Workforce Planning in the Irish Health Sector: Discussion (Resumed)

During the second session of our meeting we will deal with workforce planning in the Irish health sector. On behalf of the committee, I would like to welcome from the Irish Medical Organisation, Dr. Pádraig McGarry, president, Dr. Matthew Sadlier, member of the consultant committee, Mr. Anthony Owens, director of industrial relations, and Ms Vanessa Hetherington, assistant director, policy and international affairs.

I wish to draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this 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 or her identifiable. I advise witnesses that any opening statements they make may be published on the committee's website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I invite Dr. McGarry to make his opening statement.

Dr. Pádraig McGarry

I will outline the statement on the medical workforce planning to the committee. The Irish Medical Organisation would like to thank the Chairman and the committee for the invitation to discuss the critical issue of medical workforce planning and the crisis in medical staffing, which is having a significant impact on the delivery of healthcare services in Ireland. The Irish Medical Organisation, IMO, is the trade union and representative body for all doctors in Ireland and welcomes the opportunity to highlight the issues of recruitment and retention that exist across our health services in both the acute and community settings.

The main point we wish to make today is that the crisis in medical manpower this country is facing is having severe adverse effects on patients with growing waiting lists and inability to deliver appropriate and timely care. During the austerity years we repeatedly warned that cuts to our health services would lead to a reduction in services, longer waiting lists and an inability to recruit and retain medical practitioners. It gives us no pleasure to say this has now come to pass but we again use this opportunity to call on this committee and the Government to seriously address the deficits that exist in our medical workforce as to do so would improve the overall health of our nation.

The key contributing factors to the current crisis in medical manpower can be identified as including the absence of planning and investment for the number of doctors required to meet the health needs of a changing demographic of patients. Also, Ireland's population is growing but the key factor in terms of planning is the increase in the rate of growth of those over the age of 60. In order to meet the increased but expected needs of the population we need more doctors. To put that in perspective, up to 2008, one in ten patients were over the age of 65, between 2008 and 2028, one in five patients will be over the age of 65 and, by 2040, one in four patients will be over the age of 65. That gives members an idea of the scale of the problem that awaits us down the road. The latest OECD figures show that with 1.44 specialists per 1,000 population, Ireland has the lowest number of medical specialists in the EU, with the EU average being 2.48 per 1,000 population. The HSE's national doctor training and planning, NDTP, office shows approximately 520 consultant posts remain unfilled or filled on a temporary basis while figures obtained by the IMO show that almost half of consultant posts advertised by the HSE in 2018 received few suitable candidates or qualified applicants, or none at all. The demographic of the workforce at specialist level is very challenging with a high level of expected retirements in the coming years. More than 700 general practitioners are due to exit the system in the next five years, a quarter of consultants are due to retire in the next ten years and 50% of our public health specialists are due to retire in the next five years. The direct consequences of this lack of planning are that in many areas such as consultant staffing levels, the staffing levels fall well below the recommended ratios by the national clinical programmes and colleges. In orthopaedics, paediatrics and psychiatry, the consultant staffing levels are 50% below recommended staffing levels while in ophthalmology the staffing levels can be up to 70% lower than what is recommended. More than 770,000 patients are currently on hospital waiting lists. In many areas of the country patients cannot register with a GP due to lack of capacity which has a negative knock-on effect of increased presentations to an already stretched GP out-of-hours service and in emergency departments across the country.

A significant factor is that a poorly resourced health service and a hostile overly pressurised work environment are leading to high levels of emigration of doctors. More than 700 graduates enter basic training each year in Ireland, however, we are training are doctors for export. Since 2015, the number of voluntary withdrawals from the register has almost doubled from 828 to 1,453 in 2018. Data from the Medical Council show that approximately a third are Irish graduates while almost a quarter leave the specialist register. While a small percentage leave to retire, the vast majority, almost 70%, leave to practise medicine in another country. Reasons cited include understaffing, expectation to carry out many non-core tasks, lack of respect, limited career progression, higher earnings abroad, family reasons, more flexible training options abroad, lack of support from employer, longer working hours, poor quality of training and the list goes on. There is a growing body of evidence that demonstrates that doctors are suffering from burnout due to the highly pressurised working environment and this, coupled with a lack of support from the employer, is a significant contributing factor to emigration. Doctors are trained over many years to deliver high quality and appropriate care to patients. The lack of investment in our public health services makes it almost impossible for doctors to deliver that care in a timely manner due to the lack of beds, understaffing, poor access to diagnostics and access to other healthcare professionals, including counselling services, occupational health services and physiotherapy. This starts with GPs being unable to access timely referrals for patients and carries on through to the hospital system or community system with intolerable and dangerous waiting times for outpatient appointments and then in many cases long delays before the prescribed treatment can be delivered. The health capacity report clearly identifies the deficits in terms of infrastructure within the system yet the policy of the Government is to significantly increase investment in the private system through the National Treatment Purchase Fund while starving the public system of the required investment. Our GP workforce is also emigrating. A survey by the Irish College of General Practitioners, ICGP, of GP trainees and graduates in 2017 revealed that one in five recently qualified GPs had already emigrated, while a further 30% of newly qualified GPs were considering emigration. While more than 50% of GP trainees envisage themselves as GP principals in a partnership or group practice in ten years’ time, and that signifies intent, concerns about the viability of general practice, financial prospects and quality of life are the key factors influencing their decision to migrate. It is important to note that the recent GP agreement merely provided a pathway to reinstate the funds lost during the years of austerity and what is required is significant planned investment in the development of GP services for patients.

Another factor is the failure to make our public health services an employer of choice for medical professionals and a culture of disrespect of doctors by the employer and the Government. Our doctors continue to emigrate to health systems that pay more, offer better supports and reasonable working environments and that value doctors.

Over the past five years, the IMO, on behalf of its members, has been forced by the Government and the HSE to take legal action to enforce legally binding contracts entered into by the employer. This has been necessary to ensure doctors work safe and legal hours and to allow doctors to be represented in respect of contractual matters. This does not assist in the development of a culture of respect in which employees are valued. Consultants who were employed prior to 2012 were denied their contractual payments. Those payments were eventually secured on foot of legal action. Consultants who were employed after 2012 were subject to a discriminatory and unilateral cut of 30% in addition to the cuts applied across the public service. The impact of this policy has been the HSE's inability to recruit consultants, which has led to more than 500 vacant posts and more than 100 non-specialist doctors working in consultant posts. Examples of this shortcoming can be seen throughout the country. It has been most recently evidenced by the inability to recruit sufficient consultants for the opening of the first phase of the national children's hospital and the increasing problems in psychiatry services.

Rather than increasing our consultant staffing levels, we are becoming increasingly reliant on foreign-trained doctors. More than 40% of doctors who are registered in Ireland received their training overseas. Research shows that most foreign-trained doctors intend to move on by returning home or migrating onwards. They are concerned about deskilling and are disillusioned by the lack of training and career opportunities. In effect, we are creating a transient workforce in perpetuity. That is not good for the health service or for patients. NCHD contracts are routinely breached by hospitals. Doctors are forced to work in excess of legal hours and are not paid for all the hours worked. Many of them have spoken of poor and inflexible training with poor career progression options. Our research suggests that two thirds of NCHDs perceive pay to be the principal reason for emigrating. Some 83% of them believe the pay disparity at consultant level will be a factor when they are deciding whether to apply for consultant posts in Ireland. The pay disparities between consultants who were employed before and after 2012 are up to €50,000 a year. These colleagues are doing the same job and carrying the same level of responsibility.

Ireland differs from other English-speaking countries because specialists in public health medicine are not remunerated on an equal basis to other consultant specialists in the health system, even though they are required to be on the specialist register and must undergo specialist training. If they were properly resourced, public health doctors could play a pivotal role in commissioning services, analysing health data, conducting needs assessments, assembling the evidence base for interventions, monitoring services and quality-assuring parts of the health service such as screening services. The development of general practice is the cornerstone of many reform proposals, including Sláintecare. Until recently, GPs have been left to shoulder the burden of reduced funding while delivering a greater level of service. There is no clear strategy or funding for the development of general practice. All the factors that have led to this crisis have been much publicised and highlighted by the profession and the IMO for many years. Lack of commitment, investment and respect by successive Governments and the HSE have led to low morale among the existing workforce and high levels of emigration. There is an inability to recruit sufficient doctors to deliver existing levels of care or develop new services. We are at a tipping point. Unless we seriously address this problem, doctors fear for the health service and the safe delivery of care to patients. More reports and promises of reform are not required by the health service and patients. It is not helpful to talk about black holes in the health budget. Contrary to the spin about high levels of health spending, the budget is insufficient to meet the needs of the population. It is time for politicians and policymakers to be honest about this.

