychiatry and a certain amount to primary care services. As Dr. Plunkett put it more eloquently than I could when we were discussing it earlier, I will ask her to outline the issue again. We are worried about a further dilution in the new set-up.

Dr. Roisín Plunkett

It is a fundamental cultural problem. There is the lack of clarity on the distinction and delineation between primary mental health care and psychiatric services and secondary care services. Part of the problem is that psychiatry is actually housed within community health care organisations, CHOs. It is housed within the primary care CHO structure rather than within the acute medical division as such. There are cultural and historical reasons for this. In the old asylum culture the asylums provided social, psychiatric and institutional forensic care, with all kinds of function rolled into very messy and difficult arrangements. Now that this has changed and deinstitutionalisation has happened, there has, unfortunately, not been a delineation between primary and secondary psychiatric and mental health care services.

Primary care services have large resource needs because of the number of users. In primary care services there are always more people with a lower acuity of illness. They require resources because there are so many of them. Within secondary care services there are smaller numbers but higher levels of complexity. Therefore, these services have different needs which also require resources. When resources for both are drawn from the same pool, there is a very clear problem. That is why primary care and secondary care services have different budgets in order that the amount that can be drawn from either is limited and both are ultimately protected. Without that structure within mental health and psychiatric care services, there is a real risk that nobody would be well served.

Chairman

I ask Deputy James Browne whether his questions have been answered. Senator Máire Devine made the very good point that the committee should perhaps invite representatives of the HSE to appear before it again to explain what the restructuring is all about. Is that agreed?

That is a good idea.

Dr. John Hillery

A question about specialists and consultants was asked. We do not actually have numbers, but we worry that it is becoming normalised and not safe. People are not overseen to the proper level when they are the final decision maker on the provision of treatment. I have given an example of the concerns I have come across in my daily work. We must realise part of the problem is the delay in appointing people about whom Deputy Pat Buckley. Locum posts are not attractive to specialist trainees. They want consultant posts in which they can do something. As they cannot do it in a locum post, they will go elsewhere. This means that people who are not as highly trained occupy the positions. As they will also move on, there is no service development. As well as being unsafe for the individual, it is unsafe for the region because a service does not evolve with a leader in place. One wonders if this is influenced by the consideration that if temporary staff were used, the same pension and leave issues would not arise as in the case of a permanent appointment, but I am sure that is not a factor. Perhaps the committee might explore this issue with the employers who would be more able to answer the question than we are. It is a worry.

Dr. Kennedy was our leader on the issue of competence assurance. She will outline what a specialist is about and what we expect of specialists which is not expected of non-specialists.

Dr. Miriam Kennedy

People who have gone through basic specialist and higher specialist training have been trained not only in a range of clinical competencies but also in the areas of management, leadership and research. Dr. Hillery has noted that people on our specialist register have to keep up with continuing professional development requirements every year. They must show that they have updated their competencies not just by keeping a log but also by having a work plan. Many of them also work in peer groups, which is incredibly useful. They must declare this to the Medical Council.

The reason we cannot refer to numbers is that some people who are passing through are on the general register. This requires a practitioner to somehow maintain his or her level of competency. They have to come to us to get into that system. As such, we do not have the numbers, although the employers would.

Dr. John Hillery

They are not answerable in the way specialists are.

I offer my apologies to the Chairman. I had to leave to attend another meeting.

I wish to ask a general question. I constantly hear about recruitment. Obviously, the weight accorded to salary, job description, work patterns and so on depends on one's point of view. The importance of these considerations is also affected by various campaigns professional bodies may support. Do work practices or salary represent a larger impediment in recruitment? Which would the delegates consider to be more important?

Dr. Roisín Plunkett

That is a false dichotomy. When the Deputy thinks about his own job, are work practices and salary the more important considerations? Both are important. If the two were divorced, one would be left with an either-or, which would be really false. It is the employee's whole job. On quality of life-----

Is Dr. Plunkett saying both considerations are equal?

Dr. Roisín Plunkett

Both are important, but they are not the only considerations. There is a context-----

Have the delegates carried out any study of this? A lot of what I am hearing is anecdotal. Are there statistics or studies of the specifics?

Dr. Roisín Plunkett

The MacCraith report focused on the specific reasons people were leaving the country and not staying in the health service. There are a huge number of statistics and more robustly gathered data included in the report which is a very good resource. However, it has not been fully implemented. I would definitely direct the Deputy towards it. It found that both considerations were important.

Would anybody else like to offer an opinion?

Dr. John Hillery

The feedback we get from trainees and reports such as the McCraith report indicates that both considerations matter. People are looking for a fair income, but what is most important for them is being able to practise what they set out in life to practise. That means having the necessary teams around them and access to treatment places such as inpatient beds - such access is becoming rarer and rarer - or day hospitals. Most importantly, our philosophy is to treat people where they live and work. To do this, we need staff. As I said at another meeting earlier this year, we are the boots on the ground part of medicine. We need recruits, be they doctors, nurses or psychologists. without whom we cannot treat people in their communities. The other risk is that without them, figures can be used to show that it is cheaper than an inpatient service. I have to keep saying everywhere I go that in running a proper community service one will not save money, but it will make for better quality outcomes for citizens of the State.

If we save money, people will suffer. Perhaps one could save money by locking people up in institutions that are badly run. To have a proper, modern, mental health service, however, which we all believe should minimise the amount of time people spend in hospital, we need staff.

The conundrum the committee has is we are giving new moneys to the HSE to implement it but we are not getting a breakdown of how much new money is being spent and how much is being put into specific services.

