I am joined here today by my commission colleagues Mr. Peter McLoone and Mr. Michael Kelly and by Ms Joan Curry, head of the secretariat to the commission. The commission is happy to take the opportunity to contextualise and discuss its recent report and to help the committee in its work in whatever way we can.
The commission was established to advise Government on public sector remuneration policy and in this regard its terms of reference are broad. In May 2017 the commission published its first report, providing input on how the unwinding of the financial emergency measures in the public interest, FEMPI, legislation should proceed. In this second phase of the commission's work we were obligated by our terms of reference to undertake an examination of whether, and to what extent, there are difficulties in recruiting and retaining staff in key areas of the public service which were identified in our first report. The broad frame in which we operate requires us to take into account current Government policy on public service pay, including the planned pay restoration provided for by the public service stability agreement, the general backdrop of fiscal sustainability and the many competing priorities for public investment. We were also aware of other developments in respect of the public service pay bill such as new entrants' pay and the settlement of the case taken by hospital consultants. Given the very specific terms of reference for this phase of our work, we adopted an evidence-based approach to all our considerations and we believe the conclusions we have drawn are well founded.
It is clear that the 2009 moratorium on recruitment and promotions in the public service had a significant effect on numbers in the public health service. The commission recognised the reductions during the period up to 2013, which across the nursing and midwifery grades was 9%, bringing the numbers to 33,676, and acknowledged that the level of demand for services did not reduce and has noticeably increased over the past decade with an increasing and ageing population. There is evidence that numbers have increased since 2013, although the number at the end of 2017, which stood at 36,777, was still not at pre-moratorium levels. Submissions to the commission confirm this increase is not simply a result of the lifting of the moratorium, but also required the development of a range of initiatives to attract and retain healthcare workers.
An early and very positive conclusion is that medicine and nursing and midwifery remain very attractive as career choices if we judge by the popularity of these courses among young people at university entry stage. Of this year's 57,000 school leavers, 9.6% have selected nursing as their first preference, with a further 5.6% choosing medical undergraduate education programmes. This means that this year, in common with many recent years, nursing and medical education programmes are oversubscribed. We continue to produce high-quality graduates in numbers which should meet our domestic needs; indeed, Ireland produces the highest number of medical graduates per capita in the OECD. We are also attracting significant numbers internationally. However, we are seeing some retention problems and Irish-trained graduates do not seem as inclined as previously to return after taking up international appointments.
We realised very quickly that Ireland is going through the same experience as many other health systems internationally. Healthcare skills are in short supply and all indications are that such shortages will continue. As a relatively small player in a highly competitive global market for health skills, we are facing a sizeable challenge in attracting and retaining competent practitioners. The commission acknowledges that numbers working in the public healthcare sector have increased since the lifting of the moratorium on recruitment. However, there is evidence of both recruitment and retention difficulties over recent years in the groups we examined. Much attention has already been given to resolving these difficulties, and the commission referenced and drew upon the findings of other relevant reports on the various aspects of these complex challenges in reaching our conclusions. We also noted that we are now beginning to see a positive impact from many of the measures already taken. Some examples include offering permanent contracts to nursing and midwifery graduates, increasing undergraduate places, improving access to training and providing flexible working hours.
A significant amount of work has already been done, often in a collaborative framework, but from our analysis there is no room for complacency. We are saying very clearly that recruitment and retention must continue to be prioritised and we point to a number of areas where policy and practice need further strengthening. In particular the commission reiterated its view, put forward in its initial report, that measures need to be put in place to address data gaps in collecting and analysing the transactional data necessary to monitor, manage and maintain an adequate and appropriate workforce.
Our work was informed by many sources, direct evidence provided by the parties and a review of international published work and domestic publications, including the Sláintecare report. It points to the need for integrated workforce planning as a major input to future service planning and delivery. This more rigorous approach should lead to a more reliable basis for planning workforce requirements and measuring more definitively where any possible recruitment or retention deficits may be. We found evidence of some small pockets of this discipline in practice, and very early indicators are positive. We invited submissions from employers and staff representatives. In the absence of consensus on the scale of the problem and, more particularly, on the likely solutions, we commissioned our own independent research. We looked at destinations and conditions of employment in the main host countries, and an opportunity was provided to staff for direct input via surveys and interviews. We acknowledge that the response rates were low and the results may reflect a group with views different from those of the generality of the cohorts surveyed. Therefore, while needing to be treated as indicative, the responses are nonetheless informative.
A consistent finding from all our research is that the decision to take up a particular post or to remain with a particular employer for a prolonged period is influenced by a multiplicity of factors.
These factors include the extent to which mentoring facilities are provided for new entrants, the degree of staff engagement within the employment, the relativities of remuneration, access to training and promotion opportunities available. Chapter 5 of our report deals with this in some depth and chapters 6, 7 and 8 include some of the key findings with regard to attitudes to recruitment and retention from the survey and interviews for each of the groups.
Based on our analysis, we have identified a number of measures for consideration in relation to each of the three groups we examined. These include strengthening human resources, HR, functions, a funded multi-annual workforce plan, an increase in certain allowances and a reduction in the service requirement necessary to reach the grade of senior staff nurse. We were also mindful of the commitment in A Programme for a Partnership Government to the full implementation of the MacCraith report to assist in the recruitment and retention of key medical staff and endorsed the recommendations contained in that report.
Turning specifically to mental health care, which is this committee's area of concern, the commission's report highlighted specialties within the mental health care area which were experiencing particular difficulties with recruitment and retention. We found that among nurses, the psychiatric staff nurse and the intellectual disability staff nurse grades recorded the most significant average annual declines of any nursing specialty between 2013 and 2017. We also concluded that while there is a general difficulty recruiting hospital consultants, with more significant problems in certain specialties and locations, psychiatry in particular was a specialty highlighted as experiencing recruitment challenges across a number of indicators.
The recommendations we have made should have equal relevance in mental health services as in other areas. The commission, however, stopped short of making sector or specialty-specific recommendations, due to the wide nature of its mandate. We hope our report will be helpful to the committee in its work and we will be pleased to clarify any aspects of my contribution or the commission's findings.