Joint Committee on Health díospóireacht -
Wednesday, 2 May 2018

Medical Council Specialist Register: Discussion

Chairman

There is nothing to be inferred from the seating arrangements. Those who are at the bottom and those who are at the top have represent a purely random selection.

We are meeting this morning with representatives of the Medical Council, the HSE, the Irish Hospital Consultants Association and the Irish Medical Organisation, IMO, in order to discuss recent media reports that suggest that some 650 medical consultants are not registered in the specialist division of the medical register. On behalf of the committee I would like to welcome Ms Rosarii Mannion and Professor Frank Murray on behalf of the HSE; Mr. Bill Prasifika and Dr. Anthony Breslin on behalf of the Medical Council; Dr. Tom Ryan and Mr. Martin Varley on behalf of the Irish Hospital Consultants Association, and Dr. Peadar Gilligan and Mr. Anthony Owens on behalf of the IMO.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, 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 they 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 House or an official either by name or in such a way as to make him or her identifiable.

I also wish to advise that any opening statements made to the committee may be published on the committee's website after this meeting.

Ms Rosarii Mannion

My name is Rosarii Mannion, national HR director of the HSE. I am joined by Professor Frank Murray, director for national doctors training and planning. I want to begin by thanking the Chairman and the committee for inviting us here today to discuss recent media reports that suggest that some 650 medical consultants are not registered in the specialist division of the medical register.

In March 2008, the HSE amended the qualifications specified for consultant posts to require registration in the relevant specialist division of the register of medical practitioners at the Medical Council. The consultant contract 2008 reflects this requirement, the details of which were contained in HSE HR circular 021/2017 concerning qualifications required for consultant posts. The effect of this is that applicants who are not registered in the relevant specialist division cannot be appointed to a permanent consultant post in a HSE hospital or service or in a section 38 agency funded by the HSE. The rationale for the change was the imperative to ensure that consultants employed in the public health system have the appropriate training, skills, competences and qualifications to deliver care as assessed by the Medical Council, which has the statutory role of protecting the public by promoting the highest professional standards amongst doctors practising in the State.

It remains the case that there are a number of consultants employed who are not registered in the relevant specialist division. As of 14 April, this number stood at 127 out of a consultant workforce of 2,977 whole-time equivalents, or 4.3% of the workforce. This number can be broken down into two main cohorts.

The first cohort consists of consultants employed prior to 2008. There are 52 consultants in permanent employment who took up their posts before the introduction in 2008 of the contractual requirement to be registered in the relevant specialist division. This represents 1.7% of the consultant workforce. Of this number, 49 are employed in acute hospitals, one in the Irish Blood Transfusion Service, IBTS, and two in mental health services.

The second cohort comprises consultants employed post 2008. There are 75 consultants currently in employment who took up posts since the introduction in 2008 of the contractual requirement to be registered in the relevant specialist division. They represent 2.5% of the consultant workforce and are on short-term specific purpose contract, SPC, basis, a short-term locum basis or are engaged through an agency. SPCs are used to fill permanent vacancies pending the filling of a new or replacement consultant post on a permanent basis after the necessary approval from the HSE’s consultants appointments advisory committee, the selection process at the Public Appointments Service for HSE posts or within the section 38 agency, and the post-recruitment formalities of reference-checking, Garda vetting, and pre-employment occupational health status assessment. Short-term locums are either employed directly by the HSE or section 38 agency, or are engaged through an agency in instances where cover is required for the annual leave of permanent consultants or for other temporary absences. It can often be the case that appropriately qualified consultants registered in the relevant specialist division do not present as applicants for short-term locum posts or for SPC posts pending the filling of a new or replacement permanent post. Service requirements have therefore led to the engagement of the consultants in this category. HR circular 21/2017 details requirements for consultant appointments. I have set out in the opening statement the breakdown by hospital group and community healthcare organisation, CHO, of where the consultants are appointed. I will not go through it, but the committee members have that information to hand.

I will now outline measures to address the issue, starting with risk mitigation measures. The national clinical adviser and clinical programme group lead for mental health has sought and received assurances from the executive clinical directors in mental health services of risk mitigation measures, to include oversight of the practice of post-2008 consultants not in the specialist division. Similarly, within acute services, hospital managers and clinical directors have put in place monitoring arrangements appropriate to the circumstances of the practice of post-2008 consultants not in the relevant specialist division.

A further measure consists of incentivising eligible pre-2008 consultants to apply for specialist registration. The acute services division and the mental health services division are working to establish which of the pre-2008 consultants would be eligible for registration in the relevant specialist division on the basis of their having completed higher specialist training or equivalent. As a once-off measure, the HSE will fund the Medical Council directly for the cost of the application process, such that the consultant will not incur any personal expenditure.

I refer also to upskilling post-2008 consultants who have not completed higher specialist training. Colleagues in mental health are engaging with the Royal College of Psychiatrists to explore additional competence-based training for consultants to allow them to apply for specialist registration. This approach will be a more complex issue in the acute services, given the greater number of consultants involved, the greater number of specialties, the procedure-based nature of training in some of those specialties and the greater number of training bodies etc.

The HSE is also minimising the timeline for filling new or replacement permanent consultant posts.

Clinical directors in mental health services and acute services are seeking to clarify the position with each post-2008 consultant post currently filled, by definition on a non-permanent basis, in order to establish where the post is on the continuum from approval at the consultants advisory committee for a new or replacement post, to advertisement, to shortlisting and interviewing at the Public Appointments Service, to post-selection formalities undertaken by Health Business Services recruitment prior to the offer of a contract. The aim is to identify any impediments at any stage of this process with a view to elimination of these or otherwise to minimise the impact on the timeline for filling new or replacement permanent consultant posts. The hospital groups’ HR leads will work with the HSE national doctors training and planning’s doctors integrated management e-system, DIME, to access real-time data contained within DIME to allow full compliance with consultant specialist registration requirements and to ensure in the interim 100% compliance with the matching of approved posts on DIME to all occupied posts in the hospitals.

The recent appointment of an interim chief clinical officer will assist the delivery system to address the issue. Addressing the issue is a key priority for the HSE. Work is ongoing between the HSE, Medical Council and training bodies to address issues which I anticipate will be concluded at the earliest opportunity.

Dr. Anthony Breslin

On behalf of the Medical Council, I welcome the opportunity to discuss this important issue with the Oireachtas Joint Committee on Health.

I will say a few words about the role of the Medical Council, which is very relevant in the context of this discussion and recent media commentary. The Medical Council is the statutory body responsible for the regulation of doctors in Ireland. Its purpose is to protect the public by promoting and ensuring the highest standards among doctors. From the day a student first enters medical school until the day he or she retires from practice, the Medical Council works to ensure medical education and training remain up to date and are benchmarked to the highest international standards.

The Medical Council sets standards for all undergraduate education and postgraduate training of doctors and also requires that all doctors fulfil ongoing professional competence requirements to ensure they keep their knowledge and skills up to date throughout their professional lives.

The Medical Council provides guidance to doctors on matters relating to conduct and ethics through its Guide to Professional Conduct and Ethics for Registered Medical Practitioners.

The Medical Council is also where the public may make a complaint against a doctor.

Regarding relevant information about doctors' practice, each year the Medical Council, during the annual retention period when doctors renew their registration, seeks out additional self-declared information which we then use for the production of the medical workforce intelligence report, which provides a detailed overview of doctors’ practice in Ireland, including the exit rates of doctors, the density of doctors in Ireland by county and the globalisation of the workforce.

Since 2012 the Medical Council has been seeking this additional information from registered medical practitioners to learn more about the scope of their practice. These reports have been developed not only to support the council’s work but also to inform wider health system planning and the evolution of systems of care. The detailed insights enabled through the workforce intelligence presented in these reports continue to highlight a number of key challenges, including retention of doctors, variances in skills mix and models of care and practice arrangements.

Regarding doctors on the general division in hospital consultant roles, through sharing information about these challenges, the Medical Council looks to assist all bodies that shape the professional lives of doctors to ensure that the design, development and oversight of the medical workforce continues to foster good professional practice and to protect patients.

This information is based on self-declarations and although the figure for doctors on the general division who describe themselves as hospital consultants seems quite high, once the figure is further examined and broken into its component parts, it reduces. As this question is based on self-declared information, it also includes doctors who are working outside Ireland, doctors in locum or temporary positions, doctors in acting-up positions, some doctors in training or further education, those currently not in a role etc. A number of doctors, who qualified as specialists before the new legislation, did not “grandfather” or transfer over to the specialist register in time, as they were entitled to.

The latest medical workforce intelligence report is still in draft and due to be published in the coming months. However, we have taken the information most relevant to today’s meeting and have made it available to the members of the committee and to the other organisations presenting here, with a full breakdown of the figures.

The supplementary information provided to the committee shows that 698 doctors on the general division have self-declared as hospital consultants in 2017. Delving further into the figures and removing a number of exclusions such as those working abroad, the number of general division doctors indicating that they practise in Ireland as hospital consultants is 254. Of the 254 doctors registered in the general division, 172 practice solely in Ireland with 149 of these working solely in publicly funded services. A total of 165 declared they work in both public and private settings, and 81 indicated that they have a mix of working inside and outside of Ireland.

It is worth noting the term consultant is not defined under the Medical Practitioners Act, to which the council operates. Accordingly the employer is free to hire anyone they want as a consultant, with the only limitation being that the doctor is on the Medical Council register. However, a consultant cannot falsely represent themselves as a specialist if they are not on the specialist register. The council only enters those practitioners on the specialist division who have the requisite higher qualifications in that discipline.

Doctors must be in compliance with maintenance of professional competence requirements and enrolled in a professional competence scheme relevant to their area of practice. A registered medical practitioner must maintain their professional competence on an ongoing basis pursuant to a professional competence scheme applicable to that practitioner.

The register of medical practitioners is a living database. Each working day at the Medical Council offices, doctors are entered in the register, are removed from the register and transferred between different parts of the register. The figures we have provided today are based on data from the 2017 retention period which is a snapshot from one moment in time.

I take this opportunity to thank Mr. Justice Peter Kelly, President of the High Court, for further highlighting this issue recently and allowing the council to address the court on this topic on Monday.

It is also worth highlighting that we are seeing a shift in the make-up of the medical registers which we maintain. The number of doctors on the specialist division is increasing and in 2017 the specialist division was larger than the general division for the first time which is a welcome development.

I thank the Chairman and the committee members for the invitation to address them today. Both Mr. Prasifka and I are happy to address any questions members may have.

Dr. Tom Ryan

I thank the Chairman and committee members for the opportunity to address them on the importance of specialist registration for hospital consultant appointments.

The 2008 contract defines a consultant as a registered medical practitioner who by reason of his or her training, skill and expertise in a designated specialty, is consulted by other registered medical practitioners.

It is worthwhile to review what is involved in training a consultant and why the integrity of this process is of such importance. The majority of medical students enter medical school after their leaving certificate examination and then complete a five-year course in medical college. This is followed by a year-long internship before progressing to sub-specialty training. In most sub-specialties doctors will complete two or three years of basic training to provide a foundation of specialist knowledge and to develop both as individuals and doctors.

Then they complete five or six years of higher specialist training which is punctuated by specialist examinations, usually finishing with an exit examination and a professional qualification conferred by a recognised postgraduate college. Only at this point will a doctor become eligible for specialist registration, which is regarded as a basic qualification for doctors who wish to apply for a position as a consultant. I say basic because the vast majority of doctors who become eligible for inclusion in the specialist register will subsequently travel abroad, usually in order to gain clinical or research experience in a prestigious recognised international institution. This has been the pattern for many years, and is likely to continue, because consultants in Ireland wish to provide patient care to a recognised contemporary standard and wish to gain the experience in an early stage in their career that will act as a foundation for their subsequent profession.

This model of training has several advantages for the healthcare system and for patients. In the past there was a consistent supply of well-trained and experienced consultants in the Irish health system. This was good for patients as they received the benefit of the consultants’ prolonged and sometimes arduous training. It was good for the health system as there was a continuous supply of talented consultants entering the health system, and these newer consultants brought with them fresh thinking, vision and new approaches to what, on occasion, seemed intractable problems.

The health system also benefited as a whole because many of these motivated individuals became leaders within their professions and sub-specialties. As a collateral benefit, the quality of patient care in the health system consistently improved.