Immediate steps must be taken to resolve the medical manpower issue. The discriminatory pay issue for consultants must be resolved. Until this has been dealt with, there can be no new contract discussions, which are required for any reform measures, and we cannot hope to recruit consultants to our public health services. There is no defence for the current policy. The impact of this politically motivated 30% cut has been disastrous for patients and services. There is a need to invest in capacity and supports within general practice to allow it to develop and deliver a fuller range of care in the community. Eligibility for medical cards and doctor visit cards should be expanded on the basis of means or medical need, rather than on the basis of age. The long-held tradition of successive Governments using medical cards as vote-getting exercises must stop.

The training of doctors must be modernised to reflect changes in the practice of medicine and in the demographics of doctors in training. Initiatives are required to bring arrangements for the duration of training into line with international norms. A differentiated model, which provides clearer career paths with greater predictability of training arrangements, responsibilities, locations and working conditions, must be developed in line with the recommendations of the report of the strategic review of medical training and career structures, which is known as the MacCraith review. In excess of 700 doctors enter basic specialist training every year, but an average of just 484 doctors enter higher specialist training. We are just about training enough specialists to replace the number of specialists who leave the register each year. There seems to be a mismatch in the number of posts on offer. Approximately 55 higher specialist training posts are not filled each year in other specialties. There are insufficient training posts on offer to meet demand or the shortage of consultants in that speciality. Vacant posts in public health and community health are putting health planning and the delivery of vital vaccination and screening programmes at risk. The Crowe Horwath report, which was commissioned by the Department of Health, must be implemented to improve the role and function of public health specialists and the training and career structure of public health medicine. Its implementation is required to ensure public health specialists are valued and offered contractual terms in line with other specialists.

Doctors want to work in a system in which they can care for patients. That is why we became doctors. Care delayed is care denied. The cost of denying care has never been assessed in terms of the personal cost to the patient's quality of life, the cost to the system of delivering more expensive and complex care at later stages and the cost to society of days of work lost and benefit payments as many patients await care that will allow them to live full and productive lives. We need reform that makes a difference to patients. Any reform is simply impossible in the context of the current medical workforce crisis. In the absence of significant and appropriate investment, reports and reform proposals are making the situation worse rather than better. There can be no hope of reforming the system, or developing new and much needed services, if the current level of understaffing in the system persists. We must have a system that cares for patients and values doctors. We have seen the consequences of a system that does neither.

I thank Dr. McGarry. The first member to ask questions will be Deputy Donnelly.

I thank Dr. McGarry for his statement and all the witnesses for their time. It is difficult to know where to start with his statement. It is pretty damning stuff. It depicts a healthcare system and a workforce in crisis. How many doctors are we short? Dr. McGarry might start with the hospitals before moving onto GPs. There are meant to be approximately 3,300 hospital consultants, but we are approximately 500 short in terms of full-time posts. Even if an additional 500 consultants were recruited tomorrow, Ireland would still have the lowest number of hospital consultants anywhere in Europe. It can be estimated that to get to the European average, the additional 500 consultants we are currently missing would need to be hired as well as another 2,500 thereafter. If the Government is ambitious about our healthcare system, it must admit that the shortfall is approximately 3,000 consultants rather than 500. Given that we have approximately 3,000 hospital consultants, the Government needs to double the current number to get to the European average. We should probably be a bit more ambitious for our country and for our people than to be at the European average.

Dr. McGarry has given us worrying figures relating to to public health specialists.

Up to half of them are due to retire in the next five years. We have about half the number of orthopaedic surgeons, paediatricians and psychiatrists we need and 30% of the number of ophthalmologists. There is a crisis with the shortage of hospital consultants in particular hospitals and specialties. For particular towns, villages and cities, it is even worse.

Do the witnesses know if there is a plan anywhere in the HSE or the Department that states this is the number of consultants required per hospital, per specialty or per hospital group, or even just for the country, over the next five to ten years? Is there a workforce plan which states the number of consultants needed to be hired, including all those we know who will retire, which will get us to an agreed figure, say the European average? Does that exist?

Dr. Matthew Sadlier

I do not know what documents the Minister for Health has on his desk. Maybe he does have one that the Deputy has in mind. If he does, he has not shared with the rest of us.

There are multiple different strategies. In my speciality, psychiatry, we have A Vision for Change. There are models of care in different specialties. There is a variety of documents which state the numbers needed for the population. Some 17 years ago, we had the Hanly report, which stated how many consultants were needed for our population.

The problem is that it is disparate. There does not seem to be one single document or one single plan. While I appreciate the Deputy’s point, when one looks at the statistics from the Central Statistics Office, the population increased by 64,000 between April 2018 and April 2019. Even if we have a document stating how many consultants we need now, if that rate of increase continues, then in five years’ time the population will have increased by 300,000. Then we will have to build another hospital the size of-----

We can assume that if there is a plan, somebody has taken account of the fact that the population is growing and ageing. It is implicit in my question that the plan includes that.

Dr. Matthew Sadlier

I would not be sure of that.

Have the witnesses seen a plan that states we need an extra 3,000 consultants, listing the specialties, the hospitals, the demographics, the number retiring, the number leaving, and how this will be achieved? Does that exist?

Mr. Anthony Owens

We are not aware of any such plan existing. We hope it exists. We need it to exist. Its existence so far, however, has not been shared with us.

Is it fair to say that, as the union representing the doctors of Ireland, that if it existed then the IMO would probably know about it?

Mr. Anthony Owens

I can certainly say if it existed, then we should know about it.

I have not seen it either for what it is worth.

We have a massive shortage of GPs. We have a GP population in crisis, dealing with all sorts of stuff which is compelling them to leave or cut back practice or leave the country and practise elsewhere. Is there a plan anywhere that states these are the number GPs we need?

Dr. Pádraig McGarry

There are projections for the number of GPs required. Currently, we are training approximately 180 per year. It is expected that should rise to 280 to deal with the requirements. That is in the expectation, however, that if one trains 280, they will be retained within the system. Our problem is that they are not being retained in the system. It is difficult to put a plan in place from a numbers point of view if one does not know how many will stay. The problem is that they are not choosing to enter general practice in Ireland. Instead, they are choosing to do so in other jurisdictions. There is a notional number out there of how many are needed but that does not reflect the situation on the ground.

When Dr. McGarry says there is a notional figure out there, does that mean there is an agreed Department-HSE target stating we need X number of GPs? Does that mean we must hire, recruit, train and retain a certain number? Is there an agreed target and a plan to reach that target?

Dr. Pádraig McGarry

The expectation is that one will train 280.

I am not asking for the numbers. Is there a plan to hit those numbers? Is there an operational plan that states how the public healthcare system will get to the number of GPs needed?

Dr. Pádraig McGarry

Through the ICGP, Irish College of General Practitioners, there is an agreement that it will expand its training to that level. At the end of that level, one would expect to arrive at the numbers needed. That is what is on the ground. The problem, however, is that we are not retaining them and, unfortunately, they are going elsewhere. The underlying problems causing the lack of retention are the real issue. One could possibly retain them through creating the right environment. Many GPs have left Ireland If the environment in which GPs work was brought to a more favourable position, one could see a return of numbers which may make up the shortfall. At the moment, that is not the case.

That has been laid out very well.

Several times the witnesses spoke about the health service being underfunded and under-resourced. I absolutely agree that the system is in crisis across the board. I absolutely accept that the money is not being spent the way it should be spent. Putting aside how the total pot of money is spent, is it the witnesses’ contention that the total amount - €17 billion for this year and €18 billion for next year - represents underinvestment in public healthcare?

Ms Vanessa Hetherington

One has to look at the fact we are playing catch-up after decades of investment. The pot of funding is constantly playing catch-up. If one looks at our investment and the amount of spending, there is all sorts of talk about our spending being among the highest. If we compare our public spending with that of our European counterparts, we are lower than the average EU 15.

Are we? On what metric?

Ms Vanessa Hetherington

On public investment in the services.

Measured in what way?

Ms Vanessa Hetherington

It is measured per patient.

Is Ms Hetherington sure?

Ms Vanessa Hetherington

I would be almost sure of that. An extra €1 billion last year would have brought those figures up slightly. However, we are not the highest public spenders. We are the highest overall spenders on health in the EU but not in public spending. We have to take that into account.

What does Ms Hetherington think the right figure is? We are at €18 billion for next year.

Ms Vanessa Hetherington

I do not know what the exact right figure is.

Dr. Matthew Sadlier

We are not health economists. I want a fully staffed team in my specialty of old age psychiatry in north Dublin. I want my team staffed as per the numbers in A Vision for Change. As to how much that costs and whether the budget has been spent incorrectly, for those of us working on the front line, we do not know. I am not a health economist. I do not know where the €18 billion distils down to.

I am not having a go but, with respect, the witnesses are making economic statements. If one is going to say not enough money is being spent on public healthcare, then one needs to be able to back that up. If the witnesses are not health economists, then they should not say it. I am not having a go. I am really trying to understand it.

