JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 6 Oct 2011

Non-Consultant Hospital Doctors: Discussion

Chairman

Three groups are appearing before us today. The public session at last week's meeting when there was only one representative before the committee took two hours. Many members spoke for an inordinate amount of time. In order to make the best use of our time and maximise the coverage the committee receives, I appeal to members to restrict themselves to asking questions rather than making speeches. I will stop them after one minute and ask them to put a question. I will not stop anyone asking questions, but it is important to have a dialogue rather than a monologue. As Chairman, I spoke for only 13 minutes. It is important to have balance and give everyone an opportunity to speak. We should, therefore, restrict contributions to questions rather than Second Stage speeches, which is the pattern that has emerged. I ask for co-operation, as I am not looking for an adversarial approach between the Chairman and members. I want members to be succinct. Is that agreed? Agreed.

At this meeting we will deal with only one issue, the current concerns regarding the shortage of non-consultant hospital doctors; the recruitment, appointment, education and training of junior doctors, and the viability and appropriateness of reliance on junior doctors in staffing our hospitals. That is the sole item on the agenda and the only topic I will members to address; any other health matter can be dealt with at another meeting. The Chairman will not be in conflict with members who, to be fair, have been very co-operative. To date, meetings have run smoothly.

The order of speakers is as follows: the Minister for Health will speak first, followed by Mr. Seán McGrath, Professor Kieran Murphy, Deputies Kelleher, Ó Caoláin and Healy and then other members. I welcome the representatives of the Medical Council and the HSE, with the Minister and his officials. I now invite the Minister to make his opening remarks.

Minister for Health (Deputy James Reilly)

I am pleased to advise the committee that excellent progress has been made in filling vacant non-consultant hospital doctor posts over the past three months. It should be noted that this is being achieved against a background of a general shortage of NCHDs affecting western Europe. It is important that these vacancies are filled having regard to service needs and achieving compliance with the European working time directive.

As of 29 September, approximately ten NCHD posts of the 190 identified as vacant by the HSE before the recruitment of doctors from India and Pakistan remain vacant. The decision to recruit from abroad was made owing to an ongoing vacancy level of approximately 150 NCHDs and a significant number of additional vacancies anticipated in July 2011 arising from the cyclical rotation of posts. Some 259 NCHDs have been appointed from centralised recruitment and as of Thursday, 29 September, a further 231 doctors have been recruited in India and Pakistan for the July rotation.

Given the shortage of NCHDs over the past two years, the HSE developed a range of strategies and initiatives to maximise recruitment, including the development of a centralised recruitment process for service or non-training posts. All vacant service NCHD posts were advertised as professional development posts under two year contracts to one of the four HSE areas, with a minimum of six months in a regional centre and participation in a professional development scheme under the relevant postgraduate training body. Notwithstanding these measures, approximately 150 posts remained vacant and it was decided to undertake a recruitment campaign in India and Pakistan.

I introduced legislation on 8 July to amend the Medical Practitioners Act 2007 to facilitate the registration of these doctors, which allowed for the creation of a new supervised division on the medical register. Registration in the supervised division means that a person is registered for a period not exceeding two years in an identified post approved by the Medical Council and subject to supervision by the employer in line with criteria set down by the Medical Council.

The Medical Council then introduced new rules for the supervised division and, with co-operation from the medical schools and postgraduate training bodies, organised specialty specific examinations for the candidates. Some 236 candidates were successful and as of 29 September, 231 of these, to which I have alluded, have been registered on the supervised division. More will be registered in the coming days. Approximately 80 additional doctors are expected to sit further assessments for the supervised division and, if successful, will be offered employment.

These doctors are making significant contributions to vacancies which existed in areas such as anaesthetics, paediatrics, emergency medicine and general surgery, delivering a safe, effective service to patients. In addition, they are reducing the HSE reliance on agency staff, reducing overtime costs, improving the quality of the service and ensuring further compliance with the European working time directive.

The committee may be aware that the Commission issued a reasoned opinion on 29 September last concerning failure by Ireland to fully implement the European working time directive in respect of doctors in training, that is, NCHDs. Under Article 258 of the treaty, the Commission has invited Ireland to take the necessary measures to comply with this opinion within two months of receipt. The opinion states that while Irish law provides for limits to doctors' working time, in practice public hospitals often do not apply the rules to doctors in training or other non-consultant hospital doctors.

I am committed to achieving compliance at the earliest possible date and recognise that the working hours of NCHDs must be reduced and rest breaks granted in accordance with the provisions of the directive. Progress on compliance has been hindered given the shortage of NCHDs experienced over the past two years. It is also necessary to appreciate that the recent recruitment initiative will not in itself deliver European working time directive compliance. Compliance will require significant changes in the manner in which hospital services are organised and delivered, in particular in smaller hospitals where the numbers of NCHDs do not support European working time directive compliant rosters and to the manner in which hospitals rely on NCHDs.

At a more general level, I remind the committee that Government policy in regard to medical education and training in Ireland is guided primarily by the report of the undergraduate medical education and training group, the Fottrell report of 2006, and the report of the postgraduate medical education and training group, the Buttimer report of 2006. Both reports represented a significant review of medical education and training carried out in Ireland and made a series of comprehensive recommendations for its development and reform. The recommendations formed a multi-annual programme requiring implementation over a period of years leading to the successful reform of medical education in both the undergraduate and postgraduate sectors. They also provided a comprehensive evaluation of the provision of medical education and training and how it can best be delivered to prepare doctors in Ireland to meet the health needs of the 21st century.

Many of the significant recommendations of the Buttimer report on postgraduate medical education and training were implemented through the Medical Practitioners Act 2007. These include the assignment of appropriate medical education and training functions to the HSE and the Medical Council, better workforce planning by the HSE to align the number of doctors in training with projected consultant vacancies based on the staffing needs of the service, and the restructuring of the register of medical practitioners. A joint Department of Health and Department of Education and Skills interdepartmental policy steering group on medical education and training has responsibility for the ongoing development of strategy and policy on medical education and training and continues to co-ordinate and progress implementation of Government policy based on the recommendation of the Fottrell and Buttimer reports.

Officials of my Department and the Department of Education and Skills are currently reviewing the extent to which both reports have been implemented. My Department is assessing the adequacy of the current medical education and training work programme and overall direction in meeting the policy requirements and health sector service needs. Government policy in this area is that we should move from a consultant-led health service to a consultant delivered service. This would require a significant increase in the number of hospital consultants and a corresponding reduction in the current reliance on NCHDs. It will be appreciated, however, that the current economic climate will impact on the extent to which this can be achieved.

Against this background, and having regard to the recent shortage of NCHDs, I have asked my Department to develop proposals regarding the creation of a new associate specialist grade of non-consultant hospital doctor. In the UK, a specialty doctor grade has been established. Initially, these doctors deliver routine and emergency clinical care under the supervision of a consultant but with time take on more responsibility. Doctors at the top end of the grade work with only indirect supervision. At all levels, the specialty doctor is part of a team led by a consultant and takes part in all the activities of their specialty, including teaching students and junior doctors. It is not my intention that the specialist grade we would introduce would be exactly same. I want to give a clear assurance to people that these would be clinically autonomous individuals answerable not to the local consultant but to the clinical director and that it would be a progressive step towards becoming a full consultant and they would not, as some allege and others fear, be left in limbo and in this position for many years.

