I will outline the consultant recruitment and appointment process. Many factors influence successful recruitment and retention of consultants, for example, the supply of appropriately-trained candidates, structure of posts, configuration of service, geographic location, and terms and conditions, including remuneration. In 2015, the then director general of the HSE requested Professor Frank Keane, the national clinical lead in psychiatry and a former president of the Royal College of Surgeons in Ireland, RCSI, to lead a process to address a range of issues associated with the creation and approval of consultant posts and successful recruitment to these posts. Professor Keane's report, which is available on our website, followed close engagement with all stakeholders. It diagnosed a consultant recruitment and retention crisis and noted that, "a key driver of the large number of vacant posts was a Consultant recruitment and retention crisis".
A range of factors contributed to this crisis, which are outlined in my submission and I will take as read, although I would be happy to go through them if the committee wishes. In addition, the report found that, "some hospitals [and healthcare settings] struggle to recruit Consultants in any specialty or in a particular specialty". It noted:
[...] a key concern for many potential candidates for Consultant posts in recent years has been salary. Starting salary, progression through points on the salary scale and how new appointees compare to colleagues appointed in earlier years are all reported as influencing decisions by potential candidates to apply or to accept an offer of a post.
The 2015 salary rates represent a partial restoration of the pre-2012 rates, albeit consultants appointed under these rates take longer to progress to the final point on the scale and that final point is lower than the one for consultants appointed before 2012. There are two tiers of pay for consultants.
While access to private practice differs according to contract type, it also varies by specialty and location of post. The 2008 contract aimed to address this by providing for a substantial difference between a type A salary, where the consultant has no access to private practice, and types B, B* and C, where they have some access to private practice. However, changes to consultant remuneration have reduced the difference between type A and other contract types.
Data from the Public Appointments Service, PAS, regarding the number of applicants for 45 consultant posts indicate that the lowest number of applicants - zero to one in most cases - were for consultant posts in level 2 or 3 hospitals, which are smaller hospitals; psychiatry, particularly psychiatry outside urban centres; emergency medicine irrespective of location; radiology, including radiation oncology; and pathology, including histopathology. Data provided by the PAS regarding 129 posts indicate that, of the 102 consultant posts across all disciplines that received fewer than five applications each, 31 were in psychiatry. Psychiatry seems particularly difficult to recruit into. Table 3 shows 16 posts that were advertised in 2016 but received no applicants. They are consultant psychiatric posts across all psychiatric subspecialties and in all parts of the country, particularly in mental health services that are remote from urban centres.
The tenure of consultants is an indicator of difficulties with recruitment and retention. Data from the NDTP DIME database, which is a medical database, for this year to date indicate that psychiatry has one of the highest percentages of non-permanent consultant post holders at approximately 20%. That is high.
The consultant applications advisory committee, CAAC, is a part of the recruitment process. I have been asked to outline it to members, so I will discuss it, although a colleague who is present, Mr. Andrew Condon, has a longer history with the CAAC than me. Consultant posts in publicly-funded hospitals, mental health services and health agencies are regulated under law. Between 1971 and 2004, posts were regulated under the Health Act 1970 by Comhairle na nOspidéal, an independent statutory body under the Department of Health. In 2005, regulation transferred from Comhairle na nOspidéal to the HSE. The HSE's regulatory function covers all consultant appointments in the public health system, including HSE hospitals, voluntary hospitals, mental health services and other agencies, be those additional, replacement, temporary or locum appointments and irrespective of the extent of the commitment involved or source of funding for the appointments.
In response, the CAAC was established by the chief executive officer, CEO, of the HSE under the 2008 consultants contract. The purpose of the CAAC is to provide independent and objective advice to the HSE on applications for medical consultants and qualifications for consultant posts. The CAAC provides a significant opportunity for consultants and national clinical directors to contribute their expertise and professional knowledge to the decision-making processes for the development of consultant services in all specialties throughout the country. The CAAC considers all new and replacement consultant posts for mental health services. My submission lists the CAAC's membership. It meets ten times per year and provides advice on each post. That advice can be to approve, seek clarification, amend the post or refuse approval to the post.
The CAAC advises the HSE on the appropriate qualifications for consultants. Advice provided by the CAAC is forwarded by the NDTP to the national director of human resources, to whom responsibility for the regulation of consultant posts has been delegated by the CEO of the HSE. In turn, the national director regulates each post, taking into account the advice provided. When the CAAC considers a post and recommends its acceptance, it still has to go through several other processes before it is filled. The CAAC is a middle part of the recruitment process.
Table 4 of my submission lists the number of consultant psychiatry posts that appeared before the CAAC. Table 5 shows the number of consultant posts in psychiatry, which has increased by 50 in approximately five years.
This abbreviated statement summarises the roles of NDTP and the CAAC. I am happy to address whatever questions committee members may have.