The figures I see are that we are well above average in public spending per capita in healthcare. We need to figure out how it is we are spending so much money on healthcare but not getting what we quite rightly need, namely, fully staffed teams.

I am trying to understand if the Irish Medical Organisation believes the issue is the quantum of cash involved. I am very open to that being the case, but the figures I have seen do not back it up, or is it the case that Ireland spends well above the average on healthcare per person and that, therefore, we are not doing what the IMO rightly demands and needs - the right number of staff to treat patients?

Dr. Matthew Sadlier

That is the question to which I too would like an answer.

We can come back to it. Am I done, time wise?

The Deputy has one more minute.


My next question concerns the FEMPI legislation. I spent a good deal of time interacting with the IMO which has repeatedly told me that the number one priority is the reversal of the FEMPI cuts for general practitioners, GPs, for whom Fianna Fáil and I went to bat very hard. We got a provision for its reversal this year. It was not done as quickly as we wanted, but we achieved it for the IMO. Is it working?

Dr. Pádraig McGarry

The reversal of the FEMPI cuts will take place over a 30-month period. The first amount was paid in July. While it is elcome to see the reversal, it is very early days. There has been a history among younger doctors of looking at older doctors struggling under the FEMPI legislation and they have almost been conditioned to be beaten down. The change of attitude will take a while. I hope the reversal of the FEMPI cuts will bring it about. It behoves us to educate younger GPs coming on board that there is a future because of the reversal. One must remember that it is not additional money, that it is only restoring what was taken off in the first place. The top line cut was 38%-----

I know what it is. I am asking if, having achieved it, is it working?

Dr. Pádraig McGarry

It left practices unviable-----

I know, which is why we batted so hard.

Dr. Pádraig McGarry

It created an environment-----

I understand that, but what I am asking is if we are seeing a difference on the ground?

Dr. Pádraig McGarry

There in an increased level of optimism. Interestingly, I use as a barometer talking to reps because they all see GPs. They certainly believe there is an increased optimism in general practice as a result of the restoration of the FEMPI cuts. This appears to be the case across the board. I expect it will translate into a feelgood factor, but it is still early days.

I welcome our guests and thank them for their submission. Having sat where they are on more than one occasion, I know that they are not health economists and I do not expect them to be, but they have given the committee a very interesting and important perspective from the front line, to which we would do well to listen.

One of my questions relates to the production of reports. I am aware that people might say, "If we just had another consultant's report," or that if we just fling another few million euro at one of the big consulting firms, somehow a solution will fall out of the sky. I share Dr. Sadlier's aspiration to have a fully staffed team in north Dublin, but I do not think it will come via the few million euro spent on a consultant's report. Sinn Féin asked about issue this recently in a parliamentary question. Millions of euro are spent by the Department of Health on reports. One could line the walls of this place with them. They possibly could do it to provide extra insulation and it would provide value for the money spent. Nothing is done. A Vision for Change is a great strategy, but not if it is not implemented. I contend that there is a lot of evidence that more implementation plans or another consultant's report are not needed, that what is actually needed is the political will to get on and get the job done. The first moratorium on recruitment in the health service was brought forward two years ahead of everywhere else in 2007. We cannot ignore the fact that while the moratorium had a detrimental impact on every Department, for the Department of Health and the HSE the impact was felt two years earlier. Sometimes this is forgotten when we talk about the overall health spend. It is a large amount of money, but Dr. Sara Burke, for example, has said we are just plugging a gap and trying to make up for decades of under-investment, with a population increase. I am interested in hearing the delegates' views on whether another report might help. I do not believe it would, but I am open to hearing from the representatives if they think one is necessary.

Dr. Matthew Sadlier

I have to agree with the Deputy. There is definitely a phenomenon of reform fatigue among people like us on the front line of the health service. We need incremental improvements on the front line, not overarching structural changes to the structure of the health service. I did not start my working life in the HSE, I started it in the health boards. I have worked for 19 years in the HSE, health boards, community health organisations, integrated care areas and the National Hospitals Office. Again, we are to have another set of reforms and another set of structural top-level reforms. Will they, however, deliver an extra occupational therapist in Mulhuddart? Will they deliver an extra clinical psychologist in another part of the country? The point is that we are advocating for front-line services. We know where the deficits are and hat the problems are.

Mr. Anthony Owens

By a way of illustration, Dr. McGarry referred to the Crowe Horwath report on public health medicine. The report was commissioned in 2015 or 2016 and presented to the Department of Health in 2018. We had to threaten industrial action to see it, not even to implement it. Do we need more reports? Perhaps we might get on with discussing and implementing the reports we have received, rather than going for more. The current consultants' committee chairman has said there is one iron law in health - no report has ever been fully implemented.

That is very true and worth noting. We often hear people say if there was another report by a consultancy firm, it might crack it, but I cannot see it.

The IMO's colleagues from the Irish Hospital Consultants Association were before the committee last week. I have also spoken to colleagues who are members of both unions and neither and they have referred to the revolving door created by the National Treatment Purchase Fund, NTPF. They have outlined a scenario where the person who has waited the longest will be offered an appointment in the private health sector with a consultant, with the patient then being returned to be added to another list for treatment. Is that the delegates' experience of how the system operates? It appears to be a very cynical exercise in waiting list manipulation which does not necessarily move people any closer to receiving the treatment they need. I am interested in hearing the views of the delegates in that regard.

Dr. Matthew Sadlier

It does not happen massively in my specialty. However, I have heard from those involved in other specialties that some of the movement of patients to the appointments with the NTPF takes place under the triage system. There is no doubt that some of those on waiting lists will be removed by use of the triage system to be assessed. Some patients who need surgery or a procedure to be performed, as the Deputy said, will join a further waiting list.

It is a revolving door.

Dr. Matthew Sadlier

The other issue within the waiting list system that is not often captured concerns the internal waiting list. In the case of community mental health teams, for example, often there will be a waiting time to be seen by the team, but once a person is seen, he or she is put on an internal invisible waiting list to be seen by a psychologist, an occupational therapist, a social worker and so on. There are internal waiting lists within the system that are blind when it comes to the public figures.

We do not actually see those figures, but they also indicate a wait, which is very worrying.

On non-consultant hospital doctors, NCHDs, it is 12 years since I was appointed to the working group on the European working time directive. I believe the Minister for Health at the time was former Deputy Mary Harney and Fianna Fáil was in government. Is Ireland any closer to compliance with the European working time directive for NCHDs?

Mr. Anthony Owens

I think I sit on the group in its current iteration. It has been renamed-----

I have nothing but sympathy for Mr. Owens in that regard.

Mr. Anthony Owens

I am not the one who deserves sympathy.

The doctors who work the hours deserve the sympathy but I appreciate the Deputy's sentiment. The figures that we are being presented with seem to show that we are on the cusp of compliance with the working time directive. These are HSE figures but anecdotal evidence and evidence from the Medical Council's own surveys suggests that we are quite some way from compliance. We are conducting a survey at the moment, which is still open. We have had several hundred responses so far, which is pretty good in medical terms because doctors are suffering from survey fatigue as well as work fatigue. Approximately half of those who have responded to us are still working in excess of 24-hour shifts, with a slightly smaller number working in excess of 48-hour weeks. The Your Training Counts survey suggested that one third of respondents were working in excess of 60 hours per week. This is not good. We are not there yet but we are better than we were previously. There is still some way to go but we cannot begin to crack the nut until we see accurate and transparent figures from the HSE and other employers.

Does Mr. Owens know why there is a difference between the HSE figures and those of the Medical Council?

Mr. Anthony Owens

I suspect the figures that we are being presented with are rostered-hours figures. There can be compliance on a roster but an individual may have to work----

Indeed, I recall that from my days on the working time directive compliance committee. If every NCHD worked his or her rostered hours, we would not have been sitting in the room. The issue is the additional hours that are worked on top of the rostered hours. Hopefully, that will be reflected in the Medical Council's survey because it is important. I am not seeking to undermine or contradict the HSE figures but it would be wrong to believe that the problem is fixed. Admittedly, it is closer to being fixed which is very welcome.

On the issue of those who are not on the specialist register but who are practising as consultants, I have seen correspondence from the HSE advising that no specific supervision arrangements are in place for that group of doctors. My reading is that there could not be specific, one-to-one supervision because if there was someone available to do such supervision, he or she could do the work. I have had conversations with people in the HSE about this issue. There does not seem to be any target in terms of converting these people. I would not try to interfere with any person's lawful entitlement to a contract of indefinite duration but there does not seem to be any major push from the HSE to get these people onto the register or to intervene. When a person has a lawful entitlement to a contract of indefinite duration, there is nothing that can, or should, be done about that. Does the Medical Council have any information to suggest that there is any effort being made to tackle this? I also ask the witnesses to comment on the supervision arrangements.