I acknowledge the co-operation and positive support of all parties in both Houses in regard to the legislation necessary to achieve these outcomes which have been a resounding success in regard to addressing the huge gap in the service requirements of our health service. I also thank all the doctors who came to this country and sat the examination. Most of them were successful and passed it but others were not and they will have the opportunity to re-sit it. I am sure the Medical Council will have something to say about that.

Mr. Seán McGrath

We have circulated a detailed brief to members. I would like to introduce Dr. Philip Crowley, who is the national director of clinical care and quality, and Professor Gerard Bury, who is head of medical education and training in the HSE. We will answer any questions members may have.

Professor Kieran Murphy

I would like to introduce Ms Caroline Spillane, who is the chief executive officer of the Medical Council. I am the president of the council.

On behalf of the Medical Council I welcome the opportunity to provide the committee with an overview of the role the Medical Council has played in the registration of NCHDs to address the acute shortage of junior doctors in HSE-run hospitals. I would like first to say a few brief words about the role of the Medical Council. This is very relevant in the context of a discussion about the registration of doctors. The Medical Council is the statutory body responsible for the regulation of doctors in Ireland. Our purpose is to protect the public by promoting and ensuring the highest standards among doctors. From the day a student first enters medical school until the day they retire from practice, the Medical Council works to ensure that medical education and training is up to date and in line with the highest international standards. The Medical Council sets standards at undergraduate and postgraduate levels and we have recently introduced professional competence requirements to ensure doctors keep their skills up to date throughout their professional lives.

While people tend to be most aware of our role in monitoring the standards of doctors and in the handling of complaints, our focus today is to discuss one of our primary functions, which is to maintain the register of doctors. Doctors must be registered with the Medical Council to practise medicine in Ireland. In the interests of patient safety and the protection of the public, the council has been vested by the Oireachtas with sole responsibility to ensure that only those doctors with the necessary education, training and skills are registered to practise safely in Ireland. At the end of 2010, there were almost 19,000 doctors registered with the Medical Council.

A key requirement before any doctor can be registered is the verification process our registration staff undertake. This confirms the identity of each application, ensures they meet the requisite standards of education and training and verifies that they have not been subject to either criminal or disciplinary proceedings in another country. In the case of doctors who did not train in Ireland or the European Economic Area, they must also undertake an examination specifically designed by the council to test doctors' clinical competence, which includes an assessment of their ability to communicate.

Turning specifically to the registration of the doctors recruited by the HSE in India and Pakistan to fill service gaps for the July rotation, I want to reassure the committee that the registration of these doctors was one of the Medical Council's top priorities this summer and we did everything possible to complete this process as efficiently as possible. When the HSE undertook its recruitment drive to India and Pakistan, the intention was to register the recruited doctors to the general division of the register. Registration to the general division requires the doctor to sit a pre-registration examination. This is a general examination across a range of specialties and is similar to the model of examination held in other jurisdictions. The examination is general in nature as once in the general division, the doctor can work in a range of settings, from non-consultant hospital doctor posts to unsupervised locum GP posts.

After consultation between the Department, the Medical Council and the HSE it was decided that a new supervised division of the medical register would be created. This would enable doctors trained in a particular specialty to undergo an examination in that specialty and to achieve temporary registration for a maximum period of two years while working in supervised posts.

The Medical Council welcomed the passing of legislation in July to establish the supervised division of the register. The council had previously sought a return of a form of temporary registration, which had been abolished with the 2007 Medical Practitioners Act, as it allows for greater supervision of doctors in specific posts. Once this legislation was passed, the Medical Council immediately put in place a process to allow registration to the division to happen as efficiently as possible.

I am conscious that registration processes may sometimes appear from the outside to be somewhat bureaucratic. However, we cannot underestimate the importance of having robust systems in place to ensure the protection of the public. Patient safety is always our main focus, and our registration processes are designed to ensure that when a patient is in need of treatment, they will have confidence in the ability of their doctor to treat them safely.

Ms Caroline Spillane

The amendment to the Medical Practitioners Act by the Oireachtas specifically allows for doctors in the supervised division to fill publicly funded posts. An application for registration to the supervised division can only be considered after the HSE has proposed a post to the council, proposed a doctor to that post and provided a completed and signed declaration confirming the supervisory arrangements in place. When the council has been provided with this information by the HSE, we then assess the disciplinary history, qualifications and employment history of each candidate to ensure they have the education and training to provide safe and appropriate care. The doctor is then deemed eligible to undertake an examination in his particular specialty, which assesses his clinical judgement, communication skills and relevant data interpretation skills.

These steps combine to create a robust system of checks and balances aimed at ensuring that each doctor is fit to practise medicine in this country and that they are adequately supervised within the hospital setting. It is worth noting that generally doctors must complete each step to registration in sequence. Conscious of the urgent need for the HSE to fill the NCHD vacancies, however, the council allowed candidates for the supervised division to complete each of the three steps at the same time.

Over a six week period the council and the HSE co-operated in the registration of doctors recruited from India and Pakistan to fill vacant NCHD posts. The council's registration staff assessed in excess of 270 applications from doctors and our education and training staff established and implemented seven new speciality specific examinations for approximately 270 candidates in conjunction with the postgraduate medical training bodies and the medical schools. This involved an enormous effort and I would like to place on the record my appreciation to everyone involved.

These exams were taken by 266 candidates and 236 passed. The exam results were published in August and shortly afterwards the HSE began submitting declarations for the doctors whose posts had been proposed to the council. Having met each of the registration requirements, the first doctors were registered at the end of August and to date approximately 230 doctors have been registered on the supervised division. This means sufficient doctors have now been registered to fill the 190 vacancies previously identified by the HSE.

We are all aware that junior doctor vacancies arise in January and July of each year. The creation of the supervised division will place the HSE and the Medical Council in a stronger position to ensure registration and workforce planning processes work in tandem in order that doctors can be registered to fill vacant NCHD posts in line with clinical service needs. The Medical Council and the HSE have now signed and agreed a formal arrangement document outlining the roles, responsibilities and timelines for future registration processes for the supervised division.

We are all conscious that 30 doctors failed the examination in August and a number have arrived in Ireland since the seven examinations were held. At present, we do not have the necessary information relating to candidates who arrived in Ireland since August to allow them to be registered. We have agreed with the HSE that if hospital managers propose the candidate for posts immediately and the candidates themselves have submitted the information required as part of the assessment process, we will then hold examinations to ensure doctors are registered as soon as possible. For the remaining candidates identified to fill posts in the January rotation, our strongest advice to doctors is that they should not come to Ireland until they and the HSE have completed the first two stages of the registration process and until a date for exams has been set.

I reassure the committee that we take very seriously our responsibility to protect patients. It is at the heart of everything we do. However, we know we do not operate in a vacuum. We are acutely aware of how important it is to our health system that junior doctor vacancies are filled without undue delay. We will continue to work collaboratively with the HSE but we must at all times remain conscious of patient safety concerns. Patients need to have confidence in our health care system, and our role is to ensure that the doctors working in this country meet appropriate standards which in turn meet the expectations of the public.

