Mental Health Services: Discussion (Resumed)

I welcome Professor Frank Murray, Director, and Mr. Andrew Condon, medical workforce lead in the national doctors training and planning division, HSE. On behalf of the committee, I thank them for their attendance.

The format of the meeting is that the witnesses will be invited to make a brief opening statement and this will be followed by a question and answer session.

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

I remind members and witnesses to switch their mobile phones to aeroplane mode as even on silent they interfere with the broadcast. I also wish to advise the witnesses that any submission or opening statement they have to make to the committee will be published on the committee website after this meeting.

Earlier I asked Professor Murray not to read his entire statement into the record but it will be included in the report. He will give an edited version. I call Professor Murray to make his opening statement.

Professor Frank Murray

I thank the Chairman and members of the committee for inviting us here today.

My name is Frank Murray and I am the director of the HSE's national doctors training and planning unit. I am grateful for the opportunity to appear before this committee to advise members on the role of the national doctors training and planning, NDTP, in consultant recruitment and retention in mental health services, as well as to discuss the role of the consultant applications advisory committee, which has the unfortunate acronym of CAAC.

I shall outline the role of the NDTP division. The division was established in November 2014. It is a division of the HSE's national directorate for human resources. The NDTP's statutory remit is outlined in the Health Act 2004 and the Medical Practitioners Act 2007.

I will read the first paragraph of my presentation in order to set the scene but abbreviate the rest. The main objective of the NDTP is to ensure that the Irish health service is provided with an appropriate number of specialists, who possess the required skills and competencies to deliver high quality and safe care, and whose training is matched to the model of healthcare delivery in Ireland, regardless of location. In order to meet this overarching objective, NDTP focuses on the three core domains of medical education and training, medical workforce planning, and the consultant post approval process. It is important to state that NDTP does not recruit non-consultant hospital doctors, NCHDs, or consultants for the HSE or HSE-funded agencies.

The recruitment and retention of doctors has been evaluated in the report entitled Strategic Review of Medical Training and Career Structure 2014, which is also known as the MacCraith report. I am sure the members are familiar with the report. It contained 27 recommendations on several themes, including training, consultant issues, hospital configuration, medical workforce planning and specific recommendations for service specialties. I have provided a tabular statement that shows three categories of outcomes: positive outcomes; areas of progress, and slow progress. I will leave members to read it themselves.

I will outline the HSE's approach to training numbers in mental health as it is an area of interest for the committee today. The NDTP, in conjunction with the postgraduate medical training bodies, agrees on the intake numbers of doctors in training for each specialty on an annual basis. The principles utilised by the HSE-NDTP to underpin the number and types of specialist training posts required by the health service remains consistent from year to year. I have listed the principles. Will I take them as read?

Professor Frank Murray

In terms of medical training in mental healthcare, to meet legislative obligations the HSE has established formal, structured contractual arrangements with any organisation that provides medical education and training. These arrangements have been formally incorporated through service level agreements between the HSE and training bodies. For mental health, the service level agreement is with the College of Psychiatrists of Ireland, which is the formal recognised training that is credited by the Medical Council.

It is important that I outline how postgraduate training, which takes place after an intern year, is structured. Traditionally, postgraduate specialist training is delivered in a two-stage process. First, there is basic or initial specialist training. Members will know it as senior house officers or SHOs, which is a term that we still use today. Second, there is higher specialist training, which is known as specialist registrars. In recent years there have been significant changes in the delivery of postgraduate training in Ireland. Many training programmes have transitioned towards a model of streamlined or continual training so that people move directly from initial specialist training to higher specialist training. The next paragraph of my presentation is on streamlined training, which I shall take as read.

It is worth reflecting on doctors in training in mental health. In 2017, as many as 233 trainees undertook initial specialist training in psychiatry and 104 undertook higher specialist training in psychiatry. That means there are 337 doctors in total training to be specialists in psychiatry. They are divided into two streams. Child and adolescent psychiatry has 20% of the trainees and adult psychiatry has 80% of the trainees. I have outlined the numbers in my presentation. I have also provided some charts showing data. Figure 1 shows the number of trainees per year in initial specialist training over the past several years.

On page 4, tabular statement No. 2 shows data about consultants. One can see the following: 104 doctors work in child and adolescent psychiatry; 259 doctors work in adult psychiatry; 43 doctors work in the sector called the psychiatry of learning disability; and 52 doctors work in the sector called the psychiatry of old age. The total is 458 consultants and we have half the number of trainees as we have consultants in psychiatry.

Figure 3 shows the age profile in psychiatry. Between a quarter and a third of consultants are more than 55 years of age, indicating problems for the future in terms of retirements.

Figure 4 shows a topic that has been discussed a considerable amount in recent weeks, namely, the number of psychiatry consultants not on the specialist register. This figure shows that, depending on the subspecialty, between 4% and 9% of doctors working in psychiatry are not on that register. In other words, they do not have a certificate of completion of training.

Members will note from figure 5 on the number of doctors in psychiatry that, depending on the subspecialty, between 13% and 22% of consultant psychiatrists hold non-permanent contracts of one sort or another.

Figure 6 shows the geographical distribution of psychiatric consultant posts by healthcare setting.

These tables show more or less the first half of what I want to address in an abbreviated form, that being, the role of the HSE's national doctors training and planning, NDTP, with a particular emphasis on psychiatry. I am happy to take questions on this or to proceed to the second part, as the committee wishes.

