JOINT COMMITTEE ON HEALTH AND CHILDREN debate

Non-Consultant Hospital Doctors: Discussion (Resumed)

Chairman

From the Irish Medical Organisation, IMO, I welcome Ms Shirley Coulter, assistant director of industrial relations, Mr. Mark Murphy, chairman of the non-consultant consultant doctor, NCHD, committee, and Mr. Patrick Plunkett, consultant in emergency medicine. From the Irish Hospital Consultants Association, IHCA, I welcome Dr. Margo Rigley, president, Mr. Denis Evoy, vice president, and Mr. Martin Varley, secretary general.

This is our third and final meeting on the topic of junior doctors, from their recruitment, appointment, education and training to the viability and appropriateness of our reliance on junior doctors for staffing hospitals. Our visitors today will speak from the perspective of medical practitioners.

Witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence in regard to a particular matter and they continue to do so, they are entitled thereafter only to qualified privilege in respect of that evidence. They are directed that only evidence connected with the subject matter of these proceedings should be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

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

I invite Ms Coulter to make her opening statement.

Ms Shirley Coulter

I thank the committee for its invitation to present our views.

Non-commissioned hospital doctors play a vital role in the delivery of the country's health services, but this role is unappreciated and undervalued by the policy makers and HSE managers who control the service. There is disconnection between the attitude of the HSE towards NCHDs as cost effective, highly skilled labour to staff hospitals without due regard to career planning on the one hand and the aspirations of NCHDs themselves on the other, for whom their time as NCHDs is a critical step on their career path and during which they expect to receive training and hands on experience leading to specialist posts. Add in absolute disregard by the hospital management for the NCHD contract of employment and appropriate working conditions and the consequences are as inevitable as they are damaging - a crisis in morale among NCHDs best exemplified by the finding of the recent IMO benchmark survey that 57% of NCHDs would not recommend a career as an NCHD to a family member. This crisis in morale, together with poor manpower planning by the HSE, directly leads to NCHDs travelling abroad to complete their specialist training while the Irish health services are left tackling a doctor shortage that threatens the ability of many hospitals to continue to function.

When manpower planning for the health service, consideration must be given to the need to recruit, retain and motivate doctors with the qualifications, skills and flexibility required to exercise their responsibilities. The report of the postgraduate medical education and training group, chaired by Dr. Jane Buttimer, warned of the urgent need to make significant efforts to improve the working and training environment for NCHDs "to avoid a ‘brain drain' from Irish medicine".

Alarmingly, according to the results of the IMO benchmark survey, 61% of NCHDs described their current level of morale as fairly low or very low, 60% stated that this morale had declined or declined greatly with their level of morale as an NCHD three years ago, 75% would describe the general level of morale among their colleagues as fairly low or very low and 32% would not choose medicine again if they had a choice.

This low morale and disillusionment among NCHDs is most acutely evidenced by the NCHD recruitment and retention difficulties experienced by the HSE in the past two years. The IMO has engaged with the HSE on the issue of NCHD shortages since the issue arose in early 2010. While the HSE has attributed the problem to a worldwide shortage of NCHDs, the IMO has repeatedly highlighted that it is a retention rather than a recruitment issue. It is the position of the IMO that the NCHD vacancies that have existed since January 2010 may be attributed to difficult working conditions and inappropriate tasks, long working hours and the consequent negative effects on patient care.

NCHDs are key to the provision of front line services and are the only workers in the health service who are required to work compulsory overtime. The provisions of the European Working Time Directive, EWTD, and its application to NCHDs in the majority of hospitals is disregarded. The 2010 NCHD contract and a High Court settlement agreement between the IMO and the HSE in January 2010 allow for the flexible application of the EWTD to NCHDs, including a maximum on-site shift of 24 hours on a 1:5 basis and the recording of time separated into working and training time. However, NCHDs are frequently required to work in excess of the maximum average of 48 hours per week. According to the survey, some 30% work 50-60 hours per week, 24% work 61-70 hours per week and 16% work in excess of 71 hours on site per week. Some 56% of NCHDs work on-site shifts of more than the 24 hours. Many NCHDs do not have access to proper breaks and are not granted compensatory rest.

With regard to the breakdown of hours worked on site, 70% of NCHD time is spent on clinical and associated administrative work, namely, patient contact and associated administration. Alarmingly, 30% of their time is spent on other tasks, including portering bloods and X-rays, administering routine medications and ensuring investigations occur. Implementation of the European working time directive was largely only achievable during the national implementation group project on the directive by the removal of inappropriate tasks from NCHDs, including the introduction of phlebotomy and cannulation teams. Long working hours, beyond affecting patient care adversely, predispose NCHDs to fatigue-related health effects. NCHDs are often unable to achieve any semblance of a normal personal and family life owing to the frequent requirement to move house and job. They spend a disproportionately long time away from their families. More family-friendly work practices abroad will continue to attract our graduates overseas unless these issues are addressed.

The least an NCHD should reasonably expect while working in the health service is a fair and proper application of his or her contractual terms and conditions of employment. However, the reality is that on a daily basis NCHDs in hospitals throughout the country are subject to unilateral breaches of contract, including non-payment for hours worked, non-granting of educational leave, lack of locum cover, resulting in doctors having to work even longer hours to compensate for colleagues' absences, excessive working hours, illegal work patterns and restricted access to training. According to the benchmark survey, only 54% of NCHDs are in a position to avail of educational leave, 55% do not get paid for all hours worked, while 79% say sufficient locum cover is not provided. The disregard for NCHDs' rights by hospital management, including contractual rights and the entitlement to a proper work-life balance, is endemic in the hospital system. The IMO welcomes the Minister's acknowledgment of this to the committee on 6 October when he stated there were hospitals in which NCHDs did not want to work because of the manner in which they were treated.

The NCHD contract replaces a previous refund system for NCHD training activities with a centralised purchasing system, whereby the HSE directly funds NCHD training via service level agreements with the training bodies for a defined list of training activities. It is clear that this system has failed NCHDs on a number of levels, including a significant lack of clarity regarding what training is provided and how to access it, limits on the amount and type of training activity covered and the removal of any NCHD autonomy in choosing training activities.

With regard to protected training time, the IMO-HSE High Court settlement agreement of January 2010 envisages protected training time for NCHDs, but no attempt has been made by the HSE to introduce this. According to the benchmark survey, 90% of NCHDs noted that they experienced difficulties in matching prescribed training requirements with service provision, while 81% find it difficult to meet training requirements and training needs.

All of these issues have led to very low morale among the NCHD cohort and a lack of motivation to pursue a career in the health service, with no guarantee of the necessary improvements in working conditions or future career prospects. The recent HSE recruitment campaign in India and Pakistan and the resulting debacle of doctors from these countries residing here unemployed and unpaid was unacceptable and must never be repeated. The campaign by the HSE was a reactive, short-term response to an issue that required planned long-term solutions.

According to the IMO benchmark survey, the current NCHD cohort has the following career goals: 54% want to become a consultant, predominantly clinical, in Ireland; 19% want to become a general practitioner in Ireland, while 13% want to pursue a career as a consultant-GP outside Ireland. Some 58% of NCHDs believe there are insufficient training places in their chosen specialty, while 74% believe there are insufficient consultant posts within their desired specialty area. Some 80% of NCHDs agree that it will be essential to gain experience abroad to further their careers in Ireland. Alarmingly, 60% of NCHDs are unlikely to return to Ireland owing to a shortage of consultant posts. Some 94% of respondents disagree with the statement "There are sufficient consultant-GP posts in Ireland following training for doctors who wish to pursue a career as a consultant-GP".

A key aim of the health service is to move from the current consultant-led to a consultant-delivered service. This move, combined with the proposed change in delivery of certain health services from tertiary to primary care, requires significant increases in the number of specialist and GP posts in Ireland. The health service does not require more training posts to fill specialist-GP posts, rather a restructuring of the approximate 1,000 non-training posts is required. These posts must be restructured into either training or specialist posts. We must match production with replacement value. While there is no guarantee on the chosen career path of any NCHD, we should at the very least be producing the required numbers of specialists in Ireland rather than recruiting them from developing countries in contravention of World Health Organization guidelines on ethical recruitment. We must produce internationally recognised trainees, but, equally, we should not be training doctors for export, as is happening.

A number of NCHDs with significant years of service, some of whom have achieved contracts of indefinite duration but are not on formally recognised training schemes, are frustrated by the lack of opportunities to progress their careers within the health service. According to the benchmark survey, of those NCHDs not on a training scheme who had applied for higher specialist training, HST, but had been unsuccessful, 36% were not confident of gaining a HST place in the future.

The associate specialist grade recently proposed by the Minister for Health, while offering a better solution than the creation of a staff grade, must only be considered as part of a planned and strategic long-term approach to manpower and career path planning. Any such grade must assure patient safety and clinical governance. In the absence of these, it is merely a short-term solution to a long-term problem which will not address any of the key issues regarding the recruitment and retention of NCHDs or the long-term medical staffing of the health service. The creation of a new grade may exacerbate the problem of NCHD retention in part owing to the fact that Ireland is regarded as not providing attractive working conditions for doctors. A new grade may not be as attractive as going and remaining abroad. While the IMO welcomes the Minister's recent statement to the committee on 6 October that an associate specialist grade would not be a grade of infinite duration but a progressive step towards becoming a full consultant, it is vital that the creation of this grade is not regarded as the solution to the current difficulties in retaining NCHDs in the health service. It can form only one part of an effective manpower plan for NCHDs which addresses training and career paths for all grades of doctor, the chief objective of which must be to increase the number of consultant-GP posts.

