I welcome to the meeting Professors Eilis McGovern, Sean Tierney and Frank Murray, Mr. Leo Kearns and Dr. Michael O'Connell and thank them for their attendance. This is the second of the joint committee's ongoing series of meetings on the issue of junior doctors, encompassing matters such as recruitment, deployment, education and training of doctors, as well as the viability and appropriateness of Ireland's reliance on junior doctors in training to staff the hospitals. Today's visitors, who are very welcome, provide an important function in respect of the education of people in the medical profession. I ask Professor McGovern to begin by giving a PowerPoint presentation, after which Professor Murray will give the second part of the presentation.
Non-consultant Hospital Doctors: Discussion (Resumed)
Professor Eilis McGovern
I thank the joint committee for the invitation to share some of our thoughts with members. We thought we would start by using surgery as an example to inform members of how it has had an impact with regard to the recent non-consultant hospital doctor, NCHD, problem. We consider surgery to be a good example because it is a front line specialty that is to be found in all acute hospitals and which operates on a 24-7 basis. The slide being displayed to members shows that approximately 1,200 doctors deliver the surgical service in Ireland. There are approximately 400 consultants and approximately 400 junior doctors who are on the training register and who are in recognised training posts. There is then a third tranche of approximately 400 doctors who are not consultants but who are not in training posts. They are on the Medical Council's general register and fill a service gap that is left when one takes out the consultants and the trainees. It is in this last group that vacancies arose that were the cause of what is referred to as the most recent NCHD crisis. Members should note there are very few vacancies among the group represented on the left-hand triangle on the slide, that is, those junior doctors who are in recognised training posts. The vast bulk of the vacancies arose in the group represented on the other triangle.
If one considers these 1,200 people in a little more detail, the bottom left-hand corner of the slide shows that approximately 80 young doctors join basic surgical training each year after their intern year. It is a three-year programme, during which they rotate through different specialties. At the end of that only about 30 or 40 can progress on to higher specialist training, which is the precursor to a consultant post, so there is an attrition rate. Some people decide that surgery is not for them and others fail to perform. A certain number fail to progress to higher surgical training.
About 30 to 40 people per year are taken in to para-surgical training across all surgical specialties. That is a six-year programme in Ireland usually followed by some time abroad and sometimes by some time in research. The committee can see that members of that group become the future consultants, but only about 20 consultant vacancies occur in surgery in Ireland every year so there is a mismatch between the number of people who are trained to be consultants and the posts that are available for them.
Consultant staffing is approximately 400 across all surgical specialties. The largest specialty is general surgery - about 150 - and orthopaedic surgery would be the next biggest.
According to the HSE's own data, there has been an increase of about 15% in the number of consultant surgeons in Ireland since 2005. This is the smallest percentage increase across all medical specialties, where the average increase has been 25%. Surgery has therefore lagged behind in terms of the development of new posts.
The third part of that triangle is the 400 surgical doctors who are in non-training posts. The total number in that group is about 1,200 in Ireland, but about 400 of those are surgical. In 2010, the HSE designated a large number of posts as non-training posts following recommendations in the Medical Practitioners Act. That group of doctors are predominantly non-EU and that number has been increasing progressively since the 1990s. Most of those posts are in non-teaching, smaller, peripheral hospitals. They would be posts which have always been regarded as less attractive than junior doctor posts in teaching hospitals and hospitals in larger towns in Ireland. Now that they are not recognised for training, they are even less attractive. It is into that group where the vacancies arose that the doctors who have just been brought in from Pakistan, and who are now in the supervised division, have gone.
I now wish to look at medical migration both into and out of Ireland. We have here a diagrammatic representation of a snapshot of emigration from countries around the world. It shows that Ireland, which is the largest of the pink dots, has always had a high rate of emigration of doctors compared with other countries around the world. The number is skewed because we train a lot of medical students who come from outside Ireland. That has been a tradition here, so not all that 40% would be Irish or EU doctors. It is absolutely true to say, however, that we have always had a strong tradition in Ireland of our young doctors going abroad, either temporarily or permanently. We do not believe that this is the real cause of the current NCHD problem.
There are two circumstances in which our young Irish doctors go abroad. One of them is a lifestyle choice where it is like a delayed gap year. A lot of young people go to Australia, especially at the moment. That is regarded as a temporary situation. These are people who intend to come back and they just want to experience a year in somewhere like Australia.
The second circumstance in which Irish surgical trainees go abroad is towards the end of their training to get sub-specialty experience. That is good for the health service and is a long-standing tradition which is encouraged and supported by the HSE through Dr. Richard Steevens' fellowships. They support young Irish doctors financially to go to centres of excellence abroad to learn skills that are either not available here or for which the training is not available here. Doctors going abroad by choice to do specialty training is something that enhances patient care in Ireland. It has always happened and it is strongly encouraged by their trainers.
I will now get back to the staffing issues which crystallised particularly in July this year. In surgery, about 60 to 80 vacancies arose among that group of doctors who were carrying out service posts in surgery in the health service. There were very few vacancies in the training triangle as displayed on the left-hand side of the slide. That dynamic probably arose from fewer people coming into the system because there is a turnover in that group of 400 general register doctors, and probably more of them leaving the country.
If we look at the reasons, we will see they are obviously multi-factorial. It is not simple or for one reason. I have already mentioned the fact that these posts are not recognised for training, which makes them less attractive. In the same way as Irish doctors go abroad to get specialised training, a young foreign doctor coming here wants to be in a post where he or she will be actively trained and not just delivering service. That would be one reason they are less attractive.
As part of the Medical Practitioners Act a new exam has been brought in which non-EU doctors must sit to get registered to work in Ireland. It is an expensive exam and for one part of it the doctor has to travel to Ireland to sit the exam, which is a disincentive to doctors travelling from abroad to come here. There was an issue in the past about work permits which has been resolved but it is a bit of a legacy issue. It is probably a contributory factor to the problem today.
It may be that some overseas doctors perceive that the terms and conditions of junior doctors in Ireland have disimproved over recent years. There is no doubt that the income of junior doctors has reduced, partly because of public sector pay cuts and partly because although the European working time directive has not been completely rolled out in Ireland, overall the fewer hours that doctors are working are. That means the overtime they earn is less, so their overall income has gone down.