Professor Murray should proceed.

Professor Frank Murray

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.

I thank Professor Murray. Selected members will be given seven minutes each to ask questions and hear his answers. Before I hand over to them, though, I wish to clarify a matter, mainly for myself, but possibly for other members as well. We all know that there are problems with the recruitment and retention of staff.

The committee that works with the NDTP - is this a paid position for your committee?

Professor Frank Murray

No.

So the NDTP is one committee and it looks at the actual qualifications of potential candidates. The next crowd is CAAC, I think the witness called them. There is a huge amount of stuff going on in recruitment before the job is even advertised. I just want Professor Murray to clarify that. His charts show, for example, approved consultant posts; approving posts is very different from advertising consultant posts. Is that true?

Professor Frank Murray

You are absolutely correct in identifying that there are several steps in the recruitment process for consultants. The first is that the hospital has to identify a need, either for a new post or for replacement of somebody who has retired or is coming up to retirement. If it is within the acute hospitals, it has to go to the acute hospitals to get approval for funding. That is step one. That has nothing to do with NDTP. NDTP only has a role in running the CAAC committee in respect of actual recruitment and retention. It does have a role in workforce planning but that would not have anything to do with this process at all. Once it is funded, it comes before the committee which looks at several main things, including how the application fits in with the national strategy for a particular specialty. There is a comment from the specialty lead, for instance, Philip Dodd, in respect of mental health posts. The committee also considers how the post is structured, whether it is feasible and workable and whether the resources are there. That would be the second issue. They are the real things that are considered at the consultants appointment committee.

I am not going to ask any more questions as the members need to ask them. We have Deputy Pat Buckley and then Senator Colette Kelleher.

I was going to be a gentleman and give the first slot to Senator Kelleher as the lady.

The Deputy is obviously not well prepared.

I am very well prepared.

Deputy Buckley has been a total gentleman on so many occasions; that was a bit of a cheap shot. I thank the witnesses for being present. I have some questions on their submission but would first like to ask a couple of more discursive questions. The witnesses are focusing on the technicalities, numbers of people in and people out, who is approved, what is advertised and all of that, and we do need to drill down there as well.

Would Professor Murray say that the Irish mental health system is consultant led? Would that be a fair way of describing it? What bearing does that have on the kind of mental health system we have? We have a big concern in this committee about reliance on medication as opposed to all the other types of support. We are not against medication but we do think there is a preponderance of that.

I would be interested to know - again more from their experience in the clinical side of their work - how the witnesses feel doctors and consultants in the mental health system work with psychologists and therapists. It takes a whole team to enable a person to get better. What is the witnesses' commentary on interdisciplinary work? Is it the norm in Ireland? Are there any good examples we can draw on as a committee?

The submission states that in 2016, 16 mental health consultant posts were advertised and received no application and that they were in the smaller hospitals in rural areas - Sligo-Leitrim, Cavan-Monaghan, Oberstown, Carlow-Kilkenny, Donegal, Longford-Westmeath, Laois-Offaly, Waterford-Wexford and south Cork. Can the witnesses give us an idea of what that means, particularly in a psychiatry-led service, if that is how they agree we could describe the mental health service? What does it mean in terms of the child or adult seeking support? Have the posts been filled?

Given the recruitment and retention difficulties in psychiatry, the impending retirements and the 20% reliance on non-permanent positions, do the witnesses see an alternative to a psychiatry-led mental health system? Has there been any thinking done on that? Is it done anywhere in the world? Is there anything that would be worth exploring for our committee? I know the witnesses have responsibility for specialists but what is their view on GP training? The GP clinic is where people come to in the first instance and the GP is the person who will be with them in the long run. What is their commentary on the state of mental health training for GPs? Is it in accordance with best practice? Is it adequate?

I thank the Senator and ask Professor Murray to answer as succinctly as possible.

Professor Frank Murray

I thank the Senator for her questions. Without being evasive, I am not a content expert and I do not think I can answer several of her first questions in terms of the kind of system, whether it is doctor led, or the issue of medication excess. I am not a psychiatrist. I am a physician. I do not think I could make a comment that would be in any way expert.

Could Professor Murray point us in the right direction?

Professor Frank Murray

I would like to. I certainly would say the College of Psychiatrists of Ireland would be a place to go as it is the leading medical provider of psychiatric care.

Surely it will say that psychiatrists are great and we need more of them. What I am trying to get at is that we have a system based on a particular model and reliant on a particular profession. We are having huge difficulties in recruiting and retaining people from that profession, which has a huge bearing on the person who needs help. I am trying to find out if we can explore alternatives. Obviously Professor Murray is working on the technicalities and I appreciate that.

Perhaps the Professor could respond to us by email or letter indicating where we could go to find that information.

Mr. Andrew Condon

There were distinct management structures in the HSE for mental health services. They have been merged as part of organisational changes in the HSE but certainly we can suggest our senior management colleagues in the HSE and Philip Dodd as the national clinical lead for mental health to engage with the committee to address those specific issues. We could do it in two ways-----

Senator Kelleher is absolutely right. We invited people in to talk about mental health. We are not really interested in the anaesthetists or anyone else. It was specifically mental health. Why were you two selected to come in for that?

Mr. Andrew Condon

The invitation related to the work of NDTP and the CAAC and the specific issues surrounding recruitment as opposed to the generality of service-----

For mental health. This is a mental health committee.