Chairman

I thank the witnesses for that presentation. The committee decided to hold a series of meeting on the NCHD issue following the widespread national shortage. It is important that today's deliberations help to instil confidence in the health care system. It is important that we send out a message that the posts are filled by qualified personnel and there is joined-up thinking between the Department, the HSE and the Medical Council because this is a matter of great concern to patients, families and to those working in the health service. We must be proactive on this issue.

Deputy Billy Kelleher

When we speak about non-consultant hospital doctors who have come from abroad, they have gone through a rigorous programme of screening, exams and registration and we must send out a strong signal that these are highly qualified, professional people. We should be conscious of that in our discussions. These issues can be expressed in the context of the racist undertones that can exist in broader society. We hear people express their views on doctors and nurses when talking about overcrowding in hospitals. We must insist publicly on the highest standards in health care, and that we have confidence in the registration process and the recruitment of staff. In the broader context of the proposed changes in the programme for Government and the proposal that individual hospitals will be set up as independent trusts, with their own boards, will there still be a centralised recruitment process which has been so successful and efficient in allowing the HSE to plan ahead to meet potential shortages? If we return to a system where individual hospitals take responsibility for recruitment, by its nature, that will undermine the process of centralised recruitment.

Obviously, doctors who have been educated and trained in Ireland are leaving. They have expressed the view that there are no clear training programmes in place and that careers paths are not laid out in a way that gives them confidence about staying here. How far down the road have we advanced in outlining clear training programmes and careers pathways? These are the key issues for non-consultant hospital doctors. Hospital posts rotate every six months, will we be in a similar position next January and July? What measures have we put in place to ensure these difficulties do not arise again?

I congratulate everybody involved, the Minister and members for their co-operation in passing legislation, the Medical Council and the HSE in addressing the serious issue facing the health service in general.

Deputy Caoimhghín Ó Caoláin

I join in the welcome to all of our guests. I thank the Minister, the HSE representatives and the Medical Council for their presentations. I acknowledge that members were briefed by the Medical Council earlier this week. I do not intend to go over the ground covered at the briefing earlier in the week or the exchanges in the Dáil Chamber last week during questions to the Minister. It is only fair to acknowledge that the process of recruitment and the allocation of posts under the new supervised division have been, the Minister will be glad to hear, broadly successful. It behoves political voices to state this view. The Minister will recall that when we facilitated the passage of the emergency legislation in the Dáil prior to July, we all acknowledged at the time it was a stopgap measure until the appropriate steps were taken to achieve the necessary fundamental reform to avoid a repetition. The Minister has made this point to us this morning and I cite two sentences from his contribution:

Government policy in this area is that we should move from a consultant-led health service to a consultant delivered service. This, of course, would require a significant increase in the number of hospital consultants and a corresponding reduction in the current reliance on NCHDs.

Sadly, however, the Minister indicated that the current economic climate will impact on the extent to which this can be achieved in the short-term. I am in unison, as I believe all voices on the committee must be, with the Minister.

That brings me to the next point in the Minister's address, the need to create a new associate specialist grade of non-consultant hospital doctor. I again record my support for this proposal. Will the Minister advise us of the steps he has taken or intends to take for the creation of the new associate specialist grade? This is an important step, especially in addressing the haemorrhage of Irish trained doctors, as the highest proportion of doctors trained here, who are leaving our shores on a year in-year out basis. Will the Minister indicate his position at this time? The planning and implementation of the measures which he has signalled are required, and which we accept, will take time. The implications will be felt in the nature of education and training and also in terms of the throughput of numbers. While the Medical Council has advised that the situation in January will not be anything of the order or scale that we witnessed in July, I would like to know what steps are being taken to avoid having to revisit the panic measures required in 2011.

I have made the point time and again that we cannot expect to put in place an increased number of consultants and the new associated specialist grade of non-consultant hospital doctor without taking a number of key steps. One of these steps is opening up access to medical education to talented and committed young people on the basis of their ability and their wish to be involved in the profession as against the situation heretofore where many young people who would undoubtedly have proved to be excellent doctors in the system were excluded because of the economic reality that entering medical school entailed. Does the Minister have proposals to open up access to training within the ambit of the medical profession to talented young people across the board who would not be excluded on the basis of their ability to pay?

It may not be very popular to revisit the issue of consultants' pay, but excessive salaries and expenses paid to hospital consultants only contribute to a curtailment of their numbers in the current economic circumstances. We want to ensure greater numbers of consultants come through the system. Will the Minister grapple with both of these issues?

The Minister did not refer to the consultant contract that gives consultants the opportunity to take a year off before retiring on a pension and to be re-employed as paid locums, thus receiving a double payment for that year?

Chairman

The Deputy is straying from the topic.

Deputy Caoimhghín Ó Caoláin

No, Chairman, this is related. With respect, we signalled on Tuesday that we would address this issue. I clearly recall the Chairman acknowledging this.

Chairman

I have checked the agenda.

Deputy Caoimhghín Ó Caoláin

I am closing my remarks with that question. It is a fair one to ask and I think the Minister will answer it.

Chairman

I remind members that they have been asked to put questions.

Deputy Seamus Healy

I will take cognisance of that request.

I welcome the Minister, the representatives from the HSE and the Medical Council and thank them for their presentations. It is only fair to compliment all involved in overcoming the difficulties encountered earlier in the year. I hope this will also be the case in the long term.

On the number of university places for medicine, the role of the University of Limerick in medical training has been of some assistance in this respect. Will additional places be provided for medical students?

The emigration of large numbers of qualified Irish doctors was raised, as was the question of training posts versus service posts. I welcome the Minister's suggestion that we will move towards a consultant delivered rather than a consultant-led service. I also support his proposal to introduce an associate specialist grade, although my support is conditional on how the grade will operate and so forth. What progress has been made on creating the new grade? Have job specifications or conditions of employment been drawn up? Will the Minister provide details on how the grade will work?

The Minister stated: "Compliance will require significant changes in the manner in which hospital services are organised and delivered, in particular in smaller hospitals where the numbers of NCHDs do not support European working time directive compliant rosters, and to the manner in which hospitals rely on NCHDs." I caution against using the difficulties being experienced in respect of non-consultant hospital doctors as a means of furthering the misguided policy of centralisation being pursued by the Health Service Executive. In general, however, I compliment all concerned on the manner in which the immediate emergency has been largely overcome.

Deputy James Reilly

I join members in making special mention of the great co-operation that took place between the Medical Council, the colleges which set the examinations, the Health Service Executive and the Department. Extraordinary efforts were made, as members acknowledged. Every cloud has a silver lining and in this case, not alone did we achieve success but we also now have the bones of a process which will allow us to expedite the introduction of a specialist grade. The relevant bodies will work with the Medical Council and colleges to develop a proposal on the specialist grade. It is much too early to discuss terms and conditions or the numbers involved. I hope this goes some way towards answering Deputy Healy's question.

I echo the concerns voiced by others about the number of doctors who are leaving the country, despite being qualified to the point of specialist registrar and eligible to apply for a consultant post. We have heard proposals for a form of indenture to apply to those whose medical education up to the point of becoming an intern has been paid for by the State. The cost of their training is almost €150,000, rising to nearly €1 million for those who reach specialist registrar grade. From a value for money perspective, these are the last people we want to leave the country. It should be noted, however, that an important part of medical education is exposure to other centres of excellence outside the country. It is healthy for the system to have exchanges of specialists and training of doctors across jurisdictions, although the traffic should be in both directions.