The sustaining of these improved standards of care on a consistent basis now requires continuous recruitment of consultants who are trained to the highest international standards. If we deviate from this paradigm of training and recruitment, we are at risk of compromising the standard of patient care in our healthcare service and there will be inevitable and unacceptable consequences for patients. Therefore, at all stages of training we must foster a culture of academic achievement and clinical excellence in order that we can provide the best possible care for our patients. In our efforts to achieve clinical excellence we must insist that doctors who act as consultants in our healthcare system are appropriately trained in that they are deemed eligible for specialist registration. After all, this is the most basic of professional standards for doctors who wish to practise as consultants in Ireland. We cannot deviate from international best practice whereby doctors are required to comply with recognised specialty-specific training criteria in order that the quality and consistency of patient care is protected.

Unfortunately, it has become apparent that these most basic standards are not being observed when filling an increasing number of consultant posts and there is a concern that this development is not in the best interests of patient care. There are similar concerns about the appointment of non-consultant hospital doctors who have trained in countries outside the EU and the EEA who are no longer required to pass Irish Medical Council examinations, a requirement which applied until recently. It was standard practice that doctors from some countries, following their intern year, completed the Medical Council's pre-registration examination system, PRES, clinical exam before they were deemed eligible to take up posts in the acute hospital services in Ireland. We are of the view that the public deserves to receive a consistent standard of care across all public hospital and mental health services based on a uniform standard of training. The failure to verify, by way of examinations, the basic and sub-specialty training and competencies is at odds with contemporary international practice in other European jurisdictions and English-speaking countries. There is a serious concern that, in the absence of Medical Council exams for non-consultant hospital doctors, NCHDs, inconsistent standards of medical training and competence will undermine the care patients receive. Overall, the concerns relating to the appointment to specialist consultant posts of doctors who are not eligible to be on the Irish Medical Council specialist register have the potential to compromise seriously the standards of care we provide to our patients in our healthcare system. That is our major concern.

Chairman

I thank Dr. Ryan. Finally, I ask Dr. Peadar Gilligan, on behalf of the IMO, to make his opening statement.

Dr. Peadar Gilligan

The IMO thanks the Chairman and members of the Joint Committee on Health for the invitation to discuss recent media reports which suggest that up to 650 doctors are employed as consultants without being registered on the specialist division of the register of medical practitioners. The figures in circulation from the Medical Council are self-declaration figures from 2015 of those who describe themselves as hospital consultants. The figures would also include some people who are abroad, are in training, have not been grandfathered to the specialist register, are in locum positions, are in acting-up roles and are temporary consultants.

Ireland is a challenging place to work as a consultant. Significant capacity issues impact on a consultant's ability to provide safe quality care to patients. According to the health service capacity review, we require an additional 1,260 acute beds immediately and will likely require up to 7,000 hospital beds by 2031 in view of the current extent and pace of investment and reform. Bed occupancy rates in Irish hospitals have risen to an average of 97% and sit even higher, at an average of 104%, in model 4 hospitals, well above internationally recognised safe occupancy rates of 85%. The HSE full capacity protocol is now the norm, having been implemented on hundreds of occasions in 2017 in our major hospitals in Waterford, south Tipperary, Galway , Limerick, Cork and Beaumont. Constant overcrowding, cancellation of lists and rolling theatre closures impact not only on patient care, but also on the ability of trainee specialists to maintain and develop their skills.

Hospital doctors in our health system work excessive hours and show high levels of stress and burnout. The Royal College of Surgeons in Ireland's A National Study of Wellbeing of Hospital Doctors in Ireland showed that, on average, hospital doctors work 57 hours per week, and one in three shows symptoms of burnout. Antagonism of consultants by employers, politicians and the media adds to the poor morale of doctors. Reluctance on behalf of the Government to engage with doctors in a meaningful way and political interference in contractual disputes reflect the inadequate value our politicians place in the medical profession.

I would also like to take this opportunity to say a few words on specialist registration and the industrial relations environment. Doctors who have achieved specialist registration may practise independently without supervision and may present themselves as specialists. Attaining such registration is, and should be, the goal for trainee doctors in the health system. It should be a sine qua non for appointment to a consultant post that one should be so registered. We have no doubt but that among this group of consultants who do not currently have specialist registration are many fine and committed doctors who do their utmost to deliver patient care in the most trying of circumstances, in a system starved of capacity and resources and where crisis management appears to be the default setting. Nonetheless, the practice of appointing doctors who do not hold the correct registration to consultant posts is inappropriate and should cease. Patients who require specialist care should receive it from a registered specialist. There are potentially significant indemnity issues that arise from non-specialist doctors working as consultants in an under-resourced and overstretched health service.

Consultant-delivered care, it is worth reminding ourselves, is associated with better clinical outcomes for patients, increased patient safety and more efficient use of healthcare resources. However, we strongly contend that this present issue is just part of a wider problem, one which has culminated in the Irish public health service not being the employer of choice for medical personnel, and the profoundly concerning circumstance in which consultant posts are advertised but not filled. This was the case with 22 of 84 closed consultant recruitment campaigns in 2016.

Why has this come about? It is important to go back to basics. The current consultant contract, to which I have already alluded, contains a series of pay promises that were not honoured and that are now the subject of costly litigation. No other group of public servants who had signed contracts in good faith would ever be treated in this fashion. Furthermore, consultant salaries were unilaterally and unfairly reduced by 30% in 2012. Again, no other group of public servants was singled out and treated in this fashion. While the work of the IMO has ameliorated much of the effects of this cut, the price that we had to pay was a longer pay scale with lower starting and finishing points and very significant reduction in pensions for consultants appointed since 2012. Less well remembered from that time were attempts by the then Minister for Health to introduce a consultant level 1 role that would sit below the existing consultant cohort. This strain of thinking, viewing consultants not as a valuable resource but as an obstacle to be overcome, continues to influence and infect policy-making today. The health service, however, suffered dreadful reputational damage. Why would highly trained specialists who operate in a global market work in a system that could dismiss their contractual entitlements in such an offhand fashion? It is for this very reason that 450 consultant posts, posts for which there once would have been fierce competition, now lie vacant or are filled on a temporary basis only. When taken in the context of our comparative shortage of doctors, we have 2.9 practising physicians per 100,000 population, compared to an EU average of 3.4 per 100,000 population. This should be profoundly troubling for any party interested in health service delivery. In a recent IMO survey, over one quarter of consultants indicated that they were considering taking up a post abroad in the foreseeable future, while over 70% believe that their remuneration, training supports and access to colleagues would be improved by moving abroad. In summary, we have a public health system which struggles to recruit doctors into consultant posts and which struggles increasingly to retain those doctors once appointed.

This is the backdrop against which non-specialists are appointed to specialist posts. Long hours, poor access to supports and inability to deliver the type of care for which consultants have trained have served to turn a generation of talented medics off the idea of working in the Irish public health service. We cannot afford to alienate these doctors. This is because there are approximately 2,700 consultants in the public system, when the Report of the National Task Force on Medical Staffing recommended a figure of 4,400. However, patients must be seen, and the service requires that consultant appointments be made.

It must never be the responsibility of the patient to determine whether their specialist is in fact a specialist; that is the responsibility of the employer. Patients must have confidence that their consultant is a specialist and that the care they receive is of the appropriate standard.

I will finish with a quote from the consultant survey that the Irish Medical Organisation, IMO, conducted last year. We gave respondents the opportunity to provide us with a comment. Many of those comments were eye-opening, but the one that struck me most was provided by a recently appointed consultant, who wrote:

I would resign now, except that I have to pay a mortgage and provide for my family. I’m sorry I came back.

The blocks to specialist recruitment to consultant posts must be addressed as a matter of urgency.

Chairman

We are here because media reports suggested there are approximately 650 consultants not on the specialist register. Dr. Breslin has clarified that and Dr. Gilligan has also referred to it. Perhaps the witnesses could clarify the figures, because it is obvious that many of those doctors are not practising in Ireland even though they are on the register, hence the disparity. The HSE said in February of this year that 73 consultants were not on the specialist register. The Irish Hospital Consultants Association said there were 81 such consultants in October 2017. The figures have changed again and now stand at 127. Can the witnesses clarify the extent of the issue?

Dr. Anthony Breslin

The figure is a live figure. People register and de-register for a number of reasons. The number of doctors on the general register indicating that they practice in Ireland as consultants is 254. That figure covers the public and private sectors. Of those, 165 say they practise in both public and private services, and 149 indicated that they work as hospital consultants in the public service only. Under that 149, approximately 62 people were working as consultants and employed as such before 2008, before specialist registration was enacted in the 2007 Act. Those people had the opportunity to go on the specialist register, to "grandfather" across because they had experience, but they did not do so for one reason or another. The council is in discussion with the HSE about that number of individuals, as the HSE has mentioned. There is then a balance of people who started post-2008 and who have not completed formal specialist training and are not entitled to be on the specialist register at present, unless they are assessed in another fashion. I hope that clarifies some of the numbers. The numbers will vary slightly depending on when they are looked at because of the live nature of the register.

Dr. Peadar Gilligan

The IMO figure is generated from the figures provided by the Medical Council.

Chairman

What is the breakdown between those who are not on the specialist register working in the public service and those working in the private sector?

Dr. Anthony Breslin

Some 165 doctors work across both the public and private sector as consultants who are not on the specialist register. Approximately 90 people are employed in the private sector as consultants who are not on the specialist register.

Chairman

Is it the case that 90 consultants work in both?

Dr. Anthony Breslin

No, 165 work in both but approximately 90 work entirely in the private sector.

Senator Colm Burke

I thank the witnesses for their comprehensive presentations this morning and for the work they have done in preparing them. My understanding is that the number of medical practitioners registered in Ireland is approximately 18,000, of whom approximately 39% are non-Irish graduates. Can the witnesses provide a more accurate figure?

For those who have come to Ireland, perhaps even from outside of Europe, who completed part of their training outside Ireland, is there a process to follow to get onto the specialist register here? What do they have to do? My understanding is that Irish graduates will get on the specialist register after a five-year programme and then move on to the consultant posts, but my question relates to people who come to Ireland with three or four years of training outside Ireland and who want to enter the Irish system. How do those people get on the specialist register, if they want to stay in Ireland?

I also want to raise the issue of the grandfather clause. I spoke to a person a number of months ago who was employed pre-2008. That person has made a number of attempts, through that person's specialist area, to get onto the specialist register and on each occasion, was told that people were not aware of what the process was. In the last 12 months that person has been in contact with the Medical Council to ask what the process was. That person was advised by the Medical Council that it did not have a process for getting on the specialist register for someone who took up a job pre-2008. Can that be clarified? What is the process for people who were employed pre-2008 who are not now on the specialist register but who have been practising for quite a long time in this country? Those people are saying to me that the Medical Council has advised that it is not aware of the process in place. Perhaps the people who not on the specialist register of whom the witnesses are aware could be communicated with to advise them what the process is. The information I have is that these people do not know what the process is and that the Medical Council was not able to advise them. The institutions they work for were unable to assist them either. Perhaps the witnesses can clarify.

For those who are post-2008, I presume there would be no difficulty in communicating with them to advise what the process is. Has there been communication with those people to date or will it be done at this stage?

A specialist training programme was set up where people are on the programme for a number of years, go through the system and are then entitled to apply for consultant posts here. Of the number who have come through the training process under the specialist training programme over the past ten years, what percentage have stayed in Ireland? Does that programme now need to be reviewed in order to keep people in Ireland? I know that both the IMO and the Irish Hospital Consultants Association, IHCA, have said that part of the problem is pay and conditions but are there other issues we need to look at to make sure we can retain the maximum number of people possible in this country?

Deputy Margaret Murphy O'Mahony

I welcome the witnesses this morning and thank them for giving up their time to come to speak to us.

The word "consultant" is not defined under the Medical Practitioners Act. Is it the case that a self-declared consultant is not recognised by the Medical Council, given that the word is not defined in the first instance? What system is in place to close the loophole between the specialist division and the self-declared consultants?

Those who are not registered in the relevant specialist division cannot be appointed to a permanent position in a HSE hospital or a section 38 agency.

