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.