The introduction of a new grade could go a long way towards creating a much more clear career path, as noted by Deputy Kelleher. I am concerned about this issue. Irish doctors, specifically younger doctors, leave the country for a number of reasons. For instance, some of the behaviour at some of the hospitals has been problematic. I have asked the special delivery unit to examine the implementation of a proper code of behaviour between doctors, their peers, those who work for and with them and patients to ensure they all understand they have a duty in respect of how they interact with others.

To answer Deputy Kelleher's question on central recruitment, the current process will remain in place, certainly pro tempore. We may at some stage have networks of hospitals. The establishment of networks would offers a way forward as it would address the problem of everyone wanting to have periods of employment in large hospitals on their curriculum vitae. If hospital networks are in place, doctors will work in the north-west or south-east group of hospitals, rather than specific hospitals.

The specialist grade is part of having a clear career path which will ensure people finishing their specialist registrar training do not fall off a cliff, as it were. They will enter the specialist grade where they will enjoy autonomy, answer to a clinical leader and, ultimately, progress to becoming a consultant.

Deputy Ó Caoláin referred to a stop gap measure. We want a consultant delivered service. The specialist grade will form a large part of moving to such a service. As I noted, we established the group and have asked it to take the step. Having successfully completed the initial task of addressing the shortage of non-consultant hospital doctors, the group, with additional inputs from other bodies, will examine the establishment of the specialist grade. The clear message I wish to send to those who will finish specialist registrar training at the end of the July is that an alternative will be available to them at that point and they should not start making plans to leave the country. That is my intention and we have received full co-operation on the issue thus far. I hope this co-operation continues as the introduction of the new grade is in the interests of all those involved.

The number of doctors graduating has increased as the result of the provision of postgraduate training and additional training places for general practitioners. While we all agree that the number of places in medicine is insufficient, it will be difficult to resolve the issue in the current economic climate. However, we will continue to push this issue as hard as we can. Primary care is an integral part of the new system required to deliver health care. Chronic illness care should move from the hospitals back into the community and larger hospitals should focus on complex procedures and move less complex surgical and other procedures to smaller hospitals. This approach reflects the need to have patients treated at the lowest level of complexity, while ensuring treatment is safe, timely, efficient and as near to home as possible.

Notwithstanding that some of the other issues raised strayed from the issue of non-consultant hospital doctors, I propose to deal with them briefly. On the issue of hospital consultant pay, I am more interested in fixing the health service than focusing on pay. If consultants can deliver the flexibility required to provide care on Saturdays and Sundays, with discharges and ward rounds, etc., I will go down that route. If, however, that approach proves unsuccessful, the consequence will be that other options will come to bear quickly. The Cabinet is very clear on this matter.

I will defer to Mr. McGrath on the issue raised concerning the final year of employment and rest days for consultants.

Mr. Seán McGrath

We raised the issue of historical rest days with the associations, both the Irish Medical Organisation and Irish Hospital Consultants Association, slightly more than four weeks ago as part of an ongoing engagement on the Croke Park agreement which is considering a number of work practices. We believe we can create some efficiencies within this process. There are also processes we can work through with the associations under the umbrella of the Cork Park agreement. This issue is ongoing.

Chairman

Before I call Senator Burke, I remind members that they should ask questions rather than make statements.

Senator Colm Burke

I thank all those present for attending. I also thank those whom I have met in the past eight weeks to discuss some of the issues associated with junior doctor shortages. The reason I highlight these issues is to ensure the process we use does not result in a repeat of the problems that occurred this year. I met some of the junior doctors who came through the system. Some have been in the country for the past eight weeks and are demoralised as they do not have a date to sit the examination. That issue needs to be dealt with.

In regard to setting up the process, a file was given to me by a junior doctor from India. He made his initial application on 30 December 2010 in response to an advertisement but was not interviewed until 9 May 2011. What was the reason for the delay from the time of advertising until the job interviews took place? I understand from speaking to hospital consultants and hospital managers that the normal process for filling July vacancies is that advertisements would run in late January or early February and that interviews would be over by the end of February, so that applicants would know where they stood by mid-March as regards the filling of posts for July. The major complaint from hospital managers, especially the smaller hospitals, was that they were totally excluded from the whole exercise. I have a letter from a consultant who wrote to me in early June stating that the centralised process has been a fiasco for niche jobs and small services such as his. He stated that six weeks earlier he had tried to find out why the job he could have taken on 1 July was not advertised.

My question concerns the inclusiveness of local hospital management and consultants at a local level in the centralised process if that process is to be maintained. Many hospitals were left in limbo at the end of May not knowing what jobs were filled and what jobs were not filled. That issue needs to be clarified.

Why did it take so long for the HSE and the Medical Council to come up with the supervisory division? We knew this time last year that there would be a problem. On 29 June the junior doctors first received a letter stating that they would have to sit a clinical assessment. I have some of those letters with me, one dated 25 June which states that one does not have to sit the PRES examination or the IELTS examination but there was no mention that one had to sit any other examination. I want to ensure that such a scenario does not arise again, that the process is in place at an early stage, that the interviews are held and that the date for any clinical examination is set in good time. The date for starting in these jobs was 11 July yet in October there are some who did not have the opportunity to sit the examinations.

The Medical Council and Andrew Condon, of the HSE, wrote to some people on 5 August advising them not to travel to Ireland and on 9 August Mr. Dan McCarthy wrote to them asking them to come. I have copies of those letters. They are people who are sitting around waiting to sit examinations. That is where there is much uncertainty with these junior doctors. These are the people we expect to provide care for our people and we need to be careful how we treat them. To ensure such a scenario does not arise again we must have joined-up thinking between the Medical Council, the HSE and the Department in dealing with these issues.

I wish to raise one or two other issues and I will leave it at that. In regard to the specialist register programme I spoke with the masters of one of the Dublin hospitals recently. They advised that they have three people on the specialist rotation so that they are in a recognised training programme. There are two other registrars who are not in a recognised training programme, yet all five do the same type of work and two will not get any recognition in real terms for the work they are doing. We need to review that whole process. Some people are in a recognised training process while others are not. How can we deal with the issue where people are getting the same level of training in real terms, but yet one group gets recognition and the other does not?

I understand a report on consultants will be issued within the next few days. It will indicate that the number of applicants for consultant posts in Ireland has decreased substantially and that this is tied into the training issue. If we are not getting the traineeship programme and the numbers right, then the number applying for consultant posts will continue to fall. I understand there has been a substantial reduction in the past three years in the number of applicants for consultant posts that are being advertised. I understand the figure has reduced from an average of six applicants per job in 2008 to less than two per job in 2010.

Deputy Robert Dowds

I thank the Chairman, the Minister and staff from the HSE and the Medical Council for appearing before the committee. Most of the questions I wanted to ask have already been asked, therefore, I will confine my questions to cultural issues. Do the delegates have an assurance that the doctors coming from India and Pakistan have good English, as we understand it here? Has provision been made for them to understand something of the culture of this country? Those questions may appear inappropriate but I ask them because I am aware that nurses have been brought in to Ireland in the past who did not have a good standard of English or any knowledge of our culture. Given that doctors work directly with very sick people it is very important that they can relate to them.