What is the position with regard to section 39 employees? As of 14 April, 127 consultants are still not registered in the relevant specialist workforce. As consistency surely is imperative, why has nothing been done to date to rectify this?

Dr. Ryan stated most specialist doctors who become consultants are required to complete two to three years of basic specialist training. How then is the term "self-declared consultant" acceptable given the extent of the training the others must do? Are doctors filling vacancies to make up numbers as opposed to having been adequately trained for the positions they fill? I ask Dr. Gilligan the extent to which this ambiguity is affecting the day-to-day running of hospitals. The current bed situation and hospital overcrowding has an obvious impact on medical staff in any event. To what extent is this impacting on patient safety?

Dr. Anthony Breslin

I will deal with Senator Colm Burke's questions. I was asked about overseas graduates entering specialist training. There is a difference between EU and non-EU graduates. EU graduates have an automatic right to enter basic specialist training and then higher specialist training as long as they do their entry exams and so on along the way and are appropriately assessed. For non-EU graduates, it is a more complex programme. They must have a certificate of equivalent experience to the Irish internship. We have that in place for a number of countries including Pakistan, for those people who started their internships after January 2009, Sudan, New Zealand, Australia, South Africa after 1 July 2006, and Malaysia, the UK and Malta. That was set up under the Act and the council has to consider the equivalent certificate of experience and that would exempt the applicant from doing the examination.

In order to deal with the significant number of people trying to register in Ireland, we established an adjudication group with representatives from Ireland and overseas to determine the requirements to ensure we had a high standard of doctors finishing their internships before we would register them here. After reviewing evidence based on the quality of medical schools, quality of internships, the time taken and type of work done, the adjudication group recommended that internships undertaken in the countries I mentioned met the council's standards. In addition, a person seeking to take up a training post in Ireland must have performed a higher examination. He or she must demonstrate a level of education and training above the internship.

The current situation is disadvantageous to a number of doctors working in Ireland in that they have sufficient qualifications to work here but, due to legislation, they do not qualify to get onto training schemes. One can have two doctors working on the same clinical team, one of whom is on a formal training scheme run by the Royal College of Physicians of Ireland or the Royal College of Surgeons in Ireland while the other is not eligible for that scheme. We have had representations from a number of junior doctors and countries like Nigeria and India to try to deal with this. The proposed amendments to the Act, which have been agreed between the council and the Department of Health, would get rid of that variation and allow those who are working here and providing good service to the country access to the training scheme. It would also help the public by encouraging those people who are doing a job here to stay in the long term. A lot of them come here to try to get on a training scheme. When they cannot, they leave to go to Australia, Canada and so on. As such, we are losing a valuable resource there. I hope that clarifies matters.

Senator Colm Burke referred to people pre-2008 who did not grandfather across and who are now seeking to get onto the specialist register. We have a standard process to assess these individuals. That process is available on our website. When someone makes an application, he or she is told what documents and evidence are required. That comes to the council and the documentation and evidence are provided to the relevant postgraduate training body for surgeons, psychiatrists or physicians, which reviews the documentation and reverts to the council with a recommendation for the registration committee, which I chair. As such, I know the process. While the process is predicated on a person being in training today, we make allowances for the fact that someone might have trained a number of years ago. We take into consideration the fact that conditions and requirements were different in 2002 than today. In some situations, a college assessing an application might consider that by today's standards, an applicant does not meet the requirements for specialist registration. In committee meetings, however, we consider the evidence the doctor has sent to us and consider what was in place when he or she was in training. On a significant number of occasions, we have agreed to recommend that those people go on the specialist register. Such a recommendation goes to the full council meeting for approval. In a small number of situations, there might be a reason the doctor cannot be registered on the specialist register. In such situations, a doctor has a right of appeal and can go before an assessment group and that assessment will go to the whole council, which can make a recommendation. There is a clear process and we are cognisant of the issues for someone who trained a number of years ago. We make allowances for that.

People coming to the country post-2008 go through the same assessment process. We also make allowances for what training they have done and when they have done it. Again, the assessment goes out to the relevant postgraduate training bodies and comes back to my committee where we will make a final decision. Again, while we make allowances for people who have trained in different locations and at different times, we try to ensure they meet the relevant standard to practice in today’s environment in Ireland. All of that information is available on the council's website. Some people can be put off by the requirements regarding relevant evidence and documentation. For instance, if someone worked in the UK or Australia 15 years ago, it may be difficult to get proof that he or she worked in a certain hospital or carried out certain procedures. However, we make allowances for that. If there is any way for us to assist a doctor to achieve specialist registration where we think it is appropriate, we have no issue doing it. If the Senator feels we should communicate that to doctors and make it more visible on our website, we have no issue doing that.

Senator Colm Burke's final question was on the percentage of doctors who train in Ireland and leave. I cannot provide a figure off the top of my head but we know it is an issue. Some doctors do their basic training and then leave before they do their higher training. Some doctors leave after their internships while others complete their higher training but leave due to issues around consultant recruitment and get consultant posts overseas. We are trying to assess those numbers at present but I cannot give the Senator a figure off the top of my head.

Senator Colm Burke

The specific figure I am looking for is the number of those people who have completed the senior training.

Dr. Anthony Breslin

I understand. I do not have that figure to hand but I will get it to the Senator as soon as possible.

Mr. William Prasifka

On the percentage of doctors who have completed specialty training and stayed, we cannot provide the figure right now. However, a great deal of work has been done on this topic of doctor emigration. The Royal College of Surgeons in Ireland has a doctor emigration project and it is something in which all stakeholders are actively involved.

We will endeavour to forward to the committee the best information we have in this regard.

Deputy Murphy O'Mahony correctly stated that "consultant" is not a defined term under the Medical Practitioners Act. This is not surprising because the Medical Practitioners Act does not give the Medical Council a role in the employment status of doctors within the health system. It also does not give the Medical Council the status of regulator of hospitals or employers. If it did, we would be a very different body with different powers and, presumably, very different resources. In terms of the doctors who are self declared, the self-declaration does not give them any status. The workforce intelligence report, which we compile and has been well received by stakeholders, is a snapshot of, and a source of information about, the medical workforce. It is very useful, particularly when we know there are lots of stresses and strains in that workforce and very high emigration. It is a useful tool but, in and of itself, it does not confer any status on anyone. What we are discussing is to how to uphold standards in the profession. Obviously, the Medical Council would be, and is, extremely concerned if consultant posts are not being filled by people who meet the specialist qualification.

Chairman

Have all of Deputy Murphy O'Mahony's questions been answered?

Deputy Margaret Murphy O'Mahony

No.

Mr. William Prasifka

The remaining questions were for the other stakeholders.

Ms Rosarii Mannion

On Senator Colm Burke's question of whether communication has issued, in terms of the cohort of the public health sector about which we are speaking now, there are 127. We are case managing those on an individual basis to assist and support the relevant doctors to come through this process as appropriate. This is happening at hospital group level. With the appointment of our interim chief clinical officer we will have greater visibility at a central level and we will be attending to that in a very focused way.

Deputy Murphy O'Mahony asked if a similar process is in place for the section 39 agencies. By way of clarification, because I would not like to mislead the committee, under the Protection of Employees (Fixed Term Work) Act 2003, employees can acquire a contract of indefinite duration. Within the cohort post-2008, we have ten that will acquire a contract of definite duration. In terms of the section 39 agencies, as the Deputy will be aware - this has been the subject of discussion by this committee - section 39 staff are not our employees. However, a similar process should apply and we do part-fund some of those agencies.

On the Deputy's second question of why nothing has been done to date, I do not accept that. It might not be visible, but quite a lot has been done to date. I have previously referenced the report commissioned by our director general and chaired by Professor Frank Keane: Towards Successful Consultant Recruitment, Appointment and Retention, which was published in February 2007 and is available on our website, which I can share with the committee. It picked up on this issue as one for us to address. It is also on the organisation's risk register at the most senior level. We are attending to it but we need to progress it.

Deputy Margaret Murphy O'Mahony

Do we need to do more?

Ms Rosarii Mannion

I always believe more can be done and more will be done. I am confident that we will be in a stronger position come December in terms of the level of focused attention on this particular issue.

On the point regarding the medical workforce, from February to date we have grown our medical workforce by 98 additional consultants and 288 additional NCHDs. Notwithstanding that we are growing our medical workforce and moving in the right direction, I accept that as per the capacity review that has been referenced we need to do grow it further with greater speed and efficiency. We are picking up the issues around recruitment and hope to focus more on the retention issues etc. through the good offices of my colleague, Professor Frank Murray. To alleviate any doubt, there is quite a lot happening.

Chairman

Would Dr. Gilligan like to respond?

Dr. Peadar Gilligan

Deputy Murphy O'Mahony asked about the day-to-day impact of this issue on hospitals and whether it is impacting in terms of overcrowding and patient safety. The question is why do we have 450 vacant consultant posts throughout the country. The reason for this is clear - Ireland is not regarded as an attractive place to work. Why is that? It is because we have a dishonoured consultant contract, significant cuts to consultants' pay, at three times that of all other public sector workers, and because consultants, particularly surgical colleagues, looking at potentially taking up a position in Ireland are finding that there is no operating theatre time available to them in the hospitals to which they are to be appointed or there is no outpatient clinical available to them. They also may not have the administrative support they require or they not have a team to provide the care that they wish to provide. As a result, they are choosing to remain where they are, which may be Canada, America, Australia or the UK and the patients of Ireland are missing out on this talent. This is a very real impact.

In regard to the unfilled consultant posts, it is fair to say that services are not being provided to patients. As I have stated previously in this committee, patients who require stroke care are not receiving it in as timely a manner as they would if there was a consultant in post. Patients requiring surgery are waiting longer because we do not have the number of surgeons that we need to provide the care.

Deputy Margaret Murphy O'Mahony

Patients are being impacted.

Dr. Peadar Gilligan

They are very definitely being impacted, which is why it is key that we address this matter with a level of urgency.

Dr. Tom Ryan

Deputy Murphy O'Mahony also asked about the training period. Most young people, when they qualify as a doctor and finish their internship, need time to find their feet. They need time to consider what they want to do long term. It is generally at this point that doctors would do two years of general training, usually in medicine. They then enter some specialty training. Following the sub-specialty training, they go abroad to round off their professionalism and to gain more experience. A problem arises when in the two years before they get into specialist training they go abroad. When they finish their specialist training they will go abroad. Whereas the system here almost shuns junior doctors or doctors in training, when they go abroad they are embraced with open arms. If they want to do more work and treat more patients they are given access to the resources, staff and administrative support they need to do so. I know from direct personal experience of going abroad that when doctors go abroad they are treated very well. If one wants to treat more patients everyone is delighted and one is given immediate access to whatever one wants. There is no delay. Doctors from experience at home know that the system is not conducive to providing excellence, either clinical, academic or training. Young talented people see the disconnect between what is possible abroad and what pertains at home and they take a message from it. They are not valued at home but they are valued abroad and so they emigrate. We are exporting fully trained doctors to the rest of the world such that our health system is dependent on foreign-trained doctors. We import doctors from poorer countries. We take into our health care system doctors who have been trained in developing and Third World countries and as such we are not doing their countries of origin any justice. At the same time, we are exporting large numbers of fully trained, confident medical professionals to thrive and practice abroad.

Deputy Margaret Murphy O'Mahony

A double whammy.

Mr. Martin Varley

To add to what Dr. Ryan said, currently there are approximately 200 Irish trained doctors who completed their intern year last year working in hospitals in Perth. This is replicated across other parts of the English speaking world.

The major concern we have is that they are not coming back, they are remaining and going on to other posts and completing their training abroad. We are training a sufficient number of doctors at graduate level, but we are losing them. The key question is why that is the case. I have been in this post for approximately ten years, but prior to that I worked as a civil servant in the Department of Finance. During a previous recession, we had a golden rule in the Civil Service at the time that in spite of the financial difficulties the State would not breach contracts. If I were to reflect on the past ten years, I would say the root cause of this problem is the fact that the State and the health service management is party to persistent and blatant breaches of contracts. The examples are fairly obvious, the 2008 contract which was agreed with consultants ten years ago still has not been honoured. It has been ignored. That is sending a very negative message to professionals who are in very high demand internationally. To sum up, it means that the longer serving consultants today, partly because of the financial emergency measures in the public interest, FEMPI, but also significantly because of the breach of contract are being paid 30% less than they should have been if the contract was honoured effective from 1 June 2009. The new entrant consultants are being paid 45% less than was agreed practically ten years ago. Of course, other jurisdictions have moved on in the interim and they have been increasing salaries. The big difference is that highly trained professionals are embraced in other jurisdictions and in other hospital settings whereas, unfortunately, the opposite is the case here. To resolve this problem one has to address and resolve those issues, the breach of contract and the discrimination against new entrants. I think that is the key to the resolution of the problem. We did not have that problem prior to those two developments.