Professor Frank Murray

I thought we were coming in to talk about the mental health recruitment issues.

That is it. Everything else is thrown in. The witnesses are not able to respond to Senator Kelleher's questions.

Professor Frank Murray

In terms of the content, no. I am aware that Philip Dodd will be here. He would be an appropriate person. He is the national clinical lead for mental health services. I would suggest he would be a content expert and a better person to answer Senator Kelleher's questions than me. I am not trying to be evasive. I am happy to address the other issues she has raised which I do know a little bit about. She was asking if training in psychiatry should be a part of general practice training. It is a very important part of general practice as well as hospital-based medicine and I think it is a good idea. In terms of the issue about-----

Is Professor Murray recommending that?

Professor Frank Murray

As an individual I would support it rather than recommend. I am just a bit wary of what I say. I would be supportive of the person looking after me knowing about the psychological aspects of health as well.

I think it is up to the committee to make a recommendation, anyway, Senator.

Professor Frank Murray

In terms of the unfilled posts and the 20% non-permanent staff, there are critical issues in recruitment and retention of consultants in all specialties. It is particularly marked in psychiatry. As the Senator identified herself, some of those posts are in the more rural settings.

That is a problem in Ireland and everywhere. It is much more difficult in most jurisdictions to recruit consultants to non-urban centres for a whole variety of reasons. Partly it is to do with people making lifestyle choices. It is also partly to do with the fact that when one is working in a smaller setting, for instance, it can be much more challenging. When one is working in a setting with more colleagues, one has a greater range of expertise and sense of working in a team which makes work a lot less stressful. These are almost existential questions. They are worse in psychiatry and mental health services than they are in other specialties. If one looks at consultant posts with no or one applicant, psychiatry is, unfortunately, a leading specialty in that regard.

What are the alternatives in these circumstances? My own long-term view is that psychiatry being doctor-led is probably the right way to go. In some settings which are remote and more difficult to staff, however, we need to be more creative. If one looks at Canada, for instance, where remoteness is on a different order of magnitude to here, it has some differences in how it recruits and retains medical staff and other staff. We possibly could learn from Canada as well. However, I would argue that what we judge as remote is not really remote by Canadian standards. Canadians talk about two-hour plane trips in terms of being remote.

We are looking at the problem of recruitment and retention. Professor Murray spoke about two committees making decisions before there is even a recruitment process.

Professor Frank Murray

No, I will get Mr. Andrew Condon to clarify that.

Mr. Andrew Condon

NDTP is an administrative unit of the HSE. It was established in 2007 specifically to focus on doctors and doctors’ training. In 2007, the HSE allocated certain functions regarding the regulation of training posts and the number of training posts in the system by the Medical Practitioners Act 2007. The HSE set up a unit of administrators and clinical staff to address that issue.

One of the functions of the NDTP is workforce planning. Another is the negotiation of service level agreements with the training bodies to control the number of trainees, to deal with issues around rotation and quality of training. A third function is providing support to the consideration of consultant posts. If one goes back 40 years to the 1970s, there was an agency, Comhairle na nOspidéal, whose only function was to regulate consultants. It decided whether an application for a consultant post was fit for purpose. That was a statutory function under the Health Act 1970. That function was given to the HSE. Between 2005 and 2008, the HSE did that on its own without input from the wider clinical community, training bodies, patient representatives and so on. In 2008, a committee was set up under the consultant contract, namely, the consultant applications advisory committee, CAAC to which Professor Murray referred. It really is a means of bringing in the wider clinical community and patient community.

How long does that process take?

Mr. Andrew Condon

To describe a typical application, once an application is received by NDTP, it takes an average of six weeks from the email arriving to an approval letter issuing. I sign approval letters for consultant posts within 24 hours to 72 hours. The application is funded. It is received by NDTP which will put it in front of the next meeting of the CAAC, which meets on a monthly basis. If there are no issues, it will be approved on the day. An approval letter will be drafted rapidly. Once that is drafted and signed, it goes to recruitment. This is the administrative process, but it reflects the legal obligations the HSE has under the Health Acts. It reflects the idea that sometimes what is proposed in the system is not fit for purpose. For example, a particular surgical post will not be put in place in a hospital which does not provide that service. Historically, there has been that need to regulate the system. It does act as a control on the number of posts because the number of consultant posts has actually increased exponentially over the past ten years, going up by 41% since 2008. It does not act as a limiter. It acts as a quality control piece on consultant posts.

We have an administrative unit and one committee. That is a six-week process.

I thank the witnesses for attending the committee.

It was stated a hospital must identify the need for an extra psychiatrist or clinician but then must make a funding case. If hospital management sees a lack of services which are needed, then there should be a common sense approach. For example, among psychiatric nurses, there is a significant concern that within the next five to six years more than 1,700 of them will retire. However, there has not been one mention of forward planning to fill those gaps. Between 300 and 500 positions need to be filled to bring psychiatric services to where they should actually be but there is a process where we cannot get applicants. How is it Tallaght and St. Loman’s have 43 vacancies, St. Joseph’s in Portrane, 58 vacancies, Waterford, 26, and Louth-Meath, 34? Is there somebody in control to say we need these vacancies filled?