It is possible that the perception of Ireland abroad has been affected by the economic situation here. We do know that there are more attractive markets in other countries for doctors where they may feel they will have better prospects.
There is a worldwide shortage of doctors and health care workers, so other countries are actively recruiting mobile doctors. The United States and Australia, in particular, are actively recruiting in south east Asia. There are multiple reasons fewer of these doctors are coming to Ireland and why we ended up with a manpower crisis.
There is an ethical aspect to Ireland recruiting doctors from low income countries. Although there is an error in this diagram displayed, it shows that Ireland has one doctor for every 360 inhabitants. The second line should read "India". We have been recruiting doctors from India and Pakistan. In India there is one doctor for every 1,700 inhabitants, while Pakistan has one doctor for every 1,400 inhabitants. Therefore we are taking doctors from countries which are short of doctors.
Ireland has signed up to the World Health Organization's guidelines which address the ethical recruitment of health care workers. Mary Robinson was a champion of that WHO initiative. The key provisions are that countries which recruit health care workers from a low income country have an obligation to support medical education in the home country from which these health care workers are coming. They also have an obligation to train and develop health care workers who come to Ireland. Those people, when they return home, will enhance health care in the low-income country. By definition the posts of those 400 doctors in the triangle, who are mostly from outside of Ireland and who provide the service requirement of surgical health care in Ireland, are not recognised for training and those posts into which the doctors who have been recruited from Pakistan and who have been placed on the supervised register are going into, also are not recognised for training. They have been brought here purely to fill a service gap. There is an ethical issue to what we are doing in bringing doctors in from outside countries.
In passing, the college of surgeons has an involvement internationally in health care education. In terms of those WHO guidelines, we have involvement in medical schools in countries where there is a low proportion of doctors. We are also involved in health care management and leadership training for doctors abroad. We are involved in a major surgical training initiative in sub-Saharan Africa that is supported by Irish Aid, looking at training surgeons and others who could perform surgical procedures in rural areas in sub-Saharan Africa where there are long distances between hospitals and where people live. It is important that we highlight the ethical aspects of medical migration at home and abroad.
To get back to the triangle, this is something that will not be resolved by continuing to recruit on an annual basis doctors from low-income countries to fill a service gap in the Irish health service. The long-term solution would encompass probably an increase in numbers of consultants or specialists to deliver the care supported by an increase in trainee numbers because the two are matched, and a reduced reliance on these service doctors and, instead, looking at a different skill mix of professionals within the health service who could fill that gap. We would be looking at matters such as extending the role of specialist nurses and new professionals, for example, physician assistants. A physician assistant is a health care professional post that does not exist in Ireland but is very common in North America. It is somebody who is trained to deliver health care in a supervised way but who is neither a doctor or a nurse. I refer to a mix of professionals to fill a gap, not merely relying on service doctors who come here on a short-term basis.
The crisis that crystalised in July of this year cannot be addressed by a short-term solution. We need a more radical approach to prevent this happening again. We recommend setting up a high-level group to look at possible solutions to this problem. Part of that group's work would be a manpower exercise that would look, not only at numbers but at skill mix in the delivery of the health service, and it would incorporate new grades. Part of that also would involve networking of hospitals because better care is provided where hospitals are networked in terms of quality and the safe care of patients.
I thank Professor McGovern for her thought-provoking and interesting presentation. I now ask Professor Murray to make a few remarks.
Professor Frank Murray
I thank the committee for inviting us here today. I am pleased to speak on behalf of the Royal College of Physicians of Ireland, which is the largest single training body in post-graduate medical education and training in Ireland, and the Institute of Obstetricians and Gynaecologists, which my colleague, Dr. Michael O'Connell, is from.
Many of the comments by Professor McGovern are common to all of our training programmes in terms of the triangle she has shown the committee already on the crisis that has been precipitated by the alteration in the recognition of many registrar posts around the country. It is worth saying that in the training programmes for which we are responsible there are approximately 1,200 posts and virtually all of those posts are filled. That is in sharp contrast to the registrar posts, which are outside training programmes. Why is that? In recent years we have taken initiatives to recognise programmes rather than posts. We do not recognise simply a post in a hospital for training. If an individual enters a training programme with us, he or she is locked into it for two and a half years. It is a balanced proportionate training programme, at basic level for two years, and, subsequently, at higher specialist training for four or five years, rather akin to what Professor McGovern has already stated. Those training posts are virtually all filled and the big deficit, in terms of junior doctors or non-consultant doctors, is in non-training posts, mainly in hospitals which are outside the metropolitan areas. We have addressed that in as far as we could in the sense that we have made our training programmes geographically dispersed and many posts rotate through smaller hospitals in networks also, as Professor McGovern stated already.
However, there is a shortage of NCHDs. Undoubtedly that has increased in recent years. There are many factors in this, many of which have been referred to already by Professor McGovern in her presentation. Part of it is that Irish graduates are moving abroad in large numbers. Last year, for instance, almost half of the interns, who finished internship in Ireland, moved abroad. Part of that is, as Professor McGovern stated, a gap year, but many of those graduates do not come back. That reflects a number of issues. Partly it reflects the unattractiveness and uncertainty about medical career structures in Ireland - where people will end up. The committee will have noted that Professor McGovern showed a triangle with a small number of consultants at the top, and that applies. In many specialties, there is uncertainty about the outcome. Undoubtedly, having better career and workforce planning would help in terms of retention.
Doctors in registrar posts have left Ireland in large numbers and continue to do so. It is difficult to recruit doctors from abroad to come and work in those posts because they are not training. Most of us around this side of the table have gone abroad to work in posts from which we return enriched in terms of our training. Many of those who traditionally came to Ireland from economically deprived parts of the world with a view to getting trained, as Professor McGovern stated already, are no longer attracted to come here because they cannot get recognition of their time working here, and that is a real issue.
There has been a reduction in applications, not only to registrar training posts but to all posts in Ireland. Even though we are filling our posts, more people are going abroad and it is less attractive to be a trainee in Ireland. There is emerging evidence also that it is less attractive to be a consultant in Ireland. Many of these matters are linked. There has been a significant reduction in the numbers of people applying for consultant posts in Ireland in many specialties.