Chairman

Where is the lack of understanding in the Department of Health and the HSE about what is the central issue? How come the Department and the HSE cannot come to grips with the issue?

Mr. Martin Varley

Unfortunately, from where we sit, that issue is being ignored. It is the central issue. An employer knows that one must honour contracts with employees, if one hopes to retain them and recruit. That issue is being ignored and has been ignored for several years. The problem is increasing because of it. I cannot understand how profession HR management would ignore such a central issue.

Chairman

I thank Mr. Varley and invite Ms Mannion to contribute.

Ms Rosarii Mannion

I thank the Chairman. What Mr. Varley is referring to is the subject of court action at present so it would be inappropriate to respond in any great detail on the issue at this forum. Suffice to say there is no intention on the employer's behalf to dishonour contracts at all or to undervalue any member of our staff.

Chairman

I thank Ms Mannion. I will now address a question to Professor Murray. Are sufficient numbers of people coming into the training programmes in Ireland and are we losing them once they have qualified?

Professor Frank Murray

I thank the Chairman for inviting us to appear before the committee today.

People are lost at all stages from the training programme both here and abroad. It is not just an Irish issue. The problem is particularly marked here, especially after internship where many doctors go away, as Mr. Varley said, and a proportion do not come back and then particularly at the end of higher surgical training, HST. I personally believe that we urgently need to attack the issue of recruitment and retention. It is a fundamental issue and feeds back to many of the other issues that create unhappiness from consultant to trainee consultant level. Some of those steps include making Ireland a very good place to work. Other improvements include optimising the process of appointing consultants so that it is a kind of one-stop-shop rather than having a number of steps and reducing as much as we can isolated or silo thinking and joining things up as best we can. I argue that we are losing trainees at all stages and that we should make the end, that is being a consultant or a general practitioner, so attractive that people want to stay rather than leave.

Chairman

I call Deputy Durkan.

Deputy Bernard J. Durkan

I welcome our guests. I was very interested in the very desolate picture painted by Dr. Peadar Gilligan and others. It is true and we all understand the difficulties in filling posts throughout the health services. Some of the issues have been in existence for years, even before the downturn in the economy. I served on one health board and I can recall distinctly posts being left unfilled for some considerable time because it was not possible to find suitably qualified people to fill the positions. I think it is exacerbated by some of the contracts on offer in other countries. It is possible to get a two or three year tax-free lucrative contract in the Middle East. We cannot compete in this jurisdiction with that. We need to bear that in mind.

I take the point made by Dr. Gilligan that we tend to dumb down the morale and the quality of the services in Ireland by constantly criticising them, even where criticism is not warranted. That is not taking away from the fact that we do have the right to a good reliable health service that we can be proud of. We want that to happen.

We need to understand that all staff throughout the public service suffered salary cuts. It was a very sad thing at the time to break contracts. The options available at that time are well known. I am not making excuses for it, but the fact of the matter is that the entire public sector was assessed to ascertain the extend to which economies could be made. The cuts were drastic and severe, but I would like that to be borne in mind.

There is a figure of 450 vacancies; has that figure increased or decreased in the past number of years? Is the number of unfilled vacancies rising, as would appear to be the case? Can the non-EU graduates who are available practise in practise in any other EU country?

A number of graduates cannot get a place on a training scheme and I would like to know the main reasons for that and how has that number fluctuated in the past couple of years. Has the number increased or decreased? In the case of practitioners who have not completed their registration but are practising, does that in any way affect insurance cover in so far as insurance underwriting in the health services is concerned? Has there been any noticeable difference in the number of legal challenges against those who have not completed their registration as consultants and those who have?

Chairman

I thank Deputy Durkan. I call Deputy Donnelly.

Deputy Stephen S. Donnelly

Chairman, I will wait. The questions I wish to ask are relevant to each other so I need responses to them as we go, if that is okay.

Chairman

Perhaps Dr. Breslin can address those issues.

Dr. Anthony Breslin

I will respond to Deputy Durkan's question on whether non-EU graduates registered in Ireland can practise in other countries.

If a non-EU graduate is registered here, that does not give him or her an automatic right to practise elsewhere in the EU. He or she would have to register with that individual country. If someone was registered here and wanted to practise in Portugal, for example, he or she would have to register in Portugal. Portugal would be subject to the same EU regulation about registering them as we are here.

Deputy Bernard J. Durkan

Would that apply in third countries if our graduates emigrate? Do they have to have individual registration in each country or is it general-----

Dr. Anthony Breslin

Each country requires its own individual registration. If an Irish graduate went to Portugal, as long as he or she meets basic criteria, he or she would be automatically registered in Portugal, for example. If the graduate had to go to Australia, America or Canada, since there are different registration processes are different, the graduate would have to meet different criteria. An Irish graduate would have an easier time registering in an EU country but every country has to have an individual registered in that country. If someone is practising in Portugal, that person has to be registered in Portugal.

Deputy Bernard J. Durkan

Are other EU countries having difficulty filling posts, as we are here? I am conscious of the cost of the services and the fact that we are not the lowest spenders on health generally, but we may be the lowest spenders on consultant posts. That is a query.

Dr. Anthony Breslin

The UK is having issues with recruitment. I think that is more due to Brexit than other reasons. Many other countries have their own internal issues with recruitment.

Deputy Bernard J. Durkan

People who emigrate to Dubai or Abu Dhabi, that is, graduates who want experience and presumably want to do the best they can for themselves have a choice. They can go to Australia, the United States and do the registration and whatever else. The choices are to go to the Middle East or to Australia. What is the difference there? How can we compete with that?

Dr. Anthony Breslin

It is very difficult for us to compete with everything there. Young people nowadays tend to have wanderlust. They want to travel and get experience. As previous speakers have said, some of them go abroad for a number of years then come back and start training here. That might have been the intention of others but once they go abroad, they stay abroad. The same thing applies to the UK. People are going to Australia, Canada etc. That is a common issue for a number of EU countries.

Dr. Tom Ryan

The choices are quite wide. North America is wide open for an Irish graduate. It is a huge medical market. It is worth putting the scale of this problem in context. We have approximately 1.1 consultants per 1,000 population. The Organisation for Economic Co-operation and Development, OECD, average is 1.8. We are approximately 40% or 50% lower than we should be and many of the consultant posts we have are unfilled, while some are filled by doctors who are not registered as specialists and who may not be qualified to act as specialists. There is an enormous problem here. For us to provide complex, sophisticated healthcare to a contemporary international standard, we will have to greatly expand the number of consultants we have. We cannot even fill the posts advertised at the moment. It is not just the Middle East that offers superior contracts. It is Australia, New Zealand, the United States and Canada.

Deputy Bernard J. Durkan

English-speaking countries.

Dr. Tom Ryan

English-speaking countries. They embrace Irish medical graduates with open arms. It is not that we cannot compete with these people. We do not have a choice - we have to. We cannot set out to fail.

Mr. Anthony Owens

The Deputy referred to how there has been difficulty filling consultant posts in certain circumstances for a long time. The issue now is the length of time that consultant posts lie vacant and the number of applicants for the posts that are advertised. The number of applicants for many posts can be quite low. Some posts get no applicants. It can be difficult to put together a panel from which to appoint somebody.

Deputy Bernard J. Durkan

There are no applicants for some posts? Are those posts particularly unattractive and, if so, for what reason?

Mr. Anthony Owens

We made a fairly detailed submission to the Public Service Pay Commission on this. There are issues which we survey which revolve around remuneration, access to supports, administrative supports, surgery and clinical time, and so on. There is a variety of issues. There is no one reason why every post is unattractive. It is post-specific in many cases. The Deputy mentioned that doctors go abroad, including the Middle East. The people we would look to bring in as consultants, the Irish-trained doctors, would tend not to go to the Middle East. They would be more likely to go to the UK, Canada or Australia. They would pay tax in those jurisdictions but they would also have access to a far greater range of supports, work shorter hours and so on. There are other factors around that. There are remuneration issues too. The Deputy asked if the number of empty consultant posts is going up or down. The figure is probably tipping up slightly. It includes temporary and short-term appointments, which is part of the reason that we are here today, discussing this. I will finish on the Middle East. We have found that doctors, at later stages in their careers, are more inclined to go to the Middle East. It is an issue for general practice more so, in our experience, than for hospital doctors.

Chairman

Before we continue, some of our Deputies are under a certain amount of pressure this morning. I ask Deputy Donnelly to come in, if that is okay, and we will come back to Mr. Varley.

Deputy Stephen S. Donnelly

I will bring the conversation back to what the committee was for today. We are talking about doctors going to the Middle East and I know it is related but the committee meeting today is about doctors working as consultants in Ireland who are not on the specialist register. That is why we are here. We are all aware of the CervicalCheck scandal that has emerged over the last few days. It is causing a lack of confidence between the public and their doctors. It is clear, in the case of Vicky Phelan, that her doctor knew about not a false negative but a missed screening of cancer in 2011, did not tell her and did not want to tell her. We know that 13 other hospitals had doctors who did not share the information. It is fracturing trust between the public and their doctors. There are big issues to ask about the level of trust between doctors and the HSE. That is where we are this week. We hear that not only may patients now be worried that their doctors are not sharing everything with them but that their consultant is not a consultant. What we have heard this morning is shocking. A professional organisation states "it has become apparent that these most basic [professional] standards are not being observed when filling an increasing number of consultant posts and there is a [grave] concern that this development is not in the best interests of patient care." That is what we are here to talk about. Who is responsible for this? Is it the Medical Council? Is it the HSE? Is it the Department? Is there another body that we are not aware of? I understand that there are no legal definitions for consultants but for specialists. In the eyes of the public, in layman's terms, people hear that their consultant may not be a consultant. Whose responsibility is it to make sure that, when a member of the public is referred to a consultant, that man or woman is in fact a registered consultant?

Professor Frank Murray

I might address that. If one looks at the situation today, approximately 127 doctors are not on the specialist register who are working as consultants in the public service. As we have heard already, 52 antedate 2008 when it was not a requirement and ten are permanent people in consultant posts since then. It reflects that there is a serious challenge in recruiting consultants in Ireland.

Deputy Stephen S. Donnelly

I do not mean to cut across Professor Murray. This morning, we are trying to have a conversation about specialists being registered and it moves off to why it is so difficult to hire doctors. I do not mean to cut across Professor Murray but, in the interests of time, can I get an answer to the question?

I do not want to get into a conversation on why it is hard to hire doctors. I know the reasons and acknowledge it is a very important conversation. Who has the responsibility in this country to make sure that when a member of the public goes to see his or her consultant, that the consultant is, in fact, a registered consultant or specialist?

Professor Frank Murray

I believe the employers are supposed to make sure that these individuals are on the specialist division of the register. In practice, it turns out that 127 are not and they are employed through the hospitals or the mental health services. I will not return to the general point but it is important to view this matter in those terms. These are difficult-to-recruit posts within a broader issue of recruitment and retention. Not only are there 120 individuals like this, there are 450 posts that are unfilled. Of the posts advertised by the Public Appointments Service, PAS, last year or 2016, a quarter were unfilled.

Deputy Stephen S. Donnelly

I appreciate that point. I acknowledge that recruitment and retention is a really important conversation but that is not what I asked about. Thus far, the answer that has been given to my question is that it is the doctor's employer. Who is a doctor's employer? Is it the hospital? Is it the HSE? Who ultimately is accountable for what is happening? Is it individual hospitals?

Professor Frank Murray

I think it is individual hospitals and individual mental health services that directly employ the individuals. Ms Mannion is an expert on this subject and I will ask for her advice but I think they are the direct employers.