Dr. Matthew Sadlier

The overall problem is that for the first time in the history of the health service, we have a massive number of consultant vacancies. Ultimately, that is the problem, in terms of trying to fill posts. We have doctors who are not on the specialist register but who should be on it. Some of those doctors are qualified and experienced and come from countries where they had difficulties with registration. That is a legal issue and we will not get into that here. Some of those doctors are operating in places where they probably need some supervision. There are local supervision arrangements in place but, at a national level, there is no supervision policy of which I am aware. The solution to the problem is to reverse the 30% pay cut for new entrants. That pay cut created this issue. It has created a cohort of agency-paid consultants who are probably costing the health service more than a reversal of the pay cut would cost. However, for reasons that I cannot understand, this system has continued since 2012.

It is not a question of "probably" costing more but rather a question of almost definitely costing more and the figures certainly support that contention.

I have one final question relating to general practice. There has been a suggestion, with which Sinn Féin agrees, that if the facility to order diagnostic tests is extended to GPs, this will have a positive impact on waiting lists. It is one thing to extend that facility but it is quite another to ensure the services are available. Has the Medical Council had discussions with the Department of Health on facilitating GPs to order diagnostic tests directly, which they currently cannot? Some of the logjam is caused by the fact that patients must be referred to a consultant before they can access diagnostic tests. In the event that the ability to order such tests is extended to GPs, the services and the physical infrastructure must be in place. Apart from that, are there other barriers? Has the Medical Council had any discussions with the HSE on this? Did it come up, for example, during the discussions on the revision of the GP contract?

Dr. Pádraig McGarry

There has not been any specific discussion on extending access to diagnostic services to GPs but it is a no-brainer that it should happen because it would take out a layer of referrals. One gets to a stage in general practice where one can no longer progress a patient's investigations beyond one's own ability or the availability of services. Hence, one gets into this referral system that goes on ad infinitum. Clearly, it is a no-brainer that if GPs can access diagnostic services locally or in a timely manner, we can remove half of the referrals in the system. Small pilot studies have been done in various places, including in Waterford, where a study was done in the context of heart failure clinics and so on but there have not been specific discussions on diagnostics. It is something that should happen but access, availability and appropriate standards are essential.

Ms Vanessa Hetherington

In 2015, the Government commissioned Indecon to look at investment in primary care centres. The Indecon report recommended a multifaceted approach with the HSE providing incentives to GPs to invest in infrastructure within their own communities but Government policy seems to directly contradict the recommendations of that report in terms of public private partnerships for the development of primary care centres.

There is a lot to be said for another report.

Ms Vanessa Hetherington

That report was published in 2015 but there are no incentives in place. Incentives are badly needed because if GPs have additional support to invest in their communities, they are more likely to stay, which is important in terms of continuity of care.

Dr. Pádraig McGarry

By way of anecdotal evidence, in my own practice an ultrasonographer comes in who is very good. She works with a consultant based in Dublin and is absolutely top class. We can access ultrasounds readily, within a few days or a week. She gives a reduction for medical card patients. It is a classic example of something that works on the ground. She met the Minister for Health when he visited our health centre last year. He was massively impressed by her set up. She has expertise in her field and is very highly regarded. It is a model that can be extended-----

Absolutely, and it should be.

Dr. Pádraig McGarry

Yes, it should.

Deputy Durkan is next.

I get more and more confused as time goes on. I am not sure if that is as a result of my hair going white or if I am missing something. I have tabled numerous questions to various Ministers about the cost of our health services and the adequacy of the annual budget to meet the requirements throughout the country each year. I have always been assured that adequate provision has been made but every year, without fail, a Supplementary Estimate has been required to meet the budget overruns. Two things happen at Estimates time.

Each Department must supply its requirements, whatever they are. This entails an evaluation of what is being delivered, how it is going to be delivered and how it was delivered last year. For some unknown reason, we do not seem to be working in the health services. We do not seem to be connecting. This year will have the lowest overrun in several years by the end of the year but I remember having the same problem when I was on the health board. We had the same problem during the boom. We have had a continuous problem. Nobody can tell me what the actual requirement in the delivery of health services is in financial terms.

Reference has been made to the operation of the delivery of the services. The Sláintecare programme was supposed to do that. That is the prototype and we have been told that it will deliver. The witnesses' colleagues appeared before us last week. Their opening statement was that politics should be taken out of the health service. Mind you, they were quite political themselves when they elucidated further and there will be another debate on that as well. I asked a question and was not given an answer. What is the cost of delivering? What more is required in terms of budget? Is it €5 billion, €10 billion or 30% of the existing budget? It would appear to be that. If it is 30% of the existing budget, I am afraid we are in the wrong place because the HSE appeared before us some time ago and told us that with regard to all appointments of consultants, GPs and specialists of all descriptions, it must compete with New York, London and Sydney. New York, London and Sydney have not been through the kind of economic crash we have been through by a long shot.

The question arises as to what we do. Can the witnesses tell us, based on their involvement inside the system, what percentage of an increase in the health budget is required and to whom do we give it to get delivery of the services that are now required? We have an increased population but that is not the only problem. We have an increased number of taxpayers as well. We also have an increased number of young people. The ageing cohort is referred to all the time as being the reason for the problems we have. This is not entirely accurate for the simple reason that a significant number of people who have come into this country in the past five years are young people so it is not all tilting towards the elderly. This is balanced by a young population. Based on their knowledge of the system, can the witnesses quantify what is needed? Reference has been made by my colleague to OECD countries and charges levelled at us at all times, and we are only members of this committee, to the effect that we are the third or fourth highest spender on health in the OECD so what is going wrong?

During the boom, things were better, although I am not sure, but the country was broke. We can very easily go back to that spot and it could happen overnight because trends can emerge very quickly, the budgetary situation can go wrong overnight and we are back to square one and will do the same thing again in ten years time because there will be more cuts. We all hear the witnesses with regard to what happened in 2012. The alternative was not going to be nice. Everybody everywhere would have been let go. There was no money to pay anybody. Pensions and all the rest of it would have been cut. There were cuts at that time that were harsh. I assure the witnesses from a Government perspective that these cuts were very difficult to sell but they were the lesser of two evils because the alternative was everything collapsing in which case we would not be here at all. What is required to be spent to deliver a comprehensive health service? Could the witnesses tell us whether they think we should have to compete with New York, London, Boston and Sydney for consultants? I have a follow-up question. Does the Chairman want me to put it now?

No, we will get an answer to the Deputy's question.

Dr. Matthew Sadlier

The points raised by the Deputy were very wide ranging. I will address his question about the cuts to salaries in 2012. The Deputy is right. We were in a financial crisis but we imposed a 30% cut on new entrants. The day that was introduced, it saved zero money for the country because there were no new entrants. Within the first year, it saved a tiny amount of money because savings are only made when people are appointed. The argument that this cut did anything to help the financial status of the country at the time of the crisis does not make sense because it was imposed on staff who had not even started working in the service. Agency fees are way beyond what we would pay if we just paid the doctors the salaries that were agreed.

I go back to my experience of working in the health service. The Hanly report was published within a year of two of my graduation. Ultimately, the question of how much the health service will cost to run is a political one because it depends on what sort of health service we want. Do we want small hospitals around the country or do we want all the hospitals to be in one big city? The Hanly report spoke about cost savings and economies of scale of moving to large centres. The question arises as to what sort of health service one wants from a political perspective. One must then cost how much it will cost to deliver that health service. We keep making comparisons with other European countries but they run their health services very differently. One could argue, probably correctly, that certain European countries have very urbanised populations, do not have the low population density we have on the west coast, can run larger hospitals and have economies of scale. However, ultimately, once we have worked out what sort of health service we want to deliver, we must then work out the cost of delivering that.

Dr. Pádraig McGarry

With regard to what Dr. Sadlier highlighted, namely, the type of health service we want, by and large, the vast majority of the costs in general practice are taken up by GPs so if we say that we will have a general practice service that is fully funded by the State, the actual amount required is exponentially more than what is currently there. As Dr. Sadlier said, what service model are we going to go for because that is not clear? If the Government decided tomorrow that it was going to run a fully State-funded general practice service, I do not think the State could not afford it. I have certainly not seen any appetite for going in that direction within the HSE. However, we hear from other sections that this is where we need to go if we are to implement Sláintecare. Deputy Durkan asked a question to which, unfortunately, there is probably no straight answer. We are not prevaricating. There are a lot of variables that do not allow us to give a straight answer to that question.

Ms Vanessa Hetherington

It is wrong to say that the ageing population is not having an impact on the system. The demographics show that we have an ageing population. While not all elderly people are sick, they do represent 50% of the expenditure on our system. The elderly population is growing rapidly and funding is not keeping up with it. We are constantly playing catch up year after year so it is very difficult to say exactly what funding is needed. Based on the current model, we would be trying to catch up with current waiting lists and the increased demand on emergency services and GP care so there is a lot but we need to look at what model we want and what investment we need and we need capital investment, something we have been very short of for the past number of years.