We do not have necessarily the solution to all of these things in our hands. Medicine is a global profession. It is internationalised. People will travel for many reasons, as Professor McGovern stated already. Decisions made elsewhere will have impact on our ability to retain and recruit here. We must be conscious that we are working in a bigger, internationalised medical environment.
In recent years Ireland is no longer the employer of choice for many doctors. They see better terms and conditions and better opportunities abroad, and a better certainty about what the outcomes may be. It is fair to say that Ireland is relatively unattractive compared to previously. This has enormous implications for the quality of health care. It is a high priority to attract and retain high-quality doctors in Ireland. There have been incidents before the Medical Council in Ireland recently about the difficulties in recruiting, for instance, even at the most basic levels. The reasons for these difficulties in recruitment and retention include the following. Workforce planning is ad hoc and ineffective. There has been a breakdown in trust between doctors and many parts of the system - the HSE, politicians, the training bodies and the media. There is a lack of clarity for many doctors about what their ultimate career opportunities and ambitions may be. Many of the training programmes are under threat by service pressures. The quality of the training programmes are under threat for a similar reason because of the increasing service pressures, which are an important matter. The service pressures are why we are here. Our first interest is to look after patients and also address issues such as optimisation of working hours.
Our goal is to produce, retain and attract high quality doctors in postgraduate training in Ireland. It is critical to the Irish health service that doctors are trained to the highest international standards and we have made considerable progress in that regard. The needs of the health service and patient care must also be met and it is important that Ireland retains and enhances its ability to attract high calibre consultants and trainees. This attractiveness is linked to the quality of the training programmes offered.
We recommend workforce planning in the medium and long term but this needs to be done in the context of deciding what sort of health service we want. If it is to be consultant provided, for example, that needs to be factored into workforce planning. Greater flexibility in career structures and progression paths are also important, particularly given that more than half of the graduates in Ireland are women. Flexibility would make it more attractive for graduates to stay in Ireland.
We must maintain our focus on quality of training. The training programmes offered in Ireland have improved enormously in recent years. As training bodies, we have concentrated our efforts in this area with on-the-ground support for training and clarity of progression through the training programme. During the training programme it is clear how one progresses but what happens afterwards is often more difficult to predict because of uncertainties about the future development of the health service. We have aligned medical training to the national clinical programmes and models of care. As members will be aware, issues arise in regard to the clinical programmes provided by the HSE and the Department of Health. We are aligning our training programmes with the needs of the health service, for example by developing an acute medicine programme, which is a priority area for the HSE and the Department.
In the shorter term, we recommend that a multi-stakeholder high level group be established to investigate the reasons for medical emigration and develop solutions to the issue. With that in mind, we are organising an NCHD retention workshop for early December which will include all the main stakeholders, including doctors, the HSE and the training bodies. The crisis in NCHDs and junior doctors will not be addressed in the short term and a collective approach is required to find a solution. Many of those who can help us deliver a solution are sitting around this table.
I thank Professor Murray for a very interesting presentation. I remind members that we will take questions rather than Second Stage speeches.
I welcome our guests and thank them for their presentation. We have been addressing this and related issues for quite some time. I am reflecting on the content of the joint submission and the points raised by Professor McGovern. Ireland is no longer an attractive location for NCHDs. I used the word "location" rather than "destination" because the issue concerns not only foreign recruited NCHDs but also domestically trained doctors. It is a serious problem. It has been mooted within the profession that newly qualified doctors be obliged to provide one year of service in Ireland. I have followed the debate in some of the medical publications and ask the witnesses their views on compelling those who come through the Irish system to remain at home rather than move abroad in their first year of qualification. Is there merit in the suggestion and what are the arguments for or against it?
We recognise the serious problems that arise in regard to the perceived lack of career opportunities in Ireland. The bottom line is that we need more consultant posts. In his most recent meeting with the committee, the Minister spoke about creating a new associate or assistant specialist post. What are the witnesses' views on the creation of another opportunity for progression in a normal career path? Clearly there is a need to lay out a career path that gives people the opportunity to meet their objective of reaching the position of consultant within a reasonable timeframe.
The current difficulties in regard to recruitment embargoes and the Department's arguments about the number of consultant posts also have to be addressed. I welcome that a national forum on retaining doctors in Ireland is being organised for early December. Opening up opportunities for career paths and creating new consultants posts are aspects of the problem but will the forum also address wider issues? Would the witnesses argue for the creation of a high level group to investigate the reasons for the wider difficulties that arise?
According to the fourth recommendation in the witnesses' submission, "[r]econfiguration of specialist services to provide critical mass and to ensure that patients have access to services of high quality will be crucial to this process." As a layperson and elected voice, albeit one with a deep interest in health matters, I have found these recommendations translate this into a recipe for the closure of services in smaller hospitals. As I come from a community which has been deeply affected by one such decision, I have to express my fundamental disagreement with this policy. This is an argument we may leave for another occasion, however.
I ask the witnesses to respond to my questions on obligatory service, the need for additional consultant posts and dealing with the current embargo and the failure to create new posts. These matters also invite a comment on pay and remuneration. Can we create additional opportunities for consultant posts by dealing with pay and remuneration in these difficult economic times?
I thank the witnesses for their presentations. Professor Murray spoke about the difference between training programmes and training posts. We have had personal experience of that difference at Roscommon county hospital. We have a hospital network but the NCHDs are not part of a training programme. What is being done to address that issue so that other hospitals do not end up in our situation? There were sufficient NCHDs in the network but because the posts were not recognised at Roscommon the emergency department closed. Is the RCSI moving away from the training posts model to training programmes? If reconfiguration is to be successful the consultants themselves will have to pull up their socks and live up to the commitments they have given on training programmes and working through the network of hospitals. That does not appear to be happening at present.
Professor McGovern noted that the work permit problem appears to be petering out and hopes it will be resolved shortly. The other aspect of immigration, however, is the visa regime, which appears to be a problem because visas are being issued on a six-month basis rather than for two years. The issue also arises of family members obtaining residency permits.
Two questions arise from the witnesses' presentations. A slide shown earlier showed India and China as bulging countries because of the low numbers of doctors as compared to population. Is the situation in the UK similar or was that a graphical error on the slide? The final diagram shows reconfiguration as part of the solution to the problem. Is it not the case that reconfiguration is being used as a solution to deal with the third triangle and that rather than being seen by the HSE as the silver bullet, reconfiguration should be seen as a smaller portion of the resolution of this issue?