Deputy Stephen S. Donnelly

I thank Professor Murray for his answer. Do we have a situation in Ireland where a rogue hospital could, because of the severe difficulties in hiring specialists, start employing unqualified people, put them in specialist roles and present them to the public as specialists? Is that possible? Is there no higher authority in the State, within the Medical Council, the Department of Health, the HSE or anywhere else, whose job it is to make sure that hospitals do not hire people who are not qualified as specialists or consultants?

Ms Rosarii Mannion

Clearly, the employer has obligations around recruitment and the hiring of staff. The HSE operates under licence from the Commission for Public Service Appointments. We have a process of audit around all recruitment.

In terms of individual hospitals, it is very easy for us to itemise where the consultants are located. When hospitals hire staff they hire them to their specific competence. It is a matter of public knowledge and record whether staff are on any given register. Any member of the public can look up the register and see the qualification level of the consultant treating him or her. In terms of individual hospitals, as the employer the hospital certainly can go ahead and undertake its own recruitment. As I said, it is under licence. It is regulated. Anybody who is issuing a contract will make sure that if mitigation measures, supervisory measures, teamwork etc. are required, they are in place.

Deputy Stephen S. Donnelly

Ms Mannion has said that it is regulated. Who is the regulator?

Ms Rosarii Mannion

For doctors it is the Medical Council.

Deputy Stephen S. Donnelly

Is it the Medical Council?

Dr. Anthony Breslin

No.

Deputy Stephen S. Donnelly

The HSE says that the Medical Council is in charge of regulating this issue.

Dr. Anthony Breslin

We are not in charge of regulating employment.

Deputy Stephen S. Donnelly

The HSE has said that the Medical Council is in charge of that but Dr. Breslin has said the Medical Council is not.

Ms Rosarii Mannion

Sorry, I was not speaking about employment but doctors.

Deputy Stephen S. Donnelly

Does Ms Mannion mean the hiring of doctors?

Ms Rosarii Mannion

Is the Deputy asking me who is the regulator in terms of recruitment in the public service?

Deputy Stephen S. Donnelly

No, I am not. Who is responsible for ensuring that consultants are actually consultants? Is it the HSE?

Ms Rosarii Mannion

Absolutely, yes.

Deputy Stephen S. Donnelly

Is the HSE responsible for what is happening here?

Ms Rosarii Mannion

Yes, we are.

Deputy Stephen S. Donnelly

How long has the HSE been aware that this was going on? I refer to the specific issue of the public walking in to see consultants who are not consultants. We have evidence from an opening statement provided by one of the professional bodies stating "the most basic professional standards are not being observed." Who has the responsibility to ensure that the most basic professional standards are observed, such as consultants actually being consultants? Is that the responsibility of the HSE?

Ms Rosarii Mannion

Yes, it is.

Deputy Stephen S. Donnelly

How long has the HSE known that this is going on?

Ms Rosarii Mannion

The requirements for consultant appointments and qualifications changed in 2008.

Deputy Stephen S. Donnelly

I know. How long has the HSE known? We have a report that 650 so-called consultants operate as specialists in this country but are not on the specialist register and the Medical Council has walked us through the figures. If the HSE is responsible for making sure that doctors are actually doctors, how long has the HSE known that specialist doctors are not specialist doctors in some cases?

Ms Rosarii Mannion

I have been aware of this issue since September 2015.

Deputy Stephen S. Donnelly

Is that only since September 2015?

Ms Rosarii Mannion

Yes.

Deputy Stephen S. Donnelly

Was the law requiring specialists to be on the specialist register changed in 2008?

Ms Rosarii Mannion

Yes.

Deputy Stephen S. Donnelly

That means the HSE never looked into this matter for seven years.

Ms Rosarii Mannion

For clarification, the Deputy asked me the direct question as to how long was I aware of the issue.

Deputy Stephen S. Donnelly

Yes

Ms Rosarii Mannion

I answered the Deputy's question honestly and truthfully.

Deputy Stephen S. Donnelly

Yes

Ms Rosarii Mannion

I am aware of the specific issue since September 2015. That was the time when I came into post, as the national human resources director, and I began looking at the issue around consultant recruitment, appointment and retention. I engaged with colleagues in the national doctors training and planning unit. I made sure that we put in integrated management electronic systems to make sure these issues were picked up. I am acutely aware of the matter since that time because it has been part of my role to be aware of it since September 2015.

Deputy Stephen S. Donnelly

Yes. It was part of the role of Ms Mannion's predecessor to be aware of the matter too. From the perspectives of Ms Mannion and ourselves, it is great that she came in and found this issue. From the public's perspective, it should not matter who is in the role within the HSE. My next question is not specifically directed at Ms Mannion. When did the HSE become aware that we had non-specialist doctors acting in specialist roles? We have evidence from the professional bodies that such a situation comes with serious patient concerns and safety concerns. How long has the HSE known about this matter?

Ms Rosarii Mannion

The choice for the HSE, in some of these circumstances, is whether it provides a service in a safe way and recruit a doctor to a specific role with all the risk mitigations that may be necessary, or not, to provide a service. That can be a decision around providing a service, or not providing a service.

Deputy Stephen S. Donnelly

I repeat, how long has the HSE known about this matter?

Ms Rosarii Mannion

I can clarify that. As I have said, I am aware of this issue since September 2015. As for how long the HSE has been aware of it, I will clarify the matter. I would say, with a high degree of confidence, that the HSE is aware of the issue since the qualifications changed in 2008. I would be surprised if it were not but I am happy to clarify the matter.

Deputy Stephen S. Donnelly

Has the HSE issued a directive to stop the practice? Does the HSE still stand behind the practice?

Ms Rosarii Mannion

A number of circulars have issued with regard to this specific issue. Circulars Nos. 14/2009, 8/2010, 9/2012, 21/2015 and 16/2017 specify the employer's position regarding this issue. I am happy to furnish the circulars to the committee.

Chairman

Professor Murray has outlined the situation. As many as 415 posts have not been filled and 127 posts have been filled by those who are not on the specialist register. Am I correct that were the non-specialist doctors not in position, then there would be no service provided by the 127 consultant posts?

Professor Frank Murray

The point Ms Mannion made is correct. Frequently, service providers such as hospitals or mental health services, must make a decision about whether to provide no service or to provide a service with somebody who is not on the specialist division of the register acting at consultant level who frequently, I think, has comparable experience, if not certified training, with those individuals who have registered with the Medical Council on the specialist division of the register. That is one of the issues that is quite important to think about. They are not doctors who, in my experience, do not have relevant experience and training. They are doctors who do not have certification in that regard, which is different. As Ms Mannion has outlined, they work in a slightly different environment where there is more mentoring rather than stand-alone work, as consultants tend to work. It is worth thinking about where these posts are located. They are mainly in smaller level 3 and 4 hospitals, in community mental health services and in hard-pressed specialties such as anaesthesia, surgery and medicine. When there is a recruitment and retention issue, which we have discussed, one will see the crises most obvious in areas that are difficult to recruit into in Ireland, which mirrors the situation abroad.

There was a question as to whether this pertains anywhere else. Scotland has a much worse recruitment and retention issue than we have. They have an awful lot of posts unfilled. Frequently, it is the remoteness and the unattractiveness, or the relatively less attractive nature, of the specialty that has worsened the recruitment and retention crisis and put pressure on the service to provide alternatives.

Chairman

Ultimately, it is the HSE which approves the appointment of doctors who are not on the specialist register to consultant posts. It is the HSE which signs off on that.

Professor Frank Murray

I am not sure that it signs off. I think these are mainly locally appointed rather than centrally appointed. If we think about how consultants are appointed into permanent, long-term posts, they go through a very rigorous process involving either the hospitals, the Public Appointments Service, PAS or the mental health services. People who are appointed to locum or specific-purpose contract positions do not go through that same process. It does not have the same number of steps within it.

Chairman

Sorry, I interrupted Deputy Donnelly.

Deputy Stephen S. Donnelly

I wish to ask the professional bodies how serious a clinical risk this is. From the public's perspective, we have heard about CervicalCheck. Doctors are withholding important information from patients in some cases to the point that, when referring to the ethical duty of consultants and activities relating to CervicalCheck, the Taoiseach said in the Chamber yesterday that the guidelines "are not optional and doctors may be struck off for not following them". We have heard today that there are non-consultant hospital doctors who are not sitting the exams and that there are also non-consultant hospital doctors who we bring into this country, who are good enough to work in our hospitals but who are not worthy of further training. We have a bizarre system of apartheid within our hospital system whereby we have one hospital doctor from Pakistan, Sudan or South Africa who is allowed to train and another from Japan, South Korea or Canada who is not allowed to train. These are serious issues. In terms of what we are hearing with regard to, for example, a member of the public believing he or she is talking to a specialist in circumstances where that individual is not, in fact, a specialist, will the professional bodies and the Medical Council indicate if there is a clinical risk involved or if this is simply an administrative issue?

Chairman

I call Dr. Ryan.

Dr. Tom Ryan

There were some comments recently that this, to some extent, was about mitigating risk. However, that is not a culture of excellence. It is not a culture of providing the best possible care that the patient deserves. I have commented that risk could be mitigated by mentoring but many of the people who are appointed to consultant posts and who are not on the specialist register are appointed in smaller, more remote hospitals where the possibilities of mentoring would be minimal. An additional complication arises from the fact that sometimes - not infrequently - doctors who are not on the specialist register are appointed to act as consultants and then receive a contract of indefinite duration and are thereby incorporated into the system for good. The problem about all this is it does not prioritise excellence or quality. It actually may prevent a hospital developing. There are situations that might arise where there may be a number of consultants in a smaller, more peripheral hospital who are not on the specialist register. Then that hospital becomes uniquely unattractive for a well trained, broadly experienced consultant to come back and work in. This practice might stymie the development of some of the smaller feeder or peripheral hospitals.

Deputy Stephen S. Donnelly

If I could ask Dr. Ryan for the short version of that answer. Does he believe there is a clinical risk attached?

Dr. Tom Ryan

I might refer to a recent High Court case which involved the Medical Council and a medical practitioner who was not on the specialist register where there was a risk involved. That is the most-----

Deputy Stephen S. Donnelly

I apologise for intervening, but for members of the public who are watching this and who are not aware of the details of the High Court case, could Dr. Ryan give me a "Yes" or "No" answer. Is there clinical risk attached to what we are talking about?

Dr. Tom Ryan

I believe there is a risk but it would be better to discuss that with the State Claims Agency. It might have better data on that than I would.

Deputy Stephen S. Donnelly

In Dr. Ryan's professional opinion-----

Dr. Tom Ryan

The whole point-----

Deputy Stephen S. Donnelly

-----is there a clinical; risk attached to what we are discussing?

Dr. Tom Ryan

Of course there is. The whole point of having professional standards is that there is a set standard of quality that people have to achieve so that they are allowed to look after patients. If one abrogates and discards those standards, then one is discarding the whole notion that one would prioritise or develop a culture of quality and excellence.

Deputy Stephen S. Donnelly

With the Chair's indulgence, could I get the opinion of Dr. Gilligan and the Medical Council on whether is there a clinical risk to the Irish public in the context of consultants who are not on the specialist register and who are working or acting as specialists?

Dr. Peadar Gilligan

I thank the Deputy. Risk can be defined as the potential for an adverse outcome. Is there a potential for an adverse outcome arising from a situation with regard to the challenge in recruitment and retention at consultant level and unfilled posts and posts filled by people who are not on the specialist register? Yes, there is significant clinical risk created.

Chairman

I call Dr. Breslin.

Dr. Anthony Breslin

I cannot give direct comment on clinical risk because I am not involved in that area but I can say that the council receives slightly more complaints regarding people not on the specialist register in comparison to those who are on it.

Deputy Stephen S. Donnelly

Could Dr. Breslin say that again?

Dr. Anthony Breslin

We get a slightly increased rate of complaints from the public and other professionals about people-----

Deputy Bernard J. Durkan

That was my original question.

Deputy Stephen S. Donnelly

I am trying to listen to the answer. Perhaps Dr. Breslin could repeat it.

Dr. Anthony Breslin

In terms of complaints from the public and other health professionals, the council receives a slightly increased rate of complaints in respect of people who are not on the specialist register versus those who are.

Deputy Bernard J. Durkan

I need an answer now. The question I raised related to the number of legal actions-----

Chairman

No, I am sorry-----

Deputy Bernard J. Durkan

The Chairman bypassed me and said he would come back.