The IMO recently launched the NCHD Engage for Change campaign, the aim of which is to foster a culture of positive engagement among NCHDs working in Ireland to ensure the health service can attract the best doctors and provide excellent training, defined career paths and the highest standards of patient care and safety. The IMO's recommendations to achieve this are full implementation of the NCHD contract 2010; improved working conditions and removal of inappropriate tasks; a reduction in onerous working hours and appropriate application of the European working time directive; improved structured training in terms of access and funding, including the introduction of more flexible, family-friendly training and restructuring of current non-training posts; a strategic planned approach to manpower planning to determine defined career paths for all grades and specialties, including addressing career progression of long service hospital doctors; an increase in the number of specialist and GP posts and the continued roll-out of clinical care programmes and expansion of primary care to contribute to a reduction in the reliance on NCHDs in staffing hospitals.

The IMO, as the representative body for NCHDs, is always ready and willing to work with the HSE, the Department of Health, the training bodies and the Medical Council to ensure the required changes to the day-to-day work, training and career paths of NCHDs are achieved in a timely fashion to ensure the highest standards of patient care in the health service now and into the future.

Chairman

I thank Ms Coulter for her presentation which was eye opening. It is clear from the IMO's presentation that from its perspective change is required. I now invite Dr. Rigley from the Irish Hospital Consultants Association to make her presentation.

Dr. Margo Rigley

I thank the Chairman and committee members for the invitation to speak to them about the Irish Hospital Consultants Association's concerns relating to medical manpower issues within the health service. This submission from the IHCA will address, in particular, the shortage of NCHDs, their recruitment, appointment, education and training. To do this, the submission briefly reviews the recommendations included in a number of key reports on these issues in the past decade, developments in the interim and the association's recommendations to ensure the appropriate levels of medical manpower are in place to deliver the acute hospital and mental health services required by an increasing and ageing population.

I preface by remarks by saying the difficulties experienced with NCHDs are not isolated, rather they are to be found throughout the health service. There were three key reports published in the early part of the last decade, between 2001 and 2003, all under the auspices of the Department of Health and Children. The report of the forum on medical manpower was published in 2001, which recognised that a package of measures was necessary to address the challenges facing hospital services. The key issues and recommendations it focused on included the need to improve non-consultant hospital doctor, NCHD, training and structured training posts, of which we have heard much already; the principles that should apply to training programmes; the need for continuing professional development and education; a flexible approach to working and training; a need for quality assurance in the delivery of hospital services; the role of consultants and clinicians in management; the need to define the role of doctors; and the need to take into account and facilitate the changing role of nurses and midwives.

The second report was that of the national joint steering group on the working hours of NCHDs, which reviewed the implications of introducing the European Working Time Directive, which mandated a 48-hour working week. It considered the consequences for the delivery of hospital services, and as part of the process a survey of 670 NCHDs in eight pilot sites established that NCHDs were working on average 75 hours per week, excluding those working off-site on-call. It is important to focus on the figure of working a 75-hour week, as it includes doctors working all day from 8 a.m. one day, for example, through to well into the next day. It is hard to imagine that people are asked to do this but it is the case.

The report concluded that the primary solution lay in increasing consultant numbers to create a consultant-provided service rather than any substantial increase in the number of NCHD posts. It was recognised that NCHDs expended significant time on duties that could and should be more appropriately undertaken by other staff. It was recommended that there should be a phased implementation to ensure greater equilibrium in the consultant to NCHD ratio in advance of the introduction of the 58-hour per week maximum, which was supposed to be in place by 2007, or four years ago. Needless to say, that was not attained and we still do not have a 58-hour week, let alone a 48-hour week. Shift working arrangements for NCHDs were shown to be an integral part of the successful reduction of NCHD hours in other jurisdictions, and flexible working arrangements and more family friendly policies needed to be agreed, with flexibility to attend at designated training times. There is some crossover between the two reports.

The third report, published in 2003, was that of the national task force on medical staffing, which was to develop an implementation plan to ensure NCHD compliance with the European working time requirements. It was to take account of the consequences for medical education and training. Its main recommendations included the priority to provide a safe, high quality service to all patients at all times; that NCHD working hours must be in line with the European Working Time Directive, or 48 hours per week; and that recruiting more NCHDs was not viewed as a solution to the problem. In addition, it was argued that medical education and training systems must attract and train doctors to provide high quality patient care and that with reductions in NCHD hours, the appointment of more consultants working in teams, reorganisation of the acute hospital system and the provision of high quality medical education and training were key components. The report also included considerations about capacity, workload and a critical mass of patients influencing where hospital services can be safely provided.

The last of those reports was in 2003 and there have been interim developments. The annual number of patients treated in public hospitals increased strongly, reflecting an increasing and aging population. There are figures to confirm this. Inpatients and day-case patients treated have increased by 67% from 788,000 to 1.32 million per year during the period 2000 - 2010. Outpatient attendances increased by 78% from 2 million to 3.5 million per year and births increased by 36% from just under 55,000 to just under 75,000 per year. There has been an enormous increase in the volume of presentation to hospitals and responses. During this time the number of acute hospital beds per 1,000 of population in Ireland has decreased, as has the average length of stay. Given the increased demand for acute hospital care, the occupancy rate for acute beds in Ireland is much higher than the OECD average.

The resources available in acute hospitals to treat patients have suffered significant reductions in recent years and this is making it more difficult to treat the increasing number of patients presenting for care. The total number of doctors working in Ireland is significantly below the OECD average on a population basis, and this gives rise to significant pressures in the delivery of primary care and acute hospital services. On the basis of the 2001 research, NCHDs worked an average of 75 hours per week, and a reduction in the average hours worked to 48 hours represents a 36% reduction on the 2001 level. Requirements for training and educational activities have remained relatively static and the reduction in NCHD availability for clinical activity would be much higher than the 36% reduction.

The HSE submission to the committee on 6 October confirmed that 39% of NCHD posts averaged 48 hours per week in 2009, meaning 61% are exceeding the European Working Time Directive requirements due to the pressures to deliver acute hospital care and mental health services. In recent years, it has proven more difficult to fill the NCHD posts at successive rotations, which take place twice a year, resulting in the need to recruit doctors from India and Pakistan this year in a specific HSE initiative.

There are a number of reasons to explain the reduction in interest in NCHD posts in Ireland. The main reason is the working hours and service delivery pressures, which are enormous. Another reason is training and career opportunities, and we support what our colleagues in the Irish Medical Organisation outlined in this regard in considerable detail. Other factors include the changes in contract terms and conditions, opportunities in other countries for Irish and other doctors and the recent designation of an increased percentage of posts as non-training.

The national task force on medical staffingreport in 2003 recommended the establishment of 3,600 hospital consultant posts by 2013 and a reduction in the number of NCHDs. The most recent HSE figures, included in its submission to the committee, confirm the number of consultant posts in the public health system at just over 2,500 in September 2011. There is a deficit of more than 1,000 with regard to the target set for 2013, and in the interim the population has increased above the level anticipated in the 2003 report on which the figures were based.

The number of acute hospital and mental health consultants in Ireland on a population basis is well below that of other countries, resulting in a severely overstretched acute hospital and mental health service that gives rise to the following effects. Consultants treat a much higher number of patients than the international norms and college recommendations, resulting in some consultants treating between 150% and 200% the number of patients treated by their peers in the UK and other countries. We have evidence of that. This means that consultants regularly work beyond their contract hours and have a higher level of on-call commitment than their international colleagues. It is now recognised that the average number of eligible applicants per advertised consultant post has declined significantly in the past three years. That is a very worrying development and mirrors what has happened with NCHDs.

The increased pressure on acute hospital delivery in Ireland combined with significant resource limitations is impacting adversely on junior doctors and consultants in terms of hours worked, time available for training and continuing medication, and work-life balance. Irish-trained doctors are highly sought after in other English speaking countries, particularly the United States, Australia, Canada, New Zealand and the United Kingdom. The resources to treat patients and the terms and conditions available in these countries are proving more attractive for our internationally mobile doctors, leading to a loss of an increasing number of doctors to these countries. The moratorium on recruitment and the budget pressures within our health service are also resulting in other critical front-line posts being left vacant. This is affecting the delivery of front-line services to patients and has an adverse effect on NCHDs. If a phlebotomy post is not replaced, for example, it is the expectation that the junior doctor fulfils that role.

The recommendation of the IHCA is that a comprehensive medical manpower action plan be implemented with the involvement of key stakeholders, taking into account the medical staffing levels required to deliver acute hospital and mental health services to an increased and ageing population. The objectives of the action plan should be to ensure that Ireland recruits and retains NCHDs that graduate from Irish medical schools and other appropriately trained doctors, and attracts highly qualified consultants to ensure the required medical staffing is appointed to treat an increasing number of patients presenting for care in acute hospitals and mental health services. I emphasise that what we need to do is not recruit outside Ireland but retain the doctors we train here.

The action plan must also take into account the requirements to implement the increased levels of service delivery, the new clinical care programmes, which the committee will be well aware of, the clinical directorate structures and the hospital trusts that are proposed which, I hope, will bring improved governance throughout the health service.