I now invite the witnesses to respond.
Professor Ellis McGovern
I will respond to the first question in regard to whether young Irish doctors should be obliged to spend a year in Ireland before going away. Members will have seen from the diagrams shown that the vacancies are in posts which are service posts. Asking Irish doctors to remain here for the first year after their internship would not address that issue. In terms of addressing deficits in the health service, I do not believe the college would agree that would resolve the acute problem we have.
Professor Frank Murray
I agree. A depth expertise is needed rather than relatively junior trainees. I would invert the question and ask how do we retain and recruit doctors to come to Ireland, in particular doctors at a more senior level? We must ensure we have a more functional health system and that posts are attractive in terms of service provision, which is what all doctors set out to achieve, and professional satisfaction. That is what people, as medics, want in their jobs. They want to be part of a system that works well and provides a good service for patients. Professor McGovern is correct that we would not in any way advance the deficits by introducing a forced year of work in Ireland after graduation. I would focus on making posts here better from a training and service point of view.
Mr. Leo Kearns
I would like to comment on that issue and to respond to the second question in regard to the associate specialist posts. If there is anything we have or should have learned over the past 30 years it is that taking specific actions which might in themselves appear to make some kind of sense in a complex organisation or environment does not work. For example, three years ago a decision was taken to remove training recognition from approximately 1,000 posts. While in theory that might have been the right thing to do, the decision was taken in isolation and led to significant problems, many of which we are experiencing today. It is multifactorial. We must avoid being sucked into making quick decisions that will make a situation worse.
With regard to the question of the year in service, if junior doctors are told they are the problem and are to be forced to remain here for one year their response will make the situation worse. I believe the same applies in respect of the associate specialist roles. Treating the situation in isolation is not the way to deal with this issue. All factors must be examined and a joined-up plan must be put together to show that over time the situation will be improved.
Professor Frank Murray
On putting in place structures that facilitate people returning, as I stated approximately half our interns are leaving. We are examining what we can do to facilitate their returning to Ireland. Our training body is in the process of organising their taking of examinations when abroad so that their re-integration into the system as a trainee might be easier. Traditionally, when they went to, say, Australia - which is where most of them went - they were out of the system and when they decided to return found most of their friends who remained at home were a year ahead of them and had started their examinations and so on. We have taken the initiative of offering from January this year the first part of training examinations in one or two centres in Australia, thus assisting people who are there to return more easily. Many of these people are working in posts in Australia which we could recognise for training because they are working in parallel with Australians who were in training in a high-quality verifiable training system. We are looking towards recognising some of that training again with a view to allowing people to re-integrate into the Irish training system.
If people want to return, we will facilitate their doing interviews over the Internet so that they do not have to fly half way round the world to attend them. While there are many initiatives being taken on a bigger scale, we have been examining what we can do to facilitate the return of Irish emigrants. We have addressed this issue at junior training level. It is also worth focusing on how senior doctors work in both training and consultant posts, thus making those posts more attractive to facilitate the recruitment of high quality medics.
I welcome that practical initiative. We are looking for practical initiatives. Perhaps the witnesses will tell us what role they are playing and what role we, collectively, can play to address the real solution, namely, the creation of more consultant posts? Are the organisations proactive with the Government in regard to the creation of additional consultant posts, a clearly defined professional career path for people through the system here which will be critical in terms of encouraging people not alone to stay but to return? Perhaps the witnesses will respond on that issue.
In regard to the forum to which I referred earlier and which was instanced in the joint presentation, the term "ad hoc“ might not be fair. The forum is described as a national forum on the retention of doctors in Ireland. Perhaps the witnesses will say if it will address the full scope of the problems we are trying to address here this morning.
The next batch of speakers are Senators Burke, Crown and Gilroy. I remind members to stick to asking questions if they can.
I thank the witnesses for attending and apologise for not being present to hear the full presentation but a Vote was taking place in the Seanad at that time. However, I read the documents supplied prior to the meeting.
I have been in contact with a number of hospitals around the country during the past three or four days and as such I am familiar with the issues that are arising. On the total number of training posts in the country, we have been told the figure is 3,700. I received a letter from the chief executive of the medical council stating it to be slightly over 3,000. There is a huge difference between 3,700 and slightly over 3,000. Perhaps the witnesses will clarify that issue. On the specialist registrar and the manner in which people get on that register in terms of the structured training programme, while it is a well developed programme, I have received complaints about it. I recently attended a medical function at which raised the issue of people working in hospitals as registrars who are not specialist registrars. While they are not on what might be termed a "structured training programme" they are acquiring much experience but there is no role for them.
I received a letter from a doctor who came to Ireland approximately seven years ago, commenced training and believed all the doors would be opened for him. He stated that after about five years of doing the rounds he felt ready to seek completion of training and sought the opinion of respected senior colleagues. He was encouraged to go for it and did so. He was, however, surprised to get feedback that he was too experienced for the SRP. His letter states that there is now no door open to him and that he is currently applying for jobs in Canada.
Another issue that arises in respect of the specialist registrar programme is the position of the person on a five-year structured programme who opts out after three years to work outside Ireland. Someone who has done, for example three years, not in a structured training programme but working in a hospital in the same type of job, is not allowed to come in or no credit is given to him or her for the years he or she has done as regards to coming in at year two or year three of the programme as opposed to starting from scratch to do the five years.
Another issue has now arisen. The HSE has issued a letter instructing all hospitals they can only employ locums who are on the specialist register, which means that many hospitals will not be able to get locums because no people are available. I am not sure how the HSE arrived at that decision.
This morning I got the figures for the number of people applying for jobs as consultants. In 2008, some 130 consultant posts were advertised with 649 applicants, which works out at approximately five applicants per job. For the first half of 2010, some 133 consultant posts were advertised with 214 applicants, which is 2.2 applicants per job advertised. Not only do we have a problem with junior doctors but we also appear to have a problem in the consultant area. How can that issue be addressed? I am aware it is not something the HSE can resolve overnight. I accept the document presented here this morning is very constructive and appropriate.
I welcome my colleagues and friends to the House. I am looking at Professor Frank Murray and hoping I remembered to pay my membership fee to the Royal College of Physicians of Ireland this year - he might check that for me.