It is also claimed there is an issue with money. I have encountered cases where common sense seems to disappear. For example, a young person is admitted to an accident and emergency department and is waiting for an assessment to child and adolescent mental health services, CAMHS, but the assessor is missing. There does not seem to be a process which will ensure the patient can be moved. Is that politics or is that under some mental health rule? That seems to be an overlapping problem. We have young children who are absolutely victimised and terrorised in an accident and emergency department because of the policy that if one cannot get it in one hospital, one will certainly not get it in another as the hospitals need to justify their numbers. There seems to be a big fudge.

We keep on hearing there is a problem with staff retention. I have spoken to qualified people around the country who have told me they cannot get a job in the services. There does not seem to be a common-sense approach.

One fifth of consultants in most psychiatry wards are working on non-permanent contracts. Professor Murray referred to the issue of consultants trying to balance between public and private systems. If they are trained at a cost to the State and contracted to the State, then they should spend more time in the public sector hospitals. Why can we not get the consultant psychologists and psychotherapists? It should involve a common-sense approach of stating a consultant is needed in ward A today and not ward B as there is an emergency. Why can we not do that?

Professor Frank Murray

We could do better on anticipating retirement. Turning 65 is generally not a surprise for most individuals. Many people will retire at that age. We should be anticipating that, when people come up towards retirement age, we put processes in place at a much earlier stage to reduce or avoid a gap between a person retiring and the next person taking up the job. That is a good point.

We should ask people when they are around 60 years of age if they are thinking of retiring early and if so, could they give us a year’s notice. This would allow us to begin the process of recruitment at an earlier stage.

Is that Professor Murray's role? Has he the authority to answer that?

Professor Frank Murray

I do not have the authority. One of the issues the committee has been bringing up is that there are many steps in the process before the job is even filled. We could do better by reviewing them to see if we can tighten them up. The ways of doing that are, first, anticipating, as just discussed-----

It is not anticipated because everyone has a date of birth and it is known when people are coming to retirement age. There seems to be, however, nobody in any of the systems who can flag this. Again, it goes back to reactive instead of proactive approaches. There is a possibility that so many staff will retire within the next 12, 16 and 18 months. Does Professor Murray believe a process should be put in place and an onus put on management to have these appropriate questions asked to ensure they can plan forward? Is Professor Murray aware of anybody who had worked in the system who retired but was then rehired? There seems to be a blind patch there too.

The crux is recruitment and retention. The barrier we are hitting all the time is that we cannot get the qualified staff. This is, apparently, because we do not have an effective way to train them or hold on to them. The only way to hold on to them is to give them a proper contract. Professor Murray referred to problems with recruiting for rural areas. I do not believe that, however, because rural areas are cheaper in which to live. We have a situation in Dublin where rents are so expensive that nurses could not be bothered coming to work in the city because they cannot survive. Many mental health instances are rural-based. We should be promoting recruitment to such areas as an option. I asked the Minister two months ago to roll out pilot projects in this area. Enough surveys and research have been done to identify the blackspots. There does not seem, however, to be any joined-up thinking. It just seems to be the various community healthcare organisations, CHOs, all pulling against each other. Looking at the figures for the vacancies, it is like shovelling snow while it is still snowing.

I just want to know who is responsible and where the buck stops. Who do we bring in here and ask why we cannot have 50% of the 26 vacancies in Waterford filled in six months? Do we have to go through the NDTP, the CAAC or someone else? Do we have to go through all the managers involved to be told at the end nobody knows who is responsible?

Deputy Buckley is right. Are the witnesses the right people to be here today? Who are the people who are supposed to recruit nationally? The NDTP does not do it.

Professor Frank Murray

Can I outline a little bit to ensure we are clear what happens with recruitments? The post has to get funded. In this case, it is through the mental health division.

We have been told over and over again that funding is not an issue.

Professor Frank Murray

I do not think it is an issue. There is a process, however, on which somebody has to sign off.

Professor Frank Murray

The mental health division.

Is that one mental health division responsible for all mental health in all CHO areas?

Professor Frank Murray

Yes.

That is good. I am not being disrespectful.

Professor Frank Murray

I understand that. I do not think the Deputy is.

Sometimes one can get so frustrated in here. We are only trying to ask the questions so we can get the answers to progress this collectively and do the right thing.

Professor Frank Murray

I think the Deputy is trying to do what is best for patients. I understand entirely his frustrations. His animation expresses how concerned he is.

I am quiet today.

Professor Frank Murray

It needs to be funded. That funding needs to be agreed. Second, it goes to the CAAC, which is, as Mr. Andrew Condon said, a process which takes several weeks. The next step is that it goes to the national recruitment service. The fourth step is the Public Appointments Service, PAS. There is no good telling PAS, which advertised the posts, to fill the posts. It has gone through the process and does not have another process to recruit people in this regard. Bringing in a participant of these four steps and dressing them down is not going to help. It has nothing to do with those processes. It has to do with what makes posts attractive, what makes people want to come back from abroad, as well as what makes people stay longer in a post.

Can I again interfere here? This is causing all of us desperate anguish. The witnesses have even written down themselves the delaying factors involved, but we are still not getting a clear picture. The floor is open for the remainder of the meeting.

Am I not the lead speaker?

I beg your pardon, Deputy Neville. I did not realise you had replaced somebody.

Will the witnesses send us a copy of the recruitment process from start to end showing how the stakeholders are involved in it? I want a straight line showing the recruitment process with dotted lines on the periphery showing the stakeholders involved, be it the CAAC or the NDTP. From my understanding of what has been presented, the NDTP is like training and development in the private sector. Is that correct?