Chairman

Thank you for your informative presentation, recommendations and the interesting statistics and figures on the volume of activity. I will take three groups together to put questions to the delegates. I will start with Deputy Ó Caoláin. I remind members to keep their contributions to questions.

Deputy Caoimhghín Ó Caoláin

I join the Chairman in welcoming the representatives of the Irish Hospital Consultants Association and the Irish Medical Organisation. They are the third group in the tranche of representative groups the committee has met. It is clear that there is an emerging consensus, certainly across all the political views represented on this committee, that the committee is not a soapbox either for visiting groups or for members. We are focused on solutions and we would very much welcome a momentum arising from these engagements that would lead to the solutions necessary.

The points made in the IMO's recommendations refer to improved working conditions and removal of inappropriate tasks. Could the representatives spell out their proposals in that regard and to whom they should be spelt out? Clearly, that is something that is part of the overall package. The delegates spoke about improved, structured training, access and funding, the introduction of more flexible and family friendly training, and the restructuring of current non-training posts. Will they elaborate on that? What is the position regarding a strategic planned approach to manpower planning? It was indicated to the committee by representatives of the Royal College of Surgeons in Ireland, RCSI, that there is a planned forum in December involving all the representative organisations, including the two organisations here today. Are the IMO and the IHCA committed to participating in that forum and are they confident that the engagement will assist in addressing all the issues across what we acknowledge to be a complex area? Can it be the catalyst for the solutions we all seek?

With regard to the 1,000 non-training posts in the health service, I accept the information will not be available today but is it possible to advise the committee subsequently where they apply, by hospital? It would give us a sense of the issue across the network if it were known where these non-training posts are located. How do we deal with the needs of hospitals that do not have training facilities? Heretofore, it has always been very difficult to attract consultants to take up positions in non-training hospitals. Certainly, NCHDs are not interested because it does not serve their career path or ambition. How can we deal with that? Is there a cohort of people in these smaller hospitals? I have no wish to see them close, as has already happened in some instances. How do we deal with that given that the standards for training will not always be achievable on the smaller hospital site? What are the organisations' respective positions in that regard?

I was interested in the elaboration on the associate specialist grade the Minister announced here in the first engagement in this series of meetings by the committee regarding the NCHD crisis that presented before July this year. What is the impact of creating a new additional grade as part of a supposedly enhanced career path? The delegates have, quite fairly, reflected that it is not the panacea if it is just another stop-gap along what is already a very long, extended career path. Yet the objective of reaching consultant status seems ever more difficult to achieve.

I welcome the contributions from both organisations. I am mindful of the time so I will not proceed further. I am anxious to receive a response to my questions from the IMO and the IHCA, particularly confirmation that both organisations are now committed to being part of a solution through the engagement with all the other stakeholders. We do not wish to have a repetition of what presented earlier this year. I am now in my fifteenth year as my party's spokesperson on health in the Oireachtas and I have never been more alarmed and concerned about our hospital services in the early stages of winter than I am today. There are serious reasons for concern as is evident from the statistics emerging from hospital sites throughout the network, and it is not even the end of October.

Chairman

I call Senator Crown.

Senator John Crown

Thank you, Chairman, for reading my mind. I had not indicated I wished to speak but I am delighted to do so.

Chairman

You are the only Independent.

Senator John Crown

I thank my colleagues and representatives of other colleagues for attending this meeting. My Oireachtas colleagues know that I am beginning to sound like a broken record when I make these points, but I will make them again. The central reality that defines most of the problems in the Irish health system, problems which Deputy Ó Caoláin mentioned could reach a crisis point over the next while, is that, by a distance, we have the smallest number of career level posts per head of population of any developed country. Every other discussion that flows from that central reality, in terms of numbers of junior doctors, implications of training and so forth, stems from the fact that we have used people other than those who are in career level posts as band aids to cover this gaping deficiency in the health system. I do not want any of us to be complicit in trying to build better band aids.

We need to get the message across relentlessly that there is something profoundly abnormal and bizarre about the way we have structured the medical career pathway here. The only thing that makes it look fairly normal, in a vague sense, is that it is not very different from what our colleagues have done in the UK, who have the second worst ratio of career level positions per head of population of any country in the western world. That is the central reality.

What is a career level doctor? It is a doctor who has responsibility and authority, in other words, he or she can independently make decisions for the benefit of the patient he or she is seeing and is responsible for the consequences of these decisions. Junior doctors do not qualify in that regard because they always defer or should always defer responsibility and authority to the career level doctor above them, be it a consultant or general practitioner. Critically, what should happen is that the career level doctor rather than the trainee should be legally and administratively in the line of fire if anything goes wrong. If every trainee, non-consultant hospital doctor or junior doctor in the country were not to come to work tomorrow, it should not make a difference because the job of a junior doctor is to be, number one, a trainee; number two, a trainee; and, number three, a trainee. That is the reason they exist. Until we come to grips with this fundamental problem, we will continue to deal with a number of lifeboat solutions rather than trying to steer Titanic away from the iceberg.

Another point which needs to be placed on the agenda of the professional and learned organisations is that we need to have a serious look at several strange paradoxes in the career and manpower structures in Irish medicine. How can it be that the country that has the largest number of medical schools per head of population in any western country has the lowest number of career level doctors? This mismatch tells us that there is something profoundly wrong. At the risk of sounding boring, whereas in Ireland the average is one medical school per 700,000 citizens, the European average is one per 1.5 million citizens. The ratio in the United States is one to more than 2 million citizens. Clearly, we are doing something wrong.

To respond to some of the points made, Deputy Ó Caoláin asked to whom we would delegate these jobs.

Chairman

The Senator should pose questions rather than answer them.

Senator John Crown

I apologise. I keep thinking this is like the board game Jeopardy! I must phrase my statements in the form of a question. I will ask the same question as my colleague, Deputy Ó Caoláin. To whom would one delegate the jobs of junior doctors? Junior doctors have been viewed as an all-purpose pool of labour into which one can dip to make up for deficiencies in secretarial, administrative, radiography and phlebotomy staff because they are, by and large, willing labour and will do everything one asks of them, in addition to the work for which they are employed. This is yet another symptom of a problem which needs to be fixed as opposed to a symptom that needs to be palliated.

Senator Colm Burke

I welcome both delegations and thank them for the assistance and support they have provided me in the past three months. They have addressed any queries I have raised and have been very helpful.

We have heard about more than 1,000 training posts and that the current number of consultants is 2,506 rather than 3,600. Can the number of training posts be increased, given the number of consultants who are available to provide the required training? I presume training posts go hand in hand with consultant posts and that if one does not have a sufficient number of the latter, one cannot increase the number of the former. What is the view of our guests on that matter?

Many junior doctor contracts are offered for six or 12 months. Is it possible to have a more structured co-ordination of contracts? I am aware that in a small number of cases a doctor may have a three year contract divided into 12 month segments, each of which relates to a different hospital. While this practice is common in the United Kingdom, it is not widely used here. Should it be considered to offer a more structured contract?

There is a great deal of uncertainty with regard to non-training posts. Someone who starts a job in the first week of January will be wondering by the first week of February where he or she will be on 1 July. This creates major uncertainty and people start to look outside the country where they can secure more structured training. Could we introduce more formal structures to encourage junior doctors to remain in this country for a longer period?

Our priority is to retain medical professionals in this country. That is the reason I raise the issue of extending the period of contracts. However, people are also trying to come to this country. The issue I raise and have raised previously with the Irish Medical Council relates to category 4 status and the unwelcoming approach taken to people recruited from abroad. I am aware of an individual who applied for a job in Ireland in February, was given a contract in March and, as of today, eight months later, has still not received Medical Council clearance to commence the job. The person in question has more than ten years experience working in hospitals outside the European Union.

It has been argued that the pre-registration examination system, PRES, is too general and some are choosing not to sit the examination as a result and choosing instead to move to countries such as Canada, the United Kingdom and the United States where the examination procedure does not appear to be as difficult as it is here. While I may be wrong in that respect, the issue has been raised with me.

On the lack of joined-up thinking, representatives of the Department of Health, the Medical Council and the Health Service Executive appeared before the committee recently. As a result of this meeting, a long overdue and welcome agreement was reached between the HSE and the Medical Council. I do not know the reason it took nine months to reach an agreement when everyone foresaw the shortage in the number of junior doctors. What action must the committee and the Minister take to create a more joined-up process among stakeholders, namely, the consultants, junior doctors, the Medical Council and the Health Service Executive? What measures are required to ensure Ireland becomes an attractive location for junior doctors from abroad to come and work here?

My other concern is that recent figures show the number of applicants for consultant posts has decreased from an average of five per post to two. In some cases, advertised posts are not attracting any applicants. What needs to be done to ensure the health service will be attractive to people from abroad?

Ms Shirley Coulter

I will answer a number of questions and then defer to my colleagues who will address specific issues. I will respond first to a number of points raised by Deputy Ó Caoláin.