I guess we need to do this like the old American television show "Jeopardy!" and make all the statements in the form of a question. Do we all have general agreement that the key staffing problem in the health system is a desperate shortage of career-level physicians? It is not that we are just a little bit short; we are off the bottom of the chart. It is only the existence of Her Britannic Majesty's United Kingdom that makes our numbers in any sense look just deficient as opposed to being abysmal because the second worst for every specialty is the UK. Together we are clustered around the bottom. For example in urology, the recommendation is to have one per 30,000 of population; we have one per 180,000 of population. The numbers are similar for dermatology and we have approximately one quarter the number of oncologists we should have.
If every junior doctor in the country left tomorrow it should make no difference to the running of the health system. Junior doctors are first trainees, second trainees and third trainees. When I hear the witnesses mention there are posts which are non-training non-consultant jobs, I wonder whether those jobs should exist. Simply put, those jobs should not be there; they represent a Band-Aid on a gaping wound of personnel shortage. The more we try to gloss over it by plugging the gap with people who are not trained to do the jobs they are doing, the longer it will be before we grasp the nettle of fixing the fundamental problem.
I am sympathetic to the point Deputy Ó Caoláin made about people leaving because there is significant public subsidisation of medical education and one could argue that people should be returning something. However, these people should not be asked to do training jobs, not because it is unfair to them but because it is unfair to the people for whom they will be working. We should not need trainees to provide the service. Someone who dropped a gold fáinne down a drain would not call a plumber's apprentice to fix it, but would get a fully trained plumber to do it. However, someone's precious daughter could have a complicated abdominal emergency and be looked after exclusively by junior doctors in many parts of Dublin and throughout the rest of the country. That is just wrong and we should not structure the system in that way.
Historically there have been two reasons for emigration. There has been much focus on the gap-year phenomenon, which may reflect differential levels of maturity of youth now compared with the past. The reality is that approximately two thirds of every medical school class of people who are in our middle years emigrated for two reasons. A significant number emigrated because there were not career opportunities here. The biggest demographic comprised people who went to the United Kingdom to train in general practice or to a lesser extent in other specialties. The second group comprised people such as Professor McGovern, Professor Murray and me, who emigrated to get training because we wanted to get upskilled in the very best places in the world and bring those skills back home. That process which is unique to Ireland has been extraordinarily positive for medicine here. Without being sectarian, I can speak with more authority on oncology than I can on other areas. We only have 31 oncologists in the country, but 26 of them have trained in the top five American centres. No other country in the world has that level of qualitative skill in a quantitatively deficient group of people. It has been extraordinarily positive for people to do it.
Typically of that demographic, the people who leave want to come back and do not need encouragement to do so. If the jobs exist, between half and two thirds of those people will at some stage apply for a job in Ireland. Obviously if the general tenor of the country changes in coming years, that may change. However, that has been the reality historically. We should not be too nervous of people going for that reason. The fix to everything, including the implications of the NCHD shortage and that people appear to be leaving for bad reasons, is to have an appropriate match between medical graduates and career-level posts. That was my first question.
I shall finish on my second question. How sustainable is it that a country of 4.5 million people can have six medical schools or one per 750,000 of population, when the European average is one per 1.5 million and the North American average is one per 2 million, while at the same time having the smallest number of career-level positions of any country in the OECD? It is bizarre.
While I do not wish to put the witnesses in an awkward position, this issue has come up twice in our House and in the Lower House also. There is substantial concern about the plight of graduates of the Royal College of Surgeons of Ireland in Bahrain. We can all argue that medical schools and politics do not agree and as a general rule that is a good principle. This is a specific situation and a question of medical ethics. The witnesses tell us how they give a very high emphasis to teaching medical ethics to their graduates - I know they do. However, there is a great deficiency in medical ethics when we are not defending doctors who do nothing other than look after sick people. These are doctors who may not have the politically correct opinions in the jurisdiction in which they live and do their duty. It would be very positive to have a forthright statement from the Royal College of Surgeons of Ireland specifically supporting these people and urging that they be released.
Further to Senator's Crown's point, I find the silence of the Royal College of Surgeons of Ireland on the situation in Bahrain rather disturbing. It suggests some ambivalence in the area, on which the witnesses might like to comment.
Professor Murray referred to the establishment of a forum to deal with doctor emigration. Why are we so far behind the curve on this? We have had many reports going back over 20 years and we are only now setting up forums to discuss it. I believe we should be well ahead of the curve. It is ironic that it will be sitting in December when the new round of doctors will be coming in January and we might be facing the same problem as we had at the start of July.
Senator Crown identified the lack of specialty places as part of the problem leading to the dysfunction of elements of our health service. All stakeholders in the health service have a responsibility in this area and have probably contributed to that level of dysfunction. What responsibility do the three colleges consider they have for the level of dysfunction in our health service?
Further to what Deputy Ó Caoláin said, how much does it cost to train a doctor from entering medical school to acquiring registration? How much of that is publicly funded? It may be a matter of social equality that there might be an onus on people, who have been subsidised heavily by the public system, to contribute back to it at an early date. I have heard the opinion of witnesses on it but do not fully agree with all of them. I ask them to elaborate.
I thank the speakers for their contributions. A number of speakers spoke about establishing a high-level group to examine the reasons people leave. With all due respect, we know why people leave. What we really need to focus on is how to retain people. I welcome the suggestions on how to entice people to return, and the moves being made to link in with those abroad to make it as easy as possible for them to do so.
I will follow up on a point made by several speakers. Precedents were set with regard to other health professionals whereby the HSE gave them a subvention for their training after which they were duty bound to work for one or two years. This is a perfectly reasonable expectation because of the amount of money from the public purse that goes into training doctors. My brother is training to be a doctor and I have many friends who emigrated for the very reason Senator Crown outlined, which is to get expertise at particular centres. However, they should be required to give something back.
We spoke about the dysfunction in the HSE. New contracts were negotiated with consultants which bound them to treat a certain number of public patients. Today, 70 to 100 consultants fail in this obligation and this feeds into the dysfunction in our public health care system. They treat more private patients than public patients in public beds.
Why must we wait until 1 July? What have we done about this crisis, which we have known was coming? Why have career paths not been developed before now? Why must task forces be established at the 11th hour? Why have we not been proactive in dealing with this difficulty?