Professor Frank Murray

The NDTP has two roles. One is in terms of workforce planning and then there is the agreement with the College of Psychiatrists in terms of the number of training posts which I have outlined. That is it across the top. The CAAC is housed in the NDTP. That is where it is run from.

Does it report to the NDTP?

Professor Frank Murray

Yes.

Given the increased demand, have the service level agreements the NDTP has with the training institutes changed over the years?

Professor Frank Murray

Yes.

Does this mean an increased number of places are coming on stream?

Professor Frank Murray

Yes.

A flow diagram showing the recruitment process from start to end, along with the stakeholders coming in on the side as it goes along, would answer a lot of questions.

Professor Murray referred to what makes posts attractive. I am going to take the end part of the recruitment process involving the candidates. Have any proactive steps been taken to address this? It is all fine talking about the attractiveness of a job specification and this, that and the other. If the recruiters are not proactively going out to headhunt and bring people into a job, then there will be a falling down. I know that from my own work in recruitment. I did headhunting for years in the private sector. Other parts of the HSE have been successful in gaining staff where there have been staff shortages. For example, the new accident and emergency department at University Hospital Limerick, UHL, saw an increase in the number of posts and recruitment attrition. The hospital was able to fill those posts because it was very proactive in its approach. Have any steps been taken to be proactive in the recruitment process in question?

Mr. Andrew Condon

There are two issues involved. First, under Professor Keane we undertook an end to end examination of the entire recruitment process. That report which we can send to the committee provides a breakdown for each of the agencies-----

When was it done?

Mr. Andrew Condon

In the period 2015 to 2016.

It is three years old.

Mr. Andrew Condon

It is still relevant today in that there has not been a significant change in the reasons behind the failure to recruit.

I am aware of the reasons from the report.

Mr. Andrew Condon

As to who recruits once the job spec has been approved and funding is in place, the HSE has a recruitment licence. This means that the Public Appointments Service handles our recruitment to fill consultant posts. It handles international advertising and headhunting.

The HSE is not directly responsible and Mr. Condon cannot tell me how the Public Appointments Service is being proactive in recruiting consultants. The delegates have told us that there have been no applications for these positions, but has everything possible been done to ensure there is proactive headhunting and recruitment?

Mr. Andrew Condon

Table 3 in our opening statement provides a good example. It outlines 16 posts, ten of which are in child and adolescent psychiatry. Most of the ten posts are located outside urban centres. Of the others, two are very specialised, being the consultant forensic child and adolescent psychiatrist post in the Central Mental Hospital and the consultant child and adolescent psychiatrist in psychiatry of learning disability post. Few individuals are trained in these areas. As such, the PAS recruitment process is focused almost entirely on child and adolescent psychiatry posts in the first instance and, second, areas outside urban centres. A third focus is on the two very specialised areas in which few people are trained.

I understand that. Mr. Condon is telling me what I already know. I asked whether anything had been identified in the recruitment process that could be done more proactively. I understand the pool of candidates is extremely small. This relates to service level agreements with training bodies and increasing the number of candidates being trained. Has the Public Appointments Service interacted with that pool of candidates? Has it advertised and then sat around waiting for an application to come in or has it asked to speak to people for a few minutes to tell them about positions X and Y that are available? I am speaking in layman's terms, but that is how headhunting is actually done.

Mr. Andrew Condon

In 2016 and 2017 the Public Appointments Service engaged an international recruitment consultant to engage directly with all potential candidates for psychiatry posts.

Who was the recruitment consultant?

Mr. Andrew Condon

I do not know the name.

Can we ask what agency was engaged?

Mr. Andrew Condon

The committee can.

It would be great if we could get an answer to that question.

Mr. Andrew Condon

It would be useful for the committee to hear directly from the Public Appointments Service since it has specific expertise.

Mr. Andrew Condon

It handles recruitment to most of the public service, including local government and the Civil Service. I am speaking at a remove.

That is why I said Mr. Condon could probably not answer the question.

Mr. Andrew Condon

In general terms, the Public Appointments Service undertook a headhunting exercise and engaged directly with any candidate for these posts it could identify at home or abroad. It also identified a couple of deficits, one of which was in the number of child and adolescent psychiatrists available elsewhere.

I am sorry if I am doing this quick-fire, but I am under time duress. Mr. Condon's comment relates to the issue of service level agreements and the number of people being trained. Given the increased demand, is the number being trained high enough?

Mr. Andrew Condon

The best way for me to answer that question is to say that in 2007, when the HSE was given functions in the regulation of training numbers, it embarked on a significant workforce planning exercise. We are 11 years on and that exercise took some years to complete. Professor Murray might discuss it further, but medical training starts in medical school. Where it relates to mental health training, people go through basic specialist training which takes a number of years to complete-----

I will ask a question.

Mr. Andrew Condon

It is a ten-year process.

It is a closed question. Does Mr. Condon believe enough people are being trained and entering the market to fulfil demand?

Mr. Andrew Condon

There certainly are-----

It is a "Yes" or a "No" answer.

Mr. Andrew Condon

A comprehensive workforce planning process is in place in the NDTP which has mapped service needs in psychiatry in the next number of decades to, I believe, 2030.

Are enough people being trained?