The commitment of the Irish Medical Organisation to engage on this issue is clear. The final point made in the submission and my first point is that the IMO is absolutely committed to doing whatever it takes. As the sole representative body for non-consultant hospital doctors, it is well placed to represent their views. Dr. Murphy is a non-consultant hospital doctor who will share his views with members. We are in touch with the reality of day-to-day work in hospitals and what is happening on the ground. There is definitely a disconnect in this respect. It has been interesting to read in recent weeks the transcripts of the oral presentations, as well as the written presentations, made to the committee by the other relevant organisations. There are a number of recurrent themes. What the IMO brings to the table on the industrial relations front are first-hand accounts of the realities of day-to-day working in hospitals. These are of vital importance and relevance in terms of the reasons for the current problems in hospitals. The current difficulties are the result both of day-to-day experiences and longer term career planning, an issue we have discussed in some detail.

While we are committed to engagement, the IMO echoes Deputy Ó Caoláin's suggestion that it must not be about a soapbox but that it must provide real solutions in a timely and efficient manner. The next changeover will take place in January and we do not want to face the same problems as we faced in previous rotations, including in July. It is essential, therefore, that a high level group involving all relevant stakeholders be established immediately. The Irish Medical Organisation is fully committed to such a process.

Deputy Ó Caoláin asked us to elaborate on the training structure and whether it was family friendly. More joined-up thinking is required, with greater communication between the training bodies, as the provider of training, the Health Service Executive, as the employer, and the Irish Medical Organisation, as the representative body. We have significant anecdotal evidence of married doctors on different training schemes whose rotations take them to opposite ends of the country. We should have some joined-up thinking that would allow them rotate through hospitals in the same area where possible. Communication and joined-up thinking with regard to how training is structured and rolled out are definitely the problem areas..

With regard to clarification on the 1,000 non-training posts, the majority of these posts are in peripheral hospitals. How do these hospitals manage without providing training? Every hospital has the ability to train. From our benchmark survey, we can see that 70% of training is on-the-job training and the majority of training is provided through carrying out the day to day tasks and working with a consultant and so on. With regard to the specifics on where these training posts are, the HSE has the responsibility, under the Medical Practitioners Act 2007, to designate posts as either training or non-training posts. Therefore, it is the HSE that has the specific information on where those posts exist.

I will defer now to Dr. Mark Murphy, an NCHD and GP trainee with more than six years experience of rotating through various hospitals and specialties in the country, and he will address the issues about the removal of the tasks and look at what NCHDs do during the day. He will also address the issue of the uncertainty surrounding the non-training posts raised by Senator Burke. I will then defer to Professor Plunkett, who will address the impact of the creation of a new grade and the query about the restructuring of the training posts and how this would relate to the numbers of consultants.

Dr. Mark Murphy

I found myself nodding furiously with the comments made by Deputy Ó Caoláin, Senator Crown and Senator Burke. I agree entirely with them on the issues they have articulated and their desire for this momentum for change to continue. The vision of the health care service we all want that provides more access than primary and secondary care and reduces the social and health inequalities in society will not exist unless we have a medical manforce in the future. Ireland's vision is lacking in terms of keeping our medical graduates here. Ireland's failing is that when someone enters medical school here, there is a good chance there will not be a consultant job for that person in the future. This is not right for society nor is it right for my friends and colleagues. I am 30 years of age now and a significant number of my friends and colleagues have been forced to emigrate because of the lack of consultancy positions.

On the issue of inappropriate roles, I will list again the issues listed by Ms Coulter, because they are part of an entire suite of problems that affect NCHDs. One issue is the lack of structured career paths. Positions are not available for the brightest and best of our NCHDs, those who are on higher specialist training and who have PhDs and all their qualifications. There are, for example 26 rheumatology higher specialist trainees, yet there are only 27 rheumatology jobs in the country. These are the brightest and best here, but there is no future here for at least half of these friends and colleagues. At the same time, Ireland has only a deplorable number of rheumatologists compared to OECD averages. This does not make sense. While this is important, all of the other issues affecting NCHDs also need to be addressed, including the inappropriate working roles; the long working hours; the effect on family and social life; and application of our terms and conditions. Our conditions are flagrantly breached on a daily basis and this must be mentioned as a significant reason NCHDs are disenfranchised.

I must be careful when speaking about inappropriate working roles. There is an onus on every health professional to do whatever it takes, whether that involves faxing a letter, putting in a cannula or doing an ECG. However, a significant amount of our working lives is consumed by roles we would not have to take on if we had an appropriate IT service and if we had appropriate X-ray facilities on computers. Our benchmark study demonstrated that running around and being a gofer takes approximately 30% or our time. This significant amount of our daily work time contributes to non-compliance on European working time. It is during the junior stage of our careers in particular that we engage in these roles and a high level discussion must take place between us and all the relevant stakeholders to address this. Issues to be addressed include things like a doctor of three or four years experience spending an entire morning taking blood pressure measurements at a stress test facility, when another health professional could do this. If a phlebotomist calls in sick, one of my friends will have to spend the morning doing that person's job. We muck in and do whatever it takes, but enough is enough. This sort of thing does not happen abroad, in New Zealand or in the United States. This issue, which was addressed in the Hanley report, illustrates the need for us to change the way our roles are performed.

Senator Burke commented on the uncertainty for doctors who are not on structured training programmes. Many NCHDs do not have security and we do not know where we will be in five or ten years time. We do not know where we will be working in a year's time. We move house every six months. This is even more true for this group, who are predominantly non-EU doctors who have been recruited into non-training jobs here. These doctors are located all over the country, but predominantly in the smaller general hospitals. I agree that they form a very frustrated workforce. It is an oxymoron to have an NCHD who is not in training. There are difficulties around this issue in terms of current consultant numbers and where these doctors can be trained. However, there is an ethical onus on the nation to train these doctors so that they can be specialists who will provide independent specialist care. We are failing this group.

These doctors face additional insecurity and uncertainty, for example, the central recruitment process. Some 900 NCHDs apply for jobs all over the country and it was a good idea to try to change the system, but it should not have been done without our involvement. The average age of a registrar is 38 and at that age he or she will probably have a family. For example, we have two Sudanese doctors, one a psychiatrist and one a paediatrician in training, and they have children in school, but the centralised recruitment process we have now puts one in Letterkenny and the other in Cork. The uncertainty among these doctors is heightened because the key stakeholders do not have an overall higher plan for our medical manpower in place. Unilateral actions such as this, which may be well-meaning, have a catastrophic effect.

Chairman

Is Dr. Murphy saying the centralised system has not worked and does not work?

Dr. Mark Murphy

I am saying there are problems with it. Some 2,500 doctors in Ireland are non-EU doctors and many of them live 150 km or more from their partners. This is deplorable. They change jobs every six months and do not know where their children will attend school. A centralised recruitment process must be cognisant of the basic securities all humans deserve. Regardless of the long working hours and their health effects, fatigue related injuries and mental health problems, common sense decisions must be made. This illustrates the necessity for a high level group to look again at the overall responsibilities and the direction we should take in the future.

Professor Patrick Plunkett

I will address the proposal or suggestion for an associate specialist grade and the question of whether we can increase training posts without increasing the number of consultants. We must take into account the concept raised by Senator Crown of a doctor who can take individual responsibility for patient care. In other countries, once one is trained to specialist level, one operates as a specialist and independent practitioner, under an overarching control mechanism or responsibility mechanism.

We do not have that system yet in this country, but we certainly need it. The difficulty is that at the moment, there is a large cohort of doctors who are in post and who are moving from one post to another in order to keep a roof over heads and to keep their children fed. Let us be quite clear about this. There is a humane element to it. They are mainly in those 1,000 posts which were previously designated as training posts and were de-designated by the centralised process. This was an attempt to improve the system in Ireland, but I think it has disimproved it for many individuals.

The process is simply not humane enough. It was stated that it is easier to get through the process in the US and Canada, but I can assure members that is not the case. The process of getting into those countries is as arduous and probably more arduous than coming here. The difficulty is in respect of who decides to go to the US, who decides to go to Ireland and who decides to stay where they are. That is a gradation issue. However, in the US they will arrange a family friendly second post. If a candidate's spouse matches a post they require and they really want the candidate because he or she is the best in the field, they will organise it so that they now have two posts filled, instead of forcing the second person to go through a process which is anonymous and which regards them merely as a plug to put into a socket. If we look at the changes in contracts that the HSE has sought over the last while, we find that they can move any person to any place they want in the country. That is not for the good of the population, let alone for the good of the doctors serving them.

Senator Crown spoke about the NCHDs being willing labour. The fact is that all doctors are willing labour and as Dr. Murphy said, they will do anything reasonable within their power to deal with the problem in front of them and the patient they have at any given time. However, working as a team with other members of the health care professions and associated grades, we can perform these tasks and provide these services much more efficiently. I work in circumstances where intravenous cannulation and drugs are given by nurses who are trained to an advanced level to diagnose and treat patients, with the backup of a consultant if needed, but without actually having to refer to any other doctor. They do so year after year, building up a base experience which enables them to make decisions.

Part of the issue about training posts is down to the chicken and egg scenario. Under the latest HSE diktat, for every consultant post put in, we must suppress two NCHD posts. This means that somebody who is at a higher level of experience and knowledge will be put in, but the contract is for 37 hours per week, whereas we have to suppress a minimum of 96 doctor hours, and probably more, given the hours that most NCHDs work. This will ensure that we cannot provide a 24 hour service of any sort in many places around the country.

The other aspect of training is that a doctor needs to see many cases of the same type. That cannot be done in the smaller hospitals. Some of my base training was in smaller hospitals and I will readily name Our Lady's Hospital in Navan, where I gained enormous experience because I saw many patients. At that time, I am not sure the patients really got the best service from me, because my experience was limited. I was a grafter and I made decisions that were probably well above my pay scale. They survived. I would not suggest that the Irish health service go back to that.