According to the Irish Medical Council there are 3,044 training posts.
A wide range of questions has been asked. With respect to the delegates, I ask members that we have one meeting only and not to speak among themselves.
I apologise. Sometimes, I forget which hat I am wearing.
Mr. Leo Kearns
With regard to numbers, I imagine the difference may be that intern posts may not be included in the Irish Medical Council figures. This could make a difference.
With regard to people in registrar posts, a registrar training programme has been introduced and has been up and running for the past two years. Anybody in a registrar post is entitled to apply for it but certain criteria must be met. The existence of this programme is plugging the hole.
With regard to people travelling outside of Ireland and then returning seeking credit for training, we can do this only if we can stand over it. If we know nothing about where they have been working, it is very difficult to apply credit. We are responsible to the Irish Medical Council for stating that the person is properly trained.
I am not sure whether the points made on locums were with regard to consultant positions. The bottom line is an issue of patient safety. If people in consultant positions, even on a locum basis, are not on the specialist registrar it is a patient safety issue.
There is a process by which people in registrar posts who feel they are fully experienced and should be credited can apply to the Irish Medical Council for registration and their experience will be assessed. There are many streams to this.
Issues were raised about the dysfunctional health service. There is no doubt that we have dysfunctional health service and this has been the case for quite a while. The feature that is most dysfunctional is the fragmentation and siloisation of anything to do with the health service. We have multiple stakeholders and it is an incredibly complex system. Health care is not a simple system. I have experience in electronics, pharmaceuticals and many other complex industries. The complexity of none of them compares to the complexity of health care. We have operated in silos for decades and not merely for the past two or three years.
It is easy to state that this is a problem for the HSE or one which the HSE created. It absolutely is not. The problem has existed for decades. The lack of co-ordination between health and education with regard to the number of medical students has existed for 30 years and was identified by the Fottrell group. In recent years, the colleges' perspective has been that we need to play a strong and fundamental role in trying to bring people together to get over the significant breakdown in trust which exists, and to try to play our part in working with other stakeholders to improve the situation.
The joint clinical programmes run by the colleges and the HSE to which Professor Murray referred are fundamental because for the first time they define how services should be provided. This initiative has been run for the past two years but it took three or four years to reach agreement that it should be done. These programmes are important for mapping out the future and they are what should be used to define how many consultants will be necessary and where the posts should be. We have never had this before and we need to see it executed. In the past, decisions on consultant posts were made in a committee room with very little visibility.
With regard to the forum which we have been planning for quite a while, it will involve the Department, multiple functions in the HSE, medical schools, training bodies, NCHDs and trainees. It will be based on the themes we have discussed at this meeting. We will not further analyse why the problem exists but what specific actions can be taken, and with all of the stakeholders around the table agreement will be reached on concrete actions to be taken. By its nature, the forum will have to consider more than emigration because some of the issues we have discussed are much more fundamental. It will not solve everything but it will be the first time all of the stakeholders come together to try to address the problem.
Who took the initiative?
Mr. Leo Kearns
The colleges represented at this meeting and a number of other colleges and training bodies. Approximately four years ago we took the initiative to form a group called the forum of postgraduate training bodies. This has been a significant factor in the improvement of quality of training. The suggestion to have a forum on retention came from this forum. We initiated it and received tremendous buy-in from the various stakeholders we mentioned.
When will the forum report?
I apologise Senator but I want to bring in Professor Murray.
Professor Frank Murray
I wish to comment on the number of consultant posts, which has been raised by a number of speakers. It is fair to state that Ireland is under-represented in terms of consultant numbers and many of us believe a significantly expanded consultant workforce would be good from many points of views in terms of patient care and would allow potential trainees to get a sense of where they may go.
On registrars and specialist registrars, there is a fundamental difference between the two. As was stated previously, the programme has a basic part for relatively newly qualified doctors and an advanced programme which brings people to consultant level. For people to get through it satisfactorily they need to pass a number of job plans and assessments in training and through formal external assessments. This does not happen for people in registrar posts, so it is very difficult to sign off people in registrar posts because they are outside the training programme. We have responsibilities to the Irish Medical Council to sign off people as being fit for purpose and having reached a certain standard of practice. We cannot do this if we do not know. Accordingly, we are restricted in our ability to recognise what people do as registrars before they enter a training programme because we do not know whether they have met the appropriate standards.
My question was on the person who is overqualified to get an SpR post.
Professor Frank Murray
That situation is different. SpR posts are competitive and taking a long time to reach a particular point may be viewed negatively in the assessment. Making progress through the system in the average period would be seen as an important part of career progression in terms of being competitive at interview, as is the case with all interviews.
Dr. Michael O’Connell
When people enter the SpR scheme in our specialty, they are usually three years post-intern. I recently read the letter to which the Senator referred. The person in question is seven, eight or ten years beyond that point in a post that, as Professor Murray stated, would not necessarily be fully assessed because some posts are not recognised as training posts. When such people apply for the SpR programme, they would be expected to enter at year 1 of our fully assessed five-year programme.
As Mr. Kearns mentioned, the person's other option is to apply through the Medical Council. If an SpR works in the same unit as the person, the latter's work is recognised if it is similar to the SpR's, but people must be able to show evidence, for example, log books. They have not done so to date. People have also been given an opportunity under the fixed-term appointment system, which has been in vogue in obstetrics since 2003. If people were senior enough and received a year or two of extra training in properly supervised posts, they would be given an opportunity to show that they were at the level required and, after being properly assessed, could be put forward for joining the specialist division. However, many people in that situation do not choose to avail of such opportunities. Consequently, we have since stopped providing them.
Professor Sean Tierney
In response to Senator Crown's point, we all recognise that we have an insufficient number of specialists but we have a reasonable number of doctors. That we have many doctors in non-specialist grades providing services to patients is a problem. We can address this by restructuring the workforce, given that increasing the number of doctors is not possible at this time. We have ended up with a dysfunctional set of arrangements, but these could be fixed without needing to start from scratch.