Chairman

I invite the Minister, Mr. Seán McGrath and Professor Kieran Murphy to respond.

Deputy James Reilly

I think Mr. McGrath will want to address many of these questions. On the issue of the Medical Council I am sure the council will have something to say. The question around English is easy enough to deal with. All these doctors were interviewed by our own consultants who went out to those countries; that was one of the parameters so their English is excellent. Perhaps Dr. Philip Crowley will address the cultural issue. I will hand over to Mr. Seán McGrath and Professor Gerard Bury will deal with Senator Colm Burke's question on the specialist register and the two new registrars.

Mr. Seán McGrath

In regard to the centralisation process, Senator Colm Burke is correct, it was a difficult coming together of 40 different activities where people previously recruited in their particular institutions. We launched that process late last year. What we tried to do was to get together cohorts of clinicians from different institutions, be it from Galway, Roscommon or Portiuncula hospitals, so they could recruit based on speciality and ensure there was enough capability and competence for the areas they had to cover in that general geographic area. We did not exclude anybody. If people felt excluded from it, it was because they just did not become involved in the interview process. We have learned many lessons from the centralisation process. Clearly our ability to ensure that we have a matching system in respect of people's demands and needs is something we can flesh out in the coming months. Many lessons have been learned. It has been a huge success given that we are all fishing from the same barrel. It is giving us a far greater information database that we had heretofore.

Professor Gerard Bury

I thank the committee for the opportunity to reflect on some issues related to medical education and training. The questions and the issues raised by members are welcome. To set the scene, there are 4,500 non-consultant hospital doctors, NCHDs, working in the Irish health care system, 3,600 of those are in structured training posts - either initial specialist training posts or higher specialist training posts. Those training posts are structured by dint of the 2007 Medical Practitioners Act into a series of service level agreements with accredited postgraduate training bodies. The HSE spends approximately €25 million annually on supporting the training of those doctors through programmes accredited by the Medical Council and largely externally benchmarked against the highest standards of training and performance. What the legislation has enabled us to do is to clarify the number of posts required for training to meet the recruitment and placement needs of the work force in the future and the service posts that exist within the health care system. Approximately 900 service posts exist within the NCHD ranks and we recently put in place professional development programmes to ensure those doctors are supported by the HSE in meeting their professional competence requirements, set by the Medical Council.

Doctors in service posts have a vital role to play. They contribute and have contributed enormously over several decades to the functioning of the health care system. However, in terms of their ongoing competence, supports may differ significantly and in the future will clearly begin to diverge from the training programmes in which the other groups of doctors participate. Doctors who hold service posts for extended periods in specific units will have access to a range of supports to ensure their competence and safety and to ensure their scope of practice is being met in that post. The issue raised by Senator Burke with regard to the distinction between doctors working in the same units and apparently doing similar functions is valid and important. One group of doctors will follow a trajectory of structured training which will bring them to the specialist register, which is the purpose of the initial and higher specialist training programmes, while others will be in a service post which they may hold for quite some time.

Mr. Seán McGrath

Senator Burke also raised the issue of timing with regard to the specialist register and the changes in that regard. This time last year, we knew there would be a crisis with NCHDs, not so much in January 2011 but more so in July, because that is when the big rotation happens, so we started two activities. We mentioned the centralisation process and it is crucial to give us more visibility at a higher level. The other element was the international recruitment. As members know, and as we outlined in our briefing document, the international recruitment of NCHDs is a very competitive market, particularly in western Europe. We were competing in particular with the NHS and we reached into Pakistan and India knowing there was a significant rich vein of qualified, English speaking doctors there.

We started that process last November-December and Irish consultants went out there and went through a serious entry round. Then we brought them to Ireland to ensure we could have the exam. The big issue we had was their perception of the pre-registration examination system, PRES, exam. They saw this as an obstacle for them coming to Ireland. For us to address the significant issues with regard to having no doctors in place, we had to make changes and the new register or supervisory register came into place. It, for us, much more suitable and is something we can build on over the coming months and years.

Senator Colm Burke

Could I come back on one issue?

Chairman

The Senator has had seven minutes. I will come back to him later, but I want to move on to Professor Murphy now.

Professor Kieran Murphy

I will take the question raised by Deputy Dowds regarding English language ability. The Deputy is correct and the Medical Council shares the Deputy's concerns that all doctors working here should have the appropriate communication skills to practise safely. Therefore, a core component of the examination for these doctors from India and Pakistan was communication skills. It was one of three key components of the clinical examination. Doctors had to demonstrate that they could communicate safely and effectively with the patient to protect patient safety. Committee members are aware, I am sure, that communication is more of an issue for doctors coming from within the European Union. The Medical Council cannot test language skills of doctors who graduate within the Union. This has caused problems for us in the past and we have discussed the issue with the Minister. We are also a co-signatory to the Berlin agreement with INTERact and 27 other medical regulatory authorities and have lobbied the European Commission for a change in the European directive which precludes the Medical Council from assessing English language competency in doctors who graduate from within the European Union. Obviously, for doctors from outside of the Union, a key component of their clinical examination is communication skills.

I will pass the operational issues raised by Senator Burke on to our CEO for a response. However, as we have heard, this was a new system that came into place following the passing of legislation in July. As Mr. McGrath said earlier, this has been a learning experience for all parties. Our CEO will outline the new system we have in place to ensure that the difficulties that were experienced over the summer, which we were able to resolve, will not happen again.

Ms Caroline Spillane

As mentioned in my statement, we are all conscious of the 30 doctors who failed the examinations and the six doctors who were unable to be accommodated and that more doctors have arrived since the seven exams were held by the Medical Council in August. We have worked with the HSE on a formal agreement to find a solution to this issue so that we will not face the same situation in January again.

The examinations are the final stage in registration. The first stage is that the HSE proposes a doctor to the post and provides us with a declaration assuring us of the supervision arrangements for that doctor. Currently, the HSE is gathering all of this information. We then give doctors a further four weeks to get their applications and all of their documentation in to the Medical Council. Within five days of that, we will hold seven exams for those candidates. We have also agreed with the HSE that if it and the doctors can provide their documentation to us earlier, we will bring the exams forward and hold them earlier. We are very conscious that there are doctors waiting for examinations and we want to be flexible and give everybody the opportunity to participate in these exams when they are held again.

Deputy Regina Doherty

In contrast to some of my colleagues, I see myself as a "half-full glass" kind of person. I compliment the Medical Council, the HSE and the Department not only for their presentations but for their reaction to what has been a serious issue over the past couple of months. Given that we faced this issue previously, the outcome this year is a credit to each group, but in particular to the Minister for the speed with which he brought through the legislation that allowed the introduction of the supervisory role.

In the context of the Commission and Article 258 of the treaty, have we ascertained the effect that will have on doctors' rotas? Will it increase the number of NCHDs and other doctors? If so, are there plans in place to address that before the two-month period runs out?

Deputy Peter Fitzpatrick

The Minister deserves credit. I was in the Dáil for the few months he was under significant pressure, but he kept his head and his promise. I congratulate him on that. I feel sure that following what he has done with the NCHDs, he will do the same for the hospital trolley problem. I also offer my congratulations on the centralised recruitment process for non-training posts.