Chairman

I will come back to the Deputy.

Deputy Bernard J. Durkan

That is overlapping and I object to that. I certainly do not intend to stay here if that is the way the Chairman intends to operate. The question was distinct and clear-----

Chairman

Sorry, I will come back to the Deputy.

Deputy Stephen S. Donnelly

I thank the Chair and I apologise to Deputy Durkan for that. I will seek an opportunity to reciprocate his generosity.

I have one question for the Medical Council in respect of CervicalCheck and the duty of candour and duty of disclosure. As I said earlier, in the Dáil yesterday, the Taoiseach stated that these "are not optional". He was talking about the duty of a doctor to tell a patient about the information he or she possesses. The Taoiseach said these "are not optional and doctors may be struck off for not following them". That is a statement that I imagine would worry many doctors throughout the country. Do the representatives from the Medical Council agree with the Taoiseach's assessment that non-disclosure in cases similar to that with which we are dealing in the context of CervicalCheck could lead to clinicians being struck off?

Mr. William Prasifka

If I can deal with that, we are the regulator in this issue and individual doctors could be coming before us. It is extremely important that we do not seem to be prejudging any particular case. Every case must be based on the facts as presented. However, our ethical guide and our standards on disclosure are very strong. The background to the ethical guide is that the patient is not a passive recipient of healthcare but is, in fact, a full partner. There should be active participation and collaboration between the healthcare provider and the patient. There is a very strong standard in the ethical guide, which was updated two years ago, and disclosure is obviously a very important prerequisite. That does not prejudge any individual case but we certainly agree there is a very strong position on disclosure.

Deputy Stephen S. Donnelly

I thank the witnesses and the Chair.

Chairman

I thank Deputy Donnelly and call Deputy Durkan.

Deputy Bernard J. Durkan

My unanswered question relates to whether there is a noticeable correlation between the number of legal actions taken against fully qualified consultants and those who are deemed not to be fully qualified.

It is a simple question so would anybody like to answer it?

Dr. Tom Ryan

The State Claims Agency may have that data. None of us individually has such information but the State Claims Agency is responsible for defending claims and it would have the data.

Deputy Bernard J. Durkan

There must be a difference in the risk between the non-qualified consultant, or whatever we would like to call it, and those who are qualified. There must be a difference in the number of cases of actions taken by patients against one or the other. It must be noticeable. If there is no difference, why is that so?

There is another question that was not answered relating to the number of graduates who cannot get on training schemes. I deliberately asked about it at a very early stage and although we have gone around the houses since, we did not get the answer to that question. I need the answer to those two questions.

Professor Frank Murray

I am afraid I did not come prepared for that question so I do not have an answer to it. There has been an increase in the number of training programme schemes in recent years. There has been an almost 50% increase in the number of intern posts in Ireland, reflecting the dramatic increase in the number of doctors being produced in Ireland since graduate entry training began, essentially. There has been a smaller increase in the number of people entering the junior or basic specialist training programmes and there also has been a significant increase in the people entering a more specialised training programme. I could not give an exact answer in that regard.

Deputy Bernard J. Durkan

The supply of practitioners is obviously a core issue at all levels, and particularly at the consultant level. However, we cannot get graduates on to training schemes and we do not know why. There is a greater urgency now than there was before. Have we taken action that would accelerate the access and availability of schemes? Why have we not done it? Are there plans to do it?

Professor Frank Murray

The process described by the Deputy has been happening. There has been an increase in the number of graduates entering training programmes. It has not been incremental but it has been steady over the years.

Deputy Bernard J. Durkan

It was stated at the beginning that quite a number of graduates cannot get on training schemes. Is that true?

Professor Frank Murray

I do not know if it is true. "Quite a number" is not quite a number. I do not know the number of people who cannot-----

Deputy Bernard J. Durkan

What is the percentage of the total requirement?

Professor Frank Murray

I am not sure that number is available.

Deputy Bernard J. Durkan

It should be.

Dr. Anthony Breslin

I cannot give the Deputy a number today but I can get it for him. Currently, because of legislation, non-EU graduates from certain countries cannot get on to Irish training schemes. The legislation has been drafted and there are discussions between the Department of Health and the Medical Council to overcome that. Unfortunately, the legislation has not yet passed the Houses of the Oireachtas or been enacted. If that was to occur, it would allow the overseas graduates working in this country into formal training schemes. It would be good for them and the public.

Chairman

I ask about medical indemnity and working within a scope of practice. If a person is working above his or her scope of practice without documentation - in other words if a person is not on the specialist register and is working in a position with consultant status - how does medical indemnity cover that?

Ms Rosarii Mannion

It is a fairly technical matter and I would not like to give any inaccuracies. I am happy to clarify that and furnish the committee with a detailed response later today.

Chairman

Does anybody from the professional organisations wish to comment on that?

Dr. Tom Ryan

It is a matter for the State Claims Agency and the indemnity bodies.

Mr. Martin Varley

Aside from the responsibility of the State Claims Agency, my understanding is that one of the main mutual indemnifiers in providing cover in Ireland would not see it as appropriate for somebody to practice outside the specialty for which he or she is registered. In other words, a person practices only as a specialist only if in the specialty. It is a matter that has raised some concerns with some members and it is the response we have received from one of the main indemnifiers.

Dr. Peadar Gilligan

I will respond to one of the points made by Deputy Durkan. It is a significant point and is part of the reason we are here today. He referenced the public service contract and the drastic and severe cuts to those. The financial emergency measures in the public interest legislation was superimposed on a contract that had never been honoured. Superimposed on that again was a 30% pay cut on all future consultants. Despite our best efforts to have that 30% cut reversed, it has not happened to the extent that it should have. Undoubtedly, that has had a massive effect on morale and on our ability to recruit and retain.

I teach specialist registrars on leadership. Around the time of the 30% cut being announced, I asked what their response would be to it at that stage in their careers. In unison, they said they would leave the profession, and that has come to pass. We have an opportunity to get this right and address the matter. We need to treat people doing the same job with the same qualifications to do that job, and working every bit as onerously as their existing colleagues, the same way. We also need to honour contracts if we want people to feel valued and want to work in the system.

Dr. Anthony Breslin

I do not know if it is appropriate but Deputy Donnelly raised the matter of junior doctors from overseas not sitting examinations. Is it okay for me to clarify that for the record? All doctors from overseas coming into Ireland either sit an examination set by the Medical Council before they register in the country or they have other reasons - including the sitting of other examinations and experience - that would allow them not to sit the examination we set. Those people have sat other examinations. No graduate from overseas goes on the Irish register without an assessment of their clinical skills.

Ms Rosarii Mannion

Deputy Durkan asked if we saw an increase in turnover levels. The turnover rate in 2017 for medical staff was 7.8%, which is keeping with international comparisons. In February 2017, we had 397 additional medical staff on the workforce, including 98 consultants and 288 non-consultant hospital doctors. Notwithstanding that, we have very significant recruitment and retention challenges in a number of the specialties, and that has been picked up in the course of the discussion. The figures are moving in the right direction, however.

Deputy Kate O'Connell

I thank the witnesses for coming into us this morning. I am sorry I was late and if I am repeating questions that have been asked, I apologise in advance. Following Deputy Durkan's questions, somebody made a comment - I think it was Dr. Breslin - that there was a marginal increase in complaints regarding people on the non-specialist register. Are there data to show how this has resulted in disciplinary action? There could be many complaints about somebody but they may not be held up. The key data we need to know are whether, with this marginal increase, these people are more or less likely than the regular guy to have disciplinary action taken against them.

The Chairman recently mentioned standards. Can Ms Mannion tell us today that the public can be assured that these doctors are competent to perform their roles? It is a fairly simple question for the head of human resources. Who is liable if somebody on this register makes a catastrophic error? Would it be the hospital manager or the Health Service Executive? There has been reference to indemnity insurance. If the indemnity insurance is not covering it and these people are employed by the State under this set-up, is it the responsibility of the State Claims Agency?

Who is paying? Are these people value for money, do they do the same job as hospital consultants? Do they do the same rate of on-call and is their net income in the year the same or higher? Is it cheaper to employ someone who is not up to the same standard? My understanding from anecdotal evidence is that these people are not performing the same on-call duties as regular hospital consultants. On-call is included in regular non-locum consultant contracts. In the current contract are they paid an hourly rate and are we getting the same bang for our buck as for a regular consultant?

I am very concerned that these individuals seem to be channelled into small peripheral hospitals. When the hospital constantly employs locums and there is nobody in situ taking responsibility it seems very obvious, without doing any study, that there will be a drop in standards in that hospital and that will have a snowball effect. When there is a drop in standards it is not an attractive place to work. No Irish qualified hospital consultant wants to be responsible legally or ethically for people who are not up to scratch working under them. The answer probably will be that this is a false economy. Somebody spoke about recruitment and retention, Mr. Gilligan said that when consultant salaries were cut by 20% or 30% consultants were leaving the country. Logically, if the locum costs 30% more we have made a bit of a bags of things because it is costing more to keep a lower standard of individual in employment.

Could somebody elaborate on the comment about locally appointed versus centrally appointed? My understanding was that HSE recruitment was central and if this is a local issue are the same governance issues in place? If the HSE has bypassed the proper methods of centralised recruitment to do it locally what is the damage to the system? The witnesses spoke about legislation drafted to overcome the barriers that prevent people getting on the consultant register. Does anybody on the panel have any issues with this legislation? Are there any concerns that this proposed legislation will in any way diminish the standards of Irish hospital consultants? Are we doing something that will lead to inferior quality? Is there, or has there been, any training programme put in place to get these people up to scratch such that a person doing the job competently wants to be a consultant but there is a technical barrier? Is there a programme to bring these people to consultant level with perhaps a pay cut in the intervening period? It seems logical that if the parameters of different countries are not aligned we would have some sort of get up to scratch course that would be approved and competency levels would have to be reached and assessed. Of those in locum positions how many have signed temporary contracts and how many are Irish graduates?

Senator Colm Burke

Many of the 127 not on the specialist register are in the small hospitals such as Cavan, Letterkenny, Portlaoise and Tullamore. Would it be true to say that the risk will always be higher in a small hospital because in a big hospital a doctor might be on a one in six or seven rota, working every day, one night in seven and one weekend in seven, whereas in the small hospitals they are likely to be on a one in two or three rota and will be under more severe pressure. Is that taken into account when talking about a higher risk?

Deputy Louise O'Reilly

Paragraph 4.1 of the HSE statement advises that "clinical directors have put in place monitoring arrangements appropriate to the circumstances of the practice of post-2008 consultants not in the relevant specialist division". How are the monitoring arrangements in place for reading radiology results? Does one person read the information and another read the same film? It strikes me as odd because the qualified person should be reading it in the first place. That seems like double jobbing. Can Ms Mannion explain how that works?

Can the HSE tell us how many of those being paid as consultants but who are not on the specialist register will in the coming four years accrue an entitlement to a contract of indefinite duration? They start to accrue that entitlement from day one. I have represented many beneficiaries of that entitlement but is it flagged up on day one that the person is accruing that entitlement under law? Their entitlement under the law cannot be prevented and neither can they be taken out of the job to frustrate that entitlement.

We know that but what steps are taken to ensure this happens? It strikes me this is an issue that will keep arising for all the reasons we have rehearsed. At the day one stage in the job, does a flag go up? The witnesses might talk me through exactly what is the process between that day and getting to year four, with the monitoring and everything that has to go into place.

There was an article in the media recently stating that doctors who qualified in Sudan, Malaysia and Pakistan no longer have to sit clinical exams. Perhaps the witnesses could advise us on that. If it has been covered already, I am happy to go back over the record as I do not want to delay people unnecessarily.

Dr. Tom Ryan

There is a problem in that if a doctor is appointed as a consultant, one is appointing an independent medical practitioner and there is no possibility of mentoring an independent medical practitioner. If I ask a consultant colleague for his opinion, I expect an opinion from him that is valid, appropriate and discerning, not an opinion from somebody else who is mentoring him. The whole point of appointing a consultant is to appoint a substantial person who can practise independently. The whole notion of bringing them up to scratch is really a nonsense because they are either an independent medical practitioner or they are not. If they are not up to scratch, they should not be doing the job.