Deputy Conway is correct, in that it is too late to start examining the issue. I have been a consultant for 11 years. When I started, I sat on a group set up by the then Minister, Deputy Martin, that examined this issue specifically. Plans to address it have been identified. The message this morning is not a new one but nothing has been done. Instead of increasing the number of specialists, we have increased the number of non-specialist, non-trainee, non-consultant hospital doctors. Patients are poorly served by this set of arrangements. As long as we continue to view the recruitment doctors from India and Pakistan who would take ten or 15 years to reach specialist level as the solution to our health care crisis, we will never solve the problem. A group needs to examine what we know to be the case. We have analysed the problem and know what it is. What we need now is a plan of action.
That was well said.
It was a good point.
Professor Frank Murray
In terms of the registrar grade, people in non-training posts could do better were their posts structured and subject to some of the parameters of an SpR post. The Royal College of Physicians of Ireland has run a programme through the training bodies to recognise individuals who are suitable for training and who have been making progress through their careers so that the people in the posts in question would have the benefit of job plans, assessments, education days, formal training, etc. This is done with a view towards enhancing the quality of education and training within those posts and allowing us to recognise part of that time worked for higher or SpR specialist training.
We have tried to be on the front foot by seizing opportunities to enhance the training and educational components of posts, even those that are not formally in our training programmes. We have also expanded our training programmes geographically with a view towards facilitating fewer posts being stand-alone non-training service posts, as Senator Crown mentioned.
Two of my questions have not been addressed.
There was also a question on the medical school.
My first question was on the situation in Bahrain. My second was on the cost of training from entry into medical school to registration.
I did not participate in the questions and answers session. I am a lay person who does not know much about doctors and so on, but I was interested in what our guests stated.
The seventh recommendation in the strategy plan is on the reconfiguration of specialist services. Accident and emergency units in some rural hospitals are being closed and people are being sent to hospitals that are more structured, possess greater expertise and specialist staff and can better cope with emergencies. Is the seventh recommendation supportive of these closures?
Professor Eilis McGovern
Networking hospitals in a hub-and-spoke model will provide the safest care for patients. Ireland's population is the size of Manchester's, yet each of our 36 acute hospitals had 24-7 emergency, surgery, medicine and anaesthesia departments until recently. Providing high-quality, safe care for patients in so many hospitals is a challenge. If we could network hospitals into groups so that the 24-7, high-demand specialties and activities were carried out in a central hospital and the network's staff and activity moved between the central and the peripheral hospitals, most of the care would be delivered on the periphery. The bulk of care provided in hospitals is of low and intermediate intensity and lends itself to being provided in hospitals that do not need intensive care units, laboratories and staff who are available 24-7. Most people would get their care close to home. A small proportion of patients in need of care that required a high level of resources and specialisation would need to travel to the centre.
Not only would networking result in better and safer care for patients, it would also go a long way towards addressing the issue under discussion, namely, how to make training posts attractive to young doctors. If the training posts were networked in a similar way, those in the smaller hospitals would be assessed by the training bodies in the context of a programme that encompassed the whole of the network. The standard of the training would increase and the posts would become more attractive and be filled.
In terms of the recruitment and retention of consultants, a post that is structured so that a consultant might have a joint appointment between a central hospital, where he or she would practice a sub-specialty, and a peripheral hospital, where he or she would practice the activity that could not be provided there, would give job satisfaction and make posts attractive. Currently, the only jobs that are available are either one or the other. They are in the major teaching hospitals and urban areas or in the small peripheral hospitals. As doctors applying for consultant posts are highly trained and, in many cases, have attended the best centres abroad, they would prefer to work in the central hospitals. We cannot make the posts in the small hospitals attractive. If one cannot get high-calibre people to fill them, the quality of care offered will not be as good. For that reason, we believe networking has the potential to address many of the issues that challenge the health service today.
As per the first slide of the presentation, it appears that in comparison with India and Pakistan, we are faring better in respect of inhabitants per doctor. Senator Crown remarked last week and again today that we are fire fighting and are only putting a Band-Aid on a gaping wound. Are the witnesses confident and satisfied that through the HSE and Medical Council of Ireland, whose representatives attended before the committee last week and have signed a memorandum of understanding with the HSE to be proactive on this matter, we will reach the point of having a significant reform process or are we simply playing handball against the haystack?
Professor Eilis McGovern
It is important to have a joined-up approach to all the different initiatives taken in the health service. The HSE clinical programmes initiative is consistent with a networking approach. The clinical programmes describe the ideal hospital unit for the particular specialty. It is important to join up all the initiatives, including the training initiative and recruitment and retention of doctors and consultants initiative. As Mr. Kearns pointed out earlier, if we take one issue in isolation and try to fix it, we will not progress. For this reason the retention workshop of which we spoke needs buy-in from all the different stakeholders involved in the health service and education sector.
Can we get that?
When is a report due?
Mr. Leo Kearns
The meeting will take place on 1 December. We would hope to have a document produced quickly after that. The document will be action orientated.
One of the problems is that we have had configuration. Configuration has been happening without any clue of how the service should be delivered or any joining up of initiatives. Only God knows by what this was being driven. It was the cart before the horse. The clinical programmes are absolutely essential because this is the first time Ireland has had clinically led programmes, which are joint programmes between the colleges and HSE. The programmes are clinically led, involving nurses, management and clinicians in regard to the running of the diabetes and acute medicine services and so on. Following agreement on how that should be done, configuration, restructuring or networking should fit with it. We must also align training with that.
The colleges are centrally involved in the clinical programmes and training. We are determined to ensure both are lined up together in order that we can make progress in the future. The nature of the beast is that we have had fragmentation, siloisation and people looking at their own area and not taking into account everything else. That must stop. We do not need more analysis. We know what needs to be done. We must join up these initiatives with all the key stakeholders. We are absolutely determined that the actions that need to be taken will be pushed from our end. We will continue to push for the actions that have to be taken in the round. For example, we are nearing conclusion of our work with the HSE on the issue of the lining up of the medical education and training activity with the clinical programmes as opposed to HR, where it is at the moment. It is hoped there will be significant actions to make real progress. This requires the Medical Council of Ireland, the Department of Health, the political system, training bodies-----
In Mr. Kearns's opinion, what role does the political system have in this regard?
Mr. Leo Kearns
We all work in a political environment. There is a huge onus on the political system, as the arbiter of what the public needs from the perspective of its health care, to work with the stakeholders who are responsible for delivering that service so that we have single leadership and direction. We have been destroyed by multiple direction and everyone looking after their own piece of the jigsaw. There is tremendous opportunity for the political system to support the key initiatives and for others to hear what is coming through from the political system.