We need consultants to supervise training posts, but at the moment, in order to bring in a consultant, we have to take away the service delivery side of it first. Most hospitals and most regional directors of operations are not really prepared to do that. They are quite right about that, because the whole system will fall over on its face.

One of the biggest things I have noticed in recent years is that there is an increasing lack of trust on the part of the medical staff - consultants and NCHDs - with regard to the delivery of contractual terms and conditions by the employer side. There is an increasing lack of engagement from the employee, who literally does not want to work for this kind of employer. People talk about students having to get 600 points and maybe not being appropriate for a human speciality in medicine. We are getting the brightest of the bright in this country going into medical school and coming out at the other side as doctors. We are then putting them in circumstances where they have to overwork in comparison to their university peers and where they cannot trust their employer to pay them the agreed rate of pay. What do they do? They look at pastures green far away. They are not the only ones. My eldest daughter told me, when she was a young teenager, that she did not want to do medicine because she did not want to work as hard as her daddy. She is now about four years postgraduate in IT. She is out of the country and she is earning more than my eight or nine year postgraduate registrars are earning in medicine in this country.

We cannot blame doctors for being a mobile workforce. They go where they have to go to get the training they want and they prefer to have good terms and conditions of service at the same time. Many Irish go abroad to train. I went abroad, as did Senator Crown and many others. Many of them would like to come back to this country, bringing the added skills they have gained elsewhere, but at the moment, there is absolutely no attraction for them. That is why we have a reduction in applications for posts.

The Irish health service is coming to a crux, and it is not just this winter, as Deputy Ó Caoláin suggests. It will be every winter and summer for the next while unless somebody big with a determination to engage in a constructive fashion with the doctors who provide the service every day is prepared to take decisions that will allow it to happen. Thus far, my experience in the health service over the past 24 years is that there has not been anybody at a high political level prepared to take this on and to deal with it. I accept that the Ministers all say that they wish to do so, but I am afraid I have seen no evidence of it.

Dr. Margo Rigley

I have jotted down the questions, so I hope I can answer them in proper order. I want to confirm the commitment of our association to proper medical manpower planning and implementation in this country. We are not able to say too much about the associate specialist grade, specifically because the Minister has referred to us but we do not have the detail of it. We are aware of where it works and works well, and we are also aware of places where it has not worked well. In particular, we would refer to the 1,000 non-training posts in the country in the moment. These doctors are generally on the supervised register, while some are on the general register. The supervised register doctors were not in a position to apply for training posts. We do not want to find ourselves in a position where these are the doctors coming into the Irish health system in a planned way.

With regard to the type of work done by NCHDs which is inappropriate, we all work as consultant led multi disciplinary teams. The problem with the health service, following the recruitment embargo, is that the disciplines are not being replaced. Essentially, we have mostly consultants and junior doctors. As I said, as those from other disciplines leave, they are not replaced and, regrettably, it is the NCHDs who are picking up the tasks. I gave the example of phlebotomists not being available, but this applies equally to the loss of administrative staff from the multidisciplinary team. These are front-line staff who are part of the team. If they are not available, NCHDs literally spend their time running around, chasing up reports, making appointments and so on. These are people who are highly and expensively trained and we need them to do the work they should be doing. That is a comment on how the situation is actively deteriorating for NCHDs.

Deputy Ó Caoláin asked whether there would be a repetition of the problem shortly. It looks as though there might be. I will give an example from my own specialty of psychiatry. I rang the college to check the number applying for vacancies in training posts in January, when between 60 and 70 vacancies will arise. There were 20 applicants for these posts, of whom only 15 were eligible, and we are not yet sure how many will actually take them up. This is a problem that will be repeated and which we anticipate will be much worse in January. I gave the example of psychiatry, but I am sure the position is the same in other specialties. My colleague may be able to speak on that issue. Sadly, repetition might be the order of the day.

Senator Crown spoke about a band-aid solution. If we look only at the NCHD problem in isolation, it will be a band-aid solution and that is, in fact, what has been happening. We have been bringing in doctors who are badly needed in other parts of the world to work in the health service, while at the same time we are training our own doctors who are leaving to go elsewhere. There is absolutely no sense in this. We need to examine how we can retain doctors. It is largely to do with how we treat NCHDs, in every sense of the word. Comment has been made about the need for mutual trust for all doctors within the health service. Respect for doctors is also required. There has been a particular issue in this regard recently.

In that context, there is a need to examine the whole system. Dr. Barry White's programmes, of which members have probably heard, are the bones of what we need to do. We need to go back to what the health service is about, which is meeting patients' needs. Essentially, it should be formed around these rather than around particular elements that cause problems at times, with changes made to respond to them because with piecemeal changes there is chaos. That is what we are seeing: as there is a problem in one area, we do one thing, and then as we have problem in another area, we do something different, and it all adds up. The best example concerns doctors who are being brought into the country. We found within the Irish Medical Council that the only register in which they could included was the general register, which would allow them to work unsupervised. Therefore, legislation had to be introduced very quickly to set up another register, the supervised division, within the Medical Council. Solving one problem should not mean that another emerges.

We must go back to basics. We need a service for patients in Ireland. How should that service be delivered? NCHDs and medical staff must be part of this. In that context, we need to consider how services should be delivered, where they should be delivered, who they should be delivered by and the resources we need to deliver them. It is not complicated, which is why many consultants and NCHD colleagues find it very frustrating. It is as plain as the nose on one's face what needs to be done, but there must be the will to do so. We need a cogent plan, but it must be an action plan, not something that takes years to put together.

Within the IHCA we have been working closely with the clinical programmes and in the mental health service we have our own programme, A Vision for Change. There are plans in various areas such as emergency medicine, acute medicine, surgery and my own area of mental health services. I am not sure what has happened in oncology, but I am sure there is a plan in that area, too. Each of these areas has a cogent plan and it starts with responding to patients' needs, including providing the staffing and material resources needed to do this. We need to get on with implementing these programmes, part of which is considering hospital structures and how they operate within that context. I cannot emphasise this too much. Whatever professional discipline one is involved in - I include administrative members of our teams - a re-emergence of trust and mutual respect is required among those who work in mental health services. As I said, this has been lacking so far.

A specific question was asked about structured training programmes, I think by Senator Burke. The specialties have structured training programmes which involve rotation. In theory, these should work well, but, as the Senator said, people often do not enter a programme knowing from the beginning they will be in area A, B or C. It does not always take into account a person's particular circumstances. In the programmes cognisance must also be taken of training requirements and the need to maintain a work-life balance. That this is not taken into account is where problems arise for NCHDs.

It is not the case that university affiliated hospitals are more attractive than smaller hospitals because smaller hospitals provide very good training. However, if they are to do this, they must be resourced in a suitable way, and there must also be networking between hospitals to ensure all this is provided for.

There is an important gap that needs urgent attention for trainees. It is not alone important that there is a good training experience which does not involve working an enormous number of hours, but also that there is something for them to focus on - ultimately, a consultant post. This is related to Senator Crown's comments about the relatively small number of career posts on offer in this country. As there is a complete moratorium on staff recruitment in the HSE, consultant posts are not being filled. This creates uncertainty for NCHDs which encourages them to leave the country. As Ireland is a relatively small country, it is good that a proportion of NCHDs do go abroad for their training in order to gain a greater breadth of experience and learn new techniques that they can bring back to Ireland. There is no doubt that the population in Ireland has benefited from our trainees' going abroad to train. However, we need to bring them back to a country in which they can work, which means the resources required must be made available to allow them to work. If one is a surgeon, one needs to know one can have time in theatre, not that theatres and day-case beds are closing. It is the same for all of us. There is anecdotal experience of consultants saying they would like to run extra clinics to clear waiting lists, but they cannot secure the backup required to run extra clinics.

There is a lot in the mix, and I am sorry if I have not put it together logically. This is, as I said, a whole-system problem, which we need to consider. We must start with patient need, move forward and slot in the bits in the appropriate way. Plans are in place and we should get on with implementing them.

Mr. Martin Varley

I will follow on from Dr. Rigley's last point and, in particular, respond to Senator Burke's question of what can be done to ensure that Ireland becomes a more attractive place for doctors and consultants to return to. This comes back to the central purpose of delivering a health service. The key concern we tend to hear from consultants who are considering taking up posts or applying for a post is whether they will have the resources to treat patients without undue delays when they are appointed. Often, we have had experiences whereby newly appointed consultants do not get the theatre operating hours or are not provided with the beds to admit patients etc. Doctors are concerned about this issue.

It links back to how we deliver care to patients without their having to wait for lengthy periods. Some of the issues therein relate to the fact that we must use the resources we have to the optimum. We are all aware that resources are a constrained commodity in the current climate. For example, approximately 10% of acute beds in hospitals are not available for new patients because clinically discharged patients are awaiting facilities in the community, whether nursing home beds or whatever. This is a concern for doctors trying to treat an increasing number of patients.

