I thank the Chair and committee members for the invitation. Doctors go into work each and every day with the objective of doing the job for which they have trained and to give their patients the best possible treatment. Unfortunately, the system in which they work does not enable them to meet that objective and, in many cases, actually puts in place obstacles that stop them meeting it. Ultimately, this has a negative effect on both patients and doctors.
The consistent narrative of record levels of health budgets and additional numbers of staff employed in the health services masks the reality of the demands on the health service and the deficits in funding for well over a decade. While the health service, like all public services, must provide value for money, it must be funded, in the first instance, appropriately to meet the needs of a growing and ageing population, and that is simply not the case currently.
Population growth and living longer are to be celebrated and supported, but it must be recognised that they have an impact on our health services as more patients seek care. That care is more complex and very often more expensive. Our health service has not matched that population growth in terms of physical capacity or increasing the workforce to the numbers required to meet the demand. The mantra of doing more with less and the call on healthcare staff to do better in the absence of appropriate funding are both insulting and demoralising.
Decades of underfunding in capacity, poor policy decisions around recruitment and retention and a lack of a coherent workforce plan have led to a system that is struggling to deliver care in a timely manner.
The provision of healthcare, if it is to be free at the point of entry for all citizens, has to be funded on the principle of demand and supply whereby we assess the healthcare needs of the population and supply the healthcare staff and facilities to meet those needs. Otherwise, we have to be honest with the population about what we cannot fund and what is available to them in terms of healthcare. These underlying systemic issues around capacity and recruitment are not theoretical issues. They have real-life consequences for patients, and for doctors, they are the background to the reality of their working lives every day.
There is no argument that decades of underfunding have led to a situation where we have too few acute hospital beds. In very many cases, this is the core of the problem. We need an additional 5,000 acute hospital beds over a relatively short period. This lack of bed capacity is most visible when it comes to the dangerous year-round levels of overcrowding in our emergency departments. The practice of boarding patients on trolleys - patients who have been deemed ill enough to be admitted - is dangerous for the patient and unsustainable for the staff working in emergency departments.
Ireland has a quoted hospital bed occupancy rate of in excess of 97%, which is in and of itself dangerous. However, the actual occupancy rate often exceeds 105% and, in some cases, goes beyond 110%. For the patients in emergency departments, this has an immediate effect in that they cannot get a bed when they need it. However, it also has a consequence for all other patients in the system who are awaiting elective or scheduled care and whose care is routinely cancelled due to a lack of bed capacity, leading to risk of poorer health outcomes.
Across a wide number of specialties, consultants are appointed, some to new posts and some to vacant posts. This is really welcome. However, very often, particularly with new appointments, they are not provided with the basic supports to enable them to do their job. It is not unusual for a consultant to be appointed with no administrative support, no medical team assigned on a permanent basis, no office, insufficient or no clinic times, insufficient or no theatre times and challenges in accessing diagnostics. It is important to know that a consultant does not operate independently. The consultants require the rest of the system to be in place to enable them.
Consultants are consistently battling in a highly bureaucratic system to get basic resources and are very often seen as cost centres, and judged as cost centres, rather than an asset that requires the support to enable them to see and treat patients. At the end of April 2024, there were 828,605 patients waiting on a National Treatment Purchase Fund, NTPF, waiting list. Almost 700,000 have yet to receive a date for their appointment or procedure. Even after patients receive their appointment, however, the inevitable next challenge is finding the resources to deliver the care they need whether that be admission, surgery, diagnostics or follow-up.
Rather than invest in our public hospitals and provide all the wraparound supports needed, the system will very often choose the alternative pathway of diverting those patients into the private system. Even when we take the capacity of the private and the public system, it is still not sufficient to meet the demand. We have been talking for more than a decade about bed capacity. There is no alternative. There is no sustainable or realistic alternative but to significantly ramp up investment in our public system. This is a choice for the political system. It is not okay to blame doctors or other people working in the health system for not being able to deliver care when they have not been provided with the resources to do so.