Many people are concerned about the supervision of the NCHDs, but Ms Caroline Spillane has clarified that issue. Professor Murphy's presentation was excellent. It is important and encouraging that the focus has been on protecting the public and on patient safety. With regard to doctors throughout the profession keeping up their skills, will he confirm whether they sit further exams or how the Medical Council follows up on that? The Medical Council deserves our congratulations because it has answered many of our questions.

I am glad to be a member of the Oireachtas Joint Committee on Health and Children because it is clear from the responses that many people are worried. It is most important that there is clear communication and that people know what is happening. There is no point in the delegates coming in here and telling us all the good things that are happening. It is important that the public knows what is happening because there is enough scaremongering. I thank the delegates for their presentation.

Deputy Catherine Byrne

I find this issue complex and as the Minister, Deputy Reilly, would know from our parliamentary party, I sometimes ask awkward questions.

This is the first meeting I have attended at which I have heard a Minister being congratulated and complimented on what he has done and I join other members of the committee in endorsing that. The issue involved is complex and it has resulted in many people being brought into the country to take up crucial jobs within the health service. I was glad to hear the Minister say that, hopefully, there will be jobs for many of our graduates in the future. I am delighted to hear that.

I have two brief questions; I do not know if they would be considered relevant but I believe they are. I note the Medical Council has to follow up 85% to 90% of applicants to obtain supporting documents. I find that strange. I would imagine that people who are so qualified would have the proper documentation with them when they go to the Medical Council for whatever reason. Is such a level of follow-up in the case of applicants due to a lack of information provided by the Medical Council or to it not having done its job properly? I am not sure if I worded that correctly.

My second question is about the number of complaints received by the Medical Council. I note that since last year there has been an increase of 66 in the number received. The document, which I have read through, does not state what has been the focus of those complaints. Are they related to Irish doctors, foreign doctors, language difficulties or medical issues? Could one of the delegates give a brief synopsis of the types of complaints with which the Medical Council deals?

Chairman

I will take questions from Senator Crown and Deputy McConalogue and I ask that they be succinct in putting their questions.

Senator John Crown

I apologise as I had a competing committee commitment I had to attend.

Chairman

There should no competition.

Senator John Crown

I am very sorry about that.

Chairman

I am joking.

Senator John Crown

I am new to this. I guess I have problems with my priorities.

I have been asked to bring to the attention of the committee that there is a perception, on the part of leading medical educators and leaders in the profession, that any problem which arose in recent months with respect to the expeditious processing of the emergency licensing of the doctors we are bringing in from some of the most medically undeserved countries in the world was not a Medical Council problem. There is a definite and consistent opinion that it was not a Medical Council problem. There may have been problems with other aspects of the health administration but it was not with the Medical Council.

I wish to bring to the attention of the committee the context in which this is happening. We are witnessing a colossal Band-Aid. I pinch myself sometimes and I would ask everybody in this room, from the Minister down, to do the exercise, when they next indulge in this discussion, of removing the words "NCHD, junior doctor, registrar, senior health officer, intern" and inserting the word "trainee" and then see how much sense what we are talking about makes. We are talking about the country which has the highest number of medical schools per head of population of any country in the western world. We have six schools for a population of 4.5 million. The European average is approximately one per 1.5 million and the average is one per 2 million in the US. However, we are anchored firmly at the bottom of the ratios of career level doctors per head of population for the specialty of general practice and for the hospital-based specialties. This is simply extraordinary. This is not the result of some kind of omerta or Sicilian Coso Nostra closed shop operated by consultants or other doctors, but the result of the policy of successive Governments, including the existing Government. It has been a definite policy that we would model ourselves on a system which deliberately under-provides the number of career level posts and plugs the service gap inappropriately by bringing in trainees to do work which should be done by fully-trained doctors. That is how we have the bizarre paradox of having six medical schools per head of population and the lowest numbers of GPs and consultants per head of population. To address that we have to fill the gap with junior doctors.

Much criticism has been voiced, highly inappropriately, about junior doctors who voted with their feet and left the country following graduation from medical school. The reality is they are trainees. Adequate training does not exist here because of the failure of the medical system to provide it and therefore junior doctors do the rational thing. They do what people like me and a generation of Irish specialists did, namely, they go abroad, get free training and free upskilling at the expense of taxpayers and insurance payers in the United Kingdom and the United States and bring those skills back here as fully-trained specialists.

These are the core problems we must address and I do not want members of this committee to leave this meeting thinking of nothing but the Band-Aid solution to the problem. The fundamentals are the problem, not the temporary shortfall in the number of non-consultant hospital doctors. It is the bizarre career structure here, and that is what must be addressed.

I have expressed in the past full support, both before and after the election, for the promises by the Minister, Deputy Reilly, to fundamentally reform the system. I have made the tasteless joke previously in this Chamber, namely, that saying we will do it after the next election is a bit like somebody standing on the altar at his wedding and saying, "I'll be faithful but after the first five years of marriage, if you don't mind". We must reform the system now. None of the problems we are dealing with now can be dealt with in the absence of reforming the fundamental context of the health system, and that is what we need to do. I thank the delegates for their time.

Deputy Charlie McConalogue

I apologise for missing the delegates' opening statements and thank them for attending today to address this important issue.

Following on from Senator Crown's comments, there is a massive issue regarding the Health Service Executive not being seen as an employer and the trainer of choice and of there not being a set career progression for medical students coming out of college who want to do their training here and work in this country. That has led to the problem of there being a shortage of NCHDs, which appears to have been chronic in recent years.

I am aware a great deal of work has been done to try to address that problem but we are now going through a process of recruiting junior doctors from abroad when, as Senator Crown outlined, there are six medical schools here and a high percentage of the students who go through them are international students but they do not get the opportunity at graduate level to enter our health system because an insufficient number of internships are offered. Many of the international students who qualify as medical graduates then go abroad to do their internships.

We are now bringing in international students and they must sit examinations. They are students who would have trained in other countries and therefore not had the experience of six years of medical training here during which they would get to know the country and the medical system. We are bringing them in at that stage having let graduates go at internship level because the number of internships we offer is too small.

I question how we could get to a position where we do not know a year or two in advance the likely dynamic in terms of graduates heading abroad, following their intern year, to take up training. I guess that is a recent phenomenon because if it had been ongoing for a number of years we would be in a position where many more would be coming back here to plug those gaps. What appears to be happening, however, is that we are losing many of them at the initial stage of their training but they are not coming back two or three years later to plug the gap in the system. We then have to recruit abroad.

An issue also arises in terms of the examinations all doctors coming into the country are required to sit because the system does not discriminate in terms of those with exceptional records, those who would be average or poorer quality candidates. Doctors with exceptional track records can go to other countries which will recognise their qualifications and recruit them whereas if they come here they must sit examinations again and study material they would have studied some years ago. That is a major issue.

Qualifying and training medical graduates is probably the most expensive training we provide to almost any student going through our education system. We provide fees, etc., and the colleges and facilities in which to do that. I do not know what it would cost - around €300,000, well over a quarter of a million euro - to train a doctor, yet we are losing them in the system. It does not make sense that we cannot provide a system in hospitals under which our investment in that training is given back to our citizens.