Mr. Andrew Condon

Enough are now being trained, but they are still in the training process.

I understand there is a process, but what I am-----

Mr. Andrew Condon

There is now an overhang.

Are enough people coming out of the training process to fulfil demand or should we increase the number further?

Mr. Andrew Condon

There are enough people in training, but the question then becomes whether enough will graduate this year. We have that implementation piece-----

Mr. Andrew Condon

If we change the training system in year one, it must funnel through the rest of the ten-year training process.

I will rephrase my question. When will demand be met? Mr. Condon is saying that, although enough people are in the training system, they may not graduate for four, five or six years. He may not have the data to hand, but when, in his opinion, will demand be met, given the current figures?

Mr. Andrew Condon

I will turn to Professor Murray, as this is a question of hiring specialist trainee numbers and-----

Professor Frank Murray

I am not sure I know the answer.

Could the information be forwarded to us?

Professor Frank Murray

Yes.

May I ask a further question?

One more, but we will then move to Deputy Catherine Martin.

The CAAC is part of the HSE. To whom does the NDTP report?

Mr. Andrew Condon

The national director of human resources.

Does the CAAC report to the NDTP or the national director of human resources?

Mr. Andrew Condon

It is an advisory committee. Its chairperson reports to Professor Murray.

Professor Frank Murray

And to the CEO of the HSE.

Does the chairperson have a dotted or direct line to Professor Murray?

Professor Frank Murray

He has a line to me and the CEO.

Who is his direct manager?

Professor Frank Murray

He is not a manager. He is in a-----

To whom does he report directly?

Professor Frank Murray

To me.

He has a straight line to Professor Murray-----

Professor Frank Murray

Yes.

-----and a dotted line to the CEO.

Professor Frank Murray

I also sit on the CAAC.

Mr. Andrew Condon

It is an independent committee that brings in people from outside the HSE - patient representatives who do not work in the HSE, clinical experts, people from training bodies, etc. - to tell it how to do it. It is an independent voice. For a number of years the HSE was doing it on its own, but that was not best practice. We now have an independent committee. Inevitably with an independent committee, there is useful tension between what it might be thinking and what-----

There is synergy. Is Professor Murray the only person within the NDTP who also sits on the CAAC?

Professor Frank Murray

Except for me, the NDTP comprises non-medical staff; therefore, I am the only doctor within it. I also sit on the CAAC. There are others who organise. The consultants appointment unit provides secretariat and management services for the CAAC. The unit is based within the NDTP. That is what Mr. Condon meant about it being based within the NDTP.

We can revert to Deputy Tom Neville, but I will hand over to Deputy Catherine Martin. Before I do, is it the case that Professor Murray, essentially, is reporting to himself? Is there not a conflict of interest?

Professor Frank Murray

No, I am not reporting to myself. Before the committee meets, I read through the applications and give a technical report. There are two main aspects of the assessment of each application. First, what is the clinical programme in psychiatry lead's recommendation regarding the post and does the it need to be amended in any way? Second, is the assessment of the post consistent internally?

It sounds complicated. I will pass over immediately to Deputy Catherine Martin.

I do not know where to start. I thank the delegates for attending.

Table 3 screams at me, as I am sure it does for everyone. As Mr. Condon stated, ten of the 16 posts are in child and adolescent psychiatry in places such as Cork, Sligo-Leitrim, Carlow-Kilkenny, Donegal and Longford-Westmeath. We are failing the children affected and their families. Everyone agrees that there is a problem in recruitment and retention and that the HSE has recognised the deficits, but who should the committee invite in order that we can tell them that not enough is being done and to, please, do more for the families affected? It is not good enough.

What can be done to accelerate the lengthy recruitment process? The CAAC meets ten times a year. Mr. Condon stated he would sign approvals within 72 hours but that he would then have to wait for the CAAC to meet, which could take one month.

Mr. Andrew Condon

I will clarify the matter. Once the hospital, agency or mental health service has funding in place for a post, the funding is confirmed. The matter then goes to the NDTP and raised at the next meeting of the CAAC. It arrives by email at the NDTP on, for example, the first day of the month and the CAAC meets on the 15th day of the month. It is approved at the CAAC meeting and an approval letter is drafted.

I sign the post once it is considered by CAAC as opposed to before then.

Is there anything we can do about that process of waiting for CAAC to meet? Does it need to meet more than ten times a year? Would that speed up the process? I see that psychiatry has one of the highest percentages of non-permanent consultant posts, at 20%. Why is this? What differentiates mental health from other branches of medicine?

Professor Frank Keane's report mentioned that a contributing factor to the crisis was the way the jobs were advertised. Has the job description improved? With this timeline of recruitment, there seem to be delays at each stage. It is the most complicated process.

Professor Frank Murray

I agree.

It is like a roller-coaster. We are brought back to where we started. How does that compare to international best practice?

Professor Frank Murray

I agree it is complex and there are ways it could be abbreviated. It has to come in with funding. I am not quite sure of the quickest way to do that.

Professor Murray agrees and has said before that it may need to be reviewed. What is frustrating is that it seems to take coming into this meeting to see that it needs to be reviewed.