Mr. Anthony Owens

Deputy Durkan asked whether we are competing with the likes of New York, London, Sydney, etc., for medical talent.

We are competing with those places. In addition, we are competing with Toronto, Calgary, Perth, Brisbane, Melbourne and all of these places, including sites across the UK. To the extent that we are competing with them, when we think about the salaries on offer, the working hours and the access to study time, training time and supports, we are not competing on the same level. It is the same level as the match last night. Ireland were playing against Switzerland but we were never in danger of winning. That is us. We are losing our young doctors to these places at the moment.

There is something missing. While this is not a reflection on anything that Mr. Owens has said, there is something wrong. We educate to a high standard and we export our graduates afterwards. Do the graduates feel they have any sort of moral responsibility to give the first year or second year to their native country? Would that help? Would it be of any benefit if they stayed for a specified period? I do not know.

Those delivering at the coalface in the health services should be able to give us some indication as to how much money is required to provide the service. This is notwithstanding the fact that, before and during the boom, we had waiting lists and we still have them. The witnesses say they are growing but if we are exporting our medical professionals, they are going to grow.

Incidentally, the way we operate, there are backlogs everywhere and waiting lists for almost everything. This has been the case for years and we have become accustomed to it. That is the culture. It is a misleading culture and it is damaging to the system, in particular to confidence in the system. We start off with long waiting lists of hundreds or thousands. When do we expect to overhaul them? It can never happen unless we have a doubling of the expenditure on health for X number of years. Do the witnesses think that is possible? I do not think it is.

To return to the first point, the population is aging but people are now working longer than they ever did before, and they have to do that because of changes in legislation, which were necessary. However, everybody avoids the cohort of new people who have come into the country, of whom there are a very large number. I am sure they are as healthy as the now aging population were when they were younger. Therefore, there is a missing part to the explanation and we are not getting it. I do not know if the witnesses are in a position to be able to give us that information. However, if we are talking about a 30% increase in the health budget, we are talking about €5 billion in a year. I do not think that kind of thing is going to happen, or not easily and not quickly, so we have to find another method. We are still stuck with the allegation that we are paying more for the service than most other OECD countries.

There are places in Australia - the outback, for example - where it is fairly expensive to deliver services over vast areas of territory but people get a service, and it is the same in parts of the United States and in Canada, which are massive countries. This economic notion that has been brought forward over the years, that we will build bigger hospitals in high population locations and will forget about the rest, does not stand up anywhere else except in this country.

Dr. Matthew Sadlier

There are a number of points and I will address two of them. The first is that idea of tying medical graduates to remaining in the country for a period of time and whether that would help our system. The answer is that it is very unlikely to help. In their first years after graduation, medical graduates are in training towards specialisms. If we were able to provide the adequate specialist training, people would not leave.

We might be able to do that if they were to remain here to provide a better quality of service.

Dr. Matthew Sadlier

We have to be able to provide a better quality of training for the doctors in order for them to get the experience and the training they need to develop the skills and qualifications they need to become specialists in order to deliver the service back to the people. That takes investment in medical education and investment in making sure we are compliant with the European working time directive, which we know we are not. It takes investment to get protected training time for trainees and to get access to the correct equipment and resources, and also to have the required posts available in all the various specialties.

Ultimately, Ireland is a small country. Nobody has ever won a Nobel prize in medicine for research done in Ireland. We will always be dependent on a certain cohort of doctors going abroad to learn new skills and new innovations because we are not a country that produces new innovations in surgical techniques or medical techniques, largely due to our size. We will always depend on doctors going abroad to train and then bring skills home, and that is a fairly logical proposition.

If we were able to provide adequate working conditions for junior doctors, similar to what they get when they move to Australia or Canada, and to provide the adequate training opportunities they get in those countries, I do not think we would be talking about doctors leaving this country in any way, shape or form.

Dr. Pádraig McGarry

With regard to retention, the question is whether to take the carrot or stick approach. In regard to general practice, a good percentage of those who complete graduate entry medicine tend to go towards general practice, and those groupings tend to bring a considerable loan with them after they qualify. Unfortunately, the terms and conditions do not offer the realistic ability to repay debts in a timely fashion so they tend to go abroad to try to mitigate that. We have suggested for those groupings which have taken on board such loans to get through medicine, and who enter into general practice, that perhaps some sort of tax rebate could be considered because they would then stay in the country, earn money in the country and provide the service. Carrot or stick - the question is which way to do it.

Unfortunately, as we all know, and we do not have to reiterate over and over again, it is not a great environment to work in. This is a legacy issue and it will take time to wash out. However, if we can provide some incentives for people to stay, rather than trying to press-gang them into staying, we might get a better return.

I have some students from UCC as my guests. I hope the witnesses' replies will not be too negative or the students might find they have to leave the country because we are getting too negative here about a lot of things.

I want to refer to Medical Council figures. I am intrigued by how we are commenting on medical practitioners in this country. My reading of the Medical Council figures is that, five years ago, there were 19,046 medical practitioners on the Medical Council register, and the latest figures for 2018 show there are 22,996, which is a 20.72% increase. I am intrigued because all of the media focus seems to be about the shortage of doctors yet there has been a 20% increase in the number working here, or who are on the medical register, most of whom I presume are working here. For instance, the number of junior doctors has increased quite substantially in the hospitals because of the working time directive but no one is talking about that. Much of what is being said is very negative and one negative creates a second negative. I am concerned about the negativity in regard to recruitment. I accept there are issues in regard to some of the doctors coming in, such as those relating to their previous training and experience, which I fully understand.

The second issue relates to consultants. I would like clarification on the number of consultant posts five years ago and the number now. Taking the number of consultant posts now, how many are occupied permanently and how many are occupied by agency or locum consultants?

My understanding is that five years ago, approximately 2,500 permanent consultants were working in the system but that number is now approximately 3,000 while another 500 posts remain unfilled.

We can go back 20 years regarding recruitment as there was a system in place where a consultant was reaching the age of 64 or 65. It was flagged within the hospital system that it needed to plan to replace that person, organise advertising and ensure somebody would be committed to taking up the job when the consultant retired. That all seems to have collapsed as the process was absorbed into the HSE. It is astonishing that positions after being advertised after a person has retired. This relates to agency and locum staff as the people who have retired may have to come back to act as a locum. Has the IMO approached the HSE about fast-tracking the process and planning? There is a lack of planning within the HSE with respect to the recruitment of consultants, which is adding to the overall problem.

Agency and locum staff cost three times as much as employing someone on a contract. I disagreed at the time with the 30% reduction that has been mentioned. I did a report in 2012 about graduates from that year. We interviewed them across all universities. A total of 60% indicated that they would leave Ireland within 12 months once the intern year was done. That report was done in addition to a report by the health committee but I am astonished there was no take-up on it by the HSE with respect to forward planning.

Retaining junior doctors is a major issue. Allowances were cut back so what has been restored? This is not about salary or anything else but rather simple elements such as days allowed for study. How much progress has been made in restoring what they had previously? What more could we be doing to make it attractive for junior doctors to stay here? We are not doing enough about that and the HSE's approach is not correct either. The approach from certain elements of HSE management is to tolerate junior doctors but if the position was made more attractive than in other jurisdictions through the provision of allowances and study leave, we would have a greater chance of retaining them in the system. What simple measures could be taken? There would not be a major cost. There are more than 6,000 junior doctors in the hospital system and many of them want to study in various other areas.

I raised a matter with the Medical Council last week about doctors dropping out of the system and I was a bit taken aback by the response. I was speaking to a medical practitioner recently about two people doing obstetrics and gynaecology. One had done nine years of training and the other had done six years. They have now dropped out and returned to GP training. I am not saying the GP system is easier but there is not the same level of stress. We discussed adverse events and the lack of support within the hospital system for doctors and nursing staff. I have heard about nursing staff facing an inquest without being given any support before or after the hearing. It is not that anybody did something wrong but that the experience is traumatic.

There are 135,000 people working for the HSE and the number of whole-time equivalents has increased across the board, including nurses, doctors, administration and management. I have a major issue with administration and management. That means an additional 16,000 whole-time equivalents are working in the HSE compared to December 2014, which is a 17% increase. I am surprised by the lack of challenge from the medical organisations to the disproportionate increase in administration and management compared with medical practitioners and nursing staff. I had to extract this information over a period. I am very much ploughing a lone furrow on this. There was a 24% increase in administration and management but an 11% increase in front-line nursing staff. I am a bit concerned as we need to have a bit more joined-up thinking across the board but there must be a challenge from within the system as well as outside.

There are at least six questions.

Dr. Pádraig McGarry

I was going to commend the committee on the new format where there is a question and answer but we seem to have slipped back to multiple questions. It can be a bit confusing. There was one about Medical Council numbers and Ms Hetherington can address it.