Deputy James Reilly

I will answer the parts of the questions that relate to me and then I will defer to various other people. I would like to let Dr. Crowley comment as he is our patient safety officer at the HSE. Deputy Dowds mentioned cultural issues, which were not addressed in the last round of questions. The questions that concern me are Senator Crown's. I will let Professor Bury address the main thrust of what he had to say. We all accept there is an over-reliance on junior doctors. I do not mean to get at anyone, but both Senator Crown and Deputy McConalogue came in late, so much of this has been said already. Reform takes time; there is no question about that. Far from the analogy made by Senator Crown, I believe it shows political maturity to accept that we cannot turn a whole system around in one five-year term; it will take a bit longer. However, we will certainly have as much of it turned around as we can and the new system will be set in stone in such a way as to allow it to be fully implemented quickly in the second term, if not in the first term. I have not given up hope of implementing as much of this as possible, including universal health insurance, as quickly as I can and by any means.

With regard to the shortage of doctors, I concur with Deputy McConalogue's point about the operation of the system. I accept this is a problem within the medical profession and also within the universities due to the manner in which they were funded in the past and the fact that they must self-fund by attracting many non-national undergraduates to fund the cost of educating the entire group of students. This is something we must consider in view of the fact that there is no money in the bank. I do not want to score political points, but we have been left with a financial morass and we have difficult decisions to make. If we do not do things with an eye to reform, which I am fully committed to, as well as keeping the service running, we are doing ourselves no favours. We are attempting to do both.

With regard to the point about the HSE not being an employer of choice, I will let Mr. McGrath answer some of that, but I will say this much. It is not the HSE that is the employer as much as the individual hospitals, and some hospitals are popular places to work while others are not. We know about the issue with regard to CVs and we have covered this area. There are some senior training hospitals that people just do not want to work in because of the manner in which junior hospital doctors are treated. That is an issue, as I said earlier, that we will address through the special delivery unit.

With regard to information, the points made are valid. In the past we have been shooting in the dark; we did not have the information. When I went to the North last year, I saw what they have available, including real-time information on consultants' waiting times. If Professor Crown's waiting list was two weeks and Dr. McConalogue's was two months-----

Senator John Crown

That would be a long way to slide, as we do not have waiting lists. That is how I run the clinic.

Deputy James Reilly

We have given Senator Crown enough recognition now, without any more self-advertisement.

If there is a big difference between the waiting times for different consultants, we need to know that. There is no point in finding out a year later; we need to know it now so we can address it now. If Senator Crown's waiting list was two months while another doctor's was two weeks, we would go down and have a chat with Senator Crown to see what the problem was. We would not send an administrator or a cardiologist to see a surgeon; we would send a surgeon. Eyeball to eyeball, the surgeon would explain what was going wrong, and if he or she needed help, we would support him or her and do everything we could. If we could not solve the problem despite all these things - if there was intransigence or a major problem with the individual - make no mistake, there would be consequences.

As I said in the Seanad yesterday, when we inquired to the HSE about the cost of setting up such an information system, we were told it would cost €10 million and take 18 months to do. However, Martin O'Connor from the special delivery unit, along with some excellent people from the HSE and with some help from the National Treatment Purchase Fund, has done it in 98 days at a cost of a quarter of a million euro. That is how this Government will proceed: we will use the resources we have within our ranks already. I have always said there are some excellent people within the HSE and in our hospitals. What we need is a new system and new leadership, and that is what we are establishing.

With regard to the specifics, I ask Dr. Crowley to address Deputy Dowds's point about cultural issues, and then I will ask Mr. McGrath to address the issue of Article 258, which is to do with the European working time directive, and Deputy Fitzpatrick's point about continuous professional development for doctors. The issues raised by Deputy Byrne about the Medical Council can be addressed by the Medical Council directly.

Dr. Philip Crowley

As I worked for five years in a developing country, I have some understanding of the importance of cultural understanding in a clinical setting. What we hope is that the observer period that was always envisaged for these doctors prior to full registration and the supervisory arrangements that exist will enable them to work in a different culture and support them in understanding that culture.

There was a linked question about how we would support the professional development of these doctors when they are in this country. They will be supported in engaging in all professional development activities available to other doctors in the settings they are working in and they will certainly be encouraged to sit higher professional examinations as appropriate.

Mr. Seán McGrath

Deputy Doherty asked about the European working time directive. We have a cohort of NCHDs or junior doctors - about a third of the total - who are now compliant with the directive, while another third can be made compliant through changes in rosters and work practices. However, it will be difficult to ensure the final third are fully compliant. These include those with certain specialties who are working in difficult areas, and it will be difficult to ensure sufficient resources in these areas. Following on from what the Minister said, we are trying to change the resource mix to achieve this. The impetus is there to get the number who are in compliance to over two thirds of the total. That is what we will be focusing on over the coming months.

Professor Kieran Murphy

I will deal first with Deputy Fitzpatrick's question about how we know these doctors are competent. With regard to the doctors from India and Pakistan who enter the supervised division, there are several ways in which we can assure ourselves and the public that these doctors are competent. In the first instance, we have a rigorous registration process in which we consider the doctors' history, evidence of competence and basic qualifications. We then assess the doctors individually by a clinical examination in the areas of clinical judgment, communication skills and data interpretation. This is a robust and rigorous system to ensure that when doctors come onto the register in the supervised division they are competent to be on that register. Once in post, they are required to be in highly supervised positions; the CEO of the relevant hospital confirms this in the form of a declaration which he or she submits to the Medical Council to confirm that the doctor is in a highly supervised and highly regulated post. In addition, as Dr. Crowley mentioned, all doctors in the supervised division are subject to professional competence requirements. It is a legal requirement for these doctors to ensure they are signed up to professional competence requirements, including internal credits, external credits, conferences, audits and so on. The entire system is designed to ensure these doctors are competent at entry, that they remain competent, and that the public may be assured of their competence.

I will deal with Deputy Byrne's question about complaints, and Ms Spillane will deal with the Deputy's other question. We publish the data about complaints on our website as it is in our annual report, but I will summarise it. More than 350 complaints were made against doctors last year. Obviously, the council takes every complaint against doctors extremely seriously and fully investigates each one. A total of 160 of the complaints related to professional standards, including inappropriate treatment, use of alcohol and so on. If the Deputy would like further information on the breakdown we can send it to her, but all these details are on our website.

In response to Deputy McConalogue's comment about examinations, although entry into the register for either the general division or the supervised division is by examination, if a doctor has a higher qualification he or she can be exempt from the examination. This is similar to the situation in other jurisdictions. By having an examination we are exercising our role in protecting the public by ensuring these doctors are competent in a way that is similar to other jurisdictions. We had published a list of qualifications that exempt doctors from sitting the examination because they have a higher qualification. I will pass the committee over to the chief executive officer to deal with the other questions.

Ms Caroline Spillane

I will deal briefly with Deputy Byrne's question regarding the 80% to 90% of doctors who fail to provide us with adequate information. It is true to say that in our experience 80% to 90% of doctors fail to provide the council with the necessary documentation to progress their registration. This documentation is absolutely central to the registration process because it provides the council with evidence of the doctor's education, qualification and training and, importantly, it provides evidence that they have not had any criminal or disciplinary action taken against them in another country. We simply cannot progress their registration if they do not provide the documentation to us. This is why we stress clearly to doctors, especially doctors coming from third countries, that they should not come here in advance of completing that stage of the process.