For both consultants and NCHDs, the failure to invest in capacity means that each and every day, they are fighting against the system to access care for their patients. They leave work feeling demoralised and frustrated. To compound matters, regular out-of-context reports are made by the employer or the political system around productivity levels, overtime payments and black holes of spending, all leading to a feeling that they are neither valued or respected. This, in turn, has led to very worrying levels of burnout among doctors. More than 80% of doctors are at very high risk of burnout. The most worrying part of this is our NCHDs, who are at the early stage of their careers and should not be experiencing burnout to the levels at which they are. That burnout is a direct consequence of the way in which they are being asked to work and the environment in which they have to work.
It is not necessarily higher incomes that drive emigration. Australia, Canada, North America, New Zealand and the UK are targeting Irish-trained doctors. They know what the problem is here, so they offer a solution for those doctors. They tell people come and work for them and they will have a work-life balance, be able to treat their patients and be able to thrive in this system. They absolutely know what the problems are and they know the solutions.
In terms of recruitment, it is ironic that we are speaking today about employment issues for doctors seven months into a recruitment embargo. It is inconceivable that such an embargo is in place at a time when we need more doctors, not less, and at a time when there is a global shortage of doctors. The message Ireland is sending out to the world is that we are not hiring.
For our NCHDs, the recruitment freeze has had a real day-to-day impact. There is an increase in Illegal and unsafe working hours, with 83% of NCHDs routinely working beyond 48 hours per week. This is illegal in terms of the Organisation of Working Time Act 1997. It is also unsafe for patients and it is a breach of contractual entitlements. This risk and illegality is embedded into the system. It has been accepted. We have threatened to strike. We have had three High Court actions and yet it is not a priority for the HSE to fulfill its legal obligations as an employer to not have people routinely work for more than 48 hours per week. It is unsafe for patients. We are introducing a level of risk to what is already a risk environment.
The day before the recruitment freeze was announced, the HSE advised the IMO that it would take targeted recruitment of up to 800 additional NCHDs to bring working hours to legal and safe levels. We left that meeting thinking there was a commitment to finally sorting this out. The next day, a recruitment embargo was announced. It is reported that 68% of NCHDs are not getting sufficient rest. They are working beyond ten consecutive days, very often without any compensatory pay or additional rest days in almost half of these cases. This is a contractual term that was brought in to reduce risk for the NCHDs and improve work-life balance. NCHDs are doctors in training. They are allowed a tiny amount of time - ten days study leave every six months - to undertake study and mandatory exams. In accountancy, for example, three months in any year is given to trainees. Figures show that 65% of NCHDs in the past year have not been able to take that study leave because of staff shortages, and 77% are pressurised to do extra shifts. This pressure is both overt and more subtle. It is not unusual for NCHDs to get a text to tell them not to let their colleagues down and do this extra shift. The NCHDs are being gaslit. They are being made to feel it is their fault and they must do something to provide extra shifts. Amazingly, the HSE cannot provide a guarantee that those NCHDs going on maternity cover will be replaced. Instead, what happens in most cases is that the rest of the team picks up all the extra on-call shifts, extra weekends and extra nights.
In 2022, an NCHD strike was averted. An agreement was reached between the IMO, the Department of Health and the HSE. The core principles of that agreement were around reducing working hours and making it safer for doctors to practice and safer for patients. On every single metric, the HSE has breached that agreement. I cannot stress enough that it is illegal. We do not allow airline pilots, taxi drivers, bus drivers or lorry drivers to work these hours. Yet, we think doctors in a high-risk environment should be working them.
Earlier this year, the Minister launched the report of the task force on NCHDs and while we welcome many of the recommendations therein, we need to see change now. We need to see good faith from the Government and the HSE that they will honour contractual entitlements. No one should be appearing before a health committee asking for their contract to be honoured. That should be a given. No one should be before the health committee asking the Government and the HSE to follow legislation. That should be a given. However, here we are again asking them please honour their contract entitlements. We are going into new contract talks on the coming weeks, but we are doing so in an environment where there is not good faith in how the employer will behave.