Professor McGovern in the first line of her last response stated: "Ireland is the same size as Manchester". It is not, although I know what she meant. That is the problem. These are the comparisons that are being made. People are trying to draw rationale out of that in terms of population numbers. Ireland is unique. It is a country in its own right. We have our own relative requirements in terms of geographic spread. Much of what has been explained I understand and accept. However, those who are devising and putting forward proposals in regard to rationalisation, regionalisation, centralisation or whatever one wishes to call it are using the analogy of numbers. The same size does not fit all. We have our unique needs as a people across a geographic spread. We also have equal rights as citizens contributing to all that provides the services. We cannot all, and will not, be forced to move to the greater Dublin area.
Professor Eilis McGovern
Up until now , one of the weaknesses of many initiatives within the health service has been communication with the public. One of the major issues around initiatives such as rationalising hospital services is that we have not successfully informed the public of its advantages and disadvantages. That is the reason there is understandable concern and unrest each time something like this is promulgated. We have the facts, figures and rationale for doing this but we have been poor at communicating that to the public. That must be addressed.
Professor McGovern is correct.
We also have the experience of the health working of it.
Mr. Leo Kearns
I come from Sligo. Many of my family continue to live there and as such I have close ties with it. I come from an area which is not too far away from Senator Crown's home town. The experience of the removal of cancer services from Sligo General Hospital was incredibly difficult. As Professor McGovern stated, it is not only that we as a system have not communicated with people but also that we have not understood the fear people have in terms of changes in service and the lack of confidence and trust that what is being put in place is better. The political system and those of us involved in the health service need to work much closer together in putting that across.
What Professor McGovern said is correct. This is a really complicated issue. It is not a question of trying to deprive the people of Monaghan of a service. The argument that some services are not safe because of insufficient put-through is grossly abused. Without wishing to be regional, I am not from Sligo. I am proud to have north Leitrim ancestry and have many connections to Sligo and as I will not ever be running for election in Sligo I can speak freely. The reality is that the former North Western Health Board area has by any international comparison a sufficient number of patients to sustain one cancer centre. At the same time as people were being told they had to leave there to come to Dublin, not one but four cancer centres were being developed in Dublin, not one of which satisfies the international criteria of a comprehensive cancer centre. It is very obvious that when this plan was being evolved, people were wrapping themselves in the cloak of international standards when it suited but in reality ignoring the same standards and laying down under the feet, so to speak, of big medical schools and hospital politics. They ensured that institutions held on to what they were getting. Nowhere else in the world would have a system where lung, pancreas and bladder treatments are specialties in different institutions. That is mad and no one else does this. Trust me, I know something about cancer services.
There are six medical schools. Are there any strategic thoughts on whether we must rationalise them? Does Professor McGovern know off the top of her head the total number of consultant level staff employed by the Royal College of Surgeons in Ireland, RCSI? That does not include health service staff doing voluntary faculty work but people who are employees of RCSI and at consultant level.
I appreciate that the Chairman is allowing me in a third time.
The Senator should be brief. I am being very generous with people today. Perhaps too generous.
Yes, and I will be brief. As democrats it is important to uphold democracy everywhere we go and champion human rights. I note that Professor McGovern may not be in a position to comment on what is happening in Bahrain.
It is not within her ambit today.
I am not rambling. This is important, and if we cannot uphold democracy and human rights, we should not be in politics at all. Will Professor McGovern arrange for the position of the Royal College of Surgeons in Ireland to be communicated to this committee in private on that issue?
Professor Eilis McGovern
I have been asked twice about this. I am happy to say that the Royal College of Surgeons in Ireland fully supports the rights of doctors to practice in any position without fear of discrimination or sanction. That absolutely goes without saying. The main criticism of the college has come from how to influence what is happening in somewhere like Bahrain. We felt all along that there are two ways in which outside bodies can influence the position in places like Bahrain. There is the public, high profile and high visibility method of trying to have influence from outside and the more low-key use of connections made over many years. We felt the way we can best influence what happens in Bahrain is to use the connections built up over 30 years, starting off running surgical exams and more recently having a permanent presence with the medical school.
We also feel that to some extent it is a case of "either" and "or" in the way we use those two modes. We feel that if we very overtly use high visibility and high profile roles, we will have connections cut with people on the ground in influential positions where, because of our relationships, we currently have very easy access to people in places of high influence. At the same time we recognise that what we and others are doing are complementary.
We would like to think there has been a positive response emanating from Bahrain over recent months where there has been an international review body on the ground and which is due to report shortly. A dialogue has been initiated and the doctors have been released from prison. The trials have been transferred from a military to a civilian court, and we would like to think that reaction from the authorities in Bahrain has resulted from the combination of the two types of external influence being brought to bear. We would liken what is happening in Bahrain to Northern Ireland, where it took many years of dialogue and reconciliation to come to the current position. If we had to rely on the high profile approach, the progress would not have been made.
Professor Frank Murray
I will wrap up on behalf of the training bodies. It is clear from the presentations today and questions that what we work in is a very complex health care, education and training environment. I know I speak on behalf of all the Irish training bodies acting through the forum in saying we would like to be part of the solution to these problems. We are making whatever steps we feel we can make towards the solution to these problems and we are happy to hear of any other constructive solutions people may have. We would certainly be happy to consider them and try to implement them if it seems the reasonable action to take.
I thank the witnesses for coming before us for what was a very constructive presentation. I wish them well in dealing with the many issues. We will do anything possible to give help from the political area, as it is for the betterment of everyone in the country that we resolve the issues in the health service. The sooner we come to a solution, the better.
I thank Professor McGovern, president of the Royal College of Surgeons in Ireland, Professor Sean Tierney from the Royal College of Surgeons in Ireland, Mr. Leo Kearns, chief executive officer of the Royal College of Physicians of Ireland, Professor Frank Murray, registrar of the Royal College of Physicians of Ireland, and Dr. Michael O'Connell, national specialty director of the Institute of Obstetricians and Gynaecologists for coming before us. They have given a very cogent and thought-provoking presentation which has raised many issues. We have learned that we must have an holistic and joined-up approach as opposed to the sectoral approach.