Let us consider the number of patients included in the HSE's national service plan and the actual outturn for the past five years. The Irish Hospital Consultants Association, IHCA, has done this and it is included in our pre-budget submission. Year after year, more patients are being treated than have been provided for in the national service plan and the budget. Doctors are striving to treat more patients and deal with the increasing demand but the plan has under-provided and underestimated the number of patients that will present. When we come to mid-year each year, doctors and management in hospitals are instructed to cut back. This creates an inevitable problem as we come toward the end of the year. We need better planning, organisation and management of the resources we have so that doctors and consultants can achieve the optimum for patients. Doctor Rigley referred to some elements of achieving this through the new clinical care programmes that are being prepared and implemented etc.

Deputy Joe McHugh

I apologise for being late. I had to speak on another issue. I had one question that I intended to ask relating to the challenges - to be nice about it - of the centralised system but I came in during the course of Dr. Murphy's contribution and I heard of a doctor in Cork and another in Donegal who were husband and wife. It beggars belief. This is a public forum and this stuff maddens the public. It maddens people that such incompetence and lack of leadership is in place and that we cannot sort out a simple problem. Such incompetence leads to waste drives the people crazy throughout the country. I apologise for the preamble.

We have a new Chairman and a new Minister for Health and one thing these gentlemen do not lack is common sense. It is important to work with both of them to try to sort out the simple problems. This can be done but it requires leadership from within. From various conversations I am aware that there are issues of trust and the usual challenges that arise within any organisation. My contact with various HSE officials and people in the medical organisations in my constituency and region indicate that good people are in place. There is general feedback to the effect that these people cannot thrive within the organisation or do the simple things and this whole challenge must be addressed. I am sorry for going on somewhat. There seems to be an issue with regard to attracting people for the specific registrar grade. I am sorry if this has been raised already. Perhaps Dr. Murphy or one of the other guests will answer my question. What plan is being put in place to attract more registrars from within the junior doctor grade? This seems to be something of a challenge in Letterkenny General Hospital. It may not be a national challenge but in my hospital they are finding it difficult to get registrars.

Deputy Regina Doherty

I thank the delegation for their presentations. They have been quite informative from my perspective. I do not have a medical background and I am coming at this from a patient's perspective. One question is screaming in my head. Why are the contracts only six months long? Why would one allow someone uncertainty in any career or at any age, even if one is only 23 or 24 years of age and out having a great time? Young people need career paths, reliability and they need to see the future. Everything else the delegation has referred to with regard to the training, progression and the opportunities to become consultants should be a given. I am somewhat frustrated and I cannot begin to think how frustrated the delegation must feel that we have not begun to address this yet. Successive previous Ministers have started off with great aspirations and then all of a sudden became involved in a quagmire and decided that it was too much of a mountain to climb.

I have confidence not only in Deputy Buttimer, but in the Minister, Deputy Reilly, and I believe he shares the vision that the delegation has described this morning. I hope the mountain does not prove to be too high. I call on the delegation to answer one question. Without trying to be mischievous, will the delegation explain why there have been difficulties, given that the organisations involved negotiated previous contracts such as the 2007 contract and are trying to negotiate new contracts now? What actions have the bodies taken as groups of employees when the terms and conditions have not been adhered to or when they are blatantly informed that they must work 70 hours? Why is this compulsory? I realise both organisations have suggested that the answer to this problem is not more non-consultant hospital doctors, NCHDs, but if 40% of the current staff are working more than 60 and 70 hours per week then we need more NCHDs. I call on the delegation to address some of these issues.

Deputy Peter Fitzpatrick

Most of the questions have already been asked. It is fantastic to have someone of Senator John Crown's experience on the committee and I should have said as much on day one. The questions he asks every week are fantastic. Most of the questions have been asked but I have one question for Ms Coulter relating to morale. I cannot understand how 61% of the NCHD's can suffer from low morale. Dr. Murphy referred to the uncertainty, the long hours and so on and Deputy Doherty suggested the six month contract was an issue but this should be examined because 61% is a high proportion. Some 32% of graduates would not choose medicine again, a high figure. I realise people may suggest that 32% is not much but I know from working that job satisfaction is important. It is important when people go to work in the morning that they are happy in their jobs. I am alarmed and worried. I know that the first person one wishes to see when one goes to a hospital is a doctor, whether a junior doctor or consultant.

Professor Patrick Plunkett has given his opinion and spoken of his experience of meeting junior doctors but I call on him to elaborate. I am concerned about this matter. It is a shame that we train Irish doctors and then they go abroad. There was a discussion about career opportunities and so on and Dr. Rigley referred to the issue. Keeping Irish doctors here is something we should approach the Minister about. As Senator Crown stated earlier, they are probably the best trained in the country.

We are concerned about the number of births rising from 55,000 to 75,000. Will the delegation explain the role of the NCHDs and their involvement in births? Many people are concerned about this at the moment. It has been a worthwhile meeting and I thank the delegation for listening to me. Many of the questions have been answered but I would appreciate if the delegation could answer some of the questions I asked.

Ms Shirley Coulter

Deputy Doherty raised a number of linked points. In answer to the question as to what action is taken by the IMO when breaches occur, this is our day-to-day business, unfortunately. We are firefighting on a national basis on behalf of our members. Without going into detail - and it is referred to in the written submission - in 2009 and 2010, significant disputes ended up in the Labour Court and in the High Court which resulted in a High Court settlement agreement. Despite this, the HSE has not as yet implemented many of the agreements put in place. One must question why NCHDs are treated in this manner. They are easy targets because of a cultural attitude within medicine. Non-consultant hospital doctors, NCHDs, are doctors in training so they provide a service while training and learning and then move on. As a result, they are focused on their careers and in many cases, hospital management takes advantage of them. Management knows that NCHDs will put in the time. Their goodwill was highlighted by the shortages last July because the current doctors in the system covered all the hours of the vacant posts. They are seen as being easy targets because management knows they will get on with the work as they have been doing for years and this is evidenced by the very long working hours of NCHDs.

The terms and conditions of work for NCHDs are relevant. The IMO sought contingency meetings with the HSE to ascertain its plans to ensure patient care and safety and the safety of doctors during the period of continuing shortages in the system. It was accepted by the HSE that it would rely on current NCHDs to provide cover. We asked that at the very least their terms and conditions of employment should be adhered to. Unfortunately, this has not happened as yet.

Deputy Regina Doherty

If I may redirect one of my questions, I am conscious that various public servants, such as nurses and firemen, are renegotiating rosters and the Irish Prison Service has completed negotiations. What will be the effect of the new EU directive in that doctors are already working over and above the hours they are supposed to work? Much more stringent EU legislation is coming and will this be ignored?

Ms Shirley Coulter

The IMO is conscious of the EU working time directive and the absolute need to reduce onerous working hours but the directive has to be applied in an appropriate manner to doctors in training and this is the reason the IMO sought and reached an agreement with the HSE about the appropriate application of the working time directive. This agreement was reached in a registered High Court settlement. It allows flexibility in the application of the directive by permitting a 24-hour on-site working shift and crucially, it protects training time. Doctors are working and also training on the job so a service is being provided while they are training. However, they must attend lectures and journal clubs during the week and these are pivotal to ensuring well-trained doctors who can provide excellent standards of patient care. Those hours could be designated as training and therefore, this allows flexibility in the 48-hour maximum. This agreement is in place. It was proposed by the IMO and it was successfully agreed with the HSE. However, now almost two years since that High Court settlement agreement - two years in January 2012 - there has been no move by the HSE to implement the agreement. We have raised the matter on a number of occasions and formally in the Labour Relations Commission as recently as last Tuesday. It is within the gift of the HSE to apply the EU working time directive in an appropriate manner to doctors in training but all that has happened is that the HSE has raised the problems and difficulties of its implementation.

Chairman

Is Ms Coulter saying there is no willingness on the part of the HSE to engage meaningfully?

Ms Shirley Coulter

Meaningfully. It is within the gift of the HSE. The High Court settlement agreement was hard fought and won by the IMO on behalf of non-consultant hospital doctors, NCHDs, to ensure that training can be protected when working hours are being reduced. There has been no meaningful engagement on the issue.

Yes, that is why I wish to be careful. It is important that we send the right message.

Professor Patrick Plunkett

I am saying that the conditions are inappropriate. If we are to fill the empty slots throughout the State, we must work to attract candidates. One attracts wasps far better with honey than with vinegar.

Deputy Pearse Doherty asked why, if we are having contractual difficulties, we keep going. There is a straightforward answer to that and it is twofold. First, we keep going because consultants in this country are committed to our work. We are older, we have families and it is very difficult for us simply to walk away from our patients and from our family setting. However, some have done so. I myself have been head-hunted from Australia. For an equivalent department in a provincial city in Australia, seeing exactly the same number of patients and having a slightly lower acuity of patient, there are the same number of non-consultant hospital doctors as I have in my department but nine consultants instead of four. It would be a far better position. Moreover, at the present time, it would also pay more. However, that is a separate matter. The second reason we keep going is that NCHDs are not doing so; rather, they are leaving the country in droves.

Ms Shirley Coulter

On Deputy Joe McHugh's question regarding a plan, the truth is there is no plan because the HSE is focusing on recruitment. The IMO has been calling on it to focus instead on retention, because it is only by doing so that it will address the issue. However, despite our calls, as far as we are aware there is no plan. Such a plan must be part of the overall career plan structure for all grades of NCHDs, including registrars.