NCHDs are our future consultants. This is the group of doctors we are relying on to look after us all in the years ahead. Yet, 75% of them do not feel valued or respected by the employer. In any other industry, that would set off alarm bells. Key management people would be brought to answer as to how and why this was happening and what will be done to solve it. A workforce needs to be treated as an asset, not as a liability. There are almost 9,000 NCHDs in the public health system. In terms of those who are in service posts, that is, doctors who are not in approved training posts, 80% are from outside of Ireland.
These doctors, who have made Ireland their home and without whom the health system could not function, are not treated equitably in terms of career progression. They, too, leave the system disillusioned with working conditions and the lack of training and career opportunities. Irish Medical Council figures show that, on average, international doctors spend six years on the register. They are frequently here on critical skills permits or multi-site general employment permits, and while they have the opportunity to apply for their family to join them, that system is so protracted and difficult they can go up to a year without their family. We have actively recruited these doctors and we need them. We cannot afford them to leave and we want them to stay, yet we will not help them have their family with them. Working as an NCHD in a hospital is not an easy task and the idea you do not even have your family to go home to makes it worse.
While the number of consultants employed in the HSE has increased, we are coming from a really low base. The number of consultants employed still falls far below the number required for a consultant-delivered service. Ireland has one of the lowest consultant-patient ratios in the OECD. Of approximately 4,500 approved consultant posts, just 3,700 are filled on a permanent basis, yet we need 6,000 consultants to provide care to patients. In some specialties, including many of the surgical specialties and psychiatry, the number of consultants employed is up to 50% below the recommended levels. This leads to long waiting lists. The committee has examined CAMHS waiting lists. There is a rationale and it relates to beds and workforce. It will keep coming back to those core issues. We can come up with lots of things to make things better for a day or two but the core issues are beds and workforce requirement.
The new public-only consultant contract became effective in March 2023 and to date 2,229 consultants are on that contract; 470 of those are new appointments since March 2023 and the balance have transferred from existing contracts. The new contract provides for the Sláintecare objective of removing private practice from public hospitals and for rostering consultants over an extended working day and week. However, the new contract will not in and of itself solve the chronic problems in the health service regarding capacity and workforce requirements. It is not realistic to infer the health service will see tangible benefits if the same number of consultants are consistently rostered outside normal working hours. With the deficits in our workforce, there is no room for manoeuvre. There is no resilience in the system. We are adopting a policy of robbing Peter to pay Paul: “Come and work on a Saturday but you won’t be working on Monday, so therefore the clinic that was scheduled for Monday will not happen.” If we want the rosters to work as envisaged, we have to put in place all the staff, not just the consultants, and all the resources and services at the same time. We are miles from this and there is no point pretending otherwise.
Through the winter, the focus has been on discharges at weekends and consultants have been going in. That is unsustainable in the long term without recruiting a huge number of consultants. It is important to point out that, no matter what contract a consultant is on, whether the 2023 public-only contract or one of the existing contracts, every consultant has an on-call commitment. A consultant service is provided through the night and at weekends. Additionally, many consultants now have to provide cross-cover for colleagues for annual leave, sick leave – whether short or extended - and other absences as, in most instances, locums are not provided. The consultant is then taking on their colleague’s workload.
Covid exposed the fragility of our health service. There was nobody in the country who did not realise beds were a problem during Covid. Endless promises were made. We and other organisations came before this committee and the Covid committee and made submissions around the issue of beds. We asked and the Government promised to significantly ramp up investment in capacity in the workforce. Unfortunately, the level of investment is not matching demand and at best we are running to stand still. The budget allocation for the HSE this year is already overrun. We said at the time that budget would not be sufficient to allow the services to continue, let alone introduce new services. There are stark choices. There are solutions but it is a political choice as to whether those solutions will be adopted. There are no solutions that are free. Putting infrastructure and workforce into a health system is a significant investment for society but it brings benefits. Health needs less to be seen as a cost to the country and more as a benefit to enable the country in its economic journey and growth. We are happy to answer any questions and we thank the committee members for their time.