Ms Vanessa Hetherington

The Senator is correct as there has been an increase in the number of registered doctors and a great increase in the number of doctors who have come from abroad to work in the system. That now represents 40% of our population. We are in contravention of WHO guidelines on ethical recruitment of healthcare professionals by recruiting doctors from developing countries where doctors are needed more urgently. Doctors traditionally come here to get experience and training but they are not even being offered those opportunities in the system. We can see them leaving again for fear of becoming deskilled or disillusioned with the opportunities in the system. It is a very transient figure.

We must examine the figures on the Medical Council register in depth. For example, 70% of doctors are working in Ireland only and many of them could remain on the register here but they have emigrated. A cohort of doctors also has come in and out as locums. We need to delve into those numbers a little further.

There has been an increase in the number of doctors.

Ms Vanessa Hetherington

Absolutely, but we must-----

The media impression is that fewer doctors are working in Ireland, and that is not correct.

Ms Vanessa Hetherington

They are not consultants. The goal since the publication of the Hanly report has been to move to a consultant-delivered service.

Ms Vanessa Hetherington

That would achieve economies to the health service. We know that in a consultant-delivered service, decisions are made more quickly, outcomes are better and there would be a reduced length of stay in hospitals. All sorts of statistics exist for a consultant-delivered service but we continue to bring doctors into service posts rather than increasing the number of consultants we have in the system.

The number of consultants-----

The Senator has asked six questions so we must get through that list. There was a question on proactive replacement of consultants.

Mr. Anthony Owens

There is a policy in place in the HSE entitled, Towards Successful Consultant Recruitment, Appointment and Retention. It should do exactly as it says on the tin. We met representatives of the HSE and discuss this policy and one of the recommendations in the report was to identify somebody reaching 64 years old and begin the process of replacing the consultant as it takes approximately a year to do it. We did not agree with everything they wanted but we had no problem with that. If it is not being done, I am at a loss as to tell the Senator the reason. There is a policy in place that allows it to be done.

I do not understand why a system working 20 years ago-----

We can continue through the list of questions. There was a question relating to making conditions more attractive for NCHDs.

Mr. Anthony Owens

The Senator said one of the key aims should be to keep doctors here and I hope we are not frightening his friends from UCC. There is also the question of restoring allowances and making work more attractive.

When we talk to non-consultant hospital doctors, NCHDs, typically, they tell us the issues are working hours, access to protected training time, support for training and training funding, family-friendly policies and reasonable working hours. Those are the non-salary issues that would incentivise doctors to stay in Ireland. As Dr. Sadlier said, if we were training people comprehensively, they would not leave Ireland. They are going, in part, because they are not getting the training here that they need.

In that regard, we recently agreed with the HSE a programme called the training support scheme, TSS, which will put a figure of approximately €10 million per annum behind NCHD training. It is applicable to all NCHDs regardless of whether they are on training schemes.

The Senator mentioned allowances. That arose from a High Court case on the living out allowance, which was abolished. That scheme is up and running now. It is not a silver bullet in that it will not make everything as it ought to be but it will help. The scheme is currently in place and we did much work with the HSE to get it in place. It was money we had to get and put behind training.

There are many measures we can take to do with working hours and, for example, family-friendly policies. Some people on training schemes are sent all around the country. They may have a spouse who is based primarily in one location while they travel around the country in pursuit of their training. Two doctors may be in a relationship and one is sent to one end of the country by a training programme and someone is sent to the other end by a training programme. These are the issues we should be thinking about resolving. They are not easy to resolve but it should be done.

Does Mr. Owens have a list of additional measures that should be put in place that are not in place now? Could we get that into the-----

Mr. Anthony Owens

We set it out in Dr. McGarry's statement, but I would be happy to expand on that.

I would appreciate that because I believe it is needed.

There was also the question of people dropping out of medicine or changing from one discipline to another.

It is the issue about adverse outcomes and the lack of back-up support.

Dr. Matthew Sadlier

That is a very easy question to answer; there should be support. Like any workforce, the HSE should be supporting its own workforce and it should have a system of welfare in place for doctors, nurses and allied health professionals. The managers and administrators often get involved in some of these cases also. It is an easy question to answer but it is probably a more difficult service to design and implement. There should be support.

Regarding the HSE having 135,000 staff members but a disproportionate increase in non-front-line staff.

Dr. Matthew Sadlier

The administration and non-front-line staff I work with are very dedicated and caring towards the service functioning. Every health service needs its support staff. I presume many reports have been done on who is in place and who is working. It is better to have an overall planning procedure in place in the HSE but we have already discussed whether that is present. One of the other witnesses might comment on that.

Mr. Anthony Owens

The voluntary retirement schemes, which were brought in by the HSE at the start of the financial downturn, were aimed primarily at clerical, administration and management supports. I suspect it is probably trying to get back to where it was from that point of view. We have been clear that we believe it should hire many more doctors but I would not say they should not hire other professionals across the system. The system needs to be built up. It would ill-behoves us to say we should not hire more people across the system.

I do not want to imply that we should not hire more staff. For instance, in terms of public health nurses, we are talking about expanding primary care but the number of public health nurses employed increased in the same period by 3.7%. I agree there must be an increase in administration management at all times but my problem is the disproportionate increase in some areas when there are other areas that need to increase their numbers. My concern is that that is not happening.

Dr. Pádraig McGarry

Without stating the obvious, is that not a political decision?

These are decisions supported by the HSE.

I thank Dr. McGarry. Senator Burke has made his point.

Regarding manpower, which is the subject of our meeting, to what extent are the gaps in manpower leading to the increase in waiting lists? Last week, we heard from witnesses from the Irish Hospital Consultants Association. They spoke about the added value a permanent member of staff brings to a department or practice in that they deliver their service and training but they are also involved in research and developing that department or practice. Not having a permanent member of staff in a department must diminish it. There is no added value to an agency locum. Dr. Sadlier might address on that.

Deputy Donnelly asked about the amount of money it takes to run the system. What is the level of inefficiency in the system currently that is leading to a waste of resources?

Regarding general practice, there is a maxim that for every euro invested in general practice, €5 will be saved in secondary services because secondary services will not have to be sought if there is a properly-resourced and funded primary care service. Dr. Sadlier might respond to those questions.

Dr. Matthew Sadlier

I will address the first two questions. On the added value of an agency locum, I do not want to be disrespectful to my colleagues. There is a value in having agency doctors who, on the whole, are very well trained and very well qualified medical practitioners. It is better to have a doctor in the post than not have one in the post but I have experience of a service where we have not been able to fill a post permanently for a number of years. Somebody will come in on a three-month contract but they cannot work beyond that because they have other commitments elsewhere. It is very difficult, therefore, to plan whether to book patients for the three months following that contract. We then get a backlog of referrals which are put to the side. If we manage to get the post filled, those patients go on the waiting list and so on. It is absolutely the case that the uncertainty in terms of being able to plan and run the service leads to a backlog in the waiting lists.

Specifically in psychiatry, where we may have community psychiatry departments with one or perhaps two consultants covering a small area, if there is a gap or absence in that area referrals become completely backlogged. We have seen that in child psychiatry services across the country, specifically outside the major urban areas. There are waiting lists in the major urban areas also but we have major problems with waiting lists outside those areas. They are services that had a small number of practitioners and if one is missing out of a team of three, the service is down by 33% but if one is missing out of a team of one, there is a 100% deficit.

On the issue of inefficiencies, I have said in this room on more than one occasion that it is to do with electronic patient records. If the Chairman asked me during the Sláintecare hearings or hearings on whatever the report was before Sláintecare, as a person working on the ground, the biggest difference that could be made to the Irish healthcare service, it is not Sláintecare or any of that. It is whether we can have an information management system that is not based in the 1990s. One could walk into an Irish hospital in 1890 and walk into one now and one would have the same information management system. Our outpatients records are paper-based. We receive letters, names have to be written into a diary, which is transcribed into another diary. One of the reasons for the delay when a patient comes into the emergency department is because it takes six hours to get that patient's charts from medical records. I work in north Dublin. For various reasons, people might go to Connolly hospital or might end up in the emergency department in the Mater hospital and to get their records from one hospital to the other we would need to hire the Secret Service. From my perspective, if there was anything that could be done to improve the efficiency of the medical service in this country it would be to have a proper information management system. That would definitely improve the efficiency of our service.

Dr. Pádraig McGarry

I have a comment on the electronic records. Part of the negotiations for the reversals of the financial emergency measures in the public interest, FEMPI, was that very issue. We have agreed that summary care records of patients should be available for hospitals, outpatients or whatever. In other words, where a patient turns up at an accident and emergency department or an outpatients' department, access to the medical record - the summary records on medications and allergies - including a set amount of information is available to the doctors attending him or her. That will bring significant efficiencies. That is expected to be expanded into an electronic record whereby everybody could be able to access a certain amount of necessary and relevant information. That will bring forward a significant benefit but, as Dr. Sadlier pointed out, the hospital system needs to catch up.