Mr. Seán McGrath

I will ask Professor Bury to comment on the broader element around medical education.

Professor Gerard Bury

I will address some of the issues raised by some of the members. Medical education and training is a strategic national asset to this country in two respects. First, it allows us to train the medical workforce that our health system requires and to tailor the training to its needs. Increasingly, we are developing the capacity to identify these needs and make these tailoring changes. Second, this is an attractive place to come to qualify as a doctor. Our undergraduate and postgraduate training programmes are esteemed internationally. They give a basis for qualification, training and practice in other countries that is well respected.

How we improve and change our health service and medical education and training system depends on several issues but, fundamentally, leadership is key to it. In 2004 the Medical Council published a series of reports on undergraduate medical education which led to reform that has been best articulated through the two reports mentioned earlier on. Subsequently, there was a major investment in undergraduate medical education through the Department of Education and Skills and the Higher Education Authority, HEA, allied with the HSE's provision of clinical facilities for training purposes.

In 2013 the number of EU graduates who will qualify from the six medical schools we have heard about will be 725. This is virtually a doubling of the number of EU graduates from ten years previously. Astutely, the committee has identified the introduction of internships as a regulatory step required to enable these doctors to obtain full registration in this country or to move to other countries.

We have increased the number of internships available from 520 last year to 560 this year. This includes a provision of more than 120 places for non-EU graduates of Irish medical schools who wish to remain in this country to complete their internship. This facility exists here although it will be a challenge in economically difficult times to maintain it. As we go towards a graduate number of 725 we must make as many places as possible available for our EU graduates. Nonetheless, the provision of 725 internship places for all EU graduates is a target. It is an important aspiration and something we are working towards. It is important to endorse or enable the non-EU graduates who wish to complete their internships in this country to do so.

The matter of specialist grade posts was raised. We have heard from the Minister and other organisations about the increased availability of such posts in future and this is to be welcomed. The availability of these as career-specialist posts will have an impact on doctors or those considering training as doctors. I believe this will have a positive effect on our training posts. It will also impact on the discrimination which we are enabled to bring to the support of doctors in service posts. As I have stated, we have already identified the numbers and we are beginning to identify the needs of these posts. Certainly, we have identified the resources to support them. As we distinguish doctors in staff grade posts at junior levels from their training counterparts, increasingly we will effectively support both grades from an educational perspective.

Chairman

Thank you. We have had a good discussion. Two members have indicated that they wish to ask a question. I am reluctant to let people back in but if it is one question, and only one question, I will be gracious and let you in. We have had a good discussion.

Deputy Caoimhghín Ó Caoláin

We have indeed and we have highlighted most of what needs to be addressed today. Obviously, this will be an area of focus in future for getting updates on progress. I highlighted one area of concern and it was as much an appeal as a request for information. With all the necessary reforms signalled at this point, it is a golden opportunity to consider what can be done to allow access to medical education for talented and interested young people who heretofore have not been able to fulfil their hopes and aspirations because of the economic barriers. Will the Minister indicate to the committee that this is an area he will examine favourably to establish what can be done to facilitate access for those who, because of their family circumstances, are unable to take on this career path today?

Senator Colm Burke

The question is for the Medical Council and relates to whether people sit the pre-registration examination system, PRES, level 4 or get an exemption because of the training they have received in a non-EU country. Is there any proposal to expedite such applications where someone claims that he or she has worked in hospitals in non-EU countries and would have the equivalent of the required training in Ireland? I realise there is an issue about documentation and that the council must check all of it. However, once all that is finalised, is there any chance we could try to expedite the processing of such applications?

Deputy James Reilly

I will let the Medical Council answer the question on expediting that matter but I imagine that we have bilateral arrangements with certain countries and that where these do not exist it becomes a problem because the information requires a greater amount of examination, but I will allow the Medical Council look after that.

I fully agree with Deputy Ó Caoláin and I have no wish to see finance as a block. I accept that it is in some situations in which people have achieved the required number of points but do not have the wherewithal to afford to rent an apartment in a town many miles from where they live. Certainly, we should and will examine that.

Deputy Caoimhghín Ó Caoláin

I thank the Minister.

Professor Kieran Murphy

With regard to the question raised by Senator Burke, I remind members of the committee of how to access the general division. It is by one of two routes. One can either do the pre-registration examination system, PRES, examination or alternatively one can obtain from one's own regulatory authority overseas a certificate of intern equivalence. This means the international regulatory body certifies that the internship experience obtained by this doctor which occurs post-qualification or after obtaining the basic medical qualification is appropriate. Since there are two routes onto the register, either by an examination or the obtaining of a certificate of experience, we must ensure that both routes are equivalent. We have no wish to have what is seen as an administrative route onto the register for the reasons set out earlier, that is to say, to protect patients and to ensure the protection of the public.

It is certainly true that there are several doctors from outside the EU who have chosen not to sit the examination and who have decided that their preference is to wait until they can obtain a certificate of experience from their international regulatory authority. The council has concerns and is keen to ensure that both routes are equivalent. I imagine members would not welcome the possibility that doctors could chose not to do an examination because they believed they may not pass it but would be happy to come to the country by the second route. It may be useful for members to be aware that in the last holding of the PRES examination earlier this year, some 40 candidates failed and they chose not to sit the examination again but to go down this secondary route. The Act states that if a doctor chooses to go down the secondary route, the internship must be the equivalent of an internship that occurs in Ireland. The committee should appreciate this applies in every country outside the EU.

There are many different regulatory authorities and a number of different ones within some countries. The council has interacted extensively with international regulatory authorities outside the EU in an attempt to try to get reassurance from each of them that the internship year obtained by the individual doctor making the application is equivalent to an Irish qualification. This has proved hugely difficult logistically because it applies to every country in the world not just India and Pakistan. The council has gone to extraordinary lengths to try to ensure we can reassure ourselves and, more importantly, the Irish public that if doctors come on to the register using this route they are appropriately qualified and have the appropriate competencies because we will not test their competency using this route.

We need to be reassured that the internship route doctors are taking is equivalent to doing an examination. We have registered doctors on this route. The major challenge for the council is to try to interact with every country outside the EU. I hope that answers the question.

Chairman

I am mindful of Senator Crown's Band-Aid remark. I compliment the Minister, the Medical Council and the HSE for their co-operation and initiative on the matter. The Minister's remarks were reassuring. Rome was not built in a day. We need reform and this is one area where we have seen it happen. I thank members for their attendance and, within reason, staying within the time limits. January is the next critical window for the issue we discussed. It is important that we have a clear path from which to advance. It is important that the SDU does its job effectively. Today was part one of a series of three meetings.

Deputy James Reilly

I thank all political parties and other organisations, such as the colleges, the HSE, the Department of Health and the Medical Council. I also thank the doctors who come to Ireland because without them we would have great difficulty in running our service. We will keep up our end of the bargain. We have to ensure they leave here having been upskilled and enriched by their experience.

Chairman

I thank the delegates. The items on the agenda of the next meeting on Tuesday, 11 October are correspondence, Deputy Fitzpatrick's submission to the Broadcasting Authority of Ireland, and Dr. Fiona Lithander's presentation to the committee on the nutritional value of cheese.

The committee went into private session at 1.14 p.m. and adjourned at 1.30 p.m until noon on Tuesday, 11 October 2011.