Professor Frank Murray

No. It has been reviewed through the Keane report and, in fact, since I was appointed director of NDTP two months ago I have begun to look at the delays in the system that can be eliminated. I completely agree with the Deputy. It goes back to what Deputy Neville said as well. It should be a fairly linear process that is expeditious. I completely concur with that. I personally feel that there may be alternatives to going through the national recruitment service, for instance, and the public appointments committee. One of the disadvantages of that is that it takes the local out of it. If it is within the public appointments committee it is done with relatively little representation of the local whereas if it was advertised and filled locally in the hospital group, for instance, or within the CHO, I think we would have a process that might have advantages in terms of recruitment.

Has Professor Murray started the review on this?

Professor Frank Murray

Yes.

When will that conclude? Is there a timeline?

Professor Frank Murray

There is not, actually. I have just taken up my post a couple of months but it does strike me that there are several delays in the process that could be optimised. To be honest I think getting all of that sorted out is not going to address those 16 empty posts. It is not a speed issue, it is a more existential issue around recruitment and retention. That is what really needs to be looked at. I think that is fundamentally the problem. We can do everything we like with the process and to be honest I think we pay far too much attention to process. We should be looking much more at outcome.

Deputy Buckley raised the retirements that are coming down the line and Professor Murray said we can do better in anticipating retirement and that we should probably ask people if they are considering retiring or to give a year's notice. I cannot believe we are not doing that already. It is not rocket science, with all respect. It is an unnecessary failing that can be avoided.

Mr. Andrew Condon

Deputy Buckley raised a related point earlier. In recruitment, one might say we should know at the start of the year what posts are funded since we have a national service plan. That is one source of posts. Another source is when people retire or leave and they have replacements. A third source is during the course of an average year in the health service, we will get additional funding for various purposes which will generate additional posts. We have posts coming from three directions, two of which we can anticipate and one of which we cannot.

In terms of retirements, NDTP already notifies hospitals of retirement dates of consultants, for example that Dr. Smith is retiring next year or in two years' time, and asks the hospital where the application is for his or her replacement. That controls the anticipated retirements to a certain degree. When people take up posts we know their retirement dates and we deal with that. What we cannot plan for is the unanticipated retirements. The other issue that arises with retirement is that while the average duration of a consultant career is 25 to 30 years, the post that was approved 25 or 30 years ago may not be the post that is needed today. When someone retires, it is not a simple matter of rolling over and getting an identikit replacement. It often sparks a local debate around the structure of the post and its nature. To go outside psychiatry, we might have a consultant respiratory physician that people want to replace with a gastroenterologist. It is not as simple a process as it might be.

It is important to remember that we have new posts, service plan posts and replacement posts, some of which we can plan for and some of which we cannot. In terms of the issues Professor Murray has mentioned regarding the posts under discussion today, the core of our recruitment issues is supply. Are the trainees there? In the case of the work of the Public Appointments Service that I discussed with Deputy Neville, we found the supply did not exist internationally. We could approve posts but we were simply creating vacancies because the candidates were not there to fill them.

The second issue that arises is location and the resources and configuration of the service. That is connected to the implementation of A Vision for Change, the multidisciplinary team and so on. The third issue is terms and conditions. Do we pay people enough? Are their contracts structured correctly? In the last years we have had our end-to-end review of the recruitment process, the Keane report. Professor Murray has started his work and we have also had industrial relations engagement with the two medical unions. We are currently engaged with the Public Service Pay Commission on the terms and conditions for consultants. One of the things we have flagged in our submission to the commission is that psychiatry is the number one recruitment challenge for consultant and medical posts in the HSE. That submission has gone in and some of the issues the Deputy has raised have been flagged in it.

The Professor made a point that the problem is getting the actual applicants. This committee has discovered it is not the problem. There is a national recruitment process whereby a panel of people, some of whom do not even have the expertise in recruiting a possible candidate, will interview people. Those who are looking for the job could be waiting for a year to be interviewed. They have no idea where they are going to be located or what the office, place or the people are like. The HSE thinks this is the correct way to recruit people. I also see that employers took lengthy periods to progress applications. Who are the employers?

Professor Frank Murray

The HSE - the hospitals, or community medical services. If I may make a comment, your frustration around recruitment and retention is palpable and correct. It would be untrue to say that there is not a very serious problem around recruitment and retention for consultants in Ireland. That crisis is at its worst in psychiatry. A lot of what we have discussed this afternoon relates to the processes that are required to get a post approved. I would argue they are not the fundamental problems. It is to do with recruiting people into posts that are approved. That is where the fundamental problem lies.

Where does that problem lie? Is it with the HSE?

Professor Frank Murray

I think a lot of that has to do with terms and conditions, to be honest, and remuneration, as was stated by Frank Keane. There is a quotation in section 5, printed in italics, stating that a key concern in recent years has been income. I think that is a fact. In other jurisdictions, posts that are more difficult to recruit into and more remote generally attract more attractive salaries. That is what happens in parts of the US and Canada.

We need to focus on what the HSE is doing here rather than Canada or anywhere else. This is another smoke screen as far as I am concerned. The college of psychiatry came up with the most perfect plan of how to retain and recruit staff. It was a magnificent report, completely ignored. Now two or three more committees have been put in place to try to address this problem.

Before I call Senator Kelleher, I wish to ask a number of questions. When we must employ consultants from other countries, which areas are best matched to meet our consultant specialty? I know there is an embargo on recruitment from some countries.

Professor Frank Murray

People from other jurisdictions in the European Union who are certified specialists can apply for posts in Ireland.

Can they?

Professor Frank Murray

Yes, they can.