Dr. Margo Rigley

To reiterate, Letterkenny is not unique in terms of the situation with registrars. It is the same throughout the country. What is happening is that NCHDs are doing the first half of their training here before deciding to complete it elsewhere. I have personal experience of this in that my daughter has just completed a medical training scheme for two years, at senior house officer level, where she received excellent training in a Dublin hospital and greatly enjoyed working in Waterford and Wexford. However, she could not tolerate the on-call nights and having to pitch up at work the next day. That is it in a nutshell. I am now a heartbroken mother as she and her boyfriend have just left for Australia where they are working in the same hospital. They have been put on the same roster in the emergency department so they can have the same time off. It is remarkable that a country like Australia can do what we should very easily be doing ourselves. One has to ask why it is not being done here. It is not beyond the intelligence of people in this State to devise a system that works.

Deputy Joe McHugh

What is the condition of the accommodation for Irish doctors in Australia and what is the system for allocating it? Is it refugee-style accommodation?

Dr. Margo Rigley

The same situation does not apply. The doctors who came to Ireland recently had to pass an examination before being accepted onto the supervised section of the Medical Council's register. In the intervening time, they were given board and lodging by the HSE at its expense. When they passed the examination they began working and secured their own accommodation. However, the Irish graduates who go to other countries are taken into posts immediately because their qualifications are recognised, so the issue of State-supplied accommodation does not arise.

It is worth reiterating that we must deal with the question of why we do not retain our own doctors. The HSE is going about it the wrong way around in this regard and there does not seem to be a plan B in place. It is not too difficult to come up with a plan B, but we must have everybody working together if we are to devise a successful one. What is required is professional, constructive engagement by all parties. The Irish Hospital Consultants Association has indicated its commitment in this regard, as has the IMO.

Deputy Peter Fitzpatrick asked about problems arising from the increased birth rate at maternity hospitals. I do not know where they are fitting the mothers and babies, as they would say themselves. The NCHD complement in the maternity hospitals is an essential part of the workforce. All staff are working much harder than they ever did. I do not work in the area, but I am hearing that new mothers are not staying in hospital as long as was the case in the past, because their beds are required for the next patient. That is essentially how the increase in births is being accommodated.

This problem is not unique to maternity hospitals. It is the same in mental health hospitals, for example, where everybody is working faster and harder in an attempt to meet the needs of patients. The increased demand is not unexpected given the increased population. In addition, we have an aging population which, although it is not relevant to maternity hospitals, is very relevant for medical and surgical specialties and for the mental health service.

Deputy Robert Dowds

I had not planned to say anything because, as a lay person, I have much to learn in this sphere. However, will the delegates indicate whether, in their view, the problem of non-retention of NCHDs arises because of incompetent administration within the HSE or primarily because of insufficient funding to cover all the posts? Are the salaries for consultants too high and, if so, would lowering them make it possible to appoint more staff? It is absolutely crazy to have people working 75 hours per week. The only time in my life that I worked those types of hours was in a canning factory in Britain, and I assure the delegates I was not keen to continue in that job for long. Two months at 80 hours per week was sufficient. I am interested in the delegates' comments on these points.

Chairman

I call Senator Colm Burke. In view of the fact that as he has already dominated proceedings, I ask him to be brief.

Senator Colm Burke

On junior doctors, some of those who graduated from college with me would have been obliged to work 136 hours one week and 76 hours the next. I am aware that the hours junior doctors work have been substantially reduced since. However, those responsible for administration still do not appear to accept that there are EU directives with which we must comply. That appears to be a problem.

I agree with Professor Plunkett on how we have treated the junior doctors who have come here from abroad. Approximately 80 of these individuals remain in guesthouses and are being given food vouchers in order that they might obtain meals in the hospitals in which they are based. That is not a satisfactory way to proceed.

Chairman

On that point, it is unacceptable that the HSE has treated people badly. This should not be tolerated. If we are intent on inviting people to come to this country in order that they might fill a gap in the health service, at the very least they should be treated decently and properly. This is the second occasion on which Senator Colm Burke has raised this matter. The committee must send a message to the HSE that its behaviour in this regard is unacceptable.

Dr. Mark Murphy

I will tackle the difficult question of consultant remuneration and whether consultants are paid too much. As I am a GP trainee, I will tell it like it is.

Friends of mine who are training to be consultants deserve an appropriate level of remuneration. It is our responsibility and that of society and the Government to decide what constitutes an appropriate level of remuneration. The current level is often deemed to be an element that would encourage Irish consultants working in America or Australia to return home. The people concerned would probably earn less money in these countries. Under the new contract - minus the deduction for new entrants to the public service - an incumbent consultant would probably earn a very generous salary, possibly in excess of €130,000, just for seeing public patients. We have to be honest about this. Consultants are professionals who have expertise and show dedication and commitment. They would have shown such commitment throughout their careers to date and must continue to show it for the remainder of their lives in seeing out their contracts.

The medical profession can often be demonised. However, we must speak up for ourselves. Consultants and GPs earn their livelihoods from medicine and are highly qualified professionals. The Minister will be obliged to tread very lightly in reducing remuneration. That will certainly be the case in attracting higher specialist trainees into the future, particularly in the light of the creation of new grades and issues of that nature. This should not be an issue. Most consultants of equivalent experience would earn more money abroad. I would welcome other opinions on that matter.

Deputy Dowds inquired what it was like to work 80 hours a week. It is brutal. One could work 100 hours one week and 65 the next.

Deputy Robert Dowds

It seems dangerous.

Dr. Mark Murphy

It is very dangerous and there is a great deal of evidence that it has an adverse effect on patient outcomes. Our capacity to process and remember information deteriorates with fatigue. It is not only patient care; our personal lives also suffer. That is a lesser issue, but it is an important one. Mental health problems, needlestick injuries and road traffic accidents all increase as a result of fatigue. I know many NCHDs who have crashed their cars - often with fatal consequences - after working 70 or 80 hours a week. This is a serious matter which is not, perhaps, sufficiently highlighted. Again, the HSE is shirking its commitment to reducing the excessive hours which people are obliged to work. There is a big difference between working between 80 and 100 hours and working less than this. Health and safety issues arise for both patients and doctors.

Dr. Margo Rigley

I thank Deputy Dowds for his questions. I wish to address the question relating to administration and finance and, in particular, to return to a point made by Deputy McHugh.

I have worked as a clinical director in the HSE and its precursors for many years. I am now one of the new clinical directors under the new contract. As a result, I know many of the administrators and managers who work in the health service. I have found them very good to work with on an individual basis. They are bright people who have ideas. In my new role as executive clinical director in mental health services, we are as one in finding ourselves frustrated by the system under which we now work. It is an extremely centralised, command and control system. Many of my colleagues and I believe that if we were allowed to run services in a more autonomous way, they would operate much better. What I mean by this is that if services were given budgets, they would control them and be able to operate on the basis of assessed patient need. If such a system was adopted, we would not find ourselves moving into the second half of the year and being told that more money had to be saved, that the budgets required for particular services could not be provided or that vacant positions could not be filled.

The service in which I work is in dire straits as a result of the number of psychiatric nurses who are about to retire. One half of the service is going to be down by 40 psychiatric nurses. I do not know who is going to do the work or who is going to care for the patients in such circumstances. That is the dilemma we face. As a result of the fact that the overall staff complement in the HSE is above the count, we find that we are not able to recruit new personnel. As a result, patients will be left without services. That is a major source of frustration for me, as a professional, and the managers with whom I work in the service. There is no doubt that there are economies of scale which could be achieved if the service was allowed to be run in a more autonomous fashion.

Mr. Martin Varley

On consultants' salaries, there is an evolving problem in recruiting consultants which has largely arisen as a result of the fact that in the past three years consultants' salaries have - despite existing contractual arrangements - been cut by between 30% and 40%.

Deputy Robert Dowds

I inquired about salaries across the public service.

Mr. Martin Varley

Yes, it is a contributory factor. The outcome is that the number of eligible applicants for consultant posts has declined significantly in the same period. In 2009 there were in excess of ten consultant posts for which there were no eligible applicants. We do not yet know what the figure for 2010 was. If the terms and conditions on offer here were more attractive than those available elsewhere, there would have been a significant increase in the number of applicants for consultant posts. There has been no such increase. On the contrary - as indicated - the opposite is the case. Highly trained and qualified doctors from Ireland are going abroad. We regularly receive telephone calls from doctors abroad who, after completing successful interviews, are being offered consultant positions and whose key concern is whether, if they return to this country, they will have the resources necessary to allow them to treat patients and whether salaries will be further reduced. This is militating against the recruitment of high quality, internationally mobile doctors. As previous speakers indicated, consultants can earn more in other English-speaking countries.

Mr. Denis Evoy

Professor Patrick Plunkett

Deputy Robert Dowds's question on remuneration ties in the with the other issue about contractual difficulties. I believe I am the only one present who was on the contract negotiation team for the last contract. It was an extremely protracted and difficult negotiation and there was absolute intransigence on the part of the HSE as far as I could see. In the heel of the hunt the Minister of the day announced that an agreement had been reached and everybody was happy to a certain extent. There were aspects of it about which we were unhappy but we were prepared to proceed. We signed the contract but before the ink on it was dry, as in the case of the Treaty of Limerick, it was broken because the Minister reneged on the last tranche of payment long before the Financial Emergency Measures in the Public Interest Act was even thought of. She simply said it would not be paid and we have not got beyond that position. She broke the contract. We do not trust the HSE or the Minister at this stage for that reason.