Mr. Anthony Owens

The Chairman asked about the value added by a permanent consultant staff member. Our consultants are very highly trained, very highly specialised and very highly sought after across the world but we sometimes forget that they are also trainers. They are developing the next generation of consultants. If we do not have people in the posts now developing the next generation of consultants, we are simply storing up another set of problems, which will manifest themselves when we do not have the people coming through. One reason we are losing the non-consultant hospital doctors, NCHDs, which we have discussed quite a bit today, is the difficulty in getting high-quality training in an overwhelmingly service-driven environment.

Dr. Pádraig McGarry

On the question the Chairman asked about investment in general practice, as the Chairman stated, it is quite clear that a euro invested brings a fivefold return into the secondary care. Certainly, that was one issue we always have had in mind when we went to discuss chronic disease management within the negotiations. I am glad to see that movement has come on that, whereby we have an agreed set approach to managing patients who probably are more appropriately to be seen in general practice as opposed to secondary care. There has been investment in chronic disease management, which will roll over the next number of years. It is expected that should be ready in January but that will depend on a functioning IT system at that time. The Chairman will be aware that will bring great benefits to patients.

Further investment is needed as not only does one need chronic disease management, one needs the allied services such as the public health nurses, the practice nurses, the dietitians etc. who will be able to make that function. That certainly is in the plan. Hopefully, it will be acted on. The Chairman touched on it earlier in reference to access to diagnostics. If it can be done in general practice at an appropriate level, of course that will be efficient and give pay back.

I thank Dr. McGarry. We have 15 minutes before we must vacate this room. We will allow the members who have stayed diligently throughout the meeting five minutes each before we wrap up.

It was a long time to wait for five minutes.

We must allow the next committee in. Otherwise, I could get into trouble.

Do not mind the next committee. We will be brief. I have many questions. I will ask them quickly and if the witnesses can answer them quickly, we will move through them as fast as we can in five minutes.

NCHDs and consultants have stated repeatedly how poor the working practices are. I fully agree and I fully accept that. It begs the question as to why. The other healthcare systems where our doctors go have sorted this out. Other parts of the public system in Ireland can be great places to work and there is a bunch of good companies in Ireland which are fantastic places to work. It begs the question, why, in the modern age? Do the witnesses have a sense for what is wrong with our system? What is wrong with our hospitals? What is wrong with the HSE that it allows this toxic work environment to continue?

Dr. Matthew Sadlier

The short answer is numbers. At the Deputy can see, the number of specialists per head of population is quite small. Invariably, one works in small teams, which means that one is running to catch up on the service demands of the post and the training demands of the post get put into second place. On the NCHD question, the ability to have protected time to engage in training, both as a consultant as a trainer or as an NCHD as a trainee, is a difficulty. As for how that has evolved, as we talked about, there has been chronic underfunding for many years.

I was surprised at the IMO's opposition to the National Treatment Purchase Fund, NTPF, in that GP are private sector employees and the NTPF is actually for public and private hospitals. The €50 million last year got 21,000 procedures done. That €50 million comprises 0.33% of the health budget. For 0.33% of the health budget, 21,000 people, who would still be waiting today, got seen. The IMO cannot be ideologically opposed to it because it represents GPs, who are private sector workers. Given that for a relatively small amount of money tens of thousands of people are being treated, what is the IMO's opposition to it?

Ms Vanessa Hetherington

We have a number of national clinical programmes, including the clinical programme for elective surgery. If we invested in that with the staffing necessary to deliver on that programme, we would not need to be purchasing care from the private sector. One is robbing Peter to pay Paul. One is investing in a private sector and yet not funding what one has in the public system to deliver those services.

Is one robbing Peter to pay Paul if one pays a GP, because there are GPs who work in the public system as well? Is one doing something intrinsically wrong?

Dr. Pádraig McGarry

But one is not paying them on the double. One is already invested in staff in the public system to carry out-----

The NTPF is not paying on the double. That is the point of it.

Dr. Pádraig McGarry

No, but one is paying a second time to get that done.

One is not paying a second time. One is paying once, which is why it is so effective. Anyway, we will move on.

On the IMO's solutions, I am delighted to see practical solutions to how we address this. One of the issues is new entrant pay inequality. Have talks started?

Dr. Pádraig McGarry

Not yet, but they are due to start soon.

Dr. Pádraig McGarry

Tomorrow, in fact.

That is soon. Are they concerned that there is no provision in the budget for any movement next year?

Mr. Anthony Owens

Yes. We will go into the talks anyway. We know what the talks need to produce. There should have been provision for it but the fact that there is not will not prevent us from entering into negotiations.

Have I time for a final question?

Great. I will put two together. The witnesses said we need to invest more in GP support and capacity. I fully agree. Could they give us the top one, two or three things that they would do?

I am really concerned by the issue they raised of insufficient specialist training posts. If that is the case, we are setting ourselves up to fail. It seems such a glaringly obvious thing to not get wrong. Why have we got that wrong?

Dr. Pádraig McGarry

In relation to general practice, and especially with the roll-out of chronic disease programmes, we see that there probably will be significant need for additional practice nurses. Unfortunately, we still do not have the resources within general practice to attract additional nurses into the system at present. We would be hopefully taking them from the HSE but, unfortunately, the perks that would be involved in normal employment within the HSE simply cannot be matched in the sector. We would like to see an additional resource supplied to provide that.

Second, the transition of general practitioners who are trained into full-time general practice and into being principals is a huge issue. Interestingly, the Irish College of General Practitioners, ICGP, indicates that up to 50% of trained GPs would see themselves as principals in a ten-year period but there is a sort of transition period in between. We would like to think a support, similar to the practice nurse support, could be brought in to bring those GPs into a practice, get their feet under the table, see what it is like and, hopefully, allow a smoother transition into general practice. One may solve some of the retention problems in that way. One needs to get them engaged first to see what it is like. We have that problem where they are just not getting engaged at this point in time.

Ms Vanessa Hetherington

On the issue of the higher specialist training posts, there is an absolute mismatch.

For example, we have a great shortage of psychiatrists. Although we have 60 people leaving basic specialist training, very few of them can get onto higher specialist training because there simply are not enough posts. Many of the approximately 30 posts that exist are being filled by people referred from previous years. Only six posts are left open this year to that cohort of 60 people leaving basic specialist training. There is, therefore, a great need to increase the number of higher specialist training posts.

I accept that. Seeing as this is such a glaringly obvious failure, however, why is it happening? It is deadly serious if we are not even training future consultants.

Dr. Matthew Sadlier

Several reasons explain why this is happening. The first aspect concerns the vacant consultant posts. Most college rules state that a trainer needs to be a permanent consultant. Consultants who are rotating might be there for the duration of training, but equally they might not. Extra supports are also needed for such posts, however. The problem is that our service is struggling to survive; it is running to keep up. The problem with a training post is that it requires a doctor to be engaged in non-service provision for a certain percentage of his or her week. That is especially the case in the higher specialist training, where the percentage might be as high as 20% to 30% of the week. That is a luxury that cannot be afforded when there are huge waiting lists.

All of this comes back to three major aspects. I refer to this being a numbers game, the difficulty with the recruitment of consultants and trainers and, as I mentioned at the start, the ongoing difficulty of Ireland's rapidly increasing population. That accounts for many of our problems in general. Some 64,000 people were added to the population last year and it will be similar next year. Our population has increased by 50% in just over 20 years. That is a great thing, but there is a requirement for the provision of the requisite extra infrastructure and services. The situation at the moment means that we can set our target figures for this year, but they will have shifted by the time of delivery.

I have to be fair to everybody, so I have to move on to Deputy O'Reilly.

Dr. Pádraig McGarry

I was going to expand on the three things.

Dr. McGarry might work his answers into his responses to the questions from Deputy O'Reilly and she might address a question to Dr. McGarry.

I will. Regarding the NTPF, we never agree on it over on this side of the House. We are not, however, necessarily talking about 21,000 procedures but 21,000 appointments. Not all of those appointments result in subsequent procedures and, indeed, I believe many do not. I have two questions. One concerns doctors and consultants working abroad. We know that the 30% pay cut, and the resulting disparity, is a barrier to those people returning home. This issue was not resolved in the budget. If it was to be settled, however, how far away are we from those doctors coming home? What is the lead-in time to that happening?

My second question is for Dr. McGarry and is on practice nurses and other staff working in primary care centres. He referenced the need for additional practice nurses. Would he see that increase happening in conjunction with an expanded role for those practice nurses, or would he simple see more practice nurses doing the same things they do now? We all agree that is a bit of everything and they do it very well.