This is a confusion of risk and quality. In any other industry, like the aeroplane or transport industries, the industry does not act to mitigate risk, it acts to improve quality. It does not wait until the train or the aeroplane crashes and a person ends up in the courts or in front of the Medical Council; it ensures that the pilots are appropriately trained, the aeroplanes are appropriately maintained and good quality processes are in place. A basic quality process is to ensure that the staff who are supposed to practise independently are appropriately trained and qualified. It should never come to the fact that someone detects there is a problem only when a doctor ends up in front of the Medical Council or the High Court for malpractice. There should be quality programmes, and a basic part of a quality programme is to stick with basic professional standards and to ensure that all consultant staff who can practise independently are up to scratch and appropriately qualified. This is just the most basic standard that we would use to base any quality programme on. The whole notion that one would wait until somebody had caused a problem with the Medical Council and then flag up a risk is a problem. It is not prioritising quality of care, excellence of standards and an aspiration for either academic or clinical excellence. I believe the dialogue is misguided.

Mr. Martin Varley

Deputy O'Connell made reference to false economy. We would be very much of the view this is a false economy and it is something that could have been addressed and dealt with. The health service managers have been aware of it for a long time. The root cause, as I said, goes back to the State and the health service management being in breach of contract and discriminating against new entrant consultants. There is no getting away from that, and that is where the solution lies. Why is it a false economy? First, it is a false economy because we have a large number of posts which are vacant and which are depriving patients in our hospitals of timely care. Second, there is the question of quality care and risk. Third, there is the issue that we are actually paying temporary consultants, some 70-something of whom we now know are not on the specialist register, significantly more than we are paying the permanent contract holders, in fact, two to three times what we are paying new entrants and even longer-serving consultants. The agency bill-----

Deputy Kate O'Connell

Excuse me. Is Mr. Varley saying we are paying locum SPRs who are not on the consultant register two to three times what we paying an Irish-registered hospital consultant, in net terms, for the same work?

Mr. Martin Varley

In gross terms we are paying two to three times the approved salary for long-serving consultants-----

Deputy Kate O'Connell

Locums who are not up to scratch.

Mr. Martin Varley

-----to agency contract doctors who are not on the specialist register. I have had that confirmed under FOI from various employers.

Deputy Kate O'Connell

Therefore, no matter what anyone says to us, it is a false economy.

Mr. Martin Varley

It is a false economy both in a financial sense and, as we have been discussing all morning, in the much wider patient care sense.

Deputy Kate O'Connell

In light of recent news, there is quite a common thread.

Mr. Martin Varley

Yes. It is one of the main issues causing difficulty for consultants, namely, that we cannot recruit and replace in a timely fashion. If we are filling posts now, we are, in effect, filling gaps with people who are not meeting the HSE standards or the Medical Council requirements, as we see them.

Deputy Durkan raised questions about the recruitment crisis. While there were always challenges in recruiting in previous decades, in the last decade the scale of the challenge has become far more prolonged and deep to the extent that a quarter of the posts advertised the year before last had no applicants and possibly another quarter had one applicant, so, in effect, for half of the advertised posts, there was no competition. On balance, we would be talking about the rest of the posts having, say, two applicants and let us not forget there could be five or six consultant anaesthetist posts advertised at any one time so, in fact, we could be seeing similar people applying for similar posts. The scale of competition is much reduced compared with the position prior to 2008. This comes back to the absolute breach of trust and the failure to honour basic contract terms, which is very unfortunate.

Another development we note is the increase in the number of consultants resigning from their posts to practise in private hospitals or to practise abroad, which is a new and increasing phenomenon. Again, I think this goes back to the breach of trust and also the lack of resources to provide timely care to patients. The third development we note in recent times is that more and more consultants are considering working part-time because of the stress and lack of resources, and, no doubt, also because of the breach of contract. Unfortunately, we are seeing a growing problem that is beginning to mushroom out into the system.

I do not have the luxury of seeing the most recent data circulated by the HSE but we were provided with data on where these posts were back in October. All I would say is that this is becoming more and more extensive and, at that time, it was affecting posts in 15 specialties throughout 15 acute hospitals and ten mental health services. In fact, the list I have seen suggests it is also impacting tertiary hospitals and cancer centres. While I am not sure what is in the current data, it is becoming quite extensive, which is a concern on several fronts.

Chairman

With regard to the advertising of posts, I am aware that many posts are advertised very late or after the consultant has retired or left his position, so there is a long run-in to the appointment of a replacement, perhaps up to a year. Is there anticipatory advertising of posts when consultants are coming up to retirement?

Dr. Tom Ryan

No.

Professor Frank Murray

I would like to comment on that. I have just taken up post as director of National Doctors Training and Planning, NDTP, and one of the things I am focusing on is having an efficient, timely process that anticipates people retiring and considers proleptic appointments. We know many people retire when they are 65 and some retire before that. We should question people, when they are considering retiring, not in order to push them out but just to get a sense of what needs to be done to minimise the gaps. The point Mr. Varley made is a fair one. We want to minimise the gaps and have an efficient and effective recruitment process. That is only part of what we are trying to do. The problems with recruitment are not single-factorial but multifactorial and that is clear from the discussions we have had here this morning. I would see it as my responsibility to make sure we improve all of those processes as best we can.

There was a question from Deputy O'Connell on value for money I would like to address directly. The best way to do things is to do things the correct way for the correct reason. That is what we should be aspiring to do. We should not have protracted periods with doctors working as locums at consultant level. We should aim to minimise that. One of the targets I am going to set is to reduce our dependence on locums right through the system.

I would also like to answer another of the Deputy's questions on locally appointed and centrally appointed staff. Centrally appointing staff to a substantive post includes going through a process called CAAC, the consultant appointment approval committee; and the approval of a consultant through a competition either at hospital level or through the PAS, the Public Appointments Service. For many locum posts, this process does not operate; there is a short-term gap, somebody retires or is ill or there is an extra post and that post is then filled locally rather than centrally. That is the difference between locally and centrally appointed or centrally approved.

Deputy Kate O'Connell

I understand that. The witness need not have explained that. It seems a bit strange, in a population the size of the city of Manchester, that one would have CAAC and two separated streams of recruitment for the same job. We are the size of the United States of America. The witness spoke about what he is going to set, which is aspirational. We have all had enough of aspirational plans. This is about real patients who have an expectation of seeing a consultant and every person waits for the consultant's opinion when they have something seriously wrong with them. When the consultant who is presented is not up to scratch, it really diminishes confidence in a system.

The witness mentioned multi-factorial. It is absolutely shocking and no surprise if a person is reaching 65 years of age that they are going to retire. It is only a surprise if they are 45. Does this same ad hoc - and I realise that the witness is only taking up this post - approach apply when it comes to maternity leave, for instance? It is generally never a surprise that a person reaches eight months in a pregnancy and they will be off work - I understand in the health service it is for the six months plus the three months plus some holidays, so usually in the region of a year. Is the same approach taken for maternity as is taken for retirement or whatever other instances?

Deputy Louise O'Reilly

That applies where people are actually being replaced but the unfortunate thing is that they are not in many instances.

Deputy Kate O'Connell

Is it the same thing where the reaction is "oh no, we are missing a consultant, we had better go and get one". Is that the sort of planning we are dealing with here?

Professor Frank Murray

To be honest, I am only six weeks in post so it is a little difficult for me to be dogmatic-----

Deputy Kate O'Connell

Ms Mannion is beside the witness----=

Professor Frank Murray

We should anticipate people retiring, facilitate their early retirement if they so wish, and anticipate and set up that process of recruitment, which does take a time to do. There is a process that has to be gone through. Once a job is advertised and a competition held, the person who has succeeded is declared, and that part alone often takes six to 12 months, leaving aside the planning component.

Deputy Kate O'Connell

I understand that but the witness just said there was no competition for many posts so should it not happen quickly?

Professor Frank Murray

There is still a competition process that has be followed. I will give an undertaking that I will enhance that process of managing predictable and early retirements and having an accelerated process.

The issue raised by the Deputy regarding maternity is an important issue and one of the things that we have not really done is catered, at all levels in the medical profession, for unscheduled or less scheduled absences from work. That is a project I have just started looking into.

The points the Deputy is making and the questions she is asking are fair and demand action.

Deputy Kate O'Connell

All of these answers would be fine if the HSE was born yesterday but it was not born yesterday, it was born ten years ago. This appears one of the most bizarre way and a way in which I would not run my corner shop.

Ms Rosarii Mannion

Thank you very much, Chair. I will start by taking Deputy O'Connell's questions in sequence, because a lot of them pick up the latter points. I have referenced this previously in the discussion this morning and on two previous occasions when I attended the committee here. None of these issues is new to me or surprise me regarding the requirement for planning for the workforce, for maternity leave, for scheduled and unscheduled absences; and governance regarding recruitment, adhering to our licence etc., all of which are set out in minute detail in this particular report which was chaired by Professor Tom Keane, and which we have referenced previously.

I know we have a lot of reports and I am happy to share this report, but there is also a detailed implementation plan that accompanies this document that we have been working on very diligently since the publication of the report in February 2017. It will alleviate some of the concerns that Deputy O'Connell has raised about advanced planning, and some of Deputy O'Reilly's questions regarding how we monitor contracts of indefinite duration, whereby we have introduced a fully integrated, automated e-recruitment system for doctors. We are getting live feeds from the Medical Council in terms of data. That is the doctors integrated management e-eystem, DIME. I have previously offered Deputies a visual demonstration on this system if they would like that and I trust that might alleviate some of the concerns regarding these issues for the Deputy. Very quickly, if I could go down through the questions-----

Chairman

Can we have the title of that report for clarification, please?

Ms Rosarii Mannion

Towards Successful Consultant Recruitment, Appointment and Retention, which was specifically commissioned to address a number of the issues that were raised here. A lot of these are legacy issues, and a lot of the time we would not start from where we are at which is neither here nor there. We have been working through, in a very fastidious way, the recommendations and the implementation plan and I am delighted to say that we are making progress. Thus the figures for February 2018 are that we have in excess of 300 additional medical staff on the payroll over what we had in 2017, almost 100 more consultants, and 260 non-consultant hospital doctors, NCHDs, and I can furnish all of that information.

Chairman

Will the witness furnish this report to the members of the committee?

Ms Rosarii Mannion

I certainly will, Chair.

Deputy Kate O'Connell

Does the witness attribute these additional 300 staff to the implementation of Professor Keane's report that is now in circulation for 14 months?

Ms Rosarii Mannion

It is a factor.

Deputy Kate O'Connell

Would it have happened anyway?

Ms Rosarii Mannion

It is a factor. There is no quick-fix to some of the issues that have emerged over a number of years and that are a response to a number of unplanned instances. We are absolutely aware of the issues and are working through them. The addition of 98 consultants on our payroll in February 2018 is certainly a factor in respect of some of the improvements that were made.

Would I say that I was entirely happy with all of that and that we have made all of the improvements we need to make? Absolutely not. Will we be certainly be making more improvements in the course of the year? Absolutely. Will we be in a better space next year? I believe we will.

As I have already stated to the committee, there are significant issues here. There is a global shortage in a lot of the medical personnel across all jurisdictions. It is not a unique issue to the Irish health service. Notwithstanding that, of course we can do better.

Moving to the questions, if that is okay-----

Deputy Kate O'Connell

If we can leave the questions for the moment, I wish to deal with the reference of the witness to other countries. Do other countries have a plan in place? When we are making comparisons in international or global terms, do other countries plan for maternity leave, retirement and unplanned absences? One cannot plan for every eventuality, for someone who might be killed on the way to work for instance. It is fairly obvious if a cohort of women are working in a place, that a portion will be on maternity leave. If there is a portion of people reaching 60 years of age, it is obvious they will be moving on in time. When one is making comparisons with other countries, have they planned for these things, or are they operating in the same way as we are?

Senator Colm Burke

If one chooses to look back I have consistently raised this issue over the past four to five years. If one goes back 15 years ago, there was a different process for recruitment and there was forward planning and then that system was absorbed into the HSE. Now the whole system that existed seems to have disappeared. We are trying to recreate that system and I fully accept that movement is in the right direction. What I would like to know is why that system was abolished at the time and absorbed into the HSE and the process that was already in place ignored. This does not make sense.