We accept the fact that the public finances are in a powerless state and that all public servants have taken cuts. The amount of money I get before taxation is 24% below what is written on my contract. I will accept what every other public servant accepts but I have an enormous difficulty about the reneging from contractual terms before we ran into the national problem.

Chairman

There is a new Minister in office now. Can the trust in the relationship with the HSE be re-earned? Can there be a harmonious relationship between the two? Everything we have spoken about over the course of the last three meetings has been predicated upon a joined-up approach, a willingness by all parties to engage properly, as was stated by Senator Burke in terms of dealing with the Medical Council and the HSE sending a new memorandum of understanding. Is Professor Plunkett saying that from his perspective he cannot have a working relationship with the HSE based on his inability to trust it?

Professor Patrick Plunkett

I will ask Ms Shirley Coulter to deal with that question but before doing so I will make one comment from a personal point of view, namely, that there are still issues with unilateral decisions on what is stated in the contract.

Ms Shirley Coulter

We can work with the Minister, the Department, the HSE and all the stakeholders. We have been attempting to do that and to engage in recent years. The difficulty is that there appears to be a lack of accountability within the HSE and nobody seems to be willing to take responsibility for the existing problems.

Chairman

Can Ms Coulter expand on that?

Ms Shirley Coulter

Yes. For example, within the HSE south a number of decisions were taken by hospitals since August regarding a clear contractual term in the NCHD contract of employment, which is that because NCHDs must work compulsory overtime they are working these hours. There is much focus in the media on overtime earnings but what we must examine is if they have worked the hours and there is a clear contractual right to be paid for those hours. However, a number of hospitals in HSE south have issued unilateral diktats putting a blanket ban on payment for these hours worked, specifically unrostered hours. Someone might be rostered to work from 8 a.m. to 5 p.m. but a clinic might overrun or an emergency occur and they might be in the hospital to 7 p.m. or 8 p.m. They are unrostered hours and it is those that have been targeted for non-payment. One hospital went as far as to write that there would be non-payment of these hours even in exceptional circumstances. It is acknowledging, therefore, that these hours are worked in exceptional circumstances. When the IMO commenced the process of trying to resolve these difficulties the buck was passed from person to person. A hospital manager told me it was the not the hospital that had taken a decision but the assistant national director of human relations within the area because of financial constraints.

Chairman

Ms Coulter is referring to HSE south.

Ms Shirley Coulter

Yes. I tried a number of times to get clarification but was not successful. I heard subsequently that it was within the office of the regional director of operations. I then had a meeting in the Labour Relations Commission on Tuesday with the HSE director of human resources nationally. They say these decisions are being taken but nobody is taking responsibility. It is within their gift to immediately stop these unilateral decisions but these memos are in the system since August. We have been engaging on a local, regional and national level, yet to this day in hospitals in HSE south these directives are being let go unchecked by the HSE nationally. That is crazy.

When I told one hospital manager that I have contacted the HSE nationally and that it agrees with the IMO that the contractual position is clear, that person said the HSE is talking out of both sides of its mouth. In other words, pressures are being exercised with regard to the financial position, etc. It is difficult because nobody is willing to take responsibility. There is no accountability. The buck is being passed, the doctors are continuing to have their contract breached and they are leaving the country.

Senator John Crown

I will make a brief point to follow up-----

Deputy Robert Dowds

Part of my question was not answered. By implication, Ms Coulter has answered the question about money in the sense that there is not enough money to go around in terms of the various areas of national spending but the question of restrictive practices was not answered. I may be wrong about this but I want to find out the position for my own satisfaction. Are there restrictive practices in terms of the appointment of consultants either by the Irish Hospital Consultants Association or by the Health Service Executive for its part if it refuses to release money for posts?

Senator John Crown

In reference to the systems in place for dealing with misbehaviour by career-level doctors, I will not go into the details of the case but it is illustrative of the profound pathology in the Irish system. A very famous case occurred in the 1990s involving a critical national referral centre which, at the time, was either the only one or one of two centres in the country, but it was certainly the one in Dublin which had responsibility for 80% of the geographical catchment area of the country for one very critical and specialised area. It was paralysed and brought to its knees because of what effectively amounted to an internal dispute between members of staff which ended in multiple people going to the High Court and several people ultimately having their jobs terminated as a result.

In a rational system where there is a boss, he would have asked for Mr. Smith and Mr. Jones to be sent in to him - fictional names - and he would tell them they had two minutes to fix the problem or they would both be looking for jobs. That is how it would work. We do not have that because, in reference to what Deputy Dowds said, we have a major restrictive practice in terms of specialist appointments in hospitals. He is absolutely correct; there is a restrictive practice that has not been seen since the Soviet Union, and that is that one State bureaucracy is the only one that has the authority to appoint consultants. No consultant has the right to make or to bar jobs. No consultant has the right to say he or she will have more specialists in an area. Every consultant body I know, every professional and specialist body I know has been clamouring for more appointments. They have been arguing against the restrictive practice. The restrictive practice is vested in one entity, namely, the HSE. In its previous incarnation it was a group called Comhairle na n-Ospidéal. It was a form of professional birth control exercised not by doctors - I am intrigued because I have just been given the form on trap-neuter-return which they have not quite advocated for doctors yet - but by the people who ultimately pay for the health system because they know that in addition to the salary of every consultant every consultant also generates more work, waiting lists get shorter and there is more throughput in the system. Therefore, a very effective way of controlling costs in the system is to control the number of specialists. Deputy Dowds is correct that there is a restrictive practice, but it is not the one he thinks.

Professor Patrick Plunkett

What I wish to say almost mirrors what Senator Crown has said. The application for consultants comes from within the consultant body, in essence, identifying what the need is for the population and bringing it up through a system which seems designed to prevent it getting anywhere. I started as a consultant in 1988. By 1989 I had identified that we needed more consultants in emergency medicine within departments, not single-handed consultants. It took me until 1991 to persuade my hospital that this was the case and in 1992 a formal application went to Comhairle na n-Ospidéal. It was not until 1999 when I threatened, cajoled and ultimately stopped admitting patients under my care but only saw them in the emergency department that a second consultant was appointed.

As things had moved on significantly in our neighbouring island in the meantime, which is where most trainees in my specialty have trained, and they had moved on to multi-consultant departments we had applications approved internally for a further two posts by 2000 or 2001 - I cannot remember the exact date - when the Minister of the day announced that he would double the number of consultants in the specialty immediately. Our fully worked up applications were on the desk in Comhairle na n-Ospidéal by 5 p.m. that afternoon. They put in a temporary consultant then and it took until 2003 to appoint one consultant. We appointed the second consultant last year but only because we had suppressed an associate specialist post who had left us to go to a consultant post elsewhere. We are still waiting for one consultant. There is a huge push from consultants to expand the number. In any free market economy that would automatically drive down the price. Ultimately, it will drive down the price and it is being resisted, but not by us.

Chairman

By the HSE.

Dr. Margo Rigley

To reiterate what Senator Crown and Professor Plunkett have said, at the moment the clinical programmes are what will bring about the big improvement to services for patients in this country. Crucial to the clinical programmes is the appointment of a number of key consultant posts. Sadly, as Senator Crown said, that has been put on hold specifically by the centralised area of the HSE. I know that is something that would be of concern to the Minister as he is fully supportive of the programmes, as we are too.

Chairman

I thank the witnesses, Ms Coulter, Dr. Murphy, Professor Plunkett, Mr. Evoy, Dr. Rigley and Mr. Varley. I thank those who made presentations, in particular Dr. Murphy for his honest appraisal of where we are at. It is a human story which it is important for the committee to hear. It is important that when we complete our work that we will not hide from the reality. From the evidence today it appears that there is a need for joined-up thinking. In particular, what is alarming to me personally is how the HSE has been doing its business. If what has been outlined today is correct - I have no reason to doubt it - then the HSE has many questions to answer. There is a need to bring about reform. It is incumbent on all of us, and in particular those of us involved in the health sector, to work together but leadership needs to be shown by the HSE.

The joint committee went into private session at 2.06 p.m. and adjourned at 2.10 p.m. until 11.30 a.m. on Tuesday, 25 October 2011.

JOINT COMMITTEE ON HEALTH AND CHILDREN debate - Thursday, 20 Oct 2011

Non-Consultant Hospital Doctors: Discussion (Resumed)

Ms Shirley Coulter

Dr. Margo Rigley

Ms Shirley Coulter

Dr. Mark Murphy

Dr. Mark Murphy

Professor Patrick Plunkett

Dr. Margo Rigley

Mr. Martin Varley

Ms Shirley Coulter

Ms Shirley Coulter

Ms Shirley Coulter

Ms Shirley Coulter

Dr. Mark Murphy

Professor Patrick Plunkett

Professor Patrick Plunkett

Professor Patrick Plunkett

Professor Patrick Plunkett

Professor Patrick Plunkett

Professor Patrick Plunkett

Ms Shirley Coulter

Dr. Margo Rigley

Dr. Margo Rigley

Dr. Mark Murphy

Dr. Mark Murphy

Dr. Margo Rigley

Mr. Martin Varley

Mr. Martin Varley

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Mr. Denis Evoy

Professor Patrick Plunkett

Professor Patrick Plunkett

Professor Patrick Plunkett

Ms Shirley Coulter

Ms Shirley Coulter

Ms Shirley Coulter

Professor Patrick Plunkett

Dr. Margo Rigley

JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 20 Oct 2011