Dr. Pádraig McGarry

I will deal with that issue because it might also address Deputy Donnelly's question. One of the absolutely necessary things mentioned is the advent of chronic disease management being brought into general practice. That is a more appropriate location and that is where one of the major roles for practice nurses will be, given the present set-up in those general practices. Many things can happen and it should never be carved in stone that someone does the same thing ad infinitum. If it is possible for some people to do different things, then so be it. It may be that an administrative assistant could be trained up to do various things such as phlebotomies, ECGs, etc. That would allow the practice nurse greater availability. I am not adverse to that idea at all. Provision has been made for more practice nurses in the context of chronic disease management. It has yet to be decided how that will be implemented. The intention exists, however, and it should be expanded. For the first time, the plan for chronic disease management sets in place the requirement that any additional work needs to be resourced. That has to be expanded upon. The other thing that needs to be done for general practice is the addressing of the inequity of the out-of-hours arrangements around the country. That needs to be addressed urgently. The Department commissioned its own report on this matter about two years ago, but it has never been released and nothing has happened. This issue presents a major barrier to people going into practices, especially in rural areas.

Dr. Matthew Sadlier

Reversing the consultant cut would benefit the service in three ways. The first and primary impact concerns junior doctors. A person coming out of medical school, after finishing his or her internship, may look at Irish consultant posts and think those are unattractive. That person is then almost forced to emigrate in order that he or she can plug into the training system of another country and be in line to get a permanent post there. One of the knock-on effects of the pay cut, therefore, was the emigration of doctors at the start of their careers. That was because taking up permanent consultancy posts in other countries may require extra exams and qualifications in that country. It depends on the location, but there can be slight differences in training and speciality. If the pay cut were reversed, therefore, we would see many more interns staying within the health service and taking up posts here.

Regarding the vacant consultant posts, many of them would be filled within 12 to 18 months. From my own friends, I know of four doctors working in Australia who are constantly in contact with me about when the situation will change. If they were to return, they would, of course, have to untangle themselves from their current posts abroad, given the needs of notice periods, advertising and recruitment. The current problems have pertained for seven years, though, so a waiting period of 12 to 18 months is not a bad result.

The immediate impact would be people not be leaving.

Dr. Matthew Sadlier

Medical jobs in Ireland usually run from July to July. Immediately after that cut was reversed, I guarantee that only about 40% of interns would leave instead of the current 70%. The 40% who leave, however, would also return to Ireland the year after. Some 70% of newly-qualified doctors leave at the moment and perhaps only some 20% come back.

Mr. Anthony Owens

The pay commission told us that after the pay cut was brought in October 2012, there was a collapse in the number of people applying for consultant posts. There was a slight increase from 2015 onwards, when the IMO negotiated a new-entrant pay scale. There was an increase from one person per post to two people, or thereabouts, per post. Those are the facts that we know. We can also surmise that the longer this situation continues, then the more people will put down roots abroad and may not come back. We need to get this process started, at the very least. As Dr. Sadlier said, there will then be a lead-in period involved in getting back the people we lost abroad and who we need back to Ireland.

I thank Mr. Owens and Deputy O'Reilly. I call Deputy Durkan for a short concluding question.

All of my interventions have been short. I am thinking again about what I learned over the years. One of those things was the argument about Ireland having too many hospital beds. We heard that argument being made until about five years ago. Every time we had a meeting anywhere, it stated that there were too many hospital beds. That was the lead-in to the notion that nobody wanted to be a consultant in a small hospital down the country. The idea was that they all wanted to be in a big urban centre in a hospital with all types of specialties. I can understand that because job satisfaction is important. How much of medicine now consists of a vocation? That used to be high on the agenda. There was a view that a particular type of person was suited to the role and would be committed to it.

We also had the district hospital doctor, who was perhaps the second or third generation working in the same hospital and taking personal pride in his own patch. I believe that has shifted now and it is more of a job. The same thing happened in the local authorities, an area we know well, where the county manager was a permanent fixture. The manager took full responsibility and pride in delivering to what he or she saw as his or her patch. That is gone now because it is now a contract. The same pride is not carried with it because it is a job. It is a route towards promotion somewhere else. I am not suggesting that I know more about this than the IMO representatives, but I am deeply concerned about it. In medicine in particular there is a need to have that unique vocational commitment.

Three questions were put relating to the number of hospital beds, the vocation of medicine and finally the pride in the job, continuity of employment and continuity giving a better quality of service.

Dr. Pádraig McGarry

I am a general practitioner - I have been a GP for over 30 years. I do not think anyone could do this job without a vocational attitude. There is no such thing as watching the clock - it is a continuum. I do not see that has majorly changed. Perhaps people want to be a little more organised, but I do not see a lack of vocation in the job. People want more of a work-life balance. When a doctor is in front of a patient, he is dealing with the patient's problem there and then. That is how he deals with it. I do not think a doctor can switch on and off just like that. A person either has it or does not have it. I do not see any change in the new doctors coming out in that regard. That is what I can see.

The next question was about the number of hospital beds.

Dr. Matthew Sadlier

The number of hospital beds is related to the population. The population is expanding so our need for beds is expanding.

I wish to come back to the core issue about vocation. I would not consider myself old but there has been considerable change from the time I graduated in 1999 to now. If a person had a stroke and came into a hospital 20 years ago, when I graduated, things were different compared to now. The possibilities now include thrombolysis or trying to melt the clot and restore the blood supply to the affected part of the brain so that the patient has a limited deficit from the stroke. If a person had a heart attack when I qualified the management of those procedures was markedly different. In the first days, it was pain relief and then into cardiac care and hope for the best. Nowadays, a patient can have angioplasty or have the clot removed. The damage to a patient's heart muscle can be minimised.

I am unsure whether the county manager job in the past 20 years has moved with the technical changes we have seen in medicine during the past 20 years. That has led to a difference. I agree 100% that this has had to lead to a difference in how doctors work. We have had to become a little more specialised. We have had to become more specialised towards individual skills and procedures. If I was a patient and had someone sticking a needle into my groin that would go all the way into one of the arteries in my heart, I certainly would want someone who was doing that procedure every day of the week, and not a general county physician who was doing it every third Tuesday. The difference in medicine in recent years has been phenomenal in terms of the benefits we can give to patients. The treatment survival rates in cancer care, cardiovascular disease and stroke have been phenomenal. We want everyone in the country to benefit from those technical changes. They should be available not based on where a person lives but available to everyone in the country.

Thank you, Dr. Sadlier. The other question related to continuity of care and having people in the post long-term.

Dr. Pádraig McGarry

Certainly, the essence of general practice is continuity of care. That is what is seen as the best outcome. In fact, the independent practitioner model has that continuity of care and that is probably the most favoured. We see it being fragmented perhaps where corporates are entering the scene. We may well have doctors coming in for a transient phase and we lose that continuity of care. In recent years, because of the way general practice has been allowed to come under threat there has been a vacuum. Corporates have come in and filled that vacuum. There is a serious danger with that type of model. Whereas it serves a purpose, it certainly will not go across the board. It certainly will not go into rural Ireland or into the smaller deprived areas. It will cherry-pick particular areas. Continuity of care will be lost under that type of model.

We need to support the independent practitioner model, including the doctor who works for 30 or 40 years. You understand that only too well, Chairman, because you have been in that role. I am unsure whether it should be passed from generation to generation, but people tend to follow in that regard. Children of gardaí become gardaí, children of publicans become publicans and children of farmers become farmers. Children of doctors tend to understand what is involved, especially in general practice. This is because, by and large, the practice is in the house so the family know what is involved. That was certainly the case in my house. Then, when someone from the next generation goes into it, he understands what is involved and has bought into it. It becomes part of the DNA. Things evolve, as Dr. Sadlier said, and nothing stands still but I believe we have to be careful not to throw the baby out with the bathwater.

Thank you, Dr. McGarry. The final comment before we conclude is with Mr. Anthony Owens.

Mr. Anthony Owens

I thank the Deputy for his question. I will go back to the idea of vocation. I work a good deal with non-consultant hospital doctors, who are doctors in training. They are the next generation of consultants and GPs and so on. A series of issues arise for them year after year, including long working hours, lack of access to training time and lack of family-friendly policies. Their working hours often require them to stay very late at very short notice, but it has to be done. Oftentimes, they do not even get paid when they stay late. Then, we get involved in a protracted row with the hospital and eventually get them paid. Eventually, we might get them paid one year later. I do not know about vocation, but as far as I am concerned it is a wonder we do not lose more of them.

Thank you very much, Mr. Owens. On behalf of the Joint Committee on Health, my thanks go to Mr. Anthony Owens, Dr. Sadlier, Dr. McGarry and Ms Vanessa Hetherington for giving evidence today. We will have several other meetings on medical manpower, discussing not only doctors but nurses and allied professionals as well. We hope to produce a report at the end of it.

The joint committee adjourned at 1.50 p.m. until 9 a.m. on Wednesday, 23 October 2019.