Dr. John Hillery

We find it hard to get that information too.

That is why I am asking. I am trying to get as much information from witnesses in order that when we meet the HSE again we will be able to ask its representatives these questions.

Chairman

Dr. Plunkett said new graduates go into a chaotic world.

I want an opinion on whether, when those graduates start studying, they are given information about the systems. What drives them to start studying when work conditions and salaries are not strong enough? Students are still going into practice. What kind of information is being given to them? What drives it? When I worked in recruitment, I found that many of the incentives for working in a job were much softer than the work patterns or salary. It could be because of the love of the job. Have any studies been done on how long they have been in practice before leaving? Is it two years? Have they gone into practice for a while? Have studies been done on that? Is the information in the report?

Dr. John Hillery

All our trainees train in practice. Medical-----

Are there any statistics on when they leave to go to other jurisdictions such as Australia?

Dr. John Hillery

The feedback we get is that the reasons are remuneration and quality of life, including the job.

I understand that but how long do they practice before they leave?

Dr. John Hillery

If they go through our full training scheme, they will have been practising in the Irish health system for at least seven years, if not eight.

Are there any statistics on whether they have been practising for nine, ten or 12 years, for example, when they decide to leave? Have any studies been done on that?

Dr. John Hillery

We are in a difficult position in Ireland. What we are seeing now is medical graduates finishing their intern year. One cannot register as a doctor until one has finished one's intern year. One does five to six years' study and an intern year during which time one works in a hospital under strict supervision. They decide at that stage to go to Australia because their friends are going or because they want to be a psychiatrist and have seen what happens in Ireland. The decision is made on perceptions, which is not helpful, but it is driving people away. When they get to these other places, the feedback we get is their quality of life is better. The salary may be a bit better but the tax may be higher, as it is in Australia,-----

The tax is higher there.

Dr. John Hillery

-----but they know they will have a better quality of life. They know that if they are rostered to work from 9 a.m. to 5 p.m., it would be very unusual for them to still be there at 7 p.m. that evening because someone else will come and take over. They know if they are rostered to work overnight from 10 p.m. to 9 a.m., they will be going home at 9 a.m. and will not still be there at 11 a.m., as we see in our hospitals. It is by word of mouth. It is not a very-----

It is a cultural thing.

Dr. John Hillery

-----satisfactory answer for the committee because it is not based on figures; it is a cultural thing.

Dr. Margaret Kennedy

A few months ago in the British Journal of Psychiatry, there were some figures on the UK experience of people dropping out. Interestingly, something like 40% were interested in doing psychiatry when they entered medical school but that figure dropped significantly, to below 10%, by the time they left. Some people reflected that it is not necessarily a bad thing. What is the perception of psychiatry about? It has led us to think we do not want everybody to be interested in psychiatry because one needs mental agility, passion and love for it and one must withstand exposure to things like suicide. There are many different things. If we could get 4% or 8% of medical students we would still be able to attract the people we need, who are leaders. There are some figures we could send on which indicate there is a drift in this regard. We do not want the people who come to psychiatry to get burnout. There is more and more information about burnout and it is recognised as the push in the system. The mental health of physicians is an issue. We want to attract 4% or 8% to our training programme and we want to ensure they stay. I agree thoroughly with the Deputy that the culture within which one works is probably the biggest factor in deciding whether one will function well and whether one will burn out and still smoulder on. We can send on those figures if the Deputy is interested.

May I ask one final question?

Chairman

Yes.

I have been a Deputy for two years. Has anybody returned in those two years?

Dr. Roisín Plunkett

That is a really great point. If the committee is getting the NDTP in to talk, it will talk about the MacCraith report. When it was being looked at, it was clear that one of the points at which people were being lost was after basic specialist training, BST, and before higher specialist training, HST. The reason for that was there was a bottleneck because more people were recruited into basic specialist training than into higher specialist training. The response to that by the HSE's NDTP was to try to make it less of a pyramidal structure and more of a funnel structure, so there would be the same number recruited at BST as at HST, and therefore graduating out as consultants. In theory, I understand why that would be the response to stop people leaving but what happens is that people who leave to do a fellowship, have a baby or train abroad and who want to come back are restricted from returning because of the funnel system. We used to have a pyramid system in which people would train for four years in BST. They would get their membership and would be partially qualified as specialists. They would be able to go abroad with marketable skills and there was clear competition to get into higher specialist training. There was a loss of some people but they could come back in and compete for higher specialist training later. Now it is much more restricted and getting into higher specialist training is more difficult if one does not run through. That is as a result of the HSE's NDTP's decision to change it from a pyramidal structure to a funnel structure. It is something we are trying but it can limit people returning.

What was the HSE's rationale for changing it to a funnel system? Why did it do it?

Dr. Roisín Plunkett

It did it to avoid people leaving, to make it more difficult to leave because if one stays and trains all the way up, then one is fully cooked.

That is an important point. I thank Dr. Plunkett. I appreciate it.

Chairman

I thank Deputy Neville. We have come to the end. I do not know about the rest of the members but I am much clearer about the problem of recruitment now. One of the essential things that has come about today is that we will invite the HSE committees in. The HSE has said it cannot recruit anybody and I think members will agree we have heard why today. I thank the witnesses. All they have said today will be included in our report. We will let them know when we invite the committees in. It was an astounding meeting and I thank the witnesses.

The joint committee adjourned at 4.38 p.m. until 1.30 p.m. on Wednesday, 28 March 2018.