Is there an advertising campaign broadcast in other countries?

Professor Frank Murray

My colleague, Mr. Andrew Condon, confirms that yes, the campaign is run in other countries.

What is the position of those from countries that are not allowed to come to Ireland?

Professor Frank Murray

In Ireland 40% of the doctors working in the health services are foreign. This is, I think, the highest rate in the world, but it is certainly the highest rate in the European Union.

That is out of order with the World Health Organisation, WHO code of practice for recruiting doctors from developing countries.

I think we need to focus on trying to ensure that we can recruit and retain people who are coming through the training programmes here. That is what we should focus on doing.

I have a brief comment. It is like groundhog day. We go round and round in a circle about the fact that we do not have psychiatrists in a service that we are determinedly saying has to be psychiatry led. In the meantime real people are not getting the supports. We had a heartbreaking letter from a family who had to take their daughter in absolute abject distress through a carpark to get to a CAMHS centre which did not have a consultant. They were told they could take their daughter back the road from Cork to Killarney, an hour's trip. This child was absolutely in extremis. Today, tomorrow, there are young and older people in extremis, while we talk about and try to fix the system which does not seem to be fixable.

I know that Professor Murray did his best today and perhaps we are not speaking to the right people but this committee keeps on getting pushed from Billy to Jack to Jane to Joe. Nobody is able to make the interventions that would mean that this child who needed to see somebody got to see that somebody as soon as possible. That is the problem. That is why we are so exercised.

Deputy Neville wishes to ask a question.

Am I correct that the chairperson of the Consultant Appointments Advisory Committee, CAAC, is obviously not Professor Murray?

Professor Frank Murray

Yes.

Does Professor Murray report to the chief executive or to whom does he report?

Professor Frank Murray

I report to the national director of HR. It is proposed that I would report also to the chief clinical officer in addition.

To whom does Professor Murray report directly?

Professor Frank Murray

Currently, it is with the national director of human resources.

And there is a dotted line to the clinical side. Is that correct?

Professor Frank Murray

Correct.

Senator Kelleher referred to the diagrammatic form. When could Professor Murray have that diagrammatic form of the recruitment process with the stakeholders?

Professor Frank Murray

This day next week.

Perfect. With the permission of the Chair, may I make the following proposal, that we would speak to the individual to whom Professor Murray reports directly, that is the national director of human resources together with the lead person in recruitment?

Professor Frank Murray

Recruitment is done entirely through the PAS for the mental health services.

Chairman, I want the national director of human resources with the lead person in recruitment sitting together so there is synergy there when we question them, because recruitment is just a part of HR.

The Deputy is absolutely correct. I will allow a question from Deputy Buckley

I do not wish to put Professor Murray in a precarious position. We all form our opinions, but what is Professor Murray's opinion on the following: should the current level of recruitment and-or retention not change, will we face a national emergency in the mental health system? I believe the predictions show that we are recruiting and retaining fewer staff and losing more and that as a result in the next five years the people who need support from the system will die. Are we facing an emergency in the mental health services in the next five years?

Professor Frank Murray

It is critical that recruitment and retention are satisfactorily resolved.

That is a very fair answer. I did not mean to put Professor Murray on the spot.

Professor Frank Murray

That is okay.

That is recorded. I thank Professor Murray for his honesty.

Did Deputy Harty wish to contribute?

I apologise for being late, so I may be repeating the points made. From my experience the recruitment of consultants comes down to workload and conditions. I have seen it in my own area, where it has been difficult to recruit because of workload and conditions of service. There is a deficiency in support staff and support services. When a consultant takes up a post, he or she may find that he has no office, no secretary, and that many of the members of his community psychiatric team are not there: there is no psychologist, no psychiatrist, no social worker or senior social worker or there is half a social worker or a part-time psychologist who is shared between two or three catchment areas. Pay and conditions are obviously an issue and the years of austerity decimated the pay and conditions of consultants.

During a debate in the Dáil last evening another Deputy said that we are the greatest exporter and greatest importer of doctors in the world. We educate them and then we export them and then we trawl the world looking for replacements. That is surely a damning indictment of our health service.

I wish to raise the issue of anticipatory recruitment. The post of a consultant who is about to retire may not be advertised until he has retired from his job.

That is correct.

He or she may have flagged well in advance when he is leaving. It may take a year to recruit somebody, if one can recruit such a consultant. It all comes down to a lack of trust and a lack of respect. I think there is a lack of trust from the medical profession of the HSE and the HSE does not respect the staff they have in place. The HSE does not embrace them and does not see them as a natural resource, but sees them sometimes as an impediment.

There is also the issue of consultants who are not on the specialist register. One either has no service or a service provided by a person who is acting up. That is obviously not satisfactory. I think that one in 25 consultants is not on the register and many of those are in psychiatry.

I thank Deputy Harty for his contribution.

This was a tough meeting for Professor Murray. There were many issues that he cannot answer, but he was so good in what he did answer and he was put to the pin of his collar with some of the questions. I do not think we had the correct people before us. I think it was unfair to put Professor Murray in that position when there are so many inadequacies further down the track. We will send the transcript of this meeting to the national director of HR and PAS.

I thank the witnesses for attending today and for the very useful information that we have been given, which will greatly assist the committee in its future work.

The joint committee adjourned at 3 p.m. until 1.30 p.m. on Wednesday, 16 May 2018.