Ms Rosarii Mannion

If there is learning there, we are happy to take that on board and we will review that. Is that okay?

Can I return to the-----

Chairman

Yes of course.

Ms Rosarii Mannion

I will proceed down through Deputy O'Connell's questions fairly quickly and feel free to interrupt me if I am omitting anything.

Are we more likely or less likely to have disciplinary action in relation to the 127 consultants that are not on the specialists register? Of the 52 pre-2008 and the 75 post-2008 there is no visible variation at a central level in relation to disciplinary sanctions in that cohort.

The Deputy asked me whether the doctors are competent to perform the roles. I am advised that they are absolutely competent to perform the roles and there are-----

Deputy Kate O'Connell

By whom is the witness advised?

Ms Rosarii Mannion

I was advised by the relevant clinical directors.

Deputy Kate O'Connell

The relevant clinical directors of the group?

Ms Rosarii Mannion

Yes, the group that have oversight in respect of the 127 that are not on the specialist register. I am advised that they are absolutely competent. I clearly do not have performance management responsibility for clinical staff, but I have had no reports of incompetence in respect of those 127. On the question of who is liable if there is an adverse incident, it is the organisation that is liable.

Deputy Kate O'Connell

It is the organisation?

Ms Rosarii Mannion

Absolutely, it is. In respect of value for money, VFM, and the issue of agency staff, I have never heard the HSE as an employer saying that agency staff provide a VFM solution to us. In fact, it is the contrary. Agency staff are a feature of the workplace and always will be for unplanned absences etc. We do not, however, want agency staff ingrained in the workplace or a permanent feature of the workforce. Over the last number of years we have had specific targets in respect of agency conversion. The Deputy will be familiar with this from across other grades in addition to the medical staff. It is not always easy and it is not always the choice of the individuals concerned. I can think of one or two hospitals - that I will not mention here - that have quite a preponderance of agency staff. Dedicated efforts and focused attempts were made to convert agency staff but we have been unsuccessful. Of the 127-----

Deputy Kate O'Connell

Why would they want to earn a third less?

Chairman

Deputy O'Connell please-----

Deputy Kate O'Connell

I am being reasonable here. Why would anyone want to convert and earn a third less?

Chairman

-----allow Ms Mannion to go through the questions.

Ms Rosarii Mannion

Of the 127, 28 are currently employed through agency. On governance issues, they are all set out clearly in this report. I am happy to sit down with the Deputy, go through that and brief her on an individual basis if necessary. In respect of the requirement for a training programme for this cohort that are not on the specialist register, it was covered earlier in the briefing. We are case managing the 127 - who they are, where they are, what mentoring support is available, how we can communicate, how we can assist and how we can work in a collegiate way with other stakeholders such as the Medical Council etc. To the best of my knowledge, a specific training programme is not in existence because of the plethora of grades involved in the specialties. Again, my colleague, Professor Frank Murray, might want to speak to that. I think that covers all the questions.

Chairman

I thank the witness and call Dr. Breslin.

Dr. Anthony Breslin

I will be very brief and will clarify some of Deputy O'Connell's questions. She mentioned data on disciplinary actions. I said earlier that we have noticed an increase in complaints from those not on the specialist register. That is reflected in those who go on to fitness to practise and the number that are found guilty of poor professional performance. In respect of competence, we do have a-----

Deputy Kate O'Connell

The witness is contesting what-----

Dr. Anthony Breslin

I cannot give the exact figures but we can get them for the Deputy.

Senator Colm Burke

I raised the issue of consultants in smaller hospitals. They are on a more demanding rota. Is that not taken into account as well?

Dr. Anthony Breslin

It may be depending on the circumstances that arise. Then in respect of-----

Senator Colm Burke

It is not a fair comparison.

Dr. Anthony Breslin

Pardon?

Senator Colm Burke

It is an unfair comparison if we take it from a global point of view rather than comparing it to consultants who are on the specialist register in the smaller hospitals.

Dr. Anthony Breslin

When we are investigating a complaint we compare like with like. If someone is working in a small hospital, we look at what is expected for them working there versus someone working in a larger hospital. We do take that into consideration. Deputy O'Connell mentioned competence. We do have a competence scheme set up and 97% of doctors are registered and participating in continuous professional development, CPD. We did have to do a substantial amount of work to get all doctors signed up. Again, doctors not on the special register did require more work from us and the postgraduate training bodies to be involved.

The location of issues that arise was mentioned. We do see some patterns in some of the hospitals that are more likely to have staff not on a specialist register. On the query in respect of changes to legislation on access to non-EU doctors for training posts, that should not and will not have any impact on the quality of care. It should enhance that. Deputy Louise O'Reilly has left but she did have a query on doctors from overseas not doing exams. I answered that with an earlier question. I will reiterate. Before overseas doctors are registered here, they either have to do an exam here or have an equivalent internationally recognised exam done in another country. No doctor gets on the register without some assessment of his or her clinical abilities.

Chairman

Could I ask Dr. Peadar Gilligan if there is a greater difficulty in recruiting consultants to model 2 hospitals rather than model 3 or model 4 hospitals? Is the policy that there are now joint appointments rather than full-time appointments to model 2 hospitals? Are people jointly appointed to model 3 or model 4 hospitals and then they also do a certain number of sessions in the model 2 hospitals? From my experience, model 2 hospitals struggle to recruit staff and to have a full complement of consultant staff.

Dr. Peadar Gilligan

There is a challenge in recruitment and retention for the level 2 hospitals. We are, however, seeing challenges in recruitment across the system. It is not just at consultant level but also at non-consultant hospital doctor, NCHD, level. Many hospitals around the country are relying on locum agencies to provide them with staff to provide care to their patients on an ongoing basis. It is all reflective of what Deputy O'Connell referred to as "a bags of things" having been made of recruitment and retention. We clearly need to get this right. We need to make it attractive to provide specialist care in Irish hospitals throughout the country from level 1 all the way to level 4.

The only way we are going to achieve that is by meaningfully addressing the contractual issues of consultants. I return to Deputy Durkan's point. We do have to realise that we are competing in an international market for specialists. It has to be attractive for people to work here. That certainly includes pay but it also includes the supports necessary to provide specialist care. It includes the supports that are necessary to continue because many of our specialists have a background in research and training and education. They require support in the delivery of that as well. Let us move from a bags of things to getting things right. That involves real engagement with the Government and the representative bodies to address the recruitment challenges that we have.

Deputy Bernard J. Durkan

I have a related question. We are one of the top four or five spenders on general health services. Will our guests give us an idea of where we are spending more since we have fewer consultants per thousand of the population than most of our competitors across Europe and the OECD countries. Can some light be shed on where we are spending our money to bring us up to that level? There must be some factor somewhere that is a dominant factor that will give us some insight into where we are missing out.

Dr. Tom Ryan

I will comment on that. Healthcare spending in any country is directly related to how long people live. As a greater proportion of a population becomes elderly and infirm, more medical care is needed. People in Ireland live quite long lives. We live well into our 80s - to 81 or 82 years of age. That is a key driver of healthcare spending. Over the last 20 or 30 years we have been remarkably successful at prolonging people's lives by spending more money on healthcare. There is no sign that trend will change. As people in Ireland continue to live longer, more fruitful, happy lives, more money will need to be spent to keep them alive.

Deputy Bernard J. Durkan

The proportion of our population, however, in the younger age profile is significantly higher than many other comparable OECD countries. That is because of in-migration and the fact that in the last recession many young people who left the country came back quickly, or were stuck and could not go at all.

Dr. Tom Ryan

There are good data in some of the OECD documents in Health at a Glance: Europe 2016 and Health at a Glance: Europe 2018.

They go into it in quite a level of detail and do quite complex mathematical analysis of the link between how long people live and healthcare spending, and there is quite complex regression analysis and a curve. We fall bang in line with how much we should be spending for the life expectancy of our population. If we consider in particular the improvement in people's lifespan during the past 20 years, we can see the benefits of all the money we have spent on healthcare.

Chairman

I call Professor Murray.

Professor Frank Murray

That is a very good question. One of the most stark and impressive figures in Irish healthcare is that since 2000 life expectancy in Ireland has increased from 76 to 81. That is very stark. That reflects three major factors. The first is the quantity and quality of healthcare and the way we spend our money on healthcare in Ireland, which, I believe, provides quite good value for money. When I compare what we do now for patients in terms of medications and technology with the provision 17 or 18 years ago, and my clinical colleagues will support this, everything has improved dramatically in Ireland. That is one place where our healthcare spend goes. The other two big factors involved in the reason life expectancy has increased by five years, which is very dramatic, are the reduced rate of tobacco consumption and a fall from the peak in 2001 in alcohol consumption, which, as I said here previously, is still a dreadful problem here in Ireland. If we are to continue to improve our life expectancy, improving on those three factors must come into play. However, it is worth celebrating the successes in healthcare in Ireland.

Chairman

Thank you, Professor Murray. I call Dr. Gilligan.

Dr. Peadar Gilligan

That is a very good question. It is one I have posed to many economists. If we consider the facts, we have fewer specialists, general practitioners and hospital beds per capita of population than most other OECD countries. We have a difficulty with regard to the strategic spend on health. What I mean by that specifically is the Government allocation. When we talk of the per capita expenditure on heath, we are talking of the money allocated by Government, the out-of-pocket payments that patients make and the insurance. The only element of that over which we have real strategic control as a country is the Government spend. That component of the spend needs to increase in order that we can have the hospital beds, the specialists and general practitioners that our patients need.

Deputy Bernard J. Durkan

I will not delay the meeting any further on this matter but there is another issue to consider. For instance, if we compare the age profile of the population in Germany they are at a distinct disadvantage compared to this country. We have a huge advantage in terms of our young population, which most other European or OECD countries do not have. I cannot get to the bottom of this. I have asked this question several times and I afraid I will still be asking it for some time to come. I was a member of a health board previously and I cannot find out where we are spending the extra money to bring us up to that level among the OECD countries, given all that Dr. Gilligan has told us. The mathematics of it do not add up.

Chairman

Thank you, Deputy. We are under some time pressure. I will call Mr. Varley, Senator Colm Burke can then make a brief comment if he wishes and then I will wind up this part of the meeting.

Mr. Martin Varley

Two elements are being commented on, first, the totality of the general expenditure on health and, second, the spend on acute hospitals with which we interface more and are more familiar. I understand the statistics we are talking about in terms of the general expenditure on health but if we consider the spend on acute hospitals, we have spent relatively less on two fronts. First, we have not invested adequately in capacity in terms of capital spend during the past decade or two. That obviously creates its own problem in terms of efficiency and effectiveness in delivering care. Second and very important, our assessment indicates that we are not spending as much as others in terms acute hospital spend on a per capita basis. We have to segment out the expenditure. Whatever expenditure is taking place, we are not seeing a sufficient amount of it at the front line, where patient numbers have increased because of an increase in population and demographic factors. There is a need to segment and analyse it in more detail. We are quite convinced that we are not providing adequately for acute hospital care. As was mentioned, we have the lowest number of beds, we have the highest occupancy level, 97% or 98%, and we have a medium or relatively short length of stay. We have a large number of people, unfortunately on waiting lists and trolleys, all clear indicators of a lack of capacity and front-line capability to deliver care.

Chairman

Thank you, Mr. Varley. I call Senator Colm Burke.

Senator Colm Burke

The figures Dr. Gilligan gave indicating we have the lowest ratio of doctors and consultants in the OECD and, on the other side, Professor Murray's point that people's life expectancy has improved, show the dedication and commitment of the medical profession in Ireland in being able to deliver the service despite all the pressures. We need to face up to the challenge and make sure we can recruit and retain the people we need. In particular, I refer to the figure I gave earlier, namely, that approximately 39% of our registered medical practitioners are non-Irish graduates. We rank the second highest in that respect in the OECD, with Israel ranking higher than us.

Chairman

Thank you, Senator Burke.

On behalf of the committee, I thank all those who have attended this morning, representatives from the Medical Council, the HSE, the Irish Medical Organisation, IMO, and Irish Hospital Consultant Association, IHCA,

I propose we suspend for five minutes to allow the next set of witnesses to take their seats.

Sitting suspended at 11.57 a.m. and resumed at 